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Abstract
Since first sequencing the human genome in 2003, emerging genetic/genomic technologies have ushered in a revolutionary era of medicine that purports to bridge molecular biology and clinical care. The field of translational medicine is charged with mediating this revolution. Sequencing innovations are far outpacing guidelines intended to ease their practice-based applications, including in primary care. As a result, genomic medicine’s full integration in primary care settings especially, has been slow to materialize. Researchers and clinicians alike face substantial challenges in navigating contentious ethical issues raised in translation and implementation, namely preserving the spirit of whole-person approaches to care; maintaining respect for persons and communities; and translating genetic risk into clinical actionability. This commentary therefore explores practical barriers to, and ethical implications of, incorporating genomic technologies in the primary care sector. These ethical challenges are both philosophical and infrastructural. From a primary care perspective, the commentary further reviews the ethical, legal and social implications of the Center for Disease Control’s proposed model for assessing the validity and utility of genomic testing and family health history applications. Lastly, the authors provide recommendations for future translational initiatives that aim to maximize the capacities of genomic medicine, without compromising primary care philosophies and foundations of practice.
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Poduri A, Sheidley BR, Shostak S, Ottman R. Genetic testing in the epilepsies-developments and dilemmas. Nat Rev Neurol 2014; 10:293-9. [PMID: 24733164 PMCID: PMC4090104 DOI: 10.1038/nrneurol.2014.60] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
In the past two decades, the number of genes recognized to have a role in the epilepsies has dramatically increased. The availability of testing for epilepsy-related genes is potentially helpful for clarification of the diagnosis and prognosis, selection of optimal treatments, and provision of information for family planning. For some patients, identification of a specific genetic cause of their epilepsy has important personal value, even in the absence of clear clinical utility. The availability of genetic testing also raises new issues that have only begun to be considered. These issues include the growing importance of educating physicians about when and how to test patients, the need to ensure that affected individuals and their families can make informed choices about testing and receive support after receiving the results, and the question of what the positive and negative consequences of genetic testing will be for affected individuals, their family members, and society.
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Affiliation(s)
- Annapurna Poduri
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Beth Rosen Sheidley
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sara Shostak
- Department of Sociology, Brandeis University, 415 South Street, Waltham, MA 02454, USA
| | - Ruth Ottman
- Gertrude H. Sergievsky Center and Department of Neurology, College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, 630 West 168th Street, New York, NY 10032, USA
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Etchegary H, Green J, Dicks E, Pullman D, Street C, Parfrey P. Consulting the community: public expectations and attitudes about genetics research. Eur J Hum Genet 2013; 21:1338-43. [PMID: 23591403 PMCID: PMC3831079 DOI: 10.1038/ejhg.2013.64] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 11/09/2022] Open
Abstract
Genomic discoveries and technologies promise numerous opportunities for improving health. Key to these potential health improvements, however, are health-care consumers' understanding and acceptance of these new developments. We identified community groups and invited them to a public information-consultation session in order to explore public awareness, perception and expectations about genetics and genomics research. One hundred and four members of seven community groups in Newfoundland, Canada took part in the community sessions. Content analysis of participant comments revealed they were largely hopeful about genetics research in its capacity to improve health; however, they did not accept such research uncritically. Complex issues arose during the community consultations, including the place of genetics in primary care, the value of genetics for personal health, and concerns about access to and uses of genetic information. Participants unequivocally endorsed the value of public engagement with these issues. The rapid pace of discoveries in genomics research offers exciting opportunities to improve population health. However, public support will be crucial to realize health improvements. Our findings suggest that regular, transparent dialog between researchers and the public could allow a greater understanding of the research process, as well as assist in the design of efficient and effective genetic health services, informed by the public that will use them.
