The DNA to Z of Direct-to-Consumer Genetic Testing: Separating Fact from Fiction, March 17, 2020


>>IT’S NOW 3:00. I HAVE A FEW HOUSEKEEPING ITEMS TO COVER. THE CLOSED-CAPTIONING LINK WILL BE PASTED IN THE CHAT BOX. WE ARE RECORDING SESSION, YOU’LL BE SENT A COPY OF THE RECORDING, SLIDES AND RESOURCES HANDOUT ONCE PROCESSED AND UPLOADED. ALL MICROPHONES ARE MUTED. I WILL BE TAKING QUESTIONS AT THE END OF THE PRESENTATION. YOU CAN GO AHEAD AND TYPE ANY QUESTIONS YOU HAVE IN THE CHAT BOX, AS THEY OCCUR TO YOU, OR YOU CAN HOLD THEM TO THE END WHICHEVER YOU PREFER. MAKE SURE YOU ARE SENDING TO ALL PARTICIPANTS. HANNAH, IS THAT ANY BETTER? NEVER MIND, I SEE WHAT THE PROBLEM IS. OKAY, PERFECT. ELLEN, YES, I’M SPEAKING. HOPEFULLY YOU CAN HEAR ME. OKAY. SO YOU’RE ALL MUTED. TYPE YOUR QUESTIONS TO ALL PARTICIPANTS. HANNAH WILL BE MONITORING THE CHAT BOX TO HELP ME OUT IF ANYONE HAS ANY TECHNICAL DIFFICULTIES. THIS WEBINAR DOES GRANT 1 MLA C.E.. TO CLAIM, FILL OUT THE SURVEY THAT WILL POP UP IN THE BROWSER AFTER THE WEBINAR. IF YOU DON’T SEE THE SURVEY WHEN YOU LEAVE, SEND ME AN E-MAIL AND I WILL SEND YOU THE DIRECT LINK TO THE SURVEY. SO, LET’S GET STARTED. WELCOME TO THE DNA TO Z OF DIRECT CONSUMER GENETIC TESTING, I’M KELSEY COWLES, BASED AT THE UNIVERSITY OF PITTSBURGH. TODAY I’LL BE TALKING ABOUT DIRECT TO CONSUMER OR DTC GENETIC TESTING, A TOPIC I HAVE A LOT OF PERSONAL INTEREST IN, SO BEFORE I WAS A MEDICAL LIBRARIAN, I WAS A BIOLOGIC ANTHROPOLOGIST AND HAVE CAUGHT GENETICS AT THE COLLEGE LEVEL. I’M NOT AN EXPERT OR PROFESSIONAL GENETICIST, BUT IF THERE ARE QUESTIONS THAT END UP BEING OUTSIDE MY REALM OF EXPERTISE OR SCOPE OF THE CLASS I’M VERY HAPPY TO FOLLOW UP WITH YOU VIA E-MAIL AFTER THE CLASS. AND DON’T HESITATE TO E-MAIL ME EVEN IF YOU WANT TO TALK ABOUT THE TOPIC FURTHER. THIS WEBINAR IS AN INSTALLMENT OF THE NNLM MIDDLE ATLANTIC REGION MONTHLY WEBINAR SERIES, THE NNLM SERVES AS OUTREACH AND ENGAGEMENT ARM FOR NATIONAL LIBRARY OF MEDICINE, PROVIDING TRAININGS, FUNDING OPPORTUNITIES AND MORE TO A WIDE VARIETY OF MEMBER ORGANIZATIONS TO HELP SUPPORT OUR MISSION OF ADVANCING MEDICINE AND IMPROVING PUBLIC HEALTH. MEMBERSHIP IS FREE OF CHARGE, FOR MORE INFORMATION ABOUT THE NNLM PLEASE VISIT nnlm.gov. SO AS YOU’VE PROBABLY NOTICED, IN THE PAST FEW YEARS DTC GENETIC TESTS HAVE SKYROCKETED IN POPULARITY. MILLIONS OF PEOPLE SENT IN SAMPLES TO COMPANIES FOR TESTS, PURPORTING TO REVEAL SECRETS ABOUT THEIR ANCESTRY, HEALTH, AND MUCH MORE. COMPANIES MAKE A WIDE VARIETY OF CLAIMS ABOUT THEIR TESTS. SOME CLAIMS ARE REASONABLE. SOME ARE LESS SO. BUT MOST PEOPLE DON’T REALLY HAVE THE EXPERTISE TO EVALUATE THESE CLAIMS CRITICALLY. SO MY PLAN FOR TODAY IS TO PROVIDE AN OVERVIEW OF THE HISTORY AND CURRENT STATE OF DTC GENETIC TESTING, EXPLORE DIFFERENCES BETWEEN VARIOUS TYPES OF TESTS. I’LL ASSESS THE VERACITY OF CLAIMS COMMONLY MADE BY TESTING COMPANIES. I’LL ALSO DISCUSS PRACTICAL AND ETHICAL CHALLENGES SURROUNDING THESE TESTS. MY GOAL IS TO ENABLE YOU TO UNDERSTAND DTC TESTING AND THE ISSUES THAT SURROUND IT SO YOU CAN MAKE INFORMED DECISIONS FOR YOURSELF, OR HELP OTHERS UNDERSTAND AS WELL. YOU’LL ALSO LEARN WHERE TO FIND ESSENTIAL BACKGROUND INFORMATION ABOUT GENETICS, NEEDED TO UNDERSTAND DTC TESTS, AS WELL AS MORE ADVANCED INFORMATION. SO THAT YOU CAN POINT PATRONS IN THE RIGHT DIRECTION TO MEET INFORMATION NEEDS RELATING TO DTC TESTING. I WANT TO STRESS ONE THING I’M NOT GOING TO BE DOING IN THIS CLASS IS COMPARING SPECIFICS OF COMPANY TESTS, PRIVACY POLICIES OR ANYTHING LIKE THAT. THESE THINGS ARE CHANGING REALLY FREQUENTLY, SO ANYTHING I TOLD YOU TODAY THAT WAS COMPANY SPECIFIC COULD BE DIFFERENT IN A WEEK. I’M NOT REALLY AIMING TO ADDRESS QUESTIONS LIKE WHICH COMPANY SHOULD I TEST WITH IF I WANT TO KNOW A CERTAIN PIECE OF INFORMATION, BUT RATHER QUESTIONS LIKE WHAT DOES SOMEONE NEED TO KNOW TO MAKE AN INFORMED DECISION ABOUT WHETHER, WHEN AND HOW TO TEST. SO BEFORE I JUMP INTO SOME GENETIC BASICS, I WANT TO TALK ABOUT WHY I THINK THIS TOPIC IS SO IMPORTANT FOR INFORMATION PROFESSIONALS TO BE FAMILIAR WITH. FIRST OFF, JUST LIKE ANY HEALTH LITERACY TOPIC EVEN THOUGH WE CAN’T REALLY COUNSEL PATRONS DIRECTLY ON THEIR SPECIFIC HEALTH QUESTIONS, WE CAN HELP FIND PERTINENT AND RELIABLE INFORMATION TO EMPOWER THEM TO MAKE INFORMED DECISIONS ABOUT THEIR HEALTH. AND TO HELP FRIENDS AND FAMILIES MAKE DECISIONS AS WELL. THE DTC GENETIC TESTING INDUSTRY IS A MULTI-BILLION DOLLAR INDUSTRY, THERE’S A LOT OF PUBLIC INTEREST IN AND ENTHUSIASM FOR DTC GENETIC TESTS OUT THERE. THERE ARE A WIDE CHANGE OF COMPANIES OFFERING A WIDE RANGE OF TESTS, AND THEY ARE ALL ADVERTISING THEIR SERVICES. SO IT CAN BE ALMOST IMPOSSIBLE EVEN FOR SOMEONE WITH SOME KNOWLEDGE OF GENETICS TO ASSESS VERACITY OF COMPANIES’ CLAIMS. AFTER ALL, IT’S IF THEY ARE DOING A GENETIC TESTS, RESULTS TEND TO FEEL SCIENTIFIC AND ACCURATE. LIKE THEY HAVE WEIGHT. IF YOU CAN GET A GENETIC TEST THROUGH YOUR DOCTOR WHY WOULD ONE DONE BY A PRIVATE COMPANY BE SUBSTANTIALLY DIFFERENT? AND IT’S MUCH EASIER TO ORDER A KIT IN THE MAIL, PARTICULARLY IF YOU’RE NOT TRYING TO TEST FOR SOMETHING SPECIFIC, THAN TO GO THROUGH HASSLE OF GETTING ONE THROUGH A HEALTH CARE PROVIDER. ANCESTRY TESTING CAN BE APPEALING FOR FOLKS TRYING TO FIGURE OUT MORE ABOUT THEIR FAMILY OR PAST. PEOPLE TAKE TESTS FOR A VARIETY OF REASONS INCLUDING PURCELY INFOTAINMENT AND GENEALOGICAL SCREENING AND MORE. I’M CURIOUS TO HEAR FROM ALL OF YOU, IF YOU’RE WILLING TO SHARE, TYPE INTO THE CHAT BOX WHETHER YOU’VE DONE A DTC GENETIC TEST YOURSELF OR SOMEONE CLOSE TO YOU HAS AND WHAT TYPE IT WAS OR IF YOU HAVEN’T, MAYBE SHARE WHY YOU HAVEN’T. SO IT WILL BE REALLY INTERESTING TO HEAR IF YOU’VE DONE A TEST AND WHY YOU CHOSE TO DO OR