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To investigate the relationship between tamoxifen-associated nonalcoholic fatty liver disease (NAFLD) and survival outcomes in patients with breast cancer.Patients with early-stage invasive breast cancer after curative resection from January 2009 to June 2011 were selected. A total of 646 patients who were treated with tamoxifen were included. Patients diagnosed with NAFLD on ultrasonography were classified into the NAFLD and non-NAFLD groups.The NAFLD group included 221 patients, and the non-NAFLD group included 425 patients. Patients in the NAFLD group had significantly higher body mass index than those in the non-NAFLD group (P < .001). Disease-free survival was significantly longer in the non-NAFLD group than the NAFLD group (P = .006). However, there were no significant statistical differences between these 2 groups on overall survival (P = .387). With regard to body mass index, total cholesterol, triglyceride, low-density lipoprotein cholesterol, alanine aminotransferase, and high-density lipoprotein cholesterol, the optimal cutoff points were 21.06, 4.28, 1.22, 3.13, 27.50 and 1.29, respectively, which can be identified as risk factors for distinguishing patients who developed NAFLD from those who did not (P < .05). Moreover, a risk score ≥ 3 indicated a high risk of development of NAFLD (odds ratio, 3.03; 95% confidence interval, 1.11–8.28; P = .037).NAFLD development had a negative effect on survival outcomes of patients with breast cancer. The risk score created ≥ 3 had a high-level risk of developing NAFLD, and it might be used for physicians to evaluate each patient and give instructive advice for further treatment.A total of 646 eligible patients with breast cancer were enrolled in our retrospective study at the Tumor Hospital of Harbin Medical University. We found that nonalcoholic fatty liver disease development might have a negative effect on disease-free survival of patients with early-stage breast cancer during the treatment with tamoxifen. The risk score we created might be used for treatment decision-making.