Journal of Genetic Counseling

, Volume 25, Issue 6, pp 1347–1472

Presented Abstracts from the Thirty Fifth Annual Education Conference of the National Society of Genetic Counselors (Seattle, WA, September 2016)


DOI: 10.1007/s10897-016-0027-x

Cite this article as:
J Genet Counsel (2016) 25: 1347. doi:10.1007/s10897-016-0027-x

Beverly M. Yashar,1 Tracey L. Grant,2 Molly McGinnis3

1University of Michigan, Ann Arbor, MI, USA

2RTI International, Research Triangle Park, NC, USA

3National Society of Genetic Counselors Executive Office, Chicago, IL, USA

Designated Author:

Beverly Yashar, MS, PhD, CGC

University of Michigan

Department of Human Genetics

1241 E Catherine Street

4909 Buhl Building

Ann Arbor, MI 48109

Tel: 734-763-2933

I. Abstract Awards

Best Full Member Abstract

Adapting evidenced based strategies for effective communication in cancer genetic counseling

R. Lee1, C. Guerra1, J. Ka Yen Cheng1, G. Joseph1

1. University of California, San Francisco

Thirty-six percent of Americans have limited health literacy. Gaps in effective communication are widely recognized as a major contributor to health disparities. As criteria for cancer genetic services expand, insurance coverage increases, and costs go down, counselors need strategies to communicate effectively with their increasingly diverse patient population. To examine current communication practices in cancer risk counseling, we used multiple inductive qualitative methods including systematic direct observation and audio-recording of genetic counseling sessions conducted in English, Spanish and Cantonese (n = 170), semi-structured interviews with observed genetic counselors (n = 10) and stimulated recall interviews with observed patients (n = 51) at two public hospitals. We identified a fundamental mismatch of patient information needs and information provided by counselors. Components of communication that contributed to this mismatch and resulted in ineffective communication include: (1) provision of information that lacks relevance for the patient; (2) provision of too much information; (3) conceptually difficult presentation of information; (4) imprecise discussion of screening and prevention options. To address these findings, we adapted evidenced based strategies developed in other medical settings, such as teach-back, plain talk, and proven risk communication methods, to the cancer genetic counseling context. In a pilot test, counselors learned about these strategies in a 4-hour workshop, and then spent 2 months in practicing in clinic. Preliminary results of the pilot indicate that counselors are able to apply these strategies to improve patient comprehension and engagement. Our findings indicate a need to transform the standard model of genetic counseling communication. Particularly for pre-test counseling, counselors need to adapt to the communication needs of the increasingly diverse patients who now have access to hereditary cancer testing, including the many with limited health literacy.

Beth Fine Kaplan Best Student Abstract

Genetic counseling increases parental knowledge and psychological adaptation to Turner syndrome diagnosis

C. Austin1, D. Fadoju1, C. Bellcros1, K. Cornell1, J. Parks1

1. Emory University

Although Turner syndrome (TS) is a genetic condition, many parents never see a genetics specialist regarding their child’s diagnosis. Genetic counseling has been shown to facilitate coping in multiple settings by increasing perceived personal control and reducing feelings of uncertainty and anxiety. This retrospective study explored the impact of receiving genetic counseling within 1 year of a child’s TS diagnosis. We hypothesized that parents who received genetic counseling would show increased psychological adaptation and have more medical knowledge of TS than parents who did not. Parents were recruited from a pediatric multidisciplinary TS clinic, an educational conference, and through support group email listservs. A questionnaire was distributed which measured variables relating to the diagnosis of the child, parents’ medical knowledge of TS, and included the validated Psychological Adaptation to Genetic Information Scale. Key variables were compared using chi-square analyses and two sample t-tests. Multivariate linear regression was used to assess associations between adaptation, knowledge, and use of genetic counseling, while controlling for potential confounders. Among the 68 eligible participants, 51.5 % (n = 35) had received genetic counseling and 48.5 % (n = 33) had not. The parents who received genetic counseling had significantly higher total psychological adaptation scores (p = 0.04), as well as higher scores on the support (p = 0.02), certainty (p = 0.04), and self-efficacy (p = 0.04) subscales. Parents who received genetic counseling were also more familiar with the recommended medical management of children with TS (p = 0.02). In multivariate linear regression, genetic counseling remained a significant predictor of psychological adaptation (p = 0.01) after adjusting for demographics and variables relating to the diagnosis experience. We recommend genetic counseling become a routine referral for families affected by TS as it increases adaptation, which may lead to improved health outcomes for both child and caregiver.

II. Platform Presentations

Access and Service Delivery

Information is power-ful: Experiences from a population screening initiative for inherited breast and ovarian cancer risk

K. East1, M. Cochran1, W. Kelley1, T. Moore2, R. McGlennen2, T. Shvetsova2, I. Vasenkova2, R. Bachmeyer2, D. Kloske2, N. Lamb1, R. Myers1, K. Strong1

1. HudsonAlpha Institute for Biotechnology

2. Kailos Genetics

In fall 2015 the HudsonAlpha Institute and Kailos Genetics launched an initiative offering Hereditary Breast and Ovarian Cancer (HBOC) risk information to the local community. In contrast to the current clinical testing paradigm, the Information is Power initiative provides increased access to a 23 gene panel test agnostic to personal and family cancer history. Further, the Information is Power model encourages consumer engagement and initiation of the testing process, with the goal of increasing awareness of hereditary cancer risk and identifying individuals who are unknowingly at risk. After returning the first 1000 results, the rate of reported pathogenic or likely pathogenic mutations across the 23 genes is ~3.5 %. Potential reasons for this increased incidence compared to other data include ascertainment bias, inclusion of moderate risk genes, and an actual higher incidence than expected. Many positive patients reported a strong family history (36 %). However, a significant portion of positive patients reported none (31 %) or just some (but not strong, 33 %) family history. Highly penetrant genes and variants (i.e. BRCA) were identified in all family history types. Genetic counselors at HudsonAlpha were challenged to identify strategies to scale the educational and counseling needs to a large population. Genetic counseling videos were embedded into the electronic test ordering and results return. Family history was elicited during the ordering process and reviewed to identify individuals at highest risk of false reassurance from a negative test result. These individuals received additional information about residual risk via mail or phone. Patients and providers with a positive result were contacted by a genetic counselor the day results became available to discuss the result, answer questions and recommend follow-up clinical genetic counseling. Information is Power data provides a unique lens to explore complicated issues surrounding the patient initiated genetic testing process and the incidence of HBOC risk on a population level.

Clinician education as a vehicle for improving high risk women’s path to genetic counseling: The impact of educational interventions in a community health setting

S. Greenberg1, B. Yashar1, M. Pearlman1, D. Duquette2, K. Milliron1, M. Marvin1

1. University of Michigan

2. Michigan Department of Health and Human Services

To identify women with potentially higher risk of breast cancer in a community health setting serving underserved patients, Planned Parenthood Federation of America developed a Breast Cancer Risk Screening Questionnaire (BRSQ) tool that was paired with clinician-training programs across the United States. Previous work by our group demonstrated that clinicians felt confident administering and interpreting the tool, and discussing results with clients. However, they lacked the confidence and knowledge to connect clients with genetic services and describe genetic counseling. This study explored the impact and efficacy of a novel supplementary educational intervention for 14 non-genetics clinicians at Planned Parenthood of Mid and South Michigan (PPMSM). Based on our previous work, education was needed on BRCA1/2, the genetic counseling process, insurance coverage and affordability, and high-risk medical management. To address these gaps, we developed and delivered an educational intervention of four ten-minute webinars. A novel 40-item survey addressing clinician knowledge, confidence, and utilization of the BRSQ was administered pre- (n = 14) and post- (n = 8) intervention. Analysis compared pre/post intervention measures on a five-point scale (1 = low & 5 = high). The educational intervention significantly increased clinician perceived genetic knowledge (p < .02), their acceptance of genetic testing as beneficial for patients at increased risk (p < .01) and knowledge of high-risk medical management (p = .03). The intervention also increased clinician preparedness to explain the genetic counseling process to screen-positive clients (p < .01). Clinicians also reported that training highlighted the importance of a client seeking genetic services (x̅ = 4.4; s = .94) and taught them something new (x̅ ≥ 4)., Consistent and iterative genetic-focused education can improve non-genetic clinicians’ confidence and perceived knowledge, resulting in more effective hereditary cancer screening programs for underserved populations that utilize community health settings.

A novel approach to lab-based clinical genetic counseling

K. Lynch1, D. Iacoboni1, E. Esplin1, R. Nussbaum1, K. Czape1, R. Kurz1

1. Invitae

Recent genomic advances have resulted in escalating demand for genetic counseling services without parallel increases in the number of genetic counselors (GCs). To fill this void, some commercial genetic testing laboratories employ GCs to provide genetic counseling directly to patients undergoing testing in their lab. This care model has raised concerns over potential conflicts-of-interest. This abstract presents a novel model of laboratory-based genetic counseling designed to minimize conflict-of-interest by adhering to the following principles: 1) GCs strictly abide by the NSGC Code of Ethics; 2) Patients are informed that their genetic counseling is lab-based; 3) Referring providers must requisition a test prior to genetic counseling; 4) Recommended requisition changes identified through counseling require the ordering provider’s written approval; 5) A flat pricing structure, complimentary re-requisition, and absence of quotas or commissions for GCs eliminate motivation to “upsell” testing. Using this model, remote genetic counseling was provided for 129 patients from a large primary care system over a 14-month period. After genetic counseling, 21 patients (16 %) had their order cancelled or altered. Of these 21 cases, 43 % had tests cancelled and 57 % had tests altered. Most cancelled tests had been ordered for unaffected individuals who were advised that testing should be initiated in an affected relative. Two-thirds of patients with altered tests had the panel size increased after genetic counseling revealed family history warranting analysis of additional genes. In the remaining one-third of patients with altered tests, panel size was decreased after genetic counseling revealed a known familial mutation. Of the 120 patients tested, 9 (7 %) were found to have mutations that increased their cancer risk and altered medical management. These data highlight how the principled application of lab-based genetic counseling services can benefit patients, ensure the most appropriate test is provided, limit unnecessary healthcare expenditures and improve patient care.

Finding the right mix: Optimizing the utilization of the genetic counseling skill set

P. Read1, M. Marvin1, B. Yashar1, L. Robinson2

1. University of Michigan

2. UT Southwestern Medical Center

One approach to meeting the current gap between the number of genetic service providers and the number of patients is to increase workforce efficiency. This study assessed genetic counselors’ primary time consuming tasks, their willingness to delegate these tasks, and perceived outcomes of such delegation. Clinical genetic counselors recruited via NSGC and the American Board of Genetic Counseling (ABGC) participated in a novel online 44 item survey that assessed tasks performed by genetic counselors and their staff. Tasks were categorized as genetic counseling (GC) (n = 18), administrative (ADM) (n = 13), or professional development (PD) (n = 13). For each task, respondents indicated contributing staff, largest time consumers, and willingness to delegate some portion of the task. Respondents identified barriers to and perceived outcomes of delegation. Analysis included descriptive statistics. Among 331 respondents, the mean percentages of time spent performing GC tasks, ADM tasks, and PD tasks were 63.7 %, 25.0 %, and 11.3 %, respectively. The most commonly identified top time consuming GC, ADM, and PD tasks were clinical documentation (81.5 %), completion of test ordering forms (77.0 %), and supervision of students (71.9 %), respectively. When stratified by specialty, pediatric GCs spend more time on ADM tasks than either prenatal (p < 0.01) or cancer (p < 0.05) GCs, but less time on GC tasks than prenatal GCs (p < 0.05). Additionally, 5/13 ADM tasks and 13/18 GC tasks assessed differ significantly across clinical specialties as top time consumers. Common barriers to delegation include the need for proper GC training, contribution to PD, enjoyment of tasks by GCs, and a lack of proper departmental infrastructure. Common perceived outcomes of delegation include increasing access/improving quality of care, focusing on tasks that require GC training, increasing time spent on PD, and improving overall job satisfaction. This research suggests that delegation of tasks by GCs could increase efficient allocation of clinical time and serve an important role in improving access, patient care, and professional satisfaction.

Establishing a virtual telegenetics clinic for cancer genetic counseling: Challenges and solutions

N. Reddy1, B. McCarty Wood1, D. Harris1, S. Jideama1, P. Higgins1, J. Jaeger1, A. Bradbury1

1. University of Pennsylvania

The Penn Telegenetics Program provides cancer genetic counseling services using real-time video-conferencing to community hospitals without access to genetic providers. This program grew exponentially after the conclusion of a National Institutes of Health-funded pilot-study investigating the feasibility of using video-conferencing services. One participating research site established a clinical contract to maintain continuity of service. We present several challenges and solutions from this transition to a clinical telegenetic partnership. Connection failures due to video-conferencing technology were a significant challenge. Real-time tracking and trouble-shooting with on-site personnel is critical to address technology challenges. Practical modifications and back-up communication plans must be explored and defined in advance. Identifying the process for scheduling, ordering genetic tests and transferring documentation between sites further streamlined the program. While an online survey tool was launched to make health and family history intake more efficient, accessibility and discomfort with computers and internet-based programs reduced the expected uptake. Referrals were initially low, but increased by marketing to local doctors and other surrounding community hospitals. Initial cost of the program is dependent on the devices and technology platforms used, as well as the potential need for licensing genetic counselors in multiple states. While billing for telemedicine is introduced in some states, billing for both telemedicine and genetic counseling remains a challenge. Lessons learned from the implementation of a clinical telegenetics service can provide insight and guidance for genetic counselors interested in utilizing telegenetics, thereby enhancing the dissemination of remote genetic counseling and reducing disparities in access to genetic services.

Custom EPIC work queue to improve insurance coverage of genetic testing

C. Williams1, J. Fan1, S. Figueroa1, J. Howell1, G. Gotway2, J. Park2

1. Children's Medical Center

2. UT Southwestern Medical Center

Clinical genetic testing performed by either traditional or emerging technologies may have unexpected financial consequences for patients. Many clinical genomic tests are still designated as experimental or investigational by both government and commercial insurers in the United States. Because of the high cost and unpredictable insurance coverage, patients and their families have difficulty choosing to have testing and when they do elect to have testing, they often incur unexpectedly large financial out-of-pocket (OOP) expenses in paying for these tests. In addition, hospitals employing institutional billing for outsourced genetic tests are at risk for financial loss if tests are not authorized prior to testing. A prospective insurance benefits work queue was designed and implemented within the EPIC electronic medical record system as a joint project between the genetics clinic, the patient admissions group, and the clinical laboratory. The work queue organizes all aspects of the insurance benefits process and gives the patient/family an estimated OOP expense specific for their insurance plan. The OOP expense includes the filing of preauthorization, predetermination and/or medical peer appeals. All interactions with the insurers are tracked and may be supplemented with voice recording and documenting the coverage of specific tests. Since implementation in 2014, the majority of genetic clinic patients now know their OOP expense for specific genetic testing. Due to its success, the EPIC work queue has now been expanded across all outpatient clinics in the health system. In addition to providing families with an estimated OOP expense prior to testing and improving patient/family satisfaction, there have been improvements in hospital reimbursements by obtaining preauthorization, predetermination and/or medical peer appeals prior to patient testing. This process is a model that can be emulated in other clinics and health systems to improve patient care, patient/family satisfaction and institutional financial stewardship.

Adult Genetics

LowFMR1CGG repeat length in males is associated with family history of BRCA-associated cancers

H. Adamsheck1, J. Hong2, M. Baker3, M. Brilliant4, M. Mailick2, E. Petty1

1. Department of Pediatrics SMPH, University of Wisconsin-Madison

2. Waisman Center, University of Wisconsin-Madison

3. Wisconsin State Laboratory of Hygiene

4. Center for Human Genetics, Marshfield Clinic

The FMR1 gene has been studied extensively with regard to expansions and premutations, but much less research has focused on potential effects of low CGG repeat length. Previous studies have demonstrated that BRCA1/2 positive women are more likely to have an FMR1 genotype with at least one low CGG allele, and that women with both FMR1 alleles in the low CGG repeat range are more likely to have had breast cancer compared to women with normal numbers of CGG repeats. However, there has been no research as to whether low CGG repeat length impacts cancer risks in men. Therefore, this study aimed to examine cancer incidence and related risk factors in men with low CGG repeat length in the FMR1 gene. We utilized subject data from the Marshfield Personalized Medicine Research Project to compare cancer-related diagnoses between 878 males with low CGG repeat length (<24 repeats) and 368 male controls with CGG repeats in the normal range (24 to 40 repeats). We utilized ICD-9 codes to examine various cancer diagnoses, family histories of cancer, other abnormal neoplasms, cancer surveillance, and genetic susceptibility. Men with low CGG repeats were identified to have significantly higher rates of family history of any cancer type (p = 0.011), family history of any BRCA-associated cancer (p = 0.002), and specifically, family history of prostate cancer (p = 0.007). The mean number of BRCA-associated cancer diagnoses (breast, prostate, pancreatic, and melanoma) per male in the low CGG group was slightly higher than that of the control group, with this difference trending toward significance (p = 0.091). Additionally, men with low CGG repeats had significantly higher rates of connective/soft tissue neoplasms (p = 0.026). These findings support some association between BRCA-related cancer risks and low FMR1 CGG repeats. While it is premature to develop practice guidelines based on this study, if future research substantiates these findings, this may have implications for counseling fragile X patients/families, given the frequency of FMR1 CGG repeat sizing in the clinical setting.

Genetic counseling for Alopecia areata: Recurrence risks of Alopecia areata and other associated conditions in first-degree relative

K. Agre1, P. McCarthy Veach1, M. Hordinsky1, B. LeRoy1

1. University of Minnesota

Introduction: Alopecia areata (AA) is a complex autoimmune hair loss condition that affects approximately 2.1 % of the general population. While individuals with AA have increased susceptibility to diseases like atopy and other autoimmune conditions, little is known about the risks to their first-degree relatives for developing AA and other associated conditions. This study aims to investigate the recurrence risk of AA in first-degree relatives as well as compare the prevalence of conditions associated with AA among first-degree relatives to that of the general population. This study also aims to learn more about the accuracy of self-report data by validating a self-report health survey with a review of medical records. Methods: Using the National Alopecia Areata Registry, 155 first-degree relatives of individuals with AA were recruited for participation in a medical history telephone survey. Survey items elicited information about participant’s personal medical history specifically for 70 medical conditions known to be associated with AA. Medical records were obtained for 60 participants and compared to their self-reported responses. One-sided proportional tests, in which it is assumed the disease prevalence in first-degree relatives is higher than those in the general population, were conducted with a Bonferroni correction to determine risk estimates for each condition. Results: The estimated risk of AA to first-degree relatives is 7.8 %, which is significantly higher than the general population prevalence of 2.1 %. There are significantly increased risks of 33 conditions associated with AA in first-degree family members, including atopy and other autoimmune conditions. Only 12 % of self-reported diagnoses were incongruent with medical records. Conclusions: The findings may help genetic counselors better serve their patients by supplying them with lifetime risk estimates of developing AA and other comorbid conditions that have a significant health and psychosocial impact. The findings also support the validity of self-report data in families with AA.

Exploration of communication strategies used by support persons in facilitating cognitive and emotional processing of information within Alzheimer’s disease risk disclosure visits

L. Erby1, D. Roter2, Y. Guan3, J. Roberts4, R. Green5

1. National Human Genome Research Institute

2. The Johns Hopkins Bloomberg School of Public Health

3. University of Maryland School of Medicine

4. University of Michigan School of Public Health

5. Harvard Medical School

Patients are often accompanied by a support person (SP) when receiving genetic risk information. SPs may play a particularly important role when patients have mild cognitive impairment (MCI), such as in genetic counseling for Alzheimer’s disease (AD) risk. Some quantitative evidence suggests that SPs can facilitate patients’ ability to cognitively and emotionally process risk information. However, there has not yet been the kind of rich description of these strategies possible with the use of qualitative coding. To this end, this study explored the verbatim communication of SPs involved in risk discussions derived from the fourth REVEAL (Risk Evaluation and Education for Alzheimer’s Disease) trial, a randomized controlled trial in which AD risk (with and without APOE genotype) was disclosed to patients with MCI. Recordings of risk disclosure visits were transcribed, and 30 visits were purposively selected to produce a sample that included visits from both arms of the study as well as visits presenting risks of varying magnitude. SPs were primarily spouses or adult children of the patient. An initial qualitative codebook was developed based on strategies outlined in publications offering communication guidance in the context of MCI. The codebook was iteratively refined as transcripts were coded. The four most frequently identified behaviors SPs used to facilitate patients’ cognitive processing (in about half of visits) included clarifying or expanding on a patient’s statement, introducing a relevant topic, clarifying a provider’s statement, and asking relevant questions. There were fewer examples of SP facilitation of emotional processing, including offering support or reassurance to the patient and asking about or encouraging the patient to share emotional reactions. SP behaviors that might hinder processing were present in about half of visits, including answering for the patient and discussing non-relevant information. These results provide evidence for future interventions to strengthen and support SP involvement in genetic risk communication visits.

Creating a medically actionable genetic screening panel for healthy individuals

E. Haverfield1, E. Esplin1, B. Johnson1, S. Gandomi1, A. Lynch1, S. Aradhya1, R. Nussbaum1

1. Invitae Corporation

The 2013 American College of Medical Genetics and Genomics (ACMG) policy statement recommended 56 genes for the return of incidental findings but noted that this list will, and should, evolve. Catalyzed by accelerating advances in clinical genomics, we generated an expanded gene list where pathogenic variants would be considered clinically actionable. We reviewed the ACMG56 list, the ACMG Working Group process, and expanded gene lists published by multiple genomics groups. An expert panel of genetic counselors (GCs) and medical and clinical geneticists developed criteria to review the clinical actionability of individual genes. These criteria considered penetrance, mode of inheritance, and availability of published medical management recommendations. We incorporated crucial GC input for how patients with positive results would be counseled. Our novel list of 124 clinically actionable genes included the ACMG56 plus 17 conditions (24 genes) with increased risk for a cancer-related phenotype, three conditions (38 genes) with increased risk for a cardiovascular-related phenotype, and two conditions (6 genes) with increased risk for other medically actionable disorders. The ACMG policy statement addresses variants discovered by diagnostic whole-exome or whole-genome sequencing (WES or WGS). WES/WGS is increasingly available to healthy individuals seeking to proactively inform their healthcare. The high cost and mostly uninterpretable results of these tests are obstacles for integration into routine healthcare. A focused, clinically actionable gene panel available to healthcare providers (HCPs) presents an opportunity for healthy patients to partner with their HCPs for preventive genetic testing with significant potential to inform medical care. This will significantly impact current GC practices and necessitate the development of new models for genetic counseling. GC awareness of growing interest in this information and the transition from what are considered incidental findings to primary findings represents a novel opportunity for GCs to play a significant role in the preventive care of patients.

Clinical cardiac screening of hypertrophic cardiomyopathy is less critical for family members of mutation-negative cases

C. Ko1, P. Arscott1, M. Concannon1, S. Saberi1, S. Day1, B. Yashar1, A. Helms1

1. University of Michigan Health System

Introduction: Hypertrophic cardiomyopathy (HCM) is hereditary, but genetic testing is only positive in about half of patients. In patients with negative genetic test results, the inheritance pattern and need for extensive family cardiac screening is unclear. Objective: This study compared the utility of prospective family clinical cardiac in relatives of gene test positive HCM and gene test negative HCM patients. Methods: Participants with HCM and genetic test results were prospectively enrolled in a single-center registry tracking genetic test status, family history, and clinical variables. Cardiac screening of all first-degree relatives was recommended. A survey was administered at a median follow-up time of 4 years to determine screening results. Results: 120 survey respondents (of 409, 29 %) reported the outcome of cardiac screening in 863 family members. Overall, there was a 30 % rate of screening uptake in first-degree relatives. Subjects with a positive genetic test result (n = 69, 58 %) reported a HCM diagnosis in 33 out of 185 first-degree relatives who were screened (18 %). These 33 family members were diagnosed at a median age of 30–39 years, and 16 (48 %) experienced HCM-related adverse events within 4 years of diagnosis. In contrast, gene test negative subjects with no prior family history of HCM (n = 45, 38 %) reported an HCM diagnosis in only 2 out of 82 (2.4 %) first-degree relatives who were screened. These two individuals were both diagnosed at age >40 without HCM-related adverse events. Genetically elusive familial HCM (gene test negative but positive family history or screening) was present in 7 % of the cohort (n = 8). Conclusions: Positive genetic testing and prior family history discriminate HCM patients whose relatives have an increased likelihood of being prospectively diagnosed with HCM or of developing related complications. Gene test negative and family history negative HCM is likely multifactorial and confers a low degree of heritability with much lower associated familial risk than HCM due to known autosomal dominant single gene mutations.

Patients with amyotrophic lateral sclerosis have high interest in and limited access to genetic testing

K. Wagner1, H. Nagaraja1, D. Allain1, A. Quick1, S. Kolb1, J. Roggenbuck1

1. The Ohio State University

Purpose: Although commercial genetic testing for amyotrophic lateral sclerosis (ALS) is widely available, it is unknown what proportion of patients with ALS have access to genetic counseling and testing, and patient attitudes towards ALS genetic testing have not been studied. Methods: We conducted a national survey of ALS patients enrolled in the Agency for Toxic Substances and Disease Registry, which consisted of multiple choice questions and two 12 item Likert scale series assessing respondents’ experience with and attitude toward genetic testing. Results: The survey had a 9 % response rate with 501 responses. Genetic testing was offered to 33.4 % and completed by 67.1 % of those offered. A minority of respondents (12.5 %) saw a genetic counselor, and were much more likely to be offered genetic testing (p = 0.0001). Respondents with a family history of ALS (8.4 %) were more likely to be offered testing (p = 0.0001) and complete testing (p = 0.05). Respondents with a family history of ALS were more likely to report a favorable attitude towards genetic testing (p = 0.0003), as were respondents who saw a genetic counselor (p = 0.02). The majority of respondents (82.7 %) felt that genetic testing should be offered to all patients with ALS. Conclusions: Our results indicate that ALS patients may have limited access to genetic testing, but perceive benefit from this service. Development of practice guidelines for genetic testing in ALS, to include the routine offer of genetic counseling, may result in broader and more consistent access to this service.

Building the Genetic Counseling Workforce

Movement of genetic counselors from clinical to non-clinical positions: A national workforce survey

S. Cohen1, M. Tucker2

1. St. Vincent Health

2. Indiana State University

A previous study in the state of Indiana indicated significant job movement among genetic counselors (GCs) within the past 2 years, with GCs more often leaving a clinical position for a non-clinical position. The aim of this current study was to determine if this trend of moving out of clinical positions is nationwide and identify reasons why GCs are leaving their positions. An e-blast was sent to members of the American Board of Genetic Counseling (ABGC) with a link to an on-line confidential survey. Board-eligible or board-certified GCs within the United States, Canada or US territory were eligible to participate. There were a total of 939 responses (23.5 % response rate), 98.4 % of whom are currently employed and most of whom (73 %) provide direct patient care in their current position. A third of responding GCs had changed jobs within the past 2 years. Of those who had changed jobs in the past 2 years (n = 295), 74.9 % had previously been working in a hospital/clinic setting and 79.1 % provided direct patient care but only 46.3 % currently work in a hospital/clinic setting with 56.1 % providing direct patient care. In contrast, 20.6 % of GCs who had changed jobs were previously in a laboratory setting, but 47.4 % reported currently working in a laboratory setting, demonstrating a major shift in the field (p < 0.001). The top three reasons cited for leaving a position were work environment / institutional climate, salary/benefits and a lack of feeling valued/recognized as a professional. Although the majority of GCs still work in a clinical setting, these results confirm a significant shift of genetic counselors out of clinical positions into non-clinical positions and document reasons why they are doing so.

Why do genetic counselors consider changing jobs? A national workforce study

S. Cohen1, M. Tucker2

1. St. Vincent Health

2. Indiana State University

Employment opportunities for genetic counselors (GCs) are at an all-time high and some employers struggle to fill open positions. The aim of this study is to evaluate the satisfaction of GCs in their current positions and identify factors that might help employers attract and retain board certified GCs. An e-blast was sent to members of the American Board of Genetic Counselors with a link to an on-line confidential survey. Board-eligible or board-certified GCs within the United States, Canada or US territory were eligible to participate. There were a total of 939 responses (23.5 % response rate); 98.4 % were currently employed. Overall, 52 % of GCs report being highly satisfied in their current position, although almost 2/3 think about leaving their current position; 32.4 % think about it at least monthly and 27.6 % think about leaving at least yearly. In a current position, the highest rated categories for satisfaction were autonomy (78.5 % highly satisfied) and sense of team within the department (64.4 % highly satisfied) and the lowest rated were possibility for advancement (25.5 % highly satisfied), salary/benefits (37. 9 % highly satisfied) and feeling of value from the organization (39.6 % highly satisfied). When asked to rank the top three things GCs liked about their current position, the most common responses were autonomy, flexibility and opportunities for direct patient care. The top three things least liked about a current position were opportunities for advancement, salary/benefits and workload. The top three reasons why a GC might consider leaving their current position were higher salary/better benefits, more opportunities for advancement and external factors, such as working closer to home. The top three things that would make a GC less likely to leave a position included higher salary/better benefits, more opportunities for advancement and decreased workload. These identified factors may be useful for employers to consider when trying to fill positions or retain GCs in their current position.

Flipping the classroom and the clinic: Meeting the needs of the expanding genetic counseling workforce through online branching case studies

A. Cummings1, P. McCarthy Veach1, B. LeRoy1, H. Zierhut1

1. University of Minnesota

Introduction: Genetic counseling professionals are in high demand in the United States, and demand is growing. Increasing class sizes in genetic counseling graduate programs, and subsequently the number of graduates annually, is a desirable goal often complicated by limited availability of certified clinical supervisors. Clinical rotations in which students actively participate in patient care require intensive supervision. One way to address limited availability of clinical experiences is to provide some observational experiences normally occurring within initial clinical rotations through simulated clinic situations in the classroom. Method: We created three online interactive modules using Moodle, a course management system and open-source software package. The modules consist of video recordings of simulated genetic counseling cases/sessions and accompanying stimulus questions. The simulations represent primary clinical genetic counseling specialties (prenatal, pediatric, and cancer). Each counseling session is divided into scenarios focusing on specific components (e.g., history taking, decision making). Stimulus questions consist of multiple choice items, short answer and essay questions addressing both genetics knowledge and psychosocial counseling issues and skills. Questions can be answered individually and/or in group discussion. Progression through scenarios within each module is comparable to that of an entire genetic counseling session as well as multiple subsequent sessions and variation of the same situation (e.g., an angry, an indecisive, or a very informed patient). Discussion: The modules involve virtual viewing of and reflection upon cases and are intended to reduce the time spent in physical clinical observation. Assessment of the on-line modules can be completed to evaluate the usefulness and added benefit of supplementing clinical experiences with online experiences. This technology provides a dense, systematic observational experience for students, and allows for more efficient use of the genetic counselors available for clinical supervision.

Do genetic counseling programs “like” Facebook?

T. Lepard1, L. Dean1

1. University of Arkansas for Medical Sciences

Facebook is the world’s most popular social networking site. Originally limited to students at one university, Facebook membership has expanded to anyone with an email address at least 13 years of age. The site is no longer used solely for social networking amongst friends, and is increasingly being used by businesses and other organizations. Likewise, universities are utilizing Facebook through dedicated pages, and genetic counseling training programs are no exception. We analyzed Facebook pages of genetic counseling training programs as a first step in exploring the use of Facebook as a potential educational tool for student-centered learning. A Facebook search using the term “genetic counseling” was performed, and a list of public pages were generated. Data collected from these pages included the page inception date and number of “likes.” A thematic analysis of posted content was conducted for a 1 year period (5/5/15-5/5/16). Twelve genetic counseling training programs in the United States have dedicated, public, Facebook pages. The first genetic counseling training program Facebook page was created in November 2010. Excluding two programs (due to recent creation and not being in existence for 1 year), the average number of “likes” is 210.9 (range, 48–459). Of these ten programs, the average number of posts in the year analyzed was 36 (range, 6–118). The content of page posts could be categorized into three thematic headings: social (e.g. photograph sharing, event invites); education (e.g. links to articles, student research, public events); and program specifics (e.g. alumni updates, job acceptances, program recruitment). The number of genetic counseling training programs with Facebook pages is rising and will likely increase as social media becomes more accepted amongst universities. Programs are using Facebook for more than picture sharing and social networking, including for program updates and education. The use of Facebook as a learning tool is particularly interesting and its effectiveness should be further explored.

Ask us anything! The National Society of Genetic Counselors expert media panel meets Reddit Ask Me Anything

E. Ramos1, A. Curry Sturm2

1. Illumina, Inc.

2. Ohio State University Wexner Medical Center

A social media presence is fundamental to NSGC to promote genetic counseling and fulfill its strategic plan. While NSGC members participate in a variety of social media outlets, NSGC has focused its social media outreach on social networking sites and the NSGC Blog. As part of DNA Day, the National Human Genome Research Institute invited NSGC to participate in a Reddit Ask Me Anything (AMA) series. Reddit is a grouping of online communities called subreddits. Reddit’s AMA sessions are among the most popular subreddits and allow users to ask the AMA host(s) about specific topics. The AMA was promoted via social media prior to and on the day of the event. On the day of the AMA, April 20, 2016, users were able to begin asking questions at 8am EST and the Reddit community “upvotes” or “downvotes” questions to place them in rank order. The NSGC Expert Media Panel (EMP) logged on at 1pm and responded to the most popular questions. Seven members of the EMP including the president, president-elect and past president and three past Board members participated. Each “Expert” represented a specific genetic counseling specialty. The EMP answered questions from 36 unique participants. The top-ranked question (156 points) was on genome sequencing and insurance risks. Two genetic counselors from the EMP independently categorized questions and found that the top 3 categories were professional issues (9), personalized medicine (6) and general genetics/inheritance (6). Twenty one responses pointed to or and Google Analytics showed a spike in traffic at at 1pm when the hosts began to answer. Total pageviews were 60 % higher that day than the average for April (8200 vs 5100) and nearly 6 % of the pageviews (479) were on the Find a Genetic Counselor tool. The Reddit AMA was a unique and successful opportunity for NSGC to raise awareness about genetic counseling, promote, address questions from a general population as experts on genetics and genomics and to identify topics of interest that can be targeted for future consumer education.

Exploring the role of genetic counselors in tumor genomic sequencing

M. Weinberg1

1. Mount Sinai West’s Comprehensive Breast Center

In the new era of genomics-driven medicine, tumor genomic profiling has emerged as an early success, revolutionizing the field of oncology. Evolving technology and increased clinical use raise questions with regards to the changing roles of genetic counselors involved in cancer care. One hundred and twenty-eight members of the NSGC responded to a survey to assess the current roles of genetic counselors in oncology and the roles they are anticipated to play in the clinical use of tumor genomic profiling. With regards to current roles, the majority reported that they provide genetics cancer-related expertise to other medical professionals (85.0 %, n = 85). With respect to the clinical use of tumor genomic sequencing, most responders (80.0 %, n = 80) indicated that they feel there is a role for genetic counselors. The majority of responders identified 5 roles that genetic counselors would be equipped to play in regard to tumor genomic analysis: identifying and discussing incidental germline findings uncovered by testing (97.9 %, n = 91), serving as a resources for physicians who may not be comfortable with genomic testing (76.3 %, n = 71), educating medical students, residents and fellows about tumor genomic sequencing (69.9 %, n = 65), educating medical professionals on issues around informed consent (67.7 %, n = 63) and post-test counseling of patients to help interpret tumor sequencing results (65.6 %, n = 61). Pre-test counseling for patients to help explain tumor sequence testing and informed consent was reported as a significant role by smaller numbers of responders (44.1 %, n = 41). When prompted to choose the most significant role, the majority (56.7 %, n = 51) chose identifying and discussing incidental germline findings. Furthermore, the overwhelming majority (97.0 %, n = 97) had an interest in additional training in tumor genomics, demonstrating that genetic counselors want to take advantage of opportunities to play a key role in the clinical implementation of tumor genomic sequencing.

Counseling/Psychosocial Issues

Effect of photographs of visible genetic conditions on quality of life perceptions

C. Falugi1, S. Hashmi2, C. Singletary2, A. D’Angelo3, J. Nguyen2, M. Ashfaq2, S. Elsea4

1. University of Texas Health Science Center at Houston

2. McGovern Medical School at UTHealth Science Center Houston

3. LSU School of Medicine

4. Baylor College of Medicine

Historically, medical photographs have been used to demonstrate dysmorphic features and characteristic presentations of genetic conditions. Traditional, pictorial depictions of genetic conditions typically involve nude subjects against walls to emphasize their features. These stark, black and white photographs may negatively influence students’ perceptions of the depicted individual. Natural images that depict individuals in non-clinical environments may impact perceptions of that person and of others with the genetic condition. To assess the influence of photographs on a viewer’s perceptions, 649 students from medical, nursing, dental, and genetic counseling programs were randomized and surveyed in a cross-over study to view traditional and natural photographs of three distinct genetic conditions. Student perceptions of the individual and their quality of life were evaluated using a Quality of Life Assessment(QoLA) and Perception Assessment which included Likert scale and yes/no adjective-association questions, respectively. Natural images were associated with higher QoLA scores (p < 0.001) in comparison to the traditional images. Affected individuals were more often associated with positive characteristics (beautiful, respectful, intelligence, higher quality of life) when presented in natural settings and negative characteristics (degrading, institutionalized, humiliating, neglected) when depicted in traditional photographs (p < 0.05). These associations were evident regardless of the order in which photographs were viewed. Furthermore, the nature of the first photograph influenced how much more positive or negative the second photograph was perceived. Although overall trends remained the same, the type of healthcare program influenced the magnitude of the effect; genetic counseling students had more positive perceptions than medical, dental, and nursing students (p < 0.05). These results suggest that using natural images in healthcare education may positively impact viewer’s perceptions and potentially neutralize negative biases associated with genetic conditions.

A health beliefs model investigation of fetal echocardiography uptake in mothers of children with congenital heart defects

S. Fitzgerald-Butt1, J. Jackson1, K. Gledhill2, L. Jafari2, J. Bowman1, V. Garg1, K. McBride1

1. Nationwide Children’s Hospital

2. Ohio State University Medical Center

Risk for congenital heart disease (CHD) in subsequent pregnancies among couples who had a child with CHD is high. Fetal echocardiography (FE) is recommended, but little is known regarding what motivates individuals to obtain FE. We designed a phone survey based on the Health Beliefs Model (HBM) to determine the relationship between mother’s intent to talk to her doctor about FE in a subsequent hypothetical pregnancy (SHP) and the HBM constructs including perceived CHD recurrence risk, cues to action, benefits and barriers to obtaining a FE, and self-efficacy. Descriptive statistics, Cronbach’s alphas, and Pearson’s correlations were utilized. We enrolled 35 mothers of children <4 years with a left-sided CHD. Participants averaged 32 years old (range 21–43), had 2.2 children (range 1–7), were predominantly Caucasian (94 %), received at least some college education (89 %), and reported a household income < $60,000 (60 %). The overwhelming majority of participants (89 %) reported that they planned to talk to their doctor about FE in a SHP. The average perceived recurrence risk was 33.5 % (SD 24.2, range 2–95) on a 0–100 % scale. Cues to action included the importance of a future child without CHD (M = 6.9, SD = 3.8 on a 0/not important to 10/very important scale,) and prenatal diagnosis of CHD (M = 7.9, SD = 3.3). Participants generally agreed with benefits, disagreed with barriers, and had high self-efficacy. The outcome measure, talking with a doctor about FE in a SHP, had statistically significant correlations with the following HBM constructs: cue to action-prenatal CHD diagnosis (r = .534, p = .001), barriers (r = −.625, p < .001), and self-efficacy (r = .460, p = .005) and a weaker correlation with recurrence risk (p = 0.103). Therefore, including a discussion of the value of a prenatal diagnosis and strategies to overcome barriers and improve self-efficacy may increase uptake of FE. These findings may be applied more generally to improve screening uptake through investigation of specific populations and individualized conversations to assess motivation and limitations.

Patient expectations for non-diagnostic whole exome sequencing

R. Hylind1, M. Smith1, L. Rasmussen-Torvik1, S. Aufox1

1. Boston Children’s Hospital

2. Northwestern University

Clinical genomic sequencing has improved genetic diagnoses but also poses challenges to healthcare providers preparing patients for secondary findings. Currently, little is known regarding actual patient opinions surrounding secondary findings from genomic sequencing. This study assessed the expectations and intended use of results from participants undergoing non-diagnostic genomic sequencing. Semi-structured interviews were conducted with participants enrolled in the eMERGE (Electronic Medical Records and Genomics) study. Participants in eMERGE consent to have non-diagnostic genomic sequencing, receive results, and have results returned to their physicians through their electronic medical records. Of the 14 participants, 64 % were male and 43 % identified as non-Caucasian. Recorded phone interviews continued until saturation. Interviews were transcribed verbatim and coded independently by two individuals. Discrepancies were discussed until agreement was reached. Analysis revealed five major themes and 17 sub-themes. Many themes identified validated responses from other studies exploring hypothetical scenarios and early-adopters of genomics, including participants expecting results to reveal information relevant to personal health and identify a genetic basis for diseases present in family members, as well as the expectation that results would be used to alter medical management and make lifestyle changes. A unique theme identified was “Uncertainty” with many participants expressing uncertainty about the type of diseases they expected to receive results on, the types of results they wanted to learn about and how they intended to use results. This uncertainty exposed a lack of contemplation about the type of information participants will receive from sequencing. This finding of uncertainty highlights the complex nature of the decisions and a general deficiency in genomic knowledge. Results from this study could help improve preparation for clinical genomic sequencing and guide development of a quantitative tool to examine patient expectations on a larger scale.

Family history and clinical severity predict cardiac anxiety in patients with arrhythmogenic right ventricular cardiomyopathy and their at-risk family members

C. James1, C. Tichnell2, B. Murray2, S. Sears3, H. Calkins2

1. Johns Hopkins Medicine

2. Johns Hopkins University

3. East Carolina University

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an autosomal dominant cardiomyopathy with frequent life-threatening arrhythmias. Cardiac anxiety (CA) is a triad of symptoms including cardiac-specific fear, avoidance, and excessive symptom monitoring associated with clinical and psychological morbidity. Hypothesis: We predicted CA would be elevated in ARVC patients and at-risk relatives (FM) and sought to 1) compare CA in ARVC with other genetic heart diseases, 2) identify clinical and family history predictors of CA, and 3) assess association of CA with generalized anxiety and depression. Methods: Of 396 adults enrolled in the Johns Hopkins ARVC Registry, 288 (72.8 %) completed a questionnaire designed to measure adaptation. Measures were informed by Wallander’s Risk and Resistance Model and included anxiety/depression and CA (Cardiac Anxiety Questionnaire [CAQ]). Results: Each CAQ subscale score was worse in ARVC patients (n = 224) (fear 1.8 ± 0.8, avoidance 2.1 ± 1.0, cardiac attention 1.7 ± 0.7) than published scores for other genetic cardiac conditions. FM (n = 64) had less severe CA than patients (fear 1.2 ± 0.6, p < 0.001; avoidance 0.9 ± 1.0, p < 0.001; cardiac attention 0.9 ± 0.7, p < 0.001). In multivariate analysis, independent predictors of worse CA in patients included younger age (p < 0.001), poorer functional capacity (p < 0.001), more defibrillator shocks (p = 0.037), death of a family member from ARVC (p = 0.015), and being a proband (p = 0.048). For FM, CA was associated with poorer functional capacity (p = 0.002) and carrying a mutation (p < 0.001). CAQ score predicted clinically significant anxiety in patients (p < 0.001) and FM (p = 0.002). In patients, CA also predicted depression (p < 0.001). Conclusions: CA is common and severe in ARVC. CA includes avoidance of exertion and excess symptom monitoring and can manifest as disengagement from daily activities or repeated requests for medical reassurance. Proband status and family history of ARVC-related death are risk factors. Genetic counselors are thus well-positioned to identify affected patients and make referrals for psychological and behavioral support.

Long-term impact of genetic testing reporting on understanding and prioritization of risk information

W. Kohlmann1, T. Stump1, M. Champine1, J. Taber2, S. Leachman3, L. Aspinwall1

1. University of Utah

2. Kent State University

3. Oregon Health Sciences University

Genetic counseling and testing are effective tools for enhancing patients’ understanding of disease risk. However, it is unknown how receiving genetic test results specifically contributes to patients’ perceptions beyond family history-based assessment. This study used a nonexperimental control group design to compare the effect of melanoma risk counseling based on family history to counseling paired with CDKN2A testing. Participants were members of families with known CDKN2A mutations (n = 75) or of families with >3 cases of melanoma in which CDKN2A mutations were ruled out (n = 49 no-test controls). Both groups were given equivalent information about the melanoma risk in their families and management recommendations, but genetic test results were only provided to those from the CDKN2A mutation families (carriers = 31, noncarriers = 44). Assessments at baseline, 1 month and 1 year post-counseling included a measure of understanding of melanoma risk adapted from the Psychological Adaptation to Genetic Information Scale. All groups showed improvement at 1 month, but carriers and noncarriers demonstrated greater understanding of risk compared to no-test controls. At 1 year, greater understanding about melanoma risk was sustained in carriers and noncarriers compared to no-test controls (F(2109) = 5.00, p < .01). At 1 year the testing group more strongly advocated that adherence to management recommendations was a priority (F(2109) = 7.03, p < .001), and felt more prepared to manage risk (F (92,109) = 4.91, p < .01) compared to the no-test controls. Receiving genetic test results led to sustained improvements in understanding of risk and motivation to manage risk beyond what was achieved from family history-based counseling alone. The novel design of this study provided an opportunity to isolate and evaluate the contribution of genetic testing to patients’ perception of risk. The highly personal and technical nature of genetic testing may lead to this information being highly valued by patients and contribute to greater prioritization of risk information and adherence.

Validation and extension of the reciprocal-engagement model of genetic counseling practice: A qualitative investigation of genetic counselor goals, strategies, and behaviors

K. Redlinger-Grosse1, P. McCarthy Veach1, B. LeRoy1, H. Zierhut1

1. University of Minnesota

Introduction: As the genetic counseling field steadily evolves, a validated model of practice is critical. The recently proposed Reciprocal-Engagement Model (REM) model has one prior study supporting the validity of its 17 practice goals. The purpose of the present study was to further develop and validate the REM by identifying and mapping genetic counseling strategies and behaviors to the REM goals. Methods: A secondary, qualitative analysis was conducted on data from two prior studies: 1) focus group results of genetic counseling outcomes; and 2) genetic counselors’ examples of 67 successful and 63 unsuccessful genetic counseling sessions. Results: Using directed content analysis, 337 strategies and 140 behaviors were extracted from focus group data. A Q-sort performed on the strategies yielded 15 broader strategy domains that were then mapped to the successful and unsuccessful session examples. The Q-sort provided further validation of the REM goals based on differing proportions of strategy domains identified in successful sessions versus the proportions not present in unsuccessful sessions. For successful sessions, the most frequent domains were Information Giving and Use Psychosocial Skills and Strategies. For unsuccessful sessions, the most frequently absent domains were Information Giving and Working Alliance. Discussion: Identified strategies and behaviors support the REM’s reciprocal nature, especially with regard to addressing patients’ informational and psychosocial needs. Patients’ contributions to success (or lack thereof) of sessions was also noted, supporting a REM tenet that individual characteristics and the counselor-patient relationship are central to processes and outcomes. The elaborated REM could be included in graduate program curricula to demonstrate how Accreditation Council for Genetic Counseling (ACGC) practice based competencies are accomplished. REM components could also inform process and outcomes research, such as observational or analogue studies to document and further characterize genetic counselor strategies and behaviors.

Counseling: Prenatal to Pediatrics

Patient demographics in the decision to enroll or decline whole exome sequencing (WES) in the pediatric cancer setting

K. Bergstrom1, S. Scollon1, T. Wang2, S. Hilsenbeck2, R. Raesz-Martinez1, S. Gutierrez1, D. Parsons1, S. Plon1

1. Department of Pediatrics-Oncology, Baylor College of Medicine

2. Baylor College of Medicine; Dan L. Duncan Cancer Center

There is limited information regarding the role patient demographics play in the patient’s decision to undergo WES, as well as the reasons for which they decline We provide an update of our 4 year experience with enrollment for the BASIC3 (Baylor Advancing Sequencing in Childhood Cancer Care) study, examining clinical tumor and germline WES of pediatric cancer patients. We compare clinical and demographic data between enrollees and those who decline study participation. Parents who spoke either English or Spanish were eligible for the study. Informed consent was obtained within 60 days after the diagnostic tumor surgery. Families were informed that tumor and germline WES results, including diagnostic and medically actionable pathogenic variants, would be provided to the family and oncologist, and deposited into the electronic health record. If a family declined, study staff documented the reason as stated by the family. Of 398 families approached, 70 % (280) enrolled on the study and 30 % (118) declined enrollment. Half of enrolled patients identify as Hispanic, 57.5 % as White, and 9.6 % as Black. Half are female. There was no statistically significant difference in patient demographics or tumor characteristics between the families that enrolled and those that declined, including the use of a Spanish interpreter. The decline group took significantly more days to reach a decision than the enrollment group (p = <0.001). The most common reason for declining (54, 46 %) was that families were overwhelmed with the patient’s clinical treatment. Families also expressed concern about genetic privacy risks (20, 17 %) and the potential anxiety the results may cause (21, 18 %). Our study enrollment data demonstrates strong interest in clinical WES among parents of pediatric oncology patients across racial/ethnic groups. Genetic counselors consenting pediatric cancer or other acutely ill patients for WES should consider the common feeling of being overwhelmed, and counselors consenting in a wide range of settings should address genetic privacy and potential anxiety during consent.

Whole genome sequencing for ostensibly healthy individuals: Genetic counseling challenges and early experiences

M. Cochran1, K. East1, W. Kelley1, D. Bick1, A. Hott1, N. Lamb1, H. Jacob1

1. HudsonAlpha Institute for Biotechnology

As new studies emerge demonstrating the clinical utility and cost-effectiveness of genomic sequencing in the diagnostic realm, a question often posed is, “how can we do this for individuals who are seemingly healthy?” Genetic counselors are on the front lines to help answer this question and to determine how to provide counseling and education in a way that is responsible and valuable to patients. At the Smith Family Clinic for Genomic Medicine on HudsonAlpha’s Biotechnology Campus, we meet this need through face-to-face counseling as well as online learning. This presentation will describe these efforts including the challenges faced and insights gained through exploring this new frontier of genomic medicine. When distinguishing genomic sequencing for seemingly healthy individuals from those searching for an underlying diagnosis for their symptoms, it is vital to consider the motivations, expectations, and implications of a patient’s desire for testing. As genetic counselors, we must be flexible in our messages and delivery mechanisms in order to meet the needs of a growing population of patients who would not typically be offered genomic sequencing. Early experiences have shown that while the content of informed consent for genome sequencing is similar for both populations, the ideal order and emphasis may be different. For patients seen in-person at the Smith Family Clinic for Genomic Medicine, we have developed a genetic counseling protocol that addresses common patient questions, misconceptions, and concerns unique to genomic sequencing for apparently healthy individuals. Online educational resources allow for an expanded reach beyond our campus and are also utilized by outside patients and providers ordering genomic sequencing through the HudsonAlpha Clinical Services Laboratory. Throughout an iterative design process, we have adapted counseling techniques and messages to effectively reach this unique population. These resources allow us to keep pace with rapidly increasing demand among individuals who appear healthy but desire whole genome sequencing.

Exploring the influence of prenatal aneuploidy screening on maternal-fetal bonding: Development of a theoretical model

C. Hippman1, J. Austin1

1. University of British Columbia

Background: The maternal-fetal bond (MFB) is the affectionate relationship between mother and fetus that precedes the development of the maternal-infant bond, which is crucial to child social and cognitive development. Given rapid technological advances in prenatal aneuploidy screening (PAS), emerging evidence that– regardless of result– it may have a negative impact on MFB- suggests an urgent need to improve our understanding of the impact of PAS on MFB. Purpose: To explore the impact of PAS on MFB. Methods: Pregnant women (26–34 weeks) who had made a decision about PAS were recruited from healthcare providers’ offices and community events to participate in semi-structured (45–60 min) interviews. Data analysis informed data collection using the constant comparative method. Interviews were recorded and transcribed verbatim. Constructivist grounded theory was used in data coding to generate categories and a cohesive theoretical model. Reflexive journaling and peer debriefing were used to enhance credibility, confirmability, and dependability of results. Results and Discussion: Interviews were conducted until saturation was reached (N = 24; chose PAS, −ve result-13; chose PAS, +ve result-2; no PAS-9). Overall, MFB development evolved in four parallel domains: physical, emotional, cognitive, and spiritual. MFB ‘activities’ in each domain interacted with other domains to strengthen or weaken MFB. Women who chose PAS, in particular those who planned to terminate in the event of a diagnosis, experienced a ‘pause in the pregnancy’– actively resisting MFB development in the cognitive domain to put the brakes on overall MFB development. After receiving reassuring results, there was a delay (~1 week) before women were able to re-connect with the MFB. This negative impact on the MFB appears transient; women who chose PAS were as likely to achieve a strong MFB in the 3rd trimester as women who chose not to have PAS. Our findings provide insight into patients’ experiences that can enhance clinicians’ ability to empathize with patients as they engage in PAS choices and outcomes.

Comparing data from products of conception testing of first, second and third trimester pregnancy losses highlights differences and the need for genetic counseling outside the box

K. Howard1, K. Merrion1, M. Maisenbacher1

1. Natera, Inc.

Introduction: Aneuploidy is responsible for at least 50 %(1) of first trimester losses, and the rate increases with advancing maternal age. However, little information is available about chromosome abnormality rates by gestational age (GA). Objective: Report incidence of chromosome abnormalities by GA in products of conception (POC) samples. Methods: Retrospective review of 2433 fresh POC samples analyzed with parental blood samples at a reference lab. Genotyping was performed using Illumina CytoSNP-12b microarrays with bioinformatics to rule out maternal cell contamination (MCC). Results: Of 2433 cases, 445 (18.3 %) cases with MCC and 4 (0.16 %) cases with incomplete results were excluded. Of the remaining 1984 cases, 1859 (93.7 %) were first trimester losses (average maternal age, 35.9 [range 18–51] years): 618 (33.2 %) were euploid and 1241 were (66.8 %) abnormal. Aneuploidy of every chromosome except chromosome 1 was observed. Of 125 (6.3 %) second/third trimester losses (average maternal age, 32.0 [range 16–44] years): 97 (77.6 %) were euploid and 28 (22.4 %) were abnormal. Only aneuploidy of chromosomes 13, 18, 21, 22 and X was observed. Triploidy was observed in both first and second/third trimester losses. The incidence of deletions/duplications (dels/dups) in the absence of other chromosomal abnormalities was higher in later losses (7.1 vs. 4.3 %). Conclusions: The likelihood of aneuploidy was three times higher in first trimester losses compared to later losses. Aneuploidies in later losses were narrowed to those seen in liveborns. The higher rate of euploid results and of dels/dups in later pregnancy losses suggests the need to counsel patients with later loss differently, including consideration of array testing for higher resolution than standard karyotype and setting expectations for abnormal vs. normal results. Looking for other causes of loss beyond aneuploidy may also be considered, including fetal autopsy, storage of fetal DNA for future testing, and maternal work-up.

Emerging issues with noninvasive prenatal testing: Genetic counselors’ experiences & perspectives with incidental findings

A. Orta1, A. Buchanan2, G. Annas3, J. Tsipis4

1. California Pacific Medical Center

2. Tufts Medical Center

3. Boston University School of Public Health

4. Brandeis University

Since companies began marketing the analysis of cell-free DNA in the maternal plasma as noninvasive prenatal testing (NIPT) to screen for fetal aneuploidy and other conditions, healthcare providers and patients alike have encountered discordant invasive and noninvasive testing results, with unexpected incidental findings as a rare cause. The purpose of this study was to investigate prenatal genetic counselors’ practices and perspectives regarding counseling patients for the possibility of incidental findings identified through NIPT. We emailed a 58-question anonymous survey to the NSGC membership to recruit clinical prenatal genetic counselors that offer NIPT. Of the 147 survey respondents, 74 % obtain informed consent for NIPT verbally and over half do not involve the patient in the documentation of informed consent, as the provider is responsible for documenting the patient’s consent. More than half (57 %) do not include the possibility of incidental findings in their pre-test counseling discussions. Yet, 47 % of the genetic counselor respondents have had a suspected or confirmed incidental finding identified through NIPT. Almost all respondents indicated that post-test counseling a patient with an incidental finding is challenging, citing a lack of information and variation among NIPT laboratories with how they communicate incidental findings and a lack of clinical guidelines from professional societies as the most important factors. From counselors’ responses, unknown maternal conditions account for a large proportion of the incidental findings identified by NIPT. Given these findings we recommend that pre-test counseling for NIPT include a discussion of possible unexpected findings and to establish clear expectations for the categories of results that may be returned, the creation of professional guidelines outlining how incidental findings should be discussed in both pre- and post-test counseling discussions, and the creation of a centralized database for the collection of findings, outcomes, and clinical follow-up to facilitate appropriate care for patients.

Adolescent and parent perceptions of disorders of sex development: A brief insight

L. Williams,1, B. Yashar1, J. Fitzgerald1, D. Sandberg, PhD1

1. University of Michigan

Despite the 2006 international agreement to use the term “Disorders of Sex Development” (DSD) in place of the more pejorative terms “intersex” or “hermaphrodite”, there still is considerable opposition by patient advocacy groups to the term DSD, mainly due to a perceived stigma. This stigma is strongly felt during adolescence; also a time when psychosocial issues faced by adolescents and their parents may differ causing perception of the condition to diverge. Although many studies have examined how parents perceive DSD conditions, few have investigated the child’s perspective. One established tool to measure illness perception is the semantic differential, which uses a set of bipolar adjectives to assess an individual’s underlying emotional response to a topic of interest. Through novel use of the semantic differential tool in this population, we performed an exploratory assessment of adolescent (ages 14–18) and parent perception of 3 topics: themselves (parents rated their child), the adolescent’s specific diagnosis name and the term DSD in a University of Michigan DSD Clinical Cohort (n = 6 pairs). Topics were compared to each other using an effect size measure (Cohen’s d; d = 0.8 denotes a large effect size difference). As a group, adolescents perceived themselves much differently and more positively than their specific diagnosis (d = 1.34) or DSD (d = 2.20) as well as perceiving their specific diagnosis somewhat differently and more positively than DSD (d = 0.56). Parents exhibited comparable trends, but they viewed their child’s specific diagnosis and DSD similarly (d = 0.12). Various factors modify these perceptions, including absence of a specific named diagnosis or later age of diagnosis. Overall, the semantic differential has powerful utility in distinguishing how people think of themselves, their diagnosis name and the term DSD. Understanding how both patient and parents perceive these 3 topics has value in helping healthcare providers guide a family’s conversations to deciding which nomenclature is the “best” for the family to use regarding the DSD condition.

Ethical, Legal and Social Issues

Prenatal exome sequencing: Issues of clinical utility and beyond

B. Castro1, A. Lemke2, V. Pan3, B. Blumberg4, C. Wicklund5

1. Ambry Genetics

2. Agency for Healthcare Research and Quality

3. Advocate Health Care

4. Kaiser Permanente Northern California

5. Northwestern University

Prenatal exome sequencing (PES) is now being conducted in limited clinical settings. The purpose of this study was to assess genetic counselors’ perspectives toward previously identified issues with PES and to provide insight for future professional guidelines for this technology. A survey was developed based on qualitative data, literature review, and expert opinion, which was distributed through eblast to the entire NSGC membership. Questions assessed attitudes toward issues surrounding PES, including clinical utility (CU), return of results, and others. One hundred eithty two participants completed at least some portion of the survey. 82 % agreed that there is CU using PES to diagnose fetuses with ultrasound abnormalities and 63 % to prepare for a treatable childhood-onset condition. Participants showed less agreement regarding CU of other potential indications for PES and mostly disagreed that there would be CU for preparing for adult-onset conditions (treatment: 75 %; no treatment: 85 %). 80 % agreed that PES differs from the use of ES in postnatal settings, mostly due to the option for termination (80 %). There was disagreement as to what types of results to return prenatally and the relevance of current American College of Medical Genetics and Genomics (ACMG) guidelines for return of secondary findings. Participants prioritized returning secondary findings indicating childhood-onset conditions over adult-onset, with less priority given to treatment availability. There was agreement that there could be potential barriers to access PES, such as the costs involved (overall: 93 %; out-of-pocket: 96 %). Further research into the clinical utility of PES (50 %) was ranked as the most important area of future study regarding this technology. Participants are generally supportive of the current applications of PES technology. However, they are not as supportive of other potential uses of PES, and discrepancies exist in their opinions as to what types of information should be returned. These discrepancies, along with the identified potential for harms that PES brings, illustrate a need for professional guidance for this technology.

Ramifications of excessive autosomal homozygosity detected by single nucleotide polymorphism array: Investigation of incestuous versus non-incestuous relationships

J. Chen1, S. Mulchandani1, E. Dechene1, F. Fan1, P. Scribano1, J. Feudner1, A. Boyan1, E. Zackai1, N. Spinner1, M. Luo1, M. Dulik1, L. Conlin1

1. The Children’s Hospital of Philadelphia

The broad use of single nucleotide polymorphism (SNP) microarrays has increased the chance of identifying individuals with a high percentage of autosomal homozygosity. Total autosomal homozygosity greater than 15 % can be associated with either incestuous (e.g. 1st degree) or non-incestuous consanguineous relationships (e.g. double first cousin). In Pennsylvania, incestuous relationships are illegal and are defined as a relationship between an ancestor and their descendent (e.g. parent and child), siblings (including half-siblings), or uncle/aunt and niece/nephew. When an incestuous relationship is strongly suspected, especially in cases of possible child abuse, reporting is mandatory by law in Pennsylvania and laboratory personnel are considered mandatory reporters by our institution. Since launching the clinical SNP chromosomal microarray test at CHOP, 29 of ~12,000 patients studied (0.25 %) had homozygosity suggestive of a 1st degree relationship with total autosomal homozygosity ranging from 422 Mb (15 %) to 1Gb (36 %). To further investigate whether these findings were due to incestuous relationships, we 1) reviewed patients’ charts to determine if consanguinity was known, 2) assessed whether the mother of the proband is a minor or has intellectual disability, 3) discussed the finding with the ordering clinician to see if abuse is suspected, and 4) guided the clinician to the appropriate teams for further investigation when needed (e.g. department social worker and/or child protective team). Through detailed assessments, we confirmed 7 cases to be incestuous and 8 to be non-incestuous. Of the remaining 14 cases, 6 reported consanguinity, though the exact parental relationship was unclear; 5 had suspected incest and 3 remained uncertain due to lack of information. This experience has led to the formation of a collaborative internal guideline for the laboratory, clinicians, child protective team, and ethics committee for how best to handle these situations consistently, and to provide the best care to patients and families.

Improving pre-test counseling for noninvasive prenatal testing: Women’s enduring misunderstandings after pre-test counseling

L. Little1, B. de Vrijer2, M. Evans1, M. Vanstone3

1. Western University

2. London Health Sciences Centre, Victoria Hospital

3. McMaster University

Objective(s): Noninvasive prenatal testing (NIPT) represents new counseling challenges for both primary and specialist care providers, and few studies have explored patient’s understanding about NIPT after pre-test counseling occurs. The purpose of this study is to improve pre-test counseling by highlighting misunderstandings associated with NIPT and related options. Study methods: A qualitative secondary analysis was conducted on transcribed interviews obtained from a grounded theory study of 38 Canadian women who had personal experience with NIPT. The transcripts were analysed using inductive content analysis to generate final categories focussed on misunderstandings surrounding NIPT. Results: We identified two common categories of misunderstandings about NIPT: 1) expectations surrounding clinical utility and 2) conclusions surrounding clinical and analytical validity. Many women, for example, believed that NIPT would show similar results to current screening methods or considered it as an alternative choice to amniocentesis. Misunderstandings about the clinical and analytical validity of NIPT included confusion around the application of concepts such as accuracy, sensitivity, specificity, false positive results and false negative results. For example, women showed a lack of awareness about positive and negative predictive values and the influence that these calculations have on their own personal results and subsequent decision-making. Conclusion(s): Existing literature emphasizes concepts such as analytic and clinical validity as important pieces to the pre-test counseling process for women considering undergoing NIPT. The findings reveal that these key elements may not be clearly understood by patients even after counseling occurs. Thus, this study highlights additional areas where counselor attention may prevent misunderstandings.

Have you ever Googled a patient? Social media intersects the practice of genetic counseling

N. Omaggio1, L. Conway2, M. Baker1

1. Penn State Hershey Medical Center

2. Arcadia University

Background: The internet provides new opportunities for collecting information about patients via Google, and for interacting with patients via social media tools such as Facebook, LinkedIn and twitter. Currently, few guidelines have been developed regarding social media use or patient-targeted googling (PTG) by professional societies. This study was designed to gain information on how and to what extent genetic counseling students/counselors use social media sites or Google to interact with and/or obtain information on patients. Methods: A link to an online 54-item survey was distributed to genetic counselors using the National Society of Genetic Counselors (NSGC) student research e-blast. Program directors were contacted by email and asked to forward the link to students. Responses were analyzed using descriptive statistics. Results: 423 genetic counseling students/counselors completed the survey. Almost half of the respondents (48.1 %; n = 387) answered that it is never acceptable to interact with people who are current patients via social media sites. However, 27.7 % (n = 397) have visited a patient’s social media site. Gathering information for patient care was the most common reason (76.8 %; n = 56). In regards to PTG, 33 % (n = 394) have searched online for information about a patient; common reasons included curiosity (92.7 %; n = 123), obtaining contact information (23.9 %; n = 72) and to prepare for patient sessions (22.5 %; n = 72). In response to a scenario about recontacting patients regarding variant reclassification, 48.5 % stated it would be acceptable to google a patient to find an address, while 51.5 % stated googling would not be acceptable. Conclusions: Most participants agreed that there should be boundaries between themselves and their patients on social media sites. However, there is significant disagreement regarding when use of online resources is acceptable. Development and dissemination of professional guidelines would be valuable for practicing genetic counselors and for genetic counseling programs to address with their students.

Melanoma risk genetic counseling in children: Engagement and emotional responses

M. Plona1, M. Champine2, W. Kohlmann2, Y. Wu3, T. Stump1

1. University of Utah

2. Huntsman Cancer Institute

3. Department of Family and Preventive Medicine, Division of Public Health

Pre-dispositional genetic counseling for adult-onset conditions in children, though controversial, is beneficial when risk-reduction measures begin in childhood. This study explored the engagement of children from families with CDKN2A/p16 (p16) mutations during both pre- and post-test genetic counseling sessions. Twenty children between 10 and 15 years of age received protocol-guided pre-test genetic counseling including information on the etiology of melanoma, genes and inheritance, impact of p16 mutations on melanoma risk, and the process of genetic testing. Post-test counseling included return of participants’ genetic test results, personalized melanoma risk, sun protective behaviors, and screening recommendations. Audio-recorded sessions were transcribed and coded for verbal participation, themes that emerged from children’s responses, and evaluation of genetic counseling strategies. The average talk ratio of genetic counselor to child utterances in pre-test sessions was 2.07 and in post-test sessions was 2.20. Genetic counselor use of specific, open-ended questions was most effective in eliciting responses compared to more general, closed-ended questions. Children’s responses were categorized into themes such as attitudes (71 %), emotional responses (14 %), reasons for and against genetic testing (8 %), and questions (7 %). Emotional responses expressing concern or fear were primarily about getting blood drawn. The main reasons children cited for wanting to pursue genetic testing were to know if they needed to change their sun protective and screening behaviors. During results disclosure, children expressed excitement and happiness if they tested negative and most had no initial verbal response if they tested positive. They also shared positives attitudes about sun protective behaviors. These findings suggest that children can take an active role in pre-dispositional genetic counseling for adult-onset conditions and are interested in learning about their risks in order to inform their engagement in risk-reducing preventive behaviors.

‘To disclose or not to disclose’: An investigation of counselor self-disclosure in the field of genetic counseling.

B. Volz1, K. Valverde1, S. Robbins1

1. Arcadia University

Self-disclosure (SD) by a genetic counselor (GC) in a session is debated but has not been well studied. This online experimental study compared patient perceptions of unsolicited personal SD to determine if the act of SD or prior knowledge of the GC’s personal experience influenced patient perception of the counselor. Four hypothetical cancer genetic counseling sessions were created with Qualtrics. Each session included a written background scenario and a short video clip. An actor and practicing cancer GC created the videos. Two background scenarios and two video clips were almost identical, differing only on the variable of SD, either disclosing (D) or non-disclosing (N). The four sessions comprised the possible combinations of (D) or (N) background plus video. One hundred twenty three participants, 61 males and 62 females were recruited through Amazon MechanicalTurk and randomly assigned to view one of the four genetic counseling sessions. Participants were asked to rate the counselor-patient relationship using three subscales derived from the Barrett-Lennard Relationship Inventory scale, a tool used to measure the alliance of the client-therapist interaction. An ANOVA showed a significant main effect of the video [F (1, 119) = 8.78, p < .005] influencing participants’ perceptions of the counselor-patient relationship. Participants in groups DD and ND perceived the genetic counselor to have a higher level of regard, empathic understanding, and willingness to be known (M = 88.16, SD = 31.80), compared to groups DN and NN (M = 71.68, SD = 29.94). Analysis revealed a significant background by video interaction, F (1, 119) = 4.09, p < .05, suggesting SD in the background scenario influenced participants’ perception of the overall counselor-patient alliance. This data indicates participants perceived the GC self-disclosing video more favorably in the absence of personal background information, when compared to the presence of this information. Further assessment of SD as a technique to better foster the GC-patient relationship is warranted.

Genetic/Genomic Testing

A single-center experience with clinician interpretation of variants in cardiovascular genetics indicates clinically impactful disagreement with testing laboratories

A. Bland1, K. Dunn1, M. Pariani1, J. Platt1, M. Grove1, C. Caleshu1

1. Stanford Health Care

Introduction: Data sharing has revealed that in a subset of cases there is disagreement between genetic testing labs in their classification of variants. However, the frequency of clinically impactful differences in classifications between labs and clinicians has not been investigated. Aim: We sought to describe the variant interpretation experience of a single cardiovascular genetics center, including frequency of differences in classifications between the clinical team and the genetic testing lab. Methods: We performed a retrospective review of all variants identified through clinical genetic testing done as part of patient evaluations in the Stanford Center for Inherited Cardiovascular Disease between January 2007 and July 2015. The variant classifications of the clinical team and the testing lab were compared. Results: We reviewed 578 variants across 75 genes associated with cardiovascular disease. In a minority of cases (116 variants, 20 %) classification by the clinical team was different from the testing lab (eg. likely pathogenic (LP) or pathogenic (P) vs. variant of uncertain significance (VUS); VUS vs. likely benign (LB) or benign (B)). This rate of discordance is similar to that reported between genetic testing laboratories in the ClinVar database. For 93 % of the discordant variants, the clinical team was more conservative, meaning they were less likely than the lab to consider a variant pathogenic or likely pathogenic (ex. clinical team classification: LP and lab classification: P). Of the 116 discordant variants, 100 (86 %) were medically significant, indicating the difference in classification would affect medical care of the patient and/or family (LP or P vs. VUS, LB, or B). Conclusions: Variant interpretation by clinicians specialized in cardiovascular genetics are discordant from the testing lab’s interpretation at a rate similar to discordance between genetic testing labs. The majority of these disagreements would affect medical management, with the clinicians being less likely than the lab to consider a variant pathogenic or likely pathogenic.

Does the mutation fit the family? Incidental findings from cancer gene panel testing

N. Brown1, J. Mersch1, S. Lahiri1, T. Ross1

1. UT Southwestern Medical Center

Background: The use of hereditary cancer panels to test for cancer predisposition syndromes has become increasingly common. Limited clinical data exist regarding the frequency of incidental mutations identified by panel testing in families who do not have classic features of the mutation-associated genetic syndrome. Methods: Positive test results from hereditary cancer panel tests of UT Southwestern Medical Center patients from 2013 to 2016 were analyzed. We reviewed individuals positive for mutations in APC, BRCA1, BRCA2, MLH1, MSH2, MSH6, PMS2, PTEN, and TP53 to determine whether the family with the mutation met National Comprehensive Cancer Network (NCCN) criteria for genetic testing. Results: A total of 3234 panel tests yielded 217 mutations in the nine genes evaluated. Seventeen (7.8 %) were incidental findings. All incidental findings were identified on pan-cancer panels with the exception of one case identified on a high-risk breast cancer panel. Six of ten (60 %) individuals positive for MSH6 mutations, three of six (50 %) individuals positive for PMS2 mutations, and one of eight (12.5 %) individuals positive for MSH2 mutation did not meet NCCN criteria. Four of nine (60 %) individuals with a TP53 mutation did not meet NCCN criteria. Three of five (60 %) individuals with PTEN mutations did not meet NCCN criteria. In all, 0.5 % of panel tests resulted in incidental findings. All individuals positive on panel testing for BRCA1/2 mutations (n = 162), APC mutations (n = 9), and MLH1 mutations (n = 8) met NCCN criteria for the respective syndrome associated with the mutation. Conclusions: Nearly 8 % of the mutations on hereditary cancer panels were detected incidentally in genes with established NCCN testing criteria. The identification of genes not otherwise suspected by family history can be distressing for the patient, and challenging for the practitioner when recommending appropriate management. Identifying these families can help provide information about potential cancer risks associated with incidental findings.

Genesurance: The mysterious element of genetic counseling

S. Brown1, S. Puumala1, J. Leonhard1, M. Bell1, L. Williamson Dean2, J. Flanagan1, Q. Stein1

1. Sanford Health

2. University of Arkansas for Medical Sciences

While traditional components of genetic counseling sessions are well recognized, less is known about inclusion of insurance and financial topics into a session. In this study, we sought to examine “genesurance counseling” which we defined as: that portion of a genetic counseling session, whether intentional or non-intentional, that is devoted to the topic of costs and insurance/third party coverage (particularly for genetic testing). A 29-question survey was administered to members of the National Society of Genetic Counselor’s listserv with the aim of gathering a consensus and assessment of genetic counselors’ conversations and perspectives related to genesurance counseling. Chi-square tests were used to investigate differences between specialties, impact on patient rapport, and changes in practice dynamics. Overall, an overwhelming 99 % of participants acknowledged conducting genesurance counseling, 87 % believed it to be part of their job description, and 85 % viewed it as an important aspect of genetic counseling. Respondents devoted 10 % of their session, or 6 min, to genesurance conversations representing a significant increase over what they recalled dedicating to this topic 3 years ago (p < 0.0001). Of significance, cancer genetic counselors were more likely to view genesurance counseling as part of their job description (94 %) when compared to pediatric (85 %) and prenatal genetic counselors (79 %) (p < 0.0002). Cancer genetic counselors were also more likely to report genesurance counseling to have positive impact on patient rapport, while prenatal genetic counselors were more likely to report a negative impact (p = 0.0713). Outside of the clinic, cancer and prenatal genetic counselors reported spending 2 h/week on financial/insurance topics, while pediatric genetic counselors reported spending 5 h/week (p < 0.0001). Finally, 77 % of respondents believed that trying to contain healthcare costs is the responsibility of every genetic counselor, though participants also reported finding a balance between containing costs and serving as patient advocates.

