Mackenzie's Mission: The Australian Reproductive Carrier Screening Project

This study will investigate reproductive genetic carrier screening (RGCS) in 10,000 couples across Australia. Carrier screening for approximately 1300 genes associated with severe, childhood-onset, X-linked and autosomal recessive conditions will be performed on each member of the couple. A combined result will be issued indicating whether the couple has a 'low' or 'increased' risk of having a child with a genetic condition. It is anticipated that 1-2% of couples will be at an increased risk of having an affected child.

The study will evaluate all aspects of the RGCS program to assess the feasibility and acceptability of a publicly-funded population-wide RGCS program, including:

• education of recruiting healthcare providers
• education of participating couples
• implementation and uptake of RGCS
• frequency of increased-risk couples and their reproductive decisions
• psychosocial impacts
• ethical issues
• health economic implications
• health implementation research

Study Overview

• Status: Active, not recruiting
• Conditions: Autosomal Recessive Disorder; X-Linked Genetic Diseases
• Intervention / Treatment: Other: Reproductive Genetic Carrier Screening

Detailed Description

PROTOCOL SYNOPSIS

Couples will be invited to take part in the study by their healthcare provider (HCP). The couple will enrol via an online portal, complete an education module, provide consent and complete a questionnaire. Those who consent to carrier screening will be sent mouth swab kits with samples returned by mail.The carrier screening performed will be done via accredited testing laboratories in partnership with clinical genetics services. Genetic counselling will be available to study participants throughout the process. Couples at increased risk will be offered a genetic counselling consultation and offered support to access reproductive options (i.e. prenatal diagnosis, preimplantation genetic diagnosis (PGD) which will be funded by the study for one cycle of IVF with PGD). All participants will be asked to complete an initial survey at study enrolment and invited to complete optional surveys at the time of screening, after return of screening results, and approximately 13 to 19 months after results. Subsets of participants will also be invited to take part in interviews.

GENE LIST FOR CARRIER SCREENING

The approximately 1300 genes tested in the Mackenzie's Mission carrier screening panel meet the following criteria:

1. The associated condition is one where an 'average' couple would take steps to prevent the birth of a child with that condition.

   - This includes conditions with significant negative impact on quality of life for the child, the condition being lethal in childhood, and a significant impact on the family.

2. AND/OR: There is a potential benefit for knowing about the condition to inform management in the neonatal period. This criterion was particularly important if the condition was either not included on a newborn screening panel, and/or intervention would be required prior to results from newborn screening being known.
3. AND there is strong evidence for mutations in the gene being causative of the condition in question, with enough variants reported to allow confidence in informing couples of their chance of having a child with the condition in question.

• Study Type: Interventional
• Enrollment (Actual): 18302
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Australia
  • New South Wales
    • Forster, New South Wales, Australia, 2428
      • Forster Community Health Service
    • Liverpool, New South Wales, Australia, 2170
      • Liverpool Hospital
    • Newcastle, New South Wales, Australia, 2298
      • Hunter Genetics
    • Sydney, New South Wales, Australia, 2145
      • Westmead Hospital
    • Sydney, New South Wales, Australia, 2145
      • The Children's Hospital at Westmead
    • Sydney, New South Wales, Australia, 2050
      • Royal Prince Alfred Hospital
    • Sydney, New South Wales, Australia, 2031
      • Royal Hospital for Women
    • Sydney, New South Wales, Australia, 2031
      • Sydney Children's Hospital, Randwick
    • Sydney, New South Wales, Australia, 2560
      • Campbelltown Hospital
    • Tamworth, New South Wales, Australia, 2340
      • Tamworth Communith Health Services
    • Taree, New South Wales, Australia, 2430
      • Taree Community Health Service
    • Wagga Wagga, New South Wales, Australia, 2650
      • Wagga Wagga Base Hospital
  • Northern Territory
    • Darwin, Northern Territory, Australia, 0810
      • Royal Darwin Hospital
  • Queensland
    • Brisbane, Queensland, Australia, 4029
      • Royal Brisbane and Women's Hospital
    • Cairns, Queensland, Australia, 4870
      • Cairns Hospital
    • Mareeba, Queensland, Australia, 4880
      • Mareeba Hospital
  • South Australia
    • Adelaide, South Australia, Australia, 5006
      • Women's and Children's Hospital
  • Tasmania
    • Hobart, Tasmania, Australia, 7000
      • Royal Hobart Hospital
  • Victoria
    • Melbourne, Victoria, Australia, 3084
      • Mercy Hospital for Women
    • Melbourne, Victoria, Australia, 3052
      • Victorian Clinical Genetics Services
    • Melbourne, Victoria, Australia, 3076
      • Northern Hospital
    • Warragul, Victoria, Australia, 3820
      • West Gippsland Heath Service (Warragul Hospital)
  • Western Australia
    • Joondalup, Western Australia, Australia, 6027
      • Joondalup Health campus
    • Perth, Western Australia, Australia, 6008
      • King Edward Memorial Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

