1
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Collart C, Craighead C, Yao M, Rose S, Chien EK, Frankel RM, Coleridge M, Hu B, Edmonds BT, Ranzini AC, Farrell RM. Reducing decisional conflict in decisions about prenatal genetic testing: the impact of a dyadic intervention at the start of prenatal care. J Perinat Med 2024; 52:467-477. [PMID: 38669584 PMCID: PMC11143442 DOI: 10.1515/jpm-2023-0442] [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: 10/16/2023] [Accepted: 03/19/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES Decisional conflict and regret about prenatal genetic screening and diagnostic tests may have important consequences in the current pregnancy and for future reproductive decisions. Identifying mechanisms that reduce conflict associated with the decision to use or decline these options is necessary for optimal patient counseling. METHODS We conducted a cluster-randomized controlled trial of a shared decision-making tool (NEST) at the beginning of prenatal care. Enrolled patients completed follow-up surveys at the time of testing (QTT) and in the second-third trimester (QFF), including the Decision Conflict Scale (DCS). Total DCS scores were analyzed using a multivariate linear mixed-effect model. RESULTS Of the total number of participants (n=502) enrolled, 449 completed the QTT and QFF surveys. The mean age of participants was 31.6±3.8, with most parous at the time of study participation (n=321; 71.7 %). Both the NEST (the intervention) and control groups had lower median total DCS scores at QFF (NEST 13.3 [1.7, 25.0] vs. control 16.7 [1.7, 25.0]; p=0.24) compared to QTT (NEST 20.8 [5.0, 25.0] vs. control 18.3 [3.3, 26.7]; p=0.89). Participants exposed to NEST had lower decisional conflict at QFF compared to control (β -3.889; [CI -7.341, -0.437]; p=0.027). CONCLUSIONS Using a shared decision-making tool at the start of prenatal care decreased decisional conflict regarding prenatal genetic testing. Such interventions have the potential to provide an important form of decision-making support for patients facing the unique type of complex and preference-based choices about the use of prenatal genetic tests.
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Affiliation(s)
- Christina Collart
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caitlin Craighead
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Susannah Rose
- Department of Biomedical Informatics and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward K. Chien
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Marissa Coleridge
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Angela C. Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH, USA
| | - Ruth M. Farrell
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Bioethics, Clinical Transformation, Cleveland Clinic, Cleveland, OH, USA
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2
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Lu D, Yang J, Shen W, Chen M. Attitudes toward uncertain results from prenatal exome sequencing: a national survey among healthcare professionals working in the prenatal setting. Front Med (Lausanne) 2024; 11:1335649. [PMID: 38813373 PMCID: PMC11133618 DOI: 10.3389/fmed.2024.1335649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Objective The objective of this study was to investigate the attitudes of healthcare professionals (HPs) working in the prenatal setting toward uncertain results (UR) from prenatal exome sequencing (pES) in China. Methods We conducted a national survey among HPs working in the prenatal setting. UR in our study include variants of uncertain significance (VUS), variants with variable penetrance/expressivity (VVPE), and secondary findings unrelated to the indication for testing (SFs). A total of 285 questionnaires that met the inclusion criteria were collected. Data were analyzed using IBM SPSS Statistics 26. Results When performing the pre-test counseling, only 7.4% of HPs mentioned the possibility of VUS, 6.3% discussed the possibility of VVPE, and 7.4% introduced the SFs with parents with the option to not report these variants. In post-test counseling, 73.0-82.8% HPs discussed with the parents but did not make any recommendations for managing the pregnancy after reporting UR (73.0% for VUS, 82.8% for VVPE, 74.7% for SFs, respectively). Conclusion Most parents did not have the option of opting out of reporting UR from pES in pre-test counseling. UR did not influence the pregnancy recommendation made by most HPs. Establishing national guidelines for reporting UR from pES and developing strategies to improve counseling skills may help HPs manage UR.
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Affiliation(s)
- Dongfang Lu
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Jing Yang
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Wei Shen
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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3
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Kaposy C. Prospects for limiting access to prenatal genetic information about Down syndrome in light of the expansion of prenatal genomics. New Bioeth 2022:1-21. [PMID: 36206180 DOI: 10.1080/20502877.2022.2130720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Down syndrome (Trisomy 21) is a mild to moderate intellectual disability. Historically, this condition has been a primary target for prenatal testing. However, Down syndrome has not been targeted for prenatal testing because it is an especially severe illness. The condition was just one that could be easily identified prenatally using the techniques first available decades ago. We are moving into an era in which we can prenatally test for a vast range of human traits. I argue that when we can test for anything, there is no longer any reason to continue targeting Down syndrome. I present an argument based on the value of nondiscrimination. It is justified to set limits on access to prenatal information if the information is going to be used for discriminatory purposes. I use the examples of (1) prenatal testing for misogynistic fetal sex selection, and (2) homophobia-motivated prenatal testing for potential homosexuality, as compelling analogies.
