Prior Esophageal Candida Infection Raises Esophageal Cancer Risk in Achalasia Patients: JAMA

"The results emphasize the need to enhance monitoring strategies for individuals with achalasia," the researchers wrote in JAMA Network Open. 

Achalasia, a rare esophageal motility disorder characterized by difficulty in swallowing and impaired relaxation of the lower esophageal sphincter, has long been associated with a heightened susceptibility to complications such as esophageal infections and cancer. However, the role of specific factors, including fungal infections like Candida, in influencing cancer risk has remained unclear until now. To fill this knowledge gap, Xiaopei Guo, Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues aimed to examine the prevalence of esophageal Candida infection in patients with achalasia and evaluate its association with the risk of developing esophageal cancer in this population.

For this purpose, the researchers conducted a retrospective cohort study involving patients with achalasia diagnosed or referred to Erasmus University Medical Center, Rotterdam, between January 1, 1980, and May 31, 2024. Data analysis occurred from August 1 to October 31, 2024. The study examined the prevalence of esophageal Candida infection and its association with esophageal cancer risk using time-dependent Cox proportional hazards regression models, with esophageal Candida infection as a time-varying covariate, adjusted for age at diagnosis and sex.

The following were the key findings of the study:

• The study included 234 patients with achalasia (median age at diagnosis: 45 years; 50% male) and a median follow-up time of 13 years.
• Esophageal Candida infection was identified in 12% of the patients.
• Esophageal cancer was observed in 10% of the patients.
• Risk analysis was conducted for 207 patients with two or more consecutive endoscopy follow-up visits (median age at diagnosis: 43 years; 50% male) and a median follow-up time of 16 years.
• Esophageal Candida infection was independently associated with an increased risk of EC (adjusted hazard ratio [AHR]: 8.24).
• Age at diagnosis was linked to higher EC risk (AHR: 1.06).
• Male sex was independently associated with greater EC risk (AHR: 3.34).

In conclusion, the authors highlight a notable prevalence of esophageal Candida infection among patients with achalasia and identify a significant association between prior Candida infection and an increased risk of esophageal cancer. These findings underscore the importance of enhanced documentation and monitoring of esophageal Candida infections during achalasia surveillance.

The authors recommend that patients diagnosed with esophageal Candida infection undergo regular surveillance endoscopy to facilitate the early detection of EC and improve clinical outcomes in this high-risk population.

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