【】 Objective? We aimed to create a scoring system to guide treatment options for gastric cancer patients aged≥75 years by searching for risk factors that affect the survival and prognosis. Methods? The clinical data of 180 patients with early gastric cancer aged ≥ 75 years who received gastroscopy, ESD or surgery at the Endoscopy Center of the First Affiliated Hospital of Dalian Medical University from January 2016 to January 2023 were collected.Compare the short-term complications and long-term survival outcomes of the three groups of patients under different treatment methods and find risk factors that affect patient prognosis, and create a predictive scoring system based on the scores of risk factors. Results? Among patients in the ESD group, surgery group, and conservative treatment group, CCI(P=0.014, 95%CI 1.196-4.864,HR 2.411), PNI(P=0.011, 95%CI 1.205-4.365, HR 2.294), combined multiple primary cancers(P=0.004, 95%CI 1.401-5.585,HR 2.797) are risk factors affecting survival prognosis.CCI>2, PNI≤43.275, and combined multiple primary cancers are each assigned 1 point. The optimal cutoff value for determining the score system through ROC curve is 1.5(P<0.001, AUC=0.726). The patients were divided into low-risk group and high-risk group based on score≤1 and score≥2, the overall survival(OS) of patients who received different treatments were compared between two groups. In the low-risk group, there was a statistically significant difference in overall survival(OS) between ESD, surgery and conservative treatment(P=0.003), but there was no statistically significant difference between ESD and surgery(P=0.466). In the high-risk group, there was no statistically significant difference in overall survival(OS) between ESD, surgery, and conservative treatment(P=0.152). The indicators in this scoring system(CCI, PNI, multiple primary cancers) can guide the choice of patients’ treatments. Conclusion? When the score is ≤1 point, ESD or surgery is recommended; when the score is ≥2 points, conservative treatment is a better choice which can relieve patients’ unnecessary pain.