1
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Bos W, Bunnik EM. Informed consent practices for exome sequencing: An interview study with clinical geneticists in the Netherlands. Mol Genet Genomic Med 2022; 10:e1882. [PMID: 35150093 PMCID: PMC8922961 DOI: 10.1002/mgg3.1882] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/21/2021] [Accepted: 01/14/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Genomic sequencing is being used more frequently in the clinic, not only by clinical geneticists, but also by other specialists ("mainstreaming"). The use of genomic sequencing gives rise to challenges regarding informed consent, as it can yield more, and more complex results. METHODS This study maps the informed consent process for exome sequencing in the Netherlands by means of semistructured interviews with 14 clinical geneticists. Interviewees were asked about their strategies for informing patients about exome sequencing and supporting patients in their decision making, about what they think of as essential information elements, about the challenges they experience, and about their preferences for future policy and practice. RESULTS Clinical geneticists typically discuss the following topics: the nature and aim of the test, the possible results (including unsolicited or incidental findings and Variants of Uncertain Significance) of the test and the consequences of those results for the patient and their family members. Some clinical geneticists use a layered approach to informed consent, meaning that they give short and concise information at first, and provide more detailed information depending on the situation or the needs of the patient. CONCLUSION During pre-test counseling for genomic sequencing, clinical geneticists use various strategies to enhance patient understanding and personalization of the informed consent process. Going forward, layering information may be part of a solution to ethical challenges of informed consent, also in mainstream settings.
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Affiliation(s)
- Wendy Bos
- Department of Medical Ethics, Philosophy and History of MedicineErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
| | - Eline M. Bunnik
- Department of Medical Ethics, Philosophy and History of MedicineErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
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2
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Bunnik EM, Dondorp WJ, Bredenoord AL, de Wert G, Cornel MC. Mainstreaming informed consent for genomic sequencing: A call for action. Eur J Cancer 2021; 148:405-410. [PMID: 33784533 DOI: 10.1016/j.ejca.2021.02.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 12/18/2022]
Abstract
The wider availability of genomic sequencing, notably gene panels, in cancer care allows for personalised medicine or the tailoring of clinical management to the genetic characteristics of tumours. While the primary aim of mainstream genomic sequencing of cancer patients is therapy-focussed, genomic testing may yield three types of results beyond the answer to the clinical question: suspected germline mutations, variants of uncertain significance (VUS), and unsolicited findings pertaining to other conditions. Ideally, patients should be prepared beforehand for the clinical and psychosocial consequences of such findings, for themselves and for their family members, and be given the opportunity to autonomously decide whether or not to receive such unsolicited genomic information. When genomic tests are mainstreamed into cancer care, so should accompanying informed consent practices. This paper outlines what mainstream oncologists may learn from the ethical tradition of informed consent for genomic sequencing, as developed within clinical genetics. It argues that mainstream informed consent practices should focus on preparing patients for three types of unsolicited outcomes, briefly and effectively. Also, it argues that when the chance of unsolicited findings is very low, opt-out options need not be actively offered. The use of a layered approach - integrated in information systems - should render informed consent feasible for non-geneticist clinicians in mainstream settings. (Inter) national guidelines for mainstreaming informed consent for genomic sequencing must be developed.
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Affiliation(s)
- Eline M Bunnik
- Erasmus MC, Department of Medical Ethics, Philosophy and History of Medicine, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Wybo J Dondorp
- Maastricht University, Dept of Health, Ethics and Society, CAPHRI School for Public Health and Primary Care, PO Box 616, 6200, MD, Maastricht, The Netherlands.
| | - Annelien L Bredenoord
- University Medical Center Utrecht, Julius Center, Department of Medical Humanities, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Guido de Wert
- Maastricht University, Dept of Health, Ethics and Society, CAPHRI School for Public Health and Primary Care, PO Box 616, 6200, MD, Maastricht, The Netherlands.
| | - Martina C Cornel
- Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Department of Clinical Genetics, Amsterdam Public Health Research Institute, BS7 Mail G102, PO Box 7057, 1007, MB, Amsterdam, The Netherlands.
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3
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Hitchcock EC, Study C, Elliott AM. Shortened consent forms for genome-wide sequencing: Parent and provider perspectives. Mol Genet Genomic Med 2020; 8:e1254. [PMID: 32383361 PMCID: PMC7336726 DOI: 10.1002/mgg3.1254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Consent forms for exome and/or genome sequencing, collectively called genome-wide sequencing (GWS), frequently contain detailed information on complex topics such as sequencing analysis and incidental findings. Considering recent endeavors by the health care community to simplify GWS consent forms, it is important to gain stakeholders' perspectives on the content, length, and use of consent forms. METHODS Thematic analysis was conducted on data obtained from focus groups with two participant cohorts: parents who previously provided consent for trio-based GWS as part of the translational pediatric GWS CAUSES Study, and genetic health care providers (HCP) who provide pre-test counseling for GWS. RESULTS Genetic HCP indicated that consent forms cannot replace pre-test counseling, and as such, a simplified consent form focusing on the implications of GWS would be beneficial to both patients and HCP. Although parents' primary concerns varied when considering GWS, they all highly valued information. Parents also indicated the need for community and support after the return of GWS results. Both participant cohorts recommended that consent forms be available online and include an appendix for supplementary information. CONCLUSION It is important to include both parents and HCP in the design of GWS consent forms, and also, to help connect families who have a shared diagnosis after the post-test counseling session.
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Affiliation(s)
- Emma C Hitchcock
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Causes Study
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Alison M Elliott
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada.,BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,Women's Health Research Institute, Vancouver, British Columbia, Canada
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4
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Abstract
Bone and mineral diseases encompass a variety of conditions that involve altered skeletal homeostasis and are frequently associated with changes in circulating calcium, phosphate, or vitamin D metabolites. These disorders often have a genetic etiology and comprise monogenic disorders caused by a single-gene mutation, which may be germline or somatic, or an oligogenic or polygenic condition involving multiple genetic variants. Single-gene mutations causing Mendelian diseases are usually highly penetrant, whereas the gene variants contributing to oligogenic or polygenic disorders are each associated with smaller effects with additional contributions from environmental factors. The detection of monogenic disorders is clinically important and facilitates timely assessment and management of the patient and their affected relatives. The diagnosis of monogenic metabolic bone disorders requires detailed clinical assessment of the wide variety of symptoms and signs associated with these diseases. Thus, clinicians should undertake a systematic approach commencing with careful history taking and physical examination, followed by appropriate laboratory and skeletal imaging investigations. Finally, clinicians should be familiar with the range of molecular genetic tests available to ensure their appropriate use and interpretation. These considerations are reviewed in this chapter.
