1
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Trainer AH, Goode E, Hoskins CN, Wheeler JCW, Best S. Calibrating variant curation by clinical context based on factors that influence patients' tolerance of uncertainty. Genet Med 2023; 25:100982. [PMID: 37724515 DOI: 10.1016/j.gim.2023.100982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Shared decision making manages genomic uncertainty by integrating molecular and clinical uncertainties with patient values to craft a person-centered management plan. Laboratories seek genomic report consistency, agnostic to clinical context. Molecular reports often mask laboratory-managed uncertainties from clinical decision making. Better integration of these uncertainty management strategies requires a nuanced understanding of patients' perceptions and reactions to test uncertainties. We explored patients' tolerance to variant uncertainty in 3 parameters: (1) relative causal significance, (2) risk accuracy, and (3) classification validity. METHOD Deliberative forums were undertaken with 18 patients with predictive testing experience. Uncertainty deliberations were elicited for each parameter. A thematic framework was first developed, and then mapped to whether they justified tolerance to more or less parameter-specific uncertainty. RESULTS Six identified themes mapped to clinical and personal domains. These domains generated opposing forces when calibrating uncertainty. Personal themes justified tolerance of higher uncertainty and clinical themes lower uncertainty. Decision making in uncertainty focused on reducing management regret. Open communication increased tolerance of classification validity and risk accuracy uncertainty. Using these data, we have developed a nascent clinical algorithm integrating molecular uncertainty with clinical context through a targeted communication framework. CONCLUSION Maximizing test utility necessitates context-specific recalibration of uncertainty management and communication.
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Affiliation(s)
- Alison H Trainer
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Erin Goode
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Cass N Hoskins
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jack C W Wheeler
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Stephanie Best
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre Alliance, Melbourne, VIC, Australia; Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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2
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Arbustini E, Behr ER, Carrier L, van Duijn C, Evans P, Favalli V, van der Harst P, Haugaa KH, Jondeau G, Kääb S, Kaski JP, Kavousi M, Loeys B, Pantazis A, Pinto Y, Schunkert H, Di Toro A, Thum T, Urtis M, Waltenberger J, Elliott P. Interpretation and actionability of genetic variants in cardiomyopathies: a position statement from the European Society of Cardiology Council on cardiovascular genomics. Eur Heart J 2022; 43:1901-1916. [PMID: 35089333 DOI: 10.1093/eurheartj/ehab895] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/03/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
This document describes the contribution of clinical criteria to the interpretation of genetic variants using heritable Mendelian cardiomyopathies as an example. The aim is to assist cardiologists in defining the clinical contribution to a genetic diagnosis and the interpretation of molecular genetic reports. The identification of a genetic variant of unknown or uncertain significance is a limitation of genetic testing, but current guidelines for the interpretation of genetic variants include essential contributions from clinical family screening that can establish a de novo assignment of the variant or its segregation with the phenotype in the family. A partnership between clinicians and patients helps to solve major uncertainties and provides reliable and clinically actionable information.
