PRESIDENT'S MESSAGE

This May 1998 issue of the AMP Newsletter is absolutely packed with critical, exciting, and relevant information for all of us who are engaged in clinical diagnostics and research in molecular pathology. I urge you to read this issue thoroughly from cover to cover! The detailed information in this newsletter reflects all of the hard work of our AMP Committees and our individual members and reports on our progress and accomplishments on many fronts. First, we all owe a huge debt of gratitude to Drs. Wayne Grody and Mike Watson for their tireless quest to convince the American Medical Association to approve a new and vastly expanded list of CPT Codes for Molecular Diagnostics. All AMP members are now urged to work with Dr. Grody and our Clinical Practice Committee to assist in their efforts to establish reasonable reimbursement levels for each of these new codes. Clearly, this important accomplishment will improve our ability to practice molecular diagnostics and will help to stabilize the reimbursement of diagnostic activities in our laboratories. Also included in this newsletter is a very important summary of a recent meeting coordinated by the National Institute of Standards and Technology (NIST) for the development of standards for nucleic acid diagnostic applications. We would like to thank Dr. Dennis Reeder for his excellent summary of this important and relevant meeting. Our AMP Clinical Practice Committee continues its flurry of activities under the leadership of Dr. Rick Press. All AMP members should contribute to the Clinical Practice Committee's efforts to update the AMP Molecular Pathology Test Directory and should become involved in discussions of the controversies regarding the exclusive licensing of laboratory testing for particular molecular tests. Our Training and Education Committee, led by our previous President Dr. Jeffrey Kant, has completed a manuscript that outlines recommendations for residency and fellowship training in molecular pathology, which should be of interest to all of us. Drs. Carleton Garrett and Karl Volkerding and their team have essentially completed the program for our upcoming AMP Annual Meeting to be held November 5-8, 1998 at the Crystal City Hyatt in the Washington, D.C. area. The final program, included in this newsletter, looks outstanding and I urge all of your to register as soon as your receive your meeting brochures. Our 1998 meeting, a mix of plenary session talks and interest group workshops, promises to be our best yet! As part of this meeting, we will bestow our first Association for Molecular Pathology/Visible Genetics Award for Excellence in Molecular Pathology to Dr. Francis Collins, who will deliver a keynote address. Finally, I would encourage all of you to assist Dr. Mark Sobel, our President- Elect, and members of the 1998 Nominating Committee in identifying key individuals for leadership positions in AMP. We plan to have our slate completed in early summer for a late summer election. I wish all of you the best as we head into summer. I will look forward in visiting with you at our upcoming meeting, and as always, please feel free to contact me with questions or concerns.

Cheryl L. Willman, MD, AMP President, UNM Cancer Center cwillman@unm.edu

JOURNAL AFFILIATION

The AMP Journal Negotiation Committee (Peggy Gulley, Jeff Kant and Cheryl Willman) is pursuing discussions with the American Journal of Pathology (AJP) to determine whether a companion (part B) journal might serve the needs of AMP members. In addition to original papers and reviews in basic and clinical molecular diagnostics, this journal might also include AMP position papers, commentaries on subjects of interest to the molecular diagnostics community, and abstracts of our annual meeting. The journal would be distributed as an AMP member benefit as well as circulate to the large number of library and individual subscribers to AJP. If negotiations succeed, we will seek a Senior Editor for this publication in the coming months. AMP members are encouraged to provide feedback on this process via CHAMP or through individual members of the negotiating team.

Contributed by: Peggy Gulley, MD, UT, San Antonio, TX, gulleym@uthscsa.edu

CLINICAL

PRACTICE

COMMITTEE

[ED. NOTE: I URGE YOU TO READ THIS PIECE CAREFULLY, AS DR. PRESS DESCRIBES ISSUES OF KEY IMPORTANCE TO OUR PRACTICES]

As always, there are a number of pressing clinical practice issues that are being addressed by your AMP clinical practice committee in the first quarter of 1998.

Planned Update of the AMP Test Directory

The well-received 1st edition of the AMP test directory (1996 version) is due for a second edition update in 1998. As you may remember, the test directory lists the clinical diagnostic tests offered by the laboratories of AMP members. I have personally found it to be a valuable resource to identify labs for molecular assays not performed in house, and to identify labs for proficiency sharing exercises. As test menus have clearly changed significantly over the intervening 2 years, we are planning to soon re-survey AMP member labs for updates, additions, revisions, etc., to their test directory listings. Furthermore, we are attempting to standardize the nomenclature system for our most commonly used tests, so as to make indexing more definitive and to begin to get us talking the same language. To this end, we are currently devising "recommended templates" that will list what we consider to be the most common tests from each of our 4 subdivisions. The templates will be devised in a table format with column headers: "Test name"; "Method"; "Comments". Updating one's test directory data will then hopefully be as easy as scrolling through this list of "recommended templates" and choosing those tests offered by your lab, but making sure to follow the nomenclature scheme that has been recommended. Obviously, this template list will not include the "esoteric" tests specific for only a few labs-these listings will have to be created individually. When creating your test directory entries, however, I can not overemphasize the importance of adhering to our recommended nomenclature system. A small effort on your part at the data entry stage will be of immeasurable value when we try to compile this list in a standardized manner. Other issues of relevance to the test directory include:

1. Will the information be made public? Will it be posted on the web or made freely available to all who ask for it? The consensus opinion is that the information listed in the test directory IS PUBLIC INFORMATION (whether or not we post it on the web).

2. Should the listings be restricted to AMP member labs or be open to others? The consensus opinion was that the directory listing is a benefit of AMP membership and should thus be restricted to members.

3. Should we be collaborating with other on-line directories such as HELIX? Preliminary discussions with the HELIX coordinators are now underway.

4. How can we ease the clerical burden of data entry and collation? Can we dictate data entry directly on the web (in a standardized format)? Would anyone with expertise in the area of web-based database entry like to volunteer to help with this task?? Should such expertise not become readily available (or deemed a reliable option), we will likely distribute the data entry templates by e-mail and ask for e-mail-based replies. Please look for these data entry templates soon, and return them (with the recommended formatting) as soon as possible.

Patenting Diagnostically-Relevant Disease Genes

As attested by the flurry of activity on CHAMP over this issue, there appears to be broad-based global concern that the policy of restricting the ability of labs to perform in- house assays for "patented" genes or mutations is not in the best interests of either patients, testing clinicians, the labs being restricted, or the institutions enforcing these restrictions. The impetus for these discussions was the recent purchase, by SmithKline Beecham clinical labs, of EXCLUSIVE rights to perform diagnostic gene-based testing for the HFE gene mutations associated with the very common genetic disease, hereditary hemochromatosis. The CP committee is in the process of drafting a letter to SB in which we will attempt to convey the message that it will be in SB's corporate best interests to broadly sub-license the rights to perform HFE mutation analysis rather than try to restrict other labs from performing this test and undertake all of this testing themselves. This letter will include your many good ideas (posted on CHAMP) as to why SB will ultimately benefit from broadly granting sub-licenses. Although unlikely to be included in the letter to SB, there is clearly broad support for increased legislative attention to the more global (and more difficult) question of whether genes and/or mutations are (or should be) legally "patentable". This is clearly a volatile and controversial issue which will need to be addressed in collaboration with partner societies such as CAP, ASHG, AACC, AMA, and other professional organizations with legislative clout.

