Online Health Chat with Stephanie Valente, DO and Machelle Moeller, CNP

October 17, 2012


Cleveland_Clinic_Host: According to the Centers for Disease Control and Prevention, breast cancer is the most common cancer among women. According to the American Cancer Society, over 288,000 women were diagnosed with breast cancer in 2011, and over 290,000 women will be diagnosed in 2012. Although these numbers may sound alarming, research reveals that the mortality rate could decrease by 30 percent if all women age 40 and older had a yearly mammogram. Additionally, if detected early, breast cancer has a five-year survival rate of over 95 percent. Almost 12 million women in the United States are breast cancer survivors.

Breast cancer is not limited to women, with men accounting for one percent of breast cancer cases. Additionally, although 80 percent of breast cancer cases occur in women over 50 years of age, younger women and can get breast cancer. Research indicates that children treated with radiation at an early age may be predisposed to breast cancer later in life. Women who have a history of breast cancer in the family, particularly on the mother’s side, should be even more diligent with screening (at perhaps an earlier age per her physician) and may require genetic testing for the BRCA1 (breast cancer 1, early onset human tumor suppressor gene) and BRCA2 (breast cancer type 2 susceptibility protein) genes. Moreover, breast cancer is associated with ovarian cancer in these patients, and both should be tested for regularly.

For More Information

On Cleveland Clinic
Cleveland Clinic’s Breast Center, offers a multidisciplinary team of highly skilled specialists who provide comprehensive care to patients with breast cancer. Here, you will find a full array of services, from initial screening and diagnosis to innovative breast cancer treatment and supportive counseling.
Cleveland Clinic’s Breast Center offers the highest quality care for the screening (including mammography), diagnosis and treatment of all medical and cosmetic breast problems. We are able to treat you from your initial mammography up through and including the treatment and removal of any breast cancer and breast reconstruction. Equipped with state-of-the-art technology and staffed by an unmatched team of physicians, nurses and technologists, Cleveland Clinic’s Breast Center provides patients with the latest and most innovative procedures, from mammography to treatment, available in a setting that is warm and supportive.
From screening mammography to breast cancer surgery and reconstruction, Cleveland Clinic's Breast Center offers a comprehensive prevention, detection and treatment program, including:

  • leading screening techniques, including mammography, ultrasound, breast MRI and stereotactic breast biopsy (an outpatient procedure that requires no incision and only local anesthesia) interpreted by dedicated breast imaging physicians and available at our suburban family health centers
  • comprehensive evaluation for patients at high risk due to family history or prior cancer
  • timely diagnosis and treatment, including chemotherapy, hormone therapy and bone marrow transplantation
  • second opinions
  • full range of medical and surgical treatment options for breast cancer provided by a team of experienced surgical oncologists, medical oncologists, radiation oncologists, radiologists and reconstructive surgeons
  • consultation for cosmetic surgery
  • access to the latest clinical research trials
  • access to post-treatment rehabilitation and support groups

Cleveland Clinic’s Breast Center provides patients with convenient locations throughout the Greater Cleveland area, including Hillcrest Hospital and Fairview Hospital. Patients can also visit the Cleveland Clinic Family Health Centers in Beachwood, Strongsville, Brunswick, Elyria, Independence, Solon, and Willoughby Hills, as well as the Cleveland Clinic Wooster Women’s Health Center.
All locations have dedicated physicians providing routine screening mammography and consultations for the diagnosis and management of all types of breast disease. Every member of our Cleveland breast cancer treatment team is committed to providing you with the highest quality, comprehensive, efficient and compassionate care.
 In the Taussig Cancer Institute at Cleveland Clinic, the Department of Solid Tumor Oncology specializes in the treatment of cancer of solid organs and tissues including the prostate, breast, lung, colon and rectum, skin (melanoma), bladder, kidney, thyroid, endometrium, and pancreas. Centers and programs within the department include palliative medicine and the oncology program for seniors.
Cleveland Clinic cancer care is ranked sixth in the nation, and the best in Ohio by U.S.News & World Report.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to:

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit

For Appointments

If you would like to make an appointment with Stephanie Valente, DO or Machelle Moeller, CNP, please call 800.223.2273 or request an appointment online by visiting

Anyone interested in making a Cleveland Clinic Breast Center appointment for an initial exam or a second opinion may do so by calling the Breast Center. It is not necessary for patients to be referred to Cleveland Clinic by their outside physicians. If you would like to set up a consultation with a Cleveland Clinic breast specialist, call toll free 866.223.8100.