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Affiliation(s)
- Chris Kaposy
- Centre for Bioethics, Faculty of Medicine, Memorial University, Canada
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4
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Next Generation Sequencing after Invasive Prenatal Testing in Fetuses with Congenital Malformations: Prenatal or Neonatal Investigation. Genes (Basel) 2022; 13:genes13091517. [PMID: 36140685 PMCID: PMC9498826 DOI: 10.3390/genes13091517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/21/2022] [Accepted: 08/21/2022] [Indexed: 11/24/2022] Open
Abstract
Congenital malformations diagnosed by ultrasound screening complicate 3–5% of pregnancies and many of these have an underlying genetic cause. Approximately 40% of prenatally diagnosed fetal malformations are associated with aneuploidy or copy number variants, detected by conventional karyotyping, QF-PCR and microarray techniques, however monogenic disorders are not diagnosed by these tests. Next generation sequencing as a secondary prenatal genetic test offers additional diagnostic yield for congenital abnormalities deemed to be potentially associated with an underlying genetic aetiology, as demonstrated by two large cohorts: the ‘Prenatal assessment of genomes and exomes’ (PAGE) study and ‘Whole-exome sequencing in the evaluation of fetal structural anomalies: a prospective cohort study’ performed at Columbia University in the US. These were large and prospective studies but relatively ‘unselected’ congenital malformations, with little Clinical Genetics input to the pre-test selection process. This review focuses on the incremental yield of next generation sequencing in single system congenital malformations, using evidence from the PAGE, Columbia and subsequent cohorts, with particularly high yields in those fetuses with cardiac and neurological anomalies, large nuchal translucency and non-immune fetal hydrops (of unknown aetiology). The total additional yield gained by exome sequencing in congenital heart disease was 12.7%, for neurological malformations 13.8%, 13.1% in increased nuchal translucency and 29% in non-immune fetal hydrops. This demonstrates significant incremental yield with exome sequencing in single-system anomalies and supports next generation sequencing as a secondary genetic test in routine clinical care of fetuses with congenital abnormalities.
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Collart C, Craighead C, Rose S, Frankel R, Tucker Edmonds B, Perni U, Chien EK, Coleridge M, Ranzini A, Farrell RM. The Impact of Outpatient Prenatal Care Visitor Restrictions on Pregnant Patients and Partners During the COVID-19 Pandemic. WOMEN'S HEALTH REPORTS 2022; 3:718-727. [PMID: 36147830 PMCID: PMC9436262 DOI: 10.1089/whr.2022.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/13/2022]
Abstract
Introduction: Methods: Results: Conclusions:
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Affiliation(s)
- Christina Collart
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Caitlin Craighead
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susannah Rose
- Center for Patient Experience, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Frankel
- Department of the Lerner Research Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | | | - Uma Perni
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward K. Chien
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marissa Coleridge
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Personalized Genetic Healthcare, Department of Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Angela Ranzini
- Department of OB/GYN, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Ruth M. Farrell
- Subspecialty Care for Women's Health, OB/GYN and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Personalized Genetic Healthcare, Department of Genomic Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Outram SM, Brown JEH, Zamora AN, Sahin-Hodoglugil N, Ackerman SL. Parental Hopes and Understandings of the Value of Prenatal Diagnostic Genomic Sequencing: A Qualitative Analysis. Front Genet 2022; 13:883225. [PMID: 35923691 PMCID: PMC9339950 DOI: 10.3389/fgene.2022.883225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: To provide qualitative empirical data on parental expectations of diagnostic prenatal genomic sequencing and the value of the results to families. Methods: We interviewed 15 families—mothers and/or fathers—who had had prenatal genomic sequencing about their expectations and their respective evaluations of the benefits of genomic sequencing. Results: Families’ hopes for genetic sequencing clustered around three themes: hoping to identify the cause of the fetal anomaly in a terminated pregnancy; hopes for guidance as to the likely outcome of current pregnancy; and hopes for information to support future family planning. In addition, hopes were discussed in terms of the potential for results to be beneficial in acquiring greater knowledge, while at the same time recognizing that new knowledge may raise more questions. Assessment of the value of sequencing largely mirrored these expectations when positive results seen. Negative results can also be seen as valuable in ruling out a genetic cause and in providing certainty that families had done everything that they could to know about the cause of fetal demise. Conclusion: It would appear that with guidance from genetic counsellors, families were largely able to navigate the many uncertainties of prenatal genomic sequencing and thus see themselves as benefitting from sequencing. However, support structures are essential to guide them through their expectations and interpretations of results to minimize possible harms. Engaging in the process of genomic sequencing was seen as beneficial in of itself to families who would otherwise be left without any options to seek diagnostic answers.
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7
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Peter M, McInnes-Dean H, Fisher J, Tapon D, Chitty LS, Hill M. What's out there for parents? A systematic review of online information about prenatal microarray and exome sequencing. Prenat Diagn 2021; 42:97-108. [PMID: 34747021 PMCID: PMC9298227 DOI: 10.1002/pd.6066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 11/09/2022]
Abstract
Objective To identify what online patient information (presented in English) is available to parents about prenatal microarray (CMA) and exome sequencing (ES), and evaluate its content, quality, and readability. Method Systematic searches (Google and Bing) were conducted, and websites were categorised according to their purpose. Websites categorised as patient information were included if they were: in English, directed at patients, or were a text, video, or online version of an information leaflet. Author‐developed content checklists, the DISCERN Genetics tool, and readability tests (the Flesch Reading Ease Score, the Gunning Fog Index, and the Simple Measure of Gobbledygook Index) were then used to assess those sources of patient information. Results Of the 665 websites screened, 18 met the criteria. A further 8 sources were found through a targeted search of professional organisations, resulting in 26 sources available for further evaluation. In general, this was found to be low in quality, omitted details recommended by national or international guidance, and was written at a level too advanced for average readers. Conclusion Improvements should be made to the content, quality, and readability of online information so that it both reinforces and complements the discussions between parents and clinicians about testing options during pregnancy.
What's already known about this topic?
