Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder; it is most common in the Caucasian populations, with a prevalence of about 1 per 2500 births. The disorder is associated with progressive lung disease and pancreatic enzyme deficiency, leading to considerable morbidity and mortality. The burden of disease might be reduced by either genetic screening or neonatal screening.
The aim of genetic screening is to identify carrier couples and avoid affected births. The gene responsible for CF was cloned in 1989 and includes over 700 mutations. However, about 85% of carriers or 72% of carrier couples in most countries are accounted for by just a few mutations. There have been 11 prospective intervention studies of antenatal screening, and of 57 147 women offered the test, 75% accepted. Among carrier couples 90% accepted prenatal diagnosis and 94% of affected pregnancies were terminated. The cost per case detected is considerably less than the cost of treatment. Preconceptual screening would provide more reproductive choices but would be more difficult to organise.
An alternative, although less efficient, approach is general population screening to identify individual carriers. Four studies in general practice compared actively sending invitations with opportunistic testing, and in each case only the latter achieved acceptance rates approaching those in pregnancy. Systematic ‘cascade’ screening within CF families has a high yield of carriers which falls off beyond second cousin testing, and ultimately only a small fraction of all carriers is detected.
The aim of neonatal screening is to ensure an early diagnosis, usually by immunoreactive trypsin testing of neonatal heelprick samples. The overall results from 16 studies is a 0.1% false-positive rate and 89% detection rate. The acceptance rate is very high and the cost is low, but there is little direct proof of improved prognosis. There have been 2 randomised trials of which one showed a considerable reduction in malnutrition, although the long term consequences are unknown. Malnutrition is a common consequence of CF due to the gastrointestinal disorder. The second trial was analysed as a case-control study with an apparent benefit similar to that seen in 4 geographical or historical control studies, but such studies are biased. We conclude that antenatal genetic screening has been sufficiently evaluated to recommend a routine service. And while a long term morbidity and mortality benefit of neonatal screening is difficult to demonstrate directly, the known natural history and the low cost of screening may be justification enough.
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References
Boat TF, Welsh MJ, Beaudet AL. Cystic fibrosis. In: Scriver CL, Beaudet AL, Sly S, et al., editors. Metabolic basis of inherited disease. New York: McGraw-Hill, 1989: 2649–80.
Elborn JS, Shale DJ, Britton JR. Cystic fibrosis: current survival and population estimates to the year 2000. Thorax. 1992; 46: 881–5.
Kerem B-S, Rommens JM, Buchanan JA, et al. Identification of the cystic fibrosis gene: genetic analysis. Science. 1989; 245: 1073–80.
Rommens JM, Iannuzzi MC, Kerem B-S, et al. Identification of the cystic fibrosis gene: chromosome walking and jumping. Science. 1989; 245: 1059–65.
Riordan JR, Rommens JM, Kerem B-S, et al. Identification of the cystic fibrosis gene: cloning and characteristics of complimentary DNA. Science. 1989; 245: 1066–73.
Miedzybrodzka ZH, Hall MH, Mollison J, et al. Antenatal screening for carriers of cystic fibrosis: randomised trial of stepwise v couple screening. BMJ. 1995; 310: 353–7.
Jung U, Urner U, Grade K, et al. Acceptability of carrier screening for cystic fibrosis during pregnancy in a German population. Hum Genet. 1994; 94: 19–24.
Schwartz M, Brandt NJ, Skovby F. Screening for carriers of cystic fibrosis among pregnant women: a pilot study. Eur J Hum Genet. 1993; 1: 239–44.
Brock DJH. Carrier screening for cystic fibrosis. Prenat Diagn. 1994; 14: 1243–52.
Livingstone J, Axton RA, Gilfillan A, et al. Antenatal screening for cystic fibrosis: a trial of the couple model. BMJ. 1994; 308: 1495–62.
Cuckle H, Quirke P, Sehmi I, et al. Antenatal screening for cystic fibrosis. Br J Obstet Gynaecol. 1996; 103: 795–9.
Grody WW, Dunkel-Schetter C, Tatsugawa ZH, et al. PCR-based screening for cystic fibrosis carrier mutations in an ethnically diverse pregnant population. Am J Hum Genet. 1997; 60: 935–47.
Doherty RA, Palomaki GE, Kloza EM, et al. Couple-based prenatal screening for cystic fibrosis in primary care settings. Prenat Diagn. 1996; 16: 397–404.
Harris HJ, Scotcher D, Hartley N, et al. Cystic fibrosis carrier testing in early pregnancy by general practitioners. BMJ. 1993; 306: 1580–3.
Hartley NE, Scotcher D, Harris H, et al. The uptake and acceptability to patients of cystic fibrosis carrier testing offered in pregnancy by the GP. J Med Genet. 1997; 34: 459–64.
