HCC Patients Suffer Less From Geographic Differences in Organ Availability

It has been suggested that the number of exception model for end-stage liver disease (MELD) points for hepatocellular carcinoma (HCC) overestimates mortality risk. Average MELD at transplant, a measure of organ availability, correlates with mortality on an intent-to-treat basis and varies by donation service area (DSA). We analyzed Scientific Registry of Transplant Recipients data from 2005 to 2010, comparing transplant and death parameters for patients transplanted with HCC exception points to patients without HCC diagnosis (non-HCC), to determine whether the two groups were impacted differentially by DSA organ availability. HCC candidates are transplanted at higher rates than non-HCC candidates and are less likely to die on the waitlist. Overall risk of death trends downward by 1% per MELD point (p=0.65) for HCC, but increases by 7% for non-HCC patients (p<0.0001). The difference in the change of mortality with MELD is statistically significant between HCC and non-HCC candidates p<0.0001. Posttransplant risk of death trends downward by 2% per MELD point (p=0.28) for HCC patients, but increases by 3% per MELD point in non-HCC patients (p=0.027), with the difference being statistically significant with p<0.005. In summary, increasing wait time impacts HCC candidates less than non-HCC candidates and under increased competition for donor organs, HCC candidates' advantage increases. An analysis of geographic disparities in liver transplantation shows that overall mortality for patients with hepatocellular carcinoma exception points does not increase with longer wait times, suggesting that this patient group can afford to wait longer between diagnosis and transplant. See editorial by Charlton on page 2794.