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Clifford CM, Askew N, Smith D, Iniguez J, Smith A, House MD, Leech AA. Prenatal aneuploidy screening in a low-risk Hispanic population: price elasticity and cost-effectiveness. AJOG GLOBAL REPORTS 2024; 4:100293. [PMID: 38205132 PMCID: PMC10777109 DOI: 10.1016/j.xagr.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND In October 2015, the Massachusetts Medicaid program temporarily stopped reimbursement for procedures in which the International Classification of Diseases, Tenth Edition, code for serum aneuploidy screening used by certain communities was stipulated. This change led to a substantial number of patients who went without aneuploidy screening for approximately 3 years. OBJECTIVE This study aimed to determine the change in use and cost-effectiveness of prenatal aneuploidy serum screening in a low-risk Hispanic Medicaid population in Massachusetts. STUDY DESIGN We conducted a retrospective chart review of Spanish-speaking pregnant patients younger than 35 years of age who underwent aneuploidy serum screening at a Massachusetts community health center. The study compared the aneuploidy serum screening rates for the periods before and after May 2016 when the Massachusetts Medicaid program, MassHealth, temporarily discontinued reimbursement for the screening. Based on these rates, we developed a Markov cohort simulation model to assess the economic value of reimbursed aneuploidy screening vs nonreimbursed or limited screening. Clinical outcomes included trisomy 21, live births, and therapeutic abortions for a trisomy 21 diagnosis. Economic outcomes included discounted quality-adjusted life years and lifetime medical costs, net health benefit, and incremental cost-effectiveness ratios. RESULTS Before the MassHealth policy change, 69% (55/80) of pregnant individuals selected quad or sequential screens in comparison with only 9% (10/112) who selected screens after the policy change. Traditional aneuploidy serum screening in a low-risk (aged <35 years) Hispanic population was considered to be cost-saving (ie, led to lower incremental costs and higher incremental benefits when compared with nonreimbursed or limited screening). CONCLUSION From a United States healthcare payer perspective, aneuploidy serum screening for Hispanic pregnant individuals under 35 years of age is economically advantageous when compared with limited screening.
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Affiliation(s)
- Caitlin M. Clifford
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA (Dr Clifford)
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Drs Clifford and House)
| | - Neil Askew
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN (Mr Askew and Dr Leech)
| | - Diane Smith
- Greater Lawrence Family Health Center, Lawrence, MA (Drs Smith and Iniquez)
| | - Jesus Iniguez
- Greater Lawrence Family Health Center, Lawrence, MA (Drs Smith and Iniquez)
- Department of Family Medicine, University of Washington, Seattle, WA (Dr Iniquez)
| | - Andrew Smith
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN (Drs Smith and Leech)
| | - Michael D. House
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI (Drs Clifford and House)
| | - Ashley A. Leech
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN (Mr Askew and Dr Leech)
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN (Drs Smith and Leech)
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Battarbee AN, Vora NL, Hardisty EE, Stamilio DM. Cost-effectiveness of ultrasound before non-invasive prenatal screening for fetal aneuploidy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:325-332. [PMID: 36273429 PMCID: PMC10577524 DOI: 10.1002/uog.26100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/03/2022] [Accepted: 10/14/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness of first-trimester ultrasound before fetal aneuploidy screening with cell-free DNA (cfDNA) compared with screening by cfDNA alone. METHODS A decision analytic model was constructed for 400 000 pregnant individuals with advanced maternal age who desired first-trimester aneuploidy screening with cfDNA in the USA, to compare two screening strategies: (1) cfDNA only and (2) ultrasound performed within 4 weeks before cfDNA. Input parameters included probability of fetal aneuploidy, cfDNA performance, desire for diagnostic testing, pregnancy outcomes, and pregnancy and lifetime costs and utilities. The primary outcome measure was the incremental cost-effectiveness ratio (ICER), in terms of cost in 2020 US dollars (USD) per quality-adjusted life year (QALY) gained. Secondary outcomes included procedure-related loss, pregnancy termination, live birth with aneuploidy, live birth with structural anomaly and stillbirth. Discounting was performed at 3% per year with an estimated maternal lifespan of 81 years starting at the age of 35 years. One-way, multiway and Monte Carlo probabilistic sensitivity analyses were performed. All base-case estimates and ranges of uncertainty were derived from the literature. The willingness-to-pay threshold was set at 100 000 USD per QALY. RESULTS In the base-case analysis, ultrasound before cfDNA screening was more cost-effective than cfDNA screening without pretest ultrasound, with an ICER of 12 588 USD and higher net monetary benefit (24 241 vs 20 466). The strategy involving ultrasound before cfDNA was more costly by 544 USD but also more effective (by 0.04 QALY) compared with cfDNA alone. Base-case results were robust in sensitivity analyses with the strategy involving ultrasound before cfDNA always remaining the most cost-effective approach with the highest net monetary benefit. CONCLUSION First-trimester ultrasound before cfDNA is a more cost-effective strategy for non-invasive prenatal aneuploidy screening compared with cfDNA alone. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A N Battarbee
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - N L Vora
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine and University of North Carolina Health Care, Chapel Hill, NC, USA
| | - E E Hardisty
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine and University of North Carolina Health Care, Chapel Hill, NC, USA
| | - D M Stamilio
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
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Ghiasi M, Armour C, Walker M, Shaver N, Bennett A, Little J. Issues associated with possible implementation of Non-Invasive Prenatal Testing (NIPT) in first-tier screening: A rapid scoping review. Prenat Diagn 2023; 43:62-71. [PMID: 36461628 DOI: 10.1002/pd.6278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/24/2022] [Accepted: 11/27/2022] [Indexed: 12/04/2022]
Abstract
In recent years, as the implementation and use of Non-Invasive Prenatal Testing (NIPT) have increased, the cost of the test has been decreasing. The cost of NIPT is expected to fall further in the upcoming years. As a result of the decreasing cost of NIPT, many jurisdictions may change their prenatal screening policies toward abandoning serum-based screening and instead, implement and support NIPT as the first-tier screening for all women. There are several concerns in replacing first-trimester screening with NIPT. In this scoping review, we aimed to map the existing knowledge about possible issues in the systematic implementation of NIPT as the primary method of first-tier screening and to assess if any jurisdiction has altered its policy and discontinued serum-based prenatal screening in exchange for NIPT. The Medline database (Ovid) and Google Scholar was searched and all the studies discussing, investigating, or reporting on the systematic implementation of NIPT as the primary method of first-tier screening were included. All the studies went through a two-stage screening process and included full-text articles were reviewed. We did not find any articles indicating a country or region that replaced traditional prenatal screening by NIPT. The included articles were charted, and the data about the possible issues in the systematic implementation of NIPT as the primary method of first-tier screening are summarized narratively and presented in tables in four categories. The findings of this scoping review may be informative for stakeholders and policymakers regarding recent changes in NIPT implementation policies around the world and may aid with developing policy for NIPT implementation with a broader perspective.
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Affiliation(s)
- Maryam Ghiasi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Armour
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Prenatal Screening Ontario (PSO), Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Walker
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nicole Shaver
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandria Bennett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Png ME, Yang M, Taylor-Phillips S, Ratushnyak S, Roberts N, White A, Hinton L, Boardman F, McNiven A, Fisher J, Thilaganathan B, Oddie S, Slowther AM, Shilton Osborne J, Petrou S, Rivero-Arias O. Benefits and harms adopted by health economic assessments evaluating antenatal and newborn screening programmes in OECD countries: A systematic review of 336 articles and reports. Soc Sci Med 2022; 314:115428. [PMID: 36272385 PMCID: PMC9720154 DOI: 10.1016/j.socscimed.2022.115428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 08/12/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Health economic assessments are used to determine whether the resources needed to generate net benefit from a screening programme, driven by multiple complex benefits and harms, are justifiable. We systematically identified the benefits and harms incorporated within economic assessments evaluating antenatal and newborn screening programmes. METHODS For this systematic review and thematic analysis, we searched the published and grey literature from January 2000 to January 2021. Studies that included an economic evaluation of an antenatal or newborn screening programme in an OECD country were eligible. We identified benefits and harms using an integrative descriptive analysis, and illustrated a thematic framework. (Systematic review registration PROSPERO, CRD42020165236). FINDINGS The searches identified 52,244 articles and reports and 336 (242 antenatal and 95 newborn) were included. Eighty-six subthemes grouped into seven themes were identified: 1) diagnosis of screened for condition, 2) life years and health status adjustments, 3) treatment, 4) long-term costs, 5) overdiagnosis, 6) pregnancy loss, and 7) spillover effects on family members. Diagnosis of screened for condition (115 studies, 47.5%), life-years and health status adjustments (90 studies, 37.2%) and treatment (88 studies, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Overdiagnosis and spillover effects tended to be ignored. INTERPRETATION Our proposed framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes, to prevent exclusion of important potential benefits and harms.
