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Exciting News from the Program!

group gc flyerAfter months of planning, the Program for Jewish Genetic Health is proud to announce the launch of our group genetic counseling sessions with testing for common Ashkenazi genetic diseases. This has been a long time coming and we are very excited to finally open this up to the public!

The backstory: Our program has had many successful genetic testing events at different campuses and synagogues over the years. But we have been seeing that many past participants contact us years later for an extra copy of their results because they are either in the dating/marriage or family planning stage and finally need their results for important decision-making. Pretty much every patient who calls gets an earful from me about how his or her results may be outdated, as new tests were likely added to the panel since the testing was done.

Our program leadership has been struggling with our official stance on when we believe carrier screening should be done. Since some will use their results in the pre-dating or dating phase, maybe it would make sense to recommend testing early on (think college time). But many will choose a partner and only use their results when starting to think about building a family. If those people got tested at 19 years old and will only use the results years later, chances are the testing is outdated.

The brainstorming: After much back-and-forth about this, we decided that we would not be going ‘on the road’ to campus screening events any more. We believe that the best time to get testing is before contemplating a pregnancy; and that may mean a different thing to everyone. We think that it should be up to the individual to decide when is the most appropriate time to get tested and we should not be imposing a time-frame on college students.

So how should people get tested? Until now, we have been seeing patients one-on-one in our clinical offices. In those sessions, the individual meets with a genetic counselor and a detailed medical and family history is obtained. The genetic counselor then recommends a panel of tests depending on what was reported during the session. The costs involved may differ from one patient to another since different tests may be recommended.

But for the patients who have no family history of genetic conditions or are not of mixed ancestry, the testing and genetic counseling is standard and quite straightforward. We still like the campus screening model of providing affordable and efficient carrier screening, and so we decided to try a new model of group sessions for the more “straightforward” cases.

The details: Our group sessions will be held on Fridays at 9 AM in our Bronx location. For these sessions, we are partnering with JScreen, a genetic testing group that relies on generous donors to offset the cost of testing. There will be a minimal cost for the counseling (which will likely be covered by insurance) and the total cost for testing will be $99. Pre-registration is required.

While these sessions are not a one-size-fits all, they certainly will be helpful to many. Take a look at our PJGH testing website for more information on registering for an appointment and to learn more about whether the group setting is right for you.

We look forward to meeting you!

Finally! A Genetic Test for Sephardi and Mizrahis Too

DNA code analysis

For years, when we got inquiries from Sephardi or Mizrahi patients about preconception genetic testing, we would respond that there is currently no testing panel as there is for our Ashkenazi patients. And we would feel bad about that because we know that, like in many other ethnicities, there are genetic diseases which are common in Sephardi and Mizrahi populations too.

When we hosted a genetic testing event at Yeshiva University in 2013, our flyer included a call-out to the Sephardi students to contact us privately and not to register for the event. Turns out, 22 interested students were disqualified from the event, and I have no idea how many actually called us to come in for private counseling and testing. My guess is zero.

Since the genetics for Sephardi and Mizrahi Jews differ by country of origin (and there many countries with Jews), genetics labs never really made it a priority to develop testing panels. After all, why should they develop tests that a tiny number of people will actually need? So we were left between a rock and a hard place; on the one hand, we encourage people to get tested for diseases common to individuals of their ethnicity, but on the other hand, we are unable to order any testing. We were essentially pushing a product we didn’t have.

This all changed about a month ago, when we started offering a new panel that was developed for Jews of all backgrounds. This new panel is made of 96 diseases; 48 of them are common in Ashkenazis, 38 in Sephardi/Mizrahis, and 10 overlap between the groups (it is a very large panel!). Here are some of the things that we have been finding since we upgraded:

  • People think they know what their ancestry is, but are surprised to find out they may be more mixed than they thought. A patient of ours could have sworn he was 100% Ashkenazi, but he came back as carrier for a disease that is common in Yemenite Jews. When he asked his grandmother if there was something he didn’t know, he learned that he had some North African ancestors!
  • The more diseases we screen for, the more likely someone will be a carrier. We used to say that about 1 in 3 people will screen positive for something. But so far, I think we have only had one patient who was not a carrier of anything on the panel. And of course, being a carrier, in general has no effect on one’s health and should not be considered a stigma.
  • Even though we have tripled the amount of diseases on our testing panel, the ‘classic’ Jewish diseases are still ‘classic.’ I would have thought that the more diseases we screen for, we would see a wider array of results, but we have been seeing that those diseases that have been on the panel since the beginning (the common ones, like Tay Sachs and Gaucher) are still the ones that we have been picking up most often.
  • We have  had a Jewish history lesson for our genetic counselors helping them understand the different migrations of Jews over the course of history, and how ‘Ashkenazi’, ‘Sephardi’, and ‘Mizrahi’ Jews came to be.

