Intention-to-treat survival benefit of liver transplantation in patients with hepatocellular cancer

ABSTRACT

The debate about the best approach to select patients with hepatocellular cancer (HCC) waiting for liver transplantation (LT) is still ongoing. This study aims to identify the best variables allowing to discriminate "high-" and "low-benefit" patients. To do so, the innovative concept of intention-to-treat (ITT) survival benefit of LT has been created. Data of 2103 adult HCC patients consecutively enlisted during the period 1987-2015 were analyzed. Three rigorous statistical steps were used in order to create the ITT survival benefit of LT: the development of an ITT LT and a non-LT survival model, and the individual prediction of the ITT survival benefit of LT defined as the difference between the median ITT survival with (based on the first model) and without LT (based on the second model) calculated for each enrolled patient. Four variables (MELD, alpha-fetoprotein, Milan-Criteria status and radiological response) displayed a high effect in terms of delta-benefit. According to these risk factors, four benefit groups were identified. Patients with three-four factors ("no-benefit group", n=405/2103; 19·2%) had no benefit of LT compared to alternative treatments. Inversely, patients without any risk factor ("large-benefit group", n=108; 5·1%) yielded the highest benefit from LT reaching 60 months. Conclusion: The here presented innovative ITT transplant survival benefit allows to better select HCC patients waiting for LT. The obtained stratification may lead to an improved and more equal way for organ allocation. Patients with no benefit should be de-listed, whilst patients with large benefit ratio should be prioritized for LT. This article is protected by copyright. All rights reserved.

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