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Cornelis C, Dondorp W, Bolt I, de Wert G, van Summeren M, Brilstra E, Knoers N, Bredenoord AL. Uncertain futures and unsolicited findings in pediatric genomic sequencing: guidelines for return of results in cases of developmental delay. BMC Med Ethics 2023; 24:98. [PMID: 37951889 PMCID: PMC10640744 DOI: 10.1186/s12910-023-00977-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Massively parallel sequencing techniques, such as whole exome sequencing (WES) and whole genome sequencing (WGS), may reveal unsolicited findings (UFs) unrelated to the diagnostic aim. Such techniques are frequently used for diagnostic purposes in pediatric cases of developmental delay (DD). Yet policy guidelines for informed consent and return of UFs are not well equipped to address specific moral challenges that may arise in these children's situations. DISCUSSION In previous empirical studies conducted by our research group, we found that it is sometimes uncertain how children with a DD will develop and whether they could come to possess capacities for autonomous decision-making in the future. Parents sometimes felt this brought them into a Catch-22 like situation when confronted with choices about UFs before undergoing WES in trio-analysis (both the parents' and child's DNA are sequenced). An important reason for choosing to consent to WES was to gain more insight into how their child might develop. However, to make responsible choices about receiving or declining knowledge of UFs, some idea of their child's future development of autonomous capacities is needed. This undesirable Catch-22 situation was created by the specific policy configuration in which parents were required to make choices about UFs before being sequencing (trio-analysis). We argue that this finding is relevant for reconfiguring current policies for return of UFs for WES/WGS and propose guidelines that encompass two features. First, the informed consent process ought to be staged. Second, differing guidelines are required for withholding/disclosing a UF in cases of DD appropriate to the level of confidence there is about the child's future developmental of autonomous capacities. CONCLUSION When combined with a dynamic consent procedure, these two features of our guidelines could help overcome significant moral challenges that present themselves in the situations of children undergoing genomic sequencing for clarifying a DD.
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Affiliation(s)
- Candice Cornelis
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands.
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Ineke Bolt
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Guido de Wert
- Department of Health, Ethics & Society, Maastricht University, Maastricht, the Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eva Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Genetics, University Medical Centre Groningen, Groningen, the Netherlands
| | - Annelien L Bredenoord
- Julius Center, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Philosophy, Rotterdam, the Netherlands
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Berset AE, Myers MF, Prows CA, Brinkman WB. Adolescent Decision-Making Involvement in the Receipt of Genomic Testing Results. J Pediatr 2023; 259:113492. [PMID: 37201682 PMCID: PMC10524914 DOI: 10.1016/j.jpeds.2023.113492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/11/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To examine hypothesized predictors of adolescent and parent involvement in the decision about which genomic results to receive. STUDY DESIGN We conducted a longitudinal cohort study during phase 3 of the electronic Medical Records and Genomics (eMERGE) Network. Dyads reported on how they preferred to make choices (adolescent only, parent only, or jointly). Dyads used a decision tool to choose independently the categories of genetic testing results they wanted. We summarized independent choices, identifying initially discordant dyads. After a facilitated discussion, dyads made a joint decision. Dyads then completed the Decision-Making Involvement Scale (DMIS). We conducted bivariate correlations between DMIS subscale scores and the following hypothesized predictors: adolescent age, preference for adolescent to make their own decision, and discordance on initial independent choices. RESULTS The sample included 163 adolescents, aged 13-17 years and parents (86.5% mothers). Dyads lacked agreement on how they wanted to make the final decision (weighted kappa statistic 0.04; 95% CI -0.08 to 0.16). These preferences, as well as the adolescent's age and adolescent-parent discordance on initial choices for specific categories of genetic testing results to receive, were associated with subsequent decision-making involvement behaviors as measured by DMIS subscales. Dyads with discordant initial preferences had significantly greater scores on the DMIS Joint/Options subscale than those with concordant initial preferences (adolescent report M [SD] 2.46 [0.60] vs 2.10 [0.68], P < .001). CONCLUSIONS Through facilitated discussion, adolescents and parents can work together and reach agreement about receipt of genomic screening results.
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Affiliation(s)
- Anne E Berset
- Division of General & Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Melanie F Myers
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Cynthia A Prows
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - William B Brinkman
- Division of General & Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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3
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Bowling KM, Thompson ML, Kelly MA, Scollon S, Slavotinek AM, Powell BC, Kirmse BM, Hendon LG, Brothers KB, Korf BR, Cooper GM, Greally JM, Hurst ACE. Return of non-ACMG recommended incidental genetic findings to pediatric patients: considerations and opportunities from experiences in genomic sequencing. Genome Med 2022; 14:131. [PMID: 36414972 PMCID: PMC9682742 DOI: 10.1186/s13073-022-01139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The uptake of exome/genome sequencing has introduced unexpected testing results (incidental findings) that have become a major challenge for both testing laboratories and providers. While the American College of Medical Genetics and Genomics has outlined guidelines for laboratory management of clinically actionable secondary findings, debate remains as to whether incidental findings should be returned to patients, especially those representing pediatric populations. METHODS The Sequencing Analysis and Diagnostic Yield working group in the Clinical Sequencing Evidence-Generating Research Consortium has collected a cohort of pediatric patients found to harbor a genomic sequencing-identified non-ACMG-recommended incidental finding. The incidental variants were not thought to be associated with the indication for testing and were disclosed to patients and families. RESULTS In total, 23 "non-ACMG-recommended incidental findings were identified in 21 pediatric patients included in the study. These findings span four different research studies/laboratories and demonstrate differences in incidental finding return rate across study sites. We summarize specific cases to highlight core considerations that surround identification and return of incidental findings (uncertainty of disease onset, disease severity, age of onset, clinical actionability, and personal utility), and suggest that interpretation of incidental findings in pediatric patients can be difficult given evolving phenotypes. Furthermore, return of incidental findings can benefit patients and providers, but do present challenges. CONCLUSIONS While there may be considerable benefit to return of incidental genetic findings, these findings can be burdensome to providers and present risk to patients. It is important that laboratories conducting genomic testing establish internal guidelines in anticipation of detection. Moreover, cross-laboratory guidelines may aid in reducing the potential for policy heterogeneity across laboratories as it relates to incidental finding detection and return. However, future discussion is required to determine whether cohesive guidelines or policy statements are warranted.
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Affiliation(s)
- Kevin M Bowling
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, 35806, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | | | - Melissa A Kelly
- HudsonAlpha Clinical Services Lab, LLC, HudsonAlpha Institute for Biotechnology, Huntsville, USA
| | - Sarah Scollon
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Anne M Slavotinek
- Department of Pediatrics, University of California, San Francisco, CA, 94158, USA
| | - Bradford C Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Brian M Kirmse
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, 39216, USA
| | - Laura G Hendon
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, 39216, USA
| | - Kyle B Brothers
- Norton Children's Research Institute Affiliated with UofL School of Medicine, Louisville, KY, 40202, USA
| | - Bruce R Korf
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, 25294, USA
| | - Gregory M Cooper
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, 35806, USA
| | - John M Greally
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Anna C E Hurst
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, 25294, USA.
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Johnson LM, Mandrell BN, Li C, Lu Z, Gattuso J, Harrison LW, Mori M, Ouma AA, Pritchard M, Sharp KMH, Nichols KE. Managing Pandora's Box: Familial Expectations around the Return of (Future) Germline Results. AJOB Empir Bioeth 2022; 13:152-165. [PMID: 35471132 DOI: 10.1080/23294515.2022.2063994] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pediatric oncology patients are increasingly being offered germline testing to diagnose underlying cancer predispositions. Meanwhile, as understanding of variant pathogenicity evolves, planned reanalysis of genomic results has been suggested. Little is known regarding the types of genomic information that parents and their adolescent children with cancer prefer to receive at the time of testing or their expectations around the future return of genomic results. METHODS Parents and adolescent children with cancer eligible for genomic testing for cancer predisposition were surveyed regarding their attitudes and expectations for receiving current and future germline results (ClinicalTrials.gov Identifier: NCT02530658). RESULTS All parents (100%) desired to learn about results for treatable or preventable conditions, with 92.4% wanting results even when there is no treatment or prevention. Parents expressed less interest in receiving uncertain results for themselves (88.3%) than for their children (95.3%). Most parents (95.9%) and adolescents (87.9%) believed that providers have a responsibility to share new or updated germline results indefinitely or at any point during follow-up care. Fewer parents (67.5%) indicated that they would want results if their child was deceased: 10.3% would not want to be contacted, 19.3% were uncertain. CONCLUSIONS Expectations for return of new or updated genomic results are high among pediatric oncology families, although up to one third of parents have reservations about receiving such information in the event of their child's death. These results underscore the importance of high-quality pre-and post-test counseling, conducted by individuals trained in consenting around genomic testing to elicit family preferences and align expectations around the return of germline results.
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Affiliation(s)
- Liza-Marie Johnson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Belinda N Mandrell
- Department of Pediatrics, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Chen Li
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Zhaohua Lu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jami Gattuso
- Department of Pediatrics, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lynn W Harrison
- Department of Oncology, Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Motomi Mori
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Annastasia A Ouma
- Department of Oncology, Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Michele Pritchard
- Department of Pediatrics, Division of Nursing Research, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Kim E Nichols
- Department of Oncology, Division of Cancer Predisposition, St. Jude Children's Research Hospital, Memphis, TN, USA
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5
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Eichinger J, Elger BS, Koné I, Filges I, Shaw D, Zimmermann B, McLennan S. The full spectrum of ethical issues in pediatric genome-wide sequencing: a systematic qualitative review. BMC Pediatr 2021; 21:387. [PMID: 34488686 PMCID: PMC8420043 DOI: 10.1186/s12887-021-02830-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background The use of genome-wide sequencing in pediatric medicine and research is growing exponentially. While this has many potential benefits, the normative and empirical literature has highlighted various ethical issues. There have not been, however, any systematic reviews of these issues. The aim of this systematic review is to determine systematically the spectrum of ethical issues that is raised for stakeholders in in pediatric genome-wide sequencing. Methods A systematic review in PubMed and Google Books (publications in English or German between 2004 and 2021) was conducted. Further references were identified via reference screening. Data were analyzed and synthesized using qualitative content analysis. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or when two principles come into conflict. Results Our literature search retrieved 3175 publications of which 143 were included in the analysis. Together these mentioned 106 ethical issues in pediatric genome-wide sequencing, categorized into five themes along the pediatric genome-wide sequencing lifecycle. Most ethical issues identified in relation to genome-wide sequencing typically reflect ethical issues that arise in general genetic testing, but they are often amplified by the increased quantity of data obtained, and associated uncertainties. The most frequently discussed ethical aspects concern the issue of unsolicited findings. Conclusion Concentration of the debate on unsolicited findings risks overlooking other ethical challenges. An overarching difficulty presents the terminological confusion: both with regard to both the test procedure/ the scope of analysis, as well as with the topic of unsolicited findings. It is important that the genetics and ethics communities together with other medical professions involved work jointly on specific case related guidelines to grant the maximum benefit for the care of the children, while preventing patient harm and disproportionate overload of clinicians and the healthcare system by the wealth of available options and economic incentives to increase testing. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02830-w.
