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Data Resource Profile: EULAT Eradicate GBC: the European-Latin American Research Consortium towards Eradication of Preventable Gallbladder Cancer

Year: 2025

Type: article

Abstract: The European-Latin American Research Consortium towards Eradication of Preventable Gallbladder Cancer (EULAT Eradicate GBC) has established a biorepository of >14 000 individuals as part of a Latin American gallbladder cancer (GBC) case–control study and a GBC case–control study nested within large European prospective cohorts to discover and validate biomarkers for GBC prevention. The EULAT Eradicate GBC is unique in its study design, in the combination of European and Latin American data and samples, and in the sampling of Latin American patients prior to cholecystectomy. Samples are used for molecular-genetic profiling of the study participants and complemented with clinical, lifestyle, cultural, and behavioral data with the aim of generating individual GBC risk scores. Between January 2020 and May 2025, >11 400 Latin American and >300 European individuals were included in the study, with an age range of 18–96 years. Research collaboration requests and applications for access to data and samples can be sent to [email protected]. Gallbladder cancer (GBC, ICD-10 diagnosis code C23) is a relatively rare but aggressive disease that is expected to cause 95 609 deaths worldwide in 2025 (https://gco.iarc.fr/en). Most GBC deaths occur in low- to middle-income countries, including northern and north-eastern India, Bolivia, Chile, and the surrounding Andean regions. The research into this aggressive malignancy has remained neglected for myriad reasons [1]. Host factors that increase GBC risk include age, female sex, gallstones, Indigenous American ancestry, family history of GBC, and body mass index (BMI) [2, 3]. However, individual GBC risk prediction for primary prevention remains unreliable. Surgery offers the potential to cure GBC confined to the mucosa; however, early symptoms of GBC are non-specific and, currently, there is a dearth of tests to detect gallbladder tumors early. Less than 20% of patients qualify for curative surgery at diagnosis, translating into an average 5-year survival rate of only 2% for patients with metastatic disease [4]. To improve the prevention of GBC, in 2019, we initiated the establishment of a European-Latin American research consortium— the European-Latin American Research Consortium towards Eradication of Preventable Gallbladder Cancer (EULAT Eradicate GBC), funded by the European Union’s Horizon2020 program and coordinated from Heidelberg University Hospital, Germany, with the ambitious goal of eradicating preventable GBC (https://cordis.europa.eu/project/id/825741, https://www.klinikum.uni-heidelberg.de/eulat-eradicate-gbc). The EULAT Eradicate GBC combines a multinational case–control study of Latin American patients with GBC and gallstone disease with a multinational case–control study nested within large European cohorts. This combined study design allows biomarker discovery in a case–control setting, followed by prospective validation in independent samples. Furthermore, it facilitates a comparative analysis of biomarkers of GBC risk in high-incidence (Latin America) and low-incidence (Europe) geographic regions. Following standard operating procedures and taking advantage of a web-based application for the electronic collection of socio-demographic, sample, clinical, and lifestyle data, the EULAT Eradicate GBC is building a comprehensive biorepository integrated into a specifically designed IT platform with high-quality data and samples to pursue the following specific objectives: identifying biomarkers of GBC risk that guide prophylactic cholecystectomy and translate into novel and efficient strategies for precision prevention; improving the current understanding of the causal mechanisms that link lifestyle, cultural, and behavioral factors to GBC development; unraveling novel opportunities for targeted therapy of GBC diagnosed during the implementation of prevention programs; exploiting existing and newly generated epidemiological and multi-omics data to improve early detection and optimize GBC prevention; contributing significantly to training the next generation of Latin American researchers in personalized GBC prevention. The EULAT Eradicate GBC combines a multinational study of Latin American GBC cases and gallstone disease controls with multinational European cohorts, covering data and samples from patients in regions with high (Latin America) and low (Western Europe) GBC incidence (Fig. 1). Participating countries in the EULAT Eradicate GBC. Patients affected by gallbladder cancer and gallstone disease are recruited in (a) four South American countries (Argentina, Bolivia, Chile, and Peru) and (b) Europe within the large European cohorts. Dark bullets: initial recruitment sites; light bullets: contingency recruitment sites. Maps created with MapChart. GBC cases comprise patients with a confirmed diagnosis of GBC (ICD-10 diagnosis code C23). The study includes only individuals aged >18 years and excludes patients with a porcelain gallbladder, polyps, non-cholesterol stones, or abnormalities of the pancreas or bile ducts. Gallstone disease controls without preneoplastic (gallbladder dysplasia) or neoplastic gallbladder lesions from the case–control study and controls from the cohort study are matched with the cases by sex, age, and BMI. