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Surge of Liver Cancer Patients on Transplant Waitlists
Medscape Medical News from: The Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD)
Surge of Liver Cancer Patients on Transplant Wait Lists
Miriam E. Tucker, November 12, 2013
WASHINGTON, DC — Patients with hepatocellular carcinoma account for an increasing proportion of patients infected with hepatitis C on the waiting list for liver transplantation, a retrospective cohort study has found.
"We feel that primary prevention for hepatocellular carcinoma will be key to reversing this trend," Jennifer Flemming, MD, from Queen's University in Kingston, Ontario, told Medscape Medical News.
"In patients with hepatitis C, viral eradication is the most important step in reducing an individual's risk of developing hepatocellular carcinoma," she explained. "As the landscape of antiviral treatment continues to evolve and become easier from both the patient and clinician perspective, we would hope that increased rates of sustained viral response result in a lower incidence of hepatocellular carcinoma and, subsequently, a decrease in the number of individuals listed."
Dr. Flemming presented the findings here at The Liver Meeting 2013. She began the work as a clinical research fellow at the University of California, San Francisco.
Patients with hepatocellular carcinoma are given an exception to the Model for End-Stage Liver Disease (MELD) score, developed by the United Network for Organ Sharing (UNOS) to prioritize patients in most urgent need of liver transplantation. The MELD score, which ranges from 6 to 40, takes into account bilirubin, prothrombin time, and creatinine. Patients with scores of 16 and above are considered to be transplant candidates. Patients with hepatocellular carcinoma are automatically given extra points.
Dr. Flemming's team examined data from the Scientific Registry of Transplant Recipients, which includes all liver transplant waitlist candidates in the United States.
Of the 20,325 patients with liver disease related to hepatitis C infection (about 30% of the total), the indication for listing was end-stage liver disease for 12,724 patients and hepatocellular carcinoma for 7061. Those listed for hepatocellular carcinoma were older (56 vs 52 years; P < .001) and more likely to be male (79% vs 73%; P < .001) than those listed for end-stage liver disease.
After adjustment for age and sex, the overall rate of patients with hepatitis C rose from 6.9 per 100,00 in 2003 to 10.2 per 100,000 in 2010 (P < .001). This was entirely due to the 12% annual increase in patients with hepatocellular carcinoma; the average annual increase in patients with end-stage liver disease was a nonsignificant 1%.
"Looking to the future, the demand for liver transplantation for hepatocellular carcinoma will likely continue to rise and further strain the donor pool," Dr. Flemming said. She added that this situation could "push the transplant community to consider nontransplant alternatives for the disease."
The researchers could not account for the plateau in transplant listings for end-stage liver disease in the hepatitis C population, but there are several hypotheses, Dr. Flemming told Medscape Medical News.
The management of patients with cirrhosis in the gastrointestinal and hepatology community could be improving, which might prevent or delay the development of liver decompensation.
"With the publication of clinical guidelines from the American Association for the Study of Liver Diseases [AASLD] on the management of ascites, esophageal varices, portal hypertension, and hepatocellular carcinoma, clinicians may be more educated and feel more comfortable managing complex patients than in the past," Dr. Flemming said.
In addition, increased viral clearance from recently available antiviral therapy for hepatitis C could be reducing the need for liver transplantation, she noted.
There is general agreement within the hepatology community that this exception has become increasingly unfair to non-hepatocellular carcinoma patients with end-stage liver disease, said session moderator Susan Orloff, MD, from Oregon Health & Science University, and chief of the liver transplantation program at the Portland VA Medical Center.
"The issue is that we are overadvantaging patients with hepatocellular carcinoma," she told Medscape Medical News. "Despite the fact that the total number of waitlisted patients with hepatitis C has increased, that increase is solely due to patients with this carcinoma. We have to figure out an allocation system that allows non-hepatocellular carcinoma patients to have equal access to organs," said Dr. Orloff.
There have been attempts within the AASLD and UNOS to come up with a better way of allocating donor livers, she noted.
"We're in the process of trying to sort it out. Should we require a wait time for patients with hepatocellular carcinoma before they can get activated on the list? But how would you choose those patients?"
The key will be to identify genomic biomarkers in tumors that predict the likelihood of progression, Dr. Orloff said.
"I think we have to figure out a scoring system within the hepatocellular carcinoma group to see who has a greater likelihood of progressing, so we don't put them in the hold bucket," she explained. "Those who don't have a high risk of progression could wait 6 or 8 months. But it also depends on individual biology; it's a very difficult situation. There's no hard and fast answer."
