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Introduction: Controversy exists as to whether patients with stage IV gastric cancer should undergo surgical resection. We examined advantages of resection by analyzing its association with survival.Methods: All diagnoses of gastric cancer were identified using the SEER database (1988-2005). Analyses were limited to stage IV patients, defined by AJCC staging. Further analysis examined subgroups based on whether surgery was recommended and performed. Outcome measures analyzed were one-year and overall survival. Univariate analyses included chi-square and Kaplan-Meier (KM) survival analysis. Cox proportional hazards modeling was performed to assess independent determinants of survival.Results: Of 66751 identified gastric cancer patients, 24368 had stage IV disease. One-year survival for stage IV patients was 20%. Age, race, marital status, tumor grade, and procedure type were significantly associated with one-year survival on both univariate and multivariate analyses. Three groups of stage IV gastric cancer patients were compared, excluding patients with unknown surgery status (N=526): (1) Surgery performed (N=8489), (2) Surgery recommended, not performed (N=2426), and (3) Surgery not recommended (N=12927). KM survival analysis showed resected patients had a significant survival advantage and that the survival outcome for patients who had been recommended for, but had not undergone surgery was identical to that for patients who had not been recommended for surgery. Median survival of group 1 was 8 months compared to 3 months in both groups 2 and 3 (p<0.0001) (Figure).Conclusions: Patients with stage IV gastric cancer who undergo resection have significantly greater survival than unresected patients, including those who were recommended for resection but did not receive it. These data suggest that stage IV gastric cancer patients who are reasonable operative candidates should be offered resection.