A simmering turf war: who can provide genetic counseling?

A September 2016 report by Kaiser Health News (KHN) is raising questions about a relatively new requirement by some insurers that women receive counseling by a certified genetic counselor before getting tested for cancer-predisposing mutations. Two insurers, United Healthcare and Cigna, have insisted for some time now that genetic counseling should take place prior to insurance approval for BRCA1/2 testing. Earlier this year, Cigna’s Genetic Testing and Counseling Program went further, making genetic counseling mandatory prior to testing for all forms of hereditary cancers. But that stance is not sitting well with some physician groups. In a statement released a year ago, the American College of Obstetricians and Gynecologists and the American Congress of Obstetricians and Gynecologists (collectively ACOG) released a formal statement opposing such restrictions and suggesting that the requirement would limit access to care. The statement implies that such restrictions only make it harder for patients to obtain care at a time “when delays may lead to worse outcomes.” The group states, “ACOG opposes such attempts to restrict the scope of practice of obstetrician-gynecologists, who are fully qualified to provide pre-test counseling to their patients.” Requiring women to receive genetic counseling from certified genetic counselors could particularly impact patients in underserved areas where fewer certified genetic counselors are available. In a conciliatory gesture, Cigna then stated that it had not ruled out counseling by physicians. Jeffrey F. Hankoff, medical officer for performance and quality at Cigna, told KHN that physicians who get additional training in cancer genetics could fill the genetic counseling role. —Karyn Hede, News Editor

A nail in the coffin of the thrifty gene hypothesis?

Escalating rates of obesity and diabetes among ethnic groups introduced to modern diet patterns have for decades inspired geneticists to try to explain the phenomena. The “thrifty gene” hypothesis, first posited in 1962, states that among early humans a genetic predisposition to store fat in times of famine would have been an evolutionary advantage. The concept has enjoyed great intuitive resonance and support, but the search for genes contributing to thrift has largely been unfruitful. Indeed, in recent years some evidence suggests that the hypothesis should be discounted. Now, a fresh genetic analysis published in Cell Metabolism in September 2016 that looked for positive selection pressure found that only 9 of 115 genes known to be associated with obesity might have been under positive selection. Of these nine, only four favored obesity while five favored leanness. The analysis utilized public databases such as the HapMap Consortium and the 1000 Genomes Project. “This is probably the hardest evidence so far against the thrifty gene hypothesis—our ambition here is for people to entertain a wider range of ideas about where the genetic basis of complex diseases, like obesity, comes from,” said John Speakman, a biologist at the Chinese Academy of Sciences Institute of Genetics and Developmental Biology in Beijing, who coauthored the piece with Guanlin Wang, one of his PhD students at the Chinese Academy of Sciences. “The process of evolution is a lot more complex than just the spread of favorable traits by natural selection and the thrifty gene is like an emblem of this older way of thinking about evolutionary aspects of medicine.” —Karyn Hede, News Editor