We can work it out: Hereditary cancer test utilization management in a large commercial laboratory

L. Cheng1, K. Wilson1, K. Lammers1

1. Quest Diagnostics

Background: Approximately half of physicians and hospitals in the United States are served by Quest Diagnostics (QD). QD was the one of the first laboratories to use Genetic Counselors (GCs) to verify the clinical appropriateness of molecular genetic test orders (TOs) prior to sample analysis. Here we describe our test verification process for the QD hereditary breast cancer assays. Methods: When QD began offering BRCA1/BRCA2 testing in 2013, a new TO verification protocol and insurance preauthorization process were developed. New TOs are reviewed by Special Testing Services Coordinators (STSC) for completeness and to determine if health plan coverage criteria are met. Based on a specific protocol, TOs are sent to GCs for review. If additional information is needed to verify the TO or there is an alternate test code (TC) to consider, a GC contacts the ordering provider. The GC discusses TC options applicable to the patient’s personal and family history and current practice guidelines with the provider, who then determines an appropriate TC. TO revisions are classified as verified, cancelled, modified, or returned to the STSCs for further work. For verified or modified TOs, the case is returned to the STSCs and preauthorization is pursued (if required), or orders move to test analysis. Cost-avoidance was measured for select TO revisions. Results: In a 29 month period, 3065 TOs were sent for GC review. A total of 1241 orders were modified (40.5 %) and 225 orders were cancelled by the client after discussion with a GC (7.3 %). The remainder of orders were verified (1494; 48.7 %) or returned to the STSCs (105; 3.4 %). Total cost-avoidance for TO modification from a multi-gene test to a single site test was calculated at $1,044,600.22, averaging $36,020.70 per month. Conclusions: For our hereditary breast cancer assays, an effective test verification process was developed that uses the expertise of Special Testing Services Coordinators and Genetic Counselors. Almost half of orders reviewed by GCs were modified, resulting in over $1 million in potential cost-avoidance.

Expansion of the laboratory genetic counselors role: Utilization of laboratory-based genetic counselors to build unique patient specific phenotype panels

S. Everhart1, M. Seprish1, K. Cusmano-Ozog1, S. Hofherr1

1. Children’s National Health System

Laboratory-based Genetic Counselors (LBGC) have traditionally participated in roles that involve case coordination, variant interpretation, and result reporting. Expansion of LBGCs roles within sales, marketing, and management have added additional career avenues for LBGCs; however, none of those roles utilize LBCG’s unique skillset of formulating a candidate gene list based on a patient’s phenotype. Whole exome sequencing (WES) has further suggested the decreased need for this expertise. WES has proven to be advantageous in providing diagnosis in rare disease; however, the test is expensive, associated with a lengthy turn-around-time, and raises the possibility of identifying findings unrelated to the patient’s phenotype. As a result, at Children’s National, we employ an additional testing modality that allows our LBGCs to use their specialized skill of formulating a differential gene list to create a personalized phenotype panel, specific to a given patient’s medical history. NGS technology is used to sequence the clinical exome, while bioinformatics software blinds case reviewers to only the personalized gene list created by the LBGC. To validate the diagnostic effectiveness of this approach, a retrospective blinded data analysis of 20 WES cases were reviewed. These WES tests were performed at outside labs and identified the patient’s underlying genetic etiology by reporting a heterozygous pathogenic or likely pathogenic variant in autosomal dominant syndromes or reporting homozygous or compound heterozygous pathogenic or likely pathogenic variants in autosomal recessive syndromes. This analysis revealed that a phenotype driven panel created by a LBGC would have offered the same diagnosis in a faster, more cost-effective manner in 16 of 20 cases. Thus, by applying a LBGC’s skillset to selectively choose candidate genes unique to the patient’s medical history, phenotype-driven panels provide a similar diagnostic value to WES while lowering cost, turn-around-time, and reducing the possibility of secondary findings.

The current and future contributions of genetic counselors in the field of lifestyle direct-to-consumer genetic testing: An exploratory study

H. Green-Morfesi1, K. Levandoski2, T. Field1

1. Boston University School of Medicine

2. Beth Israel Deaconess Medical Center

In the age of personalized healthcare, the range of genetic tests available for the general consumer continues to expand. Consequently, new professional roles for genetic counselors (GCs) emerge. One example is genetic tests that specifically provide lifestyle, or wellness, information and advice. Such testing is usually marketed directly to the consumer and the results, which are accompanied by personalized dietary and/or fitness plans, are based on single nucleotide polymorphisms in genes related to nutrigenomics, obesity, and exercise response. For the purposes of this study, we termed this “lifestyle direct-to-consumer genetic testing” (lifestyle DTC GT). We investigated the current and future role(s) of GCs in lifestyle DTC GT using a mix-methods design. We surveyed 225 GCs to ascertain their opinions on the roles which GCs should, or should not, have related to lifestyle DTC GT. Descriptive statistics were obtained through frequencies, and chi-square analysis was used to determine if belonging to a specific demographic cohort influenced answers to select survey questions. We also interviewed ten GCs and one medical director who have experience with lifestyle DTC GT to understand their roles. Modified grounded theory was utilized in analyzing the interview data. Survey respondents had mixed views on whether GCs should have a role related to lifestyle DTC GT, and only nineteen percent noted interest in related professional responsibilities. However, the survey and interview results determined GC involvement to be essential. GC roles included providing genetics education within a direct-to-consumer company, to other healthcare professionals, and creating relevant educational materials, but did not always include directly counseling a consumer. Our study highlighted the importance of overlap in healthcare professional expertise in order to provide consumers with accurate, helpful information when seeking lifestyle DTC GT. GCs may therefore benefit from related training to ensure the availability of GC expertise in lifestyle DTC GT.

Personal and family history in patients with high penetrance germline findings through paired tumor/normal sequencing

K. Hanson1, V. Raymond1, M. Jacobs1, E. Stoffel1, J. Innis1, D. Robinson1, Y. Wu1, P. Vats1, R. Lonigro1, C. Kumar1, R. Mody1, A. Chinnaiyan1, J. Everett1

1. University of Michigan

Introduction: The Michigan Oncology Sequencing Project (MI-Oncoseq) uses exome sequencing of tumor-normal pairs to identify therapeutic targets. Pathogenic and likely pathogenic (P/LP) germline variants in high or moderate penetrance cancer genes are disclosed. Increased use of tumor sequencing has raised concerns about unanticipated germline findings. We examined correlation between personal history (PHx), family history (FHx) of cancer, and P/LP variants in high penetrance genes. Methods: Adults with refractory tumors and pediatric patients with any cancer are study eligible. Genetic counselor-collected, cancer focused pedigrees were reviewed for patients with P/LP variants in high penetrance cancer genes to determine if genetic testing or clinical criteria were met for the gene/syndrome identified. Results: Between August 2011 and March 2016, 691 patients completed sequencing. Twenty six patients (3.8 %) had a P/LP germline variant associated with an autosomal dominant high penetrance syndrome (AIP, APC, BRCA1, BRCA2, DICER1, FH, MLH1, MSH2, PDGFRB, PTPN11, RB1, RET, SBDS, SMARCA4, SOS1, TP53). 10/26 (38.5 %) had FHx meeting testing criteria, and in 7/10 cases the variant was known from prior testing. An additional 10/26 (38.5 %) had PHx of cancer or other findings associated with the gene identified. 6/26 (23 %) did not meet clinical or testing criteria. Reasons for not meeting criteria included syndromes with non-cancer findings not queried at pedigree collection (3) and mosaicism (1). Two patients had true unanticipated P/LP variants: APC in a patient with hepatocellular carcinoma, and RET in a patient with no PHx/FHx of related cancers. Conclusion: Among patients having tumor-normal sequencing, 3.8 % had a P/LP germline variant in a gene associated with a high penetrance cancer risk syndrome. 77 % of these findings were clinically consistent with PHx/FHx. True unanticipated findings in high penetrance cancer genes were rare in our cohort (2/691; 0.2 %) suggesting that concerns about unanticipated findings are unwarranted when PHx/FHx is collected and considered.

Analysis of downstream revenue generated by a hereditary cancer syndrome diagnosis

J. Huang1, L. Robinson1, T. Ross1

1. UT Southwestern Simmons Comprehensive Cancer Center

Purpose: Evaluation of the economic impact of genetic counselors by analysis of the downstream revenue that results from the identification of individual with Hereditary Breast and Ovarian Cancer (HBOC) and Lynch syndrome (LS). Methods: We identified individuals seen from 1/2013 to 12/2014 who tested positive for a HBOC or LS mutation. Downstream billing data for patients who had all follow-up at our institution were captured through the EPIC billing system through10/2015. The data were filtered to include only revenue for encounters that would not have occurred without a genetic diagnosis. We calculated revenue as expected reimbursement minus direct/indirect costs. Results: Thirty-five patients had HBOC and 10 had LS. Twenty-six had a cancer diagnosis (18 breast, 3 ovarian, 2 colon, 2 uterine, 1 ovarian and uterine) and 19 did not. There were 12 bilateral mastectomies, 7 prophylactic risk-reducing mastectomies, 23 TAH-BSO or BSO, 1 salpingectomy, 5 breast MRIs, 8 colonoscopies, and 7 EGDs. Total downstream revenue was $757,641 ($16,836 per patient). There were 631 outpatient encounters ($1208 per encounter), and 30 inpatient encounters ($-169 per encounter). We estimated the cost of providing counseling as the 2016 NSGC Professional Status Survey base mean salary ($79,195 plus 25 % benefits) divided by an estimated 350 cases per year, equaling $283 per case. From 2013 to 2014, our program saw 1729 patients, for a total counseling cost of $488,458. Downstream revenue provided a 1.69-fold return on investment. This is an underestimate as HBOC and LS patients only represent 60 % of our patients with cancer predisposing mutations. Forty-eight percent (n = 827) of the 1729 patients seen had genetic testing for HBOC or Lynch syndrome. Using Medicare BRCA reimbursement rates ($2767), the total cost of genetic testing was $2,289,416. We estimate a cost savings from cancer prevention due to prophylactic surgeries alone to be $2,371,402. Conclusion: Downstream revenue metrics indicate that genetic counseling programs have a positive economic impact on hospital systems.

BRCA2 mutation carriers may present with primary brain tumors: A review of a multigene panel testing cohort

M. Jackson1, A. Bergner1

1. Ambry Genetics

Background: Primary brain tumors (PBTs) include both benign and malignant tumors occurring within the central nervous system that are not the result of metastasis. The contribution of germline mutations to the development of PBTs is not well understood. Given the increasing opportunity to effectively treat certain types of brain tumors based on underlying genetic mutations, and the potential impact of heritability within the family, exploring the contribution of germline genetic mutations to the development of PBTs is important for appropriate medical management and genetic counseling. Methods: All sequential cases submitted to our laboratory for hereditary cancer panels between March 2012 and December 2015 were retrospectively reviewed. Test request forms indicating at least one PBT for the proband were selected and the detection rate for this cohort was calculated. Analysis of the type of brain tumor, age of diagnosis, genetic test results, and positive gene distribution was conducted. Results: 364 probands were identified with a PBT, including glial tumors (47.8 %), meningiomas (34.3 %), medulloblastomas/PNET (3.0 %), hemangioblastomas (2.5 %), other rare types (1.1 %), and unknown (11.3 %). Of these cases, 52 (14.3 %) harbored a germline mutation. While mutations were identified in 18 genes, BRCA2 was seen in 21.2 % of positives. Mean age of the PBT for BRCA2 cases was 34.1 years (1–66). In more than half, the PBT was the first primary tumor and there was no history of breast, ovarian, or colon cancer at the time of testing. No biallelic BRCA2 mutations, associated with fanconi anemia, were found. Discussion: To our knowledge, this is the largest cohort of individuals with PBTs who have undergone germline genetic testing and the first report of heterozygous BRCA2 germline mutations identified in a cohort of individuals with PBTs. This data suggests that BRCA2 mutation carriers may present with PBTs, which could have important implications for the provision of genetic counseling and test selection. Further studies are needed to clarify this association.

Unexpected findings of germlineCDH1mutations: Implications for counseling regarding clinical management

M. Jacobs1, K. Hanson1, J. Osborne1, M. Marvin1, J. Everett1, E. Koeppe1, E. Stoffel1, H. Appelman1, S. Wong1

1. University of Michigan

Background: Germline mutations in CDH1 are implicated in Hereditary Diffuse Gastric Cancer (HDGC), associated with published lifetime gastric cancer risks of 60–80 %. These risk numbers are derived from families who meet clinical criteria for genetic screening for HDGC. The recent increase in use of multigene panels in clinical cancer genetic testing has resulted in unexpected findings of CDH1 mutations in families who do not meet these criteria. Whether prophylactic total gastrectomy is warranted in the absence of family history (FH) of gastric cancer is controversial and presents a challenge for counseling regarding recommended management. Methods: Medical records, pedigrees, endoscopy reports, and pathology reports were reviewed for all patients with pathogenic germline CDH1 mutations evaluated at the University of Michigan Cancer Genetics Clinic between 1998 and 2015. Results: 18 mutation carriers were identified within 10 families. Only 5 of the 10 families (50 %) met clinical criteria for HDGC. Five mutation carriers (50 %) were identified through multigene panel tests ordered for personal/family history of breast cancer. Thirteen individuals underwent screening upper endoscopies based on positive CDH1 testing. >40 random mucosal biopsies were collected per patient. All had endoscopically normal-appearing gastric mucosa; however 4 had abnormal histology on biopsies. Seven CDH1 carriers (3 with abnormal and 4 with normal biopsies) underwent prophylactic total gastrectomy. In situ multifocal signet ring cell gastric cancer was confirmed in gastrectomy specimens of 4 subjects (1 with normal biopsies). Of the 9 individuals screened whose histories did not meet criteria for HDGC testing, 5 (56 %) had abnormal findings on endoscopy and/or gastric cancer on gastrectomy. Conclusion: The prevalence of CDH1 mutations appears to be higher than previously appreciated and many mutation carriers do not meet current clinical criteria for genetic screening for HDGC. Prophylactic gastrectomy should be considered for CDH1 mutation carriers even in the absence of a FH of DGC.

How narrow the divide: Cross lab concordance for expanded inherited cancer panel genes in ClinVar

M. Judkins1, J. Castiblanco1, S. Candille1, C. Beaumont1, E. Olson1, E. Evans1, I. Haque1, H. Kang1, R. Mar-Heyming1

1. Counsyl

Genetic testing for hereditary cancer syndromes is a fast-growing field with multiple diagnostic laboratories offering large panels for detection of cancer predisposition. Although the American College of Medical Genetics and Genomics (ACMG) has published guidelines for the interpretation of sequence variants, issues such as reduced penetrance, varying phenotypes and inconsistent functional data may result in conflicting variant classifications across laboratories. The extent of conflicting classifications in hereditary cancer genes is not well understood. We analyzed the concordance of ClinVar submissions from 14 laboratories for genes commonly on hereditary cancer panels: APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PALB2, PMS2, PTEN, SMAD4, STK11 and TP53. We did not include BRCA1 and BRCA2 in this analysis as prior comparisons have already been reported. Variants were separated into 2 general categories according to medical management implications: pathogenic and uncertain/benign. Out of 6058 alleles reported to ClinVar, 1682 were classified by two or more laboratories. For each allele, classification concordance was calculated as the percentage of concordant classifications among all possible pairwise comparisons for that allele. The average concordance was 97.9 %. Forty-six alleles had discordant classifications across two or more labs. The majority of discordant variants were either not observed or were low frequency (<0.01 %) in control populations (ExAC). Over half of discordant variants were reported in both cancer cases and functional studies, suggesting that many discordant classifications may be due to different interpretations of data rather than a lack of information. Thirteen of the 46 (28.3 %) alleles with a discordant classification were in TP53 (p < 0.001). Classification concordance for reported variants is very high in inherited cancer genes. Most classification discordance is likely due to lab-specific interpretation and weighting of complex functional and phenotypic data. Public reporting of variant classifications can provide patients and providers with valuable insight into classification origin.

Is bigger always better? Small sequencing panels vs large scale next-generation sequencing panels in genetic testing for arrhythmogenic right ventricular cardiomyopathy

B. Murray1, C. James1, C. Tichnell1, H. Calkins1, D. Judge1

1. Johns Hopkins Hospital

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an autosomal dominant cardiomyopathy most classically due to mutations in the cardiac desmosome. Sensitivity of genetic testing is estimated at 50–60 % for small gene panels sequencing the desmosomal genes (PKP2, DSP, DSC2, and DSG2). Next-generation sequencing (NGS), however, has enabled the development of large 60–100 gene “cardiomyopathy” panels available commercially. Genetic counselors are now faced with a decision to order either small focused panels for their ARVC patients, or large multi-gene panels, which often bring increased variant of uncertain significance (VUS) rates. Hypothesis: We predicted that genetic testing on large NGS panels would increase detection rate of pathogenic variants in individuals undergoing genetic testing for ARVC. Methods: Eighty consecutive individuals enrolled in the Johns Hopkins ARVC Registry who met ARVC clinical diagnostic Task Force Criteria (TFC) underwent genetic testing from 2012-present with the availability of large NGS panels. Results: Of the 80, 32 (40 %) had an identified pathogenic mutation in the 4 desmosomal genes that would have been detected on sequencing through small panels. In addition, however, 7 (8 %) had large deletions/duplications only detected on NGS. Another 11 (14 %) had predicted pathogenic mutations in other cardiomyopathy genes. Therefore, utilizing large NGS panels increased sensitivity to 63 % (50/80). Importantly an additional 4(5 %) had not only a desmosomal mutation that would have been identified on sequencing, but had another pathogenic mutation in a cardiomyopathy gene that would have been missed on a small panel. Conclusions: Genetic counselors today are faced with a myriad of testing options and increasing genes on panels can be daunting considering the known increased rate of VUSs. Therefore, GCs should use available evidence to guide testing presented to patients. This data suggests that utilizing large NGS panels increase the detection rate in families undergoing testing for ARVC, and importantly, identify a small but critical group that have digenic inheritance.

III. Poster Presentations

Access and Service Delivery

Working with the Hmong population in a genetics setting: Genetic counselor perspectives

A. Agather1, J. Rietzler2, C. Reiser2, E. Petty2

1. Medstar Washington Hospital Center

2. University of Wisconsin-Madison

The purpose of this pilot study was to elicit the genetic counselor’s experience working with Hmong patients. The Hmong language lacks words for many familiar Western medical genetic concepts, which may impact genetic counseling sessions with Hmong individuals who have limited English proficiency. To study this interaction, qualitative, semi-structured interview questions were designed around five categories pertaining to genetic counseling sessions with Hmong patients: (1) relevant training during graduate school, (2) session preparation, (3) content of the counseling session, (4) perception of Hmong culture, and (5) reflections on working with Hmong interpreters. Genetic counselors in the three states with the largest population of Hmong individuals (California, Minnesota and Wisconsin) were invited via email to participate in a telephone interview. Eleven counselors’ interviews were transcribed and analyzed for emergent themes. Each of the counselors had served Hmong patients in a variety of clinics and possessed counseling experience ranging from approximately one to greater than 20 years. The genetic counselors identified strengths and challenges in each category. Cultural awareness and education in training programs were highlighted by all genetic counselors as valued components to patient care. All interviewees had worked with professional Hmong medical interpreters, but lacked consensus regarding their expectations for interpreters. To help improve genetic services for Hmong individuals in the United States, we offer suggestions that may help address some of the challenges mentioned and recommend further studies to investigate ways to improve the genetic counselor and interpreter relationship.

Genetic counselor workflow study: The times are they a-changin’?

C. Attard1, E. Carmany1, A. Trepanier1

1. Wayne State University

Genetic services have historically been time and labor intensive. Little information is known about the proportion of time genetic counselors (GC’s) spend face-to-face with patients in comparison to the time spent on patient-related activities (PRA). We aimed to perform a real-time workflow study of GC’s representing multiple clinics and specialties. We developed an electronic collection tool formatted in 15-min increments for real-time documentation of how the GC spent her time throughout the workday for one full week. A task list for the tool was developed through review of the literature and input from GC’s during the piloting phase. Participants were Michigan GC’s identified through the Michigan Association of Genetic Counselors or the NSGC and recruited via email solicitation. Sixteen of an estimated 70 genetic counselors (23 %) representing prenatal, cancer, adult, and pediatric genetics took part by completing a demographic survey and the workflow study. We found that GC’s spent approximately 20 % of their time on direct face-to-face patient care, 64 % on PRA including case preparation, follow-up, and administrative tasks, and 16 % on tasks unrelated to patient care like research and teaching. GC’s saw an average of 10 patients (range: 5–19) per week with an average session length of 47 min (range: 35–53 min). Approximately 2.6 h of PRA were performed for the 0.78 h (47 min) of face-to-face time with the patient. There were no significant differences based on specialty. The most time consuming task in the PRA category was letter writing. Identifying strategies to reduce the amount of time spent on PRA, such as utilizing support staff to perform appropriate tasks, could increase the amount of time GC’s have to spend on direct patient care. Such efforts are critical to help meet the growing demand for genetic counseling services and could also generate increased revenues.

Implementing multiple service delivery models to increase access to care: Experiences of a community genetics program

L. Bucheit1, C. Cropper1

1. Baptist Health System

In 2009, NSGC’s Core Skills Task Force found “in-depth knowledge of healthcare delivery” to be a core genetic counselor (GC) skill indicating GCs are able to develop clinical protocols and assist in marketing. Yet, 2016 Professional Status Survey respondents spent less than 10 % of their time on healthcare administration, clinical coordination, clinical or project management, or marketing. We describe the utility of developing and marketing novel clinical protocols in a community genetics program to increase access to genetic counseling and risk assessment (GCRA) services. The Baptist Health System Genetics Program (BHSGP) employs 2 GCs (1 remote) and receives referrals from local oncology providers. BHSGP launched telegenetics (TG) to provide video-based GCRA in July 2015 at 1 site. BHSGP expanded to offer TG GCRA at 3 sites and in-person GCRA at 2, doubling access points. Expansion has allowed BHSGP to see 5–7 more new patients per month, totaling 119 more new patients yearly compared to volumes prior to TG use. BHSGP also works with nurse navigators (NNs) and launched a Navigation Family History Screen Program (NavFhx) in January 2016. NNs obtain family history of navigated patients with breast cancer diagnosed at accredited breast centers, which BHSGP GCs review against National Comprehensive Cancer Network (NCCN) GCRA-related guidelines. As of 05/06/2016, 37/81(46 %) patients met NCCN criteria for GCRA of whom 28/37(75 %) were not referred by treating providers and may not have been offered GCRA otherwise. BHSGP GCs market to referring providers by participating in tumor boards and leadership committees, visiting offices, giving CME talks, creating collateral, and appearing on local news. BHSGP development and marketing efforts have increased average monthly referrals by 18 % when comparing year-to-year volume with TG launch as a data distinguisher. The BHSGP experience validates GCs are capable of developing creative models to expand impact and highlights benefits of investing in combination approaches of service delivery to increase access to GCRA services.

The newly redesigned genetics home reference website as a genetic counseling aid

H. Collins1, S. Calvo2, K. Greenberg1, L. Forman Neall3, S. Morrison2

1. ICF International

2. U.S. National Library of Medicine

3. Medical Science & Computing, LLC

The Genetics Home Reference team recently debuted a redesigned version of its website (, coinciding with the 13th anniversary of the site’s original launch. A trusted consumer resource from the U.S. National Library of Medicine, Genetics Home Reference has an updated look and feel to help users better access and work with the information provided. The site conveys complex genetic information through more than 2400 plain language condition, gene, and chromosome summaries, and a primer called Help Me Understand Genetics. The newly designed Genetics Home Reference can be a useful aid to genetic counselors throughout the entire counseling process:Before seeing a client, genetic counselors can review health condition summaries on the site to familiarize themselves with conditions that may be discussed during an appointment. In preparation for discussing genetic testing results, the counselor can access gene summaries, which focus on a gene’s normal function and disease relationships. During the counseling session, a genetic counselor can use Genetics Home Reference as a learning aid with the client. The new site is mobile-responsive and can be easily displayed on a variety of devices, such as tablets. Each summary page is divided into sections, which the genetic counselor can open or close depending on the current focus of the session. Additionally, condition summaries contain text-linked images, which can be a useful visual aid in explaining features of a condition. Following the counseling session, a genetic counselor can provide clients with printed versions of Genetics Home Reference summaries. Additionally, a counselor can recommend that clients review the site on their home computer, tablet, or smart phone. The newly redesigned Genetics Home Reference can be useful as a point-of-care reference and counseling aid. We hope that the improvements to the website, such as the addition of hundreds of educational images, mobile responsiveness, and improved navigation, will enhance genetic counselors’ experience using this resource.

Health care access in wisconsin amish and old order mennonite populations: A comparative study

J. Elliott1, S. Romoser2, A. Harris1, C. Seroogy1

1. University of Wisconsin-Madison

2. University of Iowa Hospitals and Clinics

Amish and Old Order Mennonite populations represent growing minority groups in North America. While both groups value similar lifestyles and separatism from mainstream or “English” society, some sects of Old Order Mennonites have access to current technology such as the telephone in the home and motorized vehicles which can be helpful in accessing health care services. Due to founder effects, allele frequencies for many recessive genetic conditions are higher in Plain communities than in the general population, putting families at increased risk for genetic disease. The objective of this study was to determine if any differences exist in access to health care services and/or frequency of complex or unmet medical needs between Wisconsin Amish and Old Order Mennonites. A survey was provided to both Amish and Old Order Mennonite families throughout the state of Wisconsin. Four hundred twenty five surveys were received, representing 2783 individuals, including 2628 children. Old Order Mennonite families were found to have a higher frequency of genetic disease doctor diagnoses when compared to Amish families (31 vs. 12 %, p < 0.0001). Amish families who reported allergic disease were found to have a significantly lower frequency of doctor’s diagnoses for these common conditions including hay fever, food allergies, asthma and eczema (46 vs. 83 %, p < 0.0001), access to genetic carrier screening (8 vs. 45 %, p < 0.0001), and reported access to newborn screening (78 vs. 93 %, p = 0.004) than Old Order Mennonite families. No significant differences were seen in the level of birth defects, hearing loss/speech problems, special needs, or unmet medical needs between the two populations. Our data suggest that Wisconsin Amish families may have less access and availability to health care services than Old Order Mennonite families. Continued efforts towards outreach, education, and alternative, accessible health care models should be implemented to best address these disparities in health care access within Amish communities.

Experiences of genetic counselors practicing in rural areas

M. Emmet1, Q. Stein2, E. Thorpe3, M. Campion1

1. Boston University

2. Sanford Health, Augustana University

3. Illumina

In-person genetic counseling clinics in rural areas are likely to improve access to genetic counseling in underserved regions, but studies have not previously examined how these clinics function or described the experience of practicing in a rural setting. The present mixed-methods study explored the professional experiences of clinical genetic counselors who practice in rural areas, including the benefits and challenges of practicing in these settings and the counselors’ motivations for doing so. The authors surveyed 20 genetic counselors who self-reported working in rural areas and conducted interviews with six individuals whose workplaces were confirmed as rural per RUCA code. Major obstacles to the provision of genetics services in rural areas included travel distance and low referral rates due to lack of awareness or skepticism. Facilitating factors included relying on resources such as professional networks and prioritizing outreach and education. Participants reported high professional satisfaction and were motivated to work in rural areas by personal experiences and qualities of the job such as being a generalist and having greater professional autonomy. These data demonstrate the feasibility of practicing in rural settings and suggest that in-person rural genetic counseling clinics may complement other strategies such as alternative service delivery models in increasing access for rural residents.

Who orders whole exome sequencing and why: Review of 181 preauthorization requests

G. Fraley1, M. Czarniecki1, K. Athman1, J. McLosky1, E. Engel1, A. Trivedi1, R. Sutphen1

1. InformedDNA

Background: Whole exome sequencing (WES) has expanded quickly from research to clinical practice. More recently, its clinical application has broadened even beyond the specialty of genetics. Genetic counselors (GCs) involved in utilization management (UM) have a unique perspective on WES ordering patterns. We reviewed preauthorization requests for whole exome sequencing (WES) from national and regional insurers to assess current WES ordering practices. Methods: We retrospectively analyzed data from 181 unique WES preauthorization requests reviewed by our UM team between June 2015 and March 2016. Cases were reviewed for provider specialty and primary indication for testing. Indications were categorized as: Epilepsy, Intellectual Disability/Autism, Mitochondrial, Musculoskeletal, Neuromuscular, Congenital Anomalies, or Other. Results: 60 % of WES requests were ordered by geneticists and 40 % (72 of 181) by non-genetics specialists. Neurologists were the most frequent non-genetics specialists who ordered WES, at 22.7 % of the requests. Insurers also received requests for WES from a wide variety of other specialties, including: Pediatrics, Dermatology, Allergy/Immunology, Perinatology, Chiropractic, Endocrinology, Hematology/Oncology and Psychiatry. GCs were involved in 22 % of cases ordered by non-genetics specialists. WES was most commonly ordered for Congenital Anomalies (38.1 % of cases), followed by Intellectual Disability/Autism (16.6 %) and Epilepsy (11.0 %). Conclusion: We found that WES is ordered frequently by non-genetics providers, often in the absence of counseling provided by a genetics professional. In addition, some indications, such as isolated intellectual disability without a significant family history, were not strongly suggestive of a genetic etiology. This is contrary to national recommendations. As payers transition to cover WES, identifying ordering patterns can inform discussions of appropriate clinical use of this technology. This research identifies opportunities for expanded provider education, GC collaboration, and public health policy.

“Now what do I do?”: A qualitative study of primary care providers and microarray analysis results of uncertain significance

C. Guy1, E. L Tolma1

1. University of Oklahoma Health Sciences Center

Genetic testing has rapidly advanced in recent years with increased utilization of microarray analysis in a variety of clinical settings, including by non-genetics providers. Unique challenges are faced by all providers when interpreting microarray results; namely the challenge of interpretation of ambiguous results. Traditionally, patients with such genetic test results were referred to genetics specialists. However, accessibility of genetics appointments has decreased. Thus, clinicians with limited genetics training are increasingly providing the clinical interpretation of ambiguous genetic test results. Prior research has explored the impact of microarray analysis on the practice of genetics providers and other specialists. However, the unique experience of primary care providers (PCPs) has not previously been described. This study explored the challenges faced by PCPs when reporting microarray test results of unclear clinical significance and the impact on their clinical practice. Seven semi-structured, individual interviews with PCPs whom have previously received a microarray result of uncertain clinical significance were conducted. Content analysis was conducted by using the qualitative research software NVIVO 9. Themes identified across interviews included: 1. PCPs see value in ordering microarray analysis, even if they do not feel confident in ordering it, 2. PCPs reported that in their experience, parents do not understand microarray analysis results, 3. PCPs use a variety of approaches to inform patients about results, 4. PCPs described the post-microarray analysis test discussions with families as being emotional, with the PCP experiencing a variety of negative feelings, 5. PCPs find the guidance from genetic testing laboratories helpful, such as recommended follow-up and references to prior research. These results provide a deeper understanding of the challenges faced by non-genetics providers and the impact of microarray results on PCP clinical practice. Recommendations for clinical genetics laboratory and genetic counseling practice are described.

Development of tools to determine communication strategies for actionable genes from Clingen’s CADRe working group

M. Hallquist1, A. Buchanan1, K. Ormond2, M. Cho2, A. Faucett5, CADRe Working Group3

1. Geisinger

2. Stanford University

3. ClinGen

As genomic information continues to permeate clinical care across specialties, with varied access to genetics clinicians across the country, genetic testing is increasingly being coordinated by non-genetics clinicians. Yet, many of these clinicians have limited training in communicating the complex ethical, legal, social, medical, and logistical issues (ELSIPlus) that can arise with genetic testing. ClinGen’s Consent and Disclosure Recommendations (CADRe) workgroup is developing tools to improve communication and patient experience of genetic testing, applying the expertise of genetics clinicians to the complex cases for which they are uniquely trained. These tools help ordering clinicians understand the relevant ELSIPlus considerations for a given gene and testing indication so that they can select the most appropriate communication approach for their patient. The CADRe consent and result disclosure rubrics propose three possible communication approaches: traditional genetic counseling with a genetics specialist, targeted discussion with the ordering clinician, or educational materials. These rubrics take into account the following ELSIPlus characteristics of the genetic test or result: complexity of testing, psychosocial impact of testing or diagnosis, potential for sudden death associated with the condition, complexity of management of the condition, and availability of quality educational materials on the test or condition. Based on these characteristics and their knowledge of the patient for whom testing is being considered, clinicians will then decide on their communication approach. Since this is a departure from the traditional approach of routinely recommending pre- and post-test genetic counseling, we are conducting online surveys, focus groups, and in-depth interviews to gather feedback about the consent rubric from stakeholders in the genetic testing process - genetics clinicians, non-genetics clinicians, and individuals who have undergone genetic testing. We hope to foster further professional discussion about this novel approach.

Scalable genetic counseling in the era of whole genome sequencing

W. Kelley1, C. Finnila1, K. East1, M. Amaral1, G. Barsh1, K. Bowling1, M. Cochran1, V. Cooper2, M. Davis2, S. Hiatt1, N. Lamb1, J. Martinez1, R. Myers1, M. Thompson1, W. Watson1, G. Cooper1

1. HudsonAlpha Institute for Biotechnology

2. Alabama Department of Rehabilitation Services

Genetic counseling services are typically provided directly between the genetic counselor and the patient, whether face-to-face or via distance communication. While these models are effective in ensuring positive patient outcomes, they are not easily scalable for a large population. The rising demand for genetic counselors coupled with the increased availability of whole exome/genome sequencing, tests that are traditionally more time- and resource-intensive during informed consent and return of results, highlights a need to explore new models for providing genetic counseling and education. Using lessons learned from participation in the Clinical Sequencing Exploratory Research (CSER) consortium, HudsonAlpha Institute for Biotechnology has partnered with the Alabama Department of Rehabilitation Services to enroll pediatric patients into a whole genome sequencing study seeking to diagnose developmental delay and multiple congenital anomalies. Currently in the pilot phase, this project attempts to decrease geographical and financial barriers to whole genome sequencing research by providing enrollment sites at the patients’ existing Children’s Rehabilitation Service clinics across the state of Alabama. Because this patient population is largely underserved and underinsured, this project also provides an opportunity to increase awareness of and access to genetic and genomic services. Perhaps most importantly, this partnership allows us to explore alternative methods of communicating genetic counseling messages. These methods include but are not limited to distance communication, an interactive patient portal, and the training of non-genetics professionals to support these efforts within the patients’ local clinics. The development of scalable models of genetic counseling and education, specific to the demands and challenges presented by genomic sequencing, allows genetic counselors at HudsonAlpha and beyond to further increase the impact of our valuable and necessary role in medicine.

The establishment of the professional society of genetic counselors in Asia: A report from the genetic counseling pre-conference workshop held at the 11th Asia-Pacific conference on human genetics in Hanoi, Vietnam

M. Laurino1, P. Abad2, B. Cham3, Y. Chu4, S. Kejriwal5, J. Lee6, D. Sternen1, J. Thompson7, K. Leppig8, C. Padilla9, M. Thong10

1. Seattle Cancer Care Alliance and University of the Philippines Manila

2. University of the Philippines Manila

3. KK Women’s and Children’s Hospital, Singapore

4. Queen Mary Hospital, Hong Kong

5. Strand Life Sciences, India

6. Asia Genomics Pte Ltd, Malaysia

7. Provincial Medical Genetics Program, Vancouver

8. Group Health Cooperative, Seattle WA

9. University of the Philippines Manila

10. University of Malaya, Malaysia

The Professional Society of Genetic Counselors in Asia (PSGCA) was recently established as a special interest group (SIG) of the Asia-Pacific Society of Human Genetics (APSHG). With support from the Global Health Genetics Group, the PSGCA was publicly launched during the genetic counseling pre-conference held at the 11th Asia-Pacific Conference on Human Genetics in Hanoi, Viet Nam, September 16, 2015. The PSGCA’s vision is to be the lead organization that advances and mainstreams the genetic counseling profession in Asia, and ensure that all individuals have equal access to genetic counseling services. Its mission is to promote quality genetic counseling services in the Asia region by fostering practice and curricular standards, research and continuing education. As such, the PSGCA will contribute to the expansion of the knowledge base for genetic counselors in Asia through collaborative research and will actively participate in developing culturally appropriate genetic counseling policies.

Evaluation of an online educational tool for carrier screening

J. Lee1, S. O’Neill1, J. Rothstein2, E. Linn3, A. Arjunan4

1. Northwestern University

2. Center for Jewish Genetics

3. Cook County Health & Hospitals System, Northwestern University

4. Center for Jewish Genetics and Counsyl Inc.

Background: Carrier screening has been recommended in the Ashkenazi Jewish (AJ) population since the early 1970s. It is currently estimated that 1 in 4 individuals of AJ ancestry is a carrier of at least one of 19 genetic disorders. As genetic testing technology has become commercially available, the demand for alternate patient educational models has increased. Online learning tools are expanding, are well accepted by patients and effective in increasing knowledge. Purpose: This study sought to better understand motivation for pursuing carrier screening, learn about participants’ opinions of online education and evaluate the effectiveness of online education. Methods: Eighty-eight participants participated in online carrier screening education through The Center for Jewish Genetics in Chicago and were invited to participate in an online survey within a week of completion. The survey included questions regarding motivations for pursing carrier screening and about participants’ experience with the online education. Knowledge was measured through the online education program. Results: Thirty-eight individuals responded to the survey for a response rate of 43.8 %. The highest ranked motivations for pursuing carrier screening were: being informed about pregnancy risks (76 %), and avoiding the birth of a child with a Jewish genetic disorder (70 %). The online education program was ranked highly with 97 % of participants feeling satisfied with the presentation and completeness of information. Knowledge increase was also measured via pre- and post-test quizzes and an increase of 16.1 percentage points was observed. (p < 0.001). Conclusion: Participants indicated high levels of satisfaction with the online education. In addition, knowledge gain was significant showing the effectiveness of the education. These results are extremely positive for The Center for Jewish Genetics and suggest that alternative educational models such as this program can be used for pre-test genetics education.

Scaling genetic counseling: A human-centered approach to creating an electronic genetic counselor platform

E. Levin1

1. Helix

Background: There are not enough genetic counselors (GCs) to meet the expanding genetic testing market demand, increasing wait times, and potentially negatively impacting both the patient and genetic counselor experience. To address this challenge, the Icahn School of Medicine at Mount Sinai sponsored an interaction design project to lead a 3-phase project to discover opportunities for developing a scalable platform that will help genetic counselors, patients, labs, and ordering providers and enhance the overall genetic/genomic testing experience. Design: The project applied a qualitative, human-centered design approach to assess the current challenges and opportunities around prenatal carrier screening. Phase 1: Collaborate with key stakeholders to create concept sketches. Phase 2: Conduct deep, in-person user interviews with patients and/or couples who had gone through prenatal carrier screening in the previous 12 months as well as genetic counselors in both the clinic and lab. Phase 3: Design user experience architecture and key workflows based on iterative user feedback. Outcomes: Four main areas were identified for deep study: Automate and enhance workforce efficiencies; centralize data aggregation and documentation; enable on-demand information access and transparency; and improve user experience for all stakeholders. Conclusions: GCs are overloaded with logistics and repetitive tasks that steal time from actual counseling. Patients bounce back and forth across stakeholders almost at every step, creating an anxiety-inducing process in which they do not feel in control. As a result, the design team focused on creating two “experiences”. The Patient Experience is a scalable, institution-agnostic self-serviceexperience curated by the GCs. The Genetic Counseling Experience, is a primary tool to help stage the patient’s journey and streamline operational workflows. Designs were created, tested, and iterated with both stakeholder groups to yield a detailed framework for software execution.

The production of prenatal genetic testing educational videos for patients

H. Lindh1, D. Lochner Doyle2, K. Stoll1

1. Genetic Support Foundation

2. Washington State Department of Health

Recent guidelines from the American College of Obstetricians & Gynecologists and Society for Maternal-Fetal Medicine recommend that all women be offered options for prenatal screening and diagnosis. Decisions about these testing options should be based on informed patient choice, and congruent with the individual needs and values of each patient. Women are now faced with decisions regarding an increasingly complex variety of prenatal tests, so there is a critical need for resources to facilitate education and values clarification regarding these tests. The Washington Department of Health (DOH) together with independent nonprofit, Genetic Support Foundation (GSF), produced a series of seven videos regarding prenatal genetic testing options. These videos became publically available in the spring of 2016. The series includes: 1) How to Decide About Prenatal Genetic Testing, 2) Conditions Commonly Tested for During Pregnancy, 3) Prenatal Cell-Free DNA Screening, 4) Traditional Maternal Serum Screening, 5) Prenatal Ultrasound, 6) Chorionic Villus Sampling, and 7) Amniocentesis. Script and storyboard development involved extensive audience testing with the intended audience of women of reproductive age as well as key stakeholders including healthcare professionals, parents of children with genetic conditions, and leaders from advocacy groups. Scripts were written with careful selection of neutral language. Reading level was assessed and lowered by shortening sentence structure and reducing medical jargon while recognizing the necessity of some complex medical words. For all seven videos, the review process led to significant script and storyboard changes, including a complete script and storyboard revision for one video based on the audience responses. This presentation will focus on the valuable lessons learned in producing educational materials for the general public and will incorporate data regarding uptake of the materials since they were launched.

The changing landscape of genetic counselors licensed in Washington state (2011–2015)

A. Mackison1, K. Stoll1

1. Genetic Support Foundation

Washington state began licensing genetic counselors in December 2010. In the 5 years Washington state has been licensing genetic counselors, there have been significant changes in the licensed workforce including the number of genetic counselors, the proportion who reside out-of-state, and the percentage who work in a clinical setting. We requested a list of licensed genetic counselors from the Washington state Department of Health in November 2015. Using this data and independent research through online resources and direct contact with genetic counselors via email correspondence, we compare changes in the licensed workforce after the first full year of licensure, December 2011, and November 2015. Trends show a 191 % increase in licensed genetic counselors during the 4 year period (78 in 2011 versus 149 total licensed in 2015). During this time, an increasing percentage of genetic counselors holding license in Washington state reside in states other than Washington. In 2011, approximately 10 % of the genetic counselors lived outside of WA when they were licensed. In 2015, 40 % were out-of-state. Additionally, a larger proportion of genetic counselors were employed by commercial laboratories in 2015 compared to 2011. In 2011, 22 % of genetic counselors licensed in Washington worked for a commercial laboratory. In 2015 42 % were employed by a commercial laboratory. There has been an increase in the number of genetic counselors holding clinical positions (47 in 2011 and 62 in 2015) however, there has been a decrease in the proportion of licensed counselors employed in a clinical setting (60 % in 2011 and 42 % in 2015).

Supporting young adults with neuromuscular disease with a new transitions tool

A. McArthur1, S. Gandomi2, L. Morgenroth3

1. Muscular Dystrophy Association

2. Invitae

3. Children’s National Health System

Neuromuscular disorders (NMD) refer to a group of rare genetic diseases that cause significant muscle weakness and, when of early onset, can impair early motor development and severely impact health. The overall prevalence may well exceed 1 in 3000 and have been determined to be more common than previously reported. Biomedical progress over the last few decades has brought about advances in the medical management of these individuals. As a result, young adults with NMDs, who previously did not survive beyond their teens, are now living well into their third decade. Living longer, however, is coupled with higher risk of life-threatening, debilitating, and costly illness. The risk for poor health-related outcomes and higher health-related costs is heightened during the transition from pediatric to adult healthcare. Adult healthcare providers have limited knowledge of rare pediatric onset diagnoses and associated complications, and youth with NMDs are poorly equipped to navigate the adult healthcare system. Information and guidance supporting optimal healthcare transitions for NMDs is lacking, for example no markers of successful transition from pediatric to adult healthcare for youth with NMD exist. To meet the evolving needs of patients ages 16–26, the Muscular Dystrophy Association (MDA) is starting an effort designed to provide patients and clinicians with vital resources necessary to ease through the process of exiting the pediatric-based system while simultaneously integrating them into an adult-focused clinic. MDA is creating a Transitions Checklist, an interactive patient-directed tool that supports patients and clinicians in meeting key developmental milestones. Working closer with genetic counselors is an opportunity to identify issues relating to genetic testing, diagnostic processes, family planning, and anticipatory guidance that may not always be adequately addressed by managing physicians. This presentation will allow for a forum to discuss the key challenges and opportunities for genetic counselors working with this population.

Genetic counseling services in a patient centered medical home

P. Robbins-Furman1, S. Marton1, H. Schwarzwald1, A. Suhag1, L. Hollier1

1. Baylor College of Medicine

A patient centered medical home is a partnership between patients, providers, other specialists and the community. The American Academy of Pediatrics introduced the concept of a pediatric medical home in 1967. An obstetric medical home is a recent phenomenon with Texas Children’s Health Plan, The Center for Children and Women receiving designation as a pilot pregnancy medical home in 2014. The Center for Children and Women provide primary care to underserved populations in a large metropolitan area. Along with primary pediatric and obstetric care; MFM consultation, optometry, behavior health, nutrition, pharmacy, laboratory, dentistry, speech therapy and radiology services are also available. Genetic counseling services were included in The Center’s concept from the beginning. We report on the experience of providing genetic counseling services in this new model of primary care. Referral indications from the pediatric providers have been varied, with developmental delay/ autism being the most common. In conjunction with the pediatric provider, the genetic counselor orders baseline labs such as fragile X and chromosome microarray. Patients are then referred to genetics clinic with baseline testing results, pedigree and history already in the electronic medical record. This allows the geneticist to immediately go to next tier testing and evaluations. Traditional prenatal counseling and diagnostic procedures are also available at The Center. Patients needing a higher level of diagnostics such as fetal MRI or fetal intervention strategies are referred to our tertiary center. Since opening 3 years ago, over 700 prenatal patients and 70 pediatric patients have been referred to the genetic counselor. The vast majority of these patients were able to obtain all services in this community setting. Previously identified barriers to care such as wait time for specialty appointments and distance to specialty clinics can be avoided by providing this alternative delivery model in the community.

A qualitative evaluation of the Pennsylvania department of health Down syndrome fact sheet

E. Royer1, L. Medne2, C. Fels3, K. Valverde1

1. Arcadia University

2. Children’s Hospital of Philadelphia

3. GenPath Diagnostics

Twelve states have passed laws requiring health care providers distribute state-approved informational materials to parents at the time the diagnosis of Down syndromeis made. Unlike other states that use existing family-friendly literature, the Pennsylvania Department of Health (PA DOH) created its own PA DS factsheet. The purpose of this qualitative study was to gather the opinions of potential recipients of the PA DS factsheet. Adults between 18 and 44 years old were recruited via Facebook to participate in semi-structured interviews. Fourteen individuals responded to this recruitment posting; 12 individuals completed interviews including 11 females and one male. The interview prompts were modeled after Van Someren’s Think Aloud Method and the National Institutes of Health’s “Clear & Simple” guide for evaluating written patient educational materials. The sessions were audio recorded, transcribed, and coded using thematic and content analysis. Interviews were discontinued when saturation was reached. All participants reported that the fact sheet provided a mix of familiar and unfamiliar information. Everyone had positive reactions to the photo of a boy with DS. 100 % reported that the fact sheet would be helpful in learning about DS, but 9/12 stated that the information was not entirely useful. 11/12 participants reported that the GI section was confusing and many terms used were unfamiliar. The description of nondisjunction and the resulting chromosome number was unclear to some participants, one participant said “a lot of numbers, it’s like I was reading a math problem.” 25 % felt that the discussion of the medical conditions associated with DS was “scary” or “discouraging.” The PA DOH revised this factsheet independently of this study. However, the concerns of the study participants were not addressed, including adding culturally diverse photos of children with DS and a discussion of the lived experience. These results provide a starting point for future study and may inform future revisions of the fact sheet.

International genetic telehealth: A case series demonstrating value in rare disease diagnosis

J. Ruschman1, C. Prada1, R. Mena1

1. Cincinnati Children’s Hospital Medical Center

An international collaboration between Cincinnati Children’s Hospital Medical Center and the Centro de Obstetricia y Ginecologia in Santo Domingo, Dominican Republic has demonstrated the value of telehealth in genetic disease diagnosis in pediatrics. Many countries lack access to genetic and genetic counseling expertise. Two providers set out to address this issue by forming an international telehealth collaboration. The physicians designed a low cost telehealth solution that connected pediatric genetics expert to the patients, families, and the treating pediatrician in the Dominican. Early results indicate this is an effective way to diagnose complex genetic disease using telehealth, and to allow for most patients to be treated in country for their condition. Pediatric patients with a variety of rare conditions have been seen by genetics experts and have received diagnosis and treatment recommendations because of this program. There is no geneticist available within country, and over a 1 year wait to see a geneticist in nearby country. Provider satisfaction scores are >90 % positive. Patient scores, while more limited, are also overwhelmingly positive. Case details will include not only new cases, where telemedicine has been used to diagnose patients with disorders including Costello syndrome, Hunter syndrome and marfan syndrome, but also ongoing management and genetic counseling for conditions including NF1, MPS, and mosaic trisomy. Using telemedicine we can connect specialists with local treating physicians to improve access to pediatric specialty consultations. These consultations, even internationally, can result in the local diagnosis and often improved treatment of patients in developing countries at a far lower cost than travel for diagnostic work-ups. However, there are still local challenges genetics professional should be aware of with available treatments and ethical considerations for identifying cases where diagnosis will lead to improve health outcomes for patients locally.

Diagnostic yield using next generation sequencing techniques in the hearing loss population

I. Shepard1, N. Meeks2, P. Yoon2, K. Kocsis2

1. University of Colorado Denver

2. Children’s Hospital Colorado

Objective: Hearing loss is the most common sensory birth defect affecting 2–3 in 1000 newborns and it is currently estimated that greater the 50 % of hearing loss is due to an underlying genetic etiology. Due to the complex genetic heterogeneity in hearing loss, comprehensive genetic screening using next generation sequencing (NGS) is the preferred approach for molecular diagnosis. It is important to review the results of NGS in a defined hearing loss population so that genetic counselors and other health professionals who evaluate such individuals can give more accurate detection estimates using NGS genetic testing options. Methods: A retrospective chart review was performed on a cohort of 167 patients with confirmed hearing loss and previous NGS-based panel testing results. Data was analyzed for diagnostic yield based on clinical features. Results: Testing resulted in identification of the underlying genetic basis for hearing loss in 78 patients. A total of 23 genes were found to be implicated in the hearing loss process in this study with an overall diagnostic yield of 46.7 %. This diagnostic yield was increased in patients presenting with sensorineural hearing loss (SNHL) and bilateral hearing loss to 49 % and 49.7 %, respectively. Conclusions: This data provides health care professionals, including genetic counselors, accurate diagnostic yield estimates when counseling patients considering this testing. This study supports the use of NGS-based panels as a first tier test for patients with bilateral hearing loss saving money and unnecessary evaluations in the diagnostic process for patients. The results from this testing may allow further counseling regarding prognostic information in cases where known genotype-phenotype information is available, accurate recurrence risk information, and in some circumstances, impact medical management.

Weathering the storm: Genetic counselor satisfaction in the age of genomic medicine

C. Spaeth1, A. Kushner1, M. Vierling1, K. Healy1

1. Cincinnati Children’s Hospital Medical Center

A recent study showed that 65 % of genetic counselors saw an increase in patient volume from 2012 to 2014. As demand increases, maximizing job satisfaction of highly skilled and experienced genetic counselors becomes critical for retention. The purpose of this project was to identify drivers of job satisfaction and to develop interventions to improve genetic counselor retention. Two interviews were conducted with each genetic counselor in our division using unique semi-structured interview guides. Business team interviews focused on job responsibilities performed during and outside of clinic; stay interviews with the clinical manager explored areas of job satisfaction. Results were analyzed using descriptive statistics and compiled across interviews to develop themes. Genetic counselors reported spending as much time on tasks outside clinic as in direct patient interactions and felt over-burdened with desk responsibilities. Further exploration determined that some of these tasks, such as faxing or tracking insurance preauthorization, could be delegated to administrative staff. Work relationships and environment were identified as key contributors to job satisfaction, whereas time spent on insurance issues was a common reason for job dissatisfaction. With the support of the business team, genetic counselors were able to successfully obtain more administrative support. Interventions intended to support job satisfaction include providing structured feedback to physician colleagues, mentoring programs for less experienced genetic counselors, monthly peer supervision meetings and designating chairs to organize social activities. Next steps include assessments to determine which interventions effectively improved job satisfaction. This project demonstrates that engagement of the business team is critical to help identify key factors associated with genetic counselor job satisfaction to promote implementation of successful interventions to maximize retention.

Increasing awareness of genetic counseling: A lesson plan for high school biology teachers

S. Turner1, A. Trepanier2

1. Geisinger Health System

2. Wayne State University School of Medicine.

There are currently more genetic counseling positions available than there are genetic counselors (GCs) to fill them, necessitating an expansion of the workforce. One step in expansion is to increase awareness of genetic counseling as a career option. Students begin considering career options in high school; however, a majority of GCs do not learn about the career until late in their undergraduate education or after. High school teachers are a potential source of career information but often lack the time to present careers due to rigorous curriculum requirements. The purpose of this project was to develop and evaluate two lesson plans that meet genetics curriculum objectives while simultaneously introducing genetic counseling as a career option. The lesson plans were developed in consultation with several high school biology and genetics educators using the Biological Sciences Curriculum Study (BSCS) 5E instructional model. The curriculum objectives were aligned with both the Michigan High School Content Expectations (Biology) and the newer Michigan Science Standards. Michigan has been recognized nationally for the quality of these standards. The plans were developed around case studies for sickle cell anemia and cystic fibrosis, diseases relevant in the context of both newborn and carrier screening. Each lesson plan includes a PowerPoint presentation, detailed instructor notes, instructions on pedigree drawing, and assignments. Nine teachers evaluated the lesson plans via an online assessment tool. Eight of the 9 indicated that they would use the lesson plan; all respondents felt their students would be interested in the plans and that they aligned with standards. Minor suggestions for improvements were provided by 2 respondents. Our next step is to broadly disseminate the plans; we will also continue to evaluate their utility. The overarching goal is that utilization in high school classrooms will increase awareness of the genetic counseling profession.

Adults are not big kids: Adults undergoing whole exome sequencing represent a unique clinical population

R. Willaert1, S. DeWard1, K. Retterer1, A. Crunk1, J. Juusola1

1. GeneDx

The diagnostic yield for whole exome sequencing (WES) ranges from 22 to 28 %, and is affected by clinical indication, age of the proband, and analysis of proband-only versus trio cases. The adult population presents unique diagnostic challenges both in the clinic and in the laboratory. Adults accounted for 19.8 % (1874/9464) of the total cases completed in our laboratory by March of 2016. The most common diagnoses in adults 30 and over were fatigue (33.4 %), muscle weakness (29.5 %), and migraine (20.4 %). In contrast, the most common diagnoses in pediatric cases, aged less than 18, were generalized hypotonia (34.8 %), developmental delay (33.3 %), and seizures (25.3 %). Phenotypic features of adults 18–29 years were a blend of those seen in the other age groups. The diagnostic rate of WES was 17.8 % in adults, which was significantly lower than 27.6 % for pediatric cases (p < 0.0001). Dividing the adults further, the positive rate in adults 18–29 years was 24.3 %, but decreased to 12.9 % (p < 0.0001) in probands 30 years or older. The majority (72 %) of pediatric cases were submitted and analyzed as traditional trios, defined as a case including a proband and both biological parents, while only 41 % of adult WES cases were trios. In contrast to the higher positive rate of WES trios (29 %) compared to proband-only (21 %) in the pediatric population, there was no significant difference in adults. Proband-only testing in young adults 18–29 years provided a definitive result in 24.8 %, and trio testing in 25.4 % (p = 0.9147). Similarly, among adults ages 30 years and older, there was no difference in diagnostic rate when comparing proband-only cases (13.7 %) to traditional trios (14.5 %, p = 0.7494). Our data demonstrate that adult WES probands, specifically those over 30 years of age, have different clinical features and detection rates than pediatric cases. Adult probands also benefit less from the trio approach.

Utility of a patient-facing family health history assessment tool to refer patients for genetic evaluation

L. Baumgart1, S. Walters2, J. Silverstein2, W. Knaus1

1. NantHealth, LLC

2. NorthShore University HealthSystem

Guidelines and evidence-based literature that aid in identifying elevated risk for cancer based on personal and family health history are complex and continuously changing, hindering use, especially in primary care. This results in unrecognized risk and lost opportunity to refer patients who may benefit from genetic services. To address this need, we developed Health Heritage (HH), a patient-facing web-based tool that combines data automatically extracted from electronic medical records with data entered by patients and shared between family members. Its evidence-based risk engine stratifies risk for common cancers and provides personalized recommendations to the patient, such as referral to a medical genetics and/or high-risk breast clinic. HH has been available (free) to patients at NorthShore University HealthSystem since May 2014 via a link in the patient portal. No other support or follow-up was provided. We queried the HH database to group patients based on who did or did not receive an HH referral and who did or did not generate a risk assessment, and queried NorthShore’s data warehouse to determine encounter rates in the clinics. Through April 2016, 3202 patients registered for HH. 1273 users generated a risk assessment, and 441 who never had an encounter with either clinic were referred by HH based on elevated risk; of these, 35 (7.9 %) have now had their first encounter. For those who generated a risk assessment but were not referred by HH for further evaluation, 7 (0.9 %) had their first encounter after their assessment. For those who have not yet generated an assessment, 32 (1.7 %) had their first encounter after registering for HH. In this implementation of HH, previously unrecognized at-risk patients pursued genetic evaluation after receiving a referral from HH with a decrease in encounters for lower risk individuals. When linked to a comprehensive individualized follow-up system, Health Heritage may identify and increase appropriate referrals for genetic evaluation without the need for specialized training of primary care and non-genetic specialists.

Genetic testing for hereditary cancer predisposition: When can a targeted discussion with a non-genetics clinician provide adequate consent?

A. Buchanan1, M. Hallquist1, A. Faucett1, M. Cho2, K. Ormond2, CADRe Working Group3

1. Geisinger

2. Stanford University

3. ClinGen

Non-genetics clinicians are increasingly coordinating germline genetic testing in oncology care. These clinicians may have limited training in the complex ethical, legal, social, medical, and logistical issues that can arise. The ClinGen Consent and Disclosure (CADRe) workgroup has developed a rubric to improve physicians’ communication and patients’ experience by identifying the appropriate communication strategy at the time of consent—traditional genetic counseling, targeted discussion with ordering clinician, or educational materials—based on the nature of the gene being tested. Using snowball recruitment, we conducted a formative evaluation to assess how 28 cancer genetics professionals responded to the recommendations for specific examples. Participants in the anonymous online survey were asked to consider the CADRe-recommended communication approaches for common testing indications for three cancer predisposition genes. For TP53, over 73 % agreed with the CADRe rubric recommendation of traditional genetic counseling for all indications. For MLH1 and CDH1, 60 % of participants agreed with the CADRe recommendation for a targeted discussion by a knowledgeable and comfortable ordering clinician for confirmatory testing, familial variant testing, and positive tumor screen (MLH1 only). Participants disagreed with the CADRe rubric recommendation for MLH1 (57 % disagreed) and CDH1 (68 % disagreed) when the consultand was unaffected with no available proband; participants indicated that traditional genetic counseling was most appropriate due to the complexity of counseling, conveying residual risk with a negative result, and implications for the family. Results show general agreement that consent for genetic testing could be completed by a non-genetics clinician in many situations. We plan to discuss the concepts that underlie adequate pretest counseling, to differentiate optimal and adequate counseling approaches, and to continue development of a model that will allow genetics and non-genetic clinicians to apply their expertise to the complex cases in their fields.

Attitudes about the use of internet support groups and the impact among parents of children with Cornelia de Lange syndrome

C. Cacioppo1, L. Conway1, D. Mehta2, I. Krantz2, S. Noon2

1. Arcadia University

2. The Children’s Hospital of Philadelphia

While many studies have assessed patient experiences with Internet support groups (ISGs), information is lacking regarding experience with ISGs in a rare disease population. ISGs could benefit this population that is often at a disadvantage for resources, reliable information, and support. The aim of the current study was to explore the experiences with ISGs for parents of children with Cornelia de Lange syndrome (CdLS), a rare genetic diagnosis, in order to better understand the impact on emotional support and their child’s medical care. An internet survey was distributed via email and postings on social media websites related to CdLS. The survey asked parents closed- and open-ended questions regarding experiences with ISGs, with a focus on the psychosocial, medical, and logistical aspects. Data was analyzed with descriptive statistics and qualitative coding for themes. Most respondents (141/170, 82.6 %) have visited an Internet-based support group to find support or information about their child’s CdLS diagnosis. The majority of respondents (84/117, 71.7 %) also reported that ISGs have been helpful in finding emotional support, with the most common areas impacted as a result of ISG participation being behavior toward their children and family dynamic. Regarding medical care, most respondents (76/119, 63.9 %) reported that ISGs have been helpful in finding medical information and support, with the most commonly impacted areas of their child’s care including day-to-day management, diet, therapy interventions, and healthcare providers. Although negative aspects were noted, such as discouraging or confusing information and lack of support for mildly affected individuals and siblings, more respondents considered the experience with ISGs to be positive (69/109, 63 %) than negative or mixed (40/109, 37 %; p = 0.005). These findings provide a greater understanding of the role of Internet networking in healthcare and may inform future approaches to medical care and psychosocial support for rare, complex genetic diagnoses.

Video-assisted genetic counseling in patients with ovarian, fallopian and peritoneal cancer

R. Covington1, L. Bokovitz1

1. West Cancer Center

Offering BRCA1/2 testing to patients with epithelial ovarian, primary peritoneal and fallopian tube carcinoma is considered standard of care by National Comprehensive Cancer Network, American Society of Clinical Oncology and Society of Gynecologic Oncology; however, national testing rates fall short at 14–25 %. Reasons for this discrepancy may include lack of guideline awareness and limited access to genetic counseling services, particularly in rural locations. To address this deficit and explore supplements to the traditional in-person genetic counseling model, our high volume oncology clinic utilized a 7 min video created by a genetic counselor to assist in pre-test education and consent of appropriate patients. At the gynecologic oncologist’s discretion, patients were consented after watching the video and submitted a blood sample for testing that same day. Patients were given the option of BRCA1/2 testing with reflex to a multi-gene panel. The genetic counselors on staff received all test results and performed results disclosure via phone call. Patients with deleterious mutations were referred for in-person genetic counseling to discuss results implications in further detail. Patients with negative or uncertain test results were mailed a summary letter highlighting limitations of testing and medical management recommendations. A retrospective review after approximately 5 months revealed a statistically significant increase in patients who received genetic testing. However, we plan to further evaluate this model of service delivery in a randomized prospective trial. Primary outcomes will include time to testing, patient understanding and adherence to national guidelines. The study will aim to assess patient understanding, adherence to national guidelines and identify who might benefit the most from in-person pre-test counseling. While there are significant limitations to using a standardized video to aid in pre-test counseling as opposed to a personalized in-person session, the growing demand for genetic counseling services and test results for treatment decisions requires an exploration of supplemental delivery models.

Utilizing contracted telephone genetic counseling services within an established cancer genetic counseling clinic: benefits and drawbacks

D. Cox1, D. Collins1

1. University of Kansas Cancer Center

Genetic counseling is in high demand as insurance companies may require counseling prior to testing and an increase in patient demand. It can be difficult to provide timely access to genetic counseling. To provide quicker access our facility contracted with a telephone-based genetic counselor (GC) service. This service utilizes GCs who send a three-generation pedigree, recommendations, and a filled-out requisition form, if testing is recommended. The facility then coordinates the blood-draw and shipment of blood. The contracted GC informs the patient of results. Benefits to utilizing this service include more access for individuals in remote/rural locations and shortened wait time for appointments. A drawback was additional screening/testing desired by the contracted GC prior to genetic testing (additional colorectal tumor testing, dermatology evaluations, or family member to seek genetic testing first). The expectation was that the patient would arrange the evaluation, and then call back for an appointment. However, no follow-up was performed by the contracted GC and these patients did not call back. There were also differences in testing practices between the contracted GCs and our GCs. The contracted GCs typically chose single gene testing while our GCs chose panel testing, leading to different levels of testing. The logistics of testing (blood draw/test kit) was another drawback and labs that arrange remote draws were rarely utilized. Positive results weren’t consistently reported to our GCs for screening/follow-up, leading to inconsistent services at our facility. Hiring GCs for increased patient demand takes time; contracted GCs can help with this demand in the interim. Contracted GCs provide timely access in remote locations and lessen the burden on clinics in need of additional GCs. However, additional screening requests, test practices, blood draws and follow-up for those with positive results are concerns. These services can be helpful for overburdened clinics while they are attempting to hire additional GCs but may not be an ideal long term solution.

Establishing a multidisciplinary hereditary cancer risk management clinic

A. Forsha1, G. Fasaye1, K. Calzone2, C. Hamilton1, C. Turner1

1. Walter Reed National Military Medical Center

2. National Cancer Institute, National Institutes of Health

Introduction: Multi-gene panel testing has led to increasing numbers of patients identified with pathogenic mutations in cancer susceptibility genes. These individuals require psychosocial support and education about cancer risk, cancer screening recommendations, risk reducing surgery options, and testing at-risk relatives. To improve long-term care continuity, a Cancer Risk Management Clinic (CRMC) was created for mutation carriers. Methods: CRMC utilizes a multidisciplinary approach to address the scope of cancers and cancer risk management strategies for mutation carriers. Providers serving the clinic include breast surgeons, gynecological oncologists, and gastroenterologists. CRMC encounters begin with provider case reviews lead by a genetic nurse and a genetic counselor who provide education about gene specific cancer risks and available evidence based management guidelines. Pedigrees are reviewed and updated at each visit to ensure that family history of cancer is always incorporated in the personalized approach to risk management. CRMC offers patients examinations, imaging referrals and discussions about surgical options. Risk reducing surgery outcomes are addressed including fertility and menopause concerns. Results: In 2015, 78 women were followed in the CRMC with pathogenic or likely pathogenic mutations in the following genes: 28 BRCA1; 19 BRCA2; 8 MSH2; 4 MSH6; 3 MLH1; 2 PMS2; 3 CHEK2; 2 PALB2; 3 RAD51D; 1 ATM; 1 BRIP1; 1 PTCH1; 1 PTEN; 1 STK11; and 1 TP53. Eight women with gene variants of uncertain significance were also seen in the CRMC because their clinical and/or family history is suggestive of hereditary cancer susceptibility. Conclusions: Genetic counselors and genetic nurses play integral roles in multidisciplinary high risk cancer clinics. The CRMC allows patients to have access to providers knowledgeable about their genetic condition. This approach ensures patients receive a coordinated plan of care, which optimizes early detection strategies, encourages dialogue amongst providers, and streamlines patients’ appointments.

Client perspectives on the utilization of genetic services in a community-based hereditary cancer screening program

S. Greenberg1, I. Miller1, B. Yashar1, M. Pearlman1, D. Duquette2, K. Milliron1, M. Marvin1

1. University of Michigan

2. Michigan Department of Health and Human Services

The large underserved populations that do not receive appropriate BRCA1/2 cancer genetic services requires developing new ways of identifying and referring high risk clients in community-based settings. Planned Parenthood Federation of America developed a novel tool, the Breast Cancer Risk Screening Questionnaire (BRSQ), based on 2012 National Comprehensive Cancer Network guidelines, for identification of their at-risk clients. This research sought to define motivators and barriers to the utilization of cancer genetic counseling services by women BRSQ-identified as high Planned Parenthood of Mid and South Michigan (PPMSM) Between September and December 2015, BRSQ-positive women identified during well-women care visits at PPMSM centers were asked by their clinician to complete a 10-item paper survey exploring demographics, interest in and likeliness to seek genetic services, as well as factors that impacted their utilization of genetic services. Descriptive, means comparisons, and factor analyses identified common themes, motivators, and barriers. Of the 109 women who completed the survey, 79.5 % expressed interest in learning more about their inherited cancer risk while 76.7 % reported intent to seek genetic counseling with increased likelihood for clients from wealthier counties (p = 0.08). The most commonly identified motivators were desire to know future cancer risk (79.8 %), the benefit to their family (68.8 %), and the impact of genetic information on health care decision-making (63.3 %). This cluster of motivators was statistically significant compared to other motivator groupings (p < 0.001). The most commonly identified barriers to seeking genetic counseling included worrying about having hereditary cancer (37.6 %) and financial concerns (cost and insurance coverage) (35 %). Tailored conversations with women screened BRSQ-positive should address the personal impact of genetic services and acknowledge potential barriers that impact utilization of genetic services. A focus on these motivators and barriers will help to maximize the efficacy of both the PPMSM and similar community programs.

Referral of triple negative breast cancer patients to cancer genetics services in the community setting

J. Handy1, J. Christiansen1, B. LeGrazie1, R. Solden1, S. Van Loon1, M. Rivera1

1. Penn Medicine Virtua Cancer Program

A multidisciplinary team comprised of nurses, surgeons, researchers and genetics professionals recognized a need for a quality initiative to ensure 100 % of patients with triple negative breast cancer (TNBC) are referred for genetic counseling at the Penn Medicine Virtua Cancer Program. The cancer genetics program functions within a community based hospital setting, serving patients and physicians within the Burlington, Camden and Gloucester counties of Southern New Jersey. TNBC is a complex subtype characterized by the lack of expression of estrogen (ER) and progesterone (PR) hormone receptors and human epidermal growth factor receptor 2 (HER2). BRCA positive breast cancer is more likely to be characterized as triple negative. Studies have reported BRCA1 mutations in 9 to 28 % of patients with triple negative breast cancer. National Comprehensive Cancer Network 2016 Guidelines recommend all TNBC patients diagnosed ages 60 and under receive genetic risk evaluation by a genetics professional. In 2013, a TNBC referral protocol was implemented in which our cancer registry identified all analytic breast cancer patients at the of time initial diagnosis and entered them into a database specifically created for the quality initiative. Cancer registry would also inform the cancer genetics program, the patient’s breast surgeon and nurse navigator to ensure a timely referral was made for genetic counseling. A data collection tool had been developed to measure impact. Quarterly analysis was planned to review the process, documentation and encountered barriers. Prior to implementation of this quality initiative, 32 % of TNBC patients were referred to cancer genetics in 2011 and 24 % were referred in 2012. Upon implementation of the quality initiative in 2013, 39 % were referred. This number continued to increase annually to 57 % in 2014 and reached 100 % in 2015. In 2016 we plan to continue with the quality initiative for referral of TNBC patients and discontinue quarterly tracking and reporting, as our goal of 100 % referral of TNBC patients has been reached.

Increasing genetic counseling referral among gyn oncology registry patients meeting National Comprehensive Cancer Network guideline criteria: A collaborative approach

K. Huelsman1, E. Gaitley2, C. Rice1, S. Browne2, M. Shearouse1, M. Caldwell1, K. Smith1, S. Weber1, K. Schuler2, J. Pavelka2, J. Basil2, J. Maher1

1. TriHealth Cancer Institute

2. TriState Gynecology Oncology

TriHealth Cancer Genetics observed a lower than desired rate of referrals among patients meeting National Comprehensive Cancer Network (NCCN) Genetic Counseling referral criteria. This is not uncommon at other centers. Michigan state cancer registry and BRCA Clinical Network data show 2–30 % of ovarian cancer (OvCa) patients diagnosed at a center with a genetics professional received genetic counseling between 2008 and 2013. We measured the percentage of patients seen/referred to Genetics among those meeting NCCN gynecologic cancer referral criteria. Patients were identified using cancer registry data at TriHealth (Ohio Department of Health Registry Study) with diagnoses of ovarian, endometrial < 60, or peritoneal carcinoma in 2012–2014. The majority of patients were treated by TriState Gynecology Oncology (TGO) practice. The proportion of patient referrals to genetics significantly increased from 2012 to 2014. The annual sample sizes in the endometrial and peritoneal cancers are low, but the OvCas are significant (n = 51). The proportion of OvCa patients referred/seen in the genetics clinic significantly increased from 18 to 37 % in 2012 to 2014. Genetic Counselors and TGO collaborated in 2014 and 2015 to identify reasons eligible patients were not seen and strategies to increase service uptake. Reasons patients were not seen include: 28 % pathology outside syndrome spectrum, 20 % referred but not seen, declined, 6 % deceased. The TGO group made adjustments by creating a tracking system for referrals and results in the EMR. Interventions to increase identification of patients include: considering pathology types not previously referred and reevaluating patients with previous diagnosis. To enhance compliance, patients will be seen by genetic counselor during infusion. The lack of national benchmarks is a challenge in evaluating referrals for quality assurance (QA). Application of registry data can provide useful QA data to measure improvement from clinical collaboration. Multi-center collaborative replication of this study would generate useful benchmark for Genetic Counseling profession.

Why is cancer genetic counseling underutilized by women identified as at risk for hereditary breast cancer? Patient perceptions of barriers following a referral letter

A. Kne1, H. Zierhut1, S. Baldinger2, K. Swenson2, P. Mink2, P. McCarthy Veach1, M. Tsai2

1. University of Minnesota

2. Allina Health

Family history information comprises an important tool in identifying and referring patients at risk for Hereditary Breast and Ovarian Cancer (HBOC) to cancer genetic counseling. Despite recommendations and support provided by numerous professional organizations, cancer genetic counseling services are underutilized by at-risk patients. This study had three aims: 1) to determine the rate of genetic counseling utilization following a referral, 2) to characterize the factors which influenced uptake of these services, and 3) to identify potential strategies for increasing utilization. Methods: This study evaluated the uptake of cancer genetic counseling among 603 screening mammography patients identified as having an increased risk for HBOC based on National Comprehensive Cancer Network (NCCN) guidelines. At risk individuals and their primary care providers were mailed a referral letter suggesting genetic counseling. Three focus groups (N = 24) were conducted to identify responses to receiving a letter recommending genetic counseling, barriers to seeking genetic counseling, and facilitating factors to utilizing these services among women who did not complete genetic counseling within a 1 year period of referral. Participant responses were qualitatively analyzed using thematic and cross case analysis. Results: Within 1 year, 50 (8 %) of the identified at-risk women completed a genetic counseling appointment. Participant perceived barriers which influenced their decision not to seek genetic counseling included lack of relevance and utility, limited knowledge about genetic counseling, and concerns about cost and insurance coverage. Participant facilitating factors which would support a decision to seek genetic counseling included greater awareness and education about genetic counseling services when receiving a referral, and improved follow up and guidance from their provider. Conclusion: Findings from this study support the need for patient and primary care provider education, and improved provider-patient communication to increase uptake of genetic counseling services.

