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Stanić Ž, Hrgović Z, Fureš R, Vusić I, Lagančić M. Ethical Aspects of Prenatal DNA Testing. Z Geburtshilfe Neonatol 2022; 226:300-303. [DOI: 10.1055/a-1904-8406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
AbstractCell-free DNA (cfDNA) first-trimester screening for fetal aneuploidies, as a
non-invasive, safe, and rather accurate method, has changed prenatal screening
policies all over the world. Owing to aggressive marketing, cfDNA screening
tests exhibit global popularity and a rapid spread in routine prenatal care.
However, wide availability of the tests, together with observed difficulties in
the test’s interpretation, bring to light several serious ethical
concerns. To date it is vital to identify and address the most important
ethical, legal, and social issues regarding prenatal screening tests.
Furthermore, guidelines and restrictions in certain cfDNA screening advancements
that may provide information regarding fetal genetic traits of unknown clinical
significance, conditions with variable penetrance, or late-onset conditions,
should be considered.
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Affiliation(s)
- Žana Stanić
- Department for Integrative Gynecology, Obstetrics and Minimally
Invasive Gynecologic Surgery, Zabok General Hospital and Croatian Veterans
Hospital, Zabok, Croatia
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer
University of Osijek, Osijek, Croatia
| | - Zlatko Hrgović
- Women's Health Clinic, J. W. Goethe University
Frankfurt, Frankfurt am Main, Germany
| | - Rajko Fureš
- Department for Integrative Gynecology, Obstetrics and Minimally
Invasive Gynecologic Surgery, Zabok General Hospital and Croatian Veterans
Hospital, Zabok, Croatia
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer
University of Osijek, Osijek, Croatia
| | - Iva Vusić
- Health Center of Bjelovar-Bilogora County, Bjelovar,
Croatia
| | - Marko Lagančić
- Emergency Department, University Hospital Dubrava, Zagreb,
Croatia
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Zhang B, Zhao S, Wan H, Liu Y, Zhang F, Guo X, Zeng W, Zhang H, Zeng L, Qu J, Wu BQ, Wan X, Cantor CR, Ge D. High-resolution DNA size enrichment using a magnetic nano-platform and application in non-invasive prenatal testing. Analyst 2021; 145:5733-5739. [PMID: 32748914 DOI: 10.1039/d0an00813c] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Precise DNA sizing can boost sequencing efficiency, reduce cost, improve data quality, and even allow sequencing of low-input samples, while current pervasive DNA sizing approaches are incapable of differentiating DNA fragments under 200 bp with high resolution (<20 bp). In non-invasive prenatal testing (NIPT), the size distribution of cell-free fetal DNA in maternal plasma (main peak at 143 bp) is significantly different from that of maternal cell-free DNA (main peak at 166 bp). The current pervasive workflow of NIPT and DNA sizing is unable to take advantage of this 20 bp difference, resulting in sample rejection, test inaccuracy, and restricted clinical utility. Here we report a simple, automatable, high-resolution DNA size enrichment workflow, named MiniEnrich, on a magnetic nano-platform to exploit this 20 bp size difference and to enrich fetal DNA fragments from maternal blood. Two types of magnetic nanoparticles were developed, with one able to filter high-molecular-weight DNA with high resolution and the other able to recover the remaining DNA fragments under the size threshold of interest with >95% yield. Using this method, the average fetal fraction was increased from 13% to 20% after the enrichment, as measured by plasma DNA sequencing. This approach provides a new tool for high-resolution DNA size enrichment under 200 bp, which may improve NIPT accuracy by rescuing rejected non-reportable clinical samples, and enable NIPT earlier in pregnancy. It also has the potential to improve non-invasive screening for fetal monogenic disorders, differentiate tumor-related DNA in liquid biopsy and find more applications in autoimmune disease diagnosis.
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Affiliation(s)
- Bo Zhang
- Apostle Inc., San Jose, CA 95134, USA.
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3
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Means C, Cirino A, Swenson KB, Austin J. "I am a Genetic Counselor": A qualitative exploration of field leaders' perceptions of the title "genetic counselor". J Genet Couns 2019; 29:97-104. [PMID: 31663200 DOI: 10.1002/jgc4.1184] [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: 06/27/2019] [Revised: 10/05/2019] [Accepted: 10/09/2019] [Indexed: 11/05/2022]
Abstract
The genetic counseling profession is 50 years old, and is growing and diversifying. Despite this evolving context, no studies have formally explored the continuing relevance or appropriateness of the title "genetic counselor." We used a qualitative research methodology (interpretive description) to explore this concept among thought leaders within the genetic counseling profession. We conducted 12 semi-structured telephone interviews, which ranged in length from 18 to 50 min, and transcribed them verbatim. Analysis and data collection unfolded in parallel. The following themes regarding participants' perceptions of the title "genetic counselor" emerged from the data: (1) others misunderstand "genetic counselor"; (2) the term "counselor" in our title produces complex and conflicting emotions; (3) risks of changing our title outweigh the benefit; and (4) we need to own the narrative surrounding our title. Despite recognition that the title "genetic counselor" may not capture the full range of diverse roles members of the profession play, our data reveal overall support for the continued relevance and appropriateness of the title, for the value of the strength that comes from unity within the profession, and for efforts to highlight that which unites us across roles, disciplines, and specialties.
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Affiliation(s)
- Chandler Means
- Graduate Medical Sciences, Master's Program in Genetic Counseling, Boston University School of Medicine, Boston, MA, USA
| | - Allison Cirino
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Kathleen B Swenson
- Graduate Medical Sciences, Master's Program in Genetic Counseling, Boston University School of Medicine, Boston, MA, USA
| | - Jehannine Austin
- Departments of Psychiatry and Medical Genetics, University of British Columbia, Vancouver, Canada
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Abstract
AbstractNon-invasive prenatal testing (NIPT) is a new technology used in prenatal testing (PT) that capitalizes on genomic platforms to transform DNA fragments in the blood of pregnant women into information about the genome of a foetus. Since its market introduction in 2011, it has travelled around the globe with remarkable speed. This article engages with the emergence of NIPT in and around Vienna, the capital city of Austria, to explore why and how this technology could travel so quickly in practice. Based on a qualitative analysis of interviews, documents, and field notes, it argues, first, that NIPT could travel so quickly because it travelled as ‘adaptable boxes’ that added on to different ‘local worlds of prenatal testing (PT)’, without disrupting them. Second, in so doing, NIPT could travel on a moral and material ground, or an ‘imaginary of PT’, built in the past. Third, the article argues that elements of this imaginary were also mobilized by commercial pioneers of NIPT, who ‘infrastructurized’ extant values, practices, and networks among biomedical professionals. Thus, various actors converged in mobilizing moral and material elements of an imaginary, transforming them into an infrastructure that facilitated the travels of NIPT, while also shaping its use.
