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Slegers I, Keymolen K, Van Berkel K, Dimitrov B, Van Dooren S, Cooreman R, Hes F, Fobelets M. Searching for a sense of closure: parental experiences of recontacting after a terminated pregnancy for congenital malformations. Eur J Hum Genet 2024; 32:673-680. [PMID: 37173410 PMCID: PMC11153649 DOI: 10.1038/s41431-023-01375-z] [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: 08/28/2022] [Revised: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Rapid advances in genetic testing have improved the probability of successful genetic diagnosis. For couples who undergo a termination of pregnancy (TOP) due to foetal congenital malformations, these techniques may reveal the underlying cause and satisfy parents' need to know. The aim of this qualitative descriptive research study was to explore couples' experience of being recontacted after a congenital malformation-related TOP, as well as their reasons for participation. A retrospective cohort of 31 eligible candidates was recontacted for additional genetic testing using a standardized letter followed by a telephone call. Fourteen participants (45%) were included. Data were collected through semi-structured interviews at a hospital genetics department (UZ Brussel). Interviews were audiotaped, transcribed and analysed using thematic analysis. We found that despite the sometimes considerable length of time that passed since TOP, participants were still interested in new genetic testing. They appreciated that the initiative originated from the medical team, describing it as a "sensitive" approach. Both intrinsic (providing answers for themselves and their children) and extrinsic motivators (contributing to science and helping other parents) were identified as important factors for participation. These results show that participants often remain interested in being recontacted for new genetic testing such as whole genome sequencing, even after several years. As such, the results of this study can offer guidance in the more general current debate on recontacting patients in the field of genetics.
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Affiliation(s)
- Ileen Slegers
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium.
| | - Kathelijn Keymolen
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
| | - Kim Van Berkel
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
| | - Boyan Dimitrov
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
| | - Sonia Van Dooren
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Brussels Interuniversity Genomics High Throughput Core (BRIGHTcore), Brussels, Belgium
| | - Rani Cooreman
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
| | - Frederik Hes
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Clinical Sciences, Research Group Reproduction and Genetics, Centre for Medical Genetics, Brussels, Belgium
| | - Maaike Fobelets
- Department of Public Health Sciences, Biostatistics and Medical Informatics (BISI) Research Group, Vrije Universiteit Brussel, Brussels, Belgium and Department of Teacher Education, Vrije Universiteit Brussel, Brussels, Belgium
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2
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Outram SM, Rego S, Norstad M, Ackerman S. The Need to Standardize the Reanalysis of Genomic Sequencing Results: Findings from Interviews with Underserved Families in Genomic Research. JOURNAL OF BIOETHICAL INQUIRY 2023:10.1007/s11673-023-10267-2. [PMID: 37624546 DOI: 10.1007/s11673-023-10267-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/06/2023] [Indexed: 08/26/2023]
Abstract
The reanalysis of genomic sequencing results has the potential to provide results that are of considerable medical and personal importance to recipients. Employing interviews with forty-seven predominantly medically underserved families and ethnographic observations we argue that there is pressing need to standardize the approach taken to reanalysis. Our findings highlight that study participants were unclear as to the likelihood of reanalysis happening, the process of initiating reanalysis, and whether they would receive revised results. Their reflections mirror the lack a specific focus upon reanalysis within consent and results sessions as observed in clinical settings. Mechanisms need to be put into place that standardize the approach to reanalysis in research and in clinical contexts. This would enable clinicians and genetic counsellors to communicate clearly with research participants with respect to potential for reanalysis of results and the process of reanalysis. We argue that that the role of reanalysis is too important to be referred to in an ad-hoc manner. Furthermore, the ad-hoc nature of the current process may increase health inequities given the likelihood that only those families who have the means to press for reanalysis are likely to receive it.
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Affiliation(s)
- Simon M Outram
- Program in Bioethics, Institute for Health & Aging/Department of Social & Behavioral Sciences, University of California, 490 Illinois St., Floor 12, San Francisco, CA, 94143, USA.
| | - Shannon Rego
- Institute for Human Genetics, University of California, San Francisco, CA, 94143, USA
| | - Matthew Norstad
- Program in Bioethics, Institute for Health & Aging/Department of Social & Behavioral Sciences, University of California, 490 Illinois St., Floor 12, San Francisco, CA, 94143, USA
| | - Sara Ackerman
- Program in Bioethics, Institute for Health & Aging/Department of Social & Behavioral Sciences, University of California, 490 Illinois St., Floor 12, San Francisco, CA, 94143, USA
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3
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Opinions and experiences of recontacting patients: a survey of Australasian genetic health professionals. J Community Genet 2022; 13:193-199. [PMID: 35013911 DOI: 10.1007/s12687-021-00570-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022] Open
Abstract
The issue of recontacting past genetics patients is increasingly relevant, particularly with the introduction of next-generation sequencing. Improved testing can provide additional information on the pathogenicity and prevalence of genetic variants, often leading to a need to recontact patients. Some international genetics societies have position statements and recommendations to guide genetic health professionals (GHPs) navigating the legal, ethical and practical issues of recontacting. In the absence of a standardised Australasian protocol, we explored the experiences and opinions of Australasian GHPs regarding patient follow-up and recontacting practices. Forty-five respondents completed an online survey. Most respondents indicated that recontacting occurred on an ad hoc basis, but most genetic services relied on patients (or family) initiating recontact. Implementation of a routine recontacting system was widely dismissed by 73% of respondents, citing lack of resources, limited information on legal responsibility and setting unrealistic expectations as common barriers. If recontact was contemplated, e-communication was an acceptable first step. This study identified the need for integrated familial cancer registries to assist under-resourced genetic services to maintain up-to-date patient records. Developing a standard recontacting protocol with flexibility to account for patient individuality and circumstances might enable provision of equitable service within Australasia.