Development and implementation of breast and ovarian cancer test criteria for a next generation sequencing panel within a large health maintenance organization

C. Kobelka1

1. Kaiser Permamente

Introduction: At Kaiser Permanente Northern California (KPNC), cancer genetic tests are provided only within genetics departments. With the implementation of next generation sequencing panel (NGSP) testing, there was a need for consistency of care for Hereditary Breast and Ovarian Cancer (HBOC) NGSP tests. Purpose: To establish KPNC HBOC NGSP test criteria and evaluate test outcomes. Methods: The KPNC Genetics Cancer Task Force reviewed National Comprehensive Cancer Network (NCCN) HBOC test criteria and peer-reviewed literature to develop KPNC criteria for HBOC NGSP tests. KPNC criteria were similar but not identical to NCCN criteria. Tests for those who did not meet criteria were approved by case-review. Ambry Genetics OvaNext NGSP was used for all tests. Results: Of 369 NGSP tests at KPNC San Francisco Genetics between 3/1/15 and 2/29/16, criteria were met for 88 % (326), and exceptions made for 12 % (43). This included 284 patients with a personal history of HBOC-related cancer, and 85 with no personal history of cancer. “Criteria met” results: 55 % (180) negative, 32 % (104) variant of uncertain significance (VUS), 12 % (38) positive for one or more pathogenic or likely pathogenic mutation, and 1 % (4) MUTYH carrier only. The positive rate was 12 % for those with a personal history of HBOC cancer, and 10 % for those with no personal history of cancer. “Exception” results: 56 % (24) negative, 30 % (13) VUS, 12 % (5) positive for pathogenic mutation, and 2 % (1) MUTYH carrier only. Three of the five positive patients met neither NCCN nor KPNC test criteria. One unaffected patient had a positive result. Conclusions: Use of KPNC test criteria found an only slightly higher positive rate in those with a personal history of HBOC cancer than in those with no personal history of cancer, suggesting sound unaffected test criteria. Positive rate was the same for patients tested by exception or by KPNC criteria, demonstrating both the importance of clinical judgment in NGSP test decisions, and that tracking test outcomes is crucial to enable review and alteration of criteria.

Attitudes towards interpretation services provided to underserved patients during cancer genetic counseling sessions in the public hospital setting: perspectives from genetic counselors and interpreters abstract

K. Lara-Otero1, C. Guerra2, J. Ka Yan Cheng1, G. Joseph1

1. California State University, Stanislaus

2. Department of Anthropology, History & Social Medicine, University of California, San Francisco

The participation of medical interpreters (MI) in medical encounters is essential for limited English proficient (LEP) patients in accessing healthcare services, mainly by overcoming communication barriers. However, interpreters’ involvement is accompanied by many challenges. Cancer genetic counseling (CGC) entails the discussion of large amounts of complex information, which can be overwhelming and confusing for low health literacy LEP patients. The participation of a MI in such sessions incorporates another layer of complexity, especially if the interpreter is not familiar with key aspects of the genetic counseling encounter, and if interpreters and provider do not establish a collaborative relationship. Some literature is available in regards to the perspectives of providers working with MIs in a variety of medical settings. Less is known about interpreters’ perspectives about working in bilingual healthcare settings, and to our knowledge, no studies have been done to evaluate interpreters’ points of view in terms of their participation in CGC. For this reason, the aim of this study was to gain in-depth knowledge about medical interpretation services in the context of hereditary cancer genetic counseling involving underserved patients, by conducting semi-structured interviews with 11 MIs and 10 genetic counselors at two public medical centers in San Francisco, CA. Five themes were identified representing the overarching perspectives of MIs and genetic counselors working with LEP patients: Interpreters’ Roles; Challenges faced by MIs during CGC encounters; Lack of respect/appreciation by providers; Genetic Counselor “correcting” the interpreter; and Trust as foundation of the Interpreter-Provider dyad. The findings of the present study identified key aspects of the interpreter and provider professional inner worlds, allowing the development of strategies and practice recommendations to help overcome many challenges inherent to the process of interpretation in the cancer genetic counseling setting, thus ultimately promoting better service to the patients.

Clinical cancer genetic testing in Singapore: A single-institution experience

S. Li1, J. Yuen1, N. Ishak1, S. Chan1, J. Ngeow1

1. National Cancer Centre Singapore

Purpose: Before the establishment of the Cancer Genetics Service (CGS) in National Cancer Centre Singapore (NCCS), the utilization of genetic testing for inherited cancers in Singapore is low. CGS was first set-up in 2014 and is the first comprehensive cancer genetic counselling and testing service in Singapore. This study will thus evaluate the progress and clinical experience of this service from 2014 to 2016. Methods: Between January 2014 and March 2016, 370 patients were seen in CGS clinic. A retrospective review was conducted to evaluate patient demographics, referral source, cancer diagnosis, decision to test and genetic testing results. Most patients received multi-gene panel testing that applies Next Generation Sequencing (NGS). Result: The average number of cases that had been seen per month increased from 7 patients in January, 2014 to 18 patients in March, 2016. 79 % of these patients were female and 58.0 % of them were referred by oncologists. The percentage of patients who opted for genetic testing increased from 30.6 % in 2014 to 51.4 % in 2015. Out of the 171 patients tested, 20.5 % of them tested positive with pathogenic mutation in 16 different cancer predisposition genes. Also, 24.0 % of these patients came back with variant of unknown significance (VUS) mutations in 31 different genes. Conclusion: Our study describes the implementation journey of setting up a formal cancer genetics services in Singapore. Our experience with NGS panel testing serves as a guide for other clinical cancer genetics services in Asia.

Health information technology in clinical genetic counseling: A multi-specialty survey project

W. Mendonca1, M. Frone2, K. Vikstrom3, A. Gaviglio4, L. Shukla5, H. Fecteau6, M. Doerr7

1. GeneDx

2. CancerGene

3. Northbay Cancer Center

4. Minnesota Department of Health

5. Indiana University

6. Origen Laboratories

7. Sage Bionetworks

With the enactment of the Health Information Technology (HIT) for Economic and Clinical Health (HITECH) Act in 2009, the government committed to an investment of ~ $26 billion to improve the delivery of healthcare through HIT initiatives. Since that time, the use of electronic medical record (EMR) systems have become widespread throughout health care systems, and many genetic counselors have begun using some combination of EMRs, risk assessment tools, or other apps and software in their daily clinical functions. A survey was distributed to the Cancer SIG in 2012 and then repeated in 2014, with expansion to the Prenatal and Cardiovascular SIGs, with the aim of establishing baseline data regarding the utilization of HIT tools within specific genetic counseling specialties. The survey results analyzed genetic counselor access to HIT resources, challenges in recording family history data, efficiency, reimbursement, and practice models as they relate to HIT. The original survey demonstrated, the use of EMR in some institutions. Although genetic counselors thought their efficiency increased by the use of their EMR system, majority of them were not satisfied with the way genetic test results and general family history was handled. The survey is now being repeated, results being analyzed to assess the changing landscape of HIT in genetics and identify needs for improvement. Genetic counselors are uniquely poised to influence the development of HIT to best suit the rapid development of genomics in medicine. This survey aims to provide baseline data on the utilization and access of HIT by genetic counselors of varying specialties and how this practice has evolved over time. We hope to identify areas for improvement for HIT that can be brought to healthcare systems and vendors to optimize their services and integration of genomic medicine into healthcare.

Prenatal testing in pregnancies established through in vitro fertilization in the era of noninvasive prenatal testing

L. Palange1, A. Matthews2, A. Parikh3, L. Rippel3

1. Cleveland Clinic

2. Case Western Reserve University

3. University Hospitals

The reluctance of women who have conceived via In vitro fertilization (IVF) to undergo prenatal diagnosis based on the risk of complications has been well-documented. The same studies have emphasized the value of genetic counseling in this population. This study examined the use of prenatal testing in IVF pregnancies during the window in which noninvasive prenatal testing was newly available, and assessed the use of genetic counseling. This study also elucidated factors influencing the decision-making process either to decline or use prenatal testing. Women establishing pregnancies through IVF since January 1, 2012 at University Hospitals Fertility Center and who delivered by March 1, 2015, were invited to participate (n = 223). Demographics (age, reason for IVF use, duration of infertility, etc.) and whether the pregnancy was considered high-risk were ascertained. Participants were asked if they were offered prenatal testing through their obstetrician, if they were referred to genetic counseling, if they used any form(s) of testing, and if so, what method(s) they chose. Finally, participants were asked to select factors impacting their decision-making. Results indicated 75.5 % of participants were offered testing by their obstetrician, while 27.7 % of participants were offered genetic counseling. Of the tests ordered, 90 % were screening tests; serum screening was ordered most frequently. The only factor significantly predicting the use of screening was the number of high-risk indications. Most participants selected multiple factors influencing their decision to undergo testing. For women who declined all forms of testing, the factor most frequently said to have the greatest influence was that information gained by testing would not change pregnancy management. These findings suggest that women who undergo IVF continue to prefer screening over diagnostic procedures. This study highlights the complex decision-making process surrounding the use of prenatal testing. Finally, this study draws attention to the underutilization of genetic counseling in IVF pregnancies.

Use of technology solutions increases efficiency of genetic counseling for hereditary cancer

L. Servais1, L. Ryan1

1. Color Genomics

Analyses of time-based effort have determined that clinical genetic services are time consuming and labor-intensive, with as little as 25–41 % of a genetic counselor’s (GC) time spent on direct patient care and up to 3.5 to 7 total hours spent per patient. Through the integration of various technology applications, the genetic counselors who provide clinical care for Color Genomics have dramatically decreased the amount of time conducting non-direct patient care activities, thus increasing the proportion of time spent on direct patient care without compromising patient satisfaction. Selected genetic counselors at Color tracked time spent providing direct patient care and conducting non-direct patient care activities to provide over 400 post-test telephone genetic counseling sessions for clients who received a 19-gene panel for Hereditary Breast and Ovarian Cancer. Over 50 % of the time a Color GC spent on a patient was providing direct patient care and the average total time spent per patient was 40 min. Surveys were conducted to assess comprehension and satisfaction with genetic counseling. There was a high degree of comprehension and satisfaction among respondents. Custom software tools have been implemented to create these time savings including: online health history collection and pedigree creation, online scheduling and rescheduling, and templatized summary notes. Broader implementation of similar software tools for all genetic counselors providing clinical care may improve efficiency and time available for both direct and non-direct patient care.

Genetic counseling clinic: Expanding genetic services to the pediatric population

K. Siefkas1, K. Foss2, E. Hendricks2, K. Shih2, L. Ramsdell2, S. Stasi3, K. Golden-Grant2, P. Chow4, D. Sternen3, J. Conta3

1. Prenatal Diagnosis & Treatment Program, Seattle Children’s

2. Division of Genetic Medicine, Seattle Children’s Hospital

3. Dept of Laboratories & PLUGS, Seattle Children’s Hospital

4. Division of Craniofacial Medicine, Seattle Children’s Hospital

There is increased demand for coordination of genetic testing and for pre- and post-test genetic counseling at our pediatric institution due to the growth in genetic testing ordered by genetic providers and other specialists. Expanding genetic services with the implementation of a genetic counseling clinic (GCC) has increased access to timely genetic counseling services. Licensed genetic counselors review cases with a physician medical advisor prior to each GCC. Medical advisors are predominantly medical geneticists or referring specialists. GCC visits are scheduled as a 90 min in-person visit with the genetic counselor only, similar to models for prenatal and cancer genetic counseling. GCC differs from our medical genetics clinic as a physical exam and evaluation for a differential diagnosis are not done. Parents may also attend the GCC without their young child. Children capable of assent for genetic testing attend the appointment. Genetic counselors are allotted 30 min to provide genetic counseling in our medical genetics clinic team visits. The added time in a GCC visit allows care focused on psychosocial counseling and education, pre- and post-test counseling, discussion of testing implications, recurrence risk, coordination of family member testing, and connecting the family to support resources. We present data here from our retrospective review of all GCC referrals from 2011 to 2015, during which 862 GCC patients were seen. GCC handled 15 % of all genetics referrals. Internal and external provider diversity, types of referrals, and diagnoses data were reviewed. We share the lessons learned from our experience and opportunities for future growth. We hypothesize that the diversity of referring provider specialties will continue to expand. Specialists who are currently referring patients for post-test genetic counseling may shift and begin referring more families for pre-test counseling as well.

Who are the cardiologists early to adopt integration of genetic counselors into clinical practice?

K. Spoonamore1, K. Orland2, C. Caleshu3

1. Indiana University School of Medicine

2. University of Wisconsin School of Medicine and Public Health

3. Stanford Center for Inherited Cardiovascular Disease

Introduction: Genetic counselors (GCs) are increasingly involved in cardiology, as practice guidelines now recommend genetic counseling for individuals with inherited heart diseases. The 2016 NSGC Professional Status Survey indicates 10 % of clinical GCs counsel patients in cardiology. Little is known about cardiologists who have integrated GCs into their practice. Aim: To characterize cardiologists who have been early-adopters of integrating genetic counselors into their clinical services. Methods: Using the NSGC cardiovascular special interest group (SIG) and our professional networks, we identified cardiologists who care for patients with inherited heart disease and/or work with GCs. These cardiologists were invited to take a brief online survey. Questions covered physician demographics and how GCs fit into their practice. Results: Eighty-five cardiologists participated. The majority reported at least some of their patients are seen by a GC without involvement of a geneticist (85.9 %). Of those, most had a GC in their cardiology department (74.6 %, for a mean of 6.4 years, mean of 1.6 GCs per department). Nearly all reported the GC they work with is specialized in cardiovascular genetics (98.6 %). Cardiologists who work with a GC predominantly work in an academic hospital setting (97.2 %), and most early-adopters perform research (91.7 % with 62.1 % specifically researching genetics). Many staff a clinic dedicated to inherited heart disease (67.1 %) and a mean of 34.2 % of their patients have inherited heart disease. Cardiologists who do genetics research have been working with a GC for almost twice as long (mean 8.3 years vs. mean 4.7 years, p = 0.001), and have more GCs in their department (mean 1.3 vs. mean 1.9, p = 0.01) compared to those who do not do genetics research. Conclusions: Cardiologists who involve genetic counselors in their patients’ care work in academic hospitals and, in most cases, have genetic counselors embedded in their cardiology department. Those who do genetics research are the earliest adopters and have more GCs in their department.

Factors associated with breadth of multigene panel testing selected by patients at risk of hereditary breast and ovarian cancer syndrome: A cohort study

J. Szender1, K. Clayback2, M. Hutton1, J. Mikkelson1, C. Dresbold3

1. Roswell Park Cancer Institute

2. John Carroll University

3. Community Physician Network Breast Care

The introduction of multigene panels has drastically altered the dynamic of genetic counseling. Currently there is no consensus as to which patients panel testing should be offered, or what size panel is most appropriate. We assessed patient choice when provided with testing options and analyzed the factors associated with breadth of testing selected. Patients referred for genetic counseling at Roswell Park Cancer Institute due to suspicion of Hereditary Breast and Ovarian Cancer syndrome from January 1 to September 30, 2015 were evaluated. Demographic variables were recorded. Patients were excluded if there was a known familial mutation or if they previously had genetic testing. Patients meeting National Comprehensive Cancer Network guidelines were offered three levels of testing: single condition, small panels with highly penetrant genes, and large panels with high and moderately penetrant genes. Analysis utilized χ2 test of independence; p-value < 0.05 was the threshold of significance. We identified 253 patients; most patients had cancer (63.6 %), reported at least some college (79.2 %), and opted to have testing (94.1 %). Most (84.9 %) opted for panel testing; however 36 patients (15.1 %) chose only BRCA1/2 testing. Large-panel testing was associated with patients having any college (RR: 1.53, 95 % CI: 1.02–2.30) or being unaffected (RR: 1.30, 95 % CI: 1.03–1.64). With the routine use of multigene panels and limited guidelines regarding such, genetics providers must weigh patient confusion and anxiety due to results with indeterminate cancer risk against the risk of missing a gene that could identify high risk and alter cancer screening. This study noted some associations with patients’ self-identified preferences for breadth of genetic testing. Although the majority of patients chose a panel, a proportion still preferred to limit their testing. These findings underscore the need for comprehensive genetic counseling prior to testing to assist in patient decision making. Further analysis of other factors, such as personality characteristics, which may influence patient decision making need to be further explored.

Navigating underinsured women from mammography to genetic counseling: Challenges and possibilities

E. Watson1, L. Robinson1, T. Ross1

1. UT Southwestern

Background: The United States Preventative Services Task Force (USPSTF) recommends unaffected women be screened for Hereditary Breast and Ovarian Cancer syndrome (HBOC). Methods: From October 2011 to March 2016, we screened 129,865 underinsured women for HBOC by using the Family History of Cancer (FHOC) tool during their mammogram. Individuals from a cancer family were contacted and offered genetic counseling. We examined data from these contacts to identify barriers to successful navigation of at-risk women and evaluated data over time to determine how barriers changed with experience. Results: Of 129,865 women who completed the FHOC tool, 6 % (n = 7425) screened positive, 5 % (n = 7091) were contacted, and 2 % (n = 3117) scheduled an appointment. Although 38 % (n = 2678) of screen-positives were unreachable, this number decreased by 6 % over 5 years. Multiple attempts to contact patients led to increases in appointments scheduled: 59 % (n = 1836) scheduled after one attempt, and an additional 27 % (n = 850) after two, and 14 % (n = 431) after three or more. On average, 5 % (n = 366) of screen-positives declined an appointment due to lack of interest, which remained consistent over time. Patients also declined due to prior genetics consultation, which was reported by 9 % (n = 614) of patients and increased by 4 % after 5 years. From 2011 to 2015, fewer patients declined an appointment (26 and 13 %, respectively) and more scheduled (33 and 42 %, respectively). In total, 20 % (n = 1415) of patients reported a family history that no longer met criteria for referral, which remained similar after 5 years. Of those who scheduled an appointment, 55 % (n = 1714) kept the appointment. Based on published frequencies, 289 patients with mutations were predicted; 70 (24 %) were identified. Conclusions: Although population based screening for HBOC has been proposed, limited outcomes data are available. Two major barriers of population screening include difficulty contacting patients and incorrect family history. Navigating patients and addressing challenges is essential to identify mutation carriers.

The utility of nondirective and directive counseling styles in clinical practice from the perspective of certified genetic counselors

A. Bansal1, B. Chamberlain1, T. Geraci1, J. Solomon1, C. Ventura-DiPersia1, D. Gruber2

1. Hofstra Northwell School of Graduate Nursing & PA Studies

2. Cohen Children’s Medical Center of New York Northwell Health

Introduction: The patient-clinician relationship is a complex exchange that has been explored in the countless studies; communication regarding medical decision-making often relies on the expertise and guidance of the overseeing clinician. While patient-centered approaches to patient care focus on patient’s autonomy, situations may arise that necessitate professional guidance from an overseeing clinician. Our study explored the role of nondirectiveness in clinical practice as well as the potential difficulties in achieving this in patient care. Methods: A recruitment email was sent to all board-certified genetic counselors who were also members of the NSGC, with an anonymous cross-sectional survey link for respondents to complete. The questionnaire consisted of 31 items that captured details related to CGC practice characteristics and attitudes and opinions related to the directiveness and nondirectiveness based on language utilized in previously published studies. Qualitative items were coded using both a priori and in vivo coding to assess common themes. Results: A total of 61 CGCs responded to the survey. The majority of respondents were female (97 %) and white (95 %); nearly half of respondents were between the ages of 23–30 (49 %) and practicing in a clinical setting (n = 53, 83 %). Regarding what “nondirectiveness” meant to respondents, 47.5 % reported that it was “ensuring clients receive all information needed to make a decision that is right for them” and 44.3 % that “counseling without bias or influencing patient decisions.” Approximately 26.2 % of respondents said that directiveness “is appropriate at times and cannot be avoided completely,” with most commonly mentioned scenario being “medical necessity with regards to risks of bodily harm/death to client” (49.2 %). Conclusions: This study elucidates the complexity that arises for clinical professionals during a counseling session. The study provided knowledge-based that could aid clinical practice to move away from strictly a practitioner-driven model to the facilitation of shared-decision making.

EpiGC: a collaborative approach to an emerging professional and clinical need

A. Bergner1, S. Gandomi2, B. Rosen Sheidley3, K. Helbig1, EpiGC Consortium

1. Ambry Genetics

2. Invitae

3. Boston Children’s Hospital

4. Ambry Genetics

Recent publications find causative de novo variants in approximately 30 % of patients with severe epilepsies and provide evidence for a strong genetic component in an even larger subset of patients with seizure disorders. In some instances, genotype specific treatment is already indicated, but the current lack of awareness about the importance of genetic testing among epilepsy clinicians puts optimal patient care at risk. The advent of next generation sequencing has changed the landscape of both epilepsy genetic testing and genetic counseling. While genetic counselors (GCs) have been involved in neurology practices for many years, until recently there were none who specialized in epilepsy. In February 2016, a group of GCs specializing in epilepsy genetics formally announced a collaboration called EpiGC ( Members of the group come from diverse backgrounds, including clinical practice, diagnostic laboratories, and clinical research. The goals of EpiGC are to: 1) serve as a resource/provide education to the neurology community and advocacy groups; 2) promote the value of genetics and genetic counseling in the clinical evaluation of patients with epilepsy; 3) promote the use of genetic testing laboratories that utilize the expertise of genetic counselors; and 4) advocate for the improved reimbursement of genetic testing for epilepsy. EpiGC has begun efforts to influence policy development and educational outreach with key professional entities. We are launching a website ( and are also exploring the possibility of establishing a not-for-profit organization which would provide education and resources to families, advocacy groups and healthcare providers. EpiGC represents a successful professional collaboration between clinical, research, and industry-based GCs to promote high quality clinical care for patients and needed education for our non-genetics medical colleagues. This type of collaboration is a unique and important model as our profession continues to evolve.

Establishing a committee to ensure appropriate utilization and standard provision of clinical exome sequencing at a pediatric tertiary care center

J. Conta1, E. Hendricks2, D. Steen1, S. Stasi1, K. Tsuchiya1, R. Jack1, J. Bennett2,3, G. Mirzaa2,3, M. Astion1,3

1. Department of Laboratories and PLUGS, Seattle Children’s Hospital

2. Division of Genetic Medicine, Seattle Children’s Hospital

3. University of Washington

Compared to gene- and disease-specific panel tests, clinical exome sequencing (CES) has a relatively high cost, complex pre- and post-test counseling requirements, and unique sample and clinical history requirements. A lack of existing practice standards for coordination and delivery of CES raised concerns regarding the risk of inappropriate orders and financial liability to patients and our institution. The CES committee was established in 2012 to guide CES orders across specialties in our institution, and includes medical geneticists, laboratory directors, and genetic counselors, with additional ad hoc expert involvement. The committee meets monthly to review CES requests, develop and disseminate standard coordination policies and procedures, provide guidance on optimal reference lab selection and review complex results. The annual volume of requests has increased steadily: 8 requests (2012), 19 (2013), 54 (2014), 73 (2015) and 23 (2016 to date). The majority of requests are from genetics providers (95 %). The committee approved 89 % of requests; the majority of denials were due to perceived low-yield of CES for the clinical indication, although some led to recommendations for alternate, more directed, testing. Only 57 % of approved tests were actually ordered, due to challenges with insurance preauthorization and coordination of pre-test counseling. Recently, the committee decided to allow geneticists to bypass the CES committee review process, but still requires committee review of requests from non-genetics providers. It is our experience that having a CES committee and review process as part of our test utilization management program encourages the submission of appropriate requests for review. The expert review process supports providers and patients. The purpose of the CES committee will evolve as the utilization of CES increases and is performed earlier in the diagnostic process. Future directions include development of diagnostic algorithms that incorporate earlier use of CES and guideline development related to rapid exome sequencing.

Overcoming challenges to provide genetics services in a county hospital system

D. Erwin1, T. Eble1, S. Dhar1

1. Baylor College of Medicine

Despite increasing public interest in genetics, access to genetics services is limited in some populations. In particular, inequality exists regarding access to genetics services for individuals with low socio-economic and minority status. Data is limited regarding the number of genetic counselors in county hospital systems, which typically serve indigent populations. Expansion of genetic counselors into county clinics may help to increase the provision of genetics services in diverse populations. To increase access to services, specialty clinics often hold satellite clinics for individuals in rural areas with geographic restrictions. However, there are similar barriers to accessing genetics services for individuals with economic restrictions, particularly in urban settings. Our clinic has evaluated and managed a total of 2547 patients from 2006 to 2016. Of these, 1320 were new patients and 1227 were return patients. The majority of individuals in the county system are self-pay (63 %), in stark contrast to the general population, where health insurance (86.3 %) is the majority payor. Providing care for the underserved in the fourth largest city in the United States provides a unique perspective on the availability of genetics services in an urban population. In our experience, barriers to genetics services include transportation, lack of awareness about genetics services and conditions, and accessibility of genetic testing. Additionally, the possible high cost of testing, documentation to qualify for financial assistance programs, and the multiple departments involved for testing approval within the hospital system lead to difficulties in securing genetic testing for our patients. To reduce these barriers, we have streamlined processes to obtain approvals for testing coverage for all payor types in the hospital system, along with identifying additional pathways for financial assistance. We present 10 years of experience operating in a county hospital clinic, with a focus on the financial considerations in coordinating genetic testing in a county hospital system.

Genetic counselor referrals to hospital chaplains

A. Gregory1, J. Quillin1, V. Pallante1, T. Ford1

1. Virginia Commonwealth University

Patients may use religious/spiritual (R/S) beliefs to cope with genetic information. Referring to a hospital chaplain (HC) is one way genetic counselors (GCs) can help meet a patient’s R/S needs, but little is known about GC referrals to HCs. This study explored the frequency of GC referrals to HCs and identified facilitators/barriers of the referral process to address this gap. GCs who work in a hospital and had seen patients in the past year were eligible. An electronic survey was sent to NSGC members, and 105 eligible participants were obtained. Respondents reported how many times they had referred to an HC in the past year. Anticipating few referrals, they were also asked how likely or unlikely they would be to refer a patient experiencing spiritual crisis to an HC. Finally, respondents reported how strongly they agreed or disagreed with potential facilitators/barriers. Adjusted odds ratios representing the relationship between agreeing with facilitators/disagreeing with barriers and making referrals to HCs or being hypothetically likely to refer were obtained after controlling for confounding demographic variables. Only 19 GCs (18.1 %) had referred to an HC in the past year, and 60 (57.1 %) reported being likely to refer a patient experiencing a spiritual crisis. Important barriers of GC referrals to HCs include not having ever considered referring to an HC, not knowing how to refer to an HC, believing referral to an HC is not a GC’s responsibility, and believing HCs are not an appropriate or capable resource for patients. The identified barriers could be targeted by providing education about the role of R/S in health, the availability and capability of HCs, using spiritual assessment tools to identify patients with R/S needs, and how to refer to an HC. This could take place through graduate training, continuing education, and job training. It will be important for future research to identify which strategies help reduce referral barrier, increase GC referrals to HCs, and ensure that the R/S needs of more patients are being met.

Additional skills required: Lessons learned through teaching telehealth

M. Hardy1, M. Sdano2

1. JScreen, Emory University

2. Lineagen, Inc

Telehealth, the use of telephone and video technology to consult with patients at a distance, has been lauded as an important method to help resolve a number of issues in healthcare including disparities in access to care. Given the growing need for genetic services and the difficulty with producing enough genetic counselors to meet the need, telehealth is being utilized in many ways to allow genetic counselors to reach a greater patient base. It is important to recognize that genetic counseling through telehealth can be impacted by a number of factors that differ from in-person consultation. Although many of the strategies taught to genetic counselors can be applied in the telehealth format, there are differences that may not be anticipated or well-navigated without education and experience. These may include technology difficulties, absence of nonverbal cues, ordering and presentation of information, as well as differences in patient and provider environment. We will present common situations that have occurred in patient cases to highlight some of the differences between telehealth and in-person consultation, and provide troubleshooting. Also, we will provide lessons learned from supervision and education of genetic counseling students in telehealth methodologies. We advocate for additional telehealth education for students including greater and varied experiences in this format. In order to better prepare upcoming students for a changing healthcare landscape, we believe that greater focus on opportunities to learn in a telehealth environment will allow students to better manage the differences in this particular type of genetic counseling.

Establishing a model for clinical exome sequencing coordination and pre-test counseling to ensure standard delivery of clinical exome sequencing at a pediatric tertiary care center

E. Hendricks1, J. Conta1, P. Chow1, K. Foss1, K. Golden-Grant1, L. Ramsdell1, K. Shih1, K. Siefkas1, S. Stasi1

1. Seattle Children’s Hospital

Due to the unique nature of clinical exome sequencing (CES) including test complexity, use of trios and cost of testing, genetic counselors in the Division of Genetic Medicine at Seattle Children’s Hospital developed a set of practice standards for coordinating CES in order to prevent inappropriate CES orders, incomplete pre-test counseling and erroneous test coordination. We outline here the established model as a guide for or comparison to other institutions in need of a standardized CES process. Requests for CES are made using a standard form and must be reviewed and approved by the CES committee at the institution. A pre-test genetic counseling appointment is required to facilitate test coordination (laboratory and test selection, consent paperwork, patient and family sample collection, and insurance preauthorization) and the necessary informed consent with the patient and family. Standardized visual aids, dictation templates and family resource packets promote efficiency. Pre-test counseling appointments are increasing yearly: 13 (2013), 26 (2014), 35 (2015). Insurance coverage for testing is coordinated using the institution’s insurance services department. An institutional financial assistance policy supports coverage of testing for patients with state-based insurance plans and families with private plans who qualify for charity care. Optimal return of exome results is provided during an in person appointment with the ordering provider and a genetic counselor scheduled at the time of pre-test counseling. Establishing practice standards ensures that patients and families undergoing CES receive reliable test coordination and detailed pre-test counseling. Further, the process has allowed the group to track CES utilization at the institution and adapt thoughtfully to evolving CES utilization practices.

The unique role of pediatric genetic counselors in a fetal health center.

J. Kussmann1, C. Lawson1, H. Kilbride1, A. Ritchey1

1. Children’s Mercy Hospital

In 2011, Children’s Mercy Hospital, a freestanding children’s hospital in Kansas City, Missouri established a “fetal health center” (FHC) to provide comprehensive care for pregnant women with fetal anomalies. All patients meet with perinatology, neonatology, genetics and social work. As the FHC is based in a children’s hospital, pediatric genetic counselors were called upon to provide genetic counseling services. The genetic counselor meets each patient considering delivery in the FHC, regardless of the indication to obtain a family history and discuss recurrence risk. Additionally the genetic counselor attends an integrated multi- specialty consult for each patient. The goal of this consult is to bring subspecialists and the family together to establish a comprehensive plan of care. The genetic counselor helps establish a differential diagnosis and provide guidance on recommended postnatal genetic testing. For complex patients, the counselor reviews the history and images with a pediatric dysmorphologist prior to the integrated consult. Differential diagnoses are discussed and a plan for postnatal testing is established. Approximately 15–20 % of FHC babies die prior to delivery or in the delivery room. Prenatal planning for postnatal genetics evaluation is essential for these patients. As the FHC has matured, the counselors’ role has evolved. In 2012, 210 genetic counseling visits were completed in the FHC and this grew to 447 by 2015. The pediatric genetic counselor has become an integral part of the prenatal integrated consultation. Participation in the integrated consult enables rapport building with families and assurance that genetic testing will be included in the delivery plan. The genetic counselors have a deeper understanding of the management of condition that commonly present and provide continuity of care between the prenatal and postnatal settings. The FHC at Children’s Mercy Hospital has established a unique role for genetic counselors, utilizing both prenatal and pediatric expertise.

Are visual aids helpful in genetic telecounseling? A case–control study

J. Miller1, S. Wieloch1, S. Sehnert1, S. Yarnall1

1. Recombine

Telemedicine is an increasingly common method of healthcare delivery. However, little formal research into genetic telecounseling has been performed and practice guidelines for telecounseling do not exist. Our research aimed to evaluate whether visual aids, a tool commonly used by clinical genetic counselors, would increase remote patients’ perceived understanding of the genetic concepts discussed and increase engagement in the session. All participants received genetic counseling following expanded carrier screening. Prior to the session, participants were randomly assigned to one of two groups: those who received visual aids (cases) and those who did not (controls). Visual aids were provided to the case group via e-mail one day before consultation. Following the session, both groups received a survey regarding the actual or perceived utility of visual aids. Informed consent was obtained. Initial evaluation of 46 cases indicated that, on average, 77.1 % felt the visual aids enhanced their understanding of the discussed concepts (genes, chromosomes, inheritance patterns, carrier status, the effect of carrier status on reproductive decisions). 74.0 % of cases viewed the visual aids prior to the telecounseling session, 78.3 % used them during the session, and 76.0 % believed they would refer to them in the future or when discussing their session with others. Of the 58 controls analyzed, 91.4 % reported they would have viewed visual aids prior to their session, 86.2 % reported they would have used the slides during their session, and 88.0 % thought they would refer to them when discussing their session with others. These results indicate the utility and benefit of visual aids for remote patients receiving telecounseling. The use of visual aids may lessen the perceived distance between patient and counselor, making telecounseling more interactive, personalized, and similar to clinical counseling. Further research could determine the optimal method of visual aid delivery, as well as their utility for illustrating more complex genetic concepts.

Interdisciplinary team approach as the ideal model for care of individuals with disorders of sex development

L. Mohnach1, C. Keegan1, E. Quint1, B. Yashar1, D. Sandberg1, M. Chen1, V. Ivancic1, R. Auchus1, S. Gadepalli1, J. Holly1, C. Kozel1

1. University of Michigan

Disorders of sex development (DSD) is an umbrella term that applies to conditions involving anomalies of the sex chromosomes, gonads, reproductive ducts and genitalia. Patients and families with DSD are faced with complex and often lifelong medical and psychosocial needs. In most cases, patients are receiving poorly coordinated care from one or more specialists who do not have experience working with this unique population. To improve the lives of patients and families affected by DSD, an interdisciplinary care team was created with subspecialists in urology, surgery, gynecology, genetics, endocrinology, psychology, social work, and child life. A genetic counselor serves as program coordinator, which is essential in keeping team members and families connected. Families are seen in our twice-monthly clinics or on an emergent basis. Management care plans are determined collaboratively by the team members who meet regularly. Monthly case conferences allow providers to keep abreast of recent findings in the field. Efforts towards research seek to improve and advance care in the field. In addition to participation in the DSD-Translational Research Network, we have developed guidelines for genital examinations and compiled evidence-based recommendations for gonadectomy. The program also organizes parent/peer support and educational activities. Since the inception of the program, the UofM DSD team has managed 155 patients with a wide variety of diagnoses including: ambiguous genitalia, androgen insensitivity syndrome, gonadal dysgenesis, and cloacal exstrophy. Regular feedback requested from families has been uniformly positive. The interdisciplinary model of care for patients and families with DSD has led to more advanced, comprehensive and sensitive management that allows patients to experience better physical, sexual, and emotional health. The integral role of a genetic counselor as program coordinator is critical to the success of the program and function of the team.

The value of a genetic diagnosis as perceived by intersex adults

T. Moscarello1, A. Hanson-Kahn1, K. Karkazis1, S. Bereknyei2, J. Bruce3, K. Hamilton1, G. Davis4

1. Stanford University

2. Stanford Center for Medical Education Research & Innovation

3. Pediatric Advocacy Program, Stanford School of Medicine

4. University of Nevada, Las Vegas

Introduction: Disorders of sex development, also known as intersex, are a group of congenital traits in which the chromosomal, gonadal or anatomic sex is considered atypical. The use of molecular genetic testing to determine the etiology of intersex traits has increased over time in parallel with genetic testing technology. However, the value of genetic testing as perceived by intersex individuals is unknown. Purpose: This study explores intersex adults’ knowledge of, experience with and attitudes towards genetic testing for intersex traits. The results of this study may shed light on how genetics professionals should discuss genetic testing with intersex individuals. Methods: Twenty-one semi-structured interviews were conducted with intersex adults with diverse clinical diagnoses. Most participants were aware of their karyotype and six had molecular genetic testing. Interviews were analyzed using a phenomenological approach. A codebook, derived inductively through multiple readings of the transcripts, was used to code data and organize it into themes. Results: Although all participants knew that intersex traits have a genetic basis, there was significant variation in depth of knowledge: participants differed in their use genetics terminology and descriptions of the scope of genetic testing. Most participants were interested in genetic testing because they viewed it as a way to learn about their traits earlier in life and avoid the devastation of clinical diagnosis as an adolescent. A major concern was using genetic testing results to terminate intersex pregnancies. Conclusions: Although current practice guidelines recommend genetic counseling, this study proposes an expanded role for genetic counselors in the care of intersex individuals. Participants’ dual desire to discover their diagnosis earlier in life and receive life-long education about their trait indicate that intersex individuals of all ages would benefit from the education and psychosocial support that genetic counseling can provide.

When mating is not so random: Coupling patterns across ethnicities in the US population

S. Nazareth1, K. Kaseniit1, J. Goldberg1, I. Haque1

1. Counsyl

Objective: US Census Data from 2010 shows 15 % of US marriages occur between spouses of different ethnicities, a more than double increase over the previous two decades. We set out to observe the inter- and intra-ethnic coupling patterns in individuals who presented for carrier screening as part of reproductive planning. Materials and Methods: Carrier screening was performed on 37,719 self-identified couples based on physician request. Ethnicity for each individual was reported by the ordering physician or patient directly using a test requisition form with 15 options for self-identification: African/African-American, Ashkenazi Jewish, French Canadian/Cajun, Mixed/Other Caucasian, East Asian, Finnish, Hispanic, Middle Eastern, Native American, Northern European, Pacific Islander, South Asian, Southeast Asian, Southern European, or Unknown. Results: Across varying ethnicities in the US population, 60.3 % choose reproductive partners of the same ethnic background. Where inter-ethnic mixing is demonstrated, there are some interesting patterns: women who identify as as East Asian, Southeast Asian and Mixed/Other Caucasian are more likely to partner with men outside of their self-reported ethnic group than are men of the same groups. By comparison, men who identify as Ashkenazi Jewish, African American or European (Northern or Southern) are more likely to partner with women outside of their self-reported ethnic group than are women from those groups. Conclusions: While the majority of individuals are still coupling within their self-identified ethnic group, the trend towards partnering outside of one’s ethnic group is increasing. In our cohort, 39.7 % of couples chose partners outside of their self-reported ethnicity. The implications of this trend on clinical genetics practice should be considered, as medical guidelines for genetic screening are based on self-reported ethnicity. This practice will become increasingly difficult to rely upon as the US population diversifies.

Cost of genetic screening influences patient decision making when weighing options of prenatal screening

L. Otto1, K. Borowski1, M. Wick1

1. Mayo Clinic

Insurance coverage and the out of pocket price of prenatal genetic screening have changed several times over the last year. We present our clinic’s experience and demonstrate that cost of genetic testing influences patient test uptake. We reviewed uptake of prenatal genetic screening at our clinic over the course of 11 months. This timeframe was selected based on the implementation of group genetic counseling sessions, which ensured that all patients were presented with the same prenatal screening options, and because several changes in cost occurred during this time. A total of 433 prenatal genetic screening tests were ordered. We compared test uptake for low risk and high-risk women before and after implementation of major cost changes. Three changes influenced the number of tests ordered: 1) Sequenom’s® VisibiliT® price reduction from $349 to $140, 2) MaterniT21® price reduction from $2700 to $200 for low-risk patients and $200 to $140 for high-risk patients, 3) implementation of Mayo medical laboratories’ noninvasive prenatal screening (NIPS) test (cell-free DNA screening) which was $0 to patients with the Mayo Medical Plan, regardless of maternal age or risk of aneuploidy. The Mayo medical plan insures approximately 50 % of our patient population. Low-risk women opted for VisibiliT® screening over first trimester screening when the price dropped from $349 to $140 (1.8 vs. 35 %). The total number of cell-free DNA screening tests ordered for both low and high risk women before NIPS became available was 110 (15.7 per month) compared to 171 (42.75 per month) after NIPS became available. The total number of patients electing to pursue any prenatal genetic screening increased from an average of 32.3 per month to 51.75 per month in this time frame. We propose patient decision making for prenatal genetic screening is heavily influenced by cost to the patient. We discuss benefits and challenges of offering low or no cost testing to patients including accessibility to a broader range of patients and misuse of tests.

Piloting a community genomics initiative using blood banks for recruitment and data collection

E. Ramos1, M. McGinniss1, E. Thorpe1, L. Fosler1, K. Schahl2, D. Ecklund3, H. Bixenman3, D. Morton3, D. Wellis3

1. Illumina, Inc.

2. InformedDNA

3. San Diego Blood Bank

Multiple studies are assessing the growth and future of personal genome sequencing, but the majority of participants fall into a fairly narrow profile – highly-educated, predominantly male, high socio-economic status individuals of Caucasian descent. This lack of diversity is a barrier to assessing the implementation of genomic testing in a population as diverse as that of the United States. Conversely, blood bank donor populations mimic United States population diversity and donors have been well-described as highly engaged, altruistic, and likely to participate in research projects, including genetic research. San Diego Blood Bank (SDBB), in collaboration with Illumina, initiated a pilot project with its donors to determine if blood banks can be used to recruit a diverse group of study participants to participate in genomics research, to include personal genome sequencing. A 13-question survey was sent via email to approximately 150,000 active, inactive, and deferred donors by the SDBB. Donors were asked if they would be interested in participating in a research study that would follow people’s health over time to understand risk and disease and what type of data they would be willing to provide. More than 300 donors expressed interest in the first 10 min. Of the 7177 unique responses collected, 71.7 % would provide genetic information, 85.5 % would complete surveys, and 84.9 % would provide information about lifestyle. A cohort of 70 individuals, demographically matched to the San Diego population, was invited to participate in the study and receive personal genome sequencing. At the return of their results, 29/62 (46.8 %) said that they participated only because of “ability to contribute to research/ participate in Precision Medicine Initiative (altruistic)” and/or “general curiosity.” The federal Precision Medicine Initiative has committed to recruiting a diverse cohort of participants. This pilot demonstrates that blood banks are trusted entities that can be leveraged to recruit large numbers of diverse volunteers willing to participate in genomic research.

Genotype-first genetic counseling: How general population genome screening has the potential to turn traditional genetics service models upside-down

M. Schwartz1, A. Buchanan1, M. Hallquist1, K. Manickam1, M. Murray1

1. Geisinger Health System

Background: Large-scale genomic testing efforts that involve disclosing medically actionable results could lead to thousands of people needing genetics experts to interpret results. Programs like the National Institutes of Health (NIH) Precision Medicine Initiative and calls for universal BRCA screening indicate an expanding interest in the use of genome screening. Here we draw from our experience in Geisinger’s GenomeFIRST program to describe a non-traditional genetics service model for returning pathogenic variants in 76 genes for 27 conditions (inclusive of the American College of Medical Genetics and Genomics [ACMG] 56) to MyCode biobank members. Methods: Over 100,000 people are enrolled in MyCode and we expect 2000–4000 of them to have a result found by screening their research whole exome sequences. Results are disclosed by non-clinical team members using a phone script. Participants are given the option of a post-test genomics encounter. Unlike traditional counseling, these individuals did not have pretest counseling or a preliminary phenotypic assessment. Results: At this time 33 patients have been seen in genomics clinic out of 96 biobank members who have received a result for HBOC syndrome, Lynch syndrome or familial hypercholesterolemia. Early experience suggests that this approach enables less complex genetics visits. When all patients have a known pathogenic variant, discussions can be targeted around the concrete recommendations for a positive result with less time spent on unclear results like variants of uncertain significance or uninformative negatives. Additionally, with less time spent on pre-test counseling, test logistics and billing, more new patient visits are possible. One challenge is that risk numbers, diagnostic criteria, and management guidelines do not exist for the general population where patients may have a positive finding but lack a compelling personal or family history related to their result. Conclusion: Additional data are needed to understand the manifestation of results in a general population sample and refine provision of genetics services using patient feedback. No emergent psychosocial issues have arisen but more research is needed.

When to take a family history: Assessing impact on genetic counseling outcomes

C. Slomp1, E. Morris1, A. Inglis1, A. Lehman1, J. Austin1

1. University of British Columbia

Background: Documentation of family history is a cornerstone of genetic counseling (GC) practice. Various strategies for obtaining family histories have evolved (e.g. pre-GC appointment online questionnaires), often to increase the efficiency of generating a product for assessing genetic risk and informing genetic testing. However, the process of patient counselor interaction to document a family history can be useful in building rapport, which is key to optimal patient outcomes of GC. No studies have evaluated the effect the timing or method of obtaining family history on patient outcomes of GC. Hypotheses: Patients whose family history was obtained by phone prior to GC (Group 1) would have greater increases in a) empowerment and b) self-efficacy than patients whose family history was collected during the GC appointment (Group 2). Methods: We conducted a retrospective chart review in a specialist psychiatric GC clinic, using data from Feb 2012 to March 2016. Family history is either documented by phone prior to GC, or at the beginning of the GC session, and patient outcomes are routinely tracked: pre-GC, and 1 month after GC empowerment is measured with the Genetic Counseling Outcome Scale (GCOS) and self-efficacy is measured by the Illness Management Self Efficacy scale (IMSES). Patients who completed GCOS and IMSES at both time points were included in the analyses (independent T-Tests and Mann–Whitney tests comparing change in GCOS and IMSES scores from pre- to post-GC between Groups 1 and 2). Results: 130 patients completed scales at both time points, and were included in analyses. There were significant increases in GCOS and IMSES scores from pre to post GC but no difference between groups in the magnitude of change in score. Conclusions: This study suggests that obtaining family history prior to versus during the GC appointment results in similar patient outcomes for empowerment and self-efficacy. Future research could compare in person and web-based family history documentation.

Genetic counselors’ perspective on the impact of spanish-speaking interpreter-mediated sessions

R. Veazey1, A. Henshaw2, R. Littlejohn3, R. Stewart1

1. University of North Carolina at Greensboro Genetic Counseling Program

2. Carolinas HealthCare System

3. Children’s Hospital of San Antonio

Background: Previous research has assessed the increasing need for interpreters in healthcare and the impact that spanish-speaking interpreters have on physician-patient relationships. There has been little research on the impact upon genetic counseling sessions. Purpose: Goals of this study were to assess the impact that spanish-speaking interpreters have on the genetic counseling process from the perspective of genetic counselors, and describe challenges and strategies used to improve interpreting outcomes. Methods: Semi-structured telephone interviews with genetic counselors were conducted. Recruitment occurred via the National Society of Genetic Counselors student research eBlast. Thematic analysis by two investigators was performed. Results: Twenty-four interviews were conducted with genetic counselors from a variety of specialties. The majority of participants reported that the involvement of an interpreter increases patients’ comfort level, and impacts the flow and length of a genetic counseling session. Interpreters also increase challenges faced by genetic counselors, such as difficulty exploring patients’ psychosocial needs. Most respondents reported that the content and goals of a session were not impacted by an interpreter. The most frequently reported barrier to the genetic counseling process was inaccurate translation, which can lead to erroneous counseling. The most common strategies employed were including open-ended questions and altering speech patterns. Conclusion: This study showed that the impact that spanish-speaking interpreters have on the genetic counseling process is multifaceted and complex. Most strategies used to ameliorate barriers are skills represented in the genetic counselor professional practice-based competencies, suggesting that genetic counselors already have many tools to navigate the interpretation process during genetic counseling sessions.

Difficult discussions: DNA banking

C. Zaleski1

1. PreventionGenetics

In order to help patients understand the value of DNA banking, they first need to appreciate the value of genetic testing and genetic medicine. Genetic counselors are uniquely trained to discuss and offer DNA banking to patients and their families. Yet, based on anecdotal evidence from genetic counselors, although they often feel they should be offering DNA banking more frequently, the reality is only a small number of counselors routinely discuss DNA banking with patients. Reasons include lack of awareness of all the situations where banking may be relevant, value not fully recognized, added time in sessions, added expense for patients, and the difficult conversations surrounding DNA banking. We sent letters to DNA banking depositors and authorized representatives (often family members) that accessed the banked DNA for testing to request testimonials from them to help raise awareness of DNA banking and provide evidence for the importance of DNA banking. These powerful testimonials demonstrate motivators from the families’ perspectives for banking. By combining clinical counseling experiences with patient feedback, we’ve developed some tips and conversational tools to enhance genetic counseling discussions on DNA banking, which often occur in difficult situations.


A community mammography high risk screening program: A precautionary tale

N. Armstrong1, E. Weber1, J. Wozny1

1. Edward Cancer Center

A primary role of a cancer risk genetic counselor is to identify individuals at increased risk to develop cancer to ensure that they are receiving appropriate care. Approximately 3 years ago, a community hospital began screening all mammography patients utilizing Epic electronic medical records with a short family history questionnaire. When criteria are met, the reviewing radiologist is prompted to insert a paragraph into the mammography report recommending an evaluation in the Cancer Risk Assessment Clinic (CRAC). 30,531 mammograms were performed in 2015, and 575 (1.8 %) patients were flagged for referral to the CRAC. Twenty-six percent (151/575) of referrals did not meet National Comprehensive Cancer Network (NCCN) (version 2.2015) guidelines for a genetic referral, primarily because age of onset of breast cancer was older than the established guidelines (61/151) or because no ages were entered (24/151). Only 11 % (64/575) had documented referrals or appointments scheduled in the CRAC; 7.3 % (42/575) of the patients were actually seen for a genetic evaluation. Of the patients with documented referrals/appointments, 66 % (42/64) attended a genetic evaluation appointment. Genetic evaluations included traditional genetic counseling and a discussion with an oncologist regarding appropriate screening and prevention. Sixty-nine percent (29/42) were offered or had already had genetic testing. One familial BRCA mutation and one CHEK2 mutation were identified. About 30 % (13/42) were not recommended to have genetic testing: 14 % because a family member was more appropriate to test, 7 % because the family did not meet the National Comprehensive Cancer Network (NCCN) criteria for genetic testing for hereditary breast and ovarian cancer, and 10 % because the appropriate family members had already had negative genetic testing. Nineteen percent (8/42) of the patients seen were recommended to have breast MRI. This data highlights the difficulties in identifying and recruiting appropriate at risk patients. Further education needs to be provided to both the individuals collecting the data and to the referring providers.

“Incidental” germline finding following somatic molecular profiling

L. Bokovitz1

1. West Cancer Center

As tumor molecular profiling becomes increasingly common in oncology, genetic counselors play a vital role in determining which patients would benefit from germline genetic testing, as demonstrated by this case. A 76-year-old male presented to the oncology clinic because of his personal history of metastatic pulmonary adenocarcinoma. He smoked 5–6 cigarettes per day most of his adult life. Upon progression of his disease, molecular profiling was ordered on his lung biopsy to determine treatment/clinical trial eligibility. Of note, this testing revealed a somatic BRCA2 mutation at 44 % allele frequency. This mutation had also previously been described as a germline mutation. The patient was adopted and was thus unable to provide family history information; however, he does have a 43-year-old daughter who was not having regular mammogram screenings. Her ovaries were intact. Germline testing for this patient was pursued to determine whether the previously identified BRCA2 somatic mutation was germline, even though he did not meet traditional criteria, given his unknown family history. He tested positive for a pathogenic germline BRCA2 mutation. His daughter subsequently underwent genetic testing and was found to carry the familial mutation. To date, she has undergone a bilateral salpingo-oophorectomy and is having regular breast imaging, with tentative plans to undergo a bilateral mastectomy. Had somatic molecular profiling not been ordered for this patient, his daughter would have been unaware of her increased cancer risks and would not have been able to take these preventative measures. Further research is needed to understand how somatic test results impact the risk for germline gene mutations. Our center orders a high volume of molecular profiles and is currently planning a research study to examine the concordance of somatic and germline results. Such cases highlight genetic counselors’ critical role in the somatic testing process, especially as our understanding evolves.

Longitudinal natural history of dermal neurofibromas in individuals with neurofibromatosis type 1

A. Cannon1, M. Chen1, A. Theos1, B. Korf1

1. University of Alabama at Birmingham

Neurofibromatosis type 1 (NF1) is a genetic disorder characterized by a predisposition to develop multiple benign tumors. A major feature of NF1 is the development of cutaneous tumors, called dermal neurofibromas (DNs). DNs manifest in >99 % of adults with NF1 and are responsible for major negative effects on quality of life for patients. Previous reports have correlated increased burden of dermal neurofibromas with age and pregnancy, but longitudinal data are not available to establish a quantitative natural history of these tumors. We have previously developed an approach to quantify the number and size of DNs using photographs, calipers, and paper frames, which provides reliable outcome measures. For the present study, we have used this approach to monitor tumor number and size in a cohort of 22 patients with NF1 followed over an 8-year period. A minimum of 6 and maximum of 18 tumors were monitored for each patient in three different body sites. Preliminary data from the first 2 years of the study showed significant (p = 0.0185) tumor growth, although the trend of increased tumor volume was slight. This will be the first reported longitudinal natural history study of DNs. Furthermore, these results will provide insight into DN development and may be useful to researchers considering clinical trials targeting DNs.

Multigene genetic testing for hereditary cancer susceptibility in the community setting: Do patients prefer more?

J. Christiansen1, P. Gor1, J. Handy1, K. Zarnawski1

1. Virtua

The advent of nextgen sequencing technology has allowed genetic counselors the option of offering multigene testing for inherited cancer susceptibility genes to patients; however, patients’ preferences have not been well studied in the literature. Virtua is a community hospital which serves patients in southern New Jersey. After the National Comprehensive Cancer Network (NCCN) guidelines update in 2015 added clinical recommendations for breast moderate risk genes (ATM, PALB2, CHEK2), the Cancer Genetics Program (CGP) at Virtua reviewed the benefits, risks and limitations of multigene testing with the Breast Program Leadership Committee, which also includes breast surgeons, medical oncologists, and radiation oncologists. After approval, the CGP routinely offered multigene testing for the clinically actionable breast high and moderate risk genes (BRCA1, BRCA2, PTEN, CDH1, STK11, TP53, ATM, CHEK2, ATM, PALB2) for all patients with a personal history or family history of breast cancer who met the NCCN criteria. The risks of multigene testing, including the increased risk for variants of uncertain significance (VUS), delayed turn-around time, and the unknown significance of unexpected test results, were routinely discussed during the counseling sessions. From August of 2015 until February of 2016, a total of 171 patients pursued genetic testing. A total of 131 (77 %) chose panel testing for all nine breast high and moderate risk genes, 6 (4 %) chose testing for the breast high risk genes only, 31 (18 %) chose testing for BRCA1/2 only, and 3 chose a customized panel of preferred genes from the nine genes offered. Of those with a personal history of breast cancer, 73 % (77/106) chose multigene testing while 83 % (54/65) of those without a personal history of breast cancer chose panel testing for all 9 genes. This study shows that patients prefer multigene testing even after learning about the potential risks. The decreased uptake for multigene testing in patients affected with breast cancer may be due to the longer turn-around time and the desire to have a more timely surgery.

Development of an iPhone application to support tracking and adherence to recommended guidelines for women with a BRCA mutation

S. Cohen1, D. Nixon1, C. Scherr2

1. St. Vincent Health

2. Northwestern University

Previous studies indicate women with a deleterious mutation in BRCA1 or BRCA2 struggle to maintain adherence surveillance guidelines, particularly over time. Based on data from a focus group conducted at our institution, an iPhone application was developed to help BRCA carriers track surveillance appointments and provide reminder alerts. As part of formative research, a live demonstration of the iPhone application was presented during the Indiana Network of Genetic Counselors educational conference for women with a BRCA mutation. Following the demonstration, patient feedback was collected via a survey on the utility, design, and appeal of the application. Descriptive statistics were used to calculate responses. All respondents had a BRCA (n = 10) mutation. All respondents indicated they would use the iPhone app (n = 9), of which some (n = 5) would use both an iPhone app and an online version, if it was available. Most (n = 7) believed the app would help them remember to schedule their appointments, but wanted additional functionality such as notes and information fields (n = 5). Most believed the home page would grab their attention (n = 5) and liked the pink and teal colors (n = 9). Participants stated seeing the tool made them feel hopeful (n = 4) and/or less stressed (n = 6) and stated they were likely to share the tool with a friend or family member (n = 10). Feedback from the demonstration encouraged the continued development and informed modification of the iPhone application, including providing additional fields for notes about results and providers. The resulting iPhone application, Scheduling Necessary Advised Procedures (SNAP) for BRCA is currently being piloted with a group of BRCA carriers to determine if it improves adherence to surveillance guidelines.

A needs assessment for the development of a hereditary breast cancer syndrome support group in Greensboro, North Carolina

K. Garbarini1, K. Powell2, G. Magrinat2, M. Vogelsinger2, R. Stewart3

1. UNC at Greensboro

2. Cone Health Cancer Center

3. UNC at Greensboro; Cone Health

Background: Individuals with hereditary breast cancer have unique support and informational needs. Literature has shown that individuals at increased risk of breast cancer have interest in support group participation. Purpose: The goal of this study is to assess interest in and preferences for a hereditary breast cancer syndrome support group in Greensboro, North Carolina. Methods: An anonymous survey was mailed to 87 individuals who underwent genetic testing, were identified with a pathogenic mutation in a hereditary breast cancer gene, and are patients in the Cone Cancer Center system. The survey responses were analyzed using descriptive statistics and chi-square analysis. Results: Twenty-two surveys were returned for a response rate of 25.3 %. Forty-five percent of respondents reported personal interest in attending a face-to-face hereditary cancer support group (n = 10). A majority of participants desired more information about Hereditary Breast and Ovarian Cancer (HBOC) genetics (77 %), treatment (77 %), coping strategies (73 %), and self-care (73 %). Most participants expressed interest in hearing about personal experiences of other individuals (82 %) and giving/receiving emotional support (86 %; 82 %). The majority of participants preferred for the group to meet at a hospital location (45 %) in the evening (55 %), once a month (64 %), in a small group format of 10 individuals or less (55 %), and facilitated by a health care professional (64 %). Conclusion: This study documented the need for a hereditary breast cancer syndrome support group by self-reported participant interest and provided evidence of unmet informational and support needs. These unmet need are supported in medical literature and include a desire for more information about HBOC genetics, treatment, coping strategies, and self-care, opportunities to hear the personal experiences of others and to give/receive emotional support. The logistics and preferences reported in this study should be incorporated into the planning of hereditary breast cancer support groups or subgroups.

Patient participation in family studies: A collection of semi-structured interviews

L. Garrett1, B. Shirts1

1. University of Washington Lab Medicine

Family segregation studies can yield powerful data to classify variants of uncertain significance (VUS), but segregation research is unavailable to many families with VUS identified by clinical testing. A potential solution is to engage patients and their families in pedigree building for segregation analysis to evaluate their own VUS. Most patients will have sufficient family members to classify a VUS if pedigrees extend to 2nd cousins, and available online genealogy and social networking tools can facilitate identifying and contacting these relatives. We are evaluating an online patient-driven VUS classification toolkit at that teaches individuals to trace how their own variants segregate in their extended family and participate meaningfully with clinical laboratories in the classifying their own VUS. We conducted semi-structured interviews to explore patient attitudes towards family studies for variant classification prior to their participation in patient-driven segregation activities. The initial group of patients had VUS in BRCA1, BRCA2, HHT, MSH2, POLE, and TP53. Patient interviews unveiled insight into the patient understanding of the clinical meaning of VUS and perceptions about family studies for variant classification. Patients interested in family studies were generally comfortable discussing genetic research with family members. Most had pre-existing ideas about whether their variant was pathogenic or benign. When asked how much time they were willing to spend on variant classification activities, patients responses ranged from 1 to 2 h per week to “whatever time is needed.” Patients most often mentioned concern for other family members as a motivation to participate in segregation studies. Surprisingly, it was not unusual for other family members to become more deeply involved in family segregation studies that the index patient. Preliminary evidence indicates that is a successful webtool benefiting patients motivated to independently gather information needed to reclassify their VUS.

The importance of cascade screening: Lessons learned from a family with atypical multiple endocrine neoplasia type 1

K. Guthrie1, K. Clift1, J. Gass1, P. Atwal1

1. Mayo Clinic Florida

Introduction: Multiple endocrine neoplasia type 1 (MEN1), caused by mutations in MEN1, is a well described syndrome associated with parathyroid adenoma, pituitary adenoma, well differentiated endocrine tumors of the gastro-entero-pancreatic tract, carcinoids, adrenocortical and other tumors. A clinical diagnosis is established in an individual with either 2 MEN1-associated tumors or one MEN1-associated tumor and an affected first degree relative. Nearly all individuals present with primary hyperparathyroidism (PHPT) which is often the first manifestation. MEN1 mutations have also been reported in familial isolated hyperparathyroidism. We describe a 76 year old female who presented to genetics clinic with a family history of two children with PHPT and a MEN1 pathogenic variant. Her medical history was unremarkable and PTH was normal. Methods: Molecular testing for the known familial mutation c.1A>G was performed using standard methods. Biochemical testing, MR brain and MR abdomen performed using standard methods. Results: Molecular testing revealed the patient was heterozygous for the familial MEN1 mutation. This variant has been reported previously in a family with isolated hyperparathyroidism. Physical exam revealed red facial papules which appear to be facial angiofibromas. Biochemical testing was normal except for pancreatic polypeptide which was seven times the upper limit of the normal range. MR brain was normal. MR abdomen revealed a 1.5 cm lesion at the tail of the pancreas. Patient underwent distal pancreatectomy and subsequent pathology was consistent with a pancreatic neuroendocrine tumor (PNET). Conclusion: It is thought that nearly all individuals with MEN1 manifest disease by age 40. We present a case of late-onset MEN1 with PNET and cutaneous findings in the absence of PHPT. This family expands the phenotype associated with the c.1A>G variant and highlights the importance of providing comprehensive assessment of MEN1 mutation carriers in families that may appear to have isolated hyperparathyroidism.

The role of genetic counselors in education and communication about cascade testing for hereditary cancer syndromes

R. Hagen1, D. Duquette2, A. Trepanier1

1. Wayne State University

2. Michigan Department of Health and Human Services

Cascade testing (CT) can increase identification of individuals at risk of hereditary cancer; however, current research suggests that it is underutilized. The aims of this qualitative study were to explore what approaches genetic counselors (GCs) use to promote CT with their gene-positive hereditary cancer patients and to identify factors that hinder their effectiveness. Eligible participants were board-certified genetic counselors (GCs) in Michigan as identified through a state cancer genetics provider directory. The instrumentation was an interview guide developed based on a review of the literature. The guide included questions about counselors’ experiences and practices regarding CT. The draft guide was piloted by two genetic counselors for content and clarity and then finalized. After email solicitation, twelve of 24 eligible subjects elected to take part. Semi-structured telephone interviews were conducted, audio-recorded, and transcribed. Two authors identified themes in a subset of the data set using inductive analysis. The entire data set was then coded by both authors independently with any discrepancies discussed and addressed. Data analysis showed that all respondents discuss CT post-testing with gene positive patients; most discuss it pre-testing as well. The main points conveyed fall into three themes: genetic information (inheritance, who is at risk), logistics (what type of testing, how to find a genetic counselor, tools to help inform relatives), and familial communication (what to say, how to say it). All participants reported using educational materials to promote CT, most commonly family letters and genetic test results. Identified barriers to CT included estranged family relationships, lack of contact information, and patient concerns about logistic factors and how to communicate genetic information. Respondents reported ways they attempt to manage barriers but some voiced concerns about their effectiveness. GCs are promoting CT using a number of different strategies. However, they recognize several factors that prevent full utilization.

The genetic counseling assistant: Dana-Farber’s experience in establishing a new role

C. Heydrich1, S. Stickevers1

1. Dana-Farber Cancer Institute

The need for cancer genetic counselors’ services has grown dramatically in the past several years. At the Dana-Farber Cancer Institute Center for Cancer Genetics and Prevention the number of genetic counseling appointments increased by 53.6 % from 2012 to 2014. In an effort to maximize the genetic counselors’ (GC) unique skill-sets and to allow more frequent and effective direct patient contact, the Center created a genetic counseling assistant (GCA) position in 2014. The job was posted as an “Administrative Support Specialist” and required applicants to have a Bachelors degree and strong interpersonal and computer skills. Prior administrative work experience was preferred and an interest in genetics was an additional advantage. Since 2014, the Center has experience hiring five GCAs, with the Center presently employing three full time GCAs. Successful GCA hires came with previous experience including insurance appeals and hospital scheduling. The GCAs’ primary responsibilities include test-requisition form completion, laboratory communication, pedigree entry, and results tracking and distribution. Each GCA supports approximately 5 GCs, which is a total of 40–50 patients per GCA per week. The GCs and GCAs meet weekly to discuss questions, concerns, and workflow. By choice, the GCAs participate in additional Center activities including the Quality Initiatives work- group, patient review, journal club, and GC shadowing, which they report has expanded their understanding of genetics. This employment opportunity has allowed the Center to better understand the successes and barriers involved in integrating this innovative position within a cancer genetics clinic. Other institutions looking to increase the number of GC appointments may wish to investigate the benefits of a GCA position.

Use of tumor histology to aid the identification of patients with Lynch syndrome

C. Mauer1, A. Holcomb1, L. Robinson1, T. Ross1

1. UT Southwestern Medical Center

Background: Patients with Lynch syndrome (LS) are often identified by absent mismatch repair proteins on immunohistochemical (IHC) tumor stains or by their family history of cancer (meets Amsterdam II criteria). LS colon tumors are commonly right-sided and often have unique histologic characteristics: tumor-infiltrating lymphocytes, mucinous features, and signet ring histology. We sought to evaluate if LS patients could be identified by this unique histology alone. Methods: Institutional databases were used to identify colon cancer patients with a diagnosis of LS between October 2009 and January 2016. One hundred twenty five patients with colon cancer and LS were identified; 55 (43 %) had complete pathology records for review of tumor characteristics. Results: Of the 55 patients, 20 (36.3 %) had mutations in MLH1, 21 (38.2 %) in MSH2, 8 (14.5 %) in MSH6 and 6 (10.9 %) in PMS2. Forty-seven patients had IHC performed; 45 (95.7 %) had absent staining that correlated with their mutation. Nineteen patients (34.5 %) met Amsterdam II criteria. Thirty-seven unique pathologists signed out the cases. Of the 55 tumors, 26 (47.2 %) tumors were right-sided, 13 (23.6 %) had infiltrating lymphocytes, 27 (49 %) had mucinous features, and eight (14.5 %) had signet ring features. MSH2-related tumors were more likely to exhibit histological features of LS (n = 21, 38.1 %), followed by MLH1-related tumors (n = 18, 32.7 %). Twenty-five (45.5 %) tumors exhibited one histological feature, 9 (16.3 %) exhibited two features, 3 (5.4 %) exhibited all three histological features, and 18 (32.7 %) did not exhibit any features. Conclusion: Colon tumor histology alone did not identify 32.7 % patients with LS, while Amsterdam II criteria missed 65.4 % of patients with LS. Thus, both histology and additional criteria to improve providers’ identification of patients with LS are necessary. Given that the majority of tumors had mucinous features, this histological feature could be incorporated into LS prediction models to improve mutation prediction.

Expanding the phenotype ofDICER1syndrome: Two years ofDICER1testing in a pediatric cancer genetics clinic

R. McGee1, E. Quinn1, R. Nuccio1, S. Hines-Dowell1, C. Kesserwan1, K. Nichols1

1. St. Jude Children’s Research Hospital

DICER1 syndrome is associated with predisposition to rare tumors including pleuropulmonary blastoma (PPB), cystic nephroma (CN), ovarian sex-cord stromal tumors (oSCST), ciliary body medulloepithelioma (CBME), botryoid embryonal rhabdomyosarcoma (beRMS), pineoblastoma (PinB) and others. Families also are at risk for benign and malignant thyroid disease, a common condition in the general population. The phenotype of this newly recognized syndrome continues to evolve. To better characterize the tumor spectrum and penetrance in DICER1 syndrome, we examined the family and cancer histories of children referred to the Cancer Predisposition Program at St. Jude Children’s Research Hospital. Between 2014 and 2016, 25 patients underwent DICER1 testing. Eight (32 %) patients harbored a pathogenic DICER1 mutation. The tumor spectrum among these patients included PinB (n = 2) unilateral oSCST (n = 2), bilateral PPB (n = 1), bilateral CN (n = 1), beRMS (cervix; n = 1), CBME (n = 1). Median age at tumor diagnosis was 3 years (range: 0.16–13 years). Remarkably, one patient had an ovary juvenile granulosa cell tumor diagnosed at 12 months. Nine of 25 (36 %) patients tested had family histories positive or suspicious for DICER1-related tumors; of these, seven had a DICER1 mutation, although one patient’s mutation was de novo. Five of the families had thyroid disease (nodules and/or cancer). Other tumor types in the affected lineage included childhood rectal polyps, colon cancer and uterine sarcoma. No other genetic diagnoses were made in patients with normal DICER1 test results. Inquiring about the presence of thyroid adenoma, multinodular goiter and thyroid cancer in the family history provides an important clue for considering DICER1 testing in children with rare tumor types. Continued identification and monitoring of families with DICER1 syndrome will contribute to the phenotype and development of appropriate tumor surveillance guidelines.

Improved uptake and efficiency of genetic counseling services via an embedded genetic counselor in a multidisciplinary breast cancer clinic

R. Noss1, N. Hussain2, H. Pederson1, S. Grobmyer1, C. Eng1

1. Cleveland Clinic

2. Case Western Reserve University School of Medicine

A significant percentage of breast cancers (5–10 %) are hereditary in nature. Identifying hereditary breast cancer is increasingly important for surgical decision-making purposes. We hypothesized that embedding a genetic counselor within our multidisciplinary breast cancer clinic would improve timeliness and appropriateness of care. The aim of this study is to compare cancer care between 2012 and 2014, prior to embedding a genetic counselor and following the intervention. Methods: A retrospective review of patients diagnosed with breast cancer in 2012 (n = 787) and 2014 (n = 764) was performed to assess number of referrals to genetic counseling; compliance with referral; and timeliness of the genetic counseling session and result disclosure. Results: There was a significant increase between 2012 and 2014 in. the likelihood of being referred to genetics (OR 1.49; CI 1.15–1.94; P = 0.003), the likelihood that the patient followed through with counseling was significantly higher (OR1.66; CI 1.02–2.71; P = 0.042), and the wait time was significantly less (OR 0.26; CI 0.18–0.37; P < 0.001). Patients were more likely to have genetic test results prior to surgery (OR 1.69, CI 1.12–2.55; P = 0.013). Additionally, despite a statistically significant increase in the number of panel tests ordered, there was no statistically significant difference in time from genetic counseling session to results disclosure between 2012 and 2014. Conclusion: Awareness of the implications of germline genetic mutations is increasingly critical in the care of breast cancer patients. Having a genetic counselor embedded in a multidisciplinary clinic allows for ease and timeliness in counseling and testing.

Cascade testing for hereditary cancer syndromes: beyond Lynch and BRCA

J. Osborne1, E. Koeppe1, M. Jacobs1, K. Hanson1, M. Marvin1, J. Everett1, T. Else1, E. Stoffel1

1. University of Michigan Cancer Genetics Clinic

Introduction: Cascade testing, defined as uptake of genetic testing among at-risk relatives of patients with a known familial mutation, plays a critical role in identifying individuals with hereditary conditions. Research efforts to date have focused primarily on evaluating and improving the efficiency of cascade testing for Lynch syndrome (LS) and hereditary breast ovarian cancer syndrome; however data regarding uptake of genetic testing among individuals with other hereditary cancer syndromes are lacking. Methods: We reviewed genetic tests records of individuals evaluated for LS, familial adenomatous polyposis (FAP), paraganglioma-pheochromocytoma (PGL-PCC), Li-Fraumeni syndrome (LFS), hereditary leiomyomatosis and renal cell cancer (HLRCC), Birt-Hogg-Dubé (BHD), and PTEN hamartoma tumor syndrome (PHTS) at the University of Michigan from 2005 to 2016. We calculated the ratio of site specific tests ordered per positive full gene analysis test result as a proxy for number of at-risk relatives tested per positive proband. Results: During the study period, a total of 3248 genetic tests were performed for LS, FAP, PGL-PCC, LFS, HLRCC, BHD, and PHTS; 2670 (71.2 %) tests utilized full gene analysis while 578 (17.8 %) were site-specific, with positive test rates of 11.3 and 46.5 %, respectively. Steady upward trends in single site testing were observed for all syndromes. PGL-PCC, LS, and LFS had the highest overall uptake with an estimated 2.8, 2.3, and 2.1 relatives tested per positive proband respectively, while <2 relatives underwent genetic testing per positive FAP, BHD, PHTS, and HLRCC proband (rates of 1.6, 1.1, 0.8, and 0.6, respectively). Conclusions: Uptake of genetic testing among at-risk relatives is increasing, however fewer than 3 relatives are tested for every individual diagnosed a hereditary cancer syndrome. Genetic testing uptake is higher for syndromes without a clinical phenotype to inform screening. The data suggests a need for interventions to facilitate communication regarding genetic information.

Genetic counseling for lung cancer

E. Palen1, M. Flynn2, E. Hoffman3

1. Geisinger University

2. Boston University

3. Littleton Adventist Hospital

Lung cancer continues to be the second-most common cancer diagnosed and the most common cause of cancer death in the U.S. The goal of the present study is to explore the role that genetic counselors play in counseling about lung cancer. Specifically, the study sets out to determine whether or not genetic counselors discuss with their patients smoking and smoking cessation, annual low-dose computed tomography (if applicable), research studies focusing on lung cancer, and germline genetic testing for lung cancer. Additionally, the study assesses if and how genetic counselors consider particular features of a patient’s personal and family history to be indicative of a hereditary lung cancer syndrome or predisposition. Four hundred five board-certified or board-eligible genetic counselors began the survey, and 316 completed the survey. The majority of counselors ask their patients about tobacco smoking histories, including quantity and duration of time, but the minority of counselors ask their patients about smoking cessation. The majority of counselors do not ask their patients about marijuana smoking history. If a family history of lung cancer is present, the vast majority of counselors answered that they ask about exposures, but few counselors have ever made referrals to or received referrals from pulmonology based on a patient’s personal or family history of lung cancer. The majority of counselors surveyed were not aware of the U.S. Preventive Services Task Force’s recommendation of low-dose computed tomography for high-risk individuals, and some felt that the discussion of this recommendation is not within a genetic counselor’s scope of practice. The majority of counselors have never discussed lung cancer research studies or genetic testing with patients, but some counselors provided information about what they considered or offered to their patients.

