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Cornelis C, Tibben A, Brilstra E, Bolt I, van Summeren M, Knoers N, Bredenoord AL. Hope, but never expect? Comparing parents' pre- and post-disclosure attitudes toward return of results from diagnostic exome sequencing for their child. Mol Genet Genomic Med 2024; 12:e2341. [PMID: 38366804 PMCID: PMC10958177 DOI: 10.1002/mgg3.2341] [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: 03/19/2023] [Revised: 11/20/2023] [Accepted: 12/05/2023] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Counseling for whole-exome sequencing (WES) could benefit from aligning parents' pre- and post-disclosure attitudes. A few studies have qualitatively compared parents' pre- and post-disclosure attitudes toward receiving WES results for their child in a diagnostic setting. This study explored these attitudes in the context of children with a developmental delay. METHODS Semi-structured interviews were conducted with parents (n = 27) of 16 children undergoing diagnostic WES in trio-analysis, both before and after receiving results. RESULTS Three key insights emerged. First, the distinction between hoping and expecting was relevant for shaping parents' experiences with receiving results related to the primary indication. Second, parents of young children whose development of autonomous capacities was uncertain sometimes found themselves in a situation resembling a Catch-22 when confronted with decisions about unsolicited findings (UFs): an important reason for consenting to WES was to gain a better picture of how the child might develop, but in order to make responsible choices about UFs, some ideas of their child's development is needed. Third, default opt-ins and opt-outs helped parents fathom new kinds of considerations for accepting or declining UFs in different categories, thereby aiding decision-making. CONCLUSION Results from this study are relevant for counseling and policy development.
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Affiliation(s)
- Candice Cornelis
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of Medical Humanities, Julius CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Aad Tibben
- Department of Clinical GeneticsLeiden University Medical CenterLeidenThe Netherlands
| | - Eva Brilstra
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ineke Bolt
- Department of Medical Ethics, Philosophy and History of MedicineErasmus Medical CenterRotterdamThe Netherlands
| | - Marieke van Summeren
- Department of General PediatricsUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Nine Knoers
- Department of GeneticsUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of GeneticsUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Annelien L. Bredenoord
- Department of Medical Humanities, Julius CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
- Erasmus School of PhilosophyErasmus University RotterdamRotterdamThe Netherlands
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2
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Cornelis C, Dondorp W, Bolt I, de Wert G, van Summeren M, Brilstra E, Knoers N, Bredenoord AL. Uncertain futures and unsolicited findings in pediatric genomic sequencing: guidelines for return of results in cases of developmental delay. BMC Med Ethics 2023; 24:98. [PMID: 37951889 PMCID: PMC10640744 DOI: 10.1186/s12910-023-00977-y] [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: 05/20/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Massively parallel sequencing techniques, such as whole exome sequencing (WES) and whole genome sequencing (WGS), may reveal unsolicited findings (UFs) unrelated to the diagnostic aim. Such techniques are frequently used for diagnostic purposes in pediatric cases of developmental delay (DD). Yet policy guidelines for informed consent and return of UFs are not well equipped to address specific moral challenges that may arise in these children's situations. DISCUSSION In previous empirical studies conducted by our research group, we found that it is sometimes uncertain how children with a DD will develop and whether they could come to possess capacities for autonomous decision-making in the future. Parents sometimes felt this brought them into a Catch-22 like situation when confronted with choices about UFs before undergoing WES in trio-analysis (both the parents' and child's DNA are sequenced). An important reason for choosing to consent to WES was to gain more insight into how their child might develop. However, to make responsible choices about receiving or declining knowledge of UFs, some idea of their child's future development of autonomous capacities is needed. This undesirable Catch-22 situation was created by the specific policy configuration in which parents were required to make choices about UFs before being sequencing (trio-analysis). We argue that this finding is relevant for reconfiguring current policies for return of UFs for WES/WGS and propose guidelines that encompass two features. First, the informed consent process ought to be staged. Second, differing guidelines are required for withholding/disclosing a UF in cases of DD appropriate to the level of confidence there is about the child's future developmental of autonomous capacities. CONCLUSION When combined with a dynamic consent procedure, these two features of our guidelines could help overcome significant moral challenges that present themselves in the situations of children undergoing genomic sequencing for clarifying a DD.
