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Disclosures Disclosures Disclosures Disclosures Genetic - - PDF document

6/24/2019 CONSUMER CONSUMER CONSUMER CONSUMER- - - -DIRECTED GENETIC TESTING DIRECTED GENETIC TESTING DIRECTED GENETIC TESTING DIRECTED GENETIC TESTING WHAT WHAT IT MEANS FOR MY PATIENT AND MY PRACTICE WHAT WHAT IT


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6/24/2019 1 CONSUMER CONSUMER CONSUMER CONSUMER-

  • DIRECTED GENETIC TESTING

DIRECTED GENETIC TESTING DIRECTED GENETIC TESTING DIRECTED GENETIC TESTING – – – – WHAT WHAT WHAT WHAT IT MEANS FOR MY PATIENT AND MY PRACTICE IT MEANS FOR MY PATIENT AND MY PRACTICE IT MEANS FOR MY PATIENT AND MY PRACTICE IT MEANS FOR MY PATIENT AND MY PRACTICE Jessica Baker, MSc, CGC Diane Salema, MSc, (C)CGC

Disclosures Disclosures Disclosures Disclosures

Genetic counsellors employed by PCRM

www.pacificfertility.ca 2

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Objectives Objectives Objectives Objectives

Understand the rise of consumer-directed genetic testing 2 Carrier screening and private pay testing 3 Resources for you and your patients 4

  • Limitations of negative results
  • Raw data analysis and false positives
  • Family secrets

1

www.pacificfertility.ca 3

What should you be aware of with direct-to-consumer (DTC) genetic testing?

4

Number of companies

  • ffering genetic tests

Consumer awareness Shift towards individualized medicine Cost Barriers to access genetic testing Turn around time

Private Pay Testing: What’s driving the market? Private Pay Testing: What’s driving the market? Private Pay Testing: What’s driving the market? Private Pay Testing: What’s driving the market?

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Current Model Gaps Current Model Gaps Current Model Gaps Current Model Gaps

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Direct Direct Direct Direct-

  • To

To To To-

  • Consumer (DTC) genetic testing

Consumer (DTC) genetic testing Consumer (DTC) genetic testing Consumer (DTC) genetic testing

www.pacificfertility.ca 6

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www.pacificfertility.ca 7

https://vitals.lifehacker.com/what-you-should-know-before-you-gift-someone-a-dna-test-1820774515

www.pacificfertility.ca 8

https://twitter.com/JenniferRaff/status/936209825364692992

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www.pacificfertility.ca 9

DTC Example: 23andMe DTC Example: 23andMe DTC Example: 23andMe DTC Example: 23andMe

Modified from https://www.23andme.com/en-ca/?fsp=true

www.pacificfertility.ca 10

23andMe Health Predisposition Panel 23andMe Health Predisposition Panel 23andMe Health Predisposition Panel 23andMe Health Predisposition Panel

Modified from https://www.23andme.com/en-ca/dna-health-ancestry/?fsp=true

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www.pacificfertility.ca 11

BRCA1/2 BRCA1/2 BRCA1/2 BRCA1/2

https://www.23andme.com/en-ca/brca/

www.pacificfertility.ca 12

BRCA1/2 BRCA1/2 BRCA1/2 BRCA1/2

https://www.23andme.com/en-ca/brca/

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6/24/2019 7 23andMe and other DTC genetic testing companies provide consumers with files of their raw genetic data. Up to 62% of consumers use third-party applications to interpret the raw data and provide health information not included in companies’ reports.1 A recent study suggests that 40% of genetic variations within DTC raw data sent for clinical confirmation are false positives.2 Common third party site: Promethease

www.pacificfertility.ca 13

Direct To Consumer Direct To Consumer Direct To Consumer Direct To Consumer -

  • Raw Sequencing Data

Raw Sequencing Data Raw Sequencing Data Raw Sequencing Data

  • 1. Wang C, Cahill TJ, Parlato A2, Wertz B, Zhong Q, Cunningham TN, Cummings JJ. Consumer use and response to online

third-party raw DNA interpretation services. Mol Genet Genomic Med. 2018;6:35–43.

  • 2. Tandy-Connor, S, Guiltinan, J, Krempely K et al. False-positive results released by direct-to-consumer genetic tests highlight

the importance of clinical confirmation testing for appropriate patient care. Genet Med 2018;1–7.

www.pacificfertility.ca 14

https://www.nytimes.com/2018/09/15/opinion/sunday/23andme-ancestry-alzheimers-genetic-testing.html

A promethease report from 23andMe raw data said he had a pathogenic PSEN1 mutation The PSEN1 mutation is associated with an early-onset form of Alzheimer’s, and it is

  • ften described as “100 percent penetrant”

Raw data used from Ancestry’s test did not identify the PSEN1 variant He eventually persuaded his doctor to order a clinical test of the PSEN1 gene. It was negative.

