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by
Susannah Gal
Department of Biological Sciences
State University of New York at Binghamton
In this true story, a woman is grappling with a potential family predisposition to breast and ovarian cancer. She is trying to get some information to confirm this predisposition from a reluctant aunt so that she can better decide whether to remove her breasts and/or ovaries prophylactically. The aunt is illiterate and poor and had previously been estranged from the rest of the family. A genetic counselor is involved to help educate the aunt and hopefully obtain consent to get a DNA sample from her. Interestingly, the DNA sequence mutation actually found in the two family members is not in the coding region for the gene. Michelle must decide for herself what course of action she should take.
This case was designed for an advanced undergraduate molecular biology course where many of the techniques discussed are being used to show their application, but the scientific information needed can be modified to make this amenable for use in an introductory biology, genetics, or ethics classes. The case was first presented for a molecular biology laboratory class by a local genetic counselor. Background information on the events and situation described was collected and verified, and the story was then personalized, with the names changed and the conversations fictionalized. I used the case for the first time at a Case Studies in Science Workshop held in June 1999 at the State University of New York at Buffalo to 13 hired undergraduates with little or no previous science course work. Coincidentally, the case presented just prior to this one at the workshop was about DNA identification and so the students did have some advanced preparation on the meaning of DNA and genes.
Since the first presentation of this case in the Fall of 1997, the aunt (named Anne in this case) has died.
This case can be done in a single 1-hour class period and I have used this approach several times in presenting the case. It should follow material on DNA, genes, and mutations in a course. This variation works well with introductory biology students, as the focus is not on the scientific content but the ethics of the science. Start class with introductory questions on cancer, then construct a list of causes of cancer following a short 2- to 3-person group discussion (1 minute). Then, one can break these down into two groups—causes we can control [like smoking, sunbathing, eating processed fatty foods] and ones that are beyond our control [like mutations from our families, family history or predisposition]. Then give the students the case to read (takes 5 to 7 minutes). The case can then be run in several different ways (which are not necessarily mutually exclusive):
End with a listing of Michelle’s options and personal vote.
I used the first approach (A) when I taught the case as part of a practice teaching session during a faculty development workshop held in Buffalo, NY, in the summer of 1999 and again at a later date when I presented the case at my laboratory meeting, but it was not ideal, as I became the center of attention and controlled the discussion. I tried the second approach (B) near the end of an upper level course on molecular biology with a good deal of success. I initiated the role-play conversation and suggested bringing in Michelle at one point, but the students really led the discussion themselves and were very lively. At one point, students from one group (acting as Anne’s daughter) verbally coached Michelle to help that group argue their case for Anne. It flowed very well without much intervention on my part and all the end-of-session comments I received from the students were positive.
This variation would work best with an advanced class that knows how to analyze sequence information and search out information on the Internet. It would take a class and a half in time.
Review cancer caused by DNA mutations, then give the students the case to read. Next summarize the main characters and dilemma for each, more or less like the first variation above. End with saying consent is given by Anne to collect a DNA sample. Then assign all students to be in one of the 7 role-playing groups described below (4-5 people for each group—not all of the roles listed below need to be represented or others could be envisaged). Have the students search out answers to the questions provided or have the students develop and answer their own questions. The groups should return the following class period ready for discussion.
Have each group present the information they have gathered. Run a facilitated discussion of the most important information. Then end by asking for Michelle’s options. The whole class votes their personal preference—what they would do if they were Michelle.
The case could be run using the Problem Based Learning jigsaw format in one and a half class periods. In the 1st class period, the class is divided into “home” groups, 5-7 people in each and the same number of groups. Each student is given the case and they read it in their groups. Each student in the home group is then assigned one of the 7 roles above and the group decides what they want to know. For example, what is the BRCA1 gene? How is genetic testing performed? Time: 15-20 minutes. Then the students are reformed into “role” groups all representing the same person (i.e., all those students role-playing Michelle get together) and they discuss again what their particular person wants to know. Time: 10 minutes.
In the second class period, the role groups reform and share the information they have gathered with each other. Time: 15 minutes. Then the “home” groups reform and the students share the information they have gathered on all of the different aspects. Time: approximately 20 minutes. The group then makes some decision on what they would do if they were Michelle. Finally, the groups share with the entire class for discussion and voting, for the remaining 15 minutes.
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For the class, before giving them the case:
To facilitate in-class discussion, after reading the case:
It is suggested that in all three variations you should have all of the students vote on what they would do as Michelle. If she can’t get the DNA from Anne or if the gene change is not characteristically associated with cancer, she can still get her breasts removed or wait and see. There may also be more pro-active things she can do in the meantime.
I have asked three questions at the conclusion of the case:
There are a number of web sites on cancer genes and testing mutations. These include two government-sponsored sites:
There are also two sites sponsored by companies:
There is also a very comprehensive web site at http://www.pitt.edu/%7Eedugene/resource/ sponsored by the University of Pittsburgh Genetics Education and Counseling Program. There are a number of links within that site, including links to two other DNA-related case studies available through the University at Buffalo Case Studies in Science Collection.
The Centers for Disease Control and Prevention has a cancer page at http://www.cdc.gov/health/cancer.htm) with information on early detection programs, while the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program web page, at http://seer.cancer.gov/, provides national statistics on breast cancer.
Food, Nutrition, and the Prevention of Cancer: a Global Perspective, published by the American Institute for Cancer Research for the World Cancer Research Fund. 1997. ISBN 1-899533-05-2. As the title implies, this book summarizes articles comparing world rates of cancer and relating that to food and nutrition in those different areas. There are sections on several types of cancer including breast and ovarian.
Understanding Gene Testing, published by the National Cancer Institute at the National Institutes of Health. 1995. This is a short booklet that describes in very simple language and with lots of pictures what genes are, how faulty genes trigger disease and what scientists do to develop predictive gene testing. It also has a glossary of common terms in cancer diagnosis and therapy. It is available free in multiple copies from the National Cancer Institute by phoning their Information Service 1-800-4-CANCER (1-800-422-6237). It is also available on the web at http://rex.nci.nih.gov/PATIENTS/INFO_TEACHER/bookshelf/NIH_gene_testing/gene00.html.
There is also a book entitled Understanding Breast Cancer Risk, written by Patricia T. Kelly, Ph.D., a specialist in breast cancer risk assessment and counseling for more than fifteen years. The book is a guide that addresses the social as well as the scientific aspects of breast cancer risk, helping health care professionals to better guide and inform their patients and helping patients to better inform themselves. It is published by Temple University Press and can be ordered on-line at http://www.dnai.com/~ptkelly/index.html, which is also a web site with other good information on breast cancer, which uses simplified language and diagrams.
Other resources include local breast cancer treatment or screening facilities, genetic counseling offices, or local chapters of the American Cancer Society.
Acknowledgements: This case was developed as part of a National Science Foundation-sponsored Case Studies in Science Workshop (NSF Award #9752799) held at the State University of New York at Buffalo on June 7–11, 1999. The author would like to acknowledge the collaborative development of this case by Jessie W. Klein, Science Department, Middlesex Community College.
Date Posted: 03/03/00 nas
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