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5
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Vanstone M, Cernat A, Nisker J, Schwartz L. Women's perspectives on the ethical implications of non-invasive prenatal testing: a qualitative analysis to inform health policy decisions. BMC Med Ethics 2018; 19:27. [PMID: 29661182 PMCID: PMC5902938 DOI: 10.1186/s12910-018-0267-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 04/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background Non-Invasive Prenatal Testing (NIPT) is a technology which provides information about fetal genetic characteristics (including sex) very early in pregnancy by examining fetal DNA obtained from a sample of maternal blood. NIPT is a morally complex technology that has advanced quickly to market with a strong push from industry developers, leaving many areas of uncertainty still to be resolved, and creating a strong need for health policy that reflects women’s social and ethical values. We approach the need for ethical policy-making by studying the use of NIPT and emerging policy in the province of Ontario, Canada. Methods Using an adapted version of constructivist grounded theory, we conducted interviews with 38 women who have had personal experiences with NIPT. We used an iterative process of data collection and analysis and a staged coding strategy to conduct a descriptive analysis of ethics issues identified implicitly and explicitly by women who have been affected by this technology. Results The findings of this paper focus on current ethical issues for women seeking NIPT, including place in the prenatal pathway, health care provider counselling about the test, industry influence on the diffusion of NIPT, consequences of availability of test results. Other issues gain relevance in the context of future policy decisions regarding NIPT, including funding of NIPT and principles that may govern the expansion of the scope of NIPT. These findings are not an exhaustive list of all the potential ethical issues related to NIPT, but rather a representation of the issues which concern women who have personal experience with this test. Conclusions Women who have had personal experience with NIPT have concerns and priorities which sometimes contrast dramatically with the theoretical ethics literature. These findings suggest the importance of engaging patients in ethical deliberation about morally complex technologies, and point to the need for more deliberative patient engagement work in this area. Electronic supplementary material The online version of this article (10.1186/s12910-018-0267-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Meredith Vanstone
- Department of Family Medicine, McMaster University, DBHSC 5003E, 100 Main St W, Hamilton, ON, L8P 1H6, Canada. .,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
| | - Alexandra Cernat
- Life Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Jeff Nisker
- Department of Obstetrics and Gynecology, Western University, London, ON, Canada.,Children's Health Research Institute, London, ON, Canada
| | - Lisa Schwartz
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Griffin B, Edwards S, Chitty LS, Lewis C. Clinical, social and ethical issues associated with non-invasive prenatal testing for aneuploidy. J Psychosom Obstet Gynaecol 2018. [PMID: 28635528 DOI: 10.1080/0167482x.2017.1286643] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Non-invasive prenatal testing (NIPT), based on analysis of cell-free foetal DNA, is rapidly becoming a preferred method to screen for chromosomal aneuploidy with the technology now available in over 90 countries. This review provides an up-to-date discussion of the key clinical, social and ethical implications associated with this revolutionary technology. Stakeholders are positive about a test that is highly accurate, safe, can be perfomed early in pregnancy, identifies affected pregnancies that might otherwise have been missed and reduces the need for invasive testing. Nevertheless, professional societies currently recommend it as an advanced screening test due to the low false positive rate (FPR). Despite the practical and psychological benefits, a number of concerns have been raised which warrant attention. These include the potential for routinisation of testing and subsequent impact on informed decision-making, an "easy" blood test inadvertently contributing to women feeling pressured to take the test, fears NIPT will lead to less tolerance and support for those living with Down syndrome and the heightened expectation of having "perfect babies". These issues can be addressed to some extent through clinician education, patient information and establishing national and international consensus in the development of comprehensive and regularly updated guidelines. As the number of conditions we are able to test for non-invasively expands it will be increasingly important to ensure pre-test counselling can be delivered effectively supported by knowledgeable healthcare professionals.
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Affiliation(s)
- Blanche Griffin
- a North East Thames Regional Genetics Service , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Samantha Edwards
- a North East Thames Regional Genetics Service , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Lyn S Chitty
- a North East Thames Regional Genetics Service , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK.,b Genetics and Genomic Medicine , UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Celine Lewis
- a North East Thames Regional Genetics Service , Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK.,b Genetics and Genomic Medicine , UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
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7
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Olaya LF, Hyett JA, McLennan SV. Effects of sample processing and storage on the integrity of cell-free miRNAs in maternal plasma. Prenat Diagn 2017; 37:744-749. [PMID: 28556966 DOI: 10.1002/pd.5075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 05/13/2017] [Accepted: 05/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cell-free fetal miRNAs have been identified as potential biomarkers for fetal abnormalities and/or placental function. Factors affecting the stability of cell-free fetal miRNA samples (type of collection tube and time interval between sampling and analysis) have not previously been reported. METHODS Blood from pregnant women (n = 12, 18 ± 4 weeks' gestation) was collected into two types of tube (EDTA and RNA BCT) and was stored at different temperatures for up to 72 h. Expression of seven apparently placental specific miRNAs was then measured to compare the effects of sampling and storage. These miRNAs were also assessed in non-pregnant women (n = 9). RESULTS The quantity of miRNA extracted was not affected by time or tube. Three miRNAs (miR-518b, miR-525 and miR-526a*) were measureable only in pregnant women, but miR-518b was not always present. Detailed study of the two pregnancy specific miRNAs showed no effect of tube type at 4 h. However, variability in miRNA level was observed with increased time and was significant for one miRNA in the BCT tube at >48 h (p < 0.005). CONCLUSION Some cffmiRNAs are placental specific, and these samples are stable when analyzed within 48 h of collection in either tube type. © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Luisa F Olaya
- Discipline of Obstetrics, Gynaecology and Neonatology and Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia.,Department of Endocrinology, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan A Hyett
- Discipline of Obstetrics, Gynaecology and Neonatology and Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Susan V McLennan
- Department of Endocrinology, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia.,NSW Health Pathology, Chemical Pathology, RPA Hospital Camperdown, New South Wales, Australia
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Rosignoli L, Tonni G. Should cell-free fetal DNA be included in first trimester screening (FTS) for common trisomy? A possible scenario on 6697 women screened over 10 years. J Eval Clin Pract 2016; 22:899-906. [PMID: 27345561 DOI: 10.1111/jep.12557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The primary aim was to determine the performance of the first trimester screening (FTS) test in a general obstetrics population. Cost-benefit analysis of a hypothetic model based on implementation of the FTS test by cell-free fetal (cff) DNA was calculated. METHODS A total of 6697 women were screened using FTS test. A two-step strategy based upon nuchal translucency, serum screening and ultrasound assessment of nasal bone (NB) was applied. Three groups were identified (high-risk: >1:250; intermediate-risk: 1:251-1:999 and low-risk group: <1:1000). Women at intermediate-risk (1:251-1:999) underwent NB assessment and recalculation of individual risk. All women at high-risk were offered fetal karyotyping. RESULTS A total of 321 women (4.8%) resulted at high-risk while 480 women (7.1%) with intermediate-risk underwent assessment of the NB, which was absent in 15 fetuses. Overall, 54 aneuploidies were detected for a 96.4% sensitivity, a 96.1% specificity, a 99.9% negative predictive value and a false positive rate of 4.8%. Audit was conducted on a yearly basis and lost to follow up was 0.47% (32 cases). CONCLUSIONS Public health system would not be able to cover the cost of including cff DNA in women undergoing first trimester screening on universal basis. However, assuming a possible scenario based on implementation of FTS by cff DNA in women at high-risk would result in a 6-fold reduction in the number of invasive procedures while avoiding two false negative results (trisomy 21) that were diagnosed in women with intermediate-risk using current screening strategy by combined test.
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Affiliation(s)
- Lucia Rosignoli
- Center for Prevention of Fetal Malformations, Department of Obstetrics and Gynecology, Hospital Meyer, Florence, Italy
| | - Gabriele Tonni
- Prenatal Diagnostic Center, Department of Obstetrics and Gynecology, Guastalla Civil Hospital, AUSL Reggio Emilia, Reggio Emilia, Italy
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McLennan A, Palma-Dias R, da Silva Costa F, Meagher S, Nisbet DL, Scott F. Noninvasive prenatal testing in routine clinical practice--an audit of NIPT and combined first-trimester screening in an unselected Australian population. Aust N Z J Obstet Gynaecol 2016; 56:22-8. [PMID: 26817523 DOI: 10.1111/ajo.12432] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 11/21/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND There are limited data regarding noninvasive prenatal testing (NIPT) in low-risk populations, and the ideal aneuploidy screening model for a pregnant population has yet to be established. AIMS To assess the implementation of NIPT into clinical practice utilising both first- and second-line screening models. MATERIALS AND METHODS Three private practices specialising in obstetric ultrasound and prenatal diagnosis in Australia offered NIPT as a first-line test, ideally followed by combined first-trimester screening (cFTS), or as a second-line test following cFTS, particularly in those with a calculated risk between 1:50 and 1:1000. RESULTS NIPT screening was performed in 5267 women and as a first-line screening method in 3359 (63.8%). Trisomies 21 and 13 detection was 100% and 88% for trisomy 18. Of cases with known karyotypes, the positive predictive value (PPV) of the test was highest for trisomy 21 (97.7%) and lowest for monosomy X (25%). Ultrasound detection of fetal structural abnormality resulted in the detection of five additional chromosome abnormalities, two of which had high-risk cFTS results. For all chromosomal abnormalities, NIPT alone detected 93.4%, a contingent model detected 81.8% (P = 0.097), and cFTS alone detected 65.9% (P < 0.005). CONCLUSIONS NIPT achieved 100% T21 detection and had a higher DR of all aneuploidy when used as a first-line test. Given the false-positive rate for all aneuploidies, NIPT is an advanced screening test, rather than a diagnostic test. The benefit of additional cFTS was the detection of fetal structural abnormalities and some unusual chromosomal abnormalities.