DIDN’T DO A TEST. WHY YOU CHOSE THE TEST YOU DID, IF YOU TOOK ONE. ANNETTE 23ANDME, NATALIE IS INTERESTED BUT CONCERNED ABOUT COST, NOT SURE WHICH TO CHOOSE. PEOPLE HAVE FAMILY MEMBERS WHO HAVE. NOT INTERESTED. DON’T REALLY FEEL LIKE IT MATTERS. LOTS OF FRIENDS AND SISTERS DID. NO, TOO EXPENSIVE. PRIVACY ISSUES, VERY INTERESTING. YES, WE’LL BE TALKING A LITTLE BIT ABOUT THAT LATER ON, STILL TRYING TO DECIDE, IMPORTANT FOR INFORMATIONAL PURPOSES, YEP, DON’T WANT TO SHARE MY GENETIC INFORMATION WITH A COMPANY. INTERESTING. DIFFERENT — MARY’S BROTHERS DID BUT GOT DIFFERENT RESULTS, LOTS OF ONES DONE FOR FAMILY HISTORY. VERY GOOD. SO I’M NOT SURPRISED. VERY MANY OF YOU EITHER HAVE TESTED OR ARE CLOSE TO SOMEONE WHO HAS OR HAVE BEEN THINKING ABOUT IT. THANKS FOR SHARING THAT WITH EVERYONE. OBVIOUSLY, DTC TESTING WE KNOW IS REALLY POPULAR. SO ITS POPULARITY IS THE BIGGEST REASON, I THINK IT’S SO IMPORTANT FOR INFORMATION PROFESSIONALS TO BE FAMILIAR WITH IT. SO UNLIKE MANY OTHER COMMON MEDICAL PROCEDURES, THERE’S AN ENTIRE PRIVATE INDUSTRY DEDICATED JUST TO OFFERING THESE TESTS DIRECTLY TO THE CONSUMER WITHOUT PROFESSIONAL INTERVENTION. TO ME, THIS REMINDS ME HOW TEACHERS OFTEN TELL THEIR STUDENTS DON’T USE WIKIPEDIA AS AN INFORMATION RESOURCE, BUT HONESTLY WE ALL REALLY KNOW EVERYONE IS GOING RIGHT TO WIKIPEDIA, EVEN THE TEACHERS. I FEEL LIKE INSTEAD OF FINDING THAT TENDENCY, IN THIS CASE WE COULD IGNORE THE FACT THAT EVERYONE IS TAKING THESE TESTS AND NOT PROVIDING HELPFUL INFORMATION, OR WE COULD JUST SAY, OH, DTC TESTS ARE JUNK SCIENCE, DON’T DO THEM, AVOID THEM. WE SHOULD BE WORKING WITH PEOPLE TO GUIDE THEM TOWARDS RELIABLE SOURCES OF INFORMATION. AND REALLY JUST TRY TO ENGAGE WITH THEM HONESTLY ABOUT BOTH THE PROMISES AND CHALLENGES OF DTC TESTING. AS WORK TOWARDS PRECISION MEDICINE INCREASING FOR EXAMPLE THREW NIH’S “ALL OF US” RESEARCH PROGRAM WHICH YOU MAY HAVE HEARD OF, IF WE WANT TO EMPOWER PEOPLE TO MAKE INFORMED DECISIONS ABOUT THEIR HEALTH THEN DTC TESTING IS A GREAT PLACE TO START BECAUSE SO MANY PEOPLE ARE INTERESTED IN IT. THIS IS TRUE WHETHER YOU WORK AT A PUBLIC LIBRARY, SCHOOL LIBRARY, ACADEMIC LIBRARY OR MANY OTHER CONTEXTS, BECAUSE DTC TESTING IS SO WIDESPREAD. MAYBE YOU CAN USE THIS WEBINAR AS AN INSPIRATION FOR SOME PROGRAMMING AT YOUR OWN LIBRARY. SO MOVING ON, IN ORDER TO UNDERSTAND SOME OF THE THINGS I’M GOING TO BE TALKING ABOUT THIS AFTERNOON, I WANT TO MAKE SURE WE’RE ALL ON THE SAME PAGE IN TERMS OF SOME GENETICS, CONCEPTS, TERMINOLOGY. SO I’M GOING TO DO A REALLY WHIRLWIND TOUR OF BASIC GENETICS, THAT’S RELEVANT TO GENETIC TESTING, DESCRIPTIONS REFER TO HUMAN GENETICS, MAY NOT HOLD TRUE FOR ALL ORGANISMS. YOUR BODY IS MADE OF TRILLIONS OF TINY STRUCTURES CALLED CELLS. ALL OF YOUR CELLS EXCEPT FOR MORE EGG CELLS CONTAIN THE SAME GENETIC MATERIAL OR DNA. HOWEVER, DNA IS EXPRESSED DIFFERENTLY IN DIFFERENT TYPES OF CELLS SO YOU HAVE AROUND 200 DIFFERENT KINDS OF SPECIALIZED CELLS, EACH OF WHICH IS GOING TO DIFFER STRUCTURALLY AND FUNCTIONALLY FROM OTHER TYPES. YOUR NEURONS CONDUCT ELECTRICAL IMPULSES IN YOUR BRAIN, LOOK AND ACT DIFFERENTLY FROM RED BLOOD CELLS THAT CARRY OXYGEN IN YOUR BLOOD, THE TWO PICTURES ON THE SLIDE. SO DNA, DEOXYRIBONUCLEIC ACID, IS FOUND IN TWO BASES IN YOUR CELLS, THE NUCLEUS, A LARGE STRUCTURE AT THE CENTER OF THE CELL WHICH CONTAIN ALMOST ALL OF THE GENETIC MATERIAL IN THE CELL, AND MITOCHONDRIA. THE NUCLEUS IN THE CELL DIAGRAM IS THE LARGE ROUND PURPLE STRUCTURE LABELED NUMBER 2. MITOCHONDRIA ARE THE ORANGE KIDNEY BEAN-SHAPED STRUCTURES NUMBER 9. I’LL TALK ABOUT DIFFERENCES IN A MOMENT. SO DNA IS A COMPLEX MOLECULE, SHAPED LIKE A TWISTED LADDER, DOUBLE HELIX. THE RUNGS ARE MADE OF PAIRS OF MOLECULES, NUCLEOTIDE BASES. THESE MOLECULES ARE ABBREVIATED A, T, G, AND C. THE SEQUENCE IS UNIQUE TO EVERY PERSON WITH THE EXCEPTION OF IDENTICAL SIBLINGS BECAUSE YOUR NUCLEAR DNA IS JUST A MIXED UP COMBINATION OF DNA FROM BOTH BIOLOGICAL PARENTS. MITOCHONDRIAL DNA, mtDNA, DIFFERS IN FOUR WAYS. MITOCHONDRIAL DNA ORGANIZES INTO A CIRCULAR SHAPE. NUCLEAR DNA ORGANIZED INTO CHROMOSOMES. IT CONTAINS LESS DNA. MITOCHONDRIAL DNA IS PASSED DOWN ALMOST EXCLUSIVELY FROM MOTHER TO OFFSPRING. EXCEPT FOR SMALL CHANGES DUE TO MUTATIONS TENDS TO REMAIN THE SAME BETWEEN GENERATIONS. GENES ARE GOING TO BE SEGMENT ALSO OF DNA THAT CONTAIN INSTRUCTIONS FOR A SPECIFIC FUNCTIONAL UNIT, LIKE A PROTEIN. DIFFERING DNA SEQUENCES RESULT IN DIFFERENCES IN THE STRUCTURES OF THE PROTEINS CREATED FROM THEM. CAN THEREFORE EXPLAIN MANY BUT NOT ALL DIFFERENCES IN PHYSICAL CHARACTERISTICS BETWEEN INDIVIDUALS. SURPRISINGLY, ONLY AROUND 1 OR CODES FOR PROTEINS, BUT THE GENES ARE OFTEN A FOCUS OF GENETIC TESTING, SINCE THEY ARE SO IMPORTANT. OTHER GENES ARE GOING TO HAVE REGULATORY STRUCTURAL OR VARIETY OF OTHER FUNCTIONS. HUMANS HAVE TWO VERSIONS OF EACH CHROMOSOME. ONE FROM EACH PARENT. EACH CONTAINS THE SAME EXAMINE THE EXCEPTION OF X. DIFFERENT VERSIONS ARE CALL ALLELES. YOUR UNIQUE SEQUENCE IS GENOTYPE, EXPRESSED CHARACTERISTICS LIKE HAIR COLOR, HEIGHT, LACTOSE INTOLERANCE, ON YOUR PHENOTYPE. MULTIPLE GENOTYPES CAN BE ASSOCIATED CAN THE SAME PHENOTYPE. FOR EXAMPLE, ONE DISEASE CAN BE CAUSED BY SEVERAL DIFFERENT MUTATIONS OR CHANGES IN GENETIC SEQUENCE. PHENOTYPE CAN ALSO BE INFLUENCED TO VARYING DEGREES BY THE ENVIRONMENT. FOR INSTANCE, PINK COLORATION IN FLAMINGOS IS INFLUENCED BY DIET. WE HAVE A ROUGH TIME LINE, HISTORY OF GENETIC TESTING. FROM EARLY 20th CENTURY THROUGH 1950s, MOST WAS KARYOTYPING, ESSENTIALLY LOOKING AT THE SHAPE OF CHROMOSOMES AND COUNTING THEM. WHAT SPECIES HAVE HOW MANY CHROMOSOMES, WHAT ARE THE CHROMOSOMES LOOKING LIKE. BY THE 1970s, RESEARCHERS WERE ABLE TO STAIN PARTICULAR CHROMOSOMAL REGIONS