Cost Basis for New Molecular CPT Codes

As detailed in Wayne Grody's comments in this newsletter [SEE IMMEDIATELY BELOW], the AMA has finally approved a number of new CPT codes for molecular pathology. Many thanks to Wayne and Mike Watson for their tireless determination (and ultimate success) on this issue. Now that these codes exist, the next challenge will be to determine rational cost structures for these codes so as to ensure fair reimbursement for the services being rendered. As such, the CP committee will soon be sending out a survey to AMP members to inquire about the costs (notthe charges) for each of the new procedures in a large number of geographically diverse settings. With these data, we then hope to cooperate with ACMG & CAP to jointly recommend fair reimbursement levels to HCFA. Without your cooperation in this matter, we may be stuck with low reimbursement rates for these codes, perhaps even as unreasonable as those associated with the first set of molecular CPT codes. That should be sufficient incentive to contribute!

As always, your CP committee welcomes your input on these and other practice- related issues. We look forward to your comments and suggestions.

Respectfully submitted by Rick Press, MD, PhD

Clinical Practice Committee Chair

Ore. Health Sci. University pressr@ohsu.edu

for the 1998 AMP Clinical Practice Committee:

Andrea Ferreira-Gonzalez, PhD (MCV-Genetics)

Linda Wasserman, MD (UCSD-Solid Tumors)

Rita Braziel, MD (OHSU-Heme-Path)

Rick Nolte, PhD (Emory-ID)

CPT CODES AT LAST

The long quest for the Holy Grail of new molecular diagnostics CPT codes is finally over. After three years of repetitive petitioning and testimony before the American Medical Association's CPT Editorial Panel, an extensive list of new and updated codes, put forth under the sponsorship of the American College of Medical Genetics with input from the College of American Pathologists, has been accepted in its entirety. These codes (see Table) go well beyond the original six molecular diagnostic codes which had become inadequate or inaccurate with the rapid advance of technology and changing criteria for reimbursement.

Updated and accurate CPT (Current Procedural Terminology) codes are needed for every medical specialty in order to properly define, recognize, monitor, report and charge for its procedures. CPT codes are the terminology used for public health monitoring by state and local national agencies and for reimbursement through Medicare under the Health Care Financing Administration (HCFA) and by many private third-party players. The existing codes in molecular diagnostics, no longer reflecting actual practice and modern technologies in the field, made for troublesome billing and forced labs to be rather "creative" (to put it euphemistically) in formulating viable pricing structures for their tests. The new codes go a long way toward correcting these discrepancies, recognizing the procedural and workload differences, for example, between single and multiplex PCR, between Southern blot and dot blot hybridization, and between analysis of a single gene and multiple DNA fragments within a gene. In addition, the new codes encompass the most contemporary techniques in use now and into the foreseeable future, such as DNA sequencing, mutation scanning by conformational analysis, protein truncation tests, and so on.

Despite the apparent logic and genuine need behind these changes, getting them accepted by the AMA Editorial Panel proved to be a frustrating experience. The AMA CPT Code Manual is revised annually, and over the course of three years of application and testimony, the molecular codes were repeatedly tabled over the most minor stylistic (not substantive) concerns of the Panel. (The same thing happened to two parallel ACMG applications, covering biochemical genetics and cytogenetics codes, while a proposal for genetic counseling codes was rejected outright.) In some cases the requested stylistic changes were so minor that they could have been corrected with a single stroke of the word processor, yet instead resulted in deferral of consideration for a whole year. Finally in early 1998 the application, essentially identical to the one submitted three years earlier, was accepted, just barely in time for inclusion in the 1999 edition of the Code Manual.

Strangely, considering the hurdles faced by this application, within the past year a large series of other molecular diagnostic codes put forth by the CAP were accepted by the Panel without question. These codes are for molecular microbiology testing, with a different CPT code specified for each particular microorganism [ED. NOTE: SEE LAST PAGE OF 1/98 AMP NEWSLETTER FOR LISTING]. The easy acceptance of this application was surprising in light of the Panel's overriding intent to avoid redundant or duplicative codes, since it appears to most of us that a PCR-dot blot test for Chlamydia, for example, could now be billed using either the specific Chlamydia DNA test code or the combined PCR and dot blot codes from the ACMG list. This situation has already led to uncertainty and confusion in the field, as reflected in recent exchanges over the CHAMP listserve. In the absence of clear guidelines, the best advice seems to be to fall back on a variation of the philosophical concept of Occam's Razor and use the simplest series of codes applicable to each particular activity.

As burdensome as this long application process with the AMA Editorial Panel seemed, an even more difficult and critical job begins now the establishment of actual reimbursement levels for the new codes. The first step in the process is to present a detailed cost analysis for each procedure to HCFA's Office of Payment Policy. To make these estimates as realistic as possible, the ACMG has begun surveying its member laboratories and has expressed interest in working with AMP and CAP as well. It will be very important to present firm numbers to HCFA and defend them staunchly, as we would prefer to avoid what happened with the previous set of CPT codes in which reimbursement for a Southern blot procedure was set at the extravagant rate of $5.67. The effort will require close cooperation among the professional organizations mentioned, with AMP perhaps best positioned to take the lead since it alone encompasses the requisite expertise and experience over all the various applications of molecular diagnostics.

Submitted by: Wayne W. Grody, MD, PhD, UCLA School of Medicine, GRODY@pathology.medsch.ucla.edu

New or Modified Molec. Diagn. CPT Codes

Code Description

83890 (M) Nuclear molecular diagnostics; nucleic acid isolation or extraction

8389X1 (N) Nucleic acid isolation or extraction, highly purified

83892 (NC) Enzymatic digestion

8389X2 (N) Dot/slot blot production

8389X3 (N) Nucleic acid transfer (e.g., Southern, Northern)

83894 (M) Separation by gel electrophoresis (e.g., agarose, polyacrylamide)

83896 (NC) Nucleic acid probe, each

83898 (M) Amplification of patient nucleic acid (e.g. PCR, LCR, RT-PCR), single primer pair, each

8389X4 (N) Amplification of patient nucleic acid, each multiplex

8390X1 (N) Hybridization and detection of molecular probe

8390X2 (N) Mutation scanning, by physical properties, e.g., single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNase A, etc., single segment, each

8390X3 (N) Mutation identification by sequencing, single segment, each

8390X4 (N) Mutation identification by allele specific transcription, single segment, each

8390X5 (N) Mutation identification by allele specific translation, single segment, each

83912 (NC) Interpretation and report

TRAINING & EDUCATION COMM.

1) Completion of the residency training guidelines manuscript and residency program survey conducted by 1997 T&E: Tom Williams and the 1997 committee are finishing these up for submission this spring.

