The selection of a management strategy for clinically localized prostate cancer is preference-sensitive and very often based on patient interpretation of the balance between treatment-specific risks and benefits. With that in mind, clinicians must inform patients thoroughly regarding the risks and benefits of the various management options. Clinicians also must elicit from patients their values, preferences, and concerns about outcomes of treatment and seek their engagement in the decision-making process. The clinician then helps the patient arrive at a decision and then evaluate that decision. This collaborative SDM process is designed to yield a well-informed, high-quality decision that is consistent with patients’ preferences and values. SDM aims to improve the quality of medical decisions by helping patients choose options consistent with their own values and in accordance with the best available scientific evidence.99-102 RCTs of SDM versus routine care have demonstrated that patients engaged in SDM are more knowledgeable, have more realistic expectations, participate more actively in the care process, and more frequently arrive at decisions aligned with their personal preferences.101, 103 The National Academy of Medicine and the AUA have both articulated strong support for the use of SDM for complex decisions such as treatment for localized prostate cancer.104, 105 Key components of SDM are illustrated by the Agency for Healthcare Research and Quality SHARE approach in Table 5. <img src="images/Guidelines/Guideline%20Images/2026%20LoPC/LoPC%202026-%20Table%205.png" alt="Table 5: AHRQ SHARE Approach to Shared Decision-Making" title="Table 5: AHRQ SHARE Approach to Shared Decision-Making" width="432" height="199" class="blockImg" /> In addition to assessing the patient’s preferences and facilitating the communication, key roles of the clinician include informing patients about the risks and benefits of each management option. Because prostate cancer is so variable in aggressiveness, clinicians should counsel patients regarding the severity of disease and documented natural history to provide perspective regarding the tradeoff between treatment-related side effects and the likelihood of disease progression. Furthermore, risk level dictates the intensity of the staging evaluation and the intensity of treatment, so a discussion of risk level sets the foundation for patient understanding of these decisions. Similarly, as the intensity of treatment is also tied to the patient’s life expectancy, an estimate of life expectancy should factor into the SDM discussion. The expected harms of treatment include immediate risks (e.g., perioperative risks associated with surgery), short-term side effects, and long-term (typically quality of life [QOL]) implications. Local treatments are associated with differing profiles of urinary, sexual, and bowel side effects (variously termed ‘functional outcomes’), which may evolve or resolve over time.107 Meanwhile, hormonal therapy, which is sometimes used in conjunction with radiation therapy, is associated with systemic side effects, some of which are symptomatic (e.g., hot flashes, fatigue, cognitive changes, sexual dysfunction) and some of which remain asymptomatic (e.g., changes in metabolic syndrome parameters). The patient must be informed about the expected risks and side effects of each management option in order to compare the options and to facilitate clear expectations. Specifying the likelihood of various outcome scenarios with each treatment can facilitate SDM, and there are tools available to estimate the likelihood of functional outcomes with each treatment.108 Since baseline function is one of the strongest predictors of functional outcomes,107 the clinician should ascertain the patient’s pre-treatment urinary, bowel, and sexual function (and hormone therapy-related domains if concurrent hormone therapy and radiation is being considered). These functional domains are best assessed using standardized instruments to minimize clinician bias and to facilitate longitudinal comparisons. The Expanded Prostate Cancer Index Composite (EPIC)-26 is one such validated instrument, and it has been selected by the International Consortium on Health Outcomes Measurement (ICHOM) as part of the ‘standard set’ of data that should be collected on each patient with clinically localized prostate cancer. A shorter instrument tailored to clinical care is the Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP).109, 110 The 5-item Sexual Health Inventory for Men (SHIM)111 is an instrument designed to assess erectile function as is the longer 15-item International Index of Erectile Function (IIEF).112 Alternative questionnaires for assessment of urinary continence include the International Continence Society Male Short-Form (ICSmaleSF)113 and International Consultation on Incontinence Questionnaires (ICIQ).114 The EORTC has developed and validated QOL instruments pertinent to a general oncology population (QLQ-C30) and has refined sets for specific cancers, including prostate cancer. The EORTC-QLQ-PR25 assesses urinary function, sexual function, bowel function, and hormone therapy symptoms.115 Similarly, the Functional Assessment of Cancer Therapy (FACT) measurement system has developed a 12-item prostate cancer subscale (PCS), appended to the 35-item FACT-G for the general oncology population.116 The Patient-Reported Outcomes Measurement Information System (PROMIS), initiated by the National Institutes of Health, curates a wide variety of QOL measures, and some have been used to assess symptoms after prostate cancer treatment.117