About the Speakers

Stephanie A. Valente, DO is a breast surgeon at the Cleveland Clinic. She is a board certified general surgeon with fellowship training in surgical breast oncology. Her special interests include oncoplastic breast surgery, minimally invasive breast surgery and intraoperative radiation therapy. Dr. Valente earned her medical degree from Ohio University College of Osteopathic Medicine, in Athens, Oh.  She completed her surgical residency at Akron City Hospital, in Akron, Oh, and her breast fellowship at the University of Southern California in Los Angeles.   She serves as the Associate Director of the Cleveland Clinic Breast Fellowship.

Machelle Moeller, CNP is a Certified Nurse Practitioner in the Solid Tumor Oncology Department at Taussig Cancer Institute. She specializes in medical breast oncology and high-risk Breast Cancer Survivorship Care. She earned her graduate nursing degree from Kent State University, in Kent, Oh.

Let’s Chat About Breast Cancer: Prevention, Treatment and Survivorship

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Stephanie Valente and Machelle Moeller. We are thrilled to have them here today for this chat on Breast Cancer: Prevention, Treatment and Survivorship.

Breast Cancer Diagnosis and Screening

PB2:What are the current breast cancer screening guidelines?
Dr__Valente: Women should begin to have their breasts examined by a healthcare provider at least once every three years after the age of 20 years old, and every year beginning at the age of 40 years old. Clinical breast examinations can detect lumps that may not be detected by mammogram. Women should have yearly mammograms starting at age 40 years old. Women should also perform monthly self breast exams.

Cleveland Clinic recommends screening mammograms annually for women who are 40 years old and over. Mammograms are an important part of your health history. If you move or go to another healthcare provider, take the film (mammogram) with you.

Visit  to learn more about screening guidelines for women.

jjstump: I felt a lump and went to the doctor. She felt it, too. However, it could not be picked up on ultrasound or mammogram. I am set up for an MRI next week. How accurate is an MRI, and why couldn’t the lump be seen on the other two?
Dr__Valente: MRI can give an additional diagnostic yield of about 3 percent for a mass not visualized on mammogram or ultrasound. Many times this is for women who have very dense breast tissue. Additionally, if the mass can be felt, but not visualized on imaging, a physician can perform a needle biopsy in the office to sample the tissue and see if there are any abnormal cells present.

playmates: What exactly does hypoechoic mean? Can you also talk about irregular margins? Are they as bad as I’ve read about?
Dr__Valente: A hypoechoic mass is usually described on ultrasound. It means that it appears darker than the surrounding tissues. It can indicate a benign mass, cyst or possibly cancer. Irregular margins make the mass more suspicious for cancer and a biopsy may be recommended.

jennyj: If you wait a long time for biopsy results, does that mean the results are good? Wouldn’t they contact you immediately if there was something wrong?
Machelle_Moeller_CNP: Length of time for biopsy results to be reported do not necessarily indicate good or bad results. At Cleveland Clinic, we make every attempt to call with results as soon as they are available, regardless of the result. Sometimes the length of time from biopsy to results is delayed depending on the extent of testing requested by the ordering physician. Should you have questions regarding your biopsy results, feel free to call the doctor's office to decrease any unnecessary anxiety. They often can provide additional information about the status of your test results for you.


Signs and Symptoms and Risk Factors

who_cares: What are the signs of breast cancer?
Dr__Valente: Breast cancer can present in many ways.