In order to take part in the study, couples need to have visited a recruiting HCP who will assess them for eligibility based on the criteria below:

INCLUSION CRITERIA

• Planning to become pregnant or in early pregnancy (less than 10 weeks gestation at enrolment and less than 11 weeks gestation at sample receipt by the laboratory)
• Both members of the couple available to participate in the study and available to provide a sample for testing at the same time.
• If the couples are using an egg/sperm donor/s, the donor/s need to be available to provide a DNA sample for testing and consent to having carrier screening.

NB: If both members of the couple are known carriers of the same autosomal recessive condition, or the female is a known carrier of an X-linked recessive condition, they will still be eligible to have RGCS through the study, but will only be considered an 'increased-risk' couple for the purposes of this study if they are identified through the study testing to be carriers of pathogenic variants in a different gene.

EXCLUSION CRITERIA

Participating couples meeting any of the following requirements will be excluded from this study:

• Pregnant and greater than 10 weeks gestation at enrolment.
• Only one member of the couple agrees to participate in the study.
• One or both members of the couple are less than 18 years old.
• Both members of the couple are not available to be tested at the same time.
• The couple are using an egg/sperm donor/s and the donor/s are not available for testing or the couple are using an anonymous donor.
• One member of the couple has already been screened as part of the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Participating Couples; Reproductive Genetic Carrier Screening	Other: Reproductive Genetic Carrier Screening; Carrier screening for approximately 1300 genes associated with severe autosomal recessive and X-linked recessive conditions affecting children will be performed on each member of the couple. A combined result will be issued indicating whether the couple has a 'low' or 'increased' risk of having a child with a genetic condition