The bottom line is that carrier screening is recommended before contemplating a pregnancy for anyone that is at least ¼ Jewish. It doesn’t make a difference if one has mixed ancestry, if he/she knows that a relative tested negative in the past, or if he/she chooses to affiliate with a movement within Judaism. Our genes do not choose to be transmitted only to the “more Jewish” people. Most of the diseases on the panel are a burden on the affected person and the family and testing a couple before a pregnancy is one of the best preventative actions one can take to avoid heartache. Visit PJGHtesting.com to learn more about the testing.

Updating Your Carrier Screening

update carrier screening croppedWhen I was at a recent sisterhood event at my synagogue, a friend of mine approached me to ask if she should “do her genetic testing again” since she and her husband were first tested in 2007 and have not been tested since. I answered with an emphatic “YES!” I appreciated that she knew to even ask this question, but our conversation got me thinking. Do other people know that new diseases are regularly being added to the Ashkenazi  Jewish panel?

The best time to get screened is well before a pregnancy. Since the 1980s when Tay-Sachs testing was introduced to the Ashkenazi Jewish world, there has been much progress in the realm of genetic testing. Currently, we screen for about 18 diseases that are common in this population. And testing for Sephardi and Mizrahi Jews as well as Jews of mixed ancestry has become more commonplace. But someone who was tested in 2001, for example, and was negative, is not “in the clear” since many more diseases have been added to the panel since then.

Many people ask me, “If I am already married, why should I bother updating my testing? It will only make me more anxious as I continue having children.” My response is that I’d rather find out that you are both carriers of the same genetic disorder by doing a blood test, rather than finding out after you have an affected child. There are other options besides for stopping childbearing, rolling the dice with each pregnancy, and breaking up! Other family planning options include testing the fetus early in the pregnancy, using an egg or sperm donor, and adoption. In-vitro fertilization with pre-implantation genetic diagnosis (PGD) is another great alternative for couples who want to know their child’s genetic status before it is even in-utero. By doing genetic testing this early on, a couple will avoid getting pregnant with an affected embryo and will circumvent any ethical or issues related to Jewish law that may arise.  Robin’s Story, a short public service announcement on MyJewishGeneticHealth.com, will open your eyes as to the importance of updating your screening and learning your options. And be sure to register to watch Dr. Lieman’s longer webinar about PGD and Chani’s lesson about preconception carrier screening!

Finally, while testing for diseases that are common in specific populations is currently recommended by professional genetics groups, there are labs who are now offering screening for many more diseases. These expanded carrier screening panels claim to be “one size fits all” and are marketed to all ethnicities, but a negative result on a broader screening does not fully eliminate the risk of having a child affected with one of the tested disorders, it only reduces the risk. Furthermore, expanded carrier screening does not cover all diseases that could affect offspring.

I wish I could go into every synagogue, preschool, sisterhood, and other places where women in their childbearing years hang out to remind them to update their carrier screening! But since that is impossible, please take the time to mention it to your family and friends and help me spread the message. Let’s avoid heartache together!

Forty Years

Operation Gene Screen

Last week I went to a retirement party for Dr. Sachiko (Sachi) Nakagawa, a former colleague of mine from my time in the genetic testing lab at Jacobi Medical Center.   When preparing for the speech I delivered at the party, I reviewed her invaluable contributions in the realm of Tay-Sachs disease screening, and I thought that you all needed to hear a bit (or maybe more than just a bit) about those.

Sachi was trained as a biochemist and ended up here at Einstein in the late 1960s for additional training after receiving her Ph.D.  In the early 1970s, she joined the group of Dr. Harold Nitowsky, who was on the verge of setting up the Tay-Sachs community carrier screening program known as Operation Gene Screen.  To quote Sachi directly, “this is how I ended up doing Tay-Sachs carrier screening till now … and nobody told us we made any mistake for the last 40 years.

Forty years devoted to Tay-Sachs enzyme screening! Hard to imagine—especially if you knew that she hardly missed a day of work or took a vacation!  Sachi must have tested tens of thousands of samples, starting with for the early Einstein screens, and then for commercial laboratories, for infertility clinics, and for Jewish genetic screening programs nationwide, including our own Program for Jewish Genetic Health.   To Sachi, the focus was never the total number of samples—each sample was treated with the utmost care, and each was tested and retested to ensure an accurate classification.

