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Amorim M, Silva S, Machado H, Teles EL, Baptista MJ, Maia T, Nwebonyi N, de Freitas C. Benefits and Risks of Sharing Genomic Data for Research: Comparing the Views of Rare Disease Patients, Informal Carers and Healthcare Professionals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148788. [PMID: 35886636 PMCID: PMC9319916 DOI: 10.3390/ijerph19148788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 01/25/2023]
Abstract
Assessing public and patients’ expectations and concerns about genomic data sharing is essential to promote adequate data governance and engagement in rare diseases genomics research. This cross-sectional study compared the views of 159 rare disease patients, 478 informal carers and 63 healthcare professionals in Northern Portugal about the benefits and risks of sharing genomic data for research, and its associated factors. The three participant groups expressed significantly different views. The majority of patients (84.3%) and informal carers (87.4%) selected the discovery of a cure for untreatable diseases as the most important benefit. In contrast, most healthcare professionals revealed a preference for the development of new drugs and treatments (71.4%), which was the second most selected benefit by carers (48.3%), especially by the more educated (OR (95% CI): 1.58 (1.07–2.34)). Lack of security and control over information access and the extraction of information exceeding research objectives were the two most often selected risks by patients (72.6% and 50.3%, respectively) and carers (60.0% and 60.6%, respectively). Conversely, professionals were concerned with genomic data being used to discriminate citizens (68.3%), followed by the extraction of information exceeding research objectives (54.0%). The latter risk was more frequently expressed by more educated carers (OR (95% CI): 1.60 (1.06–2.41)) and less by those with blue-collar (OR (95% CI): 0.44 (0.25–0.77) and other occupations (OR (95% CI): 0.44 (0.26–0.74)). Developing communication strategies and consent approaches tailored to participants’ expectations and needs can benefit the inclusiveness of genomics research that is key for patient-centred care.
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Affiliation(s)
- Mariana Amorim
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), 4050-600 Porto, Portugal; (M.A.); (T.M.); (N.N.)
- EPIUnit—Instituto de Saúde Pública, Universidade do Porto, 4050-600 Porto, Portugal
| | - Susana Silva
- Centro em Rede de Investigação em Antropologia, Universidade do Minho, 4710-057 Braga, Portugal;
- Instituto de Ciências Sociais, Universidade do Minho, 4710-057 Braga, Portugal;
| | - Helena Machado
- Instituto de Ciências Sociais, Universidade do Minho, 4710-057 Braga, Portugal;
| | - Elisa Leão Teles
- Centro de Referência de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal;
| | - Maria João Baptista
- Centro de Referência de Cardiopatias Congénitas, Centro Hospitalar Universitário São João, 4200-319 Porto, Portugal;
- Departamento de Ginecologia, Obstetrícia e Pediatria, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal
| | - Tiago Maia
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), 4050-600 Porto, Portugal; (M.A.); (T.M.); (N.N.)
- EPIUnit—Instituto de Saúde Pública, Universidade do Porto, 4050-600 Porto, Portugal
| | - Ngozi Nwebonyi
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), 4050-600 Porto, Portugal; (M.A.); (T.M.); (N.N.)
- EPIUnit—Instituto de Saúde Pública, Universidade do Porto, 4050-600 Porto, Portugal
| | - Cláudia de Freitas
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), 4050-600 Porto, Portugal; (M.A.); (T.M.); (N.N.)
- EPIUnit—Instituto de Saúde Pública, Universidade do Porto, 4050-600 Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, 4200-319 Porto, Portugal
- Correspondence:
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2
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Posey LL, Thistle PD. Genetic testing and genetic discrimination: Public policy when insurance becomes "too expensive". JOURNAL OF HEALTH ECONOMICS 2021; 77:102441. [PMID: 33676198 DOI: 10.1016/j.jhealeco.2021.102441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
We examine public policy toward the use of genetic tests by insurers when a positive test makes actuarially fair insurance too expensive for some consumers. With state-dependent utility, consumers may decline actuarially fair insurance if the probability of becoming ill exceeds a threshold. In markets with adverse selection, a positive genetic test may cause all or some high risks to drop out of the market (complete and partial genetic discrimination, respectively). Full participation in the market by all consumers requires cross-subsidization. We show that the consent law and mandatory testing are equivalent. Under complete genetic discrimination, the duty to disclose is never Pareto dominated, but either the code of conduct or consent law can yield the same outcome. Under partial genetic discrimination, the duty to disclose is never Pareto dominated. However, partial genetic discrimination and cross-subsidization imply the information ban is noncomparable to the other policy alternatives.
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Affiliation(s)
- Lisa L Posey
- Department of Risk Management, Pennsylvania State University, 369 Business Building University Park, PA, 16802, United States.
| | - Paul D Thistle
- Department of Finance, Lee Business School, University of Nevada, Las Vegas, 4505 Maryland Parkway, Box 456008, Las Vegas, NV, 89154-6008, United States.