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Screening Uptake (Quantitative)	Practitioners offering screening will be asked to record the number of couples offered screening which will allow calculation of screening uptake.	At offer of screening
Frequency of Increased-Risk Couples	Analysis of carrier frequencies of the genes tested and the frequency of identification of increased-risk couples	At reporting of results (~Weeks 5-6 since enrolment)
Reproductive Choices made by Increased-Risk Couples	For pregnant couples, the investigators will ascertain how many have prenatal diagnosis (PND), and of those who have PND and an affected fetus is identified, how many terminate the pregnancy. For those who are not pregnant at the time of screening, the investigators will ascertain choices for future pregnancies that occur during the timeframe of the study, including how many choose preimplantation genetic diagnosis (PGD), how many choose a naturally conceived pregnancy with PND and how many choose a naturally conceived pregnancy without any testing.	Reproductive choices made by couples will be tracked from the date an increased-risk result is received until study closure on 31 December 2022. A subset of couples will be interviewed ~19 months after receiving an increased-risk result.
Cohort Characteristics of those who decline and those who accept RGCS	Short survey capturing personal information: age, country of birth, language spoken at home, ethnicity, religion and religiosity, education level, employment status, household income, marital status, pregnancy history and family/genetic history information.	Couples who decline screening;at offer or at enrolment (Day 0); optional. Couples who accept screening; at enrolment (Day 0); compulsory.
Predictors of Uptake - Decliners	Survey asking main reason(s) for declining to participate informed by the Health Belief Model (HBM). The HBM is used to predict and explain uptake of a health behaviour. It includes four components: perceived benefits, perceived susceptibility, perceived severity and perceived barriers (Janz and Becker 1984). A subset of declining couples will be invited for interview to explore the decision-making process and their reasons for declining testing.	Couples who decline screening; at offer or enrolment (Day 0); optional
Predictors of Uptake - Decliners	Survey asking main reason(s) for declining to participate informed by the Health Belief Model (HBM). The HBM is used to predict and explain uptake of a health behaviour. It includes four components: perceived benefits, perceived susceptibility, perceived severity and perceived barriers (Janz and Becker 1984). A subset of declining couples will be invited for interview to explore the decision-making process and their reasons for declining testing.	At decision not to provide samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Predictors of Uptake - Acceptors	Survey asking main reason(s) for choosing to participate informed by the Health Belief Model (HBM). The HBM is used to predict and explain uptake of a health behaviour. It includes four components: perceived benefits, perceived susceptibility, perceived severity and perceived barriers (Janz and Becker 1984)	Couples who accept screening; at offer or enrolment (Day 0); compulsory.
Predictors of Uptake - Acceptors	Survey asking main reason(s) for choosing to participate informed by the Health Belief Model (HBM). The HBM is used to predict and explain uptake of a health behaviour. It includes four components: perceived benefits, perceived susceptibility, perceived severity and perceived barriers (Janz and Becker 1984)	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Participant Experience - Attitudes/Perceptions	Survey assessing attitudes towards carrier screening in the general population, and the attitudes of the couple towards carrier screening for themselves.	Couples who decline screening;at offer or at enrolment (Day 0); optional. Couples who accept screening; at enrolment (Day 0); compulsory.
Participant Experience - State-Anxiety - pre-screening	Six-item short-form of the state-anxiety scale of the Spielberger State-Trait Anxiety Inventory (STAI) (Marteau and Bekker 1992). This scale measures how the respondent feels "right now, at this moment". Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Couples who decline screening; at enrolment (Day 0); optional. Couples who accept screening; at enrolment (Day 0); compulsory.
Participant Experience - State-Anxiety - pre-screening II	Six-item short-form of the state-anxiety scale of the Spielberger State-Trait Anxiety Inventory (STAI) (Marteau and Bekker 1992). This scale measures how the respondent feels "right now, at this moment". Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - State-Anxiety - post-result	Six-item short-form of the state-anxiety scale of the Spielberger State-Trait Anxiety Inventory (STAI) (Marteau and Bekker 1992). This scale measures how the respondent feels "right now, at this moment". Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Low-risk and increased-risk couples; post-result (~Weeks 17-18 since enrolment); optional
Participant Experience - State-Anxiety - long-term follow-up	Six-item short-form of the state-anxiety scale of the Spielberger State-Trait Anxiety Inventory (STAI) (Marteau and Bekker 1992). This scale measures how the respondent feels "right now, at this moment". Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Low-risk couples; long-term follow-up (~13 months since enrolment); optional. Increased-risk couples; long-term follow-up (~19 months since enrolment); optional
Participant Experience - Trait-Anxiety - pre-screening	20-item trait-anxiety scale (Form Y2) of the Spielberger State-Trait Anxiety Inventory (STAI). This scale measures how the respondent "generally" feels. Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Couples who decline screening; at enrolment (Day 0); optional. Couples who accept screening; at enrolment (Day 0); compulsory.
Participant Experience - Trait-Anxiety - pre-screening II	20-item trait-anxiety scale (Form Y2) of the Spielberger State-Trait Anxiety Inventory (STAI). This scale measures how the respondent "generally" feels. Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Trait-Anxiety - post-result	20-item trait-anxiety scale (Form Y2) of the Spielberger State-Trait Anxiety Inventory (STAI). This scale measures how the respondent "generally" feels. Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Low-risk and increased-risk couples; post-result (~Weeks 17-18 since enrolment); optional
Participant Experience - Trait-Anxiety - long-term follow-up	20-item trait-anxiety scale (Form Y2) of the Spielberger State-Trait Anxiety Inventory (STAI). This scale measures how the respondent "generally" feels. Scores range from 20 to 80. A high score indicates the presence of high levels of anxiety.	Low-risk couples; long-term follow-up (~13 months since enrolment); optional. Increased-risk couples; long-term follow-up (~19 months since enrolment); optional
Health Economic Impact - Assessment of Quality of Life - pre-screening	12-item Assessment of Quality of Life-4D (AQoL-4D) questionnaire (Hawthorne, Richardson and Osbourne 1999; Richardson and Hawthorne 1998). This questionnaire measures health-related quality of life in four dimensions: Independent Living, Relationships, Mental Health and Senses. Total scores range from a minimum of 12 to a maximum of 48. Higher scores indicate a lower health-related quality of life.	Couples who decline testing, at enrolment (Day 0); optional. Couples who accept testing, at enrolment (Day 0); compulsory
Health Economic Impact - Assessment of Quality of Life - post-result	12-item Assessment of Quality of Life-4D (AQoL-4D) questionnaire (Hawthorne, Richardson and Osbourne 1999; Richardson and Hawthorne 1998). This questionnaire measures health-related quality of life in four dimensions: Independent Living, Relationships, Mental Health and Senses. Total scores range from a minimum of 12 to a maximum of 48. Higher scores indicate a lower health-related quality of life.	Low-risk and increased-risk couples; post-result (~Weeks 17-18 since enrolment); optional
Health Economic Impact - Assessment of Quality of Life - long-term follow-up	12-item Assessment of Quality of Life-4D (AQoL-4D) questionnaire (Hawthorne, Richardson and Osbourne 1999; Richardson and Hawthorne 1998). This questionnaire measures health-related quality of life in four dimensions: Independent Living, Relationships, Mental Health and Senses. Total scores range from a minimum of 12 to a maximum of 48. Higher scores indicate a lower health-related quality of life.	Low-risk couples; long-term follow-up (~13 months since enrolment); optional. Increased-risk couples; long-term follow-up (~19 months since enrolment); optional
Health Economic Impact - Participants' willingness to pay	Questions with randomised monetary values to assess maximum amount participants would be willing to pay, and whether the test should be government, privately or Medicare funded.	Couples who decline screening, at enrolment (Day 0); optional. Couples who accept screening, at enrolment (Day 0); compulsory
Participant Experience - Health Literacy	Questions to assess health literacy level	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Evaluation of Educational and Decision-Aid Materials	Questions to evaluate resources developed for participating couples e.g. decision aid, website, brochure	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Decisional Conflict	16-item scale measuring personal perception of uncertainty, factors contributing to uncertainty, and effective decision making. Includes five subscores: uncertainty, informed, values clarity, support, effective decision making (O'Conner 1993 (updated 2010)). Total scores range from 0 [no decisional conflict] to 100 [very high decisional conflict].	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Deliberation	6-item scale measuring decision deliberation. Dichotomous scale: responses below the midpoint (11 or under) classified as not deliberated and those at or above the midpoint as deliberated (Van den Berg, Timmermans, Ten et al 2006)	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Decision-Making Approach	Survey evaluating decision-making approach i.e. whether it was an individual or shared decision and who was involved in the decision-making process, e.g. couples, family, health-professional	At provision of samples for screening, anticipated to be within ten days of enrolment (Days 2-10); optional
Participant Experience - Genomics Outcome Scale (GOS-6)	6-item scale measuring empowerment as an outcome of clinical genetics services. Total scores range from a minimum of 6 to a maximum of 30. Higher scores indicate higher levels of empowerment (Grant et al. 2018)	Increased-risk couples, before and after genetic counselling session (~Weeks 5-6 since enrolment)
Participant Experience - Decisional Regret - post-result	A 5-item scale measuring distress and remorse after a health care decision. Scores range from 0 [no regret] to 100 [high regret]. Subset of low-risk couples to be contacted for interview to explore experience of having testing and receiving a low-risk result.	Low-risk and increased-risk couples; post-result (~Weeks 17-18 since enrolment); optional
Participant Experience - Decisional Regret - long-term follow-up	A 5-item scale measuring distress and remorse after a health care decision. Scores range from 0 [no regret] to 100 [high regret]. Subset of low-risk couples to be contacted for interview to explore experience of having testing and receiving a low-risk result.	Low-risk couples; long-term follow-up (~13 months since enrolment); optional. Increased-risk couples; long-term follow-up (~19 months since enrolment); optional
Participant Experience - Qualitative Interviews	Subset of low-risk couples to be contacted for interview to explore longer-term experience of having testing and receiving a low-risk result. Subset of increased-risk couples to be contacted for interview to explore the experience of receiving a increased-risk result, the use of this information in reproductive decision-making, and the communication of genetic information within families.	Low-risk couples; long-term follow-up (~13 months since enrolment); optional. Increased-risk couples; long-term follow-up (~19 months since enrolment); optional