IN CHROMOSOME BANDING TO ANALYZE STRUCTURE, INVESTIGATE GENETIC CONDITIONS INVOLVING LARGE SEGMENTS OF DNA. IN THE 1980s, AUTOMATED GENETIC SEQUENCING BECAME POSSIBLE ALLOWING THE EMERGENCE OF HUMAN GENOME PROJECT IN THE PROLIFERATION OF VARIOUS DIFFERENT TYPES OF LAB GENETIC TESTING IN THE ’90s. THE 2000s IS WHEN THE FIRST DTC GENETIC TESTING COMPANIES EMERGED. AND THEN IN THE 2010s ADVANCES IN SEQUENCING WERE REDUCING COST AND TIME REQUIRED FOR GENETIC TESTING. SO THIS IS WHEN WE REALLY START TO SEE THE PROLIFERATION OF DTC TESTS AND TESTING COMPANIES. SO WE KNOW DTC TESTING IS VERY POPULAR, BUT IS IT MORE GENETIC ASTROLOGY OR MORE SOLID SCIENCE? IN REALITY, IT’S OFTEN A BIT OF BOTH, PROPORTIONS DEPEND ON TYPE OF TESTS YOU’RE LOOKING AT. SO, I’M GOING TO TAKE A CLOSER LOOK AT SOME DIFFERENT CATEGORIES OF TESTS ON OFFER. I’LL BE GIVING EXAMPLES OF SOME TESTING COMPANIES OFFERING FOR EACH TEST CATEGORY BUT NOT COMPARING SPECIFICS OF PARTICULAR COMPANIES’ TESTS BUT RATHER PROVIDING AN OVERVIEW OF THE MAJOR CATEGORIES. CONSUMER GENETIC TESTS FALL INTO TWO BROAD CATEGORIES. THESE ARE GENEALOGICAL TESTS WHICH CAN PROVIDE INFORMATION ABOUT ANCESTRY, ETHIC ORIGIN, FAMILIAL RELATIONSHIPS, AND HEALTH-RELATED TESTS WHICH IS A REALLY BROAD CATEGORY AS SORT OF COBBLED TOGETHER TO ENCOMPASS TESTS THAT PURPORT TO PROVIDE INFORMATION ABOUT GENETIC DISEASES, NATURAL APTITUDES LIKE ATHLETIC ABILITIES, PERSONALITY, RECOMMENDED DIET, FOOD PREFERENCES, AND LOTS MORE. I’M GOING TO TALK ABOUT GENEALOGICAL TESTING FIRST AND COVER HEALTH TESTING AND MORE GENERAL ISSUES THAT APPLY TO DTC GENETIC TESTS IN GENERAL. REGARDLESS OF WHICH COMPANY IS PERFORMING THE TEST, GENEALOGICAL TESTING WILL PRIMARILY COMPARE AUTOSOMAL DNA EXPENSES OR SEQUENCES OF DNA LOCATED ON STANDARD NUCLEAR CHROMOSOMES. TO GENETIC DATABASE OF REFERENCE SAMPLES TAKEN FROM PEOPLE AROUND THE WORLD. SOME TESTS MAY ALSO LOOK AT Y CHROMOSOME AND MITOCHONDRIAL HAPLOGROUPS BUT MOST COMPANIES DON’T OFFER THIS. HAPLOGROUPS ARE GROUPS WHO SHARE A COMMON ANCESTOR ON THE PATRA LINE FOR Y OR MATRA LINE FOR MITOCHONDRIAL DNA. THESE WILL BE BROAD GROUPS AND SO WE’RE NOT GENERALLY PRIMARILY RELIED UPON FOR DETERMINING CLOSE FAMILIAL RELATIONSHIPS FOR GENEALOGICAL PURPOSES BUT CAN PROVIDE INFORMATION ABOUT DEEPER ANCESTRY SO Y CHROMOSOME TESTING CAN BE USEFUL FOR DETERMINING FOR INSTANCE WHETHER TWO FAMILIES WITH THE SAME SURNAME ARE RELATED, OFTEN PASSED DOWN PATRA LINEALLY. AND MITOCHONDRIAL DNA IS SOMETIMES USED IN GENEALOGICAL STUDIES, CAN PROVIDE INFORMATION ABOUT FEMALE ANCESTOR THAT MIGHT HAVE BEEN LOST FROM THE HISTORICAL RECORD DUE TO SURNAME CHANGES. SO BY CHAIRING AN INDIVIDUAL’S ALLELES OR GENETIC VARIANTS TO ALLELES COMMON IN MOST PARTS OF THE WORLD COMPANIES MAKE INFERENCES ABOUT WHERE IN THE WORLD THE INDIVIDUAL’S DNA AND BY EXTENSION THE INDIVIDUAL CAME FROM, SO TO SPEAK. ESSENTIALLY RESTING ON THE ASSUMPTION IF YOU SHARE A SIGNIFICANT NUMBER OF GENETIC MARKERS WITH DATABASE’S REFERENCE SAMPLES FROM A GIVEN COUNTRY OR REGION IT’S LIKELY YOU HAVE SIGNIFICANT ANCESTRY FROM THAT AREA. GENEALOGICAL TESTING CAN GIVE YOU INFORMATION ABOUT PEOPLE WHO ARE RELATED TO YOU, WHO HAVE BEEN TESTED ALREADY BY THE SAME COMPANY OR WHO HAVE THEIR INFORMATION IN SHARED DATABASES. MOST WELL-KNOWN DTC TESTS ARE SOLD BY ANCESTRY DNA, MY HERITAGE, 23ANDME AND FAMILY TREE DNA. TESTING. THESE COMPANIES
ARE NOT RECOMMENDATIONS BUT EXAMPLES AND ANYONE INTERESTED IN GENEALOGICAL TESTING SHOULD CAREFULLY COMPARE OFFERINGS, STRENGTHS, WEAKNESSES OF ANY TESTS THEY ARE CONSIDERING. SO, ALL OF YOU HAVE PROBABLY SEEN OR HEARD GENEALOGICAL TESTING ADVERTISEMENTS ON TV, RADIO, ONLINE, IN PRINT, EVERYWHERE. THEY OFTEN SHOW PEOPLE LEARNING ABOUT AND CULTURALLY EMBRACING PREVIOUSLY UNKNOWN HERITAGE. PERHAPS BY DONNING TRADITIONAL CLOTHING FROM THAT PART OF THE WORLD. AS PART OF A JOURNEY OF SELF DISCOVERY. USUALLY THERE’S A SNAPSHOT OF TEST RESULTS SHOWING PERCENTAGES COMING FROM DIFFERENT COUNTRIES, REGIONS, ETHNIC GROUPS. THERE ARE TWO MAJOR IMPLICATIONS MADE BY THESE TYPES OF ADVERTISEMENTS. GENETIC ANCESTRY, ETHNICITY AND CULTURE ARE INTERCHANGEABLE CONCEPTS, AND ANCESTRY TESTING GIVES ACCURATE AND PRECISE PICTURE WHERE IN THE WORLD YOUR ANCESTORS LIFT TO A PERCENTAGE OR TENTH OF A PERCENTAGE OF YOUR DNA. AND BOTH OF THESE IMPLICATIONS OR ASSUMPTIONS HAVE SOME FLAWS. THE FIRST THAT GENETIC ANCESTRY, ETHNICITY AND CULTURE ARE INTERCHANGEABLE RAISES TORNY QUESTIONS ABOUT INTERSECTION OF RACE, ETHNICITY, CULTURE AND BIOLOGY, THE IDEA GENES IDENTIFY CULTURE IS FRAUGHT, RACIST PSEUDOSCIENCE, RESEARCH HAS SHOWN AMONG PEOPLE WITH LOW GENETIC KNOWLEDGE TAKING A GENETIC TEST TENDS TO STRENGTHEN BELIEFS ABOUT RACIAL ESSENTIALISM, OR THE IDEA GENES DETERMINE RACE AND RACIAL GROUPS HAVE PARTICULAR INNATE ABILITIES. SO WITHOUT PUTTING ON MY ANTHROPOLOGIST HAT AND TALKING ABOUT THIS ISSUE, SUFFICE IT TO SAY SCIENTISTS AGREE THIS IS NOT THE CASE, CULTURE, ETHNICITY, RACE AND BIOLOGY ARE ALL INTERRELATED BUT DISTINCT CONCEPTS. ON THE OTHER HAND, A GREATER UNDERSTANDING OF ONE’S ANCESTRY CAN BE A POSITIVE EXPERIENCE, JUST LIKE DEPICTED IN THE COMMERCIALS. AND INTERESTINGLY, THE SAME RESEARCH THAT SHOWED THAT GENETIC TESTS TEND TO STRENGTHEN BELIEFS ABOUT RACIAL ESSENTIALISM AMONG PEOPLE WITH LOW GENETIC KNOWLEDGE, IT ALSO SHOWED WITH HIGHER KNOWLEDGE THESE TESTS DECREASE RACIAL ESSENTIALIST VIEWS. SO KEEPING WITH TODAY’S THEME, DTC TESTING IS REALLY A TWO-SIDED COIN. AND BACK TO THE SECOND IMPLICATION, ANCESTRY TESTING GIVES AN ACCURATE AND PRECISE PICTURE OF WHERE IN THE WORLD YOUR ANCESTORS LIVED, THERE ARE FEW COMPLICATIONS TO THE IDEA. SO THINK BACK TO HOW GENEALOGICAL TESTS WORK. THEY ARE COMPARING VARIOUS SEQUENCES IN THE TESTER’S