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Standing the test of time: Outcomes of a decade of prioritizing patients with hepatocellular carcinoma, results of the UNOS natural geographic experiment
Author(s) -
Halazun Karim J.,
Patzer Rachel E.,
Rana Abbas A.,
Verna Elizabeth C.,
Griesemer Adam D.,
Parsons Ronald F.,
Samstein Benjamin,
Guarrera James V.,
Kato Tomoaki,
Brown Robert S.,
Emond Jean C.
Publication year - 2014
Publication title -
hepatology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.488
H-Index - 361
eISSN - 1527-3350
pISSN - 0270-9139
DOI - 10.1002/hep.27272
Subject(s) - hepatocellular carcinoma , test (biology) , natural (archaeology) , medicine , oncology , demography , geography , biology , ecology , archaeology , sociology
Priority is given to patients with hepatocellular carcinoma (HCC) to receive liver transplants, potentially causing significant regional disparities in organ access and possibly outcomes in this population. Our aim was to assess these disparities by comparing outcomes in long waiting time regions (LWTR, regions 5 and 9) and short waiting time regions (SWTR regions 3 and 10) by analyzing the United Network for Organ Sharing (UNOS) database. We analyzed 6,160 HCC patients who received exception points in regions 3, 5, 9, and 10 from 2002 to 2012. Data from regions 5 and 9 were combined and compared to data from regions 3 and 10. Survival was studied in three patient cohorts: an intent‐to‐treat cohort, a posttransplant cohort, and a cohort examining overall survival in transplanted patients only (survival from listing to last posttransplant follow‐up). Multivariate analysis and log‐rank testing were used to analyze the data. Median time on the list in the LWTR was 7.6 months compared to 1.6 months for SWTR, with a significantly higher incidence of death on the waiting list in LWTR than in SWTR (8.4% versus 1.6%, P < 0.0001). Patients in the LWTR were more likely to receive loco‐regional therapy, to have T3 tumors at listing, and to receive expanded‐criteria donor (ECD) or donation after cardiac death (DCD) grafts than patients in the SWTR ( P < 0.0001 for all). Survival was significantly better in the LWTR compared to the SWTR in all three cohorts ( P < 0.0001 for all three survival points). Being listed/transplanted in an SWTR was an independent predictor of poor patient survival on multivariate analysis ( P < 0.0001, hazard ratio = 1.545, 95% confidence interval 1.375‐1.736). Conclusion : This study provides evidence that expediting patients with HCC to transplant at too fast a rate may adversely affect patient outcomes. (H epatology 2014;60:1956–1961)