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A Note on Genetic Testing
Genetic testing confuses many patients. Some patients falsely assume any genetic test is a chromosome test. Others assume that all genetic tests involve direct analysis of the DNA (versus a linkage study or enzyme analysis). Patients also mistakenly think that when they have a DNA test, their DNA is screened for all genetic diseases. It is always important to obtain documentation of the patient’s or family member’s actual laboratory result.
The Healthy Person with An Abnormal Genetic Test Result: The Difference between a Presymptomatic or Asymptomatic Carrier and an Obligate Carrier
Advances in genetic testing now allow us to test a healthy person for a genetic condition that they may or will develop in the future. Many geneticists reserve the description presymptomatic carrier for a healthy person who is likely to develop a genetic disease in his or her lifetime (Bennett et al, 1995). For example, a healthy person at risk for Huntington disease who has a CAG expansion of more than 40 repeats is likely to have symptoms of HD if he or she reaches the age of 70 (Brinkman et al., 1997). In contrast, a woman who has a mutation in a breast cancer gene has a higher lifetime risk to develop breast and possibly other cancers, but the development of cancer is not inevitable. This is usually referred to as predisposition or susceptibility genetic testing. The description asymptomatic carrier is sometimes used for a person who carries a susceptibility or predisposition mutation. Many geneti-
DOCUMENTING MEDICAL EXAMINATIONS AND EVALUATIONS
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Figure 3.9 How to document results of medical evaluations and genetic testing on a pedigree (including presymptomatic testing and obligate carrier status) (reprinted with permission from Bennett et al., 1995, University of Chicago Press).
54 GETTING TO THE ROOTS: RECORDING THE FAMILY TREE
cists take exception to the use of the terminology “predictive testing” because no genetic test provides an absolute predictive gaze into a person’s medical future.
A person who “carries” a gene mutation but will not develop clinical symptoms is referred to as an obligate carrier (Bennett et al., 1995). For example, the parents of children affected with a classic autosomal recessive disorder are obligate carriers. A healthy mother of two boys with an X-linked recessive condition (such as Duchenne muscular dystrophy) is an obligate carrier.
Figure 3.9 demonstrates how to document genetic test results, and asymptomatic/presymptomatic and obligate carrier status. Individuals who are obligate carriers are represented on the pedigree with a dot in the middle of the male (square) or female (circle) symbol. Persons who are asymptomatic or presymptomatic carriers are represented with a line down the middle of the pedigree symbol. If the person later develops the disease, the symbol is shaded.
PEDIGREE ETIQUETTE The Skeletons in the Closet
For many reasons, people tend to keep genetic information private. There is often a sense of stigmatization, even embarrassment, about the “bad blood” or “curse” in the family. An episode from the popular television series Northern Exposure described a person with a potential genetic disorder as a “genetic Chernobyl” (Nelkin, 1998). As Francis Galton observed, “Most men and women shrink from having their hereditary worth recorded. There may be family diseases of which they hardly dare to speak, except on rare occasions, and then in whispered hints, or obscure phrases, as though timidity of utterance could hush thoughts . ..” (Resta, 1995). People may also be reluctant to share information because of fear they will be “blamed” for the “family imperfections.”
Choose Your Words Wisely
When you take a medical family history, you are inquiring about the very essence of an individual. You are asking not only about the individual’s personal health, but also about their intimate relationships and the health of family members (with whom they may have little contact). Before you begin taking a genetic family history, it is helpful to warn the client: “I need to ask you some personal questions about the health of people in your family. Your answers to these questions are an important part of providing you with appropriate medical care.”
The clinician should be careful not to perpetuate feelings of guilt and stigmatization. Use words such as “altered” or “changed” to describe genes, instead of “mutated” or “bad.” Emphasize to the patient that people have no choice in the genetic conditions that are “passed” in a family; the disease is nobody’s fault.
Be sensitive to terms like an “uneventful pregnancy.” Although a healthy pregnancy may be uneventful to the clinician, it is very eventful to the proud parents! I