Direct-to-Consumer Genetic Testing and Clinical Application
Laura J. Bruce BMH 490 Capstone Project 01 May 2014
Bruce 1 I. Introduction Personalized medicine has been deemed the future of healthcare (Meyer and Ginsburg). This strategy promotes the customization of all stages of a patients medical care based on their personal characteristics, needs, and preferences (vant Veer and Bernards). While personalized medicine involves systematic strategies such as care coordination and shared decision-making, an increasingly important factor is the use of genetic testing to tailor medical treatment itself (Meyer and Ginsburg). The use of genetic testing is by no means new, and has been routinely employed for decades in forensics, genealogy, fetal and newborn screening, prenatal planning, and to some extent, disease diagnosis (Brookes). Recently, however, technological developments and the completion of the Human Genome Project in 2003 have enabled genomics to become increasingly applicable in the clinical setting (Peterson-Iyer). This project mapped the entire human genome and shed light on how our genes influence our physiology. In combination with genome-wide association studies (GWAS), this project has rendered scientists increasingly capable of understanding the relationships between genotype, the molecular coding of genes for a particular trait, and phenotype, the physical manifestation of that particular trait, which can also be impacted by environmental factors (Crews et al.; Weston and Hood). Therefore, analysis of a patients genetic makeup can be used, to some extent, to diagnose a current condition, identify mutations that may be associated with future disease, and recognize variability in drug response and metabolism via what is known as pharmacogenomics (Peterson-Iyer). As a result of these advancements, genetic testing has become readily accessible and affordable for individuals to purchase from private companies. In direct-to-consumer (DTC) genetic testing, private companies market affordable genetic testing directly to consumers,
Bruce 2 independent of a healthcare provider (Su). Although both services are often marketed together, this paper focuses on DTC genetic health testing, and not DTC genetic ancestry testing, which is much less controversial and has little to no clinical application. The main purpose of DTC genetic health testing is empowerment: allowing customers to obtain wide-ranging personal genetic information from a single source (Su). Individuals may choose DTC genetic health testing for a variety of reasons, including to identify disease-related risk information, to complement healthcare and lifestyle choices, or to fulfill personal curiosity (Caulfield and McGuire). Well-known DTC genetic testing companies include 23andMe, Navigenics, deCODE genetics, Pathway Genomics, Genetic Testing Laboratories (GTL), and GeneDx (Su). After ordering from a DTC genetic testing company, customers may be sent an at-home saliva kit, which they must register, spit into, and mail back to the company, or they may be required to visit a professional laboratory to undergo blood testing (Peikoff). Within about 6 weeks, the company provides customers with information regarding disease risk, inherited conditions, and drug response for prices that range from approximately $99 to $2000 (Su). Once the DTC genetic company has received a tissue or blood sample, the process of extracting customer DNA, manipulating it in the laboratory, and interpreting the resulting data can begin. Notably, these services do not rely on full genome sequencing, which is expensive and can provide data that is currently incomprehensible. Rather, DTC genetic testing companies employ a technical process that accesses and analyzes interpretable single nucleotide polymorphisms (SNPs) for an individual (Brookes). These polymorphisms consist of a variation in only one base pair between nitrogenous bases in DNA. For instance, one type of SNP occurs when an adenine-thymine pair is converted to a guanine-cytosine pair (International Human
Bruce 3 Genome Sequencing Consortium). Since these variations occur reasonably frequently in a population, they are not automatically considered to be mutations. While some SNPs do not cause any changes in an individuals phenotype, other SNPs may be linked to recognizable traits or serious diseases (Brookes).
II. Ethical Issues As with many innovations in medical technology, myriad ethical conflicts arise in direct- to-consumer (DTC) genetic health testing. These conflicts were brought to public attention in November 2013, when the US Food and Drug Administration (FDA) sent a warning letter to the DTC genetic testing company 23andMe, mandating that they stop marketing their Personal Genome Service (PGS) and the associated saliva collection kit. This request was grounded in the lack of communication between the company and the FDA, and the fact that the FDA had not authorized the marketing of the saliva collection kit, which is considered to be a medical device over which the FDA has jurisdiction (Annas and Elias). More specifically, the FDA was concerned that 23andMe had not analytically or clinically validated the PGS for its intended uses (Annas and Elias). What intended uses was the FDA referring to? Likely, the agency was referencing 23andMes television commercial, which states that customers can take charge of their health by Chang[ing] what you can, and manag[ing] what you can't (Annas and Elias). Since this implies a clinical application, the agency was concerned about how customers might act once they received information from 23andMe about their health risks. Two main ethical dilemmas arise from this discussion and will be explored in this paper. The first is a question of centralization and the accessing of genetic information. Should a third party DTC genetic testing company be consulted as a source of clinically applicable health information, or is it better to centralize all genetic testing under certified healthcare providers?
