damien bruno - victorian clinical genetics services - genomics and pre-natal screening
DESCRIPTION
Damien Bruno delivered the presentation at the 2014 Genomics in Healthcare Conference. The Genomics in Healthcare Conference 2014 explored the current uses of genomics and forecast the potential for the discipline. Supported by the Garvan Institute of Medical Research who aim to further the use of genomic information in healthcare, the conference covered the policy, economics, legal and social aspects of genomics. For more information about the event, please visit: http://bit.ly/genomics14TRANSCRIPT
Genomics and pre-natal screening
Damien Bruno PhD
Translational Genomics Unit Head &
Deputy Laboratory Director
VCGS
Australian Bureau of Statistics
Genomics and Perinatal Care. Bodurtha et al. NEJM 2012
• Broadening indications (….-> whole genome)
• Greater complexity (options, choices, informed consent, parental anxiety, commercial interests)
• Increasing diagnostic accuracy
• Acceptance into clinical practice • Professional guidelines and best practice lagging behind uptake• Delay in access to public funding (equity of access issue)
Into the maelstrom
Blood Tests Invasive (samplefetus with needle!)
Spectrum of Prenatal Tests
2.56 Mb deletion 22q11.21arr 22q11.21(17,224,632-19,792,353)x1(DiGeorge / Velocardiofacial syndromes)
FISH: 22q11.2 deletion
del(22)(q11.2q11.2)
• truncus arteriosus (CVS)
1.7 Mb deletion 2q13[hg19] arr 2q13(111,395,603-113,093,928)x1
Rare deletion, de novo, absence of any published clinico-genotype correlations
Issues/Complexities:
- Variants of unknown or uncertain significance- Incidental findings- Consanguinity- Late onset conditions - Informed consent - Targeted vs genome-wide arrays (platform vs analysis)
Clinical Adoption in Australia:
- Available through a small number of providers - Major fetal structural abnormalities, replacement test whenpatient opts for invasive procedure, parental anxiety - Access to Medicare rebate + patient fee
Prenatal Microarrays
Illumina
How is this even possible?
Taken from Bianchi Nat Med 2012
New, Cutting Edge Technology
Ultrasound PracticesPublic Hospitals (Genetics)e.g. PathWest
Commercial Landscape
Medicare Funding for NIPT
- it is now on the agenda!
“Prospective, publicly-funded studies assessing the
cost-effectiveness of various screening strategies should
be performed as a matter of urgency”
While NIPT has lived up to many of its promises,
its appropriate integration with ultrasound (and
first trimester screening) is still evolving Hui et al, Ultrasound Obstet Gynecol. 2014 Oct 17.
BENEFITS OF NIPT
• Less women having invasive tests
• Test earlier in pregnancy
• No risk of miscarriage
• Detects the most common trisomies
• Higher detection sensitivity and lower false positive rates than MSS
LIMITATIONS
• NOT DIAGNOSTIC. IT IS ADVANCED SCREENING
• TEST FAILURE RATES (low fetal fractions)
• PPV (high risk results)
- Confirmatory testing needed
• False negatives do occur
MOVING TARGETS
• Total cost, out of pocket cost ($)
• TATs
• Australian laboratory provider (NATA accreditation)
• Medicare reimbursement
• Changing technology
• Broadening indications
THE NEXT WAVE
FUTURE DIRECTIONS
• Move to nth generational sequencing (NGS, single molecule seq.)
• Move to whole genome or genome/exome-wide analysis
• Greater complexity in terms of choices for patients, informed consent, result interpretation, pathology funding and clinical decision making
similar as for other applications of genomics but exacerbated due to time
constraints, parental anxiety, irreversible medical intervention
Thank You