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www.pacificfertility.ca 15

Modified from https://www.23andme.com/en-ca/?fsp=true

www.pacificfertility.ca 16

Family Secrets Family Secrets Family Secrets Family Secrets

https://www.vox.com/2014/9/9/5975653/with-genetic-testing-i-gave-my-parents-the-gift-of-divorce-23andme

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6/24/2019 9 Non-paternity Adoption Anonymous sperm/egg donor Incest Infidelity Resource: Watershed DNA https://www.watersheddna.com/

www.pacificfertility.ca 17

Family Secrets Family Secrets Family Secrets Family Secrets

www.pacificfertility.ca 18

Modified from https://www.23andme.com/en-ca/?fsp=true

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www.pacificfertility.ca 19

Modified from https://www.23andme.com/en-ca/?fsp=true

www.pacificfertility.ca 20

Obligatory Genetics Review Obligatory Genetics Review Obligatory Genetics Review Obligatory Genetics Review

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www.pacificfertility.ca 21

46 chromosomes 46 chromosomes 46 chromosomes 46 chromosomes

Gene

www.pacificfertility.ca 22

Gene mutations Gene mutations Gene mutations Gene mutations

Source: https://www.pinclipart.com/maxpin/wRimhh/

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www.pacificfertility.ca 23

Autosomal Recessive Inheritance Autosomal Recessive Inheritance Autosomal Recessive Inheritance Autosomal Recessive Inheritance

www.pacificfertility.ca 24

Autosomal Recessive Autosomal Recessive Autosomal Recessive Autosomal Recessive I I I Inheritance nheritance nheritance nheritance

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6/24/2019 13 Most people carry at least a few recessive mutations

www.pacificfertility.ca 25

This is normal This is normal This is normal This is normal

www.pacificfertility.ca 26

SOGC SOGC SOGC SOGC-

  • CCMG Opinion

CCMG Opinion CCMG Opinion CCMG Opinion

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  • 1. A primary discussion about the value and risk of reproductive

carrier screening should be offered to all women/families

considering a pregnancy (pre-conception) and to all pregnant women at their first prenatal visit, regardless of gestational age at the time of presentation. (III-A) (GRADE low/moderate)

www.pacificfertility.ca 27

SOGC SOGC SOGC SOGC-

  • CCMG Opinion

CCMG Opinion CCMG Opinion CCMG Opinion

SOGC-CCMG: Direct-to-consumer or self-pay physician ordered carrier testing

Patients should be made aware prior to testing that access to formal genetic counselling may be limited As well, additional confirmatory testing may be required but access may be limited by local resources or availability of the test in accredited laboratories. Ideally, individuals or couples who have been identified to be “at risk” for the transmission of a clinically significant genetic condition to their offspring by their primary care giver should be referred in the pre-conception period to a reproductive medical genetic provider for education and discussion of the implications for the couple and their offspring. (III-A) (GRADE moderate/moderate)

www.pacificfertility.ca 28

SOGC SOGC SOGC SOGC-

  • CCMG Opinion

CCMG Opinion CCMG Opinion CCMG Opinion

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23andMe

Testing 29 variants Detection Rate Ashkenazi Jewish: 95% European: 89% Hispanic/Latino: 73% African American: 65% Asian: 55%

www.pacificfertility.ca 29

Example Example Example Example – – – – Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Clinical Lab

130 variants

  • N. European: 95%

Expanded Carrier Screen (Invitae)

Full gene sequencing (+del/dup) All ethnicities: 99%

www.pacificfertility.ca 30

Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis -

  • 23andMe report

23andMe report 23andMe report 23andMe report

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www.pacificfertility.ca 31

Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis Cystic Fibrosis – – – – Invitae Invitae Invitae Invitae report report report report

Autosomal recessive Polycystic Kidney Disease

European

Detection rate = 25% 1 in 70  1 in 93

Middle Eastern and Turkish

Detection rate = <1% 1 in 70  1 in 70

www.pacificfertility.ca 32

23andMe: AR 23andMe: AR 23andMe: AR 23andMe: AR-

  • PKD

PKD PKD PKD

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www.pacificfertility.ca 33

Expanded Panels Expanded Panels Expanded Panels Expanded Panels

www.pacificfertility.ca 34

Results Results Results Results

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2 out of 3 people are identified as a carrier of at least one condition1 ~2% (1/50) of couples are identified as both being carriers of the same condition1

www.pacificfertility.ca 35

Expanded carrier screen Expanded carrier screen Expanded carrier screen Expanded carrier screen stats stats stats stats

