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Nolan JJ, Forrest J, Ormondroyd E. Additional findings from the 100,000 Genomes Project: A qualitative study of recipient perspectives. Genet Med 2024; 26:101103. [PMID: 38411041 DOI: 10.1016/j.gim.2024.101103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Participants in the 100,000 Genomes Project, a clinical/research initiative delivered through the UK National Health Service, were offered screening for "additional findings" (AFs): pathogenic/likely pathogenic secondary findings in genes associated with familial hypercholesterolemia or a cancer predisposition syndrome. Understanding the psychological and behavioral responses to secondary findings can inform the clinical utility of a search and disclose policy. METHODS Thirty-two adult AF recipients took part in semi-structured interviews analyzed using deductive and inductive thematic analysis. RESULTS Five themes were constructed: cognitive responses to an AF, emotional and psychological responses, personal control, perceived risk of AF-associated disease, and family implications. Many participants had misunderstood or incompletely remembered consent for AFs, and most were surprised or shocked to receive an AF. Although many ultimately appreciated knowing about the risk conferred, some struggled to make sense of their disease risk, which complicated decision making about risk management, particularly for women with a BRCA AF. Recipients sought control through seeking clinical evaluation and information, and informing relatives. Difficulties with conceptualizing risk and lack of AF-associated disease family history meant that some hesitated to inform relatives. CONCLUSION Genome sequencing programs offering secondary findings require attention to consent processes. Post-disclosure care should aim to promote recipients' perceived personal control.
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Affiliation(s)
- Joshua J Nolan
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jamie Forrest
- Oxford Centre for Genomic Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; University of Manchester, Manchester, United Kingdom
| | - Elizabeth Ormondroyd
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom.
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2
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Novel Phenotype in Unbalanced 7;9 Translocation with Critical Incidental Finding. Case Rep Genet 2022; 2022:7510079. [PMID: 35620252 PMCID: PMC9130017 DOI: 10.1155/2022/7510079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/15/2022] [Indexed: 11/17/2022] Open
Abstract
This case discusses a now 13-year-old boy who underwent chromosome analysis and fluorescence in situ hybridization (FISH) for subtelomeric rearrangements due to dysmorphic features at birth. This testing revealed a diagnosis of an unbalanced 7;9 translocation resulting in monosomy for 7q34-qter and trisomy for 9pter-p21, which resulted in a very complex medical course. At the age of 12, due to persistent complex neurodevelopmental concerns, the patient was referred by neurology for whole-exome sequencing. This testing revealed an incidental pathogenic heterozygous KCNH2 deletion, which is associated with long QT-syndrome type II. Prior to this point, the patient had no symptoms of long QT syndrome and had multiple EKGs with normal QT intervals. However, due to this association, the patient underwent Holter monitoring, which revealed clinical evidence of long-QT syndrome type II. Preventative treatment was then initiated and the patient remains asymptomatic. This case expands on the phenotype of this patient’s unbalanced 7;9 translocation as well as highlights the importance of secondary findings in genetic testing.
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3
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Molecular Diagnostic Outcomes from 700 Cases: What Can We Learn from a Retrospective Analysis of Clinical Exome Sequencing? J Mol Diagn 2022; 24:274-286. [PMID: 35065284 PMCID: PMC9904168 DOI: 10.1016/j.jmoldx.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 11/29/2021] [Accepted: 12/10/2021] [Indexed: 01/19/2023] Open
Abstract
Clinical exome sequencing (CES) aids in the diagnosis of rare genetic disorders. Herein, we report the molecular diagnostic yield and spectrum of genetic alterations contributing to disease in 700 pediatric cases analyzed at the Children's Hospital of Philadelphia. The overall diagnostic yield was 23%, with three cases having more than one molecular diagnosis and 2.6% having secondary/additional findings. A candidate gene finding was reported in another 8.4% of cases. The clinical indications with the highest diagnostic yield were neurodevelopmental disorders (including seizures), whereas immune- and oncology-related indications were negatively associated with molecular diagnosis. The rapid expansion of knowledge regarding the genome's role in human disease necessitates reanalysis of CES samples. To capture these new discoveries, a subset of cases (n = 240) underwent reanalysis, with an increase in diagnostic yield. We describe our experience reporting CES results in a pediatric setting, including reporting of secondary findings, reporting newly discovered genetic conditions, and revisiting negative test results. Finally, we highlight the challenges associated with implementing critical updates to the CES workflow. Although these updates are necessary, they demand an investment of time and resources from the laboratory. In summary, these data demonstrate the clinical utility of exome sequencing and reanalysis, while highlighting the critical considerations for continuous improvement of a CES test in a clinical laboratory.
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4
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Cheung F, Birch P, Friedman JM, Elliott AM, Adam S. The long‐term impact of receiving incidental findings on parents undergoing genome‐wide sequencing. J Genet Couns 2022; 31:887-900. [DOI: 10.1002/jgc4.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Faith Cheung
- Department of Medical Genetics Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Patricia Birch
- Department of Medical Genetics Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
- BC Children’s Hospital Research Institute Vancouver British Columbia Canada
| | - J. M. Friedman
- Department of Medical Genetics Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
- BC Children’s Hospital Research Institute Vancouver British Columbia Canada
| | - Alison M Elliott
- Department of Medical Genetics Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
- BC Children’s Hospital Research Institute Vancouver British Columbia Canada
- BC Women’s Health Research Institute Vancouver British Columbia Canada
| | - Shelin Adam
- Department of Medical Genetics Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
- BC Children’s Hospital Research Institute Vancouver British Columbia Canada
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5
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Matsui K, Yamamoto K, Tashiro S, Ibuki T. A systematic approach to the disclosure of genomic findings in clinical practice and research: a proposed framework with colored matrix and decision-making pathways. BMC Med Ethics 2021; 22:168. [PMID: 34953504 PMCID: PMC8709972 DOI: 10.1186/s12910-021-00738-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Whether and how to disclose genomic findings obtained in the course of genomic clinical practice and medical research has been a controversial global bioethical issue over the past two decades. Although several recommendations and judgment tools for the disclosure of genomic findings have been proposed, none are sufficiently systematic or inclusive or even consistent with each other. In order to approach the disclosure/non-disclosure practice in an ethical manner, optimal and easy-to-use tools for supporting the judgment of physicians/researchers in genomic medicine are necessary. Methods The bioethics literature on this topic was analyzed to parse and deconstruct the somewhat overlapping and therefore ill-defined key concepts of genomic findings, such as incidental, primary, secondary, and other findings. Based on the deconstruction and conceptual analyses of these findings, we then defined key parameters from which to identify the strength of duty to disclose (SDD) for a genomic finding. These analyses were then applied to develop a framework with the SDD matrix and systematic decision-making pathways for the disclosure of genomic findings. Results The following six major parameters (axes), along with sub-axes, were identified: Axis 1 (settings and institutions where findings emerge); Axis 2 (presence or absence of intention and anticipatability in discovery); Axis 3 (maximal actionability at the time of discovery); Axis 4 (net medical importance); Axis 5 (expertise of treating physician/researcher); and Axis 6 (preferences of individual patients/research subjects for disclosure). For Axes 1 to 4, a colored SDD matrix for genomic findings was developed in which levels of obligation for disclosing a finding can be categorized. For Axes 5 and 6, systematic decision-making pathways were developed via the SDD matrix. Conclusion We analyzed the SDD of genomic findings and developed subsequent systematic decision-making pathways of whether and how to disclose genomic findings to patients/research subjects and their relatives in an ethical manner. Our comprehensive framework may help physicians and researchers in genomic medicine make consistent ethical judgments regarding the disclosure of genomic findings.
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Affiliation(s)
- Kenji Matsui
- Division of Bioethics and Healthcare Law, The Institute for Cancer Control, The National Cancer Center Japan, Tsukiji 5-1-1, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Keiichiro Yamamoto
- Office of Bioethics, The Center for Clinical Sciences, The National Center for Global Health and Medicine, Tokyo, Japan
| | - Shimon Tashiro
- Department of Sociology, Graduate School of Arts and Letters, Tohoku University, Sendai, Japan
| | - Tomohide Ibuki
- Institute of Arts and Sciences, Tokyo University of Science, Noda-shi, Japan
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6
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Rini C, Roche MI, Lin FC, Foreman AKM, Khan CM, Griesemer I, Waltz M, Lee K, O'Daniel JM, Evans JP, Berg JS, Henderson GE. Burden or benefit? Effects of providing education about and the option to request additional genomic findings from diagnostic exome sequencing: A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2021; 104:2989-2998. [PMID: 33966955 PMCID: PMC8553797 DOI: 10.1016/j.pec.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 04/22/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Many people prefer to learn secondary or "additional" findings from genomic sequencing, including findings with limited medical actionability. Research has investigated preferences for and effects of learning such findings, but not psychosocial and behavioral effects of receiving education about them and the option to request them, which could be burdensome or beneficial (e.g., causing choice overload or satisfying strong preferences, respectively). METHODS 335 adults with suspected genetic disorders who had diagnostic exome sequencing in a research study and were randomized to receive either diagnostic findings only (DF; n = 171) or diagnostic findings plus education about additional genomic findings and the option to request them (DF + EAF; n = 164). Assessments occurred after enrollment (Time 1), after return of diagnostic results and-for DF + EAF-the education under investigation (Time 2), and three and six months later (Times 3, 4). RESULTS Time 2 test-related distress, test-related uncertainty, and generalized anxiety were lower in the DF + EAF group (ps = 0.025-0.043). There were no other differences. CONCLUSIONS Findings show limited benefits and no harms of providing education about and the option to learn additional findings with limited medical actionability. PRACTICE IMPLICATIONS Findings can inform recommendations for returning additional findings from genomic sequencing (e.g., to research participants or after commercial testing).
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Affiliation(s)
- Christine Rini
- Department of Medical Social Sciences, Northwestern University, Chicago, IL 60611, USA; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL 60611, USA.
| | - Myra I Roche
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC 27599, USA; Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27599, USA
| | | | - Cynthia M Khan
- U.S. Government Accountability Office, 441G Street NW, Washington, DC 20548, USA
| | - Ida Griesemer
- Department of Health Behavior, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC 27599, USA
| | - Margaret Waltz
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kristy Lee
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Julianne M O'Daniel
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - James P Evans
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
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7
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Lessons learned from unsolicited findings in clinical exome sequencing of 16,482 individuals. Eur J Hum Genet 2021; 30:170-177. [PMID: 34697415 PMCID: PMC8821629 DOI: 10.1038/s41431-021-00964-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 08/02/2021] [Accepted: 09/09/2021] [Indexed: 12/31/2022] Open
Abstract
Unsolicited findings (UFs) are uncovered unintentionally and predispose to a disease unrelated to the clinical question. The frequency and nature of UFs uncovered in clinical practice remain largely unexplored. We here evaluated UFs identified during a 5-year period in which 16,482 index patients received clinical whole-exome sequencing (WES). UFs were identified in 0.58% (95/16,482) of index patients, indicating that the overall frequency of UFs in clinical WES is low. Fewer UFs were identified using restricted disease-gene panels (0.03%) than when using whole-exome/Mendeliome analysis (1.03%). The UF was disclosed to 86 of 95 individuals, for reasons of medical actionability. Only 61% of these UFs reside in a gene that is listed on the “ACMG59”-list, representing a list of 59 genes for which the American College of Medical Genetics recommends UF disclosure. The remaining 39% were grouped into four categories: disorders similar to “ACMG59”-listed disorders (25%); disorders for which disease manifestation could be influenced (7%); UFs providing reproductive options (2%); and UFs with pharmacogenetic implications (5%). Hence, our experience shows that UFs predisposing to medically actionable disorders affect a broader range of genes than listed on the “ACMG59”, advocating that a pre-defined gene list is too restrictive, and that UFs may require ad hoc evaluation of medical actionability. While both the identification and disclosure of UFs depend on local policy, our lessons learned provide general essential insight into the nature and odds of UFs in clinical exome sequencing.