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Affiliation(s)
- Andrew McLennan
- Sydney Ultrasound for Women, Sydney, New South Wales, Australia.,Sydney University, Sydney, New South Wales, Australia
| | - Ricardo Palma-Dias
- Women's Ultrasound, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Fabricio da Silva Costa
- University of Melbourne, Melbourne, Victoria, Australia.,Monash Ultrasound for Women, Melbourne, Victoria, Australia
| | - Simon Meagher
- Monash Ultrasound for Women, Melbourne, Victoria, Australia
| | - Debbie L Nisbet
- Women's Ultrasound, Melbourne, Victoria, Australia.,Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Fergus Scott
- Sydney Ultrasound for Women, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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Michie M, Kraft SA, Minear MA, Ryan RR, Allyse MA. Informed decision-making about prenatal cfDNA screening: An assessment of written materials. ACTA ACUST UNITED AC 2016; 2:362-371. [PMID: 27699200 DOI: 10.1016/j.jemep.2016.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES The introduction of prenatal cfDNA screening for fetal aneuploidy and other genetic conditions has exacerbated concerns about informed decision-making in clinical prenatal testing. To assess the information provided to patients to facilitate decisions about cfDNA screening, we collected written patient education and consent documents created by laboratories and clinics. METHODS Informed consent documents (IC) were coded by two independent coders. Each IC was assessed for readability, attention to elements of informed consent, and completeness of information about the test and the screened conditions. RESULTS We found variance between IC produced by commercial laboratories versus those provided by local clinics or health care systems, and considerable variance among materials from all sources. "Commercial" IC were longer and written at a more difficult reading level than "non-commercial" IC, and were less likely to state explicitly that cfDNA only screens for certain conditions. About one-third of IC were combined with laboratory order forms. Though most IC recommended confirmatory testing for positive results, only about half clearly stated that results could be incorrect-including mentions of false positives or false negatives. About one-third of IC explicitly stated that cfDNA screening was optional. While nearly all IC from any source listed the conditions screened by the test, only about half of the IC included any phenotypic descriptions of these conditions. Few IC mentioned psychosocial considerations, and only one IC mentioned the availability of support groups for families of children with genetic conditions. CONCLUSIONS Based on our findings, we recommend that written and well-informed consent be sought before performing cfDNA screening, and we offer minimal and recommended standards for patient education and consent materials.
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Affiliation(s)
- Marsha Michie
- Institute for Health & Aging, University of California, San Francisco
| | | | | | - Roberta R Ryan
- Institute for Health & Aging, University of California, San Francisco
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Lee DE, Lim JH, Kim MH, Park SY, Ryu HM. Novel Epigenetic Markers on Chromosome 21 for Noninvasive Prenatal Testing of Fetal Trisomy 21. J Mol Diagn 2016; 18:378-387. [PMID: 26947512 DOI: 10.1016/j.jmoldx.2015.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/25/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022] Open
Abstract
Until now, fetal placenta-specific epigenetic markers for noninvasive prenatal testing of fetal trisomy 21 (T21) have been identified based only on differences in tissue-specific epigenetic characteristics between placenta and maternal blood, but these characteristics have not been validated in T21 placenta. We aimed to discover novel epigenetic markers on chromosome 21 that show a hypermethylated pattern in fetal placenta compared with blood, regardless of the presence of T21. We performed a high-resolution tiling array analysis of chromosome 21 using the methylated-CpG binding domain protein-based method. We identified 93 epigenetic regions that showed fetal placenta-specific differential methylation patterns; among these, three regions showed fetal placenta-specific methylation patterns in T21 placenta samples. The methylation patterns of these three regions in the array were confirmed by bisulfite direct sequencing. The three regions were detectable in first-trimester maternal plasma. Moreover, a combination of their methylation ratio achieved high diagnostic accuracy for noninvasive prenatal testing of fetal T21 by further statistical analysis. These three novel regions with fetal placenta-specific differential methylation patterns on chromosome 21 were identified irrespective of the presence of T21. Our findings suggest that epigenetic characteristics of markers according to the presence or absence of T21 should be considered in the development of noninvasive prenatal testing of fetal T21 using fetal placenta-specific epigenetic markers.
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Affiliation(s)
- Da Eun Lee
- Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center, Seoul, Republic of Korea
| | - Ji Hyae Lim
- Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center, Seoul, Republic of Korea
| | - Min Hyoung Kim
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - So Yeon Park
- Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center, Seoul, Republic of Korea.
| | - Hyun Mee Ryu
- Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women's Healthcare Center, Seoul, Republic of Korea; Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea.
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12
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Gekas J, Langlois S, Ravitsky V, Audibert F, van den Berg DG, Haidar H, Rousseau F. Non-invasive prenatal testing for fetal chromosome abnormalities: review of clinical and ethical issues. Appl Clin Genet 2016; 9:15-26. [PMID: 26893576 PMCID: PMC4745955 DOI: 10.2147/tacg.s85361] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Genomics-based non-invasive prenatal screening using cell-free DNA (cfDNA screening) was proposed to reduce the number of invasive procedures in current prenatal diagnosis for fetal aneuploidies. We review here the clinical and ethical issues of cfDNA screening. To date, it is not clear how cfDNA screening is going to impact the performances of clinical prenatal diagnosis and how it could be incorporated in real life. The direct marketing to users may have facilitated the early introduction of cfDNA screening into clinical practice despite limited evidence-based independent research data supporting this rapid shift. There is a need to address the most important ethical, legal, and social issues before its implementation in a mass setting. Its introduction might worsen current tendencies to neglect the reproductive autonomy of pregnant women.
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Affiliation(s)
- Jean Gekas
- Prenatal Diagnosis Unit, Department of Medical Genetics and Pediatrics, Faculty of Medicine, Université Laval, Québec City, QC, Canada
- Department of Medical Biology, CHU de Québec, Québec City, QC, Canada
| | - Sylvie Langlois
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Vardit Ravitsky
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - François Audibert
- Department of Obstetrics and Gynecology, Hospital Sainte-Justine, Montreal, QC, Canada
| | - David Gradus van den Berg
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Hazar Haidar
- Bioethics Program, Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - François Rousseau
- Department of Medical Biology, CHU de Québec, Québec City, QC, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec City, QC, Canada
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13
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Royère D. The impact of introducing combined first-trimester trisomy 21 screening in the French population. Eur J Public Health 2015; 26:492-7. [DOI: 10.1093/eurpub/ckv214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Dondorp W, de Wert G, Bombard Y, Bianchi DW, Bergmann C, Borry P, Chitty LS, Fellmann F, Forzano F, Hall A, Henneman L, Howard HC, Lucassen A, Ormond K, Peterlin B, Radojkovic D, Rogowski W, Soller M, Tibben A, Tranebjærg L, van El CG, Cornel MC. Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening. Eur J Hum Genet 2015; 23:1438-50. [PMID: 25782669 PMCID: PMC4613463 DOI: 10.1038/ejhg.2015.57] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/15/2015] [Accepted: 02/19/2015] [Indexed: 12/25/2022] Open
Abstract
This paper contains a joint ESHG/ASHG position document with recommendations regarding responsible innovation in prenatal screening with non-invasive prenatal testing (NIPT). By virtue of its greater accuracy and safety with respect to prenatal screening for common autosomal aneuploidies, NIPT has the potential of helping the practice better achieve its aim of facilitating autonomous reproductive choices, provided that balanced pretest information and non-directive counseling are available as part of the screening offer. Depending on the health-care setting, different scenarios for NIPT-based screening for common autosomal aneuploidies are possible. The trade-offs involved in these scenarios should be assessed in light of the aim of screening, the balance of benefits and burdens for pregnant women and their partners and considerations of cost-effectiveness and justice. With improving screening technologies and decreasing costs of sequencing and analysis, it will become possible in the near future to significantly expand the scope of prenatal screening beyond common autosomal aneuploidies. Commercial providers have already begun expanding their tests to include sex-chromosomal abnormalities and microdeletions. However, multiple false positives may undermine the main achievement of NIPT in the context of prenatal screening: the significant reduction of the invasive testing rate. This document argues for a cautious expansion of the scope of prenatal screening to serious congenital and childhood disorders, only following sound validation studies and a comprehensive evaluation of all relevant aspects. A further core message of this document is that in countries where prenatal screening is offered as a public health programme, governments and public health authorities should adopt an active role to ensure the responsible innovation of prenatal screening on the basis of ethical principles. Crucial elements are the quality of the screening process as a whole (including non-laboratory aspects such as information and counseling), education of professionals, systematic evaluation of all aspects of prenatal screening, development of better evaluation tools in the light of the aim of the practice, accountability to all stakeholders including children born from screened pregnancies and persons living with the conditions targeted in prenatal screening and promotion of equity of access.
