As populations age, increasing numbers of patients ≥75 years undergo endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), yet optimal management in the elderly remains uncertain. We evaluated real-world practices and long-term outcomes to inform treatment strategies.

This nationwide, multicenter, retrospective cohort study included 5,406 patients ≥75 years who underwent ESD for EGC between 2011 and 2020. We evaluated overall survival (OS), disease-specific survival (DSS), and recurrence according to age, eCura-based curability, and surgical status. Inverse probability of treatment weighting (IPTW) was applied to reduce selection bias. 

Curative resection (CR) was achieved in 76.2%. Over a mean follow-up of 80.4 months, 1,741 patients (32.2%) died. Curability significantly predicted OS and DSS at ages 75–79, but its impact for OS declined with age due to competing non-gastric cancer mortality, while DSS differences remained evident in patients ≥85 years. Among eCuraC-2 patients, the rate of additional gastrectomy decreased with age. Without additional surgery, OS was lower, particularly at ages 80–84; DSS did not differ by surgical status. After IPTW adjustment, additional gastrectomy improved DSS but not OS. Non-curative resection was associated with increased local and extragastric recurrence, whereas metachronous recurrence predominated after CR. Helicobacter pylori eradication rates decreased with age but remained stable in CR patients. 

ESD is effective in elderly EGC, but the clinical weight of curability lessens with age due to competing risks. Management should favor less-invasive, individualized strategies balancing oncologic control with comorbidities, nutritional and functional status, and patient preferences.