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8
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Response to letter entitled: Re: Mainstreaming informed consent for genomic sequencing: A call for action: Discussing opt-out options during informed consent discussions in mainstream settings. Eur J Cancer 2021; 155:310-312. [PMID: 34391611 DOI: 10.1016/j.ejca.2021.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 11/22/2022]
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9
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Saelaert M, Mertes H, Moerenhout T, Van Cauwenbergh C, Leroy BP, Devisch I, De Baere E. A qualitative study among patients with an inherited retinal disease on the meaning of genomic unsolicited findings. Sci Rep 2021; 11:15834. [PMID: 34349199 PMCID: PMC8339116 DOI: 10.1038/s41598-021-95258-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/05/2021] [Indexed: 12/30/2022] Open
Abstract
Exome-based testing for genetic diseases can reveal unsolicited findings (UFs), i.e. predispositions for diseases that exceed the diagnostic question. Knowledge of patients’ interpretation of possible UFs and of motives for (not) wanting to know UFs is still limited. This lacking knowledge may impede effective counselling that meets patients’ needs. Therefore, this article examines the meaning of UFs from a patient perspective. A qualitative study was conducted and an interpretative phenomenological analysis was made of 14 interviews with patients with an inherited retinal disease. Patients assign a complex meaning to UFs, including three main components. The first component focuses on result-specific qualities, i.e. the characteristics of an UF (inclusive of actionability, penetrance, severity and age of onset) and the consequences of disclosure; the second component applies to a patient’s lived illness experiences and to the way these contrast with reflections on presymptomatic UFs; the third component addresses a patient’s family embedding and its effect on concerns about disease prognosis and genetic information’s family relevance. The complex meaning structure of UFs suggests the need for counselling procedures that transcend a strictly clinical approach. Counselling should be personalised and consider patients’ lived illness experiences and family context.
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Affiliation(s)
- Marlies Saelaert
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium.
| | - Heidi Mertes
- Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Tania Moerenhout
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium.,Bioethics Centre, University of Otago, Dunedin, New Zealand.,Department of Philosophy and Moral Sciences, Ghent University, Ghent, Belgium
| | - Caroline Van Cauwenbergh
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium.,Department of Head and Skin, Ghent University, Ghent, Belgium
| | - Bart P Leroy
- Department of Ophthalmology, Ghent University Hospital, Ghent, Belgium.,Department of Head and Skin, Ghent University, Ghent, Belgium.,Center for Medical Genetics Ghent (CMGG), Ghent University Hospital, Ghent, Belgium.,Division of Ophthalmology & Center for Cellular & Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ignaas Devisch
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics Ghent (CMGG), Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
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10
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Staley BS, Milko LV, Waltz M, Griesemer I, Mollison L, Grant TL, Farnan L, Roche M, Navas A, Lightfoot A, Foreman AKM, O'Daniel JM, O'Neill SC, Lin FC, Roman TS, Brandt A, Powell BC, Rini C, Berg JS, Bensen JT. Evaluating the clinical utility of early exome sequencing in diverse pediatric outpatient populations in the North Carolina Clinical Genomic Evaluation of Next-generation Exome Sequencing (NCGENES) 2 study: a randomized controlled trial. Trials 2021; 22:395. [PMID: 34127041 PMCID: PMC8201439 DOI: 10.1186/s13063-021-05341-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/26/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Exome sequencing (ES) has probable utility for shortening the diagnostic odyssey of children with suspected genetic disorders. This report describes the design and methods of a study evaluating the potential of ES as a routine clinical tool for pediatric patients who have suspected genetic conditions and who are in the early stages of the diagnostic odyssey. METHODS The North Carolina Clinical Genomic Evaluation by Next-generation Exome Sequencing (NCGENES) 2 study is an interdisciplinary, multi-site Phase III randomized controlled trial of two interventions: educational pre-visit preparation (PVP) and offer of first-line ES. In this full-factorial design, parent-child dyads are randomly assigned to one of four study arms (PVP + usual care, ES + usual care, PVP + ES + usual care, or usual care alone) in equal proportions. Participants are recruited from Pediatric Genetics or Neurology outpatient clinics in three North Carolina healthcare facilities. Eligible pediatric participants are < 16 years old and have a first visit to a participating clinic, a suspected genetic condition, and an eligible parent/guardian to attend the clinic visit and complete study measures. The study oversamples participants from underserved and under-represented populations. Participants assigned to the PVP arms receive an educational booklet and question prompt list before clinical interactions. Randomization to offer of first-line ES is revealed after a child's clinic visit. Parents complete measures at baseline, pre-clinic, post-clinic, and two follow-up timepoints. Study clinicians provide phenotypic data and complete measures after the clinic visit and after returning results. Reportable study-related research ES results are confirmed in a CLIA-certified clinical laboratory. Results are disclosed to the parent by the clinical team. A community consultation team contributed to the development of study materials and study implementation methods and remains engaged in the project. DISCUSSION NCGENES 2 will contribute valuable knowledge concerning technical, clinical, psychosocial, and health economic issues associated with using early diagnostic ES to shorten the diagnostic odyssey of pediatric patients with likely genetic conditions. Results will inform efforts to engage diverse populations in genomic medicine research and generate evidence that can inform policy, practice, and future research related to the utility of first-line diagnostic ES in health care. TRIAL REGISTRATION ClinicalTrials.gov NCT03548779 . Registered on June 07, 2018.
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Affiliation(s)
- Brooke S Staley
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Campus Box #7295, Chapel Hill, NC, 27599-7295, USA.
| | - Laura V Milko
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Margaret Waltz
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ida Griesemer
- Department of Heath Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lonna Mollison
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Tracey L Grant
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Myra Roche
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, 27599, USA
| | - Angelo Navas
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Alexandra Lightfoot
- Department of Heath Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ann Katherine M Foreman
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Julianne M O'Daniel
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Suzanne C O'Neill
- Department of Oncology, Georgetown University, Washington, DC, 20007, USA
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Tamara S Roman
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Alicia Brandt
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Bradford C Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Christine Rini
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Jeannette T Bensen
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Campus Box #7295, Chapel Hill, NC, 27599-7295, USA
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11
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Anderson JL, Pilarski R, Kirschner L, Brock P. Genetic evaluation of patients and families with concern for hereditary endocrine tumor syndromes. Fam Cancer 2021; 21:93-100. [PMID: 33409929 DOI: 10.1007/s10689-020-00222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022]
Abstract
Hereditary endocrine tumor syndromes are rare conditions with overlapping features. It is imperative that healthcare providers differentiate between these syndromes for proper patient care. Advances in genetic testing technologies have increased utilization of genetic counseling and testing in this field; however, few endocrine cancer genetics clinics exist. Two years ago, a genetic counselor (GC) specializing in endocrine cancer genetics was added to the multidisciplinary team of the James Neuroendocrine/Thyroid Clinic at The Ohio State University. Here, we report on this experience. In total, 358 patients were seen. The majority were referred by medical oncology (n = 204; 57%) for a personal history of disease (n = 249; 81%). The most common referral indications were pancreatic neuroendocrine tumors (n = 44; 17%), multiple primary tumors (n = 37; 14%), and pheochromocytoma/paraganglioma (n = 35; 14%). Most patients completed genetic testing after genetic counseling (n = 200; 65%). Targeted gene panel testing was the most common testing ordered (n = 98; 32%). Thirty-one patients (15.5%) had ≥ one likely pathogenic variant (LPV) or pathogenic variant (PV) identified. Approximately 37% (n = 11) did not meet genetic testing guidelines for the gene they tested positive for. The most common genes with LPV/PVs were the SDH genes (n = 8) and MEN1 (n = 7). Referral indications with the highest likelihood of LPV/PVs were paraganglioma, medullary thyroid carcinoma, and multiple primary tumors. We believe this data can provide valuable guidance to healthcare providers who see patients with endocrine neoplasia or who are seeking to establish hereditary endocrine cancer clinics.
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Affiliation(s)
- Jennifer L Anderson
- Center for Individualized Medicine, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert Pilarski
- Division of Human Genetics, Department of Internal Medicine and James Comprehensive Cancer Center, The Ohio State University, 2012 Kenny Road, Columbus, OH, 43202, USA
| | - Lawrence Kirschner
- Division of Endocrinology, Diabetes, and Metabolism, The Ohio State University Wexner Medical Center, 5Th Floor McCampbell Hall, 1581 Dodd Street, Columbus, OH, 43210, USA
| | - Pamela Brock
- Division of Human Genetics, Department of Internal Medicine and James Comprehensive Cancer Center, The Ohio State University, 2012 Kenny Road, Columbus, OH, 43202, USA.
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12
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Vu M, Degeling K, Martyn M, Lynch E, Chong B, Gaff C, IJzerman MJ. Evaluating the resource implications of different service delivery models for offering additional genomic findings. Genet Med 2020; 23:606-613. [PMID: 33214711 DOI: 10.1038/s41436-020-01030-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the resource implications of different delivery models for the provision of additional findings (AF) in genomics from a health-care purchaser perspective. METHODS Data from the Additional Findings study were used to develop and validate a discrete event simulation model that represented the pathway of delivering AF. Resource implications were estimated by microcosting the consultations, sample verifications, bioinformatics, curation, and multidisciplinary case review meetings. A proof-of-concept model was used to generate costing, and then the simulation model was varied to assess the impact of an automated analysis pipeline, use of telehealth consultation, full automation with electronic decision support, and prioritizing case review for cases with pathogenic variants. RESULTS For the proof-of-concept delivery model, the average total cost to report AF was US$430 per patient irrespective of result pathogenicity (95% confidence interval [CI] US$375-US$489). However, the cost of per AF diagnosis was US$4349 (95% CI US$3794-US$4953). Alternative approaches to genetic counseling (telehealth, decision support materials) and to multidisciplinary case review (pathogenic AF cases only) lowered the total per patient cost of AF analysis and reporting by 41-51%. CONCLUSION Resources required to provide AF can be reduced substantially by implementing alternative approaches to counseling and multidisciplinary case review.
