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Chemoradiotherapy (CRT) has been proposed as an alternative therapy to esophagectomy for esophageal cancer, because of its favorable survival rate and mild toxicity. However, no comparative studies of esophagectomy and CRT have been reported in patients with clinical stage I esophageal squamous cell carcinoma.A total of 54 patients with clinical stage I esophageal squamous cell carcinoma were treated with definitive CRT and 116 patients with esophagectomy at Osaka Medical Center for Cancer and Cardiovascular Diseases between 1995 and 2008, and were included in the analysis. Overall survival and recurrence rates were evaluated.Complete follow-up data were available for 169 of the 170 patients (99%). The median (range) observation period was 67 (10–171) months in the esophagectomy group and 30 (4–77) months in the CRT group (P<0.0001). The 1- and 3-year overall survival rates were 97.4% and 85.5%, respectively, in the esophagectomy group and 98.1% and 88.7%, respectively, in the CRT group (P=0.78). Cox proportional hazards modeling showed that the overall survival was comparable between the two groups after adjusting for age, sex, and tumor size. The hazard ratio of CRT for overall survival was 0.95 (95% confidence interval 0.37–2.47). The incidence of local recurrence, including metachronous esophageal cancer, was significantly higher in the CRT group than in the esophagectomy group (P<0.0001). Most local recurrences in the CRT group were intramucosal carcinomas, and were cured after salvage treatment, mainly using endoscopy.The overall survival rate of patients with clinical stage I esophageal cancer treated with CRT was comparable to that in those treated with esophagectomy, despite a high local recurrence rate. Locally recurrent carcinoma was endoscopically treatable in most patients, with no effect on overall survival. CRT seems to be a viable alternative to esophagectomy in patients with clinical stage I esophageal cancer.