Slide 1

The Perils & Promises of Genomic Medicine Carrie Iwema, PhD, MLS, AHIP 13 th January 2015 NN/LM MAR Boost Box

Slide 2

Slide 3

Predictive Am I at risk for a genetic disease? Diagnostic Does my disease have a genetic basis? Carrier Might I pass on a genetic mutation to a potential child? Prenatal What can I learn about the genetic profile of my fetus? Genetic Testing Rationale

Slide 4

How an individuals genetic inheritance affects the bodys response to drugs Pharmacogenomics

Slide 5

HER2 oncogene Over-expressed in 25-30% patients Cancer cell replication increased Treat w/Herceptin, a monoclonal antibody inhibiting HER2 BENEFITS Herceptin targets ONLY cancerous cells, thus eliminating need to administer large drug doses Identification of ONLY patients w/gene over-expression, thus preventing unnecessary treatments Examplebreast cancer

Slide 6

Predictive Use patients genome to determine probability of developing certain diseases Preventive Based on individual risk profile, start therapies in advance to reduce likelihood of illness Personalized Create drug therapies to suit each genome Participatory Patients will maintain own health by learning about their predispositions Human Genome, US Medicine, & the 4 Psthe 4 Ps

Slide 7

Timeline: Human Genome Sequence 1995 2014? 2000 2003 2007 2010 Human Genome Draft Sequence Complete Human Reference Genome Individual Human Diploid Genome Jim Watsons Genome $2.7 B 13 yrs $24 K 15 days $1 M 1 mth $1K 15 mins 1 st sequenced genome of a free living organism: Haemophilus Influenzae 2007

Slide 8

Impossible to see, the future is.

Slide 9

Sequencing cost over time

Slide 10

Sequencing & analysis of an individuals genome Looks for mutations & differences in your genome compared to others Whole Genome Sequencing (WGS) vs Genotyping vs Exome sequencing Genotype versus Phenotype What is Personal Genomics?

Slide 11

From the cell to nucleotides

Slide 12

Slide 13

SNP: single nucleotide polymorphism

Slide 14

Gene Chips

Slide 15

Next Gen Sequencing (NGS)

Slide 16

1.Order kit 2.Spit into a tube 3.Send tube back 4.Company puts your DNA sample on a chip 5.science occurs 6.Report mailed back to you; may only be raw data 7.Genotype NOT full sequence (typically) 8.Consultations, analysis, worry, confusion DTC: Direct-To-Consumer Genetic Testing

Slide 17

Slide 18

Walgreens, Pathway Genomics, & FDA (May 2010) Government Accountability Office (GAO) 22 July 2010 DTC genetic testing companies provide results that are misleading and of little or no practical use. Companies: 23andMe, Navigenics, Pathway Genomics + others Degree of Regulation vs Public Right to Personal Info Congress & DTC

Slide 19

Federal Regulation

Slide 20

Access & Trust

Slide 21

Slide 22

GINA: Genetic Information Non-discrimination Act The first civil rights legislation of the 21st century -Senator Ted Kennedy Signed 28 May 2008 (After 13 years of debate.)

Slide 23

GINA GINA : Prohibits genetic discrimination in health insurance & employment Title 1: Prohibits discrimination in group and individual health insurance plans. Forbids genetic information being used to deny coverage, adjust premiums, or require someone to take a genetic test. Title 2: Prohibits employers from using genetic information to make hiring, firing or promotion decisions. Severely limits employers rights to request, require, or purchase an employees genetic information. California

Slide 24

Genome Statute & Legislation DB

Slide 25

2009 BRCA1 and BRCA2 Back & forth in court (Supreme Court 4/15/13) Isolated genes CANNOT be patented, but cDNA CAN (9-0) (6/13/13) Myriad sued Ambry Genetics & Gene by Gene 2014: GxG settled; Ambry denied Australia upheld Myriads claim! Are Genes Patentable?

Slide 26

Source: Mark Hakkarinen and Bob Cook-Deegan, DNA Patent Database, 12 February 2014 Creative Commons "free use with attribution" license, with the attribution to Genomics Policy Resource.

Slide 27

11 th Oct 2012 Data access & sharing policies Privacy protections Security Compliance w/regulatory schemes (HIPAA) Informed consent process & issues Facilitate research progress Public benefit

Slide 28

Incidental Findings? 22 March 2013 Labs performing genome/exome clinical sequencing to also report on 56 specific genes No age restrictions, no choice to not know (since revised to include opt out) Clinicians provide pre- & post-test counseling Modified as needed due to technical advances

Slide 29

Slide 30

Genetic Counselors

Slide 31

SNPedia: wiki investigating human genetics SNPedia Promethease: uses SNPedia to analyze & Promethease help explain your DNA Do it yourself?

Slide 32

Slide 33

Crowdsourcing Health Info

Slide 34

Slide 35

Noninvasive Fetal Sequencing I am your father.

Slide 36

Mom the worrier You Crazy Uncle Ben Skeptical brother- in-law Early adopter sister Dad already signed up to get sequenced Grandpa says no way! Uncle Q-G worried about losing his insurance because of his sons DNA sequence Cousin Chewie wants to donate his sequence to science and make it totally public Great-Grandpa is gone, but a sample of his DNA still exists Impact on FamilyFamily Your niece & nephew Your potential kid?

Slide 37

Perils of genetic testing What are the privacy concerns for individual and families? How much should we fear discrimination at work and with insurance? How far ahead is the technology of its clinical usefulness? Will fair weight given to environmental & social factors? How can we ensure access for all who want to be sequenced? What surprises and secrets might be revealed? How realistic are promises of anonymity?

Slide 38

1997

Slide 39

Slide 40

Promises of genetic testing Ideas for more tests and interventions if I learn Im at risk Finding the right drugs, in the right doses, for my conditions Motivation to change my habits Might reveal details of my family tree and genealogy Planning for my long term medical and financial needs I am an early adopter and information altruist I want to use my genome as a social networking tool To inform my reproductive decisions

Slide 41

Online Resources Internet resources in medical genetics. Waggoner DJ. Curr Protoc Hum Genet. 2014 Jan 21;80:Unit 9.12.. doi: 10.1002/0471142905.hg0912s80. PMID: 24510683 Genetic Testing Databases GeneTests; GTR; GeneReviews; Clinic Directory; Testing Labs Microarray & Next Gen Sequencing UCSC Genome; DECIPHER; ISCA; DGV; HGMD; dbSNP; OMIM Newborn Screening National Newborn Screening & Global Resource Center; Babys First Test Genetic Disease Resources, Advocacy, & Support Groups Genetic Alliance; GHR; Unique; The Genetics Education Center; NORD; NIREHG Genetics Professional Societies ACMG; ASHG; NSGC; ISNG; AMP; ABMG; ABGC; APHMG

Slide 42

Carrie Iwema, PhD, MLS, AHIP Information Specialist in Molecular Biology Health Sciences Library System University of Pittsburgh iwema@pitt.edu