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3
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Dragojlovic N, Kopac N, Borle K, Tandun R, Salmasi S, Ellis U, Birch P, Adam S, Friedman JM, Elliott AM, Lynd LD. Utilization and uptake of clinical genetics services in high-income countries: A scoping review. Health Policy 2021; 125:877-887. [PMID: 33962789 DOI: 10.1016/j.healthpol.2021.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 02/11/2021] [Accepted: 04/14/2021] [Indexed: 12/23/2022]
Abstract
Ongoing rapid growth in the need for genetic services has the potential to severely strain the capacity of the clinical genetics workforce to deliver this care. Unfortunately, assessments of the scale of this health policy challenge and potential solutions are hampered by the lack of a consolidated evidence base on the growth in genetic service utilization. To enable health policy research and strategic planning by health systems in this area, we conducted a scoping review of the literature on the utilization and uptake of clinical genetics services in high-income countries published between 2010 and 2018. One-hundred-and-ninety-five unique studies were included in the review. Most focused on cancer (85/195; 44%) and prenatal care (50/195; 26%), which are consistently the two areas with the greatest volume of genetic service utilization in both the United States and other high-income countries. Utilization and uptake rates varied considerably and were influenced by contextual factors including health system characteristics, provider knowledge, and patient preferences. Moreover, growth in genetic service utilization appears to be driven to a significant degree by technological advances and the integration of new tests into clinical care. Our review highlights both the policy challenge posed by the rapid growth in the utilization of genetic services and the variability in this trend across clinical indications and health systems.
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Affiliation(s)
- Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Nicola Kopac
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Kennedy Borle
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Rachel Tandun
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Shahrzad Salmasi
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Ursula Ellis
- Woodward Library, University of British Columbia, 2198 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Patricia Birch
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Shelin Adam
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Jan M Friedman
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | | | - Alison M Elliott
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, C201 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada; BC Children's Hospital Research Institute, 938 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada; BC Women's Hospital Research Institute, H214 - 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada; Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, 588-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC, V6Z 1Y6.
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4
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Jensen MP, Barker RA. Disease-Modification in Huntington's Disease: Moving Away from a Single-Target Approach. J Huntingtons Dis 2019; 8:9-22. [PMID: 30636742 DOI: 10.3233/jhd-180320] [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] [Indexed: 01/06/2023]
Abstract
To date, no candidate intervention has demonstrated a disease-modifying effect in Huntington's disease, despite promising results in preclinical studies. In this commentary we discuss disease-modifying therapies that have been trialled in Huntington's disease and speculate that these failures may be attributed, in part, to the assumption that a single drug selectively targeting one aspect of disease pathology will be universally effective, regardless of disease stage or "subtype". We therefore propose an alternative approach for effective disease-modification that uses 1) a combination approach rather than monotherapy, and 2) targets the disease process early on - before it is clinically manifest. Finally, we will consider whether this change in approach that we propose will be relevant in the future given the recent shift to targeting more proximal disease processes-e.g., huntingtin gene expression; a timely question given Roche's recent decision to take on the clinical development of a promising new drug candidate in Huntington's disease, IONIS-HTTRx.
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Affiliation(s)
- Melanie P Jensen
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Roger A Barker
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Cambridge Stem Cell Institute, Cambridge, UK
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5
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Clarke AJ, Wallgren-Pettersson C. Ethics in genetic counselling. J Community Genet 2019; 10:3-33. [PMID: 29949066 PMCID: PMC6325035 DOI: 10.1007/s12687-018-0371-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 05/15/2018] [Indexed: 12/22/2022] Open
Abstract
Difficult ethical issues arise for patients and professionals in medical genetics, and often relate to the patient's family or their social context. Tackling these issues requires sensitivity to nuances of communication and a commitment to clarity and consistency. It also benefits from an awareness of different approaches to ethical theory. Many of the ethical problems encountered in genetics relate to tensions between the wishes or interests of different people, sometimes even people who do not (yet) exist or exist as embryos, either in an established pregnancy or in vitro. Concern for the long-term welfare of a child or young person, or possible future children, or for other members of the family, may lead to tensions felt by the patient (client) in genetic counselling. Differences in perspective may also arise between the patient and professional when the latter recommends disclosure of information to relatives and the patient finds that too difficult, or when the professional considers the genetic testing of a child, sought by parents, to be inappropriate. The expectations of a patient's community may also lead to the differences in perspective between patient and counsellor. Recent developments of genetic technology permit genome-wide investigations. These have generated additional and more complex data that amplify and exacerbate some pre-existing ethical problems, including those presented by incidental (additional sought and secondary) findings and the recognition of variants currently of uncertain significance, so that reports of genomic investigations may often be provisional rather than definitive. Experience is being gained with these problems but substantial challenges are likely to persist in the long term.