  • It may be found as a suspicious area noted on your routine annual mammogram. It may also be noted as firm lump or mass felt by you or your physician.
  • Sometimes the skin or nipple appears abnormal compared to the other breast.
  • Breast cancer usually is not painful, but it can be. It is important to have anything new or unusual evaluated by your doctor.

candyl: I have a clear yellow nipple discharge. I have read in one place that this is OK and to only be worried if discharge is bloody. I read somewhere else that yellow can be indicative of cancer. Which is correct?
Dr__Valente: We worry about bloody or clear nipple discharge. With a new symptom of yellow nipple discharge, you should see your physician for a breast examination and imaging studies to make sure nothing else is going on in your breast.

take_a_hike: Can having work done on your breast, such as reduction, implants or lifts, cause breast cancer or increase your risk for breast cancer?
Dr__Valente: No, having surgery on your breast does not increase your risk for breast cancer. However, implants and surgeries create scarring in the breast tissue, which may make it slightly more difficult for the radiologists to read your annual mammograms. Usually this means that you may have to have additional imaging such as an ultrasound performed on your breasts. However, most women who have had prior breast surgery do not have any issue with their annual mammograms.

glendale: What causes nipple retraction? Can this indicate cancer?
Dr__Valente: Nipple retraction that is new should be brought to the attention of your physician because, in some cases, nipple retraction can be associated with breast cancer. A breast examination and imaging studies should be performed.

sandyb: Could pain in breast indicate cancer? If not, what else could cause it?
Dr__Valente: There are many causes of breast pain. Breast cancer is not usually painful, but it could be. You should see your doctor for a breast examination and make sure you have had a recent mammogram.

Other causes of breast pain could be related to caffeine intake, changes in your hormones related to timing of your menstrual cycle or menopause. You also want to make sure you are wearing a bra that supports well. You should discuss any new changes in your breast with your doctor.

Cat666: Does having biopsies increase your risk of getting breast cancer?
Dr__Valente: Biopsies themselves do not increase your risk of breast cancer. However, the risk is that your breasts have changes on imaging which appear suspicious and for which biopsies are recommended.


Family History and Genetics

drumo333: Is breast cancer inherited?
Dr__Valente: Most women who get breast cancer do not have any family history of breast cancer. Just because a family member had breast cancer does not always mean that you will get breast cancer.

We do know that there are some genes associated with a known increased risk of breast cancer. These are BRCA 1 (breast cancer 1, early onset human tumor suppressor gene) and BRCA 2 (breast cancer type 2 susceptibility protein). Only 10 percent of women with breast cancer have these inherited genes. These women usually get breast cancer at a young age and have multiple family members with breast or ovarian cancer.

nyst: Would you explain the breast cancer genes BRCA1 and BRCA2? I have had a hysterectomy for uterine cancer and it has been suggested that I be tested. What does this involve?
Dr__Valente: There are two genes that we know of that are associated with an increased risk of breast cancer—BRCA1 (breast cancer 1, early onset human tumor suppressor gene) and BRCA2 (breast cancer type 2 susceptibility protein).

If you have a family history of breast cancer in multiple relatives or have breast or ovarian cancer yourself, you can talk with a genetics counselor about your risk. Cleveland Clinic offers genetic counseling, and, if you are a candidate, it involves a blood draw or a swab of saliva from your mouth.

If you would like to schedule an appointment you can call Cleveland Clinic Taussig Cancer Institute for genetic counseling at 800.998.4785.

Cat666: What age is a young age for the 10 percent of women with BRCA1 and BRCA2, and family history?
Machelle_Moeller_CNP: Age-related indications for a medical genetics referral is generally a diagnosis before the age of 50 years old, although not all women referred require testing. Testing is based on many factors including family history and ages of family members diagnosed. Referrals for discussion of testing are appropriate for breast cancer diagnosis before the age of 50 years old and ovarian cancer before the age of 40 years old.

jotto: When family history increases the risk of breast cancer for other family members, are men included in this increased risk?
Machelle_Moeller_CNP: Unfortunately, men can get breast cancer and account for one percent of all breast cancer patients. When looking at family history, particularly in those families known to have a genetic mutation (BRCA1 or BRCA2), males should absolutely be included in that review. Men with breast cancer should be tested for the BRCA gene. 


