ECS, UM, Braga Postgrad. Course on NGS 12/5/2013 Jorge Sequeiros 1 Next Generation Sequencing in Diagnosis: do we need a next-generation ethics? Jorge Sequeiros ICBAS e IBMC, Univ. Porto IV Jornada sobre EnfermedadesGenéticas y Discapicidad Barcelona, 3 octubre 2013
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Next Generation Sequencing in DiagnosisMEDICAL APPLICATIONS BIOMEDICAL RESEARCH basic research clinical research PUBLIC HEALTH GENETICS population genetic screening CLINICAL GENETICS
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ECS, UM, Braga Postgrad. Course on NGS 12/5/2013
Jorge Sequeiros 1
Next Generation Sequencing in Diagnosis:
do we need a next-generation ethics?
Jorge Sequeiros
ICBAS e IBMC, Univ. Porto
IV Jornada sobre
Enfermedades Genéticas y Discapicidad
Barcelona, 3 octubre 2013
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Jorge Sequeiros 2
Centre for Predictive and Preventive Geneticswww.cgpp.eu
HeLa cells• Cervix cancer, Jan. 1951• Cells taken without her knowledge• 1st cell line immortalized in vitro• The most used ever• Initials of “Helen Lane” and “Helen Larson”• Name of Henrietta Lacks disclosed in 1971
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� More cells in circulation than during life� Many important discoveries:
• Anti-polio vaccine (Jonas Salk, 50’s)• Effects of zero gravity in space• Correct human chromosome number• >60,000 scientific articles• Contribution for ENCODE• Pharmacological assays
� Multimilionary businesses � Some protests from her family
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The director of the US National Institutes of Health
(NIH), Francis Collins met Lacks family members to
discuss what should be done with genome data
from their matriarch’s cell line.
On 8 August, Kate Hudson and F. Collins announced
that the family has endorsed case-by-case release of
the information, subject to approval by a committee
that will include family members.
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BLURRING OF THE DIFFERENCE
BETWEEN
RESEARCH AND HEALTH CARE
Conclusion 2.
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3. NGS in health care
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GWAs• GWA studies identify genetic variants with small effects• Need to validate findings and establish clinical relevance
• Insufficient evidence that genomic profiling is useful in measuring individual risks for common diseases, or developing personalised diet or lifestyle recommendations for disease prevention (Janssens et al., Am J Hum Genet 2008; 82: 593-599)
• Only 2 out of 5 genes in ‘osteogenomic profiles’ were significantly associated with some disease, but none with bone disease (Janssens et al., Am J Hum Genet 2008; 82: 593-599)
• This genetic astrology regarded as producing no more than entertaining horoscopes;potential for harm and need to ensure these tests are evaluated and used appropriately (Melzer et al., BMJ 2008; 336: 590-593)
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DTC
genetic testing
• direct-to-consumer (DTC) testing: • over the counter
• over the web
• marketing strategies (bypassing health professionals)
• override medical indications
• suppress prior information and genetic counselling
OTHER MEDICAL APPLICATIONS ART: � pre-implantation genetic screening (aneuploidy screening)
Drug treatment: � pharmacogenetics testing (adverse drug reactions, drug efficacy)
Somatic Cancer prognosis: � testing for somatic mutations in cancer
Modified from:Sequeiros J (2010): Regulating Genetic Testing: the relevance of appropriate definitions. Ch.3. In: Kristoffersson U, Schmidtke J, Cassiman JJ (Eds): Quality Issues in Clinical Genetic Services, Springer (ISBN: 978-90-481-3918-7).
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Table 3. Context definitions of “genetics laboratory-based testing” and “genetic information”
GENETIC INFORMATION
Genetics laboratory-based testing:
Cytogenetics tests (chromosomal-based) – identification of numerical or structural anomalies of individual chromosomes or chromosomal complement
Molecular genetics tests (DNA or RNA-based) – identification at the nucleic acid level of sequence alterations in the DNA molecule and its functional significance, and epigenetic (non-covalent) changes
Biochemical genetics tests (proteins, metabolites) – identification at the protein level of sequence alterations in the DNA molecule and its functional significance
Other sources of genetic information:
Family history
Personal history and physical examination
Other laboratory exams (haematological, biochemical, physiological, image, functional) exams
Sequeiros J (2010): Regulating Genetic Testing: the relevance of appropriate definitions. Ch.3. In: Kristoffersson U, Schmidtke J, Cassiman JJ (Eds): Quality Issues in Clinical Genetic Services, Springer (ISBN: 978-90-481-3918-7).
