title: Comparison of Liver Transplant-Related Survival Benefit in Patients With Versus Without Hepatocellular Carcinoma in the United States.
abstract: OBJECTIVE
  Patients with T2 hepatocellular carcinoma (HCC) can obtain an exception that allows them to undergo liver transplantation with much lower actual Model for End-Stage Liver Disease (MELD) scores than patients without HCC. We compared patients who received liver transplants, with and without HCC, with regard to transplantation-related survival benefit.
  
  
  METHODS
  We modeled the post-transplantation survival of adult, first-time liver transplant recipients with HCC (n = 9135) or without (n = 25,890) from 2002 through 2013 using Cox proportional hazards regression. We modeled waitlist survival of patients listed for transplantation with HCC (n = 15,605) or without (n = 85,229) using competing risks analysis and combined outcomes of death or liver failure (defined as MELD score ≥30). We used these survival models to calculate monthly transition probabilities and 5-year life expectancies. Survival benefit was calculated as the difference between post-transplantation and waitlist life expectancy.
  
  
  RESULTS
  The 5-year survival benefit increased with actual MELD score for patients with and without HCC, ranging from just a few months in patients with low MELD scores (ie, 6-8) to 4 years in patients with the highest MELD scores (ie, 36-40). The survival benefit of patients with HCC was similar to that of patients without HCC who had the same actual MELD score, irrespective of tumor burden or serum level of α-fetoprotein. However, because patients with HCC received liver transplants when they had a lower mean MELD score (13.3 ± 6.2) than patients without HCC (21.8 ± 8.0), a much lower mean 5-year survival benefit was achieved by providing liver transplants to patients with HCC (0.12 years/patient) than patients without HCC (1.47 years/patient).
  
  
  CONCLUSIONS
  The HCC MELD exception policy has unintentionally resulted in a large reduction in transplantation-related survival benefit.
authors.affiliation: Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.
authors.forename: Kristin
authors.initials: K
authors.lastname: Berry
authors.affiliation: Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington. Electronic address: georgei@medicine.washington.edu.
authors.forename: George N
authors.initials: GN
authors.lastname: Ioannou
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002648:Child; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists; D055815:Young Adult
keywords: Exception Points; Liver Cancer; Priority; UNOS