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5
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Rosier M, Guedj M, Calvas P, Julia S, Garnier C, Cambon-Thomsen A, Muñoz Sastre MT. Attitudes of French populations towards the disclosure of unsolicited findings in medical genetics. J Health Psychol 2019; 26:1767-1779. [PMID: 31707852 DOI: 10.1177/1359105319886622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Next-generation sequencing techniques enable unsolicited findings to be detected. This discovery raises ethical questions concerning the return of these findings. Our study aimed to highlight the views of the general public, patients under supervision and health professionals concerning the acceptability of disclosing unsolicited results to patients. In total, 449 participants assessed scenarios, consisted of all combinations of three factors (patient's information and consent, prevention and treatment of the unsolicited disease and doctor's decision). The response profiles were grouped into six clusters. The participants took ethical aspects into account, but health professionals also considered the medical aspects to a greater extent.
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6
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Gore RH, Bridges JFP, Cohen JS, Biesecker BB. Challenges to informed consent for exome sequencing: A best-worst scaling experiment. J Genet Couns 2019; 28:1189-1197. [PMID: 31553105 DOI: 10.1002/jgc4.1171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 09/02/2019] [Accepted: 09/04/2019] [Indexed: 12/27/2022]
Abstract
As exome sequencing expands as a diagnostic tool, patients and providers have voiced concerns about communicating the breadth and scope of potential results when obtaining informed consent. This study aimed to understand how genetic counselors prioritize essential components of the informed consent process and whether counselor factors influence these decisions. Development of a best-worst scaling experiment was informed by a systematic literature review and two focus groups. In all, 11 choice sets were created using a balanced incomplete block design, where participants selected the most and least important object in each set. Mean best-worst (BW) scores were calculated to summarize the relative importance of each object, and mediation analyses assessed whether responses were associated with genetic counselor factors and attitudes. In all, 342 members of the National Society of Genetic Counselors completed the online survey. Ranking of BW scores suggests that participants prioritize collaborative decision-making, assessing understanding and managing expectations, with the least emphasis placed on discussing technological complexities. Stratified analyses found that counselors more experienced with obtaining informed consent for exome sequencing and those reporting higher perceptions of patients' ability to manage information rated discussing variants of uncertain significance as significantly more important (p < .05). Our results suggest that genetic counselors report intentions to prioritize individual patient needs when obtaining informed consent for exome sequencing. Professional characteristics and attitudes may influence preemptive discussion of uncertain results.
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Affiliation(s)
- Rachel H Gore
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
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7
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Yu JH, Appelbaum PS, Brothers KB, Joffe S, Kauffman TL, Koenig BA, Prince AE, Scollon S, Wolf SM, Bernhardt BA, Wilfond BS. Consent for clinical genome sequencing: considerations from the Clinical Sequencing Exploratory Research Consortium. Per Med 2019; 16:325-333. [PMID: 31313633 DOI: 10.2217/pme-2018-0076] [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: 02/06/2023]
Abstract
Implementing genome and exome sequencing in clinical practice presents challenges, including obtaining meaningful informed consent. Consent may be challenging due to test limitations such as uncertainties associated with test results and interpretation, complexity created by the potential for additional findings and high patient expectations. We drew on the experiences of research teams within the Clinical Sequencing Exploratory Research (CSER1) Consortium on informed consent for clinical genome and exome sequencing (CGES) to negotiate consensus considerations. We present six considerations for clinicians and 12 key points to communicate as they support patients in deciding whether to undergo CGES. These considerations and key points provide a helpful starting point for informed consent to CGES, grounded in the Clinical Sequencing Exploratory Research (CSER1) experience.
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Affiliation(s)
- Joon-Ho Yu
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital & Research Institute, Seattle, WA 98101, USA
| | - Paul S Appelbaum
- Department of Psychiatry, Columbia University Medical Center, NY, 10032, USA
| | - Kyle B Brothers
- Department of Pediatrics, University of Louisville, Louisville, KY 40202, USA
| | - Steven Joffe
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, PA 19104, USA
| | - Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR 97227, USA
| | - Barbara A Koenig
- Program in Bioethics, University of California, San Francisco, CA 94143, USA
| | - Anya Er Prince
- College of Law, University of Iowa, Iowa City, IA 52242, USA
| | - Sarah Scollon
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Susan M Wolf
- Law School; Medical School; Consortium on Law & Values in Health, Environment & the Life Sciences, University of Minnesota, Minneapolis, MN 55455, USA
| | - Barbara A Bernhardt
- Division of Translational Medicine & Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Benjamin S Wilfond
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital & Research Institute, Seattle, WA 98101, USA
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8
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Smith EE, du Souich C, Dragojlovic N, Elliott AM. Genetic counseling considerations with rapid genome-wide sequencing in a neonatal intensive care unit. J Genet Couns 2018; 28:263-272. [DOI: 10.1002/jgc4.1074] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Emma E. Smith
- Department of Medical Genetics; University of British Columbia; Vancouver BC Canada
| | - Christèle du Souich
- Department of Medical Genetics; University of British Columbia; Vancouver BC Canada
- BC Children’s Hospital Research Institute; Vancouver BC Canada
| | - Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver BC Canada
| | - Alison M. Elliott
- Department of Medical Genetics; University of British Columbia; Vancouver BC Canada
- BC Children’s Hospital Research Institute; Vancouver BC Canada
- BC Women’s Health Research Institute; Vancouver BC Canada
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9
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Dwarte T, Barlow-Stewart K, O’Shea R, Dinger ME, Terrill B. Role and practice evolution for genetic counseling in the genomic era: The experience of Australian and UK genetics practitioners. J Genet Couns 2018; 28:378-387. [DOI: 10.1002/jgc4.1053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/26/2018] [Accepted: 10/20/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Tanya Dwarte
- Discipline of Genetic Medicine, Faculty of Medicine and Health, Northern Clinical School; University of Sydney, St Leonards; NSW Australia
| | - Kristine Barlow-Stewart
- Discipline of Genetic Medicine, Faculty of Medicine and Health, Northern Clinical School; University of Sydney, St Leonards; NSW Australia
| | - Rosie O’Shea
- Discipline of Genetic Medicine, Faculty of Medicine and Health, Northern Clinical School; University of Sydney, St Leonards; NSW Australia
| | - Marcel E. Dinger
- Kinghorn Centre for Clinical Genomics; Garvan Institute of Medical Research; Darlinghurst NSW Australia
- St Vincent’s Clinical School, UNSW Medicine, UNSW Sydney; Kensington NSW Australia
| | - Bronwyn Terrill
- Kinghorn Centre for Clinical Genomics; Garvan Institute of Medical Research; Darlinghurst NSW Australia
- St Vincent’s Clinical School, UNSW Medicine, UNSW Sydney; Kensington NSW Australia
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10
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Rosier M, Guedj M, Calvas P, Julia S, Garnier C, Cambon-Thomsen A, Muñoz Sastre MT. French People’s Views on the Appropriateness of Disclosing an Unsolicited Finding in Medical Genetics: A Preliminary Study. UNIVERSITAS PSYCHOLOGICA 2018. [DOI: 10.11144/javeriana.upsy17-4.fpva] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With progress in medical genetics, genome-sequencing techniques are becoming more and more efficient. However, these genetic tests may lead to the detection of unsolicited genetic findings, i.e. findings that are not the primary purpose of the screening. New ethical issues have emerged, in particular the question of whether to disclose these unsolicited findings to the patient or not. Forty-seven patients under supervision in a Medical Genetics service, 15 health professionals and 107 members of the French general population expressed their opinion regarding the appropriateness of disclosing an unsolicited high penetrance genetic finding in 36 scenarios containing three pieces of information on: a) patient information and consent;b) possibility of prevention and treatment of the detected genetic disease; and c) disclosure of the results by the physician (e.g., no disclosure of the unsolicited results). Four positions were found that were called Respect for patient’s autonomy, Beneficence to patient, Non-maleficence, and Always appropriate.