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Affiliation(s)
- Candice Cornelis
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands.
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Ineke Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Guido de Wert
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eva Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University Medical Centre Groningen, Groningen, the Netherlands
| | - Annelien L Bredenoord
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Philosophy, Rotterdam, the Netherlands
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3
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Lenahan A, Mietzsch U, Wood TR, Callahan KP, Weiss EM, Miller DE, German K, Natarajan N, Puia-Dumitrescu M, Esposito V, Kolnik S, Law JB. Characteristics, Genetic Testing, and Diagnoses of Infants with Neonatal Encephalopathy Not Due to Hypoxic Ischemic Encephalopathy: A Cohort Study. J Pediatr 2023; 260:113533. [PMID: 37269901 DOI: 10.1016/j.jpeds.2023.113533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/29/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To characterize the presentation and evaluation of infants with neonatal encephalopathy (NE) not due to hypoxic-ischemic encephalopathy (non-HIE NE) and to describe the genetic abnormalities identified. STUDY DESIGN Retrospective cohort study of 193 non-HIE NE neonates admitted to a level IV NICU from 2015 through 2019. For changes in testing over time, Cochrane-Armitage test for trend was used with a Bonferroni-corrected P-value, and comparison between groups was performed using Fisher exact test. RESULT The most common symptom of non-HIE NE was abnormal tone in 47% (90/193). Ten percent (19/193) died prior to discharge, and 48% of survivors (83/174) required medical equipment at discharge. Forty percent (77/193) underwent genetic testing as an inpatient. Of 52 chromosomal studies, 54 targeted tests, and 16 exome sequences, 10%, 41%, and 69% were diagnostic, respectively, with no difference in diagnostic rates between infants with and without an associated congenital anomaly and/or dysmorphic feature. Twenty-eight genetic diagnoses were identified. CONCLUSIONS Neonates with non-HIE NE have high rates of morbidity and mortality and may benefit from early genetic testing, even in the absence of other exam findings. This study broadens our knowledge of genetic conditions underlying non-HIE NE, which may enable families and care teams to anticipate the needs of the individual, allow early initiation of targeted therapies, and facilitate decisions surrounding goals of care.
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Affiliation(s)
- Arthur Lenahan
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Ulrike Mietzsch
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Thomas R Wood
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Katharine Press Callahan
- Department of Pediatrics, Children's Hospital of Philadelphia, PA; Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elliott M Weiss
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Danny E Miller
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA; Department of Laboratory Medicine and Pathology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Kendell German
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Niranjana Natarajan
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA; Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Mihai Puia-Dumitrescu
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Valentine Esposito
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Sarah Kolnik
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Janessa B Law
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA.
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Sheen D, Peasgood T, Goranitis I. Eliciting Societal Preferences for Non-health Outcomes: A Person Trade-Off Study in the Context of Genomics. Clin Ther 2023; 45:710-718. [PMID: 37524571 DOI: 10.1016/j.clinthera.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 08/02/2023]
Abstract
PURPOSE Economic evaluations of health technologies traditionally aim to maximize population health outcomes measured by using quality-adjusted life-years (QALYs). Non-health outcomes, however, may have high social value, and their exclusion has the potential to bias decisions regarding allocation of health care resources. This research positions Australian participants as societal decision-makers to explore their willingness to trade-off health gains in adults for non-health benefits in families with a child affected by a rare disease. METHODS To estimate the social value of the different health care interventions, a person trade-off (PTO) method was used. PTOs present participants with groups of beneficiaries that vary in terms of the number of individuals who will benefit, the individuals' characteristics, their expected benefits, or a combination, and ask which group should be prioritized. Each trade-off presented health gains from the treatment of moderate physical and mental health conditions described by the 3-level version of the EuroQol 5-Dimension (EQ-5D-3L) health states. The health gains in these groups were traded-off against non-health gains in families accessing diagnostic genomic testing, and equivalence values were calculated, using median and ratio of means methods, based on the ratio of the group sizes at the point of equivalence. Participants were recruited through Prolific and were stratified according to age, sex, and education. The impact of participant characteristics on equivalence values was assessed using Kruskal-Wallis H tests and ordinary least-squares log-linear regressions. FINDINGS Participants (N = 434) positioned as societal decision-makers were generally willing to trade-off adult health gains with the familial non-health benefits of genomic testing, showing a preference for valuing both types of outcomes within public health policy. The aggregation of preferences generated 2 weightings for genomic testing against each health treatment, an unadjusted value and a reweighted value to match target demographic characteristics. Converted into QALY value per test, it was found that participants valued the non-health benefits of genomic testing between 0.730 and 0.756 QALY. A minority of participants always prioritized diagnostic genomic testing over the physical (6.0%) or mental (4.6%) health treatments, with a larger minority always prioritizing the physical (15.4%) or mental (14.8%) health treatments. IMPLICATIONS The findings indicate that participants perceived the non-health parental benefits in children experiencing rare disease to have comparable value to health gains in adults experiencing the moderate physical or mental health conditions described using EQ-5D-3L. These findings suggest that the benefits of genomic tests would be underestimated if only health benefits are included in economic evaluations.
