Breast-conserving therapy is widely embraced for the majority of women with early-stage breast cancer, but its appropriateness in patients with germline mutations of BRCA1 and BRCA2 remains controversial. These breast cancer susceptibility genes are associated with a progressive risk of second cancers, although the prognosis of BRCA-associated breast cancer is similar to that in patients with sporadic disease. The BRCA1/2 genes are involved in the cellular response to DNA damage, but their molecular functions are not fully understood. Preclinical evidence of radiation sensitivity has led to concerns regarding radiation-induced complications in patients with BRCA1/2 mutations. The published literature on conservative management of patients with BRCA1/2 mutations is reviewed in this article. Several studies report no adverse sequelae and recurrence rates and overall survival comparable to those in sporadic disease controls. With longer follow-up, the literature suggests an increase in late second primary breast cancers, highlighting the need for preventive strategies. The potential role of tamoxifen and oophorectomy in modifying the rate of second events is discussed.