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Affiliation(s)
- Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Elijah R Behr
- Cardiology Research Section and Cardiovascular Clinical Academic Group, Institute of Molecular and Clinical Sciences, St George's, University of London and St George's University Hospitals NHS Foundation Trust, London, UK
| | - Lucie Carrier
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Cornelia van Duijn
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Evans
- Department of Infection, Immunity and Cardiovascular Disease, and INSIGNEO Institute, University of Sheffield, Sheffield S10 2RX, UK
| | | | - Pim van der Harst
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, Oslo 0424, Norway
- University of Oslo, Boks 1072 Blindern, Oslo 0316, Norway
| | - Guillaume Jondeau
- CNMR Syndrome de Marfan et apparentés, Member of VASCERN, AP-HP Hopital Bichat, Service de Cardiologie, 46 rue Henri Huchard, Paris 75018, France
- INSERM LVTS U1148, Paris 75018, France
- Université de Paris, Paris, France
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany
- German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany
| | - Juan Pablo Kaski
- Institute of Cardiovascular Science, University College London, London, UK
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, UK
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart Loeys
- Cardiogenomics, Center for Medical Genetics, Antwerp University Hospital/University of Antwerp, Antwerp, Belgium
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antonis Pantazis
- The Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Yigal Pinto
- Department of Experimental Cardiology, University of Amsterdam, Amsterdam University Medical Center, Meibergdreef 15, Amsterdam 1105 AZ, The Netherlands
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, München, Germany
- Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), Munich Heart Alliance, Munich, Germany
| | - Alessandro Di Toro
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Mario Urtis
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Department of Medical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Johannes Waltenberger
- Department of Cardiology and Cardiovascular Medicine, Medical Faculty, University of Münster, Münster, Germany
- Cardiovascular Medicine, Hirslanden Klinik Im Park, Seestrasse 220, Zürich 8027, Switzerland
| | - Perry Elliott
- Barts Heart Centre St Bartholomew's Hospital, London, UK
- Institute for Cardiovascular Science, University College London, London, UK
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3
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Acharya M, Maselli D, Mariscalco G. Genetic screening in heritable thoracic aortic disease—rationale, potentials and pitfalls. Indian J Thorac Cardiovasc Surg 2022; 38:24-35. [PMID: 35463717 PMCID: PMC8980988 DOI: 10.1007/s12055-020-01124-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022] Open
Abstract
Thoracic aortic aneurysms are silent yet deadly clinical entities which may elude detection until an acutely life-threatening aortic dissection or rupture occurs. Approximately 20% of patients with thoracic aortic aneurysms or dissection have a positive family history, indicating a strong genetic component to the aetiology. Genetic screening in such hereditary thoracic aortic disease (HTAD) may thus be beneficial in detecting causative genetic mutations in affected patients, identifying asymptomatic family members who may be at risk, and in guiding the optimal timing of preventative surgery in those with confirmed genetic aortopathy. Genetic screening can facilitate personalised aortic care tailored to an individual's specific genetic abnormality, with the aim of mitigating the significant morbidity burden and premature mortality associated with HTAD. This review examines the rationale for genetic screening in HTAD, its potential applications, current limitations and potential future directions.
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Affiliation(s)
- Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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4
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McWalter K, Torti E, Morrow M, Juusola J, Retterer K. Discovery of over 200 new and expanded genetic conditions using GeneMatcher. Hum Mutat 2022; 43:760-764. [PMID: 35224800 PMCID: PMC9306743 DOI: 10.1002/humu.24351] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/31/2022] [Accepted: 02/11/2022] [Indexed: 11/27/2022]
Abstract
GeneMatcher is a platform through which various stakeholders can connect with others interested in candidate gene findings. GeneDx, a diagnostic laboratory, has utilized GeneMatcher over the last seven years to successfully facilitate connections between clinicians and researchers, generating fruitful research collaborations. Our ultimate goal in reporting candidate gene findings is to amass sufficient evidence to establish novel disease–gene relationships (DGRs), thus providing diagnostic answers to families and clinicians. Our database of over 300,000 clinical exomes has been a major driver of DGR discovery. Our laboratory accounts for over 20% of total GeneMatcher submissions. Largely fueled by GeneMatcher matches, we have published over 200 articles involving new DGRs or expanded phenotypes for known disease‐causing genes in the past three years. These endeavors require commitments to sharing data and dedicating resources to investigate potential matches. Ultimately, GeneMatcher enables collaboration on a broad scale: we are grateful to the clinicians, researchers, patients, and caregivers who have partnered with us to accelerate the pace of DGR discovery. GeneMatcher opens the door to new partnerships, new discoveries, and families finding answers that otherwise may not have been possible.
