A novel model measuring the harm of transplanting hepatocellular carcinoma exceeding Milan criteria.
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.
Volk
M L
ML
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
Vijan
S
S
Marrero
J A
JA
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