Breast Cancer Follow Up

Christy: What is the appropriate follow up for breast cancer patients? Why isn’t my provider recommending routine scans or laboratory testing?
Machelle_Moeller_CNP: In regard to follow up, Cleveland Clinic follows the American Society of Clinical Oncology recommendations for follow up. These guidelines recommend regular clinical exams and mammograms when appropriate. There is no recommendation for routine scans or laboratory tests, including tumor markers, since they can provide false positive and false negative results. Also, they are not particularly helpful in the absence of symptoms. In regard to scans, the recommendations are to decrease the exposure to unnecessary radiation, as radiation exposure can lead to secondary cancers. Scans or laboratory tests that are ordered by your physician may be appropriate and necessary though, and are driven by certain symptoms. These symptoms would include any concerns lasting longer than two weeks, those getting worse with time, or something that just doesn't seem normal to you. Specific concerns might include any new lumps, bumps, nausea, vomiting, cough, shortness of breath, bone pain (specific sites more concerning than generalized pain) and headaches with double vision. If you ever have a question or concern, you should always discuss it further with your healthcare provider.

sunbeam: Can breast cancer recur several years later after having mastectomies?
Machelle_Moeller_CNP: The further out from diagnosis, the less likely breast cancer is to recur. Unfortunately, breast cancer can recur at any time regardless of treatment or type of surgery. However, the intent of surgery and other treatments, including chemotherapy, endocrine therapy and radiation, is to reduce the overall risk of recurrence. Nevertheless, it does not eliminate that risk in its entirety.

gaauga: As an  ER+ HER2+ (estrogen receptor-positive, human epidermal growth factor receptor 2-positive gene cancer) survivor, is there a point where my risk of my cancer spreading is considered greatly reduced? I hear people say five years, seven years and so on.
Machelle_Moeller_CNP: Unfortunately, there is no absolute time that one never has to think about a recurrence. However, it is generally accepted that more aggressive tumors, such as a HER2+, are more likely to recur within the first couple of years after diagnosis and have a general trend downward (meaning there is a decreased risk with each year further out). There is nothing magical about five or seven years. However, most survival rates are based on 5- or 10-year measurement periods, which is why you might hear those numbers thrown around.


Hormone Replacement Therapy

Flashpan: I know that I have breast cancer and shouldn't use hormone replacement therapy for either hot flashes or vaginal dryness symptoms. Are there other things that I can use to help these discomforts, or do I just need to tough it out?
Machelle_Moeller_CNP: It is true that hormone replacement therapy should be avoided for management of either hot flashes or vaginal dryness. This is most true for hormone receptor positive cancers, although is a good recommendation to follow for all patients to decrease the risk of further unnecessary exposures. In regards to hot flashes, there are a number of lifestyle modifications to consider, specifically avoiding alcohol, decreasing stress, avoiding caffeine and increasing exercise. An additional recommendation would be to try magnesium 200 mg twice daily and vitamin E 400 IU daily. But, always check with your healthcare providers to make sure that there are no other contraindications to taking these over-the-counter supplements. If this still does not minimize hot flashes to a manageable level, you should discuss other potential non-hormone related treatments with your healthcare provider. In regards to vaginal dryness, even estrogen-based topical creams and gels can provide some risk, and should be avoided if possible. Over-the-counter Astroglide® or K-Y® Brand Jelly can be helpful in decreasing acute symptoms. Replens®, also a water soluble vaginal lubricant, used two to three times weekly can be beneficial as well. However, it sometimes can take up to two to three months for this intervention to take effect, but it is an intervention that shouldn't be overlooked as the benefits can be great with minimal or no risk.


Breast Cancer Treatment

go_on: Who is involved in treating breast cancer?
Machelle_Moeller_CNP: At Cleveland Clinic, we approach the treatment of breast cancer in a multidisciplinary manner, meaning that there are multiple members of your treatment team. Typically, you will meet with a breast surgeon, medical oncologist and radiation oncologist. With each of these specialists is a team of healthcare providers, which often includes a nurse and social worker. Other members of the care team may include a genetic counselor, plastic surgeon, a nutritionist and specific treatment nurses as well. You may not need all of these resources, but the multidisciplinary approach allows us to take care of the individual needs of the patients. Not all hospitals or clinics that care for breast cancer patients may approach care in the same manner. Ask your healthcare providers for specific resources that may be available if you have concerns or questions regarding your specific care team.

