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Proposal to Delay the HCC Exception Score Assignment

Address disparities in transplant/drop-out rates for HCC and non-HCC patients by delaying HCC score assignment. Evidence shows benefits of delaying in certain regions. Committee members must stay informed and monitor cases accordingly.

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Proposal to Delay the HCC Exception Score Assignment

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  1. Proposal to Delay the HCC Exception Score Assignment Liver and Intestinal Organ Transplantation Committee Spring 2014

  2. The Problem • Candidates with HCC exceptions receive high priority on the waiting list • Scores may increase automatically every three months • Most patients treated (90%), many with stable tumors • HCC: Significantly lower dropout rates than non-HCC • Exception: areas of the country with long waiting times • These areas also have a built in “test for biology” • How to even out transplant rates for HCC vs non-HCC?

  3. Overall Dropout Rates for HCC and Non-HCC Candidates: Listed 4/14/04-12/31/07 p < 0.0001

  4. The Problem (cont’d) Massie, et al: Both HCC and other exceptions “were associated with decreased risk of waitlist mortality compared to non-exception patients with equivalent listing priority” p<0.001

  5. % Dropout within 12 Months: HCC and Non-HCC Candidates by RegionCandidates Added 7/1/08 – 6/30/11

  6. Goal of the Proposal • The proposed solution will address the disparities in transplant/drop-out rates between patients with HCC exceptions and those without by delaying the HCC score assignment

  7. Additional Background • Currently, as long as the candidate meets criteria, the initial score assignment is 22, followed by increases every 3 months

  8. Supporting Evidence • LSAM modeling: delay led to similar transplant rates between HCC and non-HCC • At least in regions with lower waiting times • Study by Halazun, et al: Recipients with HCC exceptions have worse outcomes in regions with shorter waiting times • “Biologic test” not met due to rapid transplantation

  9. Transplant Rates by HCC StatusLSAM Modeling Results

  10. What Members will Need to Do • Understand changes in the score assignment • For HCC cases submitted as “Other, specify”: will be monitored by the Committee

  11. Questions? • David C. Mulligan, MD Committee Chair david.mulligan@yale.edu • Name Region # Representative Email • Committee Liaison

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