Bruce 4 While genetic testing is highly regulated for validity and confidentiality when it originates from a clinical setting, the regulation of private DTC companies is currently inadequate. When third parties are consulted, the company also has profit-based interests, and the validity of the provided information can be questionable. Further, third parties might not adequately maintain customer privacy, especially if customer data is used for research and if explicit guidelines regarding which stakeholders (physicians, insurance companies) may access the data in future are not established. The second ethical issue encompasses the struggle between medical (or government) paternalism and individuals' right to information about themselves. Should the FDA be able to prevent individuals from accessing information about their own genetic makeup by restricting companies like 23andMe, or do individuals have the right to obtain their own information even if there are risks associated with it? Are DTC genetic testing customers provided with adequate informed consent? When considering these important questions, there are many relevant stakeholder groups. This includes the DTC genetic testing companies, the customers of DTC genetic testing companies, their healthcare providers (physicians, genetic counselors), their relatives, the governmental entities (FDA, CMS, FTC) that can regulate DTC genetic testing, legislators who develop privacy legislation, health insurance companies, and professional organizations such as the American Medical Association (AMA) and the American College of Medical Genetics (ACMG), who have an important voice in influencing the government entities (Caulfield and McGuire).
Bruce 5 III. Central Claim In light of these ethical issues, I will argue in favor of medical (governmental) paternalism in the case of DTC genetic health testing. This does not imply that DTC genetic testing should be prohibited entirely or that the concept of a third party providing genetic health information is unethical in itself. Rather, the regulation of this industry needs to be expanded with regards to scope, analytical validity, clinical validity, clinical utility, and privacy in order to avoid ethical issues and to protect customers. Until these guidelines are developed, I maintain that DTC companies providing non-validated information regarding health risks are behaving unethically and that their services should be prohibited due to the potential for clinical damages and privacy violations. While the FDAs current regulatory span only applies to companies that market at-home kits (which are considered medical devices), I will argue that the agencys jurisdictions should be extended to oversee genetic testing which occurs in laboratory developed tests (LDTs) for DTC companies (Kaye).
IV. Support and Reasoning In evaluating the ethical issues brought about by DTC genetic health testing, there are three main areas to consider: (1) the reliability and regulation of data provided by this industry, (2) the clinical utility and application of the results of the testing, and (3) patient concerns that arise due to the inherent connection between genetics and healthcare services.
(1) Reliability and Regulation The process of SNP genotyping makes the reliability of data provided via DTC genetic testing questionable. Genetics may only account for between 5 and 20 percent of the attributable risk in developing complex diseases, and beyond that, SNPs are merely a small sampling of the
Bruce 6 entire genome, constituting less than 1 percent of an individuals DNA (Emahazion et al.). Some SNPs are valuable biomarkers, however. For conditions with low genetic complexity, such as Huntingtons Disease or certain types of breast cancer, it is easy to identify accurate genetic origins via a small number of SNPs (Brookes). However, for chronic and heterogeneous conditions that are affected by a variety of genetic and environmental factors such as coronary heart disease and Alzheimers Disease, respectively, the multiple SNPs evaluated by DTC genetic testing companies might not be inclusive or significant. Further, it is not always clear how these SNP markers are affected by a customers lifestyle (Emahazion et al.). Because DTC companies use different SNP biomarkers to assess the same conditions, the results are not always consistent. Individuals have frequently reported receiving varied results when undergoing testing from different DTC companies (Peikoff). This occurs because there are no are no widespread standards to determine what constitutes as high, average, or low risk for assessable conditions based on the different biomarkers. For instance, 23andMe previously listed the average risk for obesity to be around 60 percent, while GTL reported this risk as only 30 percent (Peikoff). The existence of these discrepancies is unethical, because consumers are likely to apply DTC genetic testing data to their clinical decision-making. This will be addressed in the following section. To avoid these discrepancies, there is a need for governmental paternalism. Currently, three federal agencies in the US regulate genetic tests. The Federal Trade Commission (FTC) plays a small role in preventing false or misleading advertising from DTC genetic testing companies, although the ethical problem is likely not a result of the advertising, but instead a result of the genetic tests themselves. The Centers for Medicare and Medicaid Services (CMS) plays a role in regulating the clinical laboratories used for genetic testing. In compliance with
