Patients with hepatocellular carcinoma (HCC) waiting for a liver transplant in the USA are now significantly less likely to receive a new liver than they were around a decade ago. A nationwide study presented today at The International Liver Congress 2018 in Paris, France, has confirmed that patients with HCC on the liver transplant list in the USA were more than 50% less likely to receive a transplant in 2014-2016 than they were in 2005-2007. Patients with Medicaid insurance were also significantly less likely to undergo liver transplantation than those with private/commercial insurance. 'This is a very worrying trend and reflects the continued imbalance between the number of patients with HCC in need of liver transplantation and the limited number of donor livers available', said Dr. Jennifer Wang from the California Pacific Medical Center, San Francisco, USA, who presented the study findings today.
Hepatocellular carcinoma is the most common primary tumour of the liver, with average survival estimated to be 18 months. Liver transplantation is a guideline-recommended treatment for people with HCC, although individuals must meet strict criteria in order to join the waiting list. A recent study has shown that HCC is the most common indication for liver transplantation and placement on the waiting list in the USA.4 However, limited organ availability and an increasing demand has extended transplant waiting times, and increased morbidity and mortality amongst those listed.
The study presented today was undertaken to evaluate overall trends in the probability of receiving a liver transplant among US adults with HCC on the transplant list. Data from the United Network for Organ Sharing Liver Transplant Registry were analyzed by year of listing (2005-2007, 2008-2010, 2011-2013, and 2014-2016), and stratified by age and insurance type. When stratified by age, the probability of receiving a liver transplant within 1 year of listing was highest amongst HCC patients aged 50-59 years (64.6%) and lowest amongst those aged 60-69 years (58.1%) (p<0.01). When stratified by insurance type, the probability of receiving a liver transplant within 1 year was highest amongst those with private/commercial insurance (63.6%) and lowest amongst those with Medicare insurance (52.8%) (p<0.001). In 2005-2007, the probability of receiving a liver transplant in the first year of joining the waiting list was 81.5% compared with just 51.7% in 2014-2016 (p<0.001). A multivariate regression analysis confirmed that HCC patients who joined the liver transplant waiting list in 2014-2016 were significantly less likely to receive a transplant than those who joined the list in 2005-2007 (HR 0.43; 95% CI 0.40, 0.46; p<0.001).
'This means that, despite the increasing numbers of adults with HCC waiting for a liver transplant in the USA, patients are now 57% less likely to receive one than they were in the mid-2000s', said Dr. Wang.
As well as the lack of donor livers, Dr. Wang believes that the findings from her study also reflect disparities in the rates of liver transplantation amongst HCC patients—especially patients from ethnic minority backgrounds and those with Medicaid-type insurance. She also believes that the increasing burden of non-alcoholic fatty liver disease as a cause of HCC and the increasing numbers of patients with early-stage HCC that are eligible for liver transplantation have contributed to the current situation.
'Ultimately, this situation will only improve when newer therapies and more curative options for HCC become available', said Dr. Wang. 'In the meantime, we need more research to help us understand the disparities identified in our study so that targeted interventions can be developed to ensure more equitable access to liver transplantation for all our HCC patients'.
'This increase in the proportion of patients who are potential candidates for liver transplantation will be associated with an irremediable increase in the waiting time and of the drop-out due to tumour progression', said Prof. Alejandro Forner from the Hospital Clinic Barcelona, Spain, and EASL Governing Board Member. 'Efforts should be directed to design prioritising strategies to facilitate access to liver transplantation for patients affected by HCC, without harming the patients listed due to impaired liver function'.
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