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4
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Dahle Ommundsen RM, Strømsvik N, Hamang A. Assessing the relationship between patient preferences for recontact after BRCA1 or BRCA2 genetic testing and their monitoring coping style in a Norwegian sample. J Genet Couns 2021; 31:554-564. [PMID: 34716741 DOI: 10.1002/jgc4.1526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 10/09/2021] [Accepted: 10/14/2021] [Indexed: 12/19/2022]
Abstract
Recontacting former patients regarding new genetic information is currently not standard care but might be implemented in the future. Little information is available on the implications of this practice from the point of view of former patients. The aim of this study was to investigate preferences for recontact when new genetic information becomes available among patients tested for BRCA pathogenic variants. We further wanted to investigate whether having a high or low information-seeking coping style (monitoring) impacts preferences. Preferences for recontact were assessed using a self-constructed questionnaire. The Threatening Medical Situations Inventory (TMSI) was used to measure monitoring coping style. The questionnaires were sent to 500 randomly selected patients who had previously been tested for BRCA pathogenic variants within the time frame 2001-2014 at one genetic clinic in Norway. We received 323 completed questionnaires. Most respondents wanted to be recontacted with advances in genetic medicine (81.1%) and to receive highly personalized updates. Genetic counselors/geneticists were believed to be most responsible for recontact. There was a significant relationship between being a high monitor and wanting recontact to learn about own cancer risk and receive ongoing support. Patients have a high interest in being recontacted. The findings indicated a tendency for high monitors to prefer more detailed and personalized information.
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Affiliation(s)
- Randi Marlene Dahle Ommundsen
- Department of Medical Genetics, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Global Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nina Strømsvik
- Faculty of Health and Social Sciences, Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Medical Genetics, Northern Norway Familial Cancer Center, University Hospital of North-Norway, Tromsø, Norway
| | - Anniken Hamang
- Department of Medical Genetics, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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5
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Doheny S. Recontacting in medical genetics: the implications of a broadening knowledge base. Hum Genet 2021; 141:1045-1051. [PMID: 34459979 PMCID: PMC9160136 DOI: 10.1007/s00439-021-02353-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
The practice of recontacting patients has a long history in medicine but emerged as an issue in genetics as the rapid expansion of knowledge and of testing capacity raised questions about whether, when and how to recontact patients. Until recently, the debate on recontacting has focussed on theoretical concerns of experts. The publication of empirical research into the views of patients, clinicians, laboratories and services in a number of countries has changed this. These studies have filled out, and altered our view of, this issue. Whereas debates on the duty to recontact have explored all aspects of recontact practice, recent contributions have been developing a more nuanced view of recontacting. The result is a narrowing of the scope of the duty, so that a norm on recontacting focuses on the practice of reaching out to discharged patients. This brings into focus the importance of the consent conversation, the resource implications of this duty, and the role of the patient in recontacting.
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Affiliation(s)
- Shane Doheny
- Cardiff University Institute of Cancer and Genetics, Cardiff, SGM, UK.
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6
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Roberts JL, Foulkes AL. GENETIC DUTIES. WILLIAM AND MARY LAW REVIEW 2020; 62:143-211. [PMID: 37654734 PMCID: PMC10471136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Most of our genetic information does not change, yet the results of our genetic tests might. Labs reclassify genetic variants in response to advances in genetic science. As a result, a person who took a test in 2010 could take the same test with the same lab in 2020 and get a different result. However, no legal duty requires labs or physicians to inform patients when a lab reclassifies a variant, even if the reclassification communicates clinically actionable information. This Article considers the need for such duties and their potential challenges. In so doing, it offers much-needed guidance to physicians and labs, who may face liability, and to courts, which will hear these cases.
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7
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Mueller A, Dalton E, Enserro D, Wang C, Flynn M. Recontact practices of cancer genetic counselors and an exploration of professional, legal, and ethical duty. J Genet Couns 2019; 28:836-846. [PMID: 31058402 DOI: 10.1002/jgc4.1126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 03/15/2019] [Accepted: 03/17/2019] [Indexed: 01/07/2023]
Abstract
The duty to recontact continues to be revisited in the field of clinical genetics and is currently relevant for cancer genetic counseling given the transition from single-gene to multi-gene panel testing. We recruited cancer genetic counselors through the National Society of Genetic Counselors list-serv to complete an online survey assessing current practices and perspectives regarding recontacting patients about diagnostic genetic tests. Forty-one percent of respondents reported that they have recontacted patients to offer updated (new) diagnostic genetic testing (40/97). A majority (61%, 17/28), of genetic counselors who reported recontact specifically for panel testing indicated that the availability of management recommendations for genes not previously tested routinely was an important factor in the decision to recontact. All respondents who recontacted patients reported "improved patient care" as a perceived benefit. Respondents indicated that recontact is mostly a patient responsibility (49%), followed by a shared responsibility between the provider and patient (43%). Few respondents (2%) reported a uniform ethical duty to recontact patients regarding new and updated testing, while the majority (89%) felt that there was some degree of ethical duty. A greater percentage of those who reported past recontact practices reported intention to recontact in the future (p = 0.001). There is little consensus among the genetic counselor respondents about how to approach the recontacting of patients to offer updated genetic testing.
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Affiliation(s)
- Amy Mueller
- Center for Cancer Risk Assessment, Massachusetts General Hospital, Boston, Massachusetts.,MS Genetic Counseling Program, Boston University School of Medicine, Boston, Massachusetts
| | | | - Danielle Enserro
- Boston University School of Public Health, Boston, Massachusetts
| | - Catharine Wang
- Boston University School of Public Health, Boston, Massachusetts
| | - Maureen Flynn
- MGH Institute of Health Professions, Boston, Massachusetts
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8
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Bombard Y, Brothers KB, Fitzgerald-Butt S, Garrison NA, Jamal L, James CA, Jarvik GP, McCormick JB, Nelson TN, Ormond KE, Rehm HL, Richer J, Souzeau E, Vassy JL, Wagner JK, Levy HP. The Responsibility to Recontact Research Participants after Reinterpretation of Genetic and Genomic Research Results. Am J Hum Genet 2019; 104:578-595. [PMID: 30951675 PMCID: PMC6451731 DOI: 10.1016/j.ajhg.2019.02.025] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/25/2019] [Indexed: 11/16/2022] Open
Abstract
The evidence base supporting genetic and genomic sequence-variant interpretations is continuously evolving. An inherent consequence is that a variant's clinical significance might be reinterpreted over time as new evidence emerges regarding its pathogenicity or lack thereof. This raises ethical, legal, and financial issues as to whether there is a responsibility to recontact research participants to provide updates on reinterpretations of variants after the initial analysis. There has been discussion concerning the extent of this obligation in the context of both research and clinical care. Although clinical recommendations have begun to emerge, guidance is lacking on the responsibilities of researchers to inform participants of reinterpreted results. To respond, an American Society of Human Genetics (ASHG) workgroup developed this position statement, which was approved by the ASHG Board in November 2018. The workgroup included representatives from the National Society of Genetic Counselors, the Canadian College of Medical Genetics, and the Canadian Association of Genetic Counsellors. The final statement includes twelve position statements that were endorsed or supported by the following organizations: Genetic Alliance, European Society of Human Genetics, Canadian Association of Genetic Counsellors, American Association of Anthropological Genetics, Executive Committee of the American Association of Physical Anthropologists, Canadian College of Medical Genetics, Human Genetics Society of Australasia, and National Society of Genetic Counselors.