Genetic counselors and physicians play separate but important roles in cancer risk management decision making

A. Puski1, J. Bachman1, A. Toland1, L. Senter1, S. Hovick1

1. The Ohio State University

Women with a BRCA mutation have an increased risk for breast and ovarian cancer and are recommended to have increased screening and/or prophylactic surgery. The process of deciding if and when to undergo prophylactic surgery is complex and difficult for many carriers. Little is known about the involvement of others in this process. This qualitative study evaluated BRCA mutation carriers’ risk management decision-making (DM) process, including the involvement of various groups. Interviews about risk perceptions and personalized risk information were conducted with 20 BRCA mutation carriers, during which participants naturally discussed their cancer risk management DM process. DM information was analyzed and coded using grounded theory. Mutation carriers who had not had breast cancer (previvors) had a more difficult time coming to a cancer risk management decision than women with a breast cancer history. Physicians were noted to be integral in the DM process by providing support and management recommendations. Family members and other mutation carriers filled a similar role in the DM process by providing decisional and emotional support for carriers. Genetic counselors were found to be short-term providers of risk information and management recommendations. If a carrier was not receiving information or support needed from one of these groups, our results showed she most often turned to others, including healthcare providers. Data from this study suggest that previvors may need additional support and information during the DM process. Due to the integral involvement of healthcare providers, it is important they have a good understanding of risk-management strategies for women with BRCA mutations and work with mutation carriers through the DM process.

Assessing clinician confidence and preferences when incorporating genomics in the pediatric oncology clinic: Insights from an institutional survey

E. Quinn1, L. Johnson1, J. Valdez1, R. McGee1, R. Nuccio1, S. Hines-Dowell1, C. Kesserwan1, B. Mandrell1, K. Nichols1

1. St. Jude Children’s Research Hospital

Genomic sequencing is increasingly being utilized in the pediatric oncology clinical setting. Such testing holds promise to elucidate somatic genetic pathways that can be targeted to improve cancer treatment, and identify germline genetic lesions that guide tumor surveillance and provide information relevant to reproductive decision-making. Although the availability and clinical applications of genomic sequencing are on the rise, the knowledge and attitudes of pediatric oncology clinicians about genomic testing are not well understood. At St. Jude Children’s Research Hospital, we recently initiated Genomes for Kids, a research study examining the feasibility, acceptance and impact of clinical genomic sequencing using paired tumor and germline tissue samples. In preparing for this study, we administered an IRB exempt 20 question online survey to pediatric oncology providers to assess their confidence in interpreting and communicating somatic and germline genomic sequencing results. The survey was sent to 180 clinicians, 86 (48 %) of whom responded including attending physicians, hematology/oncology fellows, nurse practitioners, and physician assistants. Overall, confidence in interpreting genomic results was low with 28 % reporting confidence in interpreting somatic results and 28 % reporting confidence in interpreting germline results. Of note, 90 % indicated that they would like to speak with a genetic counselor prior to discussing genomic results with their patients and 65 % wished for a genetic counselor to be present during these discussions. In contrast, 29 % indicated that they would like to be the first to convey germline genomic results prior to the patients meeting with a genetic counselor. Our findings reveal that most pediatric oncology providers are not comfortable interpreting and communicating with patients and their families about germline genomic sequencing results. Although there is variance among providers, these results suggest that the expertise of genetic counselors is highly valued during the process of pediatric cancer genomic testing.

CDH1in the era of multigene panel testing: Discrepancies between the literature and observed phenotypes for missense variant carriers.

M. Roberts1, L. Susswein1, M. Marshall1, L. Yackowski1, R. Klein1, K. Hruska1

1. GeneDx

Background: Pathogenic variants in CDH1 are associated with Hereditary Diffuse Gastric Cancer (HDGC) as well as lobular breast cancer. While the majority of pathogenic CDH1 variants are loss-of-function, roughly 18–33 % are missense variants shown to have abnormal function in in vitro assays. However, the clinical presentation of patients with such missense variants is not always typical for HDGC, bringing into question the clinical significance of these variants. Methods: We selected three recurrent CDH1 missense variants and retrospectively compared the clinical histories of individuals identified via multi-gene panel testing at GeneDx who harbor one of these CDH1 variants (p.Thr340Ala, p.Glu781Asp, and p.Val832Met) with the clinical histories reported in the literature. Results: All three CDH1 missense variants have published functional evidence suggesting pathogenicity and have been published in individuals with a personal and/or family history of diffuse gastric cancer (DGC). In our cohort, none (0 %, 0/26) of the female individuals heterozygous for one of these variants had a personal history of DGC or other type of gastric cancer. While gastric cancer, type unknown, was reported in five family members from three probands (21 %, 3/14) who harbor Thr340Ala or Val832Met, all of these individuals were reportedly of Asian descent. Nineteen (73 %, 19/26) individuals reported a personal history of breast cancer, but only one (5 %, 1/19) indicated lobular pathology. Conclusions: While these three CDH1 missense variants are classified as pathogenic in the literature, our data show that they are often observed in individuals with no, or very little, personal and family history suggestive of HDGC. The apparent discordance between published data and observations from multi-gene panel testing suggests that the CDH1 literature may be subject to ascertainment bias and should be referenced with caution. These data also highlight the complexity of using in vitro functional assays to classify CDH1 variants.

Germline implications of somatic tumor profiling and the evolving role of genetic counselors in oncology: A case series

B. Roscow1, L. Brzeskiewicz1, B. Goetsch1, D. Huismann1, C. Campbell1

1. Rocky Mountain Cancer Centers

Tumor profiling utilizing somatic next-generation sequencing (SNGS) is becoming standard of care in oncology for the identification of targeted treatments and prognostic information. With the increase in SNGS testing, individuals are being identified with tumor mutations that may have germline implications. Oncology genetic counselors are seeing their role expand and evolve as the complex results for germline next-generation sequencing (GNGS) and SNGS are beginning to overlap. The case series presented reports three such cases. Proband 1 is a 55-year old male with nasopharyngeal cancer and a family history of leukemia, lung, and colon cancers. SNGS identified a BRCA2 mutation at a mutant allele frequency (MAF) of 49 % that was confirmed to be germline on a 29-gene GNGS panel. The family history reported did not meet National Comprehensive Cancer Network guidelines for genetic testing of BRCA1/2. Proband 2 is 33-year old male with cholangiocarcinoma of the bile duct and a family history of ovarian cancer. SNGS identified a BRCA1 mutation at a MAF of 62 % and single site analysis confirmed it to be germline. His cancer is atypical for a BRCA1 mutation carrier; while the family history was suggestive of a BRCA mutation, SNGS was critical for an accurate diagnosis for the patient in an otherwise untested family. Proband 3 is an 80-year old female with pancreatic adenocarcinoma and a family history of endometrial, pancreatic, gallbladder, lung, brain and prostate cancers. SNGS identified a PALB2 mutation at a MAF of 87 % that was confirmed to be germline on a 49-gene GNGS panel. This family’s cancer history was not suggestive of a PALB2 mutation, which is mainly associated with a high risk for breast cancer. These cases illustrate how SNGS results are becoming an important aspect of oncology based genetic counseling and risk assessment. Additionally, SNGS can help identify individuals with a hereditary cancer predisposition that may not have been elicited by traditional means, as well as expand our current knowledge of the variability within hereditary cancer syndromes.

The psychosocial effects of the Li-Fraumeni education and early detection program on individuals with Li-Fraumeni syndrome

J. Ross1, J. Bojadzieva2, S. Noblin1, R. Yzquierdo2, M. Askins2, R. Krahe2, S. Peterson2, L. Strong2

1. UT Health

2. M.D Anderson Cancer Center

Li-Fraumeni syndrome (LFS) is a hereditary cancer syndrome that leads to an increased risk of multiple different cancers. In the past 5 years new comprehensive screening protocols have been developed that provide improved screening options for individuals with LFS. These protocols helped to detect cancers early and increase survivability for these patients. Prior to comprehensive screening, individuals going through traditional hereditary cancer screening were reported to have a lower quality of life and increased levels of distress. However, at this time, very little has been published on the psychosocial impacts of comprehensive screening. One case report suggested possible testing fatigue and exhaustion as a result of comprehensive screening; however, this hypothesis has not been thoroughly investigated. The goals of this study are to determine how participation in comprehensive screening impacts individuals psychosocially, to discover the benefits and drawbacks of screening, and to evaluate possible barriers to continued screening. This qualitative study consists of phone interviews with 20 individuals in an LFS screening program at M.D. Anderson Cancer Center. Participants were asked a series of semi-structured questions that addressed the individual’s experiences and emotions related to screening. Data analysis using grounded theory approach showed that perceived benefits of screening included early detection, peace of mind, centralized screening, knowledge providing power, and screening making LFS seem more livable. Perceived drawbacks included logistical issues, difficulty navigating the system, screening being draining, and significant negative emotional reactions such as anxiety, fear, and skepticism. Regardless of the emotions that were present, 100 % of participants plan on continuing screening in the program. Our data indicates that the perceived benefits of screening outweigh the drawbacks of screening. Individuals in this screening program appear to have improved psychosocial well-being because of their access to the screening program.

Preliminary baseline data from the scheduling necessary advised procedures for BRCA iPhone application

C. Scherr1, D. Nixon2, S. Cohen2

1. Northwestern University

2. St. Vincent Health

Difficulty with adherence to screening guidelines for BRCA carriers due to lack of awareness and challenges with tracking and scheduling has been documented. The scheduling necessary advised procedures (SNAP) for BRCA iPhone application was developed to assist women in managing their surveillance according to published guidelines. As part of a study to assess the effectiveness of SNAP, participants completed an on-line multiple choice baseline survey to evaluate beliefs about screening guidelines and questions grounded in the transtheoretical model of behavior change to assess adherence. Participants were recruited for this study on-line through BRCA support groups and by genetic counselors who were informed of the study via the NSGC Cancer SIG. Women with a BRCA mutation over the age of 18 with at least one breast or ovary were eligible to participate if they owned an iPhone and provided their email address. Descriptive statistics were calculated using SPSS v.23. Of the 83 women who completed the survey, 56 met eligibility criteria with a mode age-range of 35–39 (n = 17; 30.4 %). The majority believed they should have annual mammogram (n = 42; 75.0 %), annual breast MRI (n = 46; 82.1 %), clinical breast exam twice a year (n = 23; 41.1 %), breast self-exams once a month (n = 41; 73.2 %), transvaginal ultrasound twice a year (n = 23; 41.1 %), and annual CA-125 testing (n = 22; 39.3 %). Assessing for adherence, the majority had a mammogram in the last 12 months (n = 33; 58.9 %), breast MRI in the last 12 months (n = 34; 60.7 %), clinical breast exam in the last 6 months (n = 44; 78.6 %), self-breast exam in the last month (n = 37; 66.1 %), transvaginal ultrasound (n = 29; 51.8 %), and CA-125 testing (n = 26; 46.4 %) in the last year. Despite the majority’s awareness and adherence to surveillance guidelines, overall awareness was higher than adherence, with approximately half of respondents adhering to recommended guidelines. These results support the need for a tool such as the SNAP application. Recruitment continues and a follow-up survey will be sent after 18 months of SNAP use to assess for changes in surveillance practices.

Case report: Phenotypic expression related to a germlinePOLD1mutation in a large expanded pedigree

B. Smith1, B. Martin1

1. Benefis Sletten Cancer Institute

Germline genetic mutations in the exonuclease domains of POLE and POLD1 have been associated with a recently characterized, autosomal dominant hereditary colon polyposis and colon cancer syndrome referred to as polymerase proofreading-associated polyposis (PPAP). The clinical spectrum of disease associated with mutations in these genes is still being determined but has, in published literature, included overlapping features of familial adenomatous polyposis (FAP), attenuated FAP (AFAP) and Lynch syndrome (LS). This case report describes the clinical presentation associated with a POLD1 mutation (p.L474P) tracking through a large kindred (with at least 70 family members) spanning 3 generations. The proband was diagnosed at age 53 with a well-differentiated endometrioid endometrial cancer (EndoCa) and had a total of 24 colon polyps resected between ages 53 and 59 (17 hyperplastic polyps, 6 tubular adenomas and one mixed serrated/hyperplastic polyp). The most common cancers documented among affected relatives are EndoCa and colon cancer, however, pancreatic cancer and ovarian cancer have also been identified in obligate carriers. At least 3 individuals have presented with multiple primary tumors including one patient with a total of 4 primary colon cancers during his lifetime (3 synchronously diagnosed at age 86), and two women with metachronous colon and gynecologic malignancies (one with ovarian and one with uterine cancer). The presentation of adenomatous colon polyps has been documented in individuals as young as their early 20’s with greater than 20–30 cumulative colon polyps in multiple relatives. The clinical presentation within this family helps to define the phenotypic spectrum of disease associated with POLD1 mutations and reinforces the necessity to include PPAP as a differential diagnosis in families presenting with features of LS and/or colon polyposis.

A case report illustrating the utility of DNA banking, an underutilized genetic counseling strategy

K. Stoll1, R. Resta2

1. Genetic Support Foundation

2. Swedish Cancer Institute

In 2012 a terminally ill woman with ovarian cancer and who had a strong family history of breast, ovarian, uterine, and brain cancer underwent genetic counseling. Genetic testing of the BRCA1 and BRCA2 genes was offered but was not performed due to lack of authorization by insurance and the out of pocket cost to the family. The family decided to bank the patient’s DNA. Two years after the death of this patient, an unaffected daughter presented for genetic counseling. No living affected relatives were available for testing. A multigene panel on the daughter revealed a variant of unknown significance in the TP53 gene. The deceased mother’s DNA was then tested through a research program at a Clinical Laboratory Improvement Amendments (CLIA) approved lab at the University of Washington, which revealed a pathogenic BRCA1 mutation. The patient’s daughter and other family members were tested; only one of 5 living at-risk women in the family was determined to carry the familial BRCA1 mutation. The identification of the familial BRCA1 mutation was made possible through banked DNA and clinical research. This finding was important not only for informative testing that allowed at-risk relatives to obtain “true-negative results,” but also for the significant healthcare cost savings made possible by more targeted testing for the familial mutation and eliminating the need for high risk screening and potentially unnecessary surgeries in the non-carrier women. Although the cost of DNA Banking is typically less than two hundred dollars, given the lack of insurance reimbursement, discomfort with approaching this topic with individuals at end of life, and skepticism about the usefulness of banked DNA, genetic counselors may be reluctant to offer this option. However, this case illustrates the powerful utility of banked DNA for future risk assessment for relatives in high-risk families, as well as the potential cost savings from cascade testing when banking provides an opportunity to find the disease causing mutation in a deceased relative.

Incidental or not so incidental finding…that is the question: Tumor profiling leads to germlineFANCAmutation identification in a male breast cancer patient

H. Vig1, S. Wong1, D. Toppmeyer1, S. Ganesan1, L. Rodriguez1, K. Hirshfield1

1. Rutgers Cancer Institute of New Jersey

Introduction: A 62 year-old Caucasian male of Italian (paternal) and Irish (maternal) descent presented with left pectoral soreness. He underwent a modified left mastectomy for an ER+/PR+/Her2-, poorly differentiated, infiltrating ductal carcinoma. Staging studies demonstrated bony metastases (stage IV). Treatments included chemotherapy and hormonal therapy. Somatic tumor genomic profiling of a bone metastasis through our Precision Medicine Initiative showed a FANCA P1037fs*14 mutation as well as other alterations. Family history was significant for a mother with breast cancer at age 82 and maternal aunt with breast cancer at age 60. Previous germline genetic testing was negative for BRCA1/2 mutations. Discussion: Due to the clinical presentation and tumor profiling results, germline testing was done and confirmed the same (novel) pathogenic FANCA mutation. Chromosomal breakage analysis studies confirmed carrier status for the patient. Currently, only case reports have shown possible association of female breast cancer with monoallelic FANCA mutations. This case demonstrates an evolving spectrum of cancers associated with FANCA mutations and how secondary germline testing provided insight on targeted treatment recommendations for DNA cross linking agents, i.e. mitomycin C. In addition, this finding has potential reproductive significance addressed by genetic counseling for the patient’s daughter, age 31, given the biallelic features of Fanconi anemia. This case represents an anticipated incidental finding and underscores the importance of genetic counselors in helping to identify potentially significant germline alterations on somatic tumor profiling.

Racial variation in the frequency and genotype–phenotype correlations of MLH1, MSH2, MSH6, and PMS2 gene mutations; and performance of PREEM1,2,6 in ethnically diverse individuals: A cross-sectional study

R. Alsulaiman1, F. Kastrinos2, C. Davis1

1. Sarah Lawrence College

2. Columbia University Medical Center

Purpose: To explore ethnic and racial variations in the frequency, genotype–phenotype correlations, and performance of the PREMM1,2,6 model in a large, ethnically diverse cohort of individuals undergoing mismatch repair (MMR) genetic testing within the United States. Methods: A total of 52,758 individuals with personal and/or family history suggestive of Lynch syndrome (LS) submitted blood samples for genetic testing of MLH1, MSH2, MSH6, PMS2, and EPCAM to Myriad Genetic Laboratories between July 2006 and June 2013. Results: A total of 37,665 subjects were eligible for analyses with the majority of subjects being Caucasian. Prevalence of MMR genes: Among all ethnicities, MLH1 and MSH2 were the most commonly mutated genes. Non-Caucasian mutation carriers had a higher proportion of MLH1 gene mutations, while the proportion of MSH2, MSH6 and PMS2 mutations was higher in Caucasian carriers. Overall, the detection of variants of uncertain significance was highest among non-Caucasians for all MMR genes. Genotype-Phenotype correlation: Non-Caucasians more often reported a personal history of colorectal cancer (CRC) than Caucasians and were younger at diagnosis. Across all ethnic groups, MLH1 mutation carriers reported a higher frequency of CRC. Conversely, extracolonic LS associated malignancies, including endometrial cancer, were more frequently reported in Caucasians and were associated with higher rates of MSH2 and MSH6 gene mutations. There were very few PMS2 and EPCAM mutation carriers overall and no statistical significance was observed between all carriers of racial/ethnic groups. PREMM1,2,6: The PREMM1,2,6 had an overall c-statistic of 0.8252, performing equally well among non-Caucasians with a range between. Conclusion: This study provides novel data on the frequency and genotype-phenotype correlations for MMR gene mutation carriers among a large, racially and ethnically diverse population. The PREMM1,2,6 model has excellent discriminatory capacity among all ethnic groups and these results may reassure healthcare professionals of the utility of this model to identify individuals at risk for LS, regardless of race.

Factors influencing uptake of risk-reducing salpingo-oophorectomy by BRCA1 and BRCA2 mutation carriers

V. Breen1, M. Munsell2, J. Czerwinski3, C. Sun2, K. Lu2, D. Nebgen2, M. Daniels2

1. Scripps Health

2. University of Texas MD Anderson Cancer Center

3. University of Texas Health Science Center at Houston

Germline mutations in the BRCA1 and BRCA2 genes are associated with significantly increased risks for ovarian cancer (OvCa). The National Comprehensive Cancer Network (NCCN) currently recommends that female BRCA mutation carriers undergo risk-reducing salpingo-oophorectomy (RRSO) after age 35; however, not all women elect this option. The purpose of this study was to prospectively survey women with BRCA mutations currently undergoing OvCa screening about their intention to have an RRSO and the various factors influencing their decision. Of the 26 women who completed our survey, 26 (100 %, CI: 86.8–100) plan to undergo an RRSO in their lifetime. The average woman reported 6.7 motivations and 2.9 barriers to RRSO, indicating that in our population women tend to have more reasons for electing, rather than avoiding, this surgery. We further found that while most women appeared to share the same motivations for surgery, they often had unique barriers that were not common to others. The most important reasons in favor of surgery included a desire to reduce one’s risk for OvCa and live longer for family members. The most important barrier to RRSO was fear of the symptoms related to menopause. We believe these results will assist healthcare providers when discussing the option of RRSO with BRCA mutation carriers undergoing OvCa screening.

Factors predicting BRCA1 and BRCA2 mutation carriers’ preference for communication of risk estimates

S. Crowdes1, S. Hovick1, L. Senter-Jamieson1, K. Sweet1

1. The Ohio State University

Women with Hereditary Breast and Ovarian Cancer syndrome (HBOC), caused by mutations in BRCA1 or BRCA2, have increased lifetime risks of certain cancers, including breast and ovarian cancers. Lifetime cancer risks are presented to BRCA mutation carriers during genetic counseling, often with the addition of statistical figures and graphs. This study examines how factors such as demographic characteristics, health numeracy, graph literacy, and HBOC knowledge affect BRCA mutation carriers’ preferences for and understanding of different cancer risk estimate formats, including line graph, bar graph, icon array, and text only. An anonymous online survey was completed by 82 BRCA mutation carriers that assessed attitudes, comprehension of, and preferences for the cancer risk estimate formats. Participants best understood lifetime cancer risks when presented using the text-only format, but preferred their lifetime cancer risk be presented graphically. The line graph was the most preferred and most easily understood graphical format for presenting lifetime cancer risks. Increased comprehension of the line graph was associated with higher graph literacy (p < .05), while increased comprehension of the bar graph and icon array were associated with higher health numeracy (p < .05). Results suggest that when presented with lifetime cancer risks in genetic counseling, BRCA mutation carriers may benefit most from a combination of text and graphic displays, particularly a line or bar graph, to help describe their risks. Line graphs may be more effective for patients with higher graph literacy, whereas bar graph may be more effective for patients with higher health numeracy.

Favorable psychosocial outcomes in high or moderate risk mutation carriers identified by hereditary cancer panel testing

J. Culver1, C. Ricker1, A. Kurian2, R. Koff2, D. Sturgeon1, K. Lowstuter1, C. Hong1, K. McDonnell1, B. Allen3, C. Rowe-Teeter2, K. Kingham2, N. Chun2, U. Ladabaum2, J. Ford2, S. Gruber1, G. Idos1

1. USC Norris Comprehensive Cancer Center

2. Stanford University Cancer Institute

3. Myriad Genetics, Inc.

Hereditary cancer panels can identify mutations in high and moderate risk genes. Some providers contend that testing moderate risk genes may lead to patient confusion given limited understanding of penetrance and expressivity as well as screening guidelines that rely heavily on expert opinion. We are accruing to a multicenter, prospective trial of a 25 gene panel. A 3-month follow-up survey was administered with a response rate of 57.1 % (593/1039). Here we report an interim analysis of the mutation-positive subset (n = 67). The Multidimensional Impact of Cancer Risk Assessment (MICRA) was used to measure distress, uncertainty, and positive experience (0 never, 1 rarely, 3 sometimes, 5 often). Mean responses were compared between those positive for a mutation in a high (High) or moderate (Mod) risk gene using t-tests. The 67 participants included 38 High (APC, BRCA1, BRCA2, CDKN2A, MLH1, MSH2, MSH6, PALB2, PMS2) and 29 Mod (APC I1307K, ATM, BARD1, BRIP1, CHEK2, MUTYH monoallelic, NBN, or RAD51C). Participants were 45 % Hispanic, 37 % Caucasian, 15 % Asian, and 3 % Black. They had a mean age of 52 years; 78 % were female; 72 % had personal cancer history; 72 % were English-speaking; and 38 % had a college degree. Mean responses found patients were rarely upset about their result (mod = 0.83, high = 1.08, p = 0.48) and rarely had difficulty making decisions about cancer prevention (mod = 0.93, high = 0.97, p = 0.91). Patients rarely or only sometimes felt worry about cancer risk (mod = 2.00, high = 2.08, p = 0.85), uncertainty about cancer risk (mod = 1.59, high = 1.73, p = 0.72), or frustration about no definite guidelines (Mod = 1.59, High = 1.42, p = 0.72). Mod carriers reported significantly more relief about results (mod = 2.14, high = 1.14, p = 0.028). High risk carriers reported slightly better understanding of choices for cancer prevention (mod = 1.97, high = 2.81, p = 0.086). Both groups showed high levels of trust in the genetics team (mod = 3.86, high = 3.78, p = 0.44), on a scale of 1–4. High and moderate risk mutation carriers undergoing genetic counseling reported similar, favorable psychosocial outcomes.

The importance of discussing lifestyle risk factors in cancer genetic counseling

V. Dickens1, A. Forman2, L. Kessler1, N. Galpern2, M. Daly2

1. Arcadia University

2. Fox Chase Cancer Center

Introduction: In addition to aging, environment, and genetics, research has discovered significant lifestyle risk factors (LRFs) for cancer, including smoking, hormone use, poor diet, obesity, and sedentary lifestyle. Previous research demonstrates that these factors may not be consistently discussed within the healthcare setting. In this study, we gathered information from patients and genetic counselors (GCs) to gauge their interest in discussing LRFs for cancer. Methods: A link to a RedCAP survey was emailed to patients who consented to participate in the Risk Assessment Program (RAP) Registry at Fox Chase Cancer Center in 2013 and 2014 (N = 879), and members of the NSGC Cancer special interest group (CaSIG) (N = 979). Participants answered questions pertaining to the importance of discussing LRFs (smoking, alcohol use, diet, obesity, and exercise) in genetic counseling sessions. Data was analyzed with descriptive statistics and chi-squared comparisons. Results: 298 out of 879 patients contacted (34 %) and 204 out of the 979 members of the NSGC CaSIG (21 %) responded. At least 81 % of patients rated every lifestyle factor as very or extremely important to discuss in genetic counseling, compared to between 29 % (diet) and 69 % (smoking) of GCs. 73 % of GCs currently mention some LRFs for cancer. GCs reported most often discussing risk factors when patients asked about them. Reasons for not consistently discussing this topic included limited time, expertise, and scope of practice concerns. Discussion: Patients expressed a desire for more information on LRFs and felt genetic counseling was an appropriate setting for this discussion. Based on counselor feedback, this discussion should have minimum impact on session length, provide current data, and encourage further discussion with other healthcare providers in order to prevent scope of practice infringement. Further studies are needed to examine how best to incorporate LRFs into cancer genetic counseling sessions.

Unaffected women’s decisions to have prophylactic risk-reducing mastectomies

S. Galloway1, P. Walker2, K. Jeffcoat3, S. O’Neill4

1. Medical University of South Carolina

2. University of South Carolina

3. Lexington Medical Center

4. Lombardi Comprehensive Cancer Center, Georgetown University

Background: When a woman is at an increased risk of developing breast cancer due to a pathogenic mutation or a significant family history of the disease, she will be faced with choosing from among multiple management options, including risk-reducing mastectomies (RRM). The relative rate of RRM for both diagnosed and unaffected high-risk women has increased in recent years. Previous research has investigated the factors that influence women diagnosed with the disease to undergo RRM, but has not fully addressed how unaffected women make their decisions to choose RRM as an option when they are still healthy. Objective: This study was designed to specifically focus on decision-making factors of unaffected women at high risk for breast cancer due to a known pathogenic mutation or family history, and who had completed prophylactic RRM. Methods: Factors such as perceived risk; anxiety about personal cancer risk; family implications; “closeness” to cancer; information from healthcare providers; and body image were studied for possible influence on the participants’ decision-making process. Quantitative analyses included frequencies of responses, Spearman’s rho, one way ANOVA, and independent t-tests. Twenty-five women participated by completing demographic information; answering multiple Likert scale questions; reporting genetic mutation results and visits with various healthcare specialists. Themes were analyzed by grounded theory from the open-ended questions to extrapolate on influencing factors and the reasons they made their RRM decisions. Results: Results showed that personal health and family implications were two of the most important influencers, and that association between concern for their sexuality and body image was significant. All 25 participants reported satisfaction with their decisions. Conclusion: This study allows the voices of women to speak to genetic counselors and other healthcare specialists about the various important factors that influence healthy high-risk women to make life-changing decisions for themselves and their family members.

Single nucleotide polymorphism testing in breast cancer risk assessment: Patient interest, knowledge, and education

C. Heydrich1, J. Sotelo1, K. Hehir1, J. Garber1, S. Gray1

1. Dana-Farber Cancer Institute

Most individuals evaluated in a high-risk clinic for hereditary breast cancer (BC) test negative. A single nucleotide polymorphism (SNP) score that modifies breast cancer risk (BCR) can be integrated into clinical risk prediction models to further refine BCR estimates. At Dana Farber Cancer Institute, 81 women with family histories of BC and negative multi-gene panel testing participated in a pilot survey that assessed participants’ interest in SNP testing as a part of BCR assessment and their SNP-related knowledge (12 item measure). The survey additionally asked the women to quantify their perceived BCR and reflect on their prior decision to undergo genetic testing. Eighteen women later participated in a 30-min genetic counselor guided SNP education session in order to provide feedback on a BC SNP educational tool and completed a post-education survey. Of all participants, 4.9 % were previously aware of SNP testing for BC. If SNP testing might indicate a significant increased BCR, 83 % of participants would definitely have testing compared to 66 % for a significant decreased BCR. Post-education, similar trends in interest were observed. The average score on the SNP-related knowledge measure was 42.8 %. The 18 women who participated in the education session demonstrated a 78.8 % improvement in accuracy on the SNP-related knowledge measure going from an average score of 51.8 to 92.6 %. When asked to quantify their lifetime risk of BC, 60.8 % of participants overestimated their risk compared to a Tyrer-Cuzick based risk. Most of the women felt that pursuing genetic testing had been the right decision. Despite low awareness of BC SNP testing, women with family histories of BC and a high perception of BCR expressed interest in SNP testing as part of their risk assessment. While all aspects of SNP-related knowledge improved after an education session, questions about the level of risk conferred by SNPs were the least likely to be answered correctly. More research is necessary to determine how to best incorporate SNP scores into BCR assessment and how to best educate individuals as they consider expanded genomic testing options.

Oncologists’ awareness, understanding and usage of germline next generation sequencing based multigene panel tests for heritable cancer susceptibility in patients and their families

C. Kurpad1, M. Farmer1, T. Swain1, G. McGwin1, G. Sonpavde1, C. Hurst1

1. University of Alabama at Birmingham

Germline next generation sequencing (NGS)-based multigene panels that test for hereditary cancer susceptibility are a newer technology that present challenges. Previous surveys of genetic counselors and other healthcare professionals including physicians (not stated to be oncologists) indicated that clinical experience with these tests was limited, and that greater education was necessary on these tests. Experiences or opinions of oncologists with NGS-based multigene panel tests have not been reported. We conducted a survey of oncologists to assess their awareness, understanding, and usage of these tests. The survey was distributed via email to members of the American Society of Clinical Oncology. We found significant differences in oncologists’ comfort in offering pre-test counseling in two specific situations of early onset breast cancer among those that had or had not ordered different NGS-based multigene panel tests. A majority of oncologists felt unprepared to provide counseling to patients undergoing analysis of genes that are commonly included in pan-cancer, comprehensive disease specific, or smaller disease specific panels. This suggests that oncologists may be ordering these tests without being familiar with the exact genes included in the panel. Our data suggest that those in practice for a longer duration were more comfortable with ordering these tests and considered them more useful. Our hypothesis was validated in that oncologists are generally not prepared to interpret results and counsel patients or family members based on these germline tests. The majority of oncologists (50.7 %) were not comfortable making cancer surveillance recommendations for family members of patients when test results were inconclusive. Only 18.8 % of oncologists referred 100 % of patients for pre and post-test genetic counseling, although approximately two-thirds of participants agreed that all patients undergoing testing should have pre-test and post-test counseling. Our results indicate a need for better education on NGS-based multigene panel tests, and better access to genetic counseling services.

Pre-test genetic counseling as a requirement for germline hereditary cancer testing: What do patients do?

G. Lazarin1, K. Sedgwick1, D. Doyle1, I. Haque1, K. Ready1

1. Counsyl

Background: To ensure informed consent and appropriate test utilization, certain health insurers require individuals seeking certain hereditary cancer (HC) genetic testing to undergo pre-test genetic counseling (GC). The effect of this requirement on patient access to HC testing has not been fully studied. Methods: We evaluated BRCA1/2 or Lynch syndrome test orders to Counsyl for 157 members of two national health insurers who affirmatively accepted or declined pre-test GC to evaluate their status with respect to National Comprehensive Cancer Network (NCCN) guidelines for identification of individuals at high risk of an HC syndrome. NCCN was used as a proxy for insurance coverage criteria given similarities. Counsyl holds contract agreements with these payors. Patients are referred to a third-party fee-based GC service per the plan requirements. Patients were provided an estimated cost based on plan benefits and predicted risk category (high/low). All patients were offered a discounted self-pay option, regardless of insurance status. We examined patient decision making with respect to payment action, risk status, and GC action. Results: 124 patients (79 %) met NCCN high-risk criteria based on information provided on the test requisition. In total, 19 patients (12 %) canceled their tests after being informed of likely costs and required for pre-test GC; 12 of these 19 were high-risk (9.7 % of all high-risk patients). Of those continuing with testing, 30/112 (27 %) high-risk and 19/26 (73 %) low-risk individuals elected self-pay. 27/30 (90 %) high-risk and 13/19 (68 %) low-risk self payers declined GC. Conclusion: 31 % of patients meeting NCCN guidelines did not complete the pre-test GC requirement for insurance coverage, instead choosing to avoid the requirement through self-pay or canceling the test altogether. 9.7 % of all high-risk patients canceled their testing. These data suggest the requirement for pre-test GC may not accomplish the stated goal of improving patient education, and may be seen as an impediment or unnecessary expense by patients.

Genetic counseling complexities ofCHEK2positivity: Medical management implications for patients and families

C. Lewis1, D. Almanza1, T. Pal1

1. Moffitt Cancer Center

Background: The expanded use of multi-gene panel (MGP) testing for inherited cancer risk, inclusive of moderate penetrance genes, has resulted in management complexities. Many MGPs include CHEK2 which is a moderate penetrance breast cancer (BC) gene. Heterozygous CHEK2 mutations confer >20 % lifetime BC risk, the threshold at which annual breast MRIs are a consideration per national guidelines. Estimated colorectal cancer (CRC) risk is two-fold among carriers, similar to the risk level for individuals with a first-degree relative (FDR) with CRC. We sought to assess the impact of CHEK2 positivity on breast cancer surveillance recommendations for at-risk relatives and CRC surveillance for probands. Methods: Clinical, demographic and family history data was collected from a registry and clinical cohort of 32 CHEK2 positive probands. Lifetime BC risks were calculated for unaffected female FDRs and second-degree relatives (SDRs) <age 80 using BOADICEA and summary statistics were generated for level of BC risk. Similarly, family history of CRC among FDRs and SDRs was abstracted. Results: Among 32 eligible families, 61 FDRs and 48 SDRs met inclusion criteria for BC risk estimation. The majority (92.6 %) of FDRs and SDRs in our sample had lifetime BC risk estimates <20 %. Thus, CHEK2 positivity would impact BC surveillance recommendations above that based on family history of BC alone. Eighty-four (n = 27) percent of probands did not have an FDR with CRC, thus CHEK2 mutation status may impact CRC surveillance recommendations beyond what may be recommended based on family history. Conclusions: This data highlights the potential clinical utility of CHEK2 mutation positivity among the majority of FDRs and SDRs of CHEK2 mutation carriers to inform cancer risk management for both BC and CRC based on inherited risk over that based on family history alone. More research is needed to clarify if cancer risk may differ across mutation type.

Endometrial cancer risk perception in women diagnosed with Lynch syndrome

M. Lubaton1, J. Scott2, A. Allenby3, K. Zarnawski4, S. Dixon1

1. University of Maryland

2. University of Maryland Medical Center

3. Anne Arundel Medical Center

4. Virtua Center for Health and Wellness

Purpose: Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer, HNPCC) is categorized by the identification of an inherited germline pathogenic variant in a mismatch repair gene (MMR) or by a comprehensive family history of Lynch­associated cancers (Amsterdam I or II criteria). While colorectal cancer risk perception has been studied, little work has been done to assess endometrial cancer (EndoCa) risk perception. This study aims to examine the factors that affect a woman’s risk perception to develop EndoCa after a diagnosis of Lynch syndrome (LS). Patients and Methods: A total of 320 women with a self­-reported diagnosis of LS participated in this study. Women completed an online questionnaire that asked about demographics, pathogenic variants, experience with health professionals, personal and family cancer history, as well as an estimate of their EndoCa risk compared to other women their age. A multivariate logistic regression model was used to assess the factors associated with a correct risk perception to develop EndoCa. Results: Of the 320 individuals surveyed, 74 % correctly estimated their EndoCa risk. Women with a personal history of EndoCa trended towards being two times more likely to correctly perceive their EndoCa risk (odds ratio [OR], 2.1; 95 % CI, .096­4.6). Additionally, women with a family history of EndoCa trended towards being less likely to correctly perceive their risk to develop EndoCa (OR, 0.58; 95 % CI, 0.33­1.0). Conclusion: Three quarters of women with LS correctly perceive their risk to develop EndoCa, regardless of if they have had a hysterectomy. This correct risk perception is more likely to be associated with having had a personal history of EndoCa and less likely to be associated with a family history of EndoCa.

Patient reported clinical outcomes and personal perspectives after risk reducing surgery

C. Mauer1, M. Mann1, D. Richardson1, J. Lea1, D. Miller1, S. Kehoe1

1. UT Southwestern Medical Center

Background: Risk-reducing bilateral salpingo-oophorectomy (RRBSO) is recommended for women at increased risks for ovarian and fallopian tube cancers due to a mutation in the BRCA1, BRCA2, or Lynch syndrome (LS) genes. Undergoing RRBSO prior to menopause can lead to long-term physical and emotional symptoms. Our study sought to evaluate these psychological and physical effects of RRBSO directly from women who had undergone the procedure for risk-reduction. Methods: Institutional databases were used to identify patients with BRCA1, BRCA2 or LS mutations between 2004 and 2014. Eligible patients were unaffected with gynecological cancer and had undergone RRBSO. Patients were contacted in clinic or by mail and asked to complete a questionnaire. Results: Ninety-one questionnaires were distributed; 42 patients (46 %) returned completed questionnaires. Seventeen patients were BRCA1 positive, 21 patients were BRCA2 positive, and four patients had LS mutations. Thirty-three patients (80 %) were informed of their mutation by a genetic counselor. Twenty-six women were premenopausal prior to surgery. Thirty-five (83 %) patients felt they were provided with enough information about expected menopausal symptoms. Twenty-seven (61 %) patients reported being informed about possible changes in sexual function after surgery. Of 41 patients that answered, thirteen (32 %) patients reported an increase in depression and six (15 %) patients reported an increase in their anxiety level after RRBSO. A total of fifteen (58 %) patients reported taking some form of HRT after surgery to mitigate symptoms. Overall, 41 (98 %) of patients were content with their decision to undergo risk-reducing surgery. Conclusions: The majority of patients who underwent RRBSO reported no regret and a sense of relief. However, many patients did report clinical symptoms including worsening anxiety and depression. While the majority of patients felt well counseled preoperatively, this study identifies areas for improvement in the counseling of patients prior to RRBSO.

Unexpected CDH1 mutations in probands with non-lobular breast cancer

S. Rao1, R. Covington2, D. Pencarinha3, G. Wiesner1

1. Vanderbilt University Medical Center

2. West Cancer Center

3. Wellmont Health System

Introduction: Pathogenic mutations in CDH1 cause Hereditary Diffuse Gastric Cancer (HDGC), typically characterized by early-onset gastric cancer and lobular breast cancer. We report 3 women referred to the hereditary cancer clinic with non-lobular breast cancer and no presenting family history of gastric cancer who were found to have CDH1 mutations after multi-gene panel testing. Case report: Patient 1: 44-year-old adopted African American woman with ER+PR+/HER2+ invasive ductal carcinoma, CDH1 mutation on panel testing. Bilateral mastectomy found LCIS in contralateral breast. Gastric biopsies and gastrectomy found signet-ring carcinoma in multiple areas. Patient 2: 36-year-old African-American woman had breast ER-/PR-/HER2- ‘carcinosarcoma’ without lobular features at age 31 and negative family history. Panel testing identified a CDH1 mutation and gastric biopsy confirmed carcinoma. Gastrectomy is scheduled. Patient 3: 45-year-old Caucasian woman with ER+PR+/HER2+ infiltrating ductal carcinoma at age 42 was initially tested negative for BRCA1/2. Additional panel testing was done after CDH1 mutation was found in paternal lineage. Extended family history showed paternal third-degree relatives with gastric cancer. Biopsy and gastrectomy were positive for signet-ring carcinoma. Discussion: These kindred illustrate that the tumor spectrum for CDH1 is very broad and may not depend on family history criteria. Such unexpected findings do benefit patients as lifesaving screening and/or gastrectomy can be recommended. Presenting all the possible scenarios at initial counseling can be challenging for the genetic counselor. Current NSGC position statement primarily addresses incidental findings in the context of whole exome/genome testing rather than multi-gene panel testing. Comprehensive counseling should address the key concept of unexpected positive results in genes not typically associated with presenting phenotypes. We propose that specific language about ‘unexpected positive’ results should be added to NSGC practice guidelines.

Lynch syndrome phenocopy identified by novel tumor/normal technique for identifying sporadic mutations

M. Rashkin1, A. Kulchak Rahm2, J. Koenig2

1. Icahn School of Medicine at Mount Sinai

2. Geisinger Health System

Molecular genetic testing does not always identify a pathogenic mutation in individuals who screen positive through universal Lynch syndrome screening (ULS). This leaves patients and their first-degree relatives with discrepant information: Molecular testing does not indicate intensive prophylactic cancer screening, while ULS results coupled with personal and/or family history may support intensive screening. Recent studies suggest that up to 4 % of individuals with a mismatch repair protein deficient tumor may not have an identifiable germline mutation, and 50–70 % of these individuals may have two somatic mutations instead. Here, we report the case of a 76 year-old male diagnosed with prostate cancer at 68 (Gleason 6) and a moderately differentiated, mucin-producing, invasive adenocarcinoma of the transverse colon at 76. Immunohistochemistry (IHC) results showed absent MLH1/PMS2, however, molecular genetic testing results were negative. The patient was subsequently diagnosed with a sebaceous adenoma with absent MSH2 on IHC, raising the possibility of Muir-Torre. Family history met four out of five Amsterdam II criteria, only missing the last criteria because the relative’s age of onset was at 50, not before. University of Washington ColoSeq was ordered and tested 22 cancer predisposition genes in peripheral blood and both tumor samples. This testing identified two somatic MLH1 mutations in the colon tumor and two somatic MSH2 mutations in the sebaceous adenoma. The somatic mutations are predicted to result in impaired protein expression in both tumor tissues. Sporadic etiology of the tumors was thus confirmed, and screening recommendations were made based on family history. This approach demonstrates a powerful technique to clarify results and screening recommendations for patients with abnormal IHC and negative germline sequencing, thus saving both the healthcare system and patient substantial expense. Counselors should consider encouraging labs to offer this testing and prepare patients for a possibly lengthy diagnostic “journey” after ULS.

Through the eyes of the patient: Understanding variants of uncertain significance in the era of multi-gene panels

C. Reuter1, N. Chun1, M. Pariani2, A. Hanson-Kahn1

1. Stanford University School of Medicine

2. Stanford Center for Inherited Cardiovascular Disease

Identification of variants of uncertain significance (VUS) on multi-gene panels is common since next generation sequencing (NGS) has grown in clinical use. VUSs, or genetic changes whose association with disease risk are uncertain, are frequently disclosed to patients although they are ambiguous and not clinically actionable. To better facilitate the genetic counseling process, it is important to understand how patients think and make sense of a VUS. Few studies have assessed recall, reaction to, and interpretation of a VUS identified on a multi-gene panel and factors that may influence these. Our study explores these questions, with the aim of informing effective disclosure practices among genetic counselors. Adults who had a VUS identified on multi-gene panel testing in a hereditary oncology clinic were recruited from a west coast hospital. A semi-structured interview guide was developed consisting of questions about the VUS result, personal and family history, and motivations for and expectations of genetic testing. We conducted 11 phone interviews. The coded transcripts identified major themes: spectrum of factual recall, response to a VUS, perceived clinical and etiologic significance, and influence of motivations and expectations. A majority of participants (8/11) recalled that they had a VUS, despite variation in the vocabulary they used. Participants responded both emotionally and intellectually to receiving information about having a VUS, which was often a result of their expectations and motivations prior to testing. Overall, participants understood the clinical significance of a VUS independent of the vocabulary used to describe it. Participants understood the etiologic significance of a VUS within the context of personal and family history. Together these data suggest that there are many dimensions to the way patients think about and make sense of VUSs. Genetic counselors can better facilitate patients’ understanding of a VUS result by exploring how their personal perspective impacts their response and perceived significance.

The experiences of transgender individuals in cancer genetic counselling

C. Robertson1, J. Fitzpatrick1, L. Kasprzak1

1. McGill University

Transgender individuals, or those who have gender identities, expressions or behaviours not typically associated with those of their sex assigned at birth, belong to a community that often encounters issues related to social discrimination, psychosocial challenges and community behavioural risk factors. This population also has distinct healthcare needs and patients often seek specialized medical interventions related to transitioning. Previous research has found that genetic counselors are generally comfortable working with LGBTQ individuals, but that increased education and awareness regarding this patient population are necessary to reduce counselor anxiety and lack of familiarity with the social and medical barriers faced by LGBTQ people. However, transgender individuals were not represented in this research, and as such, there exists a dearth of literature investigating their experiences in genetic counselling. The purpose of the present study is to give voice to transgender patients and to describe the experiences of two individuals in cancer genetic counselling. Meaningful themes that were identified included the impact of family conflict related to participants’ gender identities and transitions, the uncertainty of cancer risks for transgender individuals with hereditary cancer predisposition syndromes and the influence of their place in the transition process on the topics discussed during counselling, as well as their comfort in talking about them. Overall, transgender participants described their experiences in cancer genetic counselling as being generally positive, if not unremarkable with respect to issues surrounding their gender identity.

Penetrance of a rare familial gene predisposing to papillary thyroid cancer

D. Saporito1, H. Hampel1, R. Nagy2, J. Sipos1, S. Liyanarachchi1, S. Fernandez1

1. Ohio State University

2. Guardant Health

Background: Familial non-medullary thyroid cancer (FNMTC) is clinically defined as ≥2 first-degree relatives with NMTC following an autosomal dominant inheritance pattern. About 5–7 % of NMTC is hereditary and affects multiple generations, appears with a younger age of onset, and may predispose to a greater risk of malignancy and recurrence thus altering surveillance and treatment recommendations. The aim of this study was to determine the age-specific penetrance of thyroid cancer and benign thyroid disease in individuals from a large family with FNMTC due to a previously identified mutation at 4q32A>C. Methods: Participants of the large family with FMNTC were assessed on their clinical history of thyroid disease and/or cancer, age at diagnosis, treatment, mutation status and family history. Data were obtained for a total of 115 individuals. Mutation status and/or known obligate carrier status was identified in 68 individuals, with 34 positive and 34 negative. Age-specific penetrance of thyroid cancer and benign thyroid disease was determined using the inverted Kaplan-Meier method of segregation analysis. Results: Individuals with the 4q32A>C mutation have a 68.9 % (95 % CI, 46.5–88.7 %) risk of developing thyroid cancer by age 70. Individuals with the 4q32A>C mutation have a 65.3 % (95 % CI 46.0–83.8 %) risk of developing benign thyroid disease by age 70. The age-specific penetrance for thyroid cancer risk in those individuals with the 4q32A>C mutation is 0.0 % by age 10, 6.1 % by age 20, 13.0 % by age 30, 25.7 % by age 40, 36.3 % by age 50, 41.6 % by age 60, and 68.9 % by age 70. The age-specific penetrance of benign thyroid disease in those individuals with the 4q32A>C mutation is 0.0 % by age 10, 9.8 % by age 20, 20.3 % by age 30, 40.5 % by age 40, 50.4 % by age 50, 65.3 % by age 60 and 65.3 % by age 70. Conclusion: The 4q32A>C mutation significantly increases the risk to develop thyroid cancer in individuals in this family with the mutation compared to those without it. Early thyroid surveillance with annual ultrasound is recommended for individuals testing positive.

A “second class status”: The experience of men with BRCA mutations

A. Suttman1, L. Senter1, R. Pilarski1, D. Agnese1, S. Freidman2, S. Hovick1, J. Bachman1

1. The Ohio State University

2. Facing Our Risk of Cancer Empowered

Introduction: Hereditary Breast and Ovarian Cancer syndrome (HBOC) is a cancer- predisposition syndrome that affects both men and women, with more significant cancer risk elevations in women. Knowledge about the needs of males with HBOC and how males share genetic information is limited. The aims of this study include: to describe participants’ feelings and opinions about HBOC; to ascertain participants’ extent of information sharing with family and medical personnel; and to describe the needs of participants for information and resources provided by genetic counselors and other health care providers. Methods: We interviewed 21 primarily Ashkenazi Jewish men who were accrued through Facing Our Risk of Cancer Empowered (FORCE). Interviews focused on family cancer history, experiences with cancer and genetic testing, motivations to pursue genetic testing and subsequently disclose genetic test results, information sharing patterns, healthcare provider response, and participants’ emotional support systems. The interviews were transcribed in their entirety, coded, and analyzed based on grounded theory. Results: Eighteen transcripts were used for the analysis. Results can be classified into 5 themes and two major categories: psychosocial impacts/needs and communication patterns. Participants (n = 8) were most concerned about cancer risk for their children and female family members, and most (n = 11) mentioned HBOC provides them increased personal awareness, but has a negligible impact on their life overall (n = 9). Participants (n = 9) took on active and open communication roles with family members and health care providers. Men (n = 11) were interested in a male focused support group to discuss HBOC. The majority of participants (n = 14) discussed the need for knowledge and awareness among the health care community and general population regarding male HBOC risks. Conclusion: This study serves as a pilot study and contributes to limited research by providing important and novel insights into psychosocial impacts/needs and communication patterns of males with HBOC.

“A change in perspective”: Exploring the experiences of adolescents with hereditary tumor predisposition

E. Weber1,2, C. Shuman1,2, J. Wasserman1, M. Barrera1, A. Patenaude3, K. Fung1, D. Chitayat1,2, D. Malkin1, H. Druker1,2

1. The Hospital for Sick Children

2. University of Toronto

3. Dana-Farber Cancer Institute

Introduction: Hereditary tumor predisposition syndromes are being more frequently recognized in the context of pediatric neoplasms. As more adolescents are identified with hereditary tumor predisposition, insight from their experiences can guide the provision of health care including genetic counseling. Previous research indicates that disclosure of tumor susceptibility is a significant event in adolescents’ lives. However, no previous research has explored the experiences and perceptions of adolescents following the diagnosis of a hereditary tumor predisposition syndrome. Purpose: We explored the lived experiences of adolescents with hereditary tumor predisposition syndromes and their perceptions of living at risk. Methods: Participants were sampled purposively from the cancer genetics program at the Hospital for Sick Children, and included adolescents with pediatric-onset hereditary tumor predisposition syndromes, irrespective of personal or family history of tumors. Seven adolescents (ages 14–17) with five different syndromes were interviewed by telephone or in person using a semi-structured interview guide. We explored the disclosure process, support systems, and the benefits and disadvantages of knowledge of tumor susceptibility. Interviews were transcribed verbatim and analyzed via interpretive description. Results: Four major themes emerged from the data: 1) The benefits of knowing about tumor susceptibility outweigh the harms; 2) Tumor susceptibility leads to a change in life perspective and choices made with respect to the future; 3) Perceptions are shaped by the disclosure process within one’s health and family contexts; 4) Self-concept is not defined by tumor risk. Conclusions: Adolescents recognize the challenges associated with awareness of tumor predisposition, but also identify positive aspects in their life experiences. Results of this study can guide pre- and post-test genetic counseling of adolescents for hereditary tumor syndromes, facilitating the incorporation of this genetic information into an adolescent’s self-concept in an adaptive manner.

Genetic counseling and companion diagnostics for PARP inhibitors

K. Wilson1, K. Postula2, A. Eppolito3, T. Vu4, J. Osborne5

1. Quest Diagnostics

2. GeneDx

3. Piedmont Cancer

4. Carilion Clinic Cancer Genetics Program

5. University of Michigan Cancer Genetics Clinic

In December 2014, the U.S. Food and Drug Administration (FDA) approved Lynparza (olaparib), a PARP inhibitor, to treat ovarian cancer (OvCa) patients who have germline mutations in BRCA1 or BRCA2. The FDA also approved BRACAnalysis CDx as a companion diagnostic test (CD test) to detect BRCA mutations and determine Lynparza eligibility. The purpose of this study was to evaluate genetic counselors’ experiences and attitudes toward BRCA CD testing for PARP inhibitors. The initial survey was conducted in Feb 2015 to assess current practice, anticipated changes to clinical service, and referral patterns. A follow up survey was performed in 4/2016 to evaluate whether the availability of CD testing changed genetic counselors’ practices. In both surveys, a majority of respondents report seeing five or fewer OvCa patients per month referred by a gyn/med oncologist. When asked in the initial survey whether participants intended to discuss CD testing with OvCa patients who are not specifically referred for CD test discussion, 51 % said that they would discuss it with all OvCa patients, 29 % said they would discuss with select OvCa patients, and 20 % said they do not intend to discuss. In the follow-up survey, 43 % of respondents reported not discussing CD testing with any OvCa patients who are not referred for CD discussion, and just over half discuss CD testing with all or select OvCa patients. In the follow up survey, a majority of respondents report either no change in referrals (59 %) or a slight increase in referrals (32 %) since the availability of CD testing. In summary, this study demonstrates that FDA approval of CD testing for PARP inhibitor eligibility did not change genetic counseling practice as significantly. Almost half of respondents did not discuss CD testing if the patient was not referred for this reason. Additionally, the initial survey brought to light some issues regarding genetic counseling referrals from gyn/med oncologists that could be explored in future studies.

Assessing the possibility ofRUNX1related germline predisposition in myeloid neoplasms in a somatic cancer setting

K. Barber1, R. Daber1, M. Hiemenz1

1. GenPath/Bioreference Labs

Recently the World Health Organization (WHO) released a new classification category identifying germline predispositions for some myeloid neoplasms. This update has a dramatic effect on the scope of practice for diagnosing and treating these neoplasms. The Cancer Genomics Laboratory at GenPath/BioReference offers next generation sequencing (NGS) on myeloid neoplasms using a custom 37 gene panel. For this study, we performed a retrospective analysis on the RUNX1 gene, which is associated with “familial platelet disorder with associated myeloid malignancy”. Our goal was to analyze each of the cases in our laboratory in which RUNX1 variants were detected to determine the demographics of patients with these mutations and how the new classification released by WHO would affect our strategy in reporting RUNX1 variants. RUNX1 variants have been detected in 170 cases in our lab out of the total ~3300 myeloid cases analyzed over the last 14 months. The youngest patient we saw with a RUNX1 variant was 25 years old while the oldest patient was 94 years old, with a median age of 71. We determined that of the cases where a diagnosis was known, RUNX1 variants were most commonly seen in myelodysplastic syndromes. A total of 204 unique RUNX1 alterations were reported, 76 % were known disease associated alterations while 24 % were novel or unclear variants. Of the 49 novel or unclear variants reported, 26 were found to have an allele frequency suggestive of being a germline alteration. Through this study we determined that RUNX1 alterations arise commonly in myeloid malignancies in a variety of different patients. The possibility of identifying a germline mutation changes the way that RUNX1 variants are reported. We conclude that including a statement regarding the possibility of a germline mutation is reasonable in reporting RUNX1 variants where the allele frequencies are suggestive of not being somatically acquired. This particular situation also demonstrates the value of having a genetic counselor present within a somatic cancer testing team.

Characterizing the clinical cancer presentation of individuals with pathogenic variants inFANCC

J. Bissonnette1, R. Klein1, K. Hruska1

1. GeneDx

Background: FANCC is one of a group of genes associated with autosomal recessive Fanconi Anemia. In addition, heterozygous pathogenic variants in FANCC confer an increased risk for developing breast cancer. Our aim was to review the clinical characteristics of patients heterozygous for a single pathogenic/likely pathogenic variant (PV/LPV) in FANCC. Methods: We retrospectively reviewed our cohort of over 38,000 individuals tested for an inherited cancer panel including the FANCC gene. Personal and family history was extracted from pedigrees and requisition forms of individuals with a FANCC PV/LPV, unless research inclusion was not granted. Results: In our cohort, 88 patients had a PV/LPV in FANCC (0.2 %). Four patients with a PV in another high or moderate risk cancer gene were excluded from the analysis. Almost all (83/84) PV/LPV were deleterious truncating variants (frameshift, nonsense, large deletions, or splice site variants). Of these, three variants, c.456+4A>T, c.67delG, and p.Arg548Ter, accounted for over 50 % of cases with a PV/LPV. Pedigree review revealed that 55/84 (65 %) of those with PV/LPV results had cancer; including 42 patients with breast cancer. Three of these patients were reported to have had multiple primary breast cancers. Four patients with breast cancer also reported another primary cancer at a different site (peritoneal, pancreatic, melanoma, non-melanoma skin cancer). In addition, 7 individuals were reported to have ovarian/peritoneal cancer, 6 of whom did not have another primary cancer. Conclusion: The inclusion of FANCC in multi-gene cancer panels accounts for hereditary cancer only in a very small number of patients with breast cancer. The vast majority of PV/LPV in FANCC are truncating variants. Albeit our data are still limited, the finding of a personal history of ovarian cancer in >8 % of individuals with a single FANCC PV/LPV may suggest an association.

Mosaic variants in hereditary cancer genes identified on next generation sequencing panels

J. Bissonnette1, J. Mester1, L. Susswein1, P. Murphy1, L. Cremona1, R. Klein1, K. Hruska1

1. GeneDx

Mosaicism may be identified during genetic testing, when blood or other specimens are analyzed to identify germline variants responsible for personal/family history of disease. Emerging data suggests that mosaic variants in genes associated with leukemia/lymphoma, including TP53 and ATM, can be present in peripheral blood samples from apparently healthy individuals prior to the diagnosis of a hematologic malignancy. We undertook a retrospective review of patients with mosaicism in genes related to inherited cancer predisposition identified through hereditary cancer panels performed on blood or oral rinse samples. Between October 2013 and February 2016, 144 instances of mosaicism were identified in 142 individuals. Genes for which mosaicism was most often detected were TP53 (54/144, 37.5 %), CHEK2 (33/144, 22.9 %), and ATM (30/144, 20.84 %). Among 41 individuals mosaic for pathogenic/likely pathogenic TP53 variants, none met classic Li-Fraumeni Syndrome criteria, but 5 met 2015 Chompret testing criteria based on breast cancer diagnosed under 31 years of age. Eleven of 142 (7.8 %) individuals had a previous history of leukemia/lymphoma. Confirmatory fibroblast testing was performed on one patient who had a whole gene deletion of ATM detected in blood, this variant was not detected in fibroblasts. Children of 17/142 (11.9 %) individuals pursued targeted testing for a parent’s mosaic variant, none testing positive. While testing of fibroblasts or other tissues may be pursued to determine whether a mosaic variant is constitutional or somatic, in this patient series, clinical histories and further testing results suggest these variants are unlikely to be present in the germline. Given emerging data regarding hematologic malignancy in patients with somatic variants in certain genes, determining the somatic vs. germline nature of these findings may have greater importance, and closer follow-up of individuals with somatic mosaic variants may be warranted.

Impact of FDA approval of PARP inhibitor treatment on genetic counseling and testing practices for ovarian cancer patients

K. Buchtel1, K. Vogel Postula2, C. Willia1, S. Weiss3, M. Pineda1, S. Weissman2

1. Northwestern University

2. GeneDx

3. Myriad Genetic Laboratories

Background: In December 2014, the U.S. Food and Drug Administration (FDA) granted approval of olaparib, a poly(ADP-ribose) polymerase inhibitor (PARPi) for ovarian cancer (OvCa) patients who have failed three or more lines of chemotherapy and who have a germline BRCA1/2 mutation identified through an FDA-approved companion diagnostic test offered exclusively by Myriad Genetics called BRACAnalysis CDx™ (CDx™). Since FDA approval of PARPi, there have been no studies assessing the impact of CDx™ on genetic counseling and testing practices. This study explored the impact of FDA approval of PARPi and CDx™ on genetic counselors’ (GC) approaches when working with OvCa patients. Methods: An online survey regarding referral patterns, genetic testing strategies, and insurance coverage of PARPi was completed by 123 GCs with at least 2 years’ experience in cancer genetics. Results: Following PARPi approval, 40 % of respondents reported an increase in overall referrals of OvCa patients and 20 % had an increase in post-test counseling only referrals. Few GCs reported referrals for patients previously tested for BRCA1/2 to discuss retesting via CDx™ (9.1 % and 7.1 % for previously positive and negative patients, respectively). The majority (61.9 %) reported no change in genetic testing strategy following PARPi/CDx™ approval, and when selecting a testing laboratory GCs reported no changes in factors that influenced their decision. The vast majority of respondents (98.1 %) who had experience with insurance companies covering PARPi treatment indicated approval when BRCA status was obtained through a non-CDx™ platform. Conclusion: Respondents indicated an increase in referral volume following PARPi/CDx™ approval, but did not report changes in testing strategies for OvCa patients nor did they indicate that the availability of CDx™ testing strongly influenced lab choice. Respondents were not aware of patients being denied PARPi insurance coverage in the absence of CDx™ testing.

Novel large rearrangement ofRAD51Din an ovarian and breast cancer family

B. Burnett1, T. Ekstein2, E. O’Leary2, S. Michalski2, H. Kang2, M. Powers2, K. Ouyang2

1. Sharp Healthcare

2. Invitae

Several recent studies have established RAD51D as an important ovarian cancer (OvCa) predisposition gene. The lifetime risk of OvCa in carriers of a pathogenic RAD51D variant is approximately 7–12 %, and updated guidelines recommend consideration of risk-reducing salpingo-oophorectomy in at-risk individuals. RAD51D pathogenic variants described thus far are nucleotide substitutions and deletions/insertions of a few bases—such as nonsense substitutions, frameshift indels, and consensus splice site substitutions—leading to a premature stop codon. To date, no gross genomic deletions have been reported in the literature. Herein, we report a novel gross deletion involving RAD51D exons 9 and 10 in an individual with OvCa and a family history of breast and ovarian cancer. The proband was diagnosed with epithelial OvCa at age 61 and underwent germline sequencing and deletion/duplication analysis of a 35 gene breast and gynecologic cancer panel. A gross deletion of the genomic region encompassing exons 9 and 10 of the RAD51D gene was detected and confirmed with an orthogonal assay. The results for all other tested genes were negative. The proband’s paternal cousin, subsequently confirmed to carry this deletion, was diagnosed with ductal carcinoma in situ at age 61 and OvCa at age 68. The affected cousin’s mother (deceased at age 51) is an obligate carrier of this deletion and was reportedly diagnosed with an abdominal cancer, presumed to be ovarian, at age 49. Additional family history includes another paternal aunt with breast cancer diagnosed at age 59 and the proband’s niece, with breast cancer at age 42. This aunt and niece have not yet been tested for the familial deletion in RAD51D, so it is unknown whether their breast cancers segregate with this genetic finding. This is the first report of a gross deletion involving exons 9 and 10 of RAD51D in a family with a substantial history of ovarian and breast cancers. These findings suggest that large deletions in RAD51D may account for a proportion of hereditary OvCa cases.

Assessing VHL p.pro81leu: A low penetrance, pheo-predominant variant?

K. Dilzell1, K. Nathanson1

1. University of Pennsylvania Health System

von Hippel Lindau disease (vHL) is an inherited tumor predisposition syndrome caused by pathogenic variants in VHL, characterized by hemangioblastomas of the central nervous system and retina, clear cell renal cell carcinomas, pheochromocytomas, neuroendocrine tumors, pancreatic and renal cysts, among other findings. Most pathogenic VHL variants are nearly 100 % penetrant, though there is variable expressivity. There are some specific genotype/phenotype correlations described, with certain missense mutations associated with “pheo-predominant” or vHL Type 2C disease. We report on a 12-year-old female who was diagnosed with a symptomatic right adrenal pheochromocytoma secreting normetanephrines, who was identified to have a variant in VHL (c.242C>T, p.Pro81Leu), classified as pathogenic. Single nucleotide polymorphism (SNP) array on the patient’s tumor revealed a mosaic whole 3p deletion including VHL in ~50–60 % of cells, consistent with the second inactivating event. This variant was found to be inherited from her unaffected mother. Of the now 13 confirmed carriers of this VHL variant in her family (ranging in age from 11 to 67, three being over the age of 60), she remains the only individual with any vHL manifestations. This variant has previously been described in two patients with extra-adrenal paragangliomas and one patient with vHL type 2C, without known family histories. It is labeled as likely-pathogenic by three laboratories in ClinVar. It has not been reported in population databases including NHLBI ESP and 1000 Genomes, and is highly conserved in primates. However, predictive software are inconsistent in their predictions of pathogenicity. Based on currently available data, including the patient’s tumor being consistent with a vHL-related pheochromocytoma, the p.Pro81Leu mutation appears to be a low-penetrance mutation primarily associated with pheochromocytoma/paraganglioma. This has important implications for counseling of at-risk relatives and other identified carriers.

Types and frequencies of Lynch syndrome mutations identified through multigene panel testing

C. Espenschied1, H. LaDuca1, R. McFarland1, S. Li1, C. Gau1, H. Hampel2

1. Ambry Genetics

2. The Ohio State University Comprehensive Cancer Center

Lynch syndrome (LS) is a well-known hereditary cancer syndrome, caused by mutations in the mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2) and EPCAM. We retrospectively reviewed consecutive cases that had multigene panel testing including the MMR and EPCAM genes between March 2012 and June 2015 (N = 35,252). Pathogenic and likely pathogenic MMR and EPCAM mutations were reviewed and statistical analyses performed. Overall, 630 MMR and EPCAM mutations were identified in 622 patients; 346 (54.9 %) were unique and 107 (17 %) recurrent. Mutations in MSH6 were most frequent (30.3 %), followed by PMS2 (25.1 %), MSH2 (22.9 %), MLH1 (20.6 %), and EPCAM (1.1 %). Among unique mutations, truncating indels and substitutions were most frequent (N = 189, 54.6 %), followed by non-truncating indels and substitutions (N = 66, 19.1 %), large deletions and duplications (del/dups; N = 59, 17 %), splicing (N = 28, 8.1 %), AUG/5’UTR (N = 3, 0.9 %), and synonymous mutations (N = 1, 0.3 %) with small indels being the most frequent sub-type (N = 139, 40.2 %). The proportions of truncating, large del/dup, AUG/5’UTR, and silent mutations were similar to those reported by InSiGHT (International Society for Gastrointestinal Hereditary Tumors), while our proportions of non-truncating and splicing mutations were significantly higher (P < 0.001) and lower (P < 0.01), respectively. Four mutations were seen more than ten times. PMS2 c.137G>T p.S46I (N = 21) is reported as a European founder mutation and MSH2 c.1906G>C p.A636P (N = 13) is a known Ashkenazi Jewish founder. MSH2 c.942 + 3A>T (N = 18) and MSH6 c.3261dupC p.F1088Lfs*5 (N = 16) are recurrent mutations occurring in microsatellite tracts. Mutation types and most frequently seen mutations support previous literature. While most previous studies suggest that MLH1 and MSH2 are the most common causes of LS, MSH6 and PMS2 were most common in this cohort. This may be relevant to evolving genotype-phenotype correlations. The high frequency of indels in this cohort highlights the importance of utilizing an NGS assay highly sensitive for indels in analyzing cases suspicious for LS.

Breast and colorectal cancer risk in monoallelicMUTYHcarriers ascertained via multigene panel testing

K. Fulk1, H. LaDuca1, C. Espenschied1, D. Qian1, Y. Tian1, A. Yussuf1, K. Jasperson1

1. Ambry Genetics

Whether monoallelic MUTYH mutation carriers are at increased risk of breast cancer (BC) and/or colorectal cancer (CRC) remains controversial. We aimed to determine whether monoallelic MUTYH mutations are associated with increased BC and/or CRC risk by comparing the frequency of MUTYH mutations among BC and CRC cases to controls from a multi-gene panel testing (MGPT) cohort. Cases included Caucasian individuals with female BC (N = 16,867) or CRC (N = 2571) who had MGPT including MUTYH at a clinical diagnostic laboratory. Control cohorts for the BC (N = 10,854) and CRC (N = 27,439) comparisons included Caucasian individuals who had MGPT including MUTYH at the same laboratory without personal history of BC or CRC, respectively. Frequencies of the two most common MUTYH founder mutations, p.G396D and p.Y179C, were assessed independently as well as combined. Odds ratios (OR) were obtained from logistic regression analyses after adjusting for covariates. No association was found between female BC and carrier status of p.G396D alone (OR = 0.9, 95 % CI = 0.7–1.1, p = 0.26), p.Y179C alone (OR = 0.9, 95 % CI = 0.6–1.4, p = 0.69) or both mutations combined (OR = 0.9, 95 % CI = 0.8–1.1, p = 0.24) after controlling for personal and family history of CRC and carrier status of mutations in other genes. Similarly, no association was found between CRC and carrier status of p.G396D alone (OR = 1.2, 95 % CI = 0.8–1.7, p = 0.33), p.Y179C alone (OR = 0.7, 95 % CI = 0.3–1.4, p = 0.31) or both mutations combined (OR = 1.1, 95 % CI = 0.8, 1.4, p = 0.72) after controlling for personal and family history of female BC and carrier status of mutations in other genes. In summary, these data do not support a significant association of BC or CRC risk with monoallelic MUTYH carrier status. To our knowledge, this is the largest BC cohort used to assess BC risks among MUTYH monoallelic carriers and the first study to assess cancer association in MUTYH carriers identified on MGPT. Additional studies that include other MUTYH mutations, in addition to having larger CRC cohorts, are needed to confirm these results.

Evaluation of two risk prediction models for patients with endometrial cancer seen in a hereditary cancer clinic

C. Garby Haskins1, K. Ray1, C. Lewis1, T. Pal1

1. Moffitt Cancer Center

Background: Current national practice guidelines (National Comprehensive Cancer Network v2.2015) recommend germline testing for Lynch syndrome (LS) among patients at ≥5 % pre-test probability to have a mutation in a LS gene, based on a risk prediction model. Among a clinic-based sample of patients with endometrial cancer (EndoCa), we sought to evaluate and compare the clinical utility of two risk assessment models (MMRPro and PREMM1,2,6) in the prediction of LS gene mutation positivity. Methods: Clinical information, including results of germline genetic testing, was abstracted for a high-risk clinic-based sample of patients evaluated between January 2015 and April 2016 with EndoCa and germline genetic testing encompassing LS genes. Likelihood of LS mutation positivity was generated on all patients based on the two prediction models. A threshold of ≥5 % pre-test probability was compared to germline genetic test results to determine the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of these two models. Results: Of 31 eligible patients, the mean age of EndoCa diagnosis was 49.7 years. Of the 14 patients (45.2 %) identified with a mutation in an inherited cancer gene, 7 were in a LS gene and 7 were in another inherited cancer gene (i.e., BRCA2, CHEK2 and APC). For MMRPro the PPV, NPV, sensitivity and specificity was 40, 85.7, 57.1 and 75 %, respectively. For PREMM1,2,6 the PPV, NPV, sensitivity and specificity was 23.3, 100, 100 and 4.2 %, respectively. Conclusion: The rate of mutation positivity in our sample was unexpectedly high. MMRPro had a higher PPV and specificity for LS compared to PREMM1,2,6. Conversely, the PREMM1,2,6 overestimated risk for LS compared to MMRPro with a higher number of false positives. Within our cohort the MMRPro model provided better clinical utility. Overall, despite the utility of risk prediction models to inform testing practices, our data underscores the continued importance of clinical judgement in the evaluation of inherited cancer risk.

Design and enhanced validation of a 36-gene guideline-compliant inherited cancer panel

G. Gould1, G. Hogan1, X. Wang1, A. Robertson1, M. Theilmann1, L. Spurka1, P. Grauman1, V. Vysotskaia1, J. Maguire1, P. Kang1, I. Haque1, K. Ready1, E. Evans1

1. Counsyl, Inc

Next generation sequencing (NGS) allows for large scale, low cost sequence analysis of cancer-risk associated genes. These sequencing results in turn inform our patients’ healthcare decisions. Here we describe the validation of the Counsyl inherited cancer screen, an NGS-based screen to identify SNPs, indels, and copy number variants (CNVs, also known as del/dup or rearrangement analysis) in 36 genes outlined in National Comprehensive Cancer Network guidelines for inherited cancer testing in high-risk individuals and cancer patients. The panel focuses on genes implicated in breast, ovarian, colorectal, gastric, endometrial, pancreatic, and paraganglioma cancers: APC, ATM, BARD1, BMPR1A, BRCA1, BRCA2, BRIP1, CDH1, CDK4, CDKN2A,CHEK2, EPCAM, GREM1, MEN1, MLH1, MRE11A, MSH2, MSH6, MUTYH, NBN, PALB2, PMS2, POLD1, POLE, PTEN, RAD50, RAD51C, RAD51D, RET, SDHA, SDHB, SDHC, SMAD4, STK11, TP53, and VHL. Our validation procedure assessed analytical accuracy, inter-run reproducibility, intra-run reproducibility, and comparability between blood and saliva testing. To validate our panel, we used a combination of de-identified patient blood and saliva samples, negative controls, and reference samples including Genome-in-a-Bottle (GiaB), other 1000 Genomes, and other Coriell samples with known variants. All discordances found in GiaB/1000 Genomes samples were resolved by Sanger sequencing. Our validation procedure went beyond standard analytical accuracy, repeatability, and reproducibility procedures to include in silico simulations of CNVs that are difficult to validate exhaustively due to the absence of positive control samples for every possible variant in our genes of interest. To characterize our ability to call CNVs, we performed in silico simulations to assess our ability to call single-exon, multi-exon, and whole gene duplications and deletions for all of the genes on our panel. Additionally, using a custom analytical solution we can identify the Portuguese founder mutation (Alu insertion) in BRCA2 and a second novel deleterious Alu insertion in BRCA2 in patient samples.

Suspected germline variants in SNnaPshot next generation sequencing tumor genotyping and genetic counseling implications

K. Gravelin1, G. Chan-Smutko1, E. Hiller2, V. Nardi3

1. Brandeis University

2. Quest Diagnostics

3. Massachusetts General Hospital

SNaPshot next generation sequencing (NGS) tumor genotyping is used to guide clinical decision-making in the diagnosis, prognosis and treatment of cancer patients at Massachusetts General Hospital. Analysis focuses on somatic alterations in tumor tissue; however, variants of suspected germline origin may be incidentally identified. Our study examined how frequently suspected germline variants (SGVs) were detected for non-lung cancer patients who underwent SNaPshot NGS between December 1, 2014 and May 31, 2015. We selected cases with at least 1 variant present at an allelic fraction between 42 and 58 % in a gene associated with a hereditary cancer syndrome in order to identify cases likely to have SGVs warranting genetic counseling referral. We used ClinVar, COSMIC and ExAC to assess the clinical germline significance for each SGV. Thirty-eight of 599 patients (6.3 %) had at least one deleterious SGV of potential clinical germline significance; 98 patients had SGVs that were deemed to have low potential for clinical germline significance. Report annotation indicating suspected germline origin was present for 19.5 % of deleterious SGVs of potential clinical germline significance, and for 32.5 % of SGVs of low potential for clinical germline significance. We determined risk for hereditary cancer syndromes by considering SGV assessment and concordance with personal and/or family history; 11 patients were considered to be at high or moderate risk for a hereditary cancer syndrome. We did not find evidence of genetic counseling referrals made based on SGVs in the timeframe of our study. Our data show that SGVs of clinical significance for hereditary cancer syndromes may be detected through SNaPshot NGS tumor genotyping, and highlight the challenges in the reporting of and genetic counseling follow-up for SGVs. A multi-disciplinary effort involving medical oncology, genetics and molecular pathology practices may be an optimal approach to identifying patients at high risk for a hereditary cancer susceptibility.