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Affiliation(s)
- Johanna Eichinger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland. .,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany.
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Center for legal medicine (CURML), University of Geneva, Geneva, Switzerland
| | - Insa Koné
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
| | - Isabel Filges
- Medical Genetics, Institute of Medical Genetics and Pathology, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Bettina Zimmermann
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
| | - Stuart McLennan
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.,Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany
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6
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Tibben A, Dondorp W, Cornelis C, Knoers N, Brilstra E, van Summeren M, Bolt I. Parents, their children, whole exome sequencing and unsolicited findings: growing towards the child's future autonomy. Eur J Hum Genet 2021; 29:911-919. [PMID: 33456055 DOI: 10.1038/s41431-020-00794-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 10/07/2020] [Accepted: 11/26/2020] [Indexed: 01/09/2023] Open
Abstract
In a previous study we found that parents of children with developmental delay (DD) favoured acceptance of unsolicited findings (UFs) for medically actionable conditions in childhood, but that preferences diverged for UFs with no medical actionability, or only in adulthood, and regarding carrier status. Sometimes the child's future autonomy formed a reason for withholding UFs for the present, despite an unfavourable prognosis concerning the child's cognitive capabilities. This might be different for children undergoing whole exome sequencing (WES) for reasons other than DD and who are expected to exert future autonomy. This is the focus of the current study. We conducted nine qualitative, semi-structured interviews with parents of children, ages <1-15, after consenting to WES, but prior to feedback of results, and with three adolescent children. Several parents wished to receive any information that might in whatever way be relevant to the health and well-being of their child, and to a lesser extent wished the inclusion of information about non-actionable disorders and information concerning carrier status of autosomal recessive disorders. Although parents understood the rationale behind the centre's UFs disclosure policy, they also felt that they needed this information in order to be able to exert their parental responsibility and take good care of a child still dependent on them. Parents reason from their notion of parental responsibility but are also inclined to take adolescent children's preferences seriously and acknowledge the child's incipient autonomy as a ground for granting an increasing degree of self-determination on the road to adulthood.
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Affiliation(s)
- Aad Tibben
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands.
| | - Wybo Dondorp
- Department of Health, Ethics & Society, Research School for Public Health & Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Candice Cornelis
- Ethics Institute, Utrecht University, Utrecht, the Netherlands.,Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nine Knoers
- Department of Genetics, University Medical Center Groningen, Groningen, the Netherlands
| | - Eva Brilstra
- Department of Medical Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marieke van Summeren
- Department of General Pediatrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ineke Bolt
- Ethics Institute, Utrecht University, Utrecht, the Netherlands.,Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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7
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Hoell C, Wynn J, Rasmussen LV, Marsolo K, Aufox SA, Chung WK, Connolly JJ, Freimuth RR, Kochan D, Hakonarson H, Harr M, Holm IA, Kullo IJ, Lammers PE, Leppig KA, Leslie ND, Myers MF, Sharp RR, Smith ME, Prows CA. Participant choices for return of genomic results in the eMERGE Network. Genet Med 2020; 22:1821-1829. [PMID: 32669677 DOI: 10.1038/s41436-020-0905-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Secondary findings are typically offered in an all or none fashion when sequencing is used for clinical purposes. This study aims to describe the process of offering categorical and granular choices for results in a large research consortium. METHODS Within the third phase of the electronic MEdical Records and GEnomics (eMERGE) Network, several sites implemented studies that allowed participants to choose the type of results they wanted to receive from a multigene sequencing panel. Sites were surveyed to capture the details of the implementation protocols and results of these choices. RESULTS Across the ten eMERGE sites, 4664 participants including adolescents and adults were offered some type of choice. Categories of choices offered and methods for selecting categories varied. Most participants (94.5%) chose to learn all genetic results, while 5.5% chose subsets of results. Several sites allowed participants to change their choices at various time points, and 0.5% of participants made changes. CONCLUSION Offering choices that include learning some results is important and should be a dynamic process to allow for changes in scientific knowledge, participant age group, and individual preference.
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Affiliation(s)
- Christin Hoell
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Julia Wynn
- Columbia University Irving Medical Center, New York, NY, USA
| | - Luke V Rasmussen
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Keith Marsolo
- Department of Population Health Sciences, and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Sharon A Aufox
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Wendy K Chung
- Columbia University Irving Medical Center, New York, NY, USA
| | - John J Connolly
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Robert R Freimuth
- Department of Health Sciences Research, Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Kochan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hakon Hakonarson
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaret Harr
- Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ingrid A Holm
- Division of Genetics and Genomics, and the Manton Center for Orphan Diseases Research, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Iftikhar J Kullo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Nancy D Leslie
- Division of Human Genetics, Cincinnati Children's Hospital, and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Melanie F Myers
- Division of Human Genetics, Cincinnati Children's Hospital, and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard R Sharp
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
| | - Maureen E Smith
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital, Cincinnati, OH, USA.
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8
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Adolescents' and Parents' Genomic Testing Decisions: Associations With Age, Race, and Sex. J Adolesc Health 2020; 66:288-295. [PMID: 31685375 PMCID: PMC7007858 DOI: 10.1016/j.jadohealth.2019.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE Adolescents will increasingly be involved in decisions about the return of genomic results. We examined adolescents' and parents' decisions about learning actual genomic research results for the adolescent and whether choices were associated with participants' demographic factors. METHODS Adolescents aged between 13 and 17 years and a parent (dyads) were recruited through flyers, social media, employee emails, and clinic visits at a pediatric hospital. Dyads used a decision tool to independently choose the categories of conditions they wanted to learn about the adolescent. They then came together to discuss their independent decisions and make final joint decisions. Conditions were categorized by preventability, treatability, adult-onset conditions, and carrier status. Participants could make granular choices by including or excluding conditions in each category. Categorical choices were collapsed into the "aggregate choice" to learn all or not all results. RESULTS Study visits were completed by 163 dyads. Adolescents were less likely than their parents to independently choose to learn all results (64.4% vs. 76.1%; p = .0056). Parents were less likely to independently choose to learn all results for their daughters than their sons (odds ratio = .41, 95% confidence interval .18-.96; p = .032). Black adolescents were less likely to independently choose to learn all results than white adolescents (odds ratio = .22; 95% confidence interval .08-.55; p = .0015). After making joint decisions, 70.6% of dyads chose to learn all results. CONCLUSIONS Adolescents independently wanted to learn less genomic information than their parents. Although adolescents cannot legally make genomic testing decisions without parental permission, adolescents' should be engaged in decisions about the return of genomic results.
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9
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Abstract
Next generation DNA sequencing (NGS) has the potential to improve the diagnostic and prognostic utility of newborn screening programmes. This study assesses the feasibility of automating NGS on dried blood spot (DBS) DNA in a United Kingdom National Health Service (UK NHS) laboratory. An NGS panel targeting the entire coding sequence of five genes relevant to disorders currently screened for in newborns in the UK was validated on DBS DNA. An automated process for DNA extraction, NGS and bioinformatics analysis was developed. The process was tested on DBS to determine feasibility, turnaround time and cost. The analytical sensitivity of the assay was 100% and analytical specificity was 99.96%, with a mean 99.5% concordance of variant calls between DBS and venous blood samples in regions with ≥30× coverage (96.8% across all regions; all variant calls were single nucleotide variants (SNVs), with indel performance not assessed). The pipeline enabled processing of up to 1000 samples a week with a turnaround time of four days from receipt of sample to reporting. This study concluded that it is feasible to automate targeted NGS on routine DBS samples in a UK NHS laboratory setting, but it may not currently be cost effective as a first line test.
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10
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De S, Pietilä AM, Iso-Touru T, Hopia A, Tahvonen R, Vähäkangas K. Information Provided to Consumers about Direct-to-Consumer Nutrigenetic Testing. Public Health Genomics 2019; 22:162-173. [PMID: 31779000 DOI: 10.1159/000503977] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nutrigenetic tests are often considered to be less serious compared to other health-related genetic tests, although they share similar ethical concerns. Nutrigenetic tests are mainly available through direct-to-consumer genetic testing (DTC GT) and increasing in popularity. OBJECTIVE To analyze the contents of nutrigenetic DTC GT websites with respect to the adequacy of the information provided to support a well-informed decision of purchasing the tests. METHODS The websites of DTC GT companies selling nutrigenetic tests that could be ordered online without involving any healthcare professional, available in English, marketing tests in Europe, the USA, Australia, or Canada, and accessible from Finland were included in the study (n = 38). Quantitative and qualitative content analyses of the websites were carried out with the help of a codebook. RESULTS Of the 38 websites, 8 included a clearly identifiable and easy-to-find information section about genetics. The quality and contents of these sections were often insufficient and/or misleading. Fourteen websites had specific sections discussing the risks related to GT, and on 13 signed informed consent was requested for GT. Furthermore, only 2 of the companies offered any kind of pretest consultation and 13 offered mostly separately charged posttest consultation. The complex structure of the websites made it difficult to find all key information, with many important aspects buried in legal documents, which were challenging to comprehend even for a professional. CONCLUSION The structure of the websites and the amount and quality of the content therein do not support a well-informed decision.