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. All participants provide written informed consent before enrolment. Two distinct types of GBC patients are recruited in Argentina, Bolivia, Chile, and Peru (Fig. 2). (i) Pre-surgical samples and interview data are collected from gallstone disease patients before cholecystectomy. Upon pathological review, 1%–3% of resected gallbladder specimens show preneoplastic or neoplastic lesions and are included in the GBC case population. (2) Post-diagnostic samples and data are collected from patients still carrying the primary GBC tumor (mainly patients with unresectable GBC from oncology and palliative care units). Recruitment strategy and samples collected in Latin America. Two types of patients are recruited: (a) presurgical samples and interview data are collected from patients with gallstones before cholecystectomy. After pathological review, we include patients with neoplastic findings or cancer in the case group. (b) Post-diagnostic samples and interview data are also collected from patients already diagnosed with GBC. Controls are selected from the group of cholecystectomized patients without (pre-)neoplastic gallbladder lesions and matched to GBC cases by age, sex, BMI, and recruitment center. Controls without preneoplastic or neoplastic lesions in the gallbladder are selected from the group of cholecystectomized patients and matched for sex, age, and BMI to the locally recruited GBC patients. In addition to sporadic GBC patients, we invite families with more than one member affected by GBC to participate in the study. Standard operating procedures (SOPs) are in place at each recruitment center to identify patients (i) undergoing cholecystectomy or (ii) diagnosed with GBC. Upon invitation by the physician, a trained study nurse provides eligible participants with detailed information about the study and answers any questions that the patient may have. If the patient agrees to participate and signs the informed-consent form, then the study nurse interviews the patient and collects blood, saliva, urine, and stool samples according to the EULAT Eradicate GBC SOPs and all ethical and legal regulations for biomedical research. The study nurse also invites relatives of GBC patients who report a family history of GBC during the interview [e.g. mother or sister(s) also affected by GBC] to participate in the study—after pathological confirmation of the diagnosis in the relative. We conduct patient interviews by using an application developed specifically for the EULAT Eradicate GBC project—EULAT eCollect [5]. EULAT eCollect ensures standardized data and sample collection across all recruitment centers and greatly facilitates monitoring local recruitment rates, and data and sample quality control. We organized EULAT eCollect into four separate modules (Table 1): Module 1—socio-demographic interview, Module 2—sample information, Module 3—case report form, and Module 4—food-frequency questionnaire [6]. Module of the web application EULAT eCollect. We have designed and are constantly updating an IT platform to store the extensive socio-demographic, biospecimen, clinical, dietary, and molecular-genetic data generated within the EULAT Eradicate GBC to facilitate the monitoring of recruitment rates, quality of collected data, and preanalytical quality of collected samples by using Standard PREanalytical Codes (SPRECs) and to provide researchers with information on data and sample availability [7]. The IT platform is designed to fulfill the regulations, concepts, and technical recommendations that apply to the security and protection of personal data on the basis of the EU General Data Protection Regulation (GDPR), as well as the specific regulations in the Latin American beneficiary countries of the project (Argentina, Bolivia, Chile, and Peru). In addition to providing secure access to comprehensive anonymized biospecimen, epidemiological, and multi-omics information, we expect the IT platform to be a fundamental tool to strengthen collaboration and networking among all consortium members. We have established a continuously expanding biobank with samples from Latin American and European patients with gallstone disease and GBC. Following detailed SOPs, samples are collected and processed in >17 Chilean, 9 Peruvian, 4 Bolivian, and 3 Argentinean centers (sample specifications are presented in Table 2). Samples are aliquoted into 2D barcoded cryovials to ensure unambiguous sample identification and localization and stored at –80°C. One-third of the samples (series B) are stored locally as part of the EULAT Eradicate GBC biorepository and two-thirds (Series A) are sent to Heidelberg University for molecular-genetic characterization and long-term storage. Biospecimen collected within the EULAT Eradicate GBC. Whole blood: 2×1000 µl Serum: 3×1000 µl Plasma: 3×1000 µl Buffy coat: 1×1000 µl Whole blood: 1×2000 µl Serum: 1×2000 µl Plasma: 1×2000 µl Patient recruitment and sample processing are harmonized across all recruitment sites according