Introduction Achalasia is a chronic oesophagal motility disorder characterised by impaired lower oesophagal sphincter relaxation and food stasis. Long-standing stasis, bacterial overgrowth, and chronic inflammation have raised concerns about an increased risk of oesophagal cancer, particularly squamous cell carcinoma.
Introduction
Achalasia is a chronic oesophagal motility disorder characterised by impaired lower oesophagal sphincter relaxation and food stasis. Long-standing stasis, bacterial overgrowth, and chronic inflammation have raised concerns about an increased risk of oesophagal cancer, particularly squamous cell carcinoma. However, previous studies were small and lacked adjustment for key confounders such as smoking and alcohol. The association with adenocarcinoma has remained even more uncertain.
Problem Statement
Clinicians often struggle with two key questions:
👉 Does achalasia independently increase the risk of oesophagal cancer?
👉 Should these patients undergo structured cancer surveillance?
Existing data have been limited by small sample sizes and inadequate adjustment for major risk factors. In particular, whether achalasia contributes to adenocarcinoma risk beyond associated gastroesophageal reflux remains unclear.
Summary
This large multinational population-based study from Nordic countries provides robust evidence addressing these gaps.
Achalasia was found to be strongly associated with oesophagal squamous cell carcinoma, with nearly a 9-fold increased risk, even after adjusting for smoking and alcohol. This confirms that achalasia itself is an independent risk factor for squamous malignancy.
In contrast, achalasia showed only a modest association with oesophagal adenocarcinoma, which became non-significant after adjusting for GERD. This suggests that the observed risk of adenocarcinoma is largely driven by reflux rather than achalasia per se.
Interestingly, patients who had undergone treatment such as myotomy or dilation had an even higher risk of squamous cell carcinoma, likely reflecting longer disease duration and persistent mucosal exposure to stasis-related injury.
Overall, the study clearly differentiates cancer risk patterns in achalasia:
high and independent risk for squamous cell carcinoma
Limited and GERD-mediated risk for adenocarcinoma
These findings reinforce the need for heightened awareness of squamous cancer risk in long-standing achalasia while suggesting a more nuanced approach toward adenocarcinoma surveillance.
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