UK clinicians' knowledge of and attitudes to the prenatal diagnosis of single gene disorders

The knowledge value-chain of genetic counseling for breast cancer: an empirical assessment of prediction and communication processes

The aim of this paper is twofold: to analyze the genetic counseling process for breast cancer with a theoretical knowledge transfer lens and to compare generalists, medical specialists, and genetic counselors with regards to their genetic counseling practices. This paper presents the genetic counseling process occurring within a chain of value-adding activities of four main stages describing health professionals' clinical practices: (1) evaluation, (2) investigation, (3) information, and (4) decision. It also presents the results of a cross-sectional study based on a Canadian medical doctors and genetic counselors survey (n = 176) realized between July 2012 and March 2013. The statistical exercise included descriptive statistics, one-way ANOVA and post-hoc tests. The results indicate that even though all types of health professionals are involved in the entire process of genetic counseling for breast cancer, genetic counselors are more involved in the evaluation of breast cancer risk, while medical doctors are more active in the decision toward breast cancer risk management strategies. The results secondly demonstrate the relevance and the key role of genetic counselors in the care provided to women at-risk of familial breast cancer. This paper presents an integrative framework to understand the current process of genetic counseling for breast cancer in Canada, and to shed light on how and where health professionals contribute to the process. It also offers a starting point for assessing clinical practices in genetic counseling in order to establish more clearly where and to what extent efforts should be undertaken to implement future genetic services.

Expanded carrier screening in reproductive healthcare: perspectives from genetics professionals

STUDY QUESTION

How do genetics professionals assess the potential benefits and challenges of expanded carrier screening (ECS) in reproductive healthcare?

SUMMARY ANSWER

Genetics professionals believe that current ECS products have major limitations and are not ready for routine use in reproductive healthcare.

WHAT IS KNOWN ALREADY

Non-targeted approaches to carrier screening have been met with uneven enthusiasm from relevant professional organizations. With declining genotyping costs, it is reasonable to expect that the number of genetic conditions evaluated by carrier-screening products will continue to increase. Reproductive healthcare providers will play a critical role in the adoption of ECS and need to be prepared for the potential challenges that lie ahead.

STUDY DESIGN, SIZE, DURATION

Focus groups were convened at six academic medical centers in the USA in March 2011 to examine genetics professionals' views on ECS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Forty genetic professionals participated in six focus groups for this study. A clinical case report was presented to each focus group to examine participants' opinions about the use of highly multiplexed forms of carrier screening in reproductive healthcare. Focus group transcripts were analyzed for major themes and thematic density across sites using qualitative data analysis software (ATLAS.ti v5.8).

MAIN RESULTS AND THE ROLE OF CHANCE

Participants believed that current ECS products have major limitations pertaining to the analysis of select alleles and genetic mutations. Participants highlighted multiple interpretive and counseling challenges that reproductive healthcare providers may face in communicating ECS results to patients. Participants stressed the importance of communicating these and other limitations to patients before recommending ECS. Participants recommended collaboration with genetic counselors and medical geneticists in providing ECS.

LIMITATIONS, REASONS FOR CAUTION

To the extent that ECS products have not been widely used to date, participants may have had limited familiarity and direct clinical experience with these products. Given that this study was conducted with genetic professionals from academic medical centers in the USA, participant perspectives may not be representative of professional practices and norms in other healthcare settings.

WIDER IMPLICATIONS OF THE FINDINGS

In considering the use of ECS products in their practices, reproductive healthcare providers may find it helpful to consider the perspectives of genetics professionals. These specialists have considerable experience with diverse forms of genetic testing and can provide valuable insights regarding new genomic risk assessment tools such as ECS.

Preimplantation genetic diagnosis: does age of onset matter (anymore)?

