Achalasia Cardia and Oesophagal Cancer: Gastroenterology | September 2026

Introduction:

Achalasia has long been linked to oesophagal cancer, particularly oesophagal squamous cell carcinoma (ESCC). This large Nordic study strengthens evidence that achalasia independently increases ESCC risk, while its association with oesophagal adenocarcinoma (EAC) appears largely related to GERD.

Why was this study needed?

Chronic food stasis may cause inflammation, epithelial proliferation and dysplasia, promoting ESCC.

Previous studies were small and inadequately adjusted for smoking and alcohol.

Whether achalasia independently increases EAC risk remained uncertain.

Study Design:

Using registries from five Nordic countries (1987–2023), investigators compared more than 35,000 esophageal cancer cases with 355,000 controls, accounting for smoking, alcohol and GERD.

Achalasia and Squamous Cell Carcinoma: A Strong Association

Achalasia was strongly associated with ESCC, independent of smoking and alcohol.

Achalasia → food stasis → chronic inflammation → dysplasia → ESCC

The association was stronger after myotomy or dilation, but this does not imply that treatment causes cancer; disease duration and severity may contribute.

What About Esophageal Adenocarcinoma?

The association between achalasia and EAC weakened substantially after accounting for GERD, suggesting:

Achalasia/treatment → reflux and acid exposure → potential EAC risk

Thus, a strong independent relationship with EAC is less certain.

The Key Message: ESCC and EAC Should Not Be Considered Together

ESCC: Strong association, likely related to chronic stasis and inflammation.

EAC: Weaker association, largely related to GERD.

Does This Mean Every Patient With Achalasia Needs Surveillance Endoscopy?

Not yet. The study does not establish that routine surveillance improves outcomes. However, new or progressive dysphagia, weight loss, anaemia, bleeding or unexplained symptom changes should prompt endoscopic evaluation.

Clinical Impact:

Achalasia should be recognised as an important risk condition for ESCC, and changing symptoms should not automatically be attributed to the underlying motility disorder.

Bottom Line:

Achalasia is strongly associated with ESCC, whereas its relationship with EAC appears largely mediated by GERD. Routine surveillance is not yet established, but new or changing symptoms warrant prompt investigation for oesophagal cancer.