DNA TO SEQUENCES FROM INDIVIDUALS IN REFERENCE POPULATIONS THE COMPANY COLLECTED, AND VARIOUS AREAS AROUND THE WORLD. YOU’RE NOT QUITE LEARNING WHERE YOU AS AN INDIVIDUAL COME FROM. YOU’RE FINDING OUT WHERE IN THE WORLD OTHER PEOPLE LIVE WHO HAVE DNA THAT’S SIMILAR TO YOURS IN CERTAIN AREAS OF THE GENOME. THE DISTINCTION HERE IS KIND OF SUBTLE BUT I THINK IT’S IMPORTANT. ESPECIALLY IN AREAS WHERE THE NUMBER OF REFERENCE SAMPLES COLLECTED IS SMALL, WHICH TENDS TO BE MOST PLACES IN THE WORLD EXCEPT EUROPE. IT’S HARD TO KNOW WHETHER THE INDIVIDUAL’S TESTED FOR REFERENCE HAVE DNA THAT’S ACTUALLY REPRESENTATIVE OF THAT AREA’S POPULATION AS A WHOLE, LET ALONE AREA’S POPULATION, HUNDREDS OR THOUSANDS OF YEARS IN THE PAST. SO THINK ABOUT IT THIS WAY. IF A GROUP OF PEOPLE MIGRATE FROM AN AREA THAT WILL SAY TODAY IS CALLED MODERN COUNTRY A, AND THEY MOVE TO MODERN COUNTRY B, HUNDREDS OR A FEW THOUSAND YEARS AGO, AND YOUR ANCESTORS DIDN’T STICK WITH THE MAIN GROUP, SO THEY WERE WITH THE MAIN GROUP BUT SPLIT OFF BEFORE THE MIGRATION HAPPENED. IT’S POSSIBLE ANCESTRY TEST COULD INDICATE YOU HAVE A LOT OF MODERN COUNTRY B ANCESTRY WHICH ISN’T ACTUALLY THAT ACCURATE OR INFORMATIVE. IF THERE ARE TWO THINGS THAT HUMANS HAVE BEEN REALLY GOOD AT THROUGHOUT OUR LONG HISTORY IT’S MIGRATING AND INTERBREEDING. ANCESTRY TESTING ISN’T GREAT AT ACCOUNTING FOR THESE. IT GENERALLY ATTEMPTED TO IMPOSE MODERN GEOPOLITICAL BOUNDARIES ON HUMAN VARIATION, GENERALLY MORE CONTINUOUS THAN IT IS SEGMENTED. MODERN GEOPOLITICAL BOUNDARIES DON’T REFLECT OLDER GEOPOLITICAL BOUNDARIES, AND CULTURE IS ANOTHER COMPLICATED LAYER TO ADD THAT DOESN’T NECESSARILY MAP WELL ONTO THOSE GEOPOLITICAL LINES. ANCESTRY TESTING IS MUCH MORE ACCURATE AT THE CONTINENTAL LEVEL THAN MORE GRANULAR LEVELS BUT IF TESTS ONLY TOLD YOU THAT YOUR ANCESTORS WERE FROM A PARTICULAR CONTINENT RESULTS WOULD BE LESS INTERESTING FOR PEOPLE. FINALLY EACH TESTING COMPANY IS GOING TO USE SLIGHTLY DIFFERENT METHODOLOGIES AND ALGORITHMS, USE DIFFERENT REFERENCE POPULATIONS, THEY WILL BE LOOKING AT DIFFERENT GEOPOLITICAL AREAS. SO RESULTS FROM ONE TEST ARE OFTEN A LITTLE BIT DIFFERENT FROM RESULTS FROM ANOTHER TEST. ALSO AN ETHNIC GROUP WITH A SMALL RANGE OF GENETIC VARIATION, FOR EXAMPLE ASHKENAZI JEWS ARE USED AS AN EXAMPLE OF THIS, IT CAN EVEN BE DIFFICULT FOR TESTS TO DIFFERENTIATE RELATIVELY CLOSE RELATIVES LIKE DISTANT COUSINS, FROM THE GROUP AS A WHOLE. SO AS REFERENCE DATA EXPANDS, ESTIMATES CAN CHANGE, AND SOMETIMES SENDING THE SAME SAMPLE TO THE SAME COMPANY DOESN’T ALWAYS YIELD THE SAME RESULTS BECAUSE AS WITH ANY GENETIC TEST THERE IS A POSSIBILITY FOR ERROR. SOME GENETIC GENEALOGISTS ACTUALLY RECOMMEND IGNORING ANCESTRY PERCENTAGES UNDER 10% IN A TEST, WHICH IS KIND OF AN INDICATOR THAT THESE TEST RESULTS SHOULD BE TAKEN WITH AT LEAST A SMALL GRAIN OF SALT. SO THESE PERCENTAGES CAN ALSO BE FUDGED TO ADD TO AROUND 100% FOR YOUR REPORT. AND THERE’S LITTLE OVERSIGHT OF COMPANIES’ METHODOLOGY TO ENSURE ACCURACY, PRECISION AND REPEATABILITY. THERE’S CONCERNS THERE BUT TAKING A GENETIC GENEALOGY TEST CAN BE USEFUL FOR GENEALOGICAL PURPOSES TO HELP YOU IDENTIFY RELATIVES AND TRACE FAMILY HISTORY. OF COURSE, IT CAN BE REALLY FUN AND INTERESTING OR LEAD TO A GREATER INTEREST IN FAMILY HERITAGE, WHICH IS GREAT. BUT TESTERS SHOULD BE AWARE AND PREPARED THAT WHEN DISCOVERY OF RELATIVES IS INVOLVED, THERE’S ALWAYS THE POTENTIAL FOR UNWELCOME SURPRISES. FOR EXAMPLE, RELATING TO PARENTAGE. TESTERS SHOULD BE AWARE THERE ISN’T A LOT OF INFRASTRUCTURE AVAILABLE TO HELP THEM INTERPRET RESULTS FROM THESE COMPANIES. SO THEY SHOULD TAKE CARE AND NOT NECESSARILY TAKE THEM EXACTLY AT FACE VALUE. FOR EXAMPLE, IF YOUR REPORT SAYS YOU HAVE 50% SCANDINAVIAN ANCESTRY, YOU SHOULDN’T READ IT SO MUCH AS 50% OF MY ANCESTORS CAME FROM SCANDINAVIA BUT MORE LIKE APPROXIMATELY HALF OF THE GENETIC MARKERS EXAMINED BY THIS TEST WERE COMMONLY FOUND IN REFERENCE INDIVIDUALS WHO CURRENTLY LIVE IN SCANDINAVIA. WHEN IN TESTERS SHOULD CONSIDER SEEKING PROFESSIONAL ASSISTANCE IN INTERPRETATION OF RESULTS. ALL RIGHT. NEXT I’M GOING TO TALK ABOUT HEALTH TESTING, WHICH IS A BROAD CATEGORY THAT I LIKE TO LUMP EVERYTHING THAT ISN’T ANCESTRY TESTING INTO, ALTHOUGH WE WILL SEE THERE’S SOME HETEROGENEITY WITHIN THIS GROUP. SCIENTIFICALLY THESE TESTS ARE SIMILAR TO BUT A BIT SIMPLER THAN ANCESTRY TESTS. THEY CAN COMPARE AUTOSOMAL DNA SEQUENCES AT LOCATIONS FROM HUNDREDS TO THOUSANDS, DEPENDING ON THE COMPANY AND TEST. WITH GENETIC SEQUENCES THAT ARE KNOWN OR SUSPECTED FROM BIOMEDICAL RESEARCH, TO BE ASSOCIATED WITH PHENOTYPIC DIFFERENCES OR PARTICULAR DISEASES. THE MOST WELL-ESTABLISHED TESTS ARE THOSE THAT TEST FOR VARIANTS ASSOCIATED WITH PARTICULAR DISEASES, FOR INSTANCE THE WELL KNOWN BRCA VARIANTS ASSOCIATED WITH BREAST CANCER. HOWEVER THERE ARE OTHER TESTS THAT PURPORT TO PROVIDE INFORMATION ABOUT ATHLETIC ABILITY, MENTAL ABILITIES, PERSONALITY, WHAT TYPE OF WINE SHOULD YOU DRINK, DIET, FOR INSTANCE, WHAT FOODS SHOULD YOU EAT TO LOSE WEIGHT. AND A LOT MORE. THERE ARE A TON OF COMPANIES OFFERING TESTS IN THESE DOMAINS, AND A FEW ARE LISTED HERE ON THE SLIDE. I WANT TO BE CLEAR THESE ARE EXAMPLES AND NOT RECOMMENDATIONS, THESE ARE EXAMPLES OF COMPANIES YOU MIGHT COME ACROSS ADVERTISING FOR IT. FOR NOW I’M GOING TO FOCUS MAINLY ON THE MEDICAL TESTS. OBVIOUSLY, THERE’S SOME ADVANTAGES FOR DTC TEST AS OPPOSED TO A TEST YOUR DOCTOR MIGHT ORDER. YOUR DOCTOR MIGHT ONLY ORDER A TEST IF THERE’S ALREADY A REASON TO SUSPECT YOU HAVE A PARTICULAR CONDITION, DEPENDING ON YOUR INSURANCE, COST MIGHT BE A FACTOR, ALTHOUGH INSURANCE DOESN’T USUALLY COVER DTC TESTING AND IT’S MUCH MORE LIKELY TO COVER TESTS ORDERED THROUGH A HEALTH CARE PROVIDER. ON THE OTHER