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Affiliation(s)
| | - E. Torti
- GeneDx Gaithersburg MD 20877 USA
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5
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Return of individual research results from genomic research: A systematic review of stakeholder perspectives. PLoS One 2021; 16:e0258646. [PMID: 34748551 PMCID: PMC8575249 DOI: 10.1371/journal.pone.0258646] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 10/02/2021] [Indexed: 12/19/2022] Open
Abstract
Despite the plethora of empirical studies conducted to date, debate continues about whether and to what extent results should be returned to participants of genomic research. We aimed to systematically review the empirical literature exploring stakeholders’ perspectives on return of individual research results (IRR) from genomic research. We examined preferences for receiving or willingness to return IRR, and experiences with either receiving or returning them. The systematic searches were conducted across five major databases in August 2018 and repeated in April 2020, and included studies reporting findings from primary research regardless of method (quantitative, qualitative, mixed). Articles that related to the clinical setting were excluded. Our search identified 221 articles that met our search criteria. This included 118 quantitative, 69 qualitative and 34 mixed methods studies. These articles included a total number of 118,874 stakeholders with research participants (85,270/72%) and members of the general public (40,967/35%) being the largest groups represented. The articles spanned at least 22 different countries with most (144/65%) being from the USA. Most (76%) discussed clinical research projects, rather than biobanks. More than half (58%) gauged views that were hypothetical. We found overwhelming evidence of high interest in return of IRR from potential and actual genomic research participants. There is also a general willingness to provide such results by researchers and health professionals, although they tend to adopt a more cautious stance. While all results are desired to some degree, those that have the potential to change clinical management are generally prioritized by all stakeholders. Professional stakeholders appear more willing to return results that are reliable and clinically relevant than those that are less reliable and lack clinical relevance. The lack of evidence for significant enduring psychological harm and the clear benefits to some research participants suggest that researchers should be returning actionable IRRs to participants.
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6
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Kalke K, Studd H, Scherr CL. The communication of uncertainty in health: A scoping review. PATIENT EDUCATION AND COUNSELING 2021; 104:1945-1961. [PMID: 33593644 DOI: 10.1016/j.pec.2021.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty. METHODS Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article. RESULTS All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%). CONCLUSIONS Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients. PRACTICE IMPLICATIONS Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.
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Affiliation(s)
- Kerstin Kalke
- Department of Communication Studies, Northwestern University, Chicago, IL, USA.
| | - Hannah Studd
- Department of Communication Studies, Northwestern University, Chicago, IL, USA
| | - Courtney L Scherr
- Department of Communication Studies, Northwestern University, Chicago, IL, USA
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7
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Richmond CM, James PA, Pantaleo SJ, Chong B, Lunke S, Tan TY, Macciocca I. Clinical and laboratory reporting impact of ACMG-AMP and modified ClinGen variant classification frameworks in MYH7-related cardiomyopathy. Genet Med 2021; 23:1108-1115. [PMID: 33568804 DOI: 10.1038/s41436-021-01107-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/29/2022] Open
Abstract
PURPOSE ClinGen provides gene-specific guidance for interpretation of sequence variants in MYH7. We assessed laboratory and clinical impact of reclassification by the American College of Medical Genetics and Genomics-Association for Molecular Pathology (ACMG-AMP) and ClinGen recommendations in 43 MYH7 variants reported by a diagnostic laboratory between 2013 and 2017. METHODS Fifty-two proband reports containing MYH7 variants were reinterpreted by original ACMG-AMP and ClinGen guidelines. Evidence items were compared across schemes and reasons for classification differences recorded. Laboratory impact was assessed by number of recommended report reissues, and reclassifications coded as clinically "actionable" or "equivalent." Available pedigrees were reviewed to describe projected cascade impact. RESULTS ClinGen produced a higher proportion of diagnostic classifications (65% of variants) compared with ACMG-AMP (54%) and fewer variants of uncertain significance (30% versus 42%). ClinGen classification resulted in actionable changes in 18% of variants with equal upgrades and downgrades from original report. ClinGen's revisions to PM1 and PS4 contributed to classification differences in 21% and 19% of variants respectively. Each classification change per proband report impacted, on average, 3.1 cascade reports with a further 6.3 first- and second-degree relatives potentially available for genotyping per family. CONCLUSION ClinGen's gene-specific criteria provide expert-informed guidance for interpretation of MYH7 sequence variants. Periodic re-evaluation improves diagnostic confidence and should be considered by clinical and laboratory teams.
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Affiliation(s)
- Christopher M Richmond
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Genetic Health Queensland, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Paul A James
- Genomic Medicine Department, Royal Melbourne Hospital, Melbourne, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Sarah-Jane Pantaleo
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Belinda Chong
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Sebastian Lunke
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
| | - Tiong Y Tan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia. .,University of Melbourne, Parkville, VIC, Australia.
| | - Ivan Macciocca
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia.
