The importance of cell-free fetal DNA (cffDNA) pre-test counseling: an overview and 3 years of implementation

experience in teaching university hospital

Vedran Stefanovic Dept of Obstetrics and Gynecology

Helsinki University Hospital FINLAND

Vedran.stefanovic@hus.fi

www.cogen2017.cme-congresses.com Disclosure information: Nothing to declare

Pre-test counseling

‘If you want to know about

trisomy 21, we take a tube of

blood and let you know in a

week or so whether your

baby is affected”

Mamma chat on the internet....

www.babycenter.com.au

Nomenclature 1.NIPT – Non-Invasive Prenatal Testing misleading

2.cffDNA- Cell-free ”fetal” DNA misleading

3.NIPD- Non-Invasive Prenatal Diagnosis misleading

misleading(?) Many supportive studies have demonstrated its diagnostic sensitivity which ranges from 95–100% with specificities of over 99% van der Schoot,2008

The presence of Rhesus D gene sequences in analyzing fetal free DNA in D-negative women indicates that the fetus is D-positive; if the Rhesus D sequence is not present then the fetus is predicted to be D-negative

HUS (hospital district) has introduced revolutionary fetal screening method, which does not include a miscarriage risk This new NIPT method enables detection of the common chromosomal abnormalites from maternal blood sample instead of amniocentesis

NIPT replaces risky amniocentesis – HUS has introduced a new screening method

”Fetal cell-free DNA screening reduces the need for the Invasive procedures”

Helsinki metro is very ACCURATE! One means usually ”on time”

It is also accurate concerning safety ! There are other features of my metro such as 1.FAST 2.CLEAN 3.AMUSING 4.COMFORTABLE but 5.EXPENSIVE Metro is plan A for my trip from home to the hospital (the fastest and the most punctual) Plan B – Bus (always full, uncomfortable, bumpy ride, not well air-conditioned) -Bike (cheaper, more healthy, very slow)

Who should be counseling the patients?

-Several studies have addressed that websited´s did not provide balanced or comprehensive information and were written at higher than recommended reading level -Marketing has increased patients´awarenes of the availability of genetical testing, but it has done much less to educate providers about when and where such tests are appropriate -Genetic counselors has reported adverse outcomes from the provision of genetic tests by uninformed nonspecialists and the lack of the time available Adverse outcomes included: Mismanagement Loss of trust in medical providers Unnecessary use of health care resources Inadequate counseling

Counseling challenges

Precounseling assessment: history and ultrasound

-Although, due to logistic or financial reasons, it is not applied universally, early sonographic confirmation of intrauterine pregnancy can be very helpful before discussing and planning any further testing in pregnancy

-In 2–10 % of fetuses with enlarged NT a chromosome aberration would be missed by current NIPT approaches (Srebniak,Mol Cytognet,2016)

-NIPT should not be recommended for genetic evaluation of the etiology of ultrasound anomalies, as both resolution and sensitivity, or negative predictive value, are inferior to those of conventional karyotyping and microarray analysis (Beulen et al, Ultrasound Obstet Gynecol, 2017)

Analysis of cell-free DNA in maternal blood in screening for aneuploidies: updated meta-analysis

Gil et al., UOG,2017

• Screening by analysis of cfDNA in maternal blood in singleton pregnancies could detect > 99% of fetuses with trisomy 21, 98% of trisomy 18 and 99% of trisomy 13 at a combined FPR of 0.13%

• The number of reported cases of SCA is too small for accurate assessment of performance of screening

Discordant NIPT positive results

• CPM- Confined placental mosaicism (1-2% of all pregnancies)

• Another major reasons-deceased twin (usually with singleton female fetus and Y chromosomal DNA detected), undected twin or triploid fetus, maternal malignancy or large tumour as well as maternal mosaicism

• In several cases of malignancy- results reported multiple aneuploidies or test failure

• CPM • Trisomy 21 2% • Trisomy 13 22% • Monosomy X 59% • Trisomy 18 4%

should

• What are trisomies 21, 18 and 13?