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Affiliation(s)
- Yvonne Bombard
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON M5B 1T8, Canada.
| | - Kyle B Brothers
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA
| | - Sara Fitzgerald-Butt
- National Society of Genetic Counselors, Chicago, IL 60611, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Nanibaa' A Garrison
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA 98101, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98101, USA
| | - Leila Jamal
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; National Society of Genetic Counselors, Chicago, IL 60611, USA; National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Cynthia A James
- National Society of Genetic Counselors, Chicago, IL 60611, USA; Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Gail P Jarvik
- Executive Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington, Seattle, WA 98195, USA
| | - Jennifer B McCormick
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Humanities, College of Medicine, Pennsylvania State University, Hershey, PA 17033, USA
| | - Tanya N Nelson
- Canadian College of Medical Geneticists, Kingston, ON K7K 1Z7, Canada; BC Children's Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V6T 2B5, Canada; Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Kelly E Ormond
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Heidi L Rehm
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; Medical and Populations Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Julie Richer
- Canadian College of Medical Geneticists, Kingston, ON K7K 1Z7, Canada; Department of Pediatrics, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON K1H 8L1, Canada; University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Emmanuelle Souzeau
- Canadian Association of Genetic Counsellors, Oakville, ON L6J 7N5, Canada; Department of Ophthalmology, Flinders University, Flinders Medical Centre, Adelaide, SA 5042, Australia
| | - Jason L Vassy
- Department of Pathology, Harvard Medical School, Boston, MA 02115, USA; Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, USA; VA Boston Healthcare System, Boston, MA 02130, USA
| | - Jennifer K Wagner
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17822, USA
| | - Howard P Levy
- Social Issues Committee, American Society of Human Genetics, Rockville, MD 20852, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA; McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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9
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Sirchia F, Carrieri D, Dheensa S, Benjamin C, Kayserili H, Cordier C, van El CG, Turnpenny PD, Melegh B, Mendes Á, Halbersma-Konings TF, van Langen IM, Lucassen AM, Clarke AJ, Forzano F, Kelly SE. Recontacting or not recontacting? A survey of current practices in clinical genetics centres in Europe. Eur J Hum Genet 2018; 26:946-954. [PMID: 29681620 PMCID: PMC6018700 DOI: 10.1038/s41431-018-0131-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/16/2018] [Accepted: 02/23/2018] [Indexed: 11/09/2022] Open
Abstract
Advances in genomic medicine are improving diagnosis and treatment of some health conditions, and the question of whether former patients should be recontacted is therefore timely. The issue of recontacting is becoming more important with increased integration of genomics in 'mainstream' medicine. Empirical evidence is needed to advance the discussion over whether and how recontacting should be implemented. We administered a web-based survey to genetic services in European countries to collect information about existing infrastructures and practices relevant to recontacting patients. The majority of the centres stated they had recontacted patients to update them about new significant information; however, there were no standardised practices or systems in place. There was also a multiplicity of understandings of the term 'recontacting', which respondents conflated with routine follow-up programmes, or even with post-test counselling. Participants thought that recontacting systems should be implemented to provide the best service to the patients and families. Nevertheless, many barriers to implementation were mentioned. These included: lack of resources and infrastructure, concerns about potential negative psychological consequences of recontacting, unclear operational definitions of recontacting, policies that prevent healthcare professionals from recontacting, and difficulties in locating patients after their last contact. These barriers are also intensified by the highly variable development (and establishment) of the specialties of medical genetics and genetic counselling across different European countries. Future recommendations about recontacting need to consider these barriers. It is also important to reach an 'operational definition' that can be useful in different countries.
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Affiliation(s)
- Fabio Sirchia
- Department of Medical Sciences and Medical Genetics Unit, Città della Salute e della Scienza University Hospital, University of Torino, Torino, Italy
| | | | - Sandi Dheensa
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Caroline Benjamin
- School of Community Health & Midwifery, University of Central Lancashire (UCLan), Preston, England, UK
- Liverpool Women's NHS Hospital Trust, England, UK
| | - Hülya Kayserili
- Department of Medical Genetics, Koç University School of Medicine İstanbul, İstanbul, Turkey
| | | | - Carla G van El
- Department of Clinical Genetics, Section Community Genetics and Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter D Turnpenny
- Clinical Genetics, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Bela Melegh
- Department of Medical Genetics, and Szentagothai Research Ctr, University of Pécs Medical School, Pécs, Hungary
| | - Álvaro Mendes
- UnIGENe and CGPP-Centre for Predictive and Preventive Genetics, IBMC-Institute for Molecular and Cell Biology, i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
| | - Tanya F Halbersma-Konings
- Deparment of Genetics, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Irene M van Langen
- Deparment of Genetics, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Anneke M Lucassen
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Clinical Genetics Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | | | - Francesca Forzano
- Clinical Genetics Department, Guy's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
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10
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Beunders G, Dekker M, Haver O, Meijers-Heijboer HJ, Henneman L. Recontacting in light of new genetic diagnostic techniques for patients with intellectual disability: Feasibility and parental perspectives. Eur J Med Genet 2017; 61:213-218. [PMID: 29191497 DOI: 10.1016/j.ejmg.2017.11.017] [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: 08/17/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 11/28/2022]
Abstract
A higher diagnostic yield from new diagnostic techniques makes re-evaluation in patients with intellectual disability without a causal diagnosis valuable, and is currently only performed after new referral. Active recontacting might serve a larger group of patients. We aimed to evaluate parental perspectives regarding recontacting and its feasibility in clinical genetic practice. A recontacting pilot was performed in two cohorts of children with intellectual disability. In cohort A, parents were recontacted by phone and in cohort B by letter, to invite them for a re-evaluation due to the new technologies (array CGH and exome sequencing, respectively). Parental opinions, preferences and experiences with recontacting were assessed by a self-administered questionnaire, and the feasibility of this pilot was evaluated. 47 of 114 questionnaires were returned. In total, 87% of the parents believed that all parents should be recontacted in light of new insights, 17% experienced an (positive or negative) emotional reaction. In cohort A, approached by phone, 36% made a new appointment for re-evaluation, and in cohort B, approached by letter, 4% did. Most parents have positive opinions on recontacting. Recontacting might evoke emotional responses that may need attention. Recontacting is feasible but time-consuming and a large additional responsibility for clinical geneticists.
