Patients with locally advanced breast cancer (equating with stage III in the American Joint Committee TNM system) are at high risk for local and distant recurrence. Primary surgery alone leads to an unacceptably high rate of local recurrence. Radiotherapy of more than 60 Gy with boosts to large tumor masses can achieve excellent rates of local control, but leads to unacceptable side effects in about 20% of patients. Chemotherapy produces responses in 60% to 90% of patients; chemotherapy followed by mastectomy or radiotherapy produces equivalent survival and local recurrence rates. A good response to primary chemotherapy may allow for limited surgery followed by radiotherapy and excellent local control rates in many patients. Patients with extensive inflammatory breast cancer are probably best managed with initial systemic therapy and radiotherapy, since the role of surgery in this patient group has not been clearly defined.