Introduction
According to the Global Cancer Observatory (Globocan), an increase of 47% new cancer cases worldwide is estimated by the year 2040. Due to demographic changes and an accumulation of cancer risk factors, transitioning countries like Armenia are expected to be affected more severely (+ 64–95% new cases) than already transitioned countries. According to these reports, it is inevitable infrastructure for cancer prevention and research is strengthened so as and to provide the increasing needs of cancer care in these countries1. Armenia with its approximately three million population2 is one of these transitioning countries, affected by increasing numbers of cancer cases, with cancer incidence rising and becoming currently the second leading cause of death nation-wide3. Besides aging and population growth, the main cancer risk factors in Armenia include smoking, physical inactivity, obesity, and alcohol use4. The latter two are assumed to arise due to the socioeconomic development5 in transitioning countries and have been particularly prominent in Armenia6,7.
Additionally, hereditary cancer risk factors have to be taken into account. According to the United States Center for Disease Control (CDC), 5–10% of breast cancer is due to genetic factors, for ovarian cancer the value lies between 10 and 15%8. Armenian researchers recently investigated pathogenic gene mutations, responsible for an increased risk for hereditary breast and ovarian cancer (HBOC). Previous small-scale studies in Armenia showed the lack of founder mutations in the investigated panels and indicated that there might exist population-specific mutations, that are responsible for hereditary breast cancers9. In Armenia’s first large-scale study, investigating population-specific genes, 44 variants were identified responsible for breast cancer9. This is significant, as it demonstrates the need for further large-scale, population-specific studies, to further understand the genetic predisposition of the Armenian population to certain cancer types.
Yet, despite the predicted increase in cancer cases and the occurrence of population-specific hereditary cancers, as described above, Armenia is one of the lowest performing countries world-wide, regarding scientific and technical papers10. In comparison, in 2020 Austria had a 23-fold higher scientific output than Armenia and Germany, one of the leading academic countries in Europe, showed a publication rate that was 200-times higher10,11. This demonstrates the considerable knowledge gap that exists both locally and internationally, as there is very limited research conducted locally, and as such not being visible in the international stage.
On the ground in Armenia, cancer research itself, when undertaken, is insufficient for the population needs and tends to be conducted in silos, rather than as part of a connected healthcare system12. The Center of Medical Genetics and Primary Health Care (CMG) at Yerevan State Medical University (YSMU) is one of the few active research units, with hereditary cancers and personalized treatment of cancer the major topics of its research, in addition to the provision of pharmacogenetic testing for cancer patients for all oncological centres of Armenia.
To support the development of cancer research and set the foundations for the subsequent research on cancer treatment and prevention, a consortium was formed, with the participation of the Yerevan State Medical University (YSMU); the International Agency for Research on Cancer, World Health Organization (IARC/WHO); the Medical University of Graz (MUG); and the Charles University (CU). Together they conceptualised the Twinning for the Armenian Research Infrastructure on Cancer (ARICE) programme, funded by the European Commission. The main objective of the ARICE project was to support YSMU in enhancing its research capacity in the field of infrastructure development for clinical genetic research, including foundational aspects such as the standardised collection and use of biological material and associated clinical data. This publication presents the outline and experiences from ARICE as a reflection point from the last months of the project.
Methods
The methodology for establishing a stronger cancer research capacity in Armenia had four pillars: evaluation, co-creation, delivery and assessment. This approach had been implemented previously successfully for educational activities of all three international partners as part of independent projects. Specifically, Charles University was part of the BRoTHER project, standing for ‘‘Biobank Research on Telemedical approaches for Human biobanks in a European Region,’’ which was an interactive, inter-regional biobank network of Czech and Bavarian biobanks13, leading to the creation of the eduBRoTHER training and educational component14,15. The Medical University of Graz has been delivering targeted post-graduate education courses for several years including courses with a mix of academic and technical components, e.g., the ‘Master of Science in Biobanking’16. IARC/WHO has been coordinating the Biobank and Population Cohort Network, with targeted educational material for resource-restricted settings17, as well as its well-established summer-school18. Beyond the direct experience of the international partners, there have been a recent review of educational programmes regarding research infrastructures and biobanks, and these experiences were also considered as part of this work15,19,20.