• What are risks for these anomalies in general?

• What are the a priori risks for trisomy for this individual patient? • Age-related risk, risk after FTS or mid-trimester screening (pre- and post test)

• In case of a fetal trisomy, what are the chances of spontaneous miscarriage/perinatal demise from time of testing onwards? • Between 12 weeks gestation and term an estimated 49% of pregnancies

diagnosed with T13 and 72% of pregnancies diagnosed with T18 end in a miscarriage or stillbirth.

• 48% (T18) and 46% (T13) infants survive following birth, for a median of 1.5 days (T18) and 7 days (T13) (Houlihan,2013)

• Between the first trimester and term, around 30% of fetuses with Down syndrome are lost spontaneously.

• What are the remaining risks for other major fetal anomalies when trisomies are excluded? • 3% of live-born children have a major congenital anomaly

• Excluding trisomies (average risk, 2 in 1000) lowers the risk for anomalies from 30 per 1000 to 28 per 1000

• What are the chances of detecting other fetal anomalies using (routine) ultrasound in the first and second trimesters? • First-trimester anomaly scan by a well-trained operator may detect up to 47%

of major malformations.

• The routine 20-week anatomy scan detects 50–60% of malformations

• From what testing options can the pregnant woman choose? • According to the local setting, other options should be told

• Depends on regional or national guidelines, laws and health insurance policies.

• What are the chances of a failed test, of the need for redraw and of an uninterpretable result? • 1-5%, use your own data (if you have) • The information that needs to come across is that, in a small percentage of cases,

tests can fail, redraw can be necessary, and the result may be uninterpretable

• When is the result available? • In most cases, without need for retesting, NIPT results can be in the clinician’s office

7–10 days after the blood draw. • Do not use term WORKING DAY !

• How is the result communicated (negative and positive, high/low probability, risk score)?

• What does it mean when the result is positive? • Discuss PPV

• How accurate is each of these tests; what are the benefits, limitations and risks?

Joint SOGC-CCMG Clinical Practice Guideline, No. 261,2011

• What are the options when the test is positive?

• What are the options when the diagnosis of trisomy is confirmed?

• What is the remaining risk for trisomy when NIPT is negative?

• Is the sex of the fetus tested, is the result communicated, and how reliable is this?

• Cultural preference for a male child is common in Asia but more broadly in the East.

• Common countries in this category are Japan, China, Thailand, Malaysia and India,Pakistan and some Middle East countries.

• There are the issues of male preference with tradition of males carrying forward the family name, notion of males providing old age security and support, male patriarchy, and rigorous gender stereotyping.

• Chinese laws , however, prohibit the use of technologies for gender selection for social reasons

Sex selection

Sex chromosome aneuploidy detection by noninvasive prenatal testing: helpful or hazardous?

Reiss et al, Prenatal Diagnosis, 2017

• Noninvasive prenatal testing predicted SCA in 18/2851 patients (0.63%). All had diagnostic testing of fetal or newborn samples. No patients terminated pregnancies on the basis of NIPT

• False positive rate for monosomy X was surprisingly high (91%).

• Prediction of other SCA was more accurate. Diagnostic fetal chromosome analysis should be offered after abnormal NIPT or in the presence of cystic hygromas despite normal NIPT. NIPT limitations should be explained in pretest counseling.