Lost in translation: How medical interpreters modify the communication of whole exome sequencing results during translation for spanish-speaking families

A. Gutierrez1, J. Robinson1, E. Statham1, M. Slashinski2, S. Scollon3, K. Bergstrom3, R. Street4, D. Parsons3, S. Plon3, A. McGuire1, L. McCullough1

1. Center for Medical Ethics, Baylor College of Medicine

2. University of Massachusetts at Amherst

3. Department of Pediatrics, Baylor College of Medicine

4. Department of Communication, Texas A&M University

Introduction: As genome sequencing is increasingly used in clinical care, physicians and genetic counselors (GCs) will be required to communicate complex genetic information to non-English speaking families. While utilizing trained medical interpreters mitigates sociocultural differences and improves physician-patient communication, it is unclear how genomic information might be altered during interpretation. Purpose: We aim to describe the modifications made by interpreters during clinicians’ communication of whole exome sequencing (WES) results to spanish-speaking families. Methods: The BASIC3 study evaluates the impact of WES on pediatric cancer care. All BASIC3 WES result disclosure sessions are audio-recorded including those in which spanish-speaking parents discuss their child’s tumor and germline results with their primary oncologist, study GC, and one of 14 trained hospital interpreters not associated with the study. Using a thematic qualitative analysis, a team of four coders (two bilingual in english-spanish) independently identified and collectively reconciled codes of modifications made by interpreters in 25 transcripts. Results: The disclosure sessions averaged 27 min in length. Observed modifications by interpreters included simplifying and softening clinician language and alterations to (1) genomic terms such as “variants of unknown significance”; (2) genomic concepts such as carrier status; and (3) key clinical words, for example “risk”. In some cases, these modifications changed the meaning and/or altered the significance of the information presented by the clinician. Conclusions: Interpreters’ modifications may be an attempt to bridge cultural gaps between clinician and family but can potentially alter the meaning of genomic information. These findings suggest that clinicians and interpreters should collaborate to determine standardized genomic terms in other languages and modifications that are culturally sensitive yet preserve the clinical meaning. Such resources could be utilized in the training of both medical interpreters and clinicians.

BRCA/2 breast and ovarian cancer risks by variant location

S. Hiraki1, L. Susswein1, L. Yackowski1, M. Marshall1, R. Klein1, K. Hruska1

1. GeneDx

Background: Pathogenic variants in BRCA1 and BRCA2 are known to increase the risks of breast (BC) and ovarian cancer (OvCa); however, genotype-phenotype correlations have yet to be fully delineated. Specific breast and ovarian cancer cluster regions (BCCRs and OCCRs), with higher risks of BC and OvCa than variants in other regions of the genes, have recently been proposed. Purpose: To evaluate whether BRCA1/2 variant location is associated with prevalence of BC and OvCa in our testing cohort. Methods: We retrospectively reviewed the results of all women tested for BRCA1/2 at GeneDx between August 2013 and April 2016. Pathogenic or likely pathogenic variants (P/LPV) in BRCA1/2 were categorized by location within a cancer cluster region. Women with more than one P/LPV in BRCA1/2 (n = 5) were excluded from the analyses. The relative risk of BC and OvCa was calculated for the BRCA1/2 cluster regions. Results: Of over 60,000 women tested for BRCA1/2, either alone or as part of a panel, 2826 carried a P/LPV in BRCA1/2. In the BCCRs of BRCA1 and BRCA2, the relative risk of BC was 1.11 (95 % CI:1.0–1.23, p = 0.055) and 1.05 (95 % CI:0.94–1.18, p = 0.384), respectively. In the OCCRs of BRCA1 and BRCA2, the relative risk of OvCa was 1.4 (95 % CI:1.1–1.8, p = 0.008) and 1.55 (95 % CI:1.52–2.10, p = 0.004), respectively. Similar analyses showed a trend towards a lower risk of BC in the OCCRs as well as a lower risk of OC in the BCCRs. Based on these relative risks, the relative risk ratios of BC:OvCa in the BCCRs were 1.63 (BRCA1) and 1.13 (BRCA2), and in the OCCRs were 0.57 (BRCA1) and 0.71 (BRCA2). Discussion: The results from this cohort are consistent with previous assertions of breast/ovarian cancer cluster regions. We found that variants in the OCCR conferred a higher risk of OvCa than those outside the OCCR, and conferred a higher risk of ovarian versus breast cancer. Results from variants in the BCCR were not significant, but trended toward a higher breast cancer risk than variants outside the region. These findings can aid in the development of more personalized and accurate risk assessment.

When the family history leads you astray: A case report

J. Humanski1, M. Bower1, B. Hirsch1, J. Holle1, M. MacMillan1, B. Thyagarajan1, J. Wagner1, R. Tryon1

1. University of Minnesota

Introduction: Fanconi anemia (FA) is a primarily autosomal recessive condition characterized by congenital anomalies, bone marrow failure, and an increased risk for developing certain cancers. Currently, variants in 18 different genes are known to cause FA, including a number of genes associated with cancer risks in carriers such as BRCA2 and PALB2. Case Report: A 7-year-old male patient was referred for blood & marrow transplant (BMT) following a recent diagnosis of myelodysplastic syndrome (MDS). A positive chromosome breakage assay lead to a diagnosis of FA, presumptively from mutations in BRCA2 (FANCD1) based on the early onset of MDS and a maternal family history of breast cancer associated with a BRCA2 variant (c.5722_5733del). As the clinical management (i.e. method of BMT and screening for tumor development) differs based on the FA genotype, sequencing and deletion/duplication analysis of BRCA2 was performed. This analysis revealed heterozygosity for the c.5722_5733del variant. No second variant was identified. These findings were confirmed on fibroblast cultures. As part of the cytogenetic workup of the MDS, a microarray was performed which revealed a deletion of part of FANCA in addition to loss of heterozygosity of BRCA2. Follow up analysis of the FANCA gene on cultured fibroblasts revealed compound heterozygosity for a deletion of exons 1–6 and a splice site variant called c.1359+1G>C. Discussion: Despite a family history of a BRCA2 variant and an early onset myeloid malignancy suggestive of FA-D1, comprehensive genetic analyses were necessary for the accurate and clinically significant diagnosis of FA-A. This case illustrates how differentiating germline from malignancy acquired genetic variation by testing a tissue source such as fibroblasts can be particularly valuable.

Unknown synergistic effect of digenetic inheritance of MMR pathogenic mutations: Double heterozygosity in Lynch syndrome, a single case report and family study

A. Jacquart1, R. McFarland2, M. Depas1, D. Basel1

1. The Medical College of Wisconsin

2. Ambry Genetics

Introduction: Lynch syndrome (LS) is a well-known cause of hereditary colon cancer. Pathogenic variants (mutations) in mismatch repair (MMR) genes: MLH1, MSH2, MSH6 and PMS2 along with deletions of EPCAM have been associated with LS. Biallelic mutations in MMR genes result in constitutional mismatch repair deficiency (CMMR-D) syndrome. Double heterozygosity for MMR mutations does not cause CMMR-D syndrome, but is expected to be associated with cancer risks similar to LS. Case Report: The proband is a 22-year-old male diagnosed with locally advanced rectal adenocarcinoma. The tumor demonstrated microsatellite instability and loss of MLH1, MSH6, and PMS2 expression with retention of MSH2 by immunohistochemistry. His family history was significant for endometrial cancer in his paternal grandmother diagnosed at age 52. The remaining family history was non-contributory. The patient underwent multigene panel testing and was found to be heterozygous for a mutation in the MSH6 gene (p.R482*) and a mutation in the PMS2 gene (EX6_8del). The patient’s nuclear family members underwent genetic testing to determine the segregation of the MSH6 and PMS2 mutations and to better clarify their personal cancer risks. We confirmed the MSH6 mutation was paternally inherited and the PMS2 mutation was maternally inherited. The patient’s oldest sister is heterozygous for the PMS2 mutation, his younger brother is also heterozygous for the PMS2 mutation, and his adolescent sister is a double heterozygote. Discussion: There are few case reports of LS double heterozygotes published in the literature. In a cohort of over 75,000 cases tested for two or more MMR genes at a clinical diagnostic laboratory, seven double heterozygotes were identified (~0.009 %). Due to this rarity, the interactive effect of harboring mutations in two different MMR genes is unknown and the relative cancer risk cannot be predicted. Further studies are needed exploring the functional impact of double heterozygous MMR mutations to help clarify lifetime cancer risks and appropriate management for these patients.

Confirmation of tumor biomarker results in the germline

M. Marshall1, M. Roberts1, A. Thompson1, S. Keilman1, Y. Wang1, R. Klein2, K. Hruska1

1. GeneDx

2. Bioreference Laboratories

Objectives: Biomarker testing, including tumor sequencing, is becoming integral for personalized cancer care. Utilization includes guiding therapeutic treatment with U.S. Food and Drug Administration (FDA)-approved or off-label drugs, prognostic prediction, clinical trial enrollment, and tumor result clarification. Although tumor next-generation sequencing (TNGS) intends to identify actionable somatic alterations, results from tumor-only or circulating tumor DNA (ctDNA) analysis may contain both somatic and germline variants, which cannot be differentiated without additional testing. We aim to determine the extent to which variants identified by biomarker testing are confirmed to be germline at a clinical diagnostic laboratory. Methods: We retrospectively reviewed all cases submitted for germline analysis by either a next-generation sequencing panel, single gene testing or targeted variant testing, for which prior biomarker testing was completed at an outside laboratory indicating a variant in an inherited cancer susceptibility gene. Results: Fifty-three individuals underwent germline testing, at least in part, as a result of one or more variants being detected in a variety of genes by biomarker testing of the patient’s tumor or ctDNA. Three cases were excluded from analysis as the variant of interest was either not specified or the gene of interest was not included in the panel ordered. In almost half of the cases (23/50; 46 %), at least one variant found in the tumor was found to be present in the germline, including 19 pathogenic/likely pathogenic variants, 1 variant of uncertain significance and 3 benign polymorphisms. Conclusions: Overall, almost half of variants identified by biomarker testing were confirmed in the germline. In addition, 3 variants identified by TNGS were classified as benign germline polymorphisms, cautioning against extrapolating variant classifications from biomarkers to the germline since classification objectives and processes differ. Future research is needed to help clinicians distinguish when germline testing for a tumor biomarker result may be warranted.

Outcomes of next-generation panel testing in adolescents and young adults with colorectal cancer

M. Mork1, S. Bannon1, Y. You1, P. Lynch1, M. Rodriguez-Bigas1, E. Vilar1

1. University of Texas MD Anderson Cancer Center

Background: The extreme phenotype of adolescents and young adults with colorectal cancer (CRC) has attracted recent attention, with previous research identifying one-third of patients diagnosed with CRC at or below 35 with an inherited predisposition. We aimed to study the subset of young patients diagnosed with CRC without a family history or syndromic presentation to determine if a CRC-specific next-generation gene panel increased the yield of genetic workup. Methods: Genetic counseling patients with CRC at 35 or younger and evaluated during 05/2014-05/2016 were identified from the genetic counseling database. Medical records were reviewed for personal and family history and outcomes of genetic counseling. Results: Eighty-four patients with CRC at 35 or younger were seen over a 2-year period. Fifty-two (61.9 %) had panel testing of CRC genes. Thirty-two (38.1 %) did not undergo a panel, instead having syndrome-directed testing, declining, or lost to follow-up. Twenty-three had a genetic syndrome (27.3 %), including Lynch syndrome (14), mutation-negative Lynch syndrome (1), familial adenomatous polyposis [FAP] (7), and juvenile polyposis (1). Nineteen of the 23 hereditary patients were identified via syndrome-directed testing. The other 4 hereditary patients (3 Lynch, 1 FAP) were found via a panel, but were suspected based on the reported history. Nineteen (36.5 %) had at least one variant of uncertain significance. The remaining 28 had negative panel testing. Conclusions: In our series, 27 % of patients had a hereditary syndrome, consistent with previous findings. Panel testing in patients without a clear phenotype did not increase diagnostic yield, but did find variants in over one-third. Disease-specific panel testing is of low yield in young patients without a suggestive personal or family history. Further research is warranted in this young cohort, including using broader gene panels to account for overlapping phenotypic presentations of hereditary syndromes.

Panel testing reveals presence of likely pathogenic variants inCDH1in two probands with personal and/or family history of breast cancer. Subsequent gastrectomy confirms the presence of a diffuse gastric tumor in one of the unaffected probands.

F. Oh1, J. Homer1

1. Hoag Hospital

A mutation in the CDH1 gene is associated with Hereditary Diffuse Gastric Cancer (HDGC), a dominantly inherited condition causing a susceptibility to diffuse gastric cancer, lobular breast cancer and signet ring colorectal cancer. Mutations in CDH1 confer an 83 % risk for females and 67 % risk for males to develop stomach cancer by age 80. There is also a 39 % risk of developing lobular breast cancer, and there may also be an increased risk of signet ring colorectal cancer. The proband from family#1 is a 45 year-old Caucasian female who was first seen in 2009 due to her family history of breast cancer, in which time she underwent BRCA1/2 testing, and no mutation was found. She returned in 2015 to discuss her options for additional genetic testing. DNA sequencing of the following genes was performed: ATM, BARD1, BRCA1, BRCA2, BRIP1, CDH1, CHEK2, MRE11A, MUTYH, NBN, NF1, PALB2, PTEN, RAD50, RAD51C, RAD51D and TP53. This panel testing identified a genetic variant, likely pathogenic in the CDH1 gene (c.1008G>A). Subsequently she underwent gastrectomy which confirmed the presence of a diffuse gastric tumor with signet rings. The proband from family#2 is a 51 year-old Caucasian woman who had the same panel testing due to her personal history of bilateral breast cancer (at 28 and 41) and was found to have a variant, likely pathogenic in CDH1 (c.1137+1delG). Subsequently, she also underwent a total gastrectomy and did not report any abnormal findings. Our study shows that further analysis of CDH1 mutation penetrance will be important in determining the risk for CDH1 carriers without a family history of HDGC which can assist them in making decisions regarding risk-reducing interventions and surveillance measures.

Multigene panels in prostate cancer patients with familial risk: Unexpectedly high mutation rates in non-brca genes

C. Radford1, C. Garvey2, E. Ledet2, A. Sartor2

1. Invitae

2. Tulane Cancer Center, New Orleans, LA

Introduction: Prostate cancer (PC) is the most common nondermatologic cancer in males with an incidence similar to that of female breast cancer (BC). Like BC, at least 5–10 % of PC cases are due to inherited risk. However, despite these similarities to BC, men with PC are seldom seen by a genetic counselor. One reason for this is the perception that the number of genes linked to PC is low. This study sought to provide data on the spectrum of mutations found in a cohort of PC patients. Methods: Between June 2015 and May 2016 personal and family history information was collected for PC patients presenting to Tulane Cancer Center. Documented clinical factors included age and PSA level at diagnosis, Gleason score, and the presence of metastasis. Family history information was collected for first-, second-, and third-degree relatives. For patients meeting the 2015 National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing, a panel of at least 25 genes was offered. Results: Seventy-two men proceeded with testing. Excluding monoallelic MUTYH, 12.5 % of participants carried at least one pathogenic variant. Of the 11 non-MUTYH pathogenic variants identified, only 45 % were in BRCA1/2. To date, family testing has been performed on 12 individuals, five of whom carry a familial mutation. Conclusion: In our cohort, at least 1 in 8 men meeting the 2015 NCCN criteria for BRCA testing carried an identifiable and actionable germline mutation. In line with inherited BC statistics, utilizing a testing strategy analyzing solely BRCA1/2 would have failed to identify >50 % of men with germline mutations. Further, like BC, germline mutations have implications in PC treatment, such as sensitivity to PARP inhibitors and/or Carboplatin, as well as providing individuals and their at-risk family members the ability to create a personalized cancer surveillance and risk-reduction plan. Given that genetic counselors routinely counsel patients with BC and the genetics of PC appear to be similar, evaluating PC patients for inherited risk should become part of routine practice.

Identification of patients for genetic follow-up: Results from tumor gene profiles

B. Reys1, M. McDuffee2, M. Ning2, T. Ross1

1. UT Southwestern

2. Sarah Lawrence College

Purpose: We sought to determine if review of tumor profiling data can identify patients appropriate for genetics referral to evaluate for cancer predisposition syndromes. Methods: We reviewed 523 tumor profiling results from Foundation Medicine (23 % pediatric). Patient’s age, cancer diagnosis, mutations and allele frequencies were collected. Cases were reviewed for mutations in cancer predisposition genes. Full gene deletions, duplications and amplifications were not considered. Results: Data from patients with hematologic (n = 302 (58 %)) and non-hematologic malignancies (n = 221 (42 %)) were obtained. Hematologic cancers included: 220 leukemia/ lymphoma, 51 myelodysplastic syndrome, 31 other. Non-hematologic tumors included: 58 breast, 30 gastrointestinal, 29 central nervous system, 23 sarcomas, 18 genitourinary, and 69 other tumors. All cases were reviewed for two criteria to identify a potential germline cancer gene mutation from these data: 1) patients who met American College of Medical Genetics and Genomics (ACMG) genetic counseling guidelines based on tumor type and age and 2) patients with mutations in genes of interest based on the tumor diagnosis. Of all patients, 15 % met at least one of the two criteria, 4 % met ACMG criteria, 7 % met our second criteria and 3 % met both criteria. Eleven BRCA1/2 mutations were concerning for germline mutations (6 were in non-breast cancer patients). Of the 11 BRCA1/2 mutations, 8 would be deleterious and 3 would be variants of uncertain significance (VUSs) or benign if confirmed in the germline. Three patients had already seen a genetic counselor, two mutations were confirmed to be germline and deleterious and one was deemed a germline VUS. Conclusions: Tumor profiling results can be used, even in the absence of family history, to identify additional at-risk cases for genetic counseling. Guidelines for identifying at-risk patient’s based on tumor profiling results need to be established including screening for high-risk genes such as BRCA1/2 regardless of tumor type.

Average age of diagnosis of ovarian cancer for women with pathogenic variants inBRIP1, RAD51CandRAD51D

S. San Roman1, H. Gorringe1, J. Saam1, J. Kidd1, S. Manley1, L. Usha2

1. Myriad Genetic Laboratories, Inc.

2. The Rush Cancer Institute, Rush University

Background: Recently, it has been shown that pathogenic variants (PVs) in BRIP1, RAD51C and RAD51D confer an increased lifetime risk of ovarian cancer (OvCa) (5.8–14.8 %). As such, the National Comprehensive Cancer Network (NCCN) now recommends that risk-reducing salpingo-oophorectomy (RRSO) be considered for women with PVs in these genes, in addition to several high-penetrance genes. Based on the average age at diagnosis, RRSO is recommended between the ages of 35 and 40 for women with PVs in BRCA1 and as late as 45 for women with PVs in BRCA2; however, there are no specific age recommendations for women with PVs in BRIP1, RAD51C, or RAD51D. Here, we investigated the average age at diagnosis for women with OvCa who carry a PV in BRIP1, RAD51C, or RAD51D. Methods: 189 women with a personal history of OvCa were found to carry a single PV in BRIP1, RAD51C or RAD51D through clinical testing with a 25-gene panel between September 2013 and February 2016. Women identified with PVs in BRCA1, BRCA2, or the mismatch-repair (MMR) genes (MLH1, MSH2, MSH6, PMS2, EPCAM) over the same time period were evaluated for comparison. Clinical information was collected from provider completed test request forms. Results: The average age of diagnosis for women with a PV in BRIP1, RAD51C or RAD51D was 62.3, 60.6, and 56.9 years, respectively, with lower limits between 21 and 37 years for all three genes. This was similar to the average age of diagnosis for women with a PV in BRCA2 (59.0 years) and slightly older than women with a PV in BRCA1 (53.4 years) or MMR genes (44.7 to 51.5 years). Furthermore, the majority of OvCas were diagnosed after the age of 50 among women with a PV in BRIP1 (82.2 %), RAD51C (83.1 %), or RAD51D (78.3 %). Conclusions: In this study, we found that the average age of OvCa diagnosis of women with a PV in BRIP1, RAD51C or RAD51D was similar to BRCA2. Collectively, the data presented here suggests that medical management similar to that for women with PVs in BRCA2 may be suitable for women with PVs in these three genes.

Variant rate by panel type across testing laboratories

A. Schmidt1, A. Ascencio1, K. Steenblock1, J. Pruski-Clark1, M. Czarniecki1, A. Trivedi1

1. InformedDNA

Background: Variant rates are an important component of the informed consent process as the detection of variants has been shown to increase patient anxiety, misinterpretation of test results and likelihood of unnecessary interventions. Analyzing data, across multiple laboratories and panel types, allows for real-time examination of variant rates and their potential impact on informed consent and result interpretation. Methods: We reviewed the results of all panel tests ordered between March 1, 2015 and February 29, 2016. We separated the panels into 3 categories: small, high-risk, cancer-specific panels including only genes with clinical management guidelines; high/moderate-risk panels including genes targeted to one cancer type; and large, multi-cancer panels. Variant rates were calculated for each category. Results: 960 hereditary cancer panels were ordered within the study time period. One hundred sixty four were classified as high-risk panels, 295 as high/moderate-risk panels, and 501 as large, multi-cancer panels. The variant rate for small, high-risk panels was 10.4 %, for high/moderate-risk panels it was 21 %, and for large panels it was 32.1 %. Conclusions: The data provides a summary of variant rate per cancer panel type across multiple laboratories, which doubled from small, high-risk, cancer-specific panels to high/moderate-risk panels, and tripled from small, high-risk panels to large panels. This type of information is useful during the informed consent process as patients decide between various genetic testing options.

Ancestry-based cancer risks associated with APC I1307K

L. Sharma1, J. Kidd1, K. Brown1, H. Gorringe1, M. Landon1, S. Manley1, B. Leach2

1. Myriad Genetic Laboratories, Inc.

2. Cleveland Clinic

Background: Individuals with pathogenic variants in ademomatous polyposis coli (APC) may have a >99 % lifetime risk for colon cancer. APC I1307K is a polymorphism that occurs in about 10 % of individuals of Ashkenazi Jewish (AJ) ancestry and is associated with a slightly increased colon cancer risk colon cancer that has not been observed in other ancestries. The aim of this study was to evaluate ancestry-based cancer risks for APC I1307K carriers. Methods: We investigated individuals who underwent clinical genetic testing with a 25-gene hereditary cancer panel that includes APC. The proportion of APC I1307K carriers was evaluated for tested individuals who reported 1) full AJ ancestry (n = 2432), 2) partial AJ ancestry (n = 1741), and 3) no AJ ancestry (n = 136,516). Personal history of breast and colon cancer was assessed. Results: 486 APC I1307K carriers were identified, 158 of whom reported full AJ ancestry. The positive rate in this ancestry subgroup (6.5 %) was higher than that observed for individuals of partial AJ (n = 65, 3.7 %) or no AJ (n = 263, 0.2 %) ancestry. Relative to mutation-negative individuals in the same ancestry subgroups, there was a higher incidence of breast cancer among APC I1307K carriers of full AJ ancestry (24.1 vs 18.6 %, p = 0.094) and higher incidence of colon cancer among APC I1307K carriers of full AJ ancestry (5.7 vs 2.9 %, p = 0.054) or no AJ ancestry (5.3 vs 3.3 %, p = 0.079). This increased cancer incidence is trending towards significance. There was no evidence of increased breast or colon cancer risk in the other subgroups. Conclusions: Our findings support previous studies showing an increased risk of colon cancer among APC I1307K carriers of AJ ancestry compared to non-carriers. Interestingly, there was not a large difference in the colon cancer prevalence among APC I1307K carriers of AJ and non-AJ ancestry in this cohort and the increased colon cancer prevalence was trending toward significance in both groups. This potential colon cancer risk warrants further investigation and may influence medical management decisions for APC I1307K carriers regardless of ancestry.

Fanconi anemia type solid tumors in Fanconi anemia heterozygotes identified via inherited cancer gene testing

A. Stettner1, L. Susswein1, K. Hruska1, R. Klein1

1. GeneDx

Fanconi anemia (FA) is caused by pathogenic variants in one of 16 genes in the homozygous/compound heterozygous state, but autosomal dominant susceptibility to breast and/or ovarian cancer has been identified in heterozygous carriers of BRCA2, BRIP1, FANCC, PALB2, and RAD51C pathogenic variants. Apart from bone marrow failure and risk for hematologic cancers, individuals with FA have increased risks for head and neck squamous cell carcinomas (HNSCC) and for SCCs of the lower gynecologic tract (cervix, vulva, vagina) and anus. These cancers affect <1 % of the general population and many may be due to tobacco and/or HPV infection; however, they occur hundreds fold more often among those with FA. We sought to quantify the number of individuals with heterozygous FA pathogenic (PATH) or likely pathogenic (LPATH) variants who had a personal history of these types of squamous cell carcinomas. We reviewed data from patients having inherited cancer gene testing at GeneDx between August 2013 and April 2016. Patient history was abstracted from test request forms. We identified 12 patients with single FA gene PATH or LPATH variants and a personal history of HNSCC, presumed/documented SCC gynecologic cancer, and/or anal cancer. Two women with vulvar cancer tested positive for a pathogenic FA gene variant; one had a PALB2 PATH variant and the other a BRIP1 PATH variant. Another woman had vaginal SCC and a BRCA2 PATH variant. Seven women reported a personal history of cervical cancer with pathogenic variants in BRCA2 and/or PALB2. Finally, a male patient with HNSCC tested positive for a BRCA2 LPATH variant and a woman with anal cancer had a BRCA2 PATH variant. Though these numbers are small, further studies may be warranted to more thoroughly investigate any potential association between FA heterozygous PATH/LPATH variants and squamous cell carcinomas of the head and neck, lower gynecologic tract, and anus.

All in the family: A first look at outcomes when multiple relatives undergo multi-gene panel testing

M. Umali1, A. Yussuf1, K. Panchani1, H. LaDuca4

1. Ambry Genetics

In the hereditary cancer setting, single site analysis has proven to be a fast and cost-effective testing strategy for relatives once a genetic mutation has been identified in a family. However, more comprehensive testing of family members is sometimes indicated, such as in the presence of bilineal family history of cancer or when a patient’s clinical presentation is not consistent with the previously identified familial mutation. With the widespread adoption of next-generation sequencing, testing costs have decreased while efficiency has improved. While many family members still pursue targeted familial mutation testing, others are opting for multi-gene panel testing (MGPT) even in the presence of a known familial mutation. The aim of this study was to assess the results of testing in families who had multiple individuals pursue MGPT for hereditary cancer risk at the same laboratory. In total, 727 families were identified in which multiple relatives pursued MGPT, including 663 families with two individuals undergoing MGPT and 64 families with three or more relatives undergoing MGPT. In 76 families, MGPT was ordered on the same date for all relatives. In 39 families, testing for relatives was ordered before the proband’s results were reported, and in 612 families relatives were tested after the proband’s result was reported. Of 357 families where relatives pursued MGPT following identification of a mutation in the proband, additional alterations were detected on relatives’ MGPT in 68 families (19.0 %), including 12 families (3.4 %) where relatives carried mutations not identified in the proband, 53 families (14.8 %) where relatives carried variants of unknown significance (VUS) not in the proband, and three families (0.8 %) where relatives carried both mutations and VUS not in the proband. Results from this exploratory study demonstrate that, in a subset of cases, clinicians are ordering MGPT for relatives of mutation-positive probands. Further studies are needed to help identify characteristics of families who are most likely to benefit from multiple MGPTs.


Inherited cardiomyopathies in the pediatric population: What molecular testing reveals

S. Aguilar1, J. Tahiliani1, D. Beltran1, T. Callis1, A. Daly1, E. Decker1, J. Garcia1, R. Harte1, B. Herrera1, N. Johnson1, L. Murillo1, E. Haverfield1

1. Invitae

Pediatric cardiomyopathy (CM) is a heterogeneous disease that may be idiopathic or familial, occur as a result of the same pathogenic variants that cause adult CM, or exist as part of an underlying syndromic, neuromuscular, or metabolic condition of which CM may be the primary presenting feature. Although studies have evaluated the proportions of CM attributed to inherited cardiac conditions, study population characteristics and outcomes vary widely. This study analyzed the results of 57 sequential orders for CM panels in a pediatric population. Among the 57 patients aged 18 years or younger, 10 (18 %) harbored a pathogenic or likely pathogenic (P/LP) variant thought to explain the phenotype, including single heterozygous variants in MYH7 (2), PKP2 (2), TNNT2 (1), RMB20 (1), SCN5A (1), and RAF1 (1) and a hemizygous variant in TAZ. A homozygous PLN deletion was also identified as part of a larger, complex event in one patient. Of note, two (13 %) of these variants (TAZ and RAF1) were found in the 15 patients aged 1 year or younger. Syndromic and neuromuscular etiologies were important causes of infantile-onset CM. Beyond infancy, pediatric patients harbored a number of P/LP variants in genes that are also associated with adult-onset CM. Although previous studies have identified multiple mutations in up to 5 % of patients with hypertrophic CM, no instances of multiple P/LP variants, aside from the complex PLN result, were identified in our study. Previous reports may have overestimated the frequency of multiple mutations according to classification systems used before the implementation of the 2015 American College of Medical Genetics and Genomics/AMP guidelines. Additional studies are needed to clarify this frequency. Overall, the genetic analysis of pediatric CM patients aids in determining treatment and prognosis and provides insight into the significant clinical variability among CM patients.

Clinical cardiovascular genetic counselors take a leading role in team-based variant interpretation

C. Caleshu1, C. Reuter1, K. Orland2, M. Grove3, K. Spoonamore4

1. Stanford Center for Inherited Cardiovascular Disease

2. University of Wisconsin-Madison School of Medicine and Public Health

3. Stanford University Medical Center

4. Indiana University School of Medicine

Introduction: Broader genetic testing and increased recognition of disagreement among labs on test interpretation has lead to discussion regarding the role of the clinician in interpretation of clinical genetic test results. Aim: To describe the genetic test result review and interpretation practices of clinical cardiovascular genetic counselors. Methods: An online survey included questions about genetic counselors’ practices regarding review of clinical genetic test results. Members of the NSGC cardiovascular special interest group (SIG) were invited to participate and were eligible if they were currently practicing as a clinical cardiovascular genetic counselor. Results: Forty-six genetic counselors participated (means years practicing: 9.4; mean years in cardiology: 5.1). Nearly all gather additional data on variants identified through clinical genetic testing, beyond reading the test report (95.7 %). The majority also assess the classification of those variants (81 %). Variant classification was a more recent addition to practice than gathering additional information (3.3 years and 2 years, respectively; p = 0.02). Most genetic counselors reported performing variant interpretation in collaboration with their cardiologist and/or geneticist colleagues (81 %). While variant classification was often team-based, in most cases the genetic counselor was the team member primarily responsible for classification (76.7 %). Participants reported they more often agreed with the lab’s classification of variants as pathogenic (90.5 %), than likely pathogenic (81.9 %; p = 0.02) or of uncertain significance (73.3 %; p = 0.001). The relevant skills were more often gained on the job than in graduate school. Many reported team-based education, noting they learned from physician and/or genetic counselor colleagues. Conclusions: Most cardiovascular genetic counselors perform additional review and classification of clinical genetic test results. Such interpretation is done in a team-based fashion, with the genetic counselor as the team member primarily responsible for review and interpretation

Uptake of presymptomatic genetic testing and cardiac screening for children at risk for an inherited arrhythmia or cardiomyopathy

S. Christian1, J. Atallah1, R. Clegg2, M. Giuffre2, C. Huculak3, T. Dzwiniel3, J. Parboosingh3, S. Taylor1, M. Somerville1

1. University of Alberta

2. University of Calgary

3. Alberta Health Services

Background: Presymptomatic genetic testing in minors may be appropriate when clinical intervention is available. Cardiac screening, medication and lifestyle modifications are sometimes considered in children who carry a pathogenic variant for an inherited arrhythmia or cardiomyopathy. As a result presymptomatic genetic testing may be offered to this pediatric population. Objective: The objective of this study was to examine factors associated with uptake of genetic testing and cardiac screening for children in families identified to carry a pathogenic variant for long QT syndrome (LQTS), Hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC) in Alberta, Canada. Method: Families found to carry a pathogenic variant between January 1, 2005 and December 31, 2014 were identified through the Genetic Laboratory Services databases. Medical genetics and pediatric cardiology charts were reviewed to identify children at risk for LQTS, HCM and ARVC and factors associated with uptake of genetic testing and cardiac screening. Phenotype of the children was recorded from the pediatric cardiology charts. Results: We identified 104 at risk children from 58 families found to carry a pathogenic variant for LQTS, HCM or ARVC. Sixty six percent of the families pursued genetic testing and 76 % of the children underwent cardiac screening when it was indicated. Uptake of genetic testing was associated with genetic specialist recommendation, diagnosis initiating in a sibling, and female sex of the carrier parent in the absence of symptoms. Compliance with cardiac screening was more likely in patients having undergone genetic testing. Conclusion: This study provides a greater understanding of factors associated with uptake of genetic testing and cardiac screening in children at risk of an inherited arrhythmia or cardiomyopathy. These finding highlight the importance of clear, evidence based guidelines for health care professionals and identify a need to educate families about the importance of cardiac screening even in the absence of genetic testing.

Reportable variants in genes less commonly associated with cardiomyopathies

R. Latimer1, J. Mukri1, C. Antolik1, D. Macaya1

1. GeneDx

Cardiomyopathies are diseases of the heart muscle. The ABCC9, ILK, MYOZ2, PDLIM3, and TMPO genes are published in association with cardiomyopathy, however, this literature is comparatively limited. For example, MYBPC3 has over 500 variants reported as pathogenic for isolated cardiomyopathy in the Human Genome Database while, collectively, the aforementioned five genes have fewer than ten pathogenic variants reported. Because variants in these genes have been implicated in a relatively small proportion of genetic cardiomyopathies, we expected most reportable variants would be of uncertain significance. To further explore the contribution of variants in these genes to disease, we retrospectively reviewed results from a 76-gene cardiomyopathy panel. Data were reviewed from cases with a variant in ABCC9, ILK, MYOZ2, PDLIM3, and/or TMPO genes from 2132 individuals referred for cardiomyopathy panel testing. Reportable variants were categorized as either pathogenic, likely pathogenic, or of uncertain significance. Of the 2132 cases, 146 (6.8 %) had a reportable variant in one of these genes, and all were classified as variants of uncertain significance (VUS). The majority of cases (112/146; 76.7 %) did not harbor a co-occurring pathogenic or likely pathogenic variant, and 26.0 % (38/146) harbored no co-occurring variant. Both recurrent (n = 20) and novel (n = 21) VUS were identified in these five genes. In conclusion, providers can expect that a variant identified in one of these five genes will be reported with uncertain significance, given all variants identified in this study were VUS. Nevertheless, these variants remain potentially causative for disease. This study demonstrates the need for further research on these genes and highlights the need for participation in family segregation studies. Furthermore, this points to the importance of managing patient expectations about potential variant reclassification when VUS are identified, particularly in genes less commonly associated with cardiomyopathy.

De novovariant rate in pediatric hypertrophic cardiomyopathy

E. Miller1, R. Newman2, A. Shikany1, A. Lorts1, C. Villa1, S. Ware3, A. Parrott1

1. Cincinnati Children’s Hospital Medical Center

2. University of Cincinnati

3. Indiana University

Hypertrophic cardiomyopathy (HCM) is a common monogenic cardiac disorder that can affect children, adolescents and adults. Variants in genes that encode components of the sarcomere and cytoskeleton in cardiomyocytes are common causes of HCM. HCM is typically inherited in an autosomal dominant (AD) manner and exhibits significant clinical variability. Recommendations for cardiac screening in first degree relatives are based on the assumption of AD disease; however, the contribution of de novo variants to HCM is largely unknown. Leveraging the family centered approach of a large pediatric medical center; we sought to determine the rate of de novo likely pathogenic and pathogenic variants in children and adolescents with a clinical diagnosis of HCM. A descriptive quantitative cross-sectional retrospective medical record review of patients (0–18 years) with HCM gene panel testing between September 2005 and June 2015 was performed. The yield of genetic testing was defined as the proportion of subjects who had a positive gene panel compared to the number of subjects who completed testing. A variant classified as likely pathogenic or pathogenic by the clinical testing laboratory was considered a positive result. The yield of clinical HCM gene panel testing was 48 % (37/77). An additional 13 % (10/77) of subjects had a variant of uncertain significance. Of the 37 individuals with a positive result, 78 % had an inherited variant. Eight percent had a de novo variant in one of three genes (MYH7, MYBPC3, and ACTC1). Germline mosaicism and non-paternity were not observed. None of the variants with uncertain clinical significance were de novo. The status of the remaining 5 variants is unknown. Identification of a de novo variant alters recommendations for family-based cardiac and genetic screening. Genetic counseling on recurrence risk should also consider germ line mosaicism and non-paternity as potential explanations for apparently de novo variance.

Assessing medical examiners’ current practices in utilizing genetic testing for autopsy-negative sudden unexpected death in the young (sudy)

L. Moissiy1, J. Youngblom1, K. Tezcan2, K. McClelland3

1. California State University, Stanislaus

2. Kaiser Permanente

3. University of California, San Francisco

Sudden unexpected death in the young (SUDY) has long been regarded as an indication for medical autopsy, but a new means for seeking an explanation to an unexpected death in which medical autopsy reaps no answer has emerged-the genetic autopsy. To explore current practices in retaining samples for genetic testing, identify obstacles to facilitating genetic testing, and assess knowledge of the medical genetics community as a resource for medical examiners (ME). An online survey included questions about ME’s personal experiences, practices, and opinions surrounding genetic testing in autopsy-negative SUDY cases for those 40 years of age and below. Members of the National Association of Medical Examiners were invited to participate and eligible if involved in autopsy investigation as a ME or board certified forensic pathologist currently or in the last 5 years. Seventy-five MEs and forensic pathologists from across the United States and Canada participated. The majority of participants had requested or facilitated genetic testing in at least one case of autopsy-negative SUDY (59 %) but a minority of those participants did so in all of these cases (5 %) and the majority of participants did so in some of these cases (78 %). Nearly all participants (92 %) cited at least one barrier to offering genetic testing in these cases existed, with inadequate funding most commonly cited (80 %) and uncertainty of process also cited (15 %). Only 18 % of participant felt very knowledgable about a genetic counselor’s potential role in facilitating post-mortem genetic testing, and 13 % of participants reported no knowledge. Most ME have experience in requesting or facilitating genetic testing in at least one case of autopsy-negative SUDY, but inconsistencies in practice exist. The most cited barrier to offering genetic testing in these cases is inadequate funding, though other barriers, such as uncertainty of process, exist too. The relationship between ME and genetic counselors could benefit from increased knowledge of each others’ roles, with collaboration in care for families of decedents.

Numeracy and genetic knowledge’s effect on perceived recurrence risk of congenital heart defects

K. Myers1, K. O’Brien2, J. Bowman1, V. Garg1, K. McBride1, S. Fitzgerald-Butt1

1. Nationwide Children’s Hospital

2. University of Wiscosin School of Medicine and Public Health

While the genetic etiology of congenital heart defects (CHD) continues to provide insight to this complex disease, effectively educating individuals with CHD and their parents about recurrence risk becomes much more challenging. Therefore, as young adults with CHD reach reproductive age and parents of children with CHD plan future pregnancies, it is paramount to determine the knowledge constructs that underlie perceived recurrent risk (PRR). In this study, utilizing available data from an ongoing study, we sought to determine if PRR is correlated with objective numeracy (ON) and genetic knowledge (GK). Young adults (20–40 years) and parents of children (<2 years) with CHD that required surgery before 1 year old were recruited from the cardiology clinic and, after giving verbal consent, completed our survey. The survey consisted of a continuous scale (0–100 %) to assess PRR, a previously published 8-item multiple-choice ON scale, and a previously published 16-item GK measure. Data was analyzed with descriptive statistics and Pearson’s correlations. Thirty-nine individuals (14 male [35.9 %], 25 female [64.1 %]) were enrolled (mean age = 27 years, range = 20-39) and identified with Caucasian (94.9 %) and African American ethnicities (5.1 %). The average PRR was 34.6 % (range = 1–77, SD = 24.7), the average correct ON item score was 3.0 (range = 0–7, SD = 1.9), and the average correct GK item score was 12.5 (range = 5–16, SD = 2.7). Interestingly, a lower PRR was significantly correlated with a higher ON (r = −0.397, p = 0.012). Additionally, a higher ON was significantly correlated with a higher GK (r = 0.371, p = 0.020). As PRR is influenced by ON, any intervention aimed at increasing accuracy of PRR will also likely need to increase numeracy. This is likely applicable in a wide variety of clinical and research settings where medical decision making is dependent on an accurate perception of numerical risk.

Hypertrophic cardiomyopathy genotype prediction models in a pediatric population

R. Newman1, J. Jefferies2, C. Chin2, H. He2, A. Shikany2, E. Miller2, A. Parrott2

1. University of Cincinnati

2. Cincinnati Children’s Hospital Medical Center

Introduction: The Toronto Hypertrophic Cardiomyopathy (HCM) Genotype Score and Mayo HCM Genotype Predictor are risk assessment models recently developed to estimate a patient’s likelihood of testing positive for a pathogenic variant causative of HCM using gene panel testing. These models incorporate clinical factors significantly associated with likelihood of a positive genotype to generate a patient score which is correlated with a risk estimate for positive genetic testing. The models were developed from separate adult populations with HCM at two different institutions and have not yet been validated in external populations or in a pediatric cohort. Purpose: To evaluate the overall predictive abilities of the Toronto and Mayo models in a clinical pediatric HCM setting. Methods: A retrospective medical record review of 77 pediatric patients with gene panel testing for HCM between September 2005 and June 2015 was performed. Clinical variables included in the models were collected and used to calculate genotype scores for each patient. To evaluate model performance, the ability to discriminate between a carrier and non-carrier was assessed by area under the ROC curve (AUC) and overall calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit statistic. Results: The Toronto and Mayo models showed Hosmer-Lemeshow goodness-of-fit statistic p-values of 0.41 and 0.88, respectively. Discrimination assessed by AUC was 0.72 (p < 0.001) for the Toronto model and 0.65 (p = 0.009) for the Mayo model. There was no significant difference in the ability to discriminate between a carrier and non-carrier between the models (p = 0.2). Conclusions: The Toronto and Mayo models fit well to our cohort and the present findings suggest that the models are useful in predicting a positive genetic test result in a pediatric HCM setting. They may be used to aid healthcare providers in communicating risk and enhance patient decision-making regarding pursuit of HCM gene panel testing.

Universal screening for elevated cholesterol in children: Assessment of awareness of and adherence to guidelines among Ohio pediatricians

A. Onorato1, A. Wehr2, A. Sturm2

1. The Ohio State University

2. Ohio State University Wexner Medical Center

Introduction: Familial hypercholesterolemia (FH) is a common inherited condition that leads to high low-density lipoprotein (LDL) cholesterol levels from birth and a 20-fold increased risk for coronary heart disease. Early detection and initiation of drug therapy as young as 8 years drastically lowers this risk. The American Academy of Pediatrics and other organizations published guidelines in 2011 recommending universal lipid screening for children ages 9–11 and children with a family history at age 2. Studies have yet to assess pediatrician awareness of and adherence to these guidelines. Methods: A survey was sent via email to 2102 Ohio pediatricians on their knowledge of FH prevalence, risks, LDL values, and management. Their awareness of and adherence to the guidelines were also assessed, along with perceived barriers to screening. Only general pediatricians were included in the final cohort, which made 82 of 269 respondents ineligible, for a final cohort of 187. Results: FH knowledge was poor with no knowledge question answered correctly by more than one third. Few knew the correct prevalence (18.2 %) or LDL values that should raise suspicion for FH (27.8 %). Over a quarter (27 %) indicated they were not aware of the guidelines with only 27 % indicating they adhere to the guidelines. Nearly 60 % indicated they collect a family history of cardiovascular disease and high cholesterol for 75–100 % of their patients and almost 80 % noted that a patient’s family history influences their decision to screen. Even among those implementing the guidelines, knowledge of suspicious LDL values and the recommended age to consider initiating statin therapy was poor. Lack of patient interest was the highest reported barrier to following the guidelines (40.6 %). Conclusions: Pediatrician FH knowledge and awareness of and adherence to screening guidelines is low. Physician and public awareness regarding prevalence, severity, and treatability of FH should be increased in order to improve interest in screening, adherence to guidelines, and therefore the desired effectiveness of universal lipid screening.

Left ventricular noncompaction cardiomyopathy and genetic syndromes

A. Parrott1, S. Ware2, A. Shikany1, E. Miller1

1. Division of Cardiology, Cincinnati Children’s Hospital

2. Department of Pediatrics, Indiana University School of Medicine

Introduction: Left ventricular noncompaction (LVNC) is a cardiomyopathy characterized by prominent myocardial trabeculations. LVNC can occur in isolation or be observed in combination with congenital heart defects (CHD) or other cardiomyopathy subtypes including features of dilated and hypertrophic cardiomyopathies. LVNC occurs in association with a number of genetic syndromes and with variants in sarcomeric genes, however the prevalence of syndromic LVNC is largely unknown. In addition, whether cardiac presentation differs in syndromic versus non-syndromic LVNC has not been investigated. Purpose: In a cohort of patients with LVNC, we sought to identify the prevalence of syndromic cases and compare disease presentation in syndromic and non-syndromic groups. Methods: A retrospective chart review of 128 patients with LVNC age 21 and younger at a single institution was performed. Individuals with a genetic syndrome, abnormal chromosome testing, or a metabolic condition were classified as having syndromic LVNC; all others were classified as non-syndromic. Unpaired t-tests and Pearson’s chi-square analysis were used to compare clinical characteristics observed in the two patient groups. Results: Twelve patients (9.4 %) had syndromic LVNC. Diagnoses included mitochondrial disorders (4), chromosomal anomalies (3), Noonan syndrome (3), Barth syndrome, and malonic acidemia. The average age of diagnosis of LVNC in the syndromic group (2.3 years) was significantly different (p-value 0.00009) than the non-syndromic group (8.2 years). There was no difference in the LVNC phenotype presentation (co-occurrence with CHD or other features of cardiomyopathy) between groups (p-value 0.58). Conclusions: Genetic syndromes were identified in nearly 10 % of cases in an LVNC cohort age 21 and younger. The younger age of diagnosis in the syndromic group supports a need for broad genetics evaluation in individuals diagnosed at young ages. This study does not support the use of associated cardiac phenotype to identify individuals more likely to have a genetic syndrome.

Compound heterozygousNARS2mutations identified by whole exome sequencing in two sibs with infantile-onset mitochondrial multiorgan failure.

J. Propst1, R. Lewandowski1

1. Virginia Commonwealth University Health System

The NARS2 gene encodes the asparaginyl-tRNA synthetase 2 mitochondrial enzyme, which belongs to the amnioacyl-tRNA synthetase family of genes, many of which have been associated with human disease. Pathogenic mutations in the NARS2 gene cause oxidative phosphorylation deficiency, which can result in a wide spectrum of problems including myopathy, intellectual disability, seizures, developmental regression, and feeding difficulties. Only a handful of NARS2 cases have been reported with phenotypic results including Alpers syndrome, Leigh syndrome, and nonsyndromic hearing loss. We introduce 2 siblings who presented in early infancy. Infant 1 presented at 4 weeks old with cardiorespiratory failure due to left ventricular noncompaction cardiomyopathy. Heart transplant was ultimately done but he died at 3 months of age due to multiorgan failure. He expired before any genetic testing was performed, although a sample of his DNA was banked. Autopsy was declined. Infant 2 presented at 2 months old with respiratory distress, hypertension, hyponatremia, and failure to thrive. After an extensive work up, rapid whole exome sequencing (WES) was pursued. WES results revealed a pathogenic splice site mutation IVS7+2T>G and a likely pathogenic p.R251S mutation in the NARS2 gene. Targeted mutation analysis was then done on infant 1’s banked DNA which revealed he carried the same 2 mutations resulting in a diagnosis for both children and provided a means for genetic counseling. Infant 2 died at 6 months of age from cardiorespiratory decompensation resulting in multiorgan failure. Echocardiogram performed 2 days before death revealed moderate concentric left ventricular (LV) hypertrophy. This case demonstrates a widening of the disease spectrum reported in the very few patients with NARS2 mutations to include fatal infantile cardiomyopathy, as seen with other mitochondrial amnioacyl-tRNA synthetase genes. Furthermore, it demonstrates the importance of WES in complex single gene disease with a broad phenotypic spectrum.

Baseline knowledge of lipids and risk perception in patients with probable familial hypercholesterolemia or a previous diagnosis

A. Raper1, E. deGoma2, D. Rader2, T. Sikora2, L. Kessler1, K. Dilzell3

1. Arcadia University

2. University of Pennsylvania Perelman School of Medicine

3. Hospital of the University of Pennsylvania

Background: Familial hypercholesterolemia (FH) is an autosomal co-dominant disorder characterized by high levels of low-density lipoprotein cholesterol (LDL-C). The condition is largely underdiagnosed, which is problematic because patients with FH are at high risk for premature cardiovascular disease (CVD) and treatments are available. Barriers to diagnosis may be related to risk perception, which has been shown to affect adoption of healthy behaviors such as screening of family members and medication use. The purpose of the study was to evaluate baseline knowledge of FH and factors influencing risk perception of heart attack in participants with diagnosed or suspected FH. Methods: Patients with a LDL-C >220 mg/dL and/or a prior clinical diagnosis of FH were recruited from the University of Pennsylvania Health System through lipid clinic and EMR review as part of a larger ongoing study. Participants completed a baseline questionnaire assessing knowledge of lipid levels, risk perception of having a heart attack on a scale of 1–10, personal and family history of CVD, and perceived causes of high cholesterol. Data were analyzed by descriptive statistics and chi square analysis. Results: 239 patients completed the baseline questionnaire. 41 % of patients reported a previous diagnosis of FH. 72 % agreed that genetics was the primary cause of their high LDL-C. There was not a significant association between personal or premature family history of CVD and perceived heart attack risk (p = 0.4352 and p = 0.6591, respectively). Higher self-reported cholesterol levels (p = 0.0003), younger age (p = 0.0434), perception of genetics as the primary cause of high cholesterol (p = 0.0428) and appointments with a lipid specialist (p = 0.022) were significantly associated with a greater perceived risk of heart attack. Discussion: The association between perceived genetic contribution and seeing a lipid specialist with higher perceived risk of heart attack highlights the need for research on the impact of genetic counseling on risk perception, diagnosis and health behaviors in the FH population.

SMAD2associated with thoracic aortic aneurysms and dissection found on whole exome sequencing for child with congenital heart defect

C. Rigelsky1, K. Zahka1, T. Moss1, A. Psychogios1

1. Cleveland Clinic

Mutations in genes in the TGF-beta pathway have been implicated in familial thoracic aortic aneurysms and dissections and Loeys Dietz syndrome (LDS) and are known to be important in overall cardiovascular development. Recently, variants in SMAD2 were reported in 3 families with aneurysms and dissections. SMAD2 has also been implicated in congenital heart disease (CHD), specifically in 2 children with heterotaxy. We present here a case report on a father and daughter with a SMAD2 likely pathogenic variant. The daughter was diagnosed prenatally with heterotaxy that was later characterized as unbalanced arteriovenous canal, pulmonary atresia, total anomalous pulmonary venous connection, pulmonary stenosis with asplenia and intestinal malrotation. Her aortic dimensions were normal at the age of 4 years. Extensive genetic evaluations were performed including microarray, flourescence in situ hybridization (FISH) for 22q11 deletions, and a heterotaxy panel and were nondiagnostic. Ultimately, whole exome sequencing (WES) was pursued with both parents submitting samples for testing as a trio. Results were positive for a paternally inherited variant in SMAD2 [p.Ala64ProfsX24 (c.189delA)]. The father’s clinical genetics exam was significant for a high arched palate and pes planus. He lacked other clinical characteristics associated with LDS. He underwent head to pelvis imaging, which was significant for an aortic root measuring 4.0 cm. He was found to have mild laxity of his cervical spine. This case represents a situation where WES was diagnostic but it also had unanticipated results that led to medical implications for other family members. It is an important reminder for appropriate pretest genetic counseling as results can lead to a diagnosis for family members as well. Additionally, it illustrates the need for ongoing surveillance for aneurysms in children with CHD and SMAD2 mutations and provides additional support for the role of SMAD2 mutations in aneurysms and dissections.

Prevalence and natural history of aortic root dilation in a longitudinal cohort of patients with Ehlers-Danlos syndrome hypermobility type

A. Ritter1, C. Atzinger1, B. Hays1, J. James1, A. Shikany1, D. Neilson1, L. Martin1, K. Weaver1

1. Cincinnati Children’s Hospital Medical Center

Ehlers-Danlos syndrome hypermobility type (EDS-HT) is a common connective tissue disorder characterized by joint hypermobility, affecting approximately 1 in 100 individuals. The natural history of aortic root dilation (AoD), a potential complication of EDS, has yet to be well characterized in this population. AoD is particularly concerning due to the risk for aortic dissection in other connective tissue disorders such as marfan syndrome. We describe the natural history of aortic root size in a large cohort of patients with EDS-HT. The cohort, 325 patients with EDS-HT, was identified at Cincinnati Children’s Hospital Medical Center (CCHMC), using electronic medical record query. Medical records were reviewed and each participant’s height, weight, and aortic dimensions from up to four echocardiograms were documented. Aortic root z-scores were calculated using Boston for patients under the age of 21 years and Devereux for patients 15 years and older. Overall prevalence of AoD and prevalence by age were calculated. Multiple longitudinal regression analyses were performed. The prevalence of mild AoD (z-score ≥ 2.0) was 14.2 % (46/325) and moderate AoD (z-score ≥ 3.0) was 5.5 % (18/325). No significant increases in z-score were seen over time in 148 patients with multiple echocardiograms; however, z-score formulas differed over time. Participants under the age of 15 had an average decline of 0.1 standard deviations (SDs)/year using Boston. No significant change in z-score was found after the age of 15. In this cohort, AoD was infrequent, mild, and non-progressive, suggesting less frequent echocardiograms should be considered by physicians treating children and adolescents with EDS-HT. Genetic counselors should be prepared to provide anticipatory guidance to families regarding this potential complication and echocardiogram surveillance due to the common nature of EDS-HT. Additionally, consensus guidelines should be established for echocardiogram surveillance in children and adolescents with EDS-HT in order to provide evidence-based, standardized care.

Significance of family history in amyloidosis subtyping

E. Brown1, N. Johnson2, D. Judge1

1. Johns Hopkins

2. Invitae

Family history provides key information in a genetics evaluation, such as the most likely mode of inheritance. In cardiovascular genetics, an individual’s family history can also help indicate the likelihood of identifying a pathogenic variant. However, the clinical significance of a family history in transthyretin (TTR) amyloidosis has not been evaluated. TTR amyloidosis is a condition that manifests in adulthood with cardiomyopathy and/or neuropathy. Clinicians typically use tissue biopsy and genetic testing to differentiate between the hereditary and wild-type forms of TTR amyloidosis. We hypothesize that family history may provide important clues before these diagnostic tests. A retrospective review identified 118 patients diagnosed with biopsy-proven TTR amyloidosis in the cardiomyopathy clinic at Johns Hopkins between 2003 and 2016. Of these patients, 101 had confirmatory genetic testing. Fifty-eight patients were diagnosed with hereditary TTR amyloidosis, and 43 were diagnosed with wild-type TTR amyloidosis. Individuals with a family history of amyloidosis were more likely to have the hereditary form of the disease (p = 0.0015). However, individuals with a family history of heart problems and/or neuropathy were not significantly more likely to have the hereditary form of the condition (p = 0.064). Individuals with no family history suggestive of the condition were not significantly more likely to have the non-hereditary form (p = 0.18). In TTR amyloidosis, a negative family history should not exclude evaluation for the genetic form of the condition. We recommend that individuals undergo genetic testing regardless of their family history given that less than 25 % of our patients with the hereditary form had a family history of amyloidosis and only slightly more than 50 % had a family history of amyloidosis, heart problems, or neuropathy. Similarly, a positive family history should not rule out the wild-type form. Correct recognition of hereditary TTR amyloidosis is important for estimating prognosis, counselling families properly, and guiding therapy.

Athletic adults with hypertrophic cardiomyopathy have difficulty adapting to exercise recommendations

C. Caleshu1, R. Luiten2, I. Asif3, L. Post4, K. Ormond4, M. Wheeler4

1. Stanford Center for Inherited Cardiovascular Disease

2. Banner MD Anderson Cancer Center

3. University of South Carolina School of Medicine

4. Stanford University

Introduction: Individuals with hereditary cardiovascular diseases such as Hypertrophic cardiomyopathy (HCM) are advised to avoid intense and competitive athletics in order to reduce their risk of sudden death. Clinical experience suggests this can be distressing, however the psychological impact of such recommendations has not been studied. Aims: We investigated the impact of exercise recommendations on athleticism, the prevalence of psychological difficulty associated with exercise recommendations, and correlates of that difficulty. Methods: Participants with HCM recruited from a cardiovascular genetics center completed a brief survey with questions on diagnosis, athletic history, and athletic identification. To evaluate psychological difficulty, two items on a 5-point Likert scale were used: 1) exercise recommendations were “difficult for me to adjust to” and 2) changes in exercise were “upsetting or stressful.” LASSO-penalized multivariate regression was used to assess correlates of psychological difficulty. Results: Fifty-four individuals participated (37 % female, mean age 56). Half were >5 years beyond receiving exercise recommendations. There was a drop in athleticism, including mean hours of exercise/week (6.2 prior to diagnosis, 4.7 currently (p = 0.04)) and self-identification as an athlete (43 % prior to diagnosis, 15 % currently (p = 0.0005)). The majority of participants (69 %) reported that exercise recommendations were stressful or difficult to adjust to. In multivariate regression psychological difficulty was associated with history of elite or competitive athletics, athletic identity, and decrease in time spent exercising. Psychological difficulty was not associated with age, gender, time since restriction, or hours per week spent exercising currently. Conclusions: Adult athletes with HCM experience a decrease in athleticism following diagnosis. Many of them find recommendations to modify their exercise distressing, especially if they have a strong athletic identity, have competed at a high level, or decreased the time the spend exercising.

Expanding the phenotype in patients with TGFβ-pathway disorders including arterial beds affected: Experience of a tertiary care center

D. Clements1, C. Rigelsky1

1. Cleveland Clinic Foundation

Thoracic aortic aneurysms represent a common cause of sudden morbidity and mortality. Involvement of the transforming growth factor (TGFβ) superfamily member genes continues to rise with significant phenotypic overlap exists between TGFβ-related syndromes. This descriptive study involved medical record review for individuals with variants identified in TGFBR1, TGFBR2, TGFB2 and SMAD3 genes seen for genetic counseling at the Cleveland Clinic between 2008 and 2015. Age at diagnosis ranged from 7 to 62 years. We recorded affected arteries to determine if there were differences between genes and number of beds affected. Affected arterial beds were defined as head and neck (carotid, vertebral), upper limbs (brachial), visceral (superior and inferior mesenteric, celiac, renal, iliac) and lower limbs (femoral, popliteal). To reflect embryological origination, the aorta was divided into the root (lateral plate mesoderm), ascending (neural crest) and descending (paraxial mesoderm). Forty seven patients representing 36 families were identified. Of these, 12 patients had SMAD3 variants, 3 patients had TGFB2 variants, 8 patients had TGFBR1 variants and 24 patients had TGFBR2 variants. There was an overall average of 1.66 arterial beds affected. Although there was not a significant difference between the genes and the arterial beds affected, 5 patients with TGFBR2 variants had 4 or more arterial beds affected. None of the other genes had more than 3 arterial beds affected. This pilot study highlights the development of aneurysms in various arterial beds and the utility of head to pelvis screening for patients with changes in the TGF pathway genes even in absence of family history. Continued family studies will be helpful to enhance our understanding of the natural history of TGFβ diseases.

Examining psychological outcomes associated with genetic testing for primary arrhythmic disorders in adult patients

S. Colaiacovo1, E. Kelter1, P. Ahimaz2, J. Wynn2, W. Chung2

1. Sarah Lawrence College

2. Columbia University Medical Center

Introduction: The psychological impact of genetic testing for an inherited arrhythmia and its influence on future well-being has not been well studied in medical literature. By recognizing certain characteristics associated with negative psychological well-being following a positive genetic test result, genetic counselors can address these issues during pre-test sessions to better prepare patients for the potential impact of this result. Resources can also be put in place to assist individuals who are struggling to cope with this new information. Understanding this information could lead to an improved and more tailored genetic counseling experience for these patients moving forward. Methods: Thirty-seven adult patients, ranging in age from 19 to 62, who had genetic testing for primary arrhythmic conditions were asked to complete a survey which included questions from the Multidimensional Impact of Cancer Risk Assessment (MICRA) questionnaire, Impact of Events Scale (IES) and Satisfaction with Decision Scale (SWDS). Participants’ answers were used to provide more information on the genetic testing experience for individuals with primary arrhythmic conditions and allowed the authors to evaluate whether this experience had any psychological impact on them. Results: Genetic test results do have a significant impact on IES and MICRA scores (p < 0.05). Those with a positive result were seen to have elevated scores over those with a negative result. Genetic test results did not have a significant impact on SWDS scores. Conclusion: Trends were seen upon the comparison of those who had positive versus negative genetic testing results. Those with positive test results seemed to have higher stress scores and experienced a greater psychological impact. While more investigation is needed, this study serves as a good starting point to enhance our understanding of the impact of genetic testing for this population of individuals.

The impact of a Long QT syndrome diagnosis on competitive athletes’ psychological processes

B. DeGreef1, A. Bao1, S. Magasi2, E. McNally1, S. O’Neill1, L. Castillo1

1. Northwestern Medicine

2. University of Illinois at Chicago

Long QT syndrome (LQTS) is a genetic disorder that increases the risk of life threatening cardiac arrhythmias and contributes significantly to sudden death in the young. Since 2005, sports restriction recommendations for LQTS have included avoidance of strenuous exercise, swimming, and high school and collegiate level competition due to the potential occurrence of cardiac events during participation. Abrupt restriction for young athletes can make an athlete vulnerable to psychological distress. This study examined the impact of LQTS diagnosis and subsequent sport restriction on competitive athletes’ psychological processes with the goal of identifying improved interventions to better support these athletes in the healthcare setting. Twelve semi-structured interviews were conducted. Using the method of constant comparison, a thematic qualitative analysis of interview transcripts was performed. Themes were established based on emergent codes until saturation was reached. Analysis identified twelve main themes which were organized into four categories. All participants reported a comprehensive cardiac evaluation that led to a diagnosis of LQTS and sport restriction. Adjustments to psychological processes were described by participants, which involved finding alternative adaptive solutions, coping mechanisms, and changing family dynamics. With time many viewed their diagnosis and restriction as their “destiny” and exhibited resilience. Participants described how athletic competition shaped their identity, which was altered following their LQTS diagnosis. Overall, participants described the need for their health care team to make recommendations and treatment plans for their individual phenotype rather than imposing the conservative approach of complete disqualification from competitive athletics. These findings provide a framework for genetic counselors working with LQTS families to anticipate the potential psychological impact of such diagnosis in competitive athletes, which can allow earlier intervention for those at highest risk.

The pediatric arrhythmia clinic: Identifying and addressing demand for genetic counseling and genetic services

B. Helm1, N. Gralia2, M. Ayers1, A. Kean1, S. Ware1, K. Spoonamore1

1. Indiana University School of Medicine

2. Indiana University Healthy Physicians

Introduction: The 2016 NSGC Professional Status Survey data indicate 10 % of clinical genetic counselors (GCs) counsel patients in cardiology, showing expansion of genetic counseling in inherited heart disease. As this trend continues, evaluation of GC practice models can identify needs for genetic services, increase access, and demonstrate GC value in new clinical arenas. Aim: To evaluate GC patient encounters in a pediatric arrhythmia clinic over a 9-month period (Aug 2015-May 2016). Results: A total of 964 patients (average 25.4 per week) were screened via records review. Of those, 23 % (225/964) were identified as potentially requiring genetics care. Sixty percent (135/225) of them received genetic counseling services at the clinic visit. Primary reasons for not receiving counseling at the time of the visit were: patient cancellation/no-show, clinic cancellation, or GC unavailability. Genetic counseling was provided most commonly for: personal history of confirmed/suspected primary arrhythmia or cardiac arrest (37 %), family history of primary arrhythmia/sudden death (21 %), known/suspected syndromic conditions (18 %), and personal history of primary cardiomyopathy (14 %). All patients with known/suspected syndromic conditions (e.g. congenital anomalies, Holt-Oram syndrome, Danon disease, etc.) were referred to a clinical geneticist for evaluation. Conclusions/Implications: The pediatric arrhythmia clinic is enriched with patients with a variety of genetic conditions. In our experience, the GC in this setting addressed a need for counseling mostly for inherited cardiac genetic conditions (arrhythmias, cardiomyopathies). The GC also identified and referred patients with known/suspected syndromes who had not yet received appropriate genetics evaluations. These data support the importance of genetic services in pediatric arrhythmia clinics and may provide a model to improve subspecialty collaborations and expand genetic counseling access, roles, and services in this area.

How do carriers of Barth syndrome navigate reproductive options? An example of hidden fault lines for patient-based support organizations

C. James1, L. Jamal2, R. McClellan1

1. Johns Hopkins Medicine

2. Johns Hopkins School of Public Health and Berman Institute

Introduction: Barth syndrome (BS) is an X-linked cardiomyopathy characterized by pediatric onset, neutropenia, and skeletal myopathy caused by mutations in tafazzin (TAZ). Carriers are unaffected, but navigate psychological and increasingly complex reproductive challenges. Purpose / Methods: To identify and describe common psychological and reproductive challenges and explore the role of social and familial support, we conducted semi-structured telephone interviews of 28 adult carriers recruited through the Barth Syndrome Foundation. Interviews were recorded, transcribed, double-coded, and analyzed for common themes. Results: While guilt was experienced by most, but not all, mothers and grandmothers, relationships among carriers ameliorated distress by normalizing guilt. In contrast, participants held starkly different views of advanced reproductive technologies. For a few, any prenatal testing was unacceptable, but for many considering reproductive options was both morally and practically/financially challenging. Most mothers who considered pre-implantation or pre-natal diagnosis after having an affected child described a difficult decision-making process, likening affected embryos/fetuses to their sons. A few reached decisions that conflicted with long-held beliefs. In contrast to the strong mutual support carriers reported regarding the medical and practical aspects of BS, nearly all were wary of discussing reproductive planning. While nearly all stressed that their choices should not be normative for or influence others, most feared damaging relationships by broaching these personal and potentially political topics. Conclusions: Enhanced support for reproductive decision-making may best come from sources outside traditional genetic support groups. With the increasingly prominent role of patient organizations in not only aiding families but also directing the research agenda, our data highlight potential fault lines leaders may encounter as members confront the potentially polarizing issues surrounding reproductive technology and reproductive choices.

Psychosocial concerns of patients with dilated cardiomyopathy

A. McFaddin1, A. Shoben1, A. Whiting1, J. Rinehart1, W. Burke2, D. Bowen2, R. Hershberger1, A. Morales1

1. The Ohio State University

2. University of Washington

Recent advances have expanded our knowledge of the genetics of dilated cardiomyopathy (DCM). Recommendations for the genetic evaluation of patients with DCM have been published, including involvement of genetic counselors in the healthcare team caring for these individuals. However, little research is available describing the psychosocial concerns experienced by DCM patients. This study sought to identify recurring psychosocial concerns of DCM patients and their families, as well as correlations with demographic and cardiovascular genetic data. Qualitative analysis was performed on follow-up correspondence data recorded in the DCM Research Project study database. After thematic analysis was completed, selected participants representing key thematic findings were contacted for follow-up interviews. A total of 430 data points were coded from the correspondence of 239 individuals. Most were female (63.4 %) non-Hispanic Caucasian (89.5 %). Eight thematic categories were identified: concern for children/relatives (26.7 %); emotional adjustment (14.2 %); family communication (13.0 %); research (11.9 %); insurance (11.9 %); genetics (8.6 %); physician issues (8.6 %); and treatment (5.8 %). Five participants were re-consented for follow-up interviews that confirmed and revealed deeper insight into their expressed concern. Correlational analyses identified statistically significant associations (p < 0.05), including a higher prevalence of genetic concerns among those with a family history of DCM or with a genetic variant. As participant age increased, concerns for research were more likely to be expressed while concern for children were decreased. Issues with insurance and family communication were more prevalent in those with a history of heart transplant. In general, females were more likely to bring up concerns in all thematic areas compared to males, with males being less likely to discuss emotional issues and insurance concerns. These findings highlight the importance and need of education and emotional support for individuals with DCM and their families.

Assessing the perceived utility of a web-based educational video in hypertrophic cardiomyopathy patients for the dissemination of familial risk information and screening recommendations

C. Neumann1, S. Harris2, C. Ho2, N. Lakdawala2, A. Cirino2

1. Boston University School of Medicine

2. Brigham and Women’s Hospital

Hypertrophic cardiomyopathy (HCM) is the most common monogenic cardiovascular disorder and a prevalent cause of sudden death in young people. Although guidelines recommend longitudinal screening of all first-degree relatives with echocardiogram and electrocardiogram, many relatives do not comply with these recommendations. To facilitate the dissemination of screening recommendations in families, the Brigham and Women’s Hospital HCM clinic developed a web-based educational video describing the etiology, inheritance pattern, and screening recommendations of HCM. The purpose of this study was to explore patients’ perceived utility of the video. Of 52 patients who received the video, 11 (22 %) completed the entire survey. All 11 participants felt the video increased their understanding of family screening recommendations, and 64 % considered it a helpful review of inheritance information. Most participants already shared their diagnosis with their siblings (92 %), and all participants shared their diagnosis with their children. An in-person discussion was preferred when communicating a diagnosis to parents (67 %) and children (58 %), and over the phone (29 %) or in person (24 %) when communicating the diagnosis with siblings. Most participants (82 %) would not utilize the video as the primary method of sharing their diagnosis; however, 80 % of the participants endorsed sending the video as supplemental information. Participants noted several advantages to using the video, including easy and efficient to share, and provided comprehensive and accurate information. Our findings demonstrate that a web-based video is accepted by patients as a resource to facilitate communication with their at-risk relatives. The video reinforced participants’ knowledge about familial risk and screening recommendations. While the video may not be the initial method of communication, many endorsed using the video as a supplemental tool and noted multiple advantages to the web-based video platform. This platform can also be utilized for multiple conditions across various disciplines.

TruncatingTITINvariant in infantile-onset dilated cardiomyopathy: A case report and related counseling challenges

B. Psensky1

1. Cleveland Clinic

Introduction: Familial dilated cardiomyopathy (DCM) is a genetically heterogeneous cardiac disorder, most commonly with autosomal dominant transmission. Pathogenic variants in TTN are identified in 10–20 % of cases of DCM, with frameshift variants in certain regions being strongly associated with adult-onset DCM. Case Report: A 4 week old girl was diagnosed with DCM after presenting with hypothermia and respiratory distress two days following surgery for postaxial polydactyly. Family history was significant for postaxial polydactyly in multiple maternal relatives consistent with autosomal dominant inheritance, none of whom had known cardiac history. Chromosome microarray and Noonan syndrome panel obtained prenatally due to increased nuchal translucency were normal. Infectious disease workup and metabolic labs obtained at time of her DCM diagnosis were non-diagnostic. Around 7 weeks, she underwent LVAD placement while awaiting cardiac transplantation. She later developed cardiac tamponade and was found to have multiple brain infarctions. Medical support was discontinued and she expired at 8 weeks. A pan-cardiomyopathy gene panel identified a likely pathogenic frameshift variant in TTN. Variants of unknown significance were also identified in DOLK and PTPN11. Her mother was found to carry both TTN and DOLK variants; she is currently 35 weeks pregnant. Her father is presumed to have PTPN11 variant, but has declined testing. Both parents and her 9 year old sister had normal echocardiograms. Discussion: This case illustrated several challenges for genetic counseling. The likely pathogenic TTN variant may not fully explain the patient’s phenotype, but was relevant for management of her mother’s pregnancy given risk for peripartum cardiomyopathy. Other counseling challenges included discussing variant interpretation differences between laboratories, and prenatal versus postnatal testing. Finally, recurrence risk and screening recommendations for at risk relatives is challenging in the setting of multiple variants and clinical variability in a family.

Left ventricular outflow tract obstructions: Parental knowledge and uptake of familial cardiac screening

A. Shikany1, A. Parrott1, J. James1, P. Madueme1, K. Weaver1, C. Cassidy1, E. Miller1

1. Cincinnati Children’s Hospital Medical Center

Introduction: Congenital heart disease (CHD) is the most common birth defect with an estimated incidence of 1 %. Left ventricular outflow tract obstructions (LVOTO) account for approximately 14 % of CHD. LVOTO are known to cluster in families with a wide spectrum of clinical severity. The relative risk for first-degree relatives is estimated to be up to 36.9. Current recommendations suggest screening echocardiograms for first-degree relatives, and fetal echocardiography for at-risk pregnancies. Purpose: This study sought to investigate parents’ knowledge of LVOTO and genetics, and to assess uptake of familial cardiac screening. Methods: From October 2010 to May 2015, 69 families of a child with an LVOTO underwent genetic counseling in the Cardiac Intensive Care Unit. A descriptive retrospective chart review was completed and a quantitative cross-sectional survey was mailed to all families with a response rate of 33 % (23). Results: Respondents answered 6 knowledge questions relating to LVOTO and genetics, with an average of 4.6 correct answers. Among respondents’ families there were 80 at-risk first-degree relatives for whom cardiac screening was indicated. The uptake of cardiac screening was 44 % (35). Eleven at-risk pregnancies were reported among respondents post-genetic counseling of which 91 % (10) underwent fetal echocardiography. Of parents who indicated they did not intend to pursue cardiac screening (13), 62 % (8) noted the reason was being unaware of the recommendation. Seventy-seven percent of respondents (17) indicated they would approach their cardiologist or genetic counselor with questions regarding LVOTO and genetics. Discussion: Respondents demonstrated good knowledge of genetics and LVOTO, answering the majority of questions correctly. The uptake of cardiac screening is substantially higher among at-risk pregnancies than in at-risk family members, which may be due to follow-up counseling by obstetricians. Consideration of follow-up genetic counseling in the outpatient cardiology setting may increase the uptake of familial cardiac screening.