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Affiliation(s)
- Wybo Dondorp
- Department of Health, Ethics & Society, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands
| | - Guido de Wert
- Department of Health, Ethics & Society, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands
| | - Yvonne Bombard
- Li Ka Shing Knowledge Institute of St Michael's Hospital & Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Diana W Bianchi
- Department of Pediatrics, Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA, USA
| | - Carsten Bergmann
- Center for Human Genetics Bioscientia, Ingelheim, Germany
- Department of Medicine, University Freiburg Medical Center, Freiburg, Germany
| | - Pascal Borry
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, Leuven University, Belgium
| | - Lyn S Chitty
- Clinical and Molecular Genetics Unit, UCL Institute of Child Health, Great Ormond Street Hospital and UCLH NHS Foundations Trusts, London, UK
| | - Florence Fellmann
- Service of Medical Genetics, University Hospital of Lausanne, Lausanne, Switzerland
| | | | | | - Lidewij Henneman
- Section Community Genetics, Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Heidi C Howard
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Anneke Lucassen
- Department of Clinical Ethics and Law (CELS), University of Southampton and Wessex Clinical Genetic Service, Southampton, UK
| | - Kelly Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | - Borut Peterlin
- Clinical Institute of Medical Genetics, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Dragica Radojkovic
- Laboratory for Molecular Biology, Institute of Molecular Genetics and Genetic Engineering (IMGGE), University of Belgrade, Belgrade, Serbia
| | - Wolf Rogowski
- Deutsches Forschungszentrum für Gesundheit und Umwelt, Helmholtz Zentrum, München, Germany
| | - Maria Soller
- Division Clinical Genetics, University and Regional Laboratories Region Skåne, Lund University Hospital, Lund, Sweden
| | - Aad Tibben
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisbeth Tranebjærg
- Department of Audiology, Bispebjerg Hospital/Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Genetics, The Kennedy Center, University of Copenhagen, Copenhagen, Denmark
- Institute of Cellular and Molecular Medicine, ICMM, University of Copenhagen, Copenhagen, Denmark
| | - Carla G van El
- Section Community Genetics, Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Martina C Cornel
- Section Community Genetics, Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Silcock C, Liao L, Hill M, Chitty LS. Will the introduction of non-invasive prenatal testing for Down's syndrome undermine informed choice? Health Expect 2015; 18:1658-71. [PMID: 26039796 PMCID: PMC5060845 DOI: 10.1111/hex.12159] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2013] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To investigate whether the introduction of non-invasive pre-natal testing for Down's syndrome (DS) has the potential to undermine informed choice. PARTICIPANTS Three hundred and ninety-three health professionals; 523 pregnant women. METHODS A cross-sectional questionnaire study across nine maternity units and three conferences in the UK designed to assess opinions regarding test delivery and how information should be communicated to women when offered Down's syndrome screening (DSS) or diagnosis using invasive (IDT) or non-invasive testing (NIPT). RESULTS Both pregnant women and health professionals in the NIPT and DSS groups were less likely than the IDT group to consider that testing should take place at a return visit or that obtaining written consent was necessary, and more likely to think testing should be carried out routinely. Compared to health professionals, pregnant women expressed a stronger preference for testing to occur on the same day as pre-test counselling (P = 0.000) and for invasive testing to be offered routinely (P = 0.000). They were also more likely to indicate written consent as necessary for DSS (P = 0.000) and NIPT (P < 0.05). CONCLUSIONS Health professionals and pregnant women view the consenting process differently across antenatal test types. These differences suggest that informed choice may be undermined with the introduction of NIPT for DS into clinical practice. To maintain high standards of care, effective professional training programmes and practice guidelines are needed which prioritize informed consent and take into account the views and needs of service users.
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Affiliation(s)
- Caroline Silcock
- University College London Hospitals NHS Foundation Trust & UCL Institute for Women's HealthLondonUK
| | - Lih‐Mei Liao
- University College London Hospitals NHS Foundation Trust & UCL Institute for Women's HealthLondonUK
| | - Melissa Hill
- UCL Institute of Child HealthGreat Ormond Street Hospital for Children NHS Trust, and Fetal Medicine Unit, University College London Hospitals NHS Foundation TrustLondonUK
| | - Lyn S. Chitty
- UCL Institute of Child HealthLondonUK
- Great Ormond Street Hospital for Children NHS Trust and Fetal Medicine UnitUniversity College London Hospitals NHS Foundation TrustLondonUK
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Kotsopoulou I, Tsoplou P, Mavrommatis K, Kroupis C. Non-invasive prenatal testing (NIPT): limitations on the way to become diagnosis. ACTA ACUST UNITED AC 2015. [PMID: 29540035 DOI: 10.1515/dx-2015-0002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
With the discovery of existing circulating cell-free fetal DNA (ccffDNA) in maternal plasma and the advent of next-generation sequencing (NGS) technology, there is substantial hope that prenatal diagnosis will become a predominately non-invasive process in the future. At the moment, non-invasive prenatal testing (NIPT) is available for high-risk pregnancies with significant better sensitivity and specificity than the other existing non-invasive methods (biochemical and ultrasonographical). Mainly it is performed by NGS methods in a few commercial labs worldwide. However, it is expected that many other labs will offer analogous services in the future in this fast-growing field with a multiplicity of in-house methods (e.g., epigenetic, etc.). Due to various limitations of the available methods and technologies that are explained in detail in this manuscript, NIPT has not become diagnostic yet and women may still need to undergo risky invasive procedures to verify a positive finding or to secure (or even expand) a negative one. Efforts have already started to make the NIPT technologies more accurate (even at the level of a complete fetal genome) and cheaper and thus more affordable, in order to become diagnostic screening tests for all pregnancies in the near future.
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Affiliation(s)
- Ioanna Kotsopoulou
- 1Department of Clinical Biochemistry, Attikon University General Hospital, University of Athens Medical School, Athens, Greece
| | | | | | - Christos Kroupis
- 1Department of Clinical Biochemistry, Attikon University General Hospital, University of Athens Medical School, Athens, Greece
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17
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Dondorp W, Page-Christiaens G, de Wert G. Genomic futures of prenatal screening: ethical reflection. Clin Genet 2015; 89:531-8. [DOI: 10.1111/cge.12640] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 12/15/2022]
Affiliation(s)
- W.J. Dondorp
- Department of Health, Ethics and Society, Research Schools GROW, CAPHRI; Maastricht University; Maastricht The Netherlands
| | - G.C.M.L. Page-Christiaens
- Wilhelmina Children's Hospital Birth Centre; Utrecht University Medical Centre; Utrecht The Netherlands
| | - G.M.W.R de Wert
- Department of Health, Ethics and Society, Research Schools GROW, CAPHRI; Maastricht University; Maastricht The Netherlands
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Vanstone M, Yacoub K, Giacomini M, Hulan D, McDonald S. Women's Experiences of Publicly Funded Non-Invasive Prenatal Testing in Ontario, Canada: Considerations for Health Technology Policy-Making. QUALITATIVE HEALTH RESEARCH 2015; 25:1069-84. [PMID: 26063605 DOI: 10.1177/1049732315589745] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Non-invasive prenatal testing (NIPT) via fetal DNA in maternal blood has been publicly funded in Ontario, Canada, for high-risk women since 2014. We solicited women's experiences and values related to this new health technology to describe how this test is currently being used in Ontario and to provide information about patient priorities to inform future policy decisions about the use of NIPT. Guided by constructivist grounded theory methodology, we interviewed 38 women who had diverse personal experiences with NIPT. Participants' accounts of their values for decision making about NIPT heavily relied on three mutually modulating factors: timing, accuracy, and risk. The values expressed by women conflict with the way that publicly funded NIPT has typically been implemented in Ontario. We offer recommendations for how NIPT might be integrated into prenatal care pathways in a way more consistent with women's values.
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Chitty LS, Lo YMD. Noninvasive Prenatal Screening for Genetic Diseases Using Massively Parallel Sequencing of Maternal Plasma DNA. Cold Spring Harb Perspect Med 2015; 5:a023085. [PMID: 26187875 PMCID: PMC4561399 DOI: 10.1101/cshperspect.a023085] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The identification of cell-free fetal DNA (cffDNA) in maternal plasma in 1997 heralded the most significant change in obstetric care for decades, with the advent of safer screening and diagnosis based on analysis of maternal blood. Here, we describe how the technological advances offered by next-generation sequencing have allowed for the development of a highly sensitive screening test for aneuploidies as well as definitive prenatal molecular diagnosis for some monogenic disorders.
