To find clinical factors related to administration of substandard treatment in older patients with head and neck cancer.Historic cohort.Patients of 70 years of age of older with diagnosis of resectable head and neck cancer were included. Treatment offered to patients was classified as standard or substandard by experienced surgeons. Relation of age, clinical stage, comorbidities, performance status, and treatment with substandard treatment was explored. The effect of substandard treatment on survival was assessed.Three hundred twelve patients were included. Substandard treatment was offered to 19.9% of patients. Associated factors related to selection of substandard treatment were higher age, oro/hypopharynx tumor site, severe comorbidity, advanced clinical stage, and low Karnofsky Index. Patients submitted to substandard treatment had lower overall and cancer-specific survival (45.9% vs. 19.9% and 63.0% vs. 33.1%, respectively).Selection of substandard treatment decreases overall and cancer-specific survival. Selecting substandard treatment for reasons such as chronologic age, tumor site, or moderate or mild comorbidities worsen patient prognosis.