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Affiliation(s)
- May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Miaoqing Yang
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Svetlana Ratushnyak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Ashley White
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lisa Hinton
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Sam Oddie
- Bradford Institute for Health Research, Bradford Children's Research, Bradford, UK
| | | | - Jenny Shilton Osborne
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK,Corresponding author. National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Old Road Campus, University of Oxford, OX3 7LF, UK
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Avram CM, Caughey AB, Norton ME, Sparks TN. Cost-Effectiveness of Exome Sequencing versus Targeted Gene Panels for Prenatal Diagnosis of Fetal Effusions and Non-Immune Hydrops Fetalis. Am J Obstet Gynecol MFM 2022; 4:100724. [PMID: 35995366 PMCID: PMC9938838 DOI: 10.1016/j.ajogmf.2022.100724] [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: 05/15/2022] [Revised: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Although exome sequencing has a greater overall diagnostic yield than targeted gene panels in the evaluation of nonimmune hydrops fetalis and fetal effusions, the cost-effectiveness of this approach is not known. OBJECTIVE This study aimed to evaluate the costs and outcomes of targeted gene panels vs exome sequencing for prenatally diagnosed nonimmune hydrops fetalis and fetal effusions when next-generation sequencing is pursued following nondiagnostic standard nonimmune hydrops fetalis evaluations, including karyotype or chromosomal microarray. STUDY DESIGN A decision-analytical model was designed using TreeAge Pro to compare 10 genetic testing strategies, including a single test only (RASopathy, metabolic, or nonimmune hydrops fetalis-targeted gene panel or exome sequencing), sequential testing (RASopathy panel followed by nonimmune hydrops fetalis panel, metabolic panel followed by nonimmune hydrops fetalis panel, RASopathy panel followed by exome sequencing, metabolic panel followed by exome sequencing, and nonimmune hydrops fetalis panel followed by exome sequencing), and no additional genetic testing. Our theoretical cohort included cases with normal karyotype and/or microarray and excluded cases of alloimmunization and congenital viral infections. As nonimmune hydrops fetalis and fetal effusions can present throughout gestation, whereas pregnancy management options vary depending on gestational age, outcomes were calculated for 3 time intervals: 10 to 18, 18 to 22, and >22 weeks of gestation. The primary outcome was incremental cost per quality-adjusted life year. Additional outcomes included termination of pregnancy, stillbirth, neonatal death, and neonates born with mild, moderate, and severe or profound disease phenotypes. The cost-effectiveness threshold was $100,000 per quality-adjusted life year. RESULTS Among women <18 weeks of gestation, exome sequencing alone was the dominant strategy associated with the lowest costs ($221 million) and the highest quality-adjusted life years (10,288). Strategies with exome sequencing alone or as a sequential test resulted in more terminations but fewer stillbirths, neonatal deaths (NNDs), and affected infants than strategies without exome sequencing. Among women between 18 and 22 weeks of gestation, exome sequencing alone was also associated with the lowest costs ($188 million) and the highest quality-adjusted life years (8734), and similar trends were observed in pregnancy outcomes. Among patients >22 weeks of gestations, when termination was not available, exome sequencing was associated with lower costs ($300 million) and the highest quality-adjusted life years (8492). Exome sequencing was cost-effective up to a cost per test of $50,451 at <18 weeks of gestation, $50,423 at 18 to 22 weeks of gestation, and $9530 at >22 weeks of gestation. Targeted genetic panels and exome sequencing were cost-effective strategies compared with no additional genetic testing. CONCLUSION For cases of nonimmune hydrops fetalis and fetal effusions with nondiagnostic karyotype or microarray, next-generation sequencing was cost-effective compared with a strategy without additional genetic testing. For those that undergo next-generation sequencing, exome sequencing was the cost-effective strategy compared with all other testing strategies using targeted gene panels, leading to lower costs and fewer adverse perinatal outcomes. Exome sequencing was cost-effective in a setting without the option for pregnancy termination. These data supported the routine use of exome sequencing when next-generation sequencing is pursued for establishing a genetic diagnosis underlying otherwise unexplained nonimmune hydrops fetalis and fetal effusions.
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Affiliation(s)
- Carmen M Avram
- Duke University Medical Center, Durham, NC (Carmen M. Avram, MD).
| | - Aaron B Caughey
- Oregon Health & Science University, Portland, OR (Aaron B. Caughey, MD, PhD)
| | - Mary E Norton
- University of California, San Francisco, San Francisco, CA (Mary E. Norton, MD, Teresa N. Sparks, MD, MAS)
| | - Teresa N Sparks
- University of California, San Francisco, San Francisco, CA (Mary E. Norton, MD, Teresa N. Sparks, MD, MAS)
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Fisher SA, Miller ES, Yee LM, Grobman WA, Premkumar A. Universal First-Trimester Cytomegalovirus Screening and Valaciclovir Prophylaxis in Pregnant Persons: A Cost-Effectiveness Analysis. Am J Obstet Gynecol MFM 2022; 4:100676. [PMID: 35714861 DOI: 10.1016/j.ajogmf.2022.100676] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent studies suggest a possible benefit of valaciclovir prophylaxis to prevent vertical transmission after a positive serologic screen for primary maternal cytomegalovirus infection during pregnancy, although its cost-effectiveness remains uncertain. OBJECTIVE We sought to determine the circumstances under which universal first-trimester maternal serologic screening for maternal cytomegalovirus infection, with valaciclovir prophylaxis to prevent congenital cytomegalovirus, is cost-effective. STUDY DESIGN We performed a decision analysis from the perspective of the pregnant person to assess whether universal maternal screening in the first trimester, with subsequent valaciclovir prophylaxis (8g/day from time of positive serologic screen for primary maternal cytomegalovirus infection through 21 weeks' gestation) for those who are acutely infected, is cost-effective compared to usual care (i.e., no routine serologic screening, but amniocentesis if mid-trimester sonographic findings suggest cytomegalovirus). For baseline estimates, we assumed a 35% risk of congenital cytomegalovirus after primary maternal infection and a 71% risk reduction with valaciclovir. We varied valaciclovir's efficacy to identify whether and at what threshold universal screening would be estimated to be cost-effective, compared to usual care. Monte Carlo analyses were performed. A willingness-to-pay threshold of $100,000/quality-adjusted life year was used to define cost-effectiveness. RESULTS Under base-case estimates, first-trimester universal screening and valaciclovir prophylaxis for seropositive pregnant persons with acute cytomegalovirus infection is not cost-effective, with a cost of $137,854 per maternal QALY, but results in 14 fewer cytomegalovirus-affected children per 100,000 pregnancies compared to usual care. In one-way sensitivity analysis, universal screening and treatment is estimated to be the cost-effective strategy if the incidence of primary maternal cytomegalovirus infection exceeds 2.6%, baseline risk of vertical transmission of cytomegalovirus without prophylaxis is greater than 36.8%, and the risk reduction of vertical transmission of cytomegalovirus with valaciclovir prophylaxis exceeds 75.9%. In Monte Carlo analyses, first-trimester universal serologic screening with valaciclovir prophylaxis is estimated to be the cost-effective strategy in 46.8% of runs. CONCLUSION Universal first-trimester serologic screening with valaciclovir prophylaxis is not the cost-effective strategy for antenatal management of cytomegalovirus under the base-case estimates. Although universal screening is cost-effective in certain circumstances when the efficacy of valaciclovir exceeds the base case, that result is not robust to variation of estimates across their reasonable ranges. These data can inform future studies to evaluate screening and treatment to prevent congenital CMV.