Bruce 7 the Clinical Laboratory Improvement Amendments (CLIA) Act, CMS must certify all clinical laboratories via verification of the laboratory procedures and the technicians performing the tests. This applies to clinical laboratories in connection with healthcare providers and those in connection with DTC genetic testing companies (National Institutes Of Health). However, while this is beneficial, CMS verification does not measure the validity of the genetic tests. Under the Federal Food, Drug, and Cosmetic Act, the FDA has authority over the validity of genetic tests from labs in connection with healthcare providers and those used to process at- home kits from DTC genetic testing companies, because these tests are considered to employ medical devices (Kaye). The FDA indicates two measures of validity that genetic tests must exhibit: analytical validity, or how accurately the test measures the biomarkers that it is intended to measure, and clinical validity, or how medically accurate the test is in identifying or predicting the clinical status of individuals (U.S. Food and Drug Administration). It is difficult for the FDA to regulate the interpretation of genomic data when researchers are still investigating the connection between genetics and disease, but regardless, the current regulations are insufficient. The FDA has unique responsibilities in maintaining the ethicality of DTC genetic testing by ensuring that it is safe and effective, and thus the agency will be instrumental in determining the future of this industry (U.S. Food and Drug Administration). One issue is that the FDA does not currently have jurisdiction over DTC genetic testing companies that use laboratory-developed tests (LDTs), where the customer must visit a laboratory for the testing (National Institutes Of Health). In 2010, the FDA announced that it was planning to regulate all genetic tests, including LDTs, but this expansion has not yet occurred. Although the FDA released a report in October 2013 outlining its role in the path to personalized medicine, specific rules for direct-to-consumer (DTC) genetic testing still do not exist because the agency
Bruce 8 is still deliberating about the best approach (U.S. Food and Drug Administration; Annas and Elias). Although adequate regulation of this industry will be challenging to achieve because of the varied purposes of the testing and the varied risk levels that are reported, the FDA has a duty to develop this regulation (Caulfield and McGuire). DTC genetic testing industry cannot be considered ethical until it is properly monitored, even if this requires a stratified, multi-faceted approach.
(2) Clinical Utility and Application In addition to analytical and clinical validity, it is also important to assess genetic tests for their clinical utility, or the usefulness of the test in improving a patients healthcare outcomes. While methods for evaluating clinical utility are debatable, this measure captures the value of a medical innovation and will be increasingly pertinent (U.S. Food and Drug Administration). The reason that DTC genetic testing is unethical without proper regulation is that it has an inherent clinical application but an unclear clinical utility. DTC genetic testing companies appeal to customer empowerment by allowing them to access their genetic information, and by suggesting that such information can allow them to make better decisions for their healthcare and lifestyle (Caulfield and McGuire). Yet, genetic insights regarding health risk for conditions such as arthritis, hemochromatosis, schizophrenia, and others are not truly valuable for a customer healths without input from a healthcare professional. So, how can DTC customers make better decisions for their healthcare and lifestyle when provided with DTC genetic testing data alone? Put simply, they cannot, because genetic health information is unmistakably tied to the medical setting. To be fair, DTC genetic testing companies do provide ample disclaimers, maintaining that the health information that they provide should not be considered diagnostic, and that
Bruce 9 healthcare decisions should not be made without consulting a professional first (National Institutes Of Health). But these disclaimers and statements such as ask your doctor are not sufficient. The majority of people who purchase DTC genetic testing believe that the results are equivalent to medical diagnoses (Caulfield and McGuire). This complication, known as misattributed equivalence, occurs when the patient (or physician) considers the DTC genetic analysis to be as valid as it would be if it had originated from a more formal clinical setting (Eng and Sharp). Further, even if customers do approach healthcare professionals such as physicians and genetic counselors about their DTC testing results, the aforementioned regulatory deficiencies for the industry also render the results unusable, because clinicians cannot confirm that the data is valid, and it is not connected to the health records of their patients (Su). In fact, only around 10 percent of US physicians in 2010 reported feeling prepared to appropriately assist patients who came to them with concerns about their DTC genetic testing results (Caulfield and McGuire). DTC genetic testing results that are not validated can also result in unneeded healthcare visits and expensive, potentially unnecessary follow-up tests (Caulfield and McGuire). For these reasons, professional organizations including the AMA and the ACMG advise against genetic testing performed without participation from a healthcare professional (Caulfield and McGuire). At present, it can be considered unethical for DTC companies to provide customers with information regarding health risk because of the low clinical utility of the results. Customers have no means of making better health decisions as marketed by the companies, as the results are inherently clinical but cannot be medically applied because the data is insufficiently regulated for validity. This leaves customers subject to unnecessary confusion and uncertainty regarding their health, which is quite the opposite of empowerment.
