How would you approach an elderly patient with locally advanced breast cancer and co-morbidities, who strongly refuses surgery but is willing to consider radiation?

Presuming that this is nonmetastatic, if the local symptoms permit, I would prioritize starting with systemic therapy to cytoreduce, then treat with a hypofractionated regimen, with the understanding that this is a palliative approach if surgery is refused. This is (obviously) a very general "first ...

First, I'd try explaining the reason for the surgery again to them and see if that would change their mind. If I'm convinced they are NOT going to have any type of resection, I'd start with a PET scan to make sure it's localized advanced disease and not metastatic disease.

I'd then ask my medical on...