The Internet is an important source of information for parents during pregnancy Little is known about the availability and standard of online information about newer prenatal genetic tests like chromosomal microarray (CMA) and prenatal exome sequencing (ES)
What does this study add?Our results revealed limited online information aimed at parents about CMA and ES The information we did identify was lacking the details recommended by professional guidelines, had low quality scores, and was written at an advanced level Improvements to online information for parents are needed to support informed decision‐making regarding prenatal genetic tests
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Affiliation(s)
- Michelle Peter
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Hannah McInnes-Dean
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK.,Antenatal Results and Choices, London, UK
| | | | - Dagmar Tapon
- Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Lyn S Chitty
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Melissa Hill
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
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8
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Castleman JS, Wall E, Allen S, Williams D, Doyle S, Kilby MD. The prenatal exome - a door to prenatal diagnostics? Expert Rev Mol Diagn 2021; 21:465-474. [PMID: 33877000 DOI: 10.1080/14737159.2021.1920398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Prenatal exome sequencing (ES) allows parents the opportunity to obtain arapid molecular diagnosis of monogenic etiology when their fetus is found to have structural anomalies detected on prenatal ultrasound. Such information can improve antenatal and neonatal counseling, decision-making and management, and expand reproductive options in subsequent pregnancies.Areas covered: This review appraises the evidence, from acomprehensive search of bibliographic databases, for the introduction of ES into the fetal medicine care pathway when investigating congenital malformations. The perspectives of clinical geneticists, clinical scientists, fetal medicine specialists, and patients are explored in relation to the novel investigation and the benefits and challenges of its use in ongoing pregnancies with particular reference to UK medical practice.Expert opinion: ES provides agenetic diagnosis for more than 1 in 10 fetuses with structural differences on ultrasound and normal conventional tests (karyotype or chromosomal microarray) in carefully selected cases. The diagnostic rate increases for certain phenotypes and can range between 6% and 80% where conventional cytogenetics have not detected adiagnosis. Expert oversight is required to ensure that patients receive high-quality, evidence-based care and accurate counseling, supported by amultidisciplinary team familiar with the test and its implications.
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Affiliation(s)
- James S Castleman
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Wall
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Stephanie Allen
- West Midlands Regional Genetics Laboratory, Birmingham Women's and Children's NHS Foundation Trust, Mindelsohn Way, Edgbaston. Birmingham, UK
| | - Denise Williams
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Samantha Doyle
- Clinical Genetics Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Mark D Kilby
- West Midlands Fetal Medicine Centre, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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9
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Kilby MD. The role of next-generation sequencing in the investigation of ultrasound-identified fetal structural anomalies. BJOG 2021; 128:420-429. [PMID: 32975887 PMCID: PMC8607475 DOI: 10.1111/1471-0528.16533] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
Fetal structural anomalies have an impact on fetal mortality and morbidity. Next-generation sequencing (NGS) may be incorporated into clinical pathways for investigation of paediatric morbidity but can also be used to delineate the prognosis of fetal anomalies. This paper reviews the role of NGS in the investigation of fetal malformations, the literature defining the clinical utility, the technique most commonly used and potential promise and challenges for implementation into clinical practice. Prospective case selection with informative pre-test counselling by multidisciplinary teams is imperative. Regulated laboratory sequencing, bioinformatic pathways with potential variant identification and conservative matching with the phenotype is important. TWEETABLE ABSTRACT: Prenatal exome sequencing in fetal structural anomalies yields diagnostic information in up to 20% of cases.
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Affiliation(s)
- M D Kilby
- Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
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10
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Lou S, Petersen OB, Lomborg K, Vogel I. How do geneticists and prospective parents interpret and negotiate an uncertain prenatal genetic result? An analysis of clinical interactions. J Genet Couns 2020; 29:1221-1233. [PMID: 32453502 DOI: 10.1002/jgc4.1290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/06/2022]
Abstract
Variants of unknown significance (VUS) and susceptibility loci (SL) are a challenge in prenatal genetic counseling. The aim of this study was to explore how such uncertain genetic results are communicated, negotiated, and made meaningful by genetics healthcare providers and couples in the actual clinical setting where results are delivered. The study was based on an anthropological approach and the material consisted of observations and audio-recordings from 16 purposively sampled genetic counseling sessions where prenatal testing had identified an inherited or de novo VUS or SL result. Field notes and transcripts from audio-recordings were analyzed using thematic analysis. The analysis identified a number of specific interpretations and strategies that clinical geneticists and couples collectively used for dealing with the ambiguity of the result. Thus, the analysis resulted in a total of three themes, each with 3-4 subthemes. The theme 'Setting the scene' describes the three-stage structure of the consultation. The theme 'Dealing with uncertainty' includes 'normalizing strategies' that emphasized the inherent uncertainty in human life in general and 'contextualizing strategies' that placed the result in relation to the surrounding society, where technological developments lead to new and unforeseen challenges. The theme 'Regaining control' includes interpretations that made the knowledge useful by focusing on the value of being prepared for potential, future challenges. Other strategies were to book an extra scan-to reconfirm fetal structural health and to reconnect to the pregnancy. Finally, inquiring about the sex was clearly a way for the couple to signal their investment in the pregnancy. Based on the analysis, we propose that these interpretations served to transform and reduce ambiguity through a process of reconfiguring the biomedical information into knowledge that resonated with the couples' lifeworlds. In this process, both geneticist and couples drew on wider social and moral concerns about uncertainty and responsibility.