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8
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Vears DF, Minion JT, Roberts SJ, Cummings J, Machirori M, Murtagh MJ. Views on genomic research result delivery methods and informed consent: a review. Per Med 2021; 18:295-310. [PMID: 33822658 DOI: 10.2217/pme-2020-0139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There has been little discussion of the way genomic research results should be returned and how to obtain informed consent for this. We systematically searched the empirical literature, identifying 63 articles exploring stakeholder perspectives on processes for obtaining informed consent about return of results and/or result delivery. Participants, patients and members of the public generally felt they should choose which results are returned to them and how, ranging from direct (face-to-face, telephone) to indirect (letters, emails, web-based delivery) communication. Professionals identified inadequacies in result delivery processes in the research context. Our findings have important implications for ensuring participants are supported in deciding which results they wish to receive or, if no choice is offered, preparing them for potential research outcomes.
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Affiliation(s)
- Danya F Vears
- Melbourne Law School, University of Melbourne, Carlton 3052, Australia.,Biomedical Ethics Research Group, Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville 3052, Australia.,Center for Biomedical Ethics & Law, Department of Public Health & Primary Care, KU Leuven, Leuven 3000, Belgium.,Leuven Institute for Human Genetics & Society, Leuven 3000, Belgium
| | - Joel T Minion
- Policy, Ethics & Life Sciences (PEALS) Research Centre, Newcastle University, Newcastle NE1 7RU, UK
| | - Stephanie J Roberts
- Policy, Ethics & Life Sciences (PEALS) Research Centre, Newcastle University, Newcastle NE1 7RU, UK
| | - James Cummings
- School of Art, Media & American Studies, University of East Anglia, NR4 7TJ, UK
| | - Mavis Machirori
- School of Social & Political Sciences, University of Glasgow, G12 8QQ, UK
| | - Madeleine J Murtagh
- Policy, Ethics & Life Sciences (PEALS) Research Centre, Newcastle University, Newcastle NE1 7RU, UK.,School of Social & Political Sciences, University of Glasgow, G12 8QQ, UK
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9
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Mighton C, Shickh S, Uleryk E, Pechlivanoglou P, Bombard Y. Clinical and psychological outcomes of receiving a variant of uncertain significance from multigene panel testing or genomic sequencing: a systematic review and meta-analysis. Genet Med 2020; 23:22-33. [PMID: 32921787 DOI: 10.1038/s41436-020-00957-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 12/18/2022] Open
Abstract
This study systematically reviewed and synthesized the literature on psychological and clinical outcomes of receiving a variant of uncertain significance (VUS) from multigene panel testing or genomic sequencing. MEDLINE and EMBASE were searched. Two reviewers screened studies and extracted data. Data were synthesized through meta-analysis and meta-aggregation. The search identified 4539 unique studies and 15 were included in the review. Patients with VUS reported higher genetic test-specific concerns on the Multidimensional Impact of Cancer Risk Assessment (MICRA) scale than patients with negative results (mean difference 3.73 [95% CI 0.80 to 6.66] P = 0.0126), and lower than patients with positive results (mean difference -7.01 [95% CI -11.31 to -2.71], P = 0.0014). Patients with VUS and patients with negative results were similarly likely to have a change in their clinical management (OR 1.41 [95% CI 0.90 to 2.21], P = 0.182), and less likely to have a change in management than patients with positive results (OR 0.09 [95% CI 0.05 to 0.19], P < 0.0001). Factors that contributed to how patients responded to their VUS included their interpretation of the result and their health-care provider's counseling and recommendations. Review findings suggest there may be a need for practice guidelines or clinical decision support tools for VUS disclosure and management.
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Affiliation(s)
- Chloe Mighton
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Salma Shickh
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | | | - Petros Pechlivanoglou
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Yvonne Bombard
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada. .,Genomics Health Services Research Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
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Muller RD, McDonald T, Pope K, Cragun D. Evaluation of Clinical Practices Related to Variants of Uncertain Significance Results in Inherited Cardiac Arrhythmia and Inherited Cardiomyopathy Genes. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 13:e002789. [DOI: 10.1161/circgen.119.002789] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Increasing use of genetic tests have identified many variants of uncertain significance (VUS) in genes associated with inherited arrhythmias and cardiomyopathies. Evaluation of clinical practices, including medical management recommendations for VUS patients and their families, is important to prevent over- or under-treatment that may result in morbidity or mortality. The purpose of this study is to describe practices related to VUS results including information and medical management recommendations providers give patients and their families.
