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Barili V, Ambrosini E, Bortesi B, Minari R, De Sensi E, Cannizzaro IR, Taiani A, Michiara M, Sikokis A, Boggiani D, Tommasi C, Serra O, Bonatti F, Adorni A, Luberto A, Caggiati P, Martorana D, Uliana V, Percesepe A, Musolino A, Pellegrino B. Genetic Basis of Breast and Ovarian Cancer: Approaches and Lessons Learnt from Three Decades of Inherited Predisposition Testing. Genes (Basel) 2024; 15:219. [PMID: 38397209 PMCID: PMC10888198 DOI: 10.3390/genes15020219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Germline variants occurring in BRCA1 and BRCA2 give rise to hereditary breast and ovarian cancer (HBOC) syndrome, predisposing to breast, ovarian, fallopian tube, and peritoneal cancers marked by elevated incidences of genomic aberrations that correspond to poor prognoses. These genes are in fact involved in genetic integrity, particularly in the process of homologous recombination (HR) DNA repair, a high-fidelity repair system for mending DNA double-strand breaks. In addition to its implication in HBOC pathogenesis, the impairment of HR has become a prime target for therapeutic intervention utilizing poly (ADP-ribose) polymerase (PARP) inhibitors. In the present review, we introduce the molecular roles of HR orchestrated by BRCA1 and BRCA2 within the framework of sensitivity to PARP inhibitors. We examine the genetic architecture underneath breast and ovarian cancer ranging from high- and mid- to low-penetrant predisposing genes and taking into account both germline and somatic variations. Finally, we consider higher levels of complexity of the genomic landscape such as polygenic risk scores and other approaches aiming to optimize therapeutic and preventive strategies for breast and ovarian cancer.
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Affiliation(s)
- Valeria Barili
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Enrico Ambrosini
- Medical Genetics, University Hospital of Parma, 43126 Parma, Italy
| | - Beatrice Bortesi
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Roberta Minari
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Erika De Sensi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | | | - Antonietta Taiani
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Maria Michiara
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Angelica Sikokis
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Daniela Boggiani
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Chiara Tommasi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Olga Serra
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Francesco Bonatti
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Alessia Adorni
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Anita Luberto
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | | | - Davide Martorana
- Medical Genetics, University Hospital of Parma, 43126 Parma, Italy
| | - Vera Uliana
- Medical Genetics, University Hospital of Parma, 43126 Parma, Italy
| | - Antonio Percesepe
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Medical Genetics, University Hospital of Parma, 43126 Parma, Italy
| | - Antonino Musolino
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Benedetta Pellegrino
- Medical Oncology Unit, University Hospital of Parma, 43126 Parma, Italy
- Breast Unit, University Hospital of Parma, 43126 Parma, Italy
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May T, Smith CL, Kelley W, East K, Orlando L, Cochran M, Colletto S, Moss I, Nakano-Okuno M, Korf B, Limdi N. Does genetic testing offer utility as a supplement to traditional family health history intake for inherited disease risk? Fam Pract 2023; 40:760-767. [PMID: 36856778 DOI: 10.1093/fampra/cmad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
CONTENT This study examines the potential utility of genetic testing as a supplement to family health history to screen for increased risk of inherited disease. Medical conditions are often misreported or misunderstood, especially those related to different forms of cardiac disease (arrhythmias vs. structural heart disease vs. coronary artery disease), female organ cancers (uterine vs. ovarian vs. cervical), and type of cancer (differentiating primary cancer from metastases to other organs). While these nuances appear subtle, they can dramatically alter medical management. For example, different types of cardiac failure (structural, arrhythmia, and coronary artery disease) have inherited forms that are managed with vastly different approaches. METHODS Using a dataset of over 6,200 individuals who underwent genetic screening, we compared the ability of genetic testing and traditional family health history to identify increased risk of inherited disease. A further, in-depth qualitative study of individuals for whom risk identified through each method was discordant, explored whether this discordance could be addressed through changes in family health history intake. FINDINGS Of 90 individuals for whom genetic testing indicated significant increased risk for inherited disease, two-thirds (66%) had no corroborating family health history. Specifically, we identify cardiomyopathy, arrhythmia, and malignant hyperthermia as conditions for which discordance between genetic testing and traditional family health history was greatest, and familial hypercholesterolaemia, Lynch syndrome, and hereditary breast and ovarian cancer as conditions for which greater concordance existed. CONCLUSION We conclude that genetic testing offers utility as a supplement to traditional family health history intake over certain conditions.