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Affiliation(s)
- Suchetana De
- School of Pharmacy/Toxicology, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Pietilä
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Terhi Iso-Touru
- Production Systems/Animal Genetics, Natural Resources Institute Finland (Luke), Jokioinen, Finland
| | - Anu Hopia
- Functional Foods Forum, Faculty of Medicine, University of Turku, Turku, Finland
| | - Raija Tahvonen
- Production Systems/Food Processing and Quality, Natural Resources Institute Finland (Luke), Jokioinen, Finland
| | - Kirsi Vähäkangas
- School of Pharmacy/Toxicology, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland,
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11
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Lin JC, Hsiao WWW, Fan CT. Managing "incidental findings" in biobank research: Recommendations of the Taiwan biobank. Comput Struct Biotechnol J 2019; 17:1135-1142. [PMID: 31462969 PMCID: PMC6709371 DOI: 10.1016/j.csbj.2019.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In this article, incidental findings (IF) refer to unforeseen findings made possible through biobanking research and advances in medical diagnostic technologies that raise issues regarding the obligation and/or responsibility of biobank-users and biobanks to return clinically significant information to participants. The World Medical Association (WMA) Declaration of Taipei (2016) highlights the possibility of encountering IF and requires that research on biospecimens address biobank feedback policies in their informed consent process, leaving open the possibility that the policy may be "no return". As clinicians and researchers begin to use these "resources", the possibility of finding clinically significant IF is becoming a reality. DISCUSSION In line with the WMA's Declaration of Taipei, a pragmatic approach is needed to deal with the issue of returning IF in biobank governance. Indeed, the impacts and concerns associated with the return of IF differ across different stakeholder groups and jurisdictions. Therefore, the framework governing IF return needs to be custom-built, taking into account the nature of each research project and the unique features of biobanks. To this end, in addition to facilitating biobank transparency, establishing an endurable and horizontal connection among biobanks and clinical institutions under a public health system will improve efficiency and effectiveness. Hence, subject to contemporary Taiwanese ethical and/or legal regulations, this article argues for the establishment of an updated framework for imaging-related and genetic-related IF return within the Taiwan Biobank (TWB), mainly based on a limited obligation to disclose life-threatening information revealed by imaging, but not genetic, information. SUMMARY After discussing some of the ethical, legal and social issues encountered by the TWB and accounting for the experiences of other international biobanks, we propose a systematic framework for returning IF, mainly on a "limited obligation" basis, which offers better and more comprehensive protection for biobank-participants' rights and health.
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Key Words
- Biobanks
- Bioethics
- EGF, Ethical Governance Framework
- ELSI, Ethical, Legal and Social Implications
- ESC, European Society of Cardiology
- Framework
- GNC, German National Cohort
- GP, General Practitioners
- IF, Incidental Findings
- IRBs, Institutional Review Boards
- Incidental finding
- MRI, Magnetic Resonance Imaging
- NHI, National Health Insurance
- NIH, National Institutes of Health
- P3G, Public Population Project in Genomics and Society
- TWB, Taiwan Biobank
- The WMA Declaration of Taipei (2016)
- UNESCO, United Nations Education Scientific and Cultural Organization
- WMA, World Medical Association
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Affiliation(s)
- Jui-Chu Lin
- College of Liberal Arts and Social Sciences, National Taiwan University of Science and Technology, Taipei, Taiwan, ROC
- Law & Technology Innovation Center, National Taiwan University of Science and Technology, Taipei, Taiwan, ROC
- Ethical, Legal and Social Implications (ELSI) of the Taiwan Biobank, Taipei, Taiwan, ROC
| | - Wesley Wei-Wen Hsiao
- Law & Technology Innovation Center, National Taiwan University of Science and Technology, Taipei, Taiwan, ROC
- Genomics Research Center, Academia Sinica, Taipei, Taiwan, ROC
| | - Chien-Te Fan
- Institute of Law for Science and Technology, National Tsing Hua University, Hsin-Chu, Taiwan, ROC
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12
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McVeigh E, Jones H, Black G, Hall G. The psychosocial and service delivery impact of genomic testing for inherited retinal dystrophies. J Community Genet 2019; 10:425-434. [PMID: 30680631 PMCID: PMC6591333 DOI: 10.1007/s12687-019-00406-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022] Open
Abstract
Next-generation sequencing (NGS) provides diagnostic information for many rare conditions. The evolution of NGS for panel, exome, and genome testing is set to be the platform for transforming genomic diagnosis in the National Health Service (NHS). Inherited retinal dystrophies (IRDs) are a highly genetically heterogeneous disease group causing progressive visual impairment. IRDs are ideal for an NGS panel approach due to phenotypic overlap and were one of the first diagnostic panels to be developed in the NHS. While diagnostic yield for patients with IRD has improved significantly with NGS, a proportion of patients remain without a diagnosis. The clinical value of NGS testing is well understood; however, the patient experience of panel testing is not well documented. Semi-structured qualitative telephone interviews were conducted with 23 participants with IRD who had undergone NGS testing. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis. Participants' experiences were interpreted to explore the psychosocial and service delivery impact of this testing technology, inclusive of those who received a pathogenic, negative, carrier status or variant of uncertain significance result. Collectively, three core themes were identified: (1) the journey towards a genomic diagnosis, (2) the impact of NGS testing, (3) service delivery of NGS tests. Disclosure of results had no reported adverse implications. Participants appreciated an open discussion about the potential for an uncertain or unexpected result, prior to testing. They valued pre-test counselling discussions, expert opinions and on-going care from genomic services.
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Affiliation(s)
- Eleanor McVeigh
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK.
| | - Harriet Jones
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham Women's Hospital, Birmingham, UK.
- Genetics Health Service, Northern Hub, Auckland City Hospital, Aukland, New Zealand.
| | - Graeme Black
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
| | - Georgina Hall
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester, UK
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13
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Pervola J, Myers MF, McGowan ML, Prows CA. Giving adolescents a voice: the types of genetic information adolescents choose to learn and why. Genet Med 2019; 21:965-971. [PMID: 30369597 PMCID: PMC10445294 DOI: 10.1038/s41436-018-0320-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/14/2018] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The American College of Medical Genetics and Genomics supports parents' opting in or out of secondary analysis of 59 genes when their child has clinical exome/genome sequencing. We explored the reasons adolescents choose to learn certain types of results and the reasons they want to involve or not involve parents in decision-making. METHODS Adolescents recruited without clinical indication were offered independent, followed by joint choices with a parent to learn genomic results. After making independent choices, adolescent/parent dyads were interviewed to explore the reasons for their choices. Interviews were audio-recorded and transcribed. The constant comparative method was used to analyze 64 purposefully selected transcripts that included 31 from adolescents who excluded some or all potential results. RESULTS Three major themes informed adolescents' choices: (1) actionability of information, (2) knowledge seeking, and (3) psychological impact. Of adolescents who independently excluded some conditions (n=31), 58% changed their initial choices during the joint interview due to parental influence or improved understanding. Nearly all adolescents (98%) wanted to be involved in the decision-making process, and 53% wanted to make choices independently. CONCLUSIONS Our findings contribute empirical evidence to support the refinement of professional guidelines for adolescents' engagement and preferences in genetic testing decisions.
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Affiliation(s)
- Josie Pervola
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melanie F Myers
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michelle L McGowan
- Ethics Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics & Women's, Gender & Sexuality Studies, University of Cincinnati, Cincinnati, OH, USA
| | - Cynthia A Prows
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Patient Services, Cincinnati Children's Hospital Medical Center Cincinnati, Cincinnati, OH, USA.
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14
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Jaitovich Groisman I, Hurlimann T, Godard B. Parents of a child with epilepsy: Views and expectations on receiving genetic results from Whole Genome Sequencing. Epilepsy Behav 2019; 90:178-190. [PMID: 30583270 DOI: 10.1016/j.yebeh.2018.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/02/2018] [Accepted: 11/19/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE The use of Next Generation Sequencing technologies (NGS), such as Whole Genome Sequencing (WGS), is expected to improve the often complex and protracted course of treatment of patients with epilepsy by providing an earlier and more accurate diagnosis. As part of the "Personalized medicine in the treatment of epilepsy" project, which aimed to determine whether WGS could be used as a valuable "diagnostic tool" in pharmacoresistant epilepsies, we examined parents' expectations, hopes, and concerns upon receiving results related to their child's epilepsy, comorbidities, resistance to medication, and genetic information on unrelated conditions, and how these results could impact their and their child's life. METHODS Parents of 32 children participating in the genetic study completed either paper or online questionnaires. A descriptive analysis of responses and comments was conducted regarding parents' experience with their child's epilepsy, as well as their views on WGS, and expectations and concerns surrounding such test results. RESULTS Most respondents had trouble explaining the medical causes of their child's epilepsy (n = 27), and a majority (n = 26) feared that their child may be treated unjustly because of their epilepsy, although some acknowledged that their child had never actually been treated unjustly (n = 13). A majority of respondents had also experienced feelings of guilt due to their child's epilepsy (n = 23), and some expected WGS results to have an impact on those feelings. The anticipation of benefits for their child was the parents' primary reason to get involved in a genomic research project, closely followed by altruism. A majority expressed strong intentions to receive as many WGS results as possible, considering that any could be beneficial for them and their child, even when mutations were not found. Respondents were divided as to how and when to tell their child that they might have newly discovered predispositions to develop another disease. In proportion, more parents expressed concerns about sharing unexpected results with their family members compared with sharing results linked to epilepsy, comorbidities, and pharmacoresistance. CONCLUSION Our results reinforce the importance of having clear guidelines to help parents manage their expectations and better navigate the complexities of receiving and sharing WGS results. Despite the small size of our sample, we believe that our results are meaningful to clinical practice.
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Affiliation(s)
| | - Thierry Hurlimann
- Université de Montréal, PO Box 6128, Station Centre-ville, Montreal H3C 3J7, Canada
| | - Béatrice Godard
- Université de Montréal, PO Box 6128, Station Centre-ville, Montreal H3C 3J7, Canada.
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15
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Impact of next generation sequencing on our understanding of CAKUT. Semin Cell Dev Biol 2018; 91:104-110. [PMID: 30172048 DOI: 10.1016/j.semcdb.2018.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 08/16/2018] [Accepted: 08/28/2018] [Indexed: 12/29/2022]
Abstract
Congenital abnormalities of the kidney and urinary tract (CAKUT) form the leading cause of pediatric end-stage renal disease. Knowledge on the molecular mechanisms that underlie CAKUT leads to the improvement of DNA diagnostics and counseling regarding prognosis and recurrence risk estimation for CAKUT patients and their relatives. Implementation of next generation sequencing in research and diagnostic settings has led to the identification of the molecular basis of many developmental diseases. In this review, we summarize the efforts on next generation sequencing in CAKUT research and we discuss how next generation sequencing added to our understanding of CAKUT genetics. Although next generation sequencing has certainly proven to be a game changer in the field of disease gene identification and novel CAKUT-causing gene variants have been identified, most CAKUT cases still remain unsolved. Occurring with genetic and phenotypic heterogeneity along with incomplete penetrance, the identification of CAKUT etiology poses many challenges. We see great potential for combined -omics approaches that include next generation sequencing in the identification of CAKUT-specific biomarkers, which is necessary to optimize the care for CAKUT patients.
