Category Archives: Edwards Syndrome

Edwards Syndrome

Conventional aneuploidy screening remains “most appropriate” choice for general population


OpinionThe American Congress of Obstetricians and Gynecologists (ACOG) have updated their guidance on cell-free DNA (cfDNA) screening tests for fetal aneuploidy. In it, they state that any patient (i.e. women at high-risk OR low-risk for having an affected pregnancy) may choose cfDNA testing but they caution that conventional screening tests are more appropriate. This document replaces an earlier opinion, published in 2012, which clearly stated that cfDNA screening tests should not be offered to the general obstetrical population because they are considered to be at low-risk.

So ACOG went from recommending that cfDNA testing not be performed on low-risk women to say that they may choose cfDNA testing. Why the subtle change? Well, as ACOG correctly notes, the landscape of cfDNA is changing rapidly. New studies are published frequently and those that have examined the performance of cfDNA tests in  low-risk women have reported that the test performs just as well in them as it does in high-risk women.

However, they make an important point about a metric that doesn't get the attention it deserves. The positive predictive value (PPV). See here for background. Because the prevalence of fetal aneuploidy in low-risk women is lower than it is in high-risk women, a "positive" or "abnormal" test result in low-risk women is more likely to be a false-positive result. For example, a positive result in a 25-year-old woman gives a 33% chance that the fetus is affected but that chance increases to 87% in a high-risk woman.

The report also calls out the "no result" problem. cfDNA tests fail to produce a result in 1-8% of samples tested, usually due to a low amount of fetal DNA in the blood sample. It's becoming clear that women with samples that fail to produce a result are at increased risk of having an affected fetus. According to ACOG, these women she be offered diagnostic testing such as fetal karyotyping using amniotic fluid obtained by amniocentesis.

Other notable points contained within the updated guidance include:

  • Caution about not routinely performing microdeletion screening (offered by some labs) because it has not been fully validated in clinical studies.
  • Clearly indicating that a negative or normal result does not rule out the possibility of an affected fetus.
  • Providing genetic counseling to patients about test limitations and that decisions such as pregnancy termination should not be based on these screening tests.
  • A reminder that cfDNA tests do not screen for neural tube or ventral wall defects

This certainly won't be the final say that ACOG has on cfDNA aneuploidy screening tests. Indeed, they state that "It will be critical to remain abreast of this rapidly changing technology to provide patients with the most effective, accurate, and cost-conscious methods for aneuploidy screening."

Confusion over NIPT invites catastrophe


Timing is everything. A week after I wrote about false-positive NIPT results, the Boston Globe published an article titled "Oversold prenatal tests spur some to choose abortions" written by Beth Daley of the New England Center for Investigative Reporting. The article describes non-invasive prenatal testing (NIPT) using relatively new cell free DNA tests with a focus on women who have experienced receiving incorrect results.

The article focuses on one woman who had Sequenom's MaterniT21 PLUS test that indicated her fetus had trisomy 18 or Edwards syndrome. She initially considered immediately terminating the pregnancy and her doctor helped her locate a physician who could perform the procedure the next day. Only hours later did her doctor caution her to consider diagnostic testing which confirmed the fetus did not have trisomy 18. Additional cases in the article tell of one woman who experienced a false-positive result (confirmed by diagnostic testing) but so trusted the results of the DNA test that she aborted her pregnancy anyway and a woman who experience the trauma of a false-negative result.

Stories like this indicate a clear lack of understanding regarding the limitations of NIPT and demonstrate that physicians and consumers don't always appreciate the fact that these are screening tests. In a post on its blog about the Globe article, the Society for Maternal Fetal Medicine emphasizes just that by stating "It is important for providers to remember that cell free DNA is a screening test, and does not have the diagnostic accuracy of amniocentesis." They also point out that doctors who order DNA-based screening tests need to understand the test characteristics and they emphasize the role of genetic counseling for women who undergo screening for aneuploidy. The Society's statement was the focus of a follow-up piece by the New England Center for Investigative Reporting.