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Affiliation(s)
- Thomas May
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, United States
| | - Crystal L Smith
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
| | - Whitley Kelley
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, United States
| | - Kelly East
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, United States
| | - Lori Orlando
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Meagan Cochran
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, United States
| | - Sierra Colletto
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
| | - Irene Moss
- Department of Genetics, UAB Heersink School of Medicine, Birmingham, AL, United States
| | - Mariko Nakano-Okuno
- Department of Genetics, UAB Heersink School of Medicine, Birmingham, AL, United States
| | - Bruce Korf
- Department of Genetics, UAB Heersink School of Medicine, Birmingham, AL, United States
| | - Nita Limdi
- Department of Genetics, UAB Heersink School of Medicine, Birmingham, AL, United States
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3
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Peterson JF, Veenstra DL, Williams MS, Hao J, Guzauskas GF. Population Genomic Screening for Three Common Hereditary Conditions. Ann Intern Med 2023; 176:eL230322. [PMID: 37983801 DOI: 10.7326/l23-0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- Josh F Peterson
- Department of Biomedical Informatics and Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David L Veenstra
- The CHOICE Institute, Department of Pharmacy, and Institute for Public Health Genetics, University of Washington, Seattle, Washington
| | - Marc S Williams
- Department of Genomic Health, Geisinger, Danville, Pennsylvania
| | - Jing Hao
- Department of Genomic Health and Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
| | - Gregory F Guzauskas
- The CHOICE Institute, Department of Pharmacy, University of Washington, Seattle, Washington
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4
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Burke W, Parens E, Chung WK, Berger SM, Appelbaum PS. The Challenge of Genetic Variants of Uncertain Clinical Significance : A Narrative Review. Ann Intern Med 2022; 175:994-1000. [PMID: 35436152 PMCID: PMC10555957 DOI: 10.7326/m21-4109] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Genomic tests expand diagnostic and screening opportunities but also identify genetic variants of uncertain clinical significance (VUSs). Only a minority of VUSs are likely to prove pathogenic when later reassessed, but resolution of the uncertainty is rarely timely. That uncertainty adds complexity to clinical decision making and can result in harms and costs to patients and the health care system, including the time-consuming analysis required to interpret a VUS and the potential for unnecessary treatment and adverse psychological effects. Current efforts to improve variant interpretation will help reduce the scope of the problem, but the high prevalence of rare and novel variants in the human genome points to VUSs as an ongoing challenge. Additional strategies can help mitigate the potential harms of VUSs, including testing protocols that limit identification or reporting of VUSs, subclassification of VUSs according to the likelihood of pathogenicity, routine family-based evaluation of variants, and enhanced counseling efforts. All involve tradeoffs, and the appropriate balance of measures is likely to vary for different test uses and clinical settings. Cross-specialty deliberation and public input could contribute to systematic and broadly supported policies for managing VUSs.
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Affiliation(s)
- Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | | | - Wendy K. Chung
- Departments of Pediatrics and Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sara M. Berger
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY, USA
| | - Paul S. Appelbaum
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
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5
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Manchanda R, Lieberman S, Gaba F, Lahad A, Levy-Lahad E. Population Screening for Inherited Predisposition to Breast and Ovarian Cancer. Annu Rev Genomics Hum Genet 2020; 21:373-412. [DOI: 10.1146/annurev-genom-083118-015253] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The discovery of genes underlying inherited predisposition to breast and ovarian cancer has revolutionized the ability to identify women at high risk for these diseases before they become affected. Women who are carriers of deleterious variants in these genes can undertake surveillance and prevention measures that have been shown to reduce morbidity and mortality. However, under current strategies, the vast majority of women carriers remain undetected until they become affected. In this review, we show that universal testing, particularly of the BRCA1 and BRCA2 genes, fulfills classical disease screening criteria. This is especially true for BRCA1 and BRCA2 in Ashkenazi Jews but is translatable to all populations and may include additional genes. Utilizing genetic information for large-scale precision prevention requires a paradigmatic shift in health-care delivery. To address this need, we propose a direct-to-patient model, which is increasingly pertinent for fulfilling the promise of utilizing personal genomic information for disease prevention.
