Abstract Introduction About 3–10% of breast cancer patients have distant metastases (Stage IV) at initial presentation; standard treatment (in the Netherlands) of these patients consists of palliative systemic therapy. However, retrospective studies have shown an improved survival in patients who received surgery for their primary tumor. The aim of this study was to assess characteristics associated with surgical treatment and to determine the impact on survival in women with stage IV breast cancer. Methods A cohort of women with a diagnosis of breast cancer and concomitant distant metastases was retrospectively studied. Patient characteristics, treatment and survival distilled from medical files were evaluated using univariate and multivariable analysis. Results Of 171 patients included in this analysis, 59 underwent surgery. In multivariable analysis lower age, no medication use, lower clinical T-stage and lower grade were associated with receiving surgery. In 21 of the 59 patients (35%) who received surgery it was unknown at the time of surgery that the patient had metastatic disease. Stratified survival analyses showed an association between surgery and improved survival for young patients (HR 0.3; p  = 0.02), without comorbidity (HR 0.4; p  = 0.002), with no medication use (HR 0.5; p  = 0.009), with a small tumor (HR 0.4; p  = 0.01), no regional lymph node involvement (HR 0.4; p  = 0.01), with positive Estrogen (HR 0.6; p  = 0.02) or Progesterone receptor (HR 0.4; p  = 0.03) and with only visceral metastases (HR 0.5; p  = 0.03). In multivariable analyses, younger patients and patients without comorbidity that received surgery had an increased survival (HR 0.3; p  = 0.03 and HR 0.5; p  = 0.03, respectively). Conclusion This study showed that patients with the most favorable profile receive local surgery and that a survival gain for operated patients was seen in young patients and in patients without comorbidity.