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Affiliation(s)
- Stina Lou
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,DEFACTUM - Public Health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Olav Bjørn Petersen
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,Fetal Medicine Unit, Department of Obstetrics & Gynecology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Lomborg
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ida Vogel
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
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11
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Harding E, Hammond J, Chitty LS, Hill M, Lewis C. Couples experiences of receiving uncertain results following prenatal microarray or exome sequencing: A mixed-methods systematic review. Prenat Diagn 2020; 40:1028-1039. [PMID: 32362033 PMCID: PMC8425413 DOI: 10.1002/pd.5729] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Abstract
Background Tests in pregnancy such as chromosomal microarray analysis and exome sequencing are increasing diagnostic yield for fetal structural anomalies, but have greater potential to result in uncertain findings. This systematic review investigated the experiences of prospective parents about receiving uncertain results from these tests. Methods A systematic search of three electronic databases was conducted. Data extraction was performed for studies that met the eligibility and quality criteria. Results were synthesised following the principles of thematic analysis. Results Fourteen studies (10 qualitative, 4 quantitative) were included. Findings were grouped into three overarching themes. Sources of uncertainty included the testing procedure, the diagnosis and prognosis, and health professionals' own uncertainty. The clinical impact of the uncertainty included parents struggling to make clinical decisions with the information available, the emotional impact included decisional‐regret, shock, worry and feeling overwhelmed. To manage the uncertainty, parents sought support from healthcare professionals, friends, family, the internet and other parents as well as remaining hopeful. Conclusions Prospective parents experience a myriad of uncertainties in the prenatal setting, which must be handled sensitively. Future research should explore optimal ways of managing uncertainty to minimise harm. Recommendations are made for discussing uncertainty during pre‐ and post‐test counseling.
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Affiliation(s)
- Eleanor Harding
- BSc Paediatrics and Child Health, The UCL Great Ormond Street Institute of Child Health, London, UK.,London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jennifer Hammond
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lyn S Chitty
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Melissa Hill
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Celine Lewis
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
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12
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Abstract
OBJECTIVE To examine the choices of women with both high-risk and low-risk pregnancies who are undergoing prenatal chromosomal microarray analysis in a clinical setting regarding three challenging types of findings: variants of uncertain clinical significance, susceptibility loci for neurodevelopmental disorders, and copy number variants associated with risks for adult-onset conditions. We assessed whether women's choices were associated with indications for testing or with one-on-one pretest genetic counseling. METHODS In this cross-sectional study, medical records of women who underwent invasive prenatal chromosomal microarray analysis testing (N=1,070) at Hadassah Medical Center between June 2017 and February 2018 were examined for testing indications, choices regarding chromosomal microarray analysis findings, and type of pretest genetic counseling. Multivariable analyses to assess associations with testing indication and prior genetic counseling were carried out using logistic regression models. RESULTS In total, 56% of women (n=593) chose to be informed of all three types of findings and 20% (n=218) chose not to be informed of any of the findings beyond high-penetrance childhood-onset pathogenic findings. Variants of uncertain clinical significance as a single choice was the least-selected finding (2.5%, n=27). Low-risk pregnancies (ie, those with normal biochemical screening and fetal ultrasound examinations) were associated with increased interest in receiving genetic information about adult-onset conditions (adjusted odds ratio [aOR] 1.7; 95% CI 1.18-2.33) and susceptibility loci (aOR 1.5; 95% CI 1.08-2.10). CONCLUSION Women with both high-risk and low-risk pregnancies were generally more likely to choose to receive additional genetic information, albeit differences in preferences depend on testing indication and type of pretest counseling.
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13
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Yip T, Grinzaid KA, Bellcross C, Moore RH, Page PZ, Hardy MW. Patients' reactions and follow-up testing decisions related to Tay-Sachs (HEXA) variants of uncertain significance results. J Genet Couns 2019; 28:738-749. [PMID: 30843643 DOI: 10.1002/jgc4.1108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/16/2019] [Accepted: 02/02/2019] [Indexed: 11/10/2022]
Abstract
JScreen is a national public health initiative based out of Emory University that provides reproductive carrier screening through an online portal and follow-up genetic counseling services. In 2014, JScreen began reporting to patients variants of uncertain significance (VUSs) in the gene that causes Tay-Sachs disease (HEXA). Genetic counseling was provided to discuss the VUS and patients were offered hexosaminidase A (HEXA) blood enzyme testing to assist with VUS reclassification. To identify patient reactions and factors influencing their follow-up testing decisions after receiving these results, we conducted a retrospective quantitative study by administering online surveys to 62 patients with HEXA VUSs. Participants who pursued enzyme testing and those who did not both experienced low levels of distress when receiving the VUS results. Perceptions of HEXA carrier status after genetic counseling, decisional conflict levels, plans to have children in the near future, time available to pursue enzyme testing, and eligibility for research were significant factors influencing decision-making to pursue or not pursue enzyme testing. Genetic counseling played an important role in helping patients understand the VUS and follow-up testing options. When discussing VUSs with patients, it would be beneficial for genetic counselors to focus on the patient's perception of the VUS, anxiety related to the uncertainty of their results, and follow-up options, when available.
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Affiliation(s)
- Tiffany Yip
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
| | - Karen A Grinzaid
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
| | - Cecelia Bellcross
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
| | - Reneé H Moore
- Department of Public Health, Emory University, Atlanta, Georgia
| | - Patricia Z Page
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham School of Health Professions, Birmingham, Alabama
| | - Melanie W Hardy
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia
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14
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Durham L, Papanna R, Stevens B, Noblin S, Rodriguez-Buritica D, Hashmi SS, Krstic N. The utilization of prenatal microarray: A survey of current genetic counseling practices and barriers. Prenat Diagn 2019; 39:351-360. [PMID: 30734934 DOI: 10.1002/pd.5435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We evaluated what prenatal genetic counselor's (GCs) practices, attitudes, and barriers are in regards to prenatal microarray since the publication of the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) guidelines for microarray use. METHODS This was a survey-based cross-sectional study of English-speaking, board certified or eligible GCs who currently practice prenatal genetic counseling. RESULTS Of 192 respondents, 183 (95%) have incorporated chromosome microarray (CMA) into clinical practice, with 64% believing that the benefits of CMA outweigh the harms and 52% agreeing that CMA should be offered to all women regardless of indication. Those who reported being experts/comfortable in their knowledge of CMA (85%) and familiar with current clinical guidelines (86%) were significantly more likely to offer CMA to patients undergoing invasive testing and patients with fetal anomalies. Patient-specific concerns were the largest reported barrier (51%) when GCs do not offer CMA to patients. CONCLUSION Our study demonstrates GCs follow guidelines for CMA use when specific indications are involved, but further guidelines are needed regarding CMA use for other routine indications where utility of CMA is not clearly understood. On this basis, ACOG and SMFM should continue revising their guidelines as more information comes to light regarding utility of prenatal CMA for all indications, and organizations like the National Society of Genetic Counselors (NSGC) should consider publishing guidelines on prenatal CMA that are specialized to the GCs sphere of practice.