2) Companion manuscript on guidelines for molecular pathology fellowship training: The announcement in December on CHAMP and in the January newsletter for thoughts on this netted little response. Please contact a Committee member if you would like to offer thoughts (addresses below). We now have an outline and hope to have a draft for review and discussion at the annual meeting. Along this line, we are also in contact with the Residency Review committee (RRC) coordinator for the newly constituted pathology and genetics RRC of the ACGME. They are very desirous of input from AMP.

3) Archive of training resources in molecular pathology: Sometime in May or early June, expect to see postings on CHAMP requesting input from members on resources they find useful for a number of "themes" associated with each subsection as well as a miscellaneous group.

1998 T&E Membership

Jeffrey A. Kant (Chair): kant@np.awing.upmc.edu

Jack Lichy (Solid Tumors): lichy@e-mail.afip.osd.mil

Ethel Cesarman (Hematopathology): ecesarm@mail.med.cornell.edu

Steve Dumler (ID): sdumler@pathlan.path.jhu.edu

Greg Tsongalis (Gen.): gtsonga@Harthosp.org

ad hoc:

Vivianna Van Deerlin:

vivianna_van_deerlin@path1a.med.upenn.edu

Jeffrey Ross: jeffrey_ross@ccgateway.amc.edu

SECRETARY- TREASURER/ EDITOR'S COMMENTS

I am lucky to work at an institution that takes government affairs seriously enough to staff an office in the state capitol in Lansing, Michigan. On April 22, I met with State Representative Beverly Hammerstrom at her office in Lansing. Rep. Hammerstrom had introduced genetic privacy legislation and had invited me to participate in a meeting to discuss it. I had major problems with the bill and was extremely gratified to be included. Also attending was a professional lobbyist retained by Genentech (that this California company retains a lobbyist in Michigan, and likely other states, to follow such matters is instructive), the Beaumont Hospital government affairs representative, and two staffers from Rep. Hammerstrom's office. Scheduled, but unable to attend, were a Genentech employee and Rhoda Powsner, MD, JD, the executive director of the Michigan Commission on Genetic Privacy and Progress, charged by Governor John Engler to issue its report in November of this election year.

The one hour discussion was quite friendly. I was struck at the Representative's overwhelming desire to learn. She was most receptive. By the end of the meeting, it seemed clear to me that her bill would be recrafted in several ways. Her staffers will get a copy of HR 306, (Federal) Representative Louise Slaughter's (D-NY) bill that leaves the laboratory out of these matters, and use it as a model. The Michigan bill will restrict its language to human nucleic acids (previously no distinctions had been made for DNA or RNA from microorganisms and associated testing). Rep. Hammerstrom now understands (i) how damaging it would be to the way we practice laboratory medicine to legislate destruction of DNA/RNA samples and (ii) to legislate that the laboratory be responsible for explaining to each patient why a molecular test is being done and all the ramifications (this is the responsibility of the attending physician; the laboratory can certainly assist).

The meeting ended with some political realities. Rep. Hammerstrom's office will contact some insurance executives in an attempt to learn if policies are currently being denied or rated upward as a result of genetic testing information and to see how the industry might respond to a bill that made genetic discrimination by insurers illegal. The Representative is also running for the State Senate and from a political point of view, this will impact how this Bill proceeds. Lastly, the Michigan Commission on Genetic Privacy and Progress will issue its report around Election Day and the Governor is not likely to sign any bill into law (assuming it gets through the legislature) until he reads that report.

The "take-home" lesson here is that it was surprisingly easy to give my input. Representative Hammerstrom has an open mind to being educated about new concepts. My extrapolation from this experience is that if you, fellow AMP members, who are in an expert position to influence similar matters in your own states, have an opportunity to contribute, I hope you will consider it. You can make a difference!

On a personal note, I am leaving William Beaumont Hospital after seven years running the day-to-day operations of its DNA Diagnostics Laboratory. This is a wonderful institution and I will miss my colleagues (many of whom are AMP members), but the laboratory is in good hands. I will be taking advantage of an opportunity and joining a start-up "DNA Chip" company in Pasadena, California called Clinical Micro Sensors (CMS). CMS and I will be working very hard to develop hand-held, point of care, PCR-independent, DNA and RNA Diagnostics and ultimately larger instruments for batched runs in laboratories like yours. If you will permit me, I promise to devote the same efforts to serving AMP as Newsletter Editor and Secretary- Treasurer, as I have been doing for some time now. I still believe this is a great organization and I am proud to be associated with it. I'll be at Beaumont until sometime in June; after that, please feel free to reach me at CMS at (626) 584-5900 or farkas@microsensor.com. See you at the Annual Meeting in November.

Daniel H. Farkas, PhD, HCLD, CC, CLSp(MB)

AMP Secretary-Treasurer/Newsletter Editor

Director of Clinical Diagnostics

Clinical Micro Sensors, Pasadena, CA

Phone, (626) 584-5900

farkas@microsensor.com

'98 PROGRAM COMMITTEE REPORT

Since the last newsletter, the Program Committee has been working hard to put together our meeting this fall. Listed below is a the Program for November 6-8 with Exhibitor sponsored workshops to be held the day before. The meeting will be held at the Crystal City Hyatt which is located near National Airport across the Potomac River from Washington, DC. Please note that this is preliminary and portions are still in development. We look forward to seeing you at the meeting.

Submitted by: The AMP Program Committee

Carleton T. Garrett, MD, PhD, Chair

1998 AMP ANNUAL MEETING

Crystal City, Virginia '98

PRELIMINARY SCHEDULE

Thursday, November 5, 1998

10:00 AM-5:00 PM Premeeting Company-Sponsored Workshops

5:00 PM-8:00 PM Registration

7:30-10:30 PM AMP Committee Meetings

7:30-9:00 PM Clinical Practice Committee

7:30-9:00 PM Training & Educ. Committee

9:00-10:30 PM Nominating Committee

9:00-10:30 PM Program Committee

9:00-10:30 PM Publications Committee

Friday, November 6, 1998

7:00-7:50 AM Registration/Breakfast

7:30-7:50 AM Put Up Posters/Exhibits

7:50-8:00 AM Opening Remarks - C. Garrett

8:00-9:45 AM Plenary Session I - Genetics

- Joan Knoll, MGH: Prader Willi/Angelmann Syndromes: Recent Biologic Observations and New Diagnostic Methods

- William McGinnis, Yale: HOX/PAX Genetics

9:45-10:15 AM Break/Visit Posters/Exhibitors

10:15-NOON Plenary Session II: Hematopathology

- Cheryl Willman, U. New Mexico: Monitoring Minimal Residual Disease - New Approaches and Significance.

-Jerry Shay, U. Texas, Dallas: Telomerase

NOON-1:00 PM Lunch/Visit Posters & Exhibits

Hematopathology Section Business Meeting

Genetics Section Business Meeting

1:00-2:30 PM WORKSHOPS - SESSION A

Hematopathology - Workshop I: Sample Exchange and Protocols I

Genetics-Workshop I: Molecular Genetic Aspects of Biochemical Genetics

- Anthony Killeen, U. Michigan: CAH

- Karen Snow, Mayo Clinic: Hemoglobinopathies/ thalassemia

2:30-4:00 PM Break/Visit Posters (Attended 2:30 -3:15) & Exhibits

Update for Technologists' Certification Exam I

Cathie Leindecker-Foster and Kent Williams

4:00-5:00 PM AMP Business Meeting

5:00-6:00 PM AMP AWARD of EXCELLENCE LECTURE: Francis Collins.

