title: Incorporating DNA sequencing into current prenatal screening practice for Down's syndrome.
abstract: BACKGROUND
  Prenatal screening for Down's syndrome is performed using biochemical and ultrasound markers measured in early pregnancy such as the Integrated test using first and second trimester markers. Recently, DNA sequencing methods have been introduced on free DNA in maternal plasma, yielding a high screening performance. These methods are expensive and there is a test failure rate. We determined the screening performance of merging the Integrated test with the newer DNA techniques in a protocol that substantially reduces the cost compared with universal DNA testing and still achieves high screening performance with no test failures.
  
  
  METHODS
  Published data were used to model screening performance of a protocol in which all women receive the first stage of the Integrated test at about 11 weeks of pregnancy. On the basis of this higher risk women have reflex DNA testing and lower risk women as well as those with a failed DNA test complete the Integrated test at about 15 weeks.
  
  
  RESULTS
  The overall detection rate was 95% with a 0.1% false-positive rate if 20% of women were selected to receive DNA testing. If all women had DNA testing the detection rate would be 3 to 4 percentage points higher with a false-positive rate 30 times greater if women with failed tests were treated as positive and offered a diagnostic amniocentesis, or 3 times greater if they had a second trimester screening test (Quadruple test) and treated as positive only if this were positive. The cost per women screened would be about one-fifth, compared with universal DNA testing, if the DNA test were 20 times the cost of the Integrated test.
  
  
  CONCLUSIONS
  The proposed screening protocol achieves a high screening performance without programme test failures and at a substantially lower cost than offering all women DNA testing.
authors.affiliation: Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, London, United Kingdom. n.j.wald@qmul.ac.uk
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Wald
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Bestwick
mesh_terms: D002985:Clinical Protocols; D003365:Costs and Cost Analysis; D004247:DNA / Q000097:blood* / Q000235:genetics*; D004314:Down Syndrome / Q000175:diagnosis* / Q000235:genetics*; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D062145:Maternal Serum Screening Tests / Q000379:methods; D011247:Pregnancy; D011296:Prenatal Diagnosis / Q000191:economics / Q000379:methods*; D016216:Ultrasonography, Prenatal
chemical_list: D004247:DNA