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Affiliation(s)
- Leslie Durham
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Pediatric Development and Rehabilitation, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Blair Stevens
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Sarah Noblin
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - David Rodriguez-Buritica
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - S Shahrukh Hashmi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Nevena Krstic
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL
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15
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16
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Pregnant Genetic Counselors in an Era of Advanced Genomic Tests: What Do the Experts Test Prenatally? J Genet Couns 2018; 27:1167-1174. [DOI: 10.1007/s10897-018-0234-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 02/05/2018] [Indexed: 10/17/2022]
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17
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Richardson A, Ormond KE. Ethical considerations in prenatal testing: Genomic testing and medical uncertainty. Semin Fetal Neonatal Med 2018; 23:1-6. [PMID: 29033309 DOI: 10.1016/j.siny.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Prenatal diagnostic testing has recently progressed from karyotype to routinely available chromosomal microarray, and the potential for fetal whole exome sequencing, both through invasive diagnostic testing and, in some cases, non-invasive prenatal testing. These tests bring beneficence through providing a higher diagnostic yield, often with lower risks of miscarriage than previously available testing, but also raise the question of harms related to an increase in uncertain and unknown results. Some parents-to-be report a desire to learn as much information as possible prenatally, and there may be beneficence in providing them with this information. However, the potential uncertainty these tests may create may raise anxiety and may complicate pregnancy decision-making for both patients and providers. This article reviews current prenatal technologies and the growing research on the clinical and ethical aspects of uncertainty as it relates to expanding prenatal testing options.
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Affiliation(s)
- Anastasia Richardson
- Lucile Packard Children's Hospital Stanford, Fetal and Pregnancy Health Program, Palo Alto, CA, USA
| | - Kelly E Ormond
- Stanford University School of Medicine, Department of Genetics and Stanford Center for Biomedical Ethics, Stanford, CA, USA.
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18
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Quinlan-Jones E, Hillman SC, Kilby MD, Greenfield SM. Parental experiences of prenatal whole exome sequencing (WES) in cases of ultrasound diagnosed fetal structural anomaly. Prenat Diagn 2017; 37:1225-1231. [DOI: 10.1002/pd.5172] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Elizabeth Quinlan-Jones
- Fetal Medicine Centre; Birmingham Women's and Children's NHS Foundation Trust; Birmingham UK
| | - Sarah C. Hillman
- Unit of Primary Care, Warwick Medical School; University of Warwick; Birmingham UK
| | - Mark D. Kilby
- Fetal Medicine Centre; Birmingham Women's and Children's NHS Foundation Trust; Birmingham UK
- Birmingham Centre for Women's and New-born Health, College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Sheila M. Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
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19
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Bridging the gap from prenatal karyotyping to whole-genome array comparative genomic hybridization in Hong Kong: survey on knowledge and acceptance of health-care providers and pregnant women. Arch Gynecol Obstet 2017; 296:1109-1116. [DOI: 10.1007/s00404-017-4534-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/14/2017] [Indexed: 12/30/2022]
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20
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Expert Knowledge Influences Decision-Making for Couples Receiving Positive Prenatal Chromosomal Microarray Testing Results. Cult Med Psychiatry 2017; 41:382-406. [PMID: 28132396 DOI: 10.1007/s11013-017-9521-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To assess how participants receiving abnormal prenatal genetic testing results seek information and understand the implications of results, 27 US female patients and 12 of their male partners receiving positive prenatal microarray testing results completed semi-structured phone interviews. These interviews documented participant experiences with chromosomal microarray testing, understanding of and emotional response to receiving results, factors affecting decision-making about testing and pregnancy termination, and psychosocial needs throughout the testing process. Interview data were analyzed using a modified grounded theory approach. In the absence of certainty about the implications of results, understanding of results is shaped by biomedical expert knowledge (BEK) and cultural expert knowledge (CEK). When there is a dearth of BEK, as in the case of receiving results of uncertain significance, participants rely on CEK, including religious/spiritual beliefs, "gut instinct," embodied knowledge, and social network informants. CEK is a powerful platform to guide understanding of prenatal genetic testing results. The utility of culturally situated expert knowledge during testing uncertainty emphasizes that decision-making occurs within discourses beyond the biomedical domain. These forms of "knowing" may be integrated into clinical consideration of efficacious patient assessment and counseling.
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21
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Chen SC, Wasserman DT. A Framework for Unrestricted Prenatal Whole-Genome Sequencing: Respecting and Enhancing the Autonomy of Prospective Parents. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:3-18. [PMID: 27996923 DOI: 10.1080/15265161.2016.1251632] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Noninvasive, prenatal whole genome sequencing (NIPW) may be a technological reality in the near future, making available a vast array of genetic information early in pregnancy at no risk to the fetus or mother. Many worry that the timing, safety, and ease of the test will lead to informational overload and reproductive consumerism. The prevailing response among commentators has been to restrict conditions eligible for testing based on medical severity, which imposes disputed value judgments and devalues those living with eligible conditions. To avoid these difficulties, we propose an unrestricted testing policy, under which prospective parents could obtain information on any variant of known significance after a careful informed consent process that uses an interactive decision aid to deliver a mandatory presentation on the purposes, techniques, and limitations of genomic testing, as well as optional resources for reflection and consultation. This process would encourage thoughtful, informed deliberation by prospective parents before deciding whether or how to use NIPW.