Evolving decisions about exercise among athletes with inherited heart disease who exercise against recommendations

T. Subas1, R. Luiten2, A. Hanson-Kahn1, M. Wheeler1, C. Caleshu1

1. Stanford University

2. Banner MD Anderson Cancer Center

Introduction: Patients with hypertrophic cardiomyopathy (HCM) and long QT syndrome (LQTS) are advised to avoid certain forms of exercise in order to reduce the risk of sudden death. A significant percentage of patients with HCM and LQTS exercise more than recommended; little is known about why and how these individuals decide to exercise outside of recommendations. Aim: To describe the perspectives and decision making of individuals with inherited heart disease who exercise against physician’s recommendations. Methods: We used qualitative methodology guided by phenomenology. Purposeful sampling was used to select individuals with HCM and LQTS who self-identified as exercising outside of recommendations. Semi-structured interviews explored participants’ experiences with exercise recommendations, their decision making, and psychological impact over time. Coding was done primarily by the first author, with a subset of transcripts coded by two other team members. Results: Fifteen individuals were interviewed (LQTS: 5; HCM: 10; male: 12; mean age: 40). Though all participants exercised outside of recommendations, nearly all made some modifications to their prior exercise regimen. Often these decisions changed over time due to new information learned about the recommendations, new social cues, or onset of new symptoms. The most frequently cited reasons that participants exercised outside of the recommendations were that exercise was a critical part of their lives and that they interpreted their risk of sudden death as low or manageable. Most participants reported moderate to significant distress associated with receiving and considering the exercise recommendations. Many participants reported that family and friends were generally supportive of their decisions to exercise more than recommended. Conclusion: Athletes with HCM and LQTS who exercise outside of recommendations do make some modifications to their exercise. The evolution of exercise decisions over time underscores the importance of shared decision making conversations beyond the initial evaluation.

Thinking outside the A-band: Segregation ofTTNtruncating variants

H. Taylor1, J. Hair1, C. Antolik1, D. Macaya1

1. GeneDx

Introduction: The TTN gene encodes titin, a giant sarcomere protein that provides passive tension in muscle fibers. The N-terminus of titin is anchored in the Z-line, and it spans through the I- and A-bands to its C-terminus in the M-line. Pathogenic loss-of-function (LOF) variants in TTN account for approximately 25 % of familial dilated cardiomyopathy (DCM) and 18 % of sporadic DCM. While most of these variants occur in the A-band region, LOF variants elsewhere in TTN have been reported in nearly 3 % of control alleles. Methods: To assess whether LOF variants outside the A-band may contribute to DCM, we reviewed clinical and familial segregation data for 394 cardiomyopathy cases in which these LOF variants were identified and classified as variants of uncertain significance. Results: Of the 394 cases 269 (68 %) occurred in the A-band, while 125 (32 %) occurred outside the A-band. Of the 125 variants outside the A-band, 102 (82 %) were located in the I-band, while 13 (10 %) and 10 (8 %) were observed in the Z-disk and M-line, respectively. Twenty-one families had follow-up testing for familial LOF variants located outside the A-band. No pathogenic variants in other genes were detected in families in which the TTN LOF variant segregated with DCM. In these 21 families the variant segregated with DCM in at least one other affected family member in 14 (66 %). In 4/21 (19 %) families, the TTN variant segregated with disease in two other affected family members. In an additional family, a TNNT2 variant co-segregated with TTN in other family members with DCM. Non-segregation with DCM was observed in two families (9.5 %; 2/21). One of these variants was a splice variant in the I-band and the second was a two base-pair deletion in M-line. The other families had non-informative segregation. Conclusion: This study demonstrates that LOF variants of uncertain significance outside the A-band of titin occur at much higher frequency in patients with DCM than in controls, and thus may contribute to DCM pathogenesis. Segregation studies are critical in defining the role of these variants.

Counseling/Psychosocial Issues

Anticipated impact of children’s genetic test results on the parent–child relationship

L. Bailey1, A. Buchanan1, A. Fan1, K. Fultz1, W. Janet1, A. Rahm1

1. Geisinger Medical Center

The American College of Medical Genetics and Genomics (ACMG) and the American Academy of Pediatrics (AAP) recommend that genetic testing in children should be driven by the best interest of the child. The goal of this study is to elicit the perspectives of parents whose children are enrolled in Geisinger’s MyCode biobank. Four focus groups were conducted using two scenarios – receiving a result that is medically actionable in childhood and a result for an adult onset condition. Participants (N = 16) were adult MyCode participants whose children (ages 0–17) were also enrolled in MyCode. Parents attended groups according to their children’s ages (0–8 or 9–17 years old). Focus groups used a deliberative engagement format. Thematic analysis was conducted on verbatim transcripts of each focus group. Parents discussed the impact that a genetic test result would have on their children, their relationship with their children, and themselves. The majority indicated that a positive result would impact their relationship with their child, but still desired the information. Some parents distinguished between medically actionable and not medically actionable in childhood results. Concerns included the potential to alter the child’s life with information not currently actionable. In the 0–8 group, parents acknowledged the possible negative impact on the child. Worry for their child and prohibiting their child from preferred activities were two of the most common concerns. Yet parents stated that positive impact outweighed their concerns. Parents in the 9–17 age group, discussed anticipated impact less than the 0–8 age group. The majority of parents in the 9–17 age group did not believe any results would have an impact on their relationship with their children. Overall, this sample of parents wanted to receive results for their children regardless of immediate actionability.

Where does hope fit in? The relationship between hope, uncertainty, and coping efficacy in mothers of children with Duchenne/Becker muscular dystrophy

M. Bell1, H. Peay2

1. Sanford Health

2. RTI International and DuchenneConnect Registry

Duchenne/Becker muscular dystrophy (DBMD) is a complex, progressive, and ultimately terminal condition laden with caregiver uncertainty. While high uncertainty may make adaptation more difficult, there is evidence that caregivers managing a range of disorders may find benefits in uncertainty. Similarly, hope may influence this appraisal of uncertainty, allowing uncertainty to be seen as an opportunity as well as a threat. Hope has also been shown to positively affect coping and adaptation. The goal of this study was to explore uncertainty and the relationships between uncertainty, hope, and coping efficacy among mothers of children with DBMD. Mothers were recruited through the Duchenne Connect Registry, Parent Project Muscular Dystrophy, and Cincinnati’s Children Hospital (n = 221). Each completed a cross-sectional survey measuring maternal uncertainty (Parental Uncertainty of Children’s Health scale, revised), disorder-associated hope (scale developed for study), spirituality (Daily Spiritual Experience scale), coping efficacy (Coping Self-Efficacy scale), and maternal and child demographics. Mothers reported the most uncertainty in the domains of medical management and social support. Multivariate analysis revealed that older mothers’ age, higher hope scores, and child’s disease progression were significantly associated with less uncertainty. Mothers with lower hope scores, higher perceptions of uncertainty, and those reporting being less spiritual were less confident in their ability to cope with their child’s DMBD. Therefore, hope appears to be a factor in shaping uncertainty appraisals and facilitating coping efficacy. Additionally, because younger mothers and those with more ambulatory children perceive more uncertainty efforts to help mothers manage uncertainty may be more effective if tailored towards those who have children with new diagnoses. Although future studies are needed, interventions aimed at guiding mothers with low hope to other uncertainty reappraisal strategies may be helpful in promoting maternal adaptation in the face of uncertainty.

Patient perspectives on intimate partner violence discussion during genetic counseling sessions

C. Chen1, A. Greb1, I. Kalia2, K. Bajaj2, S. Klugman2

1. Sarah Lawrence College

2. Montefiore Medical Center

Introduction: Intimate partner violence (IPV) is a major health issue in the United States. The World Health Organization defines IPV as physical, sexual, psychological harm by an intimate partner. Purpose: Due to the psychosocial depth and nature of discussions within genetic counseling sessions, patients may disclose IPV as it relates to sexual well-being, reproductive and overall health. Several studies recognized the link between IPV and negative health outcomes such as unintended pregnancy and later stage cancer diagnosis. IPV research is limited in genetics. This study aims to assess patient perspectives on IPV screening, counseling and intervention as a role in genetic counseling practice. Methods: Patients receiving genetic counseling at an urban metropolitan hospital were anonymously surveyed about personal experiences and perspectives on IPV as a topic of disclosure and discussion during a genetic counseling session. Survey questions included fill-in-the-blank, multiple choice, and a series of prospective and retrospective statements with a five point Likert scale. Quantitative data was analyzed using frequency distributions through Statistical Package for the Social Science (SPSS). Qualitative data was analyzed and coded through the identification of emerging themes from free text responses. Results: Among 60 eligible patients, 50 completed the survey (49 females, 1 male, of which, 5 identified as LGBT), with an age range of 20 to 66. The incidence of IPV in this group was 16 % (n = 8). The majority of participants were never asked about IPV by a healthcare provider (n = 32; 64.0 %), would have felt comfortable answering questions about IPV by their healthcare provider (n = 34; 68.0 %), and would have felt comfortable answering questions about IPV by their genetic counselor (n = 39; 78.0 %). Conclusions: Perspectives from participants, notably those with IPV history, provided tremendous insights as to the role of genetic counselors in IPV screening and highlighted areas for IPV screening and counseling training.

Information needs of patients and their caregivers: Utility of genetic counselors

M. Dudek1, C. Grabarits1, J. Slamon1, M. Dorst1, S. Chennupati1, C. Ivory1, G. Jackson1

1. Vanderbilt University Medical Center

Pregnant women and their caregivers have substantial unmet information needs during and after pregnancy. Genetic counselors provide relevant patient education throughout the life cycle, and their potential to address such information needs has not been studied. This mixed methods study was designed to characterize the information needs of pregnant women and caregivers, determine if the needs were met, and identify needs that could be met by genetic counselors. Pregnant women and caregivers were recruited from low and high risk prenatal care settings at a large university medical center. Eligibility criteria included English or Spanish speaking, adult pregnant women and caregivers, and pregnancy < 36 weeks gestation. Participants completed surveys to assess sociodemographic characteristics and semi-structured interviews to assess information needs. Information needs were extracted from interview transcripts and analyzed to determine if the needs were met and could have been met by a genetic counselor. Descriptive statistics summarized participant characteristics, and qualitative methods identified themes. Data from 25 participants were analyzed; 16 pregnant women, 9 caregivers; 18 women, 7 men. The mean gestational age was 28 weeks. Four hundred four information needs were identified, 277 in pregnant women and 127 in caregivers. Needs of pregnant women differed from caregivers. One hundred eighty eight of needs were met; 50 were partially met, and 166 were not met. Fifty of 404 (12 %) could be met by genetic counselors, including 24 (48 %) unmet or partially met needs. Many unmet needs were related to risk factors for congenital anomalies and fetal prognosis, issues that genetic counselors commonly address. This study demonstrates diverse information needs in pregnant women and caregivers, many of which remain unmet during pregnancy and could be addressed by genetic counselors. Meeting information needs during pregnancy can reduce stress and improve perinatal outcomes. Additional research is needed to define whether genetic counselors can meet these needs and improve the experience of pregnancy.

Diagnosis of X-linked intellectual disability in an adult female via exome sequencing: A collaborative diagnosis between clinician and laboratory

S. Galasinski1, S. Grams2, E. Chen2, H. Wetzel1, K. Chen1, N. Geeter1, J. Yen1, J. Anderson1, D. Glazer1, M. Lefterova1, R. Chen1, M. Morra1

1. Personalis, Inc.

2. Kaiser Permanente

A 46-year-old female was assessed in medical genetics due to her severe intellectual disability (ID), short stature, hypotonia, small hands and feet, and self-stimulatory behaviors. There was no reported history of ID in the patient’s adult son, brother, two sisters, parents, or other relatives. Thus far, her workup included various metabolic studies, which were unremarkable, and array comparative genomic hybridization, which showed a 15q13.3 duplication of unknown significance. We performed whole exome sequencing (WES) on the patient and identified a heterozygous likely pathogenic variant in KIAA2022 (NM_001008537.2: c.1441C>T; p.Arg481*) associated with KIAA2022-related ID. This variant was absent in both of the patient’s sisters based on targeted capillary sequencing; the patient’s mother was unavailable for testing. At the time of analysis, KIAA2022-related ID had only been reported in males; female carriers were reported to be unaffected. Given the inconsistent mode of inheritance of an affected female carrier with a X-linked recessive disorder, a diagnosis of KIAA2022-related ID in this patient could not be made unless postulating co-existing genomic events such as skewed X-inactivation. However, the ordering clinicians identified a report published concurrently with the issuing of these results describing a female patient with a KIAA2022 variant and similar phenotype (Farach and Northrup, 2016), shedding additional light on the potential impact of this finding. Testing of the patient’s mother and X-inactivation studies are now being pursued. This case emphasizes the utility of WES in identifying potential novel disease etiologies by expanding our understanding of disease pathogenesis. This case also highlights the limitation of rigidly applying variant filtering approaches based on presumed modes of inheritance. Improved approaches shall instead consider alternate mechanisms such as mosaicism, reduced penetrance, and skewed X-inactivation in an effort to minimize the risk of missed diagnoses in WES.

Attitudes toward genetic counseling and testing in patients with inherited endocrinopathies

T. Gallagher1, M. Bucciarelli1, M. Baker2, B. Saunders3, S. Kavalukas4

1. Division of Endocrinology, Hershey Medical Center

2. Division of Genetic Counseling, Hershey Medical Center

3. Division of Endocrine Surgery, Hershey Medical Center

4. Vanderbilt University

Background: Inherited endocrinopathies are rare tumor disposition syndromes associated with significant morbidity and mortality. Although genetic counseling and testing can help inform the appropriate management of at-risk relatives, barriers to care still exist. We explored patient perceptions to identify barriers and promote the uptake of genetic counseling. Methods: An anonymous survey was mailed to patients from a multidisciplinary inherited endocrinopathy clinic at a tertiary care, university based medical center. Data collected and analyzed with chi-square and Fisher’s exact tests included demographics, socioeconomic status, perceived risks, benefits, and both motivating and dissuading factors to genetic counseling and testing. Results: 62 surveys were mailed to patients with a hereditary endocrine disorder. Twenty eight surveys (45 %) returned. Respondents had the following characteristics: 46 % aged 21–40 and 36 % aged 41–60; 56 % were female; 75 % had biological children; 71 % had multiple endocrine neoplasia-1 (MEN-1); 86 % received genetic counseling, but only 46 % pursued genetic testing. Gender, age, and diagnoses were similar in respondent group compared to entirety. Of all demographics, only a household annual income of > $50,000 was statistically associated with an increased likelihood to undergo genetic testing (p = 0.004). Concerns included cost, potential discrimination, and result implications, with the former two as the most common deterrents. Common perceived benefits were knowledge for relatives and decreased anxiety if negative. Risks included insurer discrimination and fear of false results. Conclusions: Diagnostic delay of inherited endocrinopathies can have significant impact on morbidity and mortality. Our study suggests barriers to genetic testing include cost, potential discrimination, and result implications. This highlights the importance of counseling to discuss benefits of genetic testing while dispelling misperceptions. Future research will evaluate the effect of patient information sheets on the uptake of genetic counseling and testing.

Patient and parent experiences of dual genetic diagnoses: Neurofibromatosis type 1 and an additional genetic disease

H. Grandine1, M. Walker1, C. Atzinger1, S. Collier1, E. Schorry1

1. Cincinnati Children’s Hospital Medical Center

Dual or multiple genetic diagnoses are uncommon but are anecdotally evident from clinical geneticists and genetic counselors, and have been identified in approximately 1 % of individuals who underwent whole exome sequencing. There is very limited published research on the psycho-social impact on families and patients with dual genetic diagnosis. This qualitative, exploratory study used open-ended telephone interviews to address the question: What is the experience of patients and families who have a dual diagnosis of neurofibromatosis type 1 (NF1) and another serious genetic condition? Nine individuals participated in the study: six parents who had a child with a dual diagnosis and three adults who personally had dual diagnoses. Thematic analysis was used to identify common themes in participant responses. Results indicated that the parents were strongly emotionally impacted by the diagnoses and often felt isolated. However, the affected adults did not report these negative effects and considered themselves to be only mildly affected by their genetic conditions. Both findings are consistent with previous research on individuals with one genetic condition. Additionally, the majority of parents reported that they were given inadequate information about their child’s diagnoses by healthcare providers and that they must take on the role of their child’s care coordinator in order to access needed services. Although the difficulties of complex medical management and navigating the healthcare system do exist for families dealing with one genetic diagnosis, these challenges appear to be more severe for families dealing with two diagnoses. Ascertainment of dual genetic diagnoses may increase along with advancements in genetic technology, and future research on the needs of this population can be guided by the findings from this study.

Moderating effects of trait hope and coping styles on perceived personal control in genetic counseling

M. Hackbardt1, P. Flodman2, V. Kimonis2, W. Goldberg2, K. Osann2

1. Sequenom

2. University of California, Irvine

Major goals of genetic counseling include promoting psychological well-being while educating patients about birth defects and genetic disorders, facilitating empowered health care choices. Perceived Personal Control (PPC) is an established measure of the benefit of genetic counseling. The primary purpose of this study was to examine change in PPC, trait hope, and coping following genetic counseling. A secondary purpose was to determine how trait hope and coping styles (Brief COPE) might moderate PPC in the setting of genetic counseling, an area in need of more research. Pre and post surveys were given to 59 individuals who were either a patient or a loved one attending an initial genetic counseling session. The intervention was an initial genetic counseling session in the prenatal, pediatric, adult, or cancer setting. Statistical methods include Pearson correlations, paired t-tests, and ANOVA. Results show that PPC is significantly increased after genetic counseling (p < 0.001). Although trait hope and coping did not significantly moderate change in PPC, those with lower pre-test trait hope achieved bigger gains in PPC than those with higher hope (p = 0.16); and those with lower pre-test coping scores (either adaptive or maladaptive) achieved bigger gains in PPC than those with higher coping skills (p = 0.29). Due to small sample size, the study was underpowered to detect as significant the observed moderator effects. These findings may encourage more research into the interaction between health behaviors and psychological health as it relates to improving the outcome of genetic counseling. Patients with the lowest coping and psychological skills may have the most to gain from the genetic counseling session. It will be valuable for counselors to be aware of this relationship.

Shared medical and psychosocial concerns among adolescents and young adults with craniofacial microsomia: A qualitative study

K. Hamilton1, K. Ormond1, K. Chang2, J. Bernstein2

1. Stanford University

2. Lucile Packard Children’s Hospital

Objective: The literature on the experiences of adolescents with craniofacial microsomia is limited. As adolescence is a critical phase of development, it is important to investigate adolescents’ perspectives on their condition. This study explores the views and experiences of adolescents and young adults with craniofacial microsomia, and documents the impact of growing up with the condition on daily life and sense of self. Methods: Participants were recruited through a tertiary care craniofacial center, online patient support groups, and social media sites. Eleven individual semi-structured interviews with individuals between 12 and 22 years old were conducted by a single interviewer, transcribed, iteratively coded and thematically analyzed. Results: Both medical and psychosocial factors were described by the adolescents. Most participants reported that the biggest impact on their daily lives was hearing loss. The majority of participants believed that parents should allow children to make surgical decisions regarding cosmetic reconstructive ear surgery for themselves. Participants reported negative outcomes including bullying and low self-esteem. The majority of the participants chose to hide their condition from others, citing a variety of reasons including embarrassment and shame. Participants also experienced positive influences on their personalities, including being more open-minded, less judgmental, and more independent. Participants expressed that they are strong individuals who are able to overcome challenges they face. Conclusions: We identified both medical and psychosocial concerns. Adolescents with craniofacial microsomia exhibit considerable resiliency and ability to adapt to their condition. However, the challenges they face impact their sense of self and should be routinely addressed through psychosocial support and counseling. Providers and parents should carefully consider the potential impact of hearing aids as well reconstructive ear surgery. Adolescents should be allowed to participate in the surgical decision making process.

Alzheimer’s disease development in adults with Down syndrome: A caregiver’s perspective

A. Ilacqua1, J. Benedict1, T. Jacobson2, B. Benson3, B. Skotko4, D. Allain1

1. The Ohio State University

2. Nationwide Children’s Hospital

3. The Ohio State University Medical Center

4. Massachusetts General Hospital

Research about Alzheimer’s disease (AD) in individuals with Down syndrome (DS) has predominantly focused on the genetics and neuropathology of the relationship between these two conditions. Yet, there is a paucity of data addressing how AD risk affects caregivers of adults with DS. Our study aimed to bridge this gap by exploring psychosocial aspects of AD development in adults with DS by assessing caregiver knowledge, concerns, personal impacts, and resource utilization. Caregivers of adults with DS completed a 40 question online survey, which was distributed to potential participants by 4 DS organizations. Descriptive statistics, chi-square tests, two sample t-tests, and Pearson correlations were used for statistical analysis. Of the 100 respondents, 89 caregivers were caring for an adult with DS only (DS only) and 11 caregivers were caring for an adult with DS and AD (DS+AD). Only 31.5 % of DS only caregivers correctly answered all AD knowledge questions. DS only caregivers had an average concern rating of 5.3 (moderately concerned); the DS+AD caregivers had an average concern rating of 6.1 (very concerned). The mean overall impact ratings were identical in both groups (6.3; very strong impact) and had a significant negative correlation with the age of the adult with DS (p = 0.009). Thirty-three percent of DS only caregivers used resources for AD support and information. Less than 50 % (n = 39) of DS only caregivers utilized healthcare providers for AD information. The average satisfaction rating of the caregivers’ discussion with a healthcare provider was 4.3 (neither satisfied nor dissatisfied). Our data reveals caregiver misconceptions about AD in adults with DS. Caregivers have significant concerns about AD development in their adult with DS and an AD diagnosis drastically impacts their own personal lives. Data from this study allows genetic counselors (GC) to aid in providing anticipatory guidance about AD to caregivers of adults with DS. This study lays the foundation for further research on how GCs can better serve caregivers of aging adults with DS.

Understanding the challenges of underrespresented minority recruitment into genetic counseling: A qualitative study of underrepresented minority individuals currently in the profession

A. Kass1, L. Veres1, A. Greb1, M. Rashkin2, A. Morales3

1. Sarah Lawrence College

2. Mount Sinai

3. Ohio State University

Introduction“” is a website to recruit and provide underrepresented minority (URM) students guidance into the genetic counseling profession. The “Faces of Genetic Counseling” section highlights URM genetic counselors as role models. The purpose of this study was to understand the experiences of URM students and individuals currently in the profession and create additional structured biographies for the website. Methods: In this qualitative study, 5 genetic counselors and 3 students who identified as African-American and/or Latino participated in structured phone interviews. Questions were designed to understand their pathways into the field, training programs, and experiences in the profession. Interviews were audio recorded, transcribed and independently analyzed using thematic analysis. Themes explored included learning about genetic counseling, barriers, being an URM in a training program, motivating factors, and support/mentors. Results: Introduction to the field was later in college and the majority of participant’s expressed unconditional family support when pursing genetic counseling as a career. Participants experienced feelings of isolation, both in their training programs and the profession. None of the participants had access to role models or mentors of the same race; many expressed a desire to have racially similar role models. Participants reported instances of feeling misunderstood by faculty due to race related stereotypes. Conclusion: Lack of role models is a known barrier for recruitment of URM individuals into health care professions. The successes and challenges faced by URMs currently in our profession are illustrated in this study and support the need for URM role model visibility and accessibility. These interviews will be used to create additional structured biographies for “” and serve as a valuable recruitment tool.

GenomeConnect participant matching system: Connecting individuals with rare diseases or genomic variants

J. Koenig1, D. Azzariti2, D. Ledbetter1, C. Martin1, V. Rangel Miller3, H. Rehm2, E. Riggs1, W. Faucett1

1. Geisinger Health System

2. Laboratory for Molecular Medicine, Partners Personalized Med

3. PatientCrossroads

Advances in and increased use of genetic testing technologies have resulted in an increasing number of genomic variants identified in individuals with rare disease, common disorders and even in healthy individuals. Because of the rarity of many of these genomic variants and diagnoses, there is often limited information and support for individuals and families. GenomeConnect, an online registry developed as part of the Clinical Genome Resource (ClinGen), now provides a secure way for individuals to connect with one another while sharing their genetic and health information to enable genomic discovery. GenomeConnect is open to anyone who has had genetic testing and participation is completely online, allowing participation from around the world. As of May 2016, the growing community includes 545 consented participants from 49 US states and 20 countries. Participants have reported more than 200 different diagnoses and have uploaded genetic testing reports with genetic variants in a total of 153 genes. In April 2016, GenomeConnect launched the Participant Matching system to provide participants the opportunity to connect with one another. Participants control whether or not they wish to participate in this matching program. Those that elect to partake are able to search for other participants based on gene, diagnosis, or geographic location. If a match is found, participants can send a private, secure request to connect through the online portal to the match. After initial contact, if both participants agree, they can continue connecting outside of the registry. As of May 2016, 27 consented GenomeConnect participants have the potential to match on gene (5 %), 137 could match on a specific diagnosis (26 %), and 470 could match on US state (86 %). GenomeConnect has always empowered individuals and families to contribute to genomic discovery through sharing of their genetic and health information. Now, participants can also connect with others around the world via the Participant Matching system to exchange information and emotional support.

Genetic counseling for reproductive fitness in Fabry disease

D. Laney1

1. Emory Genetics

Fabry disease (FD) is an X-linked, progressive lysosomal storage disorder caused by pathogenic mutations in the GLA gene leading to decreased levels of the enzyme alpha-galactosidase A (AGA) in the lysosomes. The missing or reduced enzyme activity of AGA results in the abnormal storage of glolobotriaosylceramides (GL3s) and related glycolipids in multiple cell types throughout the body. A few published case reports and abstracts suggest that decreased reproductive fitness may occur in males with FD as a result of abnormal GL3 storage in the male reproductive tract. In order to further understand reproductive fitness in males with Fabry disease and provide accurate genetic counseling, this study examines a large, multi-centered population of males living with FD to determine if they have reduced reproductive fitness as compared to the general United States population data. Study data on 134 males living with Fabry disease was collected via paper and on-line surveys distributed across the United States. Data analysis focused on correlations between number of biological liveborn children and fertility rates in males with FD as compared to the general population. Information on reduced sperm count, depression, pain, use of assisted reproductive technology, and reproductive choice was also gathered and analyzed for statistical significance. Based on analysis, males affected by FD have an increased mean number of children (1.1) compared the mean number of biological children fathered by fathered by men in the United States (0.9). In conclusion, in our large multicenter sample, males with FD do not exhibit reduced reproductive fitness; on average they have more biological children then the general population in the United States. However, given the existence of azoospermia or oligospermia in some men with Fabry disease a male infertility work-up should be suggested in males having difficulties impregnating their partners. This information should assist clinicians in to providing accurate reproductive genetic counseling in the Fabry population.

Genetic counseling of hearing loss: Where we’ve been and where we’re going

S. Noon1, A. Wilkens1, E. Bedoukian1, J. Tarpinian1, S. Biswas1, I. Krantz1

1. The Children’s Hospital of Philadelphia

Hearing loss (HL) is a common condition in children, occurring in 2 out of every 1000 births with ~50 % of reported cases having a primary genetic etiology. HL is a complex diagnosis that raises many challenging genetic counseling issues related to genetic heterogeneity, newborn screening, and the Deaf culture. HL serves as the poster diagnosis for genetic heterogeneity as it has been estimated that 200–250 genes (1 % of human genes) have been implicated etiologically in causing hereditary HL. Thus far, more than 80 genes with greater than 1000 mutations and 140 loci are known to be associated with nonsyndromic HL. As testing for HL has progressed over time (from connexin testing, to arrays, to NGS panels, and now exome/exome slice) the diagnosis, testing, and genetic counseling of individuals and families with HL has become ever more complex and multifaceted for geneticists and genetic counselors. In addition, early diagnosis with the adoption of universal newborn hearing screening (NBHS) results in a greater number of referrals of newborns for genetic evaluation due to failed NBHS – where HL may be the harbinger of broader syndromic and neurologic diagnoses. Lastly, social and ethical implications must be taken into consideration when working with the Deaf community. The knowledge and beliefs that make up this community raises questions about the role of genetics and genetic counseling as this culture does not consider themselves to have a hearing impairment nor do they consider deafness something that needs to be treated. This presentation will review data and case scenarios from our 15 year experience with over 1000 encounters in The Genetics of Hearing Loss Clinic at the Children’s Hospital of Philadelphia (CHOP) as well as through the CHOP PediSeq Project (part of the The National Human Genome Research Institute’s Clinical Sequencing Exploratory Research (CSER) Consortium) in applying exome sequencing for the molecular diagnosis of HL. Issues related to genetic counseling practice for HL addressing genetic heterogeneity, NBHS, incidental/secondary findings and the Deaf culture will be reviewed.

The impact of treatment on reproductive decisions in Fabry disease

S. Pass1, M. Glassford1, D. Laney2

1. Genetic Counseling Training Program, Emory University

2. Lysosomal Storage Disease Center, Emory University

Fabry disease (FD) is an X-linked lysosomal storage disorder that affects men and women. FD is caused by a deficiency of the lysosomal enzyme α-galactosidase A, which results in an inability to breakdown globotriaosylceramide (GL-3). An accumulation of GL3 and related glycolipids begins a cascade of events that can end in fatal organ damage to the kidneys, heart, and brain. In 2003, enzyme replacement therapy (ERT) was approved for treatment for FD. Prior to approval, individuals with FD had significantly decreased life expectancy with poor quality of life related to pain and organ failure. With ERT, they have delayed onset and slowed progression of disease, which may alter how they make reproductive decisions. The purpose of this study is to determine if the availability of ERT affects the reproductive decisions of individuals with FD. This study utilized a mixed method approach of an online survey followed by in-depth interview. The online survey had 41 participants and the in-depth interviews had 15 participants. The online survey revealed individuals with FD who have existing children consider different factors than those without children, such as the availability of preimplantation genetic diagnosis, the likelihood that FD will be passed on, and experiences with FD. However, the availability of ERT did not statistically affect reproductive decisions though it was considered by some individuals. Individuals with FD did not consider ERT in their reproductive decision-making, in part because they are hoping for new, more effective treatments in the future. While no two participants had the same decision-making process, they all gave similar advice for others with FD who are going through the decision-making process. Participants suggest that individuals who are going through the decision-making process become educated with the options available to them and then make a decision that best fits their family life.

Innovative genetic genealogy Leber’s Hereditary Optic Neuropathy pilot program

L. Poincenot1, K. Trzupek2

1. LHON Project at the United Mitochondrial Disease Foundation

2. InformedDNA

LHON Project at the United Mitochondrial Disease Foundation (UMDF) is a patient advocacy group supporting those with a LHON (Leber’s Hereditary Optic Neuropathy) mitochondrial mutation. Around 33 % of those carrying a LHON mutation will experience sudden onset legal blindness during their lifetime. About 100 people become affected in the U.S. each year. Onset occurs at all ages and both genders, more frequently in men and most often at ages 15–25. There are no approved treatments in the U.S. People who know they carry a LHON mutation can reduce their risk of developing profound vision loss by avoiding certain environmental factors. Promising clinical trials are underway, generally seeking recently-affected individuals. However, for many individuals with a LHON mutation, the diagnostic odyssey is long and traumatic. By the time a diagnosis is finally obtained, the patient may have irreversible vision loss and no longer be eligible to participate in a clinical trial. They frequently do not receive appropriate support to maintain employment/education/activities of daily life, often leading to depression. Many in the LHON community would like to alert their relatives of the genetic risk, but lack the knowledge to conduct a genealogical search for their living maternal relatives or to communicate this sensitive genetic information. LHON Project at UMDF created and implemented an innovative genetic genealogy pilot program to help LHON families identify and inform extended maternal relatives that they might be part of the LHON community. A professional genealogist worked with select families to identify living maternal relatives. Genetic counseling services were made available to the participating families and to the maternal relatives identified. The pilot program was presented at the 2016 LHON Conference, videotaped, and posted online. This novel educational tool will be used to inspire LHON families and other rare disease patient advocacy organizations to consider initiating this innovative application of genetic genealogy.

“A closer look”—benefits and challenges to receiving obstetric care in the workplace as a pregnant prenatal genetic counselor

J. Rietzler1, L. Birkeland1, E. Petty1

1. School of Medicine and Public Health, University of Wisconsin – Madison

Traditional stories of pregnancy and parenthood neglect to address the unique ways in which prenatal genetic counselors are merging multiple professional and personal identities. Processing how pregnancy and/or parenthood might impact prenatal genetic counselors’ perspectives and practices is not something that genetic counselors typically learn about during the course of their training programs, nor in the context of their professional development. This study attempted to investigate how (1) counseling practices, (2) emotional well-being, and (3) feelings or thoughts of their own pregnancy and/or children, might evolve once the milestone of pregnancy/parenthood is experienced by a prenatal genetic counselor and not just their patient. To address this gap in knowledge, a total of 215 current and past prenatal genetic counselors provided insights regarding these three research domains through completion of an online survey. While participants reported that experiencing pregnancy and/or parenthood affected their perspectives and counseling practices in several ways, this paper focuses on one particular unanticipated finding—that of the changes in obstetric care (mainly ‘favors’ from colleagues) experienced by prenatal genetic counselors while working within the prenatal setting and being pregnant themselves. As a result, considerations about when to disclose a pregnancy to colleagues due to lack of anonymity in the workplace along with how to integrate personal and professional needs once expecting as a prenatal counselor surfaced. Additional findings, practice implications, and research recommendations are discussed.

The patient’s perspective: Is there a role for religious/ spiritual assessment in genetic counseling?

L. Rogers1, A. Mathews1, K. Dessoffy2, B. Shapiro3, A. Mitchell1

1. Department of Genetics and Genome Sciences, Case Western Reserve University

2. University Hospitals CMC Center for Human Genetics

3. Jack Joseph & Morton Mandel School of Applied Social Science

Introduction: The majority of Americans report having a religious affiliation or spiritual belief, which are factors that may impact patients’ healthcare decisions. In healthcare settings, most patients desire their provider to be aware of and/or discuss their religious or spiritual (R/S) beliefs in regard to their medical care. However, patients’ views of genetic counselors assessing their religious/spiritual beliefs is largely unknown. Methods: To address this gap, we conducted a survey to assess patient comfort and perceived relevance with discussing R/S beliefs during a genetics appointment. Two tools were used: the NonReligious NonSpiritual scale (NRNSS) and the HOPE spiritual assessment tool. The NRNSS is a validated tool that was used to assess level of religiosity while the H(sources of hope) O(role of organized religion) P(personal R/S practices) E(effects of R/S beliefs on health care) tool provided assessment questions regarding R/S beliefs. Results: Of the 196 participants, descriptive and analytical statistics as well as thematic analysis of short answer responses revealed that R/S beliefs are of at least moderate importance in making genetics healthcare decisions (41.5 %). The vast majority (81 %) of participants felt neutrally to very comfortable being asked the HOPE questions, with a lesser majority (62 %) viewed the HOPE questions as neutrally to very relevant to genetic counseling. Increasing level of religiosity, having a religious and/or spiritual belief, and first time appointment in the genetics clinic were statistically significant predictors for both an increased level of comfort with being asked HOPE questions and an increased level of perceived relevance of being asked HOPE questions. Conclusion: These data suggest that the majority of patients in genetics clinics would not be uncomfortable should they be asked R/S based questions (i.e., HOPE questions). Thus, genetic counselors should feel encouraged to integrate R/S assessment into their clinical practice.

The informational and emotional support needs of grandparents of children with Pompe disease

N. Rudy1, J. Edwards2, K. Berrier3, A. Lehmann4

1. University of Alabama at Birmingham

2. University of South Carolina Specialty Clinics

3. Duke University Medical Center

4. South West Thames Regional Genetics Service

Grandparents of children with special needs have unique family roles and complex emotional experiences. Previous research has not studied grandparents of children with treatable, inherited conditions such as Pompe disease (PD). The availability of treatment and heritable nature present the possibility for unique grandparent roles, experiences and needs, while the advent of newborn screening for PD makes this study timely. This study described grandparents’ roles and involvement, identified grandparents’ information and emotional support needs and explored the psychosocial impact of having a grandchild with PD. An online survey containing forced choice and open-ended questions was distributed by various PD organizations. Data were analyzed with descriptive statistics, statistical measures, and thematic analysis. Twenty-one grandparents of children diagnosed with PD participated. Grandparents provided emotional support significantly more frequently than financial support (p = 0.011), long-term child care (p < 0.0005), medical assistance (p < 0.0005), and running errands (p = 0.002). Grandchildren’s parents were the primary sources of information for grandparents. Information about treatment was most important to grandparents. Most participants learned about the genetics of PD (n = 16) and understood PD’s genetic etiology (n = 15). Grandparents identified family and religion as the most valuable sources of emotional support, but also commonly received emotional support from friends (n = 16) and Internet resources (n = 15). Psychosocial impacts included altered travel and employment plans, increased awareness of grandchildren’s limitations and medical needs, and the experience of double-grief. While grandparents are large sources of support for their families, they need considerable support themselves, yet resources for grandparents beyond their grandchild’s parents are limited. These results warrant genetic counselors’ consideration of extended family members’ support needs surrounding a genetic diagnosis and facilitation of familial communication of complex medical information.

Family impact of 1p36 deletion syndrome

R. Sheikh1, R. Hopkin2, A. Brazil2, V. Pilipenko2

1. University of Cincinnati

2. Cincinnati Children’s Hospital Medical Center

Background: 1p36 deletion syndrome is one of the most common microdeletion syndromes affecting approximately 1 in 5000–10,000 newborns. However, little is known about the impact felt by caregivers of individuals with 1p36 deletion syndrome and related caregiver needs. This study assessed the family impact and provides a resource for individuals both within and outside the healthcare field. Methods: A questionnaire consisting of the Pediatric Quality of LifeTM (PedsQL) family impact module, demographics, and phenotype assessment was distributed to caregivers at the annual 1p36 Deletion Support and Awareness conference. The PedsQLTM family impact module was scored out of 100, with lower scores indicating higher impact. Results: Of 56 participants that completed a survey, the mean total impact score of the PedsQLTM family impact module was 51.8 out of a 100 (R: 8.3–86.1). The individual caregiver dimension scores for parent functioning were 56.4 (physical functioning), 54.3 (emotional functioning), 47.4 (social functioning), 57.2 (cognitive functioning), 54.2 (problems with communication), and 43.3 (worry). Scores for family functioning were 33.9 (daily activities) and 59.5 (family relationships). Caregivers who reported that their child had behavioral challenges such as excessive friendliness and/or aggressive tendencies were found to experience significantly higher impact in several of the PedsQLTM family impact module domains. Conclusions: Our results suggest that behavioral problems were the biggest challenge for many caregivers. Healthcare providers, including genetic counselors and geneticists, should consider addressing the family impact of having a child with 1p36 deletion syndrome and related behavioral challenges.

Attitudes towards facial transplants among individuals with neurofibromatosis

D. Singman1, J. McNairn1, V. Ianonne1, R. Glaser1

1. Stevenson University

Neurofibromatosis (NF), an autosomal dominant disorder, has a phenotype ranging in severity from café-au-lait spots to multiple large tumors (neurofibromas). Surgery can remove neurofibromas but they usually regrow. Full facial transplants, which have been used to treat NF since 2013, prevent neurofibromas from reoccurring by replacing the patient’s facial tissue with donor tissue. This is the first study to assess the response of individuals with NF to facial transplants for cosmetic and functional purposes. A 26 item online survey, advertised on between June and September 2015, assessed the reactions of individuals with NF to facial transplants for cosmetic and functional purposes. In addition, data on self-esteem, social behaviors, visibility and severity of NF, as well as demographic data such as type of NF, gender, and age were also collected. SPSS was used to analyze the survey data using independent sample two-tailed t-tests and Pearson’s correlation coefficient. Overall, facial transplants for both cosmetic and functional purposes were not supported by our study population. The type of NF, visibility, and severity of the phenotype did not significantly affect the response to facial transplants. Even though our study population did not support facial transplants in general, females were significantly more likely than males to consider a cosmetic facial transplant for themselves (p = 0.042) and for others (p = 0.005). Lower self-esteem significantly correlated with a greater consideration for cosmetic facial transplant for themselves (r = −0.341, p = 0.01) and for others (r = −0.221, p = 0.05). However, self-conscious individuals were significantly more likely to consider cosmetic facial transplants only for others (p = 0.044), not themselves (p = 0.429). Our results are reminiscent of the attitudes regarding cochlear implants in deaf study populations and attitudes regarding prenatal testing for achondroplasia in achondroplasia study populations.

Ramifications of neurofibromatosis on self-esteem

D. Singman1, J. McNairn1, V. Ianonne1, R. Glaser1

1. Stevenson University

The phenotype of neurofibromatosis (NF) can range in severity from café-au-lait spots to multiple large tumors. Previous studies have examined the psychosocial ramifications and quality of life impacts of living with NF. This study focused specifically on the effect of NF on self-esteem. A 26 item online survey, advertised on between June and September 2015, was used to collect demographic data such as type of NF, gender, age, and family history of NF, as well as data on visibility and severity of NF, participants’ membership in an NF support group, and social behaviors. Self-esteem was evaluated using the Rosenberg Self Esteem Scale (RSES). SPSS was used to analyze the survey data using independent sample two-tailed t-tests and Pearson’s correlation coefficient. The average self-esteem score (SES) of all participants was 27.5/40, which was significantly lower than the SES for individuals with acquired or congenital facial deformities (p < 0.031). The average SES of our study population was also significantly lower than that of control groups with no visible facial deformity (p < 0.0001). The SES of individuals with NF1 or NF2 were not significantly different from each other (p = 0.064). There was no significant difference in the SES of females with NF1 or NF2 in this study compared to a previous study (p > 0.7). Gender, age, self-consciousness, and participation in NF-related support groups did not significantly affect self-esteem, nor did the visibility or severity of NF, even though visibility and severity of NF symptoms were significantly correlated with each other (r = 0.547, p = 0.01). Lower self-esteem was significantly negatively correlated with 11 social behaviors like isolation, anxiety, and avoidance from social and professional situations (r = −0.211 to −0.505, p < 0.05). The SES of individuals with other affected family members compared with individuals with no family history of NF was not significantly different, but approached significance (p = 0.055), suggesting that having other affected family members may negatively impact one’s self esteem.

The impact of hyperphagia and food restriction on siblings of individuals with Prader-Willi syndrome

E. Wishnefsky1, A. Matthews1, S. McCandless2, M. Merrill2, A. Goldenberg1

1. Case Western Reserve University

2. University Hospitals

Introduction: The behavioral phenotype and hyperphagia that are characteristic of Prader-Willi syndrome (PWS) are usually the most difficult and stressful aspects of the disorder to manage. While siblings are often highly involved in almost all aspects of care for their brother/sister with PWS and are immersed in the home environment, little is known of how this impacts their eating patterns, feelings towards themselves, their families or their outlook towards the future. Purpose: This qualitative study sought to understand sibling perspectives on an in-depth basis of living with a sib with PWS. Methods: Using a qualitative approach and a constant comparative thematic analysis, 24 semi-structured telephone interviews were conducted with siblings over the age of 18 of individuals with PWS. Results: Five major themes emerged from the data: “Environmental and dietary restrictions”; “Feelings towards sibling with PWS”; “Uncomfortable with friendships”; “Supportive relationships”; and “Sense of responsibility.” Feeling ambivalent and normalizing their home environment and the behaviors of their sibling with PWS was a common experience exemplified by participants. Stress surrounding strict eating regimens resulted in siblings having both positive and negative eating habits. Participants noted that the accessibility and utilization of support groups was reduced. Moreover, participants identified a present and/or future perception of responsibility to care for their sib with PWS. Conclusions: Enabling siblings to feel more adequate in the caregiving role was an important finding of this study as well as the need for support and early professional involvement. Additionally, allowing typically developing children time with their families without their sib with PWS may reduce negative feelings towards that sibling. Genetic counselors are well situated to provide siblings with more accessible resources, which may allow for less negative experiences and more positive outcomes.

Whole exome sequencing following the finding of multiple skeletal anomalies on prenatal ultrasound

L. Aptekar1, J. Roberts2, M. Gellerman3, A. Willis3, A. Chatterjee3

1. Integrated Genetics

2. Maimonides Diagnostic Perinatal Center

3. Labcorp

Significant advances in DNA sequencing technology have made large-scale sequencing, including whole exome sequencing (WES), available on a clinical basis. WES should be considered in the evaluation of a phenotypically affected individual when specific criteria are met. This includes a fetus with a “likely genetic disorder in which specific genetic tests, including targeted sequencing tests available for that phenotype, have failed to arrive at a diagnosis.” We present two cases where multiple skeletal abnormalities were identified on sonogram. In the first case, the sonogram revealed bilateral short, curved femurs and micrognathia. A heterozygous de novo likely pathogenic variant was identified in COL1A2, associated with autosomal dominant Ehlers Danlos VIIB and osteogenesis imperfecta II, III, IV. A heterozygous, maternally inherited likely pathogenic variant was also noted in GNTAB, which is associated with autosomal recessive mucolipidosis II/III. In the second case, ultrasound revealed significantly shortened limbs and a hypoplastic chest. Of note, the patient and partner are consanguineous with a previous similarly affected pregnancy (deceased). A homozygous variant of uncertain significance (VUS) was identified in WDR34 and a heterozygous VUS was identified in NEK1, associated with autosomal recessive short rib thoracic dysplasia with or without polydactyly, types 11 and 6, respectively. WES allows for the detection of rare variants which may provide an explanation for presenting phenotypic abnormalities. While it is tempting to consider these results diagnostic, without proven pathogenicity many WES results may be difficult to interpret. Additionally, further variant analysis may be limited by the absence of postnatal confirmation of phenotype. As WES is applied to the prenatal setting, determination of whether the identified variants are causative of the fetal malformations or are actually benign variants of unknown significance will create significant challenges in genetic counseling.

Secondary findings - counseling and clinical implications following identification of microdeletions and microduplications during preimplantation genetic diagnosis

R. Cabey1, D. Goldberg-Strassler1, A. Jordan1, E. Armenti1, R. Prates1, A. Hershlag2, M. Rausch2, M. Cohen2, J. Grifo3, M. Guarnaccia4, M. Konstantinidis1, S. Munne1

1. Reprogenetics

2. Northwell Fertility

3. NYU Fertility Center

4. Columbia University Center for Women’s Reproductive Care

The purpose of this study is to evaluate the relevance and implications of secondary findings identified during Preimplantation genetic diagnosis (PGD) in an effort to emphasize the need for implementing a standard procedure to report such findings. A total of 306 PGD cases were prepared from July 2015 to April 2016 via single nucleotide polymorphism (SNP) arrays (Karyomapping; Illumina, USA). During review of SNP array profiles secondary findings were revealed in 13 cases. All findings were reported to the physician and patient and recommendation for follow-up microarray testing was provided. The secondary findings comprised of 11 microduplications and 2 microdeletions, involving chromosomes 4, 14, 15, 16, 22, and X. The size of microduplications detected ranged from 0.18 megabases (Mb) to 3.5 Mb. Interestingly, three of the microduplications detected (4q35.2, 15q11.2, and 16q23.3) were each seen in 2 or more separate cases. One microdeletion identified (located on chromosome X) was determined to be of considerable size at 28 Mb, potentially associated with health implications in the carrier female. Follow-up microarray analysis was pursued in 8 cases. Four of the secondary findings were reported as variants of uncertain significance (VUS) and 3 were reported as normal population variants. Results are pending on 1 case. One patient elected to pursue PGD for the microduplication. Results from 2 PGD cycles for this patient revealed 3/9 embryos free of the microduplication, but only 1 embryo available for transfer as the other 2 were affected with the single gene disorder and/or aneuploidy. This patient is currently 6 weeks pregnant. With the implementation of new and advanced methodologies in clinical practice, it is becoming progressively more common to incidentally obtain information that is additional to the requested test but may have significant health implications to the patient, other family members and/or future children. It is vital to acknowledge and address this issue in the clinical laboratory setting and a standard procedure should be in place to handle such situations.

Parental quality of life of tyrosinemia type I

H. Campbell1, R. Singh1, E. Lisi1, E. Hall1, N. Ali1

1. Emory University

Background: Tyrosinemia type I (HT1) is an inborn error of metabolism (IEM) in which the enzyme fumarylacetoacetate hydrolase does not work correctly, causing a toxic buildup of tyrosine and succinylacetone. Current clinical guidelines for HT1 management include a lifelong specialized diet and use of the orphan drug nitisinone. There have not been any studies assessing the quality of life (QOL) of people with HT1 or their parents. The purpose of our study is to determine the QOL of parents and/or caregivers of children with HT1. Methods and Analysis: Participants were asked to complete the TYR-QOL, adapted to this population from a questionnaire validated for phenylketonuria (the PKU-QOL), a similar patient population. Per scoring guidelines developed for the PKU-QOL, questions were grouped into domains, and each Likert response was given a numerical value. Domain scores were calculated by adding values for each question and applying linear transformation, allowing all domain scores to range from 0 to 100. Scores were interpreted via four categories: little/no impact, moderate impact, major impact, and severe impact. TYR-QOL means were compared to those of the PKU population. Results: Data was obtained from 26 caregiver surveys (20 mothers, 5 fathers, and 1 grandparent). HT1 was found to have a moderate overall impact on parental QOL. HT1 symptoms had a variable impact, ranging from little/no impact to a moderate impact on QOL. Emotional aspects of HT1 had a moderate impact on QOL, while practical and social aspects of HT1 were found to have little to no impact. Domain scores for emotional, practical, social, and overall impacts on QOL were significantly higher for HT1 than for PKU. Conclusion: This is the first study to assess QOL in parents of children with HT1. Results suggest HT1 has a moderate impact on parental QOL, with emotional aspects having the greatest impact. These results can be used to better understand the psychosocial implications of HT1 in comparison with other IEMs and assist healthcare providers in addressing treatment issues.

A psychologic survey of women and men who received a prenatal diagnosis of anencephaly: The impact of genetic counseling and patient recommendations

H. Cope1, M. Garrett1, A. Ashley-Koch1

1. Duke University Medical Center

Genetic counselors often meet with expectant parents following diagnosis of multifactorial fetal anomalies, for which the likelihood of identifying a genetic etiology is low. One such anomaly is anencephaly, a lethal neural tube defect detectable by ultrasound but only associated with chromosome anomalies in approximately 1 % of cases. The impact of genetic counseling in this patient population is unknown. One hundred and sixty women and 110 of their male partners who previously received a prenatal diagnosis of anencephaly completed standardized psychologic instruments to measure symptoms of grief, post-traumatic stress and depression. Participants reported if they had seen a genetic counselor, what aspect of genetic counseling was most helpful, and what advice they would give to health care providers working with this patient population. Gender-specific analysis of variance was performed to assess mean differences in instrument scores between those who did and did not see a genetic counselor. Factors significantly associated with psychological outcome (time since pregnancy, recruitment source, pregnancy outcome and religiosity) were included as covariates. Qualitative items were coded into themes by the first author. Over half of participants had seen a genetic counselor (56 % of women, 53 % of men). Women who had seen a genetic counselor reported significantly more grief (p = 0.02) and post-traumatic stress (p = 0.03) than women who had not seen a genetic counselor. There were no psychological differences among men regardless of whether they had seen a genetic counselor. A large portion of participants who had seen a genetic counselor did not find the meeting helpful, reporting the most helpful thing was “nothing” (31 %) or “can’t remember, it was a blur” (10 %). Recommendations for health care providers emerged as eleven major themes, which were primarily psychosocial in nature. Genetic counselors may need to adjust the typical genetic counseling paradigm to focus more on psychosocial aspects when counseling patients who receive multifactorial prenatal diagnoses.

Noninvasive prenatal testing failure due to low fetal fraction: Redraw success and patient decision making in an urban population

M. Crawley1, S. To1, L. Hercher1, K. Aaron2

1. Sarah Lawrence College

2. Montefiore Medical Center

Introduction: Low fetal fraction (FF) can affect the sensitivity and specificity of noninvasive prenatal testing (NIPT) and decrease the likelihood of obtaining results. This characteristic may be especially important to consider in populations with high rates of obesity, since higher maternal weight is associated with lower FF. Purpose: To evaluate the impact of FF and weight on test failure in a general population cohort with high rates of obesity and examine how no call results impact patient decision making. Methods: This retrospective pilot study reviewed the database of Montefiore Medical Center in Bronx, NY for NIPT results from January 1, 2014 to August 24, 2015. Chart review was conducted for all no call results. Results- 282 of 3747 samples (7.53 %) failed to yield results. 67.87 % of women with no call reports repeated NIPT after initial test failure. Tests that failed solely or partly due to low FF had an overall redraw success rate of 28.75 %; this rate was higher in women ≤220 lbs (37.5 %) as compared to women >220 lbs (17.5 %). Two women (5.26 %) with FF ≤2.8 % on initial draw received results upon redraw compared to 21 women (50 %) with initial FF >2.8 %. FF decreased between initial draw and redraw in 32.89 % of cases and increased in 67.11 %. 9 % of women with no call results subsequently elected diagnostic testing, of whom 68.2 % had other abnormal prenatal screening or relevant family history. Conclusions: Redraw success rates observed in this population were lower than those reported in other studies and FF decreased between blood draws in many cases. This pilot data suggests FF may be more dynamic than previously believed and there are likely many factors affecting the amount of cell free DNA in maternal circulation that have yet to be elucidated. These observations highlight the need for more in-depth studies of test failure and FF changes in different populations. Accurate and personalized information regarding the utility of NIPT, including the likelihood of test failure and redraw success, will allow for better counseling and enable patients to make more informed prenatal decisions.

Pronounced micrognathia and other anomalies in a pregnancy with an unbalanced pericentric inversion 46,XX,der(8)del(8)(p23)dup(8)(q21)

M. Discenza1, N. Smith1, R. Reiss1

1. Brigham and Women’s Hospital

A 34-year-old G1P0 presented with a first trimester nuchal translucency (NT) measurement of 2.8 mm at 12w4d. Patient pursued noninvasive prenatal testing (NIPT) which was normal for chromosomes 13, 18, and 21. Fetal sex was predicted as female. Ultrasound at 15w4d showed micrognathia and dilated bowel with femur length in the 12th centile and humerus at 23rd centile. Amniocentesis was performed at 16w3d and microarray on cultured amniocytes revealed a 4.9 MB terminal deletion 8pter-->p23.2 and a 53.8 MB terminal duplication 8q21.3-->qter, which is close to the affected regions in recombinant 8 syndrome. Paternal karyotype was normal, 46,XY. Patient’s karyotype was 46, XX,inv(8)(p23.2q21.3). A fetal anatomic survey at 18w2d confirmed micrognathia, with normal midface, and showed lateral cerebral ventricles that appeared prominent anteriorly, right hand clinodactyly with overlapping 4th and 5th digits, and cardiac anomalies concerning for tetralogy of fallot. Researchers previously reported risk for autism in isolated 8p deletions. Researchers described isolated 8q duplications that included seizures, congenital heart defects and facial dysmorphism. Concern for phenotype was amplified, as pregnancy had larger copy number variants in both of these regions. Patient chose to terminate the pregnancy at 20 weeks gestation and underwent a D&E. Limited surgical pathology showed low set, posteriorly rotated ears, upturned nose, and the second and fifth digits of hands overlapped the third and fourth bilaterally. Family history is unremarkable for recurrent miscarriage but patient is an only child. The family is now pursuing Preimplantation genetic diagnosis (PGD) via flourescence in situ hybridization (FISH) and after 3 cycles have yet to achieve a clinical pregnancy. Of 11 embryos biopsied only 2 had normal karyotype. Patient is considering egg donation for future cycles.

Clinical utility of expanded carrier screening: Reproductive behaviors of at-risk couples

C. Ghiossi1, K. Ready2, C. Lieber2, J. Goldberg2, I. Haque2, G. Lazarin2, K. Wong2

1. California State University

2. Counsyl

Introduction: Expanded carrier screening (ECS) analyzes dozens or hundreds of recessive disease genes for couples planning to have children. The literature on the clinical utility of screening conditions is scarce. We surveyed at-risk carrier couples, identified through ECS, to learn about their reproductive decisions. Methods: Patients underwent ECS via Counsyl laboratory for up to 110 genes. At-risk carrier couples (ARCC) were those in which both partners were carriers for the same autosomal recessive diseases. We invited 537 ARCC who received their results between April 2014 and August 2015 to participate via email, SMS message, and paper survey in an IRB-approved study questionnaire. Results:Of 537 eligible participants, 76 completed the questionnaire; 12 who reported a family history were excluded from analysis. 45 (70 %) were not pregnant at time of screening. Of the 45 participants that were not pregnant, 62 % indicated that they would choose In vitro fertilization (IVF) with Preimplantation genetic diagnosis (PGD), prenatal diagnosis, gamete donation, adoption, or no reproduction. 29 % indicated that they were not planning to alter reproductive plans, indicating perceived severity as a major reason. The remainder did not indicate clear plans. Of the 19 participants that were pregnant, 42 % (8) elected prenatal diagnosis. Of the remainder, 2 reported interest in testing, but miscarried before the procedure could be done while 9 did not consider the condition sufficiently severe to consider pregnancy termination. Of 8 pregnancies that underwent prenatal diagnosis, 5 were unaffected and 3 were affected. Two of the affected pregnancies was terminated and 1 was continued. Fisher’s exact test revealed the association between the severity of the disease and clinical utility was significant (p = 0.000145), whereas the association between pregnancy status and clinical utility was not (p = 0.088). Conclusions: Most ARCC altered reproductive planning, demonstrating clinical utility of this information. Perceived severity of the condition factored into decision making with milder diseases less likely to change planning.

The benefit of genetic counseling in the preimplantation genetic screening decision

J. Isaac1, E. Mounts2, Q. Stein3, L. Williamson Dean1, T. Von Wald4, E. Barbieri2, J. Flanagan4

1. University of Arkansas for Medical Sciences

2. Oregon Reproductive Medicine

3. Augustana University

4. Sanford Health

Background: Preimplantation genetic screening (PGS) is used to identify and transfer euploid embryos for patients pursuing In vitro fertilization (IVF), thereby aiming to improve IVF success rates. Given the growing complexity of PGS technologies and the results generated, genetic counselors can play an increasingly important role in pre- and post-test counseling. However, only 21 of 2205 genetic counselors reported working in the assisted reproductive technology specialty in the 2016 Professional Status Survey. Objective: Identify the role of the genetic counselor in the PGS decision. Materials and Methods: Questionnaires were submitted to 185 patients pursuing IVF from September 2015 to February 2016 at a private fertility clinic in Oregon and a community healthcare system in South Dakota. Both of these sites have embedded clinical genetic counselors in a reproductive endocrinology (RE) setting. Participants ranked the genetic counseling session on a three-point Likert scale and chose what they found most helpful about the session and areas for improvement. Results: Ninety patients completed the questionnaire (response rate of 49 %). Of these, 64 % planned to pursue PGS. One hundred percent of participants who met with a genetic counselor (N = 75) found the session helpful in making their decision. Patients found the information about risks and limitations of PGS (78.7 %) to be most helpful, followed by information on benefits of PGS (66.7 %) and the psychosocial support provided (30.7 %). Five respondents (6.7 %) indicated they changed their decision after their genetic counseling appointment. The majority (70.67 %) of respondents did not feel there were any areas for improvement. Some cited a need for more information about PGS (10.7 %) and more psychosocial discussion (9.33 %). Conclusions: This is the first study to examine the role of genetic counselors in the PGS decision. Incorporating counselors into the RE clinic may help patients understand genetic testing as well as address psychosocial issues.

Women’s experiences with receiving the news of an abnormal prenatal ultrasound

B. Madden1, S. Spencer2, K. Hurley3, E. Simi4, D. Victorson5

1. Northwestern University Genetic Counseling Program

2. Northwestern Medicine

3. Private Practice, New York, NY

4. Insight Medical Genetics

5. Northwestern University Feinberg School of Medicine, OCIM Northwestern Medicine

Second trimester prenatal ultrasounds are utilized to screen for structural fetal anomalies. To date, there has been minimal research on the emotional impact the identification of a fetal anomaly has on women, how women make the decision to terminate or continue a pregnancy, and women’s preferences regarding the ideal time to meet with a genetic counselor. This qualitative study aimed to explore three concepts: which factors did women/couples consider when making pregnancy termination decisions, were women prepared for the possibility of an anomaly, and when is the best time to discuss implications and further testing. Twelve semi-structured interviews were conducted of pregnant women whose second trimester ultrasound detected a structural fetal anomaly. Interviews were audio recorded and transcribed verbatim. Exhaustive coding was used to create a codebook, which was assessed for inter-rater reliability (Kappa > .70). Following open coding of the data, themes were identified. In this study, participants discussed the myriad factors that affected their pregnancy decisions. The main factor to continue was based on personal beliefs, whereas quality of life was the biggest factor when considering termination. All 12 participants expressed they were not prepared for the possibility of identifying a fetal anomaly. Women’s reactions after the detection of the anomaly ranged from shock and disbelief, resilience, depression, anxiety, and anger. A majority of the women reported primarily receiving support from their family and/or partners after the anomaly was detected. Approximately half of the women would prefer to meet with a genetic counselor the same day as the identification of the anomaly in order to learn as much as they can, whereas the other half would prefer to wait a couple days in order to fully process the technical information. The results of this study may help health care providers communicate with women after the detection of an anomaly to provide them with the most sensitive and efficacious care.

Maternal age and pregnancy loss. It’s not all about the trisomies

M. Maisenbacher1, K. Merrion1, M. Young1, S. Sigurjonsson1

1. Natera

Introduction: Miscarriage occurs in 10 % of women under age 25 years and increases to over 50 % in women over age 40 year. Though correlation of miscarriage to advancing maternal age (MA) is well known, details about specific genetic causes for loss by MA have not been elucidated. Objective: Report rates of genetic causes of miscarriage including, trisomy, monosomy, triploidy, deletions/duplications (dels/dups) and other findings, by MA. Methods: Retrospective review of 15,067 fresh products of conception (POC) samples sent to a reference lab with maternal blood samples. Genotyping was performed using Illumina CytoSNP-12b microarrays with bioinformatics to rule out maternal cell contamination (MCC). Results: Of 15,067 samples, 2238 (14.9 %) had MCC, 51 (0.3 %) had incomplete results, and 12,778 (84.8 %) had fetal results. Fetal result cases were broken down by MA groups: <25 years (A), 25–29 years (B), 30–34 years (C), 40–44 years (D) and >44 years (E). Rates of single trisomy ranged from 14 % (Group A) to 60 % (Group D); multiple aneuploidy increased from 0.5 % (Group A) to 19.9 % (Group E). Rates of dels/dups were greater in women <35 years compared to women >35 years: 4.2 vs. 2.3 %. Rates of monsomy decreased as MA increased from 9.8 % (Group A) to 2.2 % (Group E). Rates of triploidy (7.7 %), uniparental disomy (UPD) (0.4 %), complex findings (<0.1 %) and MCC did not vary across MA groups. Conclusions: In this large cohort, we delineated types of chromosome abnormalities identified in miscarriages across MA groups. Going beyond general rates of miscarriage by MA, and providing rates of specific chromosome abnormalities found based on MA, adds value to patient counseling. For example, all age groups, but higher in younger women, have a potential for dels/dups that carry a recommendation of parental follow up studies to rule out balanced rearrangements. Older women have a greater likelihood of multiple aneuploidies on POC testing. And, regardless of MA, the likelihood for results of triploidy, UPD, complex findings or MCC is equal.

Factors associated with burnout in clinical genetic counselors

D. Martiniuc1, D. Rintell2, J. Rosenfield1, N. Poulos3

1. Brandeis University

2. Genzyme

3. Beth Israel Deaconess Medical Center

Burnout is defined by emotional exhaustion, depersonalization, and reduced personal accomplishment. While it is known that genetic counselors are at risk for burnout, there is limited data that identifies specific predictors of burnout in clinical genetic counselors to assist in determining those most at risk. The purpose of this study was to measure the level of burnout in practicing clinical genetic counselors, identify work-related predictors of burnout, and investigate the relationship between burnout and counselors’ thoughts of leaving their current job. A sample of 367 practicing clinical genetic counselors recruited through the NSGC listserv completed an anonymous, online survey containing the Maslach Burnout Inventory-Human Services survey and questions about demographics, social support, workload, and thoughts of leaving their current job. Results indicated that 52.9 % and 38.1 % of clinical genetic counselors experience moderate-to-high levels of emotional exhaustion and depersonalization, respectively, and 7.9 % experience low levels of personal accomplishment. Ordinal regression analysis yielded several significant predictors of burnout including low levels of social support, greater workload, younger age, and marital status. Chi-square analysis also showed that burnout and counselors’ thoughts of leaving their current job were significantly associated. The results of this study confirm that clinical genetic counselors continue to be at risk of burning out, while also providing new insights into work-related predictors of burnout. These findings convey important target areas for intervention that may be integral to a genetic counselors’ professional well-being, including receiving adequate social and administrative support. Attention to these factors are likely to reduce the risk of burnout and prevent genetic counselors from leaving clinical practice.

Decisions and understanding of noninvasive prenatal testing in a county hospital population

V. Mathur1, I. Van den Veyver1, H. Sangi-Haghpeykar1, G. Fruhman1

1. Baylor College of Medicine

Background: Patients’ knowledge of and decisions regarding noninvasive prenatal testing (NIPT) are only beginning to be investigated. Objectives: To determine what percentages of patients at a large community hospital elect NIPT, amniocentesis, or no testing after genetic counseling, the reasons behind their decisions, and their understanding of the different testing options. Methods: Patients with increased risk for aneuploidy in pregnancy were eligible for this study. After receiving genetic counseling, patients decided if they wanted NIPT, amniocentesis, or no testing. Patients that chose to participate were given a survey to complete in their native language (English or Spanish). Demographic information and frequencies of survey responses were tallied and analyzed using SAS. Results: 41 patients participated in the study. 13 (32 %) patients elected no testing, 2 chose amniocentesis, and 26 (63 %) chose NIPT. Most patients were Hispanic (n = 35, 85.4 %) with mean (SD) age of 35.5 (5.4). Patients who selected no testing were similar in age to those electing NIPT (36.6 vs 34.8, p = 0.28). Regardless of the test chosen, patients ranked wanting peace of mind (68 %), the amount of information desired (54 %), and the accuracy of the tests (43 %) as the most important factors affecting their decision. Only 39 % of respondents chose the correct procedure-related risk for amniocentesis. Patients generally understood that NIPT screens for Down syndrome (90 %), trisomy 13 (90 %), and trisomy 18 (88 %). However, few patients understood that NIPT does not screen for all aneuploidies (27 %), genetic disorders (32 %), and birth defects (32 %). Conclusions: Patients tended to choose NIPT as opposed to other options. Important factors in their decision-making were a desire for peace of mind, how much information they wanted, and the accuracy of the testing options. However, they tended to overestimate the ability of both NIPT and amniocentesis to diagnose conditions outside of common aneuploidies. Further studies are needed with larger samples in order to make definitive conclusions.

Genetic counseling outcomes and experiences with clinical whole genome sequencing in a healthy population

M. McGinniss1, E. Ramos1, E. Thorpe1, L. Fosler1, K. Schahl2, A. Hasta2, T. See2, K. Trzupek2, D. Eklund3, H. Bixenman3, D. Morton3, D. Wellis3

1. Illumina, Inc.

2. InformedDNA

3. San Diego Blood Bank

Clinical whole genome sequencing (cWGS) performed in support of genomic medicine is rapidly gaining acceptance as cost is decreasing and success rates in identifying disease-causing variants are increasing. The growing availability and uptake of genomic medicine highlights the importance of re-evaluating current approaches to genetic counseling and could warrant a shift in the traditional counseling paradigm. In an IRB-approved pilot project conducted by Illumina and the San Diego Blood Bank (SDBB), cWGS was offered to 70 SDBB blood donors. Post-test genetic counseling was performed by telephone with CGCs at InformedDNA and included family and medical history collection, results disclosure, follow-up recommendations, and psychosocial assessment. Counseling metrics, including preparation time, counseling time, and time spent on follow-up documentation were tracked and compared to the 2016 National Society of Genetic Counselors (NSGC) Professional Status Survey (PSS). Average time spent counseling participants was 66 min, while average time spent preparing for patients and completing a consultation summary was 18 and 35 min, respectively. These patient care values are in line with what has been previously reported for in the 2016 NSGC PSS. While counseling time was slightly increased compared to the median counseling time reported in the NSGC 2016 PSS, time spent preparing and documenting these patient encounters was comparable. Qualitative and quantitative metrics were also obtained surrounding the genetic counselor experience and perceptions of cWGS. This pilot study demonstrates the feasibility of providing consistent genetic counseling service to patients with cWGS results. As genomic technology evolves in anticipation of the new era of Precision Medicine, genetic counseling practices may also need to evolve. Future studies are necessary to better understand how genetic counselors are educating, counseling, and communicating cWGS results so that practice trends can be identified and best practices can be developed.

The importance of a genetic counselor as a team member in any tertiary care (fetal medicine) center

M. Menzel1, A. Lawrence1, K. Cilli1

1. Children’s National Health System

Currently, many fetal centers do not hire genetic counselors as part of their team. The need for genetic counselors to be recognized as essential team members at any fetal medicine center is critical to the growth of the profession. Our experience in demonstrating the range and depth of roles played by genetic counselors in our fetal medicine program can be a resource for genetic counselors hoping to work in this environment. Children’s National Health System in Washington, D.C. is one of several fetal medicine programs in the country that serves as a tertiary referral center for fetal imaging, including fetal MRI, and consults across all disciplines of pediatric medicine. Three genetic counselors and a nurse practitioner serve as the core clinical team. The genetic counselors provide support to families starting with the initial intake phone call, and continuing throughout all consultations, delivery and neonatal care, or until all testing is complete for cases of therapeutic termination. Unlike in other prenatal settings, the genetic counselor has the opportunity to collaborate with a team of pediatric specialists in counseling patients who are faced with uncertainty and difficult decisions. In this unique environment, our role has expanded to include implementation of referral and service guidelines, continued patient communication from initial intake through postnatal care, coordination amongst the clinical team to ensure clear communication between all providers and the patient, education of team members about the complexities of counseling in a prenatal setting, and management of conflicts within the team. Positive feedback from colleagues, patients, and referring providers clearly demonstrates that genetic counselors are an invaluable asset to a fetal medicine program. Expanding our expertise in this setting has been a rewarding experience therefore we wish to encourage others to consider this unique role.

Decision-making surrounding the use of preimplantation genetic diagnosis in couples at-risk for cystic fibrosis and spinal muscular atrophy

K. Miller1, J. Taylor2, C. Siskind3, L. Hudgins3, A. Hebner3, R. Lathi3

1. Stanford University

2. University of California, San Francisco

3. Stanford University Hospital

Preimplantation genetic diagnosis (PGD) allows genetically at-risk couples to screen embryos for genetic disease prior to implantation and greatly reduces the chance of having an affected child. This study assessed how carrier couples of cystic fibrosis (CF) or spinal muscular atrophy (SMA) weigh decision-making factors when considering the use of PGD. An anonymous online questionnaire was distributed through the Stanford Hospital Neuromuscular and Cystic Fibrosis clinics and emailed to, and posted on, social media sites for online support groups. Data analysis included chi-square tests, t-tests, and thematic analysis. One hundred and twenty-one responses were received. Of these, 34.7 % were carriers for CF (n = 42) while 65.3 % were carriers of SMA (n = 79). The majority of participants (60.5 %, n = 72) had an affected child while a minority of participants (11.5 %, n = 14) had previously utilized PGD. The factors past experience with a child with the condition and desire to avoid pain and suffering were ranked as the strongest motivations to use PGD, with mean scores of 4.15 and 4.13 on a scale of 1 to 5, in which 5 indicates strongly influencing decision-making. Cost of the procedure was the highest ranked deterrent and the third highest ranked factor overall, with a mean score of 3.86. Moral objections and religious beliefs achieved the lowest rankings, with scores of 2.03 and 2.34, respectively. Respondents who had utilized PGD ranked emotional factors such as Past experience with a child with the condition as significantly higher than those who had not used PGD (p = 0.036) and logistic barriers, such as cost, as significantly lower (p < 0.001). Cost was reported as the most strongly influencing factor in nearly half (48 %, n = 44) of free response comments. Results suggest that although couples at-risk for genetic disease are strongly motivated to use PGD based on emotional responses, logistic issues such as cost are significant concerns. Consideration of these factors may assist genetic counselors when discussing reproductive options with carrier couples.

Establishing a comprehensive genetic counseling service for patients with inherited and acquired pediatric bone marrow failure

K. Schneider1, T. Nakano1

1. University of Colorado

Despite rapid advances increasing the number of known somatic and germline mutations in patients with bone marrow failure, many patients have incomplete evaluations, receive idiopathic labels, and potentially miss chances for life-saving clinical management. Recognizing the need to standardize care guidelines, dedicate clinic time, and provide genetic counseling for this complex population, we designed and established a bone marrow failure genetic counseling program. Patients with an inherited bone marrow failure syndrome are likely to need a bone marrow transplant, requiring efficiently timed counseling, testing, and intervention for the proband and, oftentimes, relatives. Early introduction of a genetic counselor allows for consideration of the likelihood of identifying an underlying causative genetic diagnosis, psychosocial instability in patients newly diagnosed with a life-threatening disease, prolonged turn-around time for several screening tests (specifically, chromosome fragility and telomere length analyses), urgency for therapy decisions, and challenges of selecting appropriate bone marrow transplant donors and specimen(s) for genetic testing in this high risk, sometimes transfusion-dependent population. We developed a 3-step pre-test genetic counseling process to ensure standardized evaluation and timely genetic counseling and testing. At diagnosis, the genetic counselor meets the family to introduce what to expect from genetic counseling. During the first formal visit, the genetic counselor obtains medical, social, and family histories, initiates insurance prior authorizations, as appropriate, and contracts with the family for the subsequent visit, which includes the remainder of the comprehensive genetic counseling and pre-test informed consent. We provide an example of implementing genetic counseling incorporation early in the diagnosis of pediatric bone marrow failure with a goal to improve standardization of clinical evaluation, patient and family understanding of disease, and timeliness of initiating definitive therapy.