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Affiliation(s)
- Daniel Sheen
- Graduate School of Humanities and Social Sciences, University of Melbourne, Melbourne, Victoria, Australia; Health Economics Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Tessa Peasgood
- Health Economics Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ilias Goranitis
- Health Economics Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Genomics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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5
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Pereira S, Gutierrez AM, Robinson JO, Christensen KD, Genetti CA, Blout Zawatsky CL, Hsu RL, Zettler B, Uveges MK, Parad RB, Beggs AH, Holm IA, Green RC, McGuire AL. Parents' decision-making regarding whether to receive adult-onset only genetic findings for their children: Findings from the BabySeq Project. Genet Med 2023; 25:100002. [PMID: 36549595 PMCID: PMC9992280 DOI: 10.1016/j.gim.2022.100002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Most professional guidelines recommend against genetic screening for adult-onset only (AO) conditions until adulthood, yet others argue that there may be benefit to disclosing such results. We explored parents' decision-making on this issue in the BabySeq Project, a clinical trial of newborn genomic sequencing. METHODS We conducted interviews with parents (N = 24) who were given the option to receive actionable AO results for their children. Interviews explored parents' motivations to receive and reasons to decline AO genetic disease risk information, their decision-making process, and their suggestions for supporting parents in making this decision. RESULTS Parents noted several motivations to receive and reasons to decline AO results. Most commonly, parents cited early intervention/surveillance (n = 11), implications for family health (n = 7), and the ability to prepare (n = 6) as motivations to receive these results. The most common reasons to decline were protection of the child's future autonomy (n = 4), negative effect on parenting (n = 3), and anxiety about future disease (n = 3). Parents identified a number of ways to support parents in making this decision. CONCLUSION Results show considerations to better support parental decision-making that aligns with their values when offering AO genetic information because it is more commonly integrated into pediatric clinical care.
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Affiliation(s)
- Stacey Pereira
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX.
| | - Amanda M Gutierrez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Jill Oliver Robinson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Kurt D Christensen
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine at Harvard Pilgrim Health Care Institute, Boston, MA; Department of Population Medicine, Harvard Medical School, Boston, MA
| | - Casie A Genetti
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA
| | - Carrie L Blout Zawatsky
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Medical and Population Genetics, The Broad Institute, Cambridge, MA; Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Ariadne Labs, Boston, MA; The MGH Institute of Health Professions, Boston, MA
| | - Rebecca L Hsu
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Bethany Zettler
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Richard B Parad
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alan H Beggs
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; The Broad Institute of MIT and Harvard, Cambridge, MA
| | - Ingrid A Holm
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Harvard Medical School, Boston, MA; The Broad Institute of MIT and Harvard, Cambridge, MA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Ariadne Labs, Boston, MA; Harvard Medical School, Boston, MA; The Broad Institute of MIT and Harvard, Cambridge, MA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
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6
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Miner SA, Similuk M, Jamal L, Sapp J, Berkman BE. Genomic tools for health: Secondary findings as findings to be shared. Genet Med 2022; 24:2220-2227. [PMID: 35980380 PMCID: PMC9643624 DOI: 10.1016/j.gim.2022.07.015] [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: 05/26/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Whether and how to disclose secondary finding (SF) information to children is ethically debated. Some argue that genetic testing of minors should be limited to preserve the child's future autonomy. Others suggest that disclosure of SFs can occur if it is in the best interests of the child. However, the ways that parents conceptualize and weigh their child's future autonomy against the interests of their child and other family members are unknown. METHODS To explore how parents understand SF disclosure in the context of their child and other family members' lives, we conducted semistructured interviews with 30 families (40 parents in total). All parents had children who were enrolled in a genetic sequencing protocol that returned results by default. RESULTS We found that parents did not routinely conceptualize SFs as distinctive health information. Rather parents saw this information as part of their child's overall health. To make decisions about disclosure, parents weighed their child's ability to understand the SF information and their other family member's need to know. CONCLUSION Because most families desired SF information, we argue that disclosure of SF be reconceptualized to reflect the lived experiences of those who may receive this information.
