Objective To understand the factors associated with decision-making, we conducted a telephone-based survey as part of a pilot study to develop a psychoeducational intervention for men with prostate cancer who undergo active surveillance. Patients and Methods From 2007 to 2008, we conducted a cross-sectional study of 34 individuals on active surveillance for prostate cancer. We examined how specific mental health, quality of life and sociodemographic characteristics relate to decision-making. Five validated decision-making scales were used as primary outcomes reflecting the amount of satisfaction, regret and conflict a participant experienced about his decision to undergo active surveillance. A multivariate regression model was developed to identify specific psychosocial factors related to the decision-making outcomes. Results Primary analyses focused on the decisional satisfaction and conflict measures, as the decisional regret measure showed poor reliability (α < 0.70) in this sample. Four psychosocial measures showed strong associations across the decision-making subscales, including the Fife Constructed Meaning Scale (Pearson r > 0.26), Mishel Uncertainty in Illness Scale - Inconsistency (r > 0.32), Mental Health Index-5 (r > 0.33), and Lepore self-efficacy for prostate symptom management scale (r > 0.33). Individuals with higher self-efficacy for prostate cancer symptom management (P= 0.02) and higher positive meaning for cancer (P= 0.03) were less likely to express decision-making conflict as the result of uncertainty. Individuals reporting higher positive meaning for cancer (P= 0.01) and less uncertainty in illness attributed to inconsistency (P= 0.02) were less likely to exhibit decision-making conflict related to the perceived effectiveness of treatment. Conclusions Men choosing active surveillance represent a patient group with unique vulnerabilities that require new psychoeducational interventions to provide information and support that will maintain and improve quality of life. We describe specific characteristics that may put patients at higher risk during the decision-making process and indicate their increased need for such interventions. © 2011 BJU INTERNATIONAL.