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Cornelis C, Dondorp W, Bolt I, de Wert G, van Summeren M, Brilstra E, Knoers N, Bredenoord AL. Uncertain futures and unsolicited findings in pediatric genomic sequencing: guidelines for return of results in cases of developmental delay. BMC Med Ethics 2023; 24:98. [PMID: 37951889 PMCID: PMC10640744 DOI: 10.1186/s12910-023-00977-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Massively parallel sequencing techniques, such as whole exome sequencing (WES) and whole genome sequencing (WGS), may reveal unsolicited findings (UFs) unrelated to the diagnostic aim. Such techniques are frequently used for diagnostic purposes in pediatric cases of developmental delay (DD). Yet policy guidelines for informed consent and return of UFs are not well equipped to address specific moral challenges that may arise in these children's situations. DISCUSSION In previous empirical studies conducted by our research group, we found that it is sometimes uncertain how children with a DD will develop and whether they could come to possess capacities for autonomous decision-making in the future. Parents sometimes felt this brought them into a Catch-22 like situation when confronted with choices about UFs before undergoing WES in trio-analysis (both the parents' and child's DNA are sequenced). An important reason for choosing to consent to WES was to gain more insight into how their child might develop. However, to make responsible choices about receiving or declining knowledge of UFs, some idea of their child's future development of autonomous capacities is needed. This undesirable Catch-22 situation was created by the specific policy configuration in which parents were required to make choices about UFs before being sequencing (trio-analysis). We argue that this finding is relevant for reconfiguring current policies for return of UFs for WES/WGS and propose guidelines that encompass two features. First, the informed consent process ought to be staged. Second, differing guidelines are required for withholding/disclosing a UF in cases of DD appropriate to the level of confidence there is about the child's future developmental of autonomous capacities. CONCLUSION When combined with a dynamic consent procedure, these two features of our guidelines could help overcome significant moral challenges that present themselves in the situations of children undergoing genomic sequencing for clarifying a DD.
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Affiliation(s)
- Candice Cornelis
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands.
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Ineke Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Guido de Wert
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eva Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University Medical Centre Groningen, Groningen, the Netherlands
| | - Annelien L Bredenoord
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Philosophy, Rotterdam, the Netherlands
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2
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Lombardo S, Seedat F, Elliman D, Marshall J. Policy-making and implementation for newborn bloodspot screening in Europe: a comparison between EURORDIS principles and UK practice. THE LANCET REGIONAL HEALTH. EUROPE 2023; 33:100714. [PMID: 37954001 PMCID: PMC10636270 DOI: 10.1016/j.lanepe.2023.100714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 11/14/2023]
Abstract
Newborn bloodspot screening (NBS) policy is a contentious area in Europe. Variation in the screening panels on offer, in the approach to evidence assessment and in the use of health economic modelling are some of the issues which are debated on the topic. In this paper we focus on a set of patient-driven principles for newborn screening published by EURORDIS and use these as a reference point for exploration and comparison with NBS policy development and screening practice in the UK. In doing so, we share UK practice; we note the UK is generally well aligned with many of the recommended principles, but we also discuss areas of controversy and challenges. Some of these, like 'actionability', will undoubtedly continue to be debated and may never reach consensus. For others, such as patient and public voice participation in newborn screening systems, there are opportunities to continue improving existing processes and developing new mechanisms for stakeholder participation. Screening bodies in other European countries should also compare their policy-making and implementation practices with the EURORDIS principles to stimulate further discussion on the challenges and opportunities of newborn screening and provide a cross-European baseline.
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Affiliation(s)
- Silvia Lombardo
- UK National Screening Committee, Department of Health and Social Care, 39 Victoria Street, London SW1H 0EU, UK
| | - Farah Seedat
- St. George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - David Elliman
- UK National Screening Committee, Department of Health and Social Care, 39 Victoria Street, London SW1H 0EU, UK
| | - John Marshall
- UK National Screening Committee, Department of Health and Social Care, 39 Victoria Street, London SW1H 0EU, UK
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Best LG, O’Leary M, O’Leary R, Lawrence W, Torgerson DG. Return of Participants' Incidental Genetic Research Findings: Experience from a Case-Control Study of Asthma in an American Indian Community. J Pers Med 2023; 13:1407. [PMID: 37763174 PMCID: PMC10532458 DOI: 10.3390/jpm13091407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
The proper communication of clinically actionable findings to participants of genetic research entails important ethical considerations, but has been challenging for a variety of reasons. We document an instance of the return of individual genetic results in the context of a very rural American Indian community, in hopes of providing insight to other investigators about potentially superior or inferior courses of action. This was a case/control study of asthma among 324 pediatric participants. Subsequently, microarray genotype data became available, providing over 2 million variants, incidentally including some conferring risk for conditions for which the American College of Medical Genetics recommends return of results. The study investigators engaged in extensive consultation with the IRB, the tribal government, and local clinicians to better inform our approach. We were able to notify the two participants heterozygous for the one clinically actionable variant identified. One participant welcomed this information and proceeded to obtain further clinical work-up; the other participant declined further follow-up. While demanding considerable time and effort, the return of clinically actionable genetic results is important from both an ethical perspective and to provide an improved trust relationship with the community of research participants.
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Affiliation(s)
- Lyle G. Best
- School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA
- Missouri Breaks Industries Research Inc., Eagle Butte, SD 57625, USA; (M.O.); (R.O.); (W.L.)
| | - Marcia O’Leary
- Missouri Breaks Industries Research Inc., Eagle Butte, SD 57625, USA; (M.O.); (R.O.); (W.L.)
| | - Rae O’Leary
- Missouri Breaks Industries Research Inc., Eagle Butte, SD 57625, USA; (M.O.); (R.O.); (W.L.)
| | - Wendy Lawrence
- Missouri Breaks Industries Research Inc., Eagle Butte, SD 57625, USA; (M.O.); (R.O.); (W.L.)
| | - Dara G. Torgerson
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA 94158, USA;
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4
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Clayton EW, Smith ME, Anderson KC, Chung WK, Connolly JJ, Fullerton SM, McGowan ML, Peterson JF, Prows CA, Sabatello M, Holm IA. Studying the impact of translational genomic research: Lessons from eMERGE. Am J Hum Genet 2023; 110:1021-1033. [PMID: 37343562 PMCID: PMC10357472 DOI: 10.1016/j.ajhg.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
Two major goals of the Electronic Medical Record and Genomics (eMERGE) Network are to learn how best to return research results to patient/participants and the clinicians who care for them and also to assess the impact of placing these results in clinical care. Yet since its inception, the Network has confronted a host of challenges in achieving these goals, many of which had ethical, legal, or social implications (ELSIs) that required consideration. Here, we share impediments we encountered in recruiting participants, returning results, and assessing their impact, all of which affected our ability to achieve the goals of eMERGE, as well as the steps we took to attempt to address these obstacles. We divide the domains in which we experienced challenges into four broad categories: (1) study design, including recruitment of more diverse groups; (2) consent; (3) returning results to participants and their health care providers (HCPs); and (4) assessment of follow-up care of participants and measuring the impact of research on participants and their families. Since most phases of eMERGE have included children as well as adults, we also address the particular ELSI posed by including pediatric populations in this research. We make specific suggestions for improving translational genomic research to ensure that future projects can effectively return results and assess their impact on patient/participants and providers if the goals of genomic-informed medicine are to be achieved.
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Affiliation(s)
- Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN 37203, USA.
| | - Maureen E Smith
- Department of Medicine, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Katherine C Anderson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY 10032, USA
| | - John J Connolly
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Stephanie M Fullerton
- Department of Bioethics & Humanities, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Michelle L McGowan
- Biomedical Ethics Research Program, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA; Department of Women's, Gender, and Sexuality Studies, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Josh F Peterson
- Center for Precision Medicine, Department of Biomedical Informatics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, USA
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital, Cincinnati, OH 45229, USA
| | - Maya Sabatello
- Center for Precision Medicine & Genomics, Department of Medicine, and Division of Ethics, Department of Medical Humanities & Ethics Columbia University Vagelos College of Physicians and Surgeons, NY, NY 10032, USA
| | - Ingrid A Holm
- Division of Genetics and Genomics, Boston Children's Hospital; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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Best LG, O'Leary M, O'Leary R, Lawrence W, Torgerson DG. Return of Participants' Incidental Genetic Research Findings: Experience from a Case-Control Study of Asthma in an American Indian Community. RESEARCH SQUARE 2023:rs.3.rs-2485539. [PMID: 36711525 PMCID: PMC9882662 DOI: 10.21203/rs.3.rs-2485539/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE The proper communication of clinically actionable findings to participants of genetic research entails important ethical considerations, but has been challenging for a variety of reasons. We document an instance of return of individual genetic results in the context of a very rural American Indian community, in hopes of providing insight to other investigators about potentially superior or inferior courses of action. METHODS The original study was a case/control study of asthma among 324 pediatric participants. The study utilized a genotyping microarray assessing over 2 million variants, including one conferring risk for hypertrophic cardiomyopathy for which the American College of Medical Genetics recommends return of results to participants. The study investigators engaged in extensive consultation with the IRB, the Tribal government and local clinicians to better inform our approach. RESULTS With some difficulty we were able to notify the 2 participants heterozygous for this variant. One participant welcomed this information and proceeded to obtain further clinical work-up; the other participant declined further follow-up. CONCLUSION While demanding of considerable time and effort, the return of clinically actionable genetic results is important from both an ethical perspective and to provide an improved trust relationship with the community of research participants.
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Affiliation(s)
| | | | - Rae O'Leary
- Missouri Breaks Industries Research Inc, Eagle Butte
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6
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März JW. What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare? Eur J Pediatr 2022; 181:3805-3816. [PMID: 36083315 PMCID: PMC9546983 DOI: 10.1007/s00431-022-04609-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022]
Abstract
The present review analyses the implications of the best interests of the child principle, which is one of the most widely discussed principles of medical ethics and human rights, for paediatric healthcare. As a starting point, it presents the interpretation of the best interests principle by the United Nations Committee on the Rights of the Child. On this basis, it points out possible fields of application of the best interests principle with regard to paediatric healthcare and discusses the potential difficulties in the application of the best interests principle. Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing. Conclusion: The best interests principle requires action, inter alia, by health policymakers, professional associations, hospital managers and medical teams to ensure children receive the best possible healthcare. Whilst the best interests principle does not provide a conclusive solution to all ethical dilemmas in paediatric healthcare (as illustrated by the case studies), it provides children, medical teams, parents and families, and clinical ethicists with an indispensable framework for health care centred on the rights of the child. What is Known: • The best interests principle is one of the most widely discussed principles of medical ethics and human rights and one of the four general principles of the Convention on the Rights of the Child. What is New: • The present review discusses possible fields of application and potential difficulties of the best interests principle with regard to paediatric healthcare. • Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.
