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Clin Gastroenterol Hepatol. 2014 Sep;12(9):1534-40.e1. doi: 10.1016/j.cgh.2013.12.008. Epub 2013 Dec 17.

Increased long-term survival among patients with hepatocellular carcinoma after implementation of Model for End-stage Liver Disease score.

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Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
Department of Internal Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan.
Department of Medicine, Stanford University School of Medicine, Stanford, California.
Division of Medical Oncology, Stanford University Medical Center, Stanford, California.
Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California. Electronic address:



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 by 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) by 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 with 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 < .001; local tumor destruction: 37.6% vs 22.1%, P < .001; resection: 55.5% vs 39.2%, P < .001; transplantation: 77.2% vs 73.1%, P = .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 [CI], 0.83-0.91; P < .001). Compared with 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.


Liver Cancer; Racial Disparities; Resource Allocation; SEER

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