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The study objective was to evaluate trends in the use of surgical therapy for patients with early-stage (IA-IIA) non–small cell lung cancer when stereotactic ablative radiotherapy was introduced in the United States.Patients with clinical stage IA to IIA non–small cell lung cancer diagnosed from January 1, 2004, to December 31, 2013, were identified in the National Cancer Data Base. The Cochran–Armitage trend test was used to evaluate the change in the proportion of patients undergoing surgery over time. Logistic regression was used to identify the factors associated with receipt of surgery compared with radiation.Of 200,404 eligible patients from 1235 hospitals, 79.8% (n = 159,943) underwent surgery. For all stages combined, the rate of surgery decreased from 83.9% in 2004 to 75.1% in 2013 (P < .0001), with the largest decrease seen in patients with stage IIA: stage IA 86.5% to 77.1% (P < .0001); stage IB 79.6% to 71.5% (P < .0001); and stage IIA 94.7% to 70.3% (P < .001). Patients were more likely to undergo surgery if they were younger and white, had higher income, or had private or Medicare insurance.From 2004 to 2013, there was an overall decrease in the use of surgical therapy for lung cancer in early-stage disease. Because resection remains the standard of care for most patients with early-stage disease, these data suggest a potentially significant quality gap in the treatment of patients with non–small cell lung cancer.