🎈 Breast Cancer
The lump that matters, what the receptors decide, and the arm rules after node surgery.
👀 What it looks like — and what is reassuring
The classic malignant lump. Hard, irregular, fixed to surrounding tissue, painless, and most often in the upper outer quadrant — because that is where most breast tissue is, and it extends into the armpit.
Painless is the trap. Patients assume cancer hurts, so a painless lump gets ignored.
| More worrying | More often benign | |
|---|---|---|
| Feel | Hard, irregular, fixed | Soft or rubbery, smooth, mobile |
| Pain | Usually painless | Often tender, and varies with the cycle |
| Number | Usually one | Frequently several, often both breasts |
| Skin | Dimpling, peau d’orange, redness, thickening | Normal |
| Nipple | Newly inverted; bloody or one-sided discharge | Unchanged |
Other findings to report
- Peau d’orange — skin pitted like orange peel, from blocked lymphatics
- Axillary lymphadenopathy — a firm node in the armpit
- A breast that is red, warm and swollen without infection — inflammatory breast cancer, aggressive and easily mistaken for mastitis
- Any change in size or contour of one breast
🧪 Risk & how it is found
The two biggest risk factors cannot be changed: being female, and getting older. That is worth saying out loud, because patients often blame themselves.
Cannot change
- Female sex; increasing age
- BRCA1 / BRCA2 mutation
- First-degree relative with breast or ovarian cancer
- Early menarche (before 12), late menopause (after 55) — more lifetime estrogen
- Previous chest radiation; dense breast tissue
Can change
- Alcohol — risk rises with each daily drink
- Obesity after menopause
- Physical inactivity
- Combined hormone therapy after menopause
- Never having been pregnant, or first birth after 30
- Breastfeeding is protective
- Mammography is the screening test — it finds cancers before they can be felt.
- Ultrasound distinguishes a solid mass from a fluid-filled cyst, and is used in dense or young breasts.
- MRI for high-risk screening, such as a known BRCA mutation.
- Only a biopsy diagnoses cancer. Imaging raises suspicion; tissue settles it.
Before a mammogram: no deodorant, powder or lotion on the day — they show as specks that mimic microcalcifications. Schedule it a week after a period, when breasts are least tender.
🩺 Treatment — what the receptors decide
The biopsy does more than confirm cancer. It reports receptors, and the receptors choose the treatment.
| Receptor status | Meaning | Treatment it points to |
|---|---|---|
| ER / PR positive | Fed by estrogen or progesterone | Hormone therapy — tamoxifen, or an aromatase inhibitor after menopause |
| HER2 positive | Over-expresses a growth protein; grows faster | Targeted antibody — trastuzumab |
| Triple negative | ER, PR and HER2 all negative — no target | Chemotherapy; more aggressive, poorer prognosis |
Two drug points that get asked
- Tamoxifen raises the risk of endometrial cancer and clots. Teach the patient to report abnormal vaginal bleeding or a swollen, painful calf.
- Trastuzumab is cardiotoxic. Ejection fraction is checked at baseline and during treatment; report new shortness of breath or edema.
🪠 Surgery
- Lumpectomy — the tumor and a margin; almost always followed by radiation.
- Mastectomy — the whole breast, with or without reconstruction.
- Sentinel lymph node biopsy — only the first draining node is removed and tested. Far lower lymphedema risk. Warn the patient that the blue dye can turn urine blue-green and leave a temporary skin stain.
- Axillary dissection — many nodes removed when the sentinel is positive. Much higher lymphedema risk.
💪 After surgery — the arm rules
Removing lymph nodes removes drainage. Fluid can no longer leave that arm easily, so it swells — lymphedema — and once established it is permanent and hard to treat. Every rule below exists to prevent it, and it is lifelong on that side.
On the affected arm, never:
- No blood pressure cuff
- No venipuncture, IV, or injection
- No blood draws or finger sticks
- No tight sleeves, rings or watches
- No heavy lifting until cleared — then build up gradually
Put a sign above the bed and a band on the other wrist. Everyone who enters the room needs to know.
What to do instead
- Elevate the arm on a pillow, hand higher than the elbow, elbow higher than the shoulder.
- Start the prescribed exercises on schedule — hand squeezing early, then wall-climbing and shoulder work as allowed.
- Protect the skin: gloves for gardening and dishes, thimble for sewing, electric razor for underarms, sunscreen, insect repellent.
- Treat any break in the skin immediately — wash, antiseptic, cover, and report redness, warmth or fever. Cellulitis in a lymphedematous arm escalates fast.
- Compression sleeve if prescribed, including for air travel.
- Report a feeling of heaviness, tightness, or a ring or sleeve that suddenly feels tight — those are early lymphedema.
Watch the drain, and watch the dressing. Record drainage volume and color; it should lighten and lessen. Assess behind and underneath the patient for pooled blood — it tracks to the back when they are lying down and a dry front dressing can be reassuring for the wrong reason.
The part that is not physical. Body image, sexuality, fear of recurrence and identity are all in play, and they are not solved by cheerfulness. Ask directly, allow the answer to be bleak, and offer reconstruction information, prosthesis fitting and peer support without waiting to be asked.