Impact of geographic disparity on liver allocation for hepatocellular cancer in the United States

Background & Aims: Liver allocation for hepatocellular cancer (HCC) is undergoing constant re-evaluation in the United States, but the impact of geographic differences in organ access has not been examined. Methods: From February 28th, 2002 until November 20th, 2009, 9730 adult patients with T2 HCC and 326 Beyond Milan HCC patients were studied using the UNOS database. Kaplan-Meier survival curves were generated and log-rank tests were used to test for differences in survival curves. Results: Length of waiting time and presence/absence of loco-regional therapy in T2 HCC patients did not significantly impact transplant recipient (p = 0.65) and graft survival (p = 0.74) (Fig. 1B). Regions with median waiting times >6 months performed more loco-regional therapy (Fig. 1D) and had significantly higher waiting list dropout rates (Regions 1: p = 0.01; 5: p <0.001, and 9: p <0.001). T2 HCC post-transplant outcomes were not significantly different between UNOS regions (Fig. 2) or between T2 and Beyond Milan HCC patients (transplant recipient p = 0.37, and graft p = 0.72 survival) (Fig. 1C). The Beyond Milan cohort had significantly greater dropout/death (p = 0.007) and a worse overall survival trend (p = 0.11) (Fig. 1C). Conclusions: Analysis of the UNOS database shows inhomogeneous access to liver transplantation in the United States. Regions with longer waiting times had significantly higher T2 HCC dropout rates (Table 2), and used more loco-regional therapy (Fig. 1D). Conversely, T2 HCC patients had uniform liver transplant outcomes despite geographic differences (Fig. 2). Beyond Milan HCC patients showed significantly greater dropout/death (p = 0.007) and a worse overall survival trend in an intent-to-treat analysis (p = 0.11) (Fig. 1C).