Genomic Research as a Critical Pathway to Diagnosis for Individuals with Rare Disease.

Many individuals with rare monogenic disease remain molecularly undiagnosed due to challenges accessing genetic testing, ambiguity in interpretation of uncertain variants, and latency between novel disease-gene discovery and adoption into clinical pipelines. The Rare Genomes Project (RGP) provides a remote, research-based genomic sequencing (GS) service for rare disease families to overcome diagnostic barriers while advancing the understanding of the genetic basis of rare disease. Short-read GS and family-centered analysis were performed to identify causes of primary disease. Variants meeting return criteria were clinically confirmed and returned to families. Since 2017, RGP enrolled clinically heterogeneous, undiagnosed rare disease families from all fifty states, Washington DC, and Puerto Rico. Findings were returned to 272 of 1014 sequenced families, resulting in a solve rate of 23.3% and a returned strong candidate rate of 3.5%. Condition-specific return rates ranged from 15% to 40% with many families receiving a result in a known disease gene after healthcare access challenges. Research interventions contributed to returns in 16% of all families and included variants in recently discovered or non-coding disease genes, additional functional studies to resolve variant uncertainty, and real-time data sharing to empower novel disease-gene discovery. RGP demonstrates that a research-based, patient-driven remote sequencing study can effectively bridge a diagnostic gap for rare disease families underserved in current clinical care. This study also underscores the clinical utility of GS with frequent re-analysis and highlights the critical continued role of research in variant interpretation, method innovation, and genomic knowledge base expansion for rare disease diagnosis.