Enhanced Prenatal Screening Program University Hospitals MacDonald Women’s Hospital 2012

Background Since 2007, we have been offering first trimester screening through our First Check program Pros: Allows risk assessment during first trimester Does not require 2nd blood draw in 2nd trimester for full risk assessment Cons: Lower detection rates when compared to screening tests that incorporate 2nd trimester analytes Many women who screen positive on First Check may undergo invasive tests unnecessarily Currently, women get blood drawn & NT measurement on same day

Enhanced Screening By combining 1st trimester & 2nd trimester information, we can provide improved detection rates & decrease false positive rates for Down syndrome We will be implementing a contingency screening program; the second trimester blood draw depends on the first check risk We will also be offering Instant First Check which will expedite reporting of results and allow immediate counseling which improves patient convenience and lessens anxiety

Instant First Check Blood is collected in the practitioners’ office or in the lab from 9-13 weeks Patient is scheduled for an ultrasound at least 1 week after the blood draw between 11 4/7 – 14 weeks Genetic counselor is available on site (sites will rotate) to give the patient instant results

First Check Blood Draw Requisition Enter Referring MD name Complete patient information (patient can do) Check first box and fill in ultrasound date if known Complete insurance information (patient can do)

Nuchal Translucency Schedule patient for “Nuchal Translucency for Instant First Check” Please make sure that patient or whoever is scheduling tells the Imaging Schedulers that patient has already had blood drawn for First Check After NT is obtained, patient will be sent to Genetic Counselor where NT measurement will be entered with blood test results Results will be discussed with patient at that time in person If a genetic counselor is not present at that site, the genetic counselor will call the patient later in the day

“Traditional First Check” If patient is approaching 13 weeks, it is recommended to have a “traditional” First Check drawn Will allow for patient to still have early screening Patient presents to Imaging and NT will be obtained and blood drawn same day No instant First Check Results reported out by providers office Providers office must determine level of risk and need for further testing Genetics staff available for questions at 216-286-6759 Genetics staff will call patients for all abnormal results > 1/270 risk

Contingency Screening First Check risk for DS* > 1 in 65 Patient offered diagnostic testing (CVS or amnio) First Check risk for DS < 1 in 2000 Patient will not be offered further screening First Check risk for DS between 1/66 - 1/2000 Patient will be offered second trimester screening to help stratify into high risk vs. low risk groups AFP, uE3, hCG, inhibin A will be incorporated with NT & PAPP-A Increases detection rate for DS & lowers false positive rate If second trimester risk yields > 1 in 270 risk for DS, patient will be offered diagnostic testing (amnio) *DS = Trisomy 21

Ordering Second Trimester Component Fully complete this requisition for second part of contingency screen

QUAD CHECK Will still be offered for those who miss a first check DO NOT send a second trimester blood draw for contingency screening as a Quad check. This will increase the false positive rate Abnormal results, > 1/270 risk, will be called to the genetic counselors who will call patient and notify provider of the plan

Benefits of Contingency Screening 30% of patients will proceed to second trimester testing Increases detection rate to ~95% & reduces false positive rate to 3% for trisomy 21 70% of patients will not need a second trimester blood test with no change in the detection rate First trimester screening alone has 80-90% detection rate & 5% false positive rate for trisomy 21

New Prenatal Screening Option

Non-Invasive Prenatal Testing Detects cell-free fetal DNA in maternal serum Uses mass-parallel sequencing to amplify fetal DNA in order to perform genetic testing Currently reporting out increases in fetal DNA for chromosomes 13, 18 and 21 It is possible that lab will notify us if other numerical chromosome differences are detected In the future, it is possible that applications and reporting will expand

Non-Invasive Prenatal Testing (NIPT) Has only been validated in high risk women Advanced maternal age, abnormal maternal serum screens, previous trisomy, ultrasound markers or findings Requires genetic counseling prior to ordering Maternal blood draw from 10-23 weeks of pregnancy Laboratories report out if aneuploidy is detected for trisomies 13, 18, and 21 Results take 8-10 days If positive, CVS or amnio is recommended for confirmation of finding <1% of samples will not have enough fetal DNA to test Another sample will be required

verifi® NIPT Facts Sensitivity Trisomy 21 ~99.9% Trisomy 18 97.8% 78.6% Specificity Trisomy 21 100% Trisomy 18 Trisomy 13 sensitivity = ability to correctly identify positive case specificity = ability to correctly identify negative case

Costs of NIPT Given this is a newer test, it is unknown which insurance companies are currently covering NIPT We encourage submission to insurance so that insurance companies recognize that this testing is being elected Test is $1700 Patient Assistance Program can be applied for & patient is responsible for $495 Patients with Medicaid will be accepted & there will be no charge to these patients

NIPT NIPT will be offered to any high risk patient who would normally be offered invasive testing During genetic counseling, this will become a standard offering when discussing screening options When there are time constraints for reproductive decision making, this may not be the most appropriate test given the 8-10 day turnaround & need for confirmational testing

Putting this all into practice Getting Started Putting this all into practice

Supplies We will provide each practice with requisition materials to get started Once that supply runs out, it is the office’s responsibility to maintain supplies Call NTDLabs to get additional First Check cards (631-425-0800) Make sure you ask for cards with Physician Code #5367 Contingency requisition can be photocopied as needed or ordered( with #5367 physician code) All blood samples need to be routed through the Center for Human Genetics Laboratory 983-1134 New brochures that explain all options forthcoming

Resources For completion of First Check card: http://www.perkinelmer.com/content/flashFiles/DBS_Card/player.html Questions: Jane Corteville, M.D. pager 36820*, office 216-844-3787 jane.corteville@uhhospitals.org Leslie Cohen, M.S. leslie.cohen@uhhospitals.org Cisco phone 216-286-6759, office- 844-7213 pager- 36590* *Pager main line: 216-207-7243