(Supported by a grant from Visible Genetics, Inc.)

6:30-7:30 PM Welcome Reception

Saturday, November 7, 1998

7:00-7:55 AM Continental Breakfast

7:30-7:55 AM Put Up Posters/Exhibits

8:00-9:45 AM Plenary Session III-Inf. Disease

- Elizabeth Unger, CDC: Human papillomavirus

- Jan Nowak, Ill. Masonic Med Center: Helicobacter pylori- Diagnosis & Role in Cancer

9:45-10:15 AM Break & Visit Posters/Exhibits

10:15-NOON Plenary Session IV-Solid Tumors

- Fred Barr, U Penn: Translocations in solid tumors

- Dan Haber, MGH Cancer Center: Evolving definitions of tumor suppressor genes

NOON-1:00 PM Lunch/Visit Posters & Exhibits

Infectious Disease Section Business Meeting

Solid Tumors Section Business Meeting

1:00-2:30 PM WORKSHOP SESSION B

Infectious Disease-Workshop I: Economic/Outcomes Research in ID testing

Solid Tumors - Workshop I:

- Sid Finkelstein, Redpath Genetics: Diagnostic testing for prognosis and response to chemotherapy

2:30-3:30 PM Break/Visit Posters (Attended 2:30 -3:15pm) & Exhibits

Update for Technologists' Certification Exam II

Cathie Leindecker-Foster and Kent Williams

3:30-5:00 PM WORKSHOP SESSION C

Infectious Disease-Workshop II: Troubleshooting issues and Validation protocols (Member submissions)

Genetics-Workshop II:

- Mark Lovell and Wendy Golden, UVA: Mutation Nomenclature/Reporting Polymorphisms,

5:00-5:15 PM Break

5:15-6:00 PM Plenary Abstract Presentation Session

Sunday, November 8, 1998

7:00-8:00 AM Continental Breakfast

8:00-10:00 AM Plenary Session V-Special Topics

- TBA

- Doug Dolginow, OncorMed: Future uses of genetic testing in disease management

10:00-10:30 AM Break

10:30-NOON Hematopathology Workshop II

Sample Exchange and Protocols II

Solid Tumors Workshop II:

- Marc Ladanyi, MSKCC: Gene amplification in solid tumors

NOON Conference Adjourns

HEME-PATH SUBSECTION

One of the major goals of the Hematopathology Subdivision for 1998 was to set up a sample exchange program to validate protocols for several commonly performed molecular assays. Due to the diligent efforts of Dan Arber, the t(14; 18) exchange is under way. The efforts of Jeff Taubenberger have led to a pilot sample exchange for t(11;14).

Our efforts to put together the sample exchange for immunoglobulin and T cell receptor gene rearrangement have hit some snags, due to the large number of labs that want to participate and the difficulty getting the kind of samples we really wanted to go out. I believe that some samples will begin to be distributed during May, though they may not all be the "kinds of tissue samples we analyze all the time".

If you had given me an e-mail address for participating in the exchange, and did not get e-mail from either me or the sample exchange coordinators, please let me know by return e-mail at tjo@imsnet.net.

Contributed by: Tim J. O'Leary, MD, PhD, Armed Forces Institute of Pathology, tjo@imsnet.net

INFECTIOUS DISEASES SUBSECTION

Update on Standardization Issues:

1. NIST Workshop

On March 15-18, NIST (National Institute of Standards and Technology) held a workshop to address the needs for standardization of nucleic acid diagnostic testing [ED. NOTE: see Dr. Reeder's summary below]. Notice of this was on the AMP listserve in February. After years of successful work standardizing nucleic acid technologies for forensics, NIST now has a mandate to investigate what is needed and facilitate the establishment of standards for laboratory diagnostics. Representatives from government, industry (IVD manufacturers, research reagent manufacturers, and controls manufacturers) and clinical laboratories attended this symposium which addressed genetic testing, oncology and infectious diseases. In the area of infectious diseases, it was clear that standard reference materials are needed as a point of reference for

quantitative and qualitative assays. This is not anything new to all of us that have been struggling in the field without reference materials; but now established "standards organizations" like NIST and WHO are beginning to recognize this as a serious need and a priority. It was felt by the infectious disease discussion group (led by John Ticehurst, MD, CDRH/FDA and John Hopkins) that "standard reference materials" should be in clinical matrices and relevant to the clinical range of the assays. Also the availability of standards, reference materials and controls in relevant genotypes and subtypes are needed. NIST may not have the resources to produce all the materials required, but will try to "facilitate" their production. Just how this will be done and how quickly materials can be established was not discussed. The meeting seemed to be one of initiation and information-gathering for NIST, which will issue proceedings. Some AMP members who attended the meeting (many presented) were: Dan Farkas, Andrea Ferriera-Gonzalez, Wayne Grody, Roberta Madej and Tim O'Leary.

2. European Quality Control Concerted Action (QCCA).

The European Union (EU) has recently granted funds for the establishment of a Pan-European quality control organization for the "quality control of molecular technologies used for the laboratory diagnosis of virus infections". The organization is formed in collaboration with the European Society for Clinical Virology (ESCV).

During the three years of EU support, the organization plans to distribute panels against a "range of viruses", organize workshops surrounding those panels at the ESCV meetings, and work towards becoming a self supporting, continuing organization by the end of the term. The first panel scheduled for issue this fall is for Enteroviruses. Subsequent panels have not been publicized yet. If you would like more information on this organization and the availability of panels, please visit the website at www.qcca.org.uk

An interactive workshop was the request of several members at the Infectious Diseases business meeting last November. Therefore, at the 1998 meeting, the Infectious Diseases Section WILL have an interactive workshop focusing on VALIDATION AND TROUBLESHOOTING. But we will not be able to interact, if we have no submissions to discuss!! PLEASE submit your favorite validation protocols (for in-house developed tests, for manufacturers' test kits, for comparisons with and without gold standards, etc.) AND any particularly interesting troubleshooting scenarios you have come across to Roberta Madej, chair of the subsection.

e-mail: roberta_madej@cc.chiron.com

FAX, (510) 655-7733/Phone, (510) 923-4005

OR Karen Kaul, chair-elect: k-kaul@nwu.edu

FAX, (847) 570-1938/Phone, (847) 570-2052

Submitted by: Roberta Madej, Chiron

SOLID TUMOR SUBSECTION

The Solid Tumor program for this year's annual meeting has been finalized. The first plenary topic will be an update on the molecular biology and clinical applications of gene fusions in sarcomas, presented by Fred Barr of the University of Pennsylvania. The second topic will be evolving definitions of tumor suppressor genes, presented by Dan Haber of Harvard. The Solid Tumor workshops will designed to be more interactive than in the past. The first will be on establishing consensus for markers used for prognosis and response to chemotherapy, using as an example p53 analysis. The goal will be to address issues such as standardization of methods and establishing standard of care.