to comprehensive SOPs and the EULAT eCollect application also facilitates standardized data and sample collection. Harmonization activities include training recruitment staff in biobanking and biorepositories, applying technical and operational guidelines, and establishing a program for quality assurance, quality control, and standardized data management. The technical, operational guidelines in place include (i) guidelines on international biobanking best practices according to international organizations (OECD, 2009; ISBER, 2018; NCI, 2016), (ii) comprehensive SOPs describing all processes from study invitation and informed consent to collection, handling, processing, long-term storage, and shipment of biological samples, and (iii) guides on ethical, legal, and social issues (ELSI) [8]. The EULAT Eradicate GBC program on quality assurance, quality control, and standardized data management comprises sharing quality-control documentation with all recruitment sites and training recruitment staff to implement the quality-assurance/quality-control procedures partly reflected in the SPREC indicators. Audits to ensure compliance with SOPs are performed at each recruitment site at the start, during patient recruitment, and after each sample shipment. In addition, a Latin American project manager regularly monitors all processes and operations by using automated reports. In addition, we are in the process of collecting samples and data from >200 prospective GBC case–control pairs nested in the large European prospective cohorts, including the Estonian Genome Project, the European Prospective Investigation into Cancer and Nutrition (EPIC), the Finnish FINRISK and Health2000 cohorts, the Norwegian Janus Serum Bank and the Helseundersøkelsen i Nord-Trøndelag (HUNT) study, the Dutch LifeLines cohort study, the Swedish Twin Registry and the German Epidemiological Study on Prevention, Early Detection and Optimised Therapy of Chronic Diseases in the Elderly Population (ESTHER), the Cooperative Health Research in the Region of Augsburg (KORA), the Study of Health in Pomerania (SHIP), and the Heinz Nixdorf Recall studies [9–19]. This collaborative effort has resulted in a unique collection of prospective DNA, serum, and plasma samples, and extensive, high-quality lifestyle, environmental exposure, and molecular-genetic data, which we hope to expand with contributions from other studies. From January 2020 (first patient in) to March 2025, 11 453 Latin American participants were enrolled in the study (Table 3). Characteristics of the Latin American case–control study population. Most individuals were recruited in Chile (68%), followed by Peru (16%), Bolivia (14%), and Argentina (2%). The median age of the study population is 48 years and 74% of the participants are female. In terms of Indigenous ancestry, Quechua is the most represented (13%), followed by Mapuche (11%) and Aymara (5%). The majority of individuals recruited (77%) are overweight (BMI ≥ 25 kg/m2) and 38% are obese (BMI ≥ 30 kg/m2). GBC or gallbladder dysplasia was diagnosed in 12% of the study population. In addition, >400 participants from the European prospective cohorts have been included in the study. Using these datasets, we have conducted several studies on GBC risk prediction, biomarker identification, and causal mechanisms underlying GBC development. For example, we have shown the potential of individual genotype data to predict long non-coding (lnc)RNA expression in serum through lncRNA preselection, cis-expression quantitative trait loci (eQTL) validation, and association analysis between genotype-based lncRNA expression and GBC risk [20]. In separate analyses of the DNA methylation of tissue samples from patients affected by gallstones, gallbladder dysplasia, and GBC, we observed increased epigenetic alterations and copy number variations with sequential disease progression from gallstones to inflammation, dysplasia, and GBC, mainly involving the hypermethylation of cytosine–guanine dinucleotide islands and gene promoter regions [21]. In another study, through Mendelian randomization, we demonstrated a direct causal genetic link between BMI and GBC risk in the Chilean population and, instead, in the European population, an indirect effect mediated by gallstones [2]. In another study, we observed an unconfounded association between the individual proportion of Indigenous American Mapuche ancestry and GBC risk, which was also mediated by gallstones [22]. We designed and validated a 25-gene sequencing panel, which permitted the identification of several GBC predictive biomarkers (PARP, EGFR, PIK3CA, mTOR, and Hedgehog signaling inhibitors). Targeted gene panels may represent a cost-effective alternative for implementing real-world precision medicine in Latin America [23]. In a retrospective study of 473 Chilean GBC patients and 2137 population-based controls, we developed and internally validated three prediction models for GBC risk. The baseline model, which only included gallstones, sex, and birth year, performed worst with an area under the precision-recall curve of 0.44% (95% confidence interval (CI) 0.42–0.46), which increased by 0.22 (95% CI 0.15–0.29) with the inclusion of nongenetic factors (Enhanced Model I: BMI, education, Mapuche