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Raspa M, Kutsa O, Andrews SM, Gwaltney AY, Mallonee E, Creamer A, Han PKJ, Biesecker BB. Uncertainties experienced by parents of children diagnosed with severe combined immunodeficiency through newborn screening. Eur J Hum Genet 2024; 32:392-398. [PMID: 36973394 PMCID: PMC10040930 DOI: 10.1038/s41431-023-01345-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/03/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
Individuals with severe combined immunodeficiency (SCID), a group of rare, genetic conditions, are at risk for life-threatening illnesses unless diagnosed and treated early. Even after early identification through newborn screening, parents of children with SCID embark on a complex journey marked by a variety of informational and emotional support needs. This paper explored the types of uncertainties experienced by parents of a child with SCID diagnosed through newborn screening. We conducted semi-structured interviews with 26 parents to discuss the types of uncertainty experienced, including scientific, practical, personal, and existential. Each interview was recorded, transcribed, and coded. Using deductive and inductive content analysis, we describe the type of uncertainty experienced across each stage of the SCID journey. We found that uncertainties in the SCID journey were chronic and multifaceted. Some uncertainties were more prominent at certain points of the journey whereas others spanned multiple stages. Parents expressed a variety of negative emotional reactions to uncertainty, from anxiety, worry, and fear, to doubt, guilt, or grief, and even anger, frustration, and depression. The results speak to the need for healthcare providers to prepare parents for the SCID journey by providing resources to help manage and cope with uncertainty.
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Affiliation(s)
| | - Oksana Kutsa
- RTI International, Research Triangle Park, NC, USA
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Trainer AH, Goode E, Hoskins CN, Wheeler JCW, Best S. Calibrating variant curation by clinical context based on factors that influence patients' tolerance of uncertainty. Genet Med 2023; 25:100982. [PMID: 37724515 DOI: 10.1016/j.gim.2023.100982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Shared decision making manages genomic uncertainty by integrating molecular and clinical uncertainties with patient values to craft a person-centered management plan. Laboratories seek genomic report consistency, agnostic to clinical context. Molecular reports often mask laboratory-managed uncertainties from clinical decision making. Better integration of these uncertainty management strategies requires a nuanced understanding of patients' perceptions and reactions to test uncertainties. We explored patients' tolerance to variant uncertainty in 3 parameters: (1) relative causal significance, (2) risk accuracy, and (3) classification validity. METHOD Deliberative forums were undertaken with 18 patients with predictive testing experience. Uncertainty deliberations were elicited for each parameter. A thematic framework was first developed, and then mapped to whether they justified tolerance to more or less parameter-specific uncertainty. RESULTS Six identified themes mapped to clinical and personal domains. These domains generated opposing forces when calibrating uncertainty. Personal themes justified tolerance of higher uncertainty and clinical themes lower uncertainty. Decision making in uncertainty focused on reducing management regret. Open communication increased tolerance of classification validity and risk accuracy uncertainty. Using these data, we have developed a nascent clinical algorithm integrating molecular uncertainty with clinical context through a targeted communication framework. CONCLUSION Maximizing test utility necessitates context-specific recalibration of uncertainty management and communication.
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Affiliation(s)
- Alison H Trainer
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia.
| | - Erin Goode
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Cass N Hoskins
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jack C W Wheeler
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Stephanie Best
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre Alliance, Melbourne, VIC, Australia; Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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Rueda J, Vallès-Poch M. Genomic Uncertainty as a Burden for Reproductive Choice? The Problem of Probabilistic Causation in Non-Invasive Prenatal Testing. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:26-28. [PMID: 36919546 DOI: 10.1080/15265161.2023.2169391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
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Kaye DK. Addressing ethical issues related to prenatal diagnostic procedures. Matern Health Neonatol Perinatol 2023; 9:1. [PMID: 36737803 PMCID: PMC9896777 DOI: 10.1186/s40748-023-00146-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND For women of advanced maternal age or couples with high risk of genetic mutations, the ability to screen for embryos free of certain genetic mutations is reassuring, as it provides opportunity to address age-related decline in fertility through preimplantation genetic testing. This procedure has potential to facilitate better embryo selection, improve implantation rates with single embryo transfer and reduce miscarriage rates, among others, yet confers some risk to the embryo and additional costs of assisted reproductive technology. This raises questions whether, when and which patients should receive routine PGT-A prior to embryo transfer. DISCUSSION Prenatal diagnostic procedures refer to tests done when one or both genetic parents has a known genetic disorder (or has worries about the disorder) and testing is performed on them, their gametes or on the embryos to determine if the latter is likely to carry a genetic disorder. PGT is used to identify genetic defects in gametes or embryos (often created through in vitro fertilization (IVF). The procedures generate immense potential to improve health and wellbeing by preventing conception or birth of babies with undesirable traits, life-limiting conditions and even lethal conditions. However, they generate a lot of information, which often may challenge decision-making ability of healthcare providers and parents, and raise ethical challenges. CONCLUSION Prenatal diagnostic procedures have potential to address uncertainty and risk of having a child affected with a genetic disease. They, however, often raise own uncertainty and controversies, whose origin, manifestation and related ethical issues are presented. There is need to develop individual and couple decision support tools that incorporate patients' values and concerns in the decision-making process in order to promote more informed decisions, during counseling.
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Affiliation(s)
- Dan Kabonge Kaye
- grid.11194.3c0000 0004 0620 0548Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda ,grid.21107.350000 0001 2171 9311Forgarty African Bioethics Postdoctoral Fellow at Johns Hopkins Berman Institute of Bioethics and the School of Public Health, Baltimore, MD USA
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Vora NL, Norton ME. Prenatal exome and genome sequencing for fetal structural abnormalities. Am J Obstet Gynecol 2023; 228:140-149. [PMID: 36027950 PMCID: PMC9877148 DOI: 10.1016/j.ajog.2022.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/07/2022] [Accepted: 08/17/2022] [Indexed: 01/28/2023]
Abstract
As prenatal exome sequencing becomes integrated into clinical care, it is critical that providers caring for women with fetal anomalies recognize not only the benefits, but also the challenges and considerations related to this technology. This overview of prenatal sequencing includes information about indications for sequencing, methods, diagnostic yield, clinical utility, variant interpretation, ethical considerations and dilemmas, practical considerations (ie, turnaround time and cost), pre- and posttest counseling points, and psychological impact of testing on families.
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Affiliation(s)
- Neeta L Vora
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Mary E Norton
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Ni H, Jordan E, Cao J, Kinnamon DD, Gottlieb SS, Hofmeyer M, Jimenez J, Judge DP, Kransdorf E, Morris AA, Owens A, Shah P, Tang WHW, Wang J, Hershberger RE. Knowledge of Genome Sequencing and Trust in Medical Researchers Among Patients of Different Racial and Ethnic Groups With Idiopathic Dilated Cardiomyopathy. JAMA Cardiol 2023; 8:33-42. [PMID: 36383367 PMCID: PMC9669924 DOI: 10.1001/jamacardio.2022.4132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022]
Abstract
Importance Cardiovascular disease contributes outsized mortality in patients from underrepresented racial and ethnic groups. Understanding levels of trust in medical researchers and knowledge of genome sequencing may help identify barriers to research participation and develop strategies to educate patients about the role of genetics in cardiovascular disease. Objective To assess racial and ethnic differences in trust in medical researchers and genome-sequencing knowledge among patients with idiopathic dilated cardiomyopathy and determine the association between trust in medical researchers and genome-sequencing knowledge. Design, Setting, and Participants This cross-sectional study conducted by a consortium of 25 US heart failure programs included patients with idiopathic dilated cardiomyopathy defined as left ventricular systolic dysfunction and left ventricular enlargement after excluding usual clinical causes. Enrollment occurred from June 7, 2016, to March 15, 2020. Main Outcomes and Measures Percent distributions, means, and associations of genome-sequencing knowledge scores and research trust scores for Hispanic, non-Hispanic Black (hereafter referred to as Black), and non-Hispanic White participants (hereafter referred to as White). Results Among 1121 participants, mean (SD) age was 51.6 (13.6) years with 41.4% Black, 8.5% Hispanic, and 43.4% female. After accounting for site effects, the level of genome-sequencing knowledge was lower in Hispanic and Black participants compared with White participants (mean score difference, -2.6; 95% CI, -3.9 to -1.2 and mean score difference, -2.9; 95% CI, -3.6 to -2.2, respectively). The level of trust in researchers was lowest in Black participants (mean score, 27.7), followed by Hispanic participants (mean score, 29.4) and White participants (mean score, 33.9). Racial and ethnic differences remained after adjusting for education, age at enrollment, duration of dilated cardiomyopathy, and health status. A higher level of trust was associated with a higher level of genome-sequencing knowledge within different racial and ethnic groups. Conclusions and Relevance In this cross-sectional study, large racial and ethnic differences in levels of genome-sequencing knowledge and trust in medical researchers were observed among patients with dilated cardiomyopathy. Findings from this study can inform future studies that aim to enhance the uptake of genomic knowledge and level of trust in medical researchers.
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Affiliation(s)
- Hanyu Ni
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Elizabeth Jordan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Jinwen Cao
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Daniel D. Kinnamon
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | | | - Mark Hofmeyer
- Medstar Research Institute, Washington Hospital Center, Washington, DC
| | - Javier Jimenez
- Miami Cardiac & Vascular Institute, Baptist Health South, Miami, Florida
| | | | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles
| | - Ray E. Hershberger
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus
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Outram SM, Brown J, Ackerman SL. The social value of genomic sequencing for disadvantaged families facing rare disease. Soc Sci Med 2022; 314:115465. [PMID: 36279794 DOI: 10.1016/j.socscimed.2022.115465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
This study explores parental expectations and value-making processes in respect to pediatric clinical genomic sequencing for socially disadvantaged families. Drawing on interviews and ethnographic observations with parents of children with undiagnosed physical and/or intellectual differences seeking to find whether these differences have a genetic etiology, we explore expectations and parental assessments of the value of genomic sequencing within the context of an ongoing research study. We demonstrate how the value of sequencing to parents goes well beyond finding diagnostic results or receiving prescriptive guidance as to the best care and treatment of their child; instead, value is co-created by parents, clinicians, and genetic counsellors throughout the enrollment and return of results process. Parents in our study found that clinicians and genetic counsellors repeatedly reenforce that parents need to lower their expectations and be prepared to wait for genetic science to provide more definitive answers. At the same time, parents experience that clinical teams validate parents for having made a good choice in their undertaking of genomic sequencing and, no matter the result, that they are not to blame for their child's symptoms. The experience of many parents (although not all) is that genomic science reduces or removes their sense of guilt for their child's condition, providing a platform that affirms them as "good parents." Moreover, rather than being voiceless and isolated, socially disadvantaged parents who enter into diagnostic sequencing find themselves in a familial-biosocial framework wherein they are co-partners in a socially and biologically authoritative vision of the future.
