This site lists the different benefits associated with full genome sequencing DNA testing as well as the potential limitations that should be considered. Not all of the benefits or limitations will apply to every single DNA testing type. For test-specific benefits and limitations, please visit the DNA tests sites for specific target groups. Please expand each section for more information.
Please go to the above PROCEDURE tab to go to main site for educational content that Merogenomics recommends prior to purchase of any DNA test.
Step 1.1: Educate yourself
Advantages of Genome Sequencing
There are many advantages to sequencing an entire genome, some more obvious than others. Top ten reasons are listed below.
Obtaining scientific information with potential medical implications
The primary purpose of sequencing one’s genome is to obtain information of medical value for future care. Genomic sequencing can provide information on genetic variants that can lead to disease or can increase the risk of disease development, even in asymptomatic people. Thus genome sequencing has the potential to increase the ability to act preemptively prior to disease development or commence treatment for a disease that has not yet been diagnosed. For people experiencing a health-impacting condition, DNA sequencing can provide a precise diagnosis which might affect the medical management of symptoms, or provide treatment options.
Another advantage of genome sequencing is that information regarding drug efficacy or adverse effects of drug use can be obtained. The relationship between drugs and the genome is called pharmacogenomics.
The information that the client receives is based on information obtained from publically available databases for human genome variation that are continuously updated with novel research findings. The presented data will be stratified from the most to the least clinically validated, with supporting evidence provided.
The full scope of information that the client can obtain from decoding their DNA will depend on the type of DNA test selected. The different target groups that can benefit from DNA sequencing can be divided as follows:
- Presumed healthy individuals for proactive screening
- Pregnant women for fetus development screening
- Cancer patients for treatment options
- Family members with a cancer history for potential diagnosis
- People with undiagnosed conditions for potential disease diagnosis
Please see the specific target group DNA tests links below for test-specific benefits:
Nonmedical information can also be obtained, such as heritage background, nonhealth related trait information, or information with indirect medical impact, such as a predisposition to obesity.
However, clinical genome sequencing testing will not present such information, and does not investigate it. In some instances, some non-medically relevant trait information might be provided directly to the client, while the ordering physician will obtain the clinical report. It is important to note that such additional trait information often lacks the established scientific validity that is expected from the reporting of medically-relevant information, and should be seen as educational only.
The genome sequencing procedure and the data interpretation are performed according to the highest standards available to public consumers. Human genome sequencing is an innovative and state-of-the-art technology, and novel discoveries in improving data quality are constantly being made. Merogenomics selects service providers that can generate data of the highest quality based on the latest published supporting records. Merogenomics can provide third-party appraisal to ensure that these stringent criteria are met for a client interested in tests from service providers different from those recommended by Merogenomics.
The third parties endorsed by Merogenomics to isolate, sequence, and interpret a subject’s genomic DNA are of established quality. These firms have set technical competency standards and demonstrated procedural analytical validity, and collaborate with leading academic and industry research institutions. The service providers of DNA tests promoted by Merogenomics are all CLIA/CAP certified to the highest regulatory standards that are applied to clinical laboratories performing testing on human samples.
Merogenomics aims to help clients obtain quality data that can be directly interpreted by a healthcare professional.
Protection of information
Protecting the privacy of genetic information and access to informed consent are viewed as important by the general public, and are key influencing factors in public interest in direct-to-consumer genomic testing.
All of the DNA tests promoted by Merogenomics are clinical tests, and therefore require a test requisition form to be signed by the ordering physician. The service providers have experience in safeguarding a patient’s private information according to HIPAA regulations, and work accordingly with clinics and hospitals around the world.
DNA sequencing service providers take all reasonable efforts to protect the privacy of the information and samples provided by the client and the confidentiality of the data generated. All data and information is encrypted, password protected, and stored in a cloud. All tissue samples are stored in a safe biorepository until they can be safely discarded. DNA testing service providers do not distribute private and sensitive information to third parties without the agreement of the client.
Variants that are pathogenic, likely pathogenic, or suspected to be linked to a client’s disease symptoms will be reported to the public databases that collect clinical information on DNA mutations involved in human diseases. It is such databases that are used for the client’s genome sequence interpretation, and this data evidence helps in the future efforts of understanding the nature of human disease. Deposited data is anonymized and cannot be linked to the client’s specific identity. The client can request not to have any of their data deposited in such databases.
As your genome is the same throughout all the cells in your body, and is specific to each individual, accurate whole genomic sequence need be obtained only once (genome sequence does not change unless influenced by environmental factors, for example, in the development of many cancers); it is a repository of biological information that will never have to be resequenced. Genomic information is available for interpretation in perpetuity, providing an opportunity to learn new information as more scientific knowledge of the genome emerges.