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Affiliation(s)
- Martin Vu
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Koen Degeling
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Melissa Martyn
- Murdoch Children's Research Institute, Melbourne, Australia.,Melbourne Genomics Health Alliance, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Elly Lynch
- Murdoch Children's Research Institute, Melbourne, Australia.,Melbourne Genomics Health Alliance, Melbourne, Australia.,Victorian Clinical Genetics Services, Melbourne, Australia
| | - Belinda Chong
- Murdoch Children's Research Institute, Melbourne, Australia.,Victorian Clinical Genetics Services, Melbourne, Australia
| | - Clara Gaff
- Murdoch Children's Research Institute, Melbourne, Australia.,Melbourne Genomics Health Alliance, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Maarten J IJzerman
- Centre for Cancer Research and Centre for Health Policy, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia. .,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia. .,Department of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia.
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13
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Mandelker D, Donoghue M, Talukdar S, Bandlamudi C, Srinivasan P, Vivek M, Jezdic S, Hanson H, Snape K, Kulkarni A, Hawkes L, Douillard JY, Wallace SE, Rial-Sebbag E, Meric-Bersntam F, George A, Chubb D, Loveday C, Ladanyi M, Berger MF, Taylor BS, Turnbull C. Germline-focussed analysis of tumour-only sequencing: recommendations from the ESMO Precision Medicine Working Group. Ann Oncol 2020; 30:1221-1231. [PMID: 31050713 PMCID: PMC6683854 DOI: 10.1093/annonc/mdz136] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
It is increasingly common in oncology practice to perform tumour sequencing using large cancer panels. For pathogenic sequence variants in cancer susceptibility genes identified on tumour-only sequencing, it is often unclear whether they are of somatic or constitutional (germline) origin. There is wide-spread disparity regarding both the extent to which systematic 'germline-focussed analysis' is carried out upon tumour sequencing data and for which variants follow-up analysis of a germline sample is carried out. Here we present analyses of paired sequencing data from 17 152 cancer samples, in which 1494 pathogenic sequence variants were identified across 65 cancer susceptibility genes. From these analyses, the European Society of Medical Oncology Precision Medicine Working Group Germline Subgroup has generated (i) recommendations regarding germline-focussed analyses of tumour-only sequencing data, (ii) indications for germline follow-up testing and (iii) guidance on patient information-giving and consent.
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Affiliation(s)
- D Mandelker
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York.
| | - M Donoghue
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - S Talukdar
- Department of Clinical Genetics, St George's University of London, London
| | - C Bandlamudi
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - P Srinivasan
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - M Vivek
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - S Jezdic
- European Society for Medical Oncology (ESMO) Head Office, Lugano, Switzerland
| | - H Hanson
- Department of Clinical Genetics, St George's University of London, London
| | - K Snape
- Department of Clinical Genetics, St George's University of London, London
| | - A Kulkarni
- Department of Clinical Genetics, Guy and St Thomas' NHS Foundation Trust, London
| | - L Hawkes
- Department of Clinical Genetics, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - J-Y Douillard
- European Society for Medical Oncology (ESMO) Head Office, Lugano, Switzerland
| | - S E Wallace
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - F Meric-Bersntam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - A George
- Cancer Genetics Unit, The Royal Marsden NHS Foundation Trust, London; Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - D Chubb
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - C Loveday
- Division of Genetics and Epidemiology, Institute of Cancer Research, London
| | - M Ladanyi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, USA
| | - M F Berger
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York; Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York
| | - B S Taylor
- Marie-Josee and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York; Department of Clinical Genetics, St George's University of London, London; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C Turnbull
- Department of Clinical Genetics, Guy and St Thomas' NHS Foundation Trust, London; Division of Genetics and Epidemiology, Institute of Cancer Research, London; William Harvey Research Institute, Queen Mary University of London, London; Public Health England, London, UK.
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14
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Rost C, Dent KM, Botkin J, Rothwell E. Experiences and lessons learned by genetic counselors in returning secondary genetic findings to patients. J Genet Couns 2020; 29:1234-1244. [PMID: 32453499 DOI: 10.1002/jgc4.1292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/06/2022]
Abstract
Few studies have explored the real-world experiences and strategies of genetic counselors involved in the process of returning secondary findings (SFs). This study aimed to describe and categorize the experiences for the return of SFs from clinical sequencing. Semi-structured telephone interviews with 21 genetic counselors representing 56 incidences were conducted. A content analysis was conducted on the transcripts through an iterative, team-based approach. Four common categories emerged across all interviews. These included (a) the importance of pretest counseling for the return of SFs, (b) how primary test results influenced the level of importance placed on the SFs, (c) patients' emotional reactions from receiving SF results, and (d) how returning SFs changed future pretest counseling and consent. This study identified experiences and common practices by genetic counselors who returned SFs. More research is needed to assess how genetic counselors' specific strategies improve patient comprehension and medical actions.
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Affiliation(s)
- Carly Rost
- University of Utah Graduate Program in Genetic Counseling, Salt Lake City, Utah
| | - Karin M Dent
- University of Utah Graduate Program in Genetic Counseling, Salt Lake City, Utah.,Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jeffrey Botkin
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Erin Rothwell
- Department of OB/GYN, University of Utah, Salt Lake City, Utah
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15
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Mollison L, O'Daniel JM, Henderson GE, Berg JS, Skinner D. Parents' perceptions of personal utility of exome sequencing results. Genet Med 2020; 22:752-757. [PMID: 31857707 PMCID: PMC7192542 DOI: 10.1038/s41436-019-0730-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 12/04/2019] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Clinical genome or exome sequencing (GS/ES) provides a diagnosis for many individuals with suspected genetic disorders, but also yields negative or uncertain results for the majority. This study examines how parents of a child with an undiagnosed condition attribute personal utility to all types of ES results. METHODS Return of 31 exome sequencing results was observed during clinic sessions, followed by semistructured interviews with parents one month later. Observations and interviews were recorded and transcribed. Data display matrices were used for content analysis and systematic comparisons of parents' perceptions of utility. RESULTS ES results could not provide all the answers to parents' questions, especially in cases of clinically uninformative results, but parents nonetheless attributed utility to the knowledge gained. Parents across all results categories used the genomic information to rule out possible causes, end or postpone the diagnostic odyssey, and shift focus to treatment and management of symptoms. CONCLUSION This study suggests that parents value even uninformative ES results while expressing hope for future discoveries. As pediatric genetics moves toward GS/ES as a first-tier test, how parents perceive the personal utility of negative or uncertain results is an important topic for genetic counseling and further research.
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Affiliation(s)
- Lonna Mollison
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Julianne M O'Daniel
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Debra Skinner
- FPG Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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16
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Liu H, Gao M, Gu J, Wan X, Wang H, Gu Q, Zhou Y, Sun X. VEGFR1-Targeted Contrast-Enhanced Ultrasound Imaging Quantification of Vasculogenic Mimicry Microcirculation in a Mouse Model of Choroidal Melanoma. Transl Vis Sci Technol 2020; 9:4. [PMID: 32704424 PMCID: PMC7347284 DOI: 10.1167/tvst.9.3.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Investigate the involvement of vascular endothelial growth factor receptor 1 (VEGFR1) in vasculogenic mimicry (VM) formation in ocular melanoma, as well as whether or not VEGFR1-targeted contrast-enhanced ultrasound (CEUS) can evaluate and quantify VM perfusion and function in the ocular melanoma model. Methods The expression of VEGFR1 was examined using immunofluorescence, western blot, and quantitative polymerase chain reaction. VM networks were analyzed with tube formation and periodic acid Schiff staining. Targeted microbubbles (MBs) were constructed and used for targeted CEUS imaging in vivo. Comparisons were made in perfusion parameters of tumors between targeted and non-targeted CEUS imaging. Results VEGFR1 was highly expressed, and knockdown of VEGFR1 significantly decreased VM protein expression and disrupted VM formation in MUM-2B melanoma. VEGFR1-targeted MBs specifically bind to MUM-2B cell surfaces. CEUS with VEGFR1-targeted MBs showed significant imaging enhancement throughout the entire perfusion phase compared with CEUS with IgG MBs. VEGFR1-targeted imaging was able to detect a decrease in maximum intensity and mean transit time in VEGFR1 knockdown melanoma compared with control melanoma. The pathological VM patterns were consistent with VEGFR1-targeted CEUS findings. Conclusions VEGFR1 was responsible for VM network formation and was required for efficient choroidal melanoma tumor growth. This study shows that VEGFR1-targeted CEUS can track VM levels in animal models of ocular melanoma at morphological levels in vivo. This experiment is noninvasive and reproducible and indicates the possibility of real-time in vivo imaging technology for VM evaluation. Translational Relevance Based on our study results, VEGFR1 could prove to be a promising treatment that targets VM formation in choroidal melanoma. Our findings also suggest the potential use of VEGFR1-targeted CEUS for quantitative monitoring of VM processes at the molecular level in the future.
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Affiliation(s)
- Haiyun Liu
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Min Gao
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jiying Gu
- Department of Ultrasonography, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaoling Wan
- Shanghai Key Laboratory of Fundus Diseases, Shanghai, China
| | - Hong Wang
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Qing Gu
- Shanghai Key Laboratory of Fundus Diseases, Shanghai, China
| | - Yifan Zhou
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaodong Sun
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Fundus Diseases, Shanghai, China.,Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China
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17
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Manrique de Lara A, Soto-Gómez L, Núñez-Acosta E, Saruwatari-Zavala G, Rentería ME. Ethical issues in susceptibility genetic testing for late-onset neurodegenerative diseases. Am J Med Genet B Neuropsychiatr Genet 2019; 180:609-621. [PMID: 30525300 DOI: 10.1002/ajmg.b.32699] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/16/2018] [Accepted: 10/30/2018] [Indexed: 12/12/2022]
Abstract
Genome-wide association studies have revolutionized our understanding of the genetic architecture of complex traits and diseases over the last decade. This knowledge is enabling clinicians, researchers, and direct-to-consumer genetics companies to conduct disease susceptibility testing based on powerful methods such as polygenic risk scoring. However, these technologies raise a set of complex ethical, legal, social, and policy considerations. Here we review and discuss a series of ethical dilemmas associated with susceptibility genetic testing for the two most common late-onset neurodegenerative diseases, Alzheimer's and Parkinson's disease, including testing in asymptomatic individuals. Among others, these include informed consent, disclosure of results and unexpected findings, mandatory screening, privacy and confidentiality, and stigma and genetic discrimination. Importantly, appropriate counseling is a deciding factor for the ethical soundness of genetic testing, which poses a challenge for the regulation of these tests and the training of healthcare professionals. As genetic knowledge about these diseases continues growing and genetic testing becomes more widespread, it is increasingly important to raise awareness among researchers, medical practitioners, genetic counselors, and decision makers about the ethical, legal, and social issues associated with genetic testing for polygenic diseases.
