The human genome project: a false dawn? Interview by Judy Jones

Unleashing the power of human genetic variation knowledge: New Zealand stakeholder perspectives

PURPOSE

This study aimed to characterize the challenges in using genetic information in health care and to identify opportunities for improvement.

METHODS

Taking a grounded theory approach, semistructured interviews were conducted with 48 participants to collect multiple stakeholder perspectives on genetic services in New Zealand.

RESULTS

Three themes emerged from the data: (1) four service delivery models were identified in operation, including both those expected models involving genetic counselors and variations that do not route through the formal genetic service program; (2) multiple barriers to sharing and using genetic information were perceived, including technological, organizational, institutional, legal, ethical, and social issues; and (3) impediments to wider use of genetic testing technology, including variable understanding of genetic test utilities among clinicians and the limited capacity of clinical genetic services. Targeting these problems, information technologies and knowledge management tools have the potential to support key tasks in genetic services delivery, improve knowledge processes, and enhance knowledge networks.

CONCLUSION

Because of the effect of issues in genetic information and knowledge management, the potential of human genetic variation knowledge to enhance health care delivery has been put on a "leash."

Will genomics widen or help heal the schism between medicine and public health?

We discuss the "schism" between medicine and public health in light of advances in genomics and the expected evolution of health care toward personalized treatment and prevention. Undoubtedly, genomics could deepen the divide between the two worlds, but it also represents an important and perhaps unique opportunity for healing the schism, given the volume of new scientific discoveries and their potential applications in all areas of health and disease. We argue that the integration of genomics into health care and disease prevention requires a strong medicine-public health partnership in the context of a population approach to a translational research agenda that includes four overlapping areas: (1) a joint focus on prevention-a traditional public health concern but now a promise of genomics in the realm of individualized primary prevention and early detection, (2) a population perspective, which requires a large amount of population-level data to validate gene discoveries for clinical applications, (3) commitment to evidence-based knowledge integration with thousands of potential genomic applications in practice, and (4) emphasis on health services research to evaluate outcomes, costs, and benefits in the real world. A strong medicine-public health partnership in the genomics era is needed for the translation of all scientific discoveries for the benefit of population health.

'Medicine's next goldmine?' The implications of new genetic health technologies for the health service

There is considerable uncertainty about the implications of the new genetics for health services. These are the enthusiasts who argue that molecular genetics will transform health care and others argue that the scope for genetic interventions is limited. The aim of this paper is to examine some of the questions, tensions and difficulties which face health care providers particularly in developed countries as they try to come to terms with the dilemmas raised by new genetic health care technologies (NGHTs). It identifies questions for research which may help the development of robust and flexible strategies for implementation.

How acceptable are innovative health-care technologies? A survey of public beliefs and attitudes in England and Wales

There has been a continuing debate about the extent to which the public finds health-care technological innovation acceptable. The public's ambivalence about scientific medicine may have been exacerbated, more recently, by developments such as the introduction of the 'new genetics' with their associated ethical and social implications and the claims that public trust in health care and practitioners and, more widely, in society has been eroded. The aim of this paper is to examine public attitudes to a range of innovative health-care technologies to see whether (i) certain technologies are perceived as particularly problematic, and (ii) attitudes to new health-care technologies are associated more broadly with beliefs about science, trust in health care and social trust, and perceptions of the benefits and risks of complementary and alternative medicine versus orthodox (technological) medicine. These questions are examined through a statistical analysis of data collected in a national, postal survey of the adult population (n = 1187) in England and Wales. The results showed public ambivalence about new health-care technologies, although genetic technologies, as a whole, were not seen to be problematic and their acceptability depended on their ability to control serious diseases. However, there was a level of consistency in attitude across the different technologies. Those consistently against new health-care technologies were also more likely to be suspicious of science, and doubtful about the benefits of other established, orthodox technologies (screening; medications) and to have less trust in health and health-care practitioners.

An epidemiologic assessment of genomic profiling for measuring susceptibility to common diseases and targeting interventions

PURPOSE

The current clinical value of genomic profiling (testing for genotypes at multiple loci) for assessing susceptibility to common diseases and targeting behavioral and medical interventions is questionable. As common diseases result from many gene-environment interactions, epidemiologic studies should be used to examine the value of genomic profiling in terms of clinical validity (future disease positive and negative predictive value stratified by exposure), clinical utility (targeted interventions to reduce disease risk among persons with the profile) and public health utility (comparing reduction of disease burden in the population based on genomic profiling to population-wide interventions).

METHODS

We investigate these parameters for a hypothetical common disease (5% lifetime risk), for which 3 genetic variants at different loci and one environmental exposure are risk factors.

RESULTS

We show that even for modest effects of each variant alone (risk ratios from 1.5-3.0) and modest interactions between the exposure and the genes, the disease predictive value for people with 2 or more variants (especially 3) can be quite high (50-100%) in the presence of a modifiable exposure. Individual risks can then be reduced by targeted exposure intervention among persons with the genotype. However, the predictive value for multiple genotypes is much lower for rarer diseases (< 1 per 1000). Also, with increasing number of genes in a profile, the population impact of disease reduction for targeted intervention based on genotype will be smaller, especially for rare genotypes, weak associations, and weak interactions.

CONCLUSION

To assess the value of genomic profiling, well-designed epidemiologic studies are needed to quantify disease risks, in addition to costs, benefits, and risks for testing and interventions.

There may never be a final cure for breast cancer

This paper challenges the perception that the success of the human genome project has brought us to the threshold of a cure for many common cancers. Paradoxically, the message emerging from the genetics of breast cancer may be that the genetic damage associated with malignant transformation, and the mutations predisposing to the disease in our gene pool, may prove impossible to eliminate.