Issues in genetic testing for ultra-rare diseases: background and introductionLedbetter, David H; Faucett, W Andrew
doi: 10.1097/GIM.0b013e3181729d99pmid: 18496027
Since 1994, at least three national advisory committees have addressed issues involving access to high-quality genetic testing for ultra-rare genetic diseases. These included the Institute of Medicine (1994), a National Institutes of Health-Department of Energy Task Force on Genetic Testing (1997), and the Secretary's Advisory Committee on Genetic Testing (2000). All identified the limited availability of high-quality testing for these rare diseases as a very high priority and a number of recommendations to improve access were made. However, little systematic progress was made as a direct result of these committee recommendations. Beginning in 2004, a series of national workshops on “Quality Laboratory Testing for Rare Diseases” was organized by a group of clinical laboratory directors experienced in rare disease testing working with the Centers for Disease Control and the Office of Rare Diseases at National Institutes of Health. These meetings included broad-based community involvement, with stakeholders from appropriate federal agencies, professional societies, patient advocacy groups as well as clinical geneticists and clinical genetics laboratory experts. Two successful outcomes of these workshops were the formation of a National Laboratory Network for Rare Disease Testing and a National Institutes of Health-funded program to aid in the translation of new genetic tests from research laboratories to Clinical Laboratory Improvement Amendments-certified diagnostic laboratories known as the Collaboration and Education in Test Translation program. This article briefly reviews the history and current status of genetic testing for ultra-rare genetic diseases in the United States, with a primary focus on molecular genetic testing by DNA sequencing. Other articles in this series provide more detailed reports on the significant progress in improving access to quality genetic testing for rare diseases within the last few years.
Gene patenting and licensing: the role of academic researchers and advocacy groupsLedbetter, David H
doi: 10.1097/GIM.0b013e3181729dabpmid: 18496028
The subject of human gene patenting has received a great deal of media attention, and many individuals and professional societies (including the American College of Medical Genetics) have voiced strong opinions against the patenting of human genes. A particular concern of the medical genetics community is the impact of gene patenting on accessibility to high-quality genetic testing. There has been significantly less media attention and public discussion of licensing practices (e.g., exclusive versus nonexclusive) and their role in promoting or limiting access to genetic testing. Current US government policy strongly encourages universities to commercialize inventions funded by federal grants (Bayh-Dole Act, 1980). Best Practice models for technology licensing have recently been developed by the National Institutes of Health and by the Association of University Technology Managers, and strongly encourage nonexclusive licensing strategies except in cases where this model will not lead to successful commercialization. In the case of genetic testing, nonexclusive licensing strategies (e.g., CF gene) have the significant advantages of encouraging multiple laboratories to make the test readily available, encouraging test improvement, and creating cost-competition. Individual investigators involved in gene discovery, and patient advocacy groups collaborating with academic investigators, have the opportunity to influence the accessibility of diagnostic testing by strongly encouraging their institutions to follow the National Institutes of Health and Association of University Technology Managers Best Practice models of nonexclusive licensing for diagnostic rights to human gene patents.
Developing a national collaborative study system for rare genetic diseasesWatson, Michael S; Epstein, Charles; Howell, R Rodney; Jones, Marilyn C; Korf, Bruce R; McCabe, Edward R B; Simpson, Joe Leigh
doi: 10.1097/GIM.0b013e31817b80fdpmid: 18496030
There are thousands of rare genetic diseases and many genetic and nongenetic contributors to common genetic diseases. The evidence base that is currently available about the great majority of these conditions is limited to case studies and relatively small observational study sets derived from one or several institutions. Hence, the statistical power in any one study is usually quite limited. Further, in the absence of organized registries and data collection on particular patient groups, the information available is weak and the patient resources that are available are limited. It is only through organized and coordinated clinical investigation systems that a sufficient number of patients with these diseases can be accumulated to provide the statistical power needed to inform about clinical history of treated and untreated forms, provide the resources needed for clinical trials of new tests and treatments, provide a sufficiently powered evidence base for public health decision-making and other uses. The meeting in which these issues were raised resulted in a set of proposed principles and associated recommendations as to how best to achieve the vision of creating an extensive and comprehensive collaboration of professional and lay communities to enable translational research to improve clinical care and therapies for persons with rare genetic diseases.