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Affiliation(s)
- Lyn S Chitty
- UCL Institute of Child Health, Genetics and Genomic Medicine, London WC1N 1EH, United Kingdom; University College London Hospitals NHS Foundation Trust, London NW1 2PG, United Kingdom; NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, 37 Queen Square, London WC1N 3BH, United Kingdom
| | - Y M Dennis Lo
- Centre for Research into Circulating Fetal Nucleic Acids, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China; Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, China
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20
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Everett TR, Chitty LS. Cell-free fetal DNA: the new tool in fetal medicine. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:499-507. [PMID: 25483938 PMCID: PMC5029578 DOI: 10.1002/uog.14746] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 10/31/2014] [Accepted: 11/25/2014] [Indexed: 06/04/2023]
Affiliation(s)
- T R Everett
- Fetal Medicine Unit, University College London Hospital NHS Foundation Trust, London, UK
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21
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Khalil A, Mahmoodian N, Kulkarni A, Homfray T, Papageorghiou A, Bhide A, Thilaganathan B. Estimation of Detection Rates of Aneuploidy in High-Risk Pregnancy Using an Approach Based on Nuchal Translucency and Non-Invasive Prenatal Testing: A Cohort Study. Fetal Diagn Ther 2015; 38:254-61. [PMID: 25925597 DOI: 10.1159/000381182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 02/19/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim was to investigate aneuploidy detection using an approach based on nuchal translucency (NT) and non-invasive prenatal testing (NIPT). METHODS This was a cohort study including 5,306 high-risk pregnancies with NT measurements and chorionic villus samples (CVS) tested for full karyotype. RESULTS The fetal karyotype was normal in 4,172 (78.6%) cases and abnormal in 1,134 (21.4%), including 1,009 with a likely clinically significant adverse outcome. Universal CVS with full karyotyping would lead to the diagnosis of all clinically significant abnormalities. A policy of relying solely on NIPT would have led to the diagnosis of 88.9% of clinically significant abnormalities. A strategy whereby NIPT is the main method, with CVS reserved for cases with NT ≥3.0 mm, would require CVS in 21.7% of cases, identify 94.8% of significant abnormalities and avoid miscarriage in 41 pregnancies compared to CVS for all. CONCLUSIONS A policy of NIPT for increased-risk cases and CVS with full karyotype if the NT was ≥3.0 mm reduced the risk of miscarriage yet still identified 95% of clinically significant aneuploidy.
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Affiliation(s)
- Asma Khalil
- Fetal Medicine Unit, Academic Department of Obstetrics and Gynaecology, St George's University of London, London, UK
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22
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Lichtenbelt KD, Diemel BDM, Koster MPH, Manten GTR, Siljee J, Schuring-Blom GH, Page-Christiaens GCML. Detection of fetal chromosomal anomalies: does nuchal translucency measurement have added value in the era of non-invasive prenatal testing? Prenat Diagn 2015; 35:663-8. [DOI: 10.1002/pd.4589] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 02/02/2015] [Accepted: 02/28/2015] [Indexed: 12/12/2022]
Affiliation(s)
- K. D. Lichtenbelt
- Department of Medical Genetics; University Medical Center Utrecht; Utrecht The Netherlands
| | - B. D. M. Diemel
- Department of Obstetrics; University Medical Center Utrecht; Utrecht The Netherlands
| | - M. P. H. Koster
- Department of Obstetrics; University Medical Center Utrecht; Utrecht The Netherlands
| | - G. T. R. Manten
- Department of Obstetrics; University Medical Center Utrecht; Utrecht The Netherlands
| | - J. Siljee
- Department of Infectious Disease Research; Diagnostics and Screening, National Institute for Public Health and the Environment; Bilthoven The Netherlands
| | - G. H. Schuring-Blom
- Department of Medical Genetics; University Medical Center Utrecht; Utrecht The Netherlands
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23
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Fisher J, Lafarge C. Women’s experience of care when undergoing termination of pregnancy for fetal anomaly in England. J Reprod Infant Psychol 2014. [DOI: 10.1080/02646838.2014.970149] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Vanstone M, King C, de Vrijer B, Nisker J. Non-invasive prenatal testing: ethics and policy considerations. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:515-526. [PMID: 24927192 DOI: 10.1016/s1701-2163(15)30568-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
New technologies analyzing fetal DNA in maternal blood have led to the wide commercial availability of non-invasive prenatal testing (NIPT). We present here for clinicians the ethical and policy issues related to an emerging practice option. Although NIPT presents opportunities for pregnant women, particularly women who are at increased risk of having a baby with an abnormality or who are otherwise likely to access invasive prenatal testing, NIPT brings significant ethics and policy challenges. The ethical issues include multiple aspects of informed decision-making, such as access to counselling about the possible results of the test in advance of making a decision about participation in NIPT. Policy considerations include issues related to offering and promoting a privately available medical strategy in publicly funded institutions. Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities.
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Affiliation(s)
- Meredith Vanstone
- Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton ON
| | - Carol King
- Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London ON
| | - Barbra de Vrijer
- Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London ON
| | - Jeff Nisker
- Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London ON; Children's Health Research Institute, London ON
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25
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Non-invasive prenatal testing: UK genetic counselors' experiences and perspectives. J Genet Couns 2014; 24:300-11. [PMID: 25315608 DOI: 10.1007/s10897-014-9765-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 08/25/2014] [Indexed: 12/12/2022]
Abstract
To date, NIPT in the UK has been predominately used in the health service for early sexing of pregnancies at known risk of sex-linked conditions. Developments in the technology are broadening its use to diagnostic testing for paternally inherited genetic conditions and for detection of aneuploidy. This study aimed to examine the experiences of UK genetic counselors with offering NIPT for sexing, and to explore their views on future uses of the technology. Twenty interviews with practicing GC's from four centres were audiotaped, transcribed, and analyzed using modified grounded theory. Participants all had experience of counseling patients around prenatal diagnosis and 18/20 had experience of offering NIPT. GCs reported initially feeling cautious about offering the test, although they saw it as a positive advance for their patients at genetic risk. Emphasis was placed on accuracy, adequate counseling provision and gatekeeping with concerns expressed about broadening its use in the routine antenatal setting. Findings indicate the genetics model for offering prenatal testing to high risk patients can incorporate NIPT and the profession may have a role in informing its implementation in wider healthcare settings. In a wider context this study highlights the challenges new technologies bring to genetic counselors' practice and service structure.
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26
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Bromley B, Shipp TD, Lyons J, Navathe RS, Groszmann Y, Benacerraf BR. Detection of fetal structural anomalies in a basic first-trimester screening program for aneuploidy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1737-1745. [PMID: 25253819 DOI: 10.7863/ultra.33.10.1737] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether first-trimester aneuploidy screening sonography initially performed by credentialed sonographers was useful for detecting fetal anomalies between 11 and 14 weeks' gestation. METHODS We conducted a retrospective cohort study of consecutive patients referred to a private ultrasound facility between January 1, 2008, and June 30, 2012, for measurement of the nuchal translucency (NT) and crown-rump length as part of a screening protocol for aneuploidy. Patients were included if there was at least 1 live fetus with a crown-rump length between 34 and 84 mm. No specific anatomic imaging protocol was followed. The presence of anomalies was based on the sonographic report and review of the medical record. The absence of anomalies was based on the report from the anatomic survey. Anomalies were categorized as lethal, major, and minor. The anomaly category and gestational age at diagnosis (≤14 versus >14 weeks) were compared. RESULTS An NT scan was performed on 9692 fetuses. Anatomic surveys were done on 9077 (93.7%) of these fetuses at a mean of 18 weeks' gestation. Anomalies were detected in 180 fetuses (1.8%): 50 (0.5%) at the NT scan and 130 (1.3%) at the anatomic scan. Overall, 46 of 111 fetuses (41.4%) with major or lethal anomalies were detected at the NT scan. Two suspected abnormalities at the NT scan were not present at the anatomic scan. CONCLUSIONS First-trimester aneuploidy screening sonography initially performed by credentialed sonographers can identify a substantial proportion of major and lethal anomalies.
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Affiliation(s)
- Bryann Bromley
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.).
| | - Thomas D Shipp
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.)
| | - Jennifer Lyons
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.)
| | - Reshama S Navathe
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.)
| | - Yvette Groszmann
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.)
| | - Beryl R Benacerraf
- Diagnostic Ultrasound Associates, PC, Boston, Massachusetts USA (B.B., T.D.S., Y.G., B.R.B.); Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts USA (B.B., B.R.B.); Departments of Obstetrics and Gynecology (B.B., T.D.S., S.N., Y.G., B.R.B.) and Radiology (B.B., T.D.S., B.R.B.), Brigham and Women's Hospital, Boston, Massachusetts USA; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts USA (J.L.); and Harvard Vanguard Medical Associates, Boston, Massachusetts USA (R.S.N.)
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Abstract
Non-invasive prenatal diagnosis and testing by analysis of cell-free DNA in the maternal circulation is a rapidly evolving field. Current clinical applications include fetal sex determination, fetal rhesus D determination, the diagnosis of some single gene disorders, and a highly accurate screening test for aneuploidies. In the future it is likely to be used for the diagnosis of an increasing range of monogenic disorders, and may even be used to profile entire fetal genomes. The introduction of these tests into clinical practice brings clear benefits but also poses several ethical, social and service delivery challenges. Here, we discuss the current clinical applications, discuss some of the technical and ethical challenges, and look to what the future might bring as technology continues to evolve.
