Esophageal Candida Infection and Esophageal Cancer Risk in Patients With Achalasia

IMPORTANCE Patients with achalasia face a higher risk of developing esophageal cancer (EC), but
the surveillance strategies for these patients remain controversial due to the long disease duration
and the lack of identified risk factors.
OBJECTIVE To investigate the prevalence of esophageal Candida infection among patients with
achalasia and to assess the association of Candida infection with EC risk within this population.
DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with
achalasia diagnosed at or referred for treatment and monitoring to the Erasmus University Medical
Center in Rotterdam, the Netherlands, between January 1, 1980, and May 31, 2024. Data analysis was
conducted from August 1 to October 31, 2024.
EXPOSURE Esophageal Candida infection.
MAIN OUTCOMES AND MEASURES The primary outcomes were the prevalence of esophageal
Candida infection and its association with EC development among patients with achalasia.
Associations were estimated using time-dependent Cox proportional hazards regression models
with esophageal Candida infection as a time-varying covariate, adjusting for age at diagnosis and sex.
RESULTS This study included 234 patients with achalasia (median [IQR] age at diagnosis, 45 [32-63]
years; 117 [50%] male), with a median follow-up time of 13 (4-22) years. Esophageal Candida infection
was identified in 29 patients (12%), while EC was observed in 24 patients (10%). Esophageal cancer
risk analysis was performed for 207 patients with 2 or more consecutive endoscopy follow-up visits
(median [IQR] age at diagnosis, 43 [32-60] years; 104 [50%] male). The median (IQR) follow-up time
for this subgroup was 16 (9-26) years. Among these patients, esophageal Candida infection was
independently associated with an increased risk of EC (adjusted hazard ratio [AHR], 8.24 [95% CI,
2.97-22.89]). Additionally, age at diagnosis (AHR, 1.06 [95% CI, 1.03-1.10]) and male sex (AHR, 3.34
[95% CI, 1.08-10.36]) were independently associated with EC risk.
CONCLUSIONS AND RELEVANCE This retrospective cohort study found that prior esophageal
Candida infection, older age at diagnosis, and male sex were associated with increased risk of EC
among patients with achalasia. These findings provide an important rationale for optimizing the
monitoring of patients with achalasia.