Molecular genetic testing for ultra rare diseases: models for translation from the research laboratory to the CLIA-certified diagnostic laboratoryDas, S; Bale, Sherri J; Ledbetter, David H
doi: 10.1097/GIM.0b013e318172838dpmid: 18496031
Although the pace of gene discovery for rare genetic diseases has accelerated during the past decade, in part, due to the success of the Human Genome Project, translation of these discoveries to clinical utility has lagged behind. In particular, identification of the gene responsible for a Mendelian disorder immediately presents the opportunity for molecular genetics diagnostics to confirm clinical diagnoses, provide accurate genetic counseling information and recurrence risks, as well as carrier testing and prenatal diagnosis opportunities for families. To move these discoveries from a research setting to clinical utility, we describe two successful models for partnerships between research laboratories with Clinical Laboratory Improvement Amendments-certified clinical molecular diagnostic laboratories. Contrary to common misconceptions, molecular genetic testing for very rare diseases can be performed in a high-quality clinical setting in a financially self-sustaining or even profitable manner. Key elements to the success of these models include a Clinical Laboratory Improvement Act-certified diagnostic laboratory with a commitment to very rare genetic disease testing, active involvement of genetic counselors and clinical geneticists, and partnerships with research experts and patient support groups specific to each disease.
Molecular testing: improving patient care through partnering with laboratory genetic counselorsScacheri, Cheryl; Redman, Joy B; Pike-Buchanan, Lisa; Steenblock, Kelle
doi: 10.1097/GIM.0b013e31817283a5pmid: 18496032
The utility of molecular diagnostics in clinical practice has been steadily increasing and is expected to continue to do so as the applications of genomic medicine increase. The goal of this article was to describe the roles and responsibilities of genetic counselors who work in the customer service area of molecular diagnostics laboratories. In this role, genetic counselors provide recommendations to clinicians on issues that are specific to DNA-based testing. This article will address some issues that are specifically relevant to disease genetic tests. Many molecular diagnostic laboratories employ genetic counselors, who have extensive training in how to communicate genetic information, to provide information in the preanalytic, analytic, and postanalytic stages of testing. To maximize the quality of the service, it is important to establish an understanding of what can be expected of both the practitioner and the laboratory genetic counselor. Although some complications in the laboratory cannot be anticipated, discussing the case with the laboratory genetic counselors beforehand may avert certain problems. This article discusses real cases from laboratory genetic counselors to illustrate issues that arise due to technical difficulties and the inherent limitations of molecular testing. The summary describes practical ways in which clinicians and laboratory personnel can work together to either avoid or, when unavoidable, better manage problems and delays. The responsibilities of genetic counselors working in molecular diagnostics are discussed.
A model program to increase translation of rare disease genetic tests: collaboration, education, and test translation programFaucett, William Andrew; Hart, Suzanne; Pagon, Roberta A; Neall, Lisa Forman; Spinella, Giovanna
doi: 10.1097/GIM.0b013e318172837cpmid: 18496033
In 2006, The National Institutes of Health Office of Rare Diseases announced the Collaboration, Education, and Test Translation (CETT) Program, a pilot project to increase and improve the translation of genetic tests for rare diseases from research laboratories to clinical laboratories. The CETT Program created a new paradigm in which applicants must form a collaborative group consisting of a clinical laboratory, researcher, research laboratory, clinical expert, and disease-specific advocacy group. In addition, each collaborative group must assure that test results are written in a style and format appropriate for nonexpert clinicians; provide educational materials for clinicians and patients about the disease, as well as the use and limitations of the test in the care of persons with the disease; agree to collect clinical data necessary for test result interpretation; and store genotype information and clinical data in a publicly accessible deidentified database.