Newly diagnosed, early-stage breast cancer confronts the patient and her clinician with multiple treatment decisions. This review examines some of these local treatment options including the choice between breast-conserving treatment (BCT) and mastectomy, how best to treat the axilla, and the optimal sequencing of local and systemic therapy. Key elements in the selection of patients for BCT or mastectomy include preoperative mammography, careful pathological evaluation, and an assessment of patient desires in order to balance the risk of local recurrence against preservation of a cosmetically acceptable breast. Although some absolute contraindications to BCT exist, most patients are candidates for BCT. The role of axillary dissection is currently being redefined, and in the future, more limited procedures may be able to identify patients who can avoid axillary dissection. The relationship between timing of breast surgery with regard to the menstrual cycle and outcome is intriguing but not yet established. As well, the appropriate sequencing of chemotherapy and radiotherapy (RT) after conservative surgery (CS) is uncertain, although randomized trials are beginning to shed some light on this issue. Whether all patients treated with CS require treatment with RT is another question that is currently under investigation. This article addresses these issues, focusing on the specifics of treatment implementation.