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Affiliation(s)
- Gea Beunders
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Melodi Dekker
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Oscar Haver
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Lidewij Henneman
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands.
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11
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Carrieri D, Dheensa S, Doheny S, Clarke AJ, Turnpenny PD, Lucassen AM, Kelly SE. Recontacting in clinical practice: the views and expectations of patients in the United Kingdom. Eur J Hum Genet 2017; 25:1106-1112. [PMID: 28766552 PMCID: PMC5602023 DOI: 10.1038/ejhg.2017.122] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 06/14/2017] [Accepted: 06/27/2017] [Indexed: 12/17/2022] Open
Abstract
This paper explores the views and expectations of patients concerning recontacting in clinical practice. It is based on 41 semi-structured interviews conducted in the United Kingdom. The sample comprised patients or parents of patients: without a diagnosis; recently offered a test for a condition or carrier risk; with a rare condition; with a variant of unknown significance – some of whom had been recontacted. Participants were recruited both via the National Health Service (NHS) and through online, condition-specific support groups. Most respondents viewed recontacting as desirable, however there were different opinions and expectations about what type of new information should trigger recontacting. An awareness of the potential psychological impact of receiving new information led some to suggest that recontacting should be planned, and tailored to the nature of the new information and the specific situation of patients and families. The lack of clarity about lines of responsibility for recontacting and perceptions of resource constraints in the NHS tended to mitigate respondents’ favourable positions towards recontacting and their preferences. Some respondents argued that recontacting could have a preventative value and reduce the cost of healthcare. Others challenged the idea that resources should be used to implement formalised recontacting systems – via arguments that there are ‘more pressing’ public health priorities, and for the need for healthcare services to offer care to new patients.
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Affiliation(s)
| | - Sandi Dheensa
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Shane Doheny
- School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Anneke M Lucassen
- Faculty of Medicine, University of Southampton, Southampton, UK.,Wessex Clinical Genetics Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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12
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Carrieri D, Dheensa S, Doheny S, Clarke AJ, Turnpenny PD, Lucassen AM, Kelly SE. Recontacting in clinical genetics and genomic medicine? We need to talk about it. Eur J Hum Genet 2017; 25:520-521. [PMID: 28176765 PMCID: PMC5437914 DOI: 10.1038/ejhg.2017.8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Sandi Dheensa
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Shane Doheny
- School of Medicine, Cardiff University, Cardiff, UK
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Recontacting in clinical practice: an investigation of the views of healthcare professionals and clinical scientists in the United Kingdom. Eur J Hum Genet 2017; 25:275-279. [PMID: 28051074 PMCID: PMC5315519 DOI: 10.1038/ejhg.2016.188] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 11/16/2016] [Accepted: 11/22/2016] [Indexed: 11/08/2022] Open
Abstract
This article explores the views and experiences of healthcare professionals and clinical scientists in genetics about the existence of a duty and/or responsibility to recontact former patients when the genetic information relevant to their health, or that of family members, changes in a potentially important manner. It is based on N=30 semi-structured interviews guided by vignettes of recontacting scenarios. The sample included healthcare professionals in the United Kingdom from different medical specialties (clinical genetics, other 'mainstream' specialties now offering genetic testing), and scientists from regional genetics laboratories. While viewing recontacting as desirable under certain circumstances, most respondents expressed concerns about its feasibility within the current constraints of the National Health Service (NHS). The main barriers identified were insufficient resources (time, staff, and suitable IT infrastructures) and lack of clarity about role boundaries and responsibilities. All of these are further complicated by genetic testing being increasingly offered by mainstream specialties. Reaching a consensus about roles and responsibilities of clinical specialties with regard to recontacting former patients in the light of evolving genetic information, and about what resources and infrastructures would be needed, was generally seen as a pre-requisite to developing guidelines about recontact.
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14
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Carrieri D, Lucassen AM, Clarke AJ, Dheensa S, Doheny S, Turnpenny PD, Kelly SE. Recontact in clinical practice: a survey of clinical genetics services in the United Kingdom. Genet Med 2016; 18:876-81. [PMID: 26890453 PMCID: PMC5052431 DOI: 10.1038/gim.2015.194] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/07/2015] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To ascertain whether and how recontacting occurs in the United Kingdom. METHOD A Web-based survey was administered online between October 2014 and July 2015. A link to the survey was circulated via an e-mail invitation to the clinical leads of the United Kingdom's 23 clinical genetics services, with follow-up with senior clinical genetics staff. RESULTS The majority of UK services reported that they recontact patients and their family members. However, recontacting generally occurs in an ad hoc fashion when an unplanned event causes clinicians to review a file (a "trigger"). There are no standardized recontacting practices in the United Kingdom. More than half of the services were unsure whether formalized recontacting systems should be implemented. Some suggested greater patient involvement in the process of recontacting. CONCLUSION This research suggests that a thorough evaluation of the efficacy and sustainability of potential recontacting systems within the National Health Service would be necessary before deciding whether and how to implement such a service or to create guidelines on best-practice models.Genet Med 18 9, 876-881.
