Background: The management of localized prostate cancer (PC) is evolving. We sought to analyze recent management trends using a large national database. Methods: Data on patients presenting with a new diagnosis of PC between 2004 and 2011 were extracted from the National Cancer Data Base. Patients with nodal or distant metastases were excluded. Patients were categorized as low risk (LR), intermediate risk (IR) or high risk (HR) according to the National Comprehensive Cancer Network’s (NCCN) guidelines. Multivariate logistic regression was performed to identify factors associated with the receipt of surgery or radiotherapy. Results: 823,977 patients met the study criteria; 38.5% were LR, 42.7% IR and 18.9% HR. Between 2004 and 2011, for LR patients, rates of observation after diagnosis increased from 12.4% to 18.5% and receipt of radical prostatectomy (RP) increased from 40.3% to 54.4% (p for trend both <.001). In contrast, receipt of brachytherapy decreased from 24.4% to 11.4% and receipt of external beam radiation therapy (EBRT) decreased from 18.2% to 13.4% (p both <.001). For IR patients rates of observation increased from 6.1% to 7.3% and RP from 48.1% to 58.5% (p both <.001) while receipt of brachytherapy decreased from 12.1% to 6.4% (p <.001) and receipt of EBRT plus androgen deprivation therapy (ADT) fell from 14.7% to 8.7%. For HR patients, receipt of RP increased from 30.6% to 41.3% (p < .001) while receipt of EBRT plus ADT decreased from 30.4% to 28.0% (p <.001). On multivariate analysis factors predicting for a lower odds of receiving RP vs. radiotherapy (p all <.001) included black race (OR 0.52 vs. white), lack of insurance or insurance through Medicaid (OR 0.66 and 0.50 vs. private insurance) and residing in low income level areas (OR 0.85 for areas in the lowest national quartile vs. the highest). Conclusions: Utilization of radical prostatectomy for patients with localized PC increased significantly across risk groups from 2004 to 2011 while utilization of radiotherapy decreased. Rates of observation have increased in LR disease but remain low overall. Markers of poor socioeconomic status appear associated with receipt of radiotherapy. Further work is needed to elucidate the causes and appropriateness of these trends.