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van den Heuvel LM, van den Berg N, Janssens ACJW, Birnie E, Henneman L, Dondorp WJ, Plantinga M, van Langen IM. Societal implications of expanded universal carrier screening: a scoping review. Eur J Hum Genet 2023; 31:55-72. [PMID: 36097155 PMCID: PMC9822904 DOI: 10.1038/s41431-022-01178-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/08/2022] [Accepted: 08/15/2022] [Indexed: 02/08/2023] Open
Abstract
Carrier screening aims to identify couples at risk of conceiving children with a recessive condition. Until recently, carrier screening was primarily offered ancestry-based. Technological advances now facilitate expanded universal carrier screening (EUCS). This scoping review aimed to map EUCS's potential societal implications based on both theoretical studies and empirical evidence. To this aim, we performed a CoCites search to find relevant articles, including articles describing carrier screening for at-risk populations, based on five selected query articles. Forty articles were included. Three main potential societal implications were identified: (1) unwanted medicalization, (2) stigmatization and discrimination of carriers and people affected with the conditions screened and (3) challenges in achieving equitable access. Within these themes, potential positive implications are reduction of ethnic stigmatization in ancestry-based offers and increased equity. Potential negative implications are reinforcement of disability-based stigmatization, less possibility for developing expertise in healthcare and societal pressure to partake in screening. Empirical evidence on all these implications is however scarce. In conclusion, both positive and negative potential societal implications of implementing EUCS, primarily theoretical, were identified, even in at-risk groups where evidence is mostly lacking. Empirical research in EUCS pilots is needed to identify which societal implications are likely to occur and therefore should be overcome when implementing EUCS.
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Affiliation(s)
- Lieke M. van den Heuvel
- grid.4494.d0000 0000 9558 4598Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,grid.12380.380000 0004 1754 9227Department of Human Genetics and Amsterdam Reproduction and Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nina van den Berg
- grid.4494.d0000 0000 9558 4598Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,grid.12380.380000 0004 1754 9227Department of Human Genetics and Amsterdam Reproduction and Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A. Cecile J. W. Janssens
- grid.189967.80000 0001 0941 6502Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Erwin Birnie
- grid.4494.d0000 0000 9558 4598Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lidewij Henneman
- grid.12380.380000 0004 1754 9227Department of Human Genetics and Amsterdam Reproduction and Development research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Wybo J. Dondorp
- grid.5012.60000 0001 0481 6099Department of Health, Ethics & Society, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands
| | - Mirjam Plantinga
- grid.4494.d0000 0000 9558 4598Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Irene M. van Langen
- grid.4494.d0000 0000 9558 4598Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Expanded Preconception Carrier Screening in Clinical Practice: Review of Technology, Guidelines, Implementation Challenges, and Ethical Quandaries. Clin Obstet Gynecol 2020; 62:217-227. [PMID: 30908290 DOI: 10.1097/grf.0000000000000437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the last 10 years, expanded preconception carrier screening has become widely available and helps patients/couples make more informed decisions with regard to their reproductive options and facilitates more effective preconception planning, prenatal diagnosis, condition-specific counseling, and condition-specific care. This review provides an overview of expanded preconception carrier screening's high-throughput genotyping and sequencing approaches, current guidelines, implementation challenges and evolving ethical quandaries.
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Expanded genetic carrier screening in clinical practice: a current survey of patient impressions and attitudes. J Assist Reprod Genet 2019; 36:709-716. [PMID: 30761454 DOI: 10.1007/s10815-019-01414-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/28/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Expanded genetic carrier screening (ECS) is an important part of gynecological practice and preconception planning. We evaluated the awareness and attitudes among women regarding ECS and factors that may influence decision-making in a family planning context. METHODS A 32-question survey in an academic university practice was given to 521 women who were either currently pregnant (n = 108), undergoing gynecologic care who were considering future fertility (n = 308), and considering or receiving fertility treatment (n = 105). Data are reported descriptively. RESULTS Forty-seven percent (n = 246) of patients were aware of ECS. Though most reported feeling positive or neutral towards ECS, 51% (n = 263) reported no desire for testing. Fifty-eight percent (n = 303) felt it beneficial to know their carrier status, and 55% (n = 257) said it was their responsibility to undergo testing. Those considering future fertility were found to have a more positive attitude towards ECS (51.4%) than those considering or receiving fertility treatment (34%). For positive carriers of a genetic disorder, 228 (49%) of patients would proceed with having their partner screened, 58 (13%) would undergo prenatal screening only and 12 (2.6%) would continue with vitro fertilization (IVF). Related to cost for ECS, 53.5% (n = 191) would be willing to pay at least $50-100 for testing, while 29% (n = 146) would not pay anything out of pocket. CONCLUSIONS Despite patients' beliefs that it would be beneficial and their responsibility to undergo carrier status testing, the majority reported no desire for ECS and many were unwilling to pay out of pocket. Further education is necessary to reconcile the gap between technology and patient decision-making.