1. Fulgent Genetics internal data

Options Options Options Options

www.pacificfertility.ca 36

PGT-M Donor sperm or egg Prenatal diagnosis Nothing

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How do I order expanded carrier screening? How do I order expanded carrier screening? How do I order expanded carrier screening? How do I order expanded carrier screening?

Invitae – www.invitae.com

288-gene customizable panel*

Males: 267-gene panel (no X-linked disorders) +13 optional add-on genes

1st partner: $250 USD  ~$350 CAD 2nd partner: $100 US  ~140 CAD

www.pacificfertility.ca 37

*Note: does not include Congenital Adrenal Hyperplasia due to 21- hydroxylase deficiency Carrier freq = ~1:60

How do I order expanded carrier screening? How do I order expanded carrier screening? How do I order expanded carrier screening? How do I order expanded carrier screening?

Fulgent’s Beacon – www.fulgentgenetics.com

327-gene customizable panel

Males: 292-gene panel (no X-linked disorders) +9 optional add-on genes

$349 USD  ~475 CAD self-pay price $100 USD  $140 CAD for partner if samples sent at same time

www.pacificfertility.ca 38

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Services at PCRM Services at PCRM Services at PCRM Services at PCRM

Private Genetic Counselling - $250 CAD for couple

Preconception counselling Detailed family history assessment Review carrier screening options Review of prenatal screening options Pre- and post-test counselling with informed consent

Expanded Carrier Screening

Invitae - $500 CAD for 1st partner / $300 CAD for 2nd partner

Sample collection at PCRM Sample tracking Results delivery

Fulgent – cost TBD

www.pacificfertility.ca 39

Reproductive/preconception genetic counselling

Contact PCRM Genetic Counsellors directly at genetics@pacificfertility.ca or 604-422-7276

Private genetic counselling services (telehealth)

GeneMatters: https://www.gene-matters.com/ MyGeneTeam: https://www.mygeneteam.com/ Watershed DNA: https://www.watersheddna.com/

BRCA 1/2 genetic testing with counselling

LifeLabs Genetics The Screen Project

www.pacificfertility.ca 40

What other options are available? What other options are available? What other options are available? What other options are available?

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www.pacificfertility.ca 41

Women’s College Hospital, Toronto Women’s College Hospital, Toronto Women’s College Hospital, Toronto Women’s College Hospital, Toronto

The Screen Project is a Canadian National initiative to make BRCA1 & BRCA2 screening available to all Canadians over 18 years of age at an accessible price.

Podcasts:

Freakonomics Radio

Episode 378 (05/15/2019) - “23andMe (and You, and Everyone Else)”

The Beagle Has Landed

9/25/2018 – Interview with Matt Fender -23andMe raw data 10/09/2018 – Interview with Brianne Kirkpatrick of Watershed DNA 10/29/2018 – Interview with Sek Kathiresan on polygenic risks scores 04/11/2019 – Interview with Elissa Levin of Helix on the DTC sector

Articles:

Wired, “23andMe’s New Diabetes Test Has Experts Asking Who It’s For” (03/10/2019) The Atlantic, “When a DNA Test Shatters Your Identity” (07/18/2018) Ramos E, Weissman SM. The dawn of consumer-directed testing. Am J Med Genet Part C Semin Med Genet. 2018

GECKO - Genetics Education Canada - Knowledge Organization

www.pacificfertility.ca 42

Further reading and listening Further reading and listening Further reading and listening Further reading and listening

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6/24/2019 22 Questions?

www.pacificfertility.ca 43

Thank You Thank You Thank You Thank You

www.pacificfertility.ca 44

23andMe Health Predisposition Panel 23andMe Health Predisposition Panel 23andMe Health Predisposition Panel 23andMe Health Predisposition Panel

Modified from https://www.23andme.com/en-ca/dna-health-ancestry/?fsp=true

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6/24/2019 23 Polygenic risk scores (PRS) Self-generated data (2.5 million customers) Not FDA-approved Representation and ethnicity

www.pacificfertility.ca 45

Type 2 Diabetes Type 2 Diabetes Type 2 Diabetes Type 2 Diabetes