Objective To identify risk factors affecting survival outcomes in elderly patients (≥75 years) with early gastric cancer (EGC) and establish a predictive scoring system to aid in treatment decision‑making. Methods A retrospective analysis was conducted on EGC patients who underwent gastroscopy, endoscopic submucosal dissection (ESD), surgical resection, or conservative treatment at the Endoscopy Center of the First Affiliated Hospital of Dalian Medical University between January 2016 and January 2023. Clinical data were analyzed to identify prognostic risk factors and develop a predictive scoring system. The low‑risk group and high‑risk group were divided according to the scores, and the overall survival of patients who received different treatments were compared between two groups. Results A total of 180 patients were included, of whom 50 underwent ESD, 97 surgery, and 33 conservative treatment. Cox proportional risk model multivariate analysis identified three independent risk factors for survival: Charlson comorbidity index (CCI) >2 (P=0.014, HR=2.411, 95%CI: 1.196-4.864), prognostic nutritional index (PNI) ≤43.275 (P=0.011, HR=2.294, 95%CI: 1.205-4.365), and presence of multiple primary cancers (P=0.004, HR=2.797, 95%CI: 1.401-5.585). A weighted scoring system assigned 1 point each for CCI>2, PNI≤43.275, and multiple primary cancers. Receiver operating characteristic curve analysis determined an optimal cutoff score of 1.5 (P<0.001, area under curve=0.726). Patients were stratified into low-risk (score≤1) and high-risk (score≥2) groups. In the low-risk group, both ESD and surgical resection demonstrated superior overall survival compared with conservative treatment (95.1%, 87.5%, and 61.5%, respectively, P=0.003), with no significant difference between ESD and surgery (P=0.466). In the high-risk group, no statistically significant overall survival difference was observed among ESD, surgery, and conservative treatment (55.6%, 64.7%, and 30.0%, respectively, P=0.152). Conclusion CCI, PNI, and multiple primary cancers are critical prognostic factors for elderly EGC patients. The proposed scoring system (total 3 points) guides treatment decisions: ESD or surgery is recommended for low-risk patients (score≤1), while conservative management may benefit high-risk patients (score≥2).