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Affiliation(s)
- Skye A Miner
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; Department of Medical Humanities and Bioethics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Morgan Similuk
- Centralized Sequencing Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Leila Jamal
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; NHGRI/NCI/JHU Genetic Counseling Training Program, National Human Genome Research Insitute, Bethesda, MD
| | - Julie Sapp
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD; Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Benjamin E Berkman
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD.
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7
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Should we respect parents' views about which results to return from genomic sequencing? Hum Genet 2021; 141:1059-1068. [PMID: 33987713 DOI: 10.1007/s00439-021-02293-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/06/2021] [Indexed: 01/22/2023]
Abstract
Genomic sequencing (GS) is now well embedded in clinical practice. However, guidelines issued by professional bodies disagree about whether unsolicited findings (UF)-i.e., disease-causing changes found in the DNA unrelated to the reason for testing-should be reported if they are identified inadvertently during data analysis. This extends to a lack of clarity regarding parents' ability to decide about receiving UF for their children. To address this, I use an ethical framework, the Zone of Parental Discretion (ZPD), to consider which UF parents should be allowed to choose (not) to receive and examine how well this assessment aligns with existing professional recommendations. Assessment of guidelines shows recommendations ranging from leaving the decision to the discretion of laboratories through to mandatory reporting for UF for childhood onset, treatable/preventable conditions. The ZPD suggests that parents' decisions should be respected, even where there is no expected benefit, provided that there is not sufficient evidence of serious harm. Using this lens, parents should be able to choose whether or not to know UF for adult-onset conditions in their children, but only insofar as there is insufficient evidence that this knowledge will cause harm or benefit. In contrast, parents should not be allowed to refuse receiving UF for childhood-onset medically actionable conditions. The ZPD is a helpful tool for assessing where it is appropriate to offer parents the choice of receiving UF for their children. This has implications for refinement of policy and laboratory reporting practices, development of consent forms, and genetic counselling practice.
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8
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Tibben A, Dondorp W, Cornelis C, Knoers N, Brilstra E, van Summeren M, Bolt I. Parents, their children, whole exome sequencing and unsolicited findings: growing towards the child's future autonomy. Eur J Hum Genet 2021; 29:911-919. [PMID: 33456055 DOI: 10.1038/s41431-020-00794-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/07/2020] [Accepted: 11/26/2020] [Indexed: 01/09/2023] Open
Abstract
In a previous study we found that parents of children with developmental delay (DD) favoured acceptance of unsolicited findings (UFs) for medically actionable conditions in childhood, but that preferences diverged for UFs with no medical actionability, or only in adulthood, and regarding carrier status. Sometimes the child's future autonomy formed a reason for withholding UFs for the present, despite an unfavourable prognosis concerning the child's cognitive capabilities. This might be different for children undergoing whole exome sequencing (WES) for reasons other than DD and who are expected to exert future autonomy. This is the focus of the current study. We conducted nine qualitative, semi-structured interviews with parents of children, ages <1-15, after consenting to WES, but prior to feedback of results, and with three adolescent children. Several parents wished to receive any information that might in whatever way be relevant to the health and well-being of their child, and to a lesser extent wished the inclusion of information about non-actionable disorders and information concerning carrier status of autosomal recessive disorders. Although parents understood the rationale behind the centre's UFs disclosure policy, they also felt that they needed this information in order to be able to exert their parental responsibility and take good care of a child still dependent on them. Parents reason from their notion of parental responsibility but are also inclined to take adolescent children's preferences seriously and acknowledge the child's incipient autonomy as a ground for granting an increasing degree of self-determination on the road to adulthood.