Bruce 10 (3) Patient Concerns One common concern with DTC genetic testing is related to the psychosocial response that may be evoked when customers receive their results, and how this response might affect their behavior. This may manifest as anxiety or distress upon receiving unfavorable information, or as a misinterpretation of the weight of an elevated health risk or a decreased health risk (Caulfield and McGuire; Su). The presentation of health risks may be affiliated with customer response. For instance, in one of 23andMes assessments of risk for Lupus (Systemic Lupus Erythematosus), a risk level of 0.94 percent as compared to the average 0.25 percent risk is presented to the customer as being 3.81 times higher than average (23andMe). While this may be statistically accurate, the difference between 0.25 percent and 0.94 percent is likely not clinically meaningful and might cause unnecessary anxiety to the customer (Caulfield and McGuire). Currently, however, the psychosocial impacts of DTC genetic testing are unclear, because sustained psychological and behavioral responses in DTC genetic testing customers are not well recorded (Su). Still, considering the lack of validity and utility in DTC results, this is a warranted ethical concern that may also be alleviated by paternalism in the form of regulation. Notably, knowledge of genetic makeup can not only affect individual customers, but also their family members (Moldrup). When someone is informed of his or her health risks, this reveals information about their individual risk profile, but it can also reveal information about biological relatives, who are genetically similar. This may compromise a family members personal decision regarding knowledge of their genetic information and can have a psychosocial impact on them as well. A more significant ethical issue in DTC genetic testing is related to patient privacy and the confidentiality of their genetic information. Though all customers must provide consent
Bruce 11 before beginning the DTC testing process, this might not be true informed consent if the individual does not understand the ramifications about how their information will be used and accessed in the future, by the DTC company, researchers, medical professionals, and insurance companies. Without proper informed consent and protection of customer confidentially, it is DTC genetic testing can be considered unethical. A point of concern highlighted by the AMA and ACMG is that many consumers wrongly assume that the confidentiality rules for physician- patient relationships also apply to the DTC company-customer relationship, although they do not (Caulfield and McGuire). In fact, DTC genetic testing companies are not necessarily subject to the regulations outlined in the Health Insurance Portability and Accountability Act (HIPAA), which serves to ensure that medical records are only available to authorized individuals such as patients and physicians (Annas and Elias). Moreover, though the Genetic Information Nondiscrimination Act (GINA) was signed into law in 2008 to prohibit employers or health insurance companies from discriminating against individuals on the basis of genetic information, the specific coverage details are not outlined, and the law does not apply to life insurance or disability insurance (23andMe). It is unclear how genetic information that DTC genetic testing customers share with their physicians, friends, employers, or family members might be integrated into their medical records and if insurance companies will be able to access this information in future (Annas and Elias). This is further problematic because some genetic information that has little meaning at present may become extremely meaningful in future, depending on scientific research progress. Some DTC companies, such as 23andMe, are careful to warn customers that their genetic information could be used against them, but other companies do not, and 23andMe does not offer much support for customers with regards to privacy. In their Terms of Service, 23andMe rightly alerts customers
Bruce 12 that in future, [i]f you are asked by an insurance company whether you have learned genetic Information about health conditions and you do not disclose this to them, this may be considered to be fraud, followed by the recommendation that customers ask a lawyer (23andMe). In the case of maintaining customer confidentiality in research, clinical genomics and personalized medicine are rapidly evolving fields that rely on genome wide association studies (GWAS) with large amounts of genomic data (Weston and Hood). Thus, many DTC companies have stated that their long-term goals are associated with this research. For example, 23andMe plans to collect genetic data from customers in order to create a biobank that can be sold for research and used for the development of profitable discoveries (Annas and Elias). While this is ethically permissible if consent is obtained and privacy is upheld, these ideals are difficult to achieve, especially if