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Affiliation(s)
- Julian W März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, 8006, Zurich, Switzerland.
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7
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Miner SA, Similuk M, Jamal L, Sapp J, Berkman BE. Genomic tools for health: Secondary findings as findings to be shared. Genet Med 2022; 24:2220-2227. [PMID: 35980380 PMCID: PMC9643624 DOI: 10.1016/j.gim.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Whether and how to disclose secondary finding (SF) information to children is ethically debated. Some argue that genetic testing of minors should be limited to preserve the child's future autonomy. Others suggest that disclosure of SFs can occur if it is in the best interests of the child. However, the ways that parents conceptualize and weigh their child's future autonomy against the interests of their child and other family members are unknown. METHODS To explore how parents understand SF disclosure in the context of their child and other family members' lives, we conducted semistructured interviews with 30 families (40 parents in total). All parents had children who were enrolled in a genetic sequencing protocol that returned results by default. RESULTS We found that parents did not routinely conceptualize SFs as distinctive health information. Rather parents saw this information as part of their child's overall health. To make decisions about disclosure, parents weighed their child's ability to understand the SF information and their other family member's need to know. CONCLUSION Because most families desired SF information, we argue that disclosure of SF be reconceptualized to reflect the lived experiences of those who may receive this information.
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Affiliation(s)
- Skye A Miner
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; Department of Medical Humanities and Bioethics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Morgan Similuk
- Centralized Sequencing Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Leila Jamal
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; NHGRI/NCI/JHU Genetic Counseling Training Program, National Human Genome Research Insitute, Bethesda, MD
| | - Julie Sapp
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD; Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Benjamin E Berkman
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD; Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD.
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Spencer SJ, Fullerton SM. Population genomic screening: Ethical considerations to guide age at implementation. Front Genet 2022; 13:899648. [PMID: 36267415 PMCID: PMC9577139 DOI: 10.3389/fgene.2022.899648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Currently, most genetic testing involves next generation sequencing or panel testing, indicating future population-based screening will involve simultaneous testing for multiple disease risks (called here "panel testing"). Genomic screening typically focuses on single or groups of related disorders, with little utilization of panel testing. Furthermore, the optimal age for test ordering is rarely addressed in terms of whether it should coincide with the age of majority (18 years old) or after the age of majority (26 years old). We conducted an ethical analysis utilizing a hypothetical "narrow" panel test comprised of the CDC Tier 1 Genomic Applications: Familial Hypercholesterolemia (FH), increases individuals' cardiovascular risk due to elevated low-density lipoprotein (LDL) cholesterol levels; Hereditary Breast and Ovarian Cancer (HBOC), increases lifetime risk of developing cancer; and Lynch Syndrome (LS), increases lifetime risk of developing colorectal cancer. We conducted a utilitarian analysis, on the assumption that health systems seek to maximize utility for patients. Screening at the "age of majority" is preferred for FH due to lowering FH patients' cholesterol levels via statins providing high lifetime benefits and low risks. Screening "after the age of majority" is preferred for HBOC and LS due to availability of effective surveillance, the recommendation for screening activities to begin at age 26, and prophylactic interventions connected to surveillance. We also utilized a supplemental principlist-based approach that identified relevant concerns and trade-offs. Consideration of clinical, non-clinical, and family planning implications suggests narrow panel testing would be best deployed after 26 (rather than at 18) years of age.
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Affiliation(s)
- Scott J. Spencer
- Institute for Public Health Genetics, University of Washington, Seattle, WA, United States
| | - Stephanie M. Fullerton
- Department of Bioethics and Humanities,University of Washington, Seattle, WA, United States
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Kolarcik CL, Bledsoe MJ, O'Leary TJ. Returning Individual Research Results to Vulnerable Individuals. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:1218-1229. [PMID: 35750259 DOI: 10.1016/j.ajpath.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Although issues associated with returning individual research results to study participants have been well explored, these issues have been less thoroughly investigated in vulnerable individuals and populations. Considerations regarding return of research results to these individuals and populations, including how best to ensure truly informed consent, how to minimize the risks and benefits of the return of research results, and how best to ensure justice may differ from those of the population at large. This article discusses the issues and challenges associated with the return of individual research results (such as genomic, proteomic, or other biomarker data) to potentially vulnerable individuals and populations, including those who may be vulnerable for cognitive, communicative, institutional, social, deferential, medical, economic, or social reasons. It explores factors that should be considered in the design, conduct, and oversight of ethically responsible research involving the return of research results to vulnerable individuals and populations and discuss recommendations for those engaged in this work.
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Affiliation(s)
- Christi L Kolarcik
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Timothy J O'Leary
- Office of Research and Development, Veterans Health Administration, Washington, District of Columbia; Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland.
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10
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Pezeshkpoor B, Oldenburg J, Pavlova A. Experiences in Routine Genetic Analysis of Hereditary Hemorrhagic, Thrombotic, and Platelet Disorders. Hamostaseologie 2022; 42:S5-S12. [PMID: 35226963 DOI: 10.1055/a-1726-4793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Hemostasis is a complex and tightly regulated system that attempts to maintain a homeostatic balance to permit normal blood flow, without bleeding or thrombosis. Hemostasis reflects the subtle balance between procoagulant and anticoagulant factors in the pathways of primary hemostasis, secondary hemostasis, and fibrinolysis. The major components in this interplay include the vascular endothelium, platelets, coagulation factors, and fibrinolytic factors. After vessel wall injury, the subendothelium is exposed to the blood stream, followed by rapid activation of platelets via collagen binding and von Willebrand factor-mediated platelet adhesion to the damaged vessel wall through platelet glycoprotein receptor Ib/IX/V. Activated platelets change their shape, release bioactive molecules from their granules, and expose negatively charged phospholipids on their surface. For a proper function of this process, an adequate number of functional platelets are required. Subsequently, a rapid generation of sufficient amounts of thrombin begins; followed by activation of the coagulation system and its coagulation factors (secondary hemostasis), generating fibrin that consolidates the platelet plug. To maintain equilibrium between coagulation and anticoagulation, the naturally occurring anticoagulants such as protein C, protein S, and antithrombin keep this process in balance. Deficiencies (inherited or acquired) at any level of this fine-tuned system result in pathologic bleedings or increased hypercoagulability states leading to thrombosis. This review will focus on genetic diagnosis of inherited bleeding, thrombotic, and platelet disorders, discussing strengths and limitations of existing diagnostic settings and genetic tools and highlight some important considerations necessary for clinical application.
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Affiliation(s)
- B Pezeshkpoor
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
| | - A Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Clinic Bonn, Bonn, Germany
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Comber DA, Davies B, Roberts JD, Tadros R, Green MS, Healey JS, Simpson CS, Sanatani S, Steinberg C, MacIntyre C, Angaran P, Duff H, Hamilton R, Arbour L, Leather R, Seifer C, Fournier A, Atallah J, Kimber S, Makanjee B, Alqarawi W, Cadrin-Tourigny J, Joza J, Gibbs K, Robb L, Zahavich L, Gardner M, Talajic M, Virani A, Krahn AD, Lehman A, Laksman ZWM. Return of Results Policies for Genomic Research: Current Practices & The Hearts in Rhythm Organization Approach. Can J Cardiol 2021; 38:526-535. [PMID: 34715283 DOI: 10.1016/j.cjca.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/02/2022] Open
Abstract
Research teams developing biobanks and/or genomic databases must develop policies for the disclosure and reporting of potentially actionable genomic results to research participants. Currently, a broad range of approaches to the return of results exist, with some studies opting for non-disclosure of research results while others follow clinical guidelines for the return of potentially actionable findings from sequencing. In this review, we describe current practices and highlight decisions a research team must make when designing a return of results policy, from informed consent to disclosure practices and clinical validation options. The unique challenges of returning incidental findings in cardiac genes, including reduced penetrance and the lack of clinical screening standards for phenotype-negative individuals are discussed. Lastly, the National Hearts in Rhythm Organization (HiRO) Registry approach is described to provide a rationale for the selective return of field-specific variants to those participating in disease-specific research. Our goal is to provide researchers with a resource when developing a return of results policy tailored for their research program, based on unique factors related to study design, research team composition and availability of clinical resources.
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Affiliation(s)
- Drake A Comber
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brianna Davies
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jason D Roberts
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Western University, London, ON, Canada
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Martin S Green
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | | | | | - Christian Steinberg
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | | | - Paul Angaran
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Henry Duff
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Robert Hamilton
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada
| | - Laura Arbour
- Department of Medical Genetics, University of British Columbia and Island Health, Victoria, BC, Canada
| | | | - Colette Seifer
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Anne Fournier
- Division of Pediatric Cardiology, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Joseph Atallah
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Shane Kimber
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Bhavanesh Makanjee
- Heart Health Institute, Scarborough Health Network, Scarborough, ON, Canada
| | - Wael Alqarawi
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Julia Cadrin-Tourigny
- Cardiovascular Genetics Center, Montreal Heart Institute, and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada
| | - Karen Gibbs
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Laura Robb
- Cardiovascular Genetics Center, Montreal Heart Institute, and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Laura Zahavich
- The Hospital for Sick Children (SickKids), Toronto, ON, Canada
| | | | - Mario Talajic
- Cardiovascular Genetics Center, Montreal Heart Institute, and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Alice Virani
- Department of Medical Genetics, The University of British, Columbia, Vancouver, British Columbia, Canada
| | - Andrew D Krahn
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anna Lehman
- Department of Medical Genetics, The University of British, Columbia, Vancouver, British Columbia, Canada
| | - Zachary W M Laksman
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Denburg AE, Giacomini M, Ungar WJ, Abelson J. The Moral Foundations of Child Health and Social Policies: A Critical Interpretive Synthesis. CHILDREN-BASEL 2021; 8:children8010043. [PMID: 33450842 PMCID: PMC7828333 DOI: 10.3390/children8010043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/16/2022]
Abstract
Background: Allusions to the uniqueness and value of childhood abound in academic, lay, and policy discourse. However, little clarity exists on the values that guide child health and social policy-making. We review extant academic literature on the normative dimensions of child health and social policy to provide foundations for the development of child-focused public policies. Methods: We conducted a critical interpretive synthesis of academic literature on the normative dimensions of child health and social policy-making. We employed a social constructivist lens to interpret emergent themes. Political theory on the social construction of target populations served as a bridge between sociologies of childhood and public policy analysis. Results: Our database searches returned 14,658 unique articles; full text review yielded 72 relevant articles. Purposive sampling of relevant literature complemented our electronic searches, adding 51 original articles, for a total of 123 articles. Our analysis of the literature reveals three central themes: potential, rights, and risk. These themes retain relevance in diverse policy domains. A core set of foundational concepts also cuts across disciplines: well-being, participation, and best interests of the child inform debate on the moral and legal dimensions of a gamut of child social policies. Finally, a meta-theme of embedding encompasses the pervasive issue of a child’s place, in the family and in society, which is at the heart of much social theory and applied analysis on children and childhood. Conclusions: Foundational understanding of the moral language and dominant policy frames applied to children can enrich analyses of social policies for children. Most societies paint children as potent, vulnerable, entitled, and embedded. It is the admixture of these elements in particular policy spheres, across distinct places and times, that often determines the form of a given policy and societal reactions to it. Subsequent work in this area will need to detail the degree and impact of variance in the values mix attached to children across sociocultural contexts and investigate tensions between what are and what ought to be the values that guide social policy development for children.