Evaluation: The existing training courses of YSMU for cancer research were identified, and the course content was evaluated on three parameters: recency of content and reference material; relevance of content and reference material; and linkage of content and reference material to other educational units. By relevance is meant the degree to which the material is applicable to resource-restricted settings, and its alignment with the current international standards, e.g., ISO standards in medical laboratories, in biobanking, in quality management system, etc. As a result, there was a relevant prioritization for addressing content that was of relative low recency, low alignment to international standards and high potential of being used across one or more areas of cancer research.
Co-creation: A comprehensive educational program was designed over the course of one year to increase the competences of YSMU research staff in fields related to cancer research. The training included components for the transfer of theoretical and practical knowledge. The discipline-specific training was complemented with workshops concerning scientific writing, competitive grant funding application coaching and conference attendance and presentation to improve complementary oral and written skills in scientific presentation.
Delivery: The delivery of the co-created educational material was designed to be both online and in-person, and was delivered over the course of two and a half years, and due to the COVID-19 pandemic, parts of the training that were initially intended to be in-person were either delivered online or in a compressed form in-person when conditions allowed the in-person delivery with appropriate permissions and precautions.
Assessment: The assessment of the impact of these courses was measured in two ways: in terms of scientific output (i.e., number of publications as a result of consortium activities), and in terms of attendee satisfaction in the courses.
Results
Educational program
The following two in-person educational programs were created by the international partners and used as the basis for the training that took place (two × two-day workshops per year for three years):
- Research on cancer biomarkers, including sub-topics Biomarkers in Oncology, Circulating Biomarkers, Precision Medicine and Clinical challenges for cancer research.
- Research on biological samples and data, including handling clinical samples, biobanking best practices (in alignment with international laboratory, ethical and legal standards), pathology methods modelling and training in sequencing, and FAIR data requirements.
Biobanking received particular attention considering the existing knowledge gap and the importance of high-quality and research-ready sample acquisition and storage under appropriate ethical and legal policies with the objective of providing well-documented and annotated samples for research either nationally or internationally.
Regarding the use of associated clinical data for cancer research, it became clear through the development and delivery of the educational material that further development of the existing legal and ethical frameworks is required in Armenia.
The in-person workshops were complemented by frequent online training materials. Specifically, the interaction of ARICE with BCNet was promoted with the cross-posting of information and educational opportunities across the regular newsletters of the two networks (a minimum of three such interactions per year). Furthermore, there were online webinars (2 per year) arranged on the topics identified above, and all these were complemented by the free access to the IARC/WHO online educational platform21.
As part of the project there were four publications, relating to the general overview of setting up biobanks for cancer research in resource-restricted settings22,23, the analysis of stakeholders involved in such foundational research activities24, as well as the overview of the Armenian cancer research field12. Finally, the combined activities of ARICE were communicated through dedicated social media platforms: website (https://www.arice.am/) and LinkedIn (https://www.linkedin.com/in/arice-armenia-67035a248/).
Discussion
The ARICE project combined a theoretical and practical learning process, with the acquisition of practical skills supported during the initial implementation under the supervision of international mentors. Knowledge transfer was conducted based on the Dreyfus Model of Skill Acquisition25. Teaching and mentoring provided by the expert institutions allowed researchers to develop new skills and witness the close interaction between theoretical knowledge and its implementation in practice. The multidisciplinary approach of the project enabled YSMU researchers from multiple fields to come in contact with the groups from the expert institutions, setting the foundations for potential future collaborations. The involvement of different overlapping expertise by the international experts was made available to a broad range of researchers at YSMU, and allowed for complementarity, in particular when COVID-19 necessitated the adaptation of course design to the new realities in the ground.