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Affiliation(s)
- Angus J Clarke
- Institute of Medical Genetics, Division of Cancer & Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff, Wales, CF14 4XN, UK.
| | - Carina Wallgren-Pettersson
- The Folkhaelsan Department of Medical Genetics, Topeliusgatan, 20 00250, Helsinki, Finland
- The Folkhaelsan Institute of Genetics and the Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
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6
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Smith RA, Sillars A, Chesnut RP, Zhu X. Investigating Married Adults' Communal Coping with Genetic Health Risk and Perceived Discrimination. COMMUNICATION MONOGRAPHS 2017; 85:181-202. [PMID: 29731540 PMCID: PMC5930874 DOI: 10.1080/03637751.2017.1404618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/28/2017] [Indexed: 06/08/2023]
Abstract
Increased genetic testing in personalized medicine presents unique challenges for couples, including managing disease risk and potential discrimination as a couple. This study investigated couples' conflicts and support gaps as they coped with perceived genetic discrimination. We also explored the degree to which communal coping was beneficial in reducing support gaps, and ultimately stress. Dyadic analysis of married adults (N = 266, 133 couples), in which one person had the genetic risk for serious illness, showed that perceived discrimination predicted more frequent conflicts about AATD-related treatment, privacy boundaries, and finances, which, in turn, predicted wider gaps in emotion and esteem support, and greater stress for both spouses. Communal coping predicted lower support gaps for both partners and marginally lower stress.
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Affiliation(s)
| | | | | | - Xun Zhu
- The Pennsylvania State University
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7
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Rauscher EA. Investigating Uncertainty in Genetic Counseling Encounters: Managing Information About Genetic Cancer Risk. JOURNAL OF HEALTH COMMUNICATION 2017; 22:896-904. [PMID: 29125386 DOI: 10.1080/10810730.2017.1373875] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The Theory of Motivated Information Management (TMIM) was used to investigate how individuals at increased risk of developing hereditary cancer seek information from genetic counselors. Results show the TMIM model fit the data well in predicting participants' intentions to seek information from genetic counselors. Participants felt an uncertainty discrepancy that elicited feelings of anxiety, which in turn negatively predicted both outcome expectancies and efficacy assessments. Efficacy assessments, but not anxiety, significantly predicted participants' intentions to seek information from a genetic counselor in the future. Findings showed no significant relationship between outcome expectancies and efficacy assessments. One implication for genetic counselors is the need to more closely monitor emotional response to genetic disease risk-whether that emotional response be positive or negative-as that response may influence information-seeking intentions. Further, genetic counselors might also pay more attention to building efficacy for themselves (making patients feel the counselor is more credible) and their patients (increasing patient ability to communicate effectively about genetic disease risk). Analysis also extends TMIM theory by showing that in a relationship where information exchange is the primary function the model still showed good fit. However, outcome expectancies functioned differently than in previous tests of the model.
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Affiliation(s)
- Emily A Rauscher
- a Department of Communication , Texas A&M University , College Station , Texas , USA
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8
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Thomas EA. DNA methylation in Huntington's disease: Implications for transgenerational effects. Neurosci Lett 2016; 625:34-9. [PMID: 26522374 PMCID: PMC4864163 DOI: 10.1016/j.neulet.2015.10.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/08/2015] [Accepted: 10/23/2015] [Indexed: 12/29/2022]
Abstract
Huntington's disease (HD) is a devastating, neurodegenerative disorder caused by a CAG repeat mutation in the HTT gene. A growing body of evidence suggests that epigenetic modifications play a key role in HD pathogenesis. Expression of the disease protein, huntingtin, leads to extensive transcriptional dysregulation due to disruption of histone-modifying complexes and altered interactions with chromatin-related factors. Such epigenetic mechanisms also readily respond to environmental factors, which are now thought to influence the risk, onset and progression of neurodegenerative disorders, including HD. DNA methylation is an epigenetic modification that has been studied intensively, however, its role in HD is just emerging. In this review, DNA methylation differences associated with HD will be summarized, as well as the role of environmental factors to alter DNA methylation in a manner that could alter disease phenotypes. Further, transgenerational epigenetic inheritance will be discussed in the context of relevant environmental factors and their potential links to HD. The study of epigenetic states in HD presents an opportunity to gain new insights into risk factors and pathogenic mechanisms associated with HD, as well as to inform about treatment options.
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Affiliation(s)
- Elizabeth A Thomas
- Department of Molecular and Cellular Neuroscience, The Scripps Research Institute, La Jolla, CA, United States.
