Background: Patients with metastatic renal cell carcinoma (mRCC) are heterogenous, with significant variation in clinical course. The use of vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin (mTOR) kinase inhibitors has dramatically changed the prognosis for these patients. However, these treatments are non-curative, necessitating chronic therapy. There is a cohort of patients with indolent disease in whom the initiation of systemic therapy is often deferred. It is inferred that the planned deferment of systemic therapy does not negatively impact on clinical benefit, but there is a lack of published data in the ‘kinase inhibitor era’ to support this contention. Methods: This was a retrospective study. Patients with mRCC treated with sunitinib who had a planned period of observation prior to the initiation of systemic therapy because of asymptomatic or slowly progressive disease were analysed. The primary objective was to determine the progression free survival (PFS) of patients on deferred first-line systemic therapy. Results: Records of 251 patients treated with sunitinib between 2005 and 2010 were reviewed; 64 patients who met the criteria were identified. The median age at diagnosis was 56 years and 75% were male; 80% had clear cell mRCC. All patients but one had a favourable or intermediate prognosis (Heng). The median time from diagnosis of metastases to starting treatment was 14.7 months (95% CI 10.4-16.3) Initial systemic therapy was interferon for 28% of patients and sunitinib for 65% of patients. Interferon patients had a median PFS of 6.3 months (95% CI 3.3-9.9), and sunitinib patients had a median PFS of 4.3 months (95% CI 3.6-7.3). Patients who received a VEGFR kinase inhibitor as second-line therapy after interferon had a median PFS of 7 months (95% CI 4.3-12.5). The median overall survival for all patients was 35 months (95% CI 26-42.3). Conclusions: In this cohort of patients with indolent favourable or intermediate prognosis mRCC, systemic treatment was deferred by a median of over one year but the efficacy of delayed sunitinib treatment was less than expected. Further study is required to define the group of patients for whom delayed systemic therapy is optimal.