Background: National guidelines have increasingly supported active surveillance/watchful waiting (AS/WW) in low- and favorable intermediate-risk prostate cancer (PCa). It is unknown how these changes have influenced national management patterns across localized PCa. Therefore, we sought to define the U.S. trends in management of localized PCa across National Comprehensive Cancer Network (NCCN) risk groups. Methods: Using the novel and non-public Surveillance, Epidemiology, and End Results Program Prostate with AS/WW Database, we identified 164,760 men diagnosed with localized PCa and actively treated with either AS/WW, radical prostatectomy [RP], or radiation therapy [RT] from 2010-2015. Rates of initial management type over time, stratified by NCCN risk-category, were determined. Multivariable logistic regression defined adjusted odds ratios (AORs) and 95% confidence intervals (CI) for receipt of each initial management type, with year of diagnosis (2010-2015) as the independent variable of interest (Year 2010 = referent). Results: AS/WW utilization increased from 14.5% to 42.1% from 2010-2015 in low-risk disease (AOR 4.50 [95% CI 4.17–4.86, P < 0.001]); conversely, RT and RP decreased from 38.0% to 26.6% (AOR 0.55 [0.51–0.59, P < 0.001]), and from 47.4% to 31.3% (AOR 0.50, [0.47-0.54, P < 0.001]), respectively (all P_trends< 0.001). AS/WW increased in intermediate-risk disease from 5.78% to 9.60% (AOR 1.83 [1.67–2.00, P < 0.001]) and RT also decreased from 42.4% to 39.8% (AOR 0.81 [0.77–0.85], P < 0.001; P_trends< 0.001)—Yet, there was no change in RP (51.8% vs. 50.6%; AOR 1.03 [0.98–1.09, P = 0.254]). Notably, while RP for high-risk disease increased from 38.0% to 42.8% (AOR 1.41 [1.30–1.53, P < 0.001]), RT decreased from 60.1% to 55.0% (AOR 0.71 [0.65–0.77, P < 0.001]; P_trends< 0.001). Conclusions: These findings capture the rapidly shifting landscape of management for localized PCa and are suggestive of “management migration”—where down-trending RP utilization in low-risk disease (in the setting of up-trending AS/WW) may drive non-evidence based management bias toward RP over RT in higher risk disease. These national patterns serve as a targetable trend that should be addressed.