Letters to the Editor

Note added in proof. -Evidence has been reported on the effect of chemical carcinogens in causing an increased frequency oftumors in rats carrying the Eker renal cell tumor susceptibility gene (Walker et al. 1992). CHARLES E. JACKSON Henry Ford Hospital Division of Clinical and Molecular Biology Department of Medicine Detroit References Baylin SB, Hsu SH, Gann DS, Smallridge RC, Wells SA Jr (1978) Inherited medullary thyroid carcinoma: a final monoclonal mutation in one ofmultiple clones of susceptible cells. Science 199:429-431 Cavenee WK, Dryja TP, Phillips RA, Benedict WF, Godbout R, Gallie BL, Murphree AL, et al (1983) Expression of recessive alleles by chromosomal mechanisms in retinoblastoma. Nature 305:779-784 Jackson CE, Block MA, Greenawald KA, Tashjian AH Jr (1979) The two-mutational-event theory in medullary thyroid cancer. Am J Hum Genet 31:704-710 Jackson CE, Norum RA (1989) Genetic mechanisms of neoplasia in MEN 2. Henry Ford Hosp Med J 37:116-119 Jackson CE, Talpos GB, Block MA, Norum RA, Lloyd RV, Tashjian AH Jr (1984) Clinical value of tumor doubling estimations in multiple endocrine neoplasia type II. Surgery 96:981-986 Jackson CE, Tashjian AH Jr, Block MA (1973) Detection of medullary thyroid cancer by calcitonin assay in families. Ann Intern Med 78:845-852 Knudson AG Jr (1971) Mutation and cancer: statistical study of retinoblastoma. Proc Natl Acad Sci USA 68:820823

Mathew CGP, Chin KS, Easton DF, Thorpe K, Carter C, Liou GI, Fong S-L, et al (1987) A linked genetic marker for multiple endocrine neoplasia type 2A on chromosome 10. Nature 328:527-528 Ponder BAJ, Smith BA, Marcus EM, Nakamura Y, Landsvater RM, Buys CHCM, Mathew CGP (1989) Genetic events in tumorigenesis in multiple endocrine neoplasia type 2. In: Furth M, Greaves M (eds) Molecular diagnostics of human cancer, vol 7: Cancer cells. Cold Spring Harbor Laboratories, Cold Spring Harbor, NY, pp. 219221

Simpson NE, Kidd KK, Goodfellow PJ, McDermid H, Myers S, Kidd JR, Jackson CE, et al (1987) Assignment of multiple endocrine neoplasia type 2A to chromosome 10 by linkage. Nature 328:528-530 Swift M, Morrell D, Massey RB, Chase CL (1991) Incidence of cancer in 161 families affected by ataxia-telangiectasia. N Engl J Med 325:1831-1836.

1351 Walker C, Goldsworthy TL, Wolf DC, Everitt J (1992) Predisposition to renal cell carcinoma due to alteration of a cancer susceptibility gene. Science 255:1693-1695 i 1992 by The American Society of Human Genetics. All rights reserved. 0002-9297/92/5006-0031$02.00

Am. J. Hum. Genet. 50:1351-1352, 1992

On the Economics of Clinical Genetic Services in Academic Institutions To the Editor:

As a result of founding and directing a pediatric clinical genetics program in an academic institution for 23 years, I have realized two economic axioms: (1) a comprehensive clinical genetic program will not remain strong without a solid hard-money base, and (2) the latter can only come from laboratory cytogenetic services. The argument that cognitive genetic services-i.e., diagnosis, management, and counseling (Bernhardt et al. 1992)-generate other institutional monies through ancillary services (other than the cytogenetic laboratory) falls on unsympathetic administrative ears. After all, cardiologists, allergists, hematologists, nephrologists, and about every other clinical "ist" down the pike can make the same claim, usually much more lucratively. In retrospect, 15-20 years ago it might have been better for physicians developing the field of clinical genetics to have followed a more traditional approach to the medical establishment, i.e., by establishing an academy or subacademy with a corresponding ABMSrecognized medical board. Clinical turf for institutions is largely controlled by physicians, and such academies and boards can be a major factor in defining who does what. Perhaps, then, cognitive and laboratory genetic services would both still be integral components of a comprehensive clinical genetics program. Instead, the genetics laboratories, with most of the hard money, often went to clinical pathology departments that were rarely adequately trained to interpret or act on the clinical significance of the genetic test results. Contrary to Bernhardt et al. (1992), maybe we should be more cautious now in assuming that clinical genetics is necessarily still a growth field. The future of this field depends on the resolution of the abortion controversy. If pregnancy termination for fetal birth defects becomes illegal, career opportunities in clinical

Letters to the Editor

1352

genetics will decidedly shrink. What, then, would be the point of prenatal diagnostic services? "To prepare couples for the birth of a defective child" is hardly a convincing argument, in light of a 0.5%-2.0% rate of fetal wastage consequent to invasive prenatal diagnostic techniques. Without prenatal diagnosis, what would be the point ofpopulation screening for carriers of abnormal recessive genes? Some studies (Steele et al. 1986; Frets 1990) suggest that reproductive behavior of at-risk couples in that circumstance may not necessarily differ significantly from that of the general population. I doubt that "the option of making an informed reproductive decision" is a convincing substitute argument for administrators to accept the cost of such screening programs. The past 25 years have been a golden scientific era for human genetics, and this shows no signs of abating. Investigators in human genetics enjoy tremendous status in academic medical institutions. However, these endeavors are supported by soft money. Unfortunately, admiration is sometimes mixed with envy and resentment by competitors for research funds who are in the older traditional medical fields. The fallout from this occasionally must be borne by clinical genetics programs. The recent formulation of a medical genetic academy encompassing both physicians and nonphysicians and having ABMS recognition of the American Board of Medical Genetics can only be helpful to the situation. These formalities should highlight

for all the intimate relationship between physicians and nonphysicians that is so necessary for the optimal practice of clinical genetics. It is my hope that, thereby, cognitive and laboratory genetic services can again be universally wedded. Also, now may be the time to establish unequivocally that the clinical practice of gene therapy belongs to medical geneticists rather than to specialists in the diseases that are being treated. MARK W. STEELE Departments of Pediatrics and Human Genetics University of Pittsburgh Health Center Pittsburgh

References Bernhardt BA, Tumpson JE, Pyeritz RE (1992) The economics of clinical genetics services. IV. Financial impact of outpatient genetic services on an academic institution. Am J Hum Genet 50:84-91 Frets PG (1990) The reproductive decision after genetic counseling. Leeuweriklaan, Rotterdam Steele MW, Rosser L, Rodnan JB, Bryce M (1986) Effect of sibship position on reproductive behavior of couples after the birth of a genetically handicapped child. Clin Genet 30:328-334 i 1992 by The American Society of Human Genetics. All rights reserved. 0002-9297/92/5006-0032$02.00

On the economics of clinical genetic services in academic institutions.

Letters to the Editor Note added in proof. -Evidence has been reported on the effect of chemical carcinogens in causing an increased frequency oftumo...
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