Wald NJ, George L, Wald N, et al. Further observations in connection with couple screening for cystic fibrosis. Prenat Diagn. 1995; 15: 589–90.
Loader S, Caldwell P, Kozyra A, et al. Cystic fibrosis carrier population screening in the primary care setting. Am J Hum Genet. 1996; 59: 234–47.
Witt DR, Schaefer C, Hallam P, et al. Cystic fibrosis heterozygote screening in 5,161 pregnant women. Am J Hum Genet. 1996; 58: 823–35.
Denayer L, Welkenhuysen M, Evers-Kiebooms G, et al. Risk perception after CF carrier testing and impact of the test result on reproductive decision making. Am J Med Genet. 1997; 69: 422–8.
Watson EK, Mayall ES, Lamb J, et al. Psychological and social consequences of community carrier screening programme for cystic fibrosis. Lancet. 1992; 340: 217–20.
Mitchell J, Scriver CR, Clow CL, et al. What do young people think and do when the option for cystic fibrosis carrier testing is available? J Med Genet. 1993; 30: 538–42.
Wake SA, Rogers CJ, Colley PW, et al. Cystic fibrosis carrier screening in two New South Wales country towns. Med J Aust. 1996; 164: 471–4.
Flinter FA, Silver A, Mathew CG, et al. Population screening for cystic fibrosis. Lancet. 1992; 339: 1539–40.
Tambor ES, Bernhardt BA, Chase G, et al. Offering cystic fibrosis carrier screening to an HMO population: factors associated with utilization. Am J Hum Genet. 1994; 55: 626–37.
Bekker H, Modell M, Denniss G, et al. Uptake of cystic fibrosis testing in primary care: supply push or demand pull. BMJ. 1993; 306: 1584–6.
Payne Y, Williams M, Cheadle J, et al. Carrier screening for cystic fibrosis in primary care: evaluation of a project in South Wales. Clin Genet. 1997; 51: 153–63.
Surh LC, Cappelli M, MacDonald NE, et al. Cystic fibrosis carrier screening in a high-risk population: participation based on a traditional recruitment process. Arch Pediatr Adolesc Med. 1994; 148: 632–7.
Super M, Schwarz MJ, Malone G, et al. Active cascade testing for carriers of cystic fibrosis gene. BMJ. 1994; 308: 1462–7.
Sorenson JR, Cheurvront B, DeVellis B, et al. Acceptance of home and clinic based cystic fibrosis carrier education and testing by first second and third degree relatives of cystic fibrosis patients. Am J Med Genet. 1997; 70: 121–9.
Holloway S, Brock DJH. Cascade testing for the identification of carriers of cystic fibrosis. J Med Screen. 1994; I: 159–64.
Cuckle HS, Richardson GA, Sheldon TA, et al. Cost effectiveness of antenatal screening for cystic fibrosis. BMJ. 1995; 312: 908–10.
Asch DA, Patton JP, Hershey JC, et al. Reporting the results of cystic fibrosis carrier screening. Am J Obstet Gynecol. 1993; 168: 1–6.
Ginsberg G, Blau H, Kerem E, et al. Cost-benefit analysis of a national screening programme for cystic fibrosis in an Israeli population. Health Econ. 1994; 3: 5–23.
Lieu TA, Watson SE, Washington AE. The cost effectiveness of prenatal carrier screening for cystic fibrosis. Obstet Gynecol. 1994; 84: 903–12.
Garber AM, Fenerty JP. Costs and benefits of prenatal screening for cystic fibrosis. Med Care. 1991; 29: 473–89.
Wildhagen MF, Verheij JBGM, Hilderink HBM, et al. Cost of care of patients with cystic fibrosis in The Netherlands in 1990–1. Thorax. 1996; 51: 298–310.
Miedzybrodzka Z, Semper J, Shackley P, et al. Stepwise or couple antenatal carrier screening for cystic fibrosis? Women’s preferences and willingness to pay. J Med Screen. 1995; 32: 282–3.
Castellani C, Bonizzato A, Cabrini G, et al. Newborn screening strategy for cystic fibrosis: a field study in an area with high allelic heterogeneity. Acta Paediatr. 1997; 86: 497–502.
Ranieri E, Lewis BD, Gerace RL, et al. Neonatal screening for cystic fibrosis using immunoreactive trypsinogen and direct gene analysis: four years’ experience. BMJ. 1994; 308: 1469–72.
Wesley AW, Smith PA, Elliot RB. Experience with neonatal screening for cystic fibrosis in New Zealand using measurement of immunoreactive trypsinogen. Aust Pediatr J. 1989; 25: 151–5.
Bowling F, Cleghorn G, Chester A, et al. Neonatal screening for cystic fibrosis. Arch Dis Child. 1988; 63: 196–200.
Férec C, Verlingue C, Parent P, et al. Neonatal screening for cystic fibrosis: result of a pilot study using both immunoreactive trypsinogen and cystic fibrosis gene mutation analyses. Hum Genet. 1995; 96: 542–8.