Whether aneuploidy screening is performed using DNA-based tests or by traditional biochemical screening, it is a screening test. Neither are diagnostic tests. Abnormal results from any screening test must be followed up by diagnostic testing to confirm (or not) the results of the screening test. To be misinformed on this basic fact of laboratory medicine is to flirt with disaster.

The ugly stepsister: false positive NIPT test results


Positive Negative

© Stuart Miles – Fotolia.com

NIPT (non-invasive prenatal testing) continues to get lots of attention lately. Indeed, we've written about it extensively on this blog. None of this is suprising because NIPT is a new technology that is continually evolving. Two years ago, I wrote about NIPT here and provided information showing it's excellent diagnostic sensitivity and specificity. To be clear: these tests are more accurate than traditional biochemical screening for detecting fetal aneuploides but they are still screening tests, meaning that positive (or abnormal) test results must be confirmed with diagnostic testing.

As is commonplace, with time comes experience and the lens of scruitiny has recently been focused on the positive predicitive value (PPV) of NIPT. What's a PPV? It's the proportion of true positive results divided by the number of all positive results. For NIPT testing, it answers the question: "What is the probability that a positive result means that the fetus is affected?" It is very important to stress that the PPV of any test is not intrinsic to the test. The PPV is also dependent on the prevalence of the condition in the tested population. If the condition is very rare in the tested population, then the PPV will likely be low, meaning that a positive result is more likely to be a false positive. The opposite is also true (positive test results are more likely to be "true" when the condition is highly prevalent).

NIPT is done to screen for fetal aneuploidies (extra copies of specific chromosomes) such as Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), and Patau syndrome (trisomy 13). The prevelance of each of these disorders is influenced by the woman's age. As examples, the prevalence of each in a 35-year-old woman with a fetus at 10 weeks’ gestational age is 1:185, 1:470, and 1:1,500, respectively. As you might expect, the less prevalent a condition is, the more likley a positive result will be falsely positive.

This has been demonstrated for NIPT. A study published earlier this year evaluated the concordance of NIPT and cytogenetic results among cases with positive or negative NIPT results. The study examined test results from 109 consecutive specimens that were either prenatally and/or postnatally studied by fluorescence in situ hybridization, karyotyping, and/or oligo–single-nucleotide polymorphism microarray (as the definitive, or diagnostic, test). NIPT testing was performed with the Panorama (Natera, San Carlos, CA), Harmony (Ariosa Diagnostics, San Jose, CA), MaterniT21 (Sequenom, San Diego, CA), or Verifi (Illumina, Redwood City, CA).

The PPV for T21 was highest at 93% followed by a 64% PPV for T18.  The PPV for T13 was only 44%. Given the prevalence of each of these conditions, these data aren't all that surprising but they are still rather alarming. Why? Because several studies have claimed NIPT tests are >99% specific (e.g. ~1% false-positive rate). As the authors of the study described here state: "To an average clinician, the claim that a test is >99% specific leads him or her to expect that the false-positive rate will be <1%."

As I stated this above and in several other posts on this blog (but is worth emphasizing again): NIPT is a screening test, not a diagnostic test and it cannot be considered a replacement for diagnostic testing.

Should DNA-based tests for Down syndrome screening replace biochemical tests?


In a previous post I described the clinical performance of DNA-based screening tests for fetal aneuploidies like Down syndrome.  Overall, these tests have excellent detection rates (~99%) with very low false-positive rates (~0.2%).  In other words, these tests are about 99.0% sensitive and 99.8% specific.

With performance like that one might expect these to be considered diagnostic tests.  They are not! Although quite good, test results must not be interpreted as definitive evidence that a fetus does or does not have an aneuploidy.  Recent recommendations from the American College of Obstetricians and Gynecologists (ACOG) are quite clear on that issue.

