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Dive L, Laberge AM, Freeman L, Bunnik EM. Beyond severity: utility as a criterion for setting the scope of RGCS. Eur J Hum Genet 2024:10.1038/s41431-024-01640-9. [PMID: 38811715 DOI: 10.1038/s41431-024-01640-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/18/2024] [Accepted: 05/15/2024] [Indexed: 05/31/2024] Open
Abstract
Reproductive genetic carrier screening (RGCS) allows prospective parents to identify and act upon their chances of having a child with a genetic condition. In deciding which genetic conditions to include in RGCS, severity is often used as a criterion. However, the concept is inherently complex, subjective and multidimensional, and determinations of severity will remain intractably contested. We propose the concept of utility as a criterion for setting the scope of RGCS, and put forward two central arguments for doing so. First, utility is a more appropriate and effective concept as it responds to context and makes an explicit connection between the purpose of RGCS and the value of information obtained for that purpose: namely, to facilitate reproductive decision-making. Utility comprises both clinical and personal utility, and varies according to the availability and accessibility of reproductive options, including pre-implantation genetic testing, prenatal genetic diagnosis, and termination of pregnancy. Second, there are ethical reasons for preferring utility over severity. Utility is a property of the information gleaned from RGCS, while severity is a property of a genetic condition or of an instance of this condition in a person. While consideration of the severity of genetic conditions is not lost when focusing on utility, the need to rely on value judgements regarding the quality of life of people who live with genetic conditions is circumvented. Therefore, utility should replace severity as justification for the inclusion of genetic conditions in RGCS programmes.
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Affiliation(s)
- Lisa Dive
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | | | - Lucinda Freeman
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Eline M Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands
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Wang T, Scuffham P, Byrnes J, Delatycki MB, Downes M. An overview of reproductive carrier screening panels for autosomal recessive and/or X-linked conditions: How much do we know? Prenat Diagn 2023; 43:1416-1424. [PMID: 37698492 DOI: 10.1002/pd.6434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND & AIM Reproductive carrier screening seeks to identify couples at a high risk of having offspring affected by autosomal recessive and X-linked (XL) conditions. The aim of this paper is to provide a comprehensive overview of existing carrier screening panels by examining their gene content and characteristics, identifying the most common genes/conditions included in these panels, and analyzing their listed prices. METHODS A comprehensive evaluation of existing carrier screening panels was conducted by searching for web-based content, reviewing information brochures, and establishing direct contact with the providers via email or phone. RESULTS Twenty-two panels and their providers were identified with a cumulative total of 2205 unique genes. The number of genes included in these panels varied from 44 to 2054. Only 15 genes (0.7%) were included in all the panels. The carrier frequency of these 15 common genes and their associated conditions varied greatly, but the conditions associated with the genes are "severe". The price of these 22 panels ranged from $349 to $4320 per couple (USD in 2023). The correlation between the listed price and the number of selected genes among these panels was small and not statistically significant (r = 0.1023, p = 0.6959). CONCLUSION Considerable discrepancies exist among carrier screening panels. Ongoing research and monitoring are necessary to capture the dynamic nature of the carrier screening landscape, providing up-to-date information for clinical practice and informed decision-making.
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Affiliation(s)
- Tianjiao Wang
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Martin B Delatycki
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Victorian Clinical Genetics Services, Parkville, Victoria, Australia
| | - Martin Downes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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Fehlberg Z, Best S, Long JC, Theodorou T, Pope C, Hibbert P, Williams S, Freeman L, Righetti S, Archibald AD, Braithwaite J. Scaling-up and future sustainability of a national reproductive genetic carrier screening program. NPJ Genom Med 2023; 8:18. [PMID: 37524740 PMCID: PMC10390466 DOI: 10.1038/s41525-023-00357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/01/2023] [Indexed: 08/02/2023] Open
Abstract
An understanding of factors influencing implementation is essential to realise the benefits of population-based reproductive genetic carrier screening programs. The aim of this study was to synthesise data collected during the Australian Reproductive Genetic Carrier Screening Project (Mackenzie's Mission) to track how priorities shifted over time and identify important factors during scaling-up and for sustainment. We used a multi-method qualitative approach to integrate longitudinal project data collected from 10 project committees with 16 semi-structured interviews conducted with study team members. Both datasets were analysed using the Consolidated Framework for Implementation Research (CFIR) to identify constructs of interest within early, mid-point, and future implementation phases. Several CFIR constructs were present across implementation. The complexity of implementation presented challenges that were overcome through a quality-designed and packaged product, formal and informal networks and communication, and access to knowledge and information. Addressing the diverse consumer needs through resources and increasing community and non-genetic speciality engagement remained a priority throughout and for future sustainment. Going forward, further addressing program complexities and securing funding were emphasised. By applying an implementation framework, findings from this study may be useful for future effort towards building and/or sustaining reproductive genetic carrier screening programs.
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Affiliation(s)
- Zoe Fehlberg
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- Australian Genomics Health Alliance, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
| | - Stephanie Best
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia.
- Australian Genomics Health Alliance, Melbourne, Australia.
