1. Private pay, physician ordered genetic testing Developed by Dr. Judith Allanson, Ms. Shawna Morrison and Dr. June Carroll Last updated November 2015

2. Disclaimer This presentation is for educational purposes only and should not be used as a substitute for clinical judgement. GEC-KO aims to aid the practicing clinician by providing informed opinions regarding genetic services that have been developed in a rigorous and evidence-based manner. Physicians must use their own clinical judgement in addition to published articles and the information presented herein. GEC-KO assumes no responsibility or liability resulting from the use of information contained herein.

3. Objectives Following this session the learner will be able to: – Refer to their local genetics centre and/or order genetic testing appropriately regarding private, physician ordered genetic testing – Discuss and address patient concerns regarding private, physician ordered genetic testing – Find high quality genomics educational resources appropriate for primary care

4. Case 1: Julie and Chris Julie and Chris are a healthy non- consanguineous newlywed couple – Both are 33yo – Julie is of French Canadian and Northern European ancestry – Chris is of German and English ancestry and he believes there may be some Ashkenazi Jewish ancestry

5. Case 1: Julie and Chris Julie and Chris are planning to start their family Julie’s cousin, Jean, is the same age and also recently married Jean lives in Boston, MA She was offered a family planning carrier screening panel which was partly covered by her health insurance Julie would also like to have this panel and understands that she would have to self-pay and needs you to order the test She has brought all the completed paperwork to you

6. Case 1: Julie and Chris

7. What is ethnicity-based carrier screening in Canada?

8. What is ethnicity-based screening in Canada?

10. Connect with your local genetics centre for more on your local population – E.g. French Canadian from Saguenay-Lac-Saint-Jean or Charlevoix regions What is ethnicity based screening in Canada?

11. Private pay, physician ordered genetic testing

12. Self-pay expanded carrier screening is not standard of care and does not replace current screening guidelines

13. Voluntary Variable severity of conditions Conditions have different modes of inheritance Risk assessment based on accurate paternity Negative screen does not eliminate risk In some instances, test may be diagnostic or reveal information about an individual’s personal health – E.g. adult-onset ‘Tay Sachs disease’, fragile X carrier, Ataxia- Telangiectasia carriers Pre-test counselling for expanded carrier screening

14. Pre-test considerations for expanded carrier screening You may choose not to screen for all available conditions. You may exclude testing for: – Disorders which usually present in adulthood and genetic testing cannot distinguish between childhood or adult onset (e.g.  1-antitrypsin deficiency) – Genes where variants have low/no clinical utility (e.g. MTHFR) – Conditions where the most appropriate approach to screening is something other than molecular testing, often because of low penetrance (e.g. hereditary hemochromatosis)

15. Targeted mutation analysis is genetic testing for specific gene changes known to be pathogenic (also used for testing familial gene mutations) Whole gene sequencing is genetic testing where all coding regions (exons) of the gene are sequenced and compared to a reference sequence. Variants in the genetic codes are classified as benign, pathogenic or variant of uncertain significance. Targeted mutation analysis vs. Whole (exon) gene sequencing Pre-test considerations

16. Targeted mutation analysis vs. Whole (exon) gene sequencing Pre-test considerations Potential Benefits: Lower cost No chance of variants of uncertain significance Potential limitations: Low detection rate* for many conditions, ethnicity dependant

17. Targeted mutation analysis vs. Whole (exon) gene sequencing Pre-test considerations Potential Benefits: Higher detection rate (DR) across ethnicities – On average detects about 94% of known clinically significant variants – DR depends on coverage, i.e. how many times a gene region is read Potential limitations: Limited detection of some types of mutations e.g. insertions and deletions Current recommendations are that laboratories report all variants that are pathogenic or ‘likely’ pathogenic – How will you counsel for a variant? – Will your local genetics clinic provide support?

18. Genetic counselling through testing company may be available +/- extra fee You (ordering provider) should have a plan to provide accurate information and follow up to patients, including – Risk counselling and review of options – Test partner if one member of the couple is a carrier – Additional testing? Biochemical testing for non-Ashkenazi Jewish (AJ) member of a couple where the AJ member is a carrier of Tay Sachs disease – Significance of this information for other family members who may also be carriers Post-test counselling for expanded carrier screening panel

19. Back to case 4: Julie and Chris Julie and Chris are planning to start their family Julie would like you to order expanded carrier screening through a private genetic testing company You agree to arrange for expanded carrier screening and provide pre-test counselling You, Julie and Chris select the conditions to be screened for and agree to choose targeted mutation analysis versus sequencing

20. Back to case 4: Julie and Chris Julie and Chris are found to both be carriers of cystic fibrosis You refer the couple to your local genetics for follow-up counselling

21. Pearls – Private pay, physician ordered genetic testing supports patient autonomy and may help some couples avoid long wait times for genetics consults – Physicians ordering testing need to be informed about the conditions on the panels and prepared to provide pre- and post-test counselling – Currently expanded carrier screening is not standard of care

22. Resources See www.geneticseducation.ca for more details and how to connect to your local genetics centrewww.geneticseducation.ca To learn more about Canadian ethnicity-based carrier screening recommendations see the point of care toolthe point of care tool For a recent article see Edwards JG, Feldman G, Goldberg J et al. Expanded carrier screening in reproductive medicine- points to consider: a joint statement of the American College of Medical Genetics and Genomics, American College of Obstetricians and Gynecologists, National Society of Genetic Counselors, Perinatal Quality Foundation, and Society for Maternal-Fetal Medicine. Obstet Gynecol 2015;125(3):653-62