December 22, 2013

Increased Long-Term Survival Among Patients with Hepatocellular Carcinoma After Implementation of Model for End-Stage Liver Disease Score

Clinical Gastroenterology and Hepatology

Article in Press

Robert J. Wong, Pardha Devaki, Long Nguyen, Ramsey Cheung, Cheryl Cho-Phan, Mindie H. Nguyen

Received 29 July 2013; received in revised form 14 November 2013; accepted 6 December 2013. published online 19 December 2013.
Accepted Manuscript


Background & Aims

Assignment of model for end-stage liver disease (MELD) exception points to patients with hepatocellular carcinoma (HCC) who fall within Milan criteria, which began in 2003, increases their priority on liver transplantation waitlists. However, little is known about how this change affected survival of all patients with HCC (transplant eligible and ineligible). We compared long-term survival of HCC patients before and after this change.


We performed a large population-based cohort study using the Surveillance, Epidemiology, and End Results cancer registry to investigate survival times of patients with HCC before those who met the Milan criteria were given MELD exception points (1998–2003) and afterward (2004–2010), using Kaplan Meier methods. Multivariate Cox proportional hazards models evaluated independent predictors of survival.


During 2004–2010, a significantly higher percentage of patients with HCC survived for 5 years compared to 1998-2003 (21.9% vs 13.0%, P<.001). This difference remained significant among all treatment groups (no therapy: 15.2% vs 10.2%, P<0.001; local tumor destruction: 37.6% vs 22.1%, P<0.001; resection: 55.5% vs 39.2%, P<0.001; transplantation: 77.2% vs 73.1%, P =0.12). Multivariate Cox proportional hazards models, inclusive of sex, age, ethnicity, Milan criteria, number and stage of tumor, and time period, showed increased survival of patients during 2004–2010 (hazard ratio [HR], 0.87; 95% confidence interval, 0.83–0.91; P<.001). Compared to non-Hispanic whites, Asians (HR, 0.81; 95% CI, 0.77–0.86; P<.001) and Hispanics (HR, 0.89, 95% CI, 0.84–0.95; P<.001) had longer survival times, whereas blacks had a trend toward shorter survival times (HR, 1.05; 95% CI 0.98–1.13; P=.16).


Patients with HCC who met Milan criteria had significantly longer survival times after implementation of the MELD exception points, regardless of sex or ethnicity. Blacks continued to have the lowest rates of 5 year survival.

Keywords: SEER, racial disparities, liver cancer, resource allocation

Abbreviations: CI, confidence interval, HCC, hepatocellular carcinoma, HR, hazard ratio, MELD, model for end stage liver disease, SEER,surveillance, epidemiology, and end results, TACE, transarterial chemoembolization, UNOS, United Network for Organ Sharing


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