2024 Top Story in Gastroenterology: Risk of Esophageal Adenocarcinoma After H pylori Eradication Treatment

Esophageal cancer is the sixth most common cause of cancer death, with a marked increase in esophageal adenocarcinoma (EAC) over the past 4 decades. It has been hypothesized that the increased incidence of EAC is because of decreased prevalence of Helicobacter pylori infection as this infection is associated with a decreased risk of EAC. This could be owing to its ability to suppress gastric acid production. Testing for and treating H pylori infection has been the common clinical practice in order to prevent its deleterious effects, including peptic ulcer disease, gastric atrophy, and gastric cancer. This study investigated whether treatment of H pylori increases the risk of EAC.¹

Wiklund et al performed a multinational Nordic population–based cohort study of all individuals older than 18 years who received H pylori eradication treatment consisting of a minimum 7-day regimen with a proton pump inhibitor plus at least two of the following antibiotics: amoxicillin, clarithromycin, and metronidazole. The study involved 661,987 participants contributing 5,495,552 person-years with a median follow-up duration of 7.8 years after eradication treatment. Based on a total of 550 cases of EAC, the standardized incidence ratio (SIR) of observed cases among persons receiving anti–H pylori therapy to expected cases (derived from contextualized incidence in the entire Nordic population) was not increased (SIR, 0.89; 95% CI, 0.82–0.97). In fact, the SIR of EAC decreased with longer follow-up durations (SIR, 0.73; 95% CI, 0.61–0.86).¹

Obvious strengths of this study include its sample size and the depth of data obtained (eg, follow-up and contextualized incidence based on calendar period, country, sex, age, and defined risk factors including education level, comorbidity, gastroesophageal reflux disease, and medication use). Weaknesses include that the population studied was limited to Nordic countries, which harbor lower H pylori infection rates, and that successful eradication was assumed, based on prescribed treatment rather than on lab-proven eradication. Despite these weaknesses, this study found no evidence to support the hypothesis that the risk of EAC increases over time following H pylori eradication therapy. Therefore, one can conclude that eradicating H pylori is safe from the perspective of increasing the likelihood of developing EAC, and we should continue our practice of testing for H pylori when indicated and treating this infection if found.