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Affiliation(s)
- Holly Etchegary
- Clinical Epidemiology, Faculty of Medicine, Memorial University, St John's, Newfoundland and Labrador, Canada
- Eastern Health, St John's, Newfoundland and Labrador, Canada
| | - Jane Green
- Discipline of Genetics, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Elizabeth Dicks
- Clinical Epidemiology, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Daryl Pullman
- Community Health and Humanities, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Catherine Street
- Population Therapeutics Research Group, Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Patrick Parfrey
- Clinical Epidemiology, Memorial University, St John's, Newfoundland and Labrador, Canada
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Scheuner MT, Hamilton AB, Peredo J, Sale TJ, Austin C, Gilman SC, Bowen MS, Goldzweig CL, Lee M, Mittman BS, Yano EM. A cancer genetics toolkit improves access to genetic services through documentation and use of the family history by primary-care clinicians. Genet Med 2013; 16:60-9. [DOI: 10.1038/gim.2013.75] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 04/16/2013] [Indexed: 02/04/2023] Open
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Selkirk CG, Weissman SM, Anderson A, Hulick PJ. Physicians' preparedness for integration of genomic and pharmacogenetic testing into practice within a major healthcare system. Genet Test Mol Biomarkers 2013; 17:219-25. [PMID: 23390885 DOI: 10.1089/gtmb.2012.0165] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Physicians will play a large role in the delivery of genomic medicine, given the limited number of trained genetics professionals. The objective of this study was to assess physician preparedness for incorporating genomic testing (GT) and pharmacogenetic testing (PT) into practice by determining knowledge, experience, comfort level, and barriers, as well as their expectations for practice and educational needs. METHODS A 30-question survey was distributed to physicians spanning all disciplines within our healthcare system. RESULTS Perceived knowledge was poor; 40%-72% reported "no to minimal knowledge" for all genomics topics. Recent graduates or those with no patients who had undergone GT or PT had lower comfort levels. Participating physicians anticipate usage to increase; however, most were uncertain when and how to incorporate genomics into practice. Physicians perceived lack of knowledge and time to keep updated as their greatest barriers to incorporating GT and PT into practice. CONCLUSION Overall, physicians appear underprepared, perceiving they lack sufficient knowledge and confidence to incorporate GT and PT into practice. The majority of physicians expect their role in GT and PT to increase. The results underscore the importance of enhancing policies and initiatives to increase physician knowledge and comfort level.
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Affiliation(s)
- Christina G Selkirk
- Department of Medicine, Center for Medical Genetics, NorthShore University HealthSystem, Evanston, Illinois 60201, USA.
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Scheuner MT, Edelen MO, Hilborne LH, Lubin IM. Effective communication of molecular genetic test results to primary care providers. Genet Med 2012; 15:444-9. [DOI: 10.1038/gim.2012.151] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Khoury MJ, Coates RJ, Fennell ML, Glasgow RE, Scheuner MT, Schully SD, Williams MS, Clauser SB. Multilevel research and the challenges of implementing genomic medicine. J Natl Cancer Inst Monogr 2012; 2012:112-20. [PMID: 22623603 DOI: 10.1093/jncimonographs/lgs003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Advances in genomics and related fields promise a new era of personalized medicine in the cancer care continuum. Nevertheless, there are fundamental challenges in integrating genomic medicine into cancer practice. We explore how multilevel research can contribute to implementation of genomic medicine. We first review the rapidly developing scientific discoveries in this field and the paucity of current applications that are ready for implementation in clinical and public health programs. We then define a multidisciplinary translational research agenda for successful integration of genomic medicine into policy and practice and consider challenges for successful implementation. We illustrate the agenda using the example of Lynch syndrome testing in newly diagnosed cases of colorectal cancer and cascade testing in relatives. We synthesize existing information in a framework for future multilevel research for integrating genomic medicine into the cancer care continuum.
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Affiliation(s)
- Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop E61, Atlanta, GA 30333, USA.