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16
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Ottman R, Freyer C, Mefford HC, Poduri A, Lowenstein DH. Return of individual results in epilepsy genomic research: A view from the field. Epilepsia 2018; 59:1635-1642. [PMID: 30098010 DOI: 10.1111/epi.14530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/13/2018] [Accepted: 07/15/2018] [Indexed: 12/15/2022]
Abstract
Genomic findings are emerging rapidly in 2 large, closely related epilepsy research consortia: the Epilepsy Phenome/Genome Project and Epi4K. Disclosure of individual results to participants in genomic research is increasingly viewed as an ethical obligation, but strategies for return of results were not included in the design of these consortia, raising complexities in establishing criteria for which results to offer, determining participant preferences, managing the large number of sites involved, and covering associated costs. Here, we describe the challenges faced, alternative approaches considered, and progress to date. Experience from these 2 consortia illustrates the importance, for genomic research in epilepsy and other disorders, of including a specific plan for return of results in the study design, with financial support for obtaining clinical confirmation and providing ongoing support for participants. Participant preferences for return of results should be established at the time of enrollment, and methods for allowing future contacts with participants should be included. In addition, methods should be developed for summarizing meaningful, comprehensible information about findings in the aggregate that participants can access in an ongoing way.
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Affiliation(s)
- Ruth Ottman
- Departments of Epidemiology and Neurology, and G. H. Sergievsky Center, Columbia University, New York, New York.,Division of Translational Epidemiology, New York State Psychiatric Institute, New York, New York
| | - Catharine Freyer
- Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Heather C Mefford
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Annapurna Poduri
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Epilepsy Genetics Program, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, San Francisco, California
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17
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Oberg JA, Ruiz J, Ali-Shaw T, Schlechtweg KA, Ricci A, Kung AL, Chung WK, Appelbaum PS, Glade Bender JL, Levine JM. Whole-Genome and Whole-Exome Sequencing in Pediatric Oncology: An Assessment of Parent and Young Adult Patient Knowledge, Attitudes, and Expectations. JCO Precis Oncol 2018; 2:1700104. [PMID: 32913997 DOI: 10.1200/po.17.00104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose The complexity of results generated from whole-genome sequencing (WGS) and whole-exome sequencing (WES) adds challenges to obtaining informed consent in pediatric oncology. Little is known about knowledge of WGS and WES in this population, and no validated tools exist in pediatric oncology. Methods We developed and psychometrically evaluated a novel WGS and WES knowledge questionnaire, the Precision in Pediatric Sequencing Knowledge Questionnaire (PIPseqKQ), to identify levels of understanding among parents and young adult cancer survivors (≥ 18 years old), off therapy for at least 1 year from a single-institution pediatric oncology outpatient clinic. Participants also completed health literacy and numeracy questionnaires. All participants provided written informed consent. Results One hundred eleven participants were enrolled: 76 were parents, and 35 were young adults. Of the total cohort, 77 (69%) were female, 63 (57%) self-identified as white, and 74 (67%) self-identified as non-Hispanic. Sixty-six (59%) had less than a college degree. Adequate health literacy (n = 87; 80%) and numeracy (n = 89; 80%) were demonstrated. Internal consistency was high (Cronbach's α = .88), and test-retest reliability was greater than the 0.7 minimum requirement. Scores were highest for genetic concepts related to health and cancer and lowest for WGS and WES concepts. Health literacy and educational attainment were significantly associated with PIPseqKQ scores. Overall, participants felt the benefits of WGS and WES outweighed the potential risks. Conclusion Parents and young adult cancer survivors have some genetics knowledge, but they lack knowledge about WGS and WES. The PIPseqKQ is a reliable tool that can identify deficits in knowledge, identify perceptions of risks and benefits of WGS and WES, and help clinicians tailor their consent discussions to best fit families. The PIPseqKQ also may inform the development of educational tools to better facilitate the informed consent process in pediatric oncology.
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Affiliation(s)
- Jennifer A Oberg
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Jenny Ruiz
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Trisha Ali-Shaw
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathryn A Schlechtweg
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Angela Ricci
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew L Kung
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Wendy K Chung
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Paul S Appelbaum
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Julia L Glade Bender
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
| | - Jennifer M Levine
- , , , , , , and , Herbert Irving Comprehensive Cancer Center and Columbia University Medical Center; and , NewYork-Presbyterian Hospital; and , Columbia University College of Physicians and Surgeons, New York, NY
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18
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Zahed H, Sparks TN, Li B, Alsadah A, Shieh JTC. Potential Role of Genomic Sequencing in the Early Diagnosis of Treatable Genetic Conditions. J Pediatr 2017; 189:222-226.e1. [PMID: 28947054 PMCID: PMC6037534 DOI: 10.1016/j.jpeds.2017.06.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 04/02/2017] [Accepted: 06/15/2017] [Indexed: 12/18/2022]
Abstract
We present cases of 3 children diagnosed with the same genetic condition, Gitelman syndrome, at different stages using various genetic methods: panel testing, targeted single gene sequencing, and exome sequencing. We discuss the advantages and disadvantages of each method and review the potential of genomic sequencing for early disease detection.
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Affiliation(s)
- Hengameh Zahed
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Teresa N. Sparks
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Department of Obstetrics, Gynecology and Reproductive Medicine, University of California San Francisco, San Francisco, CA
| | - Ben Li
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Department of Obstetrics, Gynecology and Reproductive Medicine, University of California San Francisco, San Francisco, CA
| | - Adnan Alsadah
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Joseph T. C. Shieh
- Division of Medical Genetics, Department of Pediatrics, University of California San Francisco, San Francisco, CA
,Institute for Human Genetics, Benioff Children’s Hospital San Francisco, University of California San Francisco, San Francisco, CA
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19
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Kesselheim A, Ashton E, Bockenhauer D. Potential and pitfalls in the genetic diagnosis of kidney diseases. Clin Kidney J 2017; 10:581-585. [PMID: 28980668 PMCID: PMC5622903 DOI: 10.1093/ckj/sfx075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/13/2017] [Indexed: 12/14/2022] Open
Abstract
Next-generation sequencing has dramatically decreased the cost of gene sequencing, facilitating the simultaneous analysis of multiple genes at the same time; obtaining a genetic result for an individual patient has become much easier. The article by Ars and Torra in this issue of the Clinical Kidney Journal provides examples of the ever-increasing ability to understand a given patient's disease on the molecular level, so that in some cases not only the causative variants in a disease gene are identified, but also potential modifiers in other genes. Yet, with increased sequencing, a large number of variants are discovered that are difficult to interpret. These so-called 'variants of uncertain significance' raise important questions: when and how can pathogenicity be clearly attributed? This is of critical importance, as there are potentially serious consequences attached: decisions about various forms of treatment and even about life and death, such as termination of pregnancy, may hinge on the answer to these questions. Geneticists, thus, need to use the utmost care in the interpretation of identified variants and clinicians must be aware of this problem. We here discuss the potential of genetics to facilitate personalized treatment, but also the pitfalls and how to deal with them.
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Affiliation(s)
- Anne Kesselheim
- Centre for Nephrology, University College London, London, UK
| | - Emma Ashton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- North East Thames Regional Genetics Service, Molecular Genetics, London, UK
| | - Detlef Bockenhauer
- Centre for Nephrology, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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20
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McKay V, Efron D, Palmer EE, White SM, Pearson C, Danchin M. Current use of chromosomal microarray by Australian paediatricians and implications for the implementation of next generation sequencing. J Paediatr Child Health 2017; 53:650-656. [PMID: 28449382 DOI: 10.1111/jpc.13523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/10/2016] [Accepted: 12/21/2016] [Indexed: 11/30/2022]
Abstract
AIM Chromosomal microarray (CMA) is an important diagnostic test for children with multiple congenital anomalies or certain developmental behavioural problems suggestive of an underlying genetic diagnosis. However, there are medical and ethical complexities to its use and few Australian policies to guide practice. We aimed to describe the current practice of Australian paediatricians in relation to CMA testing. We hypothesised that there are knowledge gaps in their use of CMA. METHODS Online survey completed between September 2015 and January 2016 by paediatricians in secondary care settings. Participants were members of the Australian Paediatric Research Network. One hundred and sixty five (43%) of 383 active members responded. Our main outcome measures comprised: (i) the indications for which paediatricians request CMA; (ii) their approach to consent; (iii) their interpretation of results; and (iv) their understanding of the impact on patient management. RESULTS A significant proportion of paediatricians (21-52%) did not regularly use CMA for conditions with established evidence of diagnostic yield. Paediatricians under-estimated the potential for CMA findings to alter patient management. There was wide variability in paediatricians' approach to consent, and low use of consent forms and fact sheets. Paediatricians reported difficulties interpreting CMA results, with high rates of referral to clinical genetics services. CONCLUSIONS The reported practice of Australian paediatricians is not consistent with international standards on CMA. Australian practice could be improved by a standardised approach to ordering CMA, consenting patients and interpreting results. We provide resources for CMA ordering and make recommendations about preparation for next generation sequencing.
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Affiliation(s)
- Victoria McKay
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Daryl Efron
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth E Palmer
- Sydney Children's Hospital, Sydney, New South Wales, Australia.,Department of Women and Children's Health, Randwick Campus, University of New South Wales, Sydney, New South Wales, Australia.,Genetics of Learning Disability Service, Newcastle, New South Wales, Australia
| | - Susan M White
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Clinical Genetics Service, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Chris Pearson
- Department of General Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Margie Danchin
- Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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21
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Informed consent for next-generation nucleotide sequencing studies: Aiding communication between participants and investigators. J Clin Transl Sci 2017. [PMID: 28649453 PMCID: PMC5471895 DOI: 10.1017/cts.2016.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Obtaining informed consent from prospective participants for research studies that include next-generation nucleotide sequencing (NGS) presents significant challenges because of the need to explain all the potential implications of participating, including the possible return of "incidental" findings, in easy-to-understand language. METHODS AND RESULTS After reviewing the consent processes at other institutions, we decided to supplement the protocol-specific informed consent form with the following: (1) a short pamphlet for the prospective participant that includes a series of questions that she or he is encouraged to ask the investigator, and (2) a more detailed companion guide for investigators to help them develop simple-language answers to the questions. Both documents are available to use or modify. CONCLUSIONS We propose an approach to obtaining informed consent for NGS studies that encourages discussion of key issues without creating a complex, comprehensive document for participants; it also maximizes investigator flexibility. We also suggest mechanisms to return restricted information to participants.
