The term high-risk prostate cancer has been coined to encompass a group of patients with a poor prognosis (clinical stage T3/T4, or T1/T2 with PSA > 20 ng/ml or GS > 8). It is estimated that 20% of patients in Canada present with high-risk disease, which translates into approximately 4000 new cases each year. The optimal management approach is unclear but the standard of care in North America for this group of patients is radiation therapy (RT) with prolonged adjuvant hormonal therapy. Current clinical trials are evaluating the role of local therapy, the value of RT dose escalation, the potential benefit of regional lymph node irradiation, the appropriate duration of adjuvant hormonal therapy, as well as the possible impact of adjunctive chemotherapy. The high-risk group of patients contains a wide spectrum of disease, ranging from patients with aggressive localized disease to those with widespread occult distant metastases. The current challenge facing clinicians is appropriate treatment selection for individual patients. Information from novel biomarkers and improved imaging, as well as more effective local and adjunctive systemic therapies is necessary to improve outcomes for men with this aggressive disease.