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Affiliation(s)
- Aad Tibben
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics & Society, Research School for Public Health & Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Candice Cornelis
- Ethics Institute, Utrecht University, Utrecht, the Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Groningen, Groningen, the Netherlands
| | - Eva Brilstra
- Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ineke Bolt
- Ethics Institute, Utrecht University, Utrecht, the Netherlands.,Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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9
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Dondorp W, Bolt I, Tibben A, De Wert G, Van Summeren M. 'We Should View Him as an Individual': The Role of the Child's Future Autonomy in Shared Decision-Making About Unsolicited Findings in Pediatric Exome Sequencing. HEALTH CARE ANALYSIS 2021; 29:249-261. [PMID: 33389383 DOI: 10.1007/s10728-020-00425-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/29/2022]
Abstract
In debates about genetic testing of children, as well as about disclosing unsolicited findings (UFs) of pediatric exome sequencing, respect for future autonomy should be regarded as a prima facie consideration for not taking steps that would entail denying the future adult the opportunity to decide for herself about what to know about her own genome. While the argument can be overridden when other, morally more weighty considerations are at stake, whether this is the case can only be determined in concrete cases. Importantly, when children grow into adolescents, respect for future autonomy will have to give way to respecting their emerging autonomy. When pediatric exome sequencing is done for complex conditions not involving developmental delay, respect for the child's future or emerging autonomy should be a primary consideration for those charged with deciding on behalf of the child. Building on what Emanuel and Emanuel have termed the 'deliberative model' of shared decision making, we argue that if parents fail to give these considerations their due, professionals should actively invite them to do so. Taking a directive stance may be needed in order to make sure that the future or emerging autonomy of the child are duly considered in the decision-making process, but also to help the parents and themselves to shape their respective roles as responsible care-givers.
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Affiliation(s)
- W Dondorp
- Department of Health, Ethics and Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, De Byeplein 1, 6229 HA, Maastricht, The Netherlands.
| | - I Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Tibben
- Department of Clinical Genetics, Leiden University Medical Centre, Laan van Duivenvoorde 2-TO, 2252 AK, Voorschoten, The Netherlands
| | - G De Wert
- Department of Health, Ethics and Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, De Byeplein 1, 6229 HA, Maastricht, The Netherlands
| | - M Van Summeren
- Department of General Pediatrics, University Medical Centre Utrecht, UMC Utrecht, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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10
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Plug MB, van Wijngaarden V, de Wilde H, van Binsbergen E, Stegeman I, van den Boogaard MJH, Smit AL. Clinical Characteristics and Genetic Etiology of Children With Developmental Language Disorder. Front Pediatr 2021; 9:651995. [PMID: 34277514 PMCID: PMC8282268 DOI: 10.3389/fped.2021.651995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: Developmental language delay (DLD) is one of the most common disabilities in childhood and can negatively affect a child's communication skills and academic and/or psychosocial development. To date, an increasing number of causative genes have been identified by diagnostic techniques like next generation sequencing. An early genetic diagnosis is important to properly prepare and counsel children and parents for possible future difficulties. Despite this, genetic assessment is usually not part of a standardized diagnostic set in children with developmental language delay. In this study, we aim to assess the diagnostic outcomes of children primarily assessed for speech and language delay who were subsequently referred for genetic etiological assessment. Methods: Medical records of children referred to the department of Otorhinolaryngology of the Wilhelmina Children's Hospital for diagnostic work-up for a suspected speech and language delay between June 2011 and December 2018 who were additionally referred to a geneticist were evaluated. Study parameters concerning medical history, behavioral problems, language development, intelligence, and hearing were recorded. Outcomes of genetic analysis were evaluated. Results: A total of 127 patients were diagnosed with a developmental language delay. Genetic analysis was conducted in 119 out of 127 patients with a language delay and eligible for this study. The median time between initial speech and language assessment and the first genetic consultation was 10 months (IQR 5.0-23.0). In 34 out of 127 patients a causative genetic diagnosis was found to explain their DLD. Conclusion: In approximately a quarter of the patients (26.8%) diagnosed with developmental language delay, a causative genetic diagnosis was confirmed. This demonstrates the opportunity to identify an underlying genetic etiology in children with developmental language delay. However, in order to optimize the diagnostic process and clinical care for these children, two important research gaps need to be addressed. First, research should focus on assessing the clinical impact and effect on treatment outcomes of a genetic diagnosis. Secondly, it is important to recognize for which children genetic testing is most beneficial.
