Approaches to Providing Quality Testing for Rare

Genetic Diseases

The

Experience 2000-present

Background of the Company Founded by two long-time NIH researchers

Identified molecular basis of several rare hereditary skin disorders

Frustrated by inability to provide diagnostic, carrier, and prenatal testing (due to regulatory issues, lack of resources)

Getting our ducks in a rowCOMMERCIAL ENTITY Get finances in order, find space CLIA-certification and Maryland State License Obtain professional liability insurance Develop company website Connect with GeneTests Decide what our relationship to 3rd party payers

(health insurance) would be

Development of the Test Menu

Initial test menu included tests for 16 rare hereditary skin disorders

Within 1 month, NIH researchers asked GeneDx to provide testing for a rare hereditary periodic fever syndrome

At three months - requests from research labs to confirm mutations in CLIA setting and provide carrier tests to family members

Building the Test Menu

At the request of NIH investigators, we licensed a test for Familial Mediterranean Fever from NIH

Started getting requests from many researchers at the NIH (and elsewhere) to consider their favorite genes for our menu

Requests from patient support groups to develop testing for their disorder

Choosing the genes to add Strong evidence of clinical utility

High sensitivity (e.g. high percentage of individuals with the clinical diagnosis will have identifiable mutation)

Availability of expert clinician to serve as advisor

‘do-able’ by our methods Expect minimum of 10 cases/year Could be done at an affordable price for

patients < $3000

Personnel Clinical Director (Board-certified Ph.D.-Medical Geneticist) Scientific Director (Molecular Biology/Genetics Ph.D.) Director of Clinical Lab Operations (Board-eligible Ph.D. Molecular Diagnostics) Genetic Counselor (Board-certified MS, CGC)

Services Offered Diagnostic testing Carrier testing Pre-symptomatic testing (Gorlin Syndrome, Multiple

endocrine neoplasia 2A/FMTC, Familial Isolated hyperparathyroidism, etc., Peutz-Jeghers Syndrome, Carney

Complex) Custom mutation confirmation Prenatal testing (on menu and custom) Legal Research support Training

Test Development Development of information sheet and consent

document Review by Clinical Advisor Test developed in R&D Positive and negative report templates developed Proficiency testing plan developed Test transferred from R&D lab to clinical lab Test added to GeneDx website and listed on

GeneTests Patient support groups/research labs notified (if

relevant)

Growth history 2000 (9 months)

166 tests 2001

470 tests 2002

1313 tests 2003

2538 tests 2004

924 tests in Q1 4000 tests anticipated in 2004

Problems encountered

Reinventing the wheel consent prenatal testing proficiency testing getting CLIA to understand what we do

Sky-rocketing liability insurance costs $1500 in 2000 $40,000 in 2004

Licensing issues HIPAA

understanding how it impacts us

Current Test MenuCongenital Ichthyoses ____ Lamellar ichthyosis (TGM1) ____ Sjögren-Larsson syndrome (FALDH) ____ Epidermolytic hyperkeratosis (KRT1, KRT10) ____ Ichthyosis bullosa of Siemens (KRT2e) ____ Vohwinkel syndrome (GJB2; connexin26) ____ Erythrokeratoderma variabilis (GJB3, connexin31; GJB4, connexin30.3)

Other Keratin Disorders Pachyonychia congenita ____ KRT16, KRT6a (PC1) ____ KRT17, KRT6b (PC2) ____ Epidermolytic PPK of Vörner (KRT9) ____ Unna-Thost disease (KRT1, KRT16) ____ White sponge nevus (KRT4, KRT13) ____ Steatocystoma multiplex (KRT17) ____ Epidermolysis Bullosa Simplex (KRT5, KRT14)

Current Test MenuEctodermal Dysplasia syndromes ____ X-linked hypohidrotic ED (EDA1 aka ED1, EDA) ____ Autosomal rec/dom hypohidrotic ED (EDAR) ____ Clouston syndrome (GJB6, connexin30) ____ Ectrodactyly-ED-Clefting (TP63, p63) ____ Hay-Wells (TP63, p63)

