The variety of options now available for managing the patient with breast cancer and axillary nodal metastases is confusing. For more than 100 years, axillary lymph node dissection (ALND) was the standard approach, but now, sentinel lymph node biopsy (SLNB) alone, SLNB plus nodal radiotherapy, and neoadjuvant chemotherapy are all alternatives supported by evidence. Herein, I review the data informing patient selection for each of these approaches with the goal of minimizing the use of ALND and its associated morbidity.