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Affiliation(s)
- Avram E. Denburg
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
- Correspondence: ; Tel.: +1-416-813-8469; Fax: +1-416-813-5327
| | - Mita Giacomini
- Centre for Health Economics and Policy Analysis, Department of Health Research Methods, McMaster University, Hamilton, ON L8S 4L8, Canada; (M.G.); (J.A.)
| | - Wendy J. Ungar
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada;
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Julia Abelson
- Centre for Health Economics and Policy Analysis, Department of Health Research Methods, McMaster University, Hamilton, ON L8S 4L8, Canada; (M.G.); (J.A.)
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13
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Dondorp W, Bolt I, Tibben A, De Wert G, Van Summeren M. 'We Should View Him as an Individual': The Role of the Child's Future Autonomy in Shared Decision-Making About Unsolicited Findings in Pediatric Exome Sequencing. HEALTH CARE ANALYSIS 2021; 29:249-261. [PMID: 33389383 DOI: 10.1007/s10728-020-00425-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/29/2022]
Abstract
In debates about genetic testing of children, as well as about disclosing unsolicited findings (UFs) of pediatric exome sequencing, respect for future autonomy should be regarded as a prima facie consideration for not taking steps that would entail denying the future adult the opportunity to decide for herself about what to know about her own genome. While the argument can be overridden when other, morally more weighty considerations are at stake, whether this is the case can only be determined in concrete cases. Importantly, when children grow into adolescents, respect for future autonomy will have to give way to respecting their emerging autonomy. When pediatric exome sequencing is done for complex conditions not involving developmental delay, respect for the child's future or emerging autonomy should be a primary consideration for those charged with deciding on behalf of the child. Building on what Emanuel and Emanuel have termed the 'deliberative model' of shared decision making, we argue that if parents fail to give these considerations their due, professionals should actively invite them to do so. Taking a directive stance may be needed in order to make sure that the future or emerging autonomy of the child are duly considered in the decision-making process, but also to help the parents and themselves to shape their respective roles as responsible care-givers.
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Affiliation(s)
- W Dondorp
- Department of Health, Ethics and Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, De Byeplein 1, 6229 HA, Maastricht, The Netherlands.
| | - I Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Tibben
- Department of Clinical Genetics, Leiden University Medical Centre, Laan van Duivenvoorde 2-TO, 2252 AK, Voorschoten, The Netherlands
| | - G De Wert
- Department of Health, Ethics and Society, Faculty of Health, Medicine and Life Sciences, Maastricht University, De Byeplein 1, 6229 HA, Maastricht, The Netherlands
| | - M Van Summeren
- Department of General Pediatrics, University Medical Centre Utrecht, UMC Utrecht, PO Box 85090, 3508 AB, Utrecht, The Netherlands
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14
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Savatt JM, Wagner JK, Joffe S, Rahm AK, Williams MS, Bradbury AR, Davis FD, Hergenrather J, Hu Y, Kelly MA, Kirchner HL, Meyer MN, Mozersky J, O'Dell SM, Pervola J, Seeley A, Sturm AC, Buchanan AH. Pediatric reporting of genomic results study (PROGRESS): a mixed-methods, longitudinal, observational cohort study protocol to explore disclosure of actionable adult- and pediatric-onset genomic variants to minors and their parents. BMC Pediatr 2020; 20:222. [PMID: 32414353 PMCID: PMC7227212 DOI: 10.1186/s12887-020-02070-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/06/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Exome and genome sequencing are routinely used in clinical care and research. These technologies allow for the detection of pathogenic/likely pathogenic variants in clinically actionable genes. However, fueled in part by a lack of empirical evidence, controversy surrounds the provision of genetic results for adult-onset conditions to minors and their parents. We have designed a mixed-methods, longitudinal cohort study to collect empirical evidence to advance this debate. METHODS Pediatric participants in the Geisinger MyCode® Community Health Initiative with available exome sequence data will have their variant files assessed for pathogenic/likely pathogenic variants in 60 genes designated as actionable by MyCode. Eight of these genes are associated with adult-onset conditions (Hereditary Breast and Ovarian Cancer Syndrome (HBOC), Lynch syndrome, MUTYH-associated polyposis, HFE-Associated Hereditary Hemochromatosis), while the remaining genes have pediatric onset. Prior to clinical confirmation of results, pediatric MyCode participants and their parents/legal guardians will be categorized into three study groups: 1) those with an apparent pathogenic/likely pathogenic variant in a gene associated with adult-onset disease, 2) those with an apparent pathogenic/likely pathogenic variant in a gene associated with pediatric-onset disease or with risk reduction interventions that begin in childhood, and 3) those with no apparent genomic result who are sex- and age-matched to Groups 1 and 2. Validated and published quantitative measures, semi-structured interviews, and a review of electronic health record data conducted over a 12-month period following disclosure of results will allow for comparison of psychosocial and behavioral outcomes among parents of minors (ages 0-17) and adolescents (ages 11-17) in each group. DISCUSSION These data will provide guidance about the risks and benefits of informing minors and their family members about clinically actionable, adult-onset genetic conditions and, in turn, help to ensure these patients receive care that promotes physical and psychosocial health. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03832985. Registered 6 February 2019.
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Affiliation(s)
| | - Jennifer K Wagner
- Center for Translational Bioethics and Health Care Policy, Geisinger, Danville, PA, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Angela R Bradbury
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - F Daniel Davis
- Center for Translational Bioethics and Health Care Policy, Geisinger, Danville, PA, USA
| | - Julie Hergenrather
- Department of Psychiatry and Behavioral Health, Geisinger, Danville, PA, USA
| | - Yirui Hu
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | | | - H Lester Kirchner
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | - Michelle N Meyer
- Center for Translational Bioethics and Health Care Policy, Geisinger, Danville, PA, USA
| | - Jessica Mozersky
- Bioethics Research Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sean M O'Dell
- Department of Psychiatry and Behavioral Health, Geisinger, Danville, PA, USA
- Department of Population Health Sciences, Geisinger, Danville, PA, USA
| | - Josie Pervola
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Andrea Seeley
- Department of Pediatrics, Geisinger, Danville, PA, USA
| | - Amy C Sturm
- Genomic Medicine Institute, Geisinger, Danville, PA, USA
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15
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Chiang J, Yuen J, Shaw T, Goh HX, Li ST, Courtney E, Ngeow J. Predictive Testing for Tumor Predisposition Syndromes in Pediatric Relatives: An Asian Experience. Front Pediatr 2020; 8:568528. [PMID: 33194895 PMCID: PMC7661469 DOI: 10.3389/fped.2020.568528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/08/2020] [Indexed: 11/17/2022] Open
Abstract
Approximately 10% of pediatric cancer patients possess germline pathogenic/likely pathogenic variants (PV/LPV) in known tumor predisposition genes. Predictive testing is the optimal approach to identify asymptomatic at-risk relatives to guide gene-directed surveillance for early cancer detection and/or risk-reducing strategies. However, the uptake rate for predictive testing remains low in Asian countries. We aim to evaluate the uptake rate of predictive testing in a pediatric population (aged under 21-years-old) in a multi-ethnic Asian cancer center. Our retrospective analysis included families with PV/LPVs identified in genes associated with pediatric tumor predisposition. Of the 83 pediatric first-degree relatives (FDRs) from 49 unrelated families, 20 FDRs (24.1%) originating from 13 families (26.6%) underwent predictive testing. Genes tested in pediatric FDRs were APC, RB1, SBDS, SDHA, SDHB, SDHD, and TP53. All pediatric FDRs of probands with PV/LPVs in RB1 and biallelic PVs in SBDS underwent predictive testing, while <45% of pediatric FDRs had predictive testing for familial PV/LPVs identified in the APC, SDHA, SDHB, SDHD, and TP53 genes. Amongst the 13 families who underwent pre-test counseling, 80% of pediatric FDRs in these families proceeded with predictive testing. Malay pediatric FDRs and siblings of probands were more likely to undergo predictive testing. We conclude that the predictive testing rate in pediatric FDRs is higher than that of adult FDRs in Asia, but still below the global average. We postulate factors that may influence predictive testing uptake in pediatric FDRs includes a lack of genetics awareness, concerns regarding insurance, and genetic discrimination.
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Affiliation(s)
- Jianbang Chiang
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Jeanette Yuen
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Tarryn Shaw
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Hui Xuan Goh
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Shao-Tzu Li
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Eliza Courtney
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Center Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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16
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Ross LF, Clayton EW. Ethical Issues in Newborn Sequencing Research: The Case Study of BabySeq. Pediatrics 2019; 144:peds.2019-1031. [PMID: 31719124 PMCID: PMC6889970 DOI: 10.1542/peds.2019-1031] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2019] [Indexed: 12/12/2022] Open
Abstract
The BabySeq Project is a study funded by the National Institutes of Health and aimed at exploring the medical, behavioral, and economic impacts of integrating genomic sequencing into the care of both healthy newborns and newborns who are sick. Infants were randomly assigned to receive standard of care or standard of care plus sequencing. The protocol and consent specified that only childhood-onset conditions would be returned. When 1 child was found to carry a BRCA2 mutation despite a negative family history, the research team experienced moral distress about nondisclosure and sought institutional review board permission to disclose. The protocol was then modified to require participants to agree to receive results for adult-onset-only conditions as a precondition to study enrollment. The BabySeq team asserted that their new protocol was in the child's best interest because having one's parents alive and well provides both an individual child benefit and a "family benefit." We begin with a short description of BabySeq and the controversy regarding predictive genetic testing of children for adult-onset conditions. We then examine the ethical problems with (1) the revised BabySeq protocol and (2) the concept of family benefit as a justification for the return of adult-onset-only conditions. We reject family benefit as a moral reason to expand genomic sequencing of children beyond conditions that present in childhood. We also argue that researchers should design their pediatric studies to avoid, when possible, identifying adult-onset-only genetic variants and that parents should not be offered the return of this information if discovered unless relevant for the child's current or imminent health.