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9
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Wauters A, Van Hoyweghen I. Global trends on fears and concerns of genetic discrimination: a systematic literature review. J Hum Genet 2016; 61:275-82. [PMID: 26740237 DOI: 10.1038/jhg.2015.151] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/12/2015] [Accepted: 11/11/2015] [Indexed: 12/29/2022]
Abstract
Since the 1990s, developments in the field of genetics have led to many questions on the use and possible misuse of genetic information. 'Genetic discrimination' has been defined as the differential treatment of asymptomatic individuals or their relatives on the basis of their real or assumed genetic characteristics. Despite the public policy attention around genetic discrimination, there is currently still much confusion surrounding this phenomenon. On the one hand, there is little evidence of the occurrence of genetic discrimination. On the other hand, it appears that people remain concerned about this theme, and this fear influences their health and life choices. This article makes use of a systematic literature review to investigate what is already known about the nature, extent and background of these fears and concerns. The 42 included studies have found considerable levels of concerns about genetic discrimination. Concerns dominate in insurance contexts and within personal interactions. The extent of concerns appears to vary depending on the type of genetic illness. Furthermore, installed laws prohibiting genetic discrimination do not seem to alleviate existing fears. This raises important questions as to the origins of these fears. Based on the findings, recommendations for future research are made. First, research on the background of fears is needed. Second, future research needs to assess more fully all different forms (for example, direct and indirect) of genetic discrimination. Thirdly, it has to be studied whether genetic discrimination is a form of discrimination that is distinguishable from discrimination based on an illness or disability. Finally, a last element that should be addressed in future research is the most recent developments in research on genomics, such as next-generation sequencing or genome-wide association studies.
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Affiliation(s)
- Annet Wauters
- Life Sciences and Society Lab, Centre for Sociological Research, KU Leuven, Leuven, Belgium
| | - Ine Van Hoyweghen
- Life Sciences and Society Lab, Centre for Sociological Research, KU Leuven, Leuven, Belgium
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10
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Bombard Y. Translating personalized genomic medicine into clinical practice: evidence, values, and health policy. Genome 2015; 58:491-7. [PMID: 26577841 DOI: 10.1139/gen-2015-0145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yvonne Bombard
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy, Management & Evaluation, University of Toronto.,Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy, Management & Evaluation, University of Toronto
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11
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Bashir NS, Ungar WJ. The 3-I framework: a framework for developing public policies regarding pharmacogenomics (PGx) testing in Canada. Genome 2015; 58:527-40. [PMID: 26623513 DOI: 10.1139/gen-2015-0100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The 3-I framework of analyzing the ideas, interests, and institutions around a topic has been used by political scientists to guide public policy development. In Canada, there is a lack of policy governing pharmacogenomics (PGx) testing compared to other developed nations. The goal of this study was to use the 3-I framework, a policy development tool, and apply it to PGx testing to identify and analyze areas where current policy is limited and challenges exist in bringing PGx testing into wide-spread clinical practice in Canada. A scoping review of the literature was conducted to determine the extent and challenges of PGx policy implementation at federal and provincial levels. Based on the 3-I analysis, contentious ideas related to PGx are (i) genetic discrimination, (ii) informed consent, (iii) the lack of knowledge about PGx in health care, (iv) the value of PGx testing, (v) the roles of health care workers in the coordination of PGx services, and (vi) confidentiality and privacy. The 3-I framework is a useful tool for policy makers, and applying it to PGx policy development is a new approach in Canadian genomics. Policy makers at every organizational level can use this analysis to help develop targeted PGx policies.
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Affiliation(s)
- Naazish S Bashir
- Child Health Evaluation Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Child Health Evaluation Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Wendy J Ungar
- Child Health Evaluation Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Child Health Evaluation Sciences, The Hospital for Sick Children Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON M5G 0A4, Canada
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12
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do Nascimento Marinho AS, de Faria Domingues de Lima MA, Vargas FR. Analysis of pre-test interviews in a cohort of Brazilian patients with movement disorders. J Community Genet 2015; 6:259-64. [PMID: 25994216 DOI: 10.1007/s12687-015-0235-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/13/2015] [Indexed: 12/01/2022] Open
Abstract
Spinocerebellar ataxias and Huntington disease are heritable, adult onset, neurodegenerative disorders of movement. Both are autosomal dominant and caused by expansions in trinucleotide sequences in several genes. Because these expansions are associated with an almost complete penetrance, genetic tests are available at the diagnostic and predictive level. In this study, we describe the expectations and issues raised during pre-test interviews for genetic counselling for these diseases. Data from pre-test interviews with 97 patients and at-risk relatives for spinocerebellar ataxia (SCA) or Huntington disease was comprised of close-ended questions (demographics, personal and current disease history) and open-ended questions, where individuals were asked to describe their hopes and expectations on the genetic counselling evaluation and also their degree of knowledge about genetics and medical genetics. Amongst the main expectations identified in patients and at-risk relatives, issues related to the aetiological diagnosis and/or disclosure of the at-risk status were those most frequently mentioned (57 %). Improvement in quality of life was another identified issue (17 %). Interestingly, the issue of inheritance/transmission was identified as the main expectation by a minority of individuals (3 %). Pre-test interviews are valuable tools to identify issues raised by consultands and promote a better communication between the patient, family and the genetic counselling team.