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(1) Analysis of genetic material
(2) Genetic information
Two consensus definitions?
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Ethical concerns
• counselling of persons at-risk for Huntington disease since the mid 80s
• fears of genetic determinism surrounding the human genome project and the ELSIdiscussion
• genetic antidiscrimination laws enacted in the USA, in the early 90s
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Genetic information
• Personal
• Familial
• Powerful
• Permanent
• Highly predictive
• Potentially discriminatory
unlike
a blood count
or glucose
unlike
cholesterol,
or “pedigree”
In the case of high penetrance
monogenic diseases
HGP
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Compelling to exorcize
genetic exceptionalism
• in these modern times of sophisticated, high-throughput technologies, many policy documents began by clearly dismissing it
• many came to embrace “genetic inclusivism”• some adding their rationale was that all medical
information needs much better protection
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25%
12.5%
25%
25%12.5%12.5%
50%50%
João
PKD
50%
50% 50%
25%25% 25%
Mara
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Specificity of genetic information
• The diagnosis of a genetic disease may change the risk for relatives (who are not examined or tested and may never want to be!)
• The major aim may be “non-medical”(diagnosis, treatment or prevention of disease), but
life decisions (e.g., reproductive choices, education, profession, change life styles)
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PKDpolycystic kidney disease
• fluid-filled cysts• blood in the urine• edoema• renal failure• dyalysis• transplant
• Guidelines for testing and counselling• Quality assurance
• Data-protection• Antidiscrimination legislation
(insurance, employement, adoption)
• Clinical validity and utility of MGTs
• Verification• Sanctions
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Genetic testing
Components:
� Information, consent, preparation
� Laboratory assay
� Interpretation, support
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• Genetic counselling and psychosocial evaluation before and support after testing!
Presymptomatic testing
for late-onset incurable diseases
Candidates for
a presymptomatic test
register for counselling,
not for a mere blood test!
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PST Protocol
Written
Report
Neurological
Evaluation
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Children and adolescents
• Should not be tested for late-onset,
incurable diseases!
• Loss of autonomy
• Discrimination
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Susceptibility testing
• Common diseases - complex inheritance, i.e., mostly multifactorial, but also with a monogenic fraction (≈5%)
� many genes involved
� many non-genetic factors
• but, each with a very limited impact …!
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• professional enthusiasm (clinicians, scientists)
• urgent application to human health
• common diseases � commercial pressure(labs, biotechnology, insurance)
Susceptibility testing
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Susceptibility testing
Limitations:
• only small change in relative risk
• population diversity•
• analytical and clinical validity
• doubtful benefits for populationscreening
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Types of genetics tests
In the newborn, child, adult:
• Diagnostic testing• Presymptomatic testing (AD)
• Carrier testing (AR, XR)
• Susceptibility testing (multifactorial)
• Pharmacogenetics testing
In the foetus or embryo:
• Prenatal diagnosis• Pre-implantation diagnosis
In the population or populational group risk:
• Genetic screening
Predictivetesting
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BLURRING OF THE DIFFERENCE
BETWEEN
PREDICTIVE AND DIAGNOSTIC TESTING
Conclusion 6.
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5. Ethical issues and dilemmas
with NGS
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Applications of NGS
1. Whole-genome sequencing
2. Whole-exome sequencing
vs.
3. Panels of genes (heterogenous
disorders)
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1. NGS – ethical issues about
testing for health care purposes
(1) Sequence all genome/exome (if cheaper than
testing half a dozen of genes or even a single gene)?
• answer only the clinical question?
• what to do with all that information?
• keep rest of info. for future, if further requests?
• destroy and repeat the WGS (once it is cheap)?
(2) Do only gene panels for known diseases
(filtering the required information)?
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(1) What should/can be reported and what must not to requesting physicians?
• only disease-causing variants?
• variants of unknown clinical significance?
• normal variants?
(2) What to communicate to a patient/healthy person? • everything found?
• incl. susceptibility variants of low predictive value?
• incl. variants with no or still undetermined clinical validity and utility?
• all pathogenic variants of current or future clinical relevance?
• only mutations for diseases with treatment or preventive measures?
• information about children?
(3) What process of informed consent (opt-in, opt-out)?
