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Murphy C, Sturm S, McKenna MJ, Ormond KE. The right not to know: Non-disclosure of primary genetic test results and genetic counselors' response. J Genet Couns 2024; 33:875-887. [PMID: 37750464 DOI: 10.1002/jgc4.1797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023]
Abstract
As part of clinical genetic counseling practice, patients may request that their primary genetic test results be disclosed to someone else, such as a relative or referring provider, or request that results be disclosed to no one (non-disclosure). In making these requests, patients employ the ethical principle of the "right not to know," which argues that autonomous individuals can choose not to know relevant health information. Although the right not to know has been well-studied in medicine in general, and in the return of genomic secondary findings, we are not aware of other studies that have explored the return of primary genetic test results when patients request non-disclosure or disclosure to another individual. This study aimed to describe common clinical scenarios in which these requests occur, how genetic counselors respond, and what ethical considerations they employ in their decision-making process. We recruited participants from the National Society of Genetic Counselors' (NSGC) "Student Research Surveys and Reminders" listserv and conducted semi-structured interviews with 11 genetic counselors in the United States who described genetic counseling cases where this occurred. Interviews were transcribed and coded inductively, and themes were identified. Case details varied, but in our study data the requests for non-disclosure were most commonly made by patients with poor, often oncologic, prognoses who requested their test results be disclosed to a family member instead of themselves. Genetic counselors considered similar factors in deciding how to respond to these requests: patient autonomy, medical actionability of results for the patient and family, the relationship between the patient and the person to whom results might be disclosed, and legal or practical concerns. Genetic counselors often made decisions on a case-by-case basis, depending on how relevant each of these factors were. This study adds to the growing body of literature regarding patients' "right not to know" and will hopefully provide guidance for genetic counselors who experience this situation in clinical practice.
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Affiliation(s)
- Claire Murphy
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah Sturm
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
| | - Meghan Juliana McKenna
- Cancer Genetics and Genomics Department, Stanford Health Care, Stanford, California, USA
| | - Kelly E Ormond
- Department of Genetics, Stanford University School of Medicine, Stanford, California, USA
- Stanford Center for Biomedical Ethics, Stanford School of Medicine, Stanford, California, USA
- Health Ethics and Policy Lab, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH)-Zurich, Zurich, Switzerland
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Abstract
Among healthy volunteers in psychiatric brain functional magnetic resonance imaging (fMRI) research studies, the prevalence of incidentalomas can be as high as 34%, of which 10% show clinical significance. An incidentaloma is a lesion found by coincidence without clinical symptoms or suspicion. Like lesions and other types of accidental findings, it is found in healthy individuals recruited to take part in psychiatric studies. The prevalence of these accidental findings among specific psychiatric populations remains unknown. However, a precise understanding of cerebral neuroanatomy, neuroradiological expertise, and an appropriate choice of fMRI exploration sequences will increase the sensitivity of identifying these accidental findings and enable researchers to address their clinical relevance and nature. We present recommendations on how to appropriately inform patients or participants of the accidental findings. Additionally, we propose specific suggestions pertaining to the clinical research setting aimed for investigators and psychiatrists. Unlike current articles pertaining to incidentaloma, the current report provides a distinct focus on psychiatric issues and specific recommendations for studies involving psychiatric patients.
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Feinstein MA, Sharp RR, Sandness DJ, Feemster JC, Junna M, Kotagal S, Lipford MC, Tippmann-Peikert M, Boeve BF, Silber MH, St Louis EK. Physician and patient determinants of prognostic counseling in idiopathic REM sleep-behavior disorder. Sleep Med 2019; 62:80-85. [PMID: 31581066 DOI: 10.1016/j.sleep.2019.03.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES/BACKGROUND Prognostic counseling about the risk for developing overt neurodegenerative disorders for patients with idiopathic REM sleep-behavior disorder (iRBD) and isolated REM sleep without atonia (iRSWA) is difficult, given lack of disease-modifying interventions and uncertainty in accurate prognostication for individuals. We aimed to analyze patient and physician characteristics associated with documented prognostic discussions for patients with iRBD and iRSWA. PATIENTS/METHODS We retrospectively reviewed the medical records for 138 (112 iRBD and 26 iRSWA) patients seen at the Mayo Clinic between 2012 and 2015. We analyzed physician and patient demographics, initial complaint, and other information discussed during office visits. We then comparatively analyzed the impact of physician and patient characteristics on documented prognostic discussions using Chi Square or Fischer's exact test. RESULTS Mean iRBD patient age was 65.0 ± 13.0, and mean iRSWA age was 58 ± 15 years. Seventy-eight (69.6%) iRBD and 22 (84.6%) iRSWA patients were men. Sixty-two (55%) iRBD and three (12%) iRSWA patients received prognostic counseling about phenoconversion risk. iRBD was a secondary complaint in 67 (59.8%). Patients over age 60 years and those having iRBD as a chief complaint more frequently received prognostic discussions than those with opposite characteristics (all p < 0.05). Patient sex and antidepressant use were not associated with counseling. Sleep neurologists disclosed prognostic information most frequently, with male more likely than female clinicians to disclose prognoses. CONCLUSIONS Several patient and physician characteristics appear to influence documented prognostic counseling for iRBD/RSWA patients. Future studies of iRBD/RSWA patients' preferences are needed to clarify ethically appropriate physician-patient communication concerning prognosis.