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Affiliation(s)
- Alice Salgueiro do Nascimento Marinho
- Genetics and Molecular Biology Department, Medical Genetics Service, Hospital Universitário Gaffrée e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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13
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Genetics and Personal Insurance: the Perspectives of Canadian Cancer Genetic Counselors. J Genet Couns 2015; 24:1022-36. [PMID: 25925606 PMCID: PMC4643106 DOI: 10.1007/s10897-015-9841-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 04/08/2015] [Indexed: 11/26/2022]
Abstract
Genetic discrimination in the context of genetic testing has been identified as a concern for symptomatic and asymptomatic individuals for more than three decades. Genetic counselors are often the health care professionals who discuss risks and benefits of genetic testing with patients, thereby making them most appropriate to address patient concerns about genetics and personal insurance (i.e., life, life as related to mortgage or group insurance, disability, critical illness and travel). A pilot study was conducted to ascertain the current practices of Canadian cancer genetic counselors in regard to their discussions with patients about genetic testing and access to personal insurance. Among the 36 counselors surveyed, 100 % reported discussing the issue of genetic testing and personal insurance with their patients. Several factors influenced the content, depth and length of these discussions including age, cancer status, family members, and patients’ current and future insurance needs. Counselors reported discussing with patients the possible impact of genetic test results on access to personal insurance, possible access and use of patient genetic information by insurance companies, and whom patients should contact if they have additional questions. The most commonly reported inquiries from patients included questions about the possible impact of genetic testing on their ability to obtain insurance, and the insurability of family members. While 28 % of counselors reported having been contacted by an insurer requesting access to patient information, only one counselor was aware of or could recall the outcome of such a request. This pilot study revealed that issues concerning genetics and personal insurance are commonly discussed in Canadian cancer genetic counseling sessions. Counselors furthermore expressed a need for additional educational resources on the topic of genetics and personal insurance for themselves and their patients.
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14
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Mo C, Hannan AJ, Renoir T. Environmental factors as modulators of neurodegeneration: Insights from gene–environment interactions in Huntington's disease. Neurosci Biobehav Rev 2015; 52:178-92. [DOI: 10.1016/j.neubiorev.2015.03.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 02/13/2015] [Accepted: 03/03/2015] [Indexed: 12/11/2022]
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15
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Mo C, Renoir T, Hannan AJ. Ethological endophenotypes are altered by elevated stress hormone levels in both Huntington's disease and wildtype mice. Behav Brain Res 2014; 274:118-27. [DOI: 10.1016/j.bbr.2014.07.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 07/24/2014] [Accepted: 07/26/2014] [Indexed: 01/05/2023]
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16
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McGowan ML, Settersten RA, Juengst ET, Fishman JR. Integrating genomics into clinical oncology: ethical and social challenges from proponents of personalized medicine. Urol Oncol 2014; 32:187-92. [PMID: 24445286 DOI: 10.1016/j.urolonc.2013.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 10/09/2013] [Accepted: 10/11/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The use of molecular tools to individualize health care, predict appropriate therapies, and prevent adverse health outcomes has gained significant traction in the field of oncology under the banner of "personalized medicine" (PM). Enthusiasm for PM in oncology has been fueled by success stories of targeted treatments for a variety of cancers based on their molecular profiles. Though these are clear indications of optimism for PM, little is known about the ethical and social implications of personalized approaches in clinical oncology. OBJECTIVE The objective of this study is to assess how a range of stakeholders engaged in promoting, monitoring, and providing PM understand the challenges of integrating genomic testing and targeted therapies into clinical oncology. METHODS AND MATERIALS The study involved the analysis of in-depth interviews with 117 stakeholders whose experiences and perspectives on PM span a wide variety of institutional and professional settings. RESULTS Despite their considerable enthusiasm for this shift, promoters, monitors, and providers of PM identified 4 domains that provoke heightened ethical and social concerns: (1) informed consent for cancer genomic testing, (2) privacy, confidentiality, and disclosure of genomic test results, (3) access to genomic testing and targeted therapies in oncology, and (4) the costs of scaling up pharmacogenomic testing and targeted cancer therapies. CONCLUSIONS These specific concerns are not unique to oncology, or even genomics. However, those most invested in the success of PM view oncologists' responses to these challenges as precedent setting because oncology is farther along the path of clinical integration of genomic technologies than other fields of medicine. This study illustrates that the rapid emergence of PM approaches in clinical oncology provides a crucial lens for identifying and managing potential frictions and pitfalls that emerge as health care paradigms shift in these directions.
