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Lessons for Low-Penetrance, Treatable Diseases

Shachar Zuckerman, MSc; Amnon Lahad, MD, MPH; Amir Shmueli, PhD; Ari Zimran, MD; Leah Peleg, PhD; Avi Orr-Urtreger, MD, PhD; Ephrat Levy-Lahad, MD; Michal Sagi, PhD

JAMA. 2007;298:1281-1290.

Context  The aim of carrier screening is to prevent severe, untreatable genetic disease by identifying couples at risk before the birth of an affected child, and providing such couples with options for reproductive outcomes for affected pregnancies. Gaucher disease (GD) is an autosomal recessive storage disorder, relatively frequent in Ashkenazi Jews. Carrier screening for GD is controversial because common type 1 GD is often asymptomatic and effective treatment exists. However, screening is offered to Ashkenazi Jews worldwide and has been offered in Israel since 1995.

Objective  To examine the scope and outcomes of nationwide GD screening.

Design, Setting, and Participants  All Israeli genetic centers provided data on the number of individuals screened for GD, the number of carriers identified, the number of carrier couples identified, and the mutations identified in these couples between January 1, 1995, and March 31, 2003. Carrier couples were interviewed via telephone between January 21, 2003, and August 31, 2004, using a structured questionnaire for relevant outcome measures.

Main Outcome Measures  Screening scope (number of testing centers, tested individuals, and carrier couples), screening process (type of pretest and posttest consultations), and screening outcomes (utilization of prenatal diagnosis and pregnancy terminations).

Results  Between January 1, 1995, and March 31, 2003, 10 of 12 Israeli genetic centers (83.3%) offered carrier screening. Carrier frequency was 5.7%, and 83 carrier couples were identified among an estimated 28 893 individuals screened. There were 82 couples at risk for offspring with type 1 GD. Seventy of 82 couples (85%) were at risk for asymptomatic or mildly affected offspring and 12 of 82 couples (15%) were at risk for moderately affected offspring. At postscreening, 65 interviewed couples had 90 pregnancies, and prenatal diagnosis was performed in 68 pregnancies (76%), detecting 16 fetuses with GD (24%). Pregnancies were terminated in 2 of 13 fetuses (15%) predicted to be asymptomatic or mildly affected and 2 of 3 fetuses (67%) with predicted moderate disease. There were significantly fewer pregnancy terminations in couples who in addition to genetic counseling had medical counseling with a GD expert (1 of 13 [8%] vs 3 of 3 with no medical counseling [100%], P = .007).

Conclusions  In this study of GD screening among Ashkenazi Jewish couples in Israel, most couples did not terminate affected pregnancies, although screening was associated with a few pregnancy terminations. The main possible benefit was providing couples with knowledge and control. The divergence of these outcomes from stated goals of screening programs is likely to confront carrier screening programs for low-penetrance diseases.

Author Affiliations: Department of Family Medicine (Dr Lahad), Hebrew University-Hadassah Medical School, Jerusalem (Drs Lahad, Shmueli, Zimran, Levy-Lahad, and Sagi, and Ms Zuckerman); Gaucher Clinic (Dr Zimran) and Medical Genetics Unit (Dr Levy-Lahad and Ms Zuckerman), Shaare Zedek Medical Center, Jerusalem; Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel-Hashomer (Dr Peleg); Genetic Institute, Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv (Dr Orr-Urtreger); and Department of Human Genetics, Hadassah Hebrew University Hospital, Jerusalem (Dr Sagi), Israel.

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