Objective To determine whether quality of physician–patient relationships influences uptake of physician treatment recommendations in men with clinically localized prostate cancer (PCa). Study Setting Data were collected July 2010 to August 2014 at two cancer centers and three community facilities. Study Design Analyses were prospective and cross‐sectional. We modeled associations between quality of the patient–physician relationship and influence of physician recommendations on treatment choice using generalized estimating equations (GEE). Data Collection Data were collected via survey and medical record abstraction. Principal Findings Participants (N = 1166) were 14.7 percent minority; 37.1 percent had low‐, 47.5 percent had intermediate‐, and 15.4 percent had high‐risk PCa. Those reporting a better physician–patient relationship perceived that their physician's treatment recommendation was more influential (RR = 1.05, 95 percent CI = 1.04–1.05, p < .001) and were more likely to choose the recommended treatment (OR = 2.92, 95 percent CI = 2.39, 3.58, p < .001). A pattern of interactions emerged indicating that quality of the physician–patient relationship was more strongly associated with influence of recommendations for more, versus less aggressive treatment in those with low‐risk, but not intermediate‐risk disease. Conclusions Prioritizing quality of the physician–patient relationship through training, practice change, and patient feedback may increase adherence. However, strategies need to align with efforts to reduce physician recommendations for inefficacious treatments to prevent overtreatment.