Achalasia is a rare esophageal motor disorder with an estimated incidence between 6.5 to 15.7 per 100,000. These patients find it difficult to pass bolus of food, as the proximal and mid-esophagus squeeze in more or less synchrony, rather than in inferred waves toward the distal esophagus. Therefore, food stasis is created by first laryngeal incoordination and the second intestine lengthening with subsequent failed coordination, and the esophageal lumen may then be obstructed by bolus residue. Dysphagia with regurgitation, chest pain, heartburn, and weight loss are other symptoms that could result from this pathology. In fact, the current approaches are to provide symptomatic relief only, rather than delineate the specific etiologies for the cause of achalasia disease.
An increased risk of developing esophageal cancer (EC), in particular, esophageal squamous cell carcinoma (ESCC) upstages in achalasia patients might respectively occur. Recently, investors may have observed a higher exposure due to certain alleged meta-analyses suggesting EC incidence rates exceeding 3.3 in 1000 achalasia patients. Modern treatments for achalasia, such as these, may improve esophageal transit by reducing the resting pressure of the lower esophageal sphincter (LES). However, patients may still suffer from ongoing or recurring esophageal distention, retained food, and possibly increased risks of EC even after treatment.
This study was conducted with the aim of analyzing the retrospective cohort. Patients with achalasia who were diagnosed at the Erasmus University Medical Center or referred to the tertiary hospital for therapy and monitoring between January 1, 1980, and May 31, 2024, were found through electronic database search. To account for evolving diagnosis criteria over the course of this long study period, researchers adapted the approaches accordingly. Therefore, the diagnosis of achalasia was constantly based on clinical symptoms, barium esophagram results, esophageal manometry, and upper endoscopy findings. The research followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
The study involved 234 people with achalasia (median [interquartile range (IQR)] age at diagnosis, 45 [32-63] years; 117 [50%] male), with a median follow-up time of 13 (4-22) years. Out of the 29 patients (12%), there were 24 patients (10%) who had EC, and the rest had the infection. This research was conducted on 207 patients with more than one endoscopy bout and ages between 32 and 60 years (median [IQR] age at diagnosis, 43 [32-60] years; 104 [50%] male). The patients in this section had a median time of 16 (9-26) years of follow-up. As for those patients, esophageal candida was found to be a risk factor associated with 8.24 (95% CI, 2.97-22.89) adjusted hazard ratio, a conclusion that was reached independently of such factors as age at diagnosis and gender. Besides, the male patient had a higher exposure rate (adjusted hazard ratio [AHR], 3.34 [95% confidence interval (CI), 1.08-10.36]) whereas age at diagnosis (AHR, 1.06 [95% CI, 1.03-1.10]) was associated with EC risk.Â
Moreover, the limitation of the current study may be attributed to several factors. First, the one-center study was conducted for 42 years with a large number of people diagnosed with achalasia. Data referring to the type of achalasia was not available for most patients diagnosed with this disorder. The specific type of achalasia is less important, but loss of esophageal activity may worsen Candida during disease progression. Second, some well-known risk factors associated with ESCC like alcohol intake, smoking, and nitrosamine consumption were not included in this study as retrospective data were not available for all patients.
This retrospective cohort study revealed a high prevalence of esophageal candida among the patients who have achalasia. Also, the study showed that previous candida infection was one of the issues that led to EC risk. This study emphasizes the importance of efficiently reporting esophageal candida in patients being monitored for achalasia. Besides, it recommends that patients diagnosed with esophageal candida infection should be regularly checked with endoscopy for early detection of EC.
Reference: Guo X, Lam SY, Janmaat VT, et al. Esophageal Candida Infection and Esophageal Cancer Risk in Patients With Achalasia. JAMA Netw Open. 2025;8(1):e2454685. doi:10.1001/jamanetworkopen.2024.54685