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Affiliation(s)
- Marielle B Plug
- Department of Otorhinolaryngology Head and Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Hester de Wilde
- Department of Otorhinolaryngology Head and Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Inge Stegeman
- Department of Otorhinolaryngology Head and Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands.,Brain Center, University Medical Center Utrecht, Utrecht, Netherlands.,Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Adriana L Smit
- Department of Otorhinolaryngology Head and Neck Surgery, University Medical Center Utrecht, Utrecht, Netherlands.,Brain Center, University Medical Center Utrecht, Utrecht, Netherlands.,Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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11
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McVeigh E, Jones H, Black G, Hall G. The psychosocial and service delivery impact of genomic testing for inherited retinal dystrophies. J Community Genet 2019; 10:425-434. [PMID: 30680631 PMCID: PMC6591333 DOI: 10.1007/s12687-019-00406-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022] Open
Abstract
Next-generation sequencing (NGS) provides diagnostic information for many rare conditions. The evolution of NGS for panel, exome, and genome testing is set to be the platform for transforming genomic diagnosis in the National Health Service (NHS). Inherited retinal dystrophies (IRDs) are a highly genetically heterogeneous disease group causing progressive visual impairment. IRDs are ideal for an NGS panel approach due to phenotypic overlap and were one of the first diagnostic panels to be developed in the NHS. While diagnostic yield for patients with IRD has improved significantly with NGS, a proportion of patients remain without a diagnosis. The clinical value of NGS testing is well understood; however, the patient experience of panel testing is not well documented. Semi-structured qualitative telephone interviews were conducted with 23 participants with IRD who had undergone NGS testing. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis. Participants' experiences were interpreted to explore the psychosocial and service delivery impact of this testing technology, inclusive of those who received a pathogenic, negative, carrier status or variant of uncertain significance result. Collectively, three core themes were identified: (1) the journey towards a genomic diagnosis, (2) the impact of NGS testing, (3) service delivery of NGS tests. Disclosure of results had no reported adverse implications. Participants appreciated an open discussion about the potential for an uncertain or unexpected result, prior to testing. They valued pre-test counselling discussions, expert opinions and on-going care from genomic services.
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Affiliation(s)
- Eleanor McVeigh
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK.
| | - Harriet Jones
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK.
- Genetics Health Service, Northern Hub, Auckland City Hospital, Aukland, New Zealand.
| | - Graeme Black
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
| | - Georgina Hall
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
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12
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Clowes Candadai SV, Sikes MC, Thies JM, Freed AS, Bennett JT. Rapid clinical exome sequencing in a pediatric ICU: Genetic counselor impacts and challenges. J Genet Couns 2019; 28:283-291. [PMID: 30964580 PMCID: PMC6481675 DOI: 10.1002/jgc4.1116] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 01/02/2023]
Abstract
Exome sequencing (ES) has revolutionized molecular diagnosis in children with genetic disease over the past decade. However, exome sequencing in the inpatient setting has traditionally been discouraged, in part due to an increased risk of providers failing to retrieve and act upon results, as many patients are discharged before results return. The development of rapid turn-around-times (TATs) for genomic testing has begun to shift this paradigm. Rapid exome sequencing (rES) is increasingly being used as a diagnostic tool for critically ill infants with likely genetic disease and presents significant challenges to execute. We implemented a program, entitled the Rapid Inpatient Genomic Testing (RIGhT) project, to identify critically ill children for whom a molecular diagnosis is likely to change inpatient management. Two important goals of the RIGhT project were to provide appropriate genetic counseling, and to develop protocols to ensure efficient test coordination- both of which relied heavily on laboratory and clinic-based genetic counselors (GCs). Here, rES was performed on 27 inpatient trios from October 2016 to August 2018; laboratory and clinical GCs encountered significant challenges in the coordination of this testing. The GCs involved retrospectively reviewed these cases and identified three common challenges encountered during pretest counseling and coordination. The aim of this paper is to define these challenges using illustrative case examples that highlight the importance of including GCs to support rES programs.
