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OUP accepted manuscript. Clin Chem 2022; 68:627-632. [DOI: 10.1093/clinchem/hvac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/19/2022] [Indexed: 11/12/2022]
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McGrath SP, Peabody AE, Walton D, Walton N. Legal Challenges in Precision Medicine: What Duties Arising From Genetic and Genomic Testing Does a Physician Owe to Patients? Front Med (Lausanne) 2021; 8:663014. [PMID: 34381794 PMCID: PMC8349980 DOI: 10.3389/fmed.2021.663014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/28/2021] [Indexed: 12/23/2022] Open
Abstract
Precision medicine is increasingly incorporated into clinical practice via three primary data conduits: environmental, lifestyle, and genetic data. In this manuscript we take a closer look at the genetic tier of precision medicine. The volume and variety of data provides a more robust picture of health for individual patients and patient populations. However, this increased data may also have an adverse effect by muddling our understanding without the proper pedagogical tools. Patient genomic data can be challenging to work with. Physicians may encounter genetic results which are not fully understood. Genetic tests may also lead to the quandary of linking patients with diseases or disorders where there are no known treatments. Thus, physicians face a unique challenge of establishing the proper scope of their duty to patients when dealing with genomic data. Some of those scope of practice boundaries have been established as a result of litigation, while others remain an open question. In this paper, we map out some of the legal challenges facing the genomic component of precision medicine, both established and some questions requiring additional guidance. If physicians begin to perceive genomic data as falling short in overall benefit to their patients, it may detrimentally impact precision medicine as a whole. Helping to develop guidance for physicians working with patient genomic data can help avoid this fate of faltering confidence.
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Affiliation(s)
- Scott P McGrath
- CITRIS and the Banatao Institute, University of California, Berkeley, Berkeley, CA, United States
| | - Arthur E Peabody
- Hooper, Lundy & Bookman, Professional Corporation, Washington, DC, United States
| | - Derek Walton
- Walton Legal Professional Limited Liability Company, Salt Lake City, UT, United States
| | - Nephi Walton
- Intermountain Healthcare, Salt Lake City, UT, United States
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Roberts JL, Foulkes AL. GENETIC DUTIES. WILLIAM AND MARY LAW REVIEW 2020; 62:143-211. [PMID: 37654734 PMCID: PMC10471136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Most of our genetic information does not change, yet the results of our genetic tests might. Labs reclassify genetic variants in response to advances in genetic science. As a result, a person who took a test in 2010 could take the same test with the same lab in 2020 and get a different result. However, no legal duty requires labs or physicians to inform patients when a lab reclassifies a variant, even if the reclassification communicates clinically actionable information. This Article considers the need for such duties and their potential challenges. In so doing, it offers much-needed guidance to physicians and labs, who may face liability, and to courts, which will hear these cases.
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Wolf SM. Return of Results in Participant-Driven Research: Learning from Transformative Research Models. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:159-166. [PMID: 32342739 DOI: 10.1177/1073110520917042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Participant-driven research (PDR) is a burgeoning domain of research innovation, often facilitated by mobile technologies (mHealth). Return of results and data are common hallmarks, grounded in transparency and data democracy. PDR has much to teach traditional research about these practices and successful engagement. Recommendations calling for new state laws governing research with mHealth modalities common in PDR and federal creation of review mechanisms, threaten to stifle valuable participant-driven innovation, including in return of results.
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Affiliation(s)
- Susan M Wolf
- Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; and Professor of Medicine at the University of Minnesota. She chairs the University's Consortium on Law and Values in Health, Environment & the Life Sciences
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Marchant G, Barnes M, Evans JP, LeRoy B, Wolf SM. From Genetics to Genomics: Facing the Liability Implications in Clinical Care. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:11-43. [PMID: 32342786 PMCID: PMC7433684 DOI: 10.1177/1073110520916994] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Health care is transitioning from genetics to genomics, in which single-gene testing for diagnosis is being replaced by multi-gene panels, genome-wide sequencing, and other multi-genic tests for disease diagnosis, prediction, prognosis, and treatment. This health care transition is spurring a new set of increased or novel liability risks for health care providers and test laboratories. This article describes this transition in both medical care and liability, and addresses 11 areas of potential increased or novel liability risk, offering recommendations to both health care and legal actors to address and manage those liability risks.
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Affiliation(s)
- Gary Marchant
- Gary Marchant, B.SC., Ph.D., J.D., M.P.P., is Regents' Professor, Lincoln Professor of Emerging Technologies, Law & Ethics, and Faculty Director of the Center for Law, Science & Innovation at ASU. He researches, teaches and speaks about governance of a variety of emerging technologies including genomics, biotechnology, neuroscience, nanotechnology and artificial intelligence. Prior to starting at ASU in 1999, he was a partner in the Washington, DC office of Kirkland & Ellis. Mark Barnes, J.D., LL.M., is a partner in the life sciences practice at Ropes & Gray LLP; teaches health care law and the law of biomedical research at Yale Law School; and is founder and co-director of the Multi-Regional Clinical Trials Center (MRCT Center) of Harvard University and Brigham and Women's Hospital. James P. Evans, M.D., Ph.D., is a Medical Geneticist and Internist who is currently retired, but pursued a long-standing interest in genomics and its broad social implications. He is Professor Emeritus, University of North Carolina at Chapel Hill, Department of Genetics. Bonnie LeRoy, M.S., L.G.C., is a licensed genetic counselor with over 20 years of clinical experience. She developed and now directs the Graduate Program in Genetic Counseling at the University of Minnesota. She is a past president of the National Society of Genetic Counselors, the American Board of Genetic Counseling, and the Association of Genetic Counseling Program Directors. Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; and Chair of the Consortium on Law and Values in Health, Environment & the Life Sciences at the University of Minnesota. She is a Principal Investigator on the LawSeq project funded by NIH. Institutions are listed for author identification only
| | - Mark Barnes
- Gary Marchant, B.SC., Ph.D., J.D., M.P.P., is Regents' Professor, Lincoln Professor of Emerging Technologies, Law & Ethics, and Faculty Director of the Center for Law, Science & Innovation at ASU. He researches, teaches and speaks about governance of a variety of emerging technologies including genomics, biotechnology, neuroscience, nanotechnology and artificial intelligence. Prior to starting at ASU in 1999, he was a partner in the Washington, DC office of Kirkland & Ellis. Mark Barnes, J.D., LL.M., is a partner in the life sciences practice at Ropes & Gray LLP; teaches health care law and the law of biomedical research at Yale Law School; and is founder and co-director of the Multi-Regional Clinical Trials Center (MRCT Center) of Harvard University and Brigham and Women's Hospital. James P. Evans, M.D., Ph.D., is a Medical Geneticist and Internist who is currently retired, but pursued a long-standing interest in genomics and its broad social implications. He is Professor Emeritus, University of North Carolina at Chapel Hill, Department of Genetics. Bonnie LeRoy, M.S., L.G.C., is a licensed genetic counselor with over 20 years of clinical experience. She developed and now directs the Graduate Program in Genetic Counseling at the University of Minnesota. She is a past president of the National Society of Genetic Counselors, the American Board of Genetic Counseling, and the Association of Genetic Counseling Program Directors. Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; and Chair of the Consortium on Law and Values in Health, Environment & the Life Sciences at the University of Minnesota. She is a Principal Investigator on the LawSeq project funded by NIH. Institutions are listed for author identification only
| | - James P Evans
- Gary Marchant, B.SC., Ph.D., J.D., M.P.P., is Regents' Professor, Lincoln Professor of Emerging Technologies, Law & Ethics, and Faculty Director of the Center for Law, Science & Innovation at ASU. He researches, teaches and speaks about governance of a variety of emerging technologies including genomics, biotechnology, neuroscience, nanotechnology and artificial intelligence. Prior to starting at ASU in 1999, he was a partner in the Washington, DC office of Kirkland & Ellis. Mark Barnes, J.D., LL.M., is a partner in the life sciences practice at Ropes & Gray LLP; teaches health care law and the law of biomedical research at Yale Law School; and is founder and co-director of the Multi-Regional Clinical Trials Center (MRCT Center) of Harvard University and Brigham and Women's Hospital. James P. Evans, M.D., Ph.D., is a Medical Geneticist and Internist who is currently retired, but pursued a long-standing interest in genomics and its broad social implications. He is Professor Emeritus, University of North Carolina at Chapel Hill, Department of Genetics. Bonnie LeRoy, M.S., L.G.C., is a licensed genetic counselor with over 20 years of clinical experience. She developed and now directs the Graduate Program in Genetic Counseling at the University of Minnesota. She is a past president of the National Society of Genetic Counselors, the American Board of Genetic Counseling, and the Association of Genetic Counseling Program Directors. Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; and Chair of the Consortium on Law and Values in Health, Environment & the Life Sciences at the University of Minnesota. She is a Principal Investigator on the LawSeq project funded by NIH. Institutions are listed for author identification only
| | - Bonnie LeRoy
- Gary Marchant, B.SC., Ph.D., J.D., M.P.P., is Regents' Professor, Lincoln Professor of Emerging Technologies, Law & Ethics, and Faculty Director of the Center for Law, Science & Innovation at ASU. He researches, teaches and speaks about governance of a variety of emerging technologies including genomics, biotechnology, neuroscience, nanotechnology and artificial intelligence. Prior to starting at ASU in 1999, he was a partner in the Washington, DC office of Kirkland & Ellis. Mark Barnes, J.D., LL.M., is a partner in the life sciences practice at Ropes & Gray LLP; teaches health care law and the law of biomedical research at Yale Law School; and is founder and co-director of the Multi-Regional Clinical Trials Center (MRCT Center) of Harvard University and Brigham and Women's Hospital. James P. Evans, M.D., Ph.D., is a Medical Geneticist and Internist who is currently retired, but pursued a long-standing interest in genomics and its broad social implications. He is Professor Emeritus, University of North Carolina at Chapel Hill, Department of Genetics. Bonnie LeRoy, M.S., L.G.C., is a licensed genetic counselor with over 20 years of clinical experience. She developed and now directs the Graduate Program in Genetic Counseling at the University of Minnesota. She is a past president of the National Society of Genetic Counselors, the American Board of Genetic Counseling, and the Association of Genetic Counseling Program Directors. Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; and Chair of the Consortium on Law and Values in Health, Environment & the Life Sciences at the University of Minnesota. She is a Principal Investigator on the LawSeq project funded by NIH. Institutions are listed for author identification only