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Affiliation(s)
- Stephanie A Fisher
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - William A Grobman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Cleveland, Ohio.
| | - Ashish Premkumar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois.
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Mokveld T, Al-Ars Z, Sistermans EA, Reinders M. WisecondorFF: Improved Fetal Aneuploidy Detection from Shallow WGS through Fragment Length Analysis. Diagnostics (Basel) 2021; 12:59. [PMID: 35054227 PMCID: PMC8774687 DOI: 10.3390/diagnostics12010059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
In prenatal diagnostics, NIPT screening utilizing read coverage-based profiles obtained from shallow WGS data is routinely used to detect fetal CNVs. From this same data, fragment size distributions of fetal and maternal DNA fragments can be derived, which are known to be different, and often used to infer fetal fractions. We argue that the fragment size has the potential to aid in the detection of CNVs. By integrating, in parallel, fragment size and read coverage in a within-sample normalization approach, it is possible to construct a reference set encompassing both data types. This reference then allows the detection of CNVs within queried samples, utilizing both data sources. We present a new methodology, WisecondorFF, which improves sensitivity, while maintaining specificity, relative to existing approaches. WisecondorFF increases robustness of detected CNVs, and can reliably detect even at lower fetal fractions (<2%).
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Affiliation(s)
- Tom Mokveld
- Delft Bioinformatics Lab, Delft University of Technology, Van Mourik Broekmanweg 6, 2628 XE Delft, The Netherlands;
| | - Zaid Al-Ars
- Computer Engineering, Delft University of Technology, Mekelweg 4, 2628 CD Delft, The Netherlands;
| | - Erik A. Sistermans
- Department of Human Genetics and Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands;
| | - Marcel Reinders
- Delft Bioinformatics Lab, Delft University of Technology, Van Mourik Broekmanweg 6, 2628 XE Delft, The Netherlands;
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Farrell RM, Pierce M, Collart C, Yao M, Coleridge M, Chien EK, Rose SS, Lintel M, Perni U, Edmonds BT. Decision-making for prenatal genetic screening: how will pregnant women navigate a growing number of aneuploidy and carrier screening options? BMC Pregnancy Childbirth 2021; 21:806. [PMID: 34863134 PMCID: PMC8642756 DOI: 10.1186/s12884-021-04282-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/02/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Prenatal genetic screens, including carrier screening (CS) and aneuploidy screening (AS), comprise an important component of reproductive healthcare delivery. Clinical practice guidelines emphasize the importance of informed decision-making and patient's preferences regarding the use of these screens. Yet, it is unclear how to achieve this ideal as prenatal genetic screening options rapidly become more complex and increasingly available to patients. With increased complexity and availability of reproductive testing options, decision-support strategies are critical to prepare patients to consider AS and/or CS. METHODS A self-administered survey evaluated knowledge and decision-making preferences for expanded carrier (CS) and aneuploidy (AS) prenatal screening. The survey was administered to participants before their first prenatal visit to assess baseline decision-making needs and preference at the initiation of prenatal care. Analysis was approached as a descriptive process. RESULTS Participants had similar familiarity with the concepts associated with AS compared to CS; mean knowledge scores for CS was 0.59 [possible range 0.00 to 1.00] and 0.55 for AS. Participants reported preferences to learn about a range of conditions, including those with severe or mild impact, childhood-onset, and adult-onset. Decision-making preference with respect to learning about the associated disease phenotypes for the contained on AS and CS panel shifted with the complexity of the panel, with a greater preference to learn about conditions post-test compared pre-test education as panels increased from 5 to 100 conditions. CONCLUSION Patients' baseline knowledge of prenatal genetic screens coupled with evolving decision-making preferences presents challenges for the delivery of prenatal genetic screens. This calls for the development and implementation of innovative approaches to support pregnant patients' decision-making commensurate with advances in prenatal genomics.
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Affiliation(s)
- Ruth M Farrell
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.
- Center for Bioethics, Cleveland Clinic, Cleveland, OH, USA.
| | - Madelyn Pierce
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Christina Collart
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Meng Yao
- Quantitative Health Science Department, Cleveland Clinic, Cleveland, OH, USA
| | - Marissa Coleridge
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward K Chien
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Susannah S Rose
- Office of Patient Experience, Clinical Transformation, Cleveland Clinic, Cleveland, OH, USA
| | - Mary Lintel
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- OB/GYN and Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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9
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Schneider L, Tripathi A. Progress and Challenges in Laboratory-Based Diagnostic and Screening Approaches for Aneuploidy Detection during Pregnancy. SLAS Technol 2021; 26:425-440. [PMID: 34148381 DOI: 10.1177/24726303211021787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aneuploidy is caused by problems during cellular division and segregation errors during meiosis that lead to an abnormal number of chromosomes and initiate significant genetic abnormalities during pregnancy or the loss of a fetus due to miscarriage. Screening and diagnostic technologies have been developed to detect this genetic condition and provide parents with critical information about their unborn child. In this review, we highlight the complexities of aneuploidy as a disease as well as multiple technological advancements in testing that help to identify aneuploidy at various time points throughout pregnancy. We focus on aneuploidy diagnosis during preimplantation genetic testing that is performed during in vitro fertilization as well as prenatal screening and diagnosis during pregnancy. This review focuses on DNA-based analysis and laboratory techniques for aneuploidy detection through reviewing molecular- and engineering-based technical advancements. We also present key challenges in aneuploidy detection during pregnancy, including sample collection, mosaic embryos, economic factors, and the social implications of this testing. The goal of this review is to synthesize broad information about aneuploidy screening and diagnostic sample collection and analysis during pregnancy and discuss major challenges the field is still facing despite decades of advancements.
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Affiliation(s)
- Lindsay Schneider
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
| | - Anubhav Tripathi
- Center for Biomedical Engineering, School of Engineering, Brown University, Providence, RI, USA
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10
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Baert J, Pomar L, Quibel T. Do we need to rethink our standard genetic approach for low-risk pregnancies? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:850-851. [PMID: 33939208 DOI: 10.1002/uog.23633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/16/2020] [Indexed: 06/12/2023]
Affiliation(s)
- J Baert
- Ultrasound and Fetal Medicine Unit, Department "Woman-Mother-Child", Lausanne University Hospital, Lausanne, Switzerland
| | - L Pomar
- Ultrasound and Fetal Medicine Unit, Department "Woman-Mother-Child", Lausanne University Hospital, Lausanne, Switzerland
| | - T Quibel
- Ultrasound and Fetal Medicine Unit, Department "Woman-Mother-Child", Lausanne University Hospital, Lausanne, Switzerland
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11
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Abstract
Prenatal testing for chromosomal abnormalities is designed to provide an accurate assessment of a patient's risk of carrying a fetus with a chromosomal disorder. A wide variety of prenatal screening and diagnostic tests are available; each offers varying levels of information and performance, and each has relative advantages and limitations. When considering screening test characteristics, no one test is superior in all circumstances, which results in the need for nuanced, patient-centered counseling from the obstetric care professional and complex decision making by the patient. Each patient should be counseled in each pregnancy about options for testing for fetal chromosomal abnormalities. It is important that obstetric care professionals be prepared to discuss not only the risk of fetal chromosomal abnormalities but also the relative benefits and limitations of the available screening and diagnostic tests. Testing for chromosomal abnormalities should be an informed patient choice based on provision of adequate and accurate information, the patient's clinical context, accessible health care resources, values, interests, and goals. All patients should be offered both screening and diagnostic tests, and all patients have the right to accept or decline testing after counseling.The purpose of this Practice Bulletin is to provide current information regarding the available screening test options available for fetal chromosomal abnormalities and to review their benefits, performance characteristics, and limitations. For information regarding prenatal diagnostic testing for genetic disorders, refer to Practice Bulletin No. 162, Prenatal Diagnostic Testing for Genetic Disorders. For additional information regarding counseling about genetic testing and communicating test results, refer to Committee Opinion No. 693, Counseling About Genetic Testing and Communication of Genetic Test Results. For information regarding carrier screening for genetic conditions, refer to Committee Opinion No. 690, Carrier Screening in the Age of Genomic Medicine and Committee Opinion No. 691, Carrier Screening for Genetic Conditions. This Practice Bulletin has been revised to further clarify methods of screening for fetal chromosomal abnormalities, including expanded information regarding the use of cell-free DNA in all patients regardless of maternal age or baseline risk, and to add guidance related to patient counseling.
