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Background: Recent studies have suggested that more frequent post-operative surveillance imaging via computed tomography (CT) following lung cancer resection may not improve outcomes. We sought to validate these findings using a uniquely compiled dataset from the Veterans Health Administration, the largest integrated healthcare system in the United States.Methods: We performed a retrospective cohort study of Veterans with pathologic stage I non-small cell lung cancer (NSCLC) receiving surgery (2006-2016). We assessed the relationship between surveillance frequency (chest CT scans within 2 years after surgery) and recurrence-free survival and overall survival.Results: Among 6171 patients, 3047 (49.4%) and 3124 (50.6%) underwent low-frequency (<2 scans/year; every 6-12 months) and high-frequency (≥2 scans/year; every 3-6 months) surveillance, respectively. Factors associated with high-frequency surveillance included being a former smoker (vs. current, adjusted odds ratio [aOR] 1.18, 95% CI 1.05-1.33), receiving a wedge resection (vs. lobectomy, aOR 1.21, 95% CI 1.05-1.39), and having follow-up with an oncologist (aOR 1.58, 95% CI 1.42-1.77), whereas African American race was associated with low-frequency surveillance (vs. White race, aOR 0.64, 95% CI 0.54-0.75). With a median (IQR) follow-up of 7.3 (3.4-12.5) years, recurrence was detected in 1360 (22.0%) patients. High-frequency surveillance was not associated with longer recurrence-free survival (adjusted hazard ratio [aHR], 0.93; 95% CI, 0.83-1.04, p = 0.22) or overall survival (aHR, 1.04; 95% CI, 0.96-1.12, p = 0.35).Conclusions: We found that high-frequency surveillance does not improve outcomes in surgically treated stage I NSCLC. Future lung cancer treatment guidelines should consider less frequent surveillance imaging in patients with stage I disease. [ABSTRACT FROM AUTHOR]