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11
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Saelaert M, Mertes H, De Baere E, Devisch I. Incidental or secondary findings: an integrative and patient-inclusive approach to the current debate. Eur J Hum Genet 2018; 26:1424-1431. [PMID: 29970927 DOI: 10.1038/s41431-018-0200-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/13/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
Incidental or secondary findings (ISFs) in whole exome or whole genome sequencing have been widely debated in recent literature. The American College of Medical Genetics and Genomics' recommendations on diagnostic ISFs have strongly catalyzed the discussion, resulting in worldwide reactions and a variety of international guidelines. This article will outline how propositions on levels of terminology, policy, and underlying values are still internationally criticized and adjusted. Unsolved questions regarding ISFs include a suitable terminology, adequate counseling or informed consent procedures, opt-out possibilities, reporting ISFs to (parents of) minors and values regarding professional duty, patient autonomy, and actionability. These questions will be characterized as intrinsically related and reciprocally maintained and hence, symptomatic, single-level reflections will be marked as ineffective. Instead, a level-integrative approach of the debate that explicitly acknowledges this interaction and considers a balance between internationally significant and case-specific solutions, will be advocated. Second, the inclusion of a patient perspective will be strongly encouraged to complement the professional preponderance in the current debate. The examination of lived patient experiences, a qualitative focus on the subjective meaning of ISFs, and a contextualization of meaning processes will be suggested as specific concretizations. This integrative and inclusive approach aims for a more comprehensive understanding of ISFs, a consideration of all relevant stakeholders' perspective and, ultimately, an effective health-care policy.
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Affiliation(s)
- Marlies Saelaert
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium.
| | - Heidi Mertes
- Department of Philosophy and Moral Sciences, Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Elfride De Baere
- Center for Medical Genetics Ghent (CMGG), Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Ignaas Devisch
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
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12
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Beunders G, Dekker M, Haver O, Meijers-Heijboer HJ, Henneman L. Recontacting in light of new genetic diagnostic techniques for patients with intellectual disability: Feasibility and parental perspectives. Eur J Med Genet 2017; 61:213-218. [PMID: 29191497 DOI: 10.1016/j.ejmg.2017.11.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/20/2017] [Accepted: 11/26/2017] [Indexed: 11/28/2022]
Abstract
A higher diagnostic yield from new diagnostic techniques makes re-evaluation in patients with intellectual disability without a causal diagnosis valuable, and is currently only performed after new referral. Active recontacting might serve a larger group of patients. We aimed to evaluate parental perspectives regarding recontacting and its feasibility in clinical genetic practice. A recontacting pilot was performed in two cohorts of children with intellectual disability. In cohort A, parents were recontacted by phone and in cohort B by letter, to invite them for a re-evaluation due to the new technologies (array CGH and exome sequencing, respectively). Parental opinions, preferences and experiences with recontacting were assessed by a self-administered questionnaire, and the feasibility of this pilot was evaluated. 47 of 114 questionnaires were returned. In total, 87% of the parents believed that all parents should be recontacted in light of new insights, 17% experienced an (positive or negative) emotional reaction. In cohort A, approached by phone, 36% made a new appointment for re-evaluation, and in cohort B, approached by letter, 4% did. Most parents have positive opinions on recontacting. Recontacting might evoke emotional responses that may need attention. Recontacting is feasible but time-consuming and a large additional responsibility for clinical geneticists.
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Affiliation(s)
- Gea Beunders
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Melodi Dekker
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Oscar Haver
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Lidewij Henneman
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands.
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13
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Pediatric Whole Exome Sequencing: an Assessment of Parents’ Perceived and Actual Understanding. J Genet Couns 2016; 26:792-805. [DOI: 10.1007/s10897-016-0052-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/27/2016] [Indexed: 01/10/2023]
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14
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Mackley MP, Fletcher B, Parker M, Watkins H, Ormondroyd E. Stakeholder views on secondary findings in whole-genome and whole-exome sequencing: a systematic review of quantitative and qualitative studies. Genet Med 2016; 19:283-293. [PMID: 27584911 PMCID: PMC5447864 DOI: 10.1038/gim.2016.109] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/17/2016] [Indexed: 12/24/2022] Open
Abstract
PURPOSE As whole-exome sequencing (WES) and whole-genome sequencing (WGS) move into routine clinical practice, it is timely to review data that might inform the debate regarding secondary findings (SF) and the development of policies that maximize participant benefit. METHODS We systematically searched for qualitative and quantitative studies that explored stakeholder views on SF in WES/WGS. Framework analysis was undertaken to identify major themes. RESULTS Forty-four articles reporting the views of 11,566 stakeholders were included. Stakeholders were broadly supportive of returning "actionable" findings, but definitions of actionability varied. Stakeholder views on SF disclosure exist along a spectrum: potential WES/WGS recipients' views were largely influenced by a sense of rights, whereas views of genomics professionals were informed by a sense of professional responsibility. Experience with genetic illness and testing resulted in greater caution about SF, suggesting that truly informed decisions require an understanding of the implications and limitations of WES/WGS and possible findings. CONCLUSION This review suggests that bidirectional interaction during consent might best facilitate informed decision making about SF and that dynamic forms of consent, allowing for changing preferences, should be considered. Research exploring views from wider perspectives and from recipients who have received SF is critical if evidence-based policies are to be achieved.Genet Med 19 3, 283-293.
