title: A novel model measuring the harm of transplanting hepatocellular carcinoma exceeding Milan criteria.
abstract: No empirical studies have defined the posttransplant survival that would justify expansion of the Milan criteria for liver transplantation of hepatocellular carcinoma. We created a Markov model comparing the survival benefit of transplantation for a patient with >Milan HCC, versus the harm caused to other patients on the waiting list. In the base-case analysis, the strategy of transplanting the patient with >Milan HCC resulted in a 44% increased risk of death and a utility loss of 3 quality-adjusted years of life across the pre- and posttransplant periods for a nationally representative cohort of patients on the waiting list. This harm outweighed the benefit of transplantation for a patient with >Milan HCC having a 5-year posttransplant survival of less than 61%. This survival threshold was most sensitive to geographic variations in organ shortage, with the threshold varying from 25% (Region 3) to >72% (Regions 1, 5, 7 and 9). In conclusion, expansion of the Milan criteria will require demonstrating high survival rates for the newly eligible patients-approximately 61% at 5 years after transplantation. In regions with less severe organ shortage, a more aggressive approach to transplanting these patients may be justified.
authors.affiliation: Division of Gastroenterology, University of Michigan Health System, 6312 Medical Science Building 1, 1150 W Medical Center Drive, Ann Arbor, MI 48109, USA. mvolk@med.umich.edu
authors.forename: M L
authors.initials: ML
authors.lastname: Volk
authors.forename: S
authors.initials: S
authors.lastname: Vijan
authors.forename: J A
authors.initials: JA
authors.lastname: Marrero
mesh_terms: D006528:Carcinoma, Hepatocellular / Q000601:surgery*; D006085:Graft Survival; D006801:Humans; D008113:Liver Neoplasms / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality / Q000502:physiology*; D019520:Living Donors; D008390:Markov Chains; D009368:Neoplasm Transplantation / Q000009:adverse effects*; D018579:Patient Selection; D012189:Retrospective Studies; D016019:Survival Analysis; D014019:Tissue Donors; D016896:Treatment Outcome; D014850:Waiting Lists