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Affiliation(s)
- Amaranta Manrique de Lara
- Licenciatura en Ciencias Genómicas, Instituto de Biotecnología y Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, Mexico
| | - Liliana Soto-Gómez
- Instituto de Investigaciones Jurídicas, Universidad Nacional Autónoma de México, Coyoacán, Ciudad de México, Mexico
| | - Elisa Núñez-Acosta
- Oficina de Información Científica y Tecnológica para el Congreso de la Unión (INCyTU), Foro Consultivo Científico y Tecnológico, A.C., Coyoacán, Ciudad de México, Mexico
| | - Garbiñe Saruwatari-Zavala
- Departamento de Estudios Jurídicos, Éticos y Sociales, Instituto Nacional de Medicina Genómica, Tlalpan, Ciudad de México, Mexico
| | - Miguel E Rentería
- Department of Genetics & Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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18
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Antoniou M, Kolamunnage-Dona R, Wason J, Bathia R, Billingham C, Bliss J, Brown L, Gillman A, Paul J, Jorgensen A. Biomarker-guided trials: Challenges in practice. Contemp Clin Trials Commun 2019; 16:100493. [PMID: 31788574 PMCID: PMC6879976 DOI: 10.1016/j.conctc.2019.100493] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/06/2019] [Accepted: 11/13/2019] [Indexed: 12/14/2022] Open
Abstract
Biomarker-guided trials have drawn considerable attention as they promise to lead to improvements in the benefit-risk ratio of treatments and enhanced opportunities for drug development. A variety of such designs have been proposed in the literature, many of which have been adopted in practice. Implementing such trial designs in practice can be challenging, and identifying those challenges was the main objective of a workshop organised by the MRC Hubs for Trials Methodology Research Network's Stratified Medicine Working Group in March 2017. Participants reflected on completed and ongoing biomarker-guided trials to identify the practical challenges encountered. Here, the key challenges identified during the workshop including those related to funding, ethical and regulatory issues, recruitment, monitoring of samples and laboratories, biomarker assessment, and data sharing and resources, are discussed. Despite the complexities often associated with biomarker-guided trials, the workshop concluded that they can play an important role in advancing the field of personalised medicine. Therefore, it is important that the practical challenges surrounding their implementation are acknowledged and addressed.
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Affiliation(s)
| | | | - J. Wason
- Newcastle University and MRC Biostatistics Unit, Cambridge, UK
| | | | | | - J.M. Bliss
- Institute of Cancer Research, London, UK
| | | | - A. Gillman
- Institute of Cancer Research, London, UK
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19
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Newey PJ. Clinical genetic testing in endocrinology: Current concepts and contemporary challenges. Clin Endocrinol (Oxf) 2019; 91:587-607. [PMID: 31254405 DOI: 10.1111/cen.14053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/29/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
Recent advances in DNA sequencing technology have led to an unprecedented period of disease-gene discovery offering many new opportunities for genetic testing in the clinical setting. Endocrinology has seen a rapid expansion in the taxonomy of monogenic disorders, which can be detected by an expanding portfolio of genetic tests in both diagnostic and predictive settings. Successful testing relies on many factors including the ability to identify those at increased risk of genetic disease in the busy clinic as well as a working knowledge of the various testing platforms and their limitations. The clinical utility of a given test is dependent upon many factors, which include the reliability of the genetic testing platform, the accuracy of the test result interpretation and knowledge of disease penetrance and expression. The increasing adoption of "high-content" genetic testing based on next-generation sequencing (NGS) to diagnose hereditary endocrine disorders brings a number of challenges including the potential for uncertain test results and/or genetic findings unrelated to the indication for testing. Therefore, it is increasingly important that the clinician is aware of the current evolution in genetic testing, and understands the different settings in which it may be employed. This review provides an overview of the genetic testing workflow, focusing on each of the major components required for successful testing in adult and paediatric endocrine settings. In addition, the challenges of variant interpretation are highlighted, as are issues related to informed consent, prenatal diagnosis and predictive testing. Finally, the future directions of genetic testing relevant to endocrinology are discussed.
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Affiliation(s)
- Paul J Newey
- Division of Molecular & Clinical Medicine, Ninewells Hospital & Medical School, University of Dundee, Scotland, UK
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20
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Gladbach YS, Wiegele L, Hamed M, Merkenschläger AM, Fuellen G, Junghanss C, Maletzki C. Unraveling the Heterogeneous Mutational Signature of Spontaneously Developing Tumors in MLH1 -/- Mice. Cancers (Basel) 2019; 11:cancers11101485. [PMID: 31581674 PMCID: PMC6827043 DOI: 10.3390/cancers11101485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/18/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Mismatch repair deficient (MMR-D) tumors exemplify the prototypic hypermutator phenotype. Owing to the high mutation rates, plenty of neo-antigens are present on the tumor cells' surface, ideally shared among different cancer types. The MLH1 knock out mouse represents a preclinical model that resembles features of the human MMR-D counterpart. While these mice develop neoplasias in a sequential twin-peaked manner (lymphomas > gastrointestinal tumors (GIT)) we aimed at identification of underlying molecular mechanisms. Using whole-genome sequencing, we focused on (I) shared and (II) mutually exclusive mutations and describe the process of ongoing mutational events in tumor-derived cell cultures. The landscape of MLH1-/- tumors is heterogeneous with only a few shared mutations being detectable among different tumor entities (ARID1A and IDH2). With respect to coding microsatellite analysis of MMR-D-related target genes, partial overlap was detectable, yet recognizing shared antigens. The present study is the first reporting results of a comparison between spontaneously developing tumors in MMR-D driven tumorigenesis. Additionally to identifying ARID1A as potential causative mutation hotspot, this comprehensive characterization of the mutational landscape may be a good starting point to refine therapeutic concepts.
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Affiliation(s)
- Yvonne Saara Gladbach
- Institute for Biostatistics and Informatics in Medicine and Ageing Research (IBIMA), Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
- Faculty of Biosciences, Heidelberg University, 69120 Heidelberg, Germany.
- Division of Applied Bioinformatics, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT) Heidelberg, 69120 Heidelberg, Germany.
| | - Leonie Wiegele
- Department of Internal Medicine, Medical Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
| | - Mohamed Hamed
- Institute for Biostatistics and Informatics in Medicine and Ageing Research (IBIMA), Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
| | - Anna-Marie Merkenschläger
- Institute for Biostatistics and Informatics in Medicine and Ageing Research (IBIMA), Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
| | - Georg Fuellen
- Institute for Biostatistics and Informatics in Medicine and Ageing Research (IBIMA), Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
| | - Christian Junghanss
- Department of Internal Medicine, Medical Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
| | - Claudia Maletzki
- Department of Internal Medicine, Medical Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, University of Rostock, 18057 Rostock, Germany.
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21
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Saelaert M, Mertes H, Moerenhout T, De Baere E, Devisch I. Criteria for reporting incidental findings in clinical exome sequencing - a focus group study on professional practices and perspectives in Belgian genetic centres. BMC Med Genomics 2019; 12:123. [PMID: 31429751 PMCID: PMC6702726 DOI: 10.1186/s12920-019-0561-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/24/2019] [Indexed: 12/16/2022] Open
Abstract
Background Incidental and secondary findings (IFs and SFs) are subject to ongoing discussion as potential consequences of clinical exome sequencing (ES). International policy documents vary on the reporting of these findings. Discussion points include the practice of unintentionally identified IFs versus deliberately pursued SFs, patient opt-out possibilities and the spectrum of reportable findings. The heterogeneity of advice permits a non-standardised disclosure but research is lacking on actual reporting practices. Therefore, this study assessed national reporting practices for IFs and SFs in clinical ES and the underlying professional perspectives. Methods A qualitative focus group study has been undertaken, including professionals from Belgian centres for medical genetics (CMGs). Data were analysed thematically. Results All Belgian CMGs participated in this study. Data analysis resulted in six main themes, including one regarding the reporting criteria used for IFs. All CMGs currently use ES-based panel testing. They have limited experience with IFs in clinical ES and are cautious about the pursuit of SFs. Two main reporting criteria for IFs were referred to by all CMGs: the clinical significance of the IF (including pathogenicity and medical actionability) and patient-related factors (including the patient’s preference to know and patient characteristics). The consensus over the importance of these criteria contrasted with their challenging interpretation and application. Points of concern included IFs’ pathogenicity in non-symptomatic persons, IFs concerning variants of uncertain significance, the requirement and definition of medical actionability and patient opt-out possibilities. Finally, reporting decisions were guided by the interaction between the clinical significance of the IF and patient characteristics. This interaction questions the possible disclosure of findings with context-dependent and personal utility, such as IFs concerning a carrier status. To evaluate the IF’s final relevance, a professional and case-by-case deliberation was considered essential. Conclusions The challenging application of reporting criteria for IFs results in diversified practices and policy perspectives within Belgian CMGs. This echoes international concerns and may have consequences for effective policy recommendations.
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Affiliation(s)
- Marlies Saelaert
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium.
| | - Heidi Mertes
- Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Tania Moerenhout
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium.,Department of Philosophy and Moral Sciences, Ghent University, Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics Ghent (CMGG), Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Ignaas Devisch
- Department of Public Health and Primary Care, Philosophy of Medicine and Ethics Research Group, Ghent University, Campus Heymans (UZ Gent), Corneel Heymanslaan 10 - Building 6K3, 9000, Ghent, Belgium
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22
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Abstract
In January 2019, a new nationally commissioned Genomic Medicine Service (GMS) has now commenced in the NHS. Capitalising on the infrastructure developed through the 100,000 Genomes Project, the GMS is underpinned by seven supra-regional Genomic Laboratory Hubs (GLHs) delivering the new inherited rare disease and cancer somatic tissue genetic test directory. This replaces the UKGTN test directory, with the aim of standardising criteria for whole genome sequencing or targeted panel tests where applicable. The new test directory will define who can order specific genetic tests under prescribed eligibility criteria. In keeping with Dame Sally Davies' white paper Generation Genome, this will further democratise genetic testing and, in some situations, avoid the need to refer to clinical genetics to access testing. The aim is to simplify patient pathways and reduce regional or social inequalities. We will discuss the implications of whole genome sequencing and the potential impact of the new nationally commissioned GMS for both patients, their relatives and clinicians. We will also discuss the imminent challenges in implementing genomic medicine into the NHS, and the future impact of novel technologies on service delivery as genomic medicine becomes increasingly integrated into routine healthcare.