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Janssens S, Chokoshvili D, Vears DF, De Paepe A, Borry P. Pre- and post-testing counseling considerations for the provision of expanded carrier screening: exploration of European geneticists' views. BMC Med Ethics 2017; 18:46. [PMID: 28764782 PMCID: PMC5539885 DOI: 10.1186/s12910-017-0206-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 07/24/2017] [Indexed: 12/28/2022] Open
Abstract
Background Carrier screening is generally performed with the aim of identifying healthy couples at risk of having a child affected with a monogenic disorder to provide them with reproductive options. Expanded carrier screening (ECS), which provides the opportunity for multiple conditions to be screened in one test, offers a more cost-effective and comprehensive option than screening for single disorders. However, implementation of ECS at a population level would have implications for genetic counseling practice. Methods We conducted semi-structured interviews with sixteen European clinical and molecular geneticists with expertise in carrier screening to explore their views on the implementation of ECS in the clinical setting. Results Using inductive content analysis, we identified content categories relevant to the pre- and post-test settings. Participants believed ECS would ideally be targeted at couples before pregnancy. There was some disagreement regarding the acceptability of performing ECS in individuals, with several participants actively opposing individual-based screening. In addition, participants discussed the importance of ensuring informed and voluntary participation in ECS, recommending measures to minimize external pressure on prospective parents to undergo testing. A need for adequate counseling to foster informed, autonomous reproductive decision-making and provide support for couples found to be at risk was emphasized. Conclusions Practical challenges in optimizing pre-test education and post-test counseling should not be underestimated and they should be carefully addressed before implementing ECS in the clinical setting.
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Affiliation(s)
- Sandra Janssens
- Centre for Medical Genetics Ghent, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Davit Chokoshvili
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.,Leuven Institute for Human Genomics and Society, KU Leuven - University of Leuven, Leuven, Belgium
| | - Danya F Vears
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.,Leuven Institute for Human Genomics and Society, KU Leuven - University of Leuven, Leuven, Belgium
| | - Anne De Paepe
- Centre for Medical Genetics Ghent, University Hospital Ghent, De Pintelaan 185, 9000, Ghent, Belgium
| | - Pascal Borry
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Leuven, Belgium.,Leuven Institute for Human Genomics and Society, KU Leuven - University of Leuven, Leuven, Belgium
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Molster CM, Lister K, Metternick-Jones S, Baynam G, Clarke AJ, Straub V, Dawkins HJS, Laing N. Outcomes of an International Workshop on Preconception Expanded Carrier Screening: Some Considerations for Governments. Front Public Health 2017; 5:25. [PMID: 28286745 PMCID: PMC5323409 DOI: 10.3389/fpubh.2017.00025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/09/2017] [Indexed: 01/08/2023] Open
Abstract
Background Consideration of expanded carrier screening has become an emerging issue for governments. However, traditional criteria for decision-making regarding screening programs do not incorporate all the issues relevant to expanded carrier screening. Further, there is a lack of consistent guidance in the literature regarding the development of appropriate criteria for government assessment of expanded carrier screening. Given this, a workshop was held to identify key public policy issues related to preconception expanded carrier screening, which governments should consider when deciding whether to publicly fund such programs. Methods In June 2015, a satellite workshop was held at the European Society of Human Genetics Conference. It was structured around two design features: (1) the provision of information from a range of perspectives and (2) small group deliberations on the key issues that governments need to consider and the benefits, risks, and challenges of implementing publicly funded whole-population preconception carrier screening. Results Forty-one international experts attended the workshop. The deliberations centered primarily on the conditions to be tested and the elements of the screening program itself. Participants expected only severe conditions to be screened but were concerned about the lack of a consensus definition of “severe.” Issues raised regarding the screening program included the purpose, benefits, harms, target population, program acceptability, components of a program, and economic evaluation. Participants also made arguments for consideration of the accuracy of screening tests. Conclusion A wide range of issues require careful consideration by governments that want to assess expanded carrier screening. Traditional criteria for government decision-making regarding screening programs are not a “best fit” for expanded carrier screening and new models of decision-making with appropriate criteria are required. There is a need to define what a “severe” condition is, to build evidence regarding the reliability and accuracy of screening tests, to consider the equitable availability and downstream effects on and costs of follow-up interventions for those identified as carriers, and to explore the ways in which the components of a screening program would be impacted by unique features of expanded carrier screening.