To read the article, go to Medscape and type in the title of the article.
Surge of Liver Cancer Patients on Transplant Wait Lists
Miriam E. Tucker, November 12, 2013
WASHINGTON, DC — Patients with hepatocellular carcinoma account for an increasing proportion of patients infected with hepatitis C on the waiting list for liver transplantation, a retrospective cohort study has found.
"We feel that primary prevention for hepatocellular carcinoma will be key to reversing this trend," Jennifer Flemming, MD, from Queen's University in Kingston, Ontario, told Medscape Medical News.
"In patients with hepatitis C, viral eradication is the most important step in reducing an individual's risk of developing hepatocellular carcinoma," she explained. "As the landscape of antiviral treatment continues to evolve and become easier from both the patient and clinician perspective, we would hope that increased rates of sustained viral response result in a lower incidence of hepatocellular carcinoma and, subsequently, a decrease in the number of individuals listed."
Dr. Flemming presented the findings here at The Liver Meeting 2013. She began the work as a clinical research fellow at the University of California, San Francisco.
Patients with hepatocellular carcinoma are given an exception to the Model for End-Stage Liver Disease (MELD) score, developed by the United Network for Organ Sharing (UNOS) to prioritize patients in most urgent need of liver transplantation. The MELD score, which ranges from 6 to 40, takes into account bilirubin, prothrombin time, and creatinine. Patients with scores of 16 and above are considered to be transplant candidates. Patients with hepatocellular carcinoma are automatically given extra points.
Dr. Flemming's team examined data from the Scientific Registry of Transplant Recipients, which includes all liver transplant waitlist candidates in the United States.
Of the 20,325 patients with liver disease related to hepatitis C infection (about 30% of the total), the indication for listing was end-stage liver disease for 12,724 patients and hepatocellular carcinoma for 7061. Those listed for hepatocellular carcinoma were older (56 vs 52 years; P < .001) and more likely to be male (79% vs 73%; P < .001) than those listed for end-stage liver disease.
After adjustment for age and sex, the overall rate of patients with hepatitis C rose from 6.9 per 100,00 in 2003 to 10.2 per 100,000 in 2010 (P < .001). This was entirely due to the 12% annual increase in patients with hepatocellular carcinoma; the average annual increase in patients with end-stage liver disease was a nonsignificant 1%.
"Looking to the future, the demand for liver transplantation for hepatocellular carcinoma will likely continue to rise and further strain the donor pool," Dr. Flemming said. She added that this situation could "push the transplant community to consider nontransplant alternatives for the disease."
The researchers could not account for the plateau in transplant listings for end-stage liver disease in the hepatitis C population, but there are several hypotheses, Dr. Flemming told Medscape Medical News.
The management of patients with cirrhosis in the gastrointestinal and hepatology community could be improving, which might prevent or delay the development of liver decompensation.
"With the publication of clinical guidelines from the American Association for the Study of Liver Diseases [AASLD] on the management of ascites, esophageal varices, portal hypertension, and hepatocellular carcinoma, clinicians may be more educated and feel more comfortable managing complex patients than in the past," Dr. Flemming said.
In addition, increased viral clearance from recently available antiviral therapy for hepatitis C could be reducing the need for liver transplantation, she noted.
There is general agreement within the hepatology community that this exception has become increasingly unfair to non-hepatocellular carcinoma patients with end-stage liver disease, said session moderator Susan Orloff, MD, from Oregon Health & Science University, and chief of the liver transplantation program at the Portland VA Medical Center.
"The issue is that we are overadvantaging patients with hepatocellular carcinoma," she told Medscape Medical News. "Despite the fact that the total number of waitlisted patients with hepatitis C has increased, that increase is solely due to patients with this carcinoma. We have to figure out an allocation system that allows non-hepatocellular carcinoma patients to have equal access to organs," said Dr. Orloff.
There have been attempts within the AASLD and UNOS to come up with a better way of allocating donor livers, she noted.
"We're in the process of trying to sort it out. Should we require a wait time for patients with hepatocellular carcinoma before they can get activated on the list? But how would you choose those patients?"
The key will be to identify genomic biomarkers in tumors that predict the likelihood of progression, Dr. Orloff said.
"I think we have to figure out a scoring system within the hepatocellular carcinoma group to see who has a greater likelihood of progressing, so we don't put them in the hold bucket," she explained. "Those who don't have a high risk of progression could wait 6 or 8 months. But it also depends on individual biology; it's a very difficult situation. There's no hard and fast answer."