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Affiliation(s)
- S M Outram
- Program in Bioethics, Institute for Health & Aging, University of California, San Francisco, CA, USA.
| | - Jeh Brown
- Program in Bioethics, Institute for Health & Aging, University of California, San Francisco, CA, USA
| | - S L Ackerman
- Department of Social & Behavioral Sciences, University of California, San Francisco, CA, USA
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So PL, Hui ASY, Ma TWL, Shu W, Hui APW, Kong CW, Lo TK, Kan ANC, Kan EYL, Chong SC, Chung BHY, Luk HM, Choy KW, Kan ASY, Leung WC. Implementation of Public Funded Genome Sequencing in Evaluation of Fetal Structural Anomalies. Genes (Basel) 2022; 13:2088. [PMID: 36360323 PMCID: PMC9690018 DOI: 10.3390/genes13112088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 08/20/2023] Open
Abstract
With the advancements in prenatal diagnostics, genome sequencing is now incorporated into clinical use to maximize the diagnostic yield following uninformative conventional tests (karyotype and chromosomal microarray analysis). Hong Kong started publicly funded prenatal genomic sequencing as a sequential test in the investigation of fetal structural anomalies in April 2021. The objective of the study was to evaluate the clinical performance and usefulness of this new service over one year. We established a web-based multidisciplinary team to facilitate case selection among the expert members. We retrospectively analyzed the fetal phenotypes, test results, turnaround time and clinical impact in the first 15 whole exome sequencing and 14 whole genome sequencing. Overall, the molecular diagnostic rate was 37.9% (11/29). De novo autosomal dominant disorders accounted for 72.7% (8/11), inherited autosomal recessive disorders for 18.2% (2/11), and inherited X-linked disorders for 9.1% (1/11). The median turnaround time for ongoing pregnancy was 19.5 days (range, 13-31 days). Our study showed an overall clinical impact of 55.2% (16/29), which influenced reproductive decision-making in four cases, guided perinatal management in two cases and helped future family planning in ten cases. In conclusion, our findings support the important role of genome sequencing services in the prenatal diagnosis of fetal structural anomalies in a population setting. It is important to adopt a multidisciplinary team approach to support the comprehensive genetic service.
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Affiliation(s)
- Po Lam So
- Department of Obstetrics and Gynecology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Annie Shuk Yi Hui
- Department of Obstetrics & Gynaecology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Teresa Wei Ling Ma
- Department of Obstetrics & Gynaecology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Wendy Shu
- Department of Obstetrics & Gynaecology, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Amelia Pui Wah Hui
- Department of Obstetrics & Gynaecology, Queen Mary Hospital, Hong Kong SAR, China
| | - Choi Wah Kong
- Department of Obstetrics & Gynaecology, United Christian Hospital, Hong Kong SAR, China
| | - Tsz Kin Lo
- Department of Obstetrics & Gynaecology, Princess Margaret Hospital, Hong Kong SAR, China
| | - Amanda Nim Chi Kan
- Department of Pathology, Hong Kong Children’s Hospital, Hong Kong SAR, China
| | - Elaine Yee Ling Kan
- Department of Radiology, Hong Kong Children’s Hospital, Hong Kong SAR, China
| | - Shuk Ching Chong
- Department of Paediatrics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Brian Hon Yin Chung
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ho Ming Luk
- Clinical Genetics Service Unit, Hong Kong Children’s Hospital, Hong Kong SAR, China
| | - Kwong Wai Choy
- Prenatal Genetic Diagnosis Centre, Department of Obstetrics & Gynaecology, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anita Sik Yau Kan
- Prenatal Diagnostic Laboratory, Tsan Yuk Hospital, Hong Kong SAR, China
| | - Wing Cheong Leung
- Department of Obstetrics & Gynaecology, Kwong Wah Hospital, Hong Kong SAR, China
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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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Butow PN, Best MC, Davies G, Schlub T, Napier CE, Bartley N, Ballinger ML, Juraskova I, Meiser B, Goldstein D, Biesecker B, Thomas DM. Psychological impact of comprehensive tumor genomic profiling results for advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2022; 105:2206-2216. [PMID: 35153126 DOI: 10.1016/j.pec.2022.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 01/16/2022] [Accepted: 01/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Comprehensive tumor genomic profiling (CTGP) is increasingly used to personalize treatments, providing hope, but potentially disappointment, for patients. We explored psychological outcomes in patients with advanced, incurable cancer, after receiving CTGP results. METHODS Participants with advanced, incurable cancer (n = 560, mean age 56, 43% university educated) in this longitudinal substudy of the Molecular Screening and Therapeutics Program (MoST), completed questionnaires before and after receiving CGP results. MoST participants, recruited from Australian oncology clinics, undergo CTGP, and if there are actionable findings, are offered treatment in a related therapeutic trial if available. RESULTS Patients who received actionable results, (n = 356, 64%) had lower gene-related distress (MICRA) (p < 0.001) and Impact of Events scores (p = 0.039) than patients with non-actionable results. Those with actionable results offered ensured access to tailored treatment (n = 151) reported lower anxiety (p = 0.002) and depressive symptoms (p = 0.01) and greater hope (p = 0.002) than those not offered. Positive attitudes towards uncertainty and higher self-efficacy for coping with results were associated with lower psychological distress and uncertainty, and higher hope and satisfaction with the decision to have CTGP (ps=0.001-0.047). Those with higher knowledge reported greater anxiety (p = 0.034). CONCLUSION Receiving a non-actionable CTGP result, or an actionable result without ensured access to treatment, may cause increased distress in advanced cancer patients. Coping style was also associated with distress. PRACTICE IMPLICATIONS Pre-testing assessment and counseling addressing attitudes toward uncertainty and self-efficacy, and post-CTGP result support for patients receiving a non-actionable result or who receive an actionable results without ensured access to treatment, may benefit patients.
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Affiliation(s)
- Phyllis N Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), Level 6 (North) Lifehouse (C36Z), School of Psychology, University of Sydney, Sydney 2006 Australia.
| | - Megan C Best
- Psycho-Oncology Co-operative Research Group (PoCoG), Level 6 (North) Lifehouse (C36Z), School of Psychology, University of Sydney, Sydney 2006 Australia
| | - Grace Davies
- Psycho-Oncology Co-operative Research Group (PoCoG), Level 6 (North) Lifehouse (C36Z), School of Psychology, University of Sydney, Sydney 2006 Australia
| | - Timothy Schlub
- School of Public Health, University of Sydney, 2006 Sydney, Australia
| | - Christine E Napier
- Cancer Theme, Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, NSW 2010, Australia
| | - Nicci Bartley
- Psycho-Oncology Co-operative Research Group (PoCoG), Level 6 (North) Lifehouse (C36Z), School of Psychology, University of Sydney, Sydney 2006 Australia
| | - Mandy L Ballinger
- Cancer Theme, Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, NSW 2010, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia
| | - Ilona Juraskova
- School of Psychology, University of Sydney, Sydney 2006, Australia
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, University of NSW, Sydney 2052, Australia
| | - David Goldstein
- Dept of Medical Oncology, Prince of Wales Hospital, 320-346 Barker St, Randwick, NSW 2031, Australia
| | - Barbara Biesecker
- Newborn Screening, Ethics and Disability Studies, RTI International, Washington, DC, USA
| | - David M Thomas
- Cancer Theme, Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, NSW 2010, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia
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Umstead KL, Campbell R, Napier CE, Bartley N, Best MC, Butow PN, Biesecker BB. Further validation of the Perceptions of Uncertainties in Genome Sequencing (PUGS) scale among patients with cancer undergoing tumor sequencing. Clin Genet 2022; 102:110-116. [PMID: 35615816 DOI: 10.1111/cge.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/23/2022] [Accepted: 05/12/2022] [Indexed: 11/30/2022]
Abstract
It is important to understand how individuals perceive uncertainties and the consequent impact on their psychological well-being and health behavior. The Perceptions of Uncertainty in Genome Sequencing (PUGS) scale measures clinical, affective, and evaluative uncertainties about information from sequencing. The PUGS scale has been shown to be valid and reliable among individuals receiving results about their genomes. This study assessed whether its validity generalized to patients with cancer undergoing tumor sequencing. Exploratory factor analysis (EFA) was conducted on data from the Molecular Screening and Therapeutics Program (n=310) to identify a measurement model. Confirmatory factor analysis (CFA) was used to determine the adequacy of the resulting fit. EFA identified the same three-factor structure reported previously. CFA confirmed that the measurement model yielded a good fit (χ2/df=3.72, CFI=0.96, SRMR=0.05, RMSEA=0.09) and satisfied convergent and discriminant validity. These findings provide further evidence of the validity and reliability of the PUGS scale in measuring three types of uncertainty. Continued application will facilitate an evidence-based approach to intervention and enhance understanding of what it is like to receive results. In turn, this will improve clinical outcomes as undergoing sequencing becomes an increasingly common experience. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Rachel Campbell
- The University of Sydney, Faculty of Science, School of Psychology, Sydney Quality of Life Office, Sydney, Australia
| | - Christine E Napier
- Cancer Theme, Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Nicole Bartley
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, Australia
| | - Megan C Best
- Institute for Ethics and Society, University of Notre Dame Australia, Broadway, Australia
| | - Phyllis N Butow
- The University of Sydney, Faculty of Science, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, Australia
| | - Barbara B Biesecker
- RTI International, Genomics, Bioinformatics and Translational Science, Bethesda, MD, USA
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Psychological Impact of Ambiguous Health Messages about COVID-19. J Behav Med 2021; 45:159-171. [PMID: 34811623 PMCID: PMC8608560 DOI: 10.1007/s10865-021-00266-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 11/04/2021] [Indexed: 12/19/2022]
Abstract
Perceiving ambiguity in health information-that is, uncertainty elicited from believing information lacks credibility, reliability, or adequacy-is typically associated with pessimistic appraisals (e.g., high perceived disease risk) and behavioral avoidance. We examined the effect of ambiguous health information about COVID-19 on health cognitions and vaccination intentions, and tested a "normalized-uncertainty" intervention. Two studies with identical methodology (online adult sample: n = 299, undergraduate sample: n = 150) were conducted in March to April 2020. Participants were randomly assigned to read one of three health messages about COVID-19 that emphasized what was currently unknown (ambiguity condition), what was currently unknown but that scientific uncertainty is expected (intervention condition), or what was currently known (control condition). The ambiguity condition led to greater perceived ambiguity than the control condition and perceived ambiguity in the intervention condition was comparable to the ambiguity condition. There were few differences in health cognitions, and no differences in vaccination intentions, when examining pairwise comparisons across the three conditions. Correlational analyses collapsing across condition indicated evidence of pessimistic appraisal but not behavioral avoidance among individuals who perceived greater ambiguity. Future research should examine longer, more detailed normalized-uncertainty interventions.
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Donohue KE, Dolan SM, Watnick D, Gallagher KM, Odgis JA, Suckiel SA, Teitelman N, Gelb BD, Kenny EE, Wasserstein MP, Horowitz CR, Bauman LJ. Hope versus reality: Parent expectations of genomic testing. PATIENT EDUCATION AND COUNSELING 2021; 104:2073-2079. [PMID: 33640235 PMCID: PMC8679507 DOI: 10.1016/j.pec.2021.01.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Genomics is increasingly used for diagnostic testing in children. This study describes the expectations of parents whose child received genomic testing and whether or not they were met. METHODS A diverse stratified, purposive sample of parents of 22 children in New York City was interviewed using a semi-structured guide. Genomic test results were positive, negative, or uncertain. RESULTS Parents expressed their expectations in narrative and numeric fashion. Parents expected that their child's test would have a direct effect on their child's diagnosis. Some believed that results would be definitive, while others recognized testing limitations. Expectations reflected parents' hope to find a diagnosis and led to disappointment when results were uninformative or did not impact clinical management. CONCLUSION Results suggest pre-test genetic counseling emphasize the low likelihood of actionable results; however, parents' expectations of genomics' diagnostic capabilities are strongly rooted in their need to end the diagnostic odyssey and may be difficult to manage. PRACTICE IMPLICATIONS Parents' hope for a resolution and effective treatment for their child is a powerful context in which genetic counseling is heard. Clinicians who provide genomic testing should continue to acknowledge parents' preconceptions. Additional research in other settings will help understand how to best address and manage parent expectations of genomic medicine.