HAND, NOT EVERYONE HAS A REGULAR HEALTH CARE PROVIDER OR HEALTH INSURANCE AND IT CAN BE EASIER AND MORE ACCESSIBLE TO ORDER A TEST KIT THROUGH THE MAIL THAN A HEALTH CARE PROFESSIONAL. SOME MEDICAL TESTS ARE ALSO GOING TO BE MORE SPECIFIC OR DIAGNOSIS ORIENTED. TESTING FOR A FEW PARTICULAR VARIANTS RATHER THAN A WIDER PANEL LIKE A GENERIC DTC MEDICAL TEST WOULD. BUT A FEW IMPORTANT QUESTIONS ABOUT DTC MEDICAL TESTS REMAIN. ARE THEY ACCURATE OR HOW DOES THEIR ACCESS COMPARE TO MEDICAL GRADE TESTS? AND DO THEY PROVIDE A SCIENTIFICALLY ACCURATE PICTURE OF THE RELATIONSHIP BETWEEN GENOTYPE AND PHENOTYPE? AND TO ANSWER THESE QUESTIONS, WE NEED TO CONSIDER A FEW THINGS. FIRST, ANY GENETIC TEST HAS POTENTIAL FOR ERROR. FALSE POSITIVE OR FALSE NEGATIVE RESULT. GENEALOGY TESTING, THIS ISN’T SUPER IMPORTANT, SO MAYBE THE REPORTED PERCENTAGES MIGHT DIFFER SLIGHTLY. IT’S UNLIKELY THERE WOULD BE SERIOUS CONSEQUENCES FOR DISCREPANCY. ON THE OTHER HAND, WITH HEALTH TESTS, PEOPLE CAN MAKE MAJOR DECISIONS BASED ON RESULTS. SO A FALSE POSITIVE FOR A PATHOGENIC VARIANT COULD MAKE SOMEONE ADOPT HEALTHIER LIFESTYLE TO COMBAT THE CONDITION. GREAT, THAT’S A POSITIVE. OR THEY CAN LOOK AT TREATMENTS ONLINE AND BEGIN TO FOLLOW QUESTIONABLE HEALTH ADVICE WHICH COULD POTENTIALLY BE DANGEROUS. FALSE NEGATIVE COULD ALSO HAVE A WIDE RANGE OF EFFECTS, FOR EXAMPLE GIVING SOMEONE A FALSE SENSE OF SECURITY ABOUT THEIR HEALTH. SO EVEN TESTS THAT HAVE A REPORTED ERROR RATE THAT SOUNDS REALLY LOW, LIKE .1% OR .01%, COULD EASILY RETURN SEVERAL OR EVEN DOZENS OF ERRONEOUS RESULTS IF THEY ARE TESTING A LARGE NUMBER OF MARKERS AS SOME TESTS ARE. SO RECENT STUDY FOUND AMONG 49 PATIENT SAMPLES RECEIVED FOR FURTHER LAB TESTING AFTER A DTC TEST REPORTED A PATHOGENIC VARIANT, 40% OF THOSE REPORTED VARIANTS COULDN’T BE CONFIRMED UPON REANALYSIS IN A LAB. IN OTHER WORDS, THERE MAY BE A LOT OF FALSE POSITIVES AND POTENTIALLY FALSE NEGATIVES BEING REPORTED IN DTC TEST RESULTS. IT’S REALLY EASY IF YOU JUST DO A GOOGLE SEARCH, YOU CAN FIND LOTS OF STORIES ONLINE ABOUT PEOPLE WHO HAVE RECEIVED A FALSE POSITIVE FOR A SERIOUS VARIANT FROM A DTC TEST AND HAD THEIR LIVES TEMPORARILY TURNED UPSIDE DOWN BECAUSE OF THIS. THAT BEING SAID OF COURSE YOU CAN ALSO FIND STORIES ABOUT PEOPLE WHO GOT A RESULT FROM A DTC TEST AND ACTUALLY ENDED UP BEING IMPORTANT FOR THEIR HEALTH CARE. TWO-SIDED COIN. COMPANIES DON’T ALWAYS AGREE ON HOW TO CLASSIFY VARIANTS, SO THE SAME VARIANT THAT MIGHT BE REPORTED AS HIGH RISK BY ONE IS SOMETIMES REPORTED AS NORMAL BY ANOTHER COMPANY. SO THIS REALLY POINTS TO THE IMPORTANCE OF CONFIRMING DTC RAW DATA IN A CLINICAL LABORATORY, BEFORE MAKING HEALTH CARE DECISIONS BASED ON IT. LESS EXPENSIVE TESTS ARE SOMETIMES MORE PRONE TO INACCURACY AND FAULTY INTERPRETATION OF RESULTS. SOME TESTS REQUIRE THAT RESULTS BE UPLOADED TO A THIRD PARTY WEBSITE OR SOFTWARE FOR INTERPRETATION. AND, AGAIN, LACK OF REGULATORY OVERSIGHT AND LACK OF SUITABLE INFRASTRUCTURE TO AID AND RESULT IN INTERPRETATION ARE IMPORTANT ISSUES HERE. AND I WILL DISCUSS MORE WHEN I TALK ABOUT BROADER ISSUES AROUND DTC TESTING. SO THE GENETIC TESTS ASSOCIATED WITH SOME DISEASES ARE WELL ESTABLISHED THROUGH RESEARCH, OTHERS ARE LESS WELL ESTABLISHED. MANY CONDITIONS HAVE A COMPLETELY UNCERTAIN GENETIC ETIOLOGY. A TEST MAY OR MAY NOT BE ABLE TO TELL YOU WITH HIGH CONFIDENCE WHETHER YOUR VARIANTS ARE ASSOCIATED WITH PARTICULAR DISEASES. IN MANY CASES CONDITIONS HAVE A MULTI-FACTORIAL ETIOLOGY, SO MANY GENOTYPIC VARIANTS CAN COMBINE IN WAYS THAT AREN’T WELL UNDERSTOOD TO CONTRIBUTE TO A PARTICULAR PHENOTYPE. AND MANY PHENOTYPES HAVE MULTIPLE POTENTIAL UNDERLYING GENOTYPES, AND AS I MENTIONED EARLIER, ENVIRONMENTAL AND OTHER FACTORS CAN PLAY MAJOR ROLE IN HOW OR IF PARTICULAR GENOTYPES ARE EXPRESSED PHENOTYPICALLY. IT’S REALLY RARE THAT A SINGLE GENETIC VARIANT IS THE SOLE DETERMINANT OF A HEALTH OUTCOME. EVEN IN THESE CASES, THEY ARE LIKELY TO BE SUBSTANTIAL VARIATION IN DISEASE ONSET, SYMPTOMATOLOGY, PROGRESSION, RESPONSE TO TREATMENTS, OUTCOME. AND FOR MANY CONDITIONS, THERE ARE NO TREATMENTS TO DELAY OR PREVENT THEIR ONSET SO EVEN KNOWLEDGE OF A HIGH RISK FOR DISEASE CAN BE NOT HELPFUL AT ALL. SO BACK TO THE ORIGINAL QUESTIONS, ARE THESE TESTS ACCURATE OR HOW DO THEY COMPARE TO MEDICAL GRADE TESTS? THEY ARE NOT AS ACCURATE AS MEDICAL GRADE TESTS, THEY DO SOMETIMES PAINT A BROADER PICTURE THAN CERTAIN MEDICAL TESTS. INSURANCE DOESN’T USUALLY COVER THEM, BECAUSE THEY ARE NOT AS ACCURATE, THEY ARE NOT RECOMMENDED FOR USE IN DIAGNOSIS. AND THE SECOND QUESTION, DO THEY PROVIDE A SCIENTIFICALLY ACCURATE PICTURE OF THE RELATIONSHIP BETWEEN GENOTYPE AND PHENOTYPE? THE ANSWER IS OFTEN NOT, AND THE RESULTS CAN BE REALLY DIFFICULT FOR AN AVERAGE PERSON TO INTERPRET. SO WHILE DTC MEDICAL TESTS CAN DEFINITELY BE AN ENGAGING WAY FOR CONSUMERS TO GET IN TOUCH WITH HEALTH AND WELL BEING AN MOTIVATE POSITIVE CHANGE, TESTERS SHOULD BE AWARE THEY MAY RECEIVE TROUBLING OR UNEXPECTED RESULTS AND THEY SHOULD DEFINITELY BE PREPARED TO FOLLOW UP WITH A PROFESSIONAL AND UNDERGO FURTHER GENETIC TESTING. A COUPLE OTHER THINGS I’D LIKE TO NOTE HERE. THE GENETIC HEALTH TESTS ARE INCREASINGLY BEING USED IN PHARMACOGENOMICS, STUDY OF HOW GENES IMPACT RESPONSES TO PHARMACEUTICAL DRUGS, ALTHOUGH FDA HAS CAUTIONED AGAINST THE USE OF MOST DTC PHARMACOGENOMIC TESTS, AND ANOTHER POINT IS THAT FOR ADOPTEES OR PEOPLE WHO DON’T KNOW MUCH ABOUT THEIR FAMILY MEDICAL HISTORY, DTC TESTING CAN BE A REALLY GREAT LOW EFFORT WAY TO BEGIN TO DO SOME INVESTIGATION. BUT, AGAIN, CONSULTING A PROFESSIONAL IS ALWAYS ADVISABLE. SO I WANT TO ADDRESS SOME OF THE OTHER HEALTH-RELATED TESTS I MENTIONED ABOVE. FOR EXAMPLE, THOSE THAT CLAIM TO TEST FOR ATHLETIC