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Affiliation(s)
| | - Katie Snape
- St George's University of London, London, UK
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23
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Milko LV, O’Daniel JM, DeCristo DM, Crowley SB, Foreman AKM, Wallace KE, Mollison LF, Strande NT, Girnary ZS, Boshe LJ, Aylsworth AS, Gucsavas-Calikoglu M, Frazier DM, Vora NL, Roche MI, Powell BC, Powell CM, Berg JS. An Age-Based Framework for Evaluating Genome-Scale Sequencing Results in Newborn Screening. J Pediatr 2019; 209:68-76. [PMID: 30851990 PMCID: PMC6535354 DOI: 10.1016/j.jpeds.2018.12.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/24/2018] [Accepted: 12/06/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the performance of a standardized, age-based metric for scoring clinical actionability to evaluate conditions for inclusion in newborn screening and compare it with the results from other contemporary methods. STUDY DESIGN The North Carolina Newborn Exome Sequencing for Universal Screening study developed an age-based, semiquantitative metric to assess the clinical actionability of gene-disease pairs and classify them with respect to age of onset or timing of interventions. This categorization was compared with the gold standard Recommended Uniform Screening Panel and other methods to evaluate gene-disease pairs for newborn genomic sequencing. RESULTS We assessed 822 gene-disease pairs, enriched for pediatric onset of disease and suspected actionability. Of these, 466 were classified as having childhood onset and high actionability, analogous to conditions selected for the Recommended Uniform Screening Panel core panel. Another 245 were classified as having childhood onset and low to no actionability, 25 were classified as having adult onset and high actionability, 19 were classified as having adult onset and low to no actionability, and 67 were excluded due to controversial evidence and/or prenatal onset. CONCLUSIONS This study describes a novel method to facilitate decisions about the potential use of genomic sequencing for newborn screening. These categories may assist parents and physicians in making informed decisions about the disclosure of results from voluntary genomic sequencing in children.
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Affiliation(s)
| | | | | | | | | | | | | | - Natasha T. Strande
- Department of Genetics, UNC Chapel Hill,Department of Pathology and Laboratory Medicine, UNC Chapel Hill
| | - Zahra S. Girnary
- Department of Genetics, UNC Chapel Hill,current affiliation: Mission Fullerton Genetics Center, Asheville, NC
| | - Lacey J. Boshe
- Department of Genetics, UNC Chapel Hill,current affiliation: School of Medicine, UNC Chapel Hill
| | - Arthur S. Aylsworth
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | | | - Dianne M. Frazier
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | - Neeta L. Vora
- Department of Obstetrics and Gynecology, UNC Chapel Hill
| | - Myra I. Roche
- Department of Genetics, UNC Chapel Hill,Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | | | - Cynthia M. Powell
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
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Griesemer I, Moore E, Khan C, Roche M, Henderson G, Rini C. Psychological adaptation to diagnostic genomic sequencing results: The role of hope fulfillment. Health Psychol 2019; 38:527-535. [PMID: 30958015 DOI: 10.1037/hea0000733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Psychological adaptation is an important but understudied outcome among patients who undergo DNA evaluation to identify a cause of an unexplained health condition. This longitudinal study examines the relationship between the degree to which participants' hopes for diagnostic genomic sequencing were fulfilled and their psychological adaptation to their sequencing results over time. METHOD Secondary analyses were conducted on data from a subset of adult participants from the North Carolina Clinical Genomic Evaluation by Next-Generation Exome Sequencing study with physical health conditions of suspected genetic etiology (such as neurological disorders or cancer; n = 192). Hope fulfillment and type of hope (hopes related to personal-family health implications vs. hoping to help others-advance science) were assessed as predictors of change in psychological adaptation (Psychological Adaptation Scale) and 4 subscales (coping efficacy, self-esteem, social integration, spiritual-existential well-being), from 2 weeks to 6 months after disclosure of genomic sequencing results. RESULTS Controlling for covariates, degree of hope fulfillment was associated with increased general psychological adaptation (β = .14, p = .02), social integration (β = .17, p = .01), and spiritual-existential well-being (β = .15, p = .02). Type of hope did not modify effects of degree of hope fulfillment on adaptation outcomes. CONCLUSIONS The degree to which patients' genomic sequencing-related hopes are fulfilled may be an important driver of long-term psychological adaptation after genomic sequencing. Evaluating the degree to which patients' hopes are fulfilled may allow clinicians to gain insight into the likely trajectory for patient adaptation after learning their results from genomic sequencing. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Ida Griesemer
- Department of Health Behavior, University of North Carolina at Chapel Hill
| | - Elizabeth Moore
- Department of Health Behavior, University of North Carolina at Chapel Hill
| | - Cynthia Khan
- Thurston Arthritis Research Center, University of North Carolina at Chapel Hill
| | - Myra Roche
- Department of Pediatrics, University of North Carolina at Chapel Hill
| | - Gail Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill
| | - Christine Rini
- UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill
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Clowes Candadai SV, Sikes MC, Thies JM, Freed AS, Bennett JT. Rapid clinical exome sequencing in a pediatric ICU: Genetic counselor impacts and challenges. J Genet Couns 2019; 28:283-291. [PMID: 30964580 PMCID: PMC6481675 DOI: 10.1002/jgc4.1116] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 01/02/2023]
Abstract
Exome sequencing (ES) has revolutionized molecular diagnosis in children with genetic disease over the past decade. However, exome sequencing in the inpatient setting has traditionally been discouraged, in part due to an increased risk of providers failing to retrieve and act upon results, as many patients are discharged before results return. The development of rapid turn-around-times (TATs) for genomic testing has begun to shift this paradigm. Rapid exome sequencing (rES) is increasingly being used as a diagnostic tool for critically ill infants with likely genetic disease and presents significant challenges to execute. We implemented a program, entitled the Rapid Inpatient Genomic Testing (RIGhT) project, to identify critically ill children for whom a molecular diagnosis is likely to change inpatient management. Two important goals of the RIGhT project were to provide appropriate genetic counseling, and to develop protocols to ensure efficient test coordination- both of which relied heavily on laboratory and clinic-based genetic counselors (GCs). Here, rES was performed on 27 inpatient trios from October 2016 to August 2018; laboratory and clinical GCs encountered significant challenges in the coordination of this testing. The GCs involved retrospectively reviewed these cases and identified three common challenges encountered during pretest counseling and coordination. The aim of this paper is to define these challenges using illustrative case examples that highlight the importance of including GCs to support rES programs.
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Affiliation(s)
- Sarah V Clowes Candadai
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
- Patient-Centered Laboratory Utilization Guidance Services (PLUGS), Seattle Children's Hospital, Seattle, Washington
| | - Megan C Sikes
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jenny M Thies
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Amanda S Freed
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, Washington
| | - James T Bennett
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, Washington
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington
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Rossing M, Sørensen CS, Ejlertsen B, Nielsen FC. Whole genome sequencing of breast cancer. APMIS 2019; 127:303-315. [PMID: 30689231 PMCID: PMC6850492 DOI: 10.1111/apm.12920] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/16/2018] [Indexed: 12/29/2022]
Abstract
Breast cancer was the first to take advantage of targeted therapy using endocrine therapy, and for up to 20% of all breast cancer patients a further significant improvement has been obtained by HER2‐targeted therapy. Greater insight in precision medicine is to some extent driven by technical and computational progress, with the first wave of a true technical advancement being the application of transcriptomic analysis. Molecular subtyping further improved our understanding of breast cancer biology and has through a new tumor classification enabled allocation of personalized treatment regimens. The next wave in technical progression must be next‐generation‐sequencing which is currently providing new and exciting results. Large‐scale sequencing data unravel novel somatic and potential targetable mutations as well as allowing the identification of new candidate genes predisposing for familial breast cancer. So far, around 15% of all breast cancer patients are genetically predisposed with most genes being factors in pathways implicated in genome maintenance. This review focuses on whole‐genome sequencing and the new possibilities that this technique, together with other high‐throughput analytic approaches, provides for a more individualized treatment course of breast cancer patients.
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Affiliation(s)
- Maria Rossing
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Bent Ejlertsen
- Danish Breast Cancer Cooperative Group & Department of Clinical Oncology Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Cilius Nielsen
- Centre for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Ballinger ML, Pinese M, Thomas DM. Translating genomic risk into an early detection strategy for sarcoma. Genes Chromosomes Cancer 2018; 58:130-136. [PMID: 30382615 DOI: 10.1002/gcc.22697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 01/07/2023] Open
Abstract
Sarcomas have a strong genetic etiology, and the study of families affected by sarcomas has informed much of what we now understand of modern cancer biology. The recent emergence of powerful genetic technologies has led to astonishing reductions in costs and increased throughput. In the clinic, these technologies are revealing a previously unappreciated and rich landscape of genetic cancer risk. In addition to both known and new cancer risk mutations, genomic tools are cataloguing complex and polygenic risk patterns, collectively explaining between 15-25% of apparently sporadic sarcoma cases. The impact on clinical management is exemplified by Li-Fraumeni Syndrome, the most penetrant sarcoma syndrome. Whole body magnetic resonance imaging can identify surgically resectable cancers in up to one in ten individuals with Li-Fraumeni Syndrome. Taken together, parallel developments in genomics, therapeutics and imaging technologies will drive closer engagement between genetics and multidisciplinary care of the sarcoma patient in the 21st century.
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Affiliation(s)
- Mandy L Ballinger
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Mark Pinese
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - David M Thomas
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
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Rosier M, Guedj M, Calvas P, Julia S, Garnier C, Cambon-Thomsen A, Muñoz Sastre MT. French People’s Views on the Appropriateness of Disclosing an Unsolicited Finding in Medical Genetics: A Preliminary Study. UNIVERSITAS PSYCHOLOGICA 2018. [DOI: 10.11144/javeriana.upsy17-4.fpva] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With progress in medical genetics, genome-sequencing techniques are becoming more and more efficient. However, these genetic tests may lead to the detection of unsolicited genetic findings, i.e. findings that are not the primary purpose of the screening. New ethical issues have emerged, in particular the question of whether to disclose these unsolicited findings to the patient or not. Forty-seven patients under supervision in a Medical Genetics service, 15 health professionals and 107 members of the French general population expressed their opinion regarding the appropriateness of disclosing an unsolicited high penetrance genetic finding in 36 scenarios containing three pieces of information on: a) patient information and consent;b) possibility of prevention and treatment of the detected genetic disease; and c) disclosure of the results by the physician (e.g., no disclosure of the unsolicited results). Four positions were found that were called Respect for patient’s autonomy, Beneficence to patient, Non-maleficence, and Always appropriate.
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Factors influencing NCGENES research participants' requests for non-medically actionable secondary findings. Genet Med 2018; 21:1092-1099. [PMID: 30237575 PMCID: PMC6522134 DOI: 10.1038/s41436-018-0294-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 08/27/2018] [Indexed: 01/03/2023] Open
Abstract
Purpose: Genomic sequencing can reveal variants with limited to no medical actionability. Previous research has assessed individuals’ intentions to learn this information, but few report the decisions they made and why. Methods: The NCGENES (North Carolina Clinical Genomic Evaluation by Next Generation Exome Sequencing) project evaluated adult patients randomized to learn up to six types of “non-medically actionable secondary findings” (NMASF). We previously found that most participants intended to request NMASF and intentions were strongly predicted by anticipated regret. Here we examine discrepancies between intentions and decisions to request NMASF, hypothesizing that anticipated regret would predict requests but that this association would be mediated by participants’ intentions. Results: Of the 76% who expressed intentions to learn results, only 42% made one or more requests. Overall, only 32% of the 155 eligible participants requested NMASF. Analyses support a plausible causal link between anticipated regret, intentions, and requests. Conclusions: The discordance between participants’ expressed intentions and their actions provide insight into factors that influence patients’ preferences for genomic information that has little to no actionability. These findings have implications for the timing and methods of eliciting preferences for NMASF and suggest that decisions to learn this information have cognitive and emotional components.
