Is cascade testing a sensible method of screening a population for autosomal recessive disorders?

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Abstract
Our aim was to evaluate "cascade testing" as a method of screening a population for autosomal recessive disorders. We used computer simulations to estimate screening performance according to carrier frequency, whether testing would extend to siblings, first or second cousins of identified carriers and family size. Cascade testing in populations with the distribution of family size current in England and Wales would require locating and testing a small proportion of the population as expected, but would detect few cases. For cystic fibrosis (carrier frequency of 4%), testing all siblings and first cousins of all identified carriers would require locating and testing only 1.9% of the whole population, but would detect only 15% of all new cases. Similarly for congenital adrenal hyperplasia (carrier frequency of 1%), testing all siblings and first cousins of all identified carriers would require locating and testing only 0.1% of the whole population, but would detect only 3.1% of all new cases. The detection rate increases with increasing carrier frequency, family size and extending the testing to second cousins of identified carriers, but at the cost of greater increases in the proportion of the population located and tested. The performance of cascade testing is too poor to justify its introduction into practice as a screening test for any autosomal recessive disorder.