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Affiliation(s)
- Rebecca Daley
- North-East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Fetal Medicine Unit, University College London Hospital NHS Foundation Trust, London, UK
| | - Melissa Hill
- North-East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lyn S Chitty
- North-East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK Department of Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
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28
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Spencer K. Screening for Down syndrome. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 244:41-7. [DOI: 10.3109/00365513.2014.936680] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jafri H, Hewison J, Sheridan E, Ahmed S. Acceptability of prenatal testing and termination of pregnancy in Pakistan. J Community Genet 2014; 6:29-37. [PMID: 25081227 DOI: 10.1007/s12687-014-0198-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 07/21/2014] [Indexed: 02/06/2023] Open
Abstract
This study aimed to assess acceptability of prenatal testing (PNT) and termination of pregnancy (TOP) for a range of conditions in Pakistani parents with and without a child with a genetic condition. A structured questionnaire assessing acceptability of PNT and TOP for 30 conditions was completed by 400 Pakistani participants: 200 parents with a child with a genetic condition (100 fathers and 100 mothers) and 200 parents without an affected child (100 fathers and 100 mothers). There was a high level of interest in PNT, where over 80 % of parents in all four study groups would want PNT for the majority of the conditions. There was comparatively less interest in TOP for the same conditions (ranging from 5 to 70 % of parents, with mothers of an affected child being most interested). Parents were most likely to be interested in TOP for conditions at the serious end of the continuum. More than half of the participants in each group would consider TOP for anencephaly and quadriplegia. The interest in PNT and TOP for a range of conditions suggests that rapidly developing PNT technologies are likely to be acceptable in Pakistan, a low-middle income level and Muslim country. The comparatively lower level of interest in TOP for the same conditions highlights ethical dilemmas that such technologies are likely to raise.
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Affiliation(s)
- H Jafri
- Genetech Laboratory, 146/1 Shadman Jail Road, Lahore, Pakistan
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Fisher J, Lohr PA, Lafarge C, Robson SC. Termination for fetal anomaly: Are women in England given a choice of method? J OBSTET GYNAECOL 2014; 35:168-72. [DOI: 10.3109/01443615.2014.940291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hill M, Wright D, Daley R, Lewis C, McKay F, Mason S, Lench N, Howarth A, Boustred C, Lo K, Plagnol V, Spencer K, Fisher J, Kroese M, Morris S, Chitty LS. Evaluation of non-invasive prenatal testing (NIPT) for aneuploidy in an NHS setting: a reliable accurate prenatal non-invasive diagnosis (RAPID) protocol. BMC Pregnancy Childbirth 2014; 14:229. [PMID: 25027965 PMCID: PMC4226037 DOI: 10.1186/1471-2393-14-229] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 07/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) for aneuploidies is now available through commercial companies in many countries, including through private practice in the United Kingdom (UK). Thorough evaluation of service delivery requirements are needed to facilitate NIPT being offered more widely within state funded healthcare systems such as the UK's National Health Service (NHS). Successful implementation will require the development of laboratory standards, consideration of stakeholder views, an analysis of costs and development of patient and health professional educational materials. METHODS/DESIGN NIPT will be offered in an NHS setting as a contingent screening test. Pregnant woman will be recruited through six maternity units in England and Scotland. Women eligible for Down's syndrome screening (DSS) will be informed about the study at the time of booking. Women that choose routine DSS will be offered NIPT if they have a screening risk ≥ 1:1000. NIPT results for trisomy 21, 18, 13 will be reported within 7-10 working days. Data on DSS, NIPT and invasive testing uptake, pregnancy outcomes and test efficacy will be collected. Additional data will be gathered though questionnaires to a) determine acceptability to patients and health professionals, b) evaluate patient and health professional education, c) assess informed choice in women accepting or declining testing and d) gauge family expenses. Qualitative interviews will also be conducted with a sub-set of participating women and health professionals. DISCUSSION The results of this study will make a significant contribution to policy decisions around the implementation of NIPT for aneuploidies within the UK NHS. The laboratory standards for testing and reporting, education materials and counselling strategies developed as part of the study are likely to underpin the introduction of NIPT into NHS practice. NIHR PORTFOLIO NUMBER 13865.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Lyn S Chitty
- North East Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, Level 5, York House, 37 Queen Square, London WC1N 3BH, UK.
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Karampetsou E, Morrogh D, Chitty L. Microarray Technology for the Diagnosis of Fetal Chromosomal Aberrations: Which Platform Should We Use? J Clin Med 2014; 3:663-78. [PMID: 26237396 PMCID: PMC4449692 DOI: 10.3390/jcm3020663] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/28/2014] [Accepted: 04/01/2014] [Indexed: 12/02/2022] Open
Abstract
The advantage of microarray (array) over conventional karyotype for the diagnosis of fetal pathogenic chromosomal anomalies has prompted the use of microarrays in prenatal diagnostics. In this review we compare the performance of different array platforms (BAC, oligonucleotide CGH, SNP) and designs (targeted, whole genome, whole genome, and targeted, custom) and discuss their advantages and disadvantages in relation to prenatal testing. We also discuss the factors to consider when implementing a microarray testing service for the diagnosis of fetal chromosomal aberrations.
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Affiliation(s)
- Evangelia Karampetsou
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, 37 Queen Square, London WC1N 3BH, UK.
| | - Deborah Morrogh
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, 37 Queen Square, London WC1N 3BH, UK.
| | - Lyn Chitty
- UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
- University College Hospital NHS Foundation Trust, London NW1 2PG, UK.
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
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Morris S, Karlsen S, Chung N, Hill M, Chitty LS. Model-based analysis of costs and outcomes of non-invasive prenatal testing for Down's syndrome using cell free fetal DNA in the UK National Health Service. PLoS One 2014; 9:e93559. [PMID: 24714162 PMCID: PMC3979704 DOI: 10.1371/journal.pone.0093559] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 03/06/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) for Down's syndrome (DS) using cell free fetal DNA in maternal blood has the potential to dramatically alter the way prenatal screening and diagnosis is delivered. Before NIPT can be implemented into routine practice, information is required on its costs and benefits. We investigated the costs and outcomes of NIPT for DS as contingent testing and as first-line testing compared with the current DS screening programme in the UK National Health Service. METHODS We used a pre-existing model to evaluate the costs and outcomes associated with NIPT compared with the current DS screening programme. The analysis was based on a hypothetical screening population of 10,000 pregnant women. Model inputs were taken from published sources. The main outcome measures were number of DS cases detected, number of procedure-related miscarriages and total cost. RESULTS At a screening risk cut-off of 1∶150 NIPT as contingent testing detects slightly fewer DS cases, has fewer procedure-related miscarriages, and costs the same as current DS screening (around UK£280,000) at a cost of £500 per NIPT. As first-line testing NIPT detects more DS cases, has fewer procedure-related miscarriages, and is more expensive than current screening at a cost of £50 per NIPT. When NIPT uptake increases, NIPT detects more DS cases with a small increase in procedure-related miscarriages and costs. CONCLUSIONS NIPT is currently available in the private sector in the UK at a price of £400-£900. If the NHS cost was at the lower end of this range then at a screening risk cut-off of 1∶150 NIPT as contingent testing would be cost neutral or cost saving compared with current DS screening. As first-line testing NIPT is likely to produce more favourable outcomes but at greater cost. Further research is needed to evaluate NIPT under real world conditions.