To read the article, go to Medscape and type in the title of the article.
Best Answer
Just the reason one should not risk becoming cirrhotic... The best to all those waiting...
I recently read another article from Medscape. This information was also presented at the recent liver conference. The title of the article was Primary Care Option for Hepatitis C Treatment Cost-Effective. So anyone who wants to read the entire article can go to Medscape and look up the title.
Basically the article was talking about the cost effectiveness of treating HCV in small clinics in under served areas. I was particularly struck by this paragraph:
"Dr. Wong and his team compared the cost of pegylated interferon plus ribavirin with no treatment for each of 261 patients at the 21 ECHO sites. Mean patient age was 42 years, 73% were male, and 95% were white. A quarter had cirrhosis, 30% had moderate hepatitis, and 56% had genotype 1 hepatitis C."
They were talking about the cost effectiveness of treatment, but what I found interesting in the article is that out of 261 patients, the mean age was 42 years old and 25% had Cirrhosis. I realize there could be a lot of reasons for 25% of the people having Cirrhosis, but the mean age was only 42. So out of 261 patients with HCV, 65 of them had Cirrhosis. And they are not all 60 years old. If they were all 60 or older, I wonder what the percentage of Cirrhosis would be. It sort of debunks the long standing myth that only 20 percent EVER progress to Cirrhosis. Incidentally, I have read several articles recently in which the experts say that the percentage of people who have HCV and who progress to Cirrhosis is far greater than 20%.
I agree with Halfwatt and others that early detection and treatment of HCV is vital in order to avoid Cirrhosis and HCC. In addition, early detection and treatment also spares one the burden of extrahepatic manifestions, some of which can be very serious, and spares one increased all cause mortality.
Basically the article was talking about the cost effectiveness of treating HCV in small clinics in under served areas. I was particularly struck by this paragraph:
"Dr. Wong and his team compared the cost of pegylated interferon plus ribavirin with no treatment for each of 261 patients at the 21 ECHO sites. Mean patient age was 42 years, 73% were male, and 95% were white. A quarter had cirrhosis, 30% had moderate hepatitis, and 56% had genotype 1 hepatitis C."
They were talking about the cost effectiveness of treatment, but what I found interesting in the article is that out of 261 patients, the mean age was 42 years old and 25% had Cirrhosis. I realize there could be a lot of reasons for 25% of the people having Cirrhosis, but the mean age was only 42. So out of 261 patients with HCV, 65 of them had Cirrhosis. And they are not all 60 years old. If they were all 60 or older, I wonder what the percentage of Cirrhosis would be. It sort of debunks the long standing myth that only 20 percent EVER progress to Cirrhosis. Incidentally, I have read several articles recently in which the experts say that the percentage of people who have HCV and who progress to Cirrhosis is far greater than 20%.
I agree with Halfwatt and others that early detection and treatment of HCV is vital in order to avoid Cirrhosis and HCC. In addition, early detection and treatment also spares one the burden of extrahepatic manifestions, some of which can be very serious, and spares one increased all cause mortality.
Very interesting....
this article hits very close to home for me as I have HCC and was evaluated and "declined" for transplant at OHSU.
I believe the reason for my "decline" had more to do with the trends mentioned in the article than my actual condition. I am pretty sure my oncology team (not associated with OHSU) feels the same.
I also believe that access to a transplant should be fair to all groups of patients.
That being said, I think that sometimes when there is a pendulum swing in policy there is a tendency to swing too far in any given direction.
So, just as the pendulum may have swung too far in favor of those who have HCC, it now appears that (at least for me) the pendulum has swung too far in the other direction.
Basically this is bad time to have HCC and need a transplant.
And bear in mind that I was declined not just to have a transplant, but to even be on the LIST for a transplant.
All of which is to say that I agree with all who advocate for early detection of, and treatment for HCV, because once you have HCV your odds of ending up cirrhotic and/or developing HCC increase signifigantly.
My advice, from experience learned the hard way, is to be very proactive about detection and treatment.
Had I been more proactive in that regard I probably would not be in the position I am now.
Just my 2 cents....
Good Luck To All
halfwatt
this article hits very close to home for me as I have HCC and was evaluated and "declined" for transplant at OHSU.
I believe the reason for my "decline" had more to do with the trends mentioned in the article than my actual condition. I am pretty sure my oncology team (not associated with OHSU) feels the same.