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22
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Werner-Lin A, Barg FK, Kellom KS, Stumm KJ, Pilchman L, Tomlinson AN, Bernhardt BA. Couple's Narratives of Communion and Isolation Following Abnormal Prenatal Microarray Testing Results. QUALITATIVE HEALTH RESEARCH 2016; 26:1975-1987. [PMID: 26351292 DOI: 10.1177/1049732315603367] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In 2% to 3% of cases, prenatal microarray testing detects deletions and duplications in a fetus' genome that are undetected by conventional cytogenetics. Many of these changes are associated with variable or uncertain symptomatology. Little is known about how couples experience uncertain results. This study analyzed 24 interviews with members of 12 heterosexual U.S. couples who received pathogenic or uncertain microarray prenatal testing results. Researchers used narrative analysis to examine couples' understanding and incorporation of findings into decision making regarding pregnancy termination. Couples felt unprepared for these findings and frustrated because scant information was available to aid interpretation. Women sought information and made decisions, and men marginalized their distress to support their wives. A shift in voice from first to second person indicated attempts to normalize emotional responses by making the process "common" to all couples. Families pursuing highly sensitive prenatal testing may need expert guidance to support decision making.
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Affiliation(s)
| | - Frances K Barg
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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23
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Watanabe M, Matsuo M, Ogawa M, Uchiyama T, Shimizu S, Iwasaki N, Yamauchi A, Urano M, Numabe H, Saito K. Genetic Counseling for Couples Seeking Noninvasive Prenatal Testing in Japan: Experiences of Pregnant Women and their Partners. J Genet Couns 2016; 26:628-639. [PMID: 27830353 DOI: 10.1007/s10897-016-0038-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 10/14/2016] [Indexed: 11/28/2022]
Abstract
The recent advent of noninvasive prenatal testing (NIPT) has had a significant impact in the field of prenatal testing. Although reports on pregnant women who used NIPT have accumulated, little is known about the experiences of their male partners. In this study, we assessed the experiences of couples who were expecting a child and undergoing NIPT, with a focus on both the pregnant women and their partners. Questionnaires were administered to 282 participants focusing on their specific experiences at three time points: after pre-test counseling (first visit), when undergoing NIPT (second visit), and when results were received (third visit). Responses were analyzed to assess the differences between pregnant women and their partners. We found that more partners selected "family" as their first information source about NIPT and "my partner" as the first person to request NIPT than did pregnant women (35.6 vs. 5.9 %; p < 0.001 and 19.3 vs.1.5 %; p < 0.001). However, pregnant women more often consulted others including family and friends until undergoing NIPT than their partners (89.1 vs. 54.6 %; p < 0.001). Our findings suggest that it is important to encourage male partners to be actively involved in the NIPT decision-making process. Differences between pregnant women and their partners should be seriously considered when providing genetic counseling.
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Affiliation(s)
- Motoko Watanabe
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan.,Department of Genetic Counseling, Graduate School of Humanities and Sciences, Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo, 112-8610, Japan
| | - Mari Matsuo
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Masaki Ogawa
- Maternal and Perinatal Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toshitaka Uchiyama
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Satoru Shimizu
- Medical Research Institute, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Naoko Iwasaki
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan.,Diabetes Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Akemi Yamauchi
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Mari Urano
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan
| | - Hironao Numabe
- Department of Genetic Counseling, Graduate School of Humanities and Sciences, Ochanomizu University, 2-1-1 Otsuka, Bunkyo-ku, Tokyo, 112-8610, Japan
| | - Kayoko Saito
- Institute of Medical Genetics, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-ku, Tokyo, 162-0054, Japan.
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24
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Quinlan-Jones E, Kilby MD, Greenfield S, Parker M, McMullan D, Hurles ME, Hillman SC. Prenatal whole exome sequencing: the views of clinicians, scientists, genetic counsellors and patient representatives. Prenat Diagn 2016; 36:935-941. [PMID: 27550507 DOI: 10.1002/pd.4916] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Focus groups were conducted with individuals involved in prenatal diagnosis to determine their opinions relating to whole exome sequencing in fetuses with structural anomalies. METHOD Five representatives of patient groups/charities (PRGs) and eight clinical professionals (CPs) participated. Three focus groups occurred (the two groups separately and then combined). Framework analysis was performed to elicit themes. A thematic coding frame was identified based on emerging themes. RESULTS Seven main themes (consent, analysis, interpretation/reinterpretation of results, prenatal issues, uncertainty, incidental findings and information access) with subthemes emerged. The main themes were raised by both groups, apart from 'analysis', which was raised by CPs only. Some subthemes were raised by PRGs and CPs (with different perspectives). Others were raised either by PRGs or CPs, showing differences in patient/clinician agendas. CONCLUSIONS Prenatal consent for whole exome sequencing is not a 'perfect' process, but consent takers should be fully educated regarding the test. PRGs highlighted issues involving access to results, feeling that women want to know all information. PRGs also felt that patients want reinterpretation of results over time, whilst CPs felt that interpretation should be performed at the point of testing only. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Mark D Kilby
- Fetal Medicine Centre, Birmingham Women's NHS Foundation Trust, Birmingham, UK. .,Birmingham Centre for Women's and New-born Health, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK. .,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Michael Parker
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dominic McMullan
- West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | | | - Sarah C Hillman
- Fetal Medicine Centre, Birmingham Women's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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25
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Werner-Lin A, McCoyd JLM, Bernhardt BA. Balancing Genetics (Science) and Counseling (Art) in Prenatal Chromosomal Microarray Testing. J Genet Couns 2016; 25:855-67. [PMID: 27207687 DOI: 10.1007/s10897-016-9966-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/28/2016] [Indexed: 12/19/2022]
Abstract
Genetic counselors frequently are called upon to assist patients in understanding the implications of prenatal testing information for their pregnancies and their family's lives. The introduction of highly sensitive testing such as chromosomal microarray has generated additional kinds of uncertainty into the prenatal period. Counselors may feel uncomfortable or inadequately prepared to engage in discussions with prospective parents who are faced with making critical, and timely, decisions about a pregnancy based on uncertain information. As highly sensitive prenatal testing becomes routine in prenatal care, counselors may be in search of approaches to prenatal counseling, as well as specific skills to approach, engage with, and help families find resolution in such challenging circumstances. To assist genetic counselors, we describe practice skills and provide language for approaching conversations with prospective parents. When clinicians regularly provide care to patients and families making life-altering decisions under conditions of significant uncertainty, discomfort is common and compassion fatigue is likely. We make recommendations directly to the genetic counselor working in reproductive and perinatal settings to enhance training and self-care and to decrease discomfort in balancing the scientific- and art- demands of genetic counseling.