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Affiliation(s)
- Stephen Morris
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Saffron Karlsen
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Nancy Chung
- NHS Fetal Anomaly Screening Programme, University of Exeter, Exeter, United Kingdom
| | - Melissa Hill
- Clinical and Molecular Genetics Unit, UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Lyn S. Chitty
- Clinical and Molecular Genetics Unit, UCL Institute of Child Health and Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Beyond Trisomy 21: Additional Chromosomal Anomalies Detected through Routine Aneuploidy Screening. J Clin Med 2014; 3:388-415. [PMID: 26237381 PMCID: PMC4449689 DOI: 10.3390/jcm3020388] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 02/06/2014] [Accepted: 02/18/2014] [Indexed: 01/28/2023] Open
Abstract
Prenatal screening is often misconstrued by patients as screening for trisomy 21 alone; however, other chromosomal anomalies are often detected. This study aimed to systematically review the literature and use diagnostic meta-analysis to derive pooled detection and false positive rates for aneuploidies other than trisomy 21 with different prenatal screening tests. Non-invasive prenatal testing had the highest detection (DR) and lowest false positive (FPR) rates for trisomy 13 (DR: 90.3%; FPR: 0.2%), trisomy 18 (DR: 98.1%; FPR: 0.2%), and 45,X (DR: 92.2%; FPR: 0.1%); however, most estimates came from high-risk samples. The first trimester combined test also had high DRs for all conditions studied (trisomy 13 DR: 83.1%; FPR: 4.4%; trisomy 18 DR: 91.9%; FPR: 3.5%; 45,X DR: 70.1%; FPR: 5.4%; triploidy DR: 100%; FPR: 6.3%). Second trimester triple screening had the lowest DRs and highest FPRs for all conditions (trisomy 13 DR: 43.9%; FPR: 8.1%; trisomy 18 DR: 70.5%; FPR: 3.3%; 45,X DR: 77.2%; FPR: 9.3%). Prenatal screening tests differ in their ability to accurately detect chromosomal anomalies. Patients should be counseled about the ability of prenatal screening to detect anomalies other than trisomy 21 prior to undergoing screening.
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Benachi A, Costa JM. [Non-invasive genetic tests for fetal trisomy 21 detection: current considerations]. ACTA ACUST UNITED AC 2014; 43:195-7. [PMID: 24529921 DOI: 10.1016/j.jgyn.2013.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Alexandra Benachi
- Service de gynécologie obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart, France; Université Paris Sud, 92140 Clamart, France.
| | - Jean-Marc Costa
- Laboratoire Cerba, rue de l'Équerre, 95130 Saint-Ouen l'Aumône, France
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Twiss P, Hill M, Daley R, Chitty LS. Non-invasive prenatal testing for Down syndrome. Semin Fetal Neonatal Med 2014; 19:9-14. [PMID: 24210903 DOI: 10.1016/j.siny.2013.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Prenatal screening and diagnosis of Down syndrome and other major aneuploidies may be transformed following the identification of cell-free fetal DNA in maternal plasma at the end of the last millennium. Next generation sequencing has enabled the development of tests that accurately predict the presence of fetal trisomies by analysis of cell-free DNA in maternal blood from as early as 10 weeks of gestation. These tests are now widely available in the commercial sector but are yet to be implemented in publicly led health services. In this article we discuss the technical, social, and ethical challenges that these new tests bring.
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Affiliation(s)
- Philip Twiss
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, 37 Queen Square, London WC1N 3BH, UK
| | - Melissa Hill
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, 37 Queen Square, London WC1N 3BH, UK
| | - Rebecca Daley
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, 37 Queen Square, London WC1N 3BH, UK
| | - Lyn S Chitty
- NE Thames Regional Genetics Service, Great Ormond Street Hospital for Children NHS Foundation Trust, 37 Queen Square, London WC1N 3BH, UK; UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
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Okun N, Teitelbaum M, Huang T, Dewa CS, Hoch JS. The price of performance: a cost and performance analysis of the implementation of cell-free fetal DNA testing for Down syndrome in Ontario, Canada. Prenat Diagn 2014; 34:350-6. [PMID: 24395030 DOI: 10.1002/pd.4311] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/13/2013] [Accepted: 12/19/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To examine the cost and performance implications of introducing cell-free fetal DNA (cffDNA) testing within modeled scenarios in a publicly funded Canadian provincial Down syndrome (DS) prenatal screening program. METHOD Two clinical algorithms were created: the first to represent the current screening program and the second to represent one that incorporates cffDNA testing. From these algorithms, eight distinct scenarios were modeled to examine: (1) the current program (no cffDNA), (2) the current program with first trimester screening (FTS) as the nuchal translucency-based primary screen (no cffDNA), (3) a program substituting current screening with primary cffDNA, (4) contingent cffDNA with current FTS performance, (5) contingent cffDNA at a fixed price to result in overall cost neutrality,(6) contingent cffDNA with an improved detection rate (DR) of FTS, (7) contingent cffDNA with higher uptake of FTS, and (8) contingent cffDNA with optimized FTS (higher uptake and improved DR). RESULTS This modeling study demonstrates that introducing contingent cffDNA testing improves performance by increasing the number of cases of DS detected prenatally, and reducing the number of amniocenteses performed and concomitant iatrogenic pregnancy loss of pregnancies not affected by DS. Costs are modestly increased, although the cost per case of DS detected is decreased with contingent cffDNA testing. CONCLUSION Contingent models of cffDNA testing can improve overall screening performance while maintaining the provision of an 11- to 13-week scan. Costs are modestly increased, but cost per prenatally detected case of DS is decreased.
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Affiliation(s)
- N Okun
- Maternal Fetal Medicine Program, Mt. Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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38
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Lewis C, Hill M, Silcock C, Daley R, Chitty LS. Non-invasive prenatal testing for trisomy 21: a cross-sectional survey of service users' views and likely uptake. BJOG 2014; 121:582-94. [PMID: 24433394 DOI: 10.1111/1471-0528.12579] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the views and likely uptake of non-invasive prenatal testing (NIPT) for trisomy 21 among potential service users in the UK. DESIGN Cross-sectional survey. SETTING Four antenatal clinics in England and two websites. SAMPLE A total of 1131 women and partners. METHODS Questionnaire conducted with women (and partners) recruited through antenatal clinics, a random sample of members of the website Mumsnet, and viewers of the website and Facebook page of the support group Antenatal Results and Choices (ARC). MAIN OUTCOME MEASURES Factors impacting decision-making towards prenatal testing; views on NIPT, including service delivery and likely uptake; hypothetical scenarios, focused on current screening, invasive testing, and NIPT offered to women with a high-risk screening result. RESULTS The vast majority (95.7%; 1071/1119; 95% CI 94.4-96.8%) thought NIPT was a positive development in prenatal care, with 88.2% (972/1103; 95% CI 86.1-90%) indicating that they would use the test, including respondents who would currently decline trisomy 21 screening (P < 0.001). Of the respondents who would have NIPT, 30.7% (299/973; 95% CI = 27.8-33.7%) said that they were 'likely' to terminate an affected pregnancy (including those who would currently decline screening or invasive testing), and 36.5% (355/973; 95% CI 33.5-39.6%) were 'not likely' to terminate an affected pregnancy. Respondents overwhelmingly indicated that safety for the baby was the most important attribute of NIPT (70.1%; 712/1015; 95% CI 67.2-73%). CONCLUSION Respondents were overwhelmingly positive towards the introduction of NIPT. Uptake is likely to be high, and includes women who currently decline screening as well as those who will use the test for information only. Pre-test counselling to ensure that women understand the implications of the test result is essential.
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Affiliation(s)
- C Lewis
- Genetic Alliance UK, London, UK
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39
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Barrett AN, Chitty LS. Developing noninvasive diagnosis for single-gene disorders: the role of digital PCR. Methods Mol Biol 2014; 1160:215-228. [PMID: 24740232 DOI: 10.1007/978-1-4939-0733-5_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Cell-free fetal DNA constitutes approximately 10 % of the cell-free DNA found in maternal plasma and can be used as a reliable source of fetal genetic material for noninvasive prenatal diagnosis (NIPD) from early pregnancy. The relatively high levels of maternal background can make detection of paternally inherited point mutations challenging. Diagnosis of inheritance of autosomal recessive disorders using qPCR is even more challenging due to the high background of mutant maternal allele. Digital PCR is a very sensitive modified method of quantitative real-time PCR (qPCR), allowing absolute quantitation and rare allele detection without the need for standards or normalization. Samples are diluted and then partitioned into a large number of small qPCR reactions, some of which contain the target molecule and some which do not; the proportion of positive reactions can be used to calculate the concentration of targets in the initial sample. Here we discuss the use of digital PCR as an accurate approach to NIPD for single-gene disorders.