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Affiliation(s)
- Lainie Friedman Ross
- MacLean Center for Clinical Medical Ethics and Departments of Pediatrics, Medicine, and Surgery, The University of Chicago, Chicago, Illinois; and
| | - Ellen Wright Clayton
- Department of Pediatrics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
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17
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Milko LV, O’Daniel JM, DeCristo DM, Crowley SB, Foreman AKM, Wallace KE, Mollison LF, Strande NT, Girnary ZS, Boshe LJ, Aylsworth AS, Gucsavas-Calikoglu M, Frazier DM, Vora NL, Roche MI, Powell BC, Powell CM, Berg JS. An Age-Based Framework for Evaluating Genome-Scale Sequencing Results in Newborn Screening. J Pediatr 2019; 209:68-76. [PMID: 30851990 PMCID: PMC6535354 DOI: 10.1016/j.jpeds.2018.12.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/24/2018] [Accepted: 12/06/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the performance of a standardized, age-based metric for scoring clinical actionability to evaluate conditions for inclusion in newborn screening and compare it with the results from other contemporary methods. STUDY DESIGN The North Carolina Newborn Exome Sequencing for Universal Screening study developed an age-based, semiquantitative metric to assess the clinical actionability of gene-disease pairs and classify them with respect to age of onset or timing of interventions. This categorization was compared with the gold standard Recommended Uniform Screening Panel and other methods to evaluate gene-disease pairs for newborn genomic sequencing. RESULTS We assessed 822 gene-disease pairs, enriched for pediatric onset of disease and suspected actionability. Of these, 466 were classified as having childhood onset and high actionability, analogous to conditions selected for the Recommended Uniform Screening Panel core panel. Another 245 were classified as having childhood onset and low to no actionability, 25 were classified as having adult onset and high actionability, 19 were classified as having adult onset and low to no actionability, and 67 were excluded due to controversial evidence and/or prenatal onset. CONCLUSIONS This study describes a novel method to facilitate decisions about the potential use of genomic sequencing for newborn screening. These categories may assist parents and physicians in making informed decisions about the disclosure of results from voluntary genomic sequencing in children.
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Affiliation(s)
| | | | | | | | | | | | | | - Natasha T. Strande
- Department of Genetics, UNC Chapel Hill,Department of Pathology and Laboratory Medicine, UNC Chapel Hill
| | - Zahra S. Girnary
- Department of Genetics, UNC Chapel Hill,current affiliation: Mission Fullerton Genetics Center, Asheville, NC
| | - Lacey J. Boshe
- Department of Genetics, UNC Chapel Hill,current affiliation: School of Medicine, UNC Chapel Hill
| | - Arthur S. Aylsworth
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | | | - Dianne M. Frazier
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | - Neeta L. Vora
- Department of Obstetrics and Gynecology, UNC Chapel Hill
| | - Myra I. Roche
- Department of Genetics, UNC Chapel Hill,Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
| | | | - Cynthia M. Powell
- Department of Pediatrics, Division of Genetics and Metabolism, UNC Chapel Hill
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18
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Pervola J, Myers MF, McGowan ML, Prows CA. Giving adolescents a voice: the types of genetic information adolescents choose to learn and why. Genet Med 2019; 21:965-971. [PMID: 30369597 PMCID: PMC10445294 DOI: 10.1038/s41436-018-0320-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/14/2018] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The American College of Medical Genetics and Genomics supports parents' opting in or out of secondary analysis of 59 genes when their child has clinical exome/genome sequencing. We explored the reasons adolescents choose to learn certain types of results and the reasons they want to involve or not involve parents in decision-making. METHODS Adolescents recruited without clinical indication were offered independent, followed by joint choices with a parent to learn genomic results. After making independent choices, adolescent/parent dyads were interviewed to explore the reasons for their choices. Interviews were audio-recorded and transcribed. The constant comparative method was used to analyze 64 purposefully selected transcripts that included 31 from adolescents who excluded some or all potential results. RESULTS Three major themes informed adolescents' choices: (1) actionability of information, (2) knowledge seeking, and (3) psychological impact. Of adolescents who independently excluded some conditions (n=31), 58% changed their initial choices during the joint interview due to parental influence or improved understanding. Nearly all adolescents (98%) wanted to be involved in the decision-making process, and 53% wanted to make choices independently. CONCLUSIONS Our findings contribute empirical evidence to support the refinement of professional guidelines for adolescents' engagement and preferences in genetic testing decisions.
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Affiliation(s)
- Josie Pervola
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melanie F Myers
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle L McGowan
- Ethics Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics & Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, USA
| | - Cynthia A Prows
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Patient Services, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH, USA.
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19
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Ormond KE, O'Daniel JM, Kalia SS. Secondary findings: How did we get here, and where are we going? J Genet Couns 2019; 28:326-333. [DOI: 10.1002/jgc4.1098] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/13/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Kelly E. Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics; Stanford University School of Medicine; Stanford California
| | - Julianne M. O'Daniel
- Department of Genetics; University of North Carolina at Chapel Hill; Chapel Hill Carolina
| | - Sarah S. Kalia
- Department of Epidemiology; Harvard T.H. Chan School of Public Health; Boston Massachusetts
- Graduate School of Arts and Sciences; Harvard University; Cambridge Massachusetts
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20
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Palk AC, Dalvie S, de Vries J, Martin AR, Stein DJ. Potential use of clinical polygenic risk scores in psychiatry - ethical implications and communicating high polygenic risk. Philos Ethics Humanit Med 2019; 14:4. [PMID: 30813945 PMCID: PMC6391805 DOI: 10.1186/s13010-019-0073-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/14/2019] [Indexed: 06/09/2023] Open
Abstract
Psychiatric disorders present distinct clinical challenges which are partly attributable to their multifactorial aetiology and the absence of laboratory tests that can be used to confirm diagnosis or predict risk. Psychiatric disorders are highly heritable, but also polygenic, with genetic risk conferred by interactions between thousands of variants of small effect that can be summarized in a polygenic risk score. We discuss four areas in which the use of polygenic risk scores in psychiatric research and clinical contexts could have ethical implications. First, there is concern that clinical use of polygenic risk scores may exacerbate existing health inequities. Second, research findings regarding polygenic risk could be misinterpreted in stigmatising or discriminatory ways. Third, there are concerns associated with testing minors as well as eugenics concerns elicited by prenatal polygenic risk testing. Fourth, potential challenges that could arise with the feedback and interpretation of high polygenic risk for a psychiatric disorder would require consideration. While there would be extensive overlap with the challenges of feeding back genetic findings in general, the potential clinical use of polygenic risk scoring warrants discussion in its own right, given the recency of this possibility. To this end, we discuss how lay interpretations of risk and genetic information could intersect. Consideration of these factors would be necessary for ensuring effective and constructive communication and interpretation of polygenic risk information which, in turn, could have implications for the uptake of any therapeutic recommendations. Recent advances in polygenic risk scoring have major implications for its clinical potential, however, care should be taken to ensure that communication of polygenic risk does not feed into problematic assumptions regarding mental disorders or support reductive interpretations.
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Affiliation(s)
- A. C. Palk
- Department of Psychiatry, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - S. Dalvie
- Department of Psychiatry and SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - J. de Vries
- Department of Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
| | - A. R. Martin
- Analytic & Translational Genetics Unit, Massachusetts General Hospital, Boston, MA USA
- Stanley Center for Psychiatric Research & Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA USA
| | - D. J. Stein
- Department of Psychiatry and SA MRC Unit on Risk and Resilience in Mental Disorders, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, 7925 South Africa
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21
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Valdez JM, Walker B, Ogg S, Gattuso J, Alderfer MA, Zelley K, Ford CA, Baker JN, Mandrell BN, Nichols KE. Parent-child communication surrounding genetic testing for Li-Fraumeni syndrome: Living under the cloud of cancer. Pediatr Blood Cancer 2018; 65:e27350. [PMID: 30009566 DOI: 10.1002/pbc.27350] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/23/2018] [Accepted: 06/10/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Advances in the application of genetic technologies reveal a growing number of heritable disorders associated with an increased risk to develop cancer during childhood. As genetic testing is increasingly employed in the clinical setting, it is essential to understand whether parents communicate with their children about test results and to elucidate the factors that influence the content and outcomes of these conversations. METHODS Semistructured interviews were conducted with 14 parents whose children tested positive for Li-Fraumeni syndrome (LFS). Semantic content analysis was performed on transcribed interviews, focusing on questions related to parent-child conversations about the genetic testing process and disclosure of positive test results. RESULTS All parents emphasized the importance of involving children in conversations about LFS. The majority (93%) identified as being part of "cancer families" in which prior experiences with cancer created opportunities for communication. While all had spoken with their children about cancer, only seven (50%) specifically disclosed to their children that they had tested positive for LFS. The most common reason cited for nondisclosure at the time of this study was the young age of the children. CONCLUSION Parents of children with LFS desire open conversations about genetic testing and cancer risk. These conversations are challenging yet essential to enable child understanding of genetic risk status and enhance compliance with health-promoting and cancer surveillance measures. Development of age-appropriate educational materials and novel clinical models to facilitate parent-child conversations about genetic test results and risk status for cancer are needed.