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Scheuner MT, Hilborne L, Brown J, Lubin, for the members of the RAND IM. A Report Template for Molecular Genetic Tests Designed to Improve Communication Between the Clinician and Laboratory. Genet Test Mol Biomarkers 2012; 16:761-9. [DOI: 10.1089/gtmb.2011.0328] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Maren T. Scheuner
- RAND Corporation, Santa Monica, California
- Department of Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, Los Angeles, California
| | - Lee Hilborne
- RAND Corporation, Santa Monica, California
- Quest Diagnostics, West Hills, California
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, Los Angeles, California
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Powell KP, Christianson CA, Cogswell WA, Dave G, Verma A, Eubanks S, Henrich VC. Educational needs of primary care physicians regarding direct-to-consumer genetic testing. J Genet Couns 2011; 21:469-78. [PMID: 22207397 DOI: 10.1007/s10897-011-9471-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 12/08/2011] [Indexed: 11/24/2022]
Abstract
To assess the educational needs of North Carolina primary care physicians (PCPs) about direct-to-consumer (DTC) genetic testing, surveys were mailed to 2,402 family and internal medicine providers in North Carolina. Out of 382 respondents, 323 (85%) felt unprepared to answer patient questions and 282 (74%) reported wanting to learn about DTC genetic testing. A total of 148 (39%) were aware of DTC genetic testing. Among these, 63 (43%) thought DTC genetic testing was clinically useful. PCPs who felt either unprepared to answer patient questions (OR = 0.354, p = 0.01) or that DTC genetic testing was clinically useful (OR = 5.783, p = 0.00) were more likely to want to learn about DTC genetic testing. PCPs are interested in learning about DTC genetic testing, but are mostly unaware of DTC testing and feel unprepared to help patients with DTC testing results. Familiar and trusted channels that provide the information and tools PCPs need to help answer patient's questions and manage their care should be used when creating educational programs.
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Affiliation(s)
- Karen P Powell
- Center for Biotechnology, Genomics & Health Research, The University of North Carolina at Greensboro, Greensboro, NC 27402-6170, USA.
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Koehly LM, Ashida S, Goergen AF, Skapinsky KF, Hadley DW, Wilkinson AV. Willingness of Mexican-American adults to share family health history with healthcare providers. Am J Prev Med 2011; 40:633-6. [PMID: 21565656 PMCID: PMC3104291 DOI: 10.1016/j.amepre.2011.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 12/13/2010] [Accepted: 02/03/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Collecting family health history (FHH) information to share with healthcare providers is an important aspect of health-risk assessment. PURPOSE To examine associations between the content of FHH-informed risk feedback and willingness to share the information with a healthcare provider. METHODS Data were collected between June 2008 and July 2009 from 475 Mexican-origin adults residing in 161 households. Participants completed surveys 3 months after receiving FHH-informed risk feedback. Households were randomly assigned to feedback conditions in which household members received one or more of the following: an FHH pedigree, personalized risk assessments (PRAs), and tailored behavioral recommendations. Logistic regression models were fitted using generalized estimating equations, with exchangeable covariances, to account for the clustering of responses within and the random assignment of feedback condition to household. Analyses were completed in May 2010. RESULTS Participants who received personalized risk assessments were more willing to share their feedback with a provider than those who received a pedigree only (OR=2.25, p=0.02). The receipt of tailored behavioral recommendations did not significantly increase willingness to share feedback with a provider (OR=0.79, p=0.48). CONCLUSIONS The provision of PRAs in FHH assessments appears to motivate participants to consider sharing their FHH with a healthcare provider.
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Affiliation(s)
- Laura M Koehly
- Social and Behavioral Research Branch, National Human Genome Research Institute/NIH, 31 Center Drive, Bethesda, MD 20892, USA.
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Makeeva OA, Markova VV, Puzyrev VP. Public interest and expectations concerning commercial genotyping and genetic risk assessment. Per Med 2009; 6:329-341. [PMID: 29783514 DOI: 10.2217/pme.09.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In contrast to the modest progress made in the interpretation and clinical application of genomic data, genotyping technologies have experienced great progress. Genotyping costs are progressively decreasing making individual genotyping more commonly available. Financial availability of individual genome analysis and the strong desire of many people to know about their individual genomic characteristics, promotes the marketing of genetic tests of variable predictive value directly to the public. A survey of 2000 Russian respondents revealed very positive attitudes and beliefs towards these genetic developments: 85% of surveyed individuals would like to have their genetic risk for avoidable diseases estimated, and 89% responded stating that they would try to change their lifestyle by giving up bad habits, following a recommended diet or taking medications if a high risk of disease was identified. It is believed that with time, validated genetic information will find its rightful place in medicine, by supplementing phenotypic clinical data with validated genetic interpretations.