Hammond KB, Steven MS, Abman H, et al. Efficacy of statewide neonatal screening for cystic fibrosis by assay of trypsinogen concentrations. N Engl J Med. 1991; 325(11): 769–74.
Heeley ME, Keenan CA, Heeley AF. An update of cystic fibrosis screening in East Anglia 1980–1989. Pediatr Pulmonol Suppl. 1991; 7: 90.
Ten Kate LP, Feenstra de Gooyer I, Ploeg de Groot G, et al. Should we screen all newborns for cystic fibrosis? Int J Epidemiol 1978; 7(4): 323–30.
Roberts G, Stanfield M, Black A, et al. Screening for cystic fibrosis: a four year regional experience. Arch Dis Child. 1988; 63: 1438–43.
Wilcken B, Wiley V, Sherry G, et al. Neonatal screening for cystic-fibrosis–a comparison of 2 strategies for case detection in 1.2-million babies. J Pediatr. 1995; 127: 965–70.
Spence WC, Paulus-Thomas J, Orenstein DM, et al. Neonatal screening for cystic fibrosis: addition of molecular diagnostics to increase specificity. Biochem Med Metabol Biol. 1993; 49: 200–11.
Pollitt RJ, Dalton A, Evans S, et al. Neonatal screening for cystic fibrosis in the Trent region (UK): two-stage immunoreactive trypsin screening compared with a three-stage protocol with DNA analysis as an intermediate step. J Med Screen. 1997; 4: 23–8.
Pederzini F, Cabrini G, Faraguna D, et al. Neonatal screening for cystic fibrosis using blood trypsin with complementary meconium lactase: an advisable strategy for the population of southern Europe. Screening. 1995; 3: 173–9.
Balnaves ME, Bonacquisto L, Francis I, et al. The impact of newborn screening on cystic fibrosis testing in Victoria, Australia. J Med Genet. 1995; 32: 537–42.
Larsen J, Campbell S, Faragher EB, et al. Cystic fibrosis screening in neonates — measurement of immunoreactive trypsin and direct genotype analysis of ΔF508 mutation. Eur J Pediatr. 1994; 153: 569–73.
Chatfield S, Owen G, Ryley HC, et al. Neonatal screening for cystic fibrosis in Wales and the West Midlands: clinical assessment after five years of screening. Arch Dis Child. 1991; 66: 29–33.
Gregg RG, Simantel A, Farrell PM, et al. Newborn screening for cystic fibrosis in Wisconsin: comparison of biochemical and molecular methods. Pediatrics. 1997; 99(4): 819–24.
Dankert-Roelse JE, te Meerman GJ. Long term prognosis of patients with cystic fibrosis in relation to early detection by neonatal screening and treatment in a cystic fibrosis centre. Thorax. 1995; 50: 712–8.
Wilcken B, Chalmers G. Reduced morbidity in patients with cystic fibrosis detected by neonatal screening. Lancet. 1985; II: 1319–21.
Farrell PM, Kosorok MR, Laxova A, et al. Nutritional benefits of neonatal screening for cystic fibrosis. N Engl J Med. 1997; 337: 963–9.
Tluczek A, Mischler EH, Bowers B, et al. Parents’ knowledge of neonatal screening and response to false positive cystic fibrosis testing. Dev Behav Pediatr. 1992; 13(3): 181–6.
Farrell PM, Mischler EH. Newborn screening for cystic fibrosis. Adv Pediatr. 1992; 39: 35–70.
Orenstein DM, Boat TF, Stern RC, et al. The effect of early diagnosis and treatment in cystic fibrosis. Am J Dis Child. 1977; 131: 973–5.
Weaver LT, Green MR, Nicholson K, et al. Prognosis in cystic fibrosis treated with continuous flucloxacillin from the neonatal period. Arch Dis Child. 1994; 70: 84–9.
Bekker H, Denniss G, Modell M, et al. The impact of population based screening for carriers of cystic fibrosis. J Med Genet. 1994; 31: 364–8.
Mennie ME, Gilfillan A, Compton M, et al. Prenatal screening for cystic fibrosis. Lancet. 1992; 340: 214–6.
Axworthy D, Brock DJH, Bobrow M, et al. Psychological impact of population-based carrier testing for cystic fibrosis: 3-year follow-up. Lancet. 1996; 347: 1443–6.
Baroni MA, Anderson YE, Mischler E. Cystic fibrosis newborn screening: impact of early screening results on parenting stress. Pediatr Nurs. 1997; 23: 143–51.
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Cuckle, H., Murray, J. Screening for Cystic Fibrosis. Dis-Manage-Health-Outcomes 3, 161–172 (1998). https://doi.org/10.2165/00115677-199803040-00001
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DOI: https://doi.org/10.2165/00115677-199803040-00001