Whole genome sequencing is different from genotype screening tests or sequencing of individual genes. Whole genome sequencing looks at the entire DNA whereas genotyping or sequencing a panel of desired genes looks only at chosen fragments of the genome. Such fragments are selected to obtain specific information about a physical trait, but can run a risk of missing information important for appropriate analysis. It is also biased towards predetermined choice of which segments should be analyzed. Therefore, another important benefit of sequencing over genotyping is the discovery of rare or novel variants.
This point can be illustrated by considering BRCA gene mutations, which confer a high risk of breast and ovarian cancer development in women. Early discovery of these mutations provides options for prophylactic action. However, it is known that not all such mutations will result in cancer development, and not all prophylactic actions will guarantee the prevention of future cancer development. Therefore, additional potentially genetic factors could play role in the outcome, and such information cannot be captured by genotyping methods.
How can a client determine the difference between genotyping and whole genome sequencing? The cost is a clue; current prices for genome sequencing are in the range of thousands of dollars whereas genotyping prices are in the range of hundreds of dollars, or less. A close investigation of the procedural details is necessary to determine the substance of the product offered. Merogenomics Inc. can help prospective clients to define the test methodology and function, and to evaluate the quality of a potential procedure.
Cascade testing to other family members
If a variant with potential health implications is revealed in an individual, such information will have direct impact on closely related family members. Other family members can undergo a screening test to determine if they are at risk. This is one of the most positive effects associated with genome testing in presymptomatic or affected individuals. Secondary testing can lead to the identification of other family members that have the variant in question.
Information of value to future generations in a client’s family
The power of genomic information is compounded each time a genome sequence is obtained for an additional member of a family, especially when this occurs across generations. Direct comparisons of genome sequences of relatives for whom DNA variation is shared can infer inheritance patterns. Each additional genome sequence can make the interpretation of genomic variation easier. Therefore, genome sequence information is of value not only to the individual undertaking the procedure, but also to immediate family members and direct descendants. Such information should be treasured and safeguarded by families whose members have chosen to investigate their genomes.
Merogenomics can help clients to access multigenerational genome sequence data, and to interpret the data in the family context. Such data should be protected by long term digital data storage, and Merogenomics can help with that.
Staying ahead of nongenetic healthcare providers
A direct-to-consumer genome sequencing test allows an individual to obtain potentially health-related information privately, outside of the medical establishment, although a medical provider would be required to act upon pertinent information discovered through genome sequencing.
Genome sequencing is a relatively new technology. Although it is being rapidly incorporated in clinical care, the technology is not standard and it is likely to be used as a last alternative in diagnosis.
The utility and applicability of genome sequencing are not yet embraced fully in physician education. Therefore, many physicians are unable to provide information regarding the diagnostic opportunities of genome sequencing.
Merogenomics can inform the client and his or her treating physician of the potential utility and best available options to sequence a human genome. Merogenomics can also oversee that the test procedure and analyses are performed to standards appropriate for medical interpretation.
Sense of empowerment
Genomic knowledge enables an individual to take preventive steps to minimize disease risks, and thus provides personal empowerment. Self-empowerment is one of the stated goals of The Precision Medicine Initiative, unveiled in 2015 by President Obama in his State of the Union address. The Precision Medicine Initiative aims to sequence the genomes of more than a million Americans.
A client empowered by access to genomic knowledge can improve his or her health management by proactively treating health complications or reduce impact of negative outcomes. Knowing a specific condition exists can allow a person to psychologically prepare for it, plan for future condition detection or treatment, and evaluate future family planning. Knowledge is a human right, and access to information that impacts both the self and one’s offspring is regarded by majority of people as valuable, even if nothing can be done to improve the condition.
Certain individuals might undergo distress over a perceived disease risk if family history indicates inheritance of a disease. Although an individual deemed non-high risk for a specific disease might not be eligible to receive confirmatory medical testing, such individual can turn to direct-to-consumer testing to determine his or her genetic condition. Studies indicate that removal of disease risk uncertainty has a beneficial impact on reduction of anxiety associated with the uncertainty.
A whole genome sequencing procedure produces data that can be analyzed and interpreted in perpetuity. Once a genome is decoded it becomes a multigenerational repository of information. This replaces the current clinical approach of sequencing individual genes, or of genotyping specific areas of the genome that might or might not be informative. Access to a genome sequence reduces or removes the trial and error that frequent diagnostic tests that search for clues for undesirable and elusive health conditions and drug prescriptions that seek to alleviate such conditions. Thus, genome sequencing can result in substantial cost saving, especially when measured over the lifespan of an individual. For example, according to one report, 98% of surveyed U.S. physicians expected that patient genetic profiles would influence drug therapy, resulting in reduced treatment costs (Stanek EJ, et al. Clin Pharmacol Ther 91(3): 450-8).
Limitations can be expected in any technology, especially in a novel one. Clients should be familiar with the limitations of genome sequencing.
