Revaluation of Helicobacter pylori's role in esophageal carcinoma: A call for comprehensive research

Abstract

The study by López-Gómez et al, reports a significantly low prevalence (4.5%) of Helicobacter pylori (H. pylori) infection in esophageal cancer patients, contrasting sharply with the general population's infection rate. This finding challenges the established negative association between H. pylori and gastric malignancies, suggesting a potential protective role of H. pylori against esophageal carcinoma, particularly in the context of widespread proton pump inhibitor use. However, the study’s retrospective nature, single-center design, and small sample size limit the generalizability of the findings and raise concerns about selection bias and statistical power. Diagnostic methods primarily based on histology may not detect all cases, especially those with prior antibiotic or proton pump inhibitor use. Additionally, the study does not account for various confounding factors such as dietary habits, socio-economic status, and genetic predispositions that could affect the association between H. pylori and esophageal carcinoma. Further research with larger, more diverse cohorts and comprehensive data collection is necessary to clarify the complex relationship between H. pylori and esophageal carcinoma and substantiate these preliminary findings.

Key Words: Helicobacter pylori; Esophageal carcinoma; Helicobacter pylori prevalence; Gastric malignancies; Proton pump inhibitors; Retrospective observational study

Core Tip: The implication that widespread Helicobacter pylori (H. pylori) eradication could contribute to a rise in esophageal cancer cases warrants further investigation. Additionally, a more thorough investigation of lifestyle, dietary habits, socio-economic status, and genetic predispositions as potential confounding factors could provide clarity in understanding the relationship between H. pylori infection and esophageal cancer. The widespread nature of H. pylori worldwide and its association with many gastrointestinal malignancies make it a critical area of focus for future clinical research.

TO THE EDITOR

We read with great interest the article published in the World Journal of Gastroenterology[1]. The authors have conducted an important study that contributes significantly to our understanding of the potential relationship between Helicobacter pylori (H. pylori) infection and esophageal carcinoma.

The study's comprehensive analysis and robust methodology provide valuable insights into the prevalence of H. pylori infection among patients with esophageal carcinoma. However, we would like to address several points that may enhance the interpretation of the findings and suggest potential areas for future research.

POTENTIAL CONFOUNDING FACTORS

While the study acknowledges the role of confounding factors such as age, gender, and smoking status, it would be helpful to explore further additional confounders such as dietary habits, socio-economic status, and genetic predispositions, which might influence the prevalence of H. pylori infection and the risk of esophageal carcinoma. For instance, high salt intake and the consumption of processed meats have been associated with both H. pylori infection and the risk of gastrointestinal malignancies. Accounting for these factors could provide a more nuanced understanding of the associations observed in the study[2-4].

STRAIN-SPECIFIC ANALYSIS OF H. PYLORI

The virulence factors of different H. pylori strains, such as CagA and VacA, are known to contribute to gastric carcinogenesis. It would be interesting to investigate whether specific H. pylori strains are more prevalent in patients with esophageal carcinoma and whether these strains possess distinct virulence factors that may contribute to esophageal carcinogenesis. For example, patients harboring CagA-positive strains of H. pylori may exhibit different clinical outcomes compared to those infected with other strains. Such an analysis could elucidate whether strain-specific differences have protective or harmful effects in esophageal cancer patients[5,6].

IMPLICATIONS FOR SCREENING AND TREATMENT

The findings of this study have significant implications for the screening and treatment of H. pylori infection in populations at risk for esophageal carcinoma. Given the potential protective role of H. pylori, especially in populations with high proton pump inhibitor use, it may be prudent to reconsider current eradication strategies in certain high-risk groups. Targeted screening programs for H. pylori in patients with a history of proton pump inhibitor use or other risk factors for esophageal carcinoma could be valuable for identifying those who may benefit from more tailored approaches to eradication and management[7,8].

POOR SURVIVAL DURATION OF THE H. PYLORI-POSITIVE GROUP

In the study, it was mentioned that the H. pylori group had a survival duration not exceeding 9 months after diagnosis. However, there was no comparison made with the H. pylori-negative group, which would have provided additional insights into whether H. pylori infection, or certain strains of it, is associated with worse prognoses in esophageal carcinoma patients. Comparing these groups could help identify whether specific H. pylori strains are linked to poorer survival outcomes, opening new avenues for research into personalized therapeutic approaches[9].

LONGITUDINAL STUDIES AND CAUSALITY

Given the retrospective observational nature of the study, it is challenging to establish a causal or protective relationship between H. pylori infection and esophageal carcinoma. Prospective longitudinal studies are needed to explore the temporal relationship and potential causative role of H. pylori in the development of esophageal carcinoma. Such studies would help clarify whether H. pylori plays a protective or pathogenic role in esophageal cancer development and offer clearer guidance for clinical practice[10].

CONCLUSION

In conclusion, this study provides valuable data on the prevalence of H. pylori infection among patients with esophageal carcinoma and opens new avenues for research. Addressing the aforementioned confounding factors, strain-specific analyses, survival outcomes, and pursuing prospective studies would further strengthen the study's conclusions and provide a more comprehensive understanding of the relationship between H. pylori infection and esophageal carcinoma. Thank you for considering our comments. We look forward to future studies that build on these findings and contribute to improving the diagnosis, prevention, and treatment of esophageal carcinoma.