The second workshop will address standardizing techniques for detecting gene amplification in solid tumors, using HER-2/neu and n-myc as examples. In advance of the workshops, Marc Ladanyi (Solid Tumor Chair-elect) would like to poll the membership about turnaround time offered for oncogene amplification analysis as well as for DNA PCR (any target), RNA PCR (any target), Southern blot analysis of B and T cell receptor rearrangement, RFLP or VNTR analysis for marrow transplant engraftment status (any technique). Please include the annual caseload/tech in order to evaluate the effect of this parameter on QA turnaround time criteria. Some of this data will be presented (anonymized, of course) in the workshops. Please e-mail Marc at ladanyim@mskcc.org.

Contributed by: Tom Frank, MD, Chair Solid Tumor Subdivision; Myriad Genetics Laboratories/e-mail: tfrank@myriad.com

GENETICS SUBSECTION

The Genetics subsection chair and chair-elect have planned what they think will be an interesting and exciting program for their component of the 1998 fall AMP meeting. The plenary session will focus on the biology and clinical applications of two currently very interesting areas of genetics. Dr. Joan Knoll of the Massachusetts General Hospital will talk about Prader Willi/Angelmann syndromes, with special emphasis on recent biologic observations and new diagnostic methods. Dr. Knoll is eminently qualified to present this topic to AMP - she had been involved in the definition of the Prader Willi/Angelmann critical regions and the genes within them. The second plenary presentation will be by Dr. William McGinnis of Yale University on the biology and genetics of the HOX/PAX genes. Dr. McGinnis has been closely involved in the discovery of new genes in these families and in studying the disorders (in flies, mice and man) that result from alterations of these genes.

One of the topics of most interest to AMP members is how to translate biochemical genetics problems into the molecular genetics diagnostic setting. We have developed a workshop that uses two clinical settings where molecular genetic testing provides a real adjunct to biochemical genetics testing. Dr. Anthony Killeen will discuss the molecular diagnosis of congenital adrenal hyperplasia. Dr. Karen Snow of the Mayo Clinic will discuss molecular genetic follow-up testing of the hemoglobinopathies and the thalassemias. Both Drs. Snow and Killeen are AMP members. AMP members should come prepared with questions and clinical problems in these areas to discuss with (and/or stump) our panelists and each other.

Recently there has been lots of activity in the American Society of Human Genetics, the American College of Human Genetics and the Standing Committee on Cytogenetic Nomenclature to standardize mutation/ polymorphism and molecular cytogenetic nomenclature. The primary product of clinical molecular genetics labs is a report describing the test results. These results should be presented in as clear a way as possible - and that includes the use of mutation nomenclature that our users understand. Increasingly, we will be asked to use standard nomenclature, especially as the complexity of our testing increases. In addition, several molecular genetic tests now serve as adjuncts to molecular cytogenetic (FISH) tests (and vice versa). Thus, a clinical molecular genetics lab needs to understand molecular cytogenetic nomenclature. In our second workshop Drs. Mark Lovell (1999 Genetics Chair elect) and Wendy Golden of the University of Virginia will discuss molecular genetic and molecular cytogenetic nomenclature. There will be ample time for interactions between the leaders and those who attend of this workshop, so please bring your questions on this important area of our clinical practice.

Members with suggestions on workshop format should send them to Dr. Robert Jenkins, 1998 Genetics Chair (rjenkins@mayo.edu).

Submitted by Robert Jenkins, MD, PhD, Mayo Clinic

UPDATE FOR HOME PAGE, CHAMP

AMP Home Page: http://www.pds.med.umich.edu/users/amp

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Submitted by: Jeff Kant, kantja@msx.upmc.edu

Please contact Dr. Kant with any questions.

ON THERMAL CYCLERS

As a scientist at a company that makes thermal cyclers, I have noted an increasing number of people interested in using those instruments for diagnostic purposes. There are a lot of issues, some obvious and some not so obvious, that arise when instruments and protocols primarily developed for research are adapted for diagnostics. In this article I would like to address some of those issues, with an advance apology if any of this seems too basic.

The thermal cycling procedures employed are principally PCR and thermal cycle DNA sequencing (cycle sequencing for short). While these are quite different at the biochemical level, they have quite a few similarities from an instrumentation and procedural point of view, so I will treat them together. The two main concerns are assay design and instrument performance.

Assay Design

Although it seems that assay design has been beaten to death, we find that the impact of instrumentation on assay design is often not well understood. For instance, we often see a thermal cycling protocol listed, without any clue about what instrument it will run on. This carries the implicit assumption that protocols are easily transferred among instrument types. The assumption is false.

For instance, every major thermal cycler supplier has produced instruments with two different ways of controlling temperature, either controlling the temperature of a sample block, or controlling the temperature of the sample itself. The consequences can be large. If both types of instrument are programmed for 5 seconds at 94C, the sample in the first type may not even reach 90C, while the sample in the second type will experience the intended temperature and time. In general, protocols will be fairly transferable among those instruments with direct sample temperature control, but even that may fail, depending on details such as speed and temperature overshoots. Published protocols should mention instrument type, and ideally include protocols for more than one instrument. If this information is missing, instrument manufacturers are generally happy to assist with transferring a protocol from a competitor's machine.

A second issue in assay design is to be sure that assays are robust to small temperature variations. I will discuss temperature verification below, but no matter how often and how carefully you check your equipment, it could always suffer a failure five minutes later. Therefore, you are best off if the assay has been checked for sensitivity to variation in every temperature. For instance, the assay could be checked - with particularly demanding samples - using a range of denaturation temperatures from 88C to 96C, so that a temperature may be chosen to give the maximum margin of safety in each direction. Many common protocols may be running on the ragged edge, but there is no way to know for sure without extensive testing. To help with this situation, published protocols ought to include the limits of temperature toleration for each step. After all, if the limits are not known, how is it possible to know what levels of instrument performance is acceptable?

Instrument Performance

There are two quite different aspects of thermal cycler function: accuracy and uniformity. In fact, you may have noticed that thermal cycler manufacturers generally specify accuracy and uniformity separately.

Of the two, uniformity is by far the more important for clinical assays. As long as a thermal cycler is uniform, the control samples run in parallel with the clinical samples will report whether the instrument is performing adequately. However, if a thermal cycler is nonuniform, control samples could succeed while clinical samples fail, resulting in incorrect conclusions. Therefore, it is desirable to concentrate on uniformity when testing the function of thermal cyclers.

Luckily, it is far easier for field temperature measurements to check uniformity than accuracy, even for precision NIST-traceable equipment. Uncertainties in initial accuracy and long-term stability of meters, probes, etc. - as well as difficult-to-control factors such as operator skill and ambient temperature - result in tolerances that can add up, in the worst case, to 0.5 to 1C or even more. Nevertheless, such equipment can be used to measure uniformity. Suppose a meter has drifted by 0.5C since its initial calibration. It will report incorrect temperatures, but every thermal cycler well measured will be incorrect by the same amount. Thus a cycler that is actually accurate may be reported as inaccurate, but one that is uniform will still be reported as uniform.

