Background: Historically, there has been limited systemic therapy options for older adults with cancer attributed to underlying frailty, co-morbidities, poor functional status, and limited social supports. In the past decade, treatment for advanced NSCLC has changed with increasing availability of novel therapeutics associated with improved tolerability and efficacy, such as targeted therapy and immunotherapy. The study goal is to compare the difference in overall survival (OS) between younger adults and older adults with the introduction of novel therapeutic options. Methods: All patients with stage IV NSCLC referred to BC Cancer in 2009, 2011, 2015 and 2017 were included in the study. One-year time points were chosen based on molecular testing implementation and provincial formulary listing: baseline (2009), EGFR testing (2011), ALK testing (2015) and immunotherapy listing (2017). Age was categorized as younger (< 70 years) and older (≥70 years) adults. Baseline demographics, simplified comorbidity score (SCS ≥9 associated with poor prognosis), disease characteristics, and systemic therapy details (agent, duration, line of therapy) were collected retrospectively. Univariate analysis using X² and Fisher’s exact tests were used to compare age groups. OS was calculated using the Kaplan-Meier method and compared using the log-rank test. Results: 3325 patients with stage IV NSCLC were identified. Baseline characteristics for patients < 70 y; female 51%, non-squamous 62%, ECOG ≥2 50%, SCS ≥9 29% vs patients ≥70 y; female 49%, non-squamous 57%, ECOG ≥2 61%, SCS ≥9 58%. In the four time cohorts 2009/2011/2015/2017, systemic treatment was delivered to < 70 y 44/53/51/52 % vs ≥70 y 23/25/28/30 %. Median OS with BSC for < 70 y 3.1/2.8/2.8/2.5 m vs ≥70 y 3.8/3.3/3.4/3.1 m (p = 0.10). Median OS with systemic treatment for < 70 y 9.0/10.9/13.9/15.5 m (p < 0.001) vs ≥70 y 11.4/11.7/13.9/14.9 m (p < 0.001). Median OS by type of treatment BSC/chemotherapy only/targeted therapy/immunotherapy; < 70 y 2.8/8.9/21.4/20.2 m vs ≥70 y 3.1/10.1/21.5/20.1 m (p < 0.001). Conclusions: In this real-world retrospective review of patients with advanced NSCLC, there was an increased uptake of systemic therapy for both age groups with the introduction of novel therapeutics. Although there was a smaller proportion of older adults who received systemic therapy, those who received treatment had comparable OS to their young counterpart. The benefit of systemic therapy in both age groups was seen across the different types of treatments. This suggests with careful assessment and selection of appropriate candidates, older adults with advanced NSCLC should receive equitable access to systemic therapy.