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Affiliation(s)
- Sarah V Clowes Candadai
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
- Patient-Centered Laboratory Utilization Guidance Services (PLUGS), Seattle Children's Hospital, Seattle, Washington
| | - Megan C Sikes
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jenny M Thies
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Amanda S Freed
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, Washington
| | - James T Bennett
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington
- Division of Genetic Medicine, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, Washington
- Center for Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington
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13
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Hull LE, Vassy JL. Toward greater understanding of patient decision-making around genome sequencing. Per Med 2018; 15:57-66. [PMID: 29714114 DOI: 10.2217/pme-2017-0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the era of next-generation sequencing, it is essential to collect and understand the patient outcomes that result from this new technology. One critical determinant of these is the process by which individuals first decide whether and how to pursue genome sequencing. In this perspective article, we examine the literature on adult patient decision-making in genome sequencing and identify current research gaps to address. Several studies have explored the motivations and concerns of patients undergoing sequencing; less attention has been paid to those who decline sequencing or to individuals from lower socioeconomic groups. Many factors that might play a role in the decision to pursue or decline sequencing, including trust, family dynamics and barriers to access, have yet to be explored fully. Future research that captures the experience of the wider population will produce a more generalizable understanding of the clinical, psychosocial, and economic outcomes of pursuing or declining sequencing.
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Affiliation(s)
- Leland E Hull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA.,Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jason L Vassy
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA.,Division of General Medicine & Primary Care, Brigham & Women's Hospital, Boston, MA, 02115, USA
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14
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Werner-Lin A, Zaspel L, Carlson M, Mueller R, Walser SA, Desai R, Bernhardt BA. Gratitude, protective buffering, and cognitive dissonance: How families respond to pediatric whole exome sequencing in the absence of actionable results. Am J Med Genet A 2018; 176:578-588. [DOI: 10.1002/ajmg.a.38613] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/26/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Allison Werner-Lin
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Lori Zaspel
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Mae Carlson
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Rebecca Mueller
- Department of History and Sociology of Science; University of Pennsylvania; Philadelphia Pennsylvania
| | - Sarah A. Walser
- Department of Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Ria Desai
- College of Arts and Science; University of Pennsylvania; Philadelphia Pennsylvania
| | - Barbara A. Bernhardt
- Department of Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
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15
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Petersen I, Kaatsch P, Spix C, Kollek R. Return and Disclosure of Research Results: Parental Attitudes and Needs Over Time in Pediatric Oncology. J Pediatr 2017; 191:232-237. [PMID: 28969889 DOI: 10.1016/j.jpeds.2017.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/22/2017] [Accepted: 08/03/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To explore parental attitudes regarding the return and disclosure of research findings in pediatric cancer trials over time. STUDY DESIGN Two surveys were set up to evaluate the stability of parental attitudes. One survey was carried out among 581 parents whose child was diagnosed recently (response rate, 53.5%). A second, population-based survey was set up with a time interval of 4 years between first cancer diagnosis and survey in which 1465 parents were included (response rate, 55.1%). RESULTS Almost all surveyed parents stated a parental right to receive aggregate research results. Fifty-five percent of the parents who recently participated in trials and 62% of those asked after a multiyear time interval thought that disclosure of individual findings is in any case necessary (P = .0034). The respondents wanted to restrict the duty to disclose study results to the child according to their notion of the child's well-being, composed of child's maturity, impairment of the parent-child relationship, and the quality of the results. CONCLUSIONS Attitudes of parents regarding the return of research findings change over time. Shortly after diagnosis, parents are mainly interested in aggregate findings. Interest in individual findings appeared to increase as more time elapsed between cancer diagnosis and survey.