Only a few types of thermal cycler carry specifications better than an accuracy of +/- 0.5C and uniformity of +/- 0.5C. So a thermal cycler set for 65C could have an average block temperature of 64.5C, with some wells as low as 64.0C, and still be within spec for a new instrument. Because of field measurement uncertainties, instruments are generally allowed even more latitude in the field. However, PCR and sequencing reactions are usually rather forgiving, and a well-designed assay will not be significantly affected by temperature variations at this level.

Finally, it is worth noting that while some regulatory bodies have suggested testing temperatures in each well of a thermal cycler, most manufacturers recommend checking a subset of the wells. The former view is entirely appropriate for a situation where the directive must cover all possible instruments from all possible sources, and the machine must be treated as a "black box". However, the primary purpose of a uniformity test is not to identify the maximum and minimum temperatures in the block. Rather, the test is to determine whether there is any malfunction that could significantly compromise uniformity. Manufacturers will generally know how much local temperature variation is possible with a particular design, and can recommend a subset of wells to be tested. Since newer high-throughput instruments can have as many as 1536 wells, this can save a lot of technician burn-out.

Michael J. Finney, PhD

Chief Scientific Officer and AMP member

MJ Research, Inc.

384 Oyster Point Blvd. #8

South San Francisco CA 94080

mikef@mjr.com

AMP TEST DIRECTORY

The Clinical Practice Committee is in the process of preparing to issue a 1998 update of the AMP Test Directory. We will be contacting all AMP members shortly about the new Test Directory. Labs which were listed in the 1996 directory will be sent a copy of their previous listing to review and revise. Laboratories which were not previously listed will also be contacted and invited to participate.

Our plan is to use electronic communication as much as possible with participating laboratories. The current plan is for test directory templates to be e-mailed to AMP members for them to complete and e-mail back to Fran Pitlick (fpitlick@pathol.faseb.org) for her staff to collate and assemble. We do not have e-mail addresses for all AMP members. If you have not provided an e-mail address to Fran's office and you do have access to e-mail, we would appreciate very much if you could get your e-mail address to her. We expect to communicate with labs who do not have e-mail access by the traditional postal service route, but would prefer e- mail whenever possible. The completed directory will be available at the annual meeting in November. Participation in the Test Directory is a benefit of AMP membership and directories will be given to all AMP members.

Alliance for the Prudent Use of Antibiotics

http://www.healthsci.tufts.edu/apua/apua.html

The Alliance for the Prudent Use of Antibiotics (APUA) is the only international organization dedicated exclusively to protecting one of the world's great natural resources, antibiotics. APUA was established in 1981, following a historic meeting in the Dominican Republic. Since then, the organization has grown to include ten national chapters and a membership of concerned health professionals and officials in more than 80 countries. The organization serves as an international network for information exchange and provides support for country-based initiatives to track and curb antibiotic use and resistance at the local level. Moreover, APUA aims to improve global public health through the education of health care providers and consumers concerning more prudent use of antibiotics.

BIOTECHNOLOGY CURRICULUM

Centrally located in the East Coast's pharmaceutical and biotechnology corridor, the State of Maryland, which has about 226 companies (106 Biotechnology, 63 Medical & Pharmaceutical, 56 Instrumentation & Equipment), is one of the five major areas of concentration for Biotechnology in the nation. An important factor for the further creation of new companies and the continuous growth and progress of existing companies is the availability and steady supply of baccalaureate level laboratory scientists who are skilled in performing procedures and techniques utilized by biotechnology and pharmaceutical companies.

In 1990, in an attempt to meet the biotechnology industry needs, through the pioneering efforts of Denise Harmening, PhD, the Program of Medical Technology of the University of Maryland at Baltimore, which has the largest accredited training program for medical technologists, was redesignated as the Department of Medical and Research Technology of the School of Medicine, University of Maryland, Baltimore (DMRT-UMB). This has provided the framework to develop an additional concentration, "Biomedical Science" (Biotechnology). The curriculum for the additional concentration was developed in collaboration with industry and academic research laboratories through a structured three-phase process of: a) identification of competencies required for bioscience workers by research/bioscience industry representatives, b) incorporation of defined competency requirements in the curriculum design, and c) curriculum implementation and outcome assessment. The courses that were developed based on the industry- defined competencies are broadly categorized into: (1) biotechnology science courses, and (2) courses in communication, professional development, and laboratory management. The biotechnology science courses include: introduction to biochemistry and instrumentation, laboratory techniques, cellular and molecular biology I & II, immunology for biotechnologists, pathogenic microbiology, techniques in biotechnology, applications in biotechnology, and externships in small scale or large scale biotechnology and related company laboratories and in an academic research laboratory. The lecture components of the biotechnology courses expose the students to the basic science principles at the molecular level, whereas the laboratory components provide them with the necessary experiences on a variety of techniques such as DNA isolation & purification, amplification, cloning, detection, sequencing, protein electrophoresis, hybridoma technology, ELISA, immunofluorescence, bacterial, viral, cell & tissue cultures, HPLC, flow cytometry, ultracentrifugation, special microscopy, and laboratory animal handling. The externships provide them the opportunity to work on short term research projects under the guidance of a research mentor. Thus, students who have been admitted to the DMRT 's Biomedical Science Research Track program after they have completed 60 credits of prerequisite course work at area colleges, will complete a total of 125 credits or 2 years of training and acquiring biotechnology skills that are immediately applicable after graduation.

Contributed by:

Myrna M. Mantaring, MCI, MS, MT(ASCP) Clinical Instructor

Phone, (410) 706-1830/Fax, (410) 706-5229

e-mail: MMANTARI@medresch.umaryland.edu

Hassan Azzazy, PhD, SC (ASCP) Asst. Professor, e-mail: HAZZAZY@medresch.umaryland.edu

Denise Harmening, PhD, MT(ASCP), CLS (NCA) Chair & ProfessorDH@medresch.umaryland.edu

Development of a New ASTM Standard for Controls Needed in the Performance of Molecular Diagnostic Procedures

ASTM (American Society for Testing and Materials) is an international organization devoted to the development of written, voluntary consensus standards. ASTM's Committee E- 48 on Biotechnology is a dynamic group of more than 100 research scientists, engineers, manufacturers, government representatives and others who apply their expertise towards the development of standards in biotechnology. Types of ASTM standards include guidelines, practices, specifications, test methods and others. A recently published standard in the molecular pathology area is E1873-97: "Standard Guide for Detection of Nucleic Acid Sequences by the Polymerase Chain Reaction Technique". Two related standards presently in development concern the detection of HIV RNA or DNA by PCR and the detection by PCR of the DNA of members of the Mycobacterium tuberculosis complex. The Committee is now looking for volunteers to help develop a new standard for controls needed in the performance of DNA/RNA amplification-based and related procedures used in basic biological research and biotechnology and in the diagnosis of infectious and/or genetic diseases. We are working closely with members of other standards organizations such as NCCLS (National Committee for Clinical Laboratory Standards) so that duplications of effort can be prevented. Meetings to discuss progress on the development of this standard will usually be held in the Washington, D.C. area, but attempts would be made, whenever possible, to hold such meetings in conjunction with other planned Washington area scientific meetings of interest to members of AMP [ED NOTE: Dr. Bockstahler is aware of the dates of the AMP meeting]. Molecular biologists/pathologists interested in volunteering for this project should contact Larry E. Bockstahler, PhD, Chair, ASTM Subcommittee E48.02, (address: FDA, HFZ-113, Rockville, Maryland, 20857, Phone, (301) 443-7287, e-mail: leb@cdrh.fda.gov).