surnames, number of children, family history of GBC). The additional incorporation of genetic factors in the Enhanced Model II further improved the risk prediction by 2%. The consideration of additional information permitted the number of cholecystectomies needed to prevent one GBC case to be reduced from 115 in the baseline model to 80 in Enhanced Model II [24]. A up-to-date list of EULAT Eradicate GBC publications can be found at https://www.klinikum.uni-heidelberg.de/eulat-eradicate-gbc/publications. For various reasons, including sociopolitical and geographical ones, GBC remains a neglected disease due to a lack of research resources and efforts. Despite the aggressive nature of the disease, the treatment options remain very limited. We believe that accurate risk prediction and early detection can reduce GBC mortality in low-income, high-incidence regions. To achieve this goal, we have established the EULAT Eradicate GBC, funded by the Horizon 2020 EU research and innovation program (https://cordis.europa.eu/project/id/825741). The main strengths of this resource are the representativeness of the patients recruited in Argentina, Bolivia, Chile, and Peru [of the 10 434 cases of GBC diagnosed in Latin America and the Caribbean in 2022 according to Globocan, 4833 (46%) were diagnosed in the four participating countries], the large study size (as of May 2024, the number of patients recruited was 11 453), and the sample collection prior to cholecystectomy in gallstone disease patients (most biospecimens are treatment-naive). Furthermore, the interviews remain uninfluenced by a possible cancer diagnosis, thus most likely reflecting the patients’ lifestyles. The sample and data collection within the EULAT Eradicate GBC include blood, urine, feces, bile, and saliva. Standardized operating procedures ensure harmonized methods of data and sample collection at all recruitment sites and the comparability of the generated data. This harmonization also includes the central organization of laboratory materials, such as barcoded cryotubes, which guarantee sophisticated biobanking of the study samples. Furthermore, the multinational study design combining a case–control study with a prospective cohort enables researchers to discover disease biomarkers in the case–control design, which can then be validated in the prospective cohort. This, however, relies on the assumption that biomarker profiles are similar across study designs and are not masked by gallstone disease in the case–control group. One limitation of the study is the independently developed SOPs for data and sample collection in the European cohorts, which require careful harmonization before data analysis. Finally, a large number of gallstone disease patients need to be enrolled to recruit each case of GBC: among all cholecystectomized patients, only 1%–2% are diagnosed with GBC on histopathological examination. Currently, 115 cholecystectomies need to be performed to prevent each case of GBC, demonstrating the urgent need to develop personalized strategies to identify high-risk individuals. By establishing the EULAT Eradicate GBC, we aim to address the challenges of GBC prevention and advance the eradication of preventable GBC through the integration of a European–Latin American GBC biorepository into an IT platform with an unsurpassed collection of data and samples. The EULAT Eradicate GBC is governed by an executive board and managed by a project management office. Data and samples are available for research purposes only. Research collaboration requests and research proposals for access to data and samples are welcome and can be addressed to [email protected]. Requests for access to data and samples are assessed on the basis of scientific quality, public benefit, medical ethical considerations, compliance with the GDPR, and the risk of identification of the study participants. A processing fee may be charged for the delivery of samples and data. This study was performed in line with the principles of the Declaration of Helsinki and has been approved by the ethics committees of Servicio de Salud Metropolitano Oriente, Servicio de Salud Metropolitano Sur Oriente, and Servicio de Salud Metropolitano Central in Santiago de Chile; Servicio de Salud Coquimbo in Coquimbo, Chile; Servicio de Salud Maule in Talca, Chile; Universidad Católica del Maule in Talca, Chile; Servicio de Salud Concepción in Concepción, Chile; Servicio de Salud Araucanía Sur in Temuco, Chile; Servicio de Salud Valdivia in Chile, Centro de Bioética Universidad del Desarrollo and Clínica Alemana de Santiago in Santiago de Chile; Unidad de Investigación Hospital San Juan de Dios in Santiago de Chile; the Medical Faculties of Universidad de Chile and Pontificia Universidad Católica de Chile, Facultad de Medicina, Universidad Mayor de San Bolivia, de de Investigación de de and de Investigación del de The the study and research staff for contributions and to this research The further the data by the of and the and the German Research through and This was also funded by the Chilean Research and of This study was by the European Union’s Horizon 2020 research and innovation program under were not used in this

Source: International Journal of Epidemiology

DOI: 10.1093/ije/dyaf127