Background: Hepatocellular carcinoma (HCC) has the third-highest cancer-related mortality rate in the world because most patients are diagnosed at an intermediate to advanced stage when surgery is not suitable. Transcatheter arterial chemoembolization (TACE) is currently considered a first-line therapy for unresectable HCC (uHCC), while the efficacy of TACE alone for uHCC patients still needs to be improved. Anlotinib has shown survival benefits in the treatment of uHCC as a kind of novel tyrosine kinase inhibitors (TKIs) in previous studies. Therefore, we aimed to compare clinical outcomes of TACE combined with anlotinib versus TACE monotherapy in patients with uHCC associated with hepatitis B virus (HBV). Methods: We retrospectively collected the data of 96 uHCC patients associated with hepatitis B virus who received either TACE only (TO group; n = 64) or anlotinib combined with TACE (TA group; n = 32) between January 2017 to January 2021. The clinical outcomes including overall survival (OS), progression-free survival (PFS), and tumor response according to mRECIST and RECIST 1.1 were compared between the two groups. Adverse events (AEs) were analyzed to assess the safety profiles. Results: The median OS in the TA group was 17.6 months (95%CI, 11.3 to 24.3) versus 9.4 months (95% CI, 7.8 to 16.3) in the TO group (hazard ratio, 0.59; 95% CI, 0.39 to 0.90; p= 0.018). The median PFS was also significant longer in the TA group (6.7 vs. 3.8months; hazard ratio, 0.46; p< 0.001). Additionally, the objective response rate (ORR) and disease control rate (DCR) numerically increased in the TA group (mRECIST: ORR 65.6% vs. 46.9%, p= 0.064; DCR 90.6% vs. 85.9%, p= 0.382. RECIST 1.1: ORR 46.9% vs. 15.6%, p= 0.001; DCR 90.6% vs. 85.9%, p= 0.382; respectively). No treatment-related mortality occurred. The most common AEs included elevated transaminases (56.3%), decreased appetite (46.9%) and abdominal pain (37.5%) in TA group. Though the incidence rate of grade 3/4 was higher in TA group, all of them were acceptable and controllable. Conclusions: Anlotinib combined with TACE may significantly improve outcomes for uHCC patients associated with hepatitis B virus comparing with TACE monotherapy with a controllable safety profile. Randomized controlled trials with a large sample are warranted to further validate the efficacy.