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Bianchi L, Liò P. Opportunities for community awareness platforms in personal genomics and bioinformatics education. Brief Bioinform 2018; 18:1082-1090. [PMID: 27580620 DOI: 10.1093/bib/bbw078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Indexed: 01/16/2023] Open
Abstract
Precision and personalized medicine will be increasingly based on the integration of various type of information, particularly electronic health records and genome sequences. The availability of cheap genome sequencing services and the information interoperability will increase the role of online bioinformatics analysis. Being on the Internet poses constant threats to security and privacy. While we are connected and we share information, websites and internet services collect various types of personal data with or without the user consent. It is likely that genomics will merge with the internet culture of connectivity. This process will increase incidental findings, exposure and vulnerability. Here we discuss the social vulnerability owing to the genome and Internet combined security and privacy weaknesses. This urges more efforts in education and social awareness on how biomedical data are analysed and transferred through the internet and how inferential methods could integrate information from different sources. We propose that digital social platforms, used for raising collective awareness in different fields, could be developed for collaborative and bottom-up efforts in education. In this context, bioinformaticians could play a meaningful role in mitigating the future risk of digital-genomic divide.
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Saelaert M, Mertes H, De Baere E, Devisch I. Incidental or secondary findings: an integrative and patient-inclusive approach to the current debate. Eur J Hum Genet 2018; 26:1424-1431. [PMID: 29970927 DOI: 10.1038/s41431-018-0200-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/13/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
Incidental or secondary findings (ISFs) in whole exome or whole genome sequencing have been widely debated in recent literature. The American College of Medical Genetics and Genomics' recommendations on diagnostic ISFs have strongly catalyzed the discussion, resulting in worldwide reactions and a variety of international guidelines. This article will outline how propositions on levels of terminology, policy, and underlying values are still internationally criticized and adjusted. Unsolved questions regarding ISFs include a suitable terminology, adequate counseling or informed consent procedures, opt-out possibilities, reporting ISFs to (parents of) minors and values regarding professional duty, patient autonomy, and actionability. These questions will be characterized as intrinsically related and reciprocally maintained and hence, symptomatic, single-level reflections will be marked as ineffective. Instead, a level-integrative approach of the debate that explicitly acknowledges this interaction and considers a balance between internationally significant and case-specific solutions, will be advocated. Second, the inclusion of a patient perspective will be strongly encouraged to complement the professional preponderance in the current debate. The examination of lived patient experiences, a qualitative focus on the subjective meaning of ISFs, and a contextualization of meaning processes will be suggested as specific concretizations. This integrative and inclusive approach aims for a more comprehensive understanding of ISFs, a consideration of all relevant stakeholders' perspective and, ultimately, an effective health-care policy.
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Affiliation(s)
- Marlies Saelaert
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium.
| | - Heidi Mertes
- Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics Ghent (CMGG), Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Ignaas Devisch
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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32
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Bombard Y, Clausen M, Mighton C, Carlsson L, Casalino S, Glogowski E, Schrader K, Evans M, Scheer A, Baxter N, Hamilton JG, Lerner-Ellis J, Offit K, Robson M, Laupacis A. The Genomics ADvISER: development and usability testing of a decision aid for the selection of incidental sequencing results. Eur J Hum Genet 2018; 26:984-995. [PMID: 29703952 PMCID: PMC6018661 DOI: 10.1038/s41431-018-0144-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 02/08/2023] Open
Abstract
Guidelines recommend patients be informed of their incidental results (IR) when undergoing genomic sequencing (GS), yet there are limited tools to support patients' decisions about learning IR. The aim of this study is to develop and test the usability of a decision aid (DA) to guide patients' selection of IR, and to describe patients' preferences for learning IR following use of the DA. We developed and evaluated a DA using an iterative, mixed-methods process consisting of (1) prototype development, (2) feasibility testing, (3) cognitive interviews, (4) design and programming, and (5) usability testing. We created an interactive online DA called the Genomics ADvISER, a genomics decision AiD about Incidental SEquencing Results. The Genomics ADvISER begins with an educational whiteboard video, and then engages users in a values clarification exercise, knowledge quiz and final choice step, based on a 'binning' framework. Participants found the DA acceptable and intuitive to use. They were enthusiastic towards GS and IR; all selected multiple categories of IR. The Genomics ADvISER is a new patient-centered tool to support the clinical delivery of incidental GS results. The Genomics ADvISER fills critical care gaps, given the health care system's limited genomics expertise and capacity to convey the large volume of IR and their myriad of implications.
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Affiliation(s)
- Yvonne Bombard
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - Marc Clausen
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Chloe Mighton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | | | - Selina Casalino
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Michael Evans
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
| | - Adena Scheer
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nancy Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Cancer Care Ontario, Toronto, ON, Canada
| | | | - Jordan Lerner-Ellis
- Mount Sinai Health System, Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Kenneth Offit
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark Robson
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
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AMCP Partnership Forum: Managing Care in the Wave of Precision Medicine. J Manag Care Spec Pharm 2018; 24:583-588. [PMID: 29952713 PMCID: PMC10397937 DOI: 10.18553/jmcp.2018.24.7.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Precision medicine, the customization of health care to an individual's genetic profile while accounting for biomarkers and lifestyle, has increasingly been adopted by health care stakeholders to guide the development of treatment options, improve treatment decision making, provide more patient-centered care, and better inform coverage and reimbursement decisions. Despite these benefits, key challenges prevent its broader use and adoption. On December 7-8, 2017, the Academy of Managed Care Pharmacy convened a group of stakeholders to discuss these challenges and provide recommendations to facilitate broader adoption and use of precision medicine across health care settings. These stakeholders represented the pharmaceutical industry, clinicians, patient advocacy, private payers, device manufacturers, health analytics, information technology, academia, and government agencies. Throughout the 2-day forum, participants discussed evidence requirements for precision medicine, including consistent ways to measure the utility and validity of precision medicine tests and therapies, limitations of traditional clinical trial designs, and limitations of value assessment framework methods. They also highlighted the challenges with evidence collection and data silos in precision medicine. Interoperability within and across health systems is hindering clinical advancements. Current medical coding systems also cannot account for the heterogeneity of many diseases, preventing health systems from having a complete understanding of their patient population to inform resource allocation. Challenges faced by payers, such as evidence limitations, to inform coverage and reimbursement decisions in precision medicine, as well as legal and regulatory barriers that inhibit more widespread data sharing, were also identified. While a broad range of perspectives was shared throughout the forum, participants reached consensus across 2 overarching areas. First, there is a greater need for common definitions, thresholds, and standards to guide evidence generation in precision medicine. Second, current information silos are preventing the sharing of valuable data. Collaboration among stakeholders is needed to support better information sharing, awareness, and education of precision medicine for patients. The recommendations brought forward by this diverse group of experts provide a set of solutions to spur widespread use and application of precision medicine. Taken together, successful adoption and use of precision medicine will require input and collaboration from all sectors of health care, especially patients. DISCLOSURES This AMCP Partnership Forum and the development of the proceedings document were supported by Amgen, Foundation Medicine, Genentech, Gilead, MedImpact, National Pharmaceutical Council, Precision for Value, Sanofi, Takeda, and Xcenda.
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Aradhya S, Nussbaum RL. Genetics in mainstream medicine: Finally within grasp to influence healthcare globally. Mol Genet Genomic Med 2018; 6:473-480. [PMID: 29807392 PMCID: PMC6081234 DOI: 10.1002/mgg3.415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/24/2018] [Indexed: 01/02/2023] Open
Abstract
A modern genomics ecosystem has emerged. This commentary describes recent trends in clinical genomics that enable its successful integration in mainstream medicine. The rapid expansion of clinical genomics will have a positive impact on the healthcare of individuals worldwide.
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Affiliation(s)
- Swaroop Aradhya
- InvitaeSan FranciscoCalifornia
- Adjunct clinical associate professorStanford University School of MedicineStanfordCalifornia
| | - Robert L. Nussbaum
- InvitaeSan FranciscoCalifornia
- Volunteer facultyUniversity of California San FranciscoSan FranciscoCalifornia
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35
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AMCP Partnership Forum: Managing Care in the Wave of Precision Medicine. J Manag Care Spec Pharm 2018:1-6. [PMID: 29791243 DOI: 10.18553/jmcp.2018.18071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Precision medicine, the customization of health care to an individual's genetic profile while accounting for biomarkers and lifestyle, has increasingly been adopted by health care stakeholders to guide the development of treatment options, improve treatment decision making, provide more patient-centered care, and better inform coverage and reimbursement decisions. Despite these benefits, key challenges prevent its broader use and adoption. On December 7-8, 2017, the Academy of Managed Care Pharmacy convened a group of stakeholders to discuss these challenges and provide recommendations to facilitate broader adoption and use of precision medicine across health care settings. These stakeholders represented the pharmaceutical industry, clinicians, patient advocacy, private payers, device manufacturers, health analytics, information technology, academia, and government agencies. Throughout the 2-day forum, participants discussed evidence requirements for precision medicine, including consistent ways to measure the utility and validity of precision medicine tests and therapies, limitations of traditional clinical trial designs, and limitations of value assessment framework methods. They also highlighted the challenges with evidence collection and data silos in precision medicine. Interoperability within and across health systems is hindering clinical advancements. Current medical coding systems also cannot account for the heterogeneity of many diseases, preventing health systems from having a complete understanding of their patient population to inform resource allocation. Challenges faced by payers, such as evidence limitations, to inform coverage and reimbursement decisions in precision medicine, as well as legal and regulatory barriers that inhibit more widespread data sharing, were also identified. While a broad range of perspectives was shared throughout the forum, participants reached consensus across 2 overarching areas. First, there is a greater need for common definitions, thresholds, and standards to guide evidence generation in precision medicine. Second, current information silos are preventing the sharing of valuable data. Collaboration among stakeholders is needed to support better information sharing, awareness, and education of precision medicine for patients. The recommendations brought forward by this diverse group of experts provide a set of solutions to spur widespread use and application of precision medicine. Taken together, successful adoption and use of precision medicine will require input and collaboration from all sectors of health care, especially patients. DISCLOSURES This AMCP Partnership Forum and the development of the proceedings document were supported by Amgen, Foundation Medicine, Genentech, Gilead, MedImpact, National Pharmaceutical Council, Precision for Value, Sanofi, Takeda, and Xcenda.
