The Effects of Surgical and Endoscopic Esophageal Myotomy Versus Nonmyotomy Treatments on the Risk of Esophageal Cancer Development in Patients With Achalasia

BACKGROUND: Esophageal cancer is an uncommon but devastating complication of achalasia. There is very limited information in the literature about the effect of any type of treatment on the risk of cancer development in patients with achalasia. The aim of the study was to compare the effects of surgical and endoscopic myotomy (SEM) versus non-SEM on the esophageal cancer risk of patients with achalasia. METHODS: We performed a population-based analysis using the TriNetX Global Collaborative Network, which provides real-time access to deidentified electronic health records (EHRs) from 146 health care organizations across the United States and 16 other countries. Adult patients (≥18 y) diagnosed with achalasia between 2004 and 2024 were included. In addition, patients with achalasia who developed esophageal cancer were identified. Patients were grouped by treatment: surgery or endoscopic myotomy versus medical or no therapy. To ensure a proper timeline, the esophageal cancer had to be documented only after the diagnosis of achalasia was established. Multivariable logistic regression was used to evaluate associations with cancer risk. Kaplan-Meier analysis compared the time from achalasia diagnosis to cancer development. RESULTS: Among 50,365 patients with achalasia, 8015 (15.9%) underwent surgical or endoscopic myotomy (SEM). Esophageal cancer occurred in 394 patients (0.78%); of those, 46 (0.57%) were in the SEM group, and 348 (0.82%) were in the non-SEM group. SEM was independently associated with a significant reduction in the risk of esophageal cancer (OR=2.49, 95% CI: 1.93-3.26, P<0.0001) and longer time to diagnosis (586 vs. 92 d, log-rank P=0.0014; HR=0.609, 95% CI: 0.447-0.829). Male sex (OR=2.31, 95% CI: 2.00-2.78) and nicotine dependence (OR=8.77, 95% CI: 7.25-10.43) were significant predictors of increased esophageal cancer risk in patients with achalasia. CONCLUSIONS: Surgical or endoscopic myotomy treatment for achalasia is independently associated with reduced risk and delayed onset of esophageal cancer compared with non-SEM treatment, supporting a potential protective effect.