The Right Leader in the Right Place at the Right Time

Lori J. Pierce, MD, was, by her own estimation, a rambunctious child and “skinny as a rail.” The city girl who grew up in Washington, DC, and later Philadelphia, Pennsylvania, was determined to prove she could keep up with her cousins and their friends. They were country boys growing up in and around her father’s small, rural, and then-segregated hometown of Ahoskie, North Carolina, and unimpressed with the whip-smart kid from up north who loved math and science.

The thing is, children who are both rambunctious and skinny tend to get injured. Pierce broke some bones and spent some time in emergency departments as a result. She never let the fractures slow her down, and those visits fueled her fascination with radiation medicine.

“I could [play as hard as] the best of them, but that was how I ended up needing X-rays,” she remembered. “I was just fascinated by how you sit down, someone takes these pictures, and all of a sudden, you can see your bones. I would ask tons of questions, to the point that the technologist would have to bring in the radiologist to answer them all.”

Pierce harbored a love for science and a general desire to know things, and she was not shy about asking questions. She displayed a gift for math early in life, a trait she and her older sister, Karen, both inherited from their father, Melvin H. Pierce.

“My father, who wasn’t able to go to college because he grew up in segregated North Carolina and had to help his father on the farm, was amazingly talented in mathematics,” Pierce said. “He just had a natural gift for it, and it was just a fun thing for me to do math at home with the family.”

Melvin Pierce worked as a chauffeur for the Postmaster General in Washington, DC, and Pierce’s mother, Amy Martin Pierce, worked as a secretary at the Department of Health, Education, and Welfare (now the Department of Health and Human Services). Eventually, Melvin Pierce got new a job in the United States Postal Service when Lori Pierce was in high school, and the family moved to Philadelphia.

Both of the Pierce children would eventually matriculate to Brown University, and Karen graduated there. Following her sophomore year in college, Pierce made the practical choice to transfer to the University of Pennsylvania (Penn) after her mother took a job at the school.

“If I switched schools, I would have free tuition at Penn,” she said. “[My parents] didn’t ask me to do that, but I knew...they had to work very hard to pay for my college education, so I made the decision to transfer.”

Pierce was in Brown’s pre-med program but transferred into engineering at Penn. She graduated with a degree in biomedical engineering with a minor in chemical engineering. Pierce was already interested in radiology and felt that an engineering background would make her a more competitive applicant to medical schools. She was accepted to Duke University School of Medicine but delayed her entry for a year so she could earn money for tuition. That turned out to be one of the best decisions she ever made.

“Working as an engineer gave me a break between undergrad and medical school and an opportunity to reflect on my future career goals,” Pierce explained. She added that the experience made it clear to her that her calling was medicine and not engineering. “Work as an engineer was rewarding but it was clearly not what I ultimately wanted to do.

“In retrospect, I strongly advise students to consider taking a year to do research, travel, work, or something else significant...I think taking a break from academics and not going straight through, at least for me, was a very good thing to refresh and refocus.”

People Everywhere Are People

For that year after college, Pierce went to work in Round Rock, Texas, which is now the home of Dell Computers. In the early 1980s, however, Round Rock was a sleepy town of fewer than 12,000 people, according to the Texas Almanac. Pierce was the second shift supervisor for what was then called the McNeil Consumer Products Company, the manufacturer of Tylenol.

She was also a young, Black, college-educated woman from a big city on the East Coast tasked with supervising people her parents’ age.

“I learned a lot [there], and a lot about life,” Pierce said. “[I was in] Round Rock, a community where many people had never interacted with Black people before. And there [I was], fresh out of college, the supervisor of people who were 50 and 60 years old. It was a real learning experience.”

She called her time in Round Rock “sobering,” and said she experienced “sides of human nature” that she had never encountered before. Philadelphia and Washington, DC, have long been known as diverse, cosmopolitan cities with large Black populations. The population of Round Rock was, and is, almost entirely White and Latino—Black people make up less than 10% of the current population. In retrospect, though, Pierce said that her time in Round Rock made her “even more of a ‘person’s person.’

“Some, a small minority, decided they didn’t like me because I was Black. However, by the end of my time there, they all loved me,” she said, laughing. “We got to know one another, and it taught me and taught them. It made me realize that yes, people may look very different on the outside, and they may say things and think things that are very different than what you’ve always said, or what you have always thought, but there is a goodness to people. If you’re in the trenches together, you really get to know who they are on the inside.”

Making Less Invasive Surgery More Available

Medical students at Duke spend a year focusing on research. Pierce was planning to do research in radiology but ultimately decided on an oncology project instead. During that year, radiation oncology became a new department at the school under the leadership of inaugural department chair Leonard Prosnitz, MD, and he convinced Pierce to shadow him in the clinic while her laboratory experiments were in progress.

“That’s how I found radiation oncology,” she said. “It felt perfect for me.”

Pierce returned to Penn for her residency. She found her calling while on rotation on the breast service. “I loved it,” she said. “Barbara Fowble, [MD,] was an amazing mentor. I loved the patients, I loved working with women and their families. That is how I fell into breast cancer as my primary area of interest.”

Pierce made her first mark in the world of breast cancer research shortly after completing residency. In 1992, Pierce and her colleagues published a seminal paper in the journal Cancer analyzing the use of breast-conserving surgery plus radiation in African American women. Their findings showed that successful rates of breast conservation in Black women using conservative surgery and radiation were comparable with rates observed in White women. Further, they found that Black women were excellent candidates for breast-conserving treatment when diagnosed with early-stage disease.