How accurately and reliably genome sequencing measures genome variants is termed “analytical validity.” Analytic validity depends on how many times a nucleotide base is read by the sequencing platform during the sequencing process. The more times a particular base is read, the higher the accuracy that it was measured, or “called,” correctly at that particular position. The number of times a particular base is called is the “read depth” or “coverage depth.” The coverage depth can be affected by the quantity and quality of DNA available for sequencing, as well as the computational capabilities of the software selected to determine the DNA sequence. A certain minimum coverage depth is required as the acceptable threshold to be confident that the nucleotide base was called correctly.
Because the DNA is not read at uniform coverage across the genome, it is possible that segments of the genome could be read below the minimum coverage depth. If the depth coverage is not sufficient, it is possible that a base will be identified that is not actually present in a person’s genome. For example, if a mutation that leads to a disease is mistaken for a normal gene (a false negative), the person could think they have been successfully tested for a condition and found to be “negative” for it, whereas that might not be the case. Conversely, a gene could be misread as a mutation that is expected to lead to an adverse condition, whereas in reality, the person is not harbouring such a mutation in their genome (a false positive). A small fraction of the genome might not be sequenced if it reads below the minimum coverage depth.
It is therefore important to remember that information obtained from genome sequencing is not to be used for medical interpretation unless it is validated by additional means. It is the first step only in unravelling biological information from personal DNA. However, it should be noted that in a clinical interpretation of genome sequence, a variant that has not met the adequate threshold for statistical accuracy would not be reported to a doctor.
In summary, genome depth coverage varies throughout, and the lower the depth, the lower the probability that base was measured correctly. Conversely, the higher the coverage, the higher the probability of accurate base calling. The current standard expected is a minimum of 95% of the genome being sequenced with 95% or greater accuracy.
While technologies used to sequence DNA are highly accurate at deciphering the sequence, the majority of available technologies have limited scope in being able to determine so called structural variants. These are alterations that affect large segments of DNA at a time, such as duplications, deletions, and inversions. Such structural variants can still have important impact on health, but due to the limited scope in determining such structural genomic rearrangements by current sequencing technologies, such biological events might not be interpretable for the benefit of a client. Instead, most DNA tests allow for analysis of potential impact of individual base changes. The American College of Medical Genetics and Genomics guidelines for mandatory returns of incidental findings have also been set up with this limitation in mind, and the guidelines do not recommend a search for structural variants in the list of genes they recommend.
The best DNA testing approach to investigate structural variants is the use of full genome sequencing, which provides the most complete amount of DNA information and the most uniform coverage. This allows the service providers to use specialized bioinformatic tools to asses for most, but not all, of the structural variants. For the most comprehensive overview of structural variants in the human genome, additional technologies would have to be employed.
Although genome sequencing has the potential to reduce morbidity and mortality by enabling early identification of risk factors for various health conditions, and to aid identification of an appropriate treatment course, it is not an all-encompassing screen for every possible disease. The interpretation of sequencing results is limited by the current state of medical knowledge, and can range from almost certain clinical significance to almost certainly no significance. In some instances the data might even present contradictory evidence. Even if the interpretation of genome sequencing results is straightforward, such information might not lead to a useful ameliorative intervention for a specific condition or disease. However, since the human genome we are born with is static (it does not change unless influenced by environmental factors, for example, in the development of many cancers), it means that obtained sequence can always be reinterpreted in the future as the scientific potential expands. Please see the DNA test data reanalysis section to learn more about this topic.
A related issue is that the amount of data that need to be analyzed and curated prior to a genome sequence being delivered to a client requires considerable computer and human resources. The bioinformatics capabilities of genome sequence analysis are continuously improving by incorporating new information, and the process is increasingly automated. As the demand for clinical interpretation of the genome increases, so does the demand for appropriate platforms to deliver a higher performance standard. However, without human oversight, there is no guarantee that such automated algorithms will always be accurate, as no database is error-free.
Please note that all tests endorsed by Merogenomics are clinical tests, and the test results are overseen by a genetics expert prior to the return of the results. To learn more about the specific DNA tests available, please select one of the target groups of interest below.
Clinical validity and utility
Another often cited limitation is the lack of clinical validity and utility for systematic mass scale use of genomic sequencing technology for public’s benefit, and is only being currently investigated at clinical research institutions around the world. Simply put, currently there is no gold standard against which the performance of population genomic screening can be judged. Whether application of next generation sequencing will reduce mortality and morbidity in the population the way it has been demonstrated in individual studies is yet to be established. Numerous large scale population studies have been undertaken throughout the world to examine this issue. Increasing number of academic medical centers performing genome sequencing for human diagnostics under a Clinical Laboratory Improvement Amendments license highlights the expanding role of genomics in medical practice. Development of metrics that measure the healthcare outcomes of genomic sequencing to validate the clinical utility of genomic medicine toward effective patient care currently remains a top challenge and a priority, including Canada.
