Clinical decision making in localized prostate cancer is a complicated, multidimensional process in which men often consider their own personal preferences, the advice of their healthcare providers, the opinions of their family and friends, and outside information sources. They synthesize all of this within the framework of their own unique socioeconomic situation, their social support network, and their preconceived impressions of their health and the health-care system. This is particularly germane when considering factors that influence a patient's acceptance of and adherence to active surveillance (AS). We propose a conceptual framework based on a previously described systematic-heuristic theoretical model of decision making in this setting. We identify a number of factors that patients systematically prioritize when considering AS. These include desire for cancer control or cure, age at diagnosis, and concern regarding side effects of treatment. The way patients value these factors and effectively decide on treatment is influenced by more heuristic factors, including physician recommendation, opinion of friends and family members, and overall decision uncertainty. These heuristic factors also play an important role in adherence when a patient elects AS. Finally, some of the factors, particularly the heuristic ones, are potentially modifiable and may serve as targets for future interventions to increase acceptance of and adherence to AS.