Penn, in West Philadelphia, serves a large Black and brown population. Lumpectomy was a well-established treatment modality by the early 1990s, but Pierce noticed that most Black patients were having mastectomies and that the data showed that Black women were undergoing lumpectomy less often than White women.

“The main reason I wrote the paper was to show that a patient with breast cancer who is Black should have the same opportunities for breast conservation as a White patient with early-stage breast cancer,” Pierce said.

She added that physicians may have harbored concerns about the outcomes of radiation treatment in people of color, specifically the potential for adverse effects, and that may have been a barrier to using breast-conserving treatment as well. “To be able to show that the adverse effects were highly tolerable was important...it was also important for patients to understand that breast conservation was, indeed, an option,” she said.

In the analysis, Pierce noticed a relatively high percentage of Black women with estrogen receptor–negative disease. She also noticed that a higher percent of Black women were 40 years or younger at the time of their breast cancer diagnosis—much earlier than what is typically seen in White patients.

She later realized that those Black patients likely had triple-negative breast cancer (TNBC) and/or BRCA1/2 mutations, conditions that had yet to be identified. TNBC is associated with a poorer prognosis than other breast cancer subtypes and is more common in women of color. Women with TNBC or who carry a deleterious BRCA1/2 mutation are often diagnosed with breast cancer at a young age.

In 2000, Pierce published data from a study evaluating outcomes for patients who received breast-conserving therapy plus radiation therapy for early-stage breast cancer. Investigators enrolled 71 women with a BRCA1/2-mutated disease and 213 women with sporadic breast cancer.

Investigators found no evidence of increased radiation sensitivity or sequelae in the BRCA1/2group compared with the control group. At 5 years, the 2 groups had comparable rates of survival and tumor control in the breast. Moreover, there were no significant differences in acute or chronic morbidity in skin, subcutaneous tissue, lung, or bone.

In 2010, Pierce led a team that published results comparing outcomes for radiation therapy following either breast-conserving surgery or mastectomy in women with BRCA-mutated breast cancer. Investigators found no difference in overall survival or in regional and systemic recurrence between the 2 groups.

“The important point of those series of papers is that they helped physicians to initiate a dialogue with patients who have BRCA mutations, to explain to them what options are available,” she said. “Before that, we didn’t really have a lot of data to be able to have an open dialogue to understand the options. Those papers helped clinicians to discuss options with women with a BRCA1/2 mutation.”

Leaders Emerge When You Need Them

Throughout her career, Pierce has been known as an accomplished professor, breast cancer investigator, and radiation oncologist. In 2005, she was appointed by the University of Michigan Board of Regents as Vice Provost for Academic and Faculty Affairs, a position she still holds. However, her greatest impact on the oncology field may have come from the job she was not sure she wanted at first—president of the American Society of Clinical Oncology (ASCO).

Pierce was reluctant to serve as a candidate when she was nominated before the 2018 election. She was honored, but never believed that she would win. Nancy Davidson, MD, executive vice president and executive director for clinical affairs and director of the Clinical Research Division at Fred Hutchinson Cancer Center in Seattle, Washington, has known Pierce for more than 20 years. Davidson called Pierce “a reluctant leader,” but thought she was the perfect candidate for the time.“

We talked about the fact that I felt that the ASCO electorate was ready for somebody like Lori,” said Davidson, who is the 2021 Giants of Cancer Care award winner for breast cancer. She noted that, as a Black woman and radiation oncologist, Pierce does not look like the typical ASCO president; they have tended to be White, male medical oncologists. Davidson added, however, that ASCO needs to incorporate more women, people of color, and practitioners of other disciplines of oncology to fulfill its goal of bringing cancer care to more patients.

“I thought it was a wonderful time for us to be able to embrace all of these parts of Lori, which are parts of our organization...because we need everybody at the table if we’re going to really make a difference against cancer,” Davidson said.

It was just happenstance that the first Black woman to lead ASCO took office on June 1, 2020. Police in Minneapolis, Minnesota, had murdered George Floyd only a week earlier and the nation was entering a summer of uprisings in protest against police brutality and white supremacy.

“Sometimes leaders emerge when you need them,” Davidson said. “[Lori] ultimately ended up being the leader for our time, and in particular, over the past few years. The timing of her ASCO presidency ASCO could not have been better.”

Pierce said she made equity the theme of her presidency before many of the Black Lives Matter protests and before the COVID-19 pandemic. She was not certain at the time that “Equity: Every Patient, Every Day, Everywhere” would resonate with the ASCO membership. She eventually found that it was the perfect message given the events in the country and the world. “ASCO could not have been more receptive, more supportive, more of an advocate for equity than they were. Everything ASCO has done through the years, ever since its inception, has focused on equitable care for patients [with cancer] across the world,” Pierce said.

“Knowing that, however, there’s always a way to up your game. There were more things that I wanted to do and ASCO was there. Every person I talked to in leadership couldn’t do enough to move this agenda forward. It was the right time to have this as our agenda, and ASCO was the absolute right organization to move equity work in cancer care forward.

“I ended up, as Dr Davidson said, [to be] the right person at the right time. Who knew? I sure didn’t know at the time. But I was ASCO president and equity of care was the theme I picked. And I’m just so glad I did.”