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Affiliation(s)
- Katherine E Donohue
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Siobhan M Dolan
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dana Watnick
- Department of Pediatrics, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
| | - Katie M Gallagher
- Department of Pediatrics, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
| | - Jacqueline A Odgis
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sabrina A Suckiel
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nehama Teitelman
- Department of Pediatrics, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
| | - Bruce D Gelb
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eimear E Kenny
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Melissa P Wasserstein
- Department of Pediatrics, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States
| | - Carol R Horowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Laurie J Bauman
- Department of Pediatrics, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States; Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center / Albert Einstein College of Medicine, Bronx, NY, United States.
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14
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Ratcliff CL, Wong B, Jensen JD, Kaphingst KA. The Impact of Communicating Uncertainty on Public Responses to Precision Medicine Research. Ann Behav Med 2021; 55:1048-1061. [PMID: 34297059 DOI: 10.1093/abm/kaab050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Precision medicine research depends upon recruiting large and diverse participant cohorts to provide genetic, environmental, and lifestyle data. How prospective participants react to information about this research, including depictions of uncertainty, is not well understood. PURPOSE The current study examined public responses to precision medicine research, focusing on reactions toward (a) uncertainty about the scientific impact of sharing data for research, and (b) uncertainty about the privacy, security, or intended uses of participant data. METHODS U.S. adults (N = 674; 51.9% male; 50% non-Hispanic white; Mage = 42.23) participated in an online experimental survey. Participants read a manipulated news article about precision medicine research that conveyed either certainty or uncertainty of each type (scientific, data). Participants then rated their attitudes toward the research, trust in the researchers, and willingness to join a cohort. We tested direct and mediated paths between message condition and outcomes and examined individual characteristics as moderators. RESULTS Overall attitudes were positive and a majority of participants (65%) reported being somewhat or very likely to participate in precision medicine research if invited. Conveying uncertainty of either type had no overall main effect on outcomes. Instead, those who reported perceiving greater uncertainty had lower attitudes, trust, and willingness to join, while those with more tolerance for uncertainty, support for science, and scientific understanding responded favorably to the scientific uncertainty disclosure. CONCLUSIONS Findings suggest responses to precision medicine research uncertainty are nuanced and that successful cohort enrollment may be well-supported by a transparent approach to communicating with prospective participants.
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Affiliation(s)
- Chelsea L Ratcliff
- Department of Communication Studies, University of Georgia, Athens, GA, USA
| | - Bob Wong
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Jakob D Jensen
- Department of Communication, University of Utah, Salt Lake City, UT, USA
| | - Kimberly A Kaphingst
- Department of Communication, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
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15
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Umstead KL, Han PKJ, Lewis KL, Miller IM, Hepler CL, Thompson LJ, Wolfsberg TG, Nguyen AD, Fredriksen MT, Gibney G, Turbitt E, Biesecker LG, Biesecker BB. Perceptions of uncertainties about carrier results identified by exome sequencing in a randomized controlled trial. Transl Behav Med 2021; 10:441-450. [PMID: 31505002 DOI: 10.1093/tbm/ibz111] [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: 12/24/2022] Open
Abstract
How individuals perceive uncertainties in sequencing results may affect their clinical utility. The purpose of this study was to explore perceptions of uncertainties in carrier results and how they relate to psychological well-being and health behavior. Post-reproductive adults (N = 462) were randomized to receive carrier results from sequencing through either a web platform or a genetic counselor. On average, participants received two results. Group differences in affective, evaluative, and clinical uncertainties were assessed from baseline to 1 and 6 months; associations with test-specific distress and communication of results were assessed at 6 months. Reductions in affective uncertainty (∆x̅ = 0.78, 95% CI: 0.53, 1.02) and evaluative uncertainty (∆x̅ = 0.69, 95% CI: 0.51, 0.87) followed receipt of results regardless of randomization arm at 1 month. Participants in the web platform arm reported greater clinical uncertainty than those in the genetic counselor arm at 1 and 6 months; this was corroborated by the 1,230 questions asked of the genetic counselor and residual questions reported by those randomized to the web platform. Evaluative uncertainty was associated with a lower likelihood of communicating results to health care providers. Clinical uncertainty was associated with a lower likelihood of communicating results to children. Learning one's carrier results may reduce perceptions of uncertainties, though web-based return may lead to less reduction in clinical uncertainty in the short term. These findings warrant reinforcement of clinical implications to minimize residual questions and promote appropriate health behavior (communicating results to at-risk relatives in the case of carrier results), especially when testing alternative delivery models.
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Affiliation(s)
- Kendall L Umstead
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Katie L Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Ilana M Miller
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Charlotte L Hepler
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Lydia J Thompson
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Tyra G Wolfsberg
- Computational and Statistical Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Anh-Dao Nguyen
- Computational and Statistical Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Mark T Fredriksen
- Computational and Statistical Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Gretchen Gibney
- Computational and Statistical Genomics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Erin Turbitt
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, Bethesda, MD, USA
| | - Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, Bethesda, MD, USA
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16
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Allen CG, Peterson S, Khoury MJ, Brody LC, McBride CM. A scoping review of social and behavioral science research to translate genomic discoveries into population health impact. Transl Behav Med 2021; 11:901-911. [PMID: 32902617 PMCID: PMC8240657 DOI: 10.1093/tbm/ibaa076] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Since the completion of the Human Genome Project, progress toward translating genomic research discoveries to address population health issues has been limited. Several meetings of social and behavioral scientists have outlined priority research areas where advancement of translational research could increase population health benefits of genomic discoveries. In this review, we track the pace of progress, study size and design, and focus of genomics translational research from 2012 to 2018 and its concordance with five social and behavioral science recommended priorities. We conducted a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines for Scoping Reviews. Steps involved completing a search in five databases and a hand search of bibliographies of relevant literature. Our search (from 2012 to 2018) yielded 4,538 unique studies; 117 were included in the final analyses. Two coders extracted data including items from the PICOTS framework. Analysis included descriptive statistics to help identify trends in pace, study size and design, and translational priority area. Among the 117 studies included in our final sample, nearly half focused on genomics applications that have evidence to support translation or implementation into practice (Centers for Disease Control and Prevention Tier 1 applications). Common study designs were cross-sectional (40.2%) and qualitative (24.8%), with average sample sizes of 716 across all studies. Most often, studies addressed public understanding of genetics and genomics (33.3%), risk communication (29.1%), and intervention development and testing of interventions to promote behavior change (19.7%). The number of studies that address social and behavioral science priority areas is extremely limited and the pace of this research continues to lag behind basic science advances. Much of the research identified in this review is descriptive and related to public understanding, risk communication, and intervention development and testing of interventions to promote behavior change. The field has been slow to develop and evaluate public health-friendly interventions and test implementation approaches that could enable health benefits and equitable access to genomic discoveries. As the completion of the human genome approaches its 20th anniversary, full engagement of transdisciplinary efforts to address translation challenges will be required to close this gap.
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Affiliation(s)
- Caitlin G Allen
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
| | - Shenita Peterson
- Woodruff Health Science Center Library, Emory University, Atlanta, GA, USA
| | - Muin J Khoury
- Office of Genomics and Precision Public Health, Office of Science, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence C Brody
- Gene and Environment Interaction Section, National Human Genome Research Institute, Bethesda, MD, USA
| | - Colleen M McBride
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
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17
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Bartley N, Napier CE, Butt Z, Schlub TE, Best MC, Biesecker BB, Ballinger ML, Butow P. Cancer Patient Experience of Uncertainty While Waiting for Genome Sequencing Results. Front Psychol 2021; 12:647502. [PMID: 33967906 PMCID: PMC8100530 DOI: 10.3389/fpsyg.2021.647502] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/26/2021] [Indexed: 11/13/2022] Open
Abstract
There is limited knowledge about cancer patients' experiences of uncertainty while waiting for genome sequencing results, and whether prolonged uncertainty contributes to psychological factors in this context. To investigate uncertainty in patients with a cancer of likely hereditary origin while waiting for genome sequencing results, we collected questionnaire and interview data at baseline, and at three and 12 months follow up (prior to receiving results). Participants (N = 353) had negative attitudes towards uncertainty (M = 4.03, SD 0.68) at baseline, and low levels of uncertainty at three (M = 8.23, SD 7.37) and 12 months (M = 7.95, SD 7.64). Uncertainty about genome sequencing did not change significantly over time [t(210) = 0.660, p = 0.510]. Greater perceived susceptibility for cancer [r(348) = 0.14, p < 0.01], fear of cancer recurrence [r(348) = 0.19, p < 0.01], perceived importance of genome sequencing [r(350) = 0.24, p < 0.01], intention to change behavior if a gene variant indicating risk is found [r(349) = 0.29, p < 0.01], perceived ability to cope with results [r(349) = 0.36, p < 0.01], and satisfaction with decision to have genome sequencing [r(350) = 0.52, p < 0.01] were significantly correlated with negative attitudes towards uncertainty at baseline. Multiple primary cancer diagnoses [B = -2.364 [-4.238, -0.491], p = 0.014], lower perceived ability to cope with results [B = -0.1.881 [-3.403, -0.359], p = 0.016] at baseline, greater anxiety about genome sequencing (avoidance) [B = 0.347 [0.148, 0.546], p = 0.0012] at 3 months, and greater perceived uncertainty about genome sequencing [B = 0.494 [0.267, 0.721] p = 0.000] at 3 months significantly predicted greater perceived uncertainty about genome sequencing at 12 months. Greater perceived uncertainty about genome sequencing at 3 months significantly predicted greater anxiety (avoidance) about genome sequencing at 12 months [B = 0.291 [0.072, 0.509], p = 0.009]. Semi-structured interviews revealed that while participants were motivated to pursue genome sequencing as a strategy to reduce their illness and risk uncertainty, genome sequencing generated additional practical, scientific and personal uncertainties. Some uncertainties were consistently discussed over the 12 months, while others emerged over time. Similarly, some uncertainty coping strategies were consistent over time, while others emerged while patients waited for their genome sequencing results. This study demonstrates the complexity of uncertainty generated by genome sequencing for cancer patients and provides further support for the inter-relationship between uncertainty and anxiety. Helping patients manage their uncertainty may ameliorate psychological morbidity.