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36
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Stoll K, Kubendran S, Cohen SA. The past, present and future of service delivery in genetic counseling: Keeping up in the era of precision medicine. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018. [DOI: 10.1002/ajmg.c.31602] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Katie Stoll
- Genetic Support FoundationOlympia Washington
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37
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Balicza P, Terebessy A, Grosz Z, Varga NA, Gal A, Fekete BA, Molnar MJ. Implementation of personalized medicine in Central-Eastern Europe: pitfalls and potentials based on citizen's attitude. EPMA J 2018. [PMID: 29515690 DOI: 10.1007/s13167-017-0125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective Next-generation sequencing is increasingly utilized worldwide as a research and diagnostic tool and is anticipated to be implemented into everyday clinical practice. Since Central-Eastern European attitude toward genetic testing, especially broad genetic testing, is not well known, we performed a survey on this issue among Hungarian participants. Methods A self-administered questionnaire was distributed among patients and patient relatives at our neurogenetic outpatient clinic. Members of the general population were also recruited via public media. We used chi-square testing and binary logistic regression to examine factors influencing attitude. Results We identified a mixed attitude toward genetic testing. Access to physician consultation positively influenced attitude. A higher self-determined genetic familiarity score associated with higher perceived genetic influence score, which in turn associated with greater willingness to participate in genetic testing. Medical professionals constituted a skeptical group. Conclusions We think that given the controversies and complexities of the next-generation sequencing field, the optimal clinical translation of NGS data should be performed in institutions which have the unique capability to provide interprofessional health education, transformative biomedical research, and crucial patient care. With optimization of the clinical translational process, improvement of genetic literacy may increase patient engagement and empowerment. Relevance of the article for predictive preventive and personalized medicine The paper highlights that in countries with relatively low-genetic literacy, a special strategy is needed to enhance the implementation of personalized medicine.
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Affiliation(s)
- Peter Balicza
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
| | - Andras Terebessy
- 2Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Zoltan Grosz
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
| | - Noemi Agnes Varga
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
| | - Aniko Gal
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
| | - Balint Andras Fekete
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
| | - Maria Judit Molnar
- 1Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Tomo Street 25-29, Budapest, 1083 Hungary
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Hoang N, Cytrynbaum C, Scherer SW. Communicating complex genomic information: A counselling approach derived from research experience with Autism Spectrum Disorder. PATIENT EDUCATION AND COUNSELING 2018; 101:352-361. [PMID: 28803755 DOI: 10.1016/j.pec.2017.07.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 06/07/2023]
Abstract
Individuals with Autism Spectrum Disorder (ASD) share characteristics (impairments in socialization and communication, and repetitive interests and behaviour), but differ in their developmental course, pattern of symptoms, and cognitive and language abilities. The development of standardized phenotyping has revealed ASD to clinically be vastly heterogeneous, ranging from milder presentations to more severe forms associated with profound intellectual disability. Some 100 genes have now been implicated in the etiology of ASD, and advances in genome-wide testing continue to yield new data at an unprecedented rate. As the translation of this data is incorporated into clinical care, genetic professionals/counsellors, as well as other health care providers, will benefit from guidelines and tools to effectively communicate such genomic information. Here, we present a model to facilitate communication regarding the complexities of ASD, where clinical and genetic heterogeneity, as well as overlapping neurological conditions are inherent. We outline an approach for counselling families about their genomic results grounded in our direct experience from counselling families participating in an ASD research study, and supported by rationale from the literature.
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Affiliation(s)
- Ny Hoang
- Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Canada; Autism Research Unit, The Hospital for Sick Children, Toronto, Canada; Department of Molecular Genetics, University of Toronto, Toronto, Canada; Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada.
| | - Cheryl Cytrynbaum
- Department of Genetic Counselling, The Hospital for Sick Children, Toronto, Canada; Department of Molecular Genetics, University of Toronto, Toronto, Canada; Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada.
| | - Stephen W Scherer
- Department of Molecular Genetics, University of Toronto, Toronto, Canada; Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada; The Centre for Applied Genomics, The Hospital for Sick Children, Toronto, Canada; McLaughlin Centre, University of Toronto, Toronto, Canada.
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Curr Beamer L. Ethics and Genetics: Examining a Crossroads in Nursing Through a Case Study. Clin J Oncol Nurs 2017; 21:730-737. [DOI: 10.1188/17.cjon.730-737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Rini C, Khan CM, Moore E, Roche MI, Evans JP, Berg JS, Powell BC, Corbie-Smith G, Foreman AKM, Griesemer I, Lee K, O'Daniel JM, Henderson GE. The who, what, and why of research participants' intentions to request a broad range of secondary findings in a diagnostic genomic sequencing study. Genet Med 2017; 20:760-769. [PMID: 29261173 PMCID: PMC5920790 DOI: 10.1038/gim.2017.176] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/20/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE In a diagnostic exome sequencing study (the North Carolina Clinical Genomic Evaluation by Next-Generation Exome Sequencing project, NCGENES), we investigated adult patients' intentions to request six categories of secondary findings (SFs) with low or no medical actionability and correlates of their intentions. METHODS At enrollment, eligible participants (n = 152) completed measures assessing their sociodemographic, clinical, and literacy-related characteristics. Prior to and during an in-person diagnostic result disclosure visit, they received education about categories of SFs they could request. Immediately after receiving education at the visit, participants completed measures of intention to learn SFs, interest in each category, and anticipated regret for learning and not learning each category. RESULTS Seventy-eight percent of participants intended to learn at least some SFs. Logistic regressions examined their intention to learn any or all of these findings (versus none) and interest in each of the six individual categories (yes/no). Results revealed little association between intentions and sociodemographic, clinical, or literacy-related factors. Across outcomes, participants who anticipated regret for learning SFs reported weaker intention to learn them (odds ratios (ORs) from 0.47 to 0.71), and participants who anticipated regret for not learning these findings reported stronger intention to learn them (OR 1.61-2.22). CONCLUSION Intentions to request SFs with low or no medical actionability may be strongly influenced by participants' desire to avoid regret.
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Affiliation(s)
- Christine Rini
- John Theuer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey, USA.
| | | | - Elizabeth Moore
- Blue Cross and Blue Shield of North Carolina, Durham, North Carolina, USA
| | - Myra I Roche
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James P Evans
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan S Berg
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Bradford C Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Giselle Corbie-Smith
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann Katherine M Foreman
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ida Griesemer
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristy Lee
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julianne M O'Daniel
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gail E Henderson
- Center for Genomics and Society, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Ghouse J, Skov MW, Bigseth RS, Ahlberg G, Kanters JK, Olesen MS. Distinguishing pathogenic mutations from background genetic noise in cardiology: The use of large genome databases for genetic interpretation. Clin Genet 2017; 93:459-466. [PMID: 28589536 DOI: 10.1111/cge.13066] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 12/15/2022]
Abstract
Advances in clinical genetic testing have led to increased insight into the human genome, including how challenging it is to interpret rare genetic variation. In some cases, the ability to detect genetic mutations exceeds the ability to understand their clinical impact, limiting the advantage of these technologies. Obstacles in genomic medicine are many and include: understanding the level of certainty/uncertainty behind pathogenicity determination, the numerous different variant interpretation-guidelines used by clinical laboratories, delivering the certain or uncertain result to the patient, helping patients evaluate medical decisions in light of uncertainty regarding the consequence of the findings. Through publication of large publicly available exome/genome databases, researchers and physicians are now able to highlight dubious variants previously associated with different cardiac traits. Also, continuous efforts through data sharing, international collaborative efforts to develop disease-gene-specific guidelines, and computational analyses using large data, will indubitably assist in better variant interpretation and classification. This article discusses the current, and quickly changing, state of variant interpretation resources within cardiovascular genetic research, e.g., publicly available databases and ways of how cardiovascular genetic counselors and geneticists can aid in improving variant interpretation in cardiology.
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Affiliation(s)
- J Ghouse
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - M W Skov
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - R S Bigseth
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - G Ahlberg
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - M S Olesen
- Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Fowler SA, Saunders CJ, Hoffman MA. Variation among Consent Forms for Clinical Whole Exome Sequencing. J Genet Couns 2017; 27:104-114. [PMID: 28689263 PMCID: PMC5794809 DOI: 10.1007/s10897-017-0127-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 06/21/2017] [Indexed: 01/03/2023]
Abstract
The goal of this study was to explore variation among informed consent documents for clinical whole exome sequencing (WES) in order to identify the level of consistency with the recommendations from the American College of Medical Genetics and Genomics (ACMG) and the Presidential Commission for the Study of Bioethical Issues (Bioethics Commission) regarding informed consent for clinical WES. Recommendations were organized into a framework of key points for analysis. Content analysis was conducted on a sample of informed consent documents for clinical WES downloaded from 18 laboratory websites. We observed considerable variability in the content of informed consent documents among the sample of 18 laboratories. The mean Flesch-Kincaid Grade Level, a measure of readability, of the consent forms was 10.8, above the recommended 8th grade level. For each of the individual ACMG and Bioethics Commission recommendations, the frequency of inclusion ranged from 11% to 100%. For the overall list of 18 consent items, inclusion ranged from 11 to 17 items (Mean = 13.44, Mode = 14). This analysis will be useful to laboratories that wish to create informed consent documents that comply with these recommendations. The consistent use of standardized informed consent process could improve communication between clinicians and patients and increase understanding of genetic testing.
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Affiliation(s)
- Sara A Fowler
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Carol J Saunders
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, MO, USA.,Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Mark A Hoffman
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, MO, USA. .,Children's Mercy Hospital, 2401 Gilham Road, Kansas City, MO, 64108, USA.
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Abstract
PURPOSE OF REVIEW Genetic testing for mental illness is likely to become increasingly prevalent as the science behind it is refined. This article identifies anticipated ethical challenges for patients, psychiatrists, and genetic counselors and makes recommendations for addressing them. RECENT FINDINGS Many of the ethical challenges of psychiatric genetic testing are likely to stem from failures to comprehend the nature and implications of test results. Recent studies have identified gaps in the knowledge base of psychiatrists and genetic counselors, which limit their abilities to provide patients with appropriate education. A small number of studies have demonstrated the value of counseling in empowering patients to deal with relevant genetic information. Psychiatrists and other health professionals must be able to assist patients and families in making informed decisions about genetic testing and interpreting test results. Filling their knowledge gaps on these issues will be a critical step towards meeting these responsibilities.
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Sommen M, Wuyts W, Van Camp G. Molecular diagnostics for hereditary hearing loss in children. Expert Rev Mol Diagn 2017; 17:751-760. [PMID: 28593790 DOI: 10.1080/14737159.2017.1340834] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Hearing loss (HL) is the most common birth defect in industrialized countries with far-reaching social, psychological and cognitive implications. It is an extremely heterogeneous disease, complicating molecular testing. The introduction of next-generation sequencing (NGS) has resulted in great progress in diagnostics allowing to study all known HL genes in a single assay. The diagnostic yield is currently still limited, but has the potential to increase substantially. Areas covered: In this review the utility of NGS and the problems for comprehensive molecular testing for HL are evaluated and discussed. Expert commentary: Different publications have proven the appropriateness of NGS for molecular testing of heterogeneous diseases such as HL. However, several problems still exist, such as pseudogenic background of some genes and problematic copy number variant analysis on targeted NGS data. Another main challenge for the future will be the establishment of population specific mutation-spectra to achieve accurate personalized comprehensive molecular testing for HL.