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Affiliation(s)
- Michael P Mackley
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Benjamin Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Michael Parker
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hugh Watkins
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth Ormondroyd
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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15
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Cornelis C, Tibben A, Dondorp W, van Haelst M, Bredenoord AL, Knoers N, Düwell M, Bolt I, van Summeren M. Whole-exome sequencing in pediatrics: parents' considerations toward return of unsolicited findings for their child. Eur J Hum Genet 2016; 24:1681-1687. [PMID: 27460421 DOI: 10.1038/ejhg.2016.100] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/20/2016] [Accepted: 06/28/2016] [Indexed: 01/08/2023] Open
Abstract
Parents' preferences for unsolicited findings (UFs) from diagnostic whole-exome sequencing (WES) for their children remain largely unexplored. Our aim was to gain insight into parental considerations favoring acceptance/decline of UFs pertaining to their child. We conducted 20 qualitative, semistructured interviews with parents (n=34) of children with a developmental delay, aged <1 to 17 years, after consenting to WES, but before feedback of results. Key findings from our study were that all parents favored acceptance of UFs for medically actionable conditions in childhood, but that preferences and considerations diverged for UFs with no medical actionability, or only in adulthood, and regarding carrier-status. Sometimes non-medical utility considerations (considerations of usefulness of knowing UFs, not rooted in (preventive) medical treatment or controls) were given in favor of disclosure of UFs. Sometimes the child's future autonomy formed a reason to withhold UFs at present, despite an unfavorable prognosis concerning the child's cognitive capabilities. Some parents only preferred receiving UFs if these findings were directly related to their reasons for seeking a diagnosis. These findings are essential for developing morally responsible policy and for counseling. Further research should focus on whether considerations of non-medical utility alone can justify disclosure of UFs and whether reasons for seeking a diagnosis place further constraints on what UFs may be returned/withheld. How parents can be aided in contemplating different scenarios regarding their child's future development also deserves further inquiry.
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Affiliation(s)
- Candice Cornelis
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.,Ethics Institute, Utrecht University, Utrecht, The Netherlands
| | - Aad Tibben
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wybo Dondorp
- Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - Mieke van Haelst
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annelien L Bredenoord
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcus Düwell
- Ethics Institute, Utrecht University, Utrecht, The Netherlands
| | - Ineke Bolt
- Ethics Institute, Utrecht University, Utrecht, The Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
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16
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Pélissier A, Peyron C, Béjean S. Next-generation sequencing in clinical practice: from the patients' preferences to the informed consent process. Public Health 2016; 138:157-9. [PMID: 27112378 DOI: 10.1016/j.puhe.2016.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 11/16/2015] [Accepted: 03/07/2016] [Indexed: 11/17/2022]
Affiliation(s)
- A Pélissier
- Laboratoire d'Économie de Dijon LEDi, Université de Bourgogne Franche-Comté - CNRS UMR 6307- INSERM U1200, Dijon, France.
| | - C Peyron
- Laboratoire d'Économie de Dijon LEDi, Université de Bourgogne Franche-Comté - CNRS UMR 6307- INSERM U1200, Dijon, France.
| | - S Béjean
- Laboratoire d'Économie de Dijon LEDi, Université de Bourgogne Franche-Comté - CNRS UMR 6307- INSERM U1200, Dijon, France.
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17
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Krabbenborg L, Vissers LELM, Schieving J, Kleefstra T, Kamsteeg EJ, Veltman JA, Willemsen MA, Van der Burg S. Understanding the Psychosocial Effects of WES Test Results on Parents of Children with Rare Diseases. J Genet Couns 2016; 25:1207-1214. [PMID: 27098417 PMCID: PMC5114322 DOI: 10.1007/s10897-016-9958-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 04/06/2016] [Indexed: 01/02/2023]
Abstract
The use of whole exome sequencing (WES) for diagnostics of children with rare genetic diseases raises questions about best practices in genetic counselling. While a lot of attention is now given to pre-test counselling procedures for WES, little is known about how parents experience the (positive, negative, or inconclusive) WES results in daily life. To fill this knowledge gap, data were gathered through in-depth interviews with parents of 15 children who underwent WES analysis. WES test results, like results from other genetic tests, evoked relief as well as worries, irrespective of the type of result. Advantages of obtaining a conclusive diagnosis included becoming more accepting towards the situation, being enabled to attune care to the needs of the child, and better coping with feelings of guilt. Disadvantages experienced included a loss of hope for recovery, and a loss by parents of their social network of peers and the effort necessary to re-establish that social network. While parents with conclusive diagnoses were able to re-establish a peer community with the help of social media, parents receiving a possible diagnosis experienced hurdles in seeking peer support, as peers still needed to be identified. These types of psychosocial effects of WES test results for parents are important to take into account for the development of successful genetic counselling strategies.
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Affiliation(s)
- Lotte Krabbenborg
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands. .,Institute for Science, Innovation and Society (ISIS), Radboud University, P.O. Box 9010, 6500, Nijmegen, the Netherlands.
| | - L E L M Vissers
- Department of Human Genetics, Donders Centre for Neuroscience, Radboudumc, Geert Grooteplein 10, 6525, Nijmegen, the Netherlands
| | - J Schieving
- Department of Paediatric Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - T Kleefstra
- Department of Human Genetics, Donders Centre for Neuroscience, Radboudumc, Geert Grooteplein 10, 6525, Nijmegen, the Netherlands
| | - E J Kamsteeg
- Department of Human Genetics, Donders Centre for Neuroscience, Radboudumc, Geert Grooteplein 10, 6525, Nijmegen, the Netherlands
| | - J A Veltman
- Department of Human Genetics, Donders Centre for Neuroscience, Radboudumc, Geert Grooteplein 10, 6525, Nijmegen, the Netherlands.,Department of Clinical Genetics, Maastricht University Medical Centre, Universiteitssingel 50, 6229, Maastricht, the Netherlands
| | - M A Willemsen
- Department of Paediatric Neurology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S Van der Burg
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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18
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Cacioppo CN, Chandler AE, Towne MC, Beggs AH, Holm IA. Expectation versus Reality: The Impact of Utility on Emotional Outcomes after Returning Individualized Genetic Research Results in Pediatric Rare Disease Research, a Qualitative Interview Study. PLoS One 2016; 11:e0153597. [PMID: 27082877 PMCID: PMC4833284 DOI: 10.1371/journal.pone.0153597] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 03/31/2016] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Much information on parental perspectives on the return of individual research results (IRR) in pediatric genomic research is based on hypothetical rather than actual IRR. Our aim was to understand how the expected utility to parents who received IRR on their child from a genetic research study compared to the actual utility of the IRR received. METHODS We conducted individual telephone interviews with parents who received IRR on their child through participation in the Manton Center for Orphan Disease Research Gene Discovery Core (GDC) at Boston Children's Hospital (BCH). RESULTS Five themes emerged around the utility that parents expected and actually received from IRR: predictability, management, family planning, finding answers, and helping science and/or families. Parents expressing negative or mixed emotions after IRR return were those who did not receive the utility they expected from the IRR. Conversely, parents who expressed positive emotions were those who received as much or greater utility than expected. CONCLUSIONS Discrepancies between expected and actual utility of IRR affect the experiences of parents and families enrolled in genetic research studies. An informed consent process that fosters realistic expectations between researchers and participants may help to minimize any negative impact on parents and families.
