S1007 Risk Factors and Predictors for Esophageal Cancer Among Patients With Achalasia

Introduction: Despite the correlation between achalasia and an increased risk of esophageal cancer (EC), standardized guidelines for routine endoscopic surveillance are lacking. This study aims to identify risk factors in achalasia patients that may predispose them to developing esophageal cancer, potentially leading to targeted endoscopic surveillance. Methods: This retrospective cohort study utilized the TriNetX Analytics Platform to analyze achalasia patients aged ≥18 years between 2000 and 2024. Patients with International Classification of Diseases-10 codes for achalasia (K22.0) and EC (C15.0) were used to identify the study cohort. Odds ratios (OR) were calculated with standard methods, while Cox proportional hazards (CPH) models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for potential confounders. Time to event was measured from achalasia diagnosis to esophageal cancer diagnosis or last follow-up. Backward stepwise selection optimized the model. Patients without EC required ≥1 year of follow-up. HR and OR results were then compared. Results: Out of 62,609 patients with achalasia, 1,133 (1.81%) were diagnosed with EC, compared to a 0.072% prevalence in the non-achalasia population. Of the achalasia patients with EC, 506 had an achalasia diagnosis that preceded their EC diagnosis and were included in the final analysis. Excluding 130 EC cases diagnosed within 1 month of achalasia, the median time to EC diagnosis was 296 days. Logistic regression showed strong associations with male sex (OR 2.5; 95% CI 2.1-3.0), White race (OR 1.5, 95% CI 1.2-1.8), gastroesophageal reflux disease (GERD) (OR 2.5; 95% CI 2.1-3.0), Barrett’s esophagus (BE) (OR 8.0; 95% CI 6.2-10), esophageal ulcer (OR 9.5; 95% CI 7.2-13), smoking (OR 3.2; 95% CI 2.7-3.9), and alcohol use (OR 3.6; 95% CI 2.6-4.9) (all P < 0.0001). In the CPH model, older age (HR = 1.02; 95% CI 1.01-1.03), and elevated creatinine (HR = 1.3; 95% CI 1.1-1.6) were associated with an increased risk of EC. Interestingly, White race showed higher odds of EC (OR 1.5), but reduced hazard over time (HR 0.57; P < 0.0001). Obstruction also showed high odds (OR 5.6) but lower time-based risk (HR 1.3). Conclusion: Male sex, White race, and history of GERD, BE, esophageal obstruction or ulcer, smoking, and alcohol use are associated with increased EC risk. Given a median EC diagnosis time of 296 days, annual screening esophagogastroduodenoscopy appears reasonable.