the buyer of the genetic information does not meet the terms of the original agreement, or if the DTC genetic testing company goes bankrupt or out of business (Annas and Elias; Caulfield and McGuire). Consequently, though the future of clinical genomics is difficult to predict, paternalism is needed in order to ensure that customers are rightfully informed and that their genetic health data is kept confidential by privacy legislation. V. Objections The main objection to supporting medical and governmental paternalism in the case of DTC genetic testing is the notion of individual autonomy. Proponents of this argument claim that because an individuals genetic information belongs to them, and especially because DTC companies provide ample disclaimers, individuals should be able to access their results (even non-validated or clinically useless results) if DTC genetic testing companies have provided the means. For instance, Helgasson and Stefnsson argue that, clinical utility is a secondary issue when balanced against peoples' right to seek information about themselves at their own cost
Bruce 13 (Helgason and Stefnsson). Another related objection to paternalism in this case is that knowledge is power, and that DTC genetic testing is important for disseminating information to the public, so that individuals can make decisions regarding their genetic makeup, especially since psychopathologies have not been entirely proven in DTC genetic testing customers (Helgason and Stefnsson). Yet, while individuals do have the right to obtain their genetic information, the government (mainly via the FDA and writers of privacy legislation) is responsible for ensuring that this information is regulated for validity, utility, and security (Kaye). The aforementioned objections rely on the notion that DTC genetic tests are providing customers with what they are marketing: the ability to use genetic insights to make better decisions about health. However, as mentioned previously, for most genetically linked conditions, it is near impossible to make any significantly better decisions about health without a clinicians input (Caulfield and McGuire). Healthcare providers cannot confidently rely on the DTC testing results without validation, so in effect, the DTC genetic testing companies cannot fulfill their promise of helping customers to make better health decisions without the necessary regulations. In other words, preventing individuals from accessing inaccurate data does not deprive them of useful information, because non-validated genetic data has an inherent clinical application yet no clinical utility (Annas and Elias). Those who object to paternalism may also note that the DTC genetic testing debate is similar to the debate about patients having full access to their medical records and clinical test results, which was resolved by granting patients this access (Annas and Elias). However, this is not a sound comparison because medical records and clinical test results contain clinically validated, secure information, which is currently not the case with DTC genetic health testing
Bruce 14 results. In future, if the proper regulations are in place and DTC results are validated, clinically useful, and subject to the full provisions of HIPAA and GINA, then the comparison will be valid, customers should rightfully be granted this access. One final objection to paternalism in the case of DTC genetic testing compares this type of testing to other at-home tests. This argument maintains that DTC testing is beneficial in that it opens the door to productive discussions and follow-up tests between patients and healthcare providers, where the analytical and clinical validation can occur. DTC genetic tests are often compared to pregnancy tests to illustrate this point (Eng and Sharp). If a woman obtained positive results from an at-home pregnancy test and then consulted her obstetrician, the physician would order a clinical laboratory test to confirm the at-home test. At-home pregnancy tests are useful in that they allow women to check for a pregnancy without having to see an obstetrician each time a pregnancy is remotely suspected, which would overwhelm clinicians. Proponents of DTC genetic testing at present see this service in a similar way (Eng and Sharp). However, the flaw in this analogy is that DTC genetic testing is much more comprehensive than an at-home pregnancy test, and would require extensive, unnecessary testing as opposed to a single confirmation test. Further, at-home pregnancy tests and clinical laboratory tests for pregnancy both rely on a similar technology, while for DTC genetic tests and clinical genetic tests, there are large discrepancies in methodology and regulation. As such, at-home pregnancy tests have a high clinical utility because they are quite accurate and because a pregnancy elicits certain clinical treatments, while the results of DTC genetic tests have a low clinical utility that would not be resolved by simply following up with a physician (Eng and Sharp).