Periodic Fever Syndromes ____ Familial Mediterranean Fever (MEFV) ____ Familial Hibernian Fever / TRAPS (TNFRSF1A) ____ Hyper- IgD Syndrome (MVK) ____ Muckle-Wells /Familial Cold Urticaria/NOMID (CIAS1)

Current Test MenuImmune Deficiency Disorders Chronic Granulomatous Disease ____ X-linked (CYBB) and common recessive (NCF1) ____ Other autosomal recessive (NCF2, CYBA) Severe Combined Immunodeficiency (autosomal recessive) ____incl. Omenn Syndrome (RAG1 and RAG2) ____Jak3 Deficiency (JAK3) ____ X-linked agammaglobulinemia (BTK) ____ Leukocyte Adhesion Deficiency (ITGB2)

Bone Marrow Failure Syndromes ____ Fanconi Anemia (FANCA) cDNA sequence analysis ____ Congenital amegakaryocytic thrombocytopenia (MPL) ____ Shwachman-Diamond Syndrome (SBDS) ____ Congenital and cyclic neutropenia (ELA2) ____ Dyskeratosis Congenita, X-linked (DKC1) ____ Dyskeratosis Congenita, Autosomal (hTR) ____ Diamond-Blackfan anemia (RPS19)

Current Test MenuCancer-Associated Syndromes ____ Gorlin syndrome (PTCH) ____ Cowden syndrome (PTEN) ____ Bannayan-Riley-Ruvalcaba syndrome (PTEN) ____ Multiple endocrine neoplasia type 1 (MEN1,Menin) ____ Multiple endocrine nepoplasia type 2A/ Familial Medullary Thyroid Carcinoma (RET) ____ Multiple endocrine neoplasia 2B (RET) Hyperparathyroidism-Jaw Tumor Syndrome/ Parathyroid

carcinoma/Familial Isolated Hyperparathyroidism (HRPT2) ____ Tier 1 ___ Tier 2 ____Entire gene Familial Cutaneous Malignant Melanoma ____CDKN2A/ p16 ____ CDK4 ____ Both ____ Peutz-Jeghers syndrome (STK11) ____ Carney Complex (PRKAR1A)

Hereditary Rickets ____ X-linked dominant hypophosphataemia (PHEX) ____ Autosomal dom. hypophosphataemia (FGF23) ____ Autosomal rec. Vit. D dependent rickets (CYP27B1) Alagille Syndrome (JAG1) ____ Tier 1 ____ Tier 2 if Tier 1 is negative Coffin-Lowry syndrome (RSK2) _____Tier 1 ____Tier 2 if Tier 1 is negative Hermansky-Pudlak Syndrom (HPS1 and/or HPS3) ____ HPS1 and HPS3 Puerto Rican mutations ____ HPS3 Ashkenazi splice mutation Hereditary multiple exostoses (EXT1 and EXT2) _____ EXT1 only _____ EXT2 if EXT1 is negative _____ Both EXT1 and EXT2 Noonan Syndrome (PTPN11) _____ Exons 3 and 8 only _____ Remainder of gene (if 3 and 8 negative) _____ Entire PTPN11 gene

Current Test Menu

Current Test Menu Other Disorders ____ Alexander Disease (GFAP) ____ Androgen Insensitivity Syndrome (AR) ____ Cartilage-Hair Hypoplasia (RMRP) ____ Dent Disease/ X-linked rec nephrolithiasis (CLCN5) ____ Dopa-Responsive Dystonia (GCH1) ____ Fabry Disease (GLA) ____ Hereditary angioedema (C1NH) ____ Hirschsprung Disease (RET) ____ Holt-Oram (TBX5) ____ Holoprosencephaly (SHH, ZIC2, SIX3, TGIF) ____ LEOPARD Syndrome (PTPN11, exons 7 and 12) ____ Mucolipidosis Type IV (MCOLN1) ____ Nemaline myopathy (ACTA1) ____ Popliteal Pterygium Syndrome (IRF6) ____ Pseudoachondroplasia/Mult Epiphyseal Dys (COMP) ____ VanderWoude Syndrome (IRF6) ____ X-linked Hydrocephalus (L1CAM) ____ XY Female Gonadal Dysgenesis (SRY sequencing)

GeneDx in October 2003