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12
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Nshimyumukiza L, Beaumont JA, Rousseau F, Reinharz D. Introducing cell-free DNA noninvasive testing in a Down syndrome public health screening program: a budget impact analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:49. [PMID: 33292318 PMCID: PMC7640422 DOI: 10.1186/s12962-020-00245-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT) using cell-free fetal DNA in maternal plasma is a high accurate test for prenatal screening for Down syndrome. Although it has been reported to be cost effective as a contingent test, evidence about its budget impact is lacking. OBJECTIVE To evaluate, using computer simulations, the budget impact of implementing NIPT as a contingent test in the Quebec Program of screening for Trisomy 21. METHODS A semi-Markov analytic model built to simulate the budget impact of implementing NIPT into the current Quebec Trisomy 21 public Prenatal Screening, Serum Integrated prenatal screening (SIPS). Comparisons were made for a virtual population similar to that of expected Quebec pregnant women in 2015 in terms of size and age. Data input parameters were retrieved from a thorough literature search and in government databases, especially data from Quebec Program of screening for Trisomy 21. The 2015-2016 fiscal year budget impact was estimated from the Quebec healthcare system perspective and was expressed as the difference in the overall costs between the two alternatives (SIPS minus SPS + NIPT). RESULTS Our study found that, at a baseline cost for NIPT of CAD$ 795, NIPT as a second-tier test offered to high-risk women identified by current screening program (SIPS + NIPT) may be affordable for Quebec health care system. Compared to the current screening program, it would be implemented at a neutral cost, considering a modest annual savings of $ 80,432 (95% CI $ 79, $ 874-$ 81,462). Results were sensitive to the NIPT costs and the uptake-rate of invasive diagnostic tests. CONCLUSION Introducing NIPT as a contingent test in the Quebec Trisomy 21 screening program is an affordable strategy compared to the current practice. Further research is needed to confirm if our results can be reproduced in other healthcare jurisdictions.
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Affiliation(s)
- L. Nshimyumukiza
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Pavillon Ferdinand Vandry, Local 2432, 1050 Avenue de La Médecine, Quebec, QC G7V0A6 Canada
| | - J. A. Beaumont
- Département d’informatique et de Génie Logiciel, Faculté de Sciences et de Génie, Université Laval, Quebec, QC Canada
| | - F. Rousseau
- Centre de Recherche du Centre Hospitalier Universitaire de Québec, Québec, QC Canada
- Département de Biologie Moléculaire, Biochimie Médicale et Pathologie, Faculté de Médecine, Université Laval, Quebec, QC Canada
| | - D. Reinharz
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Pavillon Ferdinand Vandry, Local 2432, 1050 Avenue de La Médecine, Quebec, QC G7V0A6 Canada
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13
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Farrell RM, Pierce M, Collart C, Edmonds BT, Chien E, Coleridge M, Rose SL, Perni U, Frankel R. Making the most of the first prenatal visit: The challenge of expanding prenatal genetic testing options and limited clinical encounter time. Prenat Diagn 2020; 40:1265-1271. [PMID: 32441820 PMCID: PMC10114520 DOI: 10.1002/pd.5752] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Advances in prenatal genetics place additional challenges as patients must receive information about a growing array of screening and testing options. This raises concerns about how to achieve a shared decision-making process that prepares patients to make an informed decision about their choices about prenatal genetic screening and testing options, calling for a reconsideration of how healthcare providers approach the first prenatal visit. METHODS We conducted interviews with 40 pregnant women to identify components of decision-making regarding prenatal genetic screens and tests at this visit. Analysis was approached using grounded theory. RESULTS Participants brought distinct notions of risk to the visit, including skewed perceptions of baseline risk for a fetal genetic condition and the implications of screening and testing. Participants were very concerned about financial considerations associated with these options, ranking out-of-pocket costs on par with medical considerations. Participants noted diverging priorities at the first visit from those of their healthcare provider, leading to barriers to shared decision-making regarding screening and testing during this visit. CONCLUSION Research is needed to determine how to restructure the initiation of prenatal care in a way that best positions patients to make informed decisions about prenatal genetic screens and tests.
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Affiliation(s)
- Ruth M Farrell
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Madelyn Pierce
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christina Collart
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Edward Chien
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Susannah L Rose
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA.,Office of Patient Experience, Cleveland Clinic, Cleveland, Ohio, USA.,Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Uma Perni
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Frankel
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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Aagaard Nolting L, Brasch-Andersen C, Cox H, Kanani F, Parker M, Fry AE, Loddo S, Novelli A, Dentici ML, Joss S, Jørgensen JP, Fagerberg CR. A new 1p36.13-1p36.12 microdeletion syndrome characterized by learning disability, behavioral abnormalities, and ptosis. Clin Genet 2020; 97:927-932. [PMID: 32170730 DOI: 10.1111/cge.13739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 11/30/2022]
Abstract
Two 1p36 contiguous gene deletion syndromes are known so far: the terminal 1p36 deletion syndrome and a 1p36 deletion syndrome with a critical region located more proximal at 1p36.23-1p36.22. We present even more proximally located overlapping deletions from seven individuals, with the smallest region of overlap comprising 1 Mb at 1p36.13-1p36.12 (chr1:19077793-20081292 (GRCh37/hg19)) defining a new contiguous gene deletion syndrome. The characteristic features of this new syndrome are learning disability or mild intellectual disability, speech delay, behavioral abnormalities, and ptosis. The genes UBR4 and CAPZB are considered the most likely candidate genes for the features of this new syndrome.
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Affiliation(s)
| | | | - Helen Cox
- Clinical Genetics Unit, West Midlands Regional Clinical Genetics Unit Birmingham U.K., Birmingham, UK
| | - Farah Kanani
- Sheffield Clinical Genetics Service, Northern General Hospital, Sheffield, UK
| | - Michael Parker
- Sheffield Clinical Genetics Service, Northern General Hospital, Sheffield, UK
| | - Andrew E Fry
- Institute of Medical Genetics, University Hospital of Wales, Cardiff, UK
| | - Sara Loddo
- Laboratory of Medical Genetics, Bambino Gesù Childrens' Hospital, Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Bambino Gesù Childrens' Hospital, Rome, Italy
| | | | - Shelagh Joss
- Clinical Genetics, West of Scotland Genetic Services, the Queen Elisabeth University Hospital, Glasgow, UK
| | - Joan P Jørgensen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
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15
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Zhang W, Mohammadi T, Sou J, Anis AH. Cost-effectiveness of prenatal screening and diagnostic strategies for Down syndrome: A microsimulation modeling analysis. PLoS One 2019; 14:e0225281. [PMID: 31800591 PMCID: PMC6892535 DOI: 10.1371/journal.pone.0225281] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/31/2019] [Indexed: 01/07/2023] Open
Abstract
Objectives Down syndrome (DS) is the most frequently occurring fetal chromosomal abnormality and different prenatal screening strategies are used for determining risk of DS worldwide. New non-invasive prenatal testing (NIPT), which uses cell-free fetal DNA in maternal blood can provide benefits due to its higher sensitivity and specificity in comparison to conventional screening tests. This study aimed to assess the cost-effectiveness of using population-level NIPT in fetal aneuploidy screening for DS. Methods We developed a microsimulation decision-analytic model to perform a probabilistic cost-effectiveness analysis (CEA) of prenatal screening and diagnostic strategies for DS. The model followed individual simulated pregnant women through the pregnancy pathway. The comparators were serum-only screening, contingent NIPT (i.e., NIPT as a second-tier screening test) and universal NIPT (i.e., NIPT as a first-tier screening test). To address uncertainty around the model parameters, the expected values of costs and quality-adjusted life-years (QALYs) in the base case and all scenario analyses were obtained through probabilistic analysis from a Monte Carlo simulation. Results Base case and scenario analyses were conducted by repeating the micro-simulation 1,000 times for a sample of 45,605 pregnant women per the population of British Columbia, Canada (N = 4.8 million). Preliminary results of the sequential CEAs showed that contingent NIPT was a dominant strategy compared to serum-only screening. Compared with contingent NIPT, universal NIPT at the current test price was not cost-effective with an incremental cost-effectiveness ratio over $100,000/QALY. Contingent NIPT also had the lowest cost per DS case detected among these three strategies. Conclusion Including NIPT in existing prenatal screening for DS is shown to be beneficial over conventional testing. However, at current prices, implementation of NIPT as a second-tier screening test is more cost-effective than deploying it as a universal test.