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Affiliation(s)
- Allison Werner-Lin
- School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk, Caster Building, Philadelphia, PA, 19104, USA.
| | - Judith L M McCoyd
- School of Social Work, Rutgers: The State University of New Jersey, New Brunswick, NJ, USA
| | - Barbara A Bernhardt
- Translational Medicine and Medical Genetics, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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26
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Shkedi-Rafid S, Fenwick A, Dheensa S, Wellesley D, Lucassen AM. What results to disclose, when, and who decides? Healthcare professionals' views on prenatal chromosomal microarray analysis. Prenat Diagn 2016; 36:252-9. [PMID: 26743561 PMCID: PMC5067646 DOI: 10.1002/pd.4772] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/01/2015] [Accepted: 01/03/2016] [Indexed: 12/26/2022]
Abstract
Objectives This study explored the views of healthcare professionals (HCPs) in the UK about what information should be disclosed, when; and whether women/parents should be given a choice as to what they wish to know. Methods Q‐methodology was used to assess the views of 40 HCPs (genetic HCPs, fetal medicine experts, lab‐scientists). Results Most participants agreed that variants of unknown clinical significance should not be disclosed. Participants were divided between those who considered variants of uncertain clinical significance helpful for parents and clinicians, and those who considered them harmful. Although recognising the potential disadvantages of disclosing risks for adult‐onset conditions, participants thought it would be difficult to withhold such information once identified. Participants largely supported some parental involvement in determining which results should be returned. Most participants believed that information obtained via CMA testing in pregnancy should either be disclosed during pregnancy, or not at all. Conclusion HCPs taking part in the study largely believed that variants that will inform the management of the pregnancy, or are relevant to other family members, should be reported. Recent UK guidelines, published after this research was completed, reflect these opinions. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd. What's already known about this topic?Empirical data on healthcare professionals' (HCPs) and parents' experience with prenatal CMA are scarce. Published data mainly focused on issues around uncertain results obtained via CMA, and on genetic health professionals. The two main difficulties expressed by genetic counsellors associated with testing were interpreting uncertain results, and termination of pregnancies based on uncertain results
What does this study add?It is the first study examining attitudes of a wide range of professionals involved in CMA testing: laboratory professionals, fetal medicine experts, and genetic health professionals. We describe what types of results professionals think should or should not be disclosed and with whom they consider the onus for such decision making should lie. These views are reflected in the recent UK guidelines about CMA testing.
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Affiliation(s)
- Shiri Shkedi-Rafid
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Angela Fenwick
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sandi Dheensa
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Diana Wellesley
- Wessex Clinical Genetics Service, University Hospitals Southampton, Southampton, UK
| | - Anneke M Lucassen
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
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27
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Walser SA, Kellom KS, Palmer SC, Bernhardt BA. Comparing genetic counselor's and patient's perceptions of needs in prenatal chromosomal microarray testing. Prenat Diagn 2015; 35:870-8. [PMID: 25995037 DOI: 10.1002/pd.4624] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/13/2015] [Accepted: 05/17/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Chromosome microarray analysis is poised to take a significant place in the prenatal setting given its increased yield over standard karyotyping, but concerns regarding ethical and counseling challenges remain, especially associated with the risk of uncertain and incidental findings. Guidelines recommend patients receiving prenatal screening to undergo genetic counseling prior to testing, but little is known about women's specific pre-testing and post-testing informational needs, as well as their preference for return of various types of results. METHODS The present study surveys 199 prenatal genetic counselors who have counseled patients undergoing chromosome microarray analysis testing and 152 women who have undergone testing on the importance of understanding pre-test information, return of various types of results, and resources made available following an abnormal finding. RESULTS Counselors and patients agree on many aspects, although findings indicate patients consider all available information very important, while genetic counselors give more varying ratings. CONCLUSION Counseling sessions would benefit from information personalized to a patient's particular needs and a shared decision-making model, to reduce informational overload and avoid unnecessary anxiety. Additionally, policies regarding the return of various types of results are needed. © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Sarah A Walser
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine S Kellom
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven C Palmer
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara A Bernhardt
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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28
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Agatisa PK, Mercer MB, Leek AC, Smith MB, Philipson E, Farrell RM. A first look at women's perspectives on noninvasive prenatal testing to detect sex chromosome aneuploidies and microdeletion syndromes. Prenat Diagn 2015; 35:692-8. [DOI: 10.1002/pd.4594] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 02/20/2015] [Accepted: 03/13/2015] [Indexed: 12/26/2022]
Affiliation(s)
| | | | - Angela C. Leek
- Department of Bioethics; Cleveland Clinic; Cleveland OH USA
