Background <p>Elderly patients with limited-stage small cell lung cancer (LS-SCLC) are underrepresented in clinical trials, leading to a lack of evidence for optimal treatment strategies, especially for those with reduced tolerance for intensive concurrent chemoradiotherapy.</p> Methods <p>This retrospective cohort study analyzed 3,649 patients aged ≥75 years with unresectable LS-SCLC from the SEER database. Patients were categorized into active treatment (chemotherapy [C], radiotherapy [R], or both [C+R]) or palliative care groups. Propensity score matching (PSM) was used to minimize bias. Cancer-specific survival (CSS) and overall survival (OS) were compared, with subgroup analyses performed by T/N stage.</p> Results <p>Active treatment significantly was associated with median CSS (12 vs. 4 months, P&lt;0.001) and OS (11 vs. 4 months, P&lt;0.001) compared to palliative care. Among active treatments, C+R yielded the best outcomes (median CSS: 15 months). However, in early-stage disease (T1 or N0), radiotherapy alone (R) provided superior survival compared to chemotherapy alone (C) (T1: adjusted HR for CSS=0.554, P=0.001). Exploratory analysis indicated that for patients with lower disease burden (T1N0-2 or T2N0), survival with R alone was comparable to that with C+R (P&gt;0.05), while C+R was superior for more advanced stages.</p> Conclusion <p>Active treatment should be considered for elderly LS-SCLC patients. Treatment intensity should be individualized based on disease stage and patient fitness. For patients with early-stage disease (T1N0-2, T2N0), radiotherapy alone appears to be an effective option, offering survival comparable to combined therapy without the added toxicity of chemotherapy. These findings highlight the need for stage-specific, patient-centered strategies in this population.</p>