Background: Surgery is the standard of care treatment for stage I NSCLC. Improvements in surgical techiques and perioperative care over time are developed to facilitate surgery for more patients. We assessed the factors influencing the use of surgery, the interaction of these with time and the impact on population survival. Methods: Patients enrolled into SEER between 2004 and 2012, aged at least 18 years with a first malignant primary stage I NSCLC were retrospectively assessed. Patients diagnosed on the basis of autopsy or death certificate only were excluded.Time was catergorized into three periods; 2004-6, 2007-9 and 2010-12. Age, gender, marital status, race, geographic location and time were all considered exposure variables influencing surgical use and were adjusted for using logistic regression. Impact of variables with time was assessed using interaction terms between them. The impact of time on population survival was assessed using cox regression. Results: Sex, age, marital status, race, location and time all significantly influenced whether surgery was performed (all p < 0.001). The proportion undergoing sugery declined from 68.0% during 2004-6 to 62.7% during 2010-12 (adjusted HR 0.88, p < 0.001 between subsequent periods). Patients were less likely to have surgery with increasing age (adjusted HR 0.94 per year, p < 0.001) and if they were Black or Hispanic (adjusted HR 0.58, p < 0.001 and 0.87, p = 0.008 repectively) relative to Non-Hispanic Whites. There were significant differences with location. Relative to San-Fransisco-Oakland, the greatest adjusted differences were between Louisiana (HR 0.51, p < 0.001) and New Jersey (HR 1.57, p < 0.001). Age significantly interacted with time (p = 0.007). Surgical use declined from 75.5% during 2004-6 to 71.5% during 2010-12 when less than 75 years. For those older, the decline was greater, 55.3% to 46.5%. The risk of death declined with time (adjusted HR 0.94, p < 0.001 between periods). Conclusions: Since 2004, the use of surgery for stage I NSCLC has declined and done more so with increasing age. Despite this overall population survival has improved.