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Affiliation(s)
- Jessica M Valdez
- Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Breya Walker
- Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Susan Ogg
- Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jami Gattuso
- Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melissa A Alderfer
- Center for Healthcare Delivery Science, Nemours Children's Health System, Wilmington, Delaware
| | - Kristin Zelley
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Carol A Ford
- Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, Philadelphia
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Belinda N Mandrell
- Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kim E Nichols
- Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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22
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Abstract
Regulatory compliance in the direct-to-consumer genetic testing market is highly sophisticated as there are numerous federal, state, and ethical barriers to entry. In 2010, amid an underregulated market, 23andMe sought to do what few companies in the medical industry had attempted before-disregard the guidance and requests of the US Food and Drug Administration. This regulatory strategy effectively destined the company's Personal Genome Service for failure; however, the company changed course and has been granted several regulatory clearances. This exemplifies the importance of a healthy relationship with regulatory agencies, although challenges remain. The DTC industry continues to have a perplexing regulatory framework at both the federal and state level. There are also ethical concerns with the monetization of deidentified genetic health information, as genetic data have an inherent level of identifiability and are not fully protected by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in these scenarios. Although some DTC tests are now cleared in the United States, the concern that a learned intermediary is needed for interpretation of results remains. The regulatory oversight of this market will need to continue to develop to ensure the protection of consumer health and privacy.
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Affiliation(s)
- Brendan Seward
- 1 Johns Hopkins University, Employee at Clarius Mobile Health Corp, Surrey, British Columbia, Canada
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23
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Milko LV, Rini C, Lewis MA, Butterfield RM, Lin FC, Paquin RS, Powell BC, Roche MI, Souris KJ, Bailey DB, Berg JS, Powell CM. Evaluating parents' decisions about next-generation sequencing for their child in the NC NEXUS (North Carolina Newborn Exome Sequencing for Universal Screening) study: a randomized controlled trial protocol. Trials 2018; 19:344. [PMID: 29950170 PMCID: PMC6022715 DOI: 10.1186/s13063-018-2686-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/14/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Using next-generation sequencing (NGS) in newborn screening (NBS) could expand the number of genetic conditions detected pre-symptomatically, simultaneously challenging current precedents, raising ethical concerns, and extending the role of parental decision-making in NBS. The NC NEXUS (Newborn Exome Sequencing for Universal Screening) study seeks to assess the technical possibilities and limitations of NGS-NBS, devise and evaluate a framework to convey various types of genetic information, and develop best practices for incorporating NGS-NBS into clinical care. The study is enrolling both a healthy cohort and a cohort diagnosed with known disorders identified through recent routine NBS. It uses a novel age-based metric to categorize a priori the large amount of data generated by NGS-NBS and interactive online decision aids to guide parental decision-making. Primary outcomes include: (1) assessment of NGS-NBS sensitivity, (2) decision regret, and (3) parental decision-making about NGS-NBS, and, for parents randomized to have the option of requesting them, additional findings (diagnosed and healthy cohorts). Secondary outcomes assess parents' reactions to the study and to decision-making. METHODS/DESIGN Participants are parents and children in a well-child cohort recruited from a prenatal clinic and a diagnosed cohort recruited from pediatric clinics that treat children with disorders diagnosed through traditional NBS (goal of 200 children in each cohort). In phase 1, all parent participants use an online decision aid to decide whether to accept NGS-NBS for their child and provide consent for NGS-NBS. In phase 2, parents who consent to NGS-NBS are randomized to a decision arm or control arm (2:1 allocation) and learn their child's NGS-NBS results, which include conditions from standard (non-NGS) NBS plus other highly actionable childhood-onset conditions. Parents in the decision arm use a second decision aid to make decisions about additional results from their child's sequencing. In phase 3, decision arm participants learn additional results they have requested. Online questionnaires are administered at up to five time points. DISCUSSION NC NEXUS will use a rigorous interdisciplinary approach designed to collect rich data to inform policy, practice, and future research. TRIAL REGISTRATION clinicaltrials.gov, NCT02826694 . Registered on 11 July, 2016.
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Affiliation(s)
- Laura V. Milko
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Christine Rini
- Department of Biomedical Research, Hackensack University Medical Center, Hackensack, NJ 07601 USA
| | - Megan A. Lewis
- Center for Communication Science, RTI International, Research Triangle Park, NC 27709 USA
| | - Rita M. Butterfield
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Ryan S. Paquin
- Center for Communication Science, RTI International, Research Triangle Park, NC 27709 USA
| | - Bradford C. Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Myra I. Roche
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
| | - Katherine J. Souris
- Department of Heath Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Donald B. Bailey
- Center for Newborn Screening, Ethics, and Disability Studies, RTI International, Research Triangle Park, NC 27709 USA
| | - Jonathan S. Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Cynthia M. Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599 USA
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24
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Schultz CL, Alderfer MA, Lindell RB, McClain Z, Zelley K, Nichols KE, Ford CA. The Influence of Adolescence on Parents' Perspectives of Testing and Discussing Inherited Cancer Predisposition. J Genet Couns 2018; 27:10.1007/s10897-018-0267-z. [PMID: 29909594 DOI: 10.1007/s10897-018-0267-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 06/04/2018] [Indexed: 12/28/2022]
Abstract
Li-Fraumeni syndrome (LFS) is a highly penetrant cancer predisposition syndrome that may present with a first cancer before or during adolescence/young adulthood. Families offered LFS genetic testing for their children can inform our understanding of how the unique developmental context of adolescence influences parental perspectives about genetic testing and discussions of cancer risk. In this study, semi-structured interviews were conducted with 46 parents of children at risk for LFS to capture those perspectives. Analysis utilized summary descriptive statistics and inductive qualitative content coding. Most parents (33/46; 72%) expressed beliefs that adolescence influences the importance of LFS testing and/or discussions about genetic risk. Twenty-six parents related this influence to cognitive, physical, and social changes occurring during adolescence. Aspects of adolescence perceived as promoting LFS testing/discussion included developmental appropriateness, risks of cancer in adolescence, need for medical screening decisions, influence on behaviors, transition to adult health care, and reproductive risks. Aspects of adolescence perceived as complicating LFS testing/discussions included potential negative emotional impact, misunderstanding, added burden, and negative impact on self-image or future planning. Parents recognize the complex influence that adolescence has on LFS testing and conversations surrounding results. Further research is needed to understand the actual impact of genetic testing on young people, and how to best support parents and adolescents within the broader context of heritable diseases.
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Affiliation(s)
- Corinna L Schultz
- Nemours Children's Health System/A.I. duPont Hospital for Children, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Melissa A Alderfer
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- The Center for Healthcare Delivery Science, Nemours Children's Health System/A.I. duPont Hospital for Children, Wilmington, DE, USA.
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Robert B Lindell
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zachary McClain
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Craig-Dalsimer Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristin Zelley
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kim E Nichols
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Oncology, Division of Cancer Predisposition, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Carol A Ford
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Craig-Dalsimer Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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25
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Achatz MI, Porter CC, Brugières L, Druker H, Frebourg T, Foulkes WD, Kratz CP, Kuiper RP, Hansford JR, Hernandez HS, Nathanson KL, Kohlmann WK, Doros L, Onel K, Schneider KW, Scollon SR, Tabori U, Tomlinson GE, Evans DGR, Plon SE. Cancer Screening Recommendations and Clinical Management of Inherited Gastrointestinal Cancer Syndromes in Childhood. Clin Cancer Res 2018; 23:e107-e114. [PMID: 28674119 DOI: 10.1158/1078-0432.ccr-17-0790] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 11/16/2022]
Abstract
Hereditary gastrointestinal cancer predisposition syndromes have been well characterized, but management strategies and surveillance remain a major challenge, especially in childhood. In October 2016, the American Association for Cancer Research organized the AACR Childhood Cancer Predisposition Workshop in which international experts in care of children with a hereditary risk of cancer met to define surveillance strategies and management of children with cancer predisposition syndromes. In this article, we review the current literature in polyposis syndromes that can be diagnosed in childhood and may be associated with an increased incidence of gastrointestinal neoplasms and other cancer types. These disorders include adenomatous polyposis syndromes (APC and MUTYH), juvenile polyposis coli (BMPR1A and SMAD4), Peutz-Jeghers Syndrome (STK11/LKB1), and PTEN hamartoma tumor syndrome (PHTS; PTEN), which can present with a more limited juvenile polyposis phenotype. Herein, the panel of experts provides recommendations for clinical diagnosis, approach to genetic testing, and focus on cancer surveillance recommendations when appropriate during the pediatric period. We also review current controversies on genetic evaluation of patients with hepatoblastoma and indications for surveillance for this tumor. Childhood cancer risks and surveillance associated with disorders involving the mismatch repair genes, including Lynch syndrome and constitutional mismatch repair deficiency (CMMRD), are discussed elsewhere in this series. Clin Cancer Res; 23(13); e107-e14. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.
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Affiliation(s)
- Maria Isabel Achatz
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland.
| | | | - Laurence Brugières
- Child and Adolescent Cancer Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - Harriet Druker
- Division of Hematology/Oncology, Department of Genetic Counselling, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Thierry Frebourg
- Department of Genetics, Rouen University Hospital, Rouen, France
| | - William D Foulkes
- Department of Medicine, Oncology and Human Genetics, McGill University, Montreal, Canada
| | - Christian P Kratz
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Roland P Kuiper
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Jordan R Hansford
- Children's Cancer Centre, Royal Children's Hospital; Murdoch Children's Research Institute; University of Melbourne, Melbourne, Australia
| | | | | | - Wendy K Kohlmann
- Population Health Sciences Department, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Leslie Doros
- Cancer Genetics Clinic, Children's National Medical Center, Washington, DC
| | - Kenan Onel
- Department of Pediatrics, Hofstra-Northwell School of Medicine and Cohen Children's Medical Center, Manhasset, New York
| | - Kami Wolfe Schneider
- Division of Hematology, Oncology, Bone Marrow Transplant, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah R Scollon
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Uri Tabori
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Gail E Tomlinson
- Department of Pediatric Hematology-Oncology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - D Gareth R Evans
- Department of Genomic Medicine, University of Manchester, St. Mary's Hospital, Manchester, United Kingdom
| | - Sharon E Plon
- Department of Pediatrics, Division of Hematology/Oncology, Baylor College of Medicine, Houston, Texas
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Hayeems RZ, Boycott KM. Genome-wide sequencing technologies: A primer for paediatricians. Paediatr Child Health 2018; 23:191-197. [PMID: 29769805 PMCID: PMC5951083 DOI: 10.1093/pch/pxx152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Genetic testing has been a routine part of paediatic medicine for decades. Over time, the number of genetic tests available for children presenting with features thought to be explained by an underlying genetic aetiology has expanded considerably. Genome-wide sequencing approaches (e.g., whole-exome sequencing, whole-genome sequencing) are now emerging as the most comprehensive approaches to genetic diagnosis that we have seen to date; multiple serial tests that were once required for a child under diagnostic investigation can now be accomplished in a single assay. Moreover, the performance of this single assay appears to be superior to the sum of its parts. Despite this promise, technical, ethical and access-related complexities require considerable attention prior to the implementation of these tools in mainstream paediatrics. To ready paediatricians for the eventual transition to genome-based diagnostics, herein we review both the elements and delivery considerations of this emerging technology.
