Prenatal Test Market Booms as Patients Grapple With Results

Allison Shelley

March 03, 2020

When she was 4 months pregnant, Angela Crawley waited for 30 minutes in a private room to hear the results of her noninvasive prenatal testing. Her ultrasound had been flagged as high risk by the radiologist and she agreed to undergo further testing to gather information on the health of her unborn child.

As she waited for her genetic counseling appointment, she noticed somber expressions on the faces of her health team and picked up on hushed tones.

It had taken 2 years to become pregnant and the joy she felt attending prenatal care appointments was fading into a sense of dread as she sat in that small room and the minutes ticked by.

Crawley — a scientist in the chronic disease program at the Ottawa Hospital Research Institute, assistant professor at the University of Ottawa, and adjunct research professor at Carleton University in Ontario, Canada — is more qualified than most patients to absorb health information and make appropriate decisions.

And yet, "I was completely unprepared," she told Medscape Medical News as she reflected on what she now refers to as some of the darkest days of her life. "It was a nightmare and it was such a confusing, scary time."

Angela M. Crawley, PhD, scientist in the chronic disease program at the Ottawa Hospital Research Institute.

Crawley is among the more than 6 million women from at least 90 countries who have undergone noninvasive prenatal testing. During pregnancy, a mother's bloodstream contains a mix of cell-free DNA from her own cells and from placental cells, which is usually identical to the DNA of the fetus. Analysis of cell-free DNA can lead to the early detection of genetic disorders.

Testing is most often used to look for chromosomal disorders that are caused by the presence of an extra chromosome, like in trisomy 21 in the case of Down syndrome or extra or missing copies of the X and Y chromosomes in other disorders. The accuracy of the test tends to vary, depending on the condition being assessed.

Cell-free DNA testing has reduced the number of invasive prenatal diagnostic procedures, some of which can lead to miscarriage, and this noninvasive option made sense to Crawley and was covered by government health insurance.

With a market projected to surpass $13 billion by the year 2027, some experts speculate that prenatal genetic testing is the most rapidly adopted test in human history. Globally, noninvasive prenatal tests cost $500 to $3000 for patients who pay out of pocket, and all those screening options are amassing valuable genetic data troves.

The pioneer of noninvasive prenatal testing, Dennis Lo, PhD, from the Chinese University of Hong Kong, told Medscape Medical News that the success of using cell-free DNA came after a long, winding road of rejected grant applications and scientific skepticism.

Pioneer of noninvasive prenatal testing, Dennis Lo, PhD, from the Chinese University of Hong Kong.

"Initially, people did not think this would be useful for assessing chromosomal abnormalities because the thinking at the time was that we would need to count them," Lo said.

But he was enchanted by early glimpses of the capability of cell-free DNA, and felt driven to pursue unconventional research ideas even though there were significant hurdles to overcome in the lab.

"We were detecting fetal Y chromosomes in women. At first, it was just scientific curiosity," said Lo. "At the time, people worried that fetal cells would persist from one pregnancy to the next, but we discovered that fetal DNA actually clears very quickly and does not progress into the next pregnancy," he explained. "This is very important because it won't alter the accuracy of the test."

Gripped by the scientific mystery, the researcher put in long hours at the lab. "I'm fortunate I have a very understanding wife who is herself a scientist," he said. After a particularly long stretch without quality time together, Lo and his spouse, Alice Wong, went to see a Harry Potter movie.

As Lo viewed the Harry Potter H through 3D glasses, he was suddenly reminded of the male human karyotype.

"I saw the vertical stripes of the H and it hit me," he told Medscape Medical News. "There are two sets of chromosomes." The average human karyotype contains 22 pairs of autosomal chromosomes and one pair of sex chromosomes.

The average human karyotype contains 22 pairs of autosomal chromosomes and one pair of sex chromosomes.

"Our complex genetic conundrum was cracked in the middle of a Harry Potter movie in a moment when I felt completely relaxed," he recalled. "My wife said: 'You can't even watch a movie properly'."

Back at the lab, Lo shared his Harry Potter–inspired concept and the team got to work.

