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Growing recognition that active surveillance (AS) is a reasonable management option for many men diagnosed with localized prostate cancer led us to describe patients' conceptualizations of AS and reasons for their treatment decisions.Men were patients of a multidisciplinary prostate cancer clinic at a large tertiary cancer center where patients are routinely briefed on treatment options, including AS. We conducted a thematic analysis of interviews with 15 men who had chosen AS and 15 men who received radiation or surgery.Men who chose AS described it as an organized process with a rigorous and reassuring protocol of periodic testing, with potential for subsequent and timely decision-making about treatment. AS was seen as prolonging their current good health and function with treatment still possible later. Rationales for choosing AS included trusting their physician's monitoring, ‘buying time’ without experiencing adverse effects of treatment, waiting for better treatments, and seeing their cancer as very low risk. Men recognized the need to justify their choice to others because it seemed contrary to the impulse to immediately treat cancer. Descriptions of AS by men who chose surgery or radiation were less specific about the testing regimen. Getting rid of the cancer and having a cure were paramount for them.Men fully informed of their treatment options for localized prostate cancer have a comprehensive understanding of the purpose of AS. Slowing the decision-making process may enhance the acceptability of AS. Copyright © 2013 John Wiley & Sons, Ltd.