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22
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Kesserwan C, Friedman Ross L, Bradbury AR, Nichols KE. The Advantages and Challenges of Testing Children for Heritable Predisposition to Cancer. Am Soc Clin Oncol Educ Book 2017; 35:251-69. [PMID: 27249705 DOI: 10.1200/edbk_160621] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The increased application of germline genetic testing is expanding our understanding of the risk factors associated with childhood cancer development, and, in some cases, such testing is also informing clinical management. Nonetheless, the incorporation of genetic testing into the pediatric oncology setting is complex and associated with many ethical and practical challenges. The decision as to whether to pursue clinical genetic testing for hereditary cancer predisposition for children should always be guided by the best interest of the child. Despite this fundamental ethical principle, patients, parents, and health care providers may differ in their opinions. Clinical genetic testing to detect the presence of predisposition syndromes associated with childhood-onset cancers, particularly those for which surveillance and preventive measures have proven to enhance outcome, is currently well accepted. On the other hand, clinical genetic testing of children for syndromes associated with adult-onset cancers has raised many concerns about the potential for psychological harm and disrespect of patient autonomy. As a consequence, such testing is not encouraged. The challenges surrounding germline genetic testing are further complicated when testing is done in the research setting and/or when it involves whole-exome or whole-genome sequencing approaches, which can uncover genetic variants that may or may not be associated with the disease under study. Accordingly, there is great debate around these processes and the most appropriate approaches regarding the return of test results. Future research is needed to enhance knowledge about how best to incorporate genomic information into clinical practice.
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Affiliation(s)
- Chimene Kesserwan
- From the Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Departments of Pediatrics, Medicine, and Surgery, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL; Department of Medicine, Department of Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Lainie Friedman Ross
- From the Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Departments of Pediatrics, Medicine, and Surgery, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL; Department of Medicine, Department of Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Angela R Bradbury
- From the Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Departments of Pediatrics, Medicine, and Surgery, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL; Department of Medicine, Department of Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Kim E Nichols
- From the Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Departments of Pediatrics, Medicine, and Surgery, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL; Department of Medicine, Department of Medical Ethics and Health Policy, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
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23
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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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24
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Sabatello M, Appelbaum PS. Raising Genomic Citizens: Adolescents and the Return of Secondary Genomic Findings. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2016; 44:292-308. [PMID: 27338605 PMCID: PMC4922508 DOI: 10.1177/1073110516654123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Whole genome and exome sequencing (WGS/WES) techniques raise hope for a new scale of diagnosis, prevention, and prediction of genetic conditions, and improved care for children. For these hopes to materialize, extensive genomic research with children will be needed. However, the use of WGS/WES in pediatric research settings raises considerable challenges for families, researchers, and policy development. In particular, the possibility that these techniques will generate genetic findings unrelated to the primary goal of sequencing has stirred intense debate about whether, which, how, and when these secondary or incidental findings (SFs) should be returned to parents and minors. The debate is even more pronounced when the subjects are adolescents, for whom decisions about return of SFs may have particular implications. In this paper, we consider the rise of "genomic citizenship" and the main challenges that arise for these stakeholders: adolescents' involvement in decisions relating to return of genomic SFs, the types of SFs that should be offered, privacy protections, and communication between researchers and adolescents about SFs. We argue that adolescents' involvement in genomic SF-related decisions acknowledges their status as valuable stakeholders without detracting from broader familial interests, and promotes more informed genomic citizens.
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Affiliation(s)
- Maya Sabatello
- Assistant Professor of Clinical Bioethics, Department of Psychiatry, Columbia University College of Physicians and Surgeons
| | - Paul S. Appelbaum
- Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and Director for Research on Ethical, Legal & Social Implications of Psychiatric, Neurologic & Behavioral Genetics, Department of Psychiatry, Columbia University College of Physicians and Surgeons
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25
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McCullough LB, Slashinski MJ, McGuire AL, Street RL, Eng CM, Gibbs RA, Parsons DW, Plon SE. Is Whole-Exome Sequencing an Ethically Disruptive Technology? Perspectives of Pediatric Oncologists and Parents of Pediatric Patients With Solid Tumors. Pediatr Blood Cancer 2016; 63:511-5. [PMID: 26505993 PMCID: PMC4982513 DOI: 10.1002/pbc.25815] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND It has been anticipated that physician and parents will be ill prepared or unprepared for the clinical introduction of genome sequencing, making it ethically disruptive. PROCEDURE As a part of the Baylor Advancing Sequencing in Childhood Cancer Care study, we conducted semistructured interviews with 16 pediatric oncologists and 40 parents of pediatric patients with cancer prior to the return of sequencing results. We elicited expectations and attitudes concerning the impact of sequencing on clinical decision making, clinical utility, and treatment expectations from both groups. Using accepted methods of qualitative research to analyze interview transcripts, we completed a thematic analysis to provide inductive insights into their views of sequencing. RESULTS Our major findings reveal that neither pediatric oncologists nor parents anticipate sequencing to be an ethically disruptive technology, because they expect to be prepared to integrate sequencing results into their existing approaches to learning and using new clinical information for care. Pediatric oncologists do not expect sequencing results to be more complex than other diagnostic information and plan simply to incorporate these data into their evidence-based approach to clinical practice, although they were concerned about impact on parents. For parents, there is an urgency to protect their child's health and in this context they expect genomic information to better prepare them to participate in decisions about their child's care. CONCLUSIONS Our data do not support the concern that introducing genome sequencing into childhood cancer care will be ethically disruptive, that is, leave physicians or parents ill prepared or unprepared to make responsible decisions about patient care.
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Affiliation(s)
- Laurence B. McCullough
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, Correspondence to: Laurence B. McCullough, Ph.D., Center for Medical Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza MS 420, Houston, TX 77030-3411, Tel.:713 798 3505,
| | - Melody J. Slashinski
- Department of Community Health Education, University of Massachusetts at Amherst, Amherst, Massachusetts
| | - Amy L. McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Richard L. Street
- Department of Communication, Texas A&M University, College Station, Texas,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Christine M. Eng
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Richard A. Gibbs
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - D. Williams Parsons
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas,Department of Pediatrics, Baylor College of Medicine Houston, Texas
| | - Sharon E. Plon
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas,Department of Pediatrics, Baylor College of Medicine Houston, Texas
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26
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Mori T, Hosomichi K, Chiga M, Mandai S, Nakaoka H, Sohara E, Okado T, Rai T, Sasaki S, Inoue I, Uchida S. Comprehensive genetic testing approach for major inherited kidney diseases, using next-generation sequencing with a custom panel. Clin Exp Nephrol 2016; 21:63-75. [PMID: 26920127 DOI: 10.1007/s10157-016-1252-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gene identification of hereditary kidney diseases by DNA sequencing is important for precise diagnosis, treatment, and genetic consultations. However, the conventional Sanger sequencing is now practically powerless in the face of ever increasing numbers of reported causative genes of various hereditary diseases. The advent of next-generation sequencing technology has enabled large-scale, genome-wide, simultaneous sequence analyses of multiple candidate genes. METHODS We designed and verified a comprehensive diagnosis panel for approximately 100 major inherited kidney diseases, including 127 known genes. The panel was named Simple, sPEedy and Efficient Diagnosis of Inherited KIdney Diseases (SPEEDI-KID). We applied the panel to 73 individuals, clinically diagnosed with an inherited kidney disease, from 56 families. RESULTS The panel efficiently covered the candidate genes and allowed a prompt and accurate genetic diagnosis. Moreover, 18 unreported mutations suspected as the disease causes were detected. All these mutations were validated by Sanger sequencing, with 100 % concordance. CONCLUSION In conclusion, we developed a powerful diagnostic method, focusing on inherited kidney diseases, using a custom panel, SPEEDI-KID, allowing a fast, easy, and comprehensive diagnosis regardless of the disease type.
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Affiliation(s)
- Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan.
| | - Kazuyoshi Hosomichi
- Department of Bioinformatics and Genomics, Kanazawa University, Ishikawa, Japan
| | - Motoko Chiga
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Shintaro Mandai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Hirofumi Nakaoka
- Division of Human Genetics, National Institute of Genetics, Shizuoka, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Tomokazu Okado
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Tatemitsu Rai
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Sei Sasaki
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
| | - Ituro Inoue
- Division of Human Genetics, National Institute of Genetics, Shizuoka, Japan
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8519, Japan
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27
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Hofmann B. Incidental findings of uncertain significance: To know or not to know--that is not the question. BMC Med Ethics 2016; 17:13. [PMID: 26873084 PMCID: PMC4752786 DOI: 10.1186/s12910-016-0096-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/04/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although the "right not to know" is well established in international regulations, it has been heavily debated. Ubiquitous results from extended exome and genome analysis have challenged the right not to know. American College of Medical Genetics and Genomics (ACMG) Recommendations urge to inform about incidental findings that pretend to be accurate and actionable. However, ample clinical cases raise the question whether these criteria are met. Many incidental findings are of uncertain significance (IFUS). The eager to feedback information appears to enter the field of IFUS and thereby threaten the right not to know. This makes it imperative to investigate the arguments for and against a right not to know for IFUS. DISCUSSION This article investigates how the various arguments for and against a right not to know hold for IFUS. The main investigated arguments are: hypothetical utilitarianism, the right-based argument, the feasibility argument, the value of knowledge argument, the argument from lost significance, the empirical argument, the duty to disclose argument, the avoiding harm argument; the argument from principle, from autonomy, from privacy, as well as the argument from the right to an open future. The analysis shows that both sides in the debate have exaggerated the importance of incidental findings. Opponents of a right not to know have exaggerated the importance of IFUS, while proponents have exaggerated the need to be protected from something that is not knowledge. Hence, to know or not to know is not the question. The question is whether we should be able to stay ignorant of incidental findings of uncertain significance, if we want to. The answer is yes: As long as the information is not accurate and/or actionable: ignorance is bliss. When answering questions that are not asked, we need to think twice.
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Affiliation(s)
- Bjørn Hofmann
- Norwegian University of Science and Technology, Gjøvik, Norway. .,Centre for Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318, Oslo, Norway.
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28
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Not the End of the Odyssey: Parental Perceptions of Whole Exome Sequencing (WES) in Pediatric Undiagnosed Disorders. J Genet Couns 2016; 25:1019-31. [PMID: 26868367 DOI: 10.1007/s10897-016-9933-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/14/2016] [Indexed: 01/26/2023]
Abstract
Due to the lack of empirical information on parental perceptions of primary results of whole exome sequencing (WES), we conducted a retrospective semi-structured interview with 19 parents of children who had undergone WES. Perceptions explored during the interview included factors that would contribute to parental empowerment such as: parental expectations, understanding of the WES and results, utilization of the WES information, and communication of findings to health/educational professionals and family members. Results of the WES had previously been communicated to families within a novel framework of clinical diagnostic categories: 5/19 had Definite diagnoses, 6/19 had Likely diagnoses, 3/19 had Possible diagnosis and 5/19 had No diagnosis. All parents interviewed expressed a sense of duty to pursue the WES in search of a diagnosis; however, their expectations were tempered by previous experiences with negative genetic testing results. Approximately half the parents worried that a primary diagnosis that would be lethal might be identified; however, the hope of a diagnosis outweighed this concern. Parents were accurately able to summarize their child's WES findings, understood the implications for recurrence risks, and were able to communicate these findings to family and medical/educational providers. The majority of those with a Definite/Likely diagnosis felt that their child's medical care was more focused, or there was a reduction in worry, despite the lack of a specific treatment. Irrespective of diagnostic outcome, parents recommended that follow-up visits be built into the process. Several parents expressed a desire to have all variants of unknown significance (VUS) reported to them so that they could investigate these themselves. Finally, for some families whose children had a Definite/Likely diagnosis, there was remaining frustration and a sense of isolation, due to the limited information that was available about the diagnosed rare disorders and the inability to connect to other families, suggesting that for families with rare genetic disorders, the diagnostic odyssey does not necessarily end with a diagnosis. Qualitative interviewing served a meaningful role in eliciting new information about parental motivations, expectations, and knowledge of WES. Our findings highlight a need for continued communication with families as we navigate the new landscape of genomic sequencing.