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Affiliation(s)
- Cara N. Cacioppo
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Ariel E. Chandler
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Meghan C. Towne
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Alan H. Beggs
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Ingrid A. Holm
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States of America
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Li KC, Birch PH, Garrett BM, MacPhee M, Adam S, Friedman JM. Parents' Perspectives on Supporting Their Decision Making in Genome-Wide Sequencing. J Nurs Scholarsh 2016; 48:265-75. [PMID: 27061758 DOI: 10.1111/jnu.12207] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to explore parents' perceptions of their decisional needs when considering genome-wide sequencing (GWS) for their child. This is a partial report and focuses on how parents prefer to receive education and information to support their decision making about GWS. DESIGN This study adopted an interpretive description qualitative methodological approach and used the concept of shared decision making and the Ottawa Decision Support Framework. METHODS Participants were parents who had already consented to GWS, and had children with undiagnosed conditions that were suspected to be genetic in origin. Fifteen parents participated in a focus group or individual interview. Transcriptions were analyzed concurrently with data collection, iteratively, and constantly compared to one another. Repeat interviews were conducted with five of the parents to confirm, challenge, or expand on the developing concepts. FINDINGS Participants felt that their decision to proceed with GWS for their child was an easy one. However, they expressed some unresolved decisional needs, including a lack of knowledge about certain topics that became relevant and important to them later and a need for more support and resources. Participants also had ongoing informational and psychosocial needs after the single clinical encounter where their decision making occurred. CONCLUSIONS Participants expressed unmet decisional needs, which may have influenced the quality of their decisions. The strategies that participants suggested may help create parent-tailored education, counseling, decision support, and informed consent processes. CLINICAL RELEVANCE Health care professionals who offer GWS for children should assess parents' values, priorities, and informational needs and tailor information accordingly. There are opportunities for nurses to become involved in supporting families who are considering GWS for their child.
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Affiliation(s)
- Karen C Li
- Graduate Student Researcher, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patricia H Birch
- Clinical Associate Professor, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernard M Garrett
- Associate Professor, School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maura MacPhee
- Xi Eta, Associate Professor, School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shelin Adam
- Clinical Assistant Professor, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jan M Friedman
- Professor, Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
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20
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Beale S, Sanderson D, Sanniti A, Dundar Y, Boland A. A scoping study to explore the cost-effectiveness of next-generation sequencing compared with traditional genetic testing for the diagnosis of learning disabilities in children. Health Technol Assess 2016; 19:1-90. [PMID: 26132578 DOI: 10.3310/hta19460] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Learning disability (LD) is a serious and lifelong condition characterised by the impairment of cognitive and adaptive skills. Some cases of LD with unidentified causes may be linked to genetic factors. Next-generation sequencing (NGS) techniques are new approaches to genetic testing that are expected to increase diagnostic yield. OBJECTIVES This scoping study focused on the diagnosis of LD in children and the objectives were to describe current pathways that involve the use of genetic testing; collect stakeholder views on the changes in service provision that would need to be put in place before NGS could be used in clinical practice; describe the new systems and safeguards that would need to be put in place before NGS could be used in clinical practice; and explore the cost-effectiveness of using NGS compared with conventional genetic testing. METHODS A research advisory group was established. This group provided ongoing support by e-mail and telephone through the lifetime of the study and also contributed face-to-face through a workshop. A detailed review of published studies and reports was undertaken. In addition, information was collected through 33 semistructured interviews with key stakeholders. RESULTS NGS techniques consist of targeted gene sequencing, whole-exome sequencing (WES) and whole-genome sequencing (WGS). Targeted gene panels, which are the least complex, are in their infancy in clinical settings. Some interviewees thought that during the next 3-5 years targeted gene panels would be superseded by WES. If NGS technologies were to be fully introduced into clinical practice in the future a number of factors would need to be overcome. The main resource-related issues pertaining to service provision are the need for additional computing capacity, more bioinformaticians, more genetic counsellors and also genetics-related training for the public and a wide range of staff. It is also considered that, as the number of children undergoing genetic testing increases, there will be an increase in demand for information and support for families. The main issues relating to systems and safeguards are giving informed consent, sharing unanticipated findings, developing ethical and other frameworks, equity of access, data protection, data storage and data sharing. There is little published evidence on the cost-effectiveness of NGS technologies. The major barriers to determining cost-effectiveness are the uncertainty around diagnostic yield, the heterogeneity of diagnostic pathways and the lack of information on the impact of a diagnosis on health care, social care, educational support needs and the wider family. Furthermore, as NGS techniques are currently being used only in research, costs and benefits to the NHS are unclear. CONCLUSIONS NGS technologies are at an early stage of development and it is too soon to say whether they can offer value for money to the NHS as part of the LD diagnostic process. Substantial organisational changes, as well as new systems and safeguards, would be required if NGS technologies were to be introduced into NHS clinical practice. Considerable further research is required to establish whether using NGS technologies to diagnose learning disabilities is clinically effective and cost-effective. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sophie Beale
- Liverpool Reviews and Implementation Group (LRiG), University of Liverpool, Liverpool, UK
| | | | - Anna Sanniti
- Liverpool Reviews and Implementation Group (LRiG), University of Liverpool, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group (LRiG), University of Liverpool, Liverpool, UK
| | - Angela Boland
- Liverpool Reviews and Implementation Group (LRiG), University of Liverpool, Liverpool, UK
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21
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Sie AS, Spruijt L, van Zelst-Stams WAG, Mensenkamp AR, Ligtenberg MJL, Brunner HG, Prins JB, Hoogerbrugge N. High Satisfaction and Low Distress in Breast Cancer Patients One Year after BRCA-Mutation Testing without Prior Face-to-Face Genetic Counseling. J Genet Couns 2015; 25:504-14. [PMID: 26531312 PMCID: PMC4868858 DOI: 10.1007/s10897-015-9899-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/08/2015] [Indexed: 11/25/2022]
Abstract
According to standard practice following referral to clinical genetics, most high risk breast cancer (BC) patients in many countries receive face-to-face genetic counseling prior to BRCA-mutation testing (DNA-intake). We evaluated a novel format by prospective study: replacing the intake consultation with telephone, written and digital information sent home. Face-to-face counseling then followed BRCA-mutation testing (DNA-direct). One year after BRCA-result disclosure, 108 participants returned long-term follow-up questionnaires, of whom 59 (55 %) had previously chosen DNA-direct (intervention) versus DNA-intake (standard practice i.e., control: 45 %). Questionnaires assessed satisfaction and psychological distress. All participants were satisfied and 85 % of DNA-direct participants would choose this procedure again; 10 % would prefer DNA-intake and 5 % were undecided. In repeated measurements ANOVA, general distress (GHQ-12, p = 0.01) and BC-specific distress (IES-bc, p = 0.03) were lower in DNA-direct than DNA-intake at all time measurements. Heredity-specific distress (IES-her) did not differ significantly between groups. Multivariate regression analyses showed that choice of procedure did not significantly contribute to either general or heredity-specific distress. BC-specific distress (after BC diagnosis) did contribute to both general and heredity-specific distress. This suggests that higher distress scores reflected BC experience, rather than the type of genetic diagnostic procedure. In conclusion, the large majority of BC patients that used DNA-direct reported high satisfaction without increased distress both in the short term, and 1 year after conclusion of genetic testing.