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Affiliation(s)
- Robin Z Hayeems
- Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Kym M Boycott
- Department of Genetics, Children’s Hospital Eastern Ontario, Ottawa, Ontario
- Research Institute, Children’s Hospital Eastern Ontario, Ottawa, Ontario
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario
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27
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Bester JC, Sabatello M, van Karnebeek CD, Lantos JD. Please Test My Child for a Cancer Gene, but Don't Tell Her. Pediatrics 2018. [PMID: 29535250 PMCID: PMC5882554 DOI: 10.1542/peds.2017-2238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 38-year-old woman is diagnosed with Li-Fraumeni syndrome, an autosomal dominant genetic condition that predisposes to a variety of cancers. The woman has an 11-year-old daughter. The geneticist recommends that the child be tested for the Li-Fraumeni genetic variant. The mother is concerned about the impact of testing and diagnosis on Karen's psychological well-being. She describes Karen as "highly strung" and as "a worrier." The child has been diagnosed with an anxiety disorder and is managed by a psychologist for counseling. The child is otherwise well. The mother requests that testing be done without disclosing it to the child by adding the test on to routine blood work done for another reason and requests that the results only be revealed if they are positive. Experts in genetics, law, and bioethics discuss whether it is permissible to test the child without her knowledge or assent.
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Affiliation(s)
- Johan C. Bester
- Director of Bioethics, School of Medicine, University of Nevada, Las Vegas
| | - Maya Sabatello
- Department of Psychiatry, Columbia University, New York, NY
| | - Clara D.M. van Karnebeek
- Department of Pediatrics and Clinical Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam NL
| | - John D. Lantos
- Children’s Mercy Bioethics Center, Children’s Mercy Kansas City, MO 64108
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30
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Genetic predisposition in children with cancer - affected families' acceptance of Trio-WES. Eur J Pediatr 2018; 177:53-60. [PMID: 28929227 PMCID: PMC5748429 DOI: 10.1007/s00431-017-2997-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/10/2017] [Accepted: 08/13/2017] [Indexed: 11/02/2022]
Abstract
UNLABELLED A considerable percentage of childhood cancers are due to cancer predisposition syndromes (CPS). The ratio of CPSs caused by inherited versus de novo germline mutations and the risk of recurrence in other children are unknown. We initiated a prospective study performing whole-exome sequencing (WES) of parent-child trios in children newly diagnosed with cancer. We initially aimed to determine the interest in and acceptance of trio WES among affected families and to systematically collect demographic, medical, and family history data to analyze whether these point to an underlying CPS. Between January 2015 and December 2016, 83 (88.3%) of 94 families participated; only 11 (11.7%) refused to participate. Five (6.0%) children presented with congenital malignancies and three (3.6%) with tumors with a high likelihood of an underlying CPS. Two (2.5%) families showed malignancies in family members < 18 years, 11 (13.8%) showed relatives < 45 years with cancer, 37 (46.3%) had a positive cancer history, and 14 (17.5%) families had > 1 relative with cancer. CONCLUSIONS Genetic testing in pediatric oncology is of great interest to the families, and the vast majority opts for investigation into potentially underlying CPSs. Trio sequencing provides unique insights into CPS in pediatric cancers and is increasingly becoming a common approach in modern oncology, and thus, trio sequencing needs also to be integrated routinely into the practice of pediatric oncology. What is Known: • A considerable percentage of childhood cancers are due to cancer predisposition syndromes (CPS). What is New: • Knowing about an underlying CPS and, thus, the risk of recurrence in other children is of great interest to affected families.
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31
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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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32
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Nestor JG, Groopman EE, Gharavi AG. Towards precision nephrology: the opportunities and challenges of genomic medicine. J Nephrol 2017; 31:47-60. [PMID: 29043570 DOI: 10.1007/s40620-017-0448-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/10/2017] [Indexed: 12/28/2022]
Abstract
The expansion of genomic medicine is furthering our understanding of many human diseases. This is well illustrated in the field of nephrology, through the characterization, discovery, and growing insight into various renal diseases through use of Next Generation Sequencing (NGS) technologies. This review will provide an overview of the diagnostic opportunities of using genetic testing in the clinical setting by describing notable discoveries regarding inherited forms of renal disease that have advanced the field and by highlighting some of the potential benefits of establishing a molecular diagnosis in a clinical practice. In addition, it will discuss some of the challenges associated with the expansion of genetic testing into the clinical setting, including clinical variant interpretation and return of genetic results.
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Affiliation(s)
- Jordan G Nestor
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons, Columbia University, 1150 St. Nicholas Ave, Room 413, New York, NY, 10032, USA
| | - Emily E Groopman
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons, Columbia University, 1150 St. Nicholas Ave, Room 413, New York, NY, 10032, USA
| | - Ali G Gharavi
- Division of Nephrology, Department of Medicine, College of Physicians and Surgeons, Columbia University, 1150 St. Nicholas Ave, Room 413, New York, NY, 10032, USA.
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Wu YP, Mays D, Kohlmann W, Tercyak KP. Pediatric Predispositional Genetic Risk Communication: Potential Utility for Prevention and Control of Melanoma Risk as an Exemplar. J Genet Couns 2017; 26:887-893. [PMID: 28547663 PMCID: PMC5702278 DOI: 10.1007/s10897-017-0105-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 04/25/2017] [Indexed: 12/20/2022]
Abstract
Predispositional genetic testing among minor children is intensely debated due to the potential benefits and harms of providing this type of genetic information to children and their families. Existing guidelines on pediatric genetic testing state that predispositional testing could be appropriate for minors if preventive services exist that mitigate children's risk for or severity of the health condition in question. We use the example of hereditary melanoma to illustrate the rationale for and potential application of genetic risk communication for an adult-onset cancer to a pediatric population where childhood behaviors may reduce risk of disease later in life. We draw from the adult melanoma genetic risk communication and pediatric health behavior change literatures to suggest ways in which genetic test reporting and complementary education could be delivered to children who carry a hereditary risk for melanoma and their families in order to foster children's engagement in melanoma preventive behaviors. Genetic discoveries will continue to yield new opportunities to provide predispositional genetic risk information to unaffected individuals, including children, and could be delivered within programs that provide personalized and translational approaches to cancer prevention.
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Affiliation(s)
- Yelena P Wu
- Division of Public Health, Department of Family & Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT, 84108, USA.
- Huntsman Cancer Institute, Salt Lake City, UT, USA.
| | - Darren Mays
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, D.C, USA
| | | | - Kenneth P Tercyak
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, D.C, USA
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Genomic Testing in The Paediatric Population: Ethical Considerations in Light of Recent Policy Statements. Mol Diagn Ther 2017; 20:407-14. [PMID: 27251403 DOI: 10.1007/s40291-016-0210-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Genomic testing is rapidly becoming established in clinical practice and research. In this paper we consider the ethical issues arising in genomic testing in children, focusing on the clinical context. After describing how genomics can be said to depart from genetics in ethically relevant ways, we introduce two case studies involving ethical issues in paediatric genomic testing. We then summarise and critically engage with recent professional statements regarding genomic testing in children; notably the 2015 position statement from the American Society for Human Genetics. To provide a conceptual framework for these debates, we then synthesise recent bioethics literature regarding appropriate concepts to use when making decisions regarding children, and applying them to genomic testing. We recommend an approach to genomic testing in children that is child-focused and flexibly applied, driven by a core clinical question. Finally, we examine the role that age and emerging capacity should play in these debates.
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35
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Pennington JW, Karavite DJ, Krause EM, Miller J, Bernhardt BA, Grundmeier RW. Genomic decision support needs in pediatric primary care. J Am Med Inform Assoc 2017; 24:851-856. [PMID: 28339689 PMCID: PMC7651914 DOI: 10.1093/jamia/ocw184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/31/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
Clinical genome and exome sequencing can diagnose pediatric patients with complex conditions that often require follow-up care with multiple specialties. The American Academy of Pediatrics emphasizes the role of the medical home and the primary care pediatrician in coordinating care for patients who need multidisciplinary support. In addition, the electronic health record (EHR) with embedded clinical decision support is recognized as an important component in providing care in this setting. We interviewed 6 clinicians to assess their experience caring for patients with complex and rare genetic findings and hear their opinions about how the EHR currently supports this role. Using these results, we designed a candidate EHR clinical decision support application mock-up and conducted formative exploratory user testing with 26 pediatric primary care providers to capture opinions on its utility in practice with respect to a specific clinical scenario. Our results indicate agreement that the functionality represented by the mock-up would effectively assist with care and warrants further development.
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Affiliation(s)
- Jeffrey W Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dean J Karavite
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward M Krause
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey Miller
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Barbara A Bernhardt
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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36
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Schmidt HHJ, Barroso F, González-Duarte A, Conceição I, Obici L, Keohane D, Amass L. Management of asymptomatic gene carriers of transthyretin familial amyloid polyneuropathy. Muscle Nerve 2017; 54:353-60. [PMID: 27273296 PMCID: PMC5113802 DOI: 10.1002/mus.25210] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Abstract
Transthyretin familial amyloid polyneuropathy (TTR‐FAP) is a rare, severe, and irreversible, adult‐onset, hereditary disorder caused by autosomal‐dominant mutations in the TTR gene that increase the intrinsic propensity of transthyretin protein to misfold and deposit systemically as insoluble amyloid fibrils in nerve tissues, the heart, and other organs. TTR‐FAP is characterized by relentless, progressively debilitating polyneuropathy, and leads to death, on average, within 10 years of symptom onset without treatment. With increased availability of disease‐modifying treatment options for a wider spectrum of patients with TTR‐FAP, timely detection of the disease may offer substantial clinical benefits. This review discusses mutation‐specific predictive genetic testing in first‐degree relatives of index patients diagnosed with TTR‐FAP and the structured clinical follow‐up of asymptomatic gene carriers for prompt diagnosis and early therapeutic intervention before accumulation of substantial damage. Muscle Nerve54: 353–360, 2016
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Affiliation(s)
- Hartmut H-J Schmidt
- Department of Transplant Medicine, University Hospital Münster, Münster, Germany
| | - Fabio Barroso
- Department of Neurology, Institute for Neurological Research Raúl Carrea, FLENI, Buenos Aires, Argentina
| | - Alejandra González-Duarte
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Isabel Conceição
- Department of Neurology, Centro Hospitalar Norte-Hospital de Santa Maria, Lisbon, Portugal.,Translational and Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, Lisbon, Portugal
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Ethical considerations in genomic testing for hematologic disorders. Blood 2017; 130:460-465. [PMID: 28600340 DOI: 10.1182/blood-2017-01-734558] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/14/2017] [Indexed: 12/18/2022] Open
Abstract
As our technological capacities improve, genomic testing is increasingly integrating into patient care. The field of clinical hematology is no exception. Genomic testing carries great promise, but several ethical issues must be considered whenever such testing is performed. This review addresses these ethical considerations, including issues surrounding informed consent and the uncertainty of the results of genomic testing; the challenge of incidental findings; and possible inequities in access to and benefit from such testing. Genomic testing is likely to transform the practice of both benign and malignant hematology, but clinicians must carefully consider these core ethical issues in order to make the most of this exciting and evolving technology.
