OBJECTIVES: The purpose is to prospectively describe factors that may influence the choice between surgery, radiation, and watchful waiting among men newly diagnosed with local stage prostate cancer. METHODS: Beginning in December 2005, prostate cancer patients were approached shortly after diagnosis at urology clinics in Texas, California and South Carolina. Patients took home a self-administered survey to complete as they made their treatment decision. Preliminary data are available for 148 men with recruitment continuing through 2007. Logistic regression was used to identify factors associated with choice of treatment. RESULTS: Overall 65% of men returned the survey before starting treatment. A total of 82% indicated they were only considering (or had considered) a single option; 64% were only considering surgery, 9% were only considering radiation, 9% were only considering non-curative therapies, and 18% were considering multiple options or were unsure of their decision. Being married (OR 4.7; 95% CI: 1.1, 19.4), being under age 70 (OR 2.7; 95% CI: 1.0, 7.0), and having an annual household income higher than $60,000 (OR 2.9; 95% CI: 1.0, 8.1) were strongly associated with considering surgery only. CONCLUSION: Understanding why most men feel their only option is surgery is a priority to ensure that physician biases, patient misperceptions, or fear do not lead patients to select procedures that do not agree with their personal preferences. Many patients appear to make rapid treatment decisions. Interventions to aid treatment decision-making must target men soon after they receive their diagnosis.