The identification and avoidance of disease susceptibility in embryos is the most common goal of preimplantation genetic diagnosis (PGD). Most jurisdictions that accept but regulate the availability of PGD restrict it to what are characterized as 'serious' conditions. Line-drawing around seriousness is not determined solely by the identification of a genetic mutation. Other factors seen to be relevant include: impact on health or severity of symptoms; degree of penetrance (probability of genotype being expressed as a genetic disorder); potential for therapy; rate of progression; heritability; and age of onset. In the original applications of PGD, most, if not all of these factors were seen as necessary but none was seen as sufficient for determining whether a genetic condition was labelled 'serious'. This, however, is changing as impact on health or severity of symptoms is coming to eclipse the other considerations. This paper investigates how age of onset (primarily in the context of the United Kingdom (UK)) has become considerably less significant as a criterion for determining ethically acceptable applications of PGD. Having moved off the threshold of permitting PGD testing for only fatal (or seriously debilitating), early-onset diseases, I will investigate reasons for why age of onset will not do any work to discriminate between which adult-onset diseases should be considered serious or not. First I will explain the rationale underpinning age of onset as a factor to be weighed in making determinations of seriousness. Next I will challenge the view that later-onset conditions are less serious for being later than earlier-onset conditions. The final section of the paper will discuss some of the broader disability concerns at stake in limiting access to PGD based upon determinations of the 'seriousness' of genetic conditions. Instead of advocating a return to limiting PGD to only early-onset conditions, I conclude that the whole enterprise of trying to draw lines of what is to count as a 'serious' condition is itself problematic and in certain ways morally misleading.

Preimplantation genetic diagnosis for BRCA1 exon 13 duplication mutation using linked polymorphic markers resulting in a live birth

BACKGROUND

The risk of breast cancer associated with inheriting a BRCA1 mutation is extremely high, in addition, there is a 50% chance of transmitting this familial cancer mutation to any offspring.

METHODS

A 31-year-old woman with a strong maternal family history of early onset of breast cancer had experienced 3 years of primary infertility. Presymptomatic testing confirmed the woman had inherited a 6 kb duplication of exon 13 (ins6KbEx13) in BRCA1 from her mother. Neither gamete donation or adoption were acceptable options for this infertile couple, and as termination of pregnancy after prenatal diagnosis following in vitro fertilization (IVF) was not ethically acceptable, preimplantation genetic diagnosis (PGD) was sought. A single-cell PCR protocol for PGD for the breast and ovarian cancer predisposing BRCA1 exon 13 duplication mutation was developed which involved amplification of three specific gene regions, including the BRCA1 mutation (ins6KbEx13), an intragenic marker (D17S855) and a flanking marker (D17S1185).

RESULTS

In the first cycle of IVF, three embryos were analyzed and two were determined to be at low risk of having inherited the maternal BRCA1 mutation. Following the transfer of both embryos on day 5, a singleton pregnancy resulted. Declining confirmatory prenatal diagnosis, a male baby was subsequently delivered at term.

CONCLUSIONS

Successful PGD for BRCA1 resulted in the delivery of a live-born male. PGD using linked polymorphic markers provides an alternate option for reproduction for couples with or at risk of having inherited a BRCA1 mutation.

Genetic counseling in psychiatry

While psychiatrists may commonly discuss family history in clinical practice, there has been little systematic research documenting the role and effectiveness of genetic counseling for psychiatric disorders. In the coming years, the expected identification of susceptibility genes for psychiatric disorders may bring new opportunities and expectations from patients and families for the clinical translation of research findings in psychiatric genetics. We review evidence for possible increasing demand for genetic counseling, particularly if specific genes related to psychiatric disorders are identified. We then explore both the potential role of genetic counseling for psychiatric disorders and the issues involved in conveying genetic information in the clinical setting. Further research regarding the effectiveness of counseling interventions, as well as additional efforts directed at genetics education for clinicians, will be needed if emerging advances in genetic research are to be incorporated into clinical practice.

Deficiency of knowledge of genetics and genetic tests among general practitioners, gynecologists, and pediatricians: A global problem

PURPOSE

The objective of this study was to assess knowledge of genetics and awareness of genetic tests among Dutch general practitioners (GPs), gynecologists (GYNs), and pediatricians (PEDs), as well as factors influencing their knowledge and awareness.