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Ethical Issues - Assessment of ethical aspects of publicly funded preconception screening	A series of scholarly outputs (e.g. journal articles) critically considering ethical issues in publicly funded preconception screening programs. The issues being identified include (but are not limited to) reproductive autonomy, public health ethics frameworks, eugenics, secondary findings. Additional ethical issues will be considered as they arise in the trial. The method to be used is applied ethics, which is non-empirical.	Throughout study; 3 years
Implementation Outcomes - Barriers & Enablers to Implementation	Barriers and enablers to implementation will be identified and recorded at study committee meetings via responses to the following questions: What has changed over the last month or so? What has gone well/not so well? Has anything surprised you?	Study investigators; at committee meetings for the duration of the study (3 years); Jan 2019 - Dec 2022
Implementation Outcomes - Anticipated vs Actual Outcomes	To assess whether planned and anticipated outcomes are realised, study investigators will be asked to complete a time-capsule survey predicting the outcomes of the study. Following the completion of the study, the responses will be matched to the final outcomes.	Study investigators; 1 month before the study begins recruitment
Implementation Outcomes - Patient Safety Behaviour Questionnaire	Questionnaire assessing what HCPs in the wider community think about carrier screening, and what the barriers/enablers are to offering carrier screening to patients in usual care.	HCPs; at HCP conferences or professional meetings; for the duration of the study (3 years).
Implementation Outcomes - Uptake by HCPs	Survey of HCPs invited to recruit to the study, including those who agree to recruit couples and those who decline to recruit couples. The survey will explore potential barriers to RGCS, factors that might influence confidence/ability to refer appropriate couples for RGCS and readiness to change. HCPs can opt-in to be contacted for interview to provide further information about implementation.	HCPs; at invitation to become a recruiting HCP; for the duration of the study (3 years)
Implementation Outcomes - Factors influencing Recruitment by HCPs - post-education	Survey of HCPs who agree to recruit to the study, measuring factors influencing recruitment such as knowledge, ability and confidence.	Recruiting HCPs; 3 months after education
Implementation Outcomes - Factors influencing Recruitment by HCPs - post-recruitment	Survey of HCPs who have recruited to the study, measuring factors influencing recruitment. Opt-in to be contacted for interview to further explore the experience of offering RGCS to patients and any barriers/enablers of implementation.	Recruiting HCPs; 6 weeks after recruitment of first participant
Implementation Outcomes - HCP Experience - post-implementation	Survey of HCPs who have recruited to the study, examining their experience of offering reproductive genetic carrier screening.	Recruiting HCPs; 3 months after end of recruitment
Health Economic Impact - Costs per increased-risk couple identified	Cost in Australian dollars of identifying one increased-risk couple	3 months after enrolment
Health Economic Impact - Costs per affected pregnancy identified	Cost in Australian dollars of identifying one affected pregnancy	6 months after enrolment
Health Economic Impact - Costs per affected birth averted	Average cost in Australian dollars of taking reproductive measures to avoid having an affected live birth (e.g. pre-implantation genetic diagnosis, prenatal diagnosis, termination etc.)	Throughout study; 3 years
Health Economic Impact - Costs of the carrier screening program	Total costs of the carrier screening program	Throughout study; 3 years

