Abstract: Background: China accounts for approximately 50% of the global incidence of esophageal cancer (EC). There are two significant features of the distribution of EC patients in China: geographical concentration and a higher incidence of rural patients. Most EC patients present in the early stages at diagnosis and undergo a prolonged treatment process. This study aims to focus on patients with advanced esophageal cancer in the hospitals from high-incidence areas and county or prefecture-level cities to understand the general characteristics and treatment processes of these patients. Methods: This retrospective observational study collected electronic medical records of patients with advanced esophageal cancer who had their first treatment records between January 1, 2022, and June 1, 2024, from six medical centers. Descriptive analysis methods were used to statistically analyze the clinical characteristics and treatment plans of the patients. Results: 322 EC patients were included, of whom 230 were male (71.4%). The median age was 68.4 years. 315 patients (97.8%) presented with esophageal cancer-specific symptoms, and 301 patients (93.6%) were diagnosed through endoscopy. The predominant pathological type was esophageal squamous cell carcinoma, with a total of 291 cases (90.4%). 216 patients (67.1%) with advanced disease progressed from locally advanced stages. 126 patients (39.1%) had undergone surgical treatment, of whom 123 (97.5%) achieved R0 resection, and 71 (56.3%) received perioperative treatment. A total of 116 patients (36.0%) had received definitive chemoradiotherapy. The median time from surgery or radiotherapy to advanced disease is 14.1 months. Lymph node metastasis was observed in 250 patients (77.6%) in the advanced stage, with mediastinal metastasis being the most common type. Organ metastasis occurred in 176 patients (54.7%), with the most common sites being the lungs, liver, and bones. 257 patients (79.8%) were from the same county or city, 251 patients (77.9%) had resident medical insurance, and 301 patients (93.5%) initiated advanced treatment at the hospital where they diagnosis. Conclusion: This study indicate that EC patients have unique epidemiological and clinical pathological characteristics in high-incidence areas in China, providing important reference for further exploration of the disease.