METHODS

An anonymous questionnaire inquiry was used, validated with a sample of 52 clinical geneticists (CGs). The study was carried out in primary care (general practice) and secondary care (general and university hospitals) in The Netherlands. A random sample of 200 GPs, 300 GYNs, and 265 PEDs received a questionnaire. In addition, all registered CGs (58) received a questionnaire for validation. In total, 122 GPs, 187 GYNs, 164 PEDs, and 52 CGs returned a completed questionnaire. The main outcome measures were differences in knowledge scores between physicians working in different disciplines and factors influencing these scores.

RESULTS

Knowledge scores of GPs (mean 64% correct answers, 61%-66% [95% confidence interval]), GYNs (mean 75% correct answers, 73%-76% [95% confidence interval]), and PEDs (mean 81% correct answers, 79%-82% [95% confidence interval]) were lower than those in the CG validation group (mean 95% correct answers, 94%-96% [95% confidence interval]). The 5th percentile of GPs, GYNs, and PEDs was at approximately 40%, 52% and 62% correct answers, respectively. There was a specific lack of knowledge about DNA testing. In addition to specialty, important factors positively associated with the knowledge scores of nongeneticists are more recent graduation, having taken an elective course in genetics, and providing genetic counseling in their own practice.

CONCLUSION

The overall knowledge levels of genetics in many nongeneticist health care providers show clear deficiencies. This is in line with reports from other countries, showing that these deficiencies are a global problem.

Educating general practitioners about prenatal testing: approaches and challenges

OBJECTIVES

To examine the effects of an education intervention on the knowledge and practice behaviours of general practitioners (GPs) regarding prenatal screening and diagnostic testing in Melbourne, Australia.

METHODS

A single group, pre-test, repeated post-test design was used. Information on demographics, knowledge, behaviours and skills was collected via a self-administered questionnaire prior to the educational intervention. Responses to individual questions were coded and scores calculated, as well as a percent total score. Following the education, data were again collected, immediately afterwards (Post-Q) and six-to-eight months later (Foll-Q).

RESULTS

Data for all three time points were collected from 63 GPs and showed a variable, and relatively poor knowledge regarding aspects of prenatal testing, especially before education. The percent mean total score at baseline was 51.2+/-1.59% (CI 48.02 to 54.39), which increased significantly (p<0.001) in both Post-Q (62.88+/-1.51%; CI 59.86 to 65.89) and Foll-Q (58.92+/-1.6%; CI 55.71 to 62.12).

CONCLUSION

The educational intervention significantly increased knowledge and practice behaviour of GPs, even up to eight months later, but this could be improved further, to a considerable extent. There is a need for ongoing multi-faceted approaches to educating GPs on prenatal testing to ensure that they are engaged in appropriate practice.

Huntington's disease: do future physicians and lawyers think eugenically?

The availability of presymptomatic and prenatal genetic tests could give rise to societal pressures on persons at risk for Huntington's disease (HD). The objective of this study was to identify future lawyers' and physicians' views on eugenics and genetic testing for HD. Five-hundred and ninety-nine Swiss law students and advanced medical students from 11 courses received teaching about HD and patient autonomy. They filled out questionnaires after having seen an audio/video recording of an interview with an HD mutation carrier. Participation rates were 68-97%. Attitudes of future lawyers and physicians were significantly different for most questions: 73.2% of law students vs 39.4% of medical students agreed that society should do everything possible to diminish the frequency of HD, including non-governmental pressure on carriers to undergo systematic genetic testing and recommendation of sterilization; 94% of all students agreed to the systematic proposal of prenatal testing to all women at risk; and 83.4% of medical students, but only 40.3% of law students, agreed that the wishes of a person at risk not to have her/himself and future children tested must be entirely respected. More education is needed to discourage eugenic pressures and discrimination of persons at risk of HD and other genetic diseases.

Genetic susceptibility to cancer. Family physicians' experience

OBJECTIVE

To explore family physicians' experiences in dealing with genetic susceptibility to cancer.