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Affiliation(s)
- Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, United Kingdom;,
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, United Kingdom
| | - Sari Lieberman
- Medical Genetics Institute, Shaare Zedek Medical Center, Jerusalem 9103102, Israel;,
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Faiza Gaba
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London EC1M 6BQ, United Kingdom;,
- Department of Gynaecological Oncology, Barts Health NHS Trust, London E1 1FR, United Kingdom
| | - Amnon Lahad
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
- Clalit Health Services, Jerusalem 9548323, Israel
| | - Ephrat Levy-Lahad
- Medical Genetics Institute, Shaare Zedek Medical Center, Jerusalem 9103102, Israel;,
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
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6
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Waltz M, Meagher KM, Henderson GE, Goddard KA, Muessig K, Berg JS, Weck KE, Cadigan RJ. Assessing the implications of positive genomic screening results. Per Med 2020; 17:101-109. [PMID: 32125936 PMCID: PMC7147673 DOI: 10.2217/pme-2019-0067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aim: Before population screening of ‘healthy’ individuals is widely adopted, it is important to consider the harms and benefits of receiving positive results and how harms and benefits may differ by age. Subjects & methods: Participants in a preventive genomic screening study were screened for 17 genes associated with 11 conditions. We interviewed 11 participants who received positive results. Results: Interviewees expressed little concern about their positive results in light of their older age, the risk condition for which they tested positive, or other pressing health concerns. Conclusion: Researchers and clinicians should recognize that returning positive results may not have the impact they presume given the diversity of the conditions screened and those who choose to undergo screening.
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Affiliation(s)
- Margaret Waltz
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA
| | - Karen M Meagher
- Department of Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA
| | - Katrina Ab Goddard
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Kristin Muessig
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA
| | - Karen E Weck
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA.,Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA
| | - R Jean Cadigan
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA.,UNC Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA
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Newey PJ. Clinical genetic testing in endocrinology: Current concepts and contemporary challenges. Clin Endocrinol (Oxf) 2019; 91:587-607. [PMID: 31254405 DOI: 10.1111/cen.14053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/29/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
Recent advances in DNA sequencing technology have led to an unprecedented period of disease-gene discovery offering many new opportunities for genetic testing in the clinical setting. Endocrinology has seen a rapid expansion in the taxonomy of monogenic disorders, which can be detected by an expanding portfolio of genetic tests in both diagnostic and predictive settings. Successful testing relies on many factors including the ability to identify those at increased risk of genetic disease in the busy clinic as well as a working knowledge of the various testing platforms and their limitations. The clinical utility of a given test is dependent upon many factors, which include the reliability of the genetic testing platform, the accuracy of the test result interpretation and knowledge of disease penetrance and expression. The increasing adoption of "high-content" genetic testing based on next-generation sequencing (NGS) to diagnose hereditary endocrine disorders brings a number of challenges including the potential for uncertain test results and/or genetic findings unrelated to the indication for testing. Therefore, it is increasingly important that the clinician is aware of the current evolution in genetic testing, and understands the different settings in which it may be employed. This review provides an overview of the genetic testing workflow, focusing on each of the major components required for successful testing in adult and paediatric endocrine settings. In addition, the challenges of variant interpretation are highlighted, as are issues related to informed consent, prenatal diagnosis and predictive testing. Finally, the future directions of genetic testing relevant to endocrinology are discussed.
