AbstractBackgroundActive surveillance/watchful waiting (AS/WW) is feasible and effective for favorable‐risk prostate cancer (PCa). Understanding socioeconomic determinants of AS/WW may help determine the target population for social support and improve cancer‐related survival.MethodsThe Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting Database 18 Registries identified 229,428 adult men diagnosed with primary localized PCa (clinical T1‐T2c, N0M0) during a median follow‐up of 45 months between 2010 and 2016. Socioeconomic determinants included socioeconomic status (SES) tertiles, marital status (unmarried vs married), and residency (urban vs rural). Multivariable logistic regression and Cox models determined the adjusted odds ratios (aOR) for AS/WW utilization, and adjusted hazard ratio (aHR) for cancer‐specific survival (CSS) and overall survival (OS). The extent of missing data was evaluated by multiple imputation. Sensitivity analyses were performed in multiple imputation datasets.ResultsUnmarried patients were more likely to receive AS/WW in low‐risk group (aOR, 1.20 [95%CI, 1.12–1.28];p< 0.001) and favorable intermediate‐risk group (aOR, 1.41 [95%CI, 1.26–1.59];p< 0.001) than married patients. Urban patients had 0.77‐fold lower likelihood of AS/WW than rural patients in low‐risk group (95% CI, 0.68–0.87;p< 0.001), but not in favorable intermediate‐risk groups. Among patients undertaking AS/WW, a significantly worse OS was observed among unmarried patients comparing to married group (aHR, 1.98 [95% CI, 1.50–2.60];p< 0.001), and patients with high SES had better CSS than low group (aHR, 0.08 [95%CI, 0.01–0.69];p= 0.02). No significant survival difference was found between urban and rural patients.Conclusions and RelevanceUnmarried or urban patients had significantly higher rates of AS/WW. The utilization and efficacy of conservative management were affected by socioeconomic factors, which might serve as a barrier of treatment decision‐making and targeted a population in need of social support.