Factors outside the control of the service provider tasked with isolation and sequencing of DNA can negatively influence the quality of the genome sequence and therefore its interpretation. This can include the quality of the DNA sample provided for analysis, such as low quantity, high bacterial contamination, or sample degradation. Such factors can even prevent the procedure from being undertaken. In such a circumstance, the client might be obliged to deliver a new sample.
Genome sequencing can uncover data that have potential negative psychological consequences to the client and the client’s family. Some examples of data that fit this description are: the discovery of a pathogenic variant, the receipt of indecisive results with regard to certain health conditions, difficulty assimilating information that contradicts prior beliefs, and the information that the subject of the genome sequencing is not biologically related to family members as previously believed. Sharing discovered information with other individuals, especially with family members, can be an additional source of distress if all individuals are not adequately prepared.
Genome sequencing provides information about the subject of the procedure, but also about individuals who are closely related to the subject. Thus the genomic information has the potential to impact relationships with other family members. Other family members might not desire to know such information, or there could be information that the client might wish to keep private. However, such information might have important implications to the wellbeing of family members and the client might be faced with the difficult task of deciding what information to disclose and what information to conceal.
While many countries have implemented laws that ban discrimination based on genetic information, often such laws do not protect an individual in the case of a life insurance policy. It is natural for new technology to be accepted slowly, and the accurate interpretation of new laws can take time. That is why there is a lingering (and disproportionate) public fear of discrimination based on genetic information. Such discrimination can be imposed by an insurance company, an employer, or a medical, educational or financial institution. Disputing such discrimination might require an appeal to the judicial system, and that action could have unpredictable results.
In 2017, Canada passed Bill S-201 which is known as the “Anti-genetic discrimination law”. The law bars any person or institution from gaining access to a person’s genetic information in order to provide goods or services to an individual. In essence, no employer or service provider in Canada can use or access anyone’s private genetic information and utilize that information to discriminate against that person. This includes all insurance companies as well, be it for critical illness, life or disability insurance.
Additional limitations of prenatal tests
In postnatal genome sequencing the DNA is isolated from cells present in a saliva or blood sample. In a non-invasive prenatal genome sequencing test, the sequencing must be performed on DNA fragments that are circulating cell-free in the mother’s blood sample. Accurate determination of the fetal genome depends on the amount of DNA in the mother’s blood sample, and the test can fail if sufficient fetal DNA is not present in the mother’s blood sample.
In a sample population of nearly 150,000 pregnant women who underwent non-invasive prenatal screening, repeat blood sampling was required in 2.2% of the women due to quality control failure, assay failure, or low fetal DNA fraction. Only 0.1% of the cases provided no informative results.
Fetal cell-free DNA is derived from the placenta and therefore might not accurately represent the genomic information of the fetus. Extraembryonic tissue mosaicism, or a vanishing twin/cotwin demise are events that result in a mixture of genomes, which can lead to false results. Maternal chromosome abnormality, or maternal metastatic disease can also complicate interpretation of the genomic data and lead to false results.
The mother’s blood sample can harbor cell-free DNA released from cancerous cells. Such DNA contains identifiable mutant variant signatures. Therefore, women undergoing prenatal testing run a risk of incidental finding of cancer discovery.
Prenatal testing cannot be used to obtain the following information: evaluation of placental dysfunction, preterm delivery risk, fetal growth restriction, preeclampsia, placental abruption, intrauterine fetal demise, perinatal death or neural tube defects.
Non-invasive prenatal screening also does not provide information on specific DNA sequence changes, and therefore does not inform one about the presence or absence of conditions associated with such variants. However, this technologically is currently feasible and is expected to be commercially available.
For diagnostic DNA sequencing of the fetus (including full genome sequencing), invasive methods have to be employed in order to obtain a sample. This carries a small but real risk of pregnancy loss, estimated at 0.11% for amniocentesis and 0.22% for chorionic villi sampling.
Additional limitations of cancer sample tests
Cancer biopsy samples are typically a mixture of normal cells and cells at different stages of cancer development. Therefore, variable amounts of cancerous DNA might be available for genome sequencing in a cancer sample, increasing the chance of test failure. Depending on the cancer type and sequencing procedure, >10% of samples might contain an inadequate mass of DNA to obtain a reliable DNA sequence. Up to 20% of these samples can require either multiple attempts at preparation or sequencing to obtain sufficient depth coverage of DNA. Such difficulties can delay results and increase costs, and in some cases more sample must be provided. The final depth coverage determines the degree to which different genomic alterations can be identified.
The test results can provide no information of value if molecular profiling does not indicate a personalized therapy that can perform beyond standard treatment options.
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