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Affiliation(s)
- Nicci Bartley
- Psycho-Oncology Co-operative Research Group, Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Christine E Napier
- Cancer Theme, Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Zoe Butt
- Psycho-Oncology Co-operative Research Group, Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Timothy E Schlub
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Megan C Best
- Psycho-Oncology Co-operative Research Group, Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia.,Institute for Ethics & Society, The University of Notre Dame Australia, Sydney, NSW, Australia
| | | | - Mandy L Ballinger
- Cancer Theme, Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, University of NSW, Sydney, NSW, Australia
| | - Phyllis Butow
- Psycho-Oncology Co-operative Research Group, Faculty of Science, School of Psychology, The University of Sydney, Sydney, NSW, Australia
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18
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Pyeritz RE. Uncertainty in Genomics Impacts Precision Medicine. Trends Genet 2020; 37:711-716. [PMID: 33218792 DOI: 10.1016/j.tig.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 11/25/2022]
Abstract
As exacting as genetic and genomic testing have become, health professionals continue to encounter uncertainty in their applications to medical practice. As examining the human genome at more refined levels increases, so is the likelihood of encountering uncertainty about the meaning of the information. The history of this concept informs how we might confront and deal with uncertainty, and what the future might hold. Precision medicine holds great promise for establishing more accurate diagnoses, directing specific therapy to patients who will most benefit from it, and avoiding treatments in patients who are most likely to suffer adverse consequences, or at best not benefit. But its application depends importantly on the proper interpretation of a person's genotype.
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Affiliation(s)
- Reed E Pyeritz
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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19
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Impact of prenatal exome sequencing for fetal genetic diagnosis on maternal psychological outcomes and decisional conflict in a prospective cohort. Genet Med 2020; 23:713-719. [PMID: 33214710 PMCID: PMC8503913 DOI: 10.1038/s41436-020-01025-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/12/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate associations between prenatal trio exome sequencing (trio-ES) and psychological outcomes among women with an anomalous pregnancy. METHODS Trio-ES study enrolling patients with major fetal anomaly and normal microarray. Women completed self-reported measures and free response interviews at two timepoints: pre- (1) and post- (2) sequencing. Pre-sequencing responses were compared with post-sequencing responses; post-sequencing responses were stratified by women who received trio-ES results that may explain fetal findings, secondary findings (medically actionable or couples with heterozygous variants for the same recessive disorder), or negative results. RESULTS One hundred fifteen trios were enrolled. Of those, 41/115 (35.7%) received results from trio-ES, including 36 (31.3%) who received results that may explain the fetal phenotype. These women had greater post-sequencing distress compared with women who received negative results, including generalized distress (p = 0.03) and test-related distress (p = 0.2); they also had worse psychological adaptation to results (p = 0.001). Genomic knowledge did not change from pre- to post-sequencing (p = 0.51). CONCLUSION Women show more distress after receiving trio-ES results compared with those who do not, suggesting that women receiving results may need additional support or counseling to inform current and future reproductive decisions.
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20
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Goldman J, Xie S, Green D, Naini A, Mansukhani MM, Marder K. Predictive testing for neurodegenerative diseases in the age of next-generation sequencing. J Genet Couns 2020; 30:10.1002/jgc4.1342. [PMID: 33090625 PMCID: PMC10699540 DOI: 10.1002/jgc4.1342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/09/2022]
Abstract
The availability and cost of next-generation sequencing (NSG) now allow testing large numbers of genes simultaneously. However, the gold standard for predictive testing has been to test only for a known family mutation or confirmed family disease. The goal of this study was to investigate the psychological impact of predictive testing for autosomal dominant neurodegenerative diseases without a known family mutation using next-generation sequencing panels compared to single-gene testing of a known family mutation. Fourteen individuals from families with a known mutation and 10 individuals with unknown family mutations participated. Participants completed questionnaires on demographics, genetic knowledge, and psychological measures of anxiety, depression, perceived personal control, rumination, and intolerance to uncertainty at baseline and 1 and 6 months after receiving results. Decision regret was measured 1 and 6 months after receiving results. Participants completed a modified Huntington disease genetic testing protocol with genetic counseling and neurological and psychological evaluation. Genetic testing of either the known family mutation or an NGS panel of neurodegenerative disease genes was performed. Semi-structured interviews were performed at 6 months post-results about their experience. Two-sample t tests were performed on data collected at each time point to identify significant between-group differences in demographic variables, baseline psychological scores, and baseline genetic knowledge scores. Within-group change over time was assessed by a mixed-effects model. Results of this study indicate that NGS panels for predictive testing for neurodegenerative disease are safe and beneficial to participants when performed within a modified HD protocol. Though significant differences in psychological outcomes were found, these differences may have been driven by genetic results and baseline psychological differences between individuals within the groups. Participants did not regret their decision to test and were largely pleased with the testing protocol.
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Affiliation(s)
- Jill Goldman
- Dept. of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Shanghong Xie
- Dept. of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Dina Green
- Clinical Genetics Service, Memorial Sloane Kettering Cancer Center, New York, NY, USA
| | - Ali Naini
- Dept. of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Mahesh M. Mansukhani
- Dept. of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Karen Marder
- Dept. of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
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21
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Hammond J, Klapwijk JE, Hill M, Lou S, Ormond KE, Diderich KEM, Riedijk S, Lewis C. Parental experiences of uncertainty following an abnormal fetal anomaly scan: Insights using Han's taxonomy of uncertainty. J Genet Couns 2020; 30:198-210. [PMID: 32638447 PMCID: PMC8432163 DOI: 10.1002/jgc4.1311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 11/16/2022]
Abstract
For a number of prospective parents, uncertainty during pregnancy starts when an anomaly is found during a routine fetal anomaly scan. This may be followed by numerous tests to determine the etiology and nature of the anomaly. In this study, we aimed to understand how prospective parents perceive and manage uncertainty after being confronted with a structural anomaly during their routine ultrasound. Han's taxonomy of uncertainty was used as a framework to identify and understand the different types of uncertainty experienced. Interviews were held in the UK (n = 8 women and n = 1 male partner) and in the Netherlands (n = 7 women) with participants who had experienced uncertainty in their pregnancy after a fetal scan. Data were analyzed using thematic analysis, and the uncertainties experienced by parents were mapped against the dimensions of the Han taxonomy (sources, issues, and locus). Participants' experience of uncertainty was relevant to all dimensions and subcategories of the Han taxonomy, showing its applicability in the prenatal setting. Sources of uncertainty included receiving probabilistic or ambiguous information about the anomaly, or information that was complex and challenging to understand. Issues of uncertainty included were those that were scientific—such as a probable diagnosis with no further information, personal—such as the emotional impact of uncertainty, and practical—such as limited information about medical procedures and practical aspects of care. Additionally, participants described what helped them to manage uncertainty. This included active coping strategies such as searching for information on the Internet, external coping resources such as seeking social support, and internal coping resources such as using positivity and hope. Several recommendations for the healthcare professional to minimize uncertainty and help the patient deal with uncertainty have been proposed based on these findings.
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Affiliation(s)
- Jennifer Hammond
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Stina Lou
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark
| | - Kelly E Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Sam Riedijk
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Celine Lewis
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
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22
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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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23
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Moultrie RR, Paquin R, Rini C, Roche MI, Berg JS, Powell CM, Lewis MA. Parental Views on Newborn Next Generation Sequencing: Implications for Decision Support. Matern Child Health J 2020; 24:856-864. [PMID: 32424581 DOI: 10.1007/s10995-020-02953-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to understand parental decisions, perspectives, values, and beliefs on next generation sequencing in the newborn period (NGS-NBS) to inform the development of a decision aid to support parental decision making in the North Carolina Newborn Exome Sequencing for Universal Screening study. METHODS We conducted dyadic interviews with 66 current or expectant parents (33 couples) to understand overall decisions about NGS-NBS and reasons for and against learning NGS-NBS results differing by age of onset and medical actionability. Audio recordings were transcribed, coded, and analyzed using qualitative framework analyses. RESULTS Favorable views of NGS-NBS included benefits of early intervention, preparedness, child autonomy, and altruism. Unfavorable views were the potential negative effects from early intervention, psychosocial harm, and religious beliefs. Parents universally reported quality of life as important. CONCLUSION Interviews elucidated what is important in deciding to have NGS-NBS. Understanding parental perspectives, values, and beliefs and integrating evidence-based findings into a parent-centric decision aid provides value and support in making decisions related to NGS-NBS, where there is no clear course of action.
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Affiliation(s)
- Rebecca R Moultrie
- Center for Communication Science, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA.
| | - Ryan Paquin
- Center for Communication Science, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
| | - Christine Rini
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Robert H. Lurie Comprehensive Cancer Center at Northwestern University, Chicago, IL, USA
| | - Myra I Roche
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cynthia M Powell
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan A Lewis
- Center for Communication Science, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC, 27709-2194, USA
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Patient experience of uncertainty in cancer genomics: a systematic review. Genet Med 2020; 22:1450-1460. [PMID: 32424175 PMCID: PMC7462749 DOI: 10.1038/s41436-020-0829-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/07/2023] Open
Abstract
While genomics provides new clinical opportunities, its complexity generates uncertainties. This systematic review aimed to summarize what is currently known about the experience of uncertainty for adult patients undergoing cancer genomic testing. A search of five databases (2001 to 2018) yielded 6508 records. After removing duplicates, abstract/title screening, and assessment of full articles, ten studies were included for quality appraisal and data extraction. Qualitative studies were subjected to thematic analysis, and quantitative data were summarized using descriptive statistics. Cancer genomic results reduced uncertainty for patients regarding treatment decisions but did not reduce uncertainty in the risk context. Qualitative and quantitative data synthesis revealed four themes: (1) coexisting uncertainties, (2) factors influencing uncertainty, (3) outcomes of uncertainty, and (4) coping with uncertainty. Uncertainty can motivate, or be a barrier to, pursuing cancer genomic testing. Appraisal of uncertainty influences the patient experience of uncertainty, the outcome of uncertainty for patients, as well as the coping strategies utilized. While this systematic review found that appraisal of uncertainty is important to the patients' experience of uncertainty in the cancer genomic context, more mixed methods longitudinal research is needed to address the complexities that contribute to patient uncertainty across the process.
