Should public health leaders get on the genomics train?

In the past eight years – a time of swiftly moving advancement in applications of genomics in cancer treatment – the Society of Behavioral Medicine’s Annual Meeting has had one paper session and one plenary on genomics annually (among the average of 270 sessions offered). Additionally, the Centers for Disease Control and Prevention’s Evaluation of Genomic Applications in Practice and Prevention recommendations of genomic applications that are ready for implementation also went largely unnoticed by the health promotion community. Why might these recommendations be important to health promotion? Tier 1 genomic applications, backed by strong evidence of their clinical utility, support population screening to identify those at heightened risk for inherited cancers and cardiovascular disease. While accounting for less than 10% of the population, these individuals and families account for disproportionate morbidity and mortality and can benefit from targeted prevention efforts. Thus, the reticence of highly respected public health leaders is worth considering.

Critique 1: Use of genomics applications will eclipse social determinants of health 

It is now widely acknowledged that current and historical living conditions and other social factors actually become biologically embodied. In this rendering, genes are followers of social and historical influences rather than the generative force driving health outcomes.

The profile of a patient with inherited breast cancer is reflected in a younger patient presenting with a high-grade tumor that is hormone receptor-negative – characteristics more common among African American women with breast cancer than white women. Some argue this arises as the perfect storm of biology, behavior, and service access. Biology is part of reciprocal and synergistic processes where social exposures turn on gene expression and worsen health outcomes.

Critique 2: It is infeasible to disseminate high-tech and expensive genomic applications to populations that bear the greatest burden of common disease

Tier 1 screening for hereditary cancer and cardiovascular disease risk relies on relatively low-tech family history-based risk assessments. Indeed, a number of low-cost tools are in use with a broad array of audiences. Only a small subset of these individuals will be appropriate for referral to genetic counseling and testing. Moreover, the potential of these tools to broaden reach beyond the individual disease prevention efforts to engage the broader family in considering risk offers the potential for getting a bigger bang for the buck.

Critique 3: Genomic applications are unlikely to improve health promotion interventions 

Systematic reviews of genomics risk information now show that, regardless of the behavior (smoking cessation, dietary habits, and physical activity), there appears to be little benefit of genetic risk information to motivate behavior change. However, health promotion researchers were well poised to conduct this rigorous line of research, work that also provides creative and theory-based approaches to convey a technical jargon not well understood by the public.

Ongoing commercialization of genomics (e.g., companies like 23andMe), high-profile celebrities’ experiences with hereditary cancer syndromes, and popular press coverage will reinforce public expectation that genomics be included in health promotion discussions. Unfolding discovery in the burgeoning field of epigenetics is showing individual variation in response to interventions and propensities to relapse. Whether this new information can inform innovation in health promotion interventions is worth considering.

Conclusions

Health promotion researchers have critical expertise and decades of evidence that will be vital in genomic translation for health promotion. Thus, we will bear some responsibility for inappropriate translation and dissemination if we dismiss genomics. Recognizing this, the Society of Behavioral Medicine leadership has convened a presidential working group to gather members’ perspectives on genomics and how this disciplinary expertise could help shape an optimal translation vision. As health promotion researchers, we have to decide whether to show up and shape research and practice, or sideline ourselves, knowing that both have consequences. In the words of legendary historian and social activist Howard Zinn, “You can’t be neutral on a moving train.”

Featured image credit: Geometric by Manuchi. CC0 public domain via Pixabay.