2. NGS – ethical issues about
reporting results in health care
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“Incidental findings”
• Once you perform a WGS/WES, you will
necessarily have “incidental” findings
• We should talk instead of unsolicited or
unrequested findings
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CLINICAL APPLICATIONS OF NGS STILL A
MATTER OF HOT ETHICAL DEBATE
Conclusion 7.
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ABSTRACT
• In clinical exome/genome sequencing, there is potential
for the recognition and reporting of incidental or
secondary findings unrelated to the indication for
ordering the sequencing but of medical value for
patient care
• We recommend that laboratories performing clinical
sequencing seek and report mutations of the specified
classes or types in the genes listed
• ... irrespective of age, but excluding fetal samples.
• We recognize that there are insufficient data on clinical
utility to fully support these recommendations
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Primary Finding
This term is used to describe
pathogenic alterations in a gene or
genes that are relevant to the
diagnostic indication for which the
sequencing was ordered (e.g., a
mutation in MECP2 in a girl with loss of
developmental milestones).
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Incidental Finding
This term has been used in a variety of clinical andresearch contexts to indicate unexpected positive findings. Other terms have been used to describethese findings, particularly when they are soughtafter (rather than being unexpectedly discovered). These terms include “serendipitous and iatrogenic” findings, “non-incidental secondary findings”“unanticipated findings”, and “off-target results”. We use “incidental findings” in this paper to indicate the results of a deliberate search for pathogenic or likely pathogenic alterations in genes that are not apparently relevant to a diagnostic indication for which the sequencing testwas ordered.
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RECOMMENDATIONS
1. Constitutional mutations found in the genes on the minimum
list (see Table) should be reported by the laboratory, regardless
of the indication for which the clinical sequencing was ordered.
a. Additional genes may be analyzed for incidental (secondary)
variants, as deemed appropriate by the laboratory.
b. Incidental (secondary) variants should be reported
regardless of the age of the patient.
c. Incidental (secondary) variants should be reported for any
clinical sequencing conducted on a constitutional (but not
tumor) tissue. This includes the normal sample of a tumor-
normal sequenced dyad and unaffected members of a family
trio.
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RECOMMENDATIONS
2. The Working Group recommends that laboratories seek and
report only the types of variants within these genes that we
have delineated (see Table).
a. For most genes, only variants that have been previously
reported and are a recognized cause of the disorder or variants
that are previously unreported but are of the type which is
expected to cause the disorder, as defined by prior ACMG
guidelines, should be reported.
b. For some genes, predicted loss of function variants are not
relevant (e.g., COL3A1 and most hypertrophic cardiomyopathy
genes).
c. For some genes (e.g., APOB), laboratories should only report
variants for certain conditions.
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RECOMMENDATIONS3. It is the responsibility of the ordering clinician/team to
provide comprehensive pre- and posttest counseling to
the patient.
a. Clinicians should be familiar with the basic attributes
and limitations of clinical sequencing.
b. Clinicians should alert patients to the possibility that
clinical sequencing may generate incidental findings that
could require further evaluation.
c. Given the complexity of genomic information, the
clinical geneticist should be consulted at the appropriate
time that may include ordering, interpreting, and
communicating genomic testing.
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• WGA requires a justification in terms of necessity (theneed to solve a clinical problem) and proportionality(the balance of benefits and drawbacks for the patient).
• In the clinical setting, preferable to use a targetedapproach first, to avoid unsolicited findings or findingsthat cannot be interpreted (limit the analysis to specificsets of genes).
• Known genetic variants with limited or no clinicalutility should be filtered out (if possible, neitheranalyzed nor reported).
Recommendations
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Additional Protocol concerning
Genetic Testing for Health Purposes
• genetic tests for health purposes should
only be carried out once their clinical
utility has been proven, and under
individualised medical supervision
7 May 2008
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• Protocol should be in place for guidance on thereporting of unsolicited findings
• Guidelines for informed consent regardingdiagnostic testing need be developed
• Clinicians should be aware and safeguard thepatient’s position in the potential crossoverwith research
Recommendations
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• In case of testing minors, guidelines are needed as to what unsolicited information should be disclosed, to balance autonomy and interests of the child andparental rights and needs for information that may bein the interest of the family
• International collaboration to build sustainabledatabases on genotypic and phenotypic information ofvariants
• Genetic education of health-care professionals
• Inform the public and raise public awareness, enhancegenetic literacy in patients and the lay public will help to involve wider society in this debate