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Affiliation(s)
| | | | | | - Sandi Dheensa
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Shane Doheny
- School of Medicine, University of Cardiff, Cardiff, UK
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15
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Likhterov I, Osorio M, Moubayed SP, Hernandez-Prera JC, Rhodes R, Urken ML. The Ethical Implications of the Reclassification of Noninvasive Follicular Variant Papillary Thyroid Carcinoma. Thyroid 2016; 26:1167-72. [PMID: 27480127 DOI: 10.1089/thy.2016.0212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Several studies have highlighted the lack of consensus in the diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC). An international multidisciplinary panel to address the controversy was assembled at the annual meeting of the Endocrine Pathology Society in March of 2015, leading to the recent publication reclassifying encapsulated (or noninvasive) FVPTC (EFVPTC) as a benign neoplasm. Does this change in histologic taxonomy warrant a change in clinical practice, and how should it affect those who have been given this diagnosis in the past? We consider the financial and psychological impact of this reclassification and discuss the ethical, legal, and practical issues involved with sharing this information with the patients who are affected. SUMMARY The total direct and indirect cost of thyroid cancer surveillance in patients is significant. High levels of clinically relevant distress affect up to 43% of patients with papillary thyroid carcinoma, as estimated by the Distress Thermometer developed by the National Comprehensive Cancer Network for detecting distress in cancer patients. Although there are currently no legal opinions that establish a precedent for recontacting patients whose clinical status is altered by a change in nomenclature, the prudent course would be to attend to the requirements of medical ethics. CONCLUSION Informing patients with a previous diagnosis of EFVPTC that the disease has been reclassified as benign is expected to have a dramatic effect on their surveillance needs and to alleviate the psychological impact of living with a diagnosis of cancer. It is important to re-evaluate the pathologic slides of those patients at risk to ensure that the invasive nature of the tumor is comprehensively evaluated before notifying a patient of a change in diagnosis. The availability of the entire tumor for evaluation of the capsule may prove to be a challenge for a portion of the population at risk. We believe that it is the clinician's professional duty to make a sincere and reasonable effort to convey the information to the affected patients. We also believe that the cost savings with respect to the need for additional surgery, radioactive iodine, and rigorous surveillance associated with a misinterpretation of the biology of the diagnosis of EFVPTC in less experienced hands will likely more than offset the cost incurred in histologic review and patient notification.
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Affiliation(s)
- Ilya Likhterov
- 1 Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel , New York, New York
| | - Marcela Osorio
- 2 Thyroid, Head and Neck Cancer (THANC) Foundation , New York, New York
| | - Sami P Moubayed
- 1 Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel , New York, New York
| | | | - Rosamond Rhodes
- 4 Icahn School of Medicine at Mount Sinai New York , New York
| | - Mark L Urken
- 1 Department of Otolaryngology - Head and Neck Surgery, Mount Sinai Beth Israel , New York, New York
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16
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Bowdin SC, Hayeems RZ, Monfared N, Cohn RD, Meyn MS. The SickKids Genome Clinic: developing and evaluating a pediatric model for individualized genomic medicine. Clin Genet 2015; 89:10-9. [PMID: 25813238 DOI: 10.1111/cge.12579] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 02/01/2015] [Accepted: 02/23/2015] [Indexed: 01/16/2023]
Abstract
Our increasing knowledge of how genomic variants affect human health and the falling costs of whole-genome sequencing are driving the development of individualized genomic medicine. This new clinical paradigm uses knowledge of an individual's genomic variants to anticipate, diagnose and manage disease. While individualized genetic medicine offers the promise of transformative change in health care, it forces us to reconsider existing ethical, scientific and clinical paradigms. The potential benefits of pre-symptomatic identification of at-risk individuals, improved diagnostics, individualized therapy, accurate prognosis and avoidance of adverse drug reactions coexist with the potential risks of uninterpretable results, psychological harm, outmoded counseling models and increased health care costs. Here we review the challenges, opportunities and limits of integrating genomic analysis into pediatric clinical practice and describe a model for implementing individualized genomic medicine. Our multidisciplinary team of bioinformaticians, health economists, health services and policy researchers, ethicists, geneticists, genetic counselors and clinicians has designed a 'Genome Clinic' research project that addresses multiple challenges in pediatric genomic medicine--ranging from development of bioinformatics tools for the clinical assessment of genomic variants and the discovery of disease genes to health policy inquiries, assessment of clinical care models, patient preference and the ethics of consent.
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Affiliation(s)
- S C Bowdin
- Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - R Z Hayeems
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
| | - N Monfared
- Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, Canada
| | - R D Cohn
- Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, Canada.,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Canada
| | - M S Meyn
- Division of Clinical and Metabolic Genetics, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Centre for Genetic Medicine, The Hospital for Sick Children, Toronto, Canada.,Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, Canada
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17
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Otten E, Plantinga M, Birnie E, Verkerk MA, Lucassen AM, Ranchor AV, Van Langen IM. Is there a duty to recontact in light of new genetic technologies? A systematic review of the literature. Genet Med 2014; 17:668-78. [PMID: 25503495 DOI: 10.1038/gim.2014.173] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/27/2014] [Indexed: 12/27/2022] Open
Abstract
PURPOSE With rapid advances in genetic technologies, new genetic information becomes available much faster today than just a few years ago. This has raised questions about whether clinicians have a duty to recontact eligible patients when new genetic information becomes available and, if such duties exist, how they might be implemented in practice. METHODS We report the results of a systematic literature search on the ethical, legal, social (including psychological), and practical issues involved in recontacting former patients who received genetic services. We identified 1,428 articles, of which 61 are covered in this review. RESULTS The empirical evidence available indicates that most but not all patients value being recontacted. A minority of (older) articles conclude that recontacting should be a legal duty. Most authors consider recontacting to be ethically desirable but practically unfeasible. Various solutions to overcome these practical barriers have been proposed, involving efforts of laboratories, clinicians, and patients. CONCLUSION To advance the discussion on implementing recontacting in clinical genetics, we suggest focusing on the question of in what situations recontacting might be regarded as good standard of care. To this end, reaching a professional consensus, obtaining more extensive empirical evidence, and developing professional guidelines are important.
