It was not the way Adele Rivas had imagined it.
She and her husband Luis had been trying for more than three years to get pregnant, and more than one doctor had told them that they couldn’t conceive without medical help. The couple had moved in with Adele’s mother to try to save money to adopt.
Still, as she readied herself for an MRI scan, Adele asked for a pregnancy test — just in case.
“A little voice in me was like, ‘You’re really avoiding the inevitable. Why are you even asking if you’re pregnant?’”
Adele Rivas with her husband Luis and their newborn son
The urine test was inconclusive, which the doctors at Englewood Hospital in New Jersey saw as bad news. They didn’t want to wait. They didn’t know if Adele, 34, was pregnant or not, but they did know that she had cancer in her left breast, which was later identified as stage 2b.
Her first blood test was also inconclusive, but a second test 48 hours later left no doubt. Adele was three weeks pregnant.
A Rare Case, a Team of Doctors
That put Adele in an unusual position. Just 1 in 3,000 pregnant women is diagnosed with breast cancer. And rarely is anyone diagnosed so early in their pregnancy.
Pregnancy makes breast cancer difficult to detect, but Adele, whose mother was a breast cancer survivor, was an expert self-examiner.
Adele went to The Mount Sinai Hospital in New York City, where two surgeons, one oncologist, and a high-risk obstetrician oversaw her care.
Breast surgeon Dr. Christina Weltz performed a double mastectomy at The Mount Sinai Hospital’s Dubin Breast Center. Surgery in the first trimester is risky for the fetus, but the doctors felt the cancer couldn’t wait.
Risk to the fetus increases with the time the mother spends under anesthesia. The plastic surgeon who will do Adele’s reconstruction, Dr. Marco Harmaty, who would normally have stepped in immediately after the mastectomy, instead observed and helped determine where to make the incisions. The breast reconstruction is planned for next year.
Doctors did an ultrasound right before the surgery and another right after to see if the fetus was all right.
“All we saw was a little flicker of a heart beat, but seeing that little flicker after the surgery was probably one of the most emotional moments of my life,” Adele said.
Adele returned to work for a few weeks after the surgery. But as soon as she entered her second trimester, she began a 12-week course of chemotherapy.
Surprising but True: Pregnant Women Can Have Chemotherapy
Chemotherapy is so tough on the body, it’s hard to believe that it could be safe for pregnant women. But a handful of drug combinations are safe after the first trimester, when the fetus’s organs are still developing.
“It’s very surprising to people that you can pull that off, but oncologists have been doing it since the 1970s,” Weltz said. The evidence is based on poring through multiple medical centers’ records to get a sample size big enough to draw conclusions about which drugs are safe for mom and baby.
The chance to do chemotherapy while pregnant surprised Adele and Luis, 44. But it meant that they could keep their baby.
“We needed to search, search a lot, we were searching until 1 o’clock in the morning, because everything was new for us. But every new bit [of information] was a piece of hope,” Luis said.
“Adriamycin, cytoxan and Taxol constitute one regimen that is very effective for breast cancer treatment. We have the safest track record for the use of adriamycin and cytoxan in the second or third trimesters,” said Dr. Hanna Irie, an assistant professor of medicine, hematology, and oncology at the Icahn School of Medicine at Mount Sinai.
However, Adele balked at the lingering risk of heart failure these drugs present, and she opted instead for a regimen of cyclophosphamide with docetaxel (Taxotere).
Earlier this week, the European Society for Medical Oncology encouraged doctors not to shy away from treating pregnant women with evidence that children whose mothers were treated with chemotherapy during pregnancy suffer no long-term effects.
Adele Rivas at her final chemotherapy session
All throughout the pregnancy, Luis waited anxiously to see the next ultrasound.
“Every time I saw that heart again, I felt lucky, I felt like I’m born again,” he said.
‘I Wasn’t Just Fighting for Myself’
On March 10, Adele gave birth to a healthy baby boy, Constantino, in a cesarian section performed by Dr. Joanne Stone, the director of maternal fetal medicine at The Mount Sinai Hospital. Constantino, who had been at risk of premature birth because of the chemotherapy drugs, weighed in at a healthy 8 pounds, 2 ounces.
Adele had to leave the newborn at her mother's home in Washington Township every morning for six weeks while she went through radiation therapy at a local hospital. Adele's mother and mother-in-law cared for Constantino together.
Radiation was one treatment that could not be started while Adele was pregnant because it can be very harmful for developing fetuses.
Luis said he worried about Adele and the baby throughout the ordeal, but he tried to stay calm and be supportive.
“I was thinking that my responsibility as a husband, as a partner, was to give her peace and comfort, so I don’t show her my worry. You know how they say time flies? In that situation, I felt like time was slow,” he said.
The baby also offered comfort, even before he was born.
“It really, really helped me with my diagnosis,” Adele said. “As difficult as it was, I felt like I wasn’t just fighting for myself.”
‘A Beautiful Baby’
The doctors described the challenges as questions of timing: making sure that the quality of Adele’s care wasn’t compromised while protecting the fetus as well.
“There’s nothing routine about a pregnant woman with cancer,” said Irie. “It’s a very involved discussion that is multi-disciplinary. It’s almost constant communication and feedback.”
The team of doctors was glowing as much as the new parents when Adele’s baby was born healthy.
“Thank goodness we pulled it off,” Weltz said.
Baby Constantino at 5 months old
It was a precious win for doctors who specialize in tough cases.
"Doctors have a conversation with patients diagnosed with cancer early in a pregnancy about whether or not to terminate. Many choose to continue with their pregnancy," Irie said.
The takeaway, according to Stone, is, “If you are somebody that’s diagnosed when you’re pregnant, you can have a baby.”
Stone added, on a personal note, “He’s a beautiful baby.”
It was all the more poignant because Adele, her husband, and her doctors know that Adele might not have another chance for a baby of her own. Chemotherapy makes it more difficult to conceive later on, and Adele will also take a 5 to 10 year course of tamoxifen to prevent the estrogen-positive cancer from recurring. Women cannot safely get pregnant while taking the drug.
“We have a loving, happy boy, smiling all the time,” said Luis. “We’re so lucky to have him.”
Photos courtesy of Adele Rivas and the Mount Sinai Health System.