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Affiliation(s)
- Wei Zhang
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tima Mohammadi
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Julie Sou
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Aslam H. Anis
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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16
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John NM, Wright SJ, Gavan SP, Vass CM. The role of information provision in economic evaluations of non-invasive prenatal testing: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1123-1131. [PMID: 31230226 PMCID: PMC6803567 DOI: 10.1007/s10198-019-01082-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/13/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Technological progress has led to changes in the antenatal screening programmes, most significantly the introduction of non-invasive prenatal testing (NIPT). The availability of a new type of testing changes the type of information that the parent(s) require before, during and after screening to mitigate anxiety about the testing process and results. OBJECTIVES To identify the extent to which economic evaluations of NIPT have accounted for the need to provide information alongside testing and the associated costs and health outcomes of information provision. METHODS A systematic review of economic evaluations of NIPTs (up to February 2018) was conducted. Medline, Embase, CINAHL and PsychINFO were searched using an electronic search strategy combining a published economic search filter (from NHS economic evaluations database) with terms related to NIPT and screening-related technologies. Data were extracted using the Consolidated Health Economic Evaluation Reporting Standards framework and the results were summarised as part of a narrative synthesis. RESULTS A total of 12 economic evaluations were identified. The majority of evaluations (n = 10; 83.3%) involved cost effectiveness analysis. Only four studies (33.3%) included the cost of providing information about NIPT in their economic evaluation. Two studies considered the impact of test results on parents' quality of life by allowing utility decrements for different outcomes. Some studies suggested that the challenges of valuing information prohibited their inclusion in an economic evaluation. CONCLUSION Economic evaluations of NIPTs need to account for the costs and outcomes associated with information provision, otherwise estimates of cost effectiveness may prove inaccurate.
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Affiliation(s)
- Nikita M John
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Stuart J Wright
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Sean P Gavan
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Caroline M Vass
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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17
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Avram CM, Shaffer BL, Sparks TN, Allen AJ, Caughey AB. Cell-free fetal DNA screening for detection of microdeletion syndromes: a cost-effectiveness analysis. J Matern Fetal Neonatal Med 2019; 34:1732-1740. [PMID: 31327283 DOI: 10.1080/14767058.2019.1647161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Fetuses with genetic copy number variants are poorly detected through traditional prenatal screening. Microdeletions and duplications are clearly identified with diagnostic testing through chromosomal microarray, and screening of a select number of microdeletions has become available with cell-free DNA (cfDNA). Our study compares the costs and outcomes of cfDNA for five pathogenic microdeletions and aneuploidy to cfDNA for aneuploidy alone in conjunction with ultrasound. METHODS A decision-analytic model was constructed using TreeAge software to compare cfDNA with microdeletions versus traditional cfDNA in a theoretical cohort of 4,000,000 pregnancies that would also be screened with ultrasound. Probabilities, costs, and utilities were derived from literature. The primary outcomes were the incremental cost per quality-adjusted life-year (QALY), terminations, and procedure-related losses. Because the microdeletion results are available, but not reported, on all cfDNA testing we set the incremental cost of the cfDNA microdeletion screening test to zero at baseline and varied the cost in sensitivity analysis. RESULTS Screening with cfDNA for microdeletions among all pregnant women would result in 83 fewer anomalous neonates compared to traditional cfDNA with ultrasound. This reduction is due to increased diagnosis and termination of fetuses with microdeletions in this group. Routine use of cfDNA with microdeletions resulted in more procedure-related losses. cfDNA with microdeletions would improve effectiveness by 977 QALYs and decrease costs by $90,991,784. When we varied the specificity of the screening test, we found that it remained cost-effective down to a specificity of 91%. With a threshold of $100,000/QALY, microdeletion screening is cost-effective to an incremental increase in cost over cfDNA for aneuploidy alone of $47.10. CONCLUSION For detection of fetal subchromosomal abnormalities, use of cfDNA with microdeletions is a cost-effective strategy compared to cfDNA for aneuploidy alone in conjunction with ultrasound. Cell-free DNA for microdeletions is not currently recommended as routine screening for low-risk obstetric populations by the American College of Obstetrics and Gynecologists or the Society for Maternal-Fetal Medicine. The test characteristics of cfDNA with microdeletions require greater examination before being routinely recommended.
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Affiliation(s)
- Carmen M Avram
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Brian L Shaffer
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Teresa N Sparks
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Univeristy of California San Francisco, San Francisco, CA, USA
| | - Allison J Allen
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Sciences University, Portland, OR, USA
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18
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Shi J, Zhang R, Li J, Zhang R. Novel perspectives in fetal biomarker implementation for the noninvasive prenatal testing. Crit Rev Clin Lab Sci 2019; 56:374-392. [PMID: 31290367 DOI: 10.1080/10408363.2019.1631749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Noninvasive prenatal testing (NIPT) utilizes cell-free fetal DNA (cffDNA) present in maternal peripheral blood to detect chromosomal abnormalities. The detection of 21-trisomy, 18-trisomy, and 13-trisomy in the fetus has become a common screening method during pregnancy and has been widely applied in routine clinical testing because of its analytical and clinical validity. Currently, noninvasive prenatal testing involving copy number variations (CNVs) and other frequent single-gene disorders is being widely studied, and it plays an important and indispensable role in prenatal detection. The multiple approaches that have been reported and validated by various laboratories have different merits and limitations. Their clinical validity, utility, and application vary with different diseases. This review summarizes the principles, methods, advantages, and limitations of noninvasive prenatal testing for the detection of aneuploidy, CNVs and single-gene disorders. Before implementation of NIPT into clinical practice, a list of criteria that the application must meet is crucial. Essential parameters such as clinical sensitivity, clinical specificity, positive predictive value (PPV) and negative predictive value (NPV) are required to properly evaluate the clinical validity and utility of NIPT. We then discuss and analyze these clinical parameters and clinical application guidelines, providing physicians and scientists with feasible strategies and the latest research information.
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Affiliation(s)
- Jiping Shi
- Peking University Fifth School of Clinical Medicine, National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital , Beijing , China
| | - Runling Zhang
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,Graduate School, Chinese Academy of Medical Sciences, Peking Union Medical College , Beijing , China
| | - Jinming Li
- National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital , Beijing , China
| | - Rui Zhang
- Peking University Fifth School of Clinical Medicine, National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,National Center for Clinical Laboratories, National Center of Gerontology, Beijing Hospital , Beijing , China.,Beijing Engineering Research Center of Laboratory Medicine, Beijing Hospital , Beijing , China
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19
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Katz G, Pitts PJ. Implications of CRISPR-Based Germline Engineering for Cancer Survivors. Ther Innov Regul Sci 2018; 51:672-682. [PMID: 30227096 DOI: 10.1177/2168479017723401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer survivors can carry germline mutations that will be transmitted to their progeny. Today, many of these mutations have been identified and can be tracked. With the recent development of genome-editing technologies and CRISPR (clustered regularly interspaced short palindromic repeats), the possibility of genetically modifying the human germline-gametes and embryos-has never been closer. This perspective has sparked a controversy within the scientific community with reactions ranging from calls for a ban on germline modification to cautious approval of further research. This Editorial analyzes the possible adoption of CRISPR-based germline engineering to prevent the spread of cancer predispositions in the human population. We discuss whether the genomic edition of human sperm and eggs would contribute to rectifying or altering the heritable genome. We anticipate the emergence of a new form of liberal eugenics fueled by a logic of offer and demand from stakeholders such as cancer survivors and their relatives and offspring, but also from fertility clinics, biotech firms, insurers, and clinicians. From a regulatory perspective, validating the clinical safety and utility of CRISPR-based germline engineering is an essential step. However, with time, gradually perfecting the technology and assessing the economic benefits for stakeholders could soften society's resistance and align opinions in support of genomic decontamination of human germlines. This progressive shift would be justified in the name of cancer prevention as well as a moral obligation to facilitate the conception of cancer-free children at a cost that is acceptable to individuals and health systems.