callen: What are the newer treatments for breast cancer?
Machelle_Moeller_CNP: There are many treatment options available for breast cancer. The treatments recommended are based on a variety of different factors, including pathology of tumor (size, type of tumor, estrogen/progesterone receptor status, her2/neu [human epidermal growth factor receptor 2] status), nodal involvement and spread of disease. There are not many new treatments available for stage 1, 2 or 3 disease, as most treatments, which are based on the nature of study design and availability, are for metastatic patients. Once proven in that setting, the drugs will sometimes be studied in earlier cancer stages. In regards to metastatic disease, there is a new HER2+ treatment meant to be used in combination with docetaxel and Herceptin®, and it is called Perjeta™. There is also a medication that has been used for renal cell cancer (kidney cancer) in the past, and was recently FDA-indicated for hormone-positive metastatic disease, Afinitor®. While this drug is not new, the indication (reason for use) is new.

Dr Valente: From a surgical standpoint, there are many new and exciting treatments.  Many Cleveland Clinic surgeons perform oncoplastic surgery, which is an innovative surgery that uses specialized techniques to remove a breast tumor and reshape the breast all in one surgery. This allows the surgeon to take a larger piece of tissue to ensure negative margins.  We also perform skin and nipple sparing mastectomies and offer all types of immediate breast reconstruction.

We perform mammosite radiation (a balloon is placed in your lumpectomy cavity and radiation is given for five days), or for early-stage breast cancer, we offer intraoperative radiation therapy (IORT).  This is a single dose of radiation given at the time of lumpectomy. For fibroadenomas, we can perform cryoablation which is a procedure which freezes the benign lesion. Additionally, we offer numerous clinical trials.  Ask your surgeon if you are a candidate.

ha_ha_ha: Tamoxifen or not? For a woman who is high-risk, how do you decide?
Machelle_Moeller_CNP: Most, if not all, prescription and over-the-counter medications carry some risk to them. Tamoxifen, while it has side effects, has been shown to be a very beneficial medication in preventing and treating breast cancer. Not everyone at high risk of cancer is an appropriate candidate though. Tamoxifen should be avoided in patients that have a prior history of blood clots as this can be a serious side effect of the medication. The exact benefit and risk discussion is individualized and should take into account personal and family risks. There are risk assessment models available for your healthcare provider to estimate your individual risk. While these are not perfect, they do provide some guidance in treatment recommendations. After you have the information on the benefits and risks of treatment, you can then make an educated decision whether you want to proceed with the recommendation or not.

listen_to_me: What is the recommended treatment for large tumors (over 6 cm)?
Machelle_Moeller_CNP: There are many characteristics of tumors that dictate the appropriate treatment for an individual. Size of the tumor and size of the breast are two such factors. We are now doing more chemotherapy prior to surgery to decrease the size of the tumor to possibly provide an option for a lumpectomy vs. mastectomy. In this setting, tumor response to treatment will have an effect on the final recommendation. Usually after surgery, radiation will be recommended for tumors larger than 6 cm.


Breast Cancer Surgery and Reconstruction

elizabeth: How do you decide between a lumpectomy and a mastectomy?
Dr__Valente: There are many factors to consider. Briefly, for a big cancer in a small breast, it is hard to perform a lumpectomy and have a cosmetically pleasing result. These patients would be best with a mastectomy. Sometimes the surgeon will recommend that the patient receive chemotherapy prior to surgery, if they think that it will help shrink the cancer enough that the patient could then have a lumpectomy. Another factor to consider is that a patient who selects lumpectomy will need to get five to six weeks of radiation after surgery. If a cancer is small, the patient is given the option of either a mastectomy or a lumpectomy. 

up_high: What questions should I ask my surgeon before surgery?
Dr__Valente: You should make sure your surgeon goes over all of your options for surgery (mastectomy vs. lumpectomy) and the risks and benefits of each procedure. If you need a mastectomy, ask if you are a candidate for immediate breast reconstruction. Your surgeon should also discuss sampling of your lymph nodes with you.

sankers2: What about reconstructive surgery—what is the safest and longest lasting? I heard saline and silicone only last 10 years, but a trans flap is major surgery. How can one make the best decision? How long is it safe to have expanders in after a double mastectomy?
Dr__Valente: My recommendation is that someone considering reconstructive surgery should discuss all her options with a plastic and reconstructive surgeon in detail. They can discuss all of the risks and benefits of each reconstruction option as well as show you pictures.