DESIGN

Qualitative study using focus groups.

SETTING

Four Ontario sites: northern, rural, urban, and inner city.

PARTICIPANTS

Forty rural and urban FPs participated in four focus groups: 28 were male; average age was 41.

METHOD

Focus groups using a semistructured interview guide were audiotaped and transcribed. The constant comparative method of data analysis was used. Key words and concepts were identified. Data were sorted using NUD*IST software.

MAIN FINDINGS

Participants realized the escalating expectations for genetic testing and its effect on family practice. They explored an expanded role for themselves in genetic testing. Possible activities included risk assessment, gatekeeping, and ordering genetic tests. They were concerned about the complexity of genetic testing, the lack of evidence regarding management, and the implications for families.

CONCLUSION

We must help FPs struggling to integrate genetics into their practices, by addressing their concerns, enhancing the way they communicate information on genetics, and developing appropriate educational tools.

Needs assessment study of genetics education for general practitioners in Australia

PURPOSE

Because of the explosion of genetic information resulting from the Human Genome Project and other developments in genetics and genetic technologies, primary care practitioners in Australia will be expected to have a much greater role in the practice of genetic medicine; however, little is published regarding their knowledge and attitudes to genetics, technologies, or genetics education. This study aimed to determine the genetics knowledge and educational needs of general practitioners (GPs) in Victoria, Australia, and their experiences in dealing with genetics in their practices.

METHODS

Qualitative research methods were used primarily to obtain data from focus groups, interviews, and a limited survey.

RESULTS

GPs believed their knowledge of genetics was poor and they felt inadequately prepared to manage patients with genetic conditions. They identified testing and counseling as areas that particularly needed strengthening.

CONCLUSION

These data, together with GPs' suggestions about educational strategies, are essential for developing appropriate genetics education programs and resources that are relevant for Australian health care.

Disease knowledge in a high-risk population for cystic fibrosis

Cystic fibrosis (CF) has high incidence (1/936 live births) and carrier rate (1/15 inhabitants) in Saguenay-Lac-Saint-Jean (SLSJ). One objective of a major enquiry among several subsets of individuals from this high-risk population for CF was to evaluate the knowledge of the disease and its genetic transmission. The overall score of correct answers pertaining to the clinical signs of CF among medical doctors (general practitioners and specialists) was 42.2 and 65.6%, respectively; it was 84.2% for questions regarding the genetic transmission of CF. The knowledge of the clinical signs was reasonable among CF patients and their parents (about 65% of correct answers), but it was much higher for the genetics (over 88% among parents). Aunts and uncles of CF children were poorly informed of the clinical signs (33.9% of correct answers) but well informed of the genetic transmission (73.8%). Specific subsets of the SLSJ population showed important gaps in the knowledge of the clinical signs of CF but, overall, they were well informed of its genetic transmission.

Primary care physicians' perceptions of barriers to genetic testing and their willingness to participate in research

Our objective was to explore the barriers and motivations to: 1) appropriate diffusion of genetic services into primary care practice; and 2) primary care physicians' (PCPs) willingness to participate in clinical studies to assess the safety and effectiveness of emerging genetic technologies. A random sample (n = 994) of PCPs was invited to be interviewed. Of the 80 who agreed, 60 were interviewed, 52 by telephone. A semi-structured guide was used. A questionnaire mailed to 752 of the PCPs was used to elicit information from physicians who did not want to be interviewed. Among interviewees, uncertainty as to the clinical utility and clinical validity of predictive genetic testing were the leading barriers to incorporation of this technology into practice, being mentioned by 60 and 43% of subjects, respectively. Of the 100 (13. 3%) physicians returning the questionnaire who declined to be interviewed, 30% said they would be willing to participate in research on the safety and effectiveness of predictive genetic tests. Of those who were interviewed, 92% were willing to participate in such research. Most physicians do not see genetics as important in their practice today; many anticipate greater importance in the future. The proportion of physicians interested in participating in research to assess the safety and effectiveness of genetic tests is sufficient to make large scale, collaborative, practice-based evaluation feasible. Additionally, participation in research may serve as an effective medium for physician education in genetics.