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Affiliation(s)
- Max A Feinstein
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Biomedical Ethics Research Program, USA; University of California San Francisco School of Medicine, USA
| | - Richard R Sharp
- Biomedical Ethics Research Program, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - David J Sandness
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA
| | - John C Feemster
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA
| | - Mithri Junna
- Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Suresh Kotagal
- Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA; Department of Pediatrics and Adolescent Medicine, USA
| | - Melissa C Lipford
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Maja Tippmann-Peikert
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Bradley F Boeve
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Michael H Silber
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Erik K St Louis
- Mayo Center for Sleep Medicine, Department of Medicine, USA; Biomedical Ethics Research Program, USA; Department of Neurology, USA; Mayo Clinic College of Medicine, Rochester, MN, USA.
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Peyron C, Pélissier A, Béjean S. Preference heterogeneity with respect to whole genome sequencing. A discrete choice experiment among parents of children with rare genetic diseases. Soc Sci Med 2018; 214:125-132. [DOI: 10.1016/j.socscimed.2018.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 08/10/2018] [Accepted: 08/19/2018] [Indexed: 12/12/2022]
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Kaiwar C, McAllister TM, Lazaridis KN, Klee EW. Preemptive sequencing in the genomic medicine era. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1322898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Bertier G, Hétu M, Joly Y. Unsolved challenges of clinical whole-exome sequencing: a systematic literature review of end-users' views. BMC Med Genomics 2016; 9:52. [PMID: 27514372 PMCID: PMC4982236 DOI: 10.1186/s12920-016-0213-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 07/28/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Whole-exome sequencing (WES) consists in the capture, sequencing and analysis of all exons in the human genome. Originally developed in the research context, this technology is now increasingly used clinically to inform patient care. The implementation of WES into healthcare poses significant organizational, regulatory, and ethical hurdles, which are widely discussed in the literature. METHODS In order to inform future policy decisions on the integration of WES into standard clinical practice, we performed a systematic literature review to identify the most important challenges directly reported by technology users. RESULTS Out of 2094 articles, we selected and analyzed 147 which reported a total of 23 different challenges linked to the production, analysis, reporting and sharing of patients' WES data. Interpretation of variants of unknown significance, incidental findings, and the cost and reimbursement of WES-based tests were the most reported challenges across all articles. CONCLUSIONS WES is already used in the clinical setting, and may soon be considered the standard of care for specific medical conditions. Yet, technology users are calling for certain standards and guidelines to be published before this technology replaces more focused approaches such as gene panels sequencing. In addition, a number of infrastructural adjustments will have to be made for clinics to store, process and analyze the amounts of data produced by WES.