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25
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Butow P, Davies G, Napier CE, Schlub T, Best MC, Bartley N, Juraskova I, Meiser B, Ballinger ML, Biesecker B, Goldstein D, Thomas DM. Assessment of the Value of Tumor Variation Profiling Perceived by Patients With Cancer. JAMA Netw Open 2020; 3:e204721. [PMID: 32407502 PMCID: PMC7225901 DOI: 10.1001/jamanetworkopen.2020.4721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Use of tumor molecular profiling (MP) is entering routine clinical practice; however, little is known about how much and why patients value MP. OBJECTIVE To examine the perceived value of MP to patients with advanced cancer and factors associated with perceived value. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional survey that included willingness-to-pay trade-off scenarios was administered to participants after consent and before MP. A total of 777 participants (94% response rate) were recruited from the Molecular Screening and Therapeutics Program. Eligible patients had advanced solid cancers of any histologic type, were receiving or had completed their last line of effective therapy, had an Eastern Cooperative Oncology Group Performance Status 0 to 3, and had sufficient accessible tissue for MP. The participants were recruited between October 24, 2017, and March 12, 2019, and data analysis was conducted from March 13 to April 14, 2019. MAIN OUTCOMES AND MEASURES Willingness to pay for MP was assessed via hypothetical trade-off scenarios varying in the actionable return rate (1%, 20%, or 40%) and cost (A$0, A$300 [US$210], A$1000 [US $700], A$3000 [US $2100], or A$10 000 [US $7000]). Ordinal regressions were used to explore factors associated with willingness to have and pay for MP. RESULTS Of 777 participants (405 women [52%]; mean [SD] age, 55.47 [14.26] years), 689 patients (89%) would have MP for as little as a 1% actionable return rate. Fifty-six patients (7%) would require at least a 20% return rate and 11 patients (1%) would require at least a 40% return rate. Fifteen patients (2%) consistently chose not to have the test; 6 participants (0.8%) had missing values on this item. Participants were willing to pay a median of A$1000 if the actionable return rate was 1% and A$3000 for an actionable return rate of 20% to 40%. Of 762 individuals who agreed to testing, 482 patients (64%) were consistently unwilling to pay A$10 000, regardless of the actionable return rate. Patients born in Australia or New Zealand were more likely to want MP (eg, participants born in South Asia had an ordered odds for the tipping point of 7.74 [95% CI, 1.67-36.05; P = .009] times higher than Australian- and/or New Zealand-born participants). Patients born in Australia or New Zealand were also more willing to pay A$1000 or A$3000 (eg, participants born in Western Europe had an ordered odds for the tipping point for paying A$1000 of 1.74 [95% CI, 1.01-3.00; P = .048] times higher than Australian- and/or New Zealand-born participants). People with a medical- or science-related occupation and with more negative attitudes toward uncertainty were more likely to pay A$10 000 (eg, A$10 000 tipping point-ordered odds of participants with a medical- or science-related occupation was 0.49 [95% CI, 0.7-0.87; P = .02] times that of participants without a medical- or science-related occupation). CONCLUSIONS AND RELEVANCE This study found apparent high interest in but lower willingness to pay for MP among patients with advanced cancer. Ability to pay may limit access to MP. Ongoing societal debate is required to establish the value of MP and whether subsidization is needed to ensure equity of access.
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Affiliation(s)
- Phyllis Butow
- Psycho-Oncology Co-Operative Research Group, Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-Based Decision-Making, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Grace Davies
- Psycho-Oncology Co-Operative Research Group, Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Christine E. Napier
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Timothy Schlub
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Megan C. Best
- Psycho-Oncology Co-Operative Research Group, Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Nicole Bartley
- Psycho-Oncology Co-Operative Research Group, Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Ilona Juraskova
- Centre for Medical Psychology and Evidence-Based Decision-Making, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, University of New South Wales, Kensington, New South Wales, Australia
| | - Mandy L. Ballinger
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | | | - David Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - David M. Thomas
- Cancer Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
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26
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Mollison L, O'Daniel JM, Henderson GE, Berg JS, Skinner D. Parents' perceptions of personal utility of exome sequencing results. Genet Med 2020; 22:752-757. [PMID: 31857707 PMCID: PMC7192542 DOI: 10.1038/s41436-019-0730-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 12/04/2019] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Clinical genome or exome sequencing (GS/ES) provides a diagnosis for many individuals with suspected genetic disorders, but also yields negative or uncertain results for the majority. This study examines how parents of a child with an undiagnosed condition attribute personal utility to all types of ES results. METHODS Return of 31 exome sequencing results was observed during clinic sessions, followed by semistructured interviews with parents one month later. Observations and interviews were recorded and transcribed. Data display matrices were used for content analysis and systematic comparisons of parents' perceptions of utility. RESULTS ES results could not provide all the answers to parents' questions, especially in cases of clinically uninformative results, but parents nonetheless attributed utility to the knowledge gained. Parents across all results categories used the genomic information to rule out possible causes, end or postpone the diagnostic odyssey, and shift focus to treatment and management of symptoms. CONCLUSION This study suggests that parents value even uninformative ES results while expressing hope for future discoveries. As pediatric genetics moves toward GS/ES as a first-tier test, how parents perceive the personal utility of negative or uncertain results is an important topic for genetic counseling and further research.
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Affiliation(s)
- Lonna Mollison
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Julianne M O'Daniel
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jonathan S Berg
- Department of Genetics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Debra Skinner
- FPG Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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27
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Clift K, Macklin S, Halverson C, McCormick JB, Abu Dabrh AM, Hines S. Patients' views on variants of uncertain significance across indications. J Community Genet 2020; 11:139-145. [PMID: 31432391 PMCID: PMC7062975 DOI: 10.1007/s12687-019-00434-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/12/2019] [Indexed: 02/06/2023] Open
Abstract
As genomic sequencing expands into more areas of patient care, an increasing number of patients learn of the variants of uncertain significance (VUSs) that they carry. Understanding the potential psychosocial consequences of the disclosure of a VUS can help inform pre- and post-test counseling discussions. Medical uncertainty in general elicits a variety of responses from patients, particularly in the growing field of medical genetics and genomics. It is important to consider patients' responses to the ambiguous nature of VUSs across different indications and situational contexts. Genetic counselors and other providers ordering genetic testing should be prepared for the possibility of their patients' misinterpretation of such results. Pre-test counseling should include a discussion of the possibility of VUSs and what it would mean for the patient's care and its potential psychosocial impacts. When a VUS is found, post-test counseling should include additional education and a discussion of the variant's implications and medical management recommendations based on the results. These discussions may help temper subjective interpretations, unrealistic views, and decisional regret.
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Affiliation(s)
- Kristin Clift
- Mayo Clinic Center for Individualized Medicine, Jacksonville, FL, USA.
| | - Sarah Macklin
- Mayo Clinic Department of Clinical Genomics, Jacksonville, FL, USA
| | - Colin Halverson
- Center for Bioethics, Indiana University School of Medicine, Indianapolis, IN, USA
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28
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Neustadt A, Owczarzak J, Mu W, Cohen JS, Erby L. Adult patients with undiagnosed conditions and their responses to unresolved uncertainty from exome sequencing. J Genet Couns 2020; 29:992-1003. [PMID: 32030847 PMCID: PMC10150798 DOI: 10.1002/jgc4.1223] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 12/27/2022]
Abstract
Patients pursuing exome sequencing (ES) in their quest for diagnosis will most often experience unresolved uncertainty from their ES results because the majority of ES results are non-diagnostic. This study explored and compared the experiences of receiving two types of ES results that may result in diagnostic uncertainty. Semi-structured phone interviews were conducted with 23 adult patients with undiagnosed conditions who received either a negative result or a result with one or more variants of uncertain significance (VUSs) from ES. Interviews were transcribed and subjected to thematic and comparative analyses. Participants accurately understood their results and described various sources of genomic uncertainty including probability, complexity, and ambiguity. Their acclimation to illness uncertainty resulted in realistic expectations about and acceptance of their results. Participants still hoped that ES would end their diagnostic odyssey. Hope and optimism were used to cope with continued uncertainty. No thematic differences were found between the experiences of those who received negative results versus those who received VUSs. Our findings may inform clinical practices of informed consent and disclosure of negative results and VUSs through a greater consideration of patients' reactions, concerns, and challenges with adaptation to uncertainty.
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Affiliation(s)
- Ahna Neustadt
- Department of Health, Behavior, & Society Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
- Medical Genomics & Metabolic Genetics Branch National Human Genome Research InstituteNational Institutes of Health Bethesda Maryland
| | - Jill Owczarzak
- Department of Health, Behavior, & Society Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
| | - Weiyi Mu
- McKusick‐Nathans Institute of Genetic Medicine Johns Hopkins University Baltimore Maryland
| | - Julie S. Cohen
- Department of Neurology & Developmental Medicine Kennedy Krieger Institute Baltimore Maryland
| | - Lori Erby
- Department of Health, Behavior, & Society Johns Hopkins Bloomberg School of Public Health Baltimore Maryland
- Medical Genomics & Metabolic Genetics Branch National Human Genome Research InstituteNational Institutes of Health Bethesda Maryland
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29
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Park J, Zayhowski K, Newson AJ, Ormond KE. Genetic counselors' perceptions of uncertainty in pretest counseling for genomic sequencing: A qualitative study. J Genet Couns 2019; 28:292-303. [DOI: 10.1002/jgc4.1076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Jessica Park
- Department of Genetics; Stanford University School of Medicine; Stanford California
| | - Kimberly Zayhowski
- Department of Genetics; Stanford University School of Medicine; Stanford California
| | - Ainsley J. Newson
- Sydney School of Public Health, Faculty of Medicine and Health; The University of Sydney, Sydney Health Ethics; Sydney NSW Australia
| | - Kelly E. Ormond
- Department of Genetics; Stanford University School of Medicine; Stanford California
- Stanford Center for Biomedical Ethics; Stanford University School of Medicine; Stanford California
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30
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Exome sequencing in clinical settings: preferences and experiences of parents of children with rare diseases (SEQUAPRE study). Eur J Hum Genet 2019; 27:701-710. [PMID: 30710147 DOI: 10.1038/s41431-018-0332-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022] Open
Abstract
Exome sequencing (ES) has revolutionized diagnostic procedures in medical genetics, particularly for developmental diseases. The variety and complexity of the information produced has raised issues regarding its use in a clinical setting. Of particular interest are patients' expectations regarding the information disclosed, the accompaniment provided, and the value patients place on these. To explore these issues in parents of children with developmental disorders and no diagnosis with known etiology, a multidisciplinary group of researchers from social and behavioral sciences and patient organizations conducted a mixed-methodology study (quantitative and qualitative) in two centers of expertise for rare diseases in France. The quantitative study aimed to determine the preferences of 513 parents regarding the disclosure of ES results. It showed that parents wished to have exhaustive information, including variants of unknown significance possibly linked to their child's disorder and secondary findings. This desire for information could be a strategy to maximize the chances of obtaining a diagnosis. The qualitative study aimed to understand the expectations and reactions of 57 parents interviewed just after the return of ES results. In-depth analysis showed that parents had ambivalent feelings about the findings whatever the results returned. The contrasting results from these studies raise questions about the value of the information provided and parents' high expectations regarding the results. The nature of parental expectations has emerged as an important topic in efforts to optimize accompaniment and support for families during the informed decision-making process and after disclosure of the results in an overall context of uncertainty.
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31
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Lewis KL, Facio FM, Berrios CD. Using the diffusion of innovations model to guide participant engagement in the genomics era. J Genet Couns 2019; 28:419-427. [PMID: 30653790 DOI: 10.1002/jgc4.1090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/06/2018] [Accepted: 12/09/2018] [Indexed: 12/12/2022]
Abstract
Exome and genome sequencing (EGS) are increasingly the genetic testing modalities of choice among researchers owing to their ready availability, low cost, and large data output. Recruitment of larger, more diverse cohorts into long-term studies with extensive data collection is fundamental to the success of EGS research and to the widespread benefit of genomic medicine to various populations. Effective engagement will be critical to meeting this demand. The Diffusion of Innovation (DOI) model provides a framework for how new technologies are adopted in communities, including antecedents of an individual's decision to adopt the technology, how the technology's attributes influence its acceptability, the predictors of sustained use of that technology, and its diffusion through society. We apply the DOI model to frame participant engagement in EGS research and to guide the proposal of potential strategies that aim to overcome forecasted challenges. Finally, we suggest a variety of ways genetic counselors can apply their skills and training to the development and implementation of these strategies.