| | - Susan M Wolf
- Gary Marchant, B.SC., Ph.D., J.D., M.P.P., is Regents' Professor, Lincoln Professor of Emerging Technologies, Law & Ethics, and Faculty Director of the Center for Law, Science & Innovation at ASU. He researches, teaches and speaks about governance of a variety of emerging technologies including genomics, biotechnology, neuroscience, nanotechnology and artificial intelligence. Prior to starting at ASU in 1999, he was a partner in the Washington, DC office of Kirkland & Ellis. Mark Barnes, J.D., LL.M., is a partner in the life sciences practice at Ropes & Gray LLP; teaches health care law and the law of biomedical research at Yale Law School; and is founder and co-director of the Multi-Regional Clinical Trials Center (MRCT Center) of Harvard University and Brigham and Women's Hospital. James P. Evans, M.D., Ph.D., is a Medical Geneticist and Internist who is currently retired, but pursued a long-standing interest in genomics and its broad social implications. He is Professor Emeritus, University of North Carolina at Chapel Hill, Department of Genetics. Bonnie LeRoy, M.S., L.G.C., is a licensed genetic counselor with over 20 years of clinical experience. She developed and now directs the Graduate Program in Genetic Counseling at the University of Minnesota. She is a past president of the National Society of Genetic Counselors, the American Board of Genetic Counseling, and the Association of Genetic Counseling Program Directors. Susan M. Wolf, J.D., is McKnight Presidential Professor of Law, Medicine & Public Policy; Faegre Baker Daniels Professor of Law; Professor of Medicine; and Chair of the Consortium on Law and Values in Health, Environment & the Life Sciences at the University of Minnesota. She is a Principal Investigator on the LawSeq project funded by NIH. Institutions are listed for author identification only
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Spruce MW, Bowman JA, Wilson AJ, Galante JM. Improving Incidental Finding Documentation in Trauma Patients Amidst Poor Access to Follow-up Care. J Surg Res 2019; 248:62-68. [PMID: 31865160 DOI: 10.1016/j.jss.2019.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/21/2019] [Accepted: 11/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Incidental findings (IFs) are common among injured patients and create a complex problem with no standardized solution. MATERIALS AND METHODS This is a retrospective review of adult trauma patients admitted to a level I trauma center from January to May 2017. IFs from abdominal, chest, and neck imaging were categorized based on previously published guidelines focused on clinically significant IFs. Patient demographics related to access to care were collected. Outcome measures included documentation and patient notification of IFs. A univariate analysis was performed to identify characteristics that were associated with these outcomes. RESULTS Of 1671 patients, 682 met inclusion criteria, and 418 (61.3%) had any IF based on the a priori categorization scheme. In total, 67 (9.8%) were homeless, 58 (8.5%) had no health insurance, and 115 (16.9%) had no established primary care provider prior to admission. Documentation of IFs was included in discharge summaries and instructions 76.5% and 40.2% of the time, respectively. Physicians were statistically more likely to appropriately document IFs when radiologists provided specific recommendations. Transfer to another hospital service prior to discharge and discharge to another acute care facility were associated with reduced rates of successful documentation. No factors significantly affected documentation of patient notification. CONCLUSIONS Trauma patients are at risk for poor access to follow-up care of IFs. Expanding IF-specific guidelines, collaborating with radiologists to facilitate their inclusion in reports, and ensuring that IFs are part of patient hand-offs could provide systematic methods of improving their documentation.
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Affiliation(s)
- Marguerite W Spruce
- Department of Surgery, University of California Davis, Sacramento, California; Department of Surgery, David Grant USAF Medical Center, Fairfield, California.
| | - Jessica A Bowman
- Department of Surgery, University of California Davis, Sacramento, California
| | - Alice J Wilson
- School of Medicine, University of California Davis, Sacramento, California
| | - Joseph M Galante
- Department of Surgery, University of California Davis, Sacramento, California
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7
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Wu CC, Wolfe JM. Eye Movements in Medical Image Perception: A Selective Review of Past, Present and Future. Vision (Basel) 2019; 3:E32. [PMID: 31735833 PMCID: PMC6802791 DOI: 10.3390/vision3020032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/09/2019] [Accepted: 06/18/2019] [Indexed: 12/21/2022] Open
Abstract
The eye movements of experts, reading medical images, have been studied for many years. Unlike topics such as face perception, medical image perception research needs to cope with substantial, qualitative changes in the stimuli under study due to dramatic advances in medical imaging technology. For example, little is known about how radiologists search through 3D volumes of image data because they simply did not exist when earlier eye tracking studies were performed. Moreover, improvements in the affordability and portability of modern eye trackers make other, new studies practical. Here, we review some uses of eye movements in the study of medical image perception with an emphasis on newer work. We ask how basic research on scene perception relates to studies of medical 'scenes' and we discuss how tracking experts' eyes may provide useful insights for medical education and screening efficiency.
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Affiliation(s)
- Chia-Chien Wu
- Visual Attention Lab, Department of Surgery, Brigham & Women’s Hospital, 65 Landsdowne St, Cambridge, MA 02139, USA
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA
| | - Jeremy M. Wolfe
- Visual Attention Lab, Department of Surgery, Brigham & Women’s Hospital, 65 Landsdowne St, Cambridge, MA 02139, USA
- Department of Radiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA 02115, USA
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8
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Bombard Y, Brothers KB, Fitzgerald-Butt S, Garrison NA, Jamal L, James CA, Jarvik GP, McCormick JB, Nelson TN, Ormond KE, Rehm HL, Richer J, Souzeau E, Vassy JL, Wagner JK, Levy HP. The Responsibility to Recontact Research Participants after Reinterpretation of Genetic and Genomic Research Results. Am J Hum Genet 2019; 104:578-595. [PMID: 30951675 PMCID: PMC6451731 DOI: 10.1016/j.ajhg.2019.02.025] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022] Open
Abstract
The evidence base supporting genetic and genomic sequence-variant interpretations is continuously evolving. An inherent consequence is that a variant's clinical significance might be reinterpreted over time as new evidence emerges regarding its pathogenicity or lack thereof. This raises ethical, legal, and financial issues as to whether there is a responsibility to recontact research participants to provide updates on reinterpretations of variants after the initial analysis. There has been discussion concerning the extent of this obligation in the context of both research and clinical care. Although clinical recommendations have begun to emerge, guidance is lacking on the responsibilities of researchers to inform participants of reinterpreted results. To respond, an American Society of Human Genetics (ASHG) workgroup developed this position statement, which was approved by the ASHG Board in November 2018. The workgroup included representatives from the National Society of Genetic Counselors, the Canadian College of Medical Genetics, and the Canadian Association of Genetic Counsellors. The final statement includes twelve position statements that were endorsed or supported by the following organizations: Genetic Alliance, European Society of Human Genetics, Canadian Association of Genetic Counsellors, American Association of Anthropological Genetics, Executive Committee of the American Association of Physical Anthropologists, Canadian College of Medical Genetics, Human Genetics Society of Australasia, and National Society of Genetic Counselors.
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Affiliation(s)
- Yvonne Bombard
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON M5B 1T8, Canada.
| | - Kyle B Brothers
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA
| | - Sara Fitzgerald-Butt
- National Society of Genetic Counselors, Chicago, IL 60611, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Nanibaa' A Garrison
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA 98101, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98101, USA
| | - Leila Jamal
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; National Society of Genetic Counselors, Chicago, IL 60611, USA; National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Cynthia A James
- National Society of Genetic Counselors, Chicago, IL 60611, USA; Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Gail P Jarvik
- Executive Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington, Seattle, WA 98195, USA
| | - Jennifer B McCormick
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Humanities, College of Medicine, Pennsylvania State University, Hershey, PA 17033, USA
| | - Tanya N Nelson
- Canadian College of Medical Geneticists, Kingston, ON K7K 1Z7, Canada; BC Children's Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Kelly E Ormond
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Heidi L Rehm
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Medical and Populations Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Julie Richer
- Canadian College of Medical Geneticists, Kingston, ON K7K 1Z7, Canada; Department of Pediatrics, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON K1H 8L1, Canada; University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Emmanuelle Souzeau
- Canadian Association of Genetic Counsellors, Oakville, ON L6J 7N5, Canada; Department of Ophthalmology, Flinders University, Flinders Medical Centre, Adelaide, SA 5042, Australia
| | - Jason L Vassy
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA; Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, USA; VA Boston Healthcare System, Boston, MA 02130, USA
| | - Jennifer K Wagner
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17822, USA
| | - Howard P Levy
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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Experts reflecting on the duty to recontact patients and research participants; why professionals should take the lead in developing guidelines. Eur J Med Genet 2019; 63:103642. [PMID: 30904667 DOI: 10.1016/j.ejmg.2019.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/12/2019] [Accepted: 03/17/2019] [Indexed: 11/22/2022]
Abstract
Sequencing technology is increasing the scale of information that could benefit patients who have been tested in the past. This raises the question whether professionals have a duty to recontact such patients or their families. There is currently no clear basis for a legal duty to recontact, and professional guidelines are limited. We conducted interviews with 14 senior professionals from the Netherlands and UK to obtain a range of opinions on what obligations are estimated to be possible or desirable. There was (near) consensus that a lack of resources currently inhibits recontacting in clinical practice, that recontacting is less desirable in research, that information on recontacting should be part of informed consent, and that a legal duty should follow professional standards. There was a diversity of opinions on the desirability of a more systematic approach, potential obligations in hybrid clinical-research projects, and who should bear responsibility for seeking updates. Based on the literature, legal framework and these interviews, we conclude that a general duty to recontact is unlikely, but that in specific circumstances a limited duty may apply if the benefit to the individual is significant and the burden on professionals not too extensive. The variation in opinion demonstrates that further deliberations are desirable. The development of guidelines-a process the European Society of Human Genetics has begun-is important to ensure that the courts, in deciding a recontacting case, can take into account what professionals consider responsible standards in this field.
