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Erickson CM, Clark LR, Ketchum FB, Chin NA, Gleason CE, Largent EA. Implications of preclinical Alzheimer's disease biomarker disclosure for US policy and society. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2022; 14:e12339. [PMID: 36035626 PMCID: PMC9405485 DOI: 10.1002/dad2.12339] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/16/2022] [Accepted: 06/08/2022] [Indexed: 01/25/2023]
Abstract
Disclosure of Alzheimer's disease (AD) biomarkers to cognitively unimpaired adults are currently conducted only in research settings. Yet, US Food and Drug Administration approval of a disease-modifying treatment for symptomatic individuals, improved understanding of the "preclinical" phase of disease, and advancements toward more accessible biomarker tests suggest such disclosure will increase in frequency, eventually becoming routine in clinical practice. The changing landscape in AD research to focus on biomarkers has generated debate on the validity and clinical utility of disclosure to cognitively unimpaired adults. This article explores the broader social implications of more widespread AD biomarker disclosure-that is, of individuals learning their risk for developing dementia caused by AD. We identify 10 challenges and offer preliminary solutions. As the field continues to evolve, it is essential to anticipate and address these broader ethical, legal, and social implications of disclosure.
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Affiliation(s)
- Claire M. Erickson
- Neuroscience & Public Policy ProgramUniversity of Wisconsin‐Madison Schoolof Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterDepartment of MedicineDivision of Geriatrics & GerontologyUniversity of Wisconsin‐Madison School of Medicine & Public HealthMadisonWisconsinUSA
| | - Lindsay R. Clark
- Wisconsin Alzheimer's Disease Research CenterDepartment of MedicineDivision of Geriatrics & GerontologyUniversity of Wisconsin‐Madison School of Medicine & Public HealthMadisonWisconsinUSA
- Geriatric Research Education & Clinical CenterWilliam S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Fred B. Ketchum
- Department of NeurologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Nathaniel A. Chin
- Wisconsin Alzheimer's Disease Research CenterDepartment of MedicineDivision of Geriatrics & GerontologyUniversity of Wisconsin‐Madison School of Medicine & Public HealthMadisonWisconsinUSA
| | - Carey E. Gleason
- Wisconsin Alzheimer's Disease Research CenterDepartment of MedicineDivision of Geriatrics & GerontologyUniversity of Wisconsin‐Madison School of Medicine & Public HealthMadisonWisconsinUSA
- Geriatric Research Education & Clinical CenterWilliam S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Emily A. Largent
- Department of Medical Ethics and Health PolicyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
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van der Schaar J, Visser LNC, Bouwman FH, Ket JCF, Scheltens P, Bredenoord AL, van der Flier WM. Considerations regarding a diagnosis of Alzheimer's disease before dementia: a systematic review. Alzheimers Res Ther 2022; 14:31. [PMID: 35144684 PMCID: PMC8829985 DOI: 10.1186/s13195-022-00971-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The NIA-AA research framework proposes a purely biological definition of Alzheimer's disease (AD). This implies that AD can be diagnosed based on biomarker abnormalities, irrespective of clinical manifestation. While this brings opportunities, it also raises challenges. We aimed to provide an overview of considerations regarding the disclosure of AD pathology before the onset of dementia. METHODS A systematic literature review was conducted and reported according to PRISMA guidelines. We searched PubMed, Embase, APA PsycINFO, and Web of Science Core Collection (on 10 December 2020) for references on conveying AD biomarker results to individuals without dementia. Our query combined variations on the terms Alzheimer's disease, disclosure, or diagnosis, preclinical or prodromal, and biomarkers. Two reviewers independently screened the resulting 6860 titles and abstracts for eligibility and examined 162 full-text records for relevance. We included theoretical articles in English, on communicating amyloid and/or tau results to individuals with mild cognitive impairment, subjective cognitive decline, or normal cognition. MAXQDA-software was used for inductive data analysis. RESULTS We included 27 publications. From these, we extracted 26 unique considerations, which we grouped according to their primary relevance to a clinical, personal, or societal context. Clinical considerations included (lack of) validity, utility, and disclosure protocols. Personal considerations covered psychological and behavioral implications, as well as the right to (not) know. Finally, societal considerations comprised the risk of misconception, stigmatization, and discrimination. Overall, views were heterogeneous and often contradictory, with emphasis on harmful effects. CONCLUSIONS We found 26 diverse and opposing considerations, related to a clinical, personal, or societal context, which are relevant to diagnosing AD before dementia. The theoretical literature tended to focus on adverse impact and rely on common morality, while the motivation for and implications of biomarker testing are deeply personal. Our findings provide a starting point for clinicians to discuss biomarker-based diagnosis with their patients, which will become even more relevant in light of the conditional approval of a first disease-modifying drug for AD.
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Affiliation(s)
- Jetske van der Schaar
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands.
| | - Leonie N C Visser
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Femke H Bouwman
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | | | - Philip Scheltens
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wiesje M van der Flier
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
- Department of Epidemiology & Data Sciences, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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Joly Y, Dupras C, Pinkesz M, Tovino SA, Rothstein MA. Looking Beyond GINA: Policy Approaches to Address Genetic Discrimination. Annu Rev Genomics Hum Genet 2020; 21:491-507. [DOI: 10.1146/annurev-genom-111119-011436] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Concerns about genetic discrimination (GD) often surface when discussing research and innovation in genetics. Over recent decades, countries around the world have attempted to address GD using various policy measures. In this article, we survey these approaches and provide a critical commentary on their advantages and disadvantages. Our examination begins with regions featuring extensive policy-making activities (North America and Europe), followed by regions with moderate policy-making activities (Australia, Asia, and South America) and regions with minimal policy-making activities (the Middle East and Africa). Our analysis then turns to emerging issues regarding genetic testing and GD, including the expansion of multiomics sciences and direct-to-consumer genetic tests outside the health context. We additionally survey the shortcomings of current normative approaches addressing GD. Finally, we conclude by highlighting the evolving nature of GD and the need for more innovative policy-making in this area.
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Affiliation(s)
- Yann Joly
- Centre of Genomics and Policy, McGill University, Montreal, Quebec H3A 0G1, Canada
| | - Charles Dupras
- Centre of Genomics and Policy, McGill University, Montreal, Quebec H3A 0G1, Canada
| | - Miriam Pinkesz
- Centre of Genomics and Policy, McGill University, Montreal, Quebec H3A 0G1, Canada
| | - Stacey A. Tovino
- William S. Boyd School of Law, University of Nevada, Las Vegas, Nevada 89154, USA
| | - Mark A. Rothstein
- Brandeis School of Law and School of Medicine, University of Louisville, Louisville, Kentucky 40202, USA
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