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Affiliation(s)
- Michelle L McGowan
- Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Richard A Settersten
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR
| | - Eric T Juengst
- Center for Bioethics, Department of Social Medicine, University of North Carolina, Chapel Hill, NC
| | - Jennifer R Fishman
- Biomedical Ethics Unit, Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada
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Mo C, Pang TY, Ransome MI, Hill RA, Renoir T, Hannan AJ. High stress hormone levels accelerate the onset of memory deficits in male Huntington's disease mice. Neurobiol Dis 2014; 69:248-62. [DOI: 10.1016/j.nbd.2014.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 04/24/2014] [Accepted: 05/04/2014] [Indexed: 12/18/2022] Open
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Reilmann R, Leavitt BR, Ross CA. Diagnostic criteria for Huntington's disease based on natural history. Mov Disord 2014; 29:1335-41. [PMID: 25164527 DOI: 10.1002/mds.26011] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/06/2014] [Indexed: 01/10/2023] Open
Abstract
Huntington's disease (HD) is currently diagnosed based on the presence of motor signs indicating 99% "diagnostic confidence" for HD. Recent advances in the understanding of HD natural history and neurobiology indicate that disease-related brain changes begin at least 12 to 15 years before the formal diagnosis based on motor onset. Furthermore, subtle motor dysfunction, cognitive changes, and behavioral alterations are often seen before diagnosis made according to the current criteria. As disease-modifying treatments are developed, likely beginning therapy early will be desirable. We therefore suggest that expanded diagnostic criteria for HD should be adapted to better reflect the natural history of the disease, to enable the conduct of clinical trials in premanifest subjects targeting prevention of neurodegeneration, and to facilitate earlier symptomatic treatment. We propose a new set of criteria for HD diagnostic categories in the International Classification of Diseases that reflect our current understanding of HD natural history and pathogenesis. Based on defined criteria, for example, the Diagnostic Confidence Level and the Total Functional Capacity scales of the Unified Huntington's Disease Rating Scale, HD should be divided in the categories "genetically confirmed" with the subcategories "presymptomatic," "prodromal," and "manifest" and "not genetically confirmed" subdivided into "clinically at risk," "clinically prodromal," and "clinically manifest."
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Affiliation(s)
- Ralf Reilmann
- George-Huntington-Institute, Technology-Park, Muenster, Germany; Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, University of Tuebingen, Tuebingen, Germany
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Mo C, Renoir T, Hannan AJ. Effects of chronic stress on the onset and progression of Huntington's disease in transgenic mice. Neurobiol Dis 2014; 71:81-94. [PMID: 25088714 DOI: 10.1016/j.nbd.2014.07.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/01/2014] [Accepted: 07/23/2014] [Indexed: 12/13/2022] Open
Abstract
Huntington's disease (HD) is a neurodegenerative disease caused by a tandem repeat mutation encoding an expanded polyglutamine tract. Our previous work showed that memory deficits in HD transgenic mice could be accelerated by increased levels of stress hormone, while memory in WT mice remained unaffected. HD patients experience higher levels of stress compared to the general population and symptoms of HD also include motor, cognitive, psychiatric, sexual and olfactory abnormalities, and an associated decline in activities of daily living. Therefore we investigated the impact of a robust stressor (i.e. restraint) on the onset and progression of a range of behavioral phenotypes in R6/1 transgenic HD mice. Restraint was administered for 1h daily from 6weeks of age and continued until R6/1 mice were clearly motor symptomatic at 14weeks of age. Serum corticosterone levels in both R6/1 and WT littermates were elevated immediately after the last restraint session and weight gain was suppressed in restrained animals throughout the treatment period. Motor coordination and locomotor activity were enhanced by chronic restraint in males, regardless of genotype. However, there was no effect of restraint on motor performances in female animals. At 8weeks of age, olfactory sensitivity was impaired by restraint in R6/1 HD female mice, but not in WT mice. In male R6/1 mice, the olfactory deficit was exacerbated by restraint and olfaction was also impaired in male WT mice. The development of deficits in saccharin preference, Y-maze memory, nest-building and sexually-motivated vocalizations was unaffected by chronic restraint in R6/1 and had little impact on such behavioral performances in WT animals. We provide evidence that chronic stress can negatively modulate specific endophenotypes in HD mice, while the same functions were affected to a lesser extent in WT mice. This vulnerability in HD animals seems to be sex-specific depending on the stress paradigm used. It is hoped that our work will stimulate clinical investigations into the effects of stress on both pre-symptomatic and symptomatic gene-positive members of HD families, and inform the development of new therapeutic approaches.
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Affiliation(s)
- Christina Mo
- The Florey Institute of Neuroscience and Mental Health, Kenneth Myer Building, University of Melbourne, Parkville, Australia; Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Australia.
| | - Thibault Renoir
- The Florey Institute of Neuroscience and Mental Health, Kenneth Myer Building, University of Melbourne, Parkville, Australia.
| | - Anthony J Hannan
- The Florey Institute of Neuroscience and Mental Health, Kenneth Myer Building, University of Melbourne, Parkville, Australia; Department of Anatomy and Neuroscience, University of Melbourne, Parkville, Australia
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Prince AER, Roche MI. Genetic information, non-discrimination, and privacy protections in genetic counseling practice. J Genet Couns 2014; 23:891-902. [PMID: 25063358 DOI: 10.1007/s10897-014-9743-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/04/2014] [Indexed: 11/29/2022]
Abstract
The passage of the Genetic Information Non Discrimination Act (GINA) was hailed as a pivotal achievement that was expected to calm the fears of both patients and research participants about the potential misuse of genetic information. However, 6 years later, patient and provider awareness of legal protections at both the federal and state level remains discouragingly low, thereby, limiting their potential effectiveness. The increasing demand for genetic testing will expand the number of individuals and families who could benefit from obtaining accurate information about the privacy and anti-discriminatory protections that GINA and other laws extend. In this paper we describe legal protections that are applicable to individuals seeking genetic counseling, review the literature on patient and provider fears of genetic discrimination and examine their awareness and understandings of existing laws, and summarize how genetic counselors currently discuss genetic discrimination. We then present three genetic counseling cases to illustrate issues of genetic discrimination and provide relevant information on applicable legal protections. Genetic counselors have an unprecedented opportunity, as well as the professional responsibility, to disseminate accurate knowledge about existing legal protections to their patients. They can strengthen their effectiveness in this role by achieving a greater knowledge of current protections including being able to identify specific steps that can help protect genetic information.