Collaborators and Investigators

• Sponsor: Murdoch Childrens Research Institute
• Collaborators: University of Sydney; Sydney Children's Hospitals Network; Women's and Children's Hospital, Australia; Griffith University; The University of New South Wales; King Edward Memorial Hospital; Royal Brisbane and Women's Hospital; Macquarie University, Australia; The University of Western Australia; Australian Government Department of Health and Ageing; Royal Hobart Hospital; PathWest Laboratory Medicine WA; NSW Health Pathology; Harry Perkins Institute of Medical Research; Victorian Clinical Genetics Services
• Investigators: Principal Investigator: Martin Delatycki, Murdoch Children's Research Institute/Victorian Clinical Genetics Services; Principal Investigator: Edwin Kirk, Sydney Children's Hospital Network/NSW Health Pathology/UNSW; Principal Investigator: Nigel Laing, University of WA/Harry Perkins Institute/PathWest Laboratory Medicine

Study record dates

Study Major Dates

• Study Start (Actual): November 21, 2019
• Primary Completion (Actual): March 31, 2022
• Study Completion (Estimated): December 31, 2024

Study Registration Dates

• First Submitted: October 21, 2019
• First Submitted That Met QC Criteria: November 6, 2019
• First Posted (Actual): November 8, 2019

Study Record Updates

• Last Update Posted (Actual): April 9, 2024
• Last Update Submitted That Met QC Criteria: April 7, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: rare disease; reproductive genetics; carrier screening
• Additional Relevant MeSH Terms: Genetic Diseases, Inborn; Genetic Diseases, X-Linked
• Other Study ID Numbers: RCH HREC 2019.097

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: De-identified samples, genomic data and associated clinical information may be shared with researchers for other Human Research Ethics Committee approved research studies and with recognised national and international databases to advance scientific knowledge.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No