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10
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Factors Associated with Trial Outcomes in the Management of Nephrolithiasis: A Legal Database Review. UROLOGY PRACTICE 2017. [DOI: 10.1016/j.urpr.2016.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
This perspective addresses whether physicians have a duty to recontact former or current patients to update clinical advice based on newly discovered genomic information. Genetic information is unique compared with other medical data in that the underlying data do not appreciably change during the patients' lifetime, but the clinical significance of that information will continue to evolve. Based on relevant case law and guidelines, there is no general, established legal duty for physicians to affirmatively recontact former or current patients to update clinical advice based on newly discovered genetic information. However, integration of genomics into clinical practice is advancing quickly, and there may be limited, specific situations where a physician may have a duty to provide updated genetic information.
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Affiliation(s)
- Yvonne A Stevens
- Center for Law, Science & Innovation, Sandra Day O'Connor College of Law, Arizona State University, Phoenix, AZ85004, USA
| | - Grant D Senner
- Department of Family & Community Medicine, College of Medicine-Tucson, University of Arizona, Tucson, AZ85719, USA
| | - Gary E Marchant
- Center for Law, Science & Innovation, Sandra Day O'Connor College of Law, Arizona State University, Phoenix, AZ85004, USA
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12
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Dheensa S, Carrieri D, Kelly S, Clarke A, Doheny S, Turnpenny P, Lucassen A. A 'joint venture' model of recontacting in clinical genomics: challenges for responsible implementation. Eur J Med Genet 2017; 60:403-409. [PMID: 28501562 DOI: 10.1016/j.ejmg.2017.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/21/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
Advances in genomics often lead healthcare professionals (HCPs) to learn new information, e.g., about reinterpreted variants that could have clinical significance for patients seen previously. A question arises of whether HCPs should recontact these former patients. We present some findings interrogating the views of patients (or parents of patients) with a rare or undiagnosed condition about how such recontacting might be organised ethically and practically. Forty-one interviews were analysed thematically. Participants suggested a 'joint venture' model in which efforts to recontact are shared with HCPs. Some proposed an ICT-approach involving an electronic health record that automatically alerts them to potentially relevant updates. The need for rigorous privacy controls and transparency about who could access their data was emphasised. Importantly, these findings highlight that the lack of clarity about recontacting is a symptom of a wider problem: the lack of necessary infrastructure to pool genomic data responsibly, to aggregate it with other health data, and to enable patients/parents to receive updates. We hope that our findings will instigate a debate about the way responsibilities for recontacting under any joint venture model could be allocated, as well as the limitations and normative implications of using ICT as a solution to this intractable problem. As a first step to delineating responsibilities in the clinical setting, we suggest HCPs should routinely discuss recontacting with patients/parents, including the new information that should trigger a HCP to initiate recontact, as part of the consent process for genetic testing.
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Affiliation(s)
- Sandi Dheensa
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, UK; ELSI Group, Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | | | | | - Angus Clarke
- Division of Cancer & Genetics, School of Medicine, Cardiff University, UK
| | - Shane Doheny
- Division of Cancer & Genetics, School of Medicine, Cardiff University, UK
| | - Peter Turnpenny
- Egenis, University of Exeter, UK; Peninsular Genetics Service, Royal, Devon and Exeter Hospital, UK
| | - Anneke Lucassen
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, UK; ELSI Group, Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, UK
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13
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Pinheiro APM, Pocock RH, Switchenko JM, Dixon MD, Shaib WL, Ramalingam SS, Pentz RD. Discussing molecular testing in oncology care: Comparing patient and physician information preferences. Cancer 2017; 123:1610-1616. [PMID: 28140456 DOI: 10.1002/cncr.30494] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Molecular testing to inform treatment and clinical trial choices is now the standard of care for several types of cancer. However, no established guidelines exist for the type of information physicians should cover during discussions with the patient about the test or its results. The objectives of this study were to identify physician and patient preferences regarding information and who should communicate this information and how to inform guidelines for these conversations. METHODS Physicians and patients who participated in discussions regarding molecular testing were asked to choose 8 topics of most relevance out of a list of 18. The McNemar test was used to determine their top preferences. Patients were asked to identify what information they wanted to receive and who should inform them, and physicians were asked to identify the best aid to communication. RESULTS Sixty-six patients identified 12 preferred topics: the benefits of testing (88%), how testing determines treatment (88%), implications for family (71%), whether a test indicates the seriousness of disease (68%), purpose of the test (64%), incidental findings (56%), explanation of cancer genetics (53%), how the test is done (46%), limitations (44%), explanation of biomarker (42%), risks (42%), and uninformative results (38%). Physicians added cost (59%). Patients preferred receiving information about molecular testing from their nurse or physician (85%), and physicians preferred using a pamphlet (67%) to augment communication. CONCLUSIONS The topics identified as important to discuss can inform future guidelines and can contribute to effective communication regarding molecular testing. Cancer 2017;123:1610-1616. © 2017 American Cancer Society.
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Affiliation(s)
- Ana P M Pinheiro
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Margie D Dixon
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Suresh S Ramalingam
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca D Pentz
- Department of Hematology and Oncology, Winship Cancer Institute, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
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14
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Trends in medical malpractice claims in patients with cleft or craniofacial abnormalities in the United States. Int J Pediatr Otorhinolaryngol 2016; 90:214-219. [PMID: 27729136 DOI: 10.1016/j.ijporl.2016.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/22/2016] [Accepted: 09/22/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe medical malpractice trends in patients with cleft and/or craniofacial abnormalities. METHODS AND MATERIALS A modified Delphi approach was used to gather search terms. Search settings included "all jury verdicts and settlements", with jurisdiction of "all states" and "all federal courts" (by court and circuit). A retrospective review of WestLawNext legal database was conducted. Cases were excluded if they did not have a direct association from the patient's craniofacial anomaly or if they were not related to malpractice. RESULTS Forty-two cases met inclusion criteria. Cases closed between 1981 and 2014 were included. The mean payment among claims with an indemnity payment was $3.9 million. Of cases brought to trial, 62% were in favor of the plaintiff. Amongst physicians named as co-defendants, pediatricians were most commonly named (24%), followed by plastic surgeons (16%), obstetricians (7.8%), and radiologists (7.8%). "Missed diagnosis" was the most common type of negligent claim (45%), followed by "surgical error" (21%), and "medication error" (17%). "Anoxic brain injury" resulted in the highest median indemnity payment for complication of patient management ($3.5 million), followed by "wrongful birth" ($1.03 million), and "minor physical injury" ($520,000). No specific type of negligent claim (p = 0.764) nor complication of patient management (p = 0.61) was associated with a greater indemnity payment. Mean indemnity payment was $920,000 prior to 2001 and $4.4 million after 2001 (p = 0.058). CONCLUSIONS Mean indemnity payments were fourteen-fold greater in patients as compared to those in the overall population ($3.9 million versus $274,887) and seven-fold greater than those in the average pediatric population ($3.9 million versus $520,923). All healthcare providers should be aware of the associated medical malpractice claims that may be incurred when treating patients at risk for these conditions.
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15
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Exome and Genome Sequencing and Parallels in Radiology: Searching for Patient-Centered Management of Incidental and Secondary Findings. J Am Coll Radiol 2016; 13:1467-1472. [PMID: 27595197 DOI: 10.1016/j.jacr.2016.06.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 06/24/2016] [Accepted: 06/28/2016] [Indexed: 12/11/2022]
Abstract
Incidental and secondary findings have become an important by-product of diagnostic testing, and their ramifications affect clinical care, research, and policy. Given parallels in the reporting and management of such findings on diagnostic imaging, radiologists may draw from ongoing discussions in medical genetics to rethink more patient-centered approaches to analogous clinical, ethical, and medicolegal dilemmas. Low-risk incidental findings in particular may be drivers of unnecessary testing, invasive procedures, and overtreatment, with associated financial, psychological, and clinical consequences. As radiologists act in patients' best interests by strengthening standardized guidelines on how each finding merits further diagnostic testing or treatment, perhaps the greatest challenge for producing such guidelines is for low-risk incidental findings, for which adverse consequences are unlikely but associated with substantial uncertainty because of the lack of strong evidence on which to base the recommendations. More uniform recommendations for managing low-risk radiologic incidental findings should therefore aim to provide reasonable options that apply across a spectrum of patient preferences. These will require evaluation through research and will ultimately influence the quality of care. Specific areas for exploration may include (1) better gauging of patient attitudes and preferences regarding low-risk incidental findings, (2) using patient preferences to inform more uniform recommendations for low-risk findings that apply across a spectrum of preferences and help guide shared decision making, and (3) when patients endorse a strong preference not to discover low-risk incidental findings, how it might be possible for professional standards to curtail their generation in specific circumstances.