• Can other abnormalities besides trisomies 21, 18 and 13 be found by NIPT and, if so, will they be communicated? • Other trisomies, microdeletions, SCA

• Can abnormalities in maternal DNA be detected and, if so, will they be communicated? • Maternal chromosomal abnormalities

• Malignancy

53 619 births annually Maternal care is guaranteed by law, free of charge (even for the asylum seekers), maternal, neonatal and neonatal mortality (also stillbirths) rate amongst the lowest in the world Mothers with T21 fetuses continue pregnancy in 30-40% of cases in certain areas Pregnancy termination allowed up to 24+0 gestational weeks

NIPT implementation timetable

• 2013 private clinics (some cffDNA positives were referred to FMC for counseling and further examinations)

• 2014 (August-December)- intensive preparations for introduction cffDNA screening

• Literature search, search for providers, finances, defining the target groups,education of primary maternity clinics, FTS performing midwives and FMC midwives and MFM specialists, flowchart, written material and intra/internet material, developing sheats for the fast collection of data for statistics and follow-up

• January 2015, first blood sample drawn in Helsinki University Hospital

• April 2015 other University Hospitals

Overall NIPT uptake 81.6% No-call 1.2%

NIPT implementation and invasive procedures

CVS Amnio

Total invasive

HELSINKI UNIVERSITY HOSPITAL -February 2016

1.FTS risk 1:11 - 1:250 2.NT 3-3.4 mm 3.Mid-trimester screen positive 4. Maternal age > 40 yrs and FTS not performed 5. ”Common” trisomy in previous pregnancy

CVS (up to 14+6) or Amnio (from 15+0)

Abnormal

Counseling

1. NT ≥ 3.5 mm 2. Any structural abnormality (excluding SMs) 3. FTS ≥ 1:10 4.IUGR on the 2nd trimester screening

CVS (ad H14+6) Molecular karyotyping Or amnio (H15+0 )

Counseling

Counseling

NIPT

Normal Abnormal or no-call

No further follow up 2nd trimester genetic

sonogram

Counseling

Amniocentesis

Counseling

Taulukko: Vedran Stefanovic 11/2015

HELSINKI UNIVERSITY HOSPITAL -February 2016

1.FTS risk 1:11 - 1:250 2.NT 3-3.4 mm 3.Mid-trimester screen positive 4. Maternal age > 40 yrs and FTS not performed 5. ”Common” trisomy in previous pregnancy

CVS (up to 14+6) or Amnio (from 15+0)

Abnormal

Counseling

1. NT ≥ 3.5 mm 2. Any structural abnormality (excluding SMs) 3. FTS ≥ 1:10 4.IUGR on the 2nd trimester screening

CVS (ad H14+6) Molecular karyotyping Or amnio (H15+0 )

Counseling

Counseling

cffDNA

Normal Abnormal or no-call

No further follow up 2nd trimester genetic

sonogram

Counseling

Amniocentesis

Counseling

Taulukko: Vedran Stefanovic 11/2015

OBJECTIVE To investigate the factors influencing women's post-counseling choices between non-invasive prenatal testing (NIPT) and invasive prenatal diagnosis in pregnancies with elevated a priori risk of fetal chromosomal abnormalities or after the initial screening 1.Previous fetus/child with trisomy 21 2.Advanced age (>40) without FTS 3.FTS risk ≥ 1:250 4.NT 3-3.9 mm (without fetal anomalies) 5.Abnormal mid-trimester screening

Results

• In 2015, 333 women in our study group participated in prenatal testing, 260 (78.1%) initially chose NIPT, 62 (18.6%) chose CVS and 11 (3.3%) chose amniocentesis.

• There was a statistically significant difference among these three test groups with regard to gestational age (p = 0.025), counseling day (p < 0.001), certain medical indications and serum screening risk score (p = 0.028).

• However, multinomial logistic regressions only confirmed the predictive value of gestational age and counseling day on women's choice.

• Maternal age was not a strong factor affecting women's choice for prenatal further tests. Medical indications and risk scores have less influence than previously thought. Gestational age and service availability were strong factors.

• In this study, we focus on the group of women who were eligible for prenatal testing because of high risk detected by the first or the second trimester serum screening. This group accounted for the majority of women who were eligible for further testing. Other medical indications of high risk, including abnormal nuchal translucency, previous chromosomal problems and structural abnormality, have different risk indicators, with which the analysis will become complex.