I also believe that access to a transplant should be fair to all groups of patients.
That being said, I think that sometimes when there is a pendulum swing in policy there is a tendency to swing too far in any given direction.
So, just as the pendulum may have swung too far in favor of those who have HCC, it now appears that (at least for me) the pendulum has swung too far in the other direction.
Basically this is bad time to have HCC and need a transplant.
And bear in mind that I was declined not just to have a transplant, but to even be on the LIST for a transplant.
All of which is to say that I agree with all who advocate for early detection of, and treatment for HCV, because once you have HCV your odds of ending up cirrhotic and/or developing HCC increase signifigantly.
My advice, from experience learned the hard way, is to be very proactive about detection and treatment.
Had I been more proactive in that regard I probably would not be in the position I am now.
Just my 2 cents....
Good Luck To All
halfwatt
Blue great to hear from you! What a tragedy you had, beyond anything I can relate to. I can only say how very sorry I am. But taking care of your health I think would make you daughter proud. I'm sorry for your stomach aches. I'm wondering if there more related to your stress than cirrhosis. Unless you've had them for awhile. Please take care of yourself. Message me anytime!!!
Big hug to you Blue!! Kitty
Big hug to you Blue!! Kitty
Hi everyone. I want to thank each and every one who was there to support me in this horrible and tragic event. I realize that I have been off the beam for quite awhile now, and I know it. I have made up my mind that I am going to fight for my life. Alchohol played a big part in me contracting this disease years ago when I was young and stupid. For those of you that still drink, (DONT) you might not get a second chance for life. I am soooo tired I am having a lot of stomach aches, but I brought it on myself. I guess in honor of my daughters memory I am going to fight harder. God Bless and keep all of you. Encouragement is the fuel on which hope runs and that is what you all have given me. Love you guys Blue
Yes, I agree, there should be more surgeons trained in doing live liver transplants.
"My personal opinion is we don't see more of them here because insurance companies don't want to pay for two surgeries."
That and we need more centers that can do them, the cost of travel and time hurts a lot of people I'm sure.
That and we need more centers that can do them, the cost of travel and time hurts a lot of people I'm sure.
Not surprising to see more transplants as hep C is still a hidden epidemic. I certainly didn't know I had ESLD until my diagnosis.
As a happy survivor of a live liver transplant ( actually a related living donor transplant ) done in Taiwan, I think we should be doing more of them here. With living donors there is no waiting on a list.
My personal opinion is we don't see more of them here because insurance companies don't want to pay for two surgeries.
As a happy survivor of a live liver transplant ( actually a related living donor transplant ) done in Taiwan, I think we should be doing more of them here. With living donors there is no waiting on a list.
My personal opinion is we don't see more of them here because insurance companies don't want to pay for two surgeries.
Good points. What they ought to do is campaign for more donors. I think in my state you're automatically opted in unless you specifically opt out on the driver's license. Still can you imagine how many lives could be saved even as as donor angels give theirs? I often wonder what goes through the mind of someone who donates. Close to death perhaps makes one appreciate life's sweetness and to be able to pass it on to someone else is understood.
David
David
"She added that this situation could "push the transplant community to consider nontransplant alternatives for the disease."
The researchers could not account for the plateau in transplant listings for end-stage liver disease in the hepatitis C population, but there are several hypotheses, Dr. Flemming told Medscape Medical News.
The management of patients with cirrhosis in the gastrointestinal and hepatology community could be improving, which might prevent or delay the development of liver decompensation."
Flemming's presentation is half@ssed because she has no non-transplant alternatives to suggest. She also chooses to ignore what the survival rate of non-transplanted HCC patients is compared to non-transplanted cirrhotics.
As for Orloff and her genomic biomarkers: very few people want to open the Pandora's box of transplant listing based on genetic testing.
The researchers could not account for the plateau in transplant listings for end-stage liver disease in the hepatitis C population, but there are several hypotheses, Dr. Flemming told Medscape Medical News.
The management of patients with cirrhosis in the gastrointestinal and hepatology community could be improving, which might prevent or delay the development of liver decompensation."
Flemming's presentation is half@ssed because she has no non-transplant alternatives to suggest. She also chooses to ignore what the survival rate of non-transplanted HCC patients is compared to non-transplanted cirrhotics.
As for Orloff and her genomic biomarkers: very few people want to open the Pandora's box of transplant listing based on genetic testing.
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