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Christensen KD, Savage SK, Huntington NL, Weitzman ER, Ziniel SI, Bacon PL, Cacioppo CN, Green RC, Holm IA. Preferences for the Return of Individual Results From Research on Pediatric Biobank Samples. J Empir Res Hum Res Ethics 2017; 12:97-106. [PMID: 28421887 PMCID: PMC5407299 DOI: 10.1177/1556264617697839] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Discussions about disclosing individual genetic research results include calls to consider participants' preferences. In this study, parents of Boston Children's Hospital patients set preferences for disclosure based on disease preventability and severity, and could exclude mental health, developmental, childhood degenerative, and adult-onset disorders. Participants reviewed hypothetical reports and reset preferences, if desired. Among 661 participants who initially wanted all results (64%), 1% reset preferences. Among 336 participants who initially excluded at least one category (36%), 38% reset preferences. Participants who reset preferences added 0.9 categories, on average; and their mean satisfaction on 0 to 10 scales increased from 4.7 to 7.2 ( p < .001). Only 2% reduced the number of categories they wanted disclosed. Findings demonstrate the benefits of providing examples of preference options and the tendency of participants to want results disclosed. Findings also suggest that preference-setting models that do not provide specific examples of results could underestimate participants' desires for information.
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Affiliation(s)
- Kurt D. Christensen
- Brigham and Women’s Hospital, Boston (USA)
- Harvard Medical School, Boston (USA)
| | | | | | - Elissa R. Weitzman
- Harvard Medical School, Boston (USA)
- Boston Children’s Hospital, Boston (USA)
| | - Sonja I. Ziniel
- Harvard Medical School, Boston (USA)
- Boston Children’s Hospital, Boston (USA)
| | - Phoebe L. Bacon
- Johns Hopkins University School of Medicine, Baltimore (USA)
| | | | - Robert C. Green
- Brigham and Women’s Hospital, Boston (USA)
- Harvard Medical School, Boston (USA)
- Partners Personalized Medicine, Boston (USA)
| | - Ingrid A. Holm
- Harvard Medical School, Boston (USA)
- Boston Children’s Hospital, Boston (USA)
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Char DS, Lázaro-Muñoz G, Barnes A, Magnus D, Deem MJ, Lantos JD. Genomic Contraindications for Heart Transplantation. Pediatrics 2017; 139:peds.2016-3471. [PMID: 28255068 PMCID: PMC5369679 DOI: 10.1542/peds.2016-3471] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 11/24/2022] Open
Abstract
Genome sequencing raises new ethical challenges. Decoding the genome produces new forms of diagnostic and prognostic information; however, the information is often difficult to interpret. The connection between most genetic variants and their phenotypic manifestations is not understood. This scenario is particularly true for disorders that are not associated with an autosomal genetic variant. The analytic uncertainty is compounded by moral uncertainty about how, exactly, the results of genomic testing should influence clinical decisions. In this Ethics Rounds, we present a case in which genomic findings seemed to play a role in deciding whether a patient was to be listed as a transplant candidate. We then asked experts in bioethics and cardiology to discuss the implications of such decisions.
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Affiliation(s)
- Danton S. Char
- Department of Anesthesiology, and,Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California;,Division of Pediatric Cardiac Anesthesia, Stanford University Medical Center, Stanford, California
| | - Gabriel Lázaro-Muñoz
- Center for Genomics and Society, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina;,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | | | - David Magnus
- Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California
| | - Michael J. Deem
- Department of Multidisciplinary Studies, The Center for Genomic Advocacy, Indiana State University, Terre Haute, Indiana
| | - John D. Lantos
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri; and
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Public's Views toward Return of Secondary Results in Genomic Sequencing: It's (Almost) All about the Choice. J Genet Couns 2017; 26:1197-1212. [PMID: 28357777 DOI: 10.1007/s10897-017-0095-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 03/13/2017] [Indexed: 12/15/2022]
Abstract
The therapeutic use of genomic sequencing creates novel and unresolved questions about cost, clinical efficacy, access, and the disclosure of sequencing results. The disclosure of the secondary results of sequencing poses a particularly challenging ethical problem. Experts disagree about which results should be shared and public input - especially important for the creation of disclosure policies - is complicated by the complex nature of genetics. Recognizing the value of deliberative democratic methods for soliciting informed public opinion on matters like these, we recruited participants from a clinical research site for an all-day deliberative democracy (DD) session. Participants were introduced to the clinical and ethical issues associated with genomic sequencing, after which they discussed the tradeoffs and offered their opinions about policies for the return of secondary results. Participants (n = 66; mean age = 57 (SD = 15); 70% female; 76% white) were divided into 10 small groups (5 to 8 participants each) allowing interactive deliberation on policy options for the return of three categories of secondary results: 1) medically actionable results; 2) risks for adult-onset disorders identified in children; and 3) carrier status for autosomal recessive disorders. In our qualitative analysis of the session transcripts, we found that while participants favored choice and had a preference for making information available, they also acknowledged the risks (and benefits) of learning such information. Our research reveals the nuanced reasoning used by members of the public when weighing the pros and cons of receiving genomic information, enriching our understanding of the findings of surveys of attitudes regarding access to secondary results.
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Sénécal K, Thys K, Vears DF, Van Assche K, Knoppers BM, Borry P. Legal approaches regarding health-care decisions involving minors: implications for next-generation sequencing. Eur J Hum Genet 2016; 24:1559-1564. [PMID: 27302841 PMCID: PMC5110060 DOI: 10.1038/ejhg.2016.61] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/26/2016] [Accepted: 04/12/2016] [Indexed: 12/03/2022] Open
Abstract
The development of next-generation sequencing (NGS) technologies are revolutionizing medical practice, facilitating more accurate, sophisticated and cost-effective genetic testing. NGS is already being implemented in the clinic assisting diagnosis and management of disorders with a strong heritable component. Although considerable attention has been paid to issues regarding return of incidental or secondary findings, matters of consent are less well explored. This is particularly important for the use of NGS in minors. Recent guidelines addressing genomic testing and screening of children and adolescents have suggested that as 'young children' lack decision-making capacity, decisions about testing must be conducted by a surrogate, namely their parents. This prompts consideration of the age at which minors can provide lawful consent to health-care interventions, and consequently NGS performed for diagnostic purposes. Here, we describe the existing legal approaches regarding the rights of minors to consent to health-care interventions, including how laws in the 28 Member States of the European Union and in Canada consider competent minors, and then apply this to the context of NGS. There is considerable variation in the rights afforded to minors across countries. Many legal systems determine that minors would be allowed, or may even be required, to make decisions about interventions such as NGS. However, minors are often considered as one single homogeneous population who always require parental consent, rather than recognizing there are different categories of 'minors' and that capacity to consent or to be involved in discussions and decision-making process is a spectrum rather than a hurdle.
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Affiliation(s)
- Karine Sénécal
- Centre of Genomics and Policy, Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Kristof Thys
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Danya F Vears
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Kristof Van Assche
- Research Group on Personality Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium
| | - Bartha M Knoppers
- Centre of Genomics and Policy, Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
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Abstract
AIM To characterize the views of young adults toward integrating whole-genome sequencing (WGS) into standard pediatric care, particularly when used as a supplement to newborn screening. MATERIALS & METHODS This mixed methods descriptive study assessed the perspectives of a diverse group of 18- and 19-year olds (n = 145) in the USA using an informational video and online survey. RESULTS Young adults typically recommended disclosing WGS results to both parents and children during childhood. In the qualitative analysis, most participants emphasized the anticipated health benefits of pediatric WGS, while a minority discussed possible negative emotional and developmental impacts. CONCLUSION Differing preferences for pediatric WGS emphasize the importance that clinicians adopt responsive approaches when providing WGS and disclosing results to families.
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Affiliation(s)
- Christopher H Wade
- School of Nursing & Health Studies, University of Washington Bothell, Bothell, WA, USA
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Bradbury AR, Patrick-Miller L, Schwartz LA, Egleston BL, Henry-Moss D, Domchek SM, Daly MB, Tuchman L, Moore C, Rauch PK, Shorter R, Karpink K, Sands CB. Psychosocial Adjustment and Perceived Risk Among Adolescent Girls From Families With BRCA1/2 or Breast Cancer History. J Clin Oncol 2016; 34:3409-16. [PMID: 27551110 DOI: 10.1200/jco.2015.66.3450] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To evaluate the impact of breast cancer family history and maternal BRCA1/2 mutation on the psychosocial adjustment and perceived risk in girls age 11 to 19 years old. MATERIALS AND METHODS Girls age 11 to 19 years old with one or more relatives with breast cancer or a familial BRCA1/2 mutation (breast cancer family history [BCFH] positive, n = 208; n = 69 with BRCA1/2-positive mother), peers (BCFH negative, n = 112), and their mothers completed assessments of psychosocial adjustment, breast cancer-specific distress, and perceived risk of breast cancer. RESULTS General psychosocial adjustment did not differ significantly between BCFH-positive and BCFH-negative girls, either by self-report or mother report, except for higher self-esteem among BCFH-positive girls (P = .01). BCFH-positive girls had higher breast cancer-specific distress than BCFH-negative girls (P < .001), but girls from BRCA1/2-positive families did not differ from other BCFH-positive peers. BCFH-positive girls were more likely to report themselves at increased self-risk for breast cancer in adulthood than BCFH-negative peers (74% v 33%, respectively; P ≤ .001). Girls from BRCA1/2-positive families were more likely than other BCFH-positive and BCFH-negative peers to report themselves at increased risk (P < .001). In all groups, perceived risk of breast cancer was associated with older age. Higher breast cancer-specific distress among adolescent girls was associated with higher self-perceived risk of breast cancer and higher maternal breast cancer-specific distress. CONCLUSION Adolescent girls from BRCA1/2-positive and breast cancer families have higher self-esteem and do not have poorer psychosocial adjustment than peers. However, they do experience greater breast cancer-specific distress and perceived risk of breast cancer, particularly among older girls. Understanding the impact is important to optimize responses to growing up in families at familial and genetic risk for breast cancer, particularly given the debate over the genetic testing of children for cancer susceptibility in adulthood.