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Affiliation(s)
- Paul J Newey
- Division of Molecular & Clinical Medicine, Ninewells Hospital & Medical School, University of Dundee, Scotland, UK
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8
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Zhang L, Bao Y, Riaz M, Tiller J, Liew D, Zhuang X, Amor DJ, Huq A, Petelin L, Nelson M, James PA, Winship I, McNeil JJ, Lacaze P. Population genomic screening of all young adults in a health-care system: a cost-effectiveness analysis. Genet Med 2019; 21:1958-1968. [PMID: 30773532 PMCID: PMC6752319 DOI: 10.1038/s41436-019-0457-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/29/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose To consider the impact and cost-effectiveness of offering preventive population genomic screening to all young adults in a single-payer health-care system. Methods We modeled screening of 2,688,192 individuals, all adults aged 18–25 years in Australia, for pathogenic variants in BRCA1/BRCA2/MLH1/MSH2 genes, and carrier screening for cystic fibrosis (CF), spinal muscular atrophy (SMA), and fragile X syndrome (FXS), at 71% testing uptake using per-test costs ranging from AUD$200 to $1200 (~USD$140 to $850). Investment costs included genetic counseling, surveillance, and interventions (reimbursed only) for at-risk individuals/couples. Cost-effectiveness was defined below AUD$50,000/DALY (disability-adjusted life year) prevented, using an incremental cost-effectiveness ratio (ICER), compared with current targeted testing. Outcomes were cancer incidence/mortality, disease cases, and treatment costs reduced. Results Population screening would reduce variant-attributable cancers by 28.8%, cancer deaths by 31.2%, and CF/SMA/FXS cases by 24.8%, compared with targeted testing. Assuming AUD$400 per test, investment required would be between 4 and 5 times higher than current expenditure. However, screening would lead to substantial savings in medical costs and DALYs prevented, at a highly cost-effective ICER of AUD$4038/DALY. At AUD$200 per test, screening would approach cost-saving for the health system (ICER = AUD$22/DALY). Conclusion Preventive genomic screening in early adulthood would be highly cost-effective in a single-payer health-care system, but ethical issues must be considered.
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Affiliation(s)
- Lei Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, PR China.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Yining Bao
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Moeen Riaz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jane Tiller
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Xun Zhuang
- School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - David J Amor
- Victorian Clinical Genetics Services; Murdoch Children's Research Institute; Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Parkville, VIC, Australia
| | - Aamira Huq
- Department of Genomic Medicine, Royal Melbourne Hospital; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Lara Petelin
- Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Mark Nelson
- Discipline of General Practice, University of Tasmania, Hobart, TAS, Australia
| | - Paul A James
- Department of Genomic Medicine, Royal Melbourne Hospital; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Ingrid Winship
- Department of Genomic Medicine, Royal Melbourne Hospital; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - John J McNeil
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul Lacaze
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
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Morrissey C, Walker RL. The Ethics of General Population Preventive Genomic Sequencing: Rights and Social Justice. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2018; 43:22-43. [PMID: 29342286 PMCID: PMC5901094 DOI: 10.1093/jmp/jhx034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Advances in DNA sequencing technology open new possibilities for public health genomics, especially in the form of general population preventive genomic sequencing (PGS). Such screening programs would sit at the intersection of public health and preventive health care, and thereby at once invite and resist the use of clinical ethics and public health ethics frameworks. Despite their differences, these ethics frameworks traditionally share a central concern for individual rights. We examine two putative individual rights-the right not to know, and the child's right to an open future-frequently invoked in discussions of predictive genetic testing, in order to explore their potential contribution to evaluating this new practice. Ultimately, we conclude that traditional clinical and public health ethics frameworks, and these two rights in particular, should be complemented by a social justice perspective in order adequately to characterize the ethical dimensions of general population PGS programs.
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Affiliation(s)
- Clair Morrissey
- University of North Carolina, Chapel Hill, North Carolina, USA
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10
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Waltz M, Cadigan RJ, Prince AER, Skinner D, Henderson GE. Age and perceived risks and benefits of preventive genomic screening. Genet Med 2017; 20:1038-1044. [PMID: 29215654 PMCID: PMC5991986 DOI: 10.1038/gim.2017.206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/16/2017] [Indexed: 01/07/2023] Open
Abstract
Purpose As genome sequencing moves from research to clinical practice, sequencing technologies focused on “medically actionable” targets are being promoted for preventive screening despite the dearth of systematic evidence of risks and benefits and criteria for who should be screened. This study investigates researchers’ and research participants’ perceptions of these issues within the context of a preventive genomic screening study, GeneScreen. Methods We recorded researcher deliberations regarding age eligibility criteria and the risks and benefits of screening, and conducted interviews with 50 GeneScreen participants about their motivations for joining and perceptions of risks and benefits. Results Researchers made assumptions about who would want and benefit from screening based on age. After discussion, researchers opted not to have an upper age limit for enrollment. Participants of all ages perceived similar benefits, including prevention, treatment, and cascade testing, and similar risks such as insurance discrimination and worry. Conclusion While clinical benefits of preventive genomic screening for older adults are debatable, our respondents perceived a range of benefits of screening in both clinical and research settings. Researchers and clinicians should carefully consider decisions about excluding older adults and providing information about benefits and risks across age groups.