Primary care physicians' knowledge and attitudes towards genetic testing for breast-ovarian cancer predisposition

BACKGROUND

Primary health care providers are expected to be directly involved in the genetic testing for cancer susceptibility. This study assessed physicians' knowledge, attitude and perception of their role towards testing for hereditary breast ovarian cancer.

DESIGN

A mail-in survey was sent to all general practitioners, internists, obstetrician-gynecologists and oncologists in private practice in Geneva county, Switzerland. Questions included socio-demographic variables, knowledge about hereditary breast ovarian cancer, attitude towards testing and assessment of their role in the pre- and post-test procedure.

RESULTS

Two hundred fifty-nine (65%) of four hundred questionnaires were returned of which two hundred forty-three (61%) were analysed. Response rates were similar between specialties; women answered more frequently. The majority of the respondents (87%) approved of genetic susceptibility testing. The most common objection to testing was the absence of approved strategies for the prevention and detection of early breast cancer. Most physicians felt they had an active part to play in the pre-test procedure, the disclosure of results, and especially the consultants' long-term care and support (99%). Physicians correctly answered a third (32%) of the knowledge questions. The abstention rate for individual items ranged from 13% to 60%. Scores varied by specialty. Oncologists were more knowledgeable than gynecologists, internists and general practitioners.

CONCLUSIONS

The majority of the primary care physicians in this study have a favourable attitude and are ready to play a prominent role in genetic counseling and testing for breast ovarian cancer predisposition. Defective knowledge scores, however, underline the need for targeted educational programs.

Support for the availability of prenatal testing for neurological and psychiatric conditions in the psychiatric community

Faculty and residents of the University of Michigan Department of Psychiatry, members of the Alliance for the Mentally Ill (AMI), and university students were surveyed to elicit attitudes toward the availability of prenatal testing and genetic therapy or enhancement for early- and late-onset psychiatric diseases compared to neurological disorders and human traits. They were asked to complete a written questionnaire designed to assess their opinions as to whether prenatal testing and genetic therapy or enhancement should be applied to 16 selected "disease" phenotypes or human traits: eight early- and late-onset psychiatric conditions, four neurological disorders, and four human traits. Twenty-two percent returned the written survey. The majority of all respondents supported the availability of prenatal testing for well-defined, serious psychiatric or neurological phenotypes and found testing for human traits less desirable. The percentages of respondents supporting availability of testing increased if in utero curative gene therapy was available. Response to the survey differed on the basis of gender and age, as well as personal versus professional familiarity with the condition. The results of this pilot study suggest that a majority of the population, including psychiatrists, will support the public availability of prenatal diagnosis for serious psychiatric or neurological phenotypes, even if no in utero curative therapy is available. Support for testing for human traits was not strongly endorsed.

Primary care physicians' utilization and perceptions of genetics services

PURPOSE

To document primary care physicians' utilization and perceptions of genetics services.

METHODS

A randomized survey of physicians in the Pacific Northwest.

RESULTS

The greatest factor prompting a genetics referral was the patient's interest in the evaluation, and the most common reason not to obtain a consultation was the perception that it was of no benefit to the patient. Genetics consultation was rarely sought for a family history of cancer or for deafness, polycystic kidney disease, or congenital heart disease. Even when uncertain about relative risk, physicians usually counseled a patient themselves rather than referring to a specialist.

CONCLUSION

Primary care physicians need more education about the genetic component of many diseases to provide directly and to refer appropriately for genetics services.

Physician knowledge and attitudes towards molecular genetic (DNA) testing of their patients

OBJECTIVE

To better define the knowledge and attitudes of practicing physicians about genetics; specifically molecular genetics. Further, to examine differences between four practice specialties and to assess variables that affect both knowledge and attitudes.

