I would have considered neo-adjuvant chemotherapy for this patient, with the expectation that her primary would shrink and thus be more amenable to breast-conserving therapy. Given the initial mastectomy that she had, I would follow her as I would any other breast ca pt-- annual mammograms, semi-annual breast exams. She is a candidate for chemotherapy and tamoxifen. She is at very high risk for recurrence, based primarily on the size of the primary and the number of + nodes. If the tumor is high grade, that adds to the recurrence risk.