One of Sachi’s most important technical contributions was her development of the platelet assay for Tay-Sachs carrier testing. Until Sachi’s platelet test, Tay-Sachs testing of Hex A enzyme activity was being performed on serum (the part of your blood that is neither a blood cell nor a clotting factor).  While this was a good test for identifying carriers, many samples were yielding inconclusive results. I remember Sachi describing to me her “aha moment.”  While at a scientific conference, she realized that platelets (a component of the blood that is important for clotting) would be a much more homogenous sample than serum, and could possibly overcome the significant number of inconclusives.  And Sachi was correct about this.  Her platelet assay became the gold standard test that not only was a gift to the Jewish screening programs but also helped to identify Tay-Sachs carriers from ethnic backgrounds that were not 100% Ashkenazi Jewish.

Along that line, it is important to recognize that Tay-Sachs disease, in addition to in the Ashkenazi Jewish population,  also is seen more frequently in other populations including the Irish, French Canadian, and Cajun—and this is something that is often overlooked (but see also an earlier blog).  I will never, ever forget an email exchange I had with Sachi when she was asked to confirm a probable diagnosis of Tay-Sachs in a sample from a baby of Irish descent.  “There is no HexA enzyme peak,” she related, “the baby is affected with the disease.” Thankfully, we don’t see much of this anymore in the Jewish population due to the carrier screening programs, and hopefully the same trend will follow in other prone populations in the future.

A co-worker of Sachi’s told me that, on Sachi’s last day in the laboratory she said goodbye to her instrumentation and thanked it for its stellar performance.   And hearing that made me give pause for thought. The world of genetic testing is moving at rapid fire pace these days.  It is important to remember that, before DNA was discovered, and before the genes and mutations associated with specific diseases were characterized, there were biochemical genetic tests, some of which are still being used today (today we test for Tay-Sachs carriers both by looking for mutations on the DNA level and by assessing enzyme levels).  People like Sachi, who developed and ran these tests in the most dedicated manner, will never be forgotten by her colleagues.  I hope that she also will be remembered by the countless screened individuals who benefited from her expertise, as well as by the community as a whole.  Kudos to you, Dr. Sachiko Nakagawa.

A Plea for Being Prepared

I recently was introduced to a young woman at a party.When she heard that I am a genetic counselor, she said, “What a coincidence, I need to speak with a genetics expert! You see, I am engaged and my fiancé was tested for Tay-Sachs but I think we may need to do some more genetic testing before we get married.” Feeling good that she met me at the right time, I told her to set up an appointment at our office. “Great,” she replied, “Because we are getting married in 2 weeks and I would like to know the results by the wedding date. “ I tried to dissuade the young woman from getting tested now, since the results would not be back in time for the wedding, and she did not need the extra stress.  I told her to enjoy her wedding and contact me before contemplating her first pregnancy. “But we want to get pregnant the night of the wedding,” she replied.

This was not the first time I have heard of this.  In some sects of Orthodox Judaism and other religions, couples decide against contraception; they believe that family planning is up to God.  And sometimes, even couples who do use methods of birth control may be surprised to get pregnant.  My point is, whether or not you take contraceptive measures, there is always a chance you could get pregnant.   And this could have added implications if the couple is at increased risk for offspring with a genetic disease.

I am not trying to scare you; I am merely trying to set the stage for my position on carrier screening.  If a couple finds out that they are both carriers of a recessive disease such as Tay- Sachs, this means that there is a 1 in4 (or 25%) chance of having an affected child with each pregnancy. Wouldn’t it be better for such a couple to know that they are at risk before getting pregnant? Instead of achieving a pregnancy naturally and taking that 1 in 4 chance, a carrier couple may decide to do in vitro fertilization with pre-implantation genetic diagnosis (what genetics people call “IVF with PGD”). Other couples may opt to use an egg or sperm donor (who is not a carrier of the same disease), and others might decide to adopt or not have children at all. My point is that if a couple knows before getting pregnant, they have more reproductive options available to them.

And what about those couples who do not plan their pregnancies to the day? For instance, consider the woman who decides against using contraception on her wedding night, or the couple whose methods do not do the trick. Those people (ie, could be anyone!) ought to know their carrier status sooner rather than later. It’s always better to be prepared than to find out during a pregnancy when difficult decisions may be on the table, or even later with the birth of an affected child.  So remember that you cannot plan everything in life-but for those things that you DO have control over (like going to get screened), why wait?

Click here for a short PSA on the importance of getting tested

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