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Affiliation(s)
- Imme Petersen
- Hamburg University, Research Centre for Biotechnology, Society and the Environment, Research Group on Medicine and Neurosciences, Hamburg, Germany.
| | - Peter Kaatsch
- German Childhood Cancer Registry, Institute of Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Claudia Spix
- German Childhood Cancer Registry, Institute of Medical Biostatistics, Epidemiology and Informatics, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Regine Kollek
- Hamburg University, Research Centre for Biotechnology, Society and the Environment, Research Group on Medicine and Neurosciences, Hamburg, Germany
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16
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Boardman FK, Young PJ, Griffiths FE. Impairment Experiences, Identity and Attitudes Towards Genetic Screening: the Views of People with Spinal Muscular Atrophy. J Genet Couns 2017; 27:69-84. [PMID: 28664217 PMCID: PMC5794814 DOI: 10.1007/s10897-017-0122-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
Developments in genetics are rapidly changing the capacity and scope of screening practices. However, people with genetic conditions have been under-represented in the literature exploring their implications. This mixed methods study explores the attitudes of people with Spinal Muscular Atrophy (SMA) towards three different population-level genetic screening programmes for SMA: pre-conception, prenatal and newborn screening. Drawing on qualitative interviews (n = 15) and a survey (n = 82), this study demonstrates that more severely affected individuals with early-onset symptoms (Type II SMA), are less likely to support screening and more likely to view SMA positively than those with milder, later onset and/or fluctuating symptoms (Types III/ IV SMA). Indeed, this clinically milder group were more likely to support all forms of screening and view SMA negatively. This paper highlights that screening is a complex issue for people with genetic conditions, and the nature of impairment experiences plays a critical role in shaping attitudes.
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Affiliation(s)
- Felicity K Boardman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
| | - Philip J Young
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Frances E Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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17
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Kohler JN, Turbitt E, Biesecker BB. Personal utility in genomic testing: a systematic literature review. Eur J Hum Genet 2017; 25:662-668. [PMID: 28295040 DOI: 10.1038/ejhg.2017.10] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/20/2016] [Accepted: 01/11/2017] [Indexed: 11/09/2022] Open
Abstract
Researchers and clinicians refer to outcomes of genomic testing that extend beyond clinical utility as 'personal utility'. No systematic delineation of personal utility exists, making it challenging to appreciate its scope. Identifying empirical elements of personal utility reported in the literature offers an inventory that can be subsequently ranked for its relative value by those who have undergone genomic testing. A systematic review was conducted of the peer-reviewed literature reporting non-health-related outcomes of genomic testing from 1 January 2003 to 5 August 2016. Inclusion criteria specified English language, date of publication, and presence of empirical evidence. Identified outcomes were iteratively coded into unique domains. The search returned 551 abstracts from which 31 studies met the inclusion criteria. Study populations and type of genomic testing varied. Coding resulted in 15 distinct elements of personal utility, organized into three domains related to personal outcomes: affective, cognitive, and behavioral; and one domain related to social outcomes. The domains of personal utility may inform pre-test counseling by helping patients anticipate potential value of test results beyond clinical utility. Identified elements may also inform investigations into the prevalence and importance of personal utility to future test users.
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Affiliation(s)
- Jennefer N Kohler
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Erin Turbitt
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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18
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Abstract
AIM To characterize the views of young adults toward integrating whole-genome sequencing (WGS) into standard pediatric care, particularly when used as a supplement to newborn screening. MATERIALS & METHODS This mixed methods descriptive study assessed the perspectives of a diverse group of 18- and 19-year olds (n = 145) in the USA using an informational video and online survey. RESULTS Young adults typically recommended disclosing WGS results to both parents and children during childhood. In the qualitative analysis, most participants emphasized the anticipated health benefits of pediatric WGS, while a minority discussed possible negative emotional and developmental impacts. CONCLUSION Differing preferences for pediatric WGS emphasize the importance that clinicians adopt responsive approaches when providing WGS and disclosing results to families.
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Affiliation(s)
- Christopher H Wade
- School of Nursing & Health Studies, University of Washington Bothell, Bothell, WA, USA
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