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Affiliation(s)
- Aisha S. Sie
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Liesbeth Spruijt
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Wendy A. G. van Zelst-Stams
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Arjen R. Mensenkamp
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marjolijn J. L. Ligtenberg
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
- />Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Han G. Brunner
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Judith B. Prins
- />Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- />Department of Human Genetics 836, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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22
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Bernhardt BA, Roche MI, Perry DL, Scollon SR, Tomlinson AN, Skinner D. Experiences with obtaining informed consent for genomic sequencing. Am J Med Genet A 2015; 167A:2635-46. [PMID: 26198374 PMCID: PMC4980577 DOI: 10.1002/ajmg.a.37256] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/06/2015] [Indexed: 01/11/2023]
Abstract
Despite the increased utilization of genome and exome sequencing, little is known about the actual content and process of informed consent for sequencing. We addressed this by interviewing 29 genetic counselors and research coordinators experienced in obtaining informed consent for sequencing in research and clinical settings. Interviews focused on the process and content of informed consent; patients/participants' common questions, concerns and misperceptions; and challenges to obtaining informed consent. Content analysis of transcribed interviews revealed that the main challenges to obtaining consent related to the broad scope and uncertainty of results, and patient/participants' unrealistic expectations about the likely number and utility of results. Interviewees modified their approach to sessions according to contextual issues surrounding the indication for testing, type of patient, and timing of testing. With experience, most interviewees structured sessions to place less emphasis on standard elements in the consent form and technological aspects of sequencing. They instead focused on addressing misperceptions and helping patients/participants develop realistic expectations about the types and implications of possible results, including secondary findings. These findings suggest that informed consent sessions should focus on key issues that may be misunderstood by patients/participants. Future research should address the extent to which various stakeholders agree on key elements of informed consent.
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Affiliation(s)
- Barbara A. Bernhardt
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Myra I. Roche
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
- Department of Genetics, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sarah R. Scollon
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ashley N. Tomlinson
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra Skinner
- FPG Child Development Institute, University of North Carolina, Chapel Hill, North Carolina
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23
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Miles G, Rae J, Ramalingam SS, Pfeifer J. Genetic Testing and Tissue Banking for Personalized Oncology: Analytical and Institutional Factors. Semin Oncol 2015; 42:713-23. [PMID: 26433552 DOI: 10.1053/j.seminoncol.2015.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Personalized oncology, or more aptly precision oncogenomics, refers to the identification and implementation of clinically actionable targets tailored to an individual patient's cancer genomic information. Banking of human tissue and other biospecimens establishes a framework to extract and collect the data essential to our understanding of disease pathogenesis and treatment. Cancer cooperative groups in the United States have led the way in establishing robust biospecimen collection mechanisms to facilitate translational research, and combined with technological advances in molecular testing, tissue banking has expanded from its traditional base in academic research and is assuming an increasingly pivotal role in directing the clinical care of cancer patients. Comprehensive screening of tumors by DNA sequencing and the ability to mine and interpret these large data sets from well-organized tissue banks have defined molecular subtypes of cancer. Such stratification by genomic criteria has revolutionized our perspectives on cancer diagnosis and treatment, offering insight into prognosis, progression, and susceptibility or resistance to known therapeutic agents. In turn, this has enabled clinicians to offer treatments tailored to patients that can greatly improve their chances of survival. Unique challenges and opportunities accompany the rapidly evolving interplay between tissue banking and genomic sequencing, and are the driving forces underlying the revolution in precision medicine. Molecular testing and precision medicine clinical trials are now becoming the major thrust behind the cooperative groups' clinical research efforts.
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Affiliation(s)
- George Miles
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO.
| | - James Rae
- Department of Internal Medicine & Pharmacology, University of Michigan, Ann Arbor, MI
| | - Suresh S Ramalingam
- Department of Hematology and Medical Oncology, Emory School of Medicine, Winship Cancer Institute, Atlanta, GA
| | - John Pfeifer
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
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24
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Krabbenborg L, Schieving J, Kleefstra T, Vissers LELM, Willemsen MA, Veltman JA, van der Burg S. Evaluating a counselling strategy for diagnostic WES in paediatric neurology: an exploration of parents' information and communication needs. Clin Genet 2015; 89:244-50. [PMID: 25916247 DOI: 10.1111/cge.12601] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 01/17/2023]
Abstract
As whole exome sequencing (WES) is just starting to be used as a diagnostic tool in paediatric neurology for children with a neurological disorder, and patient experiences and preferences with regard to counselling are relatively underexplored. This article explores experiences and preferences of parents with pre-test and post-test counselling in a trial that uses WES for diagnostics. Second, it maps information and communication needs which exceed the counselling protocol, in order to acquire insight into how it can be improved. Data were gathered through in-depth interviews with parents of 15 children who were included in the trial. Information and communication needs of parents differed from the protocol with respect to (i) the type and amount of information provided about WES research, (ii) incidental findings, (iii) communication about progress of the study, and (iv) the communication of the results. Furthermore, parents preferred to have more of a communicative exchange with health care providers about their daily struggles and concerns related to their life with a diseased child and wanted to know how a diagnosis could offer help. There are different ways to meet parental needs, but we suggest that assigning a case manager might be a helpful option that deserves further exploration.
