Should anesthesiologists be equipped as genetic counselors?

THE ever-expanding role of anesthesiologists may soon include genetic counseling. Like other medical specialties, since the completion of the Human Genome Project, anesthesiologists have placed much research and commercial interest in the development of pharmacogenomics. The promise of personalized medicine tailored to each patient’s genetics has encouraged the exploration of various genes related to the practice of anesthesiology, with far-reaching implications. Despite the concerted effort, review of the current pharmacogenomics literature of pain management, whether in the acute or chronic setting, reveals promising but inconsistent data. Furthermore, no study has yet shown genetic testing to be beneficial to pain management, and its theoretical benefits remain controversial. The problem, however, is that the lack of beneficial evidence or controversy surrounding such tests does not always translate to lack of patients’ interest in receiving it. A similar comparison can be made of the dietary supplement industry. The use of cranberry juice or echinacea in the management of urinary tract infections or the common cold remains a controversial yet widely popular practice. The dietary supplement industry, represented largely by medically unproven pills, is a multibillion dollar global industry. Demand for a product sometimes depends more on the word of mouth or a placebo effect than on reproducible scientific evidence. Until recently, public access to medical genetic testing other than paternity tests was limited, largely because of availability and cost. Either a physician or genetic counselor directed the need for such tests or the test itself was too costly. Direct-to-consumer (DTC) genetic testing, however, is revolutionizing the public’s access to medical genetic testing. DTC testing, also known by other terms, such as directaccess testing and patient-initiated testing, is a controversial service of the genomic industry. In essence, it is a medical laboratory test that is directly marketed to and purchased by the consumer, without the consent or involvement of a physician or a third party administering or explaining the test and its results. By mail, a patient receives an “at home” genetic test kit that includes a cheek swab. Within 2–3 weeks, the patient will have online access to his or her genetic profile. James Watson, Ph.D. (1962 Nobel laureate in Physiology or Medicine, Cold Spring Harbor Laboratory, Cold Spring Harbor, New York) famously predicted that a revolution in understanding human genetic variation would take place once reading each person’s genome “gets down to the cost of a Chevrolet.” In 2007, it cost approximately $2 million to privately sequence James Watson’s genome. Today, Complete Genomics, Inc. (Mountain View, CA) can sequence your entire genome for $5,000; whereas 23andMe Inc. (Mountain View, CA) can read more than a half-million single-nucleotide polymorphisms for $499.* With unprecedented access to genetic testing, the question is, “Are people buying them?” Although private market reports of the DTC genetic testing industry exist, they are proprietary, and little is publicly known about consumer awareness and interest. A population-based survey across three states in 2006 found that awareness of nutrigenomic tests, a form of DTC genetic test, ranged from 24.4% in Michigan to 7.6% in Oregon, and less than 1% of respondents in each state had used health-related DTC genetic tests. Because of the dynamic nature of Internet-based genetic testing companies, however, 4-yr-old data may not provide an accurate picture of awareness and interest today. Some Internet-based genetic testing companies have appeared and closed within a year, and novel means of marketing has made defining a “health-related DTC genetic test” a more complicated task, further demonstrating DTC genetic testing to be a difficult industry to follow. There are efforts by companies such as 23andMe, Inc., to make personal genetic information part of an Internet-based social networking site.* Like Facebook, Inc. (Palo Alto, CA), personal genetic information is fast becoming a part of the online popular culture. As of May 2009, there were 39 DTC genetic testing companies recognized by the Johns Hopkins Genetics and Public Policy Center. With DTC genetic testing becoming so widely available, anesthesiologists should prepare to counsel patients on the results of their genetic testing. Of the many genes related to anesthesiology, perhaps the genes of most interest are related to pain. In examination of the DTC genetic testing companies, pain-related genes were some of the most popular among the list of advertised genes. Accepted for publication May 11, 2010. The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with the topic of the article.