• The counseling service for our study group of patients differs from those with slightly increased NT or those who opt for NIPT or invasive due to other risks(e.g. advanced maternal age, previous aneuploidy), so it is of great importance that all women in our cohort represent the same group.

• The NIPT group had a more advanced age than the two invasive test groups (p = 0.015).

• Women choosing NIPT were more likely to have counseling on Monday or Tuesday (p<0.001).

• Women choosing CVS had higher serum screening risk scores (p = 0.014).

During the study period (1st Jan 2015-31st Dec 2015), there were 254 women (62.5% of all participants) who participated in prenatal testing with abnormal serum screening result. NIPT was chosen by 186 women (73.2%), 39 (15.4%) chose CVS and 29 (11.4%) chose amniocentesis.

• Statistical data indicated that gestational age and counseling day were strong factors influencing women’s choice.

• Interview data revealed that women’s values and moral principles on pregnancy and childbirth chiefly determined the choices. Behavioral beliefs (e.g. safety and accuracy) and perceived choice control (e.g. easiness, rapidness and convenience) were also important

• Values are the determinants of women’s choice. Service availability and convenience are strong factors. Medical risk status in this choice context is not highly influential. Choice aids can be developed by helping women to identify their leading values in prenatal testing and by providing lists of value-matching test options and attributes.

Understanding and improving women’s choice-making experiences in prenatal screening and testing for

common aneuploidies:

A pilot study in the district of Helsinki and Uusimma in Finland

An Chen, MSc., Henni Tenhunen, MSc., Paulus Torkki, PhD., Seppo Heinonen, MD, PhD., Paul Lillrank, PhD., Vedran Stefanovic, MD, PhD.

2017 Sept.

Objectives

In this study, we aim to

• develop an understanding on women’s choice-making experiences (decisional conflict and anxiety) in prenatal screening and testing with the context of Finnish public maternal service

• explore the personal factors that potentially contribute to choice-making experience

• evaluate the effectiveness of the relevant services (individual non-directive pre-test counseling) that are designed to support women’s choice-making.

Respondents of the questionnaire regarding women’s choice-making in prenatal testing were significantly older (p = 0.002), had experienced more pregnancies (p = 0.008) and were more likely to have chromosomal problems in previous pregnancies (p <0.001) than the respondents of the questionnaire regarding women’s choice-making in prenatal screening.

Results (1)

Result 2: women’s choice-making experiences at different choice-making stages in prenatal screening and testing

Compared with the women in prenatal screening, women in prenatal testing

(before pre-test counseling) were more likely to feel that they were well

informed about the options (p <0.001), the personal values were clear (p

<0.001) , but the decisions were unsure (p = 0.078) and they had a high level

of anxiety (p <0.001).

There was no difference regarding social support.

After the individual pre-test counseling, women’s choice-making experiences

were significantly improved, in the aspects of informedness (p <0.001), values

clarity (p <0.001), felt support (p <0.001), decision certainty (p <0.001) and

anxiety level (p <0.001).

Discussion

1. Choice-making in prenatal testing is complex

• After the individual high-risk is revealed, women start to read and think more.

2. The non-directive individual counseling provided by FMC midwives is significantly effective.

3. Choice-making support services should be personalized and context-based

• Women’s personal characteristics had some impacts on choice-making experiences. • choice context (screening and testing) had a significant influence on women’s choice-making

experiences.

……

Summary

• There is a room for improvement in NIPT pre/post test counseling

• NIPT should not be just ”another blood test more”

• Counseling should be non-directional and driven by medical professionals not the companies

• Regular updating of knowledge is what we owe to our patients and their kids !

An Chen, MSc., Henni Tenhunen, MSc., Paulus Torkki, PhD., Seppo Heinonen, MD, PhD., Paul Lillrank, PhD Satu Leminen, midwife