RACP Foundation helps build research careers The story of Professor Cassandra Szoeke

More than 32,000 medical researchers carry out their research across Australia every year. For most, it is a brave choice to make; an uncertain path to take. Medical research is fraught with challenges because it is heavily dependent on funding.

That's what makes Professor Cassandra Szoeke’ s success so remarkable. She, with funding support from the RACP Foundation, has been instrumental in reviving and conducting the longest running study of women’s health in Australia. Professor Szoeke is a Consultant Neurologist, General Physician and a Clinical Academic. She is the Director of the Healthy Ageing Program at the University of Melbourne’s Centre for Medical Research at the Royal Melbourne Hospital and Principal Investigator of the ageHAPPY Women’s Healthy Ageing Project (WHAP) and generations studies. She recently published a book titled “Secrets of Women’s Healthy Ageing”, which was recently awarded the best-selling title in the genre of health in MUP’s 100-year publishing history.

We spoke with Professor Szoeke, about the remarkable success of this longitudinal prospective study. When asked about the challenges of obtaining funding as a medical researcher, Professor Szoeke said, “I've had millions of dollars of funding over the last 20 years of my career, but what I remember the most are the times when I had zero in my pocket. And that is when the RACP Foundation stepped in and helped me keep going”. It made all the difference between a three-year research career and a 20-year research career.

Elaborating on her association with the RACP Foundation, Professor Szoeke talked about wanting to do a PhD but being ineligible for NHMRC funding as she couldn’t commit to becoming a part or full-time researcher because she was in full-time basic physician training. She was interested in a study conducted throughout the 90s called the “Melbourne Women’s Midlife Health Project”. Its focus was on the transition to menopause in midlife women and her topic of interest was examining aches and joint pains in post-menopausal women. That is when the RACP Foundation stepped in and gave her the JT Tweedle Fellowship of $3000 in 2004.

This grant enabled her to conduct questionnaire-based research on the frequency of aches and joint pains in post-menopausal women. It turned out that aches and joint pains were even more common than the widely reported hot flushes, and this work received an international award and was later published. Using this research, Professor Szoeke was then able to apply for further funding to support X-rays in these women to find out whether these pains were related to joint disease.

After finishing her fellowship in Neurology at the RACP, Professor Szoeke took over as Director of the project and applied for funding to re-contact the women. All the big funders turned her down, citing low feasibility. No-one believed these women would come back to be surveyed having not been seen since her PhD.

In 2008, the Quintiles Fellowship from the RACP Foundation came to her rescue. This 15,000 grant allowed for a research assistant to contact the women from the study. It was remarkable that, 18 years after the study, 60 per cent of the cohort agreed to come in and answer the questionnaires sent to them. With a five-year retention rate of 50 per cent the norm, a 60 per cent retention rate in 20-years provided the evidence that Professor Szoeke needed to apply for an NHMRC project grant by demonstrating that more than 300 women were willing to be a part of this project.

She received an NHMRC project grant in 2012, which enabled her to re-contact the women 20 years after their initial assessments. Their responses formed the pivotal internationally recognised work in Professor Szoeke’s speciality area of Neurology, which was recently showcased in the publication, Alzheimer’s and Dementia¹, which summarised all the best work from Australia in the field.

The Women’s Healthy Ageing Project (WHAP) became such a study as it focused on women, and was written by a woman, whereas prior research had been predominantly by men, despite the fact that two-thirds of global dementia cases are women. Professor Szoeke believes that this pivotal work and her academic career, progressing from Fellow to Associate Professor and then full Academic Professor, would not have been possible without the timely support of the RACP Foundation.

Professor Szoeke and her team wanted to extend their decades of experience to address some of the issues with representation in research. They planned a Healthy Aging Project which would include all genders, have no inclusion or exclusion criteria, and would be available online so that regional and remote representation would be possible. NHMRC turned the application down, questioning the feasibility of older Australians taking part in online research.

The RACP Foundation stepped in again and gave her the Maple-Brown Research Establishment Fellowship of $60,000. A pilot program for this internet-based study included more than 20,000 participants who were similar in age distribution to those in the Australian Bureau of Statistics in-person health surveys, and this led to successful funding of ageHappy – a new $1.6 million grant in partnership with UCSF in America.

ageHappy is an online health survey accessible by all Australians over the age of 18 on their mobile phones, tablets or computers. This work became part of the International Brain registry. The Robert Maple grant also enabled Professor Szoeke to write pivotal papers on her area of research and to share her data set globally. It also secured her the Lancet Neurology paper on the global burden of dementia², and to become the Lead for the Asia Pacific node of the Women’s Brain Project.

Earlier this year the RACP Foundation awarded Professor Szoeke a Fellows Career Development Fellowship of $100,000. With this support, she can contact the study respondents again, 30 years after their original assessment, continuing the longest running women’s health study in Australia.

This study is unique in that it is the only study with a biobank that has stored DNA, RNA and blood samples. It has also stored blood glucose readings and cholesterol levels, as well as general height, weight and age data, together with the women’s stories and lifestyle data. Most other studies that lasted more than 20 years were questionnaire based.

According to Professor Szoeke, funding was the main reason that the other studies didn’t last this long. It’s difficult to get continuing funding and there are bound to be gaps between various funding cycles. That’s why organisations like the RACP Foundation help keep the momentum going.

Professor Szoeke also acknowledges all of the women in the study who remained engaged and interested in participating for over 30 years. Her latest book, Secrets of Women’s Healthy Ageing, was meant to be a gift to these women on the study’s 30th anniversary. She wanted to thank them for their contributions by writing a book for laypersons.

Past studies on menopause ended as soon as the test subjects reached menopause, so the findings from this study will help inform people about life post-menopause. We now know that women live more than a third of their lives post-menopause. The WHAP and another study in America helped inform the international “ReSTAGE” criteria for post-menopause.

Another roadblock for large studies is that most of the funders want focused research in a particular area. Grants are given to study a particular disease like diabetes or cancer and researchers must be razor focused on it to keep their funding. Both the WHO and Professor Szoeke warn that chronic diseases of ageing are our next big health challenge, and it is understood that this will not be straightforward but will have overlapping risk factors and pathophysiologies.

Studies which have taken a broader whole-of-life approach are well placed to decode the complex chronic diseases of ageing; for the Healthy Ageing Program this approach has paid rich dividends. Professor Szoeke commented that this is what differentiates the RACP Foundation from the rest; it is more flexible and gives researchers the space to explore. Her application included multimorbidity, which affects 80 per cent of Australian adults over 50³. This is especially worrying, given that nothing in the body works in isolation and each part of the body is constantly interacting with one another.