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Affiliation(s)
- Oksana A Makeeva
- Research Institute of Medical Genetics of The Siberian Branch of The Russian Academy of Medical Sciences, 10 Nab. Ushaiky, Tomsk 634050, Russia.
| | - Valentina V Markova
- Research Institute of Medical Genetics of The Siberian Branch of The Russian Academy of Medical Sciences, 10 Nab. Ushaiky, Tomsk 634050, Russia.
| | - Valery P Puzyrev
- Research Institute of Medical Genetics of The Siberian Branch of The Russian Academy of Medical Sciences, 10 Nab. Ushaiky, Tomsk 634050, Russia.
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Jakobsdottir J, Gorin MB, Conley YP, Ferrell RE, Weeks DE. Interpretation of genetic association studies: markers with replicated highly significant odds ratios may be poor classifiers. PLoS Genet 2009; 5:e1000337. [PMID: 19197355 PMCID: PMC2629574 DOI: 10.1371/journal.pgen.1000337] [Citation(s) in RCA: 201] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Recent successful discoveries of potentially causal single nucleotide polymorphisms (SNPs) for complex diseases hold great promise, and commercialization of genomics in personalized medicine has already begun. The hope is that genetic testing will benefit patients and their families, and encourage positive lifestyle changes and guide clinical decisions. However, for many complex diseases, it is arguable whether the era of genomics in personalized medicine is here yet. We focus on the clinical validity of genetic testing with an emphasis on two popular statistical methods for evaluating markers. The two methods, logistic regression and receiver operating characteristic (ROC) curve analysis, are applied to our age-related macular degeneration dataset. By using an additive model of the CFH, LOC387715, and C2 variants, the odds ratios are 2.9, 3.4, and 0.4, with p-values of 10−13, 10−13, and 10−3, respectively. The area under the ROC curve (AUC) is 0.79, but assuming prevalences of 15%, 5.5%, and 1.5% (which are realistic for age groups 80 y, 65 y, and 40 y and older, respectively), only 30%, 12%, and 3% of the group classified as high risk are cases. Additionally, we present examples for four other diseases for which strongly associated variants have been discovered. In type 2 diabetes, our classification model of 12 SNPs has an AUC of only 0.64, and two SNPs achieve an AUC of only 0.56 for prostate cancer. Nine SNPs were not sufficient to improve the discrimination power over that of nongenetic predictors for risk of cardiovascular events. Finally, in Crohn's disease, a model of five SNPs, one with a quite low odds ratio of 0.26, has an AUC of only 0.66. Our analyses and examples show that strong association, although very valuable for establishing etiological hypotheses, does not guarantee effective discrimination between cases and controls. The scientific community should be cautious to avoid overstating the value of association findings in terms of personalized medicine before their time.
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Affiliation(s)
- Johanna Jakobsdottir
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Abstract
PURPOSE OF REVIEW Advances in genetics are occurring at a rapid pace. It will ultimately be the primary care pediatrician who assimilates this knowledge and applies it to patient care. This article is written in a patient encounter format with which the pediatrician is familiar. The vignettes are from the author's own experiences in 13 years of general pediatric practice. RECENT FINDINGS The current literature reinforces the idea that changes in the complexity of the diagnostic evaluation and the time spent explaining the recommended testing will be required by the pediatrician. With this responsibility comes the need of new training strategies for medical students and established pediatricians. SUMMARY Pediatricians will be called upon to incorporate new genetic findings into patient care. This task will ultimately be no different than it was for past pediatricians to incorporate new immunizations or antibiotics into the care plan for each patient. Patient care will improve because therapy will be tailor-made for both the disease and the patient.
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