Methods:
An anonymous online survey was distributed to genetic counselors (GCs) and cardiologists who have seen at least one patient for inherited arrhythmias or cardiomyopathies. The survey explored providers’ confidence in counseling, explanation of VUSs, topics covered before and after genetic testing, and clinical recommendations using a hypothetical scenario maximizing uncertainty with an unclear clinical and molecular diagnosis. Descriptive statistics were calculated, and median confidence and likelihood of making various medical recommendations were compared across provider type.
Results:
Providers (N=102) who completed the survey included 29 cardiovascular GCs, 50 GCs from other specialties, and 23 cardiologists. GCs feel more confident than cardiologists counseling about VUS results (
P
<0.001); while both cardiovascular GCs and cardiologists feel more confident than other GCs in providing input regarding medical management recommendations (
P
=0.001 and
P
=0.01, respectively). Cardiologists were more likely than cardiac GCs to recommend clinical testing for family members even though testing in the scenario is expected to be uninformative.
Conclusions:
These findings illustrate how the expertise of different providers may impact decision processes, suggesting the need for interdisciplinary clinics to optimize care for challenging cases.
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Affiliation(s)
- Reka D. Muller
- College of Medicine, Department of Obstetrics and Gynecology (R.D.M.), University of South Florida, Tampa, FL
| | - Thomas McDonald
- College of Medicine, Department of Cardiovascular Sciences (T.M.), University of South Florida, Tampa, FL
| | - Kathleen Pope
- College of Public Health (K.P., D.C.), University of South Florida, Tampa, FL
| | - Deborah Cragun
- College of Public Health (K.P., D.C.), University of South Florida, Tampa, FL
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11
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Clift K, Macklin S, Halverson C, McCormick JB, Abu Dabrh AM, Hines S. Patients' views on variants of uncertain significance across indications. J Community Genet 2020; 11:139-145. [PMID: 31432391 PMCID: PMC7062975 DOI: 10.1007/s12687-019-00434-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
As genomic sequencing expands into more areas of patient care, an increasing number of patients learn of the variants of uncertain significance (VUSs) that they carry. Understanding the potential psychosocial consequences of the disclosure of a VUS can help inform pre- and post-test counseling discussions. Medical uncertainty in general elicits a variety of responses from patients, particularly in the growing field of medical genetics and genomics. It is important to consider patients' responses to the ambiguous nature of VUSs across different indications and situational contexts. Genetic counselors and other providers ordering genetic testing should be prepared for the possibility of their patients' misinterpretation of such results. Pre-test counseling should include a discussion of the possibility of VUSs and what it would mean for the patient's care and its potential psychosocial impacts. When a VUS is found, post-test counseling should include additional education and a discussion of the variant's implications and medical management recommendations based on the results. These discussions may help temper subjective interpretations, unrealistic views, and decisional regret.
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Affiliation(s)
- Kristin Clift
- Mayo Clinic Center for Individualized Medicine, Jacksonville, FL, USA.
| | - Sarah Macklin
- Mayo Clinic Department of Clinical Genomics, Jacksonville, FL, USA
| | - Colin Halverson
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA
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12
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Ostberg NP, Zafar MA, Ziganshin BA, Elefteriades JA. The Genetics of Thoracic Aortic Aneurysms and Dissection: A Clinical Perspective. Biomolecules 2020; 10:E182. [PMID: 31991693 PMCID: PMC7072177 DOI: 10.3390/biom10020182] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/13/2022] Open
Abstract
Thoracic aortic aneurysm and dissection (TAAD) affects many patients globally and has high mortality rates if undetected. Once thought to be solely a degenerative disease that afflicted the aorta due to high pressure and biomechanical stress, extensive investigation of the heritability and natural history of TAAD has shown a clear genetic basis for the disease. Here, we review both the cellular mechanisms and clinical manifestations of syndromic and non-syndromic TAAD. We particularly focus on genes that have been linked to dissection at diameters <5.0 cm, the current lower bound for surgical intervention. Genetic screening tests to identify patients with TAAD associated mutations that place them at high risk for dissection are also discussed.