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Affiliation(s)
- Caron M Molster
- Office of Population Health Genomics, Public Health Division, Department of Health Western Australia , Perth, WA , Australia
| | - Karla Lister
- Office of Population Health Genomics, Public Health Division, Department of Health Western Australia , Perth, WA , Australia
| | | | - Gareth Baynam
- Office of Population Health Genomics, Public Health Division, Department of Health Western Australia, Perth, WA, Australia; Genetic Services WA, Perth, WA, Australia; School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia; Institute for Immunology and Infectious Diseases, Murdoch University, Perth, WA, Australia; Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Western Australian Register of Developmental Anomalies, Perth, WA, Australia; Spatial Sciences, Department of Science and Engineering, Curtin University, Perth, WA, Australia
| | - Angus John Clarke
- Division of Cancer and Genetics, School of Medicine, Cardiff University , Cardiff , UK
| | - Volker Straub
- Institute of Human Genetics, University of Newcastle upon Tyne , Newcastle upon Tyne , UK
| | - Hugh J S Dawkins
- Office of Population Health Genomics, Public Health Division, Department of Health Western Australia, Perth, WA, Australia; Centre for Comparative Genomics, Murdoch University, Perth, WA, Australia; Centre for Population Health Research, Curtin University, Perth, WA, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Perth, WA, Australia
| | - Nigel Laing
- Centre for Medical Research, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia; Neurogenetics Unit, Department of Diagnostic Genomics, PathWest Laboratory Medicine, Department of Health Western Australia, Perth, WA, Australia
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Wilfond BS, Goddard KA. It's complicated: criteria for policy decisions for the clinical integration of genome-scale sequencing for reproductive decision making. Mol Genet Genomic Med 2015; 3:239-42. [PMID: 26247041 PMCID: PMC4521960 DOI: 10.1002/mgg3.130] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Benjamin S Wilfond
- Trueman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute Seattle, Washington ; Department of Pediatrics, University of Washington School of Medicine Seattle, Washington
| | - Katrina Ab Goddard
- Center for Health Research, Kaiser Permanente Northwest Portland, Oregon
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Attitudes of cystic fibrosis patients and parents toward carrier screening and related reproductive issues. Eur J Hum Genet 2015. [PMID: 26220700 DOI: 10.1038/ejhg.2015.160] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cystic fibrosis (CF) is a life-limiting autosomal recessive disorder affecting ~1 in 2500-4000 Caucasians. As most CF patients have no family history of the disorder, carrier screening for CF has the potential to prospectively identify couples at risk of conceiving an affected child. At-risk couples may consequently choose to act on the provided information and take steps to avoid the birth of a child with CF. Although carrier screening is widely believed to enhance reproductive autonomy of prospective parents, the practice also raises important ethical questions. A written questionnaire was administered to adult patients and parents of children with CF with the aim to explore participants' attitudes toward CF carrier screening and related reproductive issues. The study population was recruited from a CF patient registry in Belgium and comprised 111 participants (64 parents, 47 patients aged 16 or older). We found that more than 80% of all participants were in favor of preconception carrier screening for CF. However, some were concerned over potential negative consequences of population-wide CF carrier screening. Regarding future reproductive intentions, 43% of the participants indicated a desire to have children. Among these, preimplantation genetic diagnosis was found to be the most preferred reproductive option, closely followed by spontaneous pregnancy and prenatal diagnosis. Although the findings of our study suggest that patients and parents of children with CF support a population-based carrier screening program for CF, they also highlight some issues deserving particular attention when implementing such a program.
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"Is It Worth Knowing?" Focus Group Participants' Perceived Utility of Genomic Preconception Carrier Screening. J Genet Couns 2015; 25:135-45. [PMID: 26093606 PMCID: PMC4726717 DOI: 10.1007/s10897-015-9851-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/02/2015] [Indexed: 12/22/2022]
Abstract
As genome sequencing technology advances, research is needed to guide decision-making about what results can or should be offered to patients in different clinical settings. We conducted three focus groups with individuals who had prior preconception genetic testing experience to explore perceived advantages and disadvantages of genome sequencing for preconception carrier screening, compared to usual care. Using a discussion guide, a trained qualitative moderator facilitated the audio-recorded focus groups. Sixteen individuals participated. Thematic analysis of transcripts started with a grounded approach and subsequently focused on participants’ perceptions of the value of genetic information. Analysis uncovered two orientations toward genomic preconception carrier screening: “certain” individuals desiring all possible screening information; and “hesitant” individuals who were more cautious about its value. Participants revealed valuable information about barriers to screening: fear/anxiety about results; concerns about the method of returning results; concerns about screening necessity; and concerns about partner participation. All participants recommended offering choice to patients to enhance the value of screening and reduce barriers. Overall, two groups of likely users of genome sequencing for preconception carrier screening demonstrated different perceptions of the advantages or disadvantages of screening, suggesting tailored approaches to education, consent, and counseling may be warranted with each group.