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29
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Sénécal K, Rahimzadeh V, Knoppers BM, Fernandez CV, Avard D, Sinnett D. Statement of principles on the return of research results and incidental findings in paediatric research: a multi-site consultative process. Genome 2015; 58:541-8. [PMID: 26613133 DOI: 10.1139/gen-2015-0092] [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] [Indexed: 12/13/2022]
Abstract
This paper proposes a set of recommendations for the return of research results and incidental findings in paediatrics. The Network of Applied Genetic Medicine of Quebec spearheaded the initiative to develop the Statement of Principles on the Return of Research Results and Incidental Findings, which was the result of a consultation process with clinical and research experts in the field. To formulate the Statement of Principles, the authors (i) reviewed empirical and grey literature on the return of research results and incidental findings in Europe and Canada, (ii) conducted a qualitative study of stakeholder groups, (iii) developed, and (iv) validated the recommendations through consultations with the stakeholder groups. The Statement of Principles provides a useful disclosure tool for deciding when, and under what circumstances to return research results and incidental findings. It addresses the issue of return of results in genetic research generally, and has also specific principles for various research contexts, including paediatric research. It delineates ethical issues unique to paediatric research, and provides a framework to guide research ethics committees as well as the research community in addressing these issues.
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Affiliation(s)
- Karine Sénécal
- a Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University, 740, avenue Dr. Penfield, #5202 Montreal, QC H3A 0G1, Canada
| | - Vasiliki Rahimzadeh
- b Centre of Genomics and Policy, Faculty of Medicine, Department of Family Medicine, McGill University, 740, avenue Dr. Penfield, #5203, Montreal, QC H3A 0G1, Canada
| | - Bartha M Knoppers
- c Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University, Canada Research Chair in Law and Medicine, 740, avenue Dr. Penfield, #5214, Montreal, QC H3A 0G1, Canada
| | - Conrad V Fernandez
- d IWK Health Centre, Department of Pediatrics, Dalhousie University, 5850 University Avenue, P.O. Box 9700, Halifax, NS B3K 6R8, Canada
| | - Denise Avard
- a Centre of Genomics and Policy, Faculty of Medicine, Department of Human Genetics, McGill University, 740, avenue Dr. Penfield, #5202 Montreal, QC H3A 0G1, Canada
| | - Daniel Sinnett
- e Sainte-Justine University Health Center, Research Center, Department of Pediatrics, University of Montreal, 3175 Chemin de la Côte Sainte-Catherine, Montreal, QC H3T 1C5, Canada
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30
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Giarelli E, Reiff M. Mothers' appreciation of chromosomal microarray analysis for autism spectrum disorder. J SPEC PEDIATR NURS 2015; 20:244-58. [PMID: 26112659 DOI: 10.1111/jspn.12121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 05/06/2015] [Accepted: 05/11/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE The aim of this study was to examine mothers' experiences with chromosomal microarray analysis (CMA) for a child with autism spectrum disorder (ASD). DESIGN AND METHODS This is a descriptive qualitative study using thematic content analysis of in-depth interview with 48 mothers of children who had genetic testing for ASD. RESULTS The principal theme, "something is missing," included missing knowledge about genetics, information on use of the results, explanations of the relevance to the diagnosis, and relevance to life-long care. Two subordinate themes were (a) disappreciation of the helpfulness of scientific information to explain the diagnosis, and (b) returning to personal experience for interpretation. PRACTICE IMPLICATIONS The test "appreciated" in value when results could be linked to the phenotype.
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Affiliation(s)
- Ellen Giarelli
- College of Nursing and Health Professions, Doctoral Nursing Program, Drexel University
| | - Marian Reiff
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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31
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Mallett A, Patel C, Maier B, McGaughran J, Gabbett M, Takasato M, Cameron A, Trnka P, Alexander SI, Rangan G, Tchan MC, Caruana G, John G, Quinlan C, McCarthy HJ, Hyland V, Hoy WE, Wolvetang E, Taft R, Simons C, Healy H, Little M. A protocol for the identification and validation of novel genetic causes of kidney disease. BMC Nephrol 2015; 16:152. [PMID: 26374634 PMCID: PMC4570515 DOI: 10.1186/s12882-015-0148-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/07/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Genetic renal diseases (GRD) are a heterogeneous and incompletely understood group of disorders accounting for approximately 10 % of those diagnosed with kidney disease. The advent of Next Generation sequencing and new approaches to disease modelling may allow the identification and validation of novel genetic variants in patients with previously incompletely explained or understood GRD. METHODS/DESIGN This study will recruit participants in families/trios from a multidisciplinary sub-specialty Renal Genetics Clinic where known genetic causes of GRD have been excluded or where genetic testing is not available. After informed patient consent, whole exome and/or genome sequencing will be performed with bioinformatics analysis undertaken using a customised variant assessment tool. A rigorous process for participant data management will be undertaken. Novel genetic findings will be validated using patient-derived induced pluripotent stem cells via differentiation to renal and relevant extra-renal tissue phenotypes in vitro. A process for managing the risk of incidental findings and the return of study results to participants has been developed. DISCUSSION This investigator-initiated approach brings together experts in nephrology, clinical and molecular genetics, pathology and developmental biology to discover and validate novel genetic causes for patients in Australia affected by GRD without a known genetic aetiology or pathobiology.
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Affiliation(s)
- Andrew Mallett
- Kidney Health Service and Conjoint Kidney Research Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Australia. .,Centre for Kidney Disease Research, Centre for Chronic Disease and CKD.QLD, School of Medicine, The University of Queensland, St Lucia, Australia. .,Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia. .,Kidney Health Service, Level 9, Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, Qld, 4029, Australia.
| | - Chirag Patel
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Barbara Maier
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Julie McGaughran
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Michael Gabbett
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.,School of Medicine, Griffith University, Brisbane, Australia
| | - Minoru Takasato
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
| | - Anne Cameron
- Centre for Kidney Disease Research, Centre for Chronic Disease and CKD.QLD, School of Medicine, The University of Queensland, St Lucia, Australia
| | - Peter Trnka
- Queensland Child and Adolescent Renal Service, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Stephen I Alexander
- Department of Nephrology, Children's Hospital at Westmead, Sydney and Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Gopala Rangan
- Department of Nephrology, Westmead Hospital, Sydney and Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney and Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Georgina Caruana
- Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Australia
| | - George John
- Kidney Health Service and Conjoint Kidney Research Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Cathy Quinlan
- Department of Nephrology, Royal Children's Hospital, Melbourne, Australia
| | - Hugh J McCarthy
- Department of Nephrology, Children's Hospital at Westmead, Sydney and Sydney Medical School, The University of Sydney, Sydney, Australia.,Department of Genetic Medicine, Westmead Hospital, Sydney and Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Valentine Hyland
- Molecular Genetics Laboratory, Pathology Queensland and Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Wendy E Hoy
- Centre for Kidney Disease Research, Centre for Chronic Disease and CKD.QLD, School of Medicine, The University of Queensland, St Lucia, Australia
| | - Ernst Wolvetang
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, Australia
| | - Ryan Taft
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia
| | - Cas Simons
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia
| | - Helen Healy
- Kidney Health Service and Conjoint Kidney Research Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre for Kidney Disease Research, Centre for Chronic Disease and CKD.QLD, School of Medicine, The University of Queensland, St Lucia, Australia
| | - Melissa Little
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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32
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Roche MI, Berg JS. Incidental Findings with Genomic Testing: Implications for Genetic Counseling Practice. CURRENT GENETIC MEDICINE REPORTS 2015; 3:166-176. [PMID: 26566463 PMCID: PMC4633435 DOI: 10.1007/s40142-015-0075-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This paper summarizes the current controversies surrounding the identification and disclosure of "incidental" or "secondary" findings from genomic sequencing and the implications for genetic counseling practice. The rapid expansion of clinical sequencing has influenced the ascertainment and return of incidental findings, while empiric data to inform best practices are still being generated. Using the North Carolina Clinical Genomic Evaluation by Next Generation Exome Sequencing (NCGENES) research project as an example, we discuss the implications of different models of consent and their impact on patient decisions.
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Affiliation(s)
- Myra I. Roche
- />Department of Pediatrics and Genetics, School of Medicine, The University of North Carolina at Chapel Hill, 326A MacNider, Chapel Hill, NC 27599-7240 USA
| | - Jonathan S. Berg
- />Department of Genetics, The University of North Carolina at Chapel Hill, 120 Mason Farm Road, Chapel Hill, NC 27599-7264 USA
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33
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Oberg JA, Glade Bender JL, Cohn EG, Morris M, Ruiz J, Chung WK, Appelbaum PS, Kung AL, Levine JM. Overcoming challenges to meaningful informed consent for whole genome sequencing in pediatric cancer research. Pediatr Blood Cancer 2015; 62:1374-80. [PMID: 25832998 DOI: 10.1002/pbc.25520] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 02/19/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Introducing whole genome sequencing (WGS) into pediatric cancer research at diagnosis poses unique challenges related to informed consent. WGS requires tissue obtained prior to initiating treatment, when families may be overwhelmed with uncertainty and fear. Motivation to participate may be high without fully understanding the range of possible results, including secondary findings. Little is known about parental knowledge, attitudes, and beliefs about this type of research. PROCEDURE A qualitative study was conducted to investigate parental knowledge about genetic concepts and WGS, thoughts about the informed consent process, and preferences for secondary findings. Focus groups were conducted with parents/guardians of children with cancer and semi-structured interviews were conducted in a control group without cancer. All transcripts were analyzed using content analysis. RESULTS Four focus groups included 15 participants; eight semi-structured interviews included 10 participants. Basic knowledge about genetics was limited to heredity. Some knowledge of genomic analysis was present in 3/15 focus group participants. Major factors related to participation in WGS research were: (i) hope for their child and future children; (ii) no additional procedures; (iii) and protection of privacy. All favored a two-step consent process, first to store extra tissue from a diagnostic biopsy/resection, followed by consenting to WGS research, one-to-two months later. The desire to receive secondary findings was high among both groups, but there were individuals who did not want these results, fearing increased anxiety. CONCLUSIONS Parents/guardians of children with cancer have limited knowledge about WGS. A two-step consent process may improve their ability to provide meaningful informed consent.