In December 2019, Lo received the Fudan-Zhongzhi Science Award in Shanghai from Nobel laureate physicist Samuel Chao Chung Ting, chair of the award committee. The prize honors fundamental and groundbreaking achievements in biomedicine, and the laureate receives ¥3 million (about US $428,550), donated by Zhongzhi Enterprise Group.

This honor was 30 years in the making, Lo told Medscape Medical News. "I'm pleased to experience public recognition and this is a high honor in China," he added.

"Noninvasive prenatal testing is better than anything we've ever had before," said Ronald Wapner, MD, from the Columbia University Irving Medical Center in New York City, who taught a course on the transition of prenatal diagnostics from amniocentesis to whole-genome sequencing at the recent Society for Maternal–Fetal Medicine 2020 Annual Pregnancy Meeting.

"We now have the capability to improve healthcare decision-making in utero and at birth," he told Medscape Medical News. "It's remarkable."

Dennis Lo accepting the Fudan-Zhongzhi Science Award in Shanghai in December 2019.

But, Wapner said, the market grew too fast. "The National Institutes of Health didn't even play a role in these fast-paced developments. Traditional governing bodies and authorities were bypassed as cytogenetic labs marketed directly to physicians and patients," he explained.

One of the major problems with the rapid uptake in testing is a lack of preparation for patients like Crawley.

The clinician who delivered her test results was not feeling well, so "she spoke through a surgical mask," Crawley reported. "I was trying to understand what she was saying, but it was an uncomfortable exchange."

Crawley had undergone prenatal genetic testing because her ultrasound had shown irregularities in fetal leg measurements. The genetic tests confirmed no anomalies in the chromosome count, but that was it.

"There was no prognosis, just vague numbers that no one seemed to know what to do with," Crawley recalled.

With concern about growth measurements, the conversation moved quickly to options, including termination. Crawley said the dialogue felt jarring and moved too quickly for her to process all the information and possible courses of action.

She was told she could terminate and "try again to get pregnant." But Crawley was 39 years old and had been trying to conceive for 2 years.

"It was devastating," she said. "No one sat down with me before this appointment to learn about my values or preferences, and I left that conversation with more questions than I had before I arrived. I went home and had one the worst weekends of my life. My husband and I felt so overwhelmed, grieved, and alone."

Information is valuable, but it can also be toxic, depending on what individuals intend to do with what they learn.

Pretest counseling can be as important as any subsequent genetic counseling, said Blair Stevens, a prenatal expert from the National Society of Genetic Counselors and a genetic counselor at the University of Texas Health Science Center in Houston.

"Information is valuable, but it can also be toxic, depending on what individuals intend to do with what they learn," she explained. "We cannot unknow or unhear details, so it's really important to work with patients in advance to make sure their preferences guide any planning."

Uncertainty can be very unsettling, she acknowledged. "It's important to help patients balance any ambiguity, so if there is a 20% risk, there is also an 80% chance of another, perhaps more favorable, outcome."

Most clinicians don't have the time to fully assess patient goals and align counseling approaches to individual needs, Stevens explained. And public interest in prenatal testing has outpaced clinical best practices as competing labs race to expand offerings and add options to screening tests to grab a piece of the global market, which is now about 130 million births per year.

"These are not scientifically sound additions and we need more evidence," Stevens said. "There is a right way to handle this, and labs and clinicians need to collaborate on responsible methods to test and integrate expanding options."

The Blue and Pink Elephant in the Room

"The reality is that most people don't have a super high risk for chromosomal irregularities," said Stevens. "Most people are more interested in learning the sex of their baby in early pregnancy than in any actual desire for genetic information." Noninvasive prenatal testing can detect fetal sex as early as 9 weeks into a pregnancy, whereas ultrasound might not detect it until about 18 weeks.

"Honestly? I think the growing popularity of gender-reveal parties is what is actually driving the push for more prenatal testing," she added. "The problem is that a couple eager to learn the sex of their baby may wind up with way more information than they expected and have trouble processing unanticipated risk."

In February, five national medical organizations in the United States partnered with the Reproductive Genetics Technology Consortium to develop consensus recommendations and guidelines for prenatal genetic testing.

