Background <p>Studies regarding whether elderly patients (≥ 70 years) with T1b-T2N + esophageal cancer (EC) could benefit from neoadjuvant therapy (NAT) are lacking. Therefore, the aim of this study was to investigate the impact of NAT on the outcomes of elderly patients with T1b-T2N + EC.</p> Methods <p>Patients aged ≥ 70 years with stage T1b-T2N + M0 EC who underwent surgery were identified within the SEER database (2004–2019). Propensity score matching (PSM) was used to equalize differences between the NAT and non-NAT groups. Kaplan-Meier analysis and Cox proportional hazards models were used to assess the differences between groups in terms of overall survival (OS) and cancer-specific survival (CSS).</p> Results <p>After PSM, 180 elderly patients with T1b-T2N + EC were included, which achieved a balanced distribution between groups. The 3-year OS (55.6% vs. 33.1%, <i>P</i> = 0.013) and CSS (62.3% vs. 39.0%, <i>P</i> = 0.012) rates of the NAT group were significantly better than those of the non-NAT group. Multivariate Cox regression analysis demonstrated that NAT was an independent protective prognostic factor for OS (HR, 0.650; 95% CI 0.462–0.915; <i>P</i> = 0.014) and CSS (HR, 0.591; 95% CI 0.369–0.883; <i>P</i> = 0.010). In addition, subgroup analysis revealed NAT was associated with survival benefits in several subgroups, including females, white race, those with middle/upper esophageal tumors, squamous cell carcinoma, tumor size &lt; 3&#xa0;cm, examined lymph nodes &lt; 15, and T2-stage disease.</p> Conclusion <p>Compared with upfront surgery, NAT was associated with a survival benefit in elderly patients with stage T1b-2&#xa0;N + EC.</p>