DESIGN

A mail-in survey was sent to a random sample of non-geneticist physicians, with a second copy sent to non-responders. Questions included sociodemographic variables, sources of current knowledge and education in genetics, clinical experience with genetic disease, self-confidence in providing genetic counseling, attitudes towards referring patients to a genetic center, awareness of molecular genetic testing and attitudes towards its use in clinical practice and population screening.

SETTING

Responses were obtained from over 900 practicing physicians in the Canadian province of Ontario (population 10 million). Genetic services are provided through nine major and several outreach centers. Molecular diagnostic services are provided through six provincially funded laboratories. There are no direct costs to the patient for any genetic service.

PARTICIPANTS

A random sample of family physicians, obstetricians, pediatricians and internists was surveyed from both private and hospital based practices.

RESULTS AND CONCLUSION

Responses varied by specialty, years from graduation, gender, and type of practice. Pediatricians and obstetricians were more knowledgeable about genetics, had more interaction with genetic services and were more supportive of their utility. A major proportion of physicians continue to rely upon undergraduate and medical school courses for knowledge, and the specialties showed different preferences for seeking information. A majority of physicians considered their knowledge of genetics to be adequate, but a minority were confident to provide genetic counseling for simple genetic scenarios. Relatively few had actually made use of DNA diagnostic services and there was relatively poor knowledge of what services were available.

Huntington's disease

Huntington's disease (HD) is a late-onset degenerative disorder of the central nervous system, caused by a dominantly inherited mutation in a gene on chromosome 4p. The identification of the trinucleotide repeat mutation responsible for this disorder has been an important step towards understanding the molecular pathology of HD, but in the meantime has also made it possible to offer predictive testing and prenatal diagnosis to individuals at high genetic risk. Predictive testing offers obvious benefits for those who receive a favourable result, but also runs the risk of significant psychological and social problems for the families involved. Uptake of testing to date has been limited. Prenatal testing where the pregnancy is at 25% risk carries the same disadvantages as adult predictive testing, because an unfavourable result would also establish that the at-risk parent is a gene carrier; prenatal exclusion testing offers an alternative method of detecting and terminating at-risk pregnancies without revealing the genetic status of the at-risk parent.

A sociobehavioural perspective on genetic testing and counselling for heritable breast, ovarian and colon cancer

Testing for susceptibility to heritable breast, ovarian and colon cancer has unique psychosocial costs. Negative test results may not be sufficient to relieve anxiety, and positive results can cause sufficient distress to compromise patient compliance with surveillance and risk reduction measures. More needs to be learned about how sociocultural factors affect the understanding of risk, how decisions to undergo testing are made and how information about increased risk affects family dynamics. As the demand for testing and counselling grows, health care providers will be faced with new challenges and dilemmas. A better understanding of genetics by the public is needed to mitigate deterministic attitudes that can lead to the neglect of health promotion. Also of concern are the socioeconomic implications of being identified as having a high risk for heritable cancer and the dangers inherent in using genetics to explain sociological phenomena. Health care providers must take the lead in ensuring that developments in genetics are used to the benefit of all.

Knowledge of genetics among residents in obstetrics and gynecology

A supervised genetics examination was administered to 76 obstetrics and gynecology (ob/gyn) residents from 15 different institutions in the Philadelphia area. The questions were specifically designed to be applicable to obstetrical practice. Overall, the mean score was 69% (range 32%-88%). Using the nonparametric Mann-Whitney rank sum test, we found that the 25 residents from institutions with an obstetrics-gynecology-genetics (OGG) program, coordinated by an obstetrician/gynecologist board certified in clinical genetics, had statistically significant higher scores than the remaining 51 residents from institutions without an OGG program (77% vs. 65%, respectively; P < .001). This study demonstrates that knowledge of genetics among residents in ob/gyn is deficient, especially among residents at institutions without OGG programs. Special efforts should be made to provide genetics education to these individuals. We propose that more obstetricians be encouraged to pursue postgraduate training in genetics in light of the rapid development of medical genetics; its application to prenatal screening, diagnosis, and counseling; the anticipated utilization of genetics services; and the need for educational initiatives geared toward ob/gyn patients.