Smiling parents holding young children at beach

Treating breast cancer through pregnancy

June 04, 2019 | UCI Health
michelle clark-salib with husband and two sons
Michelle Clark-Salib with her husband, Fady, and their two sons, Elijah, 9, and Caleb, 6.

It wasn’t news any 28-year-old woman expects. During a routine exam in May 2012, Michelle Clark-Salib’s gynecologist detected a lump in her right breast.

It was like, ‘Oh, you should get this checked out, but it’s probably nothing.’” An ultrasound led to a biopsy. A few weeks later, the full-time working mother of a then 2-year-old son learned the lump wasn’t nothing.

It was late-stage inflammatory breast cancer — a rare, aggressive form that accounts for a mere fraction of breast cancers in the United States.

All-out attack on tumor

Moreover, it had spread to the Fontana resident’s lymph nodes and likely to her spine.

“At that point, it was just full-blown chemo — ask questions later,” Salib says.

Her Riverside-based oncologist prescribed an aggressive chemotherapy regimen.

After four months of treatment, she was scheduled for an outpatient procedure to insert a portacath — a small chamber that sits under the skin — to facilitate the infusion of chemo drugs.

“As a formality, they do a pregnancy test, but I told them there was no way I was pregnant,” says Salib, who’d been taking contraceptives until her cancer diagnosis.

Pregnancy shock

“I was shocked when one of the doctors said, ‘Uh, this pregnancy test came back positive. Any idea how far along you might be?’” 

With a confirmed second test and an ultrasound showing she was about 23 1/2 weeks pregnant, her oncologists told her and her husband, Fady Salib, that she should continue life-saving chemotherapy and end the pregnancy.

“My poor, sweet husband was sitting there. He said, ‘Yes, doctor, we understand. The most important thing is saving my wife’s life.’ All I could think was, ‘No, hold up here! I need more information!’”

For Salib, terminating the pregnancy was an absolute last resort. But there was more bad news: Her amniotic fluid was dangerously low — one of the known side effects of a cancer drug she was taking, a monoclonal antibody called Herceptin.

Immediate action needed

It was a Friday afternoon. The stunned couple went home to take stock and prepare for an obstetrician’s appointment the next week. About 5:30 p.m., the Riverside-based general obstetrician called to say that after reviewing her case, her situation was beyond his expertise.

But he told her that he had trained at “UC Irvine’s high-risk pregnancy program, and that if anyone could help me, they could.”

Because her amniotic fluid was so low, he directed the couple to drive to UCI Medical Center immediately. Waiting for her that evening was a team of doctors, including the high-risk pregnancy specialists and oncologists.

Specializing in complex cases

It’s the kind of advanced care that is usually only available at an academic medical center, like UCI Medical Center.

“We have plenty of experience with treating patients who need a multi-disciplinary approach,” says Dr. Rita Mehta, a UCI Health oncologist and international expert in metastatic breast cancer who eventually took over Salib’s cancer treatment.

Over the last 15 years, Mehta has led many advances in treating the most aggressive breast cancers. In a groundbreaking study published in 2012, she showed that a combination of the drugs anastrozole and fulvestrant was superior in controlling and improving patient survival to anastrozole alone or anastrozole followed by fulvestrant to treat hormone receptor-positive metastatic breast cancer. (Her just-published study shows the combination has also improved five-year survival.)

Mehta was also one of the first to use chemotherapy combined with Herceptin on women with breast cancer before surgery — rather than after — to help shrink tumors, the treatment Salib had been undergoing when her pregnancy was discovered.

Assessing chemo risk to her pregnancy

Mehta, along with UCI Health obstetrician and cardiologist Dr. Afshan B. Hameed and other specialists, conferred with Salib, her husband and family.

The doctors determined she’d been about seven weeks pregnant when her chemotherapy began. That meant she had only some exposure during her first trimester. It was game-changing news, the medical team told her, because chemo is far less concerning for fetal development during the second and third trimesters.

“There isn’t a lot of data out there about the effects of chemotherapy on a pregnancy because not that many people have this happen, but still the team went over absolutely every known risk,” says Salib.

Birth defects ruled out

Her ultrasounds were encouraging; many potential birth defects were ruled out. Mehta also determined that they could keep the cancer at bay temporarily with a scaled-back chemotherapy regimen, minus Herceptin, should Salib decide to carry the baby to term.

With her husband’s and family’s support, Salib pressed on.

The medical team monitored her carefully to determine when the baby could be delivered safely so that the mother could resume more aggressive chemotherapy.

Mehta hoped for delivery at 32 weeks. Salib’s obstetricians pushed for 37 weeks, when the baby would likely be able to breathe on its own.

On Jan. 8, 2013, she delivered a son, Caleb, who weighed 5 pounds, 6 ounces, but otherwise completely healthy at 37 weeks. Ten days later, mom resumed what she calls “hard-core chemo.”

New drug regimen  

As luck would have it, during her pregnancy, the U.S. Food and Drug Administration had approved pertuzumab, a second monoclonal antibody Mehta believed could improve the results of Salib’s regimen of Herceptin and the anti-cancer agent docetaxel. The new drug was added to the mix.

After five rounds of the chemo cocktail, Salib’s primary tumor began to shrink dramatically. In April 2013, she had a mastectomy. Before the surgery, she had an imaging test that gave her encouragement.

“I no longer lit up like a Christmas tree,” says Salib, who also underwent radiation treatment.

After a few years with no recurrence, she was cleared to have reconstructive breast surgery at UCI Medical Center.

“Our aim is not just survival,” Mehta says of the breast services team, which includes highly skilled plastic surgeons. “We want the patient to have a good quality of life, and Michelle was able to do everything that a mom loves to do with her baby.”

Looking to the future

At the time of the mastectomy, pathologists could find no sign of cancer in Salib’s breast tissue, an indication of “complete pathological response.” But it would take the cautious Mehta a few more years to use the phrase “long-term remission.”

Six years on, Salib remains cancer-free. But she visits the cancer center every three weeks for an infusion of monoclonal antibodies and complete hormonal blocking therapies to keep the cancer in remission.

She plans to stay on the maintenance protocol for the foreseeable future. She works full-time in the office of a steel fabrication company and keeps up with school, sports and Cub Scout schedules for sons Elijah, 9, and Caleb, now 6.

“I want to make sure I’m there when my boys go off to college, when they get married. I even want to be a grandmother someday,” she says.

“And I want people — especially young women — to know that you can stand up for yourself as a patient. You can ask questions. And even under the worst circumstances, you can be strong. You can have courage.”

Moving breast cancer care forward

Salib, who got her bachelor's degree at UC Irvine, says she’s grateful for her acute care, reconstructive surgery and ongoing survivorship care at UCI Health.

“I’m so happy that Dr. Mehta doesn’t get stuck in tunnel-vision treatment mentality. She stays up-to-date on research, new trials and drug protocols. She’ll alter treatment based on new research. My treatment has been modified several times because some new data came out that pointed a certain way, and she felt it was in my best interest to give it a try.”

Mehta, who has published her groundbreaking studies on life-extending treatment protocols in journals such as Cancer, The New England Journal of Medicine and the Journal of Clinical Oncology, calls Salib one of the “faces of all the progress we have made in breast cancer treatment.”

“Michelle had everything you could think of that would portend a horrible outcome for a patient,” she says. “Yet that didn’t happen. While we provided treatment and support, the final decisions Michelle made were all her own.”

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