Background: The role of CN remains questionable after the well intentioned two large prospective trials, SURTIME AND CARMENA, failed to show the benefit of CN for mccRCC, with Sunitinib as standard of care. Methods: We identified stage IV mccRCC only patients (pts) who received IO with or without surgery in the NCDB 2004-2018. Overall survival (OS) was calculated among three groups of IO alone (group (gr)1), IO followed by CN (gr2), CN followed by IO (gr3). Cox models compared OS by treatment group after adjusting for sociodemographic, health, and facility variables. Results: From 615,519 renal cancer cases, 2,903 met our criteria. 6.96% of ccRCC had sarcomatoid histology. Pts in the gr 2 and gr 3 had 63%, 95% CI [0.265-0.510] and 46%, 95% CI [0.487- 0.594], P= 0.001, risk reduction in mortality compared to IO alone. Black race compared to white race, education attainment quartile < 6.3% compared to > 17.6%, uninsured pts compared to privately insured, and pts treated at community cancer center compared to academic center had an increased mortality risk by 16%, 95% CI [0.980-1.387] (P= 0.083), 26%, 95% CI [1.054-1.511] (P= 0.011), 30%, 95% CI [1.003-1.683] (P= 0.047), 44%, 95% CI [1.161-1.779] (P= 0.001) respectively. Median income quartiles ranging > 63k, had 25% reduction in mortality over income quartiles < 40k, 95% CI [0.630-0.902] (P= 0.002). Regardless of the sequence of CN, partial nephrectomy was minimally used. Pts with brain and liver metastasis had a 48% (P= 0.063) and a 79% (P= 0.001) chance of increased risk of mortality. Conclusions: Pts receiving CN regardless of sequence with IO did better than IO alone in this national registry-based adjusted analysis for mccRCC. International Metastatic Renal Cell Carcinoma Database Consortium risk stratification of pts was not done however Charlson-Deyo Comorbidity Index, visceral/brain metastasis were accounted for in OS analysis. Limitations inherited in the retrospective nature of this study are lack of randomization and pts’ and physicians’ choice. We believe the role of CN does warrant prospective validation in the era of IO for stage IV ccRCC. OS at 2 and 5 yrs for all three groups, with respective 95% CI.