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Affiliation(s)
- Gregory Katz
- 1 Chaired Professor of Innovation Management & Healthcare Performance, School of Medicine, Paris-Descartes University, Paris, France
| | - Peter J Pitts
- 2 President of the Center for Medicine in the Public Interest, Former Associate Commissioner, United States Food and Drug Administration, New York, NY, USA
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20
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Phillips KA, Deverka PA, Marshall DA, Wordsworth S, Regier DA, Christensen KD, Buchanan J. Methodological Issues in Assessing the Economic Value of Next-Generation Sequencing Tests: Many Challenges and Not Enough Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1033-1042. [PMID: 30224106 PMCID: PMC6159915 DOI: 10.1016/j.jval.2018.06.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/11/2018] [Indexed: 05/05/2023]
Abstract
BACKGROUND Clinical use of next-generation sequencing (NGS) tests has been increasing, but few studies have examined their economic value. Several studies have noted that there are methodological challenges to conducting economic evaluations of NGS tests. OBJECTIVE Our objective was to examine key methodological challenges for conducting economic evaluations of NGS tests, prioritize these challenges for future research, and identify how studies have attempted solutions to address these challenges. METHODS We identified challenges for economic evaluations of NGS tests using prior literature and expert judgment of the co-authors. We used a modified Delphi assessment to prioritize challenges, based on importance and probability of resolution. Using a structured literature review and article extraction we then assessed whether published economic evaluations had addressed these challenges. RESULTS We identified 11 challenges for conducting economic evaluations of NGS tests. The experts identified three challenges as the top priorities for future research: complex model structure, timeframe, and type of analysis and comparators used. Of the 15 published studies included in our literature review, four studies described specific solutions relevant to five of the 11 identified challenges. CONCLUSIONS Major methodological challenges to economic evaluations of NGS tests remain to be addressed. Our results can be used to guide future research and inform decision-makers on how to prioritize research on the economic assessment of NGS tests.
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Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); UCSF Philip R. Lee Institute for Health Policy; and UCSF Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | | | - Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Wordsworth
- Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Dean A Regier
- Cancer Control BC, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - James Buchanan
- Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
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21
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Kim SY, Lee SM, Jun JK, Han YJ, Kim MH, Shim JY, Lee MY, Oh SY, Lee J, Kim SH, Cha DH, Cho GJ, Kwon HS, Kim BJ, Park MH, Cho HY, Ko HS, Ahn J, Ryu HM. Prospective observations study protocol to investigate cost-effectiveness of various prenatal test strategies after the introduction of noninvasive prenatal testing. BMC Pregnancy Childbirth 2018; 18:307. [PMID: 30041617 PMCID: PMC6056912 DOI: 10.1186/s12884-018-1930-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 06/28/2018] [Indexed: 01/15/2023] Open
Abstract
Background Among the non-invasive screening methods for the identification of fetal aneuploidy, NIPT (non-invasive prenatal testing) shows the highest sensitivity and specificity in high-risk pregnancies. Due to the low false positive rate of NIPT, it is assumed that the implementation of NIPT as a primary screening method may reduce the number of invasive fetal tests and result in a similar or lowered cost in the overall detection of Down syndrome. However, most previous studies are based on theoretical economic analysis. This study aims to determine the cost effectiveness of various prenatal test strategies, including NIPT, in real clinical settings in both low risk and high risk pregnancies. Methods/design In this prospective observational study, women (< 24 weeks) with singleton or twin pregnancies will be enrolled in 12 different healthcare institutions. The participants will be grouped based on the risks of fetal chromosomal abnormalities and will be counseled on the various screening or diagnostic methods, including NIPT, according to the aneuploidy risk. The final decision on screening or diagnostic methods will be made by patients after counseling. Questionnaires regarding factors affecting the decision on prenatal test will be answered by the participants and physicians. The economic analysis on final total costs will be compared according to the various prenatal test strategies. Discussion The results of present study are expected to have a significant impact on national policies in determining Korean prenatal screening test strategies and to help in developing novel and effective prenatal screening tests in the future. Electronic supplementary material The online version of this article (10.1186/s12884-018-1930-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- So Yeon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - You Jung Han
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Min Hyoung Kim
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Jae-Yoon Shim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - JoonHo Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Dong Hyun Cha
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Han-Sung Kwon
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Byoung Jae Kim
- Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Mi Hye Park
- Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, Republic of Korea
| | - Hee Young Cho
- Department of Obstetrics and Gynecology, Bundang CHA Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Hyun Sun Ko
- Department of Obstetrics and Gynecology, Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Jeonghoon Ahn
- Department of Health Convergence, Ewha Womans University, Seoul, Republic of Korea
| | - Hyun Mee Ryu
- Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea.
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Shaffer BL, Norton ME. Cell-Free DNA Screening for Aneuploidy and Microdeletion Syndromes. Obstet Gynecol Clin North Am 2018; 45:13-26. [DOI: 10.1016/j.ogc.2017.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hui L, Norton M. What is the real "price" of more prenatal screening and fewer diagnostic procedures? Costs and trade-offs in the genomic era. Prenat Diagn 2018; 38:246-249. [PMID: 29441593 DOI: 10.1002/pd.5228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 01/16/2023]
Abstract
Any screening approach, including with cell-free DNA, will have an inferior detection rate compared with 100% diagnostic testing with chromosomal microarrays. Cell-free DNA-based screening, however, should not be seen as a threat to informed choice or maximising the benefits of diagnostic testing. Screening methods have become so much better that more women are now comfortable relying on such screening and do not need the certainty of a diagnostic test. This has not lead to a decline in detection of fetal chromosome abnormalities-in fact, we are now seeing historically high yields from prenatal screening. There are both economic and ethical consequences of offering universal diagnostic testing and abandoning the presumption of a normal infant in otherwise uncomplicated pregnancies. However, for some women, comprehensive information and diagnostic accuracy are important. Offering these women all options, with a careful and comprehensive explanation of the risks and benefits of each, results in outcomes that are best aligned with woman's preferences while at the same time requiring fewer diagnostic tests and lowering costs. It is one of the primary challenges of the modern era of prenatal testing to ensure that women receive sufficient information on which to make informed decisions.
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Affiliation(s)
- Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, VIC, Australia.,Public Health Genetics Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia.,Dept. of Obstetrics and Gynaecology, The Northern Hospital, Epping, VIC, Australia
| | - Mary Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Nshimyumukiza L, Menon S, Hina H, Rousseau F, Reinharz D. Cell-free DNA noninvasive prenatal screening for aneuploidy versus conventional screening: A systematic review of economic evaluations. Clin Genet 2018; 94:3-21. [PMID: 29030960 DOI: 10.1111/cge.13155] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 12/28/2022]
Abstract
Although noninvasive prenatal testing (NIPT) for aneuploidies using cell-free fetal DNA in maternal blood has been reported to have a high accuracy, only little evidence about its cost-effectiveness is available. We systematically reviewed and assessed quality of economic evaluation studies published between January 1, 2009 and January 1, 2016 where NIPT was compared to the current screening practices consisting of biochemical markers with or without nuchal translucency (NT) and/or maternal age. We included 16 studies and we found that, at current level of NIPT prices, contingent NIPT provide the best value for money, especially for publicly funded screening programs. NIPT as first-line test was found not cost-effective in the majority of studies. The NIPT unit cost, the risk cut-offs for current screening practice, the screening uptake rates (first- and second-line screening) as well as the costs and uptake rates of invasive diagnostic screening were the most common uncertain variables. The overall quality of included studies was fair. Considering a possible drop in prices and an ongoing NIPT expansion to include other chromosomes abnormalities other than T21, T18, T13 and sex chromosomes aneuploidies, future research are needed to examine the potential cost-effectiveness of implementing NIPT as first-line test.
