Even though the incidence has decreased, locally advanced prostate cancer remains a treatment challenge. Primary androgen ablation remains an option, but must be used judiciously as a high number of patients ultimately progress and die of prostate cancer. Unfortunately, while there is not good data that more aggressive treatment impacts significantly on survival, it does appear that some patients can be rendered free of disease. The failure rate with surgery alone has been high and androgen ablation has been used as a frequent adjunct. The randomized trials completed so far suggest that holding the androgen ablation for failure is as effective for survival. Randomized data with adjuvant radiation shows a significant decrease in biochemical and clinical failure, but a survival advantage is also not yet apparent. Historically, the results of primary radiation have been poor and have been only modestly improved with the addition of androgen ablation. In retrospective studies, favorable results have been achieved with dose escalation utilizing intensity modulated external beam radiation therapy or brachytherapy without the need for androgen ablation.