Managing couple conflict during prenatal counseling sessions: An investigation of genetic counselor experiences and perceptions

K. Schoeffel1, P. McCarthy Veach1, K. Rubin2, B. LeRoy1

1. University of Minnesota

2. Fairview Health Services

Introduction: Research shows couple conflict occurs during prenatal genetic counseling sessions, and value conflicts between family members are challenging for genetic counselors. Yet, no study has explored couple conflict in depth. The current study aimed to investigate the nature and context of couple conflict in prenatal genetic counseling sessions, as well as genetic counselor conflict management strategies. Methods: Sixteen prenatal genetic counselors recruited through the National Society of Genetic Counselors participated in semi-structured phone interviews. Questions asked about how they recognize couple conflict, topics that trigger conflict, when it occurs, individual, cultural, and situational factors associated with conflict, conflict management strategies, and specific examples from their practice. Interview data were analyzed using inductive and cross-case comparison methods. Results: Genetic counselors recognize couple conflict through nonverbal and verbal cues, and conflict can occur at any time, particularly during decision-making about testing and test results and during results review of an affected pregnancy. Factors associated with conflict include: gender roles, cultural taboos about expressing conflict, age, emotional state, religious beliefs, and being forced to attend counseling. Participants identified 23 conflict management strategies classified into five themes: facilitate decision-making, encourage couple expression, act within one’s scope of practice, provide psychosocial support, and support the identified patient. Counselors emphasized their strategies are couple-dependent. Discussion: Making decisions about an unborn child is distressing and comprises a prevalent trigger of conflict, further complicated by individual, cultural, and situational factors. Genetic counselors should assess couple conflict and intervene when conflict impedes genetic counseling goals. Clinical examples from this study inform genetic counselor practice, program curricula, and continuing education workshops.

The addition of 22q11.2 deletion syndrome to noninvasive prenatal testing: Clinical utility and patient decision making

S. To1, M. Crawley1, L. Hercher1, K. Aaron2

1. Sarah Lawrence College

2. Montefiore Medical Center

Introduction: Noninvasive prenatal testing (NIPT) has been demonstrated to have high sensitivity and specificity for common aneuploidies in both high- and low-risk populations compared to maternal serum screening, but lower positive predictive values (PPV) in low-risk populations. Recently, several NIPT companies have expanded their panels by adding microdeletion syndromes, rarer conditions with resultantly lower PPVs. Purpose: To evaluate the performance of testing and impact on patient decision making of adding 22q11.2 deletion syndrome (22q11.2DS) to NIPT panels in a general population cohort. Methods: This retrospective pilot study reviewed the database of Montefiore Medical Center in the Bronx, NY for NIPT results from May 7, 2014 to August 24, 2015. Chart review was conducted for all high risk (HR) results. Results: A total of 3603 samples were collected. Of these, 1.33 % (n = 48) were identified as HR. One third of all HR samples (16) indicated a risk of 22q11.2DS. 37.5 % of women with HR results for 22q11.2DS elected diagnostic testing, compared to 62.96 % of non-miscarrying women with all other HR results. None of the women identified as being at HR for 22q11.2DS who had diagnostic testing results (n = 5) were found to have an affected pregnancy. Conclusions: The fact that one third of all HR results in this study were attributed to 22q11.2DS suggests that the addition of microdeletion syndromes to NIPT panels would significantly increase the number of false positive results in a general population cohort. Additionally, fewer women with 22q11.2DS results elected diagnostic testing compared to those with other HR results. This may be attributed to the comparatively low PPV or to patients’ perceptions that 22q11.2DS has a less severe phenotype than other aneuploidies. These findings highlight the importance of pre- and post-test counseling with NIPT. Further investigation into the performance of microdeletion testing and patient perspectives should be conducted before universal integration into NIPT panels.

Attitudes towards prenatal genetics among southeast and East Asian women: A qualitative pilot study

G. Tsai1, C. Cameron2, J. Czerwinski1, H. Mendez-Figueroa1, S. Peterson2, S. Noblin1

1. University of Texas Health Science Center at Houston

2. The University of Texas MD Anderson Cancer Center

From 2000 to 2010, the Asian population in the United States grew five times faster than the overall US population. As Asians become incorporated into the US health care system, it is important to recognize cultural differences that may arise between Asian patients and their health care providers. Prior studies show that cultural values influence genetic perceptions within Asian populations. The reputation of the family unit factors into decisions such as pregnancy termination and disclosure of family medical history, and the non-directive model of American genetic counseling conflicts with the historical Asian model of paternalistic health care. Previous studies also provide conflicting evidence regarding correlations between education, acculturation, age, and awareness and perceptions of genetic testing. Recognizing the heterogeneity of the Asian population with regards to acculturation, education, health awareness, and cultural values is vital for tailoring culturally sensitive and appropriate care. The aims of this study were to describe attitudes towards prenatal genetics among Southeast and East Asian women and to explore sociocultural factors influencing those attitudes. Twenty three Asian women who were members of Asian cultural organizations in the US were interviewed via telephone about their attitudes towards prenatal genetic counseling, prenatal genetic testing, and termination of pregnancy. Responses were transcribed and coded for common themes using a grounded theory approach. Five major themes emerged. Participants had diverse expectations for genetic counselors with regards to emotional support and non-directiveness. Attitudes towards genetic testing and pregnancy termination varied widely and were influenced primarily by religious and spiritual beliefs, risk-benefit analysis, and cultural factors including societal stigma of disabilities, availability of resources, and family authority. These findings may allow prenatal genetic counselors to gain a richer, more nuanced understanding of their Asian patients and to offer culturally tailored genetic counseling.

Duchenne muscular dystrophy population carrier screening outcomes in the US

J. Wallace1, S. Mundy1, J. Schmidt1, M. Westemeyer1, J. Saucier1, B. Gold1

1. Natera, Inc.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are caused by mutations in the largest protein-coding gene, DMD. The size/type of mutations in the DMD gene previously limited carrier screening to women with a family history of DMD/BMD. Due to advances in genetic technologies, it is now feasible to offer population-based carrier screening for DMD/BMD. In this study, chart review was performed on all carrier screening samples tested for DMD/BMD at a single reference lab via multiplex ligation-dependent probe amplification, qPCR, next generation sequencing, and/or Sanger sequencing. Of 30,232 cases, 55 women were identified as carriers of a pathogenic or likely pathogenic DMD variant (carrier frequency, 1/550). Of the 55 DMD variants reported, 24 (44 %) were deletions, 19 (35 %) were point mutations, and 12 (22 %) were duplications. Three results showed mosaicism, including 2 cases of DMD deletions and 1 frameshift point mutation. Of the identified carriers, 9 (16 %) reported family history of DMD/BMD and 9 (16 %) reported family history of unspecified genetic condition, or as being a carrier of an unspecified genetic condition. Thus, between 37 and 46 (67–84 %) of the identified carriers in this population were at increased risk for having an affected child and did not indicate they were aware of the risk. Positive DMD results were identified in women of various ethnicities, including Caucasian (45.5 %), African-American (14.5 %), Hispanic (9.1 %), Southeast Asian (5.5 %), East Asian (5.5 %), and mixed/other (7.3 %). Of the 55 carriers, 40 (73 %) were pregnant at the time of testing, with 32 (58 %) undergoing concurrent noninvasive prenatal testing (NIPT). Fourteen women (44 %) had male fetal gender results with noninvasive prenatal testing, including 3 with a known DMD/BMD family history. These data demonstrate the utility of including DMD on an expanded carrier screening panel. Women of all ethnicities, including women without a family history, can identify their risk for having an affected child with DMD/BMD at a time when reproductive decision-making can be impacted.

The frequency of incidental findings in expanded carrier screening

K. Wong1, G. Lazarin1, I. Haque1

1. Counsyl

Introduction: Expanded carrier screening (ECS) identifies couples at risk for transmitting a genetic condition to their offspring. Patients may be counseled during the informed consent process that carriers of recessive conditions usually do not experience symptoms. Yet, there are several conditions on ECS panels where carriers may have clinical health implications (CHI). We analyzed Counsyl’s laboratory experience with over 346,790 ECS to examine this frequency. Methods:Individuals were tested for carrier status in up to 108 genes by either targeted genotyping (TG) of up to 417 sites or next-generation sequencing (NGS) of the exons and selected introns of the chosen genes. Carrier frequencies for each condition were calculated as the higher of TG or NGS frequencies. Five autosomal recessive diseases were identified for their associations with CHI: NBN for cancer risk; ATM for breast cancer risk; BCHE for risk for choline ester-induced breathing complications; DPYD for toxicity risk following 5-fluorouracil chemotherapy; and F11 for bleeding risk. Carrier frequencies for each condition were computed from de-identified aggregate data, tabulated by ethnicity, weighted by US Census Data 2010, and summated to represent the ethnic distribution in the US. Results: 346,790 patients indicating “routine carrier testing” as the reason for testing were selected, where 89 % received TG and 11 % received NGS. The carrier frequencies for each condition were 1/280 (ATM), 1/24 (BCHE), 1/109 (DPYD), 1/150 (F11), and 1/560 (NBN). This summates to an overall frequency of 6.2 % for CHI on ECS. BCHE accounted for 67 % of the frequency of CHI and is more common in individuals of Ashkenazi Jewish (4.5 %) and European descent (4.9 %) than those of African (1.0 %) or Asian descent (1.2 %). Conclusions: 6.3 % of individuals (1/16) screened for these diseases will have an incidental finding - where carriers identified may experience CHI. Pre-test counseling, informed consent, reporting, and post-test counseling should educate patients and providers regarding this possibility.

Are genetic counselors screening for adolescent suicide risk? A mixed-methods study

C. Anderson1, B. Biesecker2, D. Roter3, L. Horowitz4, L. Wissow3, L. Erby2

1. Ferre Institute

2. National Human Genome Research Institute

3. Johns Hopkins Bloomberg School of Public Health

4. National Institute of Mental Health

This study describes the practices, attitudes, and beliefs of genetic counselors in relation to suicide risk screening (SRA) of adolescent clients. Suicide is a major public health issue and one of the leading causes of death for adolescents in the U.S. Analysis of suicide prevention campaigns has shown that the most effective way to decrease suicide is by training providers to recognize suicide risk factors. As chronic illness is an additional risk factor for suicide, pediatric genetic counselors encounter particularly high-risk clients and are well-positioned to screen for suicide risk due to the psychosocial nature of their work. However, the SRA practices of genetic counselors have not been previously described. In this cross-sectional study guided by the transtheoretical model of behavior change, genetic counselors were surveyed about their practices, attitudes and beliefs concerning SRA through an anonymous online questionnaire consisting of quantitative components and open-ended questions. 229 U.S. genetic counselors who counseled adolescent clients in the past year were recruited through the National Society of Genetic Counselors Student Research Survey listserv. Almost half of respondents had screened an adolescent client for suicide risk, but most had performed SRA with fewer than 10 % of their adolescent clients. Approximately 11 % of respondents used SRA as a routine part of their clinical practice. Based on logistic regression, stage of readiness to adopt SRA was associated with prior training and perceptions that SRA is within a genetic counselor’s scope of practice. While most rated SRA as important, the qualitative results suggest that many perceive barriers to SRA, often fearing negative reactions from their adolescent clients. Suicide risk assessment training specific to genetic counselors’ needs and concerns could help to increase frequency of SRA and thereby identify adolescents at risk for suicide.

Parental experience of divulging a diagnosis of fragile X syndrome to their affected child

B. Athens1, C. Hill-Chapman2, E. Jordon1, A. McConkie-Rosell3

1. University of South Carolina

2. Francis Marion University

3. Duke University Medical Center

Fragile X syndrome (FXS) is a genetic condition with varied presentation that may include intellectual and learning disabilities, behavioral and learning challenges, and certain physical characteristics. When an individual is affected with FXS, it often leads to complex discussions within the family, but current literature is lacking information on parental disclosure of a FXS diagnosis to an affected child. This study explored how a FXS diagnosis is communicated between a parent and their child diagnosed with FXS. An online questionnaire was disseminated through FXS organizations and support groups to parents who have at least one child diagnosed with FXS. The online questionnaire was supplemented by eight brief telephone interviews. Qualitative analysis was conducted on eighty-three responses. Parents commonly practiced resilient communication while providing age and developmentally appropriate information at a level their child was able to understand. Though parents would focus on how their child was different from others to explain FXS, they also used affected family members and other FXS families as examples to prevent their child from feeling isolated by the diagnosis. Parents worried that their child would not understand or that the information provided would have a negative effect on the child’s emotional being. Resources were not often used, but parents expressed a desire for a children’s book written specifically for children with FXS as well as easier access to input from other FXS families and healthcare professionals. Awareness and understanding of this experience will allow genetic counselors to provide appropriate education, support, resources, and referrals to ensure successful communication between a parent and child.

The implementation of whole exome and genome sequencing based on genetic counseling specialty

A. Blesson1, K. Maloney1, J. Cohen2, J. Frank1, S. Dixon1

1. University of Maryland School of Medicine

2. Kennedy Krieger Institute

As whole exome sequencing (WES) and whole genome sequencing (WGS) continues to improve in its interpretation of disease-causing genetic variation, genetic counselors are increasingly consulted upon to counsel about the benefits and limitations of this type of testing. In this study, we investigated how genetic counselors of varying primary specialties implement WES/WGS into their practice in order to first, determine which specialties offer WES/WGS; second, compare components of the WES/WGS process by specialty; and third, identify counseling issues and techniques that are unique to each specialty. One hundred and seventy-five members of the National Society of Genetic Counselors (NSGC) participated in an anonymous online survey and were organized into four core primary specialties: cancer, pediatrics, other postnatal, and prenatal. Our results show that cancer (37 %, n = 48), pediatric (96 %, n = 48), other postnatal (93 %, n = 44), and prenatal (29 %, n = 35) specialties offer WES/WGS. Within the WES/WGS process, these specialties only differ in the purpose, indication, and volume of tests, and the remaining aspects of pre-test and post-test counseling are similar. The increase in number of counselors offering WES/WGS and the innate counseling differences between the specialties can be attributed to the suitability for offering WES/WGS within that specialty. Coding of responses from open-ended questions revealed that all specialties shared challenges of time and result interpretation and used techniques of analogies and multiple result sessions during WES/WGS counseling. Collectively, all specialties suggested educational resources provided by the NSGC would be useful for future implementation of WES/WGS. Therefore, as WES/WGS become more accessible and fitting for different specialties, future evaluation of the WES/WGS process will help create a knowledge base for genetic counselors of any specialty.

Adolescent decision-making regarding secondary findings in whole genome sequencing

R. Byrne1,2, H. Robin1, K. Miriam1, K. Sappleton1, D. Chitayat1, C. Shuman1, N. Monfared1

1. The Hospital for Sick Children

2. University of Toronto

Background: Genomic testing is widely used to diagnose adolescent patients with suspected genetic conditions. Such testing is preceded by an educational component to support informed decision-making. Recent research suggests that adolescents benefit from participation in medical decision-making regarding their health care. However, little is known about adolescents’ understanding of the risks and benefits related to secondary findings (SFs) found in genomic sequencing. Identifying and understanding the factors that contribute to adolescents’ decision-making about SFs will inform new approaches to education and consent for adolescents undergoing genomic sequencing. Objective: To explore factors that are important to adolescents in their decision-making process related to learning about SFs in genomic research. Study Design: Using semi-structured interviews, we explored the experiences of adolescents, ages 12–19, in their decision to learn about SFs in the context of the whole genome sequencing (WGS) in a research setting. Adolescents were previously offered WGS to determine the molecular etiology of their chronic medical condition. Interview questions were used to assess adolescents’ understanding of SFs, awareness of the potential risks and benefits and the factors that adolescents consider when deciding to learn about SFs in genomic research. Results: Eight adolescents, ranging from 12 to 19 years of age, of whom 7/8 opted to learn about SFs were recruited. Thematic analysis of the transcripts using constant comparative analysis was conducted. To date, three sets of factors have emerged as influential with respect to decision-making about secondary findings: familial factors, including family history and parental discussion; personal health history; perceived value of knowledge. Conclusion: Preliminary results from the study suggest that adolescents’ personal health and family relationships impact their decision to learn about SF. This indicates the importance of exploring these factors with adolescents in the pre-test consent process for genomic sequencing.

From a trio to a duo: Non-paternity identified through diagnostic exome sequencing

T. Cain1, Z. Powis1, D. El-Khechen1, S. Tang1

1. Ambry Genetics

Family centered diagnostic exome sequencing (DES) can reveal non-paternity in which a proband’s attributed father is not the proband’s biological father. Such findings can have ethical, psychological, and medical consequences for a family. While recommendations have been made, there is no clear consensus for if, when, and to whom non-paternity findings should be disclosed. Non-paternity events detected through parent-proband trio DES from 1547 consecutive families were retrospectively reviewed. For each such case, referring clinicians were notified of non-paternity during analysis, and asked how they would like to proceed. After reporting, clinicians were re-contacted to determine if non-paternity was disclosed. Among 1547 patients analyzed, non-paternity was detected and confirmed in 7 patients (0.45 %). Two cases were excluded from the study as the possibility of non-paternity was brought up prior to testing, and DES confirmed the suspicion in these cases. Of the 5 remaining cases, clinicians chose to proceed with the analysis as a duo in 3 cases (60 %) and elected to use an additional family member’s sample for a trio in 2 cases (40 %). Clinicians also requested modified reports in which pedigree and co-segregation data were removed in 4 cases (80 %) and chose to receive an unaltered report in 1 case (20 %). Furthermore, clinicians chose not to disclose the non-paternity findings to the family in 1 case (20 %) and chose to disclose the findings to only the mother in 4 cases (80 %). Overall, despite subsequent limitations to analysis, the majority of clinicians elected to proceed with testing as a duo, and requested removal of information from the reports. While the majority of clinicians chose to disclose the non-paternity findings to the mother, none of the clinicians elected to disclose the findings to the father or the proband. Taken as a whole, these findings demonstrate a general trend towards avoiding disclosure of non-paternity findings. Non-paternity is a difficult situation, and genetic counselors are needed to discern how to respond to these findings.

Diagnosis of fragile X syndrome: A pre- and post-diagnosis comparison of carrier mothers’ emotional and support experiences

A. Catchings1, A. Egense2, S. Desai3, R. Palmquist2, S. Dixon1

1. University of Maryland School of Medicine

2. University of Maryland Medical Center

3. Kennedy Krieger Institute

As fragile X syndrome (FXS) becomes a consideration earlier in the diagnostic odyssey and newborn screening (NBS) for FXS becomes plausible, research is needed to explore the experiences of carrier mothers throughout this process. This study assessed carrier mothers’ emotional and support experiences before versus after a child’s diagnosis of FXS. Mothers of 82 children diagnosed with FXS in the first 3 years of life completed a survey that evaluated mothers’ demographic factors, emotional intensity, and utilization and helpfulness of various support systems pre- versus post-diagnosis. Mothers’ emotional intensity increased upon receiving a diagnosis of FXS for a child, yet their perceived level of support did not increase. Additionally, while mothers were more likely to access and use various support systems after a child’s diagnosis of FXS, mothers were not more likely to find these support systems helpful. Results indicated that the number of reportedly helpful support systems mothers used influenced their perceived level of support prior to a child’s diagnosis, yet the number of reportedly helpful support systems used after a child’s diagnosis did not appear to impact mothers’ perceived level of support. These study findings will help genetic counselors anticipate the emotional responses that carrier mothers might have before and after a child’s diagnosis of FXS and may direct the types of support systems to offer to best address these emotions and to ensure that mothers feel supported.

Patient preferences for recontact and their monitoring coping style following BRCA mutation testing

R. Dahle1, A. Hamang2, Å. Lunde1

1. University of Bergen, Norway

2. St. Olav’s University Hospital

Background: Advances in medical genetics are occurring at an exponential rate. There is an ongoing discussion whether genetic counselors should recontact former patients regarding updated genetic information. Little information is available on the implications of this practice, from the point of view of former patients. Aim: To investigate preferences for recontact with the genetic clinic, in a sample of patients tested for BRCA-mutations. Further investigate whether mutation status (positive/negative), type of genetic test (predictive/diagnostic) and having high information seeking coping style (monitoring) impact preferences. Knowledge from the study may be useful to achieve better communication with patients regarding recontact. Methods: Self-administered questionnaires were sent to 500 randomly selected patients who were previously tested for a BRCA-mutation between the years 2001 and 2014 at a genetic clinic in Norway. We received 280 completed questionnaires. Preferences for recontact were assessed with a self-constructed questionnaire, and the Threatening Situations Inventory (TMSI) was used to measure monitoring coping style. Results: Most respondents wanted the genetic counselor/geneticist to recontact them with advances in genetic medicine. They preferred to receive highly personalized updates. Genetic counselors/geneticists were believed most responsible for recontact. When comparing responses based on test result, type of test and high/low monitoring coping style, some, but few differences were found. The findings indicated a tendency for high monitors to prefer more detailed and personalized information. Conclusion: Patients have a high interest in being recontacted to receive updated genetic information. Receiving information relevant to own health and to receive information relevant to their own or relative’s cancer risk were main reasons for wanting recontact. Findings indicate that type of genetic test, test result and having a high or low monitoring coping-style is of minor significance for preferences.

A unique case of Down syndrome caused by nonmosaic Y;21 translocation

J. Foster1, D. Xu1, J. Little2, A. Mfizi3, E. Kamanzi4, L. Mutesa5, A. Elias1

1. Shodair Children’s Hospital

2. Jackson Pediatric Associates

3. University of Rwanda

4. University of Liège

5. National University of Rwanda

Introduction: Balanced and unbalanced Y-autosome translocations are rare. We present a case of an unbalanced Y;21 translocation, resulting in partial trisomy 21 and phenotypic features consistent with Down syndrome (DS). Case Report: The patient was born at term via repeat C-section to a 39 year old G2P2 mother and 47 year old father. The pregnancy was uncomplicated. Birth weight was 2.7 kg. Muscular hypotonia and dysmorphic features consistent with DS were noted, including upslanting palpebral fissures, epicanthal folds, and small nose with depressed nasal bridge. A large VSD and PDA, pulmonary hypertension, and tachyarrhythmia were diagnosed postnatally. External male genitalia were normal. Initial feeding was without difficulties. Chromosome studies in blood lymphocytes identified an abnormal chromosome Y, der(Y)t(Y;21)(q11.21;q11.2) in all 20 metaphase cells analyzed. Cells showed two normal homologues of chromosome 21, one normal chromosome X, and a derivative chromosome Y. The abnormal chromosome Y included the p arm and centromere (from Ypter to Yq11.2, including SRY) and most of chromosome 21 (21q11.2 to 21qter). These results indicate the following outcomes: loss of partial chromosome Y from Yq11.2 to Yqter and partial trisomy of chromosome 21 from 21q11.2 to 21qter. Results were confirmed by fluorescence in situ hybridization (FISH). In addition, FISH probes revealed the SRY locus within the der(Y). Parental chromosomes in blood lymphocytes were normal. Discussion: We present a case of a nonmosaic unbalanced Y;21 translocation resulting in truncated Y and partial trisomy 21 with a phenotype of DS. The der(Y) was likely derived from a translocation between chromosomes Y and 21 during paternal meiosis. Results indicate complete deletion of the AZF gene regions within the Yq11.2qter interval, which has possible consequences for spermatogenesis within the confounding context of trisomy 21. Although few cases of Y-autosome translocations have been described, to our knowledge, this particular cytogenetic finding has not been reported.

The psychosocial impact of diagnosis on caregivers of children with 3q29 deletion syndrome

M. Glassford1, S. Pass1, J. Mulle1, C. Bellcross1, K. Cornell2

1. Emory University School of Medicine

2. Emory University Healthcare

3q29 deletion syndrome (3q29 DS), present at a population frequency of approximately 1 in 30,000, can present with developmental delay, intellectual disability, autism spectrum disorder, psychosis, and a range of other symptoms. The phenotypic spectrum varies widely, often resulting in extended, stressful diagnostic odysseys. This is the first study to assess the psychosocial impact of the diagnosis on caregivers of individuals with 3q29 DS. Participants were recruited from the 3q29 DS registry and Facebook group. Fifteen caregivers completed a semi-structured phone interview during which they were asked questions regarding their thoughts, feelings, and experiences before, during, and after their child was diagnosed with 3q29 DS. Interview responses were transcribed verbatim, analyzed using the general inductive approach, and overarching themes were identified. Overarching themes included: difficult diagnostic odyssey, mixed feelings about diagnosis, frustration with degree of uncertainty, and importance of resources. The level of difficulty with finding a diagnosis was related to degree and specificity of symptoms and available technology. Mixed feelings surrounding the diagnosis included validation, relief, frustration, and despair. Caregivers expressed frustration with degree of uncertainty surrounding the variable phenotypic spectrum, risk for psychosis, level of independence, and long-term prognosis. Parents emphasized the importance of having knowledgeable and motivated healthcare providers, support of other affected families, and access to therapeutic resources. Our results provide insight into how caregivers experience receiving the diagnosis of 3q29 DS in their child. These results suggest that clinicians should familiarize themselves with 3q29 DS before interacting with the family, discuss and validate caregivers’ feelings surrounding the variable phenotypic spectrum, and provide educational and support resources in order to strengthen the patient-doctor relationship and improve caregiver experiences.

Communication predictors of patient and companion satisfaction with Alzheimer’s disease genetic risk disclosure sessions

Y. Guan1, D. Roter2, L. Erby3, J. Wolff2, L. Gitlin2, J. Roberst4, K. Christensen5, R. Green5

1. University of Maryland

2. Johns Hopkins Bloomberg School of Public Health

3. National Institutes of Health

4. University of Michigan School of Public Health

5. Brigham and Women’s Hospital, Harvard Medical School

Introduction: Prevention and early intervention for Alzheimer’s disease (AD) is a national priority. Despite growing reliance on APOE genotyping to identify at-risk populations, little is known about how genetic counseling processes and associated risk disclosure might influence satisfaction of patients and their visit companions. This study identifies features of AD risk communication that predict patient and companion satisfaction with risk disclosures. Methods: Secondary analyses were conducted on 79 session recordings from the fourth REVEAL trial, a randomized controlled trial of genetic risk disclosure for AD among patients with mild cognitive impairment. The Roter Interaction Analysis System (RIAS) was used to code session triadic communication among the counselor, patient and visit companion. Parallel 10-item satisfaction surveys were administered after the session to measure patient and companion satisfaction. Multivariate logistic regression was used to determine the association between communication behaviors and satisfaction taking into account patient and companion gender, educational level, and patient 3-year AD risk. Results: The average satisfaction scores were 46 and 47 out of 50 for patients and companions, respectively. Patient satisfaction was positively associated with patients’ expression of emotions (OR = 1.06, p < 0.05) and companions’ psychosocial question asking (OR = 1.75, p < 0.05) during the session. Companion satisfaction was positively related to the overall patient-centeredness of the genetic counseling session (OR = 3.97, p < 0.05). Discussion: Although communication features associated with patient and companion satisfaction with disclosure sessions differed, satisfaction of both groups was related to level of patient-centered communication. Findings from this study also suggest a significant positive role of visit companions in facilitating patient satisfaction. The study results highlight opportunities to increase patient satisfaction in genetic risk communications.

Nationwide newborn screening program for mucopolysaccharidoses in Taiwan: Confirmatory diagnosis and genetic counseling

Y. Huang1, S. Lin1, H. Lin1, C. Chuang1, C. Chiang2, H. Hornung3, M. Chan2, R. Tu1, S. Huang1

1. MacKay Memorial Hospital and Rare Disease Center,Taiwan

2. Chinese Foundation of Health, Newborn Screening Center

3. Taipei Institute of Pathology, Newborn Screening Center

Background: Mucopolysaccharidoses (MPS; OMIM252700) are a group of rare metabolic disorders caused by deficienct activity of lysosomal enzymes, leading to accumulation of glycosaminoglycans (GAGs) in various cells and tissues, and progressive multi-organ damage. Previous studies have indicated that early diagnosis and treatment could result in a better outcome. Methods: In August 2015, a newborn screening (NBS) program for MPS I, II, and VI was initiated nationwide in Taiwan. Tandem mass spectrometry (MS/MS) has been used to assess disease-specific enzyme activity from dried blood spots (DBS). DBS samples were collected by the age of 3 days. The comprehensive confirmatory diagnosis process was performed in MacKay Memorial Hospital for all suspected babies, including biochemical assays and molecular testing. A complete family pedigree was also taken and analyzed. Results: Between August 2015 and March 2016, a total of 82,197 newborns were screened in this program. Fifty-two (0.06 %) newborns, including 3 suspected MPS I, 48 suspected MPS II, and 1 suspected MPS IV, were referred to our hospital for confirmatory diagnosis. Among the 48 suspected MPS II babies, IDS gene analysis revealed that 21.2 % had c.1499C>T (p.T500I), 12.8 % had c.301C>T (p.R101C), 2.1 % had c.890G>A (p.R297H), 6.4 % had c.1478G>A (p.R493H), and the remaining had an IVS mutation of c.103 + 34_56dup. Both p.T500I and p.R101C were demonstrated to be non-pathogenic. The c.103 + 34_56dup, p.R297H, and p.R493H are still awaiting further characterization and long-term follow-up of their clinical manifestation. Conclusions: In the NBS for MPS program, most parents of newborns with suspected MPS felt overwhelmed, worried, sad, anxious, denial, etc. Although this program has allowed us to develop a promising and novel screening approach for these conditions, it has also illuminated the complex methodology and psychosocial challenges that go along with such a program. It highlights the need for genetic counselors to work closely with multidisciplinary specialists in the implementation of new screening programs.

A Delphi survey of personal utility

J. Kohler1, K. Lewis1, L. Biesecker1, B. Biesecker1

1. National Human Genome Research Institute

With the rapid integration of sequencing technologies, researchers and clinicians recognize how genomic test results affect recipients in ways distinct from clinical utility. These outcomes have been labeled as “personal utility.” Identifying elements of personal utility will help clinicians inform patients about a broader range of potential testing outcomes. This study aimed to identify key elements of personal utility and gather evidence in support of the importance of elements from stakeholders in a genome sequencing study. A systematic literature review was conducted to extract elements of personal utility. Elements identified were assembled into a Delphi method survey and administered to 40 participants in a whole-genome sequencing research study. The survey consisted of two rounds; after each round, elements were added or removed based on participant ratings. Coding of the review outcomes was used to create a 38-item Delphi survey. After round one, seven items were dropped and two were added; after round two, six additional items were dropped based on low rating. This resulted in 27 items representing 15 elements of personal utility in four domains. Elements of personal utility most relevant to participants in genome sequencing research are largely positive, suggesting that individuals anticipate and experience non-clinical benefits from their results. Findings from this study may inform shared decision-making between clinicians and individuals considering genomic testing, as well as guide pre-test counseling. The evidence-based elements may be used to inform development of efforts to assess the prevalence and importance of personal utility to test users.

Direct and indirect non-disclosure preimplantation genetic diagnosis for Huntington disease

A. Machaj1, S. Maithripala1, D. Shah1, S. Rechitsky1, A. Kuliev1, T. Pakhalchuck1

1. Reproductive Genetic Innovations

Objective: To analyze the utility of direct and indirect non-disclosure preimplantation genetic diagnosis (PGD) for a series of 32 patients at risk for Huntington Disease (HD). Design: Retrospective case review. Materials and Methods: This study evaluated the records of patients with a family history of HD who opted not to pursue pre-symptomatic genetic testing Results: Direct and indirect non-disclosure approaches to PGD provides at-risk individuals the option to pursue PGD without revealing personal gene status. Following a PGD consultation, 32 patients underwent HD non-disclosure genetic testing. 28 % of patients elected to pursue indirect non-disclosure testing and 72 % of patients elected to pursue direct non-disclosure testing. In indirect non-disclosure testing, embryos found to have inherited chromosomal material from the affected grandparent are excluded as high risk and are not recommended for transfer. As no direct genetic testing for the mutation is performed, the genetic status of the at-risk partner is not revealed to the patient or to the clinic staff. Embryos predicted to have inherited the at-risk haplotype are not recommended. There is a risk of unnecessary PGD testing if the patient did not inherit the at-risk allele. For direct non-disclosure testing, an anonymous DNA sample from the at-risk individual is sent for diagnostic testing. Aneuploidy testing is necessary for the direct method. Unaffected and/or euploid embryos are therefore suitable for embryo transfer. In order to avoid any potential deduction of genetic status the number of eggs retrieved, embryos testing, or embryos recommended for transfer should not be disclosed. Conclusions: Non-disclosure PGD offers an alternative by which pre-symptomatic individuals, who are at high risk of carrying HD can minimizing the chances of passing on the risk allele without incurring the emotional, social and financial burdens. The feasibility of each approach will depend on the patient’s family history, availability of familial DNA samples and personal preferences.

The needs and expectations of parents of children with rare conditions that are undergoing whole exome sequencing

J. Malcolmson1, J. Fischer2, G. Lyon3

1. Saint Peter’s Healthcare System

2. Long Island University – Post

3. Stanley Institute for Cognitive Genomics Cold Spring Harbor

The genetic basis of many childhood-onset neurologic conditions is unknown, and often routine genetic testing is unsuccessful in identifying a diagnosis. Whole exome sequencing (WES) has been successful in identifying pathogenic variants leading to diagnoses that would not have been made otherwise. Parents of children with rare conditions embark on a diagnostic odyssey, which can be stressful, frustrating and uncertain. The participants in this study were parents of children that have developmental delay, neurological symptoms and/or dysmorphic features. This qualitative study, involving semi-structured interviews with nine mothers of affected children, aimed to understand the parents’ needs and experiences of having no diagnosis and an uncertain prognosis for their child. An additional objective was to determine if a genetic counselor would be able to fulfill the needs of parents who are seeking a diagnosis for their child. Four of the nine respondents had received a genetic diagnosis and five were waiting for results from WES. Parents of children without a diagnosis each have a difficult and unique journey with a range of challenges and motivators for finding a diagnosis; however, not all parents are optimistic that a diagnosis will have an impact. Despite differences in parents’ circumstances, themes regarding how parental needs were met were identified. Parents tended to have a realistic view of their child’s future and were able to maintain hope and positive feelings, which fulfilled the need for understanding expectations of the future. Communication with healthcare providers was most valuable when providers advocated on behalf of the family, listened, gave explanations, recognized the parental effort and were resourceful. The need for support was often met by the partner or other family members and by encounters with other parents with shared experiences. This study suggests that a genetic counselor would be an appropriate healthcare provider to address the needs of parents seeking a diagnosis and to discuss the uncertainty that may arise in the future.

Discussing reproductive implications of exome sequencing findings with adolescents and their parents

R. Mueller1, A. Werner-Lin1, S. Walser1, B. Bernhardt1

1. University of Pennsylvania

Introduction: As the qualitative arm of a translational exome sequencing (ES) project, this study aimed to assess adolescent and parental experience of ES. Case Report: We present the case of a 19 yo female with Brugada syndrome, found to have a causal SC5NA mutation and GJB2 carrier status. We digitally recorded, transcribed, and coded the return-of-results (ROR) session and separate 3-month follow-up interviews with the adolescent and her mother. During ROR, the genetics provider explained that results could be used for “preconception or family planning” including CVS or in vitro fertilization (IVF) with Preimplantation genetic diagnosis (PGD). While the provider focused on PGD for Brugada syndrome, the proband broadened discussion to GJB2-related risks. In reflection, the proband reported feeling surprised, but pleased, that PGD was discussed and expressed interest in PGD, regardless of cost. She reported that reproductive options brought relief due to ameliorated risks and reduced pressure on romantic relationships. The proband described “fixing the gene” before pregnancy and believed her parents could have “fixed” her genes to prevent Brugada. The proband viewed discussion of reproductive options as permission to commence sexual activity and to become pregnant when she previously believed both had medical contraindications. While the proband reported discussion of reproductive issues as uniformly favorable, the proband’s mother felt ambivalent, stating she was also concerned that the conversation was “a lot for a 19 year old to absorb.” For the mother, “the downside” of testing was its transgenerational impact, extending her concerns to her daughter’s new reproductive decisions and risks to grandchildren. Discussion: ES is providing multiple reproductively relevant results to adolescence and their families. This case suggests the importance of monitoring variation in patient/parent reactions, informational needs, and comprehension. This may be useful in guiding discussion and providing follow-up counseling to correct misperceptions.

Unknown consanguinity reveals homozygousCLCN7mutations previously reported with autosomal dominant osteopetrosis type II: A case report.

R. Nuccio1, S. Hines-Dowell1, M. Boals1, R. McGee1, E. Quinn1, U. Reiss1, K. Nichols1

1. St. Jude Children’s Research Hospital

Osteopetrosis is a genetic disorder in which osteoclasts fail to resorb bone, leading to sclerosis in a variety of bony structures and increased risk for fractures. Other clinical features include poor growth, facial palsy, hearing loss, vision loss, anemia, thrombocytopenia, scoliosis, and dental anomalies. This condition presents within a wide spectrum of clinical severity and is inherited in autosomal dominant, autosomal recessive, and X-linked forms. We report the case of a 5-year-old boy diagnosed with osteopetrosis after follow-up for a left tibia fracture. Additional medical history included gross motor and developmental delays, vision impairment, microcytic anemia, and thrombocytopenia. He was sent to genetics for evaluation, and a next-generation sequencing (NGS) panel including 13 genes associated with osteopetrosis was ordered. Testing revealed a homozygous mutation (NM_001287.5:c.896C>T; p.Ala299Val) in CLCN7. This mutation has been previously reported in the heterozygous state in individuals with autosomal dominant osteopetrosis type II. The laboratory performing the testing noted that the patient was also homozygous for 15 polymorphisms in CLCN7. Given these findings, single-nucleotide polymorphism (SNP) microarray revealed multiple regions of homozygosity comprising 4.94 % of the genome, consistent with inheritance from a shared ancestor. Consanguinity was denied by the family, both in the pre-test and post-test genetic counseling sessions. Both parents were confirmed to carry this CLCN7 mutation in the heterozygous state and are asymptomatic. Unexpected common ancestry revealed by SNP array has previously been discussed in the literature. This case represents the first known report of this CLCN7 mutation in the homozygous state, and also highlights the importance of pre-test genetic counseling that includes discussing the possibility of revealing consanguinity when offering genome-based testing.

Paternal adaptation to a child’s diagnosis of Down syndrome: Predictors of personal well-being and family quality of life

M. Oliver1, J. Sheldon2, K. Partynski3, B. Yashar2

1. Spectrum Health

2. University of Michigan

3. Children’s Hospital of Orange County

Understanding the similarities and differences between maternal and paternal perspectives in families with a child with an intellectual disability is critical to ensure optimal child well-being and family quality of life (FQoL). However, while maternal experiences have been well studied, there is limited research on fathers. We examined predictors of paternal resilience to explore fathers’ well-being and FQoL in the context of Down syndrome. Via support groups, we used ten validated measures to survey fathers of children with a diagnosis of DS (N = 161) in an online format. Using hierarchical regression analyses, we assessed predictors of personal well-being and FQoL. The three predictor blocks were: 1) family environment (demographics of family members); 2) fathers’ personal perceptions/attitudes (coping style, perceived knowledge of DS, perceived disease burden, perceived stigma, social support, and positive/negative affect); and 3) family dynamics (relationship satisfaction, parenting stress, and family adaptability/cohesion). We found that similar variables predicted both outcomes. Higher personal well-being and FQoL were significantly predicted by relationship satisfaction (p = .01, p < .001, respectively) and social support (p = .002, p = .04, respectively), whereas lower personal well-being and FQoL were predicted by parenting stress (p = .01, p = .001, respectively) and perceived stigma (p = .02, p < .001, respectively). Additionally, family cohesion significantly predicted higher FQoL (p < .001). Our results suggest that the more fathers perceive stigma being directed at their child, the lower their personal well-being and FQoL. However, fathers benefit from social support and a satisfying relationship with their partner. By identifying factors that contribute to paternal positive adaptation, genetic counselors can encourage and support both the patient and the family. With guidance on how to improve resilience, fathers can become better equipped to overcome the challenges of raising a child with DS.

Understanding the psychological impact of pediatric whole exome sequencing results on parents

R. Rabin1, J. Wynn2, A. Mills3, N. Frye1, W. Chung3

1. Long Island University - Post

2. New York Presbyterian Columbia

3. Columbia University

Whole exome sequencing (WES) has proven to increase the diagnostic rate of genetic disorders; however, testing can produce uncertainty, regardless of the test result. Little research has explored the psychological impact on parents of children who undergo WES. This study aims to explore the psychological outcomes, specifically uncertainty, that parents may experience when their child has WES for a variety of clinical indications, with varying WES results. Parents of children and adults who had WES at Columbia University Medical Center (CUMC) were contacted for potential enrollment to complete a survey about their experiences with WES. The current study only examines the psychological outcomes of parents of children without secondary findings or re-analysis by analyzing a MIRCA Questionnaire. Differences in MICRA scores were examined between parents who reported receiving a positive result, a negative result, and an uncertain result. Significant differences in MICRA scores were found between groups on total MICRA scores, distress subscale scores, and uncertainty subscale scores. Parents of children who reported a positive WES result had significantly higher total MICRA scores and distress subscale scores than parents of children who reported a negative result and an uncertain result. Uncertainty subscale scores were significantly greater for parents who reported a positive result than parents who reported a negative result. Parents do experience some degree of uncertainty, and thus psychological impact, when their children undergo WES. Although positive results identify an underlying cause for the condition, many times there is scientific uncertainty regarding the prognosis. It is important for genetic counselors and other health professionals to try to identify and understand the uncertainty that parents experience, so we can adapt our counseling to allow these individuals to cope with the uncertainty and have an overall positive experience with testing.

The undiagnosed patient and the diagnostic odyssey: Current genetic counseling practices and perspectives

A. Wardyn1, E. Jordon1, K. Coing2, N. Carmichael3

1. University of South Carolina

2. Greenwood Genetic Center

3. Brigham and Women’s Hospital

Patients seen in genetics clinics often endure a diagnostic odyssey in their search for answers for their medical symptoms. This time is not only challenging for patients and their families, but also for the genetic counselors who are trying to help the patients. Previous research has shown that parents of children with undiagnosed medical disorders have specific goals and reasons for wanting to find a diagnosis, and there are many difficulties faced by these parents. Genetic counselors often serve as a prominent figure during the diagnostic odyssey, but little known research has assessed the current practices of and impact that the diagnostic odyssey has on genetic counselors. This study surveyed pediatric genetic counselors to assess their current practices and thoughts about the diagnostic odyssey. This was assessed utilizing a questionnaire, which included both multiple choice and short answer questions. We identified current genetic counseling practices including communication methods and resources provided to patients. Counselors reported a possible need to share the responsibility of communication with their patients and a lack of resources specific to patients on the diagnostic odyssey. Genetic counselors also reported feeling personally impacted by patients on the diagnostic odyssey, and described the positive and negative feelings they experience, in addition to strategies to cope with their frustrations. In conclusion, the diagnostic odyssey is a complex process for patients, and similarly challenging for the counselors who are involved in the patients’ care. Genetic counselors have an opportunity to provide additional support, resources, and hope to families during the diagnostic odyssey, although these roles may not be strictly defined in the counselors’ responsibilities.


Identifying and counseling patients amenable to mutation specific therapies in Duchenne muscular dystrophy (DMD): Knowledge of resources will fuel genetic counselors’ impact

L. Bogue1, D. Martin2, E. O’Rourke2, M. Pastore3, A. Smith4

1. Parent Project Muscular Dystrophy

2. Sarepta Therapeutics

3. Nationwide Children’s Hospital

4. University of Pittsburgh; Children’s Hospital Pittsburgh

Mutation-specific therapies are currently in clinical trials for Duchene muscular dystophy (DMD), a progressive, life-limiting X-linked neuromuscular disorder caused by mutations in the DMD gene (Xp21.2) that result in a lack of functional dystrophin. Between two current approaches, nonsense mutation suppression and exon skipping, > 60 % of DMD cases are potentially amenable. Genetic counselors are uniquely positioned to overcome barriers in determining patient eligibility for mutation-specific interventional trials. Access to genetic testing is one such barrier. In a survey of 27 U.S. physicians who manage over 2000 DMD patients, there was significant variability in genotyped patients (~25–100 %). Of participants in the DuchenneConnect national registry, an estimated 19 % have not been fully genotyped. Awareness of financially viable testing options like the Decode Duchenne program, which provides free genetic testing to eligible individuals, is essential. Accurate test result interpretation presents a second barrier between patients and mutation-specific approaches. While nonsense mutations are categorically amenable to nonsense suppression, other DMD mutations vary in amenability to exon-skipping. To counsel patients accurately, clinicians must discern if a mutation is appropriate for exon skipping and whether the mutation is amenable to particular exon skipping therapeutics. With this level of complexity, access to interpretation tools and guidance is paramount for genetic counselors to advise both patients and other providers. We present and review the DMD gene exon map, the Leiden DMD database, the Decode Duchenne program website, and the University of Utah mutation tables as tools to help genetic counselors determine DMD patients’ eligibility to exon skipping.

Incorporation of a genetics-based information module into standardized diabetes patient education

K. Drazba1, J. Denton2, F. Ovalle2, S. Griffin2, A. Wharton2, M.Ziroli2, P. MacLennan2, G. McGwin2, C. Hurst2

1. Greenwood Genetic Center

2. University of Alabama at Birmingham

The current prevalence of diabetes is a significant public health issue, and multidisciplinary prevention efforts are warranted. Genetics risk assessment and education is a newly investigated approach to increase understanding of diabetes etiology and inspire behavior modification. This study investigated the effectiveness of an educational module created to improve understanding about the genetics of diabetes. Participants completed a pre-test survey to assess three domains: 1) knowledge about diabetes etiology and genetic testing, 2) motivation to adopt healthy lifestyle behaviors, and 3) interest in genetic testing for diabetes. Participants viewed an educational module, and then completed a post-test survey to re-assess the domains. Participants increased knowledge about the genetics of diabetes (p < 0.0001) and testing (p = 0.0184), demonstrated motivation to adopt healthy behaviors (p < 0.0001), and decreased interest in genetic testing (p = 0.0522) after viewing the educational module. The results suggest that the educational module was effective in increasing understanding of diabetes and increasing motivation to adopt healthy behaviors. As the complex interaction of genetics and the environment is further elucidated, genetics professionals will likely play a larger role in risk assessment, genetic counseling, and diabetes education with the goal of facilitating a translational approach to diabetes research, prevention, and management.

Family health history communication: Cross cultural comparison of knowledge of familial disease history

A. Elrick1, M. Pokharel1, H. Canary1, M. Clayton1, M. Sukovic1, M. Champine2, K. Kaphingst1,2

1. University of Utah

2. Huntsman Cancer Institute

Introduction: Family health history (FHH) is an important tool for identifying risk for genetic conditions. Genetic counselors routinely utilize FHH to evaluate patients and determine appropriate recommendations for genetic testing and screening. To build an accurate, comprehensive FHH, individuals need to communicate with their family and be aware of familial disease histories. Research is limited about how families from diverse communities share knowledge of familial diseases. To address this gap, our study investigated knowledge of familial diseases among families from three racial and ethnic groups. Method: We conducted semi-structured, in-person interviews with 10 family dyads (i.e., siblings and parent–child) from each of three groups: Caucasian, Hispanic and Pacific Islander. Each family member was interviewed separately and then dyads were interviewed together. Interview topics included general health, knowledge of familial diseases, and communication about health within the family. Interviews averaged 90 min in length. Two coders independently coded interview transcripts using Nvivo 11. Results: Family dyads demonstrated a range of knowledge regarding familial diseases: shared (i.e., mutual knowledge), differences (i.e., knowledge held by only one person or disagreement), and unsure (i.e., “I don’t really know”). Both gender (e.g., not talking to opposite gender about health topics) and culture (i.e., cultural norms for open vs. restricted communication) were seen impacting the flow of communication within families, and thus knowledge about FHH. Discussion: Shared knowledge is critical for understanding disease risks within the family and building an accurate FHH. Our findings are novel in that they highlight patterns in family communication amongst 3 diverse communities, and indicate directions for closing the gaps in individuals’ knowledge of their FHH. The results indicate how gender and culture impact family communication about health and have implications for the development of culturally competent interventions to improve this communication.

“If I saw this, I would feel well-informed” to “in a word, it was awful”: Evaluation of a novel educational video on pharmacogenetic testing

M. Ensinger1, N. Callanan1, R. Mills2

1. The University of North Carolina at Greensboro

2. Duke University

Though the use of pharmacogenetic testing has increased in recent years, there is currently a lack of patient educational materials on this topic. Therefore, we aimed to create a patient educational video on pharmacogenetics and to conduct a formative evaluation of the novel video. A primary literature and resource review was conducted to inform the content and format of the video. The educational video was then created using a commercially available animation program and pilot tested in focus groups of the general public and by an online survey of pharmacists. Themes that emerged from the focus groups and survey indicated a desire for more specific examples of medications or conditions for which pharmacogenetic testing may be helpful, and presentation of risk information in appropriate context. Focus group participants also expressed a preference for a video with live action, and more text to reinforce concepts. Pharmacists generally felt that the video was understandable for patients and relevant for decision-making regarding testing. In conclusion, we were able to produce an educational video for patients with general, unbiased information, and we identified two concepts that are critical to include in any patient educational video about pharmacogenetic testing: specific examples and risk contextualization. Following improvements based on reviewer feedback, this resource may serve as a useful tool for a variety of healthcare providers and provide an informational foundation for patients considering pharmacogenetic testing. The video reviewed by the focus group and survey participants will be available for viewing during the poster sessions.

Development and validation of a knowledge-based questionnaire to assess comprehension of genetic counseling on advanced maternal age

C. Garcia1, K. Theoharis1, K. Spoonamore2, C. Griffith1, S. Dlouhy1, A. Patil1

1. Indiana University School of Medicine

2. Indiana University Health Physicians Cardiology Clinic

Advanced Maternal Age (AMA) confers an increased age-related risk of chromosomal abnormality in the fetus. Prenatal genetic counseling functions to review these risks and facilitate informed decision making, however there is no standardized approach for assessment of comprehension of genetic counseling in the AMA population. To address this deficiency, we sought to create and validate a knowledge-based assessment tool to assess comprehension of genetic counseling for AMA. A 19 question knowledge-based assessment tool was developed, appraised, and validated using expert review and a content validity ratio. Fourteen questions met significance and were included in a pilot study. The knowledge-based assessment tool was administered to a cohort of subjects (N = 81) before and after individual genetic counseling sessions in which age-related aneuploidy risks were discussed. Subjects were grouped by assessment site, education level, insurance type, marital status, and previous genetic counseling history for analysis. Statistical analysis was performed using Cronbach’s α to assess inter-rater reliability, paired samples t-test to compare changes in pre- and post-counseling scores, and ANOVA or independent samples t-tests to identify variability of results between groups. A final version of the assessment tool consisting of 9 questions with high inter-rater reliability (Cronbach’s α = 0.73) was used to assess comprehension of counseling. The mean pre-counseling score was 6.3 ± 1.8 and post-counseling score was 7.5 ± 2.3 (p < 0.001). Significant increases in scores were observed in all demographic groups (education level, marital status, insurance type, education level, previous genetic counseling; p < 0.05). However, specific subsets of the study cohort demonstrated significantly lower baseline knowledge and post-test scores (Medicaid insurance, high school education). The level of comprehension may vary significantly post-counseling, suggesting that a knowledge-based assessment may facilitate identification of patients needing additional assistance to make informed decisions.

Online educational information of monogenic diabetes: Which websites should genetic counselors recommend?

Y. Guan1, K. Maloney1, T. Pollin1

1. University of Maryland

Background: Approximately 1–2 % of diabetes mellitus, or at least 300,000 cases in the United States, has a monogenic etiology, and identifying these cases has important implications for treatment. The Internet is used increasingly by professionals as a tool for disseminating monogenic diabetes-related health information and by patients as an informational resource. However, health information on the Internet remains unregulated and little is known about the readability and quality of online informational resources about monogenic diabetes. This study aimed to answer these questions through a systematic content analysis of websites offering educational information on monogenic diabetes directed at the public. Methods: Fifteen key terms commonly used by patients and published literature to describe monogenic diabetes were entered into the Google, Bing, Yahoo! and Ask search engines in February 2016. The top 20 results from the 15 queries in four search engines were chosen for further analysis. Readability was determined using Simplified Measure of Goobledygook (SMOG). The Comprehensibility Assessment of Materials (SAM+CAM) scale was utilized to evaluate website quality (content, literacy demand, numeracy, graphic material, layout and topography, and learning stimulation). Results: Of 1200 websites screened, 965 were excluded because they did not contain educational content about monogenic diabetes targeted to the general public and 204 of the remaining sites were duplicates, leaving 31 unique websites for detailed analysis. All websites fail readability standards (Grade > 9 by applying SMOG); the average reading level is 13 (SD = 2). Preliminary analyses suggest that the quality of the websites is adequate (57 % on SAM+CAM; range 13 %–86 %, not suitable to superior). Discussion: Although some websites on monogenic diabetes are of adequate quality, most fail readability targets. These data identify a need for online resources on monogenic diabetes accessible to patients on a wider spectrum of literacy levels.

The impact of patient education on understanding of cell free DNA screening among pregnant women in a general risk population: The Rhode Island experience

E. Kloza1, G. Palomaki1, B. O’Brien2, E. Eklund1, G. Lambert-Messerlian1

1. Women & Infants Hospital of Rhode Island

2. Beth Israel Deaconess Medical Center, Boston

Concerns about offering cell free (cf)DNA screening in the general risk population include adequate time for patient education during routine visits, primary care providers knowledge of cfDNA screening, and access to suitable materials. The National Society of Genetic Counselors and other professional organizations discourage cfDNA screening in’low risk’ pregnancies, in part because of these concerns. In September, 2014, Women & Infants Hospital of Rhode Island initiated a demonstration project which offered cfDNA screening to the general pregnancy population through local primary care obstetrical offices. Staff were oriented and provided study-specific, validated patient pamphlets. One thousand eight hundred sixty one women from among 2685 tested volunteered to be contacted for a telephone survey to assess satisfaction with, and knowledge about, cfDNA screening; 100 women were surveyed. We reported elsewhere that 85 % of the women understood that the test helped identify Down syndrome (DS), 82 % knew there was a small chance of DS with a negative result, and 69 % knew the test was not diagnostic. However, we were also interested in examining correlations between patient knowledge and 1) length of time discussing the test (<5 vs. > 5 min), 2) whether the patient pamphlet was read or not, and 3) whether the patient was from a large or small practice. Neither reading the pamphlet nor practice size was associated with overall knowledge. However, women spending 5 min or less discussing the test with her provider (n = 58) were more likely to correctly answer questions than women having longer discussions (n = 39, P = 0.02). Both groups of women were satisfied with the amount of time spent discussing the test and the amount of information they received. The inverse correlation between the amount of time spent discussing cfDNA testing and correctly answering content questions appears paradoxical. It suggests however that lengthy counseling sessions for cfDNA testing in a general risk setting may not only be impractical, but also do not improve comprehension.

An assessment of genetic provider and parent communication patterns in genetic counseling sessions

N. Lahner1, D. Allain1, M. Pastore2, S. Havercamp1

1. The Ohio State University

2. Nationwide Children’s Hospital

Communication is critical to helping parents cope with a genetic diagnosis in their child. Previous studies on the genetic counseling communication process using parent surveys and simulated sessions reveal an emphasis on medical and genetic information and less communication about quality of life issues. Studies also reveal parent dissatisfaction with the diagnostic process. Researchers audio recorded pediatric genetic counseling sessions during which a family received an initial diagnosis in their child and surveyed parents about their counseling experience. Analysis of twenty sessions indicates that providers communicate mostly technical information such as genetic and medical aspects of the genetic disorder. Providers discuss quality of life issues less often and most often do so in response to parents/guardians’ concerns or in the context of referrals to other families. Parents and providers also engaged in various question- asking behaviors, and providers engaged parents’ feelings through empathic statements and addressing genetic guilt. The majority of parents reported helpful aspects about their genetic counseling session. All subjects were Caucasian, so our findings are not generalizable to other patient populations. Genetic providers’ communication pattern emphasizes education and information giving. Providers appear to not view quality of life issues as important to discuss at the time of an initial diagnosis. The majority of parents/guardians perceived this pattern of communication in their genetic counseling sessions to be helpful. Methods for making discussions more balanced include increasing genetic providers’ exposure to individuals with disabilities during training and opportunities to participate in advocacy groups. Training programs may also consider using standardized patient encounters to allow students to become more comfortable discussing quality of life issues.

Capitalizing on the genetic counselor role in the implementation of a lab utilization management model focused on providing education, guidelines, and clinical support for non-genetic providers surrounding genetic test navigation and interpretation.

E. Leeth1, E. McGinnis1, K. Leuer1

1. Ann and Robert H. Lurie Children’s Hospital

The expansion of multigene genetic panel use is an important development in the diagnosis of genetic disorders. While these panels may increase diagnostic yield, single gene and focused testing remain important in the testing arsenal. Lab utilization management (LUM) is a growing specialty that has evolved to address and implement appropriate testing and ordering practices. We present a case that exemplifies the inefficient testing practices that underscore the importance of LUM specialization and program development. A 4-year old male presented with characteristics of Angelman Syndrome (AS). SNRPN methylation analysis and a 70 gene epilepsy panel containing UBE3A were ordered concurrently. A novel, likely pathogenic UBE3A variant was identified. Although a clinically useful result was found, the testing strategy resulted in significant unnecessary cost. Analysis of institutional LUM data from an 18 month period showed 23 % of reviewed orders were cancelled or modified. This is in-line with what has been reported by other utilization groups. Further breakdown showed that 47 % of orders placed by non-genetic (NG) providers were cancelled or modified compared to 12 % of orders from geneticists. Given that 60 % of genetic test orders were placed by NG specialists, the need to provide education, testing algorithms and in-clinic support for the testing decision process was evident. In response, a Precision Medicine Support Center, jointly affiliated with the Department of Pathology and Division of Genetics, was developed to provide additional genetic counseling (GC) staff to allow for timely LUM consultation and to provide a physical presence in high volume NG specialty clinics. The goal of the PMSC is to increase NG provider support for navigating testing options and interpreting results. Utilization of GC in this role will help drive positive collaborative relationships between pathologists, geneticists, and other subspecialists. This highlights just one model developed to meet the educational/support needs surrounding the ever changing genetic testing environment.

Factors influencing admission into genetic counseling programs

L. Lipe1, A. Trepanier1

1. Wayne State University

Exposure to and early awareness of healthcare professions affects the recruitment of students into training programs. Recognizing that genetic counselors and genetic counseling programs (GCPs) are unequally distributed throughout the U.S. and Canada, we sought to investigate to what extent geographic versus other factors influence recruitment. Specifically, we aimed to 1) describe from which geographic areas/undergraduate institutions current genetic counseling students and recent graduates (GCS/RG) originated to determine if there are areas that are under-represented and 2) explore whether GCS/RG’s experienced barriers, geographic or otherwise, to admission. Eligible participants were genetic counseling students and graduates of the classes of 2012 or later. The instrumentation was an online survey that included questions previously used in recruitment studies in other health professions as well as novel questions. The survey was vetted by the Applicant Workgroup of the Association of Genetic Counseling Program Directors (AGCPD) and then piloted before finalized. Participants were recruited through email solicitations sent via the AGCPD listserv and the NSGC Student Research Survey Program. A total of 523 usable responses were received (~33.5 % response rate). There were 4 states and 7 Canadian provinces from which no GCS/RG had originated. Southern states tended to have the lowest number relative to state population. Most GCS/RG, 76 and 89 % in the U.S. and Canada, respectively, attended college in states/provinces with GCPs. Coded open-ended responses revealed 8 categories of barriers to admission. The most common barriers experienced were finding shadowing opportunities (39 %, 101/259) and geographic factors (35 %, 91/259) which included lack of awareness, no local shadowing, location of programs, cost of out-of-state tuition, and distance traveled for interviews. This data suggests that there are a number of barriers to admission, including geographical ones. Addressing these will be important in efforts to develop a larger, more representative workforce.

Success of noninvasive prenatal testing based on maternal weight and gestational age

R. McCullough1, S. Boshes1, J. Wardrop1, E. Almasri1

1. Sequenom Laboratories

The use of cell-free DNA (cfDNA) has increasingly become the standard of care for prenatal screening of fetal aneuploidy. Unfortunately, noninvasive prenatal testing (NIPT) has the potential to yield a non-reportable result, it is important to understand the factors impacting the ability to obtain a clinical result. Maternal weight has an inverse relationship to fetal fraction, while fetal fraction has a direct relationship with gestational age. This study reviews the success rate of obtaining an NIPT result as a function of maternal weight and gestational age (GA). A retrospective analysis of 244,310 maternal blood samples that were submitted to Sequenom Laboratories for MaterniT® 21 PLUS laboratory developed testing were stratified by maternal weight and gestational age. The percent of NIPT samples that yielded a non-reportable test result was evaluated assuming both factors are independent. Samples were subjected to DNA extraction, library preparation, and whole genome massively parallel sequencing. The average GA and maternal weight is 14.4 weeks at 161 lbs and a success rate of 98.5 %. Patients <125 lbs have 100 % success rate at GA > 27 weeks, the lowest success rate is in the highest weight population >300 lbs at 91.6 % (ranging from 89.5 to 100 % depending on GA). Stratifying these populations by GA shows only a minor impact in success rate across GA in the <200 lbs population, but a marked improvement as GA increases, matching the average population success rate in the heaviest population at 25 weeks GA. Of the two factors studied, GA and maternal weight, the later has a larger impact on NIPT success rate but it can be improved with an increase in GA. Despite a reduced success rate at extreme maternal weights, especially at early gestational age, cfDNA testing delivers results for more than 91.6 % of patients in the >300 lbs population. In this study we show that the not reportable rate of NIPT results can be improved by waiting to test at a later GA for patients >200 lbs. NIPT can be considered a viable option for aneuploidy screening in obese patients.

Knowledge and confidence of genetic counselors with state laws and training for managing the option of abortion in the setting of fetal anomalies

S. Rhine1, F. Casey1, J. Silberg1, R. Gannaway1, T. Causey1

1. Virginia Commonwealth University

Introduction: The purpose of the study is to assess the knowledge genetic counselors have of state abortion laws, and their confidence about and perception of training for discussing abortion. Insufficient knowledge and training potentially add delays to a patient’s abortion process. There are no existing studies investigating this. Hypotheses: Genetic counselors who work in states with more restrictive abortion laws will have better knowledge of their state laws. Genetic counselors who have poorer perceptions of their training will report lower confidence when discussing abortion with patients. Methods: A survey was developed and distributed to genetic counselors nationwide using the NSGC membership directory. Survey data was collected and stored using Research Electronic Data Capture (REDCap) available at Virginia Commonwealth University, and SAS statistical software was used for analyses. Accuracy of responses for state laws was judged using the Guttmacher Institute’s March 1, 2016 “State policies in brief: An overview of abortion laws.” Restrictiveness was defined using Guttmacher Institute’s ranking of states by hostility toward abortion in 2014. Results: Genetic counselors’ knowledge of state abortion laws differed by law; however, there was no correlation between knowledge of genetic counselors and restrictiveness of their state. When presented with questions asking if their training prepared them for different aspects of abortion counseling, only 41.07 % of responses were “somewhat agree” or “strongly agree.” Poorer perceptions of training was correlated with lower confidence when counseling about abortion in the first year of prenatal counseling. Conclusion: Genetic counselors’ knowledge of state abortion laws is not uniform across all laws. They reported that providing updates or reminders of abortion laws at clinics would be useful. The perceptions of training varied greatly, which may indicate that genetic counselors are not receiving equal training across all programs. Further research is needed to assess different factors affecting this finding.

Cystic fibrosis-related infertility: Thoughts and experiences of men in romantic relationships

M. Sikes1, G. Schneider1, L. Schema2, I. Pettigrew3

1. Brandeis University

2. University of Minnesota Medical Center

3. Ian Ross Pettigrew Photography

Cystic fibrosis (CF) and congenital absence of the vas deferens (CAVD) are conditions caused by mutations in the CFTR gene. Ninety-five percent of men with CF and/or CAVD have infertility due to azoospermia. Issues surrounding CF-related infertility have not received much attention since, until recently, men with CF were not likely to live into adulthood. However, as improved care and treatments continue to extend the life expectancy for individuals with CF, the need to understand how affected men are feeling about issues surrounding CF-related infertility is becoming increasingly relevant. The purpose of this study is to explore the experiences of men with CF and/or CAVD in disclosing their infertility to romantic partners, the effects that both disclosure and associated infertility have had on their romantic relationships and their thoughts on reproduction. We used an anonymous online survey and received 37 responses. We found that nearly half of our participants (44.4 %) desired more information at the time of learning about CF-related infertility, and that some wished they had learned this information at an earlier age. Over 97 % had disclosed CF-related infertility to their romantic partner and felt supported after doing so. While many men (40.0 %) stated they were concerned that their romantic partners would react negatively to the disclosure of CF-related infertility, few (21.4 %) felt their partners actually had negative reactions. In addition, the majority of men (61.1 %) in this study felt like CF-related infertility did not affect their ability to establish romantic relationships. Finally, 75.0 % of men indicated they think about having or already have children. This is one of the first studies to explore the issues men with CF and infertility face and the results provide valuable insight for other men affected by CF and CAVD, as well as the healthcare professionals who provide care for them.

Low fetal fraction prevents detection of fetal triploidy by cell-free DNA screening.

B. Tucker1, M. Zaretsky1, H. Galan1, R. Reynolds1, A. Marwan1, L. Browne1, K. Montgomery2, M. Schneider2, D. Manchester1

1. Colorado Fetal Care Center

2. Rocky Mountain Perinatology

We report a case of fetal triploidy presenting with multiple congenital anomalies that eluded detection by cell-free DNA (cfDNA) screening. Low-risk cfDNA screening was sent to a lab whose single nucleotide polymorphism (SNP) technology can detect triploidy. The test failed due to an inadequate fetal fraction of 1.3 % at 13 weeks gestation and again at 16 weeks (2.3 %), which raised concern for fetal aneuploidy. Ultrasound with a specialist was offered and revealed fetal growth lag, oligohydramnios, single umbilical artery, and possible vermian hypoplasia. The patient declined diagnostic testing and elected to pursue another round of cfDNA testing. The fetal fraction was 5 % and the screen was negative, but the test lacked the ability to detect triploidy via massively parallel sequencing. Evaluation at 27 weeks gestation, showed multiple fetal anomalies including hypertelorism, abnormal ears, and severe micrognathia. MRI confirmed these findings and revealed dysgenesis of the body and splenium of the corpus callosum and prominent retrocerebellar cerebrospinal fluid cistern. Throughout the ultrasound, the legs moved synchronously, not independently, and the right hand remained clenched. A large inlet ventricular septal defect and double outlet right ventricle were present. After extensive counseling regarding the poor fetal prognosis and the limitations of cfDNA screening, the patient declined amniocentesis. An intrauterine fetal demise occurred at 31 weeks’ gestation. Chromosomal microarray analysis on the products of conception revealed triploidy: 69,XXX. Discussion: Low fetal fraction can be due to early gestational age, maternal obesity, and fetal aneuploidy and can lead to a no-call result. When the fetal fraction is too low to yield a result, diagnostic testing should be offered. Ultimately, despite using cfDNA screening that includes SNP technology to screen for fetal aneuploidy, low fetal fractions prevented detection of triploidy, which has important medical management implications.

Storytelling and family communication about type 2 diabetes in an urban Appalachian community

K. Warsinske1,2, M. Myers1,2, R. Lee1, R. Sheikh1,2, L. Arduser1

1. University of Cincinnati

2. Cincinnati Children’s Hospital Medical Center

Type 2 diabetes mellitus (T2DM) is a public health concern for individuals of Appalachian background, contributing significantly to morbidity and mortality. Early promotion of risk recognition and behavior changes can be beneficial to mitigate health consequences, yet culturally tailored resources may not be readily available for this population. In this multi-phase study, a community-driven approach was implemented to explore the use of story circles to facilitate familial communication about T2DM. In phase I, ten individuals from a low income urban Appalachian community participated in a focus group to discuss and tailor the study design. In phase II, 18 individuals participated in one or more of three story circles to discuss T2DM experiences and conversations. In phase III, follow-up interviews with seven story circle participants were conducted, recorded, and transcribed. Transcription and content analysis of story circles recognized the sharing of participant lifestyle challenges as a part of diabetes experiences, the identification of barriers to conversations about family health history, and a variety of views about the significance of T2DM. In addition, social support and ideas for T2DM management were commonly shared among participants. Interview analysis revealed that all participants reacted positively to the story circles and many described ways participating led to changes in their communication or behavior patterns or supported their previous efforts toward diabetes management/prevention and communication with family members. Asking people of Appalachian cultural background to share stories about T2DM experiences and conversations led to dynamic discussions that allowed participants to both develop a sense of mutual support and share their experiences and knowledge about diabetes. Although support may be needed to facilitate and monitor the accuracy of information shared, incorporating group storytelling could be an effective way to better tailor diabetes care and promote the sharing of family health history in the Appalachian community.

Ethical, Legal and Social Issues

Genetic testing and life insurance: A Canadian perspective

A. Bedard1, G. St-Martin2, J. Bedard3

1. British Columbia Cancer Agency

2. California State University - Stanislaus

3. University of the Fraser Valley

Objectives: Genetic counselors often discuss the effect testing may have on patient access to life insurance, particularly in the case of adult-onset conditions. Canada has limited legal protection addressing the use of genetic test results by insurance companies, while other countries have broader laws, or introduced moratoria. This study is a baseline assessment of Canadian insurance company applications in relation to their method for inquiring about genetic testing and counseling. Methodology: We reviewed current primary applications for voluntary life insurance and critical illness insurance from eleven companies in Canada. Applications were assessed for the presence of questions related to the applicant’s medical history that could be related to genetic testing and genetic counseling, and analyzed for their depth of family medical history assessment. Results: None of the companies specifically asked about genetic testing, however 100 % of applications assessed if applicants had pursued medical testing in the past, including ‘blood tests’. The majority assessed whether the applicant had sought consultation from a health professional, including if they had been advised about testing. All applications asked about family medical history, with the majority limiting assessment to the parents and siblings. An average of 11 conditions were assessed for the family medical history, with the majority of conditions being generally multifactorial in nature, but some specific single gene disorders were frequently included. None of the applications asked if family members had sought genetic testing. Conclusion: This study provides a baseline assessment of Canadian life and critical illness insurance applications for genetic testing and genetic counseling. It is not clear to what extent the Canadian insurance industry uses this information in the underwriting process. Genetic counselors should be cognizant that patients applying for insurance will be asked not only about genetic testing, but also if they may have been advised about testing through genetic counseling.

A taxonomy of medical uncertainties in genome sequencing

B. Biesecker1, P. Han2, B. Behardt3, R. Green4, S. Joffe5, B. Koenig6, I. Krantz7, L. Biesecker8

1. The National Human Genome Research Institute, National Institute of Health

2. Maine Medical Center

3. University of Pennsylvania Health System

4. Harvard Medical School

5. University of Pennsylvania Perelman School of Medicine

6. University of California, San Francisco

7. The Children’s Hospital of Philadelphia

8. National Human Genome Research Institute

Introduction: Clinical genomic exome and genome sequencing introduce new opportunities and challenges. Simultaneously genome technologies introduce uncertainties of unprecedented scale and type. As such, clinical sequencing requires laboratories, clinicians, and patients to address and manage many uncertainties. Methods: The current study began with a conceptual taxonomy of uncertainty in health care. Expert interviews were conducted to expand the initial genome taxonomy into its multiple dimensions. In parallel we developed an interactive taxonomy website to disseminate the taxonomy to researchers to engage them in its future refinement. Results: The taxonomy divides uncertainty according to three main dimensions: source, issue, and locus. Each dimension is defined and divided into its sub-components specific to genome sequencing. The taxonomy discriminates the uncertainties into five layers with multiple domains. We illustrate how the taxonomy can be applied to findings from genome sequencing and used to guide various stakeholders to interpretation and implementation of variant results. Once the website is distributed the taxonomy will evolve after expert feedback and curation. Conclusion: It is critical to understand and distinguish uncertainties of clinical sequencing and the extent to which they are reducible by the acquisition of further knowledge. Our taxonomy is a first step toward realizing these outcomes.

Relatives and risk-reporting: An updated assessment of genetic counselors’ perspectives

K. Boggs1, B. LeRoy2, T. McConnell1, N. Callanan1

1. University of North Carolina at Greensboro

2. University of Minnesota

Introduction: As providers, genetic counselors strive to protect client privacy and autonomy. However, they also endeavor to promote the well-being of those at-risk for heritable conditions. Thus, genetic counselors struggle with a duty to warn client relatives about genetic risks. While the concept of provider duty to warn has been discussed at length, few discussions have focused on perspectives of genetic counselor practitioners. The aims of this study were to 1) explore the clinical experiences of genetic counselors with duty to warn; 2) learn how they would respond to a perceived duty to warn in hypothetical cases and; 3) understand how they motivate clients to share genetic risk information with family members. Methods: An online anonymous survey was distributed through the NSGC listserv. Four hypothetical clinical scenarios were presented. Participants’ opinions regarding the duty to warn and strategies for facilitating sharing were assessed on a four-point Likert scale and through responses to open-ended questions. Results: Greater than 50 % of the 92 participants who completed the survey reported having experience with client unwillingness to share genetic risk information with relatives. For three scenarios, participants had the opinion that genetic counselors had some or great extent of responsibility to inform the client’s family members. Strategies for approaching duty to warn scenarios included seeking an ethics consult, utilizing counseling skills to motivate clients to share information, and facilitating information-sharing through tools such as family letters or support group referrals. Conclusions: Duty to warn continues to be a challenge for genetic counselors and opinions vary. Results suggest disagreement regarding when a duty to warn supersedes the client’s desire not to share genetic risk information. Genetic counselors report diverse methods for motivating clients to share. Further exploration of genetic counselors’ perspectives and development of guidelines addressing this issue is warranted.

Bias in genetic counseling: Where does it really live?

U. Canteenwalla1, S. Foster1, S. Yaall1, A. Gamma1, N. Paolino1, S. Wieloch1, I. Carlsson1

1. Recombine

As genetic counselors (GC) take on non-traditional roles, questions regarding conflict of interest and bias have been raised. It is important for GCs to engage in open discussion regarding these topics. Our aim was to compare the structure and experience of both lab and clinic-based genetic counseling to determine where bias may exist. We surveyed 15 full- and part-time employees at a laboratory, both new graduates and tenured GCs, all of whom had also been exposed to clinical counseling. Counselors were asked to compare their experiences in the two settings, commenting on factors such as deciding criteria for test provider selection and the content/structure of counseling sessions. Responses cited cost and insurance coverage as driving factors for test provider selection within the clinical setting, as opposed to detection rate and/or the test’s technical quality. Additionally, across the different clinics, there was no consistent protocol for the review of available test options. While cost and insurance were not issues within laboratory counseling, responses indicated a frustration with the inability to assist in arranging necessary follow-up when family history warranted additional genetic testing. The majority reported that the content and structure of their sessions is the same, regardless of setting, across a number of aspects including: duration, additional testing options discussed, and family history assessment. For lab counselors, a cited difference from clinical was the lack of pre-test counseling and physical separation from the patient (telecounseling). Overall, responses indicated that counselors do not feel bias when counseling clinically or for a lab. However, our analysis revealed the potential for bias to arise in both settings. Our study encourages broader discussion of the potential for bias in genetic counseling in both settings, as well as the importance of increasing self-awareness among the GC community to ensure the impact of bias on patient care is minimized.