One of the major focus areas was biobanking, as it is becoming increasingly important as a key tool for precision medicine26–28, but neither biobanking nor precision medicine itself have generally been integrated at all in medical curricula in Armenia. However, most medical students will encounter these topics in their future careers as physicians or researchers. As such, the introduction of these new concepts, were very much appreciated by the workshop attendees. Having said that, there exist significant knowledge gaps, for example, in the ethical and legal aspects of biobanking in Armenia, not only for cancer research, but clinical research in general, that still need to be addressed, and the educational content would need to be adapted to reflect new governance and regulatory realities once the latter materialise.
Although research was not planned within ARICE, previously obtained results (i.e., results from previous YSMU research, and previously developed YSMU protocols) were used for hands-on training for educational purposes, and these were welcome by the course participants as provided a familiar starting point upon which new concepts were introduced. As a result, procedure descriptions and protocols were improved making them available for further research projects locally. Furthermore, the experiences of international exchange -as for many other similar programmes- broadened the horizons of participants and strengthened their scientific communication skills29.
Conclusions
The ARICE project aimed to support cancer research in Armenia by evaluating, co-creating and implementing educational components for internationally competitive cancer research within Armenia, led by the Yerevan State Medical University and enabling further national and international research cooperation. New scientific developments in the field of cancer prevention, especially in biomarker research and large population-based investigations under-pinned by biobanking were considered as areas of priority following the evaluation of existing resources, and as critical to facilitate success in cancer research. The international collaboration provided an example of a successful such upgrading of existing educational materials, complemented by international experts, exposure to international research networks and access to online educational resources.
Ethics and consent
Ethical approval and consent were not required.
Data availability
No data are associated with this article.
Faculty Opinions recommendedReferences
- 1.
Sung H, Ferlay J, Siegel RL, et al.:
Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries.
CA Cancer J Clin.
2021; 71(3): 209–49. PubMed Abstract
| Publisher Full Text
- 2.
World Health Organization (WHO): Globocan 2020. Armenia Cancer Fact Sheet [cited 2021 Aug 17]. Accessed on 03 January 2024. Reference Source
- 3.
WHO: Armenia Mortality Rate. Accessed on 03 January 2024.
- 4.
Institute of Medicine (US) and National Research Council (US) National Cancer Policy Board, Curry SJ, Byers T, et al.:
Fulfilling the Potential of Cancer Prevention and Early Detection. National Academies Press; 2003. PubMed Abstract
| Publisher Full Text
- 5.
Omran AR:
The epidemiologic transition: a theory of the epidemiology of population change. 2001; Accessed on 03 January 2024. Reference Source
- 6.
Ghazaryan A:
Can locally available foods provide a healthy diet at affordable costs? Case of Armenia.
Development Studies Research.
2018; 5(1): 122–31. Publisher Full Text
- 7.
Probst C, Manthey J, Ferreira-Borges C, et al.:
Cross-sectional study on the characteristics of unrecorded alcohol consumption in nine newly independent states between 2013 and 2017.
BMJ open.
2021; 11(12): e051874. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 8.
Center for Disease Control and Prevention: Hereditary Breast Cancer and BRCA Genes. Bring Your Brave | CDC; 2021; [cited 2021 Aug 17]. Accessed on 03 January 2024. Reference Source
- 9.
Moradian MM, Babikyan DT, Markarian S, et al.:
Germline mutational spectrum in Armenian breast cancer patients suspected of hereditary breast and ovarian cancer.
Hum Genome Var.
2021; 8(1): 9. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 10.
Knoema: Number of scientific journal articles by country, 2020. knoema.com; 2021; [cited 2021 Aug 19]. Accessed on 03 January 2024. Reference Source
- 11.
Knoema: Armenia Number of scientific journal articles, 1960-2020. knoema.com; 2021; [cited 2021 Aug 19]. Accessed on 03 January 2024. Reference Source
- 12.
Bedirian K, Aghabekyan T, Mesrobian A, et al.:
Overview of cancer control in Armenia and policy implications.