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Affiliation(s)
- L Krabbenborg
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Schieving
- Department of Paediatric Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - T Kleefstra
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L E L M Vissers
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M A Willemsen
- Department of Paediatric Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J A Veltman
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S van der Burg
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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25
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Aziz N, Zhao Q, Bry L, Driscoll DK, Funke B, Gibson JS, Grody WW, Hegde MR, Hoeltge GA, Leonard DGB, Merker JD, Nagarajan R, Palicki LA, Robetorye RS, Schrijver I, Weck KE, Voelkerding KV. College of American Pathologists' Laboratory Standards for Next-Generation Sequencing Clinical Tests. Arch Pathol Lab Med 2015; 139:481-93. [DOI: 10.5858/arpa.2014-0250-cp] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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26
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Clift KE, Halverson CM, Fiksdal AS, Kumbamu A, Sharp RR, McCormick JB. Patients' views on incidental findings from clinical exome sequencing. Appl Transl Genom 2015; 4:38-43. [PMID: 26937348 PMCID: PMC4745397 DOI: 10.1016/j.atg.2015.02.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This article characterizes the opinions of patients and family members of patients undergoing clinical genomic-based testing regarding the return of incidental findings from these tests. Over sixteen months, we conducted 55 in-depth interviews with individuals to explore their preferences regarding which types of results they would like returned to them. Responses indicate a diversity of attitudes toward the return of incidental findings and a diversity of justifications for those attitudes. The majority of participants also described an imperative to include the patient in deciding which results to return rather than having universal, predetermined rules governing results disclosure. The results demonstrate the importance of a patient centered-approach to returning incidental findings.
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Affiliation(s)
| | - Colin M.E. Halverson
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- University of Chicago, Department of Anthropology, Chicago, IL, USA
| | | | - Ashok Kumbamu
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
| | - Richard R. Sharp
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- Division of Health Care Research and Policy
- Division of General Internal Medicine
| | - Jennifer B. McCormick
- Mayo Clinic, Biomedical Ethics Program, Rochester, MN, USA
- Division of Health Care Research and Policy
- Division of General Internal Medicine
- Corresponding author at: 200 First Street SW, Plummer 3-30-40 Bioethics, Rochester, MN 55905, USA. Tel.: + 1 507 284 1494; fax: + 1 507 538 0850.
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27
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Vrijenhoek T, Kraaijeveld K, Elferink M, de Ligt J, Kranendonk E, Santen G, Nijman IJ, Butler D, Claes G, Costessi A, Dorlijn W, van Eyndhoven W, Halley DJJ, van den Hout MCGN, van Hove S, Johansson LF, Jongbloed JDH, Kamps R, Kockx CEM, de Koning B, Kriek M, Lekanne Dit Deprez R, Lunstroo H, Mannens M, Mook OR, Nelen M, Ploem C, Rijnen M, Saris JJ, Sinke R, Sistermans E, van Slegtenhorst M, Sleutels F, van der Stoep N, van Tienhoven M, Vermaat M, Vogel M, Waisfisz Q, Marjan Weiss J, van den Wijngaard A, van Workum W, Ijntema H, van der Zwaag B, van IJcken WFJ, den Dunnen J, Veltman JA, Hennekam R, Cuppen E. Next-generation sequencing-based genome diagnostics across clinical genetics centers: implementation choices and their effects. Eur J Hum Genet 2015; 23:1142-50. [PMID: 25626705 PMCID: PMC4538197 DOI: 10.1038/ejhg.2014.279] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 11/26/2014] [Accepted: 11/28/2014] [Indexed: 12/30/2022] Open
Abstract
Implementation of next-generation DNA sequencing (NGS) technology into routine diagnostic genome care requires strategic choices. Instead of theoretical discussions on the consequences of such choices, we compared NGS-based diagnostic practices in eight clinical genetic centers in the Netherlands, based on genetic testing of nine pre-selected patients with cardiomyopathy. We highlight critical implementation choices, including the specific contributions of laboratory and medical specialists, bioinformaticians and researchers to diagnostic genome care, and how these affect interpretation and reporting of variants. Reported pathogenic mutations were consistent for all but one patient. Of the two centers that were inconsistent in their diagnosis, one reported to have found 'no causal variant', thereby underdiagnosing this patient. The other provided an alternative diagnosis, identifying another variant as causal than the other centers. Ethical and legal analysis showed that informed consent procedures in all centers were generally adequate for diagnostic NGS applications that target a limited set of genes, but not for exome- and genome-based diagnosis. We propose changes to further improve and align these procedures, taking into account the blurring boundary between diagnostics and research, and specific counseling options for exome- and genome-based diagnostics. We conclude that alternative diagnoses may infer a certain level of 'greediness' to come to a positive diagnosis in interpreting sequencing results. Moreover, there is an increasing interdependence of clinic, diagnostics and research departments for comprehensive diagnostic genome care. Therefore, we invite clinical geneticists, physicians, researchers, bioinformatics experts and patients to reconsider their role and position in future diagnostic genome care.
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Affiliation(s)
- Terry Vrijenhoek
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ken Kraaijeveld
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Elferink
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joep de Ligt
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Elcke Kranendonk
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Gijs Santen
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Isaac J Nijman
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Godelieve Claes
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Wim Dorlijn
- Agilent Technologies Netherlands B.V., Amstelveen, The Netherlands
| | | | - Dicky J J Halley
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Lennart F Johansson
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan D H Jongbloed
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rick Kamps
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christel E M Kockx
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bart de Koning
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marjolein Kriek
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronald Lekanne Dit Deprez
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marcel Mannens
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Olaf R Mook
- Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel Nelen
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Corrette Ploem
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marco Rijnen
- Life Technologies Europe B.V., Bleiswijk, The Netherlands
| | - Jasper J Saris
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Richard Sinke
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Sistermans
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Frank Sleutels
- Center for Biomics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nienke van der Stoep
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Martijn Vermaat
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje Vogel
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Quinten Waisfisz
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Janneke Marjan Weiss
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Arthur van den Wijngaard
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Helger Ijntema
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Bert van der Zwaag
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Johan den Dunnen
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris A Veltman
- Department of Human Genetics, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Raoul Hennekam
- 1] Department of Human Genetics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands [2] Department of Pediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Edwin Cuppen
- Department of Medical Genetics, Centre for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW Exome and genome sequencing have recently emerged as clinical tools to resolve undiagnosed genetic conditions. Protocols are critically needed to identify proper patients for testing, select a test and laboratory, engage parents in shared decision-making, and for the return of results. RECENT FINDINGS Among well selected patients, the likelihood for identifying the causative gene change may be as high as 30%. It is key for pediatricians to consider whether sequencing should be the primary line of pursuit of a molecular diagnosis. Parents should understand the uncertainties inherent in this sequencing and the preference-based nature of testing. Pediatricians can engage in shared decision-making for this process and work to help parents make decisions consistent with their priorities and values. Upon receipt of a pathogenic mutation, discussion of the likelihood for future treatment is paramount to parents, as are the implications for recurrence within the family. Uncertainties inherent to genomic results need to be explained in the context of the likelihood of future research and discoveries. SUMMARY Pediatricians should make a deliberate decision with each patient whether to manage genomic testing on their own, refer the patient for such testing, or initiate the process and refer simultaneously. Regardless of which approach is taken, understanding the basics of this testing will allow the pediatrician to support the parents through the diagnostic process.