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Affiliation(s)
- Katie L Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, Bethesda, Maryland
| | - Flavia M Facio
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, Bethesda, Maryland
| | - Courtney D Berrios
- Center for Pediatric Genomic Medicine, Children's Mercy Kansas City, Kansas City, Missouri
- School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
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32
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Makhnoon S, Shirts BH, Bowen DJ. Patients' perspectives of variants of uncertain significance and strategies for uncertainty management. J Genet Couns 2019; 28:313-325. [PMID: 30636062 DOI: 10.1002/jgc4.1075] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 12/24/2022]
Abstract
Variants of uncertain significance (VUS) are a well-recognized source of uncertainty in genomic medicine. Despite the existence of straightforward clinical management recommendations, patients report feeling anxiety, worry, and uncertainty in response to VUS. We report the first structured analysis of patient perspectives of VUS-related uncertainty in genome sequencing using Han's taxonomy of genomic uncertainty. We conducted in-depth semi-structured interviews with 11 patients to elicit their thoughts regarding implications of the result for themselves and their family members. Patients' primary concern with VUS-related uncertainty involved personal and practical issues as they directly inform health-care decisions. Patients demonstrated good understanding of the epistemic nature of VUS uncertainty-that information about such variant is currently unknown. However, between-provider discordance in explanations of the implication of this uncertainty for patients' diagnosis, prognosis, and therapy was a major contributor to the overall experience of uncertainty. Strategies for uncertainty reduction involved periodically checking back for reclassification and receiving concordant and clear recommendation from providers. Other proactive strategies of uncertainty reduction-such as information seeking and reading the genetic test report-were not helpful. Collectively, these findings offer previously unreported insight into uncertainty management strategies used by patients which have the potential to guide clinical management practices.
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Affiliation(s)
- Sukh Makhnoon
- Institute of Public Health Genetics, University of Washington, Seattle, Washington
| | - Brian H Shirts
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
| | - Deborah J Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, Washington
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33
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Hall MJ, Patrick-Miller LJ, Egleston BL, Domchek SM, Daly MB, Ganschow P, Grana G, Olopade OI, Fetzer D, Brandt A, Chambers R, Clark DF, Forman A, Gaber R, Gulden C, Horte J, Long JM, Lucas T, Madaan S, Mattie K, McKenna D, Montgomery S, Nielsen S, Powers J, Rainey K, Rybak C, Savage M, Seelaus C, Stoll J, Stopfer JE, Yao XS, Bradbury AR. Use and Patient-Reported Outcomes of Clinical Multigene Panel Testing for Cancer Susceptibility in the Multicenter Communication of Genetic Test Results by Telephone Study. JCO Precis Oncol 2018; 2. [PMID: 31819920 DOI: 10.1200/po.18.00199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Multigene panels (MGPs) are increasingly being used despite questions regarding their clinical utility and no standard approach to genetic counseling. How frequently genetic providers use MGP testing and how patient-reported outcomes (PROs) differ from targeted testing (eg, BRCA1/2 only) are unknown. Methods We evaluated use of MGP testing and PROs in participants undergoing cancer genetic testing in the multicenter Communication of Genetic Test Results by Telephone study (ClinicalTrials.gov identifier: ), a randomized study of telephone versus in-person disclosure of genetic test results. PROs included genetic knowledge, general and state anxiety, depression, cancer-specific distress, uncertainty, and satisfaction. Genetic providers offered targeted or MGP testing based on clinical assessment. Results Since the inclusion of MGP testing in 2014, 395 patients (66%) were offered MGP testing. MGP testing increased over time from 57% in 2014 to 66% in 2015 (P = .02) and varied by site (46% to 78%; P < .01). Being offered MGP testing was significantly associated with not having Ashkenazi Jewish ancestry, having a history of cancer, not having a mutation in the family, not having made a treatment decision, and study site. After demographic adjustment, patients offered MGP testing had lower general anxiety (P = .04), state anxiety (P = .03), depression (P = .04), and uncertainty (P = .05) pre-disclosure compared with patients offered targeted testing. State anxiety (P = .05) and cancer-specific distress (P = .05) were lower at disclosure in the MGP group. There was a greater increase in change in uncertainty (P = .04) among patients who underwent MGP testing. Conclusion MGP testing was more frequently offered to patients with lower anxiety, depression, and uncertainty and was associated with favorable outcomes, with the exception of a greater increase in uncertainty compared with patients who had targeted testing. Addressing uncertainty may be important as MGP testing is increasingly adopted.
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Affiliation(s)
- Michael J Hall
- Fox Chase Cancer Center, Temple University Health System
| | | | | | | | - Mary B Daly
- Fox Chase Cancer Center, Temple University Health System
| | | | | | | | | | | | | | | | - Andrea Forman
- Fox Chase Cancer Center, Temple University Health System
| | - Rikki Gaber
- The John H. Stroger Jr. Hospital of Cook County
| | | | | | | | - Terra Lucas
- The John H. Stroger Jr. Hospital of Cook County
| | | | | | | | | | | | | | - Kim Rainey
- Fox Chase Cancer Center, Temple University Health System
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Joseph G, Lee R, Pasick RJ, Guerra C, Schillinger D, Rubin S. Effective communication in the era of precision medicine: A pilot intervention with low health literacy patients to improve genetic counseling communication. Eur J Med Genet 2018; 62:357-367. [PMID: 30553023 DOI: 10.1016/j.ejmg.2018.12.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 01/19/2023]
Abstract
Effective communication, where all parties share a common understanding, is necessary to realize the promise of Genomic Medicine. It is especially salient given the imperative to increase the participation of diverse populations in genomics research and to expand the reach of clinical genomics. We have previously shown that cancer genetic counseling is suboptimal for patients with limited health literacy. To address this finding, we implemented a pilot study to improve verbal communication between genetic counselors and their patients of limited health literacy that consisted of: i) curriculum development and delivery of a Genetic Counselors (GC) communication workshop; ii) two-month post-workshop interviews with GC participants (n = 9); iii) observations/audio recordings of counseling sessions involving 24 patients and two GC workshop participants; iv) post-counseling interviews with patients (n = 9). The 4.5-h workshop presented evidenced-based principles and strategies for effective communication with limited health literacy patients (e.g. use of plain language and teach-back), and offered specific techniques and exercises to practice adoption of such practices in the genetic counseling context. GCs expressed appreciation for the opportunity to refine their skills; however, they reported that some strategies were challenging given their professional training and communication habits. For example, GCs were concerned that use of plain language could undermine efforts to obtain informed consent and provide scientifically accurate information. Observations and patient interviews after the workshop revealed that GCs were able to employ the communication strategies with positive effects, with patients indicating sufficient understanding of the genetic test and its implications as well as satisfaction with the counselors' communication. While derived from research on communication with those of limited health literacy, the communication approaches taught in the GC workshop could benefit most patients, given the high rates of low health literacy in many countries, and the many factors beyond health literacy that can contribute to reduced comprehension in health care environments.
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Affiliation(s)
- Galen Joseph
- Department of Anthropology, History & Social Medicine, University of California, San Francisco, United States; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, United States.
| | - Robin Lee
- Cancer Genetics & Prevention Program, University of California, San Francisco, United States
| | - Rena J Pasick
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, United States; Department of General Internal Medicine, University of California, San Francisco, United States
| | - Claudia Guerra
- Department of General Internal Medicine, University of California, San Francisco, United States
| | - Dean Schillinger
- Department of Medicine, University of California, San Francisco, United States
| | - Sara Rubin
- Department of Social & Behavioral Sciences, University of California, San Francisco, United States
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35
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Hull LE, Vassy JL. Toward greater understanding of patient decision-making around genome sequencing. Per Med 2018; 15:57-66. [PMID: 29714114 DOI: 10.2217/pme-2017-0037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the era of next-generation sequencing, it is essential to collect and understand the patient outcomes that result from this new technology. One critical determinant of these is the process by which individuals first decide whether and how to pursue genome sequencing. In this perspective article, we examine the literature on adult patient decision-making in genome sequencing and identify current research gaps to address. Several studies have explored the motivations and concerns of patients undergoing sequencing; less attention has been paid to those who decline sequencing or to individuals from lower socioeconomic groups. Many factors that might play a role in the decision to pursue or decline sequencing, including trust, family dynamics and barriers to access, have yet to be explored fully. Future research that captures the experience of the wider population will produce a more generalizable understanding of the clinical, psychosocial, and economic outcomes of pursuing or declining sequencing.
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Affiliation(s)
- Leland E Hull
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, 02130, USA.,Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA
| | - Jason L Vassy
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA.,Division of General Medicine & Primary Care, Brigham & Women's Hospital, Boston, MA, 02115, USA
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36
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Esteban I, Lopez-Fernandez A, Balmaña J. A narrative overview of the patients' outcomes after multigene cancer panel testing, and a thorough evaluation of its implications for genetic counselling. Eur J Med Genet 2018; 62:342-349. [PMID: 30476626 DOI: 10.1016/j.ejmg.2018.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 01/07/2023]
Abstract
Massively parallel sequencing is being implemented in clinical practice through the use of multigene panel testing, whole exome sequencing and whole genome sequencing. In this manuscript we explore how the use of massively parallel sequencing, and in particular multigene cancer panel testing, is potentially changing the process of genetic counselling and how patients cope with pre-test genetic counselling and results. We found that the main challenges are around uncertainty, hopes and expectations and the amount and complexity of information that needs to be discussed. This may impact the process of genetic counselling, although genetic counsellors can still use their core skills and enhance some of them in order to evolve and meet patients' needs in the genomics era. Available data suggests that patients can cope with multigene cancer panels although more research is needed to fully understand the psychosocial implications of multigene cancer panels for patients, especially for those who have variants of unknown significance or moderate penetrance variants. Research is also needed to explore and develop communication models that maximize patients' understanding and empower them to make informed decisions.
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Affiliation(s)
- I Esteban
- Department of Clinical Genetics, Ninewells Hospital, Dundee, Scotland, UK.
| | - A Lopez-Fernandez
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - J Balmaña
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain; Medical Oncology Department, Vall D'Hebron Hospital, Barcelona, Spain
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Harris S, Gilmore K, Hardisty E, Lyerly AD, Vora NL. Ethical and counseling challenges in prenatal exome sequencing. Prenat Diagn 2018; 38:897-903. [PMID: 30171820 DOI: 10.1002/pd.5353] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/18/2018] [Accepted: 08/25/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Ethical and counseling challenges are expected with the introduction of prenatal whole exome sequencing. In this study, we describe specific challenges identified through the UNC-Chapel Hill Prenatal Exome Sequencing Study. METHODS Participants were a subset of women participating in the fetal exome study, which has enrolled 73 mother-father-fetus trios in pregnancies diagnosed with structural anomalies and normal standard genetic testing results. In this descriptive study, cases were reviewed by members of the research team, including a bioethicist, to identify counseling challenges. Illustrative cases were chosen by group consensus. RESULTS Four illustrative cases were identified for further analysis. Challenges included need for adequate counseling and informed consent, challenges in prenatal variant interpretation, performing prenatal diagnosis in subsequent pregnancies, inability to identify a genetic etiology, and identifying parental secondary findings. CONCLUSION Our study illustrates several challenges identified in an ongoing prenatal exome study. While genomic medicine is a powerful tool for prenatal diagnosis, it is important that clinicians understand the ethical implications and parental perceptions of this testing modality.