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Sutherland JE, Day MA. Advantages and disadvantages of molecular testing in ophthalmology. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Carrier screening for cystic fibrosis (CF) has been available since the early 1990s, yet there are few programs, and none funded as part of a national health care strategy. The aim of this paper is to provide a description of carrier screening for CF and examine the progress that has been made towards the establishment of universal population-based carrier screening programs. This is an evidence based commentary on population-based carrier screening for CF. Peak body recommendations were examined and existing programs for CF carrier screening are reviewed. The attitudes from the non-CF community, CF healthcare professionals and people with CF were studied. Data from health economic assessments is examined. The future of carrier screening for CF in the context of advancing genetic technologies and potentially curative therapies is considered.
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Current Practice and Attitudes of Australian Obstetricians Toward Population-Based Carrier Screening for Inherited Conditions. Twin Res Hum Genet 2013; 16:601-7. [DOI: 10.1017/thg.2012.152] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
An anonymous survey of Australian Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted with the aim of understanding current practice and attitudes toward population-based carrier screening for inherited conditions in the setting of routine pregnancy care. Of 1,121 Fellows invited to complete the online questionnaire by e-mail, 237 (21%) responded, and of these 156 were practicing obstetricians and completed the whole survey. Of the respondents, 83% expressed support for population-based carrier screening for at least some conditions, with 97% supporting carrier screening for β-thalassaemia, and 83% supporting carrier screening for cystic fibrosis (CF). A small proportion of obstetricians reported offering carrier screening as part of routine pregnancy care (20% for β-thalassaemia, 8% for CF, 5% for fragile X syndrome, and 2% for spinal muscular atrophy). The main practical barriers identified for screening were cost, time constraints, and availability of supporting services. Addressing these issues is crucial for the successful implementation of population-based carrier screening programs in Australia and internationally.
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Attitudes of health care professionals toward carrier screening for cystic fibrosis. A review of the literature. J Community Genet 2012; 5:13-29. [PMID: 23275180 DOI: 10.1007/s12687-012-0131-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022] Open
Abstract
Recent technological developments in molecular genetics facilitate the large-scale detection of inherited genetic disorders and allow an increasing number of genetic conditions to be screened for (American College of Medical Genetics 2012). This technological evolution creates the background which makes reflection necessary about the desirability to offer community-based (preconception) carrier screening in the healthcare system. A positive attitude of potential providers is vital to the success of a screening program. Therefore, the objective of this article is to elaborate a review of the attitudes of healthcare professionals toward carrier screening. Examination of existing carrier screening programs could provide such information. The literature review will be focused on the attitudes toward carrier screening for cystic fibrosis (CF). The databases Pubmed and Web of Science, as well as the interface Google Scholar, were searched using the keywords for the period 1990-2011. Studies were selected if they were published in a peer-reviewed journal in English and described the attitudes of potential providers toward carrier screening. Eleven studies were retrieved describing the attitudes toward carrier screening for CF. In total, seven studies reported attitudes toward the best time for carrier screening; four studies described opinions toward the best setting to offer CF carrier screening; six studies investigated the willingness to be involved in a carrier screening program, and in total 11 articles reported the concerns about offering carrier screening. Ten papers described a general attitude toward carrier screening. We can conclude that health care providers state willingness to be involved in a carrier screening program, but there is need for appropriate education as well as adequate support given the time constraints already present in consultation. The prospect of an increasing number of genetic disorders for which screening becomes possible, and the potential increasing demand for such screening in the future calls for the need for further debate on the desirability of carrier screening and relevant questions such as the conditions screened, the providers involved, the information provision, and counseling.
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Preconception care and genetic risk: ethical issues. J Community Genet 2011; 3:221-8. [PMID: 22205578 PMCID: PMC3419287 DOI: 10.1007/s12687-011-0074-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/07/2011] [Indexed: 01/20/2023] Open
Abstract
Preconception care to address genetic risks in reproduction may be offered either individually to couples with a known or suspected increased risk of having a child with a genetic disorder, or systematically to couples or individuals of reproductive age. The identification of couples at risk of transmitting a (serious) genetic disorder allows those couples to refrain from having children or to adapt their reproductive plans (using prenatal or preimplantation diagnosis, donor gametes, or adoption). Ethical issues concern the possible objectives of providing these options through preconception genetic counseling or screening, objections to abortion and embryo-selection, concerns about eugenics and medicalization, and issues arising in the professional–client relationship and/or in the light of the normative framework for population screening. Although enhancing reproductive autonomy rather than prevention should be regarded as the primary aim of preconception care for genetic risks, directive counseling may well be acceptable in exceptional cases, and prevention in the sense of avoiding serious suffering may be an appropriate objective of specific community-based preconception screening programmes. The seemingly unavoidable prospect of comprehensive preconception screening raises further ethical issues.
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