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Affiliation(s)
- Ellen Otten
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mirjam Plantinga
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erwin Birnie
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marian A Verkerk
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Anneke M Lucassen
- 1] Faculty of Medicine, Clinical Ethics and Law, University of Southampton, Southampton, UK [2] Wessex Clinical Genetic Service, Southampton, UK
| | - Adelita V Ranchor
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Irene M Van Langen
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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18
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Hall A, Chowdhury S, Hallowell N, Pashayan N, Dent T, Pharoah P, Burton H. Implementing risk-stratified screening for common cancers: a review of potential ethical, legal and social issues. J Public Health (Oxf) 2014; 36:285-91. [PMID: 23986542 PMCID: PMC4041100 DOI: 10.1093/pubmed/fdt078] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The identification of common genetic variants associated with common cancers including breast, prostate and ovarian cancers would allow population stratification by genotype to effectively target screening and treatment. As scientific, clinical and economic evidence mounts there will be increasing pressure for risk-stratified screening programmes to be implemented. METHODS This paper reviews some of the main ethical, legal and social issues (ELSI) raised by the introduction of genotyping into risk-stratified screening programmes, in terms of Beauchamp and Childress's four principles of biomedical ethics--respect for autonomy, non-maleficence, beneficence and justice. Two alternative approaches to data collection, storage, communication and consent are used to exemplify the ELSI issues that are likely to be raised. RESULTS Ultimately, the provision of risk-stratified screening using genotyping raises fundamental questions about respective roles of individuals, healthcare providers and the state in organizing or mandating such programmes, and the principles, which underpin their provision, particularly the requirement for distributive justice. CONCLUSIONS The scope and breadth of these issues suggest that ELSI relating to risk-stratified screening will become increasingly important for policy-makers, healthcare professionals and a wide diversity of stakeholders.
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Affiliation(s)
- A.E. Hall
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - S. Chowdhury
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - N. Hallowell
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - N. Pashayan
- UCL Department of Applied Health Research, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
| | - T. Dent
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
| | - P. Pharoah
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, University Forvie Site, Robinson Way, Cambridge CB2 OSR, UK
- Department of Oncology, University of Cambridge, Cambridge CB2 2QQ, UK
| | - H. Burton
- PHG Foundation (Foundation for Genomics and Population Health), 2 Worts Causeway, Cambridge CB1 8RN, UK
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Dondorp WJ, de Wert GMWR. The 'thousand-dollar genome': an ethical exploration. Eur J Hum Genet 2013; 21 Suppl 1:S6-26. [PMID: 23677179 DOI: 10.1038/ejhg.2013.73] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Sequencing an individual's complete genome is expected to be possible for a relatively low sum 'one thousand dollars' within a few years. Sequencing refers to determining the order of base pairs that make up the genome. The result is a library of three billion letter combinations. Cheap whole-genome sequencing is of greatest importance to medical scientific research. Comparing individual complete genomes will lead to a better understanding of the contribution genetic variation makes to health and disease. As knowledge increases, the 'thousand-dollar genome' will also become increasingly important to healthcare. The applications that come within reach raise a number of ethical questions. This monitoring report addresses the issue.
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Affiliation(s)
- Wybo J Dondorp
- Department of Health, Ethics and Society, Research Institutes CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands.
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20
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Ali-Khan SE, Daar AS, Shuman C, Ray PN, Scherer SW. Whole genome scanning: resolving clinical diagnosis and management amidst complex data. Pediatr Res 2009; 66:357-63. [PMID: 19531980 DOI: 10.1203/pdr.0b013e3181b0cbd8] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Momentum around the era of genomic medicine is building, and with it, anticipation of the benefits that whole genome analysis (personalized or individualized genomics) will bring for the provision of health care. These technologies have the potential to revolutionize genetic diagnosis; however, the expansive data generated can lead to complex or unexpected findings, sometimes complicating clinical utility and patient benefit. Here, we use our experience with whole genome scanning microarrays, an early instance of whole genome analysis already in clinical use, to highlight fundamental challenges raised by these technologies and to discuss their medical, ethical, legal and social implications. We discuss issues that physicians and healthcare professionals will face, in particular, as the resolution of testing further increases toward full genome sequence determination. We emphasize that addressing these issues now, and starting to evolve our healthcare systems in response, will be pivotal in avoiding harms and realizing the promise of these new technologies.
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Affiliation(s)
- Sarah E Ali-Khan
- McLaughlin-Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, Ontario M5G 1L7, Canada
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21
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Changing interpretations, stable genes: responsibilities of patients, professionals, and policy makers in the clinical interpretation of complex genetic information. Genet Med 2009; 10:778-83. [PMID: 18941419 DOI: 10.1097/gim.0b013e31818bb38f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Except in rare mutation-inducing events, the primary sequence of an individual's somatic genome is static; however, the interpretations or risk predictions based on complex genetic tests now being introduced into the marketplace are rapidly changing. The reality of changing interpretations for stable test results creates questions for everyone involved in genetic testing including individuals, clinicians, laboratories, professional organizations, and regulators. Individuals should be aware that their relationship with laboratories providing genetic testing may be different from their relationship with their physician, especially in direct-to-consumer testing. Moreover, individuals may need to take the initiative to revisit their genetic test results periodically. Clinicians will need to learn how to read and interpret the results of complex genetic tests, remember that interpretations change over time, and understand when to refer patients to specialists and ask for second opinions and reinterpretation of genetic information. Testing laboratories should understand that they may be replacing the clinician as the direct contact for patients, and may have responsibility to inform clients of changes in test interpretation. At minimum, laboratories should make clear what their policies are regarding reinterpretation and allow tested individuals to seek outside interpretations of their genetic test results. Professional organizations and regulators have the responsibility to develop guidelines for clinicians, laboratories, and the general public. In the future, the interpretation of genetic tests may be relatively stable; until that time, the changing interpretation of static genetic test results will create an important set of professional and ethical challenges.
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22
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Borry P, Dierickx K. What are the limits of the duty of care? The case of clinical genetics. Per Med 2008; 5:101-104. [PMID: 29783344 DOI: 10.2217/17410541.5.2.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Pascal Borry
- Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Kapucijnenvoer 35/3, 3000 Leuven, Belgium.
| | - Kris Dierickx
- Katholieke Universiteit Leuven, Centre for Biomedical Ethics and Law, Kapucijnenvoer 35/3, 3000 Leuven, Belgium.