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16
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Pinard A, Salgado D, Desvignes JP, Rai G, Hanna N, Arnaud P, Guien C, Martinez M, Faivre L, Jondeau G, Boileau C, Zaffran S, Béroud C, Collod-Béroud G. WES/WGS Reporting of Mutations from Cardiovascular "Actionable" Genes in Clinical Practice: A Key Role for UMD Knowledgebases in the Era of Big Databases. Hum Mutat 2016; 37:1308-1317. [PMID: 27647783 DOI: 10.1002/humu.23119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/22/2016] [Accepted: 09/12/2016] [Indexed: 12/27/2022]
Abstract
High-throughput next-generation sequencing such as whole-exome and whole-genome sequencing are being rapidly integrated into clinical practice. The use of these techniques leads to the identification of secondary variants for which decisions about the reporting or not to the patient need to be made. The American College of Medical Genetics and Genomics recently published recommendations for the reporting of these variants in clinical practice for 56 "actionable" genes. Among these, seven are involved in Marfan Syndrome And Related Disorders (MSARD) resulting from mutations of the FBN1, TGFBR1 and 2, ACTA2, SMAD3, MYH11 and MYLK genes. Here, we show that mutations collected in UMD databases for MSARD genes (UMD-MSARD) are rarely reported, including the most frequent ones, in global scale initiatives for variant annotation such as the NHLBI GO Exome Sequencing Project (ESP), the Exome Aggregation Consortium (ExAC), and ClinVar. The predicted pathogenic mutations reported in global scale initiatives but absent in locus-specific databases (LSDBs) mainly correspond to rare events. UMD-MSARD databases are therefore the only resources providing access to the full spectrum of known pathogenic mutations. They are the most comprehensive resources for clinicians and geneticists to interpret MSARD-related variations not only primary variants but also secondary variants.
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Affiliation(s)
| | | | | | - Ghadi Rai
- Aix Marseille Univ, INSERM, GMGF, Marseille, France
| | - Nadine Hanna
- Département de Génétique, Hôpital Bichat AP-HP, Paris, France.,Inserm U1148 LVTS, Equipe 2 Maladies Structurelles Cardiovasculaires, Hôpital Bichat, Université Paris Diderot, Sorbonne Paris Cité.,Centre National de Référence Maladies Rares, Syndrome de Marfan et pathologies apparentées, Hôpital Bichat, AP-HP, Paris, France
| | - Pauline Arnaud
- Département de Génétique, Hôpital Bichat AP-HP, Paris, France.,Inserm U1148 LVTS, Equipe 2 Maladies Structurelles Cardiovasculaires, Hôpital Bichat, Université Paris Diderot, Sorbonne Paris Cité.,Centre National de Référence Maladies Rares, Syndrome de Marfan et pathologies apparentées, Hôpital Bichat, AP-HP, Paris, France
| | - Céline Guien
- Aix Marseille Univ, INSERM, GMGF, Marseille, France
| | - Maria Martinez
- IRSD, INSERM, INRA, ENVT, UPS, Université de Toulouse, Toulouse, France
| | - Laurence Faivre
- Fédération Hospitalo-Universitaire Médecine Translationnelle et Anomalies du Développement (TRANSLAD), Centre Hospitalier Universitaire Dijon, Dijon, France.,Centre de Génétique et Centre de Référence, Anomalies du Développement et Syndromes Malformatifs de l'Inter-région Est, Centre Hospitalier Universitaire Dijon, Dijon, France.,EA 4271 GAD, Université de Bourgogne Franche-Comté, Dijon, France
| | - Guillaume Jondeau
- Centre National de Référence Maladies Rares, Syndrome de Marfan et pathologies apparentées, Hôpital Bichat, AP-HP, Paris, France.,Service de Cardiologie, AP-HP, Hôpital Bichat, Paris, France.,AP-HP, Centre de référence pour les syndromes de Marfan et apparentés, Service de Cardiologie, Hôpital Bichat, Paris, France
| | - Catherine Boileau
- Inserm U1148 LVTS, Equipe 2 Maladies Structurelles Cardiovasculaires, Hôpital Bichat, Université Paris Diderot, Sorbonne Paris Cité.,Centre National de Référence Maladies Rares, Syndrome de Marfan et pathologies apparentées, Hôpital Bichat, AP-HP, Paris, France.,AP-HP, Centre de référence pour les syndromes de Marfan et apparentés, Service de Cardiologie, Hôpital Bichat, Paris, France
| | | | - Christophe Béroud
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,AP-HM, Département de Génétique Médicale, Hôpital Timone Enfants, Marseille, France
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17
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Pinard A, Miltgen M, Blanchard A, Mathieu H, Desvignes JP, Salgado D, Fabre A, Arnaud P, Barré L, Krahn M, Grandval P, Olschwang S, Zaffran S, Boileau C, Béroud C, Collod-Béroud G. Actionable Genes, Core Databases, and Locus-Specific Databases. Hum Mutat 2016; 37:1299-1307. [PMID: 27600092 DOI: 10.1002/humu.23112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/31/2016] [Indexed: 01/04/2023]
Abstract
Adoption of next-generation sequencing (NGS) in a diagnostic context raises numerous questions with regard to identification and reports of secondary variants (SVs) in actionable genes. To better understand the whys and wherefores of these questioning, it is necessary to understand how they are selected during the filtering process and how their proportion can be estimated. It is likely that SVs are underestimated and that our capacity to label all true SVs can be improved. In this context, Locus-specific databases (LSDBs) can be key by providing a wealth of information and enabling classifying variants. We illustrate this issue by analyzing 318 SVs in 23 actionable genes involved in cancer susceptibility syndromes identified through sequencing of 572 participants selected for a range of atherosclerosis phenotypes. Among these 318 SVs, only 43.4% are reported in Human Gene Mutation Database (HGMD) Professional versus 71.4% in LSDB. In addition, 23.9% of HGMD Professional variants are reported as pathogenic versus 4.8% for LSDB. These data underline the benefits of LSDBs to annotate SVs and minimize overinterpretation of mutations thanks to their efficient curation process and collection of unpublished data.
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Affiliation(s)
| | | | | | | | | | | | - Aurélie Fabre
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,APHM, Hôpital Timone Enfants, Laboratoire de Génétique Moléculaire, Marseille, 13385, France
| | - Pauline Arnaud
- AP-HP, Hôpital Bichat, Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France.,UFR de Médecine, Diderot Paris Université Paris 7, Paris, France.,Inserm, U1148, Paris, France
| | - Laura Barré
- Aix Marseille Univ, INSERM, GMGF, Marseille, France
| | - Martin Krahn
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,APHM, Hôpital Timone Enfants, Laboratoire de Génétique Moléculaire, Marseille, 13385, France
| | - Philippe Grandval
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,AP-HM, Hôpital de la Timone, Gastroentérologie, Marseille, France
| | - Sylviane Olschwang
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,APHM, Hôpital Timone Enfants, Laboratoire de Génétique Moléculaire, Marseille, 13385, France.,Hôpital Clairval, Ramsay Générale de Santé, Marseille, France.,Hôpital Européen, Fondation Ambroise Paré, Marseille, France
| | | | - Catherine Boileau
- AP-HP, Hôpital Bichat, Centre National de Référence pour le syndrome de Marfan et apparentés, Paris, France.,UFR de Médecine, Diderot Paris Université Paris 7, Paris, France.,Inserm, U1148, Paris, France
| | - Christophe Béroud
- Aix Marseille Univ, INSERM, GMGF, Marseille, France.,APHM, Hôpital Timone Enfants, Laboratoire de Génétique Moléculaire, Marseille, 13385, France
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18
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Green RC, Goddard KAB, Jarvik GP, Amendola LM, Appelbaum PS, Berg JS, Bernhardt BA, Biesecker LG, Biswas S, Blout CL, Bowling KM, Brothers KB, Burke W, Caga-Anan CF, Chinnaiyan AM, Chung WK, Clayton EW, Cooper GM, East K, Evans JP, Fullerton SM, Garraway LA, Garrett JR, Gray SW, Henderson GE, Hindorff LA, Holm IA, Lewis MH, Hutter CM, Janne PA, Joffe S, Kaufman D, Knoppers BM, Koenig BA, Krantz ID, Manolio TA, McCullough L, McEwen J, McGuire A, Muzny D, Myers RM, Nickerson DA, Ou J, Parsons DW, Petersen GM, Plon SE, Rehm HL, Roberts JS, Robinson D, Salama JS, Scollon S, Sharp RR, Shirts B, Spinner NB, Tabor HK, Tarczy-Hornoch P, Veenstra DL, Wagle N, Weck K, Wilfond BS, Wilhelmsen K, Wolf SM, Wynn J, Yu JH. Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine. Am J Hum Genet 2016; 98:1051-1066. [PMID: 27181682 DOI: 10.1016/j.ajhg.2016.04.011] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/14/2016] [Indexed: 12/11/2022] Open
Abstract
Despite rapid technical progress and demonstrable effectiveness for some types of diagnosis and therapy, much remains to be learned about clinical genome and exome sequencing (CGES) and its role within the practice of medicine. The Clinical Sequencing Exploratory Research (CSER) consortium includes 18 extramural research projects, one National Human Genome Research Institute (NHGRI) intramural project, and a coordinating center funded by the NHGRI and National Cancer Institute. The consortium is exploring analytic and clinical validity and utility, as well as the ethical, legal, and social implications of sequencing via multidisciplinary approaches; it has thus far recruited 5,577 participants across a spectrum of symptomatic and healthy children and adults by utilizing both germline and cancer sequencing. The CSER consortium is analyzing data and creating publically available procedures and tools related to participant preferences and consent, variant classification, disclosure and management of primary and secondary findings, health outcomes, and integration with electronic health records. Future research directions will refine measures of clinical utility of CGES in both germline and somatic testing, evaluate the use of CGES for screening in healthy individuals, explore the penetrance of pathogenic variants through extensive phenotyping, reduce discordances in public databases of genes and variants, examine social and ethnic disparities in the provision of genomics services, explore regulatory issues, and estimate the value and downstream costs of sequencing. The CSER consortium has established a shared community of research sites by using diverse approaches to pursue the evidence-based development of best practices in genomic medicine.