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Affiliation(s)
- Manou Sommen
- a Center of Medical Genetics , University of Antwerp & Antwerp University Hospital , Antwerp , Belgium
| | - Wim Wuyts
- a Center of Medical Genetics , University of Antwerp & Antwerp University Hospital , Antwerp , Belgium
| | - Guy Van Camp
- a Center of Medical Genetics , University of Antwerp & Antwerp University Hospital , Antwerp , Belgium
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Mackley MP, Capps B. Expect the unexpected: screening for secondary findings in clinical genomics research. Br Med Bull 2017; 122:109-122. [PMID: 28398474 DOI: 10.1093/bmb/ldx009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Due to decreasing cost, and increasing speed and precision, genomic sequencing in research is resulting in the generation of vast amounts of genetic data. The question of how to manage that information has been an area of significant debate. In particular, there has been much discussion around the issue of 'secondary findings' (SF)-findings unrelated to the research that have diagnostic significance. SOURCES OF DATA The following includes ethical commentaries, guidelines and policies in respect to large-scale clinical genomics studies. AREAS OF AGREEMENT Research participant autonomy and their informed consent are paramount-policies around SF must be made clear and participants must have the choice as to which results they wish to receive, if any. AREAS OF CONTROVERSY While many agree that clinically 'actionable' findings should be returned, some question whether they should be actively sought within a research protocol. GROWING POINTS SF present challenges to a growing field; diverse policies around their management have the potential to hinder collaboration and future research. AREAS TIMELY FOR DEVELOPING RESEARCH The impact of returning SF and accurate estimates of their clinical utility are needed to inform future protocol design.
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Affiliation(s)
- Michael P Mackley
- Radcliffe Department of Medicine, University of Oxford, Level 6 West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Benjamin Capps
- Department of Bioethics, Faculty of Medicine, Dalhousie University, 5849 University Avenue, Room C-312, CRC Bldg, PO Box 15000, Halifax NS, Canada B3H 4R2
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Gupta S, Smith TR, Broekman ML. Ethical considerations of neuro-oncology trial design in the era of precision medicine. J Neurooncol 2017; 134:1-7. [PMID: 28555425 PMCID: PMC5543186 DOI: 10.1007/s11060-017-2502-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 05/20/2017] [Indexed: 12/29/2022]
Abstract
The field of oncology is currently undergoing a paradigm shift. Advances in the understanding of tumor biology and in tumor sequencing technology have contributed to the shift towards precision medicine, the therapeutic framework of targeting the individual oncogenic changes each tumor harbors. The success of precision medicine therapies, such as targeted kinase inhibitors and immunotherapies, in other cancers have motivated studies in brain cancers. The high specificity and cost of these therapies also encourage a shift in clinical trial design away from randomized control trials towards smaller, more exclusive early phase clinical trials. While these new trials advance the clinical application of increasingly precise and individualized therapies, their design brings ethical challenges . We review the pertinent ethical considerations for clinical trials of precision medicine in neuro-oncology and discuss methods to protect patients in this new era of trial design.
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Affiliation(s)
- Saksham Gupta
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Timothy R Smith
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Marike L Broekman
- Department of Neurosurgery, Cushing Neurosurgery Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, USA. .,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
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Abstract
In addition to the need for basic education about genetics/genomics, other approaches are suggested to include awareness campaigns, continuing education courses, policy review, and onsite clinical development. These alternative learning strategies encourage oncology nurses across the continuum of care, from the bedside/seatside to oncology nurse research, to integrate genomics into all levels of practice and research in the specialty of oncology nursing. All nurses are warriors in the fight against cancer. The goal of this article is to identify genomic information that oncology nurses, at all levels of care, need to know and use as tools in the war against cancer.
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Affiliation(s)
- Julie Eggert
- School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA; Inherited Cancer Clinic, Bon Secours St. Francis Cancer Center, 104 Innovation Drive, Greenville, SC 29607, USA.
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Public's Views toward Return of Secondary Results in Genomic Sequencing: It's (Almost) All about the Choice. J Genet Couns 2017; 26:1197-1212. [PMID: 28357777 DOI: 10.1007/s10897-017-0095-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 03/13/2017] [Indexed: 12/15/2022]
Abstract
The therapeutic use of genomic sequencing creates novel and unresolved questions about cost, clinical efficacy, access, and the disclosure of sequencing results. The disclosure of the secondary results of sequencing poses a particularly challenging ethical problem. Experts disagree about which results should be shared and public input - especially important for the creation of disclosure policies - is complicated by the complex nature of genetics. Recognizing the value of deliberative democratic methods for soliciting informed public opinion on matters like these, we recruited participants from a clinical research site for an all-day deliberative democracy (DD) session. Participants were introduced to the clinical and ethical issues associated with genomic sequencing, after which they discussed the tradeoffs and offered their opinions about policies for the return of secondary results. Participants (n = 66; mean age = 57 (SD = 15); 70% female; 76% white) were divided into 10 small groups (5 to 8 participants each) allowing interactive deliberation on policy options for the return of three categories of secondary results: 1) medically actionable results; 2) risks for adult-onset disorders identified in children; and 3) carrier status for autosomal recessive disorders. In our qualitative analysis of the session transcripts, we found that while participants favored choice and had a preference for making information available, they also acknowledged the risks (and benefits) of learning such information. Our research reveals the nuanced reasoning used by members of the public when weighing the pros and cons of receiving genomic information, enriching our understanding of the findings of surveys of attitudes regarding access to secondary results.
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Berg JS, Agrawal PB, Bailey DB, Beggs AH, Brenner SE, Brower AM, Cakici JA, Ceyhan-Birsoy O, Chan K, Chen F, Currier RJ, Dukhovny D, Green RC, Harris-Wai J, Holm IA, Iglesias B, Joseph G, Kingsmore SF, Koenig BA, Kwok PY, Lantos J, Leeder SJ, Lewis MA, McGuire AL, Milko LV, Mooney SD, Parad RB, Pereira S, Petrikin J, Powell BC, Powell CM, Puck JM, Rehm HL, Risch N, Roche M, Shieh JT, Veeraraghavan N, Watson MS, Willig L, Yu TW, Urv T, Wise AL. Newborn Sequencing in Genomic Medicine and Public Health. Pediatrics 2017; 139:e20162252. [PMID: 28096516 PMCID: PMC5260149 DOI: 10.1542/peds.2016-2252] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 12/20/2022] Open
Abstract
The rapid development of genomic sequencing technologies has decreased the cost of genetic analysis to the extent that it seems plausible that genome-scale sequencing could have widespread availability in pediatric care. Genomic sequencing provides a powerful diagnostic modality for patients who manifest symptoms of monogenic disease and an opportunity to detect health conditions before their development. However, many technical, clinical, ethical, and societal challenges should be addressed before such technology is widely deployed in pediatric practice. This article provides an overview of the Newborn Sequencing in Genomic Medicine and Public Health Consortium, which is investigating the application of genome-scale sequencing in newborns for both diagnosis and screening.
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Affiliation(s)
| | - Pankaj B Agrawal
- Divisions of Newborn Medicine and
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Alan H Beggs
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Amy M Brower
- American College of Medical Genetics and Genomics, Bethesda, Maryland
| | - Julie A Cakici
- Rady Children's Institute for Genomic Medicine, San Diego, California
| | | | - Kee Chan
- Chicago School of Public Health, University of Illinois, Chicago, Illinois
| | | | - Robert J Currier
- Genetic Disease Screening Program, California Department of Public Health, Sacramento, California
| | - Dmitry Dukhovny
- Department of Pediatrics and Division of Neonatology, Oregon Health & Science University, Portland, Oregon
| | | | | | - Ingrid A Holm
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Galen Joseph
- Department of Anthropology, History, and Social Medicine
| | | | | | - Pui-Yan Kwok
- Institute for Human Genetics
- Cardiovascular Research Institute, and Department of Dermatology
| | - John Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Steven J Leeder
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Megan A Lewis
- RTI International, Research Triangle Park, North Carolina
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; and
| | | | | | - Richard B Parad
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stacey Pereira
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; and
| | - Joshua Petrikin
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Cynthia M Powell
- Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Jennifer M Puck
- Department of Pediatrics, University of California, San Francisco, California
| | | | | | - Myra Roche
- Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Joseph T Shieh
- Institute for Human Genetics
- Department of Pediatrics, Benioff Children's Hospital, and
| | | | - Michael S Watson
- American College of Medical Genetics and Genomics, Bethesda, Maryland
| | - Laurel Willig
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Timothy W Yu
- Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tiina Urv
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland
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Langer MM, Roche MI, Brewer NT, Berg JS, Khan CM, Leos C, Moore E, Brown M, Rini C. Development and Validation of a Genomic Knowledge Scale to Advance Informed Decision Making Research in Genomic Sequencing. MDM Policy Pract 2017; 2. [PMID: 29928697 PMCID: PMC6005662 DOI: 10.1177/2381468317692582] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background This study evaluated the psychometric properties of a new, comprehensive measure of knowledge about genomic sequencing, the University of North Carolina Genomic Knowledge Scale (UNC-GKS). Methods The UNC-GKS assesses knowledge in four domains thought to be critical for informed decision making about genomic sequencing. The scale was validated using classical test theory and item response theory in 286 adult patients and 132 parents of pediatric patients undergoing diagnostic whole exome sequencing (WES) in the NCGENES study. Results The UNC-GKS assessed a single underlying construct (genomic knowledge) with good internal reliability (Cronbach's alpha = 0.90). Scores were most informative (able to discriminate between individuals with different levels of genomic knowledge) at one standard deviation above the scale mean or lower, a range that included most participants. Convergent validity was supported by associations with health literacy and numeracy (rs=0.41-0.46). The scale functioned well across subgroups differing in sex, race/ethnicity, education, and English proficiency. Discussion Findings supported the promise of the UNC-GKS as a valid and reliable measure of genomic knowledge among people facing complex decisions about WES and comparable sequencing methods. It is neither disease- nor population-specific, and it functioned well across important subgroups, making it usable in diverse populations.
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Affiliation(s)
- Michelle M Langer
- American Institutes for Research, University of North Carolina, Chapel Hill, NC
| | - Myra I Roche
- Departments of Pediatrics and Genetics, University of North Carolina, Chapel Hill, NC.,Center for Genomics and Society, University of North Carolina, Chapel Hill, NC
| | - Noel T Brewer
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Jonathan S Berg
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Cristina Leos
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC
| | - Elizabeth Moore
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC
| | - Michelle Brown
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL
| | - Christine Rini
- Center for Genomics and Society, University of North Carolina, Chapel Hill, NC.,Department of Health Behavior, University of North Carolina, Chapel Hill, NC.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
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