An assessment of the mitochondrial disease community’s knowledge and perception of the “three-person baby,” or mitochondrial replacement therapy, and the impact of the media debate that surrounds this technique

A. Fiss1, K. Singh1, N. Gallant1, V. Kimonis1

1. University of California, Irvine School of Medicine

This study was designed to assess the mitochondrial disease community’s knowledge, attitude and perception of mitochondrial replacement therapy (MRT) and determine how the media can impact such perception. MRT in conjunction with in vitro fertilization (IVF) has the ability to prevent inheritance of known pathogenic mitochondrial DNA mutations from mothers to their offspring by using a donor egg’s mitochondrial DNA. The U.S. Food and Drug Administration (FDA) is currently considering clinical human trials for this technique, dubbed “three-parent IVF”. Approval relies heavily on the mitochondrial disease community’s willingness to participate; however, the community’s perceptions of the risks, benefits and limitations associated with this procedure have yet to be adequately addressed. A short anonymous survey was distributed online to individuals within the mitochondrial community; 165 individuals completed the survey and comprised the study population. The majority of individuals found MRT ethical and agreed that they would be willing to use MRT if clinically appropriate and available. However, almost half were unaware that MRT is only useful if a mitochondrial DNA mutation has been previously identified. The majority of respondents believed the FDA should approve MRT now citing safety as their top concern, but paradoxically only a minority thought there was enough evidence already published proving its safety. The majority were aware that this technique does not change physical or personality traits of offspring; however those who believed it did also felt more strongly that this technique is “designing babies”. Media impacted a majority of respondents’ perceptions about MRT, but younger participants were not as easily swayed as hypothesized. Interestingly, the majority did not believe that the children born using MRT have three parents, so the media’s use of “three parent baby” may be unnecessarily sensationalized. Our results provide strong evidence that the mitochondrial disease community is forward-thinking about MRT; however, are not fully aware of MRT’s risks or limitations.

Physician’s experiences with and attitudes toward non-medical sex selection through preimplantation genetic diagnosis

N. Harkavy1, K. Smith2, C. Lawson3, D. Krasnewich4, L. Erby5

1. Lescale Maternal-Fetal Medicine

2. The Johns Hopkins Bloomberg School of Public Health

3. Johns Hopkins Hospital

4. National Institute of General Medical Sciences

5. National Human Genome Research Institute

Preimplantation genetic diagnosis (PGD) involves screening embryos for genetic conditions or traits before uterine implantation. Non-medical sex selection (NMSS) describes the use of PGD to choose the sex of a child for social, rather than medical, reasons. In the US, it is legal to use NMSS for “family balancing,” or the selection of an underrepresented sex in a family. Proponents of family balancing believe that NMSS is an expression of reproductive autonomy and is therefore ethically acceptable. Opponents often cite beneficence, nonmaleficence, and justice as the basis for concerns. Physicians are thought of as gatekeepers to this technology, yet there is little research exploring the experiences and concerns of physicians around NMSS. This study seeks to describe the experiences of providers around PGD for NMSS, with a focus on potential ethical concerns and decision-making. Semi-structured telephone interviews informed by Carnevale’s moral experience framework were conducted with 14 OB/GYNs and reproductive endocrinologists (REs) currently practicing in the US. Physicians were recruited through the American College of Obstetrics and Gynecology and the American Society of Reproductive Medicine. Interviews focused on attitudes toward NMSS, perceived implications of NMSS, and decision-making. Interviews were transcribed, and thematic analysis was conducted using NVivo 9.0. Findings showed that, while most physicians personally oppose NMSS, most would support patients’ wishes based on the principle of autonomy. Autonomy was discussed as a source of ethical dilemmas for physicians struggling to balance professional and personal values. Not all physicians identified themselves as gatekeepers for NMSS technology. Physicians expressed conflicting preferences about the ideal decision-making process, indicating perceived benefits to having professional societies make clear guidelines around NMSS, while also expressing a desire to preserve patient‐provider decision-making. Insights gained about physicians’ concerns can be used to inform future policy around NMSS.

Gestational surrogacy: Decision making regarding prenatal testing and genetic counseling

S. Malca1, K. French2, K. Osann3, M. Jones4, M. Bocian5

1. UC Irvine School of Medicine

While gestational surrogacy has grown in popularity in the last decade, the surrogacy process is far from homogeneous. This lack of standardization can cause problems between surrogates and intended parents and can be troublesome for healthcare providers. The purpose of this study was to understand the current practices regarding discussion of potential pregnancy complications and prenatal testing in an attempt to determine how these decisions are made. This study also examined how comfortable surrogates felt expressing their opinions with the intended parents regarding these topics. Surveys were distributed through four surrogacy agencies and included several topics that could pose a potential conflict between the surrogates and intended parents. One hundred and eleven participants were included in this study. Decisional topics included: carrier screening, fetal anomalies, and screening/testing options. The number of topics discussed by the surrogates varied, with about 1/3 of participants reporting that they discussed most or all of these topics before being matched with the intended parents. Decisions during the pregnancy were most often made together by the surrogate and the intended parents. However, in some cases, decisions were made by the surrogate alone, by the intended parents alone, or by the medical professional. Most participants felt comfortable voicing their opinions and that their opinions were considered throughout the surrogacy experience. These results indicate that surrogates generally feel comfortable and empowered throughout their experience. The results of this study revealed overall positive experiences for the surrogates. Having standardized guidelines may increase satisfaction with the surrogacy process and be beneficial in preventing serious conflicts between surrogates and intended parents. Given the recent increase in prenatal screening and testing options, standardized guidelines are needed to assist genetic counselors with facilitating discussions between surrogates and intended parents.

Noninvasive prenatal testing results concerning for maternal neoplasm: Consideration of uterine fibroids

L. Murphy1, S. Chauhan1, N. Krstic1, L. Dunnington1, J. Lucci1, E. Nugent1

1. UTHealth - University of Texas Health Science Center at Houston

We report a case of noninvasive prenatal testing (NIPT) results concerning for neoplasm, subsequently determined to most likely be due to uterine fibroids. A 41 year-old patient’s “non-reportable” NIPT results were due to multiple deletions/duplications across the genome and the laboratory communicated concern for possible malignancy. At the time, there were no case reports in the literature associating uterine fibroids and unusual NIPT results. In addition, there were no published guidelines regarding management of patients with NIPT results concerning for possible malignancy. The patient was informed that while NIPT was not validated to screen for conditions outside of specific fetal aneuploidies, her results were concerning for a potential neoplasm. The patient was counseled that exact risks for malignant neoplasm could not be assessed and in the absence of additional data and guidelines for follow-up, our recommendations would be based on information provided by the laboratory and clinical findings. The patient’s initial ultrasound showed multiple fibroids. However, given that most women with uterine fibroids do not have concerning NIPT results, further work-up was indicated and the patient was referred to Gyn/Onc. Work-up included a normal mammogram, PET CT which showed an enlarged and lobular uterus with heterogeneous metabolic activity, and CBC. Due to continued bleeding and pain following miscarriage, the patient pursued hysterectomy with bilateral salpingectomy. Pathology showed chronic endometritis and leiomyomata with degenerative changes. No atypia or malignancy was noted. Repeat NIPT sent 6 months post hysterectomy showed no genomic deletions or duplications. This case illustrates several points. Numerous complexities arise when non-validated test results are communicated to a provider. When the concern for a serious condition appears to be high, the provider may feel a duty to inform the patient. While it is difficult for providers to determine appropriate management when no practice guidelines exist, the greatest burden is to the patient.

Development of a consent resource for genomic data sharing in the clinical setting

E. Riggs1, D. Azzariti2, A. Niehaus3, S. Goehringer1, E. Ramos3, H. Rehm4, C. Martin5

1. Geisinger Health System

2. Partners Laboratory for Molecular Medicine

3. National Human Genome Research Institute, National Institutes of Health

4. Partners Laboratory for Molecular Medicine

5. ADMI, Geisinger Health System

Data sharing between clinicians, laboratories, and patients is essential for improvements in genomic medicine. The need for broad access to individual data must be balanced with respect for patient autonomy and privacy. Acknowledging that obtaining consent for sharing is hindered by lack of time and resources, the National Institutes of Health’s (NIH) Clinical Genome Resource (ClinGen) is developing broad data sharing consent resources for use by clinicians and clinical laboratories, including a 1-page consent form and brief online videos. The consent form contains language consistent with the NIH Genomic Data Sharing Policy and The National Human Genome Research Institute Informed Consent Resource, and the videos provide information on key topics, such as risks and benefits of data sharing ( ClinGen held interviews and focus groups in 4 US cities with key stakeholders [clinicians (n = 40), clinical laboratory staff (n = 33), and community members (n = 48)] for feedback. Preliminary thematic analysis suggests that participants feel that genomic data sharing is a worthwhile endeavor. Clinicians and laboratories cited potential to aid interpretation of variants of uncertain significance, and community members viewed it as a way to contribute to the “greater good.” Participants noted that a brief consent was essential, but that the videos provided valuable information. Community members requested more information on the benefits of data sharing, while clinicians and laboratory staff were concerned with “over-promising” on benefits. To assess comprehension of concepts related to genomic data sharing, participants completed a 5 question knowledge assessment before and after reviewing materials. After review, community members’ knowledge significantly improved (57 vs. 91 % correct, p ≤ 0.01), suggesting the resources effectively communicate data sharing concepts. ClinGen hopes these resources will provide a straightforward way to share genetic and health information, and help the scientific community capitalize on the largely untapped resource of data generated through routine healthcare.

All in the family: The benefit of reporting carrier results in the pediatric population

J. Schuette1, D. Cardeiro1, E. Couchon1, J. Dickerson1, T. Foss1, H. Hornung1, S. Klemm1, M. O’Leary1, D. Pineda-Alvarez1, C. Scacheri1, A. Villemaire1, M. Wayne1, S. Wong1, C. Stanley1

1. Courtagen Life Sciences, Inc.

Introduction: Laboratories performing next generation sequencing (NGS) develop criteria for filtering, classifying, and reporting variants of interest to focus assessment efforts on variants more likely to be disease causing. This may include filtering single heterozygous variants in genes exclusively associated with autosomal recessive (AR) disease and a policy of not reporting carrier results, especially in the pediatric population. We report a case in which the reporting of a pathogenic variant for AR disease had significant reproductive implications for the patient’s parents. Case Report: An NGS panel, epiSEEKR, was performed in a 7-year old male with myoclonic seizures and developmental delay. A deletion of 1 base pair in the SYNGAP1 gene was identified. Pathogenic variants in SYNGAP1 are associated with autosomal dominant intellectual disability, variable seizure types, autism, and microcephaly. Due to clinical overlap and variant curation, the interpretation was a variant of uncertain significance. A heterozygous pathogenic variant in CNTNAP2, associated with AR Pitt-Hopkins like syndrome 1, was reported as carrier status. Parental studies were negative for SYNGAP1 and positive for the CNTNAP2 variant in each parent. Subsequently the ordering provider reported parental consanguinity. The interpretation was updated to a de novo likely pathogenic variant in SYNGAP1, and importantly, a 25 % reproductive risk for a CNTNAP2-related disorder was identified. Discussion: Although controversial, carrier testing in the pediatric population is not uncommon, having been performed in siblings of an affected child or incidentally through newborn screening (NBS) or prenatal testing. In fact, there is consensus for disclosing carrier results identified in NBS due to the potential reproductive risk for parents. Our case highlights the need to also consider reporting carrier status in children undergoing NGS to ensure that the needs of patients as well as their families are met.

Participant perspectives on return of genetic research results in an ethnically diverse biobank

N. Zeid1, N. Abul-Husn2

1. Icahn School of Medicine at Mount Sinai

2. Regeneron Pharmaceuticals, Inc.

The increase in number and size of genomic biobanks raises several ethical questions, an important one being whether to return genetic research results (or a subset of these) to biobank participants. Few studies have assessed biobank participant preferences regarding return of genetic research results, and none have included ethnically diverse populations. The Mount Sinai BioMe biobank, a highly diverse biobank with over 32,000 participants, currently excludes return of results to participants. The goal of this study was to assess the preferences of BioMe participants for receiving genetic research results. We developed a survey to assess BioMe participant attitudes toward receiving various genetic research results, including life-threatening, serious, or not; treatable/preventable or not; late-onset or not; with varying degree of risk; as well as carrier status, ancestry, and pharamcogenetics. We examined potential factors including ancestry, socioeconomic status, education, and others, influencing participant preferences for receiving genetic research results. Of 72 survey respondents, the majority of BioMe participants (68–99 %) preferred to receive genetic research results regardless of severity, medical actionability, or age of onset. Responses for certain items were associated with differences in ethnicity, age, and education. For example, participants of Hispanic ancestry were more likely to be unsure about receiving certain types of genetic research results. Interestingly, 50 % of participants preferred to have results returned via mail, while 47 % preferred to have results returned by a genetic counselor. Our results suggest that participant preferences diverge from current biobank protocols that exclude return of genetic research results. However, difficulties in differentiating between types of genetic results, correctly interpreting risk assessment, and understanding the clinical impact of results could be a barrier to making informed decisions. Findings from this study could inform future policies on return of results from biobanks research.

Genetic/Genomic Testing

The utility of genomic variant databases in genetic counseling

E. Brokamp1, C. Ahern1, L. Hercher1, W. Faucett2

1. Sarah Lawrence College

2. Geisinger Health System

The American College of Medical Genetics (ACMG) and the National Society of Genetic Counselors (NSGC) are in agreement that public genomic data sharing will benefit patient care. Despite these recommendations, not all clinical laboratories share their variant data in public databases. To date, no studies have focused on current practices of genetic counselors in terms of how they use variant databases or whether or not they consider laboratory data-sharing practices as a selection criterion in choosing who to use for testing. For this study, genetic counselors were surveyed about their opinions on genomic data sharing and how they handle variants of uncertain significance (VUS) results for patients. The survey shows both clinical and laboratory genetic counselors stand behind the NSGC statement supporting sharing of variant data, especially in the case of clinical testing laboratories. The majority of clinical counselors are putting this support into action by allowing a laboratory’s data sharing practices to influence their decision on which laboratory they use for testing. At this time, data sharing is only one of many considerations that impact genetic counselors’ decisions regarding choice of testing laboratory. This study suggests that most genetic counselors are using a number of variant databases after receiving a VUS result for a patient. The study also suggests that genetic counselors do not have a standard way of processing VUS results; there is little consistency to how often genetic counselors look up variants in public databases or which databases they use. Laboratory and clinical genetic counselors collectively reported using 32 different specific databases. This inconsistency highlights the need for more professional education on how to use public genomic databases for the benefit of patient care. Guidelines for a standardized process regarding the handling of a VUS by genetic counselors would ultimately benefit patient care.

Genotype-phenotype correlation of individuals with chromosome 8p23 duplication or deletion syndromes

C. Burden1, R. Stewart1, P. Koty2, P. Reitnauer3

1. The University of North Carolina at Greensboro Genetic Counseling Program

2. Wake Forest Baptist Health

3. Cone Health Medical Genetics

The duplications and deletions of chromosome 8p23 are rare genetic conditions that display phenotypic continuums. Common symptoms of each condition include congenital heart disease (CHD), developmental delay, behavioral issues, and distinctive facial features. Due to the variable expression and rarity of these disorders, in addition to the recently enhanced ability to detect subtle genetic imbalances, there is currently limited data regarding the frequent genotype-phenotype associations for each condition. To contribute to this limited medical knowledge, clinical features of four patients with either an 8p23 deletion or duplication, as identified and characterized by genomic studies, are described. The genotypes and clinical and developmental features were compiled for each patient and compared to previously reported individuals with an 8p23 duplication or deletion. The chromosome abnormalities of the four patients of this study were all found to be clinically significant. Two patients were susceptible to a chromosome rearrangement, due to the involvement of two olfactory receptor gene clusters, REPD (REPeat Distal) and REPP (REPeat Proximal) that flank a 5 Mb region of 8p23.1. Furthermore, the genomic variation in three patients involved at least one previously suggested candidate gene (GATA4, SOX7, TNKS, MCPH1, or MSRA) within the REPD and REPP interval. In addition to GATA4, this study suggests that there may be further genes within the 8p23 region that cause CHD. Moreover, in contrast with previous research, this study did not find MCPH1 to be a candidate gene for autism. Cytogenomic characterization of additional affected individuals will provide further clarification of the genotype-phenotype correlation of 8p23 duplication and deletion syndromes. Genetic counselors should evaluate and discuss the various implications of the condition and provide resources to families.

15q overgrowth syndrome: A possible new diagnosis with the smallest reported duplication associated with an overgrowth phenotype.

J. Diaz1, E. Leon1

1. Children’s National Medical Center

The diagnosis of 15q overgrowth syndrome is characterized by increased dosage of distal 15q. Features include overgrowth, learning difficulty, characteristic facies (long, thin face with a prominent chin and nose), and renal anomalies. While contested, one candidate gene (IGFR1) is a proposed cause of the phenotype. This gene is a part of a growth factor axis including three hormones (insulin, IGF1, and IGF2) and receptors. It has been associated with cell surface signaling, proliferation, and neuronal differentiation. Notably, hemizygosity of IGFR1 is associated with growth retardation. We report a 3 year old female with a paternally inherited 15q26.3 duplication on chromosomal microarray. The 347 kb interval includes a partial duplication of one OMIM gene—IGFR1. The patient presented with tall stature, obesity, macrocephaly, developmental delays, and eye blinking spells. Birth measurements were within normal limits. By age 2 to the present, all growth parameters have persisted >97th percentile. Work-up included normal bone age, spinal x-ray, and EEG. Normal labs include leptin, free T4, TSH, HbA1c, IGF-1, and IGFBP3. C-peptide level was elevated at 6.2 ng/mL [1.1–4.4]. Renal ultrasound has not been completed. On exam, she had no appreciable dysmorphic facial features. Her father has reportedly average growth but paternal family history is significant for obesity and learning problems in several individuals. Pathogenesis of 15q overgrowth syndrome is debated as most reported cases include larger copy number variants. Here we present a case of possible 15q overgrowth syndrome with the smallest reported duplication in the literature. This case may support the IGFR1 gene as a candidate for the phenotype. Of note, decreased penetrance has not been well described. Copy number variations are rarely in the differential diagnosis of overgrowth. Chromosomal microarray should be considered in individuals with overgrowth and learning problems. Identification of others with this rare diagnosis will help to expand the phenotypic variability associated with this syndrome.

Novel pathogenic variant inHNRNPKidentified in a female with Au-Kline syndrome.

E. Fanning1, D. Cratsenberg1, K. Wierenga1

1. University of Oklahoma Health Sciences Center

Au-Kline syndrome is a newly described rare genetic disorder characterized by developmental disability, dysmorphic facial features, hypotonia, and skeletal anomalies. We report a 2-year-10-month-old female who presented to genetics clinic at 15 months of age with concerns of hypotonia, facial dysmorphisms, plagiocephaly, and developmental delay. Initial workup included creatine kinase, methylation analysis for Prader-Willi syndrome, cholesterol biosynthesis intermediates, very long chain fatty acids, ultrasound of the abdomen and kidneys, and a skull x-ray. Original workup was non-diagnostic except for metopic and sagittal craniosynostosis and mild prominence of the left renal collecting system. At 21 months of age, patient underwent cranial vault remodeling with distraction. Since workup thus far was not revealing, whole exome sequencing (WES) was ordered. The patient was found to have a de novo heterozygous novel pathogenic variant in HNRNPK (c.1009delG), consistent with a diagnosis of Au-Kline syndrome. Heterogeneous nuclear ribonucleoprotein K (HNRNPK) is an RNA binding protein with many cellular roles. Au-Kline syndrome was first reported in late 2015, when two male patients with a heterozygous variant involving HNRNPK were reported, and in addition two female patients were described with a deletion encompassing HNRNPK. Following the diagnosis, additional workup of our patient revealed the presence of mild renal upper pole thinning bilaterally with grade 1 pelviectasis, scoliosis and hip dysplasia but no significant heart disease. To our knowledge, this case provides the first documented female with a nonsense mutation in HNRNPK. The phenotype and management strategies are still evolving as this is an emerging disorder. Research into HNRNPK suggests a relationship between HNRNPK and TP53. However, an association with malignancy has not yet been described in individuals with Au-Kline syndrome, and there are no nationally recognized guidelines for surveillance to-date.

Genetic counselor consent reduces ancestry-related differences in choice to receive secondary findings in a large-scale genomic sequencing study

K. Fiallos1, C. Applegate2, D. Mathews3, J. Bollinger3, A. Bergner2, C. James4

1. Johns Hopkins University/National Human Genome Research Institute, National Institutes of Health

2. Institute of Genetic Medicine, Johns Hopkins University

3. Johns Hopkins Berman Institute of Bioethics

4. Division of Cardiology, Department of Medicine, Johns Hopkins University

Introduction: Approaches to return of secondary findings (SF) to participants in genomic sequencing (GS) research remain varied. Participants often choose whether to receive SF, but little is known about factors that influence this choice. Our institution is enrolling families with Mendelian conditions into a large-scale GS research study in which participants choose what findings to receive during informed consent (IC). Hypothesis: We anticipated most participants would desire SF but sought to identify factors associated with variation in participant choices. Methods: This is a retrospective, observational study of the first 247 families (790 individuals) enrolled into the Baylor-Hopkins Center for Mendelian Genomics through Johns Hopkins. Data related to the choice of results, the participant providing consent, and the study member engaging in IC was abstracted from consent forms. Results: 659 (83.4 %) participants chose to receive SF. Choosing to receive SF was associated with an established clinical diagnosis in the proband (87.8 vs. 79.0 %, p = 0.001) and European ancestry (EA) (87.7 vs. 73.0 %, p < 0.001). Participants of non-European ancestry (NEA) were as likely as those of EA to choose SF when a genetic counselor (GC) conducted IC (82.0 % NEA vs. 88.3 % EA, p = 0.09) but less likely to choose SF when IC was conducted by a physician (67.4 % NEA vs. 85.4 % EA, p = 0.001). Controlling for proband diagnosis, individuals of NEA were 2.13-fold (95 % CI: 1.11, 4.08) more likely to choose SF when engaging with a GC for IC. Sex, relationship to the proband, whether enrollee was affected, and whether an individual was consenting for self or a dependent were not associated with SF choice. Discussion: These data reveal a difference in decisions regarding SF between participants of EA and NEA that is modified by a GC conducting the IC discussion. GCs may be able to offset differences in SF decisions associated with ancestry due to advanced training in adapting complex genetic information to a wide variety of clients. Further studies investigating these finding are critical.

Experiences of exome sequencing in newborns: A peek into BabySeq

C. Genetti1, M. Helm2, M. Towne1, S. Pereira3, J. Robinson3, O. Ceyhan-Birsoy4, K. Machini5, P. Agrawal6, R. Parad7, H. Rehm8, I. Holm6, A. McGuire3, R. Green9, A. Beggs10

1. Boston Children’s Hospital

2. Brigham and Women’s Hospital

3. Baylor College of Medicine

4. Laborator Molecular Medicine, Partners Personalized Medicine

5. Partners Laboratory for Molecular Medicine; BWH and HMS

6. Harvard Medical School; Boston Children’s Hospital

7. Harvard Medical School; Brigham and Women’s Hospital

8. BWH and HMS; Partners LMM; Broad Institute

9. G2P; Partners Personalized Medicine; BWH and HMS

10. HMS and Boston Children’s Hospital; Manton Center

Background: Genomic newborn sequencing has the potential to provide comprehensive and clinically useful information on a wide range of conditions; however, its broad use is still considered controversial and its potential impact on future healthcare is not yet known. The BabySeq Project is a randomized controlled trial exploring the impact of newborn genomic sequencing (GS). Infants are enrolled from Brigham and Women’s Hospital’s well baby nursery and neonatal intensive care unit (ICU), as well as from Boston Children’s Hospital’s ICUs. Through this study we expect to gain insight into the intricacies of implementing GS and the impact of reporting GS results in infants. We report here on the types of results found in a preliminary subset of patients. Methods: Participants are randomized to receive family history with or without GS. Results are disclosed by a genetic counselor and study physician, sent to the infant’s pediatrician, and placed in their medical record. Genomic data is interrogated for ~1800 genes associated with childhood onset conditions. Genomic reports include monogenic disease risk variants, carrier status, and pharmacogenomic results. Results: We have enrolled 113 infants and their parents and have returned GS results to 28 families and their pediatricians. Of these 28 cases, monogenic disease risk variants have been identified in 2 cases. Carrier status for one or more conditions has been returned in 24 cases, with a range of 1–5 carrier variants identified per infant, and pharmacogenomic results have been returned in 2 cases. Conclusion: For a subset of cases, GS has provided information that may impact future healthcare decisions. Most of these cases involved carrier status for one or more recessive conditions, and while this information typically has no direct health implications for the infant, it can be useful to families for future reproductive planning. We are tracking healthcare utilization and cost outcomes by monitoring pediatric medical records, and are assessing impact on families and perceived utility via follow-up surveys.

Further clinical delineation of PACS1-related syndrome: A recurrentde novopathogenic variant

J. Hoffman1, D. Stern2, M. Cho1, R. Chikarmane1, R. Willaert1, K. Retterer1, H. Crawford3, F. Kendall4,13, M. Deardorff5, S. Hopkins6, E. Bedoukian7, A. Slavotinek8, S. Schrier Vergano9, B. Spangler9, M. McDonald10, A. McConkie-Rosell10, B. Burton12, K. Kim12, B. Baskin1, H. McLaughlin1, D. McKnight1, J. Juusola1, W. Chung2,11

1. GeneDx

2. Department of Pediatrics, Columbia University Medical Center

3. Clinical and Metabolic Genetics, Cook Children’s Health Care System

4. VMP Genetics

5. Department of Pediatrics, Division of Genetics, Children’s Hospital of Philadelphia

6. Division of Neurology, The Children’s Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine

7. Individualized Medical Genetics Center, Division of Genetics, Children’s Hospital of Philadelphia

8. Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco

9. Division of Medical Genetics and Metabolism, Children’s Hospital of The King’s Daughters

10. Division of Medical Genetics, Duke University Medical Center

11. Department of Medicine, Columbia University Medical Center

12. Division of Genetics, Birth Defects & Metabolism, Ann & Robert H. Lurie Children’s Hospital of Chicago

13. Department of Kinesiology, University of Georgia

Intellectual disability (ID) is a genetically heterogeneous neurodevelopmental disorder that occurs in approximately 1 % of the general population. Whole exome sequencing (WES) has proven to be an effective tool to identify the genetic basis of ID in many patients. Using WES, PACS1 was recently implicated as a novel gene for ID and has been associated with mental retardation, autosomal dominant 17, MIM#615009. A pathogenic, recurrent de novo variant in PACS1, p.Arg203Trp, has been identified in 19 individuals to date, all of whom have a similar phenotype, including ID, urogenital abnormalities, and craniofacial features. Using WES, we have identified seven additional individuals with the same de novo missense variant in PACS1, adding further evidence that this variant is associated with a syndromic form of ID. Consistent with the previously reported patients, all seven probands of our series have intellectual disability, impaired language development, and overlapping dysmorphic facial features including hypertelorism, downslanting palpebral fissures, long eyelashes, full eyebrows, bulbous nasal tip, and widely-spaced teeth. Other common features shared among this cohort and the previously reported patients include: seizures (in 6/7 and 12/19, respectively), structural brain abnormalities (3/5 and 12/16 who had imaging studies), oral aversion (3/7 and 11/19), hypotonia (5/7 and 8/19), aggressive outbursts (3/7 and 10/19), cryptorchidism (3/5 and 6/12 males), eye abnormalities (3/7 and 8/19), gastroesophageal reflux (5/7 and 6/19), and congenital heart disease (3/7 and 8/19). Two of the seven individuals also have hypertonia of the extremities in addition to central hypotonia, which has not been previously reported in affected individuals. Currently, no other missense variants in PACS1 have been reported as pathogenic, suggesting a specific disease mechanism for p.Arg203Trp, possibly due to a gain of function. In summary, our results add to the clinical delineation of this syndromic form of ID.

Further evidence of a likely pathogenic variant inTWIST1as causative of Saethre-Chotzen syndrome

C. Hollinger1, D. Bishay2, R. Hagelstrom2, J. Gorski1

1. University of Missouri Health Care

2. University of Nebraska Medical Center

A female patient with a personal medical history of developmental delays, microcephaly, short stature, right coronal synostosis, facial asymmetry with left-sided ptosis, and a maternal family history of craniosynostosis has been identified as having a de novo 4p15.2p15.1 likely pathogenic deletion and a likely pathogenic variant in TWIST1. The 4p15.2p15.1 deletion is proximal to the Wolf-Hirschhorn critical region and has been confirmed as a primary event. A larger deletion, also identified as de novo, has been reported in an individual with intellectual disability and epilepsy among other clinical features. The 4p15.2p15.1 deletion in this patient is perceived to provide an explanation for the patient’s developmental delays, microcephaly, and short stature. The maternal family history includes individuals with a history of craniosynostosis including the patient’s mother and grandfather; they have no reported intellectual disabilities. Further studies identified a likely pathogenic variant in TWIST1 at c.466A>G; p.Ile156Val, resulting in an isoleucine to valine change. Mutations in TWIST1 are associated with Saethre-Chotzen syndrome, a variable, autosomal dominant condition that manifests as craniosynostosis, facial asymmetry, and other dysmorphic features. The variant identified in the patient has been previously reported in a father and son pair. The son presented with bilateral radial ray hypoplasia, metopic, sagittal, and coronal synostosis, and the father was found to have features suggestive of Saethre-Chotzen syndrome. This variant affects a well-conserved residue in a key functional domain and has not been observed in control populations. The identified variant in the patient, along with the clinical history, provides a diagnosis of Saethre-Chotzen syndrome that elucidates the medical history that is not related to the 4p15.2p15.1 deletion, as well as an explanation for the family history of craniosynostosis. This case report serves to provide further evidence that the c.466A>G variant in TWIST1 is a pathogenic mutation for Saethre-Chotzen syndrome.

A comparison of self-reported ethnicity and genetic ancestry

K. Kaseniit1, C. Lo1, S. Nazareth1, K. Wong1, I. Haque1

1. Counsyl, Inc.

Introduction: Current medical guidelines dictate the use of self-reported ethnicity in determining disease selection for carrier screening. However, prior studies in personal genetics have noted that self-reported ethnicity is not fully concordant with genetic ancestry and that admixture is pervasive. We sought to explore the discordance between self-reported and true genetic ancestry in an expanded carrier screening (ECS) population. Methods: Targeted next-generation DNA sequencing was performed on 60 thousand samples for which ethnicity was self-reported with 15 options for ethnic categorization, including one for mixed ethnicity. To compute genetic ancestry, we adapted an existing algorithm [1] for use with off-target deidentified sequencing reads. Results: In a clinical setting, ethnicity is commonly unreported or unknown (21 % of samples) or misreported. For example, 15 % of the “South-East Asian” samples were genetically South Asian, potentially due to misreporting rather than true unreported mixed ancestry. Further, 4 % of all patients have at least 25 % genetic ancestry from a different population than their self-reported ethnicity, suggesting at least one ancestrally different grandparent. Of the patients with unreported or unknown ancestry, over one-sixth had genetic ancestry that would have prompted a clinician following ethnicity-based screening guidelines to recommend additional tests. We observed three clusters of admixture in the Hispanic population. “Other / Mixed Caucasian” was chosen by individuals of mostly European descent. Conclusions: Self-reported ethnicities are not fully reliable in the clinical setting, suggesting that “pan-ethnic” carrier screening models that are agnostic towards self-identified ethnicity may be a better approach in the identification of at-risk couples.

Keeping somatic mosaicism in the differential: The diagnosis of Schimmelpenning-Feuerstein-Mims syndrome through skin biopsy

L. Kehoe1, M. Seprish1, C. Ferreira1, K. Cusmano-Ozog1

1. Children’s National Medical Center

Schimmelpenning-Feuerstein-Mims syndrome (OMIM #163200) also known as linear sebaceous nevus syndrome (LNSS) is a rare, multisystemic condition characterized by the presence of large sebaceous nevi. Sebaceous nevi typically present congenitally developing on the face and scalp, central nervous system, eye, heart and/or skeleton. Individuals are at an increased risk for tumor growth and cancer. Known as a sporadic disease, LNSS is thought to be the result of somatic genetic mosaicism involving a postzygotic dominant gene mutation in the RAS-MAPK pathway (HRAS, NRAS or KRAS). We present the case of an infant male who was consulted by genetics on day two of life for multiple skin findings and facial dysmorphism. Renal, brain and cardiac imaging noted numerous masses and abnormalities including right dysplastic kidney with mass, atrial septal defect and unusual aortic arch, bilateral microphthalmia, bilateral colobomas vs. staphylomas, brain masses and brain hamartoma. Molecular workup included a negative single nucleotide polymorphism (SNP) chromosome microarray as well as negative PTEN and KRAS gene sequencing on peripheral blood. Pathological findings significant for linear sebaceous nevus led to a skin biopsy of the left flank sebaceous region. Fibroblast culture and subsequent Noonan gene panel sequencing (11 genes) discovered a pathogenic KRAS mosaic G12D mutation. In summary, mutations were not present in non-lesional skin or blood leukocytes but rather present in lesional tissue, consistent with a somatic mosaic state. This case serves as a reminder that a comprehensive genetic workup should include fibroblast somatic testing for suspected mosaic conditions.

MAP3K1mutations are a common cause of 46, XY gonadal dysgenesis

L. Mohnach1, C. Keegan1, V. Alaniz1, E. Quint1, M. Chen1, E. Vilain2

1. University of Michigan

2. University of California, Los Angeles

Disorders of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal, or anatomic sex. Some DSDs affect sex determination, the process by which the male or female gonad is formed. MAP3K1 has recently joined the growing list of genes responsible for gonadal development. Mutations in this gene have been associated with 46, XY complete or partial gonadal dysgenesis in a sex-linked dominant fashion. The phenotype can also include hypospadias and micropenis with cryptorchidism. We present five individuals from three different families who presented with 46, XY DSD caused by mutations in MAP3K1 gene. The mutations identified in our case series include: c.566T>A (p.L189Q), c.14_16insCGC (p.Ala5dup), and c.1760T>A (p.Leu587His). Three individuals had complete gonadal dysgenesis characterized by bilateral streak gonads with internal and external female genitalia. The other two presented with partial gonadal dysgenesis characterized by incomplete testicular development, clitoral enlargement and otherwise normal female external genitalia. In two families, diagnosis of the proband led to the identification of 46XY DSD in a sibling. Coordinated care was provided in the setting of an interdisciplinary DSD program. Management initially involved decisions about gonadectomy but continued follow-up will be needed to address hormone replacement, gynecological needs, education and emotional support. One individual was found to have foci of germ cell neoplasia at time of gonadectomy. One individual is experiencing gender dysphoria. These cases illustrate the importance of performing a karyotype on siblings of 46,XY DSD individuals. Our experiencealso suggests that MAP3K1 should be considered early in cases of 46, XY partial and complete gonadal dysgenesis.

Regions of homozygosity: Implications on testing and counseling strategies

R. Mostafavi1, A. Choudhri1,2, J. Ward1,2, E. Pivnick1,2

1. Le Bonheur Children’s Hospital

2. The University of Tennessee Health Science Center

Single nucleotide polymorphism chromosome microarray (CMA) can detect regions of homozygosity (ROH) indicative of uniparental disomy, consanguinity, or descent from a common ancestor, all of which increase risk of autosomal recessive (AR) conditions. Review of AR genes within ROHs in correlation with clinical presentation can facilitate the diagnostic process and allow for directed pre- and post-test counseling compared to expansive panels or whole exome sequencing. We demonstrate this in 2 patients at different stages in the diagnostic odyssey. Patient 1, a 10 year old male, presented with progressive cognitive decline, joint contractures, seizures, dysphagia and mildly coarse facial features. He was the product of consanguinity and had inconsistent family and medical care. Brain MRI revealed generalized cerebral volume loss and cystic cerebellar lesions. Analysis of AR genes within his ROHs included SGSH, the gene responsible for heparan N-sulfatase enzyme, deficiency of which is associated with Sanfilippo IIIA. Diagnosis was confirmed by urinary elevation of heparan sulfate and ~5 % leukocyte heparan-N-sulfatase activity. Patient 2, a newborn female, presented with hypotonia, dysmorphia, and ventriculomegaly. MRI of the brain showed bilateral perisylvian polymicrogyria, as well as germinolytic cysts along the lateral margin of the body of both lateral ventricles. Prenatal CMA detected ROH and analysis of AR genes identified PEX 12, one of 12 known genes associated with Zellweger syndrome (ZS). Physical exam suggested ZS and diagnosis was confirmed by elevated very long chain fatty acids and detection of a homozygous pathogenic frameshift mutation in the PEX12 gene. Combining clinical information with ROHs led to identification of single genes of interest in our patients and streamlined diagnostic workup. This approach led to targeted testing in both cases and allowed for simplified counseling focused on the possible diagnoses, which decreased counseling burdens related to time constraints, information-giving, psychosocial issues, and incidental findings.

Decreasing healthcare costs: Turnaround time reduction

M. Nelson1, C. Zaleski1, L. Drury1, A. Nysrom1

1. PreventionGenetics

As healthcare costs soar, genetic counselors need to be cognizant of not only the patient’s out of pocket expenses, but also the total cost to the healthcare system when ordering genetic testing. At the same time, quick turnaround time (TAT) of results, while maintaining accuracy and quality, is critical for progression in a patient’s diagnostic odyssey. Quick results of targeted testing becomes important to at-risk family members. The majority of familial targeted testing is performed by Sanger sequencing. Historically, PreventionGenetics has met this need for quick quality results through offering a 10-day STAT option for all our Sanger sequencing tests. This incurs a 25 % STAT surcharge. Data presented is a retrospective analysis of our TAT progress since January 2015. Using a ratio of the average total turnaround time to the overall number of tests, we have seen a two-fold reduction in TAT for Sanger tests. In January 2015 median overall TAT was 31 days. Current data shows a median overall turnaround time for Sanger sequencing tests to be 10.5 days. Outlined are our current workflow and the improvements made to both enhance the quality and efficiency of our Sanger testing to reduce TAT. These refinements include efficiency gains in specimen accessioning, DNA extraction, robotics, employee training, and expanding work hours­. Our long term goal is to complete all Sanger tests by 10 days, thus eliminating the necessity of the STAT option. Eliminating STAT surcharges during this time period would have saved nearly $156,000 in patient expenses and costs to the healthcare system. Continued efficiencies in the lab will lead to the elimination of the STAT charges while also improving testing value to patients and providers as results are received in a more timely fashion at a lower cost. Transparency of pricing is important as we all work towards lowering healthcare costs related to genetic testing.

Secondary findings in trio family members of probands undergoing diagnostic exome sequencing

Z. Powis1, T. Cain1, C. Alamillo1, K. Hagman1, L. Shamirzadi1, S. Tang1

1. Ambry Genetics

Diagnostic exome sequencing (DES) is a powerful diagnostic tool for patients with undiagnosed genetic disease, and may result in identification of secondary findings (SF). While previous recommendations and studies focused on proband SF uptake and reporting, little is known about SF testing in parents and other family members. In 2015, our laboratory began providing family members included in exome trio sequencing (to facilitate primary interpretations) the option of obtaining their SF results. We performed a retrospective analysis of ordering preferences among the first 661 trio members from 390 families offered SF results. All patients had the option to decline SF results, request gratis SF results from American College of Medical Genetics and Genomics (ACMG) recommended genes, and/or results from fee-based expanded categories of; childhood onset, adult onset, cancer predisposition, and/or recessive carrier status. Only alterations classified as pathogenic or likely pathogenic were reported, and each individual received their own report. Six hundred sixty one trio family members, 492 (74.4 %) elected results within ACMG genes; significantly less than probands (90.9 %, p < 0.0001). There were no statistically significant differences in ordering of expanded panels between probands and trio members, nor positive rates between probands and trio members within any SF category. Of the eight cases where the proband had a positive SF report and both parents were tested, only one alteration was de novo. Additionally, nine parental alterations absent in the proband were reported. The availability of family member SF testing has complex implications regarding disclosure of SF results, particularly in regards to inferring results. Interestingly, many parents did not choose SF testing for themselves but opted for their child. The identification of positive SF alterations, especially when findings are not present or declined in family members, contributes to the complexity of results disclosure. Comprehensive genetic counseling is essential, as clinical utility and penetrance varies within alteration, gene, and personal and family histories.

Continued coverage and reimbursement challenges for diagnostic exome sequencing after 5 years, genetic counselors can help to overturn denied cases

Z. Powis1, K. Hagman1, T. Cain1, L. Shamirzadi1

1. Ambry Genetics

Introduction: Since 2011, Diagnostic Exome Sequencing (DES) has proven beneficial in providing previously undiagnosed patients with molecular genetic diagnoses. Consequently, the American College of Medical Genetics and Genomics (ACMG) recommended proper utilization of DES in clinical assessment of individuals with suspected genetic conditions, where prior genetic testing fails to lead to diagnosis. Application of DES has allowed many undiagnosed patients who endured extensive genetic testing to receive definitive genetic diagnoses. Despite a belief of DES as cost-effective by the medical community, its utility, scientific and medical value is still questioned by payers. Methods: 1500 consecutive patients that had undergone DES were retrospectively analyzed to determine payer category, excluding 24 research study exomes. Additionally, 538 cases were prospectively analyzed for denial, approval and appeal information. Results: 911/1476 (61.7 %) were approved by private insurance/Medicare/Medicaid, 521 (35.3 %) institution billed, 44 (3.0 %) paid directly by the patient/patient representation. 275/ 538 (51.1 %) cases were approved for testing by private insurance/Medicare/Medicaid. 65/267 cases appealed and 21 (32.3 %) of these were subsequently approved. Reasons for denial (several cases had multiple reasons) included: 176 (46.3 %) experimental, 85 (22.4 %) not medically necessary, 83 (21.8 %) insurance policy exclusion/did not meet medical policy, 27 (7.1 %) will not impact treatment, 5 (1.3 %) other (e.g. no records given), 4 (1.1 %) does not diagnose disease. Discussion: Despite recommendations and literature demonstrating clinical utility of DES, out of 48 % denied cases, over 97 % were denied due to insurance companies’ rationalization that the DES does not have enough evidence to benefit patients. The number of overturned appeals is encouraging and eludes that genetic counselors can help in insurance authorizations and obtaining coverage for DES. While a number of insurances (both private and public) are covering DES, genetic counselors are needed to aid in education of payers and demonstration of the clinical utility of DES.

Navigating neurometabolic disorders: uncovering a rare X-linked recessive disorder in a heterozygote female

C. Rajakaruna1, T. Burrow1, B. Hallinan1, E. Partack1

1. Cincinnati Children’s Hospital Medical Center

We present the case of an 8 month old female who presented to neurometabolic clinic post work up for multiple congenital anomalies and seizures. Initial findings at birth were an anorectal malformation, choanal stenosis, dysmorphic features (midface hypoplasia, micrognathia, anteverted nares), vertebral anomalies (fused ribs on left, fused sacral tailbone), 2–3 syndactyly of right and left toes and 4–5 syndactyly of left toes. Onset of seizures was at 2 months of age in the setting of hypoglycemia likely related to the subsequent discovery of growth hormone deficiency. Congenital bilateral glaucoma, cataract of left eye, and a small PDA and PFO were present. Previous genetic testing included chromosomes, single nucleotide polymorphism (SNP) microarray, and sequencing of DHCR7 for Smith-Lemli-Opitz which were all normal. Based on the patient’s history, a large pediatric neurology region of interest panel focusing on seizures, encephalopathy, and brain malformations was ordered. A de novo, heterozygous, pathogenic deletion involving exon 4 of PHF6 was identified. Results reported that based on the X-linked recessive inheritance pattern of disorders associated with this gene, the patient is at least a carrier for Borjeson-Forssman-Lehmann syndrome. Borjeson-Forssman-Lehmann syndrome is a rare X-linked disorder characterized by severe intellectual disability, epilepsy, hypogonadism, coarse facial features, long ears, short stature, obesity, gynecomastia, tapering fingers, and shortened toes. Further, X-inactivation studies demonstrated a highly skewed X-inactivation pattern with a ratio of 100:0. This indicated our patient was on the more severe spectrum of the disorder. Female carriers tend to be mildly affected; however, at least 12 females with de novo aberrations in PHF6 have been reported. This case illustrates the importance of genetic counseling for X-linked conditions in females with neurometabolic disorders prior to ordering large genetic testing panels. As we discovered, large neurology gene panels may identify rare syndromes with a variable phenotype in female carriers.

Diagnostic yield of genetic testing at the Children’s Hospital Colorado Autism Genetics Clinic

H. Raszka1, K. Brown2, N. Meeks2

1. University of Colorado, Anschutz Medical Campus

2. Children’s Hospital Colorado

Autism spectrum disorders (ASDs) are a group of neurodevelopmental disorders characterized by limitations in communication and social interaction, and atypical repetitive behaviors. Several genetic disorders have been identified in ASDs but clinical genetic testing is diagnostic in only a minority of cases. This study examined the yield of genetic testing in children with ASD at Children’s Hospital Colorado’s Autism Specialty Genetics Clinic to better direct genetic testing for patients with ASD and to understand their counseling needs. This was a retrospective chart review of patients evaluated in the ASGC between 2007 and 2015. One hundred sixty seven patients with a documented formal ASD diagnosis and at least one chromosomal, molecular, or biochemical test were included. The yield of positive genetic testing was compared to negative testing by Fisher’s exact test to determine significance. The overall yield of positive testing was 12.57 %. 8.38 % of patients were identified to have a chromosomal abnormality and 4.19 % of patients had a single gene disorders. Females, patients with gross motor delays, and patients without a family history had significantly higher yields of testing, illustrating that these patients may benefit from more extensive testing. Other clinical features did not correlate with higher yields of testing. FMR1 analysis was uninformative, potentially indicating that other providers are recognizing Fragile X syndrome prior to referral for a genetics evaluation. Biochemical studies for inborn errors of metabolism were uninformative, supporting that these are rare causes of ASDs. 40.12 % of patients were identified to have at least one variant of uncertain significance (VUS), which indicates the need for pretest counseling to inform parents of test expectations. This study provides information about the diagnostic yield of genetic testing in an ASD specialty genetics clinic, which may inform clinical decision-making and allow geneticists and genetic counselors to provide more accurate information about the potential diagnostic yield of genetic tests.

Development of a test quality assessment tool: A professional resource for genetic counselors

J. Riley1, C. Hess2, C. Applegate3, A. Bandholz4, G. Chandratillake5, J. Cohen6, W. Faucett7, M. Frone8, M. Goodenberger9, M. Landon10, S. Liebers11, W. Mendonca12, K. Moyer13, V. Raymond14, S. White15, G. Hooker2

1. Cleveland Clinic

2. NextGxDx

3. Johns Hopkins McKusick-Nathans Institute of Genetic Medicine

4. Ambry Genetics

5. University of Cambridge

6. Kennedy-Krieger Institute

7. Geisinger Health

8. CancerGene Connect

9. Mayo Medical Labs

10. Myriad Genetics

11. Genetic Counseling Services, Inc.

12. GeneDx

13. Counsyl, Inc.

14. Trovagene

15. Stanford Healthcare

With the rapid progression of genetic technology, the availability of clinical testing options has surged over recent years, with more clinical laboratories now competing for a share of this market. Assessing the quality of these laboratories and the tests they offer is an increasingly difficult part of a genetic counselor’s practice. In 2015, a group of clinical and laboratory-based genetic counselors formed a Quality Working Group to look more closely at the issue of how to objectively and effectively evaluate the quality of clinical genetic testing options. The goal of the group was to develop a tool to guide genetic counselors through the process of evaluating quality when selecting clinical laboratories and specific tests. We held multiple conference calls in 2015 to consider the needs of the profession and determine the most important quality questions to ask. The working group sought input from attendees at the 2015 NSGC Annual Education Conference by presenting a poster with the proposed framework and discussion points for quality assessment. After incorporating additional feedback, the group developed its first tool, a Next Generation Sequencing Panel Quality Assessment worksheet. The tool is currently in a pilot phase, being tested by genetic counselors across specialties. A survey has been developed to elicit formal feedback from the initial users. The Quality Working Group will present our process and experiences in development of this tool, discuss feedback from the NSGC membership and introduce the finalized quality assessment tool as a resource for the genetic counseling profession.

Facilitating human disease gene discovery through intersection of chromosomal microarray and whole exome sequencing data

J. Rosenfeld1, T. Gambin1, J. Beuten2, A. Pursley2, P. Liu2, W. Bi2, A. Breman1, J. Smith2, C. Bacino1, F. Xia2, S. Lalani1, C. Shaw1, S. Cheung2, Y. Yang2, A. Patel2, P. Stankiewicz1

1. Baylor College of Medicine

2. Baylor Miraca Genetics Laboratories

Genome-wide testing technologies, including chromosomal microarray (CMA) testing and whole exome sequencing (WES), are powerful tools for genetic diagnosis. They examine genetic variation on a broad scale and, unlike more targeted testing modalities, do not require prior suspicion of a specific diagnosis. Given their agnostic approaches, genome-wide tests may identify variants in genes not currently associated with disease, which may be pathogenic. Pathogenicity may be difficult to determine based on single cases, but aggregation of data from large cohorts can provide sufficient evidence and facilitate disease gene discovery. We analyzed clinical CMA results from 55,227 individuals tested with custom-designed, oligonucleotide-based arrays, 39,170 of which had exon-level coverage in disease and candidate genes. From this cohort, we identified small de novo deletions (affecting ≤5 genes) involving ~100 genes not definitively associated with disease. We next searched for rare loss-of-function variants in these genes among >7000 individuals undergoing clinical WES to prioritize candidates. Parental analyses for a subset of rare loss-of-function variants identified by WES allowed identification of candidate human disease genes with de novo copy number (CNV) and single nucleotide variation (SNV): TRIP12 on 2q36.3 (3 de novo CNVs, 4 de novo SNVs, in patients with developmental delay and dysmorphic features), MEIS2 on 15q14 (1 de novo CNV, 1 de novo SNV, in patients with orofacial clefts), and PSMD12 on 17q24.2 (6 de novo CNVs, 1 de novo SNV, in patients with developmental delay). Additionally, we identified a de novo 2q24.2 deletion involving TBR1, TANK, and PSMD14. While emerging evidence supports a role for TBR1 in developmental delay and autism spectrum disorders, WES identified a de novo TANK frameshift variant in a patient with congenital heart disease, suggesting that deletions in this region could lead to more complex phenotypes, based on gene content. This approach demonstrates the power of leveraging data from large cohorts to facilitate disease gene discovery.

Pediatrician practice regarding the genetic evaluation of children with autism spectrum disorder

A. Rutz1, K. Dent1, P. Carbone1

1. University of Utah

Background: Despite recommendations for genetic evaluation of all children with autism spectrum disorder (ASD), few are referred for genetic evaluation or receive genetic testing. Pediatricians may have gaps in knowledge, negative attitudes or experience barriers that decrease access to appropriate genetic evaluation of children with ASD. Objective: The purpose of this study is to characterize the knowledge, attitudes, current practices and perceived barriers of pediatricians regarding the genetic evaluation of children with ASD in order to identify primary care level interventions to increase appropriate genetic evaluation for children with ASD. Methods: We surveyed primary care pediatrician members of the Utah American Academy of Pediatrics regarding their knowledge, attitudes, current practices and perceived barriers in obtaining a genetic evaluation of patients with ASD in their care. Descriptive statistics summarized responses to all questions. Results: Of 314 surveys sent, 108 (34 %) were returned. Knowledge: Half of respondents underestimate the yield of genetic testing and 45 % are not aware of current guidelines regarding genetic evaluation. Attitudes: A minority of respondents believe all children with ASD should be referred for genetic evaluation (21 %) or receive genetic testing (24 %). Current practice: Among all respondents,10 % routinely offer genetics referral for children with ASD. Barriers: commonly identified barriers in obtaining genetics services for children with ASD were lack of insurance coverage for evaluation (55 %) and testing (71 %), long wait time to see a geneticist (71 %) and lack of confidence in ordering the correct test (49 %). Conclusions: The majority of pediatricians are not aware of, nor adhere to, current guidelines regarding genetic evaluation of children with ASD. Efforts to educate pediatricians regarding current recommendations for genetic evaluation of children with ASD are needed as well as system level solutions regarding availability of genetic providers and reimbursement for genetic testing.

Association of airway abnormalities with 22q11.2 deletion syndrome

R. Sacca1, K. Zur2, K. Valverde1, D. McDonald-McGinn2

1. Arcadia University

2. Children’s Hospital of Philadelphia

Background: 22q11.2 deletion syndrome (DS) presents with complex but variable symptoms most frequently including cardiac, immune, palatal, endocrine, cognitive and psychiatric issues. Structural airway abnormalities have not been formally described. Given the significant morbidity and mortality observed in patients with 22q11.2DS and symptomatic airway disease, we set to document the frequency of this association. Methods: We retrospectively reviewed the medical records of patients with 22q11.2DS evaluated at the Children’s Hospital of Philadelphia between 1999 and 2015 who were referred to otolaryngology for an airway assessment. The type of airway abnormality observed and the presence of comorbidities such as congenital heart disease, the incidence of tracheostomies, and association with prenatal polyhydramnios were noted. Results: 104 patients who underwent an otolaryngology procedure (laryngoscopy or bronchoscopy) were identified. Of these, 77 %, ranging in age from 5 months to 37 years, had airway anomalies. Males and females were equally affected. Findings included: tracheomalacia (35 %), subglottic stenosis (27 %), laryngomalacia (23 %), glottic web (23 %) and bronchomalacia (15 %). The majority of patients (84 %) had an associated congenital heart defect with Ventricular Septal Defect and Tetralogy of Fallot being the most prevalent. Importantly, 28 % required a tracheostomy and 18 % were noted to have a history of polyhydramnios. Conclusion: Our findings suggest that airway abnormalities are a common feature of 22q11.2DS leading to significant morbidity particularly when combined with complex cardiac disease. Further, polyhydramnios may be a useful prenatal clue to the diagnosis of 22q11.2DS with airway anomalies. Lastly, postnatal assessment of airway structure and function should be a key component of the evaluation of patients with 22q11.2DS that will help guide patient management.

Whole exome sequencing identifies a pathogenic variant inTSC1in a father and son without typical findings of tuberous sclerosis complex

A. Schreiber1, V. Zurcher1

1. Cleveland Clinic

Our patient is an 18-month-old male with macrocephaly, hypotonia, seizures, megalocornea, cone-rod dysfunction, hyponatremia, and developmental delay. WES identified a paternally-inherited novel variant in TSC1, which destroys the splice donor site at the end of exon 17. According to American College of Medical Genetics and Genomics (ACMG) standards, the c.2208+2T>A variant is deleterious. The remainder of WES was normal, including mtDNA sequencing. Chromosome microarray and extensive metabolic testing were also normal. According to current criteria the diagnosis of TSC requires 2 major features, 1 major with 2 or more minor features, or a pathogenic variant in TSC1 or TSC2. The proband had no dermatologic or ophthalmologic findings of TSC and his brain MRI showed only delayed myelination. Echocardiogram and renal ultrasound were normal. The patient’s 33-year-old father underwent reanalysis of TSC1 through a different lab to rule out a sample switch. The same variant was identified and called pathogenic. He has 1 large hypopigmented macule, a few small scattered hypopigmented macules on sun-exposed areas, and 3 cutaneous lumps suspected to be cysts. He is neurologically intact and his brain MRI, eye exam, renal ultrasound, and echocardiogram were normal. Our proband and his father fulfill no major criteria for TSC. The proband has developmental delays and seizures, which are common in but not specific for TSC, and TSC would not explain his other medical issues. However, based on the diagnostic criteria, both he and his father have TSC due to their genetic test results. Clinicians struggle with how best to follow patients in this scenario. This family would not have been tested for TSC, but they are being followed according to TSC guidelines due to the WES results. Recurrence risk is also difficult to determine, because we cannot predict if this variant could present with classic TSC findings.

Novel finding of complete paternal uniparental isodisomy 4 in a girl with a complex congenital heart defect and bilateral optic nerve hypoplasia

A. Shealy1, J. Riley1, S. Shetty1, A. Erwin1

1. Cleveland Clinic

Introduction: Uniparental isodisomy of some chromosomes has been associated with genetic disorders and other medical/developmental concerns. The mechanisms for pathogenicity include imprinting as well as uncovering recessively inherited disorders. Here we report a child who was found to have complete paternal uniparental isodisomy of chromosome 4. Case Report: Our patient, a 6 month-old girl, came to medical attention at 1 week of age when a cardiac murmur was appreciated. She was found to have a complex congenital heart defect consisting of an aortic coarctation with transverse arch hypoplasia, PDA, muscular VSD, and a bicuspid aortic valve. Subsequently, she was diagnosed with bilateral optic nerve hypoplasia, moderate angle esotropia, and myopic astigmatism. To date, development is within normal limits. The child is nondysmorphic and family history is non-contributory. To evaluate these symptoms, genomic CHG + SNP microarray was pursued; no copy number changes were detected but testing did identify complete isodisomy of chromosome 4. Further uniparental disomy testing indicated paternal uniparental isodisomy 4. Discussion: Upon extensive literature review, this is the first reported case of paternal uniparental isodisomy 4. Congenital heart defects are not uncommon but in conjunction with optic nerve hypoplasia, it raises concern for a single underlying etiology, quite possibly the uniparental isodisomy 4. A review of the 86 genes on chromosome 4 known to be associated with recessive disorders did not produce a good match, however it is possible that either another gene whose function is not yet known is responsible or that imprinting does occur on chromosome 4. Maternal uniparental isodisomy 4 has been reported in the literature and has been associated with psychiatric concerns. The identification of this case may help develop an understanding of uniparental disomy 4. Additionally, this case may serve as a basis for future comparison, providing some guidance for other genetics professionals working with patients who have similar test results and/or symptoms.

Parental understanding of whole exome sequencing: A comparison of perceived and actual understanding.

L. Tolusso1, K. Collins1, X. Zhang1, J. Holle2, C. Valencia1, M. Myers1

1. Cincinnati Children’s Hospital Medical Center; University of Cincinnati

2. University of Minnesota Health

Whole exome sequencing (WES) is an integral tool in the diagnosis of suspected genetic conditions in pediatric patients. Healthcare providers and families have expressed concerns about the amount and complexity of information that needs to be conveyed to facilitate informed consent about WES. However, there is limited information about understanding of WES among parents who pursue WES for their children. Modeled after an existing survey assessing informed consent, we developed a survey comprised of 8 domains of informed consent (scope, description, benefits, risks, voluntary/refusal, confidentiality, future use, and secondary findings) and 17 subdomains (purpose, analysis, who will be tested, meaning of results, reporting of results, benefits, limitations, implications for other family members, choice for WES, choice for secondary findings, medical record, research, reinterpretation, discrimination, secondary findings, types of secondary findings, and implications of secondary findings) to assess perceived (subjective) and actual (objective) understanding of WES in parents who consented to WES for their child between July 2013 and May 2015. Fifty-five surveys were completed (56.7 % response rate). Mean subjective and objective understanding scores were compared using paired t-tests to identify areas where perceptions of understanding did not match actual understanding. There was no significant difference in overall mean subjective (83.1/100) and objective understanding (82.5/100). However, subjective and objective understanding differed significantly in four domains (scope, description, voluntary nature, benefits) and seven subdomains (purpose, analysis, reporting of results, benefits, reinterpretation, implications of secondary findings). Our findings suggest that parents understood the majority of information about WES that we assessed and that perceived and actual understanding were similar. Concepts participants understood less well and may warrant further attention were the possibility of insurance discrimination and methods of WES analysis.

Use of next-generation sequencing to diagnose concomitant hemolytic anemia in children with sickle cell disease

E. Varga1, K. Zajo1, S. Creary1,2

1. Nationwide Children’s Hospital

2. The Ohio State University

Introduction: Hereditary hemolytic anemia (HHA) is caused by defects in the red blood cell membranes (e.g. hereditary spherocytosis (HS) or elliptocytosis (HE)), deficiencies of red blood cell enzymes (e.g. G6PD deficiency) or hemoglobin disorders (e.g. sickle cell disease). Sickle cell disease (SCD) is the most common HHA, most often caused by homozygous point mutations (Hb S) in the HBB gene. Case Reports: Here we present 3 male probands with a diagnosis of SCD (Hb SS) who had unusually clinically severe SCD including prolonged neonatal indirect hyperbilirubinemia, persistently lower than expected hemoglobin, and the need for recurrent blood transfusions. The children were of Ghanian (1), Nigerian (2), and Somali (3) descent. Due to the underlying diagnosis of SCD, typical methods for evaluating for other HHA (e.g. enzyme levels, evaluation of peripheral smear) were not ideal, prompting genotyping for other forms of HHA. HBA/HBB genotyping was performed in all cases to confirm hemoglobinopathy status. Single gene (G6PD) testing was performed in case 3 (with reflex to a larger panel intended if negative) and a 29-gene hemolytic anemia panel was performed in the other cases. A diagnosis of HE (due to c.2373C>A in SPTA1) was made in case 1 and G6PD was confirmed in two cases (due to c.376A>G in case 2 and c.376A>G and c.202G>A in cis in case 3). Discussion: Sickle cell disease, G6PD and HS/HE are all HHAs with a high prevalence in malaria endemic regions. Evaluation of co-existing HHAs through next-generation sequencing may be appropriate for patients with SCD who have excessive hemolysis since other assays typically used to screen for these disorders may be difficult to interpret. Diagnosis of HHA is important due to specific management implications, including avoidance of medications/foods (G6PD) to limit oxidative stress, and consideration of therapeutic splenectomy (G6PD, HS/HE).

De novo deletion of GATAD2B putative regulatory region associated with clinical features consistent with GATAD2B haploinsufficiency

K. Wain1, B. Finucane1, C. Martin1, T. Challman1

1. Geisinger Autism and Developmental Medicine Institute

To date, there have been 5 individuals reported in the published literature with loss of function variants involving GATAD2B (OMIM 615074), in addition to seven deletions of variable lengths in DECIPHER and the Database of Structural Variation (dbVar). Common features amongst the previously published cases include: intellectual disability, behavior problems, hypotonia, macrocephaly, long fingers, thin blond hair, hypertelorism, and broad mouth. We describe a 2 year, 7 month old female who presented for neurodevelopmental evaluation due to global developmental delays and congenital macrocephaly. She is noted to have hypertelorism, wide nasal bridge, broad mouth, and thin blond hair, closely resembling previous cases. Chromosomal microarray revealed a de novo 178 kilobase (kb) deletion at 1q21.3 (chr1:153,859,810-154,034,971x1, hg19) which overlaps the 5’ untranslated region and non-coding exon 1 of GATAD2B, as well as 8 other genes. An additional 599 kb duplication at 4q22.3 was inherited from an unaffected father and is likely benign. The region upstream of GATAD2B is predicted to contain regulatory elements likely involved in GATAD2B expression and two small deletions of this putative regulatory region have been observed, including a de novo 38.7 kb deletion associated with macrocephaly (dbVar) and an inherited 52 kb deletion associated with intellectual disability (DECIPHER). Deletions of this putative regulatory region are not reported in control populations from the Database of Genomic Variants. Considering the close clinical correlation between our patient and those previously reported, it is likely that this deletion results in loss of GATAD2B expression due to disruption of regulatory sequences. This report is the first well-described patient with a phenotype consistent with GATAD2B haploinsufficiency due to deletion of non-coding, regulatory sequence. This case reinforces the importance of clinical correlation and the utility of data-sharing efforts in the clinical classification of copy number variation.

Sequencing the coding exon ofGJB2may be a better testing strategy for familial cases of autosomal recessive nonsyndromic hearing loss: A case report

E. Wakefield1, D. Choo1, J. Greinwald1, K. Zhang1

1. Cincinnati Children’s Hospital

This case report describes a family with three genetic mutations associated with nonsyndromic autosomal recessive hearing loss (DFNB1). The proband failed her newborn hearing screening due to profound hearing loss. Genetic testing identified the common GJB2 mutation, c.35delG, and the common GJB6 deletion, D13S1830, which confirmed a diagnosis of DFNB1. Her mother has mild hearing loss that was diagnosed in adulthood and was attributed to environmental factors. As a result, the family reported their family history as negative and the couple was provided a 25 % recurrence risk for DFNB1 in future children. No genetic confirmation of parental carrier status was performed at this time. This couple later had another child who failed her newborn hearing screening due to mild hearing loss. Targeted mutation analysis for the known familial mutations identified the GJB6 deletion but a different GJB2 mutation, c.101T>C, which correlated with her mild phenotype. This mutation was identified during targeted mutation analysis since it occurred in the same exon as c.35delG and was reported in concordance with the laboratory’s reporting policy. Given the hearing loss observed in the mother, it is most likely that she is compound heterozygous for both GJB2 mutations identified in her children rather than either mutations occurring de novo. Upon confirmation of their carrier status, the couple’s recurrence risk for DFNB1 has increased from 25 to 50 %. This case highlights the possibility that numerous GJB2 mutations may be present in a family due to the high frequency of GJB2 mutations in the US population (approximately 1 in 30). Because not all laboratories report mutations identified beyond the known familial mutations, targeted analysis in presumed carriers and at-risk siblings may miss additional GJB2 mutations. As a result, full sequencing of the coding exon in GJB2 may be a better approach for familial cases of DFNB1 to ensure no additional mutations are missed. Incomplete testing may lead to missed DFNB1 diagnoses and inaccurate recurrence risk and genetic counseling.

Test utilization and the role of genetic counseling in pediatric hematology at a tertiary care center

K. Zajo1, S. Creary2, A. Dunn1,2, S. Joshi1,2, B. Kerlin1,2, R. Kumar1,2, S. O’Brien1,2, M. Rose1,2, R. Sharma1, A. Villella1,2, E. Varga1

1. Nationwide Children’s Hospital

2. The Ohio State University

Background: With the advent of next generation sequencing (NGS), genetic testing options are rapidly expanding within medical subspecialties. Consultative genetic counseling services are provided within the Division of Hematology/Oncology/Bone Marrow Transplant at our freestanding Children’s Hospital. Methods: We performed a retrospective review of genetic counselor-facilitated evaluations of pediatric hematology patients over a 12 month period. We describe indications for referral, testing practices, and outcomes of genetic testing. Results: In 2015, 99 unique probands and 19 family members were evaluated. Of the probands, 36 were referred for an indication of cytopenia/bone marrow failure, 31 for bleeding/clotting disorder, 13 for hemoglobinopathy, 9 for hemolytic anemia and 10 for other hematologic conditions. One hundred eighteen genetic tests were ordered including 68 single gene (SG), 34 NGS and 16 familial mutations. Twenty six patients had genetic counseling without genetic testing. NGS panels were most frequently ordered for the diagnoses of hemophagocytic lymphohistiocytosis, Diamond-Blackfan Anemia and hemolytic anemia, while single gene tests were utilized for hemophilia (F8/F9), hemoglobinopathies (HBA/HBB) and thrombophilia (F2/F5). In probands, 48 pathogenic mutations were identified (37 on SG, 11 on NGS) on 101 tests, resulting in a diagnostic yield of 47.5 %. A total of 14 variants of uncertain significance (4 SG, 10 NGS) were found. Conclusions: Molecular genetic testing is widely utilized in the setting of pediatric hematology. Genetic counselors play a valuable role as part of a multidisciplinary team to evaluate genetic testing options, provide pre- and post-test counseling, result interpretation, and follow-up testing of family members. As genetic testing for hematologic conditions continues to expand, further assessment of diagnostic yield and resulting changes to medical management is needed to better characterize the impact of genetic testing in this population.

Genetic test utilization management: Trends of decreasing costs of genetic test orders

L. Zetzsche1, A. White1, A. Essendrup1, G. Pino1

1. Mayo Clinic

Genetic Counselors can serve as an advocate for patients in a variety of settings, including in the sendout laboratory. Many large healthcare organizations have adopted utilization management (UM) programs which aim to minimize the inappropriate use of expensive and complex genetic sendout testing through genetic counselor review. This review of genetic test orders helps to reduce unnecessary testing typically resulting in decreased costs for the patient and healthcare institution. Mayo Clinic-Rochester (MCR) implemented a genetic test UM program for all MCR sendout genetic tests beginning in late January 2015, following an initial pilot program in February 2014. Genetic test orders were reviewed by genetic counselors for potential errors and appropriateness of testing, as well as review of possible cost savings. In 2015, the genetic test UM review process resulted in an average savings of $201 per genetic test order. There was also an overall trend of decreasing costs of genetic test orders over time, even before the UM review. The average cost per genetic test order (pre-UM review) decreased $549 in 2015 compared to tests ordered during the 2014 UM pilot program, and decreased an additional $46 in early 2016 (January – March). We review several factors that have likely contributed to the decrease in average cost per genetic test order. The expansion of new genetic technologies such as next-generation sequencing and increased competition in the genetic testing marketplace have helped to lower genetic testing costs for many conditions. However, many non-genetics providers were unaware of newer and more cost-effective genetic testing options, and UM genetic counselors often served as a resource for this information. The creation of a genetic test UM program also contributed to a culture of greater provider and patient awareness of genetic testing costs, with an emphasis on selecting tests with highest clinical utility and reasonable cost for the patient.

Outside the lines: Detection rate of chromosomal microarray in individuals without a ‘guideline’ indication for testing

A. Baxter1, E. Harward1, R. Vanzo1, P. Rushton1, M. Serrano1, B. Wassman1

1. Lineagen, Inc.

Chromosomal microarray (CMA) is recommended as a first-tier genetic test for individuals with certain clinical features by multiple organizations including American College of Medical Genetics, American Academy of Pediatrics, and American Academy of Neurology. This recommendation is based on the detection rate of CMA in individuals with these features, including autism spectrum disorder (ASD), intellectual disability (ID), developmental delay (DD), and multiple congenital anomalies (MCA), which ranges from 5 to 25 %. Comparatively, karyotype, the previously recommended first-tier genetic test for these populations, has a detection rate of 2–5 %. While the utility of CMA in individuals with ASD, ID, DD, and MCA has been evaluated in many large studies, the value of CMA for individuals who do not have one of these ‘guideline’ indications is not as well understood. We reviewed all CMA test results through our clinical laboratory between October of 2010 and April of 2016 and identified 409 cases for which diagnostic codes did not include ASD, ID, DD, or MCA. Of these, 26.2 % had abnormal or unknown results, compared to 28.4 % in the group with ASD, ID, DD, or MCA (p = 0.408). Additionally, within the group that did not have ASD, ID, DD, or MCA, 21.1 % had an abnormal or unknown result when there was only one indication for testing, compared to 31.2 % for those who had two or more indications for testing (p = 0.045). Our experience indicates that although there is a slightly lower detection rate in individuals without ASD, ID, DD, or MCA that were tested, it is not significant when compared to ‘guideline’ indications. Additionally, CMA is significantly more likely to identify a finding in individuals who do not have ASD, ID, DD, or MCA if there is more than one clinical indication for testing (ex: seizures and hypotonia).

The utility of multi-gene sequencing in the diagnosis of congenital myasthenia and related neuromuscular disorders

K. Beattie1, A. Lindy1, S. Suchy1

1. GeneDx

Congenital myasthenia (CMS) comprises a heterogeneous group of disorders resulting from defects at the neuromuscular junction, characterized by fatigable weakness of the bulbar and proximal muscles, presenting at birth or shortly thereafter. Overlapping features and early age-of-onset can make the diagnosis of CMS and other neuromuscular disorders difficult. As specific forms of CMS respond differently to the currently available treatments, genetic testing can allow for more rapid implementation of appropriate treatment. Whole exome sequencing (WES) was evaluated as a method to diagnose CMS and related disorders. We identified 51 patients with clinical features of CMS, including myasthenia, joint contractures, ophthalmoplegia, and fatigable weakness, who underwent WES. A diagnosis was made in 33 % (17/51) of cases. However, only 2 individuals had pathogenic variants in genes associated with CMS, while 15 patients had pathogenic variants in genes associated with other neuromuscular disorders. Three individuals were compound heterozygous for pathogenic/likely pathogenic variants in the RYR1 gene, which is associated with congenital central core myopathies. The remaining 13 individuals had positive findings in genes associated with various neurodevelopmental disorders, such as Rett syndrome or Bethlem myopathy. In one patient, two pathogenic variants were identified in the CHRNG gene. Thus far, CHRNG has not been definitively associated with CMS, but it encodes a fetal acetylcholine receptor (AChR) subunit and variants in other AChR subunit genes are the most common cause of CMS. Inconclusive results were reported in 43 % (22/51) of cases, including cases with single pathogenic variants in genes causing autosomal recessive disorders or with variants of uncertain significance. These data highlight the usefulness of concurrent multi-gene sequencing in efficiently deciphering a diagnosis that may guide treatment or point to additional testing options. Furthermore, WES may facilitate the identification of previously unidentified genotype-phenotype relationships.

An individual withBRIP1andDICER1pathogenic mutations identified by whole exome sequencing trio analysis and multi-gene hereditary cancer panel testing: A case report

M. Blundell1

1. Sutter Health

Whole exome sequencing (WES) and next generation sequencing technologies are frequently incorporated in pediatric and hereditary cancer risk clinics, allowing clinicians to expedite a diagnosis and reduce costs. However, such testing has the potential to reveal unexpected information. We report a proband with pathogenic variants in both the BRIP1 and DICER1 genes, one mutation detected inadvertently through WES and the other through multi-gene hereditary cancer panel testing. A 43- year- old female was referred to the Cancer Risk Program due to a diagnosis of Sertoli-Leydig cell ovarian cancer (OvCa) at age 38, and a family history of OvCa (her mother was diagnosed at age 5, and is alive and well at age 64, and a maternal aunt reportedly died of OvCa at age 10). Additionally a BRIP1 mutation was previously identified in the proband and her daughter through WES trio analysis. The daughter had undergone a genetics evaluation due to a clinical diagnosis of juvenile Parkinson disease and dystonia at age 10. WES identified likely pathogenic mutation in BRIP1. The patient was tested with a 25-gene high risk hereditary cancer panel, including BRIP1 and DICER1. The BRIP1 mutation was confirmed; additionally a DICER1 mutation was identified in the proband that her daughter did not inherit (confirmed by the WES laboratory). BRIP1 mutations are associated with up to a 9 % lifetime risk for ovarian cancer and an increased lifetime risk for breast cancer. DICER1 mutations are associated with different tumors, including pleuropulmonary blastoma (PPB), cystic nephroma, and ovarian Sertoli-Leydig cell tumors. This case illustrates several points about genetic testing in the era of WES and multi gene panels; unexpected results from WES, and the potential impact on multiple family members, and recognizing that a second pathogenic mutation could be present in a family. More data is needed regarding the frequency of occurrence of multiple pathogenic variants, and gene interactions.

Variant classification in an unaffected population, an example from expanded carrier screening and a comparison to clinvar classifications

S. Candille1, M. Judkins1, J. Castiblanco1, C. Beaumont1, E. Olson1, E. Evans1, I. Haque1<