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Affiliation(s)
- Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Harvard Medical School, Boston, MA 02115, USA; Partners Personalized Medicine, Boston, MA 02139, USA.
| | - Katrina A B Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Gail P Jarvik
- Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA; Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Laura M Amendola
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York, NY 10032, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Barbara A Bernhardt
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Sawona Biswas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Carrie L Blout
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Kevin M Bowling
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Kyle B Brothers
- Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA
| | - Wylie Burke
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA; Department of Bioethics and Humanities, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | | | - Arul M Chinnaiyan
- Michigan Center for Translational Pathology, Ann Arbor, MI 48109, USA; Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA; Departments of Pathology and Urology, University of Michigan, Ann Arbor, MI 48109, USA; Howard Hughes Medical Institute, Ann Arbor, MI 48109, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University, New York, NY 10029, USA; Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Ellen W Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN 37203, USA
| | - Gregory M Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Kelly East
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - James P Evans
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Stephanie M Fullerton
- Department of Bioethics and Humanities, Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Levi A Garraway
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Department of Medical Oncology and Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, MA 02115, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Jeremy R Garrett
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO 64108, USA; Departments of Pediatrics and Philosophy, University of Missouri - Kansas City, Kansas City, MO 64110, USA
| | - Stacy W Gray
- Harvard Medical School, Boston, MA 02115, USA; Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Gail E Henderson
- Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Lucia A Hindorff
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Ingrid A Holm
- Harvard Medical School, Boston, MA 02115, USA; Division of Genetics and Genomics and the Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA 02115, USA
| | | | - Carolyn M Hutter
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Pasi A Janne
- Harvard Medical School, Boston, MA 02115, USA; Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Steven Joffe
- Department of Medical Ethics & Health Policy, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - David Kaufman
- Division of Genomics and Society, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Bartha M Knoppers
- Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University, Montreal, QC H3A 1B1, Canada
| | - Barbara A Koenig
- Institute for Health and Aging, University of California, San Francisco, San Francisco, CA 94118, USA
| | - Ian D Krantz
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Teri A Manolio
- Division of Genomic Medicine, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Laurence McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jean McEwen
- Division of Genomics and Society, National Human Genome Research Institute, NIH, Bethesda, MD 20892, USA
| | - Amy McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Donna Muzny
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX 77030, USA
| | - Richard M Myers
- HudsonAlpha Institute for Biotechnology, Huntsville, AL 35806, USA
| | - Deborah A Nickerson
- Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Jeffrey Ou
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Donald W Parsons
- Baylor College of Medicine and Texas Children's Cancer Center, Houston, TX 77030, USA
| | - Gloria M Petersen
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Sharon E Plon
- Baylor College of Medicine and Texas Children's Cancer Center, Houston, TX 77030, USA
| | - Heidi L Rehm
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Harvard Medical School, Boston, MA 02115, USA; Partners Personalized Medicine, Boston, MA 02139, USA; Laboratory for Molecular Medicine, Partners HealthCare, Cambridge, MA 02139, USA
| | - J Scott Roberts
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA
| | - Dan Robinson
- Michigan Center for Translational Pathology, Ann Arbor, MI 48109, USA
| | - Joseph S Salama
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; Clinical Sequencing Exploratory Research Coordinating Center, University of Washington, Seattle, WA 98195, USA
| | - Sarah Scollon
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Richard R Sharp
- Biomedical Ethics Research Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Brian Shirts
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98195, USA
| | - Nancy B Spinner
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Holly K Tabor
- Department of Pediatrics and Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
| | - Peter Tarczy-Hornoch
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA 98195, USA; University of Washington, Seattle, WA 98105, USA
| | - David L Veenstra
- Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Nikhil Wagle
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Department of Medical Oncology and Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, MA 02115, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Karen Weck
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, NC 27599, USA
| | - Benjamin S Wilfond
- Department of Pediatrics and Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
| | - Kirk Wilhelmsen
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Susan M Wolf
- Law School, Medical School, and Consortium on Law and Values in Health, Environment, & the Life Sciences, Minneapolis, University of Minnesota, MN 55455, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University, New York, NY 10029, USA
| | - Joon-Ho Yu
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
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19
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Loud JT, Bremer RC, Mai PL, Peters JA, Giri N, Stewart DR, Greene MH, Alter BP, Savage SA. Research participant interest in primary, secondary, and incidental genomic findings. Genet Med 2016; 18:1218-1225. [PMID: 27101135 PMCID: PMC5074919 DOI: 10.1038/gim.2016.36] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/08/2016] [Indexed: 01/24/2023] Open
Abstract
PURPOSE To define the frequency with which adult research participants consent to be offered clinically validated research genetic test results (RR) and incidental findings (IF). METHODS Consents were obtained from 506 adults enrolled in one of three studies within the National Cancer Institute Clinical Genetics Branch's Familial Cancer Research Program. A cross-sectional analysis was performed involving the choices indicated on study consents regarding receipt of RR and IF. RESULTS Ninety-seven percent opted to receive RR and IF. Participants who declined (n = 16) included two cancer survivors who were mutation-positive (1 = RR and 1 = both), eight who knew their primary mutation status (3 = RR; 4 = IF; 1 = both), three nonbloodline relatives (1 = RR; 2 = both), one untested but with the syndromic phenotype (1 = IF), and two parents of an affected child (2 = both). We speculate that these individuals either already had sufficient information, were not prepared to learn more, or felt that the information would not change their personal health-care decision making. CONCLUSIONS Adult research participants from families at high genetic risk for cancer overwhelmingly indicated their preference to receive both RR and IF. Future research will seek to identify the reasons for declining RR and IF and to study the impact of receipt of RR and IF on personal medical decision making.Genet Med 18 12, 1218-1225.
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Affiliation(s)
- Jennifer T Loud
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Renee C Bremer
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Phuong L Mai
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - June A Peters
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Neelam Giri
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Douglas R Stewart
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Mark H Greene
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Sharon A Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
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Hofmann B. Incidental findings of uncertain significance: To know or not to know--that is not the question. BMC Med Ethics 2016; 17:13. [PMID: 26873084 PMCID: PMC4752786 DOI: 10.1186/s12910-016-0096-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/04/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although the "right not to know" is well established in international regulations, it has been heavily debated. Ubiquitous results from extended exome and genome analysis have challenged the right not to know. American College of Medical Genetics and Genomics (ACMG) Recommendations urge to inform about incidental findings that pretend to be accurate and actionable. However, ample clinical cases raise the question whether these criteria are met. Many incidental findings are of uncertain significance (IFUS). The eager to feedback information appears to enter the field of IFUS and thereby threaten the right not to know. This makes it imperative to investigate the arguments for and against a right not to know for IFUS. DISCUSSION This article investigates how the various arguments for and against a right not to know hold for IFUS. The main investigated arguments are: hypothetical utilitarianism, the right-based argument, the feasibility argument, the value of knowledge argument, the argument from lost significance, the empirical argument, the duty to disclose argument, the avoiding harm argument; the argument from principle, from autonomy, from privacy, as well as the argument from the right to an open future. The analysis shows that both sides in the debate have exaggerated the importance of incidental findings. Opponents of a right not to know have exaggerated the importance of IFUS, while proponents have exaggerated the need to be protected from something that is not knowledge. Hence, to know or not to know is not the question. The question is whether we should be able to stay ignorant of incidental findings of uncertain significance, if we want to. The answer is yes: As long as the information is not accurate and/or actionable: ignorance is bliss. When answering questions that are not asked, we need to think twice.
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Affiliation(s)
- Bjørn Hofmann
- Norwegian University of Science and Technology, Gjøvik, Norway. .,Centre for Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318, Oslo, Norway.
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Hofstatter E, Mehra K, Yushak M, Pusztai L. Tumor profiling and the incidentalome: patient decisions and risks. Future Oncol 2015; 11:3299-305. [DOI: 10.2217/fon.15.260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
In recent years, the field of oncology has witnessed rapid advancements in genetic sequencing simultaneously with steeply declining costs of sequencing technology. As a result, genomics-driven cancer medicine and the use of tumor profiling are quickly becoming mainstays of cancer therapy. Oncology patients can benefit from tumor profiling by allowing the selection of targeted therapies tailored to their disease. However, it is increasingly recognized that the process of determining a tumor DNA sequence may lead to incidental discovery of underlying germline mutations which can impact other aspects of a patient’s health, and that of their family. How to handle the ‘incidentalome’ has been the subject of recent public debate, yet patient education about the potential risks of tumor profiling remains sparse. Patient perspectives and clinical implications of the tumor incidentalome must be specifically addressed by the oncology community as tumor profiling expands to become a new standard of care.
