Objective <p>Ablation (AL) and laser excision (LE) have shown broad application prospects in treating pulmonary malignant tumor (PMT). This study is the first to directly explore the differences in outcomes between AL and LE in treating patients with PMT at III–IV stages.</p> Methods <p>The study included 157 PMT patients from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was used to minimize the impact of clinical feature imbalances on confounding factors between the AL and LE groups. Kaplan-Meier curves, cumulative incidence function, univariable Cox regression analysis, and multivariable Cox regression analysis were used to explore prognostic factors for overall survival (OS)/cancer-specific survival (CSS).</p> Results <p>Before PSM, a trend was observed indicating poorer OS, crude CSS, and net CSS in the AL group compared to the LE group (<i>p</i> = 0.019–0.071). After PSM, the LE group demonstrated significantly longer OS (median: 18.00 months) than the AL group (median: 13.00 months; <i>p</i> = 0.048). Similarly, crude CSS (<i>p</i> = 0.017) and net CSS (<i>p</i> = 0.028) were superior in the LE group. In the post-PSM multivariable analysis, LE remained associated with improved OS (adjusted HR = 0.52 [95% CI 0.32–0.86]; <i>p</i> = 0.011). The findings were robust across multiple sensitivity analyses: the change-in-estimate analysis showed ≤ 6.3% variation in the treatment HR upon omission of any single covariate; a 60-day landmark analysis yielded a consistent HR (0.56 [95% CI 0.34–0.93]; <i>p</i> = 0.025); and, in the full cohort, IPTW and propensity-score stratification produced comparable HRs (0.63 [95% CI 0.39–1.02], <i>p</i> = 0.060; and 0.53 [95% CI 0.32–0.89], <i>p</i> = 0.016). Stage IV remained an independent predictor of worse OS compared to stage III (HR = 3.35 [95% CI 1.99–5.65]; <i>p</i> &lt; 0.001).</p> Conclusion <p>LE may offer a better prognosis than AL in treating patients with advanced-stage PMTs.</p>