Background Elderly patients with stage I non-small-cell lung cancer are less likely to undergo curative treatment. However, the introduction of new treatment options such as stereotactic ablative radiotherapy (SABR) may improve treatment rates. We evaluated time trends in treatment patterns and survival in the entire Netherlands population for patients diagnosed between 2001 and 2009. Patients and methods Details of 4605 elderly Dutch patients were obtained from the Netherlands Cancer Registry, containing data on all cancer patients in a population of 16 million. Three consecutive time periods were studied: 2001–2003 (A, before SABR became available), 2004–2006 (B, increasing availability), and 2007–2009 (C, full availability). Results Between period A and C, there was a 7% absolute reduction in patients going untreated, corresponding to an 8-month improvement in median survival ( P < 0.001). Radiotherapy utilization increased from 31% to 38%, whereas surgical utilization remained constant (37%). Significant improvements in survival were observed in the radiotherapy subgroup ( P < 0.001) and surgery subgroup ( P < 0.001), not in patients going untreated. There was no evidence of stage migration. Conclusions Population-based increases in survival of elderly stage I lung cancer patients were seen between 2001 and 2009. The introduction of SABR correlated with a decline in the number of untreated patients.