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Affiliation(s)
- Erin Hofstatter
- Section of Medical Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT 06520, USA
| | - Karishma Mehra
- Section of Medical Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT 06520, USA
| | - Melinda Yushak
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Lajos Pusztai
- Section of Medical Oncology, Yale Cancer Center, Yale School of Medicine, New Haven, CT 06520, USA
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22
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Higuchi EC, Sheldon JP, Zikmund-Fisher BJ, Yashar BM. Non-invasive prenatal screening for trisomy 21: Consumers' perspectives. Am J Med Genet A 2015; 170A:375-385. [PMID: 26553705 DOI: 10.1002/ajmg.a.37460] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 10/22/2015] [Indexed: 11/05/2022]
Abstract
Non-invasive prenatal screening (NIPS) has the potential to dramatically increase the prenatal detection rate of Down syndrome because of improvements in safety and accuracy over existing tests. There is concern that NIPS could lead to more negative attitudes towards Down syndrome and less support for individuals with Down syndrome. To assess the impact of NIPS on support for prenatal testing, decision-making about testing, and beliefs or attitudes about Down syndrome, we performed an Internet-based experiment using adults (N = 1,789) recruited through Amazon Mechanical Turk. Participants were randomly assigned to read a mock news article about NIPS, a mock news article about amniocentesis, or no article. The content in the two articles varied only in their descriptions of the test characteristics. Participants then answered questions about their support for testing, hypothetical testing decision, and beliefs and attitudes about Down syndrome. Reading the mock NIPS news article predicted increased hypothetical test uptake. In addition, the NIPS article group also agreed more strongly that pregnant women, in general, should utilize prenatal testing. We also found that the more strongly participants supported prenatal testing for pregnant women, the less favorable their attitudes towards individuals with Down syndrome; providing some evidence that NIPS may indirectly result in more negative perceptions of individuals with this diagnosis.
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Affiliation(s)
- Emily C Higuchi
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin
| | - Jane P Sheldon
- Department of Behavioral Sciences, University of Michigan-Dearborn, Dearborn, Michigan
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Beverly M Yashar
- Department of Human Genetics, University of Michigan, Ann Arbor, Michigan
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Colaco M, Heavner M, Sunaryo P, Terlecki R. Malpractice Litigation and Testicular Torsion: A Legal Database Review. J Emerg Med 2015; 49:849-54. [PMID: 26409673 DOI: 10.1016/j.jemermed.2015.06.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/15/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The litigious nature of the American medical environment is a major concern for physicians, with an estimated annual cost of $10 billion. OBJECTIVE The purpose of this study is to identify causes of litigation in cases of testicular torsion and what factors contribute to verdicts or settlements resulting in indemnity payments. METHODS Publicly available jury verdict reports were retrieved from the Westlaw legal database (Thomson Reuters, New York, NY). In order to identify pertinent cases, we used the search terms "medical malpractice" and "testicular torsion" with date ranging from 2000 to 2013. Jury verdicts, depositions, and narrative summaries were evaluated for their medical basis, alleged malpractice, findings, and indemnity payment(s) (if any). RESULTS Fifty-two cases were identified that were relevant to this study. Fifty-one percent of relevant cases were found in favor of the defendant physician, with the remaining 49% involving an indemnity payment (13% of which were settled). The most commonly sued medical providers were emergency physicians (48% of defendants), with urologists being second most common and making up 23% of the defendant pool. Emergency physicians were significantly more likely to make indemnity payments than urologists. CONCLUSION Testicular torsion is a delicate condition and requires expertise in evaluation and treatment. When emergency physicians choose not to consult an urologist for possible torsion, they leave themselves open to litigation risk. When an urologist is involved in torsion litigation, they are rarely unsuccessful in their defense. Finally, ultrasound is no guarantee for success against litigation.
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Affiliation(s)
- Marc Colaco
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew Heavner
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Peter Sunaryo
- Division of Urology, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ryan Terlecki
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Roche MI, Berg JS. Incidental Findings with Genomic Testing: Implications for Genetic Counseling Practice. CURRENT GENETIC MEDICINE REPORTS 2015; 3:166-176. [PMID: 26566463 PMCID: PMC4633435 DOI: 10.1007/s40142-015-0075-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This paper summarizes the current controversies surrounding the identification and disclosure of "incidental" or "secondary" findings from genomic sequencing and the implications for genetic counseling practice. The rapid expansion of clinical sequencing has influenced the ascertainment and return of incidental findings, while empiric data to inform best practices are still being generated. Using the North Carolina Clinical Genomic Evaluation by Next Generation Exome Sequencing (NCGENES) research project as an example, we discuss the implications of different models of consent and their impact on patient decisions.
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Affiliation(s)
- Myra I. Roche
- />Department of Pediatrics and Genetics, School of Medicine, The University of North Carolina at Chapel Hill, 326A MacNider, Chapel Hill, NC 27599-7240 USA
| | - Jonathan S. Berg
- />Department of Genetics, The University of North Carolina at Chapel Hill, 120 Mason Farm Road, Chapel Hill, NC 27599-7264 USA
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Blackburn HL, Schroeder B, Turner C, Shriver CD, Ellsworth DL, Ellsworth RE. Management of Incidental Findings in the Era of Next-generation Sequencing. Curr Genomics 2015; 16:159-74. [PMID: 26069456 PMCID: PMC4460220 DOI: 10.2174/1389202916666150317232930] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/23/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Next-generation sequencing (NGS) technologies allow for the generation of whole exome or whole genome sequencing data, which can be used to identify novel genetic alterations associated with defined phenotypes or to expedite discovery of functional variants for improved patient care. Because this robust technology has the ability to identify all mutations within a genome, incidental findings (IF)- genetic alterations associated with conditions or diseases unrelated to the patient's present condition for which current tests are being performed- may have important clinical ramifications. The current debate among genetic scientists and clinicians focuses on the following questions: 1) should any IF be disclosed to patients, and 2) which IF should be disclosed - actionable mutations, variants of unknown significance, or all IF? Policies for disclosure of IF are being developed for when and how to convey these findings and whether adults, minors, or individuals unable to provide consent have the right to refuse receipt of IF. In this review, we detail current NGS technology platforms, discuss pressing issues regarding disclosure of IF, and how IF are currently being handled in prenatal, pediatric, and adult patients.
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Affiliation(s)
| | - Bradley Schroeder
- Clinical Breast Care Project, Windber Research Institute, Windber, PA, USA
| | - Clesson Turner
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Craig D. Shriver
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Rachel E. Ellsworth
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
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26
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Ye Z, Kadolph C, Strenn R, Wall D, McPherson E, Lin S. WHATIF: An open-source desktop application for extraction and management of the incidental findings from next-generation sequencing variant data. Comput Biol Med 2015; 68:165-9. [PMID: 25890833 DOI: 10.1016/j.compbiomed.2015.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 03/26/2015] [Accepted: 03/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Identification and evaluation of incidental findings in patients following whole exome (WGS) or whole genome sequencing (WGS) is challenging for both practicing physicians and researchers. The American College of Medical Genetics and Genomics (ACMG) recently recommended a list of reportable incidental genetic findings. However, no informatics tools are currently available to support evaluation of incidental findings in next-generation sequencing data. METHODS The Wisconsin Hierarchical Analysis Tool for Incidental Findings (WHATIF), was developed as a stand-alone Windows-based desktop executable, to support the interactive analysis of incidental findings in the context of the ACMG recommendations. WHATIF integrates the European Bioinformatics Institute Variant Effect Predictor (VEP) tool for biological interpretation and the National Center for Biotechnology Information ClinVar tool for clinical interpretation. RESULTS An open-source desktop program was created to annotate incidental findings and present the results with a user-friendly interface. Further, a meaningful index (WHATIF Index) was devised for each gene to facilitate ranking of the relative importance of the variants and estimate the potential workload associated with further evaluation of the variants. Our WHATIF application is available at: http://tinyurl.com/WHATIF-SOFTWARE CONCLUSIONS: The WHATIF application offers a user-friendly interface and allows users to investigate the extracted variant information efficiently and intuitively while always accessing the up to date information on variants via application programming interfaces (API) connections. WHATIF׳s highly flexible design and straightforward implementation aids users in customizing the source code to meet their own special needs.
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Affiliation(s)
- Zhan Ye
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA.
| | - Christopher Kadolph
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA
| | - Robert Strenn
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA
| | - Daniel Wall
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA
| | - Elizabeth McPherson
- Department of Medical Genetics Services, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA
| | - Simon Lin
- Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI 54449, USA
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Otten E, Plantinga M, Birnie E, Verkerk MA, Lucassen AM, Ranchor AV, Van Langen IM. Is there a duty to recontact in light of new genetic technologies? A systematic review of the literature. Genet Med 2014; 17:668-78. [PMID: 25503495 DOI: 10.1038/gim.2014.173] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/27/2014] [Indexed: 12/27/2022] Open
Abstract
PURPOSE With rapid advances in genetic technologies, new genetic information becomes available much faster today than just a few years ago. This has raised questions about whether clinicians have a duty to recontact eligible patients when new genetic information becomes available and, if such duties exist, how they might be implemented in practice. METHODS We report the results of a systematic literature search on the ethical, legal, social (including psychological), and practical issues involved in recontacting former patients who received genetic services. We identified 1,428 articles, of which 61 are covered in this review. RESULTS The empirical evidence available indicates that most but not all patients value being recontacted. A minority of (older) articles conclude that recontacting should be a legal duty. Most authors consider recontacting to be ethically desirable but practically unfeasible. Various solutions to overcome these practical barriers have been proposed, involving efforts of laboratories, clinicians, and patients. CONCLUSION To advance the discussion on implementing recontacting in clinical genetics, we suggest focusing on the question of in what situations recontacting might be regarded as good standard of care. To this end, reaching a professional consensus, obtaining more extensive empirical evidence, and developing professional guidelines are important.
