Background: Expectant management (EM), including active surveillance and watchful waiting, is a strategy to minimize prostate cancer overtreatment. We sought to evaluate contemporary trends in EM utilization and to identify factors associated with its uptake. Methods: Using the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, we identified men with biopsy-proven low-risk (Gleason score 6 or lower, no Gleason pattern 4 or 5, cT1-cT2a) prostate cancer diagnosed between 2004 and 2011. We then classified men within this cohort as having undergone EM (no first-course surgery, radiation, hormone therapy, or chemotherapy) or active treatment. Patient and provider variables were analyzed using univariate and multivariate logistic regression models to determine predictors of EM selection. Results: Of 287,562 men with low-risk prostate cancer, we identified 34,132 patients (11.9%) who received EM. Beginning in 2008, we observed a significant and steady rise in EM usage with time (range, 9.8% to 18.6%). Compared to 2004, patients diagnosed in 2011 had 2.5 times the odds of receiving EM (odds ratio [OR] 2.52, confidence interval [CI] 2.39-2.64, p<0.0001). Aside from year of diagnosis, age, and Charlson score were strong predictors of EM usage (p<0.0001). Other strong predictors of EM included hospital type and insurance provider. Specifically, patients who were treated at comprehensive cancer centers or who had personal health insurance were significantly less likely to receive EM (OR 0.63, 0.60-0.66, p<0.0001 or OR 0.90, CI 0.88-0.93, p<0.0001, respectively). Patient race, income, and area of residence as well as hospital location were significantly but weakly associated with EM. Conclusions: In recent years, low-risk prostate cancer has been increasingly managed with EM, especially in older patients or patients with multiple comorbidities, who are least likely to benefit from active treatment. Unexpectedly, hospital type and insurance provider also predict EM usage, calling into question whether non-clinical factors are influencing EM selection.