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Affiliation(s)
- Anya E R Prince
- Center for Genomics and Society, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Rosas HD, Doros G, Gevorkian S, Malarick K, Reuter M, Coutu JP, Triggs TD, Wilkens PJ, Matson W, Salat DH, Hersch SM. PRECREST: a phase II prevention and biomarker trial of creatine in at-risk Huntington disease. Neurology 2014; 82:850-7. [PMID: 24510496 DOI: 10.1212/wnl.0000000000000187] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the safety and tolerability of high-dose creatine, the feasibility of enrolling premanifest and 50% at-risk subjects in a prevention trial, and the potential of cognitive, imaging, and blood markers. METHODS Sixty-four eligible consenting participants were randomly allocated (1:1) to 15 g twice daily of creatine monohydrate or placebo for a 6-month double-blind phase followed by a 12-month open-label extension. Subjects included premanifest (tested) and at-risk (not tested) individuals without clinical symptoms or signs of Huntington disease (HD). Primary outcomes were safety and tolerability. Exploratory endpoints included fine motor, visuospatial, and memory performance; structural and diffusion MRI; and selected blood markers. RESULTS Forty-seven HD carriers and 17 non-HD controls were enrolled. Fifteen discontinued treatment (2 assigned to placebo); all were followed for the entire study period. Primary analysis was by intent to treat. The most common adverse events were gastrointestinal. Neuroimaging demonstrated treatment-related slowing of cortical and striatal atrophy at 6 and 18 months. CONCLUSION We describe a design that preserves the autonomy of subjects not wanting genetic testing while including controls for assessing the specificity of treatment effects. Our results demonstrate the feasibility of prevention trials for HD and the safety of high-dose creatine, provide possible evidence of disease modification, support future studies of creatine, and illustrate the value of prodromal biomarkers. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that high-dose creatine is safe and tolerable.
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Affiliation(s)
- Herminia D Rosas
- From the Departments of Neurology (H.D.R., S.G., K.M., M.R., T.D.T., P.J.W., S.M.H.), Center for Neuro-imaging of Aging and Neurodegenerative Diseases (H.D.R., S.G., K.M., M.R., J.-P.C., T.D.T., P.J.W., D.H.S.), Athinoula A. Martinos Center for Biomedical Imaging (H.D.R., S.G., K.M., M.R., T.D.T., P.J.W., D.H.S.), and Radiology (H.D.R., M.R.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Biostatistics (G.D.), School of Public Health, Boston University, Boston; Harvard-MIT Division of Health Sciences and Technology (J.-P.C.), Cambridge; and Geriatric Research Education Clinical Center (W.M.), New England Veterans Administration, Bedford, MA
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22
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Keogh LA, Otlowski MFA. Life insurance and genetic test results: a mutation carrier's fight to achieve full cover. Med J Aust 2013; 199:363-6. [PMID: 23992195 DOI: 10.5694/mja13.10202] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/25/2013] [Indexed: 12/19/2022]
Abstract
Currently, there is debate about life insurance companies' use of genetic information for assessing applicants. In his early 20s, James (pseudonym) was denied full life insurance cover because he revealed that he had discussed genetic testing with a genetic counsellor. He was later tested and found to carry a mutation in the MSH6 gene; after disclosing this, he was denied cover for cancer by two other life insurance companies. Unsatisfied with the insurance companies' risk assessments, and based on his understanding that regular colonoscopy significantly reduced his risk of cancer, James made a complaint to the Australian Human Rights Commission. After informing the third insurance company that he had done so, he was offered full coverage, which suggests that the company did not have actuarial data to justify its decision. This case provides evidence of the high level of initiative and proactivity required for a consumer to achieve a fair result. Few Australians would be in a position to pursue the level of research and advocacy undertaken by James (a professional with scientific training). We call on a collaborative approach between industry, government and researchers to address the issues that James's case raises about genetic testing and life insurance.
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Affiliation(s)
- Louise A Keogh
- Centre for Women's Health, Gender and Society, University of Melbourne, Melbourne, VIC, Australia.