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Affiliation(s)
- Ellen Otten
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mirjam Plantinga
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marian A Verkerk
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anneke M Lucassen
- 1] Faculty of Medicine, Clinical Ethics and Law, University of Southampton, Southampton, UK [2] Wessex Clinical Genetic Service, Southampton, UK
| | - Adelita V Ranchor
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Irene M Van Langen
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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28
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Svider PF, Jiron J, Zuliani G, Shkoukani MA, Folbe AJ, Carron M. Unattractive Consequences: Litigation From Facial Dermabrasion and Chemical Peels. Aesthet Surg J 2014; 34:1244-9. [DOI: 10.1177/1090820x14547948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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29
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Sunaryo PL, Colaco M, Terlecki R. Penile Prostheses and the Litigious Patient: A Legal Database Review. J Sex Med 2014; 11:2589-94. [DOI: 10.1111/jsm.12649] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shkedi-Rafid S, Dheensa S, Crawford G, Fenwick A, Lucassen A. Defining and managing incidental findings in genetic and genomic practice. J Med Genet 2014; 51:715-23. [PMID: 25228303 DOI: 10.1136/jmedgenet-2014-102435] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The rapidly declining costs and increasing speeds of whole-genome analysis mean that genetic testing is undergoing a shift from targeted approaches to broader ones that look at the entire genome. As whole-genome technologies gain widespread use, questions about the management of so-called incidental findings-those unrelated to the question being asked-need urgent consideration. In this review, we bring together current understanding and arguments about (1) appropriate terminology, (2) the determination of clinical utility and when to disclose incidental findings, (3) the differences in management and disclosure in clinical, research and commercial contexts and (4) ethical and practical issues about familial implications and recontacting those tested. We recommend that greater international consensus is developed around the disclosure and management of incidental findings, with particular attention to when, and how, less clear-cut results should be communicated. We suggest that there is no single term that captures all the issues around these kinds of findings and that different terms may, therefore, need to be used in different settings. We also encourage the use of clear consent processes, but suggest that the absence of consent should not always preclude disclosure. Finally, we recommend further research to identify ways to implement the use of a genome output as a resource, accessible over time, to facilitate appropriate disclosure and recontact when the significance of a previously unclear incidental finding is clarified.
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Affiliation(s)
- Shiri Shkedi-Rafid
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Sandi Dheensa
- Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Gillian Crawford
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Angela Fenwick
- Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Anneke Lucassen
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
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31
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Angrist M, Jamal L. Living laboratory: whole-genome sequencing as a learning healthcare enterprise. Clin Genet 2014; 87:311-8. [PMID: 25045831 DOI: 10.1111/cge.12461] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 06/30/2014] [Accepted: 07/15/2014] [Indexed: 01/16/2023]
Abstract
With the proliferation of affordable large-scale human genomic data come profound and vexing questions about management of such data and their clinical uncertainty. These issues challenge the view that genomic research on human beings can (or should) be fully segregated from clinical genomics, either conceptually or practically. Here, we argue that the sharp distinction between clinical care and research is especially problematic in the context of large-scale genomic sequencing of people with suspected genetic conditions. Core goals of both enterprises (e.g. understanding genotype-phenotype relationships; generating an evidence base for genomic medicine) are more likely to be realized at a population scale if both those ordering and those undergoing sequencing for diagnostic reasons are routinely and longitudinally studied. Rather than relying on expensive and lengthy randomized clinical trials and meta-analyses, we propose leveraging nascent clinical-research hybrid frameworks into a broader, more permanent instantiation of exploratory medical sequencing. Such an investment could enlighten stakeholders about the real-life challenges posed by whole-genome sequencing, such as establishing the clinical actionability of genetic variants, returning 'off-target' results to families, developing effective service delivery models and monitoring long-term outcomes.
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Affiliation(s)
- M Angrist
- Science and Society, Social Science Research Institute and Sanford School of Public Policy, Duke University, Durham, NC, USA
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Abstract
INTRODUCTION Next-generation sequencing (NGS) is transforming the conduct of genetic research and diagnostic investigation. This creates new challenges as it generates additional information, including unsought and unwanted information. Nevertheless, this information must be deliberately managed-interpreted, disclosed and then either stored or destroyed. AREAS OF AGREEMENT Handling the process of consent to exome or genome sequencing should include discussion about the possible detection of variants of uncertain significance (VUSs) or incidental findings (IFs) that the patient may prefer not to hear about. A plan should be drawn up that specifies whether and how the patient would be recontacted in the future with new interpretations. AREAS OF CONTROVERSY There is an active debate about which IFs or VUSs should be disclosed to the patient when an exome or genome sequence has been performed, or whether all findings of any possible relevance should always be disclosed. How this is managed has important implications for the initial explanation of the test to the patient and the process of consent. The assumption is often made that all sequence information should be stored, but this may not be sustainable or useful. GROWING POINTS Efforts are being made to build a consensus on what 'incidental' information should be disclosed. These policy questions are being addressed in many centres and practices are evolving rapidly. AREAS TIMELY FOR DEVELOPING RESEARCH Those interested in genetics, public health, bioethics and medical ethics may wish to debate these issues and influence future practice in both genetic research and genetic diagnostic services.
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Affiliation(s)
- Angus J Clarke
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
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Nishimura AA, Tarczy-Hornoch P, Shirts BH. Pragmatic and Ethical Challenges of Incorporating the Genome into the Electronic Medical Record. CURRENT GENETIC MEDICINE REPORTS 2014; 2:201-211. [PMID: 26146597 DOI: 10.1007/s40142-014-0051-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recent successes in the use of gene sequencing for patient care highlight the potential of genomic medicine. For genomics to become a part of usual care, pertinent elements of a patient's genomic test must be communicated to the most appropriate care providers. Electronic medical records may serve as a useful tool for storing and disseminating genomic data. Yet, the structure of existing EMRs and the nature of genomic data pose a number of pragmatic and ethical challenges in their integration. Through a review of the recent genome-EMR integration literature, we explore concrete examples of these challenges, categorized under four key questions: What data will we store? How will we store it? How will we use it? How will we protect it? We conclude that genome-EMR integration requires a rigorous, multi-faceted and interdisciplinary approach of study. Problems facing the field are numerous, but few are intractable.
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Affiliation(s)
- Adam A Nishimura
- Department of Biomedical Informatics and Medical Education, University of Washington
| | - Peter Tarczy-Hornoch
- Department of Biomedical Informatics and Medical Education, University of Washington ; Department of Pediatrics, University of Washington ; Department of Computer Science and Engineering, University of Washington
| | - Brian H Shirts
- Department of Laboratory Medicine, University of Washington
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34
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Svider PF, Carron MA, Zuliani GF, Eloy JA, Setzen M, Folbe AJ. Lasers and Losers in the Eyes of the Law. JAMA FACIAL PLAST SU 2014; 16:277-83. [DOI: 10.1001/jamafacial.2014.21] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Peter F. Svider
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Michael A. Carron
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
- Section of Otolaryngology, Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan
| | - Giancarlo F. Zuliani
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
- Section of Otolaryngology, Department of Surgery, John D. Dingell VA Medical Center, Detroit, Michigan
| | - Jean Anderson Eloy
- Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark
- Center for Skull Base and Pituitary Surgery, Rutgers New Jersey Medical School, Newark
| | - Michael Setzen
- Rhinology Section, North Shore University Hospital, Manhasset, New York
- Department of Otolaryngology, New York University School of Medicine, New York
| | - Adam J. Folbe
- Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan
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35
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Colaco M, Sandberg J, Badlani G. Influencing Factors Leading to Malpractice Litigation in Radical Prostatectomy. J Urol 2014; 191:1770-5. [DOI: 10.1016/j.juro.2013.12.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2013] [Indexed: 01/31/2023]
Affiliation(s)
- Marc Colaco
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jason Sandberg
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gopal Badlani
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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36
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Strong KA, Zusevics KL, Bick D, Veith R. Views of primary care providers regarding the return of genome sequencing incidental findings. Clin Genet 2014; 86:461-8. [PMID: 24673592 DOI: 10.1111/cge.12390] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/13/2014] [Accepted: 03/25/2014] [Indexed: 01/18/2023]
Abstract
Sequencing of the entire exome or genome is increasingly used in clinical practice. Debate continues, however, regarding which incidental findings (IFs) should be returned and who should be involved in those decisions. Previous empirical research regarding stakeholder attitudes to the return of IFs has primarily involved genetics professionals; non-genetics health professionals have not been widely surveyed. Given this, a survey regarding return of IFs was administered at the Best Practices in Pediatrics Conference following an educational presentation on genetics terminology and genetic condition examples. A total of 258 participants completed the survey. Of particular note, respondents who were positively disposed to sequencing did not always report wanting to learn about IFs, even if actionable. This is noteworthy given recent American College of Medical Genetics and Genomics guidelines recommending particular actionable IF be returned 'without reference to patient preference'. This study's findings are important because they provide insight regarding the attitudes to the return of genome sequencing results for an important professional group, primary care providers. Ultimately, as likely gatekeepers to referrals for this technology, their opinions about the test will be key to its successful deployment.
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Affiliation(s)
- K A Strong
- Program in Genomics and Ethics, Center for Bioethics and Medical Humanities, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA; Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, WI, USA
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37
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McGuire AL, Knoppers BM, Zawati MH, Clayton EW. Can I be sued for that? Liability risk and the disclosure of clinically significant genetic research findings. Genome Res 2014; 24:719-23. [PMID: 24676095 PMCID: PMC4009601 DOI: 10.1101/gr.170514.113] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Genomic researchers increasingly are faced with difficult decisions about whether, under what circumstances, and how to return research results and significant incidental findings to study participants. Many have argued that there is an ethical-maybe even a legal-obligation to disclose significant findings under some circumstances. At the international level, over the last decade there has begun to emerge a clear legal obligation to return significant findings discovered during the course of research. However, there is no explicit legal duty to disclose in the United States. This creates legal uncertainty that may lead to unmanaged variation in practice and poor quality care. This article discusses liability risks associated with the disclosure of significant research findings for investigators in the United States.