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23
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Sexton AC, Sahhar M, Thorburn DR, Metcalfe SA. Impact of a Genetic Diagnosis of a Mitochondrial Disorder 5–17 Years After the Death of an Affected Child. J Genet Couns 2008; 17:261-73. [DOI: 10.1007/s10897-007-9145-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 12/05/2007] [Indexed: 11/25/2022]
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24
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Rubinstein WS. Roles and responsibilities of a medical geneticist. Fam Cancer 2007; 7:5-14. [PMID: 17624600 DOI: 10.1007/s10689-007-9148-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 05/14/2007] [Indexed: 02/06/2023]
Abstract
Medical geneticists must generate a differential diagnosis, practice evidence-based medicine, and apply ethical, legal, and social issue (ELSI) principles in the clinical setting. Several clinical scenarios are presented which illustrate dilemmas in the cancer genetics setting. These include the differential diagnosis of breast and gastric cancer, and the predicament posed by the need to practice evidence-based medicine in light of limitations in the medical genetics literature, which may mean recommending prophylactic surgery. Also discussed are three BRCA1/2 genetic testing scenarios which illustrate the difficulty of knowing where to "draw the line", i.e., when to offer testing and what level of testing to pursue. Decision-making about BRCA1/2 gene testing including Ashkenazi Jewish founder mutation testing, comprehensive reflex testing, and expedited testing, is explored. The duty to recontact as standard of care evolves requires that medical geneticists determine how to prospectively set expectations with patients as well as to decide which situations require recontact and to determine how to systematically do so. The case of patient recontact regarding new mutation detection techniques with improved sensitivity, e.g., BART testing which is based on the ability to detect large BRCA1/2 rearrangements, is discussed. General principles are highlighted so that these specific cases can be extrapolated to other genes and hereditary conditions by medical geneticists, genetic counselors, and others practicing in the field of cancer genetics.
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Affiliation(s)
- Wendy S Rubinstein
- Evanston Northwestern Healthcare Center for Medical Genetics, Evanston, IL 60201, USA.
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25
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Griffin CA, Axilbund JE, Codori AM, Deise G, May B, Pendergrass C, Tillery M, Trimbath JD, Giardiello FM. Patient preferences regarding recontact by cancer genetics clinicians. Fam Cancer 2007; 6:265-73. [PMID: 17308889 DOI: 10.1007/s10689-007-9117-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 01/10/2007] [Indexed: 01/04/2023]
Abstract
BACKGROUND Ongoing advances in cancer genetics lead to new opportunities for early disease detection, predictive genetic testing and potential interventions. Limited information exists on patient preferences concerning recontact to provide updated information. We evaluated colon cancer genetics patient preferences concerning recontact about advances in medical genetics. METHODS Information was mailed to 851 individuals seen at the Colon Cancer Risk Assessment Clinic at the Johns Hopkins Hospital and to participants in a colon cancer gene testing study seen during an 8-year period. Information provided included description of advances in gene testing technology, discovery of MSH6 and MYH genes, detailed fact sheets and a survey of patient preferences for notification and potential uses of new information. RESULTS Most patients wanted an ongoing relationship with genetics providers (63%), reinitiated by genetics providers (65%) and contact only with information specifically relevant to them (51%). Most preferred personalized letters as the means of contact (55%). Reasons for and against recontact and circumstances in which individuals would pursue additional genetic testing were also tabulated. There were few statistically significant differences in the responses between clinic and study participants. CONCLUSION Patients evaluated in a colon cancer risk assessment clinic want updated information at a rate similar to those who participated in a colon cancer gene testing study. These findings have implications for the consultative nonlongitudinal nature of such clinics and suggest patient preferences for personally-tailored information could be labor intensive.
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Affiliation(s)
- Constance A Griffin
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21287, USA.
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26
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Guzauskas GF, Lebel RR. The Duty to Re-Contact for Newly Appreciated Risk Factors: Fragile X Premutation. THE JOURNAL OF CLINICAL ETHICS 2006. [DOI: 10.1086/jce200617106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Harris R, Harris H. Knowledge about medical genetics in health care. Public Health Genomics 2005; 2:115-7. [PMID: 15181342 DOI: 10.1159/000016196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Effective genetic services depend upon co-operation between medical geneticists and many different non-geneticist professionals to ensure that the most appropriate patients are referred to geneticists and that those that require long-term care receive it. Important determinants of the quality of genetic services are the knowledge that professionals have about clinical genetics and the equitable distribution of adequately resourced genetic centres. Consequently, we have investigated in a European context how much clinically relevant genetics non-geneticists know, how competent non-geneticists are in counselling their own patients, how well equipped specialist genetic centres are, who refers to genetic centres and what they refer and who offers continuing care to patients and families whose problems are not resolvable at a limited genetic clinic visit.
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Affiliation(s)
- R Harris
- Department of Medical Genetics, University of Manchester, Manchester, UK
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28
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Godard B, Kääriäinen H, Kristoffersson U, Tranebjaerg L, Coviello D, Aymé S. Provision of genetic services in Europe: current practices and issues. Eur J Hum Genet 2004; 11 Suppl 2:S13-48. [PMID: 14718937 DOI: 10.1038/sj.ejhg.5201111] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This paper examines the professional and scientific views on the social, ethical and legal issues that impact on the provision of genetic services in Europe. Many aspects have been considered, such as the definition and the aims of genetic services, their organization, the quality assessment, public education, as well as the partnership with patients support groups and the multicultural aspects. The methods was primarily the analysis of professional guidelines, legal frameworks and other documents related to the organization of genetic services, mainly from Europe, but also from USA and international organizations. Then, the method was to examine the background data emerging from an updated report produced by the Concerted Action on Genetic Services in Europe, as well as the issues debated by 43 experts from 17 European countries invited to an international workshop organized by the European Society of Human Genetics Public and Professional Policy Committee in Helsinki, Finland, 8 and 9 September 2000. Some conclusions were identified from the ESHG workshop to arrive at outlines for optimal genetic services. Participants were concerned about equal accessibility and effectiveness of clinical genetic services, quality assessment of services, professional education, multidisciplinarity and division of tasks as well as networking. Within European countries, adherence to the organizational principles of prioritization, regionalization and integration into related health services would maximize equal accessibility and effectiveness of genetic actions. There is a need for harmonization of the rules involved in financial coverage of DNA tests in order to make these available to all Europeans. Clear guidelines for the best practice will ensure that the provision of genetic services develops in a way that is beneficial to its customers, be they health professionals or the public, especially since the coordination of clinical, laboratory and research perspectives within a single organizational structure permits a degree of coherence not often found in other specialties.