In those same recommendations, ACOG also states that DNA-based screening tests may be performed only on women who are at increased risk of having a fetus with aneuloidy.  Among the indications listed for women considered to be at increase risk are:

  • Maternal age 35 years or older at delivery
  • Fetal ultrasound findings suggesting aneuploidy
  • A previous aneuploid pregnancy
  • Abnormal biochemical screening test results
The ACOG is right to avoid recommending that DNA-based screening tests are acceptable to use regardless of risk factors.  Unfortunately, many women who are not at increased risk are using these new tests as a primary screening test and that's not a good idea.

To understand why, considered a population of 100,000 pregnant women from the general population and assume that the prevalence of Down syndrome is 1 in 500 pregnancies.  That means that there would be 99,800 unaffected pregnancies and 200 pregnancies with Down syndrome.  The table below compares the results of the most commonly used biochemical screening test (the Quad test) to a DNA-based screening test.

Quad vs DNA performance
Clearly, the DNA-based test has several advantages over the Quad test.  Its positive predictive value is nearly 17 times greater than the Quad's and a positive DNA-based test result substantially increases the odds of having an affected fetus.  So why not use the DNA-based test as a primary screening test?  For the following reasons:
  • No studies have been published that have evaluated the performance of DNA-based tests in women who are not at increased risk of having a fetus with an aneuploidy
  • DNA-based tests are not widely available
  • The time it takes to report results of DNA-based testing is about 3 times greater than it is with biochemical testing
  • DNA-based tests are considerably more expensive than biochemical tests
  • Relative lack of insurance coverage for DNA-based tests
Until these these limitations can be resolved, it makes more sense to use DNA-based testing as a secondary screening test.  In other words, it is only done after one of the risk factors described by ACOG (above) are met.  Doing so greatly improves the performance of both tests (see figure below).  A limitation of this approach is that the detection rate is that of the biochemical test which is not as high as it is with the DNA-based test.  Still, given the current limitations of DNA-based testing, this 2-step testing approach makes the most sense.
DNA as secondary test

DNA-based tests for Down syndrome screening show excellent clinical performance


The use of biochemical screening tests to identify pregnant women who are at high risk of having a fetus with Down syndrome is well established.  Biochemical screening began nearly 30 years ago and, over the years, the tests have evolved and improved.  Now there’s a new kid on the screening test block and it’s name is DNA.

The discovery of cell-free fetal DNA in maternal plasma in 1997 opened up new possibilities for Down syndrome and other aneuploidy screening protocols.  Rather than rely on biochemical testing to determine a biochemical phenotype, DNA-based tests have been developed that can detect the molecular pathology of aneuploidies (e.g. a fetus that has more than the expected 2 copies of chromosomes 21, 18, or 13; the cause of Down syndrome, Edwards syndrome, and Patau syndrome, respectively).

We’ve written about DNA-based screening tests before (here and here) and described the clinical performance of the Sequenom test.  Now, other clinical performance studies have been published for 3 of the 4 tests that are (or will be) commercially available.  As expected, all of them show excellent clinical performance.  As shown in the table below, the detection rates for trisomy 21 are greater than or equal to 99% with very low false-positive results.  Similar performance has been reported for trisomy 18 and 13.

DNA test performance

Table References: Genet Med 2011;13:913-920Genet Med 2012;14:296-305Obstet Gynecol 2012;119:890-901

By comparison, the detection rate of the best biochemical Down syndrome screening test (the Integrated test) is very good at 93%.  However, about 5% of all Integrated test results are false-positive.  A 5% false-positive rate may not seem very high but it is.  For example, consider a population of 100,000 pregnant women who choose Integrated testing in the second trimester.  The prevalence of Down syndrome in the second trimester is about 1 in 500 pregnancies so 200 of those 100,000 women will have a fetus with Down syndrome and 99,800 women (100,000 – 200) will have unaffected fetuses.  Of those 99,800 women with unaffected fetuses, 4,900 will have a false-positive Integrated test result.

Because the false-positive rate of the DNA-based tests is so low (about <0.2%), then if those same 100,000 women were screened there would be only 200 false-positive results, a 96% decrease!

Does this mean that DNA-based tests should replace biochemical screening tests?  Probably not but I’ll leave the explanation as to why for my next post.