ABILITY, OPTIMAL DIET, PALATE, PERSONALITY, ET CETERA. MANY OF THESE TESTS ARE BASED ON A KERNEL OF TRUTH. WHAT THEY CLAIM TO BE ABLE TO TELL A TESTER IN ADVERTISEMENTS IS USUALLY FAR BEYOND WHAT COULD BE RESPONSIBLY ASCERTAINED FROM WHAT THEY ARE TESTING. SO, FOR EXAMPLE, THERE ARE CERTAINLY GENETIC VARIANTS THAT CONTRIBUTE TO ABILITY TO RUN FAST, FOR LONG DISTANCES. HOWEVER, IN GENERAL WE KNOW VANISHINGLY LITTLE ABOUT GENETICS OF INNATE ABILITIES, A HAVE THE ENVIRONMENTAL FACTORS LIKE UPBRINGING ARE MORE INFLUENTIAL. OPTIMAL DIET, CAN DETECT VARIANTS ASSOCIATED WITH CELIAC DISEASE, DOESN’T MEAN IT CAN TELL YOU WHETHER YOU SHOULD GO ON A KETODIET OR PALEODIET OR CABBAGE SOUP DIET, MAY SELL YOU IF YOU THINK CILANTRO IS DELICIOUS AND IS IT NECESSARY TO HAVE A TEST TO TELL YOU WHAT FOODS YOU LIKE? WE DON’T KNOW ENOUGH ABOUT GENETICS OR ETIOLOGY OF TALENT, PERSONALITY, FOR TESTS TO BE ACCURATE. THEY ARE NOT PARTICULARLY LIKELY TO CAUSE HARM TO A TESTER AND COULD BE TAKEN AS A FUN BIT OF INFOTAINMENT ASSUMING ISSUES THAT APPLY TO GENETIC TESTS ARE CONSIDERED CAREFULLY. I’M GOING TO TREAT THIS LAST SECTION WHICH DEALS WITH PRIVACY, REGULATIONS AND OTHER ETHICAL CONCERNS AROUND DTC TESTING AS AN FAQ FORMAT TO MIX THINGS UP. WHO IS RESPONSIBLE FOR REGULATION AND OVERSIGHT OF DTC TESTS TO ENSURE THEY ARE VALID? THE UNDERSTAND IS ACTUALLY VERY LITTLE REGULATION OR OVERSIGHT OF THESE TESTS WHICH I ALLUDED TO BEFORE. SO THE FDA AND CENTERS FOR MEDICARE AND MEDICAID SERVICES HAVE PRIMARY AUTHORITY TO REGULATE GENETIC TESTS AND EVALUATE THEM. HOWEVER, IN PRACTICE, THERE’S VERY LITTLE REGULATION OR EVALUATION OF DTC TESTS IN THE UNITED STATES. IN GENERAL, ONLY DTC TESTS FOR MODERATE TO HIGH RISK MEDICAL PURPOSES ARE REVIEWED BY THE FDA FOR VALIDITY BEFORE BEING OFFERED TO CONSUMERS, AND TO DATE THE FDA HAS ONLY EVALUATED AND GRANTED MARKETING AUTHORIZATION FOR FOUR DIFFERENT MEDICAL TESTS FROM THE COMPANY GENETIC VARIANTS. THE FDA DOES NOT REVIEW WHAT IT CALLS LOW RISK GENERAL WELLNESS TESTS OR ANCESTRY TESTS. NEXT QUESTION, WHO CAN SEE MY GENETIC INFORMATION WHEN I USE THE DTC GENETIC TESTING COMPANY OR THIRD PARTY DATABASE? WHO OWNS THE DATA? WHAT CAN THEY DO WITH IT? THIS IS A COMPLICATED ONE. THE ANSWER TO THIS QUESTION LARGELY DEPENDS ON THE COMPANY AND THEIR POLICIES. SO SOME COMPANIES’ POLICIES MEAN THEY ESSENTIALLY OWN YOUR DATA FOREVER AND THEY CAN DO WHATEVER THEY WANT WITH IT. OTHER COMPANIES SAY THEY WILL NOT SHARE OR SELL YOUR INFORMATION AT ALL. ANOTHER IMPORTANT POINT HERE IS THAT DTC COMPANIES AREN’T COVERED BY HIPAA REGULATIONS ABOUT HEALTH INFORMATION. WHO CAN ACCESS YOUR GENETIC INFORMATION AFTER YOU TEST ALSO VARIES BETWEEN COMPANIES. READING THE FINE PRINT IS VERY IMPORTANT. ONE ANALYSIS OF 30 COMPANIES’ PRIVACY POLICIES FOUND MOST DIDN’T MEET STANDARDS OF TRANSPARENCY AND DISCLOSURE AND POLICIES CAN CHANGE. SO GENERALLY YOUR GENETIC DATA WILL BE ANONYMIZED BUT THIS IS NOT A COMPLETE GUARANTEE OF PRIVACY. GENETIC DATA FROM THESE COMPANIES’ DATABASES MAY BE PURCHASABLE BY THIRD PARTY RESEARCHERS OR ACCESSIBLE TO A CERTAIN EXTENT BY LAW ENFORCEMENT AGENCIES. FOR EXAMPLE, IN 2018 A FAMILY TREE CHANGED ITS TERMS OF SERVICE TO ALLOW LAW ENFORCEMENT OFFICIALS TO ACCESS THEIR DATABASES TO SOLVE CRIMES. THIS RAISED CONCERNS OVER ONE MILLION PEOPLE WHO USED SERVICES TO THAT POINT HAD NOT GIVEN AUTHORITY. USERS CAN OPT OUT TO BE USED BY LAW ENFORCEMENT AFFILIATED ACCOUNTS, BUT NOTE THAT’S AN OPT OUT, NOT AN OPT IN. GEN MATCH, WHERE INDIVIDUALS CAN UPLOAD FROM OTHERS FOR ADDITIONAL INTERPRETATION ALLOWS ACCESS BY LAW ENFORCEMENT AND GENEALOGY RESEARCHERS TO ITS DATABASES. IT DOES GIVE USERS SOME CONTROL ABOUT HOW MUCH INFORMATION IS AVAILABLE TO OTHERS ONLINE. PRIVACY OF MINORS IS A CONCERN HERE. DTC TESTING OF MINORS RAISES SERIOUS ISSUES AROUND PRIVACY AND ETHICS, PARTICULARLY IF ADULT ONSET DISEASES WITH NO AVAILABLE PREVENTIVE TREATMENTS ARE BEING TESTED FOR AND OF COURSE OWNERSHIP OF AND ACCESS TO GENETIC DATA ARE ALSO CONCERNS. FINALLY A FEW STUDIES HAVE DEMONSTRATED THAT EVEN ANONYMIZED GENETIC DATA CAN BE REVERSE ENGINEERED, USING FORENSIC TECHNIQUES TO REVEAL IDENTITY, DONE IN — I SEE YOUR COMMENT. THIS HAS BEEN USED IN A BUNCH OF SORT OF RECENT CASES, THERE’S BEEN SOME PODCASTS DONE ABOUT THESE CASES WHERE LAW ENFORCEMENT HAS USED GENEALOGIC DNA TECHNIQUES TO LOOK AT FAMILIAL RELATIONSHIPS AND ACTUALLY IDENTIFY SUSPECTS. SO SOMETIMES ANONYMIZED GENETIC DATA WITH BE REVERSE ENGINEERED TO REVEAL IDENTITY, AND COMBINED WITH EVER PRESENT PERFORMANCE TONINGS FOR MAJOR DATA BREACHES THIS IS A CONCERN FOR SOME PEOPLE. AS WITH ANY FORM OF PRIVATE OR MEDICAL DATA, USERS SHOULD MAKE THEMSELVES FAMILIAR WITH HOW A COMPANY PLANS TO MANAGE THE DATA, HOW IS IT BEING STORED, SHARED, KEPT SECURE. THAT WAS A LONG ANSWER, A COMPLICATED QUESTION. THE NEXT QUESTION IS, IF I’VE ALREADY TESTED, NOW I HAVE PRIVACY CONCERNS, CAN I HAVE THE COMPANY DELETE MY ACCOUNT AND MY DATA? THE ANSWER HERE IS MAYBE. OR MAYBE NOT. THE POLICY AND HOW TO ACCOMPLISH THIS AGAIN DEPENDS ON THE COMPANY. AND IN SOME CASES THIS IS REALLY DIFFICULT OR SOMETIMES IMPOSSIBLE TO DO. YOU MAY NEED TO CONTACT THE COMPANY DIRECTLY TO FIND OUT HOW. COMPANIES CAN SHARE OR SELL INFORMATION, DEPENDING ON THE TERMS OF THOSE AGREEMENTS YOU MAY LOSE ANY RIGHT TO REQUEST TO HAVE YOUR INFORMATION REMOVED FROM THOSE COMPANIES THAT PURCHASED THE DATA FROM THE ORIGINAL COMPANY. ANOTHER COMMON CONCERN CAN MY INSURANCE COMPANY INCREASE MY RATES OR DROP MY COVERAGE IF I TAKE A GENETIC HEALTH TEST AND FIND OUT I’M AT RISK FOR A DISEASE, OR COULD MY EMPLOYER FIRE ME? THE ANSWER IS MAYBE. FEDERAL REGULATIONS IN THE FORM OF GENETIC INFORMATION NON-DISCRIMINATION ACT, GINA, PROTECT CONSUMERS FROM SOME EMPLOYER OR INSURANCE PROVIDER DISCRIMINATION DUE TO GENETIC TEST RESULTS. HOWEVER BIG HOWEVER, THESE REGULATIONS DON’T APPLY TO CERTAIN EMPLOYERS OR PROVIDERS OF SOME TYPES OF INSURANCE. GINA DOES NOT APPLY TO LIFE INSURANCE, DISABILITY OR LONG TERM CARE INSURANCE. ALSO DOESN’T PROTECT THOSE WHO ARE INSURED THROUGH THE FEDERAL GOVERNMENT OR MILITARY AND SMALL BUSINESSES WITH FEWER THAN 15 EMPLOYEES ARE EXEMPT. SOME STATES HAVE STEPPED IN TO STRENGTHEN PROTECTIONS, BUT IN GENERAL THIS AREA IS SORT OF UNDERLEGISLATURED AND INDIVIDUALS COULD HAVE DIFFICULTY OBTAINING CERTAIN TYPES OF INSURANCE. THE