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Affiliation(s)
- Sarah Harris
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kelly Gilmore
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Emily Hardisty
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anne Drapkin Lyerly
- Department of Social Medicine and Center for Bioethics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Neeta L Vora
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Wynn J, Lewis K, Amendola LM, Bernhardt BA, Biswas S, Joshi M, McMullen C, Scollon S. Clinical providers' experiences with returning results from genomic sequencing: an interview study. BMC Med Genomics 2018; 11:45. [PMID: 29739461 PMCID: PMC5941324 DOI: 10.1186/s12920-018-0360-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 04/19/2018] [Indexed: 12/12/2022] Open
Abstract
Background Current medical practice includes the application of genomic sequencing (GS) in clinical and research settings. Despite expanded use of this technology, the process of disclosure of genomic results to patients and research participants has not been thoroughly examined and there are no established best practices. Methods We conducted semi-structured interviews with 21 genetic and non-genetic clinicians returning results of GS as part of the NIH funded Clinical Sequencing Exploratory Research (CSER) Consortium projects. Interviews focused on the logistics of sessions, participant/patient reactions and factors influencing them, how the sessions changed with experience, and resources and training recommended to return genomic results. Results The length of preparation and disclosure sessions varied depending on the type and number of results and their implications. Internal and external databases, online resources and result review meetings were used to prepare. Respondents reported that participants’ reactions were variable and ranged from enthusiasm and relief to confusion and disappointment. Factors influencing reactions were types of results, expectations and health status. A recurrent challenge was managing inflated expectations about GS. Other challenges included returning multiple, unanticipated and/or uncertain results and navigating a rare diagnosis. Methods to address these challenges included traditional genetic counseling techniques and modifying practice over time in order to provide anticipatory guidance and modulate expectations. Respondents made recommendations to improve access to genomic resources and genetic referrals to prepare future providers as the uptake of GS increases in both genetic and non-genetic settings. Conclusions These findings indicate that returning genomic results is similar to return of results in traditional genetic testing but is magnified by the additional complexity and potential uncertainty of the results. Managing patient expectations, initially identified in studies of informed consent, remains an ongoing challenge and highlights the need to address this issue throughout the testing process. The results of this study will help to guide future providers in the disclosure of genomic results and highlight educational needs and resources necessary to prepare providers. Future research on the patient experience, understanding and follow-up of recommendations is needed to more fully understand the disclosure process. Electronic supplementary material The online version of this article (10.1186/s12920-018-0360-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julia Wynn
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Katie Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Laura M Amendola
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Barbara A Bernhardt
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sawona Biswas
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Manasi Joshi
- The Center for Health Research, Rice University, Houston, TX, USA
| | - Carmit McMullen
- Center for Health Research - Kaiser Permanente Northwest, Portland, OR, USA
| | - Sarah Scollon
- Department of Pediatrics, Baylor College of Medicine, 1102 Bates St. FC 1200, Houston, TX, 77030, USA.
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Wynn J, Ottman R, Duong J, Wilson AL, Ahimaz P, Martinez J, Rabin R, Rosen E, Webster R, Au C, Cho MT, Egan C, Guzman E, Primiano M, Shaw JE, Sisson R, Klitzman RL, Appelbaum PS, Lichter-Konecki U, Anyane-Yeboa K, Iglesias A, Chung WK. Diagnostic exome sequencing in children: A survey of parental understanding, experience and psychological impact. Clin Genet 2018; 93:1039-1048. [PMID: 29266212 DOI: 10.1111/cge.13200] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 12/21/2022]
Abstract
Clinical exome sequencing (CES) is increasingly being used as an effective diagnostic tool in the field of pediatric genetics. We sought to evaluate the parental experience, understanding and psychological impact of CES by conducting a survey study of English-speaking parents of children who had diagnostic CES. Parents of 192 unique patients participated. The parent's interpretation of the child's result agreed with the clinician's interpretation in 79% of cases, with more frequent discordance when the clinician's interpretation was uncertain. The majority (79%) reported no regret with the decision to have CES. Most (65%) reported complete satisfaction with the genetic counseling experience, and satisfaction was positively associated with years of genetic counselor (GC) experience. The psychological impact of CES was greatest for parents of children with positive results and for parents with anxiety or depression. The results of this study are important for helping clinicians to prepare families for the possible results and variable psychological impact of CES. The frequency of parental misinterpretation of test results indicates the need for additional clarity in the communication of results. Finally, while the majority of patients were satisfied with their genetic counseling, satisfaction was lower for new GCs, suggesting a need for targeted GC training for genomic testing.
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Affiliation(s)
- J Wynn
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - R Ottman
- G.H. Sergievsky Center and Departments of Epidemiology and Neurology, Columbia University Medical Center and NY State Psychiatric Institute, New York, New York
| | - J Duong
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - A L Wilson
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - P Ahimaz
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - J Martinez
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - R Rabin
- College of Liberal Arts and Sciences, Long Island University - Post Campus, Brookville, New York
| | - E Rosen
- College of Liberal Arts and Sciences, Long Island University - Post Campus, Brookville, New York
| | - R Webster
- Columbia University Medical School, New York, New York
| | - C Au
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - M T Cho
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York.,GeneDx, Gaithersburg, Maryland
| | - C Egan
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - E Guzman
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - M Primiano
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - J E Shaw
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - R Sisson
- Division of Clinical Genetics, Department of Pediatrics, New York Presbyterian Hospital, Columbia University, New York, New York
| | - R L Klitzman
- Department of Psychiatry, Columbia University Medical Center and NY State Psychiatric Institute, New York, New York
| | - P S Appelbaum
- Department of Psychiatry, Columbia University Medical Center and NY State Psychiatric Institute, New York, New York
| | - U Lichter-Konecki
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - K Anyane-Yeboa
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - A Iglesias
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - W K Chung
- Division of Clinical Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York.,Department of Medicine, Columbia University Medical Center, New York, New York
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40
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Lawal TA, Lewis KL, Johnston JJ, Heidlebaugh AR, Ng D, Gaston-Johansson FG, Klein WMP, Biesecker BB, Biesecker LG. Disclosure of cardiac variants of uncertain significance results in an exome cohort. Clin Genet 2018; 93:1022-1029. [PMID: 29383714 DOI: 10.1111/cge.13220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 01/19/2018] [Accepted: 01/25/2018] [Indexed: 01/26/2023]
Abstract
This study examined the impact of disclosing subclassifications of genetic variants of uncertain significance (VUS) on behavioral intentions. We studied return of VUS results to 79 individuals with a cardiomyopathy-associated VUS, subclassified into VUS-high or VUS-low. Primary outcomes were perceived risk (absolute and comparative), perceived severity, perceived value of information, self-efficacy, decision regret, and behavioral intentions to share results and change behaviors. There was no significant difference between the 2 subclasses in overall behavioral intentions (t = 0.023, P = .982) and each of the individual items on the behavioral intentions scale; absolute (t = -1.138, P = .259) or comparative (t = -0.463, P = .645) risk perceptions; perceived value of information (t = 0.582, P = .563) and self-efficacy (t = -0.733, P = .466). Decision regret was significantly different (t = 2.148, P = .035), with VUS-low (mean = 17.24, SD = 16.08) reporting greater regret. Combining the subclasses, perceived value of information was the strongest predictor of behavioral intentions (β = 0.524, P < .001). Participants generally understood the meaning of a genetic VUS result classification and reported satisfaction with result disclosure. No differences in behavioral intentions were found, but differences in decision regret suggest participants distinguish subclasses of VUS results. The perceived value of VUS may motivate recipients to pursue health-related behaviors.
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Affiliation(s)
- T A Lawal
- National Institute of Nursing Research, National Institutes of Health (NIH), Bethesda, Maryland
| | - K L Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - J J Johnston
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - A R Heidlebaugh
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - D Ng
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - F G Gaston-Johansson
- Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - W M P Klein
- Behavioral Research Program, National Cancer Institute, NIH, Bethesda, Maryland
| | - B B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - L G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, Maryland
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Werner-Lin A, Zaspel L, Carlson M, Mueller R, Walser SA, Desai R, Bernhardt BA. Gratitude, protective buffering, and cognitive dissonance: How families respond to pediatric whole exome sequencing in the absence of actionable results. Am J Med Genet A 2018; 176:578-588. [DOI: 10.1002/ajmg.a.38613] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/26/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Allison Werner-Lin
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Lori Zaspel
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Mae Carlson
- School of Social Policy and Practice; University of Pennsylvania; Philadelphia Pennsylvania
| | - Rebecca Mueller
- Department of History and Sociology of Science; University of Pennsylvania; Philadelphia Pennsylvania
| | - Sarah A. Walser
- Department of Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Ria Desai
- College of Arts and Science; University of Pennsylvania; Philadelphia Pennsylvania
| | - Barbara A. Bernhardt
- Department of Medicine; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
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Interpretation of genomic sequencing: variants should be considered uncertain until proven guilty. Genet Med 2018; 20:291-293. [PMID: 29388946 DOI: 10.1038/gim.2017.269] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 01/09/2023] Open
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Berrios C, James CA, Raraigh K, Bollinger J, Murray B, Tichnell C, Applegate CD, Bergner AL. Enrolling Genomics Research Participants through a Clinical Setting: the Impact of Existing Clinical Relationships on Informed Consent and Expectations for Return of Research Results. J Genet Couns 2018; 27:263-273. [PMID: 28932961 PMCID: PMC7539290 DOI: 10.1007/s10897-017-0143-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 08/09/2017] [Indexed: 11/29/2022]
Abstract
Genetic counselors working in a clinical setting may find themselves recruiting, enrolling, and returning results for genomic research, and existing clinical relationships with study participants may impact these research interactions. We present a qualitative study using semi-structured interviews of participants enrolled in a genome sequencing/exome sequencing (GS/ES) study at the same institution where they receive clinical care. Interviews were coded for motivations to participate and expectations of this research. The interviews revealed common motivations for participation, including altruism and hope for benefit for themselves, family members, and/or others with their condition. Additionally, themes emerged related to unintentional influence based on trust of the clinical provider that recruited them to the study. Participant trust in the enrolling provider at times appeared to extend to the study team to decide which research results to return and to do so in an appropriate format. Participants also based expectations for research results return on previous clinical genetic testing experiences, which may or may not be realistic depending on study design. It is imperative that genetic counselors enrolling patients into research studies be aware of the potential influence of their clinical relationship on potential subjects, be transparent about their role on the study team, and help set expectations about the study process, including results return.
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Affiliation(s)
- Courtney Berrios
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1008, Baltimore, MD, 21287, USA
| | - Cynthia A James
- Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Karen Raraigh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1008, Baltimore, MD, 21287, USA
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Brittney Murray
- Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Crystal Tichnell
- Department of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Carolyn D Applegate
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1008, Baltimore, MD, 21287, USA
| | - Amanda L Bergner
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1008, Baltimore, MD, 21287, USA.
