BACKGROUND: A subset of patients who present with metastatic solid tumors never receive anticancer therapy. Reasons may include poor functional status, comorbidities, and patient preference. To the authors' knowledge, the prevalence and characteristics of this population have not previously been described. METHODS: The National Cancer Data Base was queried for patients diagnosed with metastatic (stage IV according to the American Joint Committee on Cancer) solid tumors (including those of the breast, cervix, colon, and kidney; small cell and nonsmall cell lung cancer NSCLC; and tumors of the prostate, rectum, and uterus) who received neither radiotherapy nor systemic therapy. Log‐binomial regression analysis was used to estimate prevalence ratios (PRs) for the percentage of untreated to treated patients with stage IV cancer. RESULTS: Between 2000 and 2008, 773,233 patients with stage IV cancer were identified, 159,284 of whom (20.6%; 95% confidence interval, 20.5%‐20.7%) received no anticancer therapy. Patients with NSCLC accounted for 55% of the untreated population. Patients with cancers of the kidney and lung had the highest rates of no treatment at 25.5% and 24.0%, respectively, whereas patients with prostate cancer had the lowest rate of no treatment at 11.1%. Across all cancer types, older age (PR range, 1.37‐1.49; all P < .001), black race (PR range, 1.05‐1.32; all P < .001), lack of medical insurance (PR range, 1.47‐2.46; all P < .001), and lower income (except for cancer of the uterus; PR range, 0.91‐0.98 for every $10,000‐increase in income all P < .001) were associated with a lack of treatment. CONCLUSIONS: Approximately 20% of patients who present with stage IV solid tumors do not receive anticancer therapy. Although there are likely multiple reasons for this lack of treatment, including appropriate indications, these findings have potential implications with regard to health care policy and access to care. Cancer 2012. © 2012 American Cancer Society. Approximately 20% of patients who present with American Joint Committee on Cancer stage IV solid tumors do not receive anticancer therapy. Although it is likely that there are multiple reasons for a lack of treatment, the finding of potential disparities has implications with regard to health care policy and access to care.