NEXT QUESTION IS CAN OTHER COMPANIES USE MY HEALTH INFORMATION TO MARKET ME PRODUCTS LIKE PHARMACEUTICALS? THIS IS NOT HAPPENING YET BUT COULD HAPPEN IN THE FUTURE. SOME DATABASES DO ALLOW RESEARCHERS INCLUDING PHARMACEUTICAL COMPANIES TO ACCESS ANONYMIZED GENETIC INFORMATION. THE ANONYMITY OF DATA IS CURRENTLY PROHIBITIVE TO INDIVIDUALIZED MARKETING EFFORTS BY PHARMACEUTICAL COMPANIES, THIS COULD CHANGE AS DTC TESTING COMPANIES FORGE CLOSER RELATIONSHIPS WITH PHARMACEUTICAL COMPANIES. THIS IS AN INTERESTING ONE TO ME. WHAT MIGHT THE EFFECTS OF GENEALOGICAL DNA BE ON SPERM AND EGG DONATION AND ADOPTION? SOME EXPERTS BELIEVE THAT GAMETE DONOR ANONYMITY IS NO LONGER POSSIBLE. BIOLOGICAL PARENTS, SPERM AND EGG DONORS, CAN BE IDENTIFIED EVEN IF ANONYMOUS PARENTS HAVEN’T HAD DNA TESTING DONE OR UPLOADED DNA, THERE’S LITTLE INCENTIVE FOR ANONYMOUS DONATION ANYMORE. EVEN INDIVIDUALS WHO MIGHT NOT KNOW THEY HAD DONOR PARENTAGE COULD DISCOVER THIS PARENTAGE AND POTENTIALLY IDENTIFY THE DONOR PARENT THROUGH DNA TESTING. A SIMILAR SITUATION EXISTS FOR ADOPTEES WITH SEALED BIRTH RECORDS, DESPITE RECORDS BEING SEALED THEY MAY BE ABLE TO IDENTIFY THEIR PARENTS THROUGH GENEALOGICAL DNA TESTING. SO NOW THAT FINISHES UP THAT SECTION. BEFORE I MOVE TO GIVE YOU GENETIC INFORMATION RESOURCES, I WANT TO SUMMARIZE THE THINGS WE’VE LEARNED TODAY FOR A MOMENT. THESE ALIGN CLOSELY WITH THE FDA’S RECOMMENDATIONS FOR PEOPLE CONSIDERING DTC TESTING. NUMBER ONE, UNDERSTAND THE POTENTIAL BENEFITS, RISKS, AND LIMITATIONS OF ANY TEST BEFORE USE. READ THE FINE PRINT. NUMBER TWO, DISCUSS TEST RESULTS WITH YOUR HEALTH CARE PROVIDER AND POTENTIALLY A GENETIC COUNSELOR OR MEDICAL GENETICIST BEFORE MAKING HEALTH-RELATED DECISIONS. NUMBER THREE UNDERSTAND THE RELATIONSHIP BETWEEN GENETIC RISK AND ACTUAL DISEASE DEVELOPMENT IS HIGHLY COMPLEX. NEGATIVE TEST DOESN’T MEAN YOU WON’T DEVELOP A PARTICULAR CONDITION. DOESN’T MEAN THAT YOU SHOULD STOP PREVENTIVE CARE AND SCREENINGS. POSITIVE RESULT CAN BE UPSETTING BUT DOESN’T ALWAYS MEAN YOU WILL DEVELOP THAT DISEASE OR CONDITION AND DOESN’T USUALLY PROVIDE MUCH INFORMATION ABOUT DISEASE PROGRESSION. NUMBER FOUR, REMEMBER THAT ALTHOUGH GINA OFFERS SOME PROTECTION, RESULT COULD IMPACT YOUR PURCHASE OF LIFE, DISABILITY, LONG-TERM CARE INSURANCE. NUMBER FIVE, REMEMBER THAT DTC TESTS ARE NOT A SUBSTITUTE FOR REGULAR HEALTH CARE. NUMBER SIX, REMEMBER THAT PRIVACY POLICIES CAN VARY WIDELY BETWEEN COMPANIES. READ THE FINE PRINT. OVERALL, THE TWO BIGGEST TAKEAWAYS ARE CONSULT A PROFESSIONAL, AND READ THE FINE PRINT. SO I’M GOING TO SHARE WITH YOU A FEW INFORMATION RESOURCES THAT CAN BE USEFUL FOR LEARNING MORE ABOUT GENETICS AND GENETIC TESTING. THESE RESOURCES AS WELL AS QUITE A FEW MORE CAN BE FOUND ON THE RESOURCES HANDOUT THAT’S BEEN LINKED IN THE CHAT AND WILL BE SENT OUT WITH THE RECORDING OF THIS PRESENTATION. SO MedlinePlus IS THE NATIONAL LIBRARY OF MEDICINE’S PRIMARY CONSUMER HEALTH INFORMATION RESOURCE WITH PAGES ABOUT GENETIC DISORDERS, GENETIC TESTING AND COUNSELING AND MORE. GENETICS HOME REFERENCE IS ANOTHER NATIONAL LIBRARY OF MEDICINE RESOURCE, IT HAS EXTENSIVE INFORMATION ABOUT GENETICS RANGING FROM INTRODUCTORY LEVEL TO MORE ADVANCED LEVEL AS WELL AS CLASSROOM RESOURCES AND GALLERY OF PUBLIC DOMAIN BIOMEDICAL IMAGES AND DIAGRAMS. NATIONAL INSTITUTES OF HEALTH’S NATIONAL HUMAN GENOME RESEARCH INSTITUTE, NHGRI, PROVIDES LOTS OF INFORMATION ABOUT GENOMICS AND A GLOSSARY OF GENETICS TERMINOLOGY AS WELL AS INFORMATION ABOUT RESEARCH AND RESEARCH FUNDING, INFORMATION FOR PATIENTS AND FAMILIES, AND INFORMATION FOR HEALTH PROFESSIONALS. THEIR EDUCATION SECTION HAS RESOURCES FOR K-12 STUDENTS AND EDUCATORS INCLUDING LESSON PLANS. THERE’S GENETIC TESTING FAQ PAGE WHICH MAY BE OF INTEREST. NATIONAL CANCER INSTITUTE HAS INFORMATION ABOUT GENETICS AS RELATES TO CANCER AS WELL AS CANCER TERMS GLOSSARY AND GENETICS DICTIONARY. GENETIC AND RARE DISEASES INFORMATION CENTER IS A GOOD SOURCE OF INFORMATION ON THE GENETICS OF HUNDREDS OF DIFFERENT DISEASES. THE NATIONAL ORGANIZATION FOR RARE DISORDERS PROVIDES LOTS OF INFORMATION ABOUT RARE DISEASES INCLUDING GENETICS, FOR BOTH PATIENTS AND FAMILIES, CLINICIANS AND RESEARCHERS. FOOD AND DRUG ADMINISTRATION, FDA, OFFERS GUIDANCE ON DIRECT TO CONSUMER TESTING, INCLUDING GENETIC TESTS, AND INFORMATION ABOUT FDA OVERSIGHT OF THESE TESTS SO YOU CAN GO ON THERE AND THEY HAVE A TABLE OF WHICH DTC TESTS HAVE UNDERGONE FDA REVIEW WHICH AS I MENTIONED EARLIER THERE’S ONLY FOUR TESTS RIGHT NOW. AND I MENTIONED THAT ONE OF THE MAIN TAKEAWAYS FROM TODAY WAS ALWAYS CONSULT A HEALTH CARE PROFESSIONAL. AND IN A LOT OF CASES, IT’S GOOD TO CONSULT A GENETIC PROFESSIONAL, SPECIFICALLY, BECAUSE NOT ALL PRIMARY CARE PROVIDERS ARE GOING TO HAVE THE GENETIC EXPERTISE TO REALLY HELP PEOPLE INTERPRET THEIR RESULTS. SO I HAVE HERE SOME RESOURCES FOR HELPING PEOPLE LOCATE GENETIC COUNSELORS WHO CAN PROVIDE GUIDANCE IN MAKING DECISIONS ABOUT AND INTERPRETING GENETIC TESTS. GENETICS HOME REFERENCE AGAIN HAS TIPS ON LOCATING PROFESSIONAL ASSISTANCE IN DNA TESTING. GENETIC AND RARE DISEASES INFORMATION CENTER PROVIDES