Tissue expanders can safely be in place for up to one year, but should be exchanged for a more permanent prosthesis once cancer treatment is complete.


Support Groups

Rellim: Do you have family or caregiver support groups?
Machelle_Moeller_CNP: At Cleveland Clinic, we do have a patient support group that is run by our social worker. It is held the third Monday of every month from 10:30 a.m. to noon, and all are welcome. It is on the third floor of the Taussig Cancer Institute. We don't have any specific family care support groups here, but are very fortunate to have access to The Gathering Place, which is a community based cancer support center for all cancers. There is a Gathering Place on the east side in Beachwood, as well as one on the west side in Westlake. I know that they have a variety of support programs including those for family members.



Cat666: Are there any foods that may prevent breast cancer?
Dr__Valente: Maintaining a healthy, balanced diet and exercise routine is best for decreasing one's risk of developing breast cancer. Research has shown that a diet low in fat and alcohol consumption has shown to reduce this risk. Additionally, studies have shown that low vitamin D levels have been linked to many cancers including breast cancer. Eating foods enriched with vitamin D or taking a vitamin D supplement may be helpful.

gaauga: I would like to visit a nutritionist for weight loss and to help me in my cancer survivorship. Are there any suggestions on what to look for in a nutritionist?
Machelle_Moeller_CNP: It is true that weight loss, particularly in the post-menopausal setting, can decrease risk of recurrence. So, it is wise to have this be a goal for ‘treatment.’ In regards to finding a good nutritionist, I would recommend that you find someone who is knowledgeable about cancer prevention and the importance of low-fat diets. At Cleveland Clinic, the Taussig Cancer Institute has a dedicated nutritionist that meets with patients and helps guide them in a well-balanced, low-fat diet. You can always ask your individual healthcare provider for a referral. I would caution against any fad dieticians or those promoting individual products, as these are often difficult diets to sustain, can be expensive and are not necessarily evidence-based medicine.


Support Groups

Rellim: Do you have family or caregiver support groups?
Machelle_Moeller_CNP: At Cleveland Clinic, we do have a patient support group that is run by our social worker. It is held the third Monday of every month from 10:30 a.m. to noon, and all are welcome. It is on the third floor of the Taussig Cancer Institute. We don't have any specific family care support groups here, but are very fortunate to have access to The Gathering Place, which is a community based cancer support center for all cancers. There is a Gathering Place on the east side in Beachwood, as well as one on the west side in Westlake. I know that they have a variety of support programs including those for family members.


Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Stephanie A. Valente, DO and Machelle Moeller, CNP is now over. Thank you Dr. Valente and Machelle Moeller for taking the time to answer our questions today about Breast Cancer: Prevention, Treatment and Survivorship.
Dr__Valente: Thank you for your questions this afternoon. I hope this was valuable. Unfortunately, we cannot identify which women who will develop breast cancer. The best tool we have to fight breast cancer is early detection.  Make sure that you perform self breast examinations at least monthly and get an annual clinical breast examination and mammogram by your doctor. If you notice anything that is concerning, you should bring this to your doctor’s attention immediately.
Machelle_Moeller_CNP: Thank you so much for joining in on the session today. I hope that you found this to be helpful and informational. When you have questions or concerns regarding your personal care or something you have read or heard, always take the time to ask your healthcare providers. The care for breast cancer is very individualized, and answering your questions is very important to us. It should be important to you as well. Take care!

Additional resources

Visit to get expert advice and resources for prevention, risk assessment and treatment.

Still have questions about Breast Cancer and Survivorship?

We are here to help you get the cancer information you need. The Cleveland Clinic Cancer Answer Line is staffed by two oncology Advanced Practice Nurses (APNs) who can answer questions about cancer and provide information about our Survivorship Clinic. The Cancer Answer Line operates from 8 a.m. to 5 p.m., Monday – Friday. You do not need to be a Cleveland Clinic patient to use this service! Call our Cancer Answer Line at 216.444.HOPE or toll free 866.223.8100.

To learn more about Breast Cancer, visit and download our free Breast Cancer treatment guide.

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