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Smagarinsky Y, Burns C, Spinks C, Semsarian C, Ingles J. Development of a communication aid for explaining hypertrophic cardiomyopathy genetic test results. Pilot Feasibility Stud 2017; 3:53. [PMID: 29152326 PMCID: PMC5680798 DOI: 10.1186/s40814-017-0205-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/31/2017] [Indexed: 01/10/2023] Open
Abstract
Background Large gene panels are now commonplace for hypertrophic cardiomyopathy (HCM), increasing the yield of uncertain genetic findings. Few resources exist which aim to facilitate communication of HCM genetic test results. We sought to develop, pilot, and refine a communication aid for probands receiving HCM genetic test results. Methods Development was a multi-step process involving expertise of a multidisciplinary team, literature review, and empirical experience. The aid went through an iterative revision process throughout the piloting phase to incorporate feedback. HCM probands attending a specialized multidisciplinary HCM clinic, aged ≥ 18 years and genetic test results available for disclosure between May and August 2016, or recently received their gene results (January–April 2015) were eligible. A purposive sampling strategy was employed, recruiting those attending clinic during the study period or those who could attend without difficulty. Results We developed and pilot tested a genetic counsellor-led communication aid. Based on clinical expertise, the aid addresses (a) what genetic testing is, (b) implications for the patient, (c) reasoning for variant classification, and (d) implications for the family. Pilot data were sought to assess knowledge, feasibility, and acceptability using a self-report survey 2 weeks post-intervention. Twelve of 13 participants completed the follow-up questionnaire. Participants valued the individualised nature of the aid, recommended use of the aid, and indicated genetic knowledge, and family communication was better facilitated. Iterative modification of images helped to more simply depict important genetic concepts. Conclusions We have developed a tool that is feasible, acceptable, and helpful to patients receiving genetic results. This is an important first step, and trial of the aid to assess effectiveness compared to usual care will follow.
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Affiliation(s)
- Yana Smagarinsky
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Charlotte Burns
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Catherine Spinks
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Vora NL, Powell B, Brandt A, Strande N, Hardisty E, Gilmore K, Foreman AKM, Wilhelmsen K, Bizon C, Reilly J, Owen P, Powell CM, Skinner D, Rini C, Lyerly AD, Boggess KA, Weck K, Berg JS, Evans JP. Prenatal exome sequencing in anomalous fetuses: new opportunities and challenges. Genet Med 2017; 19:1207-1216. [PMID: 28518170 PMCID: PMC5675748 DOI: 10.1038/gim.2017.33] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 02/04/2017] [Indexed: 12/13/2022] Open
Abstract
PurposeWe investigated the diagnostic and clinical performance of exome sequencing in fetuses with sonographic abnormalities with normal karyotype and microarray and, in some cases, normal gene-specific sequencing.MethodsExome sequencing was performed on DNA from 15 anomalous fetuses and from the peripheral blood of their parents. Parents provided consent to be informed of diagnostic results in the fetus, medically actionable findings in the parents, and their identification as carrier couples for significant autosomal recessive conditions. We assessed the perceptions and understanding of exome sequencing using mixed methods in 15 mother-father dyads.ResultsIn seven (47%) of 15 fetuses, exome sequencing provided a diagnosis or possible diagnosis with identification of variants in the following genes: COL1A1, MUSK, KCTD1, RTTN, TMEM67, PIEZO1 and DYNC2H1. One additional case revealed a de novo nonsense mutation in a novel candidate gene (MAP4K4). The perceived likelihood that exome sequencing would explain the results (5.2 on a 10-point scale) was higher than the approximately 30% diagnostic yield discussed in pretest counseling.ConclusionExome sequencing had diagnostic utility in a highly select population of fetuses where a genetic diagnosis was highly suspected. Challenges related to genetics literacy and variant interpretation must be addressed by highly tailored pre- and posttest genetic counseling.
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Affiliation(s)
- Neeta L. Vora
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bradford Powell
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alicia Brandt
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Natasha Strande
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Emily Hardisty
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kelly Gilmore
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ann Katherine M. Foreman
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- North Carolina Translational and Clinical Sciences (NC TraCS) Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kirk Wilhelmsen
- Departments of Genetics and Neurology, Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Chris Bizon
- Departments of Genetics and Neurology, Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jason Reilly
- Departments of Genetics and Neurology, Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Phil Owen
- Departments of Genetics and Neurology, Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cynthia M. Powell
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pediatrics, Division of Genetics and Metabolism, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Debra Skinner
- FPG Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christine Rini
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anne D. Lyerly
- Department of Social Medicine and Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kim A. Boggess
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Karen Weck
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jonathan S. Berg
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - James P. Evans
- Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Social Medicine and Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC
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"Possibly positive or certainly uncertain?": participants' responses to uncertain diagnostic results from exome sequencing. Genet Med 2017; 20:313-319. [PMID: 29593351 PMCID: PMC5880300 DOI: 10.1038/gim.2017.135] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/01/2017] [Indexed: 11/21/2022] Open
Abstract
Purpose Clinical genome sequencing (GS) produces uncertain diagnostic results, raising concerns about how to communicate the inherent complexities in ways that reduce potential misunderstandings and harms. This study investigates clinicians’ communications and patient/participant responses to uncertain diagnostic results arising from a clinical exome sequencing research study, contributing empirical data to the debate surrounding disclosure of uncertain genomic information. Methods We investigated the communication and impact of uncertain diagnostic results using ethnographic observations of result disclosures with 21 adults and 11 parents of child patients, followed by 2 semi-structured interviews with these same participants. Results Participants understood their uncertain results in ways that were congruent with clinical geneticists’ communications. They followed recommendations for further consultation, although family testing to resolve uncertainty was not always done. Participants were prepared for learning an uncertain result and grasped the key concept that it should not be used to guide health care or other decisions. They did not express regret for having learned the uncertain result; most regarded it as potentially valuable in the future. Conclusion This study suggests that uncertain diagnostic results from GS can be relayed to patients in ways they can understand and consistent with providers’ interpretations, without causing undue harm.
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47
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Interest in and reactions to genetic risk information: The role of implicit theories and self-affirmation. Soc Sci Med 2017; 190:101-110. [DOI: 10.1016/j.socscimed.2017.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 08/01/2017] [Accepted: 08/11/2017] [Indexed: 02/07/2023]
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Walser SA, Werner-Lin A, Mueller R, Miller VA, Biswas S, Bernhardt BA. How do providers discuss the results of pediatric exome sequencing with families? Per Med 2017; 14:409-422. [PMID: 28966657 DOI: 10.2217/pme-2017-0015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
AIM This study provides preliminary data on the process and content of returning results from exome sequencing offered to children through one of the Clinical Sequencing Exploratory Research (CSER) projects. MATERIALS & METHODS We recorded 25 sessions where providers returned diagnostic and secondary sequencing results to families. Data interpretation utilized inductive thematic analysis. RESULTS Typically, providers followed a results report and discussed diagnostic findings using technical genomic and sequencing concepts. We identified four provider processes for returning results: teaching genetic concepts; assessing family response; personalizing findings; and strengthening patient-provider relationships. CONCLUSION Sessions should reflect family interest in medical management and next steps, and minimize detailed genomic concepts. As the scope and complexity of sequencing increase, the traditional information-laden counseling model requires revision.
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Affiliation(s)
- Sarah A Walser
- Translational Medicine & Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allison Werner-Lin
- School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecca Mueller
- Department of History & Sociology of Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Victoria A Miller
- Division of Adolescent Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 9104, USA
| | - Sawona Biswas
- Division of Human Genetics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Barbara A Bernhardt
- Translational Medicine & Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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Biesecker BB, Woolford SW, Klein WMP, Brothers KB, Umstead KL, Lewis KL, Biesecker LG, Han PKJ. PUGS: A novel scale to assess perceptions of uncertainties in genome sequencing. Clin Genet 2017; 92:172-179. [PMID: 27925165 PMCID: PMC5462880 DOI: 10.1111/cge.12949] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 01/25/2023]
Abstract
Expectations of results from genome sequencing by end users are influenced by perceptions of uncertainty. This study aimed to assess uncertainties about sequencing by developing, evaluating, and implementing a novel scale. The Perceptions of Uncertainties in Genome Sequencing (PUGS) scale comprised ten items to assess uncertainties within three domains: clinical, affective, and evaluative. Participants (n=535) from the ClinSeq® NIH sequencing study completed a baseline survey that included the PUGS; responses (mean = 3.4/5, SD=0.58) suggested modest perceptions of certainty. A confirmatory factor analysis identified factor loadings that led to elimination of two items. A revised eight-item PUGS scale was used to test correlations with perceived ambiguity (r = -0.303, p < 0.001), attitudinal ambivalence (r = -0.111, p = 0.011), and ambiguity aversion (r = -0.093, p = 0.033). Results support nomological validity. A correlation with the MICRA uncertainty subscale was found among 175 cohort participants who had received results (r = -0.335, p < 0.001). Convergent and discriminant validity were also satisfied in a second sample of 208 parents from the HudsonAlpha CSER Project who completed the PUGS (mean = 3.4/5, SD = 0.72), and configural invariance was supported across the two datasets. As such, the PUGS is a promising scale for evaluating perceived uncertainties in genome sequencing, which can inform interventions to help patients form realistic expectations of these uncertainties.
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Affiliation(s)
- Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | | | - William MP Klein
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Kyle B Brothers
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky 40202
| | - Kendall L Umstead
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Katie L Lewis
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Leslie G Biesecker
- Medical Genomics and Metabolic Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Paul KJ Han
- Maine Medical Center Research Institute, Center for Outcomes Research and Evaluation, 81 Research Dr Scarborough, ME 04074
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Taber JM, Klein WMP, Lewis KL, Johnston JJ, Biesecker LG, Biesecker BB. Reactions to clinical reinterpretation of a gene variant by participants in a sequencing study. Genet Med 2017; 20:337-345. [PMID: 28771245 PMCID: PMC6611163 DOI: 10.1038/gim.2017.88] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/08/2017] [Indexed: 01/18/2023] Open
Abstract
PurposeAs genome science advances, people receiving personalized genetic information may receive reinterpretations of pathogenicity. Little is known about responses to adjusted results. We examined how reinterpretations might affect attitudes about genetic testing and intentions to share results with family.MethodsData were collected from high-socioeconomic-status participants (n = 58) in a genome sequencing study. Twenty-nine originally learned they were carriers of Duarte variant galactosemia, based on a variant that was reclassified as benign. Positive testers (n = 19) had a newly identified causative variant and remained carriers. Negative testers (n = 10) learned they were no longer carriers. Twenty-nine controls were carriers for a disease of comparable severity with no reclassification. Participants completed baseline, immediate, and 3-month follow-up surveys.ResultsApproximately 80% of participants demonstrated complete or partially accurate recall of their results and reported positive or neutral reactions to their result and about genetic information more generally. Positive testers reported lower intentions to share the change in their result with family. Controls reported the lowest intentions to learn future results. There were no significant group differences or changes over time in perceived ambiguity or negative emotions.ConclusionThe results suggest that high-socioeconomic-status participants understand reinterpretations conferring a neutral change or a change from carrier to noncarrier status. Participants' responses to changes in carrier results for a low-risk condition indicated minimal adverse effects.
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Affiliation(s)
- Jennifer M Taber
- Department of Psychological Sciences, Kent State University, Kent, Ohio, USA
| | - William M P Klein
- Behavioral Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - Katie L Lewis
- National Human Genome Research Institute, Bethesda, Maryland, USA
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