Contributed by Dr. Bockstahler

NCA MOLECULAR. BIOLOGY EXAMINATION

Last July, the National Certification Agency (NCA) introduced the first examination to certify baccalaureate-level staff who perform molecular biology techniques. This initial exam was offered at only 15 sites throughout the United States. 194 candidates took the exam; 78.87% passed. Those certified are identified as "Certified Laboratory Specialist in Molecular Biology", abbreviated CLSp(MB). Several members of AMP participated in the exam's development:Daniel Farkas, John Gerlach, Nahida Akel, Cathie Leiendecker Foster, and Greg Tsongalis.

Future exams will be given at all NCA exam centers once per year in July. Information about testing sites, exam dates, applications, etc. is posted on NCA's Web site on the internet at http://www.applmeapro.com/nca. NCA may also be contacted at P.O. Box 15945-289, Lenexa, KS 66285.

At the AMP meeting last November, Richard DiCarlo and Ann Drevon [both MT(ASCP), CLSp(MB)] from William Beaumont Hospital presented (thanks to Dan Farkas) a general review session to help prepare for this exam. An in-depth review session covering three or four specific topics is in the planning process for the meeting this November. Cathie Leiendecker Foster (612/626-2305 or foste011@tc.umn.edu) from the University of Minnesota and Kent Williams (901/495-2667 or KENT.WILLIAMS@Stjude.org) from St. Jude's Children's Hospital are planning this event and are willing to hear suggestions, ideas, and input from any interested parties.

Contributed by: Cathie Leiendecker Foster, MS, CLSp(MB)

Phone, (612) 626-2305; Fax, (612) 625-6994

Workshop Summary: STANDARDS FOR NUCLEIC ACID DIAGNOSTIC APPLICATIONS

As elucidated in the National Institute of Standards and Technology (NIST) Mission Statement, NIST promotes economic growth by working with industry to develop and apply technology, measurements, and standards. The fields of molecular biology and genomics have exploded over the past 20 years, resulting in the ability to assign causal and associative relationships between specific genes and diseases. Diagnostic tests have become available to detect the expression or mutation of a number of these genes. The tests are available on a confusing array of platforms, with varying claims made as to their specificity and sensitivity. They are currently being conducted in a number of different settings, including hospital laboratories, research laboratories, and clinical reference laboratories.

To address the standards needs and measurement concerns of this diffuse community, a workshop entitled "Standards for Nucleic Acid Diagnostic Applications" was held at NIST March 14-18, 1998. The goal for the workshop was to assemble experts representing the various aspects of DNA Diagnostics to discuss from different perspectives how standardization could assist this community in providing a higher degree of confidence in nucleic acid diagnostic tests. Representation included those developing assay systems (both academic and industrial), testing labs that perform the assays, and organizations, both regulatory and voluntary, associated with standardization of these assays (including many AMP members).

To attract the targeted audience described above, organizations with interests in the availability of standards for the nucleic acid diagnostic community were invited to co-sponsor the workshop. Groups that agreed to co-sponsor with NIST included: Health Care Financing Administration (HCFA), National Committee for Clinical Laboratory Standards (NCCLS), Food & Drug Administration- Center for Devices & Radiological Health (FDA-CDRH), Centers for Disease Control, Division of Laboratory Systems (CDC), and the Association of Government Toxicologists (AGT). Within NIST, co-sponsoring programs included the CSTL Biotechnology Division, the Standard Reference Materials Program, and the Advanced Technology Program.

The workshop organizing committee was selected based on their expressed interest in this area of diagnostic testing. Participants included representatives from government agencies (NIST and FDA-CDRH), commercial testing laboratories and consultants working with testing laboratories (SmithKline Beecham and GeneWISE), and a consultant for companies developing diagnostic tests. Members of the organizing committee were:

Catherine O'Connell, Chairwoman, NIST

Leslie Abelson, BioTek RA

Jean Amos, SmithKline Beecham Genetic Testing Center

Rosalie Elespuru, FDA-CDRH

Sharon Hansen, FDA-CDRH

Barbara Levin, NIST

Ginette Michaud, FDA, Genetics Working Group

Pat Murphy, GeneWise

The organizing committee identified the workshop scope and sessions to be included: genetic disease, infectious disease and cancer. The committee felt that the diagnostic tests performed for these areas would have many overlapping interests in standardization and measurement needs, and therefore should be considered as a whole. They were also considered as a group because both FDA and CLIA regulate them by the test type conducted, not by disease type. Session chairs were selected from those on the organizing committee with expertise in these areas and from recommendations by organizing committee members. Session chairs were: Dennis Reeder; Jean Amos; Pat Murphy; John Ticehurst, FDA-CDRH; D. Joe Boone, CDC.

The workshop included six sessions over four days. Dr. Dennis Reeder introduced NIST's involvement in standards development for nucleic acid testing, using the NIST Standard Reference Materials (SRMs) developed for the forensic community as a model system. AMP hematopathology subdivision chair, Dr. Timothy O'Leary presented the keynote address. Dr. O'Leary has considerable expertise in the area of standardization issues for clinical diagnostics, and has been an active participant on standards committees. The next two sessions covered different aspects of Genetic Testing: regulatory issues that specifically face this community, and model systems in the area of genetic testing in need of standardization. The fourth session focused on model systems for infectious disease testing, and the fifth session discussed model systems for cancer diagnostics. We included panel discussions following the afternoon sessions to stimulate discussion, and we ended the workshop with breakout sessions for each of the session topics to identify the most important standardization needs for these communities as well as vehicles to meet those needs. The workshop then re-grouped with a presentation of the discussions held in each of these breakout groups and a general wrap-up. Attendance was high at all three breakout sessions and discussions were fruitful. The list of attendees at all three breakout sessions is available from the author. The concerns and recommendations of these breakout groups, based both on the talks presented at the workshop and the expertise of the workshop attendees, are detailed below. Overall feedback obtained from the attendees was that interactions among these different scientific populations was invaluable, as discussions were based on all of their needs, including scientific, regulatory, and business driven concerns. The most common feedback was that the workshop should be lengthened and that having the all three areas presented focused the quality assurance issues facing the community.

I. SRMs FOR ASSAY VALIDATION, TRACEABILITY AND RESEARCH:

Standards are needed. The need for standard reference materials, assay controls, and proficiency testing materials was repeatedly emphasized. Although there were specific needs addressed by the different groups, based both on specific diseases and assay systems, many of them were similar in scope. The most effective mechanisms for securing these materials for the molecular diagnostics community became the focus of the breakout sessions and summary session that concluded the workshop.