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Affiliation(s)
- Margaret Waltz
- Center for Genomics and Society, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - R Jean Cadigan
- Center for Genomics and Society, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Center for Bioethics, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anya E R Prince
- Center for Genomics and Society, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,University of Iowa College of Law, Iowa City, Iowa, USA
| | - Debra Skinner
- Center for Genomics and Society, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,FPG Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gail E Henderson
- Center for Genomics and Society, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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11
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Vassy JL, Christensen KD, Schonman EF, Blout CL, Robinson JO, Krier JB, Diamond PM, Lebo M, Machini K, Azzariti DR, Dukhovny D, Bates DW, MacRae CA, Murray MF, Rehm HL, McGuire AL, Green RC. The Impact of Whole-Genome Sequencing on the Primary Care and Outcomes of Healthy Adult Patients: A Pilot Randomized Trial. Ann Intern Med 2017; 167:159-169. [PMID: 28654958 PMCID: PMC5856654 DOI: 10.7326/m17-0188] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Whole-genome sequencing (WGS) in asymptomatic adults might prevent disease but increase health care use without clinical value. Objective To describe the effect on clinical care and outcomes of adding WGS to standardized family history assessment in primary care. Design Pilot randomized trial. (ClinicalTrials.gov: NCT01736566). Setting Academic primary care practices. Participants 9 primary care physicians (PCPs) and 100 generally healthy patients recruited at ages 40 to 65 years. Intervention Patients were randomly assigned to receive a family history report alone (FH group) or in combination with an interpreted WGS report (FH + WGS group), which included monogenic disease risk (MDR) results (associated with Mendelian disorders), carrier variants, pharmacogenomic associations, and polygenic risk estimates for cardiometabolic traits. Each patient met with his or her PCP to discuss the report. Measurements Clinical outcomes and health care use through 6 months were obtained from medical records and audio-recorded discussions between PCPs and patients. Patients' health behavior changes were surveyed 6 months after receiving results. A panel of clinician-geneticists rated the appropriateness of how PCPs managed MDR results. Results Mean age was 55 years; 58% of patients were female. Eleven FH + WGS patients (22% [95% CI, 12% to 36%]) had new MDR results. Only 2 (4% [CI, 0.01% to 15%]) had evidence of the phenotypes predicted by an MDR result (fundus albipunctatus due to RDH5 and variegate porphyria due to PPOX). Primary care physicians recommended new clinical actions for 16% (CI, 8% to 30%) of FH patients and 34% (CI, 22% to 49%) of FH + WGS patients. Thirty percent (CI, 17% to 45%) and 41% (CI, 27% to 56%) of FH and FH + WGS patients, respectively, reported making a health behavior change after 6 months. Geneticists rated PCP management of 8 MDR results (73% [CI, 39% to 99%]) as appropriate and 2 results (18% [CI, 3% to 52%]) as inappropriate. Limitation Limited sample size and ancestral and socioeconomic diversity. Conclusion Adding WGS to primary care reveals new molecular findings of uncertain clinical utility. Nongeneticist providers may be able to manage WGS results appropriately, but WGS may prompt additional clinical actions of unclear value. Primary Funding Source National Institutes of Health.