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Affiliation(s)
- Jennifer A Oberg
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Julia L Glade Bender
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Elizabeth G Cohn
- School of Nursing, Division of Academics, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Marilyn Morris
- Department of Pediatrics, Division of Pediatric Critical Care, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Jenny Ruiz
- College of Physicians and Surgeons, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Wendy K Chung
- Department of Pediatrics and Medicine, Division of Pediatric Molecular Genetics, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Paul S Appelbaum
- Department of Psychiatry, Division of Law, Ethics, and Psychiatry, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Andrew L Kung
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
| | - Jennifer M Levine
- Department of Pediatrics, Division of Hematology, Oncology, Stem Cell Transplantation, Columbia University Medical Center, 161 Fort Washington Avenue, IP7, New York, New York
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Comprehensive gene panels provide advantages over clinical exome sequencing for Mendelian diseases. Genome Biol 2015; 16:134. [PMID: 26112015 PMCID: PMC4499193 DOI: 10.1186/s13059-015-0693-2] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 06/12/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND To understand the contribution of Mendelian mutations to the burden of undiagnosed diseases that are suspected to be genetic in origin, we developed a next-generation sequencing-based multiplexing assay that encompasses the ~3000 known Mendelian genes. This assay, which we term the Mendeliome, comprises 13 gene panels based on clinical themes, covering the spectrum of pediatric and adult clinical genetic medicine. We explore how these panels compare with clinical whole exome sequencing (WES). RESULTS We tested 2357 patients referred with suspected genetic diagnoses from virtually every medical specialty. A likely causal mutation was identified in 1018 patients, with an overall clinical sensitivity of 43 %, comparing favorably with WES. Furthermore, the cost of clinical-grade WES is high (typically more than 4500 US dollars), whereas the cost of running a sample on one of our panels is around 75-150 US dollars, depending on the panel. Of the "negative" cases, 11 % were subsequently found by WES to harbor a likely causal mutation in a known disease gene (largely in genes identified after the design of our assay), as inferred from a representative sample of 178. Although our study population is enriched for consanguinity, 245 (24 %) of solved cases were autosomal dominant and 35 (4 %) were X-linked, suggesting that our assay is also applicable to outbred populations. CONCLUSIONS Despite missing a significant number of cases, the current version of the Mendeliome assay can account for a large proportion of suspected genetic disorders, and provides significant practical advantages over clinical WES.
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Blackburn HL, Schroeder B, Turner C, Shriver CD, Ellsworth DL, Ellsworth RE. Management of Incidental Findings in the Era of Next-generation Sequencing. Curr Genomics 2015; 16:159-74. [PMID: 26069456 PMCID: PMC4460220 DOI: 10.2174/1389202916666150317232930] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/23/2015] [Accepted: 03/09/2015] [Indexed: 02/06/2023] Open
Abstract
Next-generation sequencing (NGS) technologies allow for the generation of whole exome or whole genome sequencing data, which can be used to identify novel genetic alterations associated with defined phenotypes or to expedite discovery of functional variants for improved patient care. Because this robust technology has the ability to identify all mutations within a genome, incidental findings (IF)- genetic alterations associated with conditions or diseases unrelated to the patient's present condition for which current tests are being performed- may have important clinical ramifications. The current debate among genetic scientists and clinicians focuses on the following questions: 1) should any IF be disclosed to patients, and 2) which IF should be disclosed - actionable mutations, variants of unknown significance, or all IF? Policies for disclosure of IF are being developed for when and how to convey these findings and whether adults, minors, or individuals unable to provide consent have the right to refuse receipt of IF. In this review, we detail current NGS technology platforms, discuss pressing issues regarding disclosure of IF, and how IF are currently being handled in prenatal, pediatric, and adult patients.
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Affiliation(s)
| | - Bradley Schroeder
- Clinical Breast Care Project, Windber Research Institute, Windber, PA, USA
| | - Clesson Turner
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Craig D. Shriver
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Rachel E. Ellsworth
- Clinical Breast Care Project, Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Kaphingst KA, Ivanovich J, Biesecker BB, Dresser R, Seo J, Dressler LG, Goodfellow PJ, Goodman MS. Preferences for return of incidental findings from genome sequencing among women diagnosed with breast cancer at a young age. Clin Genet 2015; 89:378-84. [PMID: 25871653 DOI: 10.1111/cge.12597] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 12/19/2022]
Abstract
While experts have made recommendations, information is needed regarding what genome sequencing results patients would want returned. We investigated what results women diagnosed with breast cancer at a young age would want returned and why. We conducted 60 semi-structured, in-person individual interviews with women diagnosed with breast cancer at age 40 or younger. We examined interest in six types of incidental findings and reasons for interest or disinterest in each type. Two coders independently coded interview transcripts; analysis was conducted using NVivo 10. Most participants were at least somewhat interested in all six result types, but strongest interest was in actionable results (i.e. variants affecting risk of a preventable or treatable disease and treatment response). Reasons for interest varied between different result types. Some participants were not interested or ambivalent about results not seen as currently actionable. Participants wanted to be able to choose what results are returned. Participants distinguished between types of individual genome sequencing results, with different reasons for wanting different types of information. The findings suggest that a focus on actionable results can be a common ground for all stakeholders in developing a policy for returning individual genome sequencing results.
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Affiliation(s)
- K A Kaphingst
- Department of Communication, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - J Ivanovich
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - B B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - R Dresser
- School of Law, Washington University, St. Louis, MO, USA
| | - J Seo
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | | | - P J Goodfellow
- College of Medicine, Ohio State University, Columbus, OH, USA
| | - M S Goodman
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Management and return of incidental genomic findings in clinical trials. THE PHARMACOGENOMICS JOURNAL 2014; 15:1-5. [PMID: 25348616 DOI: 10.1038/tpj.2014.62] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 08/21/2014] [Accepted: 08/28/2014] [Indexed: 01/04/2023]
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Kleiderman E, Knoppers BM, Fernandez CV, Boycott KM, Ouellette G, Wong-Rieger D, Adam S, Richer J, Avard D. Returning incidental findings from genetic research to children: views of parents of children affected by rare diseases. JOURNAL OF MEDICAL ETHICS 2014; 40:691-6. [PMID: 24356209 PMCID: PMC4173986 DOI: 10.1136/medethics-2013-101648] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
PURPOSE To explore parental perceptions and experiences regarding the return of genomic incidental research findings in children with rare diseases. METHODS Parents of children affected by various rare diseases were invited to participate in focus groups or individual telephone interviews in Montreal and Ottawa. Fifteen participants were interviewed and transcriptions were analysed using thematic analysis. RESULTS Four emergent themes underscored parental enthusiasm for receiving incidental findings concerning their child's health: (1) right to information; (2) perceived benefits and risks; (3) communication practicalities: who, when, and how; and (4) service needs to promote the communication of incidental findings. Parents believed they should be made aware of all results pertaining to their child's health status, and that they are responsible for transmitting this information to their child, irrespective of disease severity. Despite potential negative consequences, respondents generally perceived a favourable risk-benefit ratio in receiving all incidental findings. CONCLUSIONS Understanding how parents assess the risks and benefits of returning incidental findings is essential to genomic research applications in paediatric medicine. The authors believe the study findings will contribute to establishing future best practices, although further research is needed to evaluate the impact of parental decisions on themselves and their child.
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Affiliation(s)
- Erika Kleiderman
- Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Conrad V Fernandez
- Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
| | - Kym M Boycott
- Faculty of Medicine, Departments of Pediatrics and Bioethics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gail Ouellette
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ontario, Canada
| | | | - Shelin Adam
- Institute for Optimizing Health Outcomes, Canadian Organization for Rare Disorders, Toronto, Ontario, Canada
| | - Julie Richer
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise Avard
- Centre of Genomics and Policy, McGill University, Montreal, Quebec, Canada
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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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Prows CA, Tran G, Blosser B. Whole exome or genome sequencing: nurses need to prepare families for the possibilities. J Adv Nurs 2014; 70:2736-45. [DOI: 10.1111/jan.12516] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2014] [Indexed: 12/27/2022]
Affiliation(s)
- Cynthia A. Prows
- Division of Human Genetics; Department of Pediatrics; Department of Patient Services; Children's Hospital Medical Center; Cincinnati; Ohio USA
| | - Grace Tran
- The University of Texas MD Anderson Cancer Center; University of Cincinnati, Cincinnati Children's Hospital Medical Center; Ohio USA
| | - Beverly Blosser
- Division of Human Genetics; Cytogenetics Laboratory, Children's Hospital Medical Center, Cincinnati; Ohio USA
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Abstract
INTRODUCTION Next-generation sequencing (NGS) is transforming the conduct of genetic research and diagnostic investigation. This creates new challenges as it generates additional information, including unsought and unwanted information. Nevertheless, this information must be deliberately managed-interpreted, disclosed and then either stored or destroyed. AREAS OF AGREEMENT Handling the process of consent to exome or genome sequencing should include discussion about the possible detection of variants of uncertain significance (VUSs) or incidental findings (IFs) that the patient may prefer not to hear about. A plan should be drawn up that specifies whether and how the patient would be recontacted in the future with new interpretations. AREAS OF CONTROVERSY There is an active debate about which IFs or VUSs should be disclosed to the patient when an exome or genome sequence has been performed, or whether all findings of any possible relevance should always be disclosed. How this is managed has important implications for the initial explanation of the test to the patient and the process of consent. The assumption is often made that all sequence information should be stored, but this may not be sustainable or useful. GROWING POINTS Efforts are being made to build a consensus on what 'incidental' information should be disclosed. These policy questions are being addressed in many centres and practices are evolving rapidly. AREAS TIMELY FOR DEVELOPING RESEARCH Those interested in genetics, public health, bioethics and medical ethics may wish to debate these issues and influence future practice in both genetic research and genetic diagnostic services.