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Affiliation(s)
- L Nshimyumukiza
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
| | - S Menon
- International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - H Hina
- Faculté des Sciences Infirmières, Université Laval, Quebec, Canada
| | - F Rousseau
- Centre de Recherche du Centre Hospitalier Universitaire de Québec, Quebec, Canada.,Département de Biologie Moléculaire, Biochimie Médicale et Pathologie, Faculté de Médecine, Université Laval, Quebec, Canada
| | - D Reinharz
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec, Canada
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Wolfberg AJ. Conflict of interest related to clinical practice is underreported: The case of noninvasive prenatal testing. Prenat Diagn 2018; 38:219-221. [PMID: 29318630 DOI: 10.1002/pd.5209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/23/2017] [Accepted: 12/30/2017] [Indexed: 11/08/2022]
Abstract
Authors of policy statements from the American College of Obstetricians and Gynecologists and from the Society for Maternal-Fetal Medicine do not acknowledge the potential for their clinical income to influence their opinions, or the positions of the societies they represent. These policy statements were published in Obstetrics and Gynecology and the American Journal of Obstetrics and Gynecology, again, without acknowledgment of the potential for conflict of interest. The case of noninvasive prenatal testing, which has threatened the role of maternal-fetal medicine in the practice of prenatal screening and diagnosis, and has significantly reduced the demand for invasive prenatal diagnosis, illustrates the importance of identifying this potential conflict.
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Affiliation(s)
- Adam J Wolfberg
- Newton-Wellesley Hospital, Ovia Health, Boston, MA, 02110, USA
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Abstract
Screening for fetal aneuploidy in pregnant women using cell-free DNA has increased dramatically since the technology became commercially available in 2011. Since that time, numerous trials have demonstrated high sensitivity and specificity to screen for common aneuploidies in high-risk populations. Studies assessing the performance of these tests in low-risk populations have also demonstrated improved detection rates compared with traditional, serum-based screening strategies. Concurrent with the increased use of this technology has been a decrease in invasive procedures (amniocentesis and chorionic villus sampling). As the technology becomes more widely understood, available, and utilized, challenges regarding its clinical implementation have become apparent. Some of these challenges include test failures, false-positive and false-negative results, limitations in positive predictive value in low-prevalence populations, and potential maternal health implications of abnormal results. In addition, commercial laboratories are expanding screening beyond common aneuploidies to include microdeletion screening and whole genome screening. This review article is intended to provide the practicing obstetrician with a summary of the complexities of cell-free DNA screening and the challenges of implementing it in the clinical setting.
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Verma IC, Dua-Puri R, Bijarnia-Mahay S. ACMG 2016 Update on Noninvasive Prenatal Testing for Fetal Aneuploidy: Implications for India. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0116-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Irresponsible and responsible resource management in obstetrics. Best Pract Res Clin Obstet Gynaecol 2017; 43:87-106. [PMID: 28268060 DOI: 10.1016/j.bpobgyn.2016.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 01/02/2023]
Abstract
Low budgets constrain and high budgets stimulate choices. In high-income countries, this economic reality may lead to overuse of healthcare services and pose unnecessary risks for mothers and infants. Options for improvement can be created at different levels of healthcare systems. Pregnancy provides an effective opportunity to profile maternal risks and represents a vulnerable but potentially modifiable period from prenatal life to adulthood. In response to system-inherent false incentives, professional responsibility requires obstetricians to strive to improve the future health of families and their offspring despite disincentives for doing so. This chapter addresses professionally responsible resource management in obstetrics and identifies implications for patients, care givers, communities, policy makers, and academic faculties.
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Norton ME, Kuppermann M. Women should decide which conditions matter. Am J Obstet Gynecol 2016; 215:583-587.e1. [PMID: 27793311 DOI: 10.1016/j.ajog.2016.06.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 05/01/2016] [Accepted: 06/23/2016] [Indexed: 01/04/2023]
Abstract
Providing reliable prenatal screening performance estimates is critical for patient counseling and policy-making. Women who choose prenatal screening for aneuploidy are likely to be concerned not only with the common aneuploidies but with all causes of intellectual disability and serious birth defects. Sequential prenatal screening (combined serum and ultrasound testing) for aneuploidy detection commonly is offered as a primary screening test. Among women identified as screen positive, cell-free (cf)DNA has been added recently as a secondary, noninvasive screening option, before the consideration of invasive diagnostic testing (eg, amniocentesis and karyotype). With the anticipation of lower costs in the future, cfDNA might be an alternative to sequential screening in the general population. Sequential and cfDNA tests are both noninvasive, and both identify common aneuploidies. Screening via cfDNA detects more common chromosome abnormalities (eg, trisomy 21, sex trisomies). Sequential screening can identify other aneuploidies (eg, triploidy), as well as chromosome abnormalities associated with fetal structural abnormalities. When the advantages and disadvantages of routine sequential screening with routine cfDNA screening are compared, one important measure is the proportion and severity of chromosome abnormalities identified. When reporting these detection rates, authors need to carefully consider the impact of multiple well-described biases. For women to make informed choices in situations of this type, determining reliable comparative performance estimates is crucial.
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Affiliation(s)
- Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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Gregg AR, Skotko BG, Benkendorf JL, Monaghan KG, Bajaj K, Best RG, Klugman S, Watson MS. Noninvasive prenatal screening for fetal aneuploidy, 2016 update: a position statement of the American College of Medical Genetics and Genomics. Genet Med 2016; 18:1056-65. [PMID: 27467454 DOI: 10.1038/gim.2016.97] [Citation(s) in RCA: 439] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 12/17/2022] Open
Abstract
DISCLAIMER This statement is designed primarily as an educational resource for clinicians to help them provide quality medical services. Adherence to this statement is completely voluntary and does not necessarily assure a successful medical outcome. This statement should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed toward obtaining the same results. In determining the propriety of any specific procedure or test, the clinician should apply his or her own professional judgment to the specific clinical circumstances presented by the individual patient or specimen. Clinicians are encouraged to document the reasons for the use of a particular procedure or test, whether or not it is in conformance with this statement. Clinicians also are advised to take notice of the date this statement was adopted and to consider other medical and scientific information that becomes available after that date. It also would be prudent to consider whether intellectual property interests may restrict the performance of certain tests and other procedures.Noninvasive prenatal screening using cell-free DNA (NIPS) has been rapidly integrated into prenatal care since the initial American College of Medical Genetics and Genomics (ACMG) statement in 2013. New evidence strongly suggests that NIPS can replace conventional screening for Patau, Edwards, and Down syndromes across the maternal age spectrum, for a continuum of gestational age beginning at 9-10 weeks, and for patients who are not significantly obese. This statement sets forth a new framework for NIPS that is supported by information from validation and clinical utility studies. Pretest counseling for NIPS remains crucial; however, it needs to go beyond discussions of Patau, Edwards, and Down syndromes. The use of NIPS to include sex chromosome aneuploidy screening and screening for selected copy-number variants (CNVs) is becoming commonplace because there are no other screening options to identify these conditions. Providers should have a more thorough understanding of patient preferences and be able to educate about the current drawbacks of NIPS across the prenatal screening spectrum. Laboratories are encouraged to meet the needs of providers and their patients by delivering meaningful screening reports and to engage in education. With health-care-provider guidance, the patient should be able to make an educated decision about the current use of NIPS and the ramifications of a positive, negative, or no-call result.Genet Med 18 10, 1056-1065.
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Affiliation(s)
- Anthony R Gregg
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
| | - Brian G Skotko
- Department of Pediatrics, Harvard Medical School and Division of Medical Genetics, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | - Komal Bajaj
- New York City Health + Hospitals/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert G Best
- University of South Carolina School of Medicine, Greenville Health System, Greenville, South Carolina, USA
| | - Susan Klugman
- Montefiore Medical Center, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael S Watson
- American College of Medical Genetics and Genomics, Bethesda, Maryland, USA
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Benn P. Expanding non-invasive prenatal testing beyond chromosomes 21, 18, 13, X and Y. Clin Genet 2016; 90:477-485. [PMID: 27283893 DOI: 10.1111/cge.12818] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/05/2016] [Accepted: 06/07/2016] [Indexed: 12/16/2022]
Abstract
Non-invasive prenatal testing (NIPT) based on cell-free DNA in maternal plasma is being expanded to include additional chromosome abnormalities beyond those involving chromosomes 21, 18, 13, X and Y. Review of population cytogenetic data provides insight into the likely number of additional abnormalities detectable. Additional clinically significant and cytogenetically recognizable abnormalities are present in less than 0.1% of newborns but clinically significant, or potentially significant, sub-microscopic imbalances are expected to be present in 1.7%. Cytogenetic studies on chorionic villus samples suggests that after excluding abnormalities involving chromosomes 21, 18, 13, X and Y, approximately 0.6% of NIPT results may be positive for an unbalanced abnormality attributable to mosaicism but most of these will not be confirmed at amniocentesis or in newborns. NIPT has also been developed for specific microdeletion syndromes and initial experience is now available. Laboratory procedures such as deeper sequencing and additional data analytics are rapidly evolving but even with existing protocols, it is already clear that NIPT does not necessarily need to be limited to trisomies 21, 18, 13 and the sex-chromosome abnormalities. Patient educational materials and genetic counseling services need to be available for women offered expanded NIPT.