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Affiliation(s)
- Gabrielle Bertier
- Center of Genomics and Policy, McGill University, 740 Dr. Penfield Avenue, Montreal, Quebec H3A 0G1 Canada
- UMR 1027, Inserm, University of Toulouse III - Paul Sabatier, 37 allées Jules Guesde, F-31000 Toulouse, France
| | - Martin Hétu
- Center of Genomics and Policy, McGill University, 740 Dr. Penfield Avenue, Montreal, Quebec H3A 0G1 Canada
| | - Yann Joly
- Center of Genomics and Policy, McGill University, 740 Dr. Penfield Avenue, Montreal, Quebec H3A 0G1 Canada
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The Genetic Counselor’s Role in Managing Ethical Dilemmas Arising in the Laboratory Setting. J Genet Couns 2016; 25:838-54. [DOI: 10.1007/s10897-016-9957-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 03/31/2016] [Indexed: 01/23/2023]
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Clift KE, Halverson CM, Fiksdal AS, Kumbamu A, Sharp RR, McCormick JB. Patients' views on incidental findings from clinical exome sequencing. Appl Transl Genom 2015; 4:38-43. [PMID: 26937348 PMCID: PMC4745397 DOI: 10.1016/j.atg.2015.02.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This article characterizes the opinions of patients and family members of patients undergoing clinical genomic-based testing regarding the return of incidental findings from these tests. Over sixteen months, we conducted 55 in-depth interviews with individuals to explore their preferences regarding which types of results they would like returned to them. Responses indicate a diversity of attitudes toward the return of incidental findings and a diversity of justifications for those attitudes. The majority of participants also described an imperative to include the patient in deciding which results to return rather than having universal, predetermined rules governing results disclosure. The results demonstrate the importance of a patient centered-approach to returning incidental findings.
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Affiliation(s)
| | - Colin M.E. Halverson
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- University of Chicago, Department of Anthropology, Chicago, IL, USA
| | | | - Ashok Kumbamu
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
| | - Richard R. Sharp
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- Division of Health Care Research and Policy
- Division of General Internal Medicine
| | - Jennifer B. McCormick
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- Division of Health Care Research and Policy
- Division of General Internal Medicine
- Corresponding author at: 200 First Street SW, Plummer 3-30-40 Bioethics, Rochester, MN 55905, USA. Tel.: + 1 507 284 1494; fax: + 1 507 538 0850.
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Abstract
PURPOSE OF REVIEW The present study describes the recent advances in the identification of targetable genomic alterations in pediatric cancers, along with the progress and associated challenges in translating these findings into therapeutic benefit. RECENT FINDINGS Each field within pediatric cancer has rapidly and comprehensively begun to define genomic targets in tumors that potentially can improve the clinical outcome of patients, including hematologic malignancies (leukemia and lymphoma), solid malignancies (neuroblastoma, rhabdomyosarcoma, Ewing sarcoma, and osteosarcoma), and brain tumors (gliomas, ependymomas, and medulloblastomas). Although each tumor has specific and sometimes overlapping genomic targets, the translation to the clinic of new targeted trials and precision medicine protocols is still in its infancy. The first clinical tumor profiling studies in pediatric oncology have demonstrated feasibility and patient enthusiasm for the personalized medicine paradigm, but have yet to demonstrate clinical utility. Complexities influencing implementation include rapidly evolving sequencing technologies, tumor heterogeneity, and lack of access to targeted therapies. The return of incidental findings from the germline also remains a challenge, with evolving policy statements and accepted standards. SUMMARY The translation of genomic discoveries to the clinic in pediatric oncology continues to move forward at a brisk pace. Early adoption of genomics for tumor classification, risk stratification, and initial trials of targeted therapeutic agents has led to powerful results. As our experience grows in the integration of genomic and clinical medicine, the outcome for children with cancer should continue to improve.
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Allyse MA, McCormick JB, Sharp RR. Prudentia Populo: Involving the Community in Biobank Governance. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:1-3. [PMID: 26305740 DOI: 10.1080/15265161.2015.1062175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Park JY, Kricka LJ, Clark P, Londin E, Fortina P. Clinical genomics: when whole genome sequencing is like a whole-body CT scan. Clin Chem 2014; 60:1390-2. [PMID: 25114273 DOI: 10.1373/clinchem.2014.230276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jason Y Park
- Assistant Professor, Department of Pathology, University of Texas Southwestern Medical Center and Director of the Advanced Diagnostics Laboratory at Children's Medical Center, Dallas, TX; Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, TX;
| | - Larry J Kricka
- Professor and Director of General Chemistry and Director of the Critical Care Laboratory, Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Peter Clark
- Associate Scientist, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eric Londin
- Assistant Professor, Computational Medicine Center, Department of Pathology, Anatomy and Cellular Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Paolo Fortina
- Professor, Department of Cancer Biology and Medical Oncology, Cancer Genomics Laboratory, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; Department of Molecular Medicine, Sapienza Università di Roma, Rome, Italy
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12
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Erickson LA. Incidental findings in medical imaging and genetic testing: opportunities and challenges. Mayo Clin Proc 2014; 89:715-7. [PMID: 24943690 DOI: 10.1016/j.mayocp.2014.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 04/21/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Lori A Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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