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Affiliation(s)
- Nicolai P. Ostberg
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA; (N.P.O.); (M.A.Z.); (B.A.Z.)
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA; (N.P.O.); (M.A.Z.); (B.A.Z.)
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA; (N.P.O.); (M.A.Z.); (B.A.Z.)
- Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, 420012 Kazan, Russia
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA; (N.P.O.); (M.A.Z.); (B.A.Z.)
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13
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Tsai GJ, Garrett LT, Makhnoon S, Bowen DJ, Burke W, Shirts BH. Patient goals, motivations, and attitudes in a patient-driven variant reclassification study. J Genet Couns 2018; 28:558-569. [PMID: 31163102 DOI: 10.1002/jgc4.1052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/12/2018] [Accepted: 07/27/2018] [Indexed: 01/12/2023]
Abstract
Family studies to reclassify clinically ascertained variants of uncertain significance (VUS) can impact risk assessment, medical management, and psychological outcomes for patients and their families. There are limited avenues for patients and their families to actively participate in VUS reclassification, and access to family studies at most commercial laboratories is restricted by multiple factors. To explore patient attitudes about participation in family studies for VUS reclassification, we conducted semistructured pre- and post-participation telephone interviews with 38 participants in a family-based VUS reclassification study that utilized a patient-driven approach for family ascertainment and recruitment. Participants had VUS from multigene panel testing performed at multiple clinical laboratories for cancer or other disease risk. Inductive thematic analysis of transcribed interviews highlighted four major themes: (a) Participants' study goals were driven by the desire to resolve uncertainty related to the VUS, (b) Participants had mixed reactions to the VUS reclassification outcomes of the study, (c) Personal, public, and familial knowledge increased through study participation and (d) Participants used study participation to actively cope with the uncertainty of a VUS. As personalized genomic medicine becomes more prevalent, clinicians, clinical laboratories, and researchers could consider creating more opportunities for active partnership with patients and families, who are motivated to contribute data to familial VUS studies.
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Affiliation(s)
- Ginger J Tsai
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | | | - Sukh Makhnoon
- Institute of Public Health Genomics, University of Washington, Seattle, Washington
| | - Deborah J Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
| | - Brian H Shirts
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
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14
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Miller IM, Lewis KL, Lawal TA, Ng D, Johnston JJ, Biesecker BB, Biesecker LG. Health behaviors among unaffected participants following receipt of variants of uncertain significance in cardiomyopathy-associated genes. Genet Med 2018; 21:748-752. [PMID: 29997389 PMCID: PMC6330155 DOI: 10.1038/s41436-018-0083-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/31/2018] [Indexed: 11/12/2022] Open
Abstract
Purpose Studies on returning variants of uncertain significance (VUS) have predominantly included patients with a personal or family history of cancer and cancer-associated gene VUS. This study examined health behaviors amongst participants with cardiomyopathy-associated gene VUS, but without a personal history of cardiomyopathy. Methods Sixty-eight eligible participants without apparent cardiomyopathy who received VUS in cardiomyopathy-associated genes completed a survey of health behaviors, disclosure, distress, uncertainty, positive experiences, decisional conflict, and perceived value. Medical records of participants who reported cardiac testing because of their VUS were reviewed for testing indication(s). Results Two participants had cardiac testing due to their VUS alone. Four had cardiac testing because of their VUS and other clinical indications and 12 changed health behaviors, including one participant who was subsequently diagnosed with cardiomyopathy. Distress, uncertainty, and decisional conflict were low (means= 1.2, 4.2, 24.5; scale ranges= 0–30, 0–45, 15–75, respectively), and positive experiences and perceived value were moderate (means= 12.4, 14.4; scale range= 0–20, 4–20, respectively). Greater perceived value was associated with greater likelihood to engage in health behaviors (p= 0.04). Conclusion VUS can be returned to apparently unaffected individuals with modest use of healthcare resources, minimal behavioral changes, and favorable psychological reactions.
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Affiliation(s)
- Ilana M Miller
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Katie L Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.
| | - Tokunbor A Lawal
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.,Tissue Injury Branch, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - David Ng
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer J Johnston
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.,Research Triangle Institute, Raleigh, North Carolina, USA
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA.
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