Background: The impact of delay in treatment for localized renal cell carcinoma (RCC) is controversial. We sought to determine the survival impact of time to definitive surgical treatment stratified by tumor size in a group of young, healthy patients from the National Cancer Database (NCDB). Methods: The NCDB was queried for cases of localized RCC (cT1-T3N0M0) in patients <60 years of age with Charlson comorbidity score of 0 from 2004-2015. Quartiles were formed from the range of time to surgery of the entire cohort in days, with delayed treatment as the fourth quartile. Tumors were stratified into size of <2 cm, 2-4 cm, 4-7 cm and >10 cm. Overall survival (OS) between early and delayed groups was calculated with Kaplan-Meier analysis (KMA) and multivariable cox proportional hazards (MVA) and stratified by tumor size. Logistic regression was performed to determine factors associated with delay in surgical care. Results: 44,149 patients were analyzed. Median time to treatment was 35 days (IQR 19-61). Early (n = 33,144) and delayed (>61 days, n =11,005) groups had a mean follow-up of 61.5 and 57.5 months, respectively (p < 0.001). KMA showed worse 5-yr OS in patients with surgery delay versus no delay for tumors 2-4 cm in size (5-yr OS 49% vs. 54%; p<0.001), 4-7 cm (5-yr OS 47% vs. 53%; p<0.001), >7 cm (5-yr OS 45% vs. 49%;p=0.0002), but not for tumors <2 cm (5 yr OS 49% vs. 51%: p=0.5848). MVA showed worse OS with surgery delay compared to no surgery delay in patients with tumor size 2-4 cm (HR 1.24; 95%CI 1.09-1.42), 4-7 cm (HR 1.32; 95%CI 1.16- 1.50) and >7 cm (HR 1.14; 95%CI 1.01-1.30) but not tumors <2 cm (HR 0.83; 95% CI 0.65-1.05). Delay in treatment was higher with older age (OR 1.01; p<0.001), male gender (1.11; p<0.001), non-private insurance (OR 1.44; p<0.001), black race (OR 1.60; p<0.001), decreased education (OR 1.11; p<0.001) and tumors >2 cm (OR 1.23; p<0.001). Conclusions: In patients <60 years of age and CCI of 0, delay in treatment was associated with worse OS for tumors >2 cm but not for RCC <2 cm in size. While these findings support data suggesting that active surveillance for RCC < 2 cm in size is appropriate even in young and healthy patients, caution should be exercised in patients with tumors > 2 cm.