How would you manage a patient with early stage ER+ HER2+ breast CA who cannot receive definitive local therapy due to severe cardiopulmonary co-morbidities?

My management would depend on the nature of the severe cardiopulmonary co-morbidity and the clinical stage of the disease. For someone who is not a candidate for surgery (even with local axillary block, etc.), but does not have a cardiomyopathy, and is otherwise fit for systemic therapy (ECOG PS 0-2), then would consider systemic therapy using up front trastuzumab or trastuzumab/pertuzumab with taxane therapy-specific regimen tailored to clinical stage, or even trastuzumab/pertuzumab with endocrine therapy (as used in PERTAIN Trial [1]) followed by radiation could be considered (again, using radiation field or even partial breast irradiation that may be needed if pulmonary compromise). If trastuzumab is contraindicated even with medical car...