In more than 25 years of viewing posters at oncology meetings, I’ve met researchers from virtually all professional walks of life, but it was not until the 2016 Miami Breast Cancer Conference, that the author’s affiliation turned my head: It was a business school.
“Utilizing Metastatic Tumor Receptors on Relapse Worsens Patient Outcomes” was the title of a poster by T. Allen Pannell, Jr, PhD, of the Department of Business Analytics and Statistics at Lincoln Memorial University School of Business, Knoxville, Tennessee.
“There must be a story here,” I thought, and commented the same to the presenter. “Something or Someone put a statistician and breast cancer together. I like solving problems, and this one chose me,” Dr. Pannell told me.
In short, in January 2014, Dr. Pannell, a statistician, lost his wife to triple-negative breast cancer at the age of 45. Amy Foster lived about 3 years from her diagnosis and only 6 months after cancer recurrence. Her husband attributes her rapid decline to inappropriate treatment (see study here).
Amy, a choral teacher and concert pianist, was diagnosed with stage II breast cancer and underwent a lumpectomy. The couple went on a cruise while awaiting the final pathology results, believing the worst-case scenario would be chemotherapy. They returned to disheartening news, that her cancer was stage III triple-negative disease with positive nodes, requiring a double mastectomy as well as chemotherapy and radiation.
Dr. Pannell was working on his dissertation in statistics—specifically, a new statistical model for determining eligibility for mortgage loans—while teaching in the University of Tennessee Graduate School of Business. Overnight, his mission shifted, to become an advocate for Amy and a breast cancer researcher as well.
“Two years post diagnosis, we planned our first ‘get back to life’ trip, which was to go to Vermont, where I ran a half-marathon and she ran her first half-marathon,” he said. “She struggled a bit…. It turns out she ran this race with a liter of cancer-infested fluid in her lungs and widespread metastases. The first day of the rest of our lives ended up ushering in our last days.”
“Her oncologist was fairly blunt. He said, ‘If you have anything you want to do, do it now,’” Dr. Pannell said.
Her physician started her on capecitabine, predicting a 45% chance of partial response and a 5% chance of complete response, emphasizing this was not a cure. She responded robustly, demonstrating a complete response that prompted her oncologist to report, “You’re in that 5%. You may have 4 years now.”
Amy Foster Pannell on her wedding day, approximately 16 months after her initial diagnosis with breast cancer and post double mastectomy, radiation, and chemotherapy. Photo courtesy of T. Allen Pannell.
Discordance in Hormonal Status
For assurance, the couple sought a second opinion from a cancer center. The new oncologist ordered her tumor retested, which revealed discordance in hormonal status. Although initially progesterone receptor–negative, her disease now tested progesterone receptor–positive.
“She was doing great, but now we learned her tumor had changed from progesterone receptor–negative to positive, and the oncologist at the cancer center advised that we take her off capecitabine and treat her with letrozole,” he said. “We did this, and in 4 weeks, she was essentially gone. She died 3 months later.”
The local oncologist had advised against the switch, “since what we were doing was working,” but the second oncologist believed it was the right drug for her metastatic disease, with fewer side effects.
Now, having researched this issue, Dr. Pannell understands the lack of data guiding this treatment. “It’s still unclear what to do in this situation,” he said. “We made this decision without researching it, and soon we were in a hospice situation,” he said.
After Amy died, Dr. Pannell began his research in earnest. “I started researching initially so I could ask intelligent questions about what happened to Amy,” he said.
Before long, he was well versed in the published literature on the topic of tumor discordance. “I found out if it’s discordant, that’s bad, and one of the main articles suggested that it’s because patients’ treatment is switched. That’s what I believe happened to Amy,” he said.
With only 6 months remaining to finish his dissertation, he returned to the committee and confessed that he had “lost the will to finish the dissertation” and was now knee-deep in breast cancer research. An oncologist (who later became a committee member) had a solution: “Make this your dissertation,” he said, adding, “I need the answer to that question, myself.”
This led to his retrospective analysis of patients from the University of Tennessee Cancer Center, to the study he presented in Miami, and to his conclusion that metastatic patients with discordant tumors should receive first-line treatment based on their primary tumor (see page 13). Dr. Pannell is continuing his research. He said the oncologist on his dissertation committee has adopted his recommendation for his patients.
Dr. Pannell now heads up a new analytics program at Lincoln Memorial University School of Business. His year-long practicum for his students will focus on “the business side of breast cancer,” including screening, mammography, false-positives, insurance issues, and such. “I am going to turn this into a business question,” he said, “but my students will be gathering useful data on breast cancer for me. I’m a little sneaky!” ■
In a small retrospective series, patients with metastatic breast cancer treated according to the receptor status of the primary tumor, not the metastatic one, had significantly longer median overall survival. The study was reported at the 2016 Miami Breast Cancer Conference by T. Allen Pannell, Jr, ...