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Affiliation(s)
- Jason L. Vassy
- VA Boston Healthcare System, Boston, MA
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | | | | | - Joel B. Krier
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Pamela M. Diamond
- Baylor College of Medicine, Houston, TX
- UTHealth School of Public Health, Houston, TX
| | - Matthew Lebo
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Partners Healthcare Personalized Medicine, Boston, MA
| | - Kalotina Machini
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Partners Healthcare Personalized Medicine, Boston, MA
| | | | | | - David W. Bates
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Calum A. MacRae
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | | | - Heidi L. Rehm
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Partners Healthcare Personalized Medicine, Boston, MA
| | | | - Robert C. Green
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Partners Healthcare Personalized Medicine, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
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12
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Prince AER, Cadigan RJ, Henderson GE, Evans JP, Adams M, Coker-Schwimmer E, Penn DC, Van Riper M, Corbie-Smith G, Jonas DE. Is there evidence that we should screen the general population for Lynch syndrome with genetic testing? A systematic review. Pharmgenomics Pers Med 2017; 10:49-60. [PMID: 28260941 PMCID: PMC5325104 DOI: 10.2147/pgpm.s123808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The emerging dual imperatives of personalized medicine and technologic advances make population screening for preventable conditions resulting from genetic alterations a realistic possibility. Lynch syndrome is a potential screening target due to its prevalence, penetrance, and the availability of well-established, preventive interventions. However, while population screening may lower incidence of preventable conditions, implementation without evidence may lead to unintentional harms. We examined the literature to determine whether evidence exists that screening for Lynch-associated mismatch repair (MMR) gene mutations leads to improved overall survival, cancer-specific survival, or quality of life. Documenting evidence and gaps is critical to implementing genomic approaches in public health and guiding future research. MATERIALS AND METHODS Our 2014-2015 systematic review identified studies comparing screening with no screening in the general population, and controlled studies assessing analytic validity of targeted next-generation sequencing, and benefits or harms of interventions or screening. We conducted meta-analyses for the association between early or more frequent colonoscopies and health outcomes. RESULTS Twelve studies met our eligibility criteria. No adequate evidence directly addressed the main question or the harms of screening in the general population. Meta-analyses found relative reductions of 68% for colorectal cancer incidence (relative risk: 0.32, 95% confidence interval: 0.23-0.43, three cohort studies, 590 participants) and 78% for all-cause mortality (relative risk: 0.22, 95% confidence interval: 0.09-0.56, three cohort studies, 590 participants) for early or more frequent colonoscopies among family members of people with cancer who also had an associated MMR gene mutation. CONCLUSION Inadequate evidence exists examining harms and benefits of population-based screening for Lynch syndrome. Lack of evidence highlights the need for data that directly compare benefits and harms.
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Affiliation(s)
| | - R Jean Cadigan
- Center for Genomics and Society
- Department of Social Medicine
| | | | - James P Evans
- Center for Genomics and Society
- Department of Genetics
- Carolina Center for Genome Sciences
- Lineberger Comprehensive Cancer Center
- Department of Medicine
| | - Michael Adams
- Center for Genomics and Society
- Department of Genetics
| | | | | | - Marcia Van Riper
- Center for Genomics and Society
- School of Nursing, The University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Giselle Corbie-Smith
- Center for Genomics and Society
- Department of Social Medicine
- Department of Medicine
| | - Daniel E Jonas
- Center for Genomics and Society
- Department of Medicine
- Cecil G. Sheps Center for Health Services Research
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13
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Lázaro-Muñoz G, Conley JM, Davis AM, Prince AER, Cadigan RJ. Which Results to Return: Subjective Judgments in Selecting Medically Actionable Genes. Genet Test Mol Biomarkers 2017; 21:184-194. [PMID: 28146641 DOI: 10.1089/gtmb.2016.0397] [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] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Advances in genomics have led to calls for returning information about medically actionable genes (MAGs) to patients, research subjects, biobank participants, and through screening programs, the general adult population. Which MAGs are returned affects the harms and benefits of every genetic testing endeavor. Despite published recommendations of selection criteria for MAGs to return, scant data exist regarding how decision makers actually apply such criteria. METHODS The process and criteria used by researchers when selecting MAGs for a preventive genomic sequencing program targeting the general adult population were examined. The authors observed and audio-recorded the gene selection meetings, and analyzed meeting transcripts, gene scoring sheets, and meeting handouts. RESULTS To select MAGs, the committee imported, from a preexisting project, "a semiquantitative metric" that scores genes on five criteria. Numerous subjective judgments and conceptual challenges in defining and applying the five criteria complicated the selection process. Criteria-related challenges also included the limited evidence available about facts fundamental to the scoring decisions and the emergence and application of criteria that were not part of the original metric. CONCLUSIONS When identifying MAGs appropriate for screening and return, decision makers must expect and prepare to address such issues as the inevitability of subjective judgments, limited evidence about fundamental decision-making elements, the conceptual complexity of defining criteria, and the emergence of unplanned criteria during the gene selection process.