- Murdoch Children's Research Institute, Melbourne, Australia.
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia.
- Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Sir Peter MacCallum Cancer Centre Dept of Oncology, University of Melbourne, Melbourne, Australia.
| | - Janet C Long
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Tahlia Theodorou
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Hibbert
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- IIMPACT in Health, Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Sharon Williams
- School of Health & Social Care, Swansea University, Swansea, Wales, UK
| | - Lucinda Freeman
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Sarah Righetti
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
- Centre for Clinical Genetics, Sydney Children's Hospital Network, Sydney, Australia
| | - Alison D Archibald
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Heath Innovation, Macquarie University, Sydney, Australia
- Australian Genomics Health Alliance, Melbourne, Australia
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4
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Dive L, Holmes I, Newson AJ. Is It Just for a Screening Program to Give People All the Information They Want? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-9. [PMID: 37171853 DOI: 10.1080/15265161.2023.2207510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Genomic screening at population scale generates many ethical considerations. One is the normative role that people's preferences should play in determining access to genomic information in screening contexts, particularly information that falls beyond the scope of screening. We expect both that people will express a preference to receive such results and that there will be interest from the professional community in providing them. In this paper, we consider this issue in relation to the just and equitable design of population screening programs like reproductive genetic carrier screening (RGCS). Drawing on a pluralistic public health ethics perspective, we claim that generating and reporting information about genetic variants beyond the scope of the screening program usually lacks clinical, and perhaps personal, utility. There are both pragmatic and ethical reasons to restrict information provision to that which fits the stated purpose of the program.
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Goldberg JD, Pierson S, Johansen Taber K. Expanded carrier screening: What conditions should we screen for? Prenat Diagn 2023; 43:496-505. [PMID: 36624552 DOI: 10.1002/pd.6306] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/15/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
Carrier screening tests reproductive couples for their risk of having children affected by serious monogenic conditions. Carrier screening has historically been offered for certain conditions in high-risk populations. However, more recent evidence has shown that offering carrier screening to all patients, regardless of their ethnicity, more effectively and equitably identifies at-risk couples. Coupled with technology that enables screening for a nearly unlimited number of conditions, this expanded carrier screening (ECS) approach is now supported by professional society guidelines. Despite recent recommendations by the American College of Medical Genetics and Genomics to screen all patients who are pregnant or considering pregnancy for 113 conditions, questions remain about what conditions should be included on a core ECS panel. Here, we briefly review the history of carrier screening and guidelines on criteria for panel design. We then suggest which of these criteria are most critical, as well as thresholds to identify which conditions meet these criteria. Based on these interpretations, we recommend a core panel of 64 conditions that would identify the vast majority of at-risk couples. Widespread adoption of a core panel such as this would result in a marked improvement in the number of patients currently receiving comprehensive carrier screening.
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Genetic Counsellors play a key role in supporting ethically responsible expanded universal carrier screening. Eur J Hum Genet 2023; 31:5-6. [PMID: 36336712 PMCID: PMC9822903 DOI: 10.1038/s41431-022-01218-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
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Edwards S, Laing N. Genetic Counselling Needs for Reproductive Genetic Carrier Screening: A Scoping Review. J Pers Med 2022; 12:1699. [PMID: 36294838 PMCID: PMC9605645 DOI: 10.3390/jpm12101699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/03/2022] [Accepted: 10/08/2022] [Indexed: 11/17/2022] Open
Abstract
Reproductive genetic carrier screening provides individuals and couples with information regarding their risk of having a child affected by an autosomal recessive or X-linked recessive genetic condition. This information allows them the opportunity to make reproductive decisions in line with their own beliefs and values. Traditionally, carrier screening has been accessed by family members of affected individuals. In recent years, improvements to accessibility and updates to recommendations suggest that all women planning or in early pregnancy should be offered reproductive genetic carrier screening. As uptake moves towards the population scale, how can the genetic counselling needs of such large-scale screening be met? A scoping review of the literature was performed to ascertain what the genetic counselling needs of reproductive genetic carrier screening are, and what future research is needed. Four broad themes were identified in the existing literature: (1) The offer-when and in what context to offer screening; (2) Information-the importance of and what to include in education, and pre- and post-test counselling; (3) Who and how-who the genetic counselling is performed by and how; (4) Personalization-how do we find the balance between standardized and individualized approaches? Based on the existing literature, we present a set of recommendations for consideration in implementing population-scale reproductive genetic carrier screening as well as suggested areas for future research.
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Affiliation(s)
- Samantha Edwards
- Harry Perkins Institute of Medical Research and Centre for Medical Research, University of Western Australia, QEII Medical Centre, Nedlands, WA 6009, Australia
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Dungan JS, Aarabi M, Klugman S, Gregg AR. Response to Righetti et al. Genet Med 2022; 24:1162-1163. [PMID: 35221206 DOI: 10.1016/j.gim.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Jeffrey S Dungan
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mahmoud Aarabi
- Departments of Pathology and Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA; Center for Medical Genetics and Genomics, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - Susan Klugman
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Anthony R Gregg
- Department of Obstetrics and Gynecology, Prisma Health, Columbia, SC
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