Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change

Tanveen Ishaque, Allan B Massie, Mary G. Bowring, Christine E. Haugen, Jessica M. Ruck, Samantha E. Halpern, Madeleine M. Waldram, Macey Henderson, Jacqueline Garonzik, Andrew M Cameron, Benjamin Philosophe, Shane Ottmann, Anne Rositch, Dorry Segev

Research output: Contribution to journalArticle

Abstract

Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.

Original languageEnglish (US)
JournalAmerican Journal of Transplantation
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Liver Transplantation
Hepatocellular Carcinoma
Carcinoma
Mortality
Transplants
Liver

Keywords

  • cancer/malignancy/neoplasia
  • clinical research/practice
  • disparities
  • graft survival
  • liver disease: malignant
  • liver transplantation/hepatology
  • organ allocation

ASJC Scopus subject areas

  • Immunology and Allergy
  • Transplantation
  • Pharmacology (medical)

Cite this

@article{78d99a8ab700439a8ece770b9ccbf97c,
title = "Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change",
abstract = "Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37{\%} lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.",
keywords = "cancer/malignancy/neoplasia, clinical research/practice, disparities, graft survival, liver disease: malignant, liver transplantation/hepatology, organ allocation",
author = "Tanveen Ishaque and Massie, {Allan B} and Bowring, {Mary G.} and Haugen, {Christine E.} and Ruck, {Jessica M.} and Halpern, {Samantha E.} and Waldram, {Madeleine M.} and Macey Henderson and Jacqueline Garonzik and Cameron, {Andrew M} and Benjamin Philosophe and Shane Ottmann and Anne Rositch and Dorry Segev",
year = "2018",
month = "1",
day = "1",
doi = "10.1111/ajt.15144",
language = "English (US)",
journal = "American Journal of Transplantation",
issn = "1600-6135",
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T1 - Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change

AU - Ishaque, Tanveen

AU - Massie, Allan B

AU - Bowring, Mary G.

AU - Haugen, Christine E.

AU - Ruck, Jessica M.

AU - Halpern, Samantha E.

AU - Waldram, Madeleine M.

AU - Henderson, Macey

AU - Garonzik, Jacqueline

AU - Cameron, Andrew M

AU - Philosophe, Benjamin

AU - Ottmann, Shane

AU - Rositch, Anne

AU - Segev, Dorry

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.

AB - Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.

KW - cancer/malignancy/neoplasia

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KW - disparities

KW - graft survival

KW - liver disease: malignant

KW - liver transplantation/hepatology

KW - organ allocation

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