Background <p>People over 60 years old had higher cancer morbidity and mortality. We aimed to explore the factors associated with the choice of first treatment institution among elderly cancer patients in China and to provide evidence for the development of healthcare policies.</p> Methods <p>We designed a cross-sectional study. 9 hospitals in Shandong Province of China were selected as sample institutions and a questionnaire survey was conducted on cancer patients from these hospitals. The chi-square test and binary logistic regression were used to assess the factors that influence elderly patients’ choice of first treatment institution.</p> Results <p>537 respondents(97.64%) were included in this study. Of the 537 respondents, 168 (31.28%)chose a county hospital and 369(68.72%) chose a provincial or municipal hospital for their first treatment institution. The high level of medical care is the main reason for the choice of the first treatment institution for cancer patients. Patients in the 60–69 (<i>p</i> = 0.002, OR = 3.392) and 70–79 (<i>p</i> = 0.015, OR = 2.571) age groups were more likely to choose provincial and municipal hospitals for their first treatment institution. Those in the central region(<i>p</i> = 0.001, OR = 0.204), with stage I cancer(<i>p</i> = 0.001, OR = 0.168),annual household income ¥10,000-¥50,000(<i>p</i> = 0.005, OR = 0.327), and unmarried(<i>p</i> = 0.005, OR = 0.344) patients were more likely to choose county hospitals.</p> Conclusions <p>Elderly cancer patients had a significantly higher proportion of attending high-level hospitals. Improving the standard of care in county hospitals could effectively guide patients to seek care and reduce the pressure on high-level hospitals.</p>