Front Oncol.
2022; 11: 782581. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 13.
Brochhausen Ch, Kinkorová J, Becker KF, et al.:
Biobanking-an ongoing challenge for personalised medicine BRoTHER - a new biobank network in the centre of Europe to promote digitalisation in biobanking. 2018; 1–11. Reference Source
- 14.
Seidler D, Karlíková M, Topolčan O, et al.:
Establishing Biobanking in Medical Curricula—The Education Program “Precision Medicine International” (eduBRoTHER).
Biopreserv Biobank.
2023; 21(2): 200–7. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 15.
Kinkorová J:
Education for future biobankers - The state-of-the-art and outlook.
EPMA J.
2021; 12(1): 15–25. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 16.
Huppertz B, Bayer M, Macheiner T, et al.:
Biobank Graz: the hub for innovative biomedical research.
Open J Bioresour.
2016; 3(1): e3. Publisher Full Text
- 17.
Henderson MK, Kozlakidis Z:
ISBER and the biobanking and cohort network (BCNet): A strengthened partnership.
Biopreserv Biobank.
2018; 16(5): 393–4. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 18.
Faupel-Badger JM:
Non-University training programs in cancer epidemiology, emphasizing participation from Low- and Middle-Income Countries.
Cancer Epidemiology: Low-and Middle-Income Countries and Special Populations.
2013; 4: 261–278. Publisher Full Text
- 19.
Hartung ML, Baber R, Herpel E, et al.:
Harmonization of biobank education for biobank technicians: Identification of learning objectives.
BioTech (Basel).
2021; 10(2): 7. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 20.
Lawrence P, Hardy I, Caboux E, et al.:
Ten years of experience in training Biobank managers at master’s level in France. Biobanking of Human Biospecimens: Lessons from 25 Years of Biobanking Experience. 2021; 135–51. Publisher Full Text
- 21.
International Agency for Research on Cancer, World Health Organization: IARC Learning. Online Educational Platform, Accessed on 03 January 2024. Reference Source
- 22.
Sargsyan K, Huppertz B, Gramatiuk S:
Biobanks in Low- and Middle-income Countries: Relevance, Setup and Management. Springer; 2022. Publisher Full Text
- 23.
Gramatiuk S, Huppertz B, Alekseenko M, et al.:
Methods of Implementation and Set-Up of National Biobanking Networks. In: Biobanks in Low-and Middle-Income Countries: Relevance, Setup and Management. Cham: Springer International Publishing. 2022; 39–46. Publisher Full Text
- 24.
Gramatiuk S, Sarkisian T, Kozlakidis Z, et al.:
Governance and Stakeholder Analysis. In: Biobanks in Low-and Middle-Income Countries: Relevance, Setup and Management. Cham: Springer International Publishing, 2022; 73–79. Publisher Full Text
- 25.
Dreyfus SE:
The Five-Stage Model of Adult Skill Acquisition.
Bull Sci Technol Soc.
2004; 24(3): 177–81. Publisher Full Text
- 26.
Glynn P, Greenland P:
Contributions of the UK biobank high impact papers in the era of precision medicine.
Eur J Epidemiol.
2020; 35(1): 5–10. PubMed Abstract
| Publisher Full Text
- 27.
Zatloukal K, Stumptner C, Kungl P, et al.:
Biobanks in personalized medicine.
Expert Rev Precis Med Drug Dev.
2018; 3(4): 265–73. Publisher Full Text
- 28.
Kinkorová J:
Biobanks in the era of personalized medicine: objectives, challenges, and innovation: Overview.
EPMA J.
2016; 7(1): 4. PubMed Abstract
| Publisher Full Text
| Free Full Text
- 29.
Jacobs F, Stegmann K, Siebeck M:
Promoting medical competencies through international exchange programs: Benefits on communication and effective doctor-patient relationships.
BMC Med Educ.
2014; 14: 43. PubMed Abstract
| Publisher Full Text
| Free Full Text