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Affiliation(s)
- Gabriel Lázaro-Muñoz
- 1 Center for Genomics and Society, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Center for Medical Ethics and Health Policy , Baylor College of Medicine, Houston, Texas
| | - John M Conley
- 1 Center for Genomics and Society, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,3 School of Law, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Arlene M Davis
- 1 Center for Genomics and Society, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,4 Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,5 Center for Bioethics, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Anya E R Prince
- 1 Center for Genomics and Society, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - R Jean Cadigan
- 1 Center for Genomics and Society, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,4 Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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14
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Linderman MD, Nielsen DE, Green RC. Personal Genome Sequencing in Ostensibly Healthy Individuals and the PeopleSeq Consortium. J Pers Med 2016; 6:E14. [PMID: 27023617 PMCID: PMC4932461 DOI: 10.3390/jpm6020014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 12/16/2022] Open
Abstract
Thousands of ostensibly healthy individuals have had their exome or genome sequenced, but a much smaller number of these individuals have received any personal genomic results from that sequencing. We term those projects in which ostensibly healthy participants can receive sequencing-derived genetic findings and may also have access to their genomic data as participatory predispositional personal genome sequencing (PPGS). Here we are focused on genome sequencing applied in a pre-symptomatic context and so define PPGS to exclude diagnostic genome sequencing intended to identify the molecular cause of suspected or diagnosed genetic disease. In this report we describe the design of completed and underway PPGS projects, briefly summarize the results reported to date and introduce the PeopleSeq Consortium, a newly formed collaboration of PPGS projects designed to collect much-needed longitudinal outcome data.
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Affiliation(s)
- Michael D Linderman
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Daiva E Nielsen
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
- Harvard Medical School, Boston, MA 02115, USA.
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
- Harvard Medical School, Boston, MA 02115, USA.
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA.
- Partners Personalized Medicine, Cambridge, MA 02139, USA.
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15
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Adams MC, Evans JP, Henderson GE, Berg JS. The promise and peril of genomic screening in the general population. Genet Med 2015; 18:593-9. [PMID: 26540154 PMCID: PMC4860183 DOI: 10.1038/gim.2015.136] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/19/2015] [Indexed: 11/09/2022] Open
Abstract
Purpose Utilization of sequencing to screen the general population for preventable monogenic conditions is receiving substantial attention due to its potential to decrease morbidity and mortality. However, the selection of which variants to return is a serious implementation challenge. Procedures must be investigated to ensure optimal test characteristics and avoidance of harm from false positive test results. Methods We scanned exome sequences from 478 well-phenotyped individuals for potentially pathogenic variants in 17 genes representing 11 conditions that are among the most medically actionable Mendelian disorders in adults. We developed 5 variant selection algorithms with increasing sensitivity and measured their specificity in these 17 genes. Results Variant selection algorithms with increasing sensitivity exhibited decreased specificity, and performance was highly dependent on the genes analyzed. The most sensitive algorithm ranged from 88.8% to 99.6% specificity among the 17 genes. Conclusion For very low prevalence conditions, small reductions in specificity greatly increase false positives. This inescapable test characteristic governs the predictive value of genomic sequencing in the general population. To address this issue, test performance must be evaluated systematically for each condition so that the false negatives and false positives can be tailored for optimal outcomes, depending on the downstream clinical consequences.
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Affiliation(s)
- Michael C Adams
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James P Evans
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gail E Henderson
- Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan S Berg
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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May T, Strong KA, Khoury MJ, Evans JP. Can targeted genetic testing offer useful health information to adoptees? Genet Med 2015; 17:533-5. [PMID: 25905442 DOI: 10.1038/gim.2015.58] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 01/25/2023] Open
Affiliation(s)
- Thomas May
- 1] Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee, Wisconsin, USA [2] Institute for Health and Aging, University of California San Francisco, San Francisco, CA, USA
| | - Kimberly A Strong
- Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James P Evans
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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17
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Trinidad SB, Fullerton SM, Burke W. Looking for Trouble and Finding It. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:15-7. [PMID: 26147255 PMCID: PMC4526022 DOI: 10.1080/15265161.2015.1039731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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