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Affiliation(s)
- Angus J Clarke
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
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Abstract
Since first sequencing the human genome in 2003, emerging genetic/genomic technologies have ushered in a revolutionary era of medicine that purports to bridge molecular biology and clinical care. The field of translational medicine is charged with mediating this revolution. Sequencing innovations are far outpacing guidelines intended to ease their practice-based applications, including in primary care. As a result, genomic medicine’s full integration in primary care settings especially, has been slow to materialize. Researchers and clinicians alike face substantial challenges in navigating contentious ethical issues raised in translation and implementation, namely preserving the spirit of whole-person approaches to care; maintaining respect for persons and communities; and translating genetic risk into clinical actionability. This commentary therefore explores practical barriers to, and ethical implications of, incorporating genomic technologies in the primary care sector. These ethical challenges are both philosophical and infrastructural. From a primary care perspective, the commentary further reviews the ethical, legal and social implications of the Center for Disease Control’s proposed model for assessing the validity and utility of genomic testing and family health history applications. Lastly, the authors provide recommendations for future translational initiatives that aim to maximize the capacities of genomic medicine, without compromising primary care philosophies and foundations of practice.
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Reiff M, Mueller R, Mulchandani S, Spinner NB, Pyeritz RE, Bernhardt BA. A qualitative study of healthcare providers' perspectives on the implications of genome-wide testing in pediatric clinical practice. J Genet Couns 2014; 23:474-88. [PMID: 24037030 PMCID: PMC3955216 DOI: 10.1007/s10897-013-9653-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 08/22/2013] [Indexed: 12/20/2022]
Abstract
The utilization of genome-wide chromosomal microarray analysis (CMA) in pediatric clinical practice provides an opportunity to consider how genetic diagnostics is evolving, and to prepare for the clinical integration of genome-wide sequencing technologies. We conducted semi-structured interviews with 15 healthcare providers (7 genetic counselors, 4 medical geneticists, and 4 non-genetics providers) to investigate the impact of CMA on clinical practice, and implications for providers, patients and families. Interviews were analyzed qualitatively using content analysis. Most providers reported that genomic testing enhanced their professional experience and was beneficial to patients, primarily due to the improved diagnostic rate compared with earlier chromosomal studies. Other effects on practice included moving towards genotype-first diagnosis and broadening indications for chromosomal testing. Opinions varied concerning informed consent and disclosure of results. The duty to disclose incidental findings (IFs) was noted; however concerns were raised about potential psychosocial harms of disclosing pre-symptomatic findings. Tensions were revealed between the need for comprehensive informed consent for all families and the challenges of communicating time-consuming and potentially anxiety-provoking information regarding uncertain and incidental findings that may be relevant only in rare cases. Genetic counselors can play an important role in liaising with families, health professionals and testing laboratories, providing education and guidance to non-genetics providers, and enabling families to receive adequate pre-and post-test information and follow-up care.
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Affiliation(s)
- Marian Reiff
- Center for the Integration of Genetic Health Care Technologies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,
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44
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Patel A, Bi W. Incidental Finding in Copy Number Variation (CNV) Analysis. CURRENT GENETIC MEDICINE REPORTS 2014. [DOI: 10.1007/s40142-014-0050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gourna EG, Armstrong N, Wallace SE. Incidental findings from clinical sequencing in Greece: reporting experts' attitudes. J Community Genet 2014; 5:383-93. [PMID: 25048384 PMCID: PMC4159477 DOI: 10.1007/s12687-014-0194-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 07/03/2014] [Indexed: 12/20/2022] Open
Abstract
Unprecedented progress in sequencing technologies and decreasing cost have brought genomic testing into the clinical setting. At the same time, the debate in the literature concerning the return of incidental findings (IFs) has made this an important issue internationally. These developments reflect a shift in genetics that will also affect smaller countries, such as Greece, that are just starting to implement these technologies and may look to other countries for examples of good practice. Ten in-depth interviews were conducted with Greek experts in clinical sequencing. Previous experiences and attitudes toward IFs and clinical sequencing were investigated as well as views on the existing policy regarding managing genetic information generated through testing. . Interviews were analysed using thematic analysis. All participants reported the lack of any legal or other supportive mechanism. IFs are currently managed at a “local” level, i.e. within the clinic or the laboratory in an ad hoc way. All participants thought that clinically valid and actionable IFs should be returned, but always with caution and in respect to patients’ wishes, although several experts reported returning IFs according to their clinical discretion. Experts reported that most patients ask for all tests available but they felt that more counselling is needed to understand and manage genetic information. Due to the lack of any supporting mechanisms, professionals in Greece, even those with established experience in the field of genetic and genomic testing, have difficulties dealing with IFs. All experts agreed that it is now time, before the full integration of genomic testing into everyday clinical practice, for guidance to help Greek physicians work with patients and their families when IFs are discovered.
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Affiliation(s)
- E G Gourna
- Department of Health Sciences, University of Leicester, Adrian Building, Leicester, LE1 7RH, UK,
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To disclose, or not to disclose? Context matters. Eur J Hum Genet 2014; 23:279-84. [PMID: 24916647 PMCID: PMC4062531 DOI: 10.1038/ejhg.2014.108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/15/2014] [Accepted: 04/29/2014] [Indexed: 12/31/2022] Open
Abstract
Progress in understanding childhood disease using next-generation sequencing (NGS) portends vast improvements in the nature and quality of patient care. However, ethical questions surrounding the disclosure of incidental findings (IFs) persist, as NGS and other novel genomic technologies become the preferred tool for clinical genetic testing. Thus, the need for comprehensive management plans and multidisciplinary discussion on the return of IFs in pediatric research has never been more immediate. The aim of this study is to explore the views of investigators concerning the return of IFs in the pediatric oncology research context. Our findings reveal at least four contextual themes underlying the ethics of when, and how, IFs could be disclosed to participants and their families: clinical significance of the result, respect for individual, scope of professional responsibilities, and implications for the healthcare/research system. Moreover, the study proposes two action items toward anticipatory governance of IF in genetic research with children. The need to recognize the multiplicity of contextual factors in determining IF disclosure practices, particularly as NGS increasingly becomes a centerpiece in genetic research broadly, is heightened when children are involved. Sober thought should be given to the possibility of discovering IF, and to proactive discussions about disclosure considering the realities of young participants, their families, and the investigators who recruit them.
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47
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Renkema KY, Stokman MF, Giles RH, Knoers NVAM. Next-generation sequencing for research and diagnostics in kidney disease. Nat Rev Nephrol 2014; 10:433-44. [PMID: 24914583 DOI: 10.1038/nrneph.2014.95] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The advent of next-generation sequencing technologies has enabled genetic nephrology research to move beyond single gene analysis to the simultaneous investigation of hundreds of genes and entire pathways. These new sequencing approaches have been used to identify and characterize causal factors that underlie inherited heterogeneous kidney diseases such as nephronophthisis and congenital anomalies of the kidney and urinary tract. In this Review, we describe the development of next-generation sequencing in basic and clinical research and discuss the implementation of this novel technology in routine patient management. Widespread use of targeted and nontargeted approaches for gene identification in clinical practice will require consistent phenotyping, appropriate disease modelling and collaborative efforts to combine and integrate data analyses. Next-generation sequencing is an exceptionally promising technique that has the potential to improve the management of patients with inherited kidney diseases. However, identifying the molecular mechanisms that lead to renal developmental disorders and ciliopathies is difficult. A major challenge in the near future will be how best to integrate data obtained using next-generation sequencing with personalized medicine, including use of high-throughput disease modelling as a tool to support the clinical diagnosis of kidney diseases.
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Affiliation(s)
- Kirsten Y Renkema
- Department of Medical Genetics, University Medical Center Utrecht, KC04.048.02, PO Box 85090, Utrecht, 3508 AB, Netherlands
| | - Marijn F Stokman
- Department of Medical Genetics, University Medical Center Utrecht, KC04.048.02, PO Box 85090, Utrecht, 3508 AB, Netherlands
| | - Rachel H Giles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, KC04.048.02, PO Box 85090, Utrecht, 3508 AB, Netherlands
| | - Nine V A M Knoers
- Department of Medical Genetics, University Medical Center Utrecht, KC04.048.02, PO Box 85090, Utrecht, 3508 AB, Netherlands
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Hull SC, Berkman BE. Grappling with genomic incidental findings in the clinical realm. Chest 2014; 145:226-230. [PMID: 24493507 DOI: 10.1378/chest.13-1976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We have learned a remarkable amount in recent decades about genomics and its potential contributions to human health and medical practice. However, genomic sequencing technology, which is starting to become incorporated into clinical care, also raises ethical challenges. In particular, there has been significant debate about the appropriate management of genomic incidental findings (GIFs), which we define as pathogenic or likely pathogenic test results that are not apparently relevant to the diagnostic indications for which the tests were ordered. Although there is an emerging consensus that clinicians will have at least some obligation to disclose GIFs to patients, the scope of that obligation is unclear. This commentary identifies nuanced issues that clinicians will likely face in the foreseeable future regarding their emerging obligations to disclose clinically actionable GIFs. Will clinicians be expected to look actively for GIFs? Should GIFs for adult-onset disorders be disclosed to children? What obligations will clinicians have to disclose GIFs to family members of deceased patients? What role should informed consent play? There is value to exploring the range of views on these questions at this time, before genomic sequencing has fully matured as a technology, so that clinicians can anticipate how they will respond to the discovery of GIFs once sequencing becomes a more routine part of clinical care. Genomics is ultimately going to play an important role in the practice of pulmonary medicine, and it is important for pulmonologists and other subspecialists to be well informed about what to expect.
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Affiliation(s)
- Sara Chandros Hull
- Office of the Clinical Director, National Human Genome Research Institute.
| | - Benjamin E Berkman
- Office of the Clinical Director, National Human Genome Research Institute; Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
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Danielsson K, Mun LJ, Lordemann A, Mao J, Lin CHJ. Next-generation sequencing applied to rare diseases genomics. Expert Rev Mol Diagn 2014; 14:469-87. [PMID: 24702023 DOI: 10.1586/14737159.2014.904749] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Genomics has revolutionized the study of rare diseases. In this review, we overview the latest technological development, rare disease discoveries, implementation obstacles and bioethical challenges. First, we discuss the technology of genome and exome sequencing, including the different next-generation platforms and exome enrichment technologies. Second, we survey the pioneering centers and discoveries for rare diseases, including few of the research institutions that have contributed to the field, as well as an overview survey of different types of rare diseases that have had new discoveries due to next-generation sequencing. Third, we discuss the obstacles and challenges that allow for clinical implementation, including returning of results, informed consent and privacy. Last, we discuss possible outlook as clinical genomics receives wider adoption, as third-generation sequencing is coming onto the horizon, and some needs in informatics and software to further advance the field.
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Affiliation(s)
- Krissi Danielsson
- Rare Genomics Institute, 4100 Forest Park Ave, Suite 204, St. Louis, MO 63108, USA
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Berkman BE, Hull SC. The "right not to know" in the genomic era: time to break from tradition? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:28-31. [PMID: 24592837 PMCID: PMC4144176 DOI: 10.1080/15265161.2014.880313] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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