| | | | - Elliot Philipson
- Department of Obstetrics & Gynecology; Cleveland Clinic Women's Health Institute; Cleveland OH USA
| | - Ruth M. Farrell
- Department of Bioethics; Cleveland Clinic; Cleveland OH USA
- Genomic Medicine Institute; Cleveland Clinic; Cleveland OH USA
- Department of Obstetrics & Gynecology; Cleveland Clinic Women's Health Institute; Cleveland OH USA
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29
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Srebniak MI, Van Opstal D, Joosten M, Diderich KEM, de Vries FAT, Riedijk S, Knapen MFCM, Go ATJI, Govaerts LCP, Galjaard RJH. Whole-genome array as a first-line cytogenetic test in prenatal diagnosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:363-372. [PMID: 25488734 DOI: 10.1002/uog.14745] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 11/17/2014] [Accepted: 11/21/2014] [Indexed: 06/04/2023]
Affiliation(s)
- M I Srebniak
- Department of Clinical Genetics, Erasmus Medical Centre, Rotterdam, The Netherlands
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30
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Kilby M, Hillman S, Maher E, McMullan D. Reply: To PMID 23512800. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:358-359. [PMID: 24591235 DOI: 10.1002/uog.13264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- M Kilby
- School of Clinical and Experimental Medicine, College of Medicine and Dentistry, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK; Fetal Medicine Centre, Birmingham Women's Foundation Trust, Edgbaston, Birmingham, UK
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31
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Bernhardt BA, Kellom K, Barbarese A, Faucett WA, Wapner RJ. An exploration of genetic counselors' needs and experiences with prenatal chromosomal microarray testing. J Genet Couns 2014; 23:938-47. [PMID: 24569858 DOI: 10.1007/s10897-014-9702-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 02/05/2014] [Indexed: 11/28/2022]
Abstract
Because of the higher yield over traditional chromosomal analysis, chromosomal microarray analysis (CMA) is being used increasingly in prenatal diagnosis. Unfortunately, the clinical implication of many copy number variants found on prenatal CMA is uncertain, complicating genetic counseling. Recognizing that uncertain results will be encountered frequently as more of the genome is assayed prenatally, we set out to understand the experiences and needs of genetic counselors when counseling patients about uncertain prenatal microarray results, their comfort with various aspects of prenatal genetic counseling, and their interest in additional education and training about prenatal microarray testing. We first interviewed 10 genetic counselors about their experiences of providing pre- and post-test genetic counseling about prenatal CMA. Based on the findings from the counselor interviews, we developed items for a survey to assess the prevalence of genetic counselors' attitudes towards, experience and comfort with, and educational needs regarding prenatal CMA. Based on surveys completed by 193 prenatal genetic counselors, we found that when there is an uncertain CMA result, only 59% would be comfortable providing genetic counseling and only 43% would be comfortable helping a patient make a decision about pregnancy termination. Being less comfortable was associated with seeing fewer patients having prenatal CMA testing. Respondents expressed a high degree of interest in additional education about prenatal CMA and counseling about uncertain results. Further genetic counselor education and training aimed at improving counselors' personal comfort with uncertain results and communicating about them with patients is needed.
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Hall GK, Mackie FL, Hamilton S, Evans A, McMullan DJ, Williams D, Allen S, Kilby MD. Chromosomal microarray analysis allows prenatal detection of low level mosaic autosomal aneuploidy. Prenat Diagn 2014; 34:505-7. [PMID: 24464918 DOI: 10.1002/pd.4333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 01/07/2023]
Affiliation(s)
- Georgina K Hall
- West Midlands Regional Genetics Laboratory, Birmingham Women's NHS Foundation Trust, Edgbaston, Birmingham, UK
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Hillman SC, McMullan DJ, Silcock L, Maher ER, Kilby MD. How does altering the resolution of chromosomal microarray analysis in the prenatal setting affect the rates of pathological and uncertain findings? J Matern Fetal Neonatal Med 2013; 27:649-57. [PMID: 23869996 DOI: 10.3109/14767058.2013.825601] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Chromosomal Microarray Analysis (CMA) has a higher detection rate of pathogenic chromosome abnormalities over conventional (G-band) karyotyping. The optimum resolution of CMA in the prenatal setting remains debatable. Our objective was to determine if an increased detection rate was obtained by performing differing resolution of CMA on the same fetal samples and whether this resulted in an increase in variants of uncertain clinical significance (VOUS). METHODS Sixty-two fetal cases initially underwent a 1 Mb targeted BAC microarray within a clinical diagnostic setting in addition to conventional karyotyping. At the conclusion of pregnancy, a higher resolution 60 K oligonucleotide microarray was performed. RESULTS The 1 Mb BAC analysis demonstrated a detection rate of pathogenic copy number variations (CNVs) in 4.1% (95% CI 2.1-7.6) of cases and a variation of unknown significance (VOUS) rate of 0.4% (95% CI 0.07-2.2) over conventional G-band karyotyping. The 60 K array had an additional pathogenic detection rate of 4.8% (95% CI 1.6-13.3) over the BAC array but also detected an additional 8% (95% CI 1.3-14.8) VOUS. CONCLUSION As the CMA platform resolution increases detection rates increase but are associated with an increase in VOUS rates. Our findings support the need for further large scale studies to inform the national consensus on the resolution required and on reporting of VOUS in the antenatal setting.
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Affiliation(s)
- S C Hillman
- School of Clinical and Experimental Medicine, College of Medicine and Dentistry, University of Birmingham , Edgbaston, Birmingham , UK
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