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Affiliation(s)
- Angela N Barrett
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore,
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40
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Bryant L. Non-invasive prenatal testing for Down’s syndrome: psychologically speaking, what else do we need to know? J Reprod Infant Psychol 2014. [DOI: 10.1080/02646838.2014.874115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Chan YM, Leung TY, Chan OKC, Cheng YKY, Sahota DS. Patient's Choice between a Non-Invasive Prenatal Test and Invasive Prenatal Diagnosis Based on Test Accuracy. Fetal Diagn Ther 2013; 35:193-8. [DOI: 10.1159/000356075] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 10/01/2013] [Indexed: 11/19/2022]
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Lewis C, Silcock C, Chitty LS. Non-invasive prenatal testing for Down's syndrome: pregnant women's views and likely uptake. Public Health Genomics 2013; 16:223-32. [PMID: 23886854 DOI: 10.1159/000353523] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/07/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The introduction of non-invasive prenatal testing (NIPT) for Down's syndrome into routine state-funded antenatal care in the UK is approaching. METHODS We conducted qualitative one-to-one interviews with 40 pregnant women to ascertain their views on using NIPT for Down's syndrome. RESULTS The overwhelming majority of women viewed NIPT as a positive advancement in prenatal care, highlighting numerous practical and psychological advantages of a safe test that was highly accurate and could be conducted early in pregnancy. Concerns raised were that testing could become routinised, and that pressure to test might occur with women feeling less justified in declining a blood test that is available and offered by trusted health professionals; the impact on the disabled community and stigma for women who decline testing was also noted. Nevertheless, the vast majority of women said they would be likely to use NIPT, including half of the women who currently decline screening. Women's preference was for pre- and post-test counselling to be delivered by a midwife. CONCLUSION The successful introduction of NIPT into routine prenatal care will require guidelines and counselling strategies which ensure women are offered this test in a way which safeguards informed consent.
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Affiliation(s)
- C Lewis
- Genetic Alliance UK, London, UK
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43
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Lo YMD. Non-invasive prenatal diagnosis by massively parallel sequencing of maternal plasma DNA. Open Biol 2013; 2:120086. [PMID: 22773950 PMCID: PMC3390796 DOI: 10.1098/rsob.120086] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 05/14/2012] [Indexed: 12/11/2022] Open
Abstract
The presence of foetal DNA in the plasma of pregnant women has opened up new possibilities for non-invasive prenatal diagnosis. The use of circulating foetal DNA for the non-invasive prenatal detection of foetal chromosomal aneuploidies is challenging as foetal DNA represents a minor fraction of maternal plasma DNA. In 2007, it was shown that single molecule counting methods would allow the detection of the presence of a trisomic foetus, as long as enough molecules were counted. With the advent of massively parallel sequencing, millions or billions of DNA molecules can be readily counted. Using massively parallel sequencing, foetal trisomies 21, 13 and 18 have been detected from maternal plasma. Recently, large-scale clinical studies have validated the robustness of this approach for the prenatal detection of foetal chromosomal aneuploidies. A proof-of-concept study has also shown that a genome-wide genetic and mutational map of a foetus can be constructed from the maternal plasma DNA sequencing data. These developments suggest that the analysis of foetal DNA in maternal plasma would play an increasingly important role in future obstetrics practice. It is thus a priority that the ethical, social and legal issues regarding this technology be systematically studied.
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Affiliation(s)
- Yuk Ming Dennis Lo
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, People's Republic of China.
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Sillence KA, Madgett TE, Roberts LA, Overton TG, Avent ND. Non-Invasive Screening Tools for Down's Syndrome: A Review. Diagnostics (Basel) 2013; 3:291-314. [PMID: 26835682 PMCID: PMC4665531 DOI: 10.3390/diagnostics3020291] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/14/2013] [Accepted: 05/16/2013] [Indexed: 01/16/2023] Open
Abstract
Down's syndrome (DS) is the most common genetic cause of developmental delay with an incidence of 1 in 800 live births, and is the predominant reason why women choose to undergo invasive prenatal diagnosis. However, as invasive tests are associated with around a 1% risk of miscarriage new non-invasive tests have been long sought after. Recently, the most promising approach for non-invasive prenatal diagnosis (NIPD) has been provided by the introduction of next generation sequencing (NGS) technologies. The clinical application of NIPD for DS detection is not yet applicable, as large scale validation studies in low-risk pregnancies need to be completed. Currently, prenatal screening is still the first line test for the detection of fetal aneuploidy. Screening cannot diagnose DS, but developing a more advanced screening program can help to improve detection rates, and therefore reduce the number of women offered invasive tests. This article describes how the prenatal screening program has developed since the introduction of maternal age as the original "screening" test, and subsequently discusses recent advances in detecting new screening markers with reference to both proteomic and bioinformatic techniques.
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Affiliation(s)
- Kelly A Sillence
- School of Biomedical and Biological Sciences, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth University, Plymouth, PL4 8AA, UK.
| | - Tracey E Madgett
- School of Biomedical and Biological Sciences, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth University, Plymouth, PL4 8AA, UK.
| | - Llinos A Roberts
- School of Biomedical and Biological Sciences, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth University, Plymouth, PL4 8AA, UK.
| | - Timothy G Overton
- Department of Obstetrics, St Michael's Hospital, Southwell Street, Bristol, BS2 8EG, UK.
| | - Neil D Avent
- School of Biomedical and Biological Sciences, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth University, Plymouth, PL4 8AA, UK.
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Boon EMJ, Faas BHW. Benefits and limitations of whole genome versus targeted approaches for noninvasive prenatal testing for fetal aneuploidies. Prenat Diagn 2013; 33:563-8. [DOI: 10.1002/pd.4111] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Elles M. J. Boon
- Department of Clinical Genetics, Laboratory for Diagnostic Genome Analysis; Leiden University Medical Center; Leiden The Netherlands
| | - Brigitte H. W. Faas
- Department of Human Genetics; Radboud University Medical Center; Nijmegen The Netherlands
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46
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Wang E, Batey A, Struble C, Musci T, Song K, Oliphant A. Gestational age and maternal weight effects on fetal cell-free DNA in maternal plasma. Prenat Diagn 2013; 33:662-6. [PMID: 23553731 DOI: 10.1002/pd.4119] [Citation(s) in RCA: 282] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/21/2013] [Accepted: 03/24/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the effects of gestational age and maternal weight on percent fetal cell-free DNA (cfDNA) in maternal plasma and the change in fetal cfDNA amounts within the same patient over time. METHODS The cfDNA was extracted from maternal plasma from 22 384 singleton pregnancies of at least 10 weeks gestation undergoing the Harmony(TM) Prenatal Test. The Harmony Prenatal Test determined fetal percentage via directed analysis of cfDNA. RESULTS At 10 weeks 0 days to 10 weeks 6 days gestation, the median percent fetal cfDNA was 10.2%. Between 10 and 21 weeks gestation, percent fetal increased 0.1% per week (p < 0.0001), and 2% of pregnancies were below 4% fetal cfDNA. Beyond 21 weeks gestation, fetal cfDNA increased 1% per week (p < 0.0001). Fetal cfDNA percentage was proportional to gestational age and inversely proportional to maternal weight (p = 0.0016). Of 135 samples that were redrawn because of insufficient fetal cfDNA of the initial sample, 76 (56%) had greater than 4% fetal cfDNA in the sample from the second draw. CONCLUSION Fetal cfDNA increases with gestation, decreases with increasing maternal weight, and generally improves upon a blood redraw when the first attempt has insufficient fetal cfDNA.
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Affiliation(s)
- Eric Wang
- Ariosa Diagnostics, San Jose, CA, USA.
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47
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Yeo GSH, Choi C. Comment on authors' reply: Patients' perception of risk: informed choice in prenatal testing for foetal aneuploidy. Singapore Med J 2013; 54:237-8. [PMID: 23624456 DOI: 10.11622/smedj.2013083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Dey M, Sharma S, Aggarwal S. Prenatal screening methods for aneuploidies. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:182-90. [PMID: 23626953 PMCID: PMC3632021 DOI: 10.4103/1947-2714.109180] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aneuploidies are a major cause of perinatal morbidity and mortality. Therefore, it is the most common indication for invasive prenatal diagnosis. Initially, screening for aneuploidies started with maternal age risk estimation. Later on, serum testing for biochemical markers and ultrasound markers were added. Women detected to be at high-risk for aneuploidies were offered invasive testing. New research is now focusing on non-invasive prenatal testing using cell-free fetal DNA in maternal circulation. The advantage of this technique is the ability to reduce the risk of miscarriage associated with invasive diagnostic procedures. However, this new technique has its own set of technical limitations and ethical issues at present and careful consideration is required before broad implementation.
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Affiliation(s)
- Madhusudan Dey
- Department of Obstetrics and Gynaecology, Armed Forces Medical College (AFMC), Pune, India
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Skirton H, Patch C. Factors affecting the clinical use of non-invasive prenatal testing: a mixed methods systematic review. Prenat Diagn 2013; 33:532-41. [DOI: 10.1002/pd.4094] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Heather Skirton
- Faculty of Health, Education and Society; Plymouth University; Plymouth UK
| | - Christine Patch
- Guys & St Thomas' NHS Foundation Trust London; London UK
- Kings College London; London UK
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Salomon LJ. [Diagnosis of trisomy 21: a simple blood test?]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2013; 41:77-79. [PMID: 23375986 DOI: 10.1016/j.gyobfe.2012.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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