Bruce 15 VI. Implications Over the next decade, it is predicted that whole-genome sequencing will become affordable, and that genome reference materials will be adequately developed to make much of this data clinically useful. Electronic medical records (EMRs) will also likely serve as a means for individuals to store and access their full genomic data with or without healthcare providers (Annas and Elias). Considering the heightened complexity of whole genome data as compared to SNP genotyping, and the increasing importance of genomics in personalized medicine, DTC genetic testing can be seen as an important catalyst for developing an appropriate regulatory framework for clinical genomics. While I have argued in favor of medical (governmental) paternalism in the case of DTC genetic health testing, this does not mean that the products of this industry are unethical in themselves or that they should always be prohibited. Rather, widespread regulation is needed to ensure that application of clinical genomics at present and in future is approached in an ethically permissible manner: with analytical validity, clinical validity, clinical utility, and confidentiality. Currently, without the proper regulation, DTC genetic testing is unethical, but the ethical issues can be resolved if the FDA develops clear guidelines for all genetic tests, and if customer privacy is upheld by extending the provisions of HIPAA and GINA to this industry. If these requirements are met, cooperation between healthcare providers and DTC genetic testing companies will be feasible, and the testing will reach a level of ethicality and of clinical utility that can provide realistic benefits for customers. If DTC genetic testing is properly regulated, it can serve as a platform for personalized medicine and whole genome sequencing to build upon, rendering even more benefits for individuals who desire to unlock their genetic information. Granted, this relies upon continued patient interest and consent in clinical
Bruce 16 genomics, trained providers that can interpret and assist patients about their genetic data, established medical infrastructure (such as EMRs) to support the large amounts of data, and maintained regulations for validity, utility, and privacy. Nonetheless, personalized medicine is the future of medicine, and it will be greatly impacted by the fate of the DTC genetic testing industry.
Bruce 17 VII. References 23andMe. Terms of Service. N. p., 2013. Annas, George J, and Sherman Elias. 23andMe and the FDA. The New England journal of medicine (2014): 988990. Brookes, A J. The Essence of SNPs. Gene 234.2 (1999): 17786. Print. Caulfield, Timothy, and Amy L. McGuire. Direct-to-Consumer Genetic Testing: Perceptions, Problems, and Policy Responses. Annual Review of Medicine 2012 : 2333. Crews, K R et al. Pharmacogenomics and Individualized Medicine: Translating Science into Practice. Clinical pharmacology and therapeutics 92.4 (2012): 46775. Emahazion, Tesfai et al. SNP Association Studies in Alzheimers Disease Highlight Problems for Complex Disease Analysis. Trends in Genetics 2001 : 407413. Eng, Charis, and Richard R Sharp. Bioethical and Clinical Dilemmas of Direct-to-Consumer Personal Genomic Testing: The Problem of Misattributed Equivalence. Science translational medicine 2 (2010): 17cm5. Helgason, Agnar, and Kri Stefnsson. The Past, Present, and Future of Direct-to-Consumer Genetic Tests. Dialogues in clinical neuroscience 12 (2010): 6168. Print. International Human Genome Sequencing Consortium. Initial Sequencing and Analysis of the Human Genome. Nature 409.6822 (2001): 860921. Kaye, Jane. The Regulation of Direct-to-Consumer Genetic Tests. Human molecular genetics 17 (2008): R180R183. Meyer, Joanne M., and Geoffrey S. Ginsburg. The Path to Personalized Medicine. Current Opinion in Chemical Biology 2002 : 434438. Moldrup, Claus. Ethical, Social and Legal Implications of Pharmacogenomics: A Critical Review. Community genetics 4.4 (2001): 20414. National Institutes Of Health. Regulation of Genetic Tests. National Human Genome Research Institute. N. p., 2014. Web. 29 Apr. 2014. Peikoff, Kira. I Had My DNA Picture Taken. New York Times 163 (2013): D1D5. Peterson-Iyer, Karen. Pharmacogenomics, Ethics, and Public Policy. Kennedy Inst Ethics J 18 (2008): 3556. Print.
Bruce 18 Su, Pascal. Direct-to-Consumer Genetic Testing: A Comprehensive View. The Yale journal of biology and medicine 86 (2013): 35965. U.S. Food and Drug Administration. Paving the Way for Personalized Medicine Paving the Way for Personalized Medicine!: N. p., 2013. Print. vant Veer, Laura J, and Ren Bernards. Enabling Personalized Cancer Medicine through Analysis of Gene-Expression Patterns. Nature 452.7187 (2008): 56470. Weston, Andrea D, and Leroy Hood. Systems Biology, Proteomics, and the Future of Health Care!: Toward Predictive, Preventative , and Personalized Medicine Introduction!: Paradigm Changes in Health Care. (2004): 179196. Print.