BACKGROUND: Although nephrectomy cures most localized renal cancers, this oncologic benefit may be outweighed by the renal functional costs of such an approach. In this study, the authors examined overall survival in 537 patients who had localized renal tumors ≤7 cm detected at age ≥75 years to investigate whether surgical intervention improved survival compared with active surveillance. METHODS: Clinical T1 renal tumors were managed with surveillance (20%), nephron-sparing interventions (53%), or nephrectomy (27%). Cox regression models were constructed based on age, comorbidity, management type, renal function, and other variables. RESULTS: The median follow-up was 3.9 years, and death from any cause occurred in 148 patients (28%). The most common cause of death was cardiovascular (29%), and cancer progression was responsible in only 4% of deaths. Kaplan-Meier analysis revealed decreased overall survival for patients who underwent surveillance and nephrectomy relative to nephron-sparing intervention (P = .01); however, surveilled patients were older and had greater comorbidity. In multivariate analysis, significant predictors of overall survival included age (P = .0004) and comorbidity (P < .0001) but not management type (P = .3). Preoperative renal function (P = .006) and comorbidity (P = .005) were predictors of cardiovascular mortality, and nephrectomy was associated with greatest loss of renal function. CONCLUSIONS: In patients aged ≥75 years, surgical management of clinically localized renal cortical tumors was not associated with increased survival. Patients died mostly of cardiovascular causes, similar to the general elderly population. Nephrectomy accelerated renal dysfunction, which was associated with cardiovascular mortality. Current paradigms suggest that there is over treatment of localized renal tumors, and further study will be required to evaluate the advisability of various options in patients with limited life expectancy. © 2010 American Cancer Society.