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Affiliation(s)
- Angela R Bradbury
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA.
| | - Linda Patrick-Miller
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Lisa A Schwartz
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Brian L Egleston
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Dare Henry-Moss
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Susan M Domchek
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Mary B Daly
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Lisa Tuchman
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Cynthia Moore
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Paula K Rauch
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Rebecca Shorter
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Kelsey Karpink
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
| | - Colleen Burke Sands
- Angela R. Bradbury, Lisa A. Schwartz, Dare Henry-Moss, Susan M. Domchek, Rebecca Shorter, Kelsey Karpink, and Colleen Burke Sands, The Perelman School of Medicine of the University of Pennsylvania; Lisa A. Schwartz, The Children's Hospital of Philadelphia; Brian L. Egleston and Mary B. Daly, Fox Chase Cancer Center, Temple University Health System; Susan M. Domchek, The Basser Research Center for BRCA in the Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA; Linda Patrick-Miller, The University of Chicago, Chicago, IL; Lisa Tuchman, Children's National Medical Center, Washington, DC; and Cynthia Moore and Paula K. Rauch, Massachusetts General Hospital, Boston, MA
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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: 110] [Impact Index Per Article: 13.8] [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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McCullough LB, Slashinski MJ, McGuire AL, Street RL, Eng CM, Gibbs RA, Parsons DW, Plon SE. Is Whole-Exome Sequencing an Ethically Disruptive Technology? Perspectives of Pediatric Oncologists and Parents of Pediatric Patients With Solid Tumors. Pediatr Blood Cancer 2016; 63:511-5. [PMID: 26505993 PMCID: PMC4982513 DOI: 10.1002/pbc.25815] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND It has been anticipated that physician and parents will be ill prepared or unprepared for the clinical introduction of genome sequencing, making it ethically disruptive. PROCEDURE As a part of the Baylor Advancing Sequencing in Childhood Cancer Care study, we conducted semistructured interviews with 16 pediatric oncologists and 40 parents of pediatric patients with cancer prior to the return of sequencing results. We elicited expectations and attitudes concerning the impact of sequencing on clinical decision making, clinical utility, and treatment expectations from both groups. Using accepted methods of qualitative research to analyze interview transcripts, we completed a thematic analysis to provide inductive insights into their views of sequencing. RESULTS Our major findings reveal that neither pediatric oncologists nor parents anticipate sequencing to be an ethically disruptive technology, because they expect to be prepared to integrate sequencing results into their existing approaches to learning and using new clinical information for care. Pediatric oncologists do not expect sequencing results to be more complex than other diagnostic information and plan simply to incorporate these data into their evidence-based approach to clinical practice, although they were concerned about impact on parents. For parents, there is an urgency to protect their child's health and in this context they expect genomic information to better prepare them to participate in decisions about their child's care. CONCLUSIONS Our data do not support the concern that introducing genome sequencing into childhood cancer care will be ethically disruptive, that is, leave physicians or parents ill prepared or unprepared to make responsible decisions about patient care.
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Affiliation(s)
- Laurence B. McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, Correspondence to: Laurence B. McCullough, Ph.D., Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MS 420, Houston, TX 77030-3411, Tel.:713 798 3505,
| | - Melody J. Slashinski
- Department of Community Health Education, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Amy L. McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Richard L. Street
- Department of Communication, Texas A&M University, College Station, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Christine M. Eng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Richard A. Gibbs
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - D. Williams Parsons
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas,Department of Pediatrics, Baylor College of Medicine Houston, Texas
| | - Sharon E. Plon
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas,Department of Pediatrics, Baylor College of Medicine Houston, Texas
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46
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The psychological impact of genetic information on children: a systematic review. Genet Med 2016; 18:755-62. [DOI: 10.1038/gim.2015.181] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/27/2015] [Indexed: 12/12/2022] Open
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Char DS. How should whole-genome sequencing be implemented in children? A consideration of the current limitations. Per Med 2016; 13:33-42. [DOI: 10.2217/pme.15.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
In children, whole-genome sequencing (WGS) is envisioned as a tool to improve diagnosis of undiagnosed diseases and to improve population-based screening. Pilot applications have shown benefits: genomic information has been used as a diagnostic aid; pharmacogenomics can reduce medicine-related adverse events; advanced knowledge of the potential for later-onset disease can target tests and appropriate therapies. However, emerging technical, conceptual and ethical challenges may limit WGS from fulfilling the current vision for future applications. WGS platforms still struggle with reliability and accuracy. The role of the genome in long-term organismal function and disease is still being established. Ethical implications of WGS in both undiagnosed disease and population screening, particularly potential impacts of testing on children and their families are still unresolved.
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Affiliation(s)
- Danton S Char
- Department of Anesthesiology, Stanford University School of Medicine, Division of Pediatric Cardiac Anesthesia, H3580, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA
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48
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Howard HC, Knoppers BM, Cornel MC, Wright Clayton E, Sénécal K, Borry P. Whole-genome sequencing in newborn screening? A statement on the continued importance of targeted approaches in newborn screening programmes. Eur J Hum Genet 2015; 23:1593-600. [PMID: 25626707 PMCID: PMC4795188 DOI: 10.1038/ejhg.2014.289] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/20/2014] [Accepted: 12/02/2014] [Indexed: 11/24/2022] Open
Abstract
The advent and refinement of sequencing technologies has resulted in a decrease in both the cost and time needed to generate data on the entire sequence of the human genome. This has increased the accessibility of using whole-genome sequencing and whole-exome sequencing approaches for analysis in both the research and clinical contexts. The expectation is that more services based on these and other high-throughput technologies will become available to patients and the wider population. Some authors predict that sequencing will be performed once in a lifetime, namely, shortly after birth. The Public and Professional Policy Committee of the European Society of Human Genetics, the Human Genome Organisation Committee on Ethics, Law and Society, the PHG Foundation and the P3G International Paediatric Platform address herein the important issues and challenges surrounding the potential use of sequencing technologies in publicly funded newborn screening (NBS) programmes. This statement presents the relevant issues and culminates in a set of recommendations to help inform and guide scientists and clinicians, as well as policy makers regarding the necessary considerations for the use of genome sequencing technologies and approaches in NBS programmes. The primary objective of NBS should be the targeted analysis and identification of gene variants conferring a high risk of preventable or treatable conditions, for which treatment has to start in the newborn period or in early childhood.
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Affiliation(s)
- Heidi Carmen Howard
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
| | - Bartha Maria Knoppers
- Department of Human Genetics, Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
| | - Martina C Cornel
- Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN, USA
| | - Karine Sénécal
- Department of Human Genetics, Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
| | - Pascal Borry
- Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - endorsed by the European Society of Human Genetics; the P3G International Paediatric Platform; the Human Genome Organisation; and the PHG Foundation
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
- Department of Human Genetics, Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
- Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, TN, USA
- Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
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49
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Mercer D. Guidelines for Audiologists on the Benefits and Limitations of Genetic Testing. Am J Audiol 2015; 24:451-61. [PMID: 25996947 DOI: 10.1044/2015_aja-15-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 05/17/2015] [Indexed: 12/16/2022] Open
Abstract
PURPOSE This tutorial provides information to aid audiologists in determining when a referral for a genetics evaluation is appropriate for a patient with hearing loss. Direction is given on discussing the benefits and limitations of genetic testing with parents of children with hearing loss. METHOD Genetic patterns of inheritance are reviewed, particularly in reference to syndromic and nonsyndromic forms of hearing loss. A review of pertinent literature was performed. CONCLUSION Audiologists are in a unique position to facilitate investigation into the etiology of a patient's hearing loss. This is of high importance in genetic etiologies because the diagnosis can provide information on recurrence risks and other potential health implications. Suggestions are made to help audiologists recognize when a genetics referral is warranted, counsel patients and their parents about the benefits and limitations of genetic testing, and interpret genetic test results.
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Affiliation(s)
- Danielle Mercer
- The Louisiana State University Health Sciences Center, New Orleans, LA
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50
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Peters JA, Kenen R, Bremer R, Givens S, Savage SA, Mai PL. Easing the Burden: Describing the Role of Social, Emotional and Spiritual Support in Research Families with Li-Fraumeni Syndrome. J Genet Couns 2015; 25:529-42. [PMID: 26621765 DOI: 10.1007/s10897-015-9905-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/19/2015] [Indexed: 01/10/2023]
Abstract
This study presents findings of a mixed-method descriptive exploration of the role of friends and spirituality/religiosity in easing the burden of families with the rare inherited disorder, Li-Fraumeni Syndrome (LFS). LFS is caused by germline mutations in the TP53 gene and is associated with very high lifetime risk of developing one or more malignancies. During the first clinical visit we assessed several types of social support among a subset of study participants (N = 66) using an established interactive research tool called the Colored Eco-Genetic Relationship Map (CEGRM). We performed both quantitative and qualitative analyses of social relationships with LFS family members and close non-kin. Distress scores (N = 59) were mostly low normal, with some outliers. We found that reported friendships varied widely, that the friendships were often deep and enduring, and were important sources of informational, tangible, emotional and spiritual support. Confidantes tended to be best friends and/or spouses. Organized religion was important in selected families, typically from mainstream traditions. However, a number of people identified themselves as "spiritual" and reported spiritual and humanist explorations. Our results shed preliminary light on how some people in families with LFS cope in the face of tremendous medical, social and emotional challenges.
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Affiliation(s)
- June A Peters
- Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), NIH, DHHS, Rockville, MD, USA.
| | - Regina Kenen
- Department of Sociology and Anthropology, The College of New Jersey, Ewing, NJ, USA
| | - Renee Bremer
- Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), NIH, DHHS, Rockville, MD, USA
| | - Shannon Givens
- Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), NIH, DHHS, Rockville, MD, USA
| | - Sharon A Savage
- Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), NIH, DHHS, Rockville, MD, USA
| | - Phuong L Mai
- Clinical Genetics Branch (CGB), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), NIH, DHHS, Rockville, MD, USA
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