Standards materials and protocols need to be flexible. SRM, PT, and assay control needs were considered both in context of current (used for testing now or within 2 years) and future technologies. Current technologies were considered to be PCR, Southern blot hybridization, and FISH. Future technology platforms include comparative genomic hybridization (CGH) and Chip technologies. It was emphasized that due to the rapid advances in technology, any SRMs or PT materials would need to take into account differences in technologies to be flexible for the next generation of materials. These should therefore be as close to the natural test samples as possible, and preferably would be cell line-derived genomic DNA-based samples. Although not preferable, there was an understanding by the diagnostic community that some samples would be "synthetic" (e.g.: cloned DNA), or could have a "synthetic" element.

Many genetic testing laboratories conduct few tests/year. Dr. Margaret McGovern presented a pivotal talk during the workshop. In a survey conducted under contract to the CDC, Dr. McGovern surveyed all laboratories currently conducting genetic tests to determine what QA practices were being followed. With a high return rate (68%) of completed surveys, the results were considered reflective of the testing laboratories. Two salient points became the focus for further discussion by the workshop attendees: first, that the vast majority of the laboratories (64%) conducted under 200 tests per year, and secondly, that laboratories with low QA scores were generally those in a research setting and those directed by non-genetics trained directors. These findings emphasized the critical need for proficiency testing of genetics laboratories, and therefore the need for SRM materials for self-evaluation by these laboratories and PT materials for inter-laboratory evaluation.

Importance of sub-licensing to QA. A further concern of the workshop attendees was that of large laboratories unwilling to sub-license a molecular test. There are several large testing laboratories that currently have exclusive molecular tests available, and it was unclear to the workshop attendees how their performance would be monitored. It is unlikely that a PT or SRM will become available for a single user; and without a number of laboratories conducting the same test, detecting problems in a specific test is dependant on a single lab director responsible for validating all tests.

A Technical Working Group for Nucleic Acid Standards. Workshop attendees felt that appropriate QA of molecular laboratories and the laboratory surveillance critical for QA is not yet being met. The suggestion made by the session chairs that the appropriate mechanism for achieving these goals might be a technical working group for nucleic acid standards (TWGNAS) was well received. Suggestions were made that such a working group should be coordinated by NIST with AMP, ACMG, and ASHG involvement and dissemination of information and surveys to their memberships. It was felt that TWGNAS should first survey all SRM and PT materials currently available and publish this information. It was further felt that TWGNAS would be an appropriate mechanism for determining the number of laboratories currently conducting molecular diagnostic tests, and an accurate number of the specific tests conducted by each laboratory. It was felt that this information should be available before determining the specific SRM and PT needs of this community.

Specimens and specimen archives were considered to be a critical need of clinical diagnostics labs. Laboratories with materials widely used by the clinical laboratory community (primarily cell lines with specific genotypes) currently limit their products to non-commercial use. The role of these laboratories (Coriell, ATCC, others) in providing materials for clinical use needs to be clarified. They are not GMP facilities, and the materials are usually not validated. Workshop participants would like defined who will be responsible for validation of these materials: NIST? NIH? CDC? NIGMS? Is there a role for the government to work with these laboratories to extend usage of these for test validation & SRMs?

The ASR rule. An unexpected benefit to the workshop participants was the ability to discuss with the regulatory groups (FDA, CLIA, & HCFA) issues of concern. The most frequently discussed concern was the FDA rule under the FDA Modernization Act of 1997 that is still under discussion. The analyte-specific reagents (ASRs) rule within the Act controls the use of analytes in "home brew" tests and is meant to provide a measure of QA to these tests. Analytes to be covered by this rule and how the rule will affect availability and cost of these reagents are unclear to the diagnostic community. Their ability to address this concern to FDA-CDRH scientists in a public forum was very beneficial to this community.

Specific Needs. High-priority, specific concerns addressed by workshop attendees:

1. Database Needs: Databases containing disease-specific information are needed. Attendees felt these should be managed by an independent group, and would preferably be available on the WEB. Possibly there is a role for AMP or AFIP.

2. SRM Needs: Trinucleotide allelic ladders (size standards) that cover the entire range of observed alleles (Fragile X myotonic dystrophy, ataxias, Huntington's Disease) (Genetics Group) and SRMs addressing mutations (CF, b-globin, BRCA-1&2, DMD/BMD, Gaucher, MERFF, MELAS) (Cancer Group); HCV genotypes and quantitative HCV assay standards materials (Infectious Disease Group); DNA quantitation standard (A₂₆₀/A₂₈₀).

SRM materials need to be both unlabeled and fluorescently labeled; need positive controls for known mutations + sequenced wild-type; need a clinically useful collection and guided by the clinical molecular genetic community.

Development of a "tissue substrate matrix" to create a more natural substrate for artificial mixtures of cells or viruses.

3. Written Standards Availability & Needs

Consensus guidelines on how to develop controls/standards for an assay system (NCCLS?).

NCCLS MM3-18R

NCCLS Quantitation Standard (under development)

ASTM Control Standard (under development)

ASTM PCR

AMP for HIV RNA(under development)

NIH Consensus Statement for HCV

NIH Consensus Statement for CF

Standards for specimen collection, transport, storage, extraction & processing

Standards or guidelines concerning reagent quality & performance.

Some standards needs were felt to be met. Several of the highest priority public health concerns were thought to have QA practices and materials in place or soon available, including HIV; B/T cell gene rearrangement analysis; and BRCA1 & 2 mutation detection. Materials that are or will soon be available include: HIV panels distributed by FDA-CBER and the Breast Information Core (BIC), established as a clinical laboratory interface to share information and materials. The materials under development are 16 Coriell cell lines containing mutations in the BRCA1 gene.

Summary prepared by: Dennis J. Reeder, PhD, Leader, DNA Technologies Group, NIST

dennis.reeder@nist.gov

CALL FOR

NOMINATIONS

The Nominating Committee is now entertaining suggestions for:

1) the recipient of the 1999 AMP Award for Excellence in Molecular Diagnostics

2) nominees to elected positions on AMP committees and the AMP Council.

Please contact the Nominations Committee representatives from your Subdivision(s). Self-nominations are welcome. See the AMP Home Page and CHAMP for details.

http://zapruder.path.med.umich.edu/users/AMP/

Nominations Committee Representatives

Solid Tumor: Sharon P. Wilczynski: swilczynski@smtplink.coh.org and Meera Hameed: hameedmr@umdnj.edu

Infectious Disease: Richard H. Scheuermann: scheuerm@utsw.swmed.edu and Maher Albitar: (713-794-1292).

Hematopathology: Suzanne Kamel-Reid: s.kamel.reid@utoronto.ca and Richard C. Harvey: 102447.1160@compuserve.com

Genetics: Nicholas T. Potter: npotter@utk.edu and Nahida Akel: nmatta@path.med.umich.edu

Contributed by: Mark Sobel, Chair (molpath@helix.nih.gov)