GUIDE TO FINDING SPECIALISTS IN PARTICULAR GENETIC AND RARE CONDITIONS. NATIONAL SOCIETY OF GENETIC COUNSELORS OFFERS INFORMATION ABOUT GENETIC COUNSELORS AND SEARCHABLE DIRECTOR FOR UNITED STATES AND CANADA. AMERICAN BOARD OF GENETIC COUNSELING PROVIDES A SEARCHABLE DIRECTOR OF CERTIFIED GENETIC COUNSELORS WORLDWIDE. AMERICAN COLLEGE OF MEDICAL GENETICS AND GENOMICS HAS A SEARCHABLE DATABASE OF MEDICAL GENETICS CLINIC SERVICES IN THE U.S. THEY PROVIDE A LIST OF RECOMMENDED CONSIDERATIONS FOR PEOPLE THINKING ABOUT GENETIC TESTING, VIA CHOOSING WISELY CAMPAIGN, AND THEY PUBLISHED AN INTERESTING POSITION STATEMENT, BOTH LINKED IN THE RESOURCES HANDOUT. THAT CONCLUDES MY WHIRLWIND TOUR OF DTC GENETIC TESTING. WE CRAMMED A LOT INTO 50 MINUTES. WE HAVE 10 MINUTES LEFT, AND I’M GOING TO TAKE A DRINK AND SCROLL THROUGH THE CHAT BOX TO SEE WHAT SORTS OF QUESTIONS WE CAN ANSWER. ANNETTE, I SEE YOUR COMMENT ABOUT 23ANDME GETTING MORE ACCURATE OVER THE PAST SIX YEARS. THAT’S DEFINITELY TRUE. COMPANIES ARE INCREASING THEIR SAMPLE SIZES AND OBVIOUSLY AS YOUR REFERENCE SAMPLES, AS YOU HAVE MORE OF THEM, THEY WILL BE BETTER TO COMPARE TO. SO IT’S DEFINITELY NOT SURPRISING TO SEE THAT THOSE ESTIMATES ARE IMPROVING. IT’S ALWAYS INTERESTING TO COMPARE WHAT YOU KNOW FROM YOUR GENEALOGICAL RESEARCH ON YOUR FAMILY WITHOUT DNA TO WHAT YOU’RE FINDING FROM YOUR GENETIC TESTS, YEAH. LET’S SEE. OH, CECILIA LINKED A BOOK. COOL. ONE OF MY FAVORITE BOOKS COVERING THE NUANCES OF GENETIC GENEALOGY. THAT LOOKS LIKE A GREAT RECOMMENDATION. THANK YOU FOR SHARING THAT WITH EVERYONE. CAROL, THAT IS A GREAT QUESTION. OKAY, CAROL ASKS, ONE, ACCURACY AND VALIDITY AND CREDIBILITY CAN BE DIFFERENT IN TERMS OF SELECTION, WHICH PRODUCT SHOULD I PURCHASE. SINCE THESE TESTS ARE BEING PRODUCED BY A VARIETY OF COMPANIES, IS THERE A WAY TO EVALUATE THE CREDIBILITY OF THE PRODUCTS SIMILAR TO, SURE, THE CRAFT TESTS FOR EVALUATING THE CREDIBILITY OF THE WEBSITE. SO IN GENERAL, THE LARGER AND MORE WELL ESTABLISHED COMPANIES ARE GOING TO BE MORE RELIABLE, SO AGAIN I’M NOT GIVING SPECIFIC RECOMMENDATIONS BUT IF YOU HAVEN’T HEARD OF THE COMPANY BEFORE, THAT’S PROBABLY A GOOD BET THAT THERE MAY BE NEWER OR LESS ESTABLISHED POTENTIALLY SKETCHY. LET’S SEE, DEFINITELY CHECK WITH THE FDA. THEY ALWAYS UPDATE THEIR LIST OF WHAT THEY HAVE EVALUATED. AND JUST READ THE FINE PRINT AND JUST, YOU KNOW, DO YOUR RESEARCH SO YOU KNOW WHAT YOU’RE HOPING TO GET OUT OF THE TEST. ONE THING I WILL MENTION FOR ANCESTRY TESTING THAT CAN BE HELPFUL, SOME COMPANIES ARE GOING TO HAVE MORE REFERENCE SAMPLES IN CERTAIN AREAS, SO SOME COMPANIES MAY BE FOCUSED SPECIFICALLY, THERE’S ONE COMPANY THAT REALLY LOOKS AT THE BRITISH ISLES, AND SO IF YOU DON’T HAVE — IF YOU KNOW YOU DON’T HAVE A LOT OF ANCESTRY FROM THERE MAYBE DON’T GO WITH THAT TEST. READ THE PRIVACY POLICIES AS WELL. AND SEE HOW YOU FEEL ABOUT HOW ACCESSIBLE THEY ARE MAKING THIS INFORMATION. IS IT EASY FOR YOU TO FIND EXACTLY WHAT THEY ARE DOING? OR ARE THEY BEING A LITTLE BIT MORE SECRETIVE OR VAGUE ABOUT IT, I THINK THOSE WOULD BE HELPFUL THINGS TO LOOK AT. CAROL’S SECOND QUESTION, TO YOUR KNOWLEDGE HAVE ANY SITES BEEN HACKED? IF SHOW, BASED ON DISCLAIMERS, COMPROMISED PRIVACY SEEMS TO BE A SIMPLE RISK TO BE CONSIDERED BEFORE PURCHASING. I’M PERSONALLY NOT AWARE OF ANY OF THESE MAJOR COMPANIES BEING HACKED ALTHOUGH IF SOMEONE IS AWARE PLEASE DEFINITELY SHARE THAT IN THE CHAT BOX. BUT AS ALWAYS, ANYTIME YOU’RE SHARING POTENTIALLY IDENTIFIABLE HEALTH INFORMATION ONLINE, THAT’S DEFINITELY A MAJOR CONSIDERATION. AND I SEE HELEN, YOU’VE ASKED — I ASSUME YOU’RE ASKING IF I’VE TAKEN THE TEST. I HAVE NOT TAKEN THE TEST. FOR ME, I’M NOT SUPER INTERESTED IN GENEALOGY AND WHAT NOT. I HAVE A LOT OF CONCERNS ABOUT PRIVACY AS WELL AS SCIENTIFIC ACCURACY. SO YEAH, THOSE ARE THE REASONS I HAVEN’T. DEFINITELY PRIVACY IS A CONSIDERATION. I MEAN OBVIOUSLY SOME PEOPLE DON’T HAVE A TON OF PRIVACY CONCERNS, AND I THINK AS LONG AS THEY ARE MAKING AN INFORMED DECISION I THINK THAT’S OKAY. I THINK IT’S OUR JOB TO HELP PEOPLE KNOW WHERE TO FIND INFORMATION THAT THEY CAN RELY ON TO MAKE THOSE INFORMED DECISIONS. LET’S SEE. SUSAN SAYS SHE HASN’T TAKEN A TEST BUT A COUSIN DID, AND HER RESULTS VERIFIED A FAMILY RUMOR, WE’VE ALWAYS THOUGHT THEY WERE CONDITION CATHOLICS BUT THEY ARE JEWS, THAT’S INTERESTING. I FIND IT — I HAVEN’T TAKEN THE TEST BUT FIND IT FASCINATING TO READ ALL THOSE STORIES ABOUT REALLY COOL AND INTERESTING THINGS THAT PEOPLE HAVE LEARNED FROM THEIR TESTS AND HAVE BEEN ABLE TO CONFIRM THROUGH FURTHER GENEALOGICAL RESEARCH SOMETIMES. YEAH, SO LOOKS LIKE I’M AT THE BOTTOM OF THE CHAT. DOES ANYONE ELSE HAVE ANY QUESTIONS? WELL, IF NOT, REMEMBER TO PLEASE COMPLETE THE COURSE EVALUATION WHEN YOU LEAVE THE WEBINAR. IF IT DOESN’T POP UP, SEND ME AN E-MAIL AND I’LL GIVE YOU THE DIRECT LINK TO IT. A VERSION OF THE COURSE WILL ALSO BE OFFERED IN THE FUTURE SO IF YOU HAVE SUGGESTIONS FOR THINGS THAT YOU DIDN’T HEAR ABOUT TODAY THAT YOU WOULD LIKE TO HAVE SEEN COVERED OR I COVERED SOMETHING BUT YOU WANT TO HEAR MORE OR LESS ABOUT IT, FEEL FREE TO LET ME KNOW IN THE COMMENTS OF THE EVALUATION SO THAT I CAN IMPROVE THIS COURSE FOR THE FUTURE. AND THANK YOU SO MUCH FOR COMING TODAY. I KNOW THINGS ARE A LITTLE BIT WEIRD IN THE WORLD RIGHT NOW BUT I APPRECIATE YOU TAKING TIME OUT OF YOUR DAY TO COME TO THIS COURSE AND PLEASE HAVE A GREAT REST OF YOUR AFTERNOON AND STAY HEALTHY, OKAY? THANKS, EVERYONE. THANKS FOR WATCHING. THIS VIDEO WAS PRODUCED BY THE NATIONAL NETWORK OF LIBRARIES OF MEDICINE. SELECT THE CIRCULAR CHANNEL ICON TO SUBSCRIBE TO OUR CHANNEL. SELECT A VIDEO THUMBNAIL TO WATCH ANOTHER VIDEO FROM THE CHANNEL.

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