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23
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Mo C, Renoir T, Pang TY, Hannan AJ. Short-term memory acquisition in female Huntington's disease mice is vulnerable to acute stress. Behav Brain Res 2013; 253:318-22. [DOI: 10.1016/j.bbr.2013.07.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 07/19/2013] [Accepted: 07/23/2013] [Indexed: 12/28/2022]
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Joly Y, Ngueng Feze I, Simard J. Genetic discrimination and life insurance: a systematic review of the evidence. BMC Med 2013; 11:25. [PMID: 23369270 PMCID: PMC3606414 DOI: 10.1186/1741-7015-11-25] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 01/31/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the late 1980s, genetic discrimination has remained one of the major concerns associated with genetic research and clinical genetics. Europe has adopted a plethora of laws and policies, both at the regional and national levels, to prevent insurers from having access to genetic information for underwriting. Legislators from the United States and the United Kingdom have also felt compelled to adopt protective measures specifically addressing genetics and insurance. But does the available evidence really confirm the popular apprehension about genetic discrimination and the subsequent genetic exceptionalism? METHODS This paper presents the results of a systematic, critical review of over 20 years of genetic discrimination studies in the context of life insurance. RESULTS The available data clearly document the existence of individual cases of genetic discrimination. The significance of this initial finding is, however, greatly diminished by four observations. First, the methodology used in most of the studies is not sufficiently robust to clearly establish either the prevalence or the impact of discriminatory practices. Second, the current body of evidence was mostly developed around a small number of 'classic' genetic conditions. Third, the heterogeneity and small scope of most of the studies prevents formal statistical analysis of the aggregate results. Fourth, the small number of reported genetic discrimination cases in some studies could indicate that these incidents took place due to occasional errors, rather than the voluntary or planned choice, of the insurers. CONCLUSION Important methodological limitations and inconsistencies among the studies considered make it extremely difficult, at the moment, to justify policy action taken on the basis of evidence alone. Nonetheless, other empirical and theoretical factors have emerged (for example, the prevalence and impact of the fear of genetic discrimination among patients and research participants, the (un)importance of genetic information for the commercial viability of the private life insurance industry, and the need to develop more equitable schemes of access to life insurance) that should be considered along with the available evidence of genetic discrimination for a more holistic view of the debate.
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Affiliation(s)
- Yann Joly
- Department of Human Genetics, Faculty of Medicine, McGill University, 740 Dr Penfield Avenue, Suite 5200, Montreal, H3A 1A5 Canada.
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Dorsey ER, Darwin KC, Nichols PE, Kwok JH, Bennet C, Rosenthal LS, Bombard Y, Shoulson I, Oster E. Knowledge of the Genetic Information Nondiscrimination act among individuals affected by Huntington disease. Clin Genet 2012; 84:251-7. [PMID: 23167775 DOI: 10.1111/cge.12065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 11/15/2012] [Accepted: 11/15/2012] [Indexed: 11/26/2022]
Abstract
The Genetic Information Nondiscrimination Act (GINA) of 2008 was the first US legislation to address genetic discrimination. We sought to assess understanding of GINA among individuals affected by the autosomal dominant condition, Huntington disease (HD). We conducted a cross-sectional survey of individuals with varying risk of HD to assess their familiarity with GINA. As a control, individuals were surveyed about their familiarity with the Health Insurance Portability and Accountability Act (HIPAA). Those who reported familiarity with GINA were asked about their knowledge of specific provisions of the legislation. The survey was offered to 776 participants and completed by 410 (response rate 53%). Respondents across all groups were less familiar with GINA (41% slightly, somewhat, or very familiar) than with HIPAA (65%; p < 0.0001). Of individuals with or at risk for HD who reported some familiarity with GINA, less than half correctly identified GINA's protections, and less than 15% correctly identified its limitations. Thus, among individuals affected by HD, familiarity with and knowledge of GINA are low. The effectiveness of the legislation may be limited by this lack of knowledge.
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Affiliation(s)
- E R Dorsey
- Department of Neurology, Johns Hopkins Medicine, Baltimore, MD, USA.
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Otlowski M, Taylor S, Bombard Y. Genetic Discrimination: International Perspectives. Annu Rev Genomics Hum Genet 2012; 13:433-54. [DOI: 10.1146/annurev-genom-090711-163800] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - S. Taylor
- School of Sociology and Social Work, University of Tasmania, Hobart, Tasmania 7001, Australia;
| | - Y. Bombard
- Department of Epidemiology and Public Health, Division of Health Policy and Administration, Yale University, New Haven, Connecticut 06510
- Department of Epidemiology and Biostatistics, Center for Health Policy and Outcomes, Memorial Sloan-Kettering Cancer Center, New York, NY 10065;
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MacLeod R, Tibben A, Frontali M, Evers-Kiebooms G, Jones A, Martinez-Descales A, Roos RA. Recommendations for the predictive genetic test in Huntington's disease. Clin Genet 2012; 83:221-31. [PMID: 22642570 DOI: 10.1111/j.1399-0004.2012.01900.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 05/08/2012] [Accepted: 05/22/2012] [Indexed: 01/27/2023]
Affiliation(s)
- R MacLeod
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
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