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Affiliation(s)
- Amy L. McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas 77030, USA
| | | | - Ma’n H. Zawati
- Centre of Genomics and Policy, McGill University, Montreal, Quebec H3A 0G1, Canada
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee 37203, USA
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Rose C, Svider PF, Sheyn A, Meadows LN, Eloy JA, Coticchia J, Folbe AJ. Protecting the most vulnerable: Litigation from pediatric otolaryngologic procedures and conditions. Laryngoscope 2014; 124:2161-6. [DOI: 10.1002/lary.24663] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/26/2014] [Accepted: 03/04/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Christopher Rose
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Anthony Sheyn
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Lila N. Meadows
- Francis King Carey School of Law; University of Maryland; Baltimore Maryland
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Department of Neurological Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
| | - James Coticchia
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
| | - Adam J. Folbe
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan
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Dal-Ré R, Katsanis N, Katsanis S, Parker LS, Ayuso C. Managing incidental genomic findings in clinical trials: fulfillment of the principle of justice. PLoS Med 2014; 11:e1001584. [PMID: 24453945 PMCID: PMC3891615 DOI: 10.1371/journal.pmed.1001584] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Rafael Dal-Ré and colleagues discuss how incidental findings are likely to be viewed as potential benefits of research participation in genomics trials, and investigators should implement mechanisms to ensure provision of timely and appropriate care. Ensuring provision of such interventions in countries lacking a universal public health care system may prove challenging. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research Program, Pasqual Maragall Foundation, Barcelona, Spain
| | - Nicholas Katsanis
- Center for Human Disease Modeling, Department of Cell Biology, Department of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Sara Katsanis
- Duke Institute for Genome Sciences and Policy, Duke University, Durham, North Carolina, United States of America
| | - Lisa S. Parker
- Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Carmen Ayuso
- Department of Genetics, Health Research Institute–Jimenez Diaz Foundation University Hospital (IIS-FJD), Madrid, Spain
- CIBERER (Centro de Investigación Biomédica en Red de Enfermedades Raras), Instituto de Salud Carlos III, Madrid, Spain
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40
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Isasi R. Stem Cell Research and Banking: Towards Policy on Disclosing Research Results and Incidental Findings. STEM CELL BIOLOGY AND REGENERATIVE MEDICINE 2014. [DOI: 10.1007/978-1-4939-0585-0_4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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41
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Ormond KE, Cho MK. Translating personalized medicine using new genetic technologies in clinical practice: the ethical issues. Per Med 2014; 11:211-222. [PMID: 25221608 PMCID: PMC4160120 DOI: 10.2217/pme.13.104] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The integration of new genetic technologies into clinical practice holds great promise for the personalization of medical care, particularly the use of large-scale DNA sequencing for genome-wide genetic testing. However, these technologies also yield unprecedented amounts of information whose clinical implications are not fully understood, and we are still developing technical standards for measuring sequence accuracy. These technical and clinical challenges raise ethical issues that are similar to but qualitatively different from those that we are accustomed to dealing with for traditional medical genetics. The sheer amount of information afforded by genome sequencing requires rethinking of how to implement core ethical principles including, but not limited to: informed consent, privacy and data ownership and sharing, technology regulation, issues of access, particularly as new technology is integrated into clinical practice, and issues of potential stigma and impact on perceptions of disability. In this article, we will review the issues of informed consent, privacy, data ownership and technology regulation as they relate to the emerging field of personalized medicine and genomics.
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Affiliation(s)
- Kelly E Ormond
- Department of Genetics, Mail Stop-5208, Stanford University, Stanford, CA 94305-5208, USA
- Stanford Center for Biomedical Ethics, 1215 Welch Road, Modular A, Stanford, CA 94305-5417, USA
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics, 1215 Welch Road, Modular A, Stanford, CA 94305-5417, USA
- Department of Pediatrics, 300 Pasteur Drive, Stanford, CA 94305-5208, USA
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Helm BM, Langley K, Spangler B, Vergano S. Three clinical experiences with SNP array results consistent with parental incest: a narrative with lessons learned. J Genet Couns 2013; 23:489-95. [PMID: 24222483 DOI: 10.1007/s10897-013-9669-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/31/2013] [Indexed: 02/05/2023]
Abstract
Single nucleotide polymorphism microarrays have the ability to reveal parental consanguinity which may or may not be known to healthcare providers. Consanguinity can have significant implications for the health of patients and for individual and family psychosocial well-being. These results often present ethical and legal dilemmas that can have important ramifications. Unexpected consanguinity can be confounding to healthcare professionals who may be unprepared to handle these results or to communicate them to families or other appropriate representatives. There are few published accounts of experiences with consanguinity and SNP arrays. In this paper we discuss three cases where molecular evidence of parental incest was identified by SNP microarray. We hope to further highlight consanguinity as a potential incidental finding, how the cases were handled by the clinical team, and what resources were found to be most helpful. This paper aims to contribute further to professional discourse on incidental findings with genomic technology and how they were addressed clinically. These experiences may provide some guidance on how others can prepare for these findings and help improve practice. As genetic and genomic testing is utilized more by non-genetics providers, we also hope to inform about the importance of engaging with geneticists and genetic counselors when addressing these findings.
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Affiliation(s)
- Benjamin M Helm
- Department of Medical Genetics and Metabolism, Children's Hospital of the King's Daughters/Eastern Virginia Medical School, 601 Children's Lane, 2nd Floor Pediatrics, Norfolk, VA, 23507, USA,
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Patient decisions for disclosure of secondary findings among the first 200 individuals undergoing clinical diagnostic exome sequencing. Genet Med 2013; 16:395-9. [PMID: 24113345 PMCID: PMC4018499 DOI: 10.1038/gim.2013.153] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/16/2013] [Indexed: 12/15/2022] Open
Abstract
Purpose: Exome sequencing of a single individual for a clinical indication may result in the identification of incidental deleterious variants unrelated to the indication for testing (secondary findings). Given the recent availability of clinical exome testing, there is a limited knowledge regarding the disclosure preferences and impact of secondary findings in a clinical diagnostic setting. In this article, we provide preliminary data regarding the preferences for secondary findings results disclosure based on the first 200 families referred to Ambry Genetics for diagnostic exome sequencing. Methods: Secondary findings were categorized into four groups in the diagnostic exome sequencing consent: carrier status of recessive disorders, predisposition to later-onset disease, predisposition to increased cancer risk, and early-onset disease. In this study, we performed a retrospective analysis of patient responses regarding the preferences for secondary findings disclosure. Results: The majority of patients (187/200; 93.5%) chose to receive secondary results for one or more available categories. Adult probands were more likely than children to opt for blinding of secondary data (16 vs. 4%, respectively). Among responses for blinding, preferences were evenly scattered among categories. Conclusion: These data represent the unprecedented results of a large reference laboratory providing clinical exome sequencing. We report, for the first time, the preferences of patients and families for the receipt of secondary findings based on clinical genome sequencing. Overwhelmingly, families undergoing exome sequencing opt for the disclosure of secondary findings. The data may have implications regarding the development of guidelines for secondary findings reporting among patients with severe and/or life-threatening disease undergoing clinical genomic sequencing.
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Evans BJ. Minimizing liability risks under the ACMG recommendations for reporting incidental findings in clinical exome and genome sequencing. Genet Med 2013; 15:915-20. [PMID: 24030435 DOI: 10.1038/gim.2013.135] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 07/29/2013] [Indexed: 11/09/2022] Open
Abstract
Recent recommendations by the American College of Medical Genetics and Genomics (ACMG) for reporting incidental findings present novel ethical and legal issues. This article expresses no views on the ethical aspects of these recommendations and focuses strictly on liability risks and how to minimize them. The recommendations place labs and clinicians in a new liability environment that exposes them to intentional tort lawsuits as well to traditional suits for negligence. Intentional tort suits are especially troubling because of their potential to inflict ruinous personal financial losses on individual clinicians and laboratory personnel. This article surveys this new liability landscape and describes analytical approaches for minimizing tort liabilities. To a considerable degree, liability risks can be controlled by structuring activities in ways that make future lawsuits nonviable before the suits ever arise. Proactive liability analysis is an effective tool for minimizing tort liabilities in connection with the testing and reporting activities that the ACMG recommends.
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Affiliation(s)
- Barbara J Evans
- Health Law and Policy Institute, University of Houston Law Center, Houston, Texas, USA
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Ott CE, Fischer B, Schröter P, Richter R, Gupta N, Verma N, Kabra M, Mundlos S, Rajab A, Neitzel H, Kornak U. Severe neuronopathic autosomal recessive osteopetrosis due to homozygous deletions affecting OSTM1. Bone 2013; 55:292-7. [PMID: 23685543 DOI: 10.1016/j.bone.2013.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 03/18/2013] [Accepted: 04/10/2013] [Indexed: 01/12/2023]
Abstract
Autosomal recessive osteopetrosis (ARO, MIM 259700) is a genetically heterogeneous rare skeletal disorder characterized by failure of osteoclast resorption leading to pathologically increased bone density, bone marrow failure, and fractures. In the neuronopathic form neurological complications are especially severe and progressive. An early identification of the underlying genetic defect is imperative for assessment of prognosis and treatment by hematopoietic stem cell transplantation. Here we describe for the first time homozygous microdeletions of different sizes affecting the OSTM1 gene in two unrelated consanguineous families with children suffering from neuronopathic infantile malignant osteopetrosis. Patients showed an exceptionally severe phenotype with variable CNS malformations, seizures, blindness, and deafness. Multi-organ failure due to sepsis led to early death between six weeks and five months of age in spite of intensive care treatment. Analysis of the breakpoints revealed different mechanisms underlying both rearrangements. Microdeletions seem to represent a considerable portion of OSTM1 mutations and should therefore be included in a sufficient diagnostic screening.
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Affiliation(s)
- Claus-Eric Ott
- Institute of Medical Genetics and Human Genetics, Charité - Universitaetsmedizin Berlin, Berlin, Germany
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