http://www.nccn.org/professionals/physician_gls/PDF/prostate.pdf

External Beam Radiotherapy:
3D conformal or IMRT (intensity modulated radiation therapy) techniques
should be employed.
Doses of 70-75 Gy in 35-41 fractions to the prostate (± seminal vesicles
for part of the therapy) appear to be appropriate for patients
with low-risk cancers. For patients with intermediate- or high-risk
disease, doses between 75-80 Gy appear to provide improved PSAassessed
disease control.
Patients with high-risk cancers are candidates for pelvic lymph node
irradiation and the addition of neoadjuvant ± adjuvant androgen
deprivation therapy for a total of 2-3 y or 4-6 mo if they have only a
single high risk adverse factor.
Patients with intermediate risk cancer may be considered for pelvic lymph
node irradiation and 4-6 mo neoadjuvant ± adjuvant ADT
Patients with low risk cancer should not receive pelvic lymph node
irradiation or ADT.
If target (PTV) margins are reduced, such as for doses above 75 Gy, extra
attention to daily prostate localization, with techniques such
as ultrasound, implanted fiducials, or an endorectal balloon, is
indicated.

Brachytherapy
Permanent brachytherapy as monotherapy is indicated for patients with
low-risk cancers. For intermediate-risk cancers consider
combining brachytherapy with EBRT (40-50 Gy) ± neoadjuvant androgen
deprivation therapy. Patients with high-risk cancers are
generally considered poor candidates for permanent brachytherapy; however,
with the addition of EBRT and androgen deprivation
therapy, it may be effective in select patients.
Patients with a large prostate (> 60 gm) or small prostate (<15-20 gm),
symptoms of bladder outlet obstruction (IPSS score > 15), or a
previous transurethral resection of the prostate (TURP) are not
appropriate candidates because of increased risk of urinary morbidity.
Neoadjuvant androgen deprivation therapy may be used to shrink the
prostate to an acceptable size.
Post-implant dosimetry should be performed to document the quality of the
implant.
The recommended prescribed doses for monotherapy are 145 Gy for 125-Iodine
and 125 Gy for 103-Palladium. The corresponding
boost dose after 40-50 Gy EBRT are 110 Gy and 100 Gy, respectively.

Systemic chemotherapy should be reserved for patients with
castration-recurrent metastatic prostate
cancer except when studied in clinical trials.
In this group of patients, docetaxel-based regimens have been shown to
confer a survival benefit in two
phase III studies:
SWOG 9916 compared docetaxel plus estramustine to mitoxantrone plus
prednisone. Median survival
for the docetaxel arm was 18 months vs. 15 months for the mitoxantrone arm
(p=.01).
TAX 327 compared two docetaxel schedules (weekly and every 3 weeks) to
mitoxantrone and
prednisone. Median survival for the every 3 week docetaxel arm was 18.9
months vs. 16.5 months for
the mitoxantrone arm (p=.009)
Docetaxel-based regimens are now the standard of care for first-line
treatment in this group of patients.
Bisphosphonate therapy should be considered in patients with
castration-recurrent metastatic prostate
cancer since it may prevent skeletal-related events and improve bone
mineral density. Bisphosphonate
therapy can cause renal insufficiency and mandibular osteonecrosis in men
with dental disease.

Bisphosphonate therapy does not have a role in oncologic treatment of men
with newly diagnosed,
advanced prostate cancer although clinical trials are in progress.