Sunday, June 8, 2014

Questions About Genetic Testing

I've recently been asked some questions about genetic testing, some of which I think are worth mentioning in a public discussion (although please see the note above if you are interested in getting specific recommendations):

1) How can I use my DNA sequence to inform my decision making about reducing my risk of getting a disease?

In many cases, I think the actions that you can take to reduce disease risk are relatively generic (exercise, eat lots of fruits and vegetables, etc.), and these are things that you should do regardless of your genotype.

That said, there certainly are some circumstances where very specific action can be taken, based upon your genome sequence.  I am not personally aware of all such examples, and I would recommend talking to a medical professional (such as a genetic counselor) for more information.  If this is the only type of information that you wish to learn about your genome, then you may only benefit from determining the sequence for a small portion of your genome (and your family history can guide the likelihood of needing to perform any genetic tests in a clinical setting).

2) How does Promethease compare to the health reports from 23andMe?  Does Promethease mostly focus on rare mutations?

Promethease is based upon annotations that come from SNPedia (similar to wikipedia, but specifically for mutation annotations).  So, I would expect the content would depend on whatever information is entered by volunteers.  Given the amount of information that I see from by 23andMe data (which is mostly common variants), I would say it contains a large amount of information on common variants.

When I first ran Promethease, I remembered mostly seeing risk annotations (which you can see in my old post, comparing my top 23andMe risk associations), and I didn't remember seeing anything like the carrier status report.  For example, I didn't remember seeing anything reporting me as a carrier for cystic fibrosis, which is an example of a 23andMe result that was in good concordance with my family history.  However, I went back to check my specific mutation (394delTT), with a probe ID i4000313.  This particular probe ID makes it a bit harder to match the mutation.  However, if I Google the probe ID, I can see that is is included in SNPedia but without a detailed description.  If I look up 394delTT in ClinVar, then I can get more information about this variant and I can see that it corresponds to rs121908769.  If I then look this variant up in SNPedia, I can see that it provides some information from ClinVar (although there is nothing in the brief main text for mentioning cystic fibrosis), but I don't see it among any of the "cystic fibrosis" variants in my old Promethease report.

However, to be fair, I wanted to re-run my sample through Promethase to see if the reporting system has changed and/or confirm that it now recognizes this mutation in my data.  It appears that a many new features have been added within the last 3+ years, such as a more interactive interface (viewed by clicking "UI version 2" in the downloadable report). Additionally, I can tell that the "medicines" and "medical conditions" have been expanded to include more SNPs.   However, it still don't recognize my cystic fibrosis carrier status, so it can't simply considered a replacement for the old 23andMe report.

Also, in general, the information available in Promethease tends to be terse, and it won't contain the same level of detail for explaining basic concepts as would have been provided by the old 23andMe health report.

3) More specifically, I do not wish to see a doctor in order to obtain my genetic information.  Also, I want something clear and easy to understand, which doesn't require doing any additional research.  What are my options, now that 23andMe no longer offers health reports?

I am not aware of any direct-to-consumer test that provides information that is comparable to the old 23andMe health reports, and I am not aware of any tool to analyze your raw 23andMe data that will reproduce your the old 23andMe health report (especially not with all the details to help make the results easier to understand).  I believe that even Illumina's Understand Your Genome program requires meeting with a doctor to draw your blood, conduct a predisposition screen, and discuss your results.

Perhaps more importantly, I think it is worth emphasizing that the health reports previously offered by 23andMe were not really a single report: they were updated periodically as new findings were published in the genomics literature, so your estimated risk would change over time for many traits.  This should be generally true for any tool connecting you to the genomics literature, as also demonstrated for the Promethease example above.

If you were only interested in the subset of results that are unlikely to change, I think you would probably have been most interested in the carrier status reports (and a handful of the other reports).  There are tests like Counsyl that I would expect to probably be similar to the the 23andMe carrier status results (and it is something that I would want to check out, if I was planning on having a child), but I believe that you can only get that test through your doctor.  However, this is just one example: I would recommend talking to a doctor or genetic counselor if you want more specific guidance.

In my opinion, I am most uncomfortable with the request to get a result that "doesn't require doing any additional research".  Critical thinking and being able to synthesize your own opinion from multiple sources of information are important skills that should be part of everyday life, and I think "additional research" is especially important for tools designed for "research and educational purposes" (including 23andMe, Promethease, Interpretome, etc.).  For example, clinical action may be limited because 1) all the genetic influences of disease risk are not known, 2) ways to mitigate genetic risk may not be known, and 3) one current limitation to low-cost options like SNP chips is that you aren't measuring your entire genome sequence (so, some important sequences may not be covered).  This might be a problem for some people, but I think it is still OK for many people.

In other words, there certainly have been some cases where people discovered important findings from their 23andMe reports that were worth verifying in a clinical setting, but I think most 23andMe customers took no medical action based upon their reports.  Most importantly, "no medical action" need not equate to "dissatisfied": I would personally fall the category of a customer who was "very satisfied" yet has not changed by behavior because of any of the results.  I think trying to understand how your biology is influenced by your genome sequence is a life-long goal that will probably never be fully realized, but I think there is value in being able to understand on-going genome research through the context of your own genome.

Monday, June 2, 2014

Getting Advice About Genetic Testing

I recently received a call at work from an individual asking for advice about genetic testing.  While I welcome questions and comments on my blog posts, I don't think this was an appropriate course of action.  I don't think it is a huge problem (this is the first time this happened in the 3+ years since I wrote my most commonly viewed blog post), and I think this individual raised some interesting questions.  However, I think it may be important provide a brief description of myself and the role of my blog:

 I am an analyst that often studies (de-identified) patient samples for biomedical research, and it is probably safe to say I have an above-average knowledge about genetics.  However, I am not a medical professional, and I never provide consulting about genetic testing at any point during my job.  In fact, a large portion of my research involves projects that do not look for mutations in a subject's DNA sequence.  In other words, everything I write on my blog about genetic testing is my own personal perspective, independent of any professional responsibilities.

Of course, that leaves the obvious question:

Where can I find someone to discuss genetic testing options?

I would recommend contacting a genetic counselor if you wish to talk to somebody one-on-one about genetic testing options and what action can be taken as a result of those tests.  The National Society of Genetic Counselors has a tool to find a genetic counselor near you:

Again, I should emphasize that I am not a genetic counselor myself: if you are genetic counselor or medical geneticist with a better recommendation, I would encourage you to post a comment to this blog post.
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