Objectives Comparative studies of survival between stereotactic body radiation therapy (SBRT) and surgery have been limited by lack of comparisons of recurrence patterns between matched cohorts in non-small cell lung cancer (NSCLC). Methods All patients undergoing treatment with surgery or SBRT for clinical stage I NSCLC between June 2004 and December 2010 were reviewed. Age, tumor characteristics, comorbidity score, pulmonary function, overall survival (OS), disease-free survival (DFS), and recurrence data were collected and propensity matching performed. Results The mean age for surgery (n = 458) was 65.8 ± 10.5 versus 74.4 ± 9.4 for SBRT (n = 151) (P <.0001). For the entire surgical cohort, 3-year OS was 78% and DFS was 72%. For the entire SBRT cohort, 3-year OS was 47% and DFS was 42%. The overall local recurrence rate for surgery was 2.6%. The overall local recurrence rate for SBRT was 10.7%. A propensity-matched comparison based on age, tumor size, Adult Comorbidity Evaluation comorbidity score, forced expiratory volume in the first second of expiration, and tumor location resulted in 56 matched pairs. The 3-year OS was 52% versus 68% for SBRT and surgery (P =.05); DFS was 47% versus 65% (P =.01). At 3 years, local recurrence-free survival was 90% versus 92% for SBRT and surgery (P =.07). Conclusions Although surgical resection seems to result in better OS and DFS versus SBRT, matching these disparate cohorts of patients remains challenging. Participation in clinical trials is essential to define the indications and relative efficacy of surgery and radiation therapy in a high-risk population with stage I NSCLC.