The National Society of Genetic Counselors and the Society for Maternal–Fetal Medicine are among the new members that will provide a forum through which commercial laboratories can communicate about new technologies and obtain input and guidance on emerging options.

Wapner, who is a member of the consortium, said he hopes thought leaders will be at the forefront to guide this next chapter of prenatal screening. "So much money is pouring into all this testing; let's make sure we are making the right, most essential screening decisions," he said.

"Science typically advances more rapidly than the ethical and legal framework to support decision-making, and it's important for society to put protections in place," Lo acknowledged.

The misuse of screening and unethical sex-selection efforts in Asia and elsewhere in the world, where males are highly valued and females are more likely to be aborted, is dismaying, he told Medscape Medical News. "These are exploitations of the science."

In addition to scientific misuse like sex selection, data breaches are becoming a huge concern as companies amass large amounts of valuable genetic information.

Data for Ransom

In Canada, where Crawley took her test, LifeLabs — the country's largest laboratory testing company and a provider of genetic testing — paid a ransom after a major cyberattack led to the theft of lab results for 85,000 people in Ontario and the personal information of 15 million customers.

LifeLabs paid an undisclosed sum to retrieve the data, the company reported on December 17, and hired cybersecurity experts to assess the damage. The company is offering security protection services, including identity theft and fraud protection insurance, to customers.

"This has served as a reminder that we need to stay ahead of cybercrime, which has become a pervasive issue around the world in all sectors," Charles Brown, president and chief executive officer of LifeLabs, wrote in a letter to customers. "You entrust us with important health information, and we take that responsibility very seriously."

The United States has led the world in the commercial push for more prenatal testing. Other countries in Europe, for example, have proceeded with caution and have integrated the technologies with more controls. Hong Kong, where the inventor of the test is based, has been among the slowest to adopt the practice.

"I have been lobbying for 8 years for Hong Kong to offer testing," said Lo. "I think Hong Kong has been too slow to integrate, but the United States probably moved too quickly. There is a balance that I think countries like the Netherlands have found; they take the aim of screening into account, along with justice and societal aspects."

"Ideally, we will develop a great pretest model triage tool to help guide patients through this process," Stevens said. "And we have to make sure the data they receive are clinically useful and backed up by evidence to safeguard the care of every patient."

The practice of medicine is meticulously designed to assess and mitigate risk, "but this sensible objective can also be extremely negative in focus, with not-so-great delivery of information," she acknowledged. Each individual's tolerance for uncertainty and ability to cope in the face of adversity varies. "These are complex conversations that require time and empathy, and the details matter," she added.

"In my home state of Texas, where there is a large religious base, there is not as much drive for advance prenatal genetic information," Stevens explained. "We see a real advocacy movement emerging and a need for information from patients first because these can't really be clinician-led decisions," she pointed out. "Patients come to us undergoing not just the physical changes of pregnancy, but also emotional transformation as they transition to become parents. They may be nauseous or already sleep-deprived and they need our help," she added.

Everything changed in that moment. I knew that we were going to be okay no matter what happened next.

Crawley could feel the fluttering of fetal movements in her womb and said she felt connected to her child, but she remembered her trip to Ireland when she and her husband drank too much and they likely conceived. Irrational thoughts crept in: "Maybe it was something we did. What about my swimming; could it have been harmful?"

Apprehensions lingered as she waited to meet her specialist. Would the child grow and be able to walk? Be held back by disabling joint pain? Crawley sat down with her doctor at the high-risk clinic to discuss the possibilities.

"I don't see anything to be alarmed about. She's probably going to be small," said the obstetrician.

"She?!" Crawley had opted not to learn the sex of her baby, unlike so many other parents she knew, but her hope for her baby's good health soared above the accidental disclosure.

"Everything changed in that moment," Crawley said. "I knew that we were going to be okay no matter what happened next."

Crawley's pregnancy progressed to term and she gave birth to a healthy baby girl who is now 3 years old and dances ballet. Her beloved daughter is shorter than some of the other dancers in her class, but her mom says she hasn't missed a beat. "The world is a better place because my daughter is in it," Crawley said. "This, I know for sure."

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