Backgrounds <p>Current consensus guidelines lack robust evidence to advocate the optimal treatment approach for locoregional upper esophageal squamous cell carcinoma (L-UESCC). The purpose of this study was to conduct an in-depth investigation of the treatment patterns, outcomes, and prognostic factors among patients with L-UESCC.</p> Methods <p>Consecutive patients diagnosed with L-UESCC who underwent curative-intent treatment at two cancer centers from January 2013 to December 2018 were enrolled in this study. To compare overall survival (OS) and conduct prognostic analysis, we employed the Kaplan-Meier method, Cox regression models, and propensity score matching (PSM).</p> Results <p>In the entire cohort, 247 patients (64.2%) received definitive radiotherapy, whereas 138 patients (35.8%) underwent radical surgery. Multivariable Cox analysis revealed that T stage, N stage, and tumor length were independent predictors of OS. The Kaplan-Meier analysis demonstrated comparable median OS between the surgical and radiotherapy groups both before and after PSM adjustment. Before PSM, the median OS was 27.0 months in the surgical group and 29.0 months in the radiotherapy group (<i>P</i> = 0.48); after PSM, it was 23.0 and 30.0 months respectively (<i>P</i> = 0.38). Notably, the combination of chemotherapy with radiotherapy was associated with a significant survival benefit over radiotherapy monotherapy (median OS 36.0 versus 20.0 months, <i>P</i> = 0.005). In chemotherapy-naïve subgroups, surgery conferred a significant survival advantage over radiotherapy (<i>P</i> = 0.016), particularly in stage I-II (<i>P</i> = 0.003), but not in stage III (<i>P</i> = 0.54).</p> Conclusions <p>In patients with L-UESCC, surgical resection and definitive radiotherapy yielded similar OS results. Formulating personalized treatment strategies requires a multidisciplinary approach integrating systemic and local therapies.</p>