Genetic Testing and Counseling, and Gene Therapy

1. Genetic Testing and Counseling, and Gene Therapy By Jeraun Hudson, Brian Smith, and Thomas

2. Genetic Testing • Newborn screening is integrated into normal medical practice. This type of genetic testing isn’t new…. • In 1961, the Guthrie test sampled a newborn’s blood for the buildup of amino acid phenylketonuria (PKU) • Today tandem mass spectrometry used to ID metabolism errors in newborns

3. Genetic Testing • Then, the polymerase chain reaction is used to help amplify the mutations, making it easier to ID. Today the availability of testing for rare diseases is increasing.

4. Polymerase Chain Reaction

5. Carrier Screen Prenatal Test Prenatal Screen Newborn Test Diagnostic Test Predisposition Test Predictive Test Types of Tests

6. Types of Tests • In 2005, the U.S. government mandated testing for 29 conditions that are treatable and recommended testing for an additional 5 conditions that are currently untreatable.

7. Genetic Counseling • Most medical professionals receive very limited training in the field of genetics. • The role of genetic counseling is expanding • Recent definition: “shared deliberation and decision making between the counselor and the client” • Reasons people seek counseling: • Prenatal diagnosis • Disease in the family

8. Genetic Counselors • Sessions with a counselor begin with the families’ medical history being summarized in a pedigree, which includes knowledge of the risks of precurrence for other relatives • From there, they discuss the condition, and try to determine which tests to take, or if assisted reproductive technology is needed • Once the couple decides which tests are appropriate, the counselor must ask if the risks outweigh the benefits • Often, communication can be hard-counselors must be sensitive and respectful, yet give their best opinion on what would be right for the clients

9. Genetic Counselors • There are only 2,200 genetic counselors in the US with a masters degree, and most practice in urban areas. Access to their services is limited. • Other less-qualified professionals have been called in to fill their shoes • As long genetic testing becomes more commonplace medical practice, and more is learned about genes, the need for genetic counselors will continue to rise

10. Genetic Privacy • Since results of genetic tests may have large impact on a person’s life, they may want to keep such information private • Doctors must weigh the risks and benefits of keeping this info confidential, if doing so may cause harm • “Duty to warn”- Doctors must know when it is better judgment to inform someone of a patient’s genetic disease or the risks associated with it • Court cases have brought this issue to the forefront • Now, the AMA mandates a doctor may disclose info if • Harm keeping quiet outweighs harm of breaching confidentiality • Relatives at risk can be identified • Failure to warn places the patient is at great risk

11. Treating Genetic Disease Treatment has evolved in 3 phases • Replacing missing proteins w/ donations • Obtaining pure proteins w/ recombinant DNA technology • Delivering replacement genes to correct the problem, also called GENE THERAPY

12. Gene Therapy • Treating the phenotype can be simple, like supplying a missing protein in a person’s diet, or even using corrective eyewear • However, altering genes directly will have a better effect than just treating symptoms

13. Concerns: Which cells to treat, and how? Is gene overexpression dangerous? Will the immune system attack the introduced cells? Does the targeted DNA sequence occur in other genes? Does the participant truly understand the risks? If effective, how will the recipients be selected Should rare or more common disorders be the focus of research and clinical trials? Requirements: Knowledge of defect and how it causes symptoms An animal model Success in human cells growing in vitro No alternate therapies Safe experiments Genetic Therapy

14. Gene Therapy • First efforts focused on inherited disorders that researchers knew the most about • With the increasing understand of human genes and their function, gene therapy is nowadays targeting more common illnesses • 3 approaches • “Ex vivo”-cells altered outside the body, then infused with corrected gene and returned to the body • “In situ”-healthy gene plus DNA delivering it (the vector) are injected into a localized body part • “In vivo”-vector introduced directly into the body

15. Ex vivo illustration

16. In vivo illustration

17. Germline Vs. Somatic • Germline (aka inheritable) gene therapy alters DNA of a gamete or fertilized ovum; all alleles are changed, and passed on to offspring; not used on humans • Somatic gene therapy corrects only the cells an illness affects; the cure isn’t passed on to offspring, and no gametes are altered

18. Gene Delivery Three ways • Physical: electroporation, microinjection, particle bombardment • Chemical: liposomes can enclose gene cargo and other lipids that carry DNA across the plasma membrane • Biological: Vector such as a viral genome used, as the viral gene is removed and corrective genes replace it.

19. Viral genomes: types and treatment • Adeno-associated virus (AAV)– sickle cell, Canavan disease • Adeno virus (AV)– cystic fibrosis, emphysema • Herpes– brain tumors • Retroviruses– HIV, cancer, Gaucher disease

20. Sites for Gene Therapy • May be applied directly to tissue affected, or into cells that can produce a needed protein and divide, such as stem cells and progenitor cells, because they divide well and can travel fast, and change the fate of daughter cells OR These may be targeted….

21. Endothelium: genetically altered endothelium can secrete a needed protein directly into the bloodstream Skin: A skin graft can be genetically modified to secrete therapeutic proteins Muscles: in Duchenne muscular dystrophy (DMD), the dystrophin gene can be cut smaller to deliver to cells so the muscles can function normally Liver: delivering the gene that encodes for the LDL receptor, so more LDL can be produced to treat familial hypercholesterolemia (FH) Lungs: several aerosols can be used to treat cystic fibrosis by replacing the defective gene. In AAT deficiency, levels of the enzyme elastase destroy lung tissue; Increasing the amount of the AAT enzyme will help prevent this. Nerve tissue: fibroblasts used to secrete nerve growth factors or make enzymes that produce neurotransmitters Cancer: ½ of all gene therapies target cancer. Suicide gene therapy may be used, as the vector or gene is introduced which kills the cells. Also, vaccines can be used to mark tumor cells so the immune system can recognize them easier Gene Therapy Sites

22. Suicide Gene Therapy

23. Sickle Cell Disease • Sickle cell disease is perhaps the most studied/researched inheritable disease • Could “turning on” fetal hemoglobin cure sickle cell by replacing the mutant beta chains (sickle BC’s) with normal gamma globin chains (fetal hemoglobin)? • In adults, the gamma genes are normally silenced with methyl groups. A drug called “hydroxyurea” can remove these groups, exposing the gamme genes. With the increase of gamma globin molecules in the bloodstream, these bind to the mutant beta globins, which prevents some cells to take on sickle shape. This prolongs the time it takes for the beta chains to join, and RBC’s are allowed to get into the lungs. Once cells pick up oxygen, sickling can no longer occur.

24. Hydroxyurea’s Effect

25. Gradual Success, but worth the wait • Soon, gene therapy will be applied to all common disorders, not only rare diseases • Because of success in the 1980s, huge expectations were held for the 90s….however, the progress has become painstakingly slow • Not every treatment is a 100% cure; some is only minimal physically • Discoveries in the genome have revealed complexities that have yet to be worked around • Discovery of RNA inheritance may complicate gene therapy • Somatic vs. Germline • Although minimal, there IS success • The right vectors MUST be found for further progress

26. Works Cited • McGleenan, Tony. Human Gene Therapy and Slippery Slope Arguments. Journal of Medical Ethics 21(6): 350-355, December 1995. • Lysaught, M. Therese. Gene "Therapy": A Test Case for Research With Children. Genetics and Ethics: An Interdisciplinary Study, 6th ed. St. Louis, Missouri: Saint Louis University Press, 2004, pp. 216-252. • Zohar, Noam J. “Prospects for ‘Genetic Therapy’ -- Can a Person Benefit from Being Altered?”. Bioethics 5(4): 275-288, October 1991.