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Affiliation(s)
- P Benn
- Department of Genetics and Genome Sciences, University of Connecticut Health Center, Farmington, CT, USA
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Gammon BL, Kraft SA, Michie M, Allyse M. "I think we've got too many tests!": Prenatal providers' reflections on ethical and clinical challenges in the practice integration of cell-free DNA screening. ACTA ACUST UNITED AC 2016; 2:334-342. [PMID: 28180146 DOI: 10.1016/j.jemep.2016.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The recent introduction of cell-free DNA-based non-invasive prenatal screening (cfDNA screening) into clinical practice was expected to revolutionize prenatal testing. cfDNA screening for fetal aneuploidy has demonstrated higher test sensitivity and specificity for some conditions than conventional serum screening and can be conducted early in the pregnancy. However, it is not clear whether and how clinical practices are assimilating this new type of testing into their informed consent and counselling processes. Since the introduction of cfDNA screening into practice in 2011, the uptake and scope have increased dramatically. Prenatal care providers are under pressure to stay up to date with rapidly changing cfDNA screening panels, manage increasing patient demands, and keep up with changing test costs, all while attempting to use the technology responsibly and ethically. While clinical literature on cfDNA screening has shown benefits for specific patient populations, it has also identified significant misunderstandings among providers and patients alike about the power of the technology. The unique features of cfDNA screening, in comparison to established prenatal testing technologies, have implications for informed decision-making and genetic counselling that must be addressed to ensure ethical practice. OBJECTIVES This study explored the experiences of prenatal care providers at the forefront of non-invasive genetic screening in the United States to understand how this testing changes the practice of prenatal medicine. We aimed to learn how the experience of providing and offering this testing differs from established prenatal testing methodologies. These differences may necessitate changes to patient education and consent procedures to maintain ethical practice. METHODS We used the online American Congress of Obstetricians and Gynecologists Physician Directory to identify a systematic sample of five prenatal care providers in each U.S. state and the District of Columbia. Beginning with the lowest zip code in each state, we took every fifth name from the directory, excluding providers who were retired, did not currently practice in the state in which they were listed, or were not involved in a prenatal specialty. After repeating this step twice and sending a total of 461 invitations, 37 providers expressed interest in participating, and we completed telephone interviews with 21 providers (4.6%). We developed a semi-structured interview guide including questions about providers' use of and attitudes toward cfDNA screening. A single interviewer conducted and audio-recorded all interviews by telephone, and the interviews lasted approximately 30 minutes each. We collaboratively developed a codebook through an iterative process of transcript review and code application, and a primary coder coded all transcripts. RESULTS Prenatal care providers have varying perspectives on the advantages of cfDNA screening and express a range of concerns regarding the implementation of cfDNA screening in practice. While providers agreed on several advantages of cfDNA, including increased accuracy, earlier return of results, and decreased risk of complications, many expressed concern that there is not enough time to adequately counsel and educate patients on their prenatal screening and testing options. Providers also agreed that demand for cfDNA screening has increased and expressed a desire for more information from professional societies, labs, and publications. Providers disagreed about the healthcare implications and future of cfDNA screening. Some providers anticipated that cfDNA screening would decrease healthcare costs when implemented widely and expressed optimism for expanded cfDNA screening panels. Others were concerned that cfDNA screening would increase costs over time and questioned whether the expansion to include microdeletions could be done ethically. CONCLUSIONS The perspectives and experiences of the providers in this study allow insight into the clinical benefit, burden on prenatal practice, and potential future of cfDNA screening in clinical practice. Given the likelihood that the scope and uptake of cfDNA screening will continue to increase, it is essential to consider how these changes will affect frontline prenatal care providers and, in turn, patients. Providers' requests for additional guidance and data as well as their concerns with the lack of time available to explain screening and testing options indicate significant potential issues with patient care. It is important to ensure that the clinical integration of cfDNA screening is managed responsibly and ethically before it expands further, exacerbating pre-existing issues. As prenatal screening evolves, so should informed consent and the resources available to women making decisions. The field must take steps to maximize the advantages of cfDNA screening and responsibly manage its ethical issues.
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Affiliation(s)
- B L Gammon
- Biomedical Ethics Program, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - S A Kraft
- Stanford University Center for Biomedical Ethics, 1215 Welch Road, Modular A, Stanford, CA 94305, USA
| | - M Michie
- UCSF School of Nursing, 3333 Calif. Street, Laurel Heights, San Francisco, CA 94118, USA
| | - M Allyse
- Biomedical Ethics Program, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Genetic Counseling for Patients Considering Screening and Diagnosis for Chromosomal Abnormalities. Clin Lab Med 2016; 36:227-36. [DOI: 10.1016/j.cll.2016.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Kuppermann M, Norton ME, Thao K, O'Leary A, Nseyo O, Cortez A, Kaimal AJ. Preferences regarding contemporary prenatal genetic tests among women desiring testing: implications for optimal testing strategies. Prenat Diagn 2016; 36:469-75. [DOI: 10.1002/pd.4808] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 02/28/2016] [Accepted: 03/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Miriam Kuppermann
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
- Department of Epidemiology and Biostatistics; University of California; San Francisco CA USA
| | - Mary E. Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
| | - Kao Thao
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
| | - Allison O'Leary
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
| | - Onouwem Nseyo
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
| | - Abigail Cortez
- Department of Obstetrics, Gynecology, and Reproductive Sciences; University of California; San Francisco CA USA
| | - Anjali J. Kaimal
- Department of Obstetrics and Gynecology; Massachusetts General Hospital; Boston MA USA
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Sinkey RG, Odibo AO. Cost-Effectiveness of Old and New Technologies for Aneuploidy Screening. Clin Lab Med 2016; 36:237-48. [PMID: 27235909 DOI: 10.1016/j.cll.2016.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cost-effectiveness analyses allow assessment of whether marginal gains from new technology are worth increased costs. Several studies have examined cost-effectiveness of Down syndrome (DS) screening and found it to be cost-effective. Noninvasive prenatal screening also appears to be cost-effective among high-risk women with respect to DS screening, but not for the general population. Chromosomal microarray (CMA) is a genetic sequencing method superior to but more expensive than karyotype. In light of CMAs greater ability to detect genetic abnormalities, it is cost-effective when used for prenatal diagnosis of an anomalous fetus. This article covers methodology and salient issues of cost-effectiveness.
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Affiliation(s)
- Rachel G Sinkey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA.
| | - Anthony O Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
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Suskin E, Hercher L, Aaron KE, Bajaj K. The Integration of Noninvasive Prenatal Screening into the Existing Prenatal Paradigm: a Survey of Current Genetic Counseling Practice. J Genet Couns 2016; 25:1032-43. [DOI: 10.1007/s10897-016-9934-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/28/2016] [Indexed: 01/04/2023]
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SMFM Statement: clarification of recommendations regarding cell-free DNA aneuploidy screening. Am J Obstet Gynecol 2015; 213:753-4. [PMID: 26458766 DOI: 10.1016/j.ajog.2015.09.077] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 09/16/2015] [Accepted: 09/21/2015] [Indexed: 11/23/2022]
Abstract
The purpose of this statement is to clarify that the Society for Maternal-Fetal Medicine (SMFM) does not recommend that cell-free DNA aneuploidy screening be offered to all pregnant women, nor does it suggest a requirement for insurance coverage for cell-free DNA screening in women at low risk of aneuploidy. However, SMFM believes, due to the ethics of patient autonomy, that the option should be available to women who request additional testing beyond what is currently recommended by professional societies.
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