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Smith LA, Douglas J, Braxton AA, Kramer K. Reporting Incidental Findings in Clinical Whole Exome Sequencing: Incorporation of the 2013 ACMG Recommendations into Current Practices of Genetic Counseling. J Genet Couns 2014; 24:654-62. [PMID: 25403901 DOI: 10.1007/s10897-014-9794-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 11/06/2014] [Indexed: 12/23/2022]
Abstract
The purpose of this study was to investigate how the American College of Medical Genetics and Genomics (ACMG) March 2013 recommendations for reporting incidental findings (IFs) have influenced current practices of genetic counselors involved in utilizing whole exome sequencing (WES) for clinical diagnosis. An online survey was sent to all members of the National Society of Genetic Counselors; members were eligible to participate if they currently offered WES for clinical diagnosis. Forty-six respondents completed the survey of whom 34 were in practice prior to the March 2013 ACMG recommendations. Half of respondents (N = 19, 54.9 %) in practice prior to March 2013 reported that the ACMG recommendations have had a significant impact on the content of their counseling sessions. Approximately half of respondents (N = 21, 45.5 %) report all IFs, regardless of patient age, while one third (N = 14, 30.4 %) consider factors such as age and parent preference in reporting IFs. Approximately 40 % (N = 18) of respondents reported that the testing laboratory's policy for returning IFs has an influence on their choice of laboratory; of those, 72.2 % (N = 13) reported that the option to opt out of receiving reports of IFs has a significant influence on their choice of laboratory. A majority of respondents (N = 43, 93.5 %) found that most patients want to receive reports of IFs. However, respondents report there are patients who wish to decline receiving this information. This study querying genetic counselors identified benefits and challenges that the 2013 ACMG recommendations elicited. Some challenges, such as not having the option to opt out of IFs, have been addressed by the ACMG's most recent updates to their recommendations. Further investigation into larger and more inclusive provider populations as well as patient populations will be valuable for the ongoing discussion surrounding IFs in WES.
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Affiliation(s)
- Lacey A Smith
- Genetic Counseling Program, Graduate School of Arts & Sciences, Brandeis University, Waltham, MA, USA,
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30
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Bergner AL, Bollinger J, Raraigh KS, Tichnell C, Murray B, Blout CL, Telegrafi AB, James CA. Informed consent for exome sequencing research in families with genetic disease: the emerging issue of incidental findings. Am J Med Genet A 2014; 164A:2745-52. [PMID: 25251809 DOI: 10.1002/ajmg.a.36706] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 07/01/2014] [Indexed: 01/05/2023]
Abstract
Genomic sequencing technology is increasingly used in genetic research. Studies of informed consent for exome and genome sequencing (ES/GS) research have largely involved hypothetical scenarios or healthy individuals enrolling in population-based studies. Studies have yet to explore the consent experiences of adults with inherited disease. We conducted a qualitative interview study of 15 adults recently enrolled in a large-scale ES/GS study (11 affected adults, four parents of affected children). Our study had two goals: (1) to explore three theoretical barriers to consent for ES/GS research (interpretive/technical complexity, possibility of incidental findings, and risks of loss of privacy); and (2) to explore how interviewees experienced the consent process. Interviewees could articulate study goals and processes, describe incidental findings, discuss risks of privacy loss, and reflect on their consent experience. Few expected the study would identify the genetic cause of their condition. All elected to receive incidental findings. Interviewees acknowledged paying little attention to potential implications of incidental findings in light of more pressing goals of supporting research regarding their own medical conditions. Interviewees suggested that experience living with a genetic condition prepared them to adjust to incidental findings. Interviewees also expressed little concern about loss of confidentiality of study data. Some experienced the consent process as very long. None desired reconsent prior to return of study results. Families with inherited disease likely would benefit from a consent process in which study risks and benefits were discussed in the context of prior experiences with genetic research and genetic disease.
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Affiliation(s)
- Amanda L Bergner
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland
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31
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Shkedi-Rafid S, Dheensa S, Crawford G, Fenwick A, Lucassen A. Defining and managing incidental findings in genetic and genomic practice. J Med Genet 2014; 51:715-23. [PMID: 25228303 DOI: 10.1136/jmedgenet-2014-102435] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The rapidly declining costs and increasing speeds of whole-genome analysis mean that genetic testing is undergoing a shift from targeted approaches to broader ones that look at the entire genome. As whole-genome technologies gain widespread use, questions about the management of so-called incidental findings-those unrelated to the question being asked-need urgent consideration. In this review, we bring together current understanding and arguments about (1) appropriate terminology, (2) the determination of clinical utility and when to disclose incidental findings, (3) the differences in management and disclosure in clinical, research and commercial contexts and (4) ethical and practical issues about familial implications and recontacting those tested. We recommend that greater international consensus is developed around the disclosure and management of incidental findings, with particular attention to when, and how, less clear-cut results should be communicated. We suggest that there is no single term that captures all the issues around these kinds of findings and that different terms may, therefore, need to be used in different settings. We also encourage the use of clear consent processes, but suggest that the absence of consent should not always preclude disclosure. Finally, we recommend further research to identify ways to implement the use of a genome output as a resource, accessible over time, to facilitate appropriate disclosure and recontact when the significance of a previously unclear incidental finding is clarified.
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Affiliation(s)
- Shiri Shkedi-Rafid
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Sandi Dheensa
- Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Gillian Crawford
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Angela Fenwick
- Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
| | - Anneke Lucassen
- Wessex Clinical Genetic Service Faculty of Medicine, Clinical Ethics and Law at Southampton (CELS), University of Southampton, Southampton, UK
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Cornelis C, Bolt I, Van Summeren M. Contextualizing genetic testing and sequencing results for patients and parents: the need for empirical-ethical research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:10-12. [PMID: 24592829 DOI: 10.1080/15265161.2013.879957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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