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Wright C, Kerzin-Storrar L, Williamson PR, Fryer A, Njindou A, Quarrell O, Donnai D, Craufurd D. Comparison of genetic services with and without genetic registers: knowledge, adjustment, and attitudes about genetic counselling among probands referred to three genetic clinics. J Med Genet 2002; 39:e84. [PMID: 12471222 PMCID: PMC1757214 DOI: 10.1136/jmg.39.12.e84] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Genetic register services incorporating long term follow up and a proactive approach to at risk subjects have been recommended as a way of improving access to genetic counselling for families with dominant or X linked genetic disorders and chromosome translocations. The aims of the present study were to evaluate the psychosocial benefits and drawbacks of long term family contact, and to evaluate the attitudes of probands and their general practitioners towards proactive genetic counselling. We interviewed 192 people referred to three regional genetic clinics because of a family history of Duchenne or Becker muscular dystrophy, myotonic dystrophy, or chromosome translocations, and 43 of the referring GPs. Probands attending the centre using a genetic register approach were compared with those from the two centres offering the standard clinical genetic service. A very high proportion of probands in both groups were well informed about the genetic risks to themselves and their children, were satisfied with the service they had received from their local genetic clinic, and felt adequately prepared to discuss the family illness with their children. The register probands expressed approval of the ongoing contact and open access provided by the register service. Asked whether previously unaware relatives should be informed of their at risk status, 98% (188/192) said it was acceptable for this information to be disclosed by a family member, while three quarters of the probands (149/192) and just over half the GPs (27/43) thought it acceptable for the genetic service to approach them; a similar proportion of both GPs and probands also found it acceptable for GPs to do so. More than half the probands (107/190) thought it was the family's responsibility to pass on genetic risk information, but 43% said that either the genetic service or the GP should be responsible for this. The findings show that the genetic register approach incorporating long term follow up and a proactive approach to genetic counselling is highly acceptable to the families concerned, and although the register and non-register probands did not differ significantly on any of the main outcome measures used in this relatively short term study, it may be that the continuing contact associated with the register approach offers long term benefits, especially for those genetic conditions where medical surveillance may have an impact on the prognosis.
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Affiliation(s)
- C Wright
- Academic Group of Medical Genetics and Regional Genetic Service, Manchester, UK
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Peshkin BN, DeMarco TA, Brogan BM, Lerman C, Isaacs C. BRCA1/2 testing: complex themes in result interpretation. J Clin Oncol 2001; 19:2555-65. [PMID: 11331335 DOI: 10.1200/jco.2001.19.9.2555] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Since the cloning of BRCA1 and BRCA2, genetic testing for breast and ovarian cancer susceptibility has become more widespread. However, interpretation of test results is not always straightforward. To illustrate this point, five vignettes adapted from actual cases are presented. As these cases demonstrate, in many high-risk families, a deleterious mutation in BRCA1 or BRCA2 is not identified in an affected proband. There are several potential explanations for such a finding, namely that an undetected mutation in BRCA1 or BRCA2 may exist, or there could be a mutation in a rare or undiscovered gene. In addition, the possibility that women with breast cancer represent sporadic cases within hereditary cancer families must also be considered. Finally, the occurrence of BRCA1/2 variants of uncertain significance, often missense mutations, further complicates the risk assessment. In some of these instances, extending testing to relatives can be helpful to clarify results. When hereditary breast cancer cannot be ruled out, individuals may still be at increased risk for cancer and therefore need to obtain appropriate surveillance. The process of genetic counseling is critical both before and after testing to ensure that patients understand the potential medical and psychosocial implications of testing and are aware of available options and resources. A multidisciplinary approach to service delivery, which includes clinicians in genetics and oncology, can facilitate patients' decision making and provide continued access to information and support.
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Affiliation(s)
- B N Peshkin
- Department of Oncology/Division of Cancer Control, Lombardi Cancer Center, Georgetown University, Washington, DC 20007, USA.
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Deschênes M, Cardinal G, Knoppers BM, Glass KC. Human genetic research, DNA banking and consent: a question of 'form'? Clin Genet 2001; 59:221-39. [PMID: 11298677 DOI: 10.1034/j.1399-0004.2001.590403.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- M Deschênes
- Centre de recherche en droit public, Faculté de droit, Université de Montreal, Montreal, Canada, McGill University, Montreal, Canada
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Austin MA, Peyser PA, Khoury MJ. The interface of genetics and public health: research and educational challenges. Annu Rev Public Health 2001; 21:81-99. [PMID: 10884947 DOI: 10.1146/annurev.publhealth.21.1.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As the target date for the sequencing of the human genome approaches, there is growing recognition that public health practice, research, and education will be impacted by new genetic technologies and information and that a multidisciplinary approach is required. Research in the emerging field of public health genetics encompasses a broad range of disciplines and will increasingly involve the interactions among the investigators in these fields. An overview of these areas of research is provided, with illustrative examples. Education in public health genetics needs to address a variety of audiences, including public health graduate students and practitioners, students from related disciplines, and health care professionals. Two new graduate programs at the Universities of Michigan and Washington and training opportunities for public health professionals are described. These educational efforts must be ongoing so that the potential of genetic technology and information can be appropriately used to benefit the health of all.
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Affiliation(s)
- M A Austin
- Public Health Genetics Program, University of Washington, Seattle 98195-7236, USA.
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Hunter AG, Sharpe N, Mullen M, Meschino WS. Ethical, legal, and practical concerns about recontacting patients to inform them of new information: The case in medical genetics. ACTA ACUST UNITED AC 2001. [DOI: 10.1002/ajmg.1568] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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34
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Fitzpatrick JL, Huggins MJ. Reply to Sharpe. Am J Hum Genet 1999. [DOI: 10.1086/302595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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