Patients with liver cancer more likely to be on transplant waitlist
According to Arthur Caplan, the list is 'heavily oriented' toward the sickest patients
April 2, 2012, 9:21 pm·
To the surprise of many in the medical community, patients with both liver disease and a certain kind of liver cancer are eight times less likely to die than those who just suffer from the disease.
The reason, according to a Perelman School of Medicine study, is that patients with both illnesses may receive an unfair advantage on the organ transplant waitlist. The study has prompted the United Network for Organ Sharing to reevaluate some of its policies toward the liver transplant waitlist.
Between 2005 and 2009, Department of Gastroenterology professor and lead author David Goldberg and his team analyzed data from 10,000 adults suffering from liver disease. Some patients had been diagnosed with both liver disease and hepatocellular carcinoma — the type of cancer — while others were only struggling with liver disease.
They found that 24 percent of patients suffering from the disease alone were removed from the transplant waitlist because of the severity of the illness or because many patients died while on the waitlist.
Only 3 percent of cancer patients had the same fate. The results of the study are published in the April issue of Liver Transplantation.
“The current list is heavily oriented toward who’s sickest, who’s more likely to die,” bioethicist and medical ethics and policy professor Arthur Caplan said. “I think this study is surprising because many think those with liver cancer are very sick, and this study shows that those with both liver failure and cancer aren’t necessarily sicker.”
On the national waitlist, patients with the disease “are ranked according to how likely they are to die,” explained Goldberg. “They can develop liver cancer. They may not be as ‘sick,’ but they can be moved up the list.”
“Even though they have the risk of getting sicker from the cancer, the priority they were given on the list didn’t match up with real life,” he added.
Every HCC patient receives a lab value and is ranked according to their likelihood of death within a three month period, according to Ann Harper, UNOS’s Liver and Intestinal Organ Transplantation Committee spokesperson.
Goldberg said the current scoring system was adopted by UNOS in 2002, when HCC patients were given waitlist priority. To combat this, UNOS revised the scoring system in 2003, and again in 2005.
Since 2010 there has been an accumulating body of evidence showing that HCC patients still receive an unfair advantage, Harper said.
“Sometimes it takes a few years to see issues with policies,” Harper said. “Sometimes the committee needs to make adjustments to policies.”
Harper’s committee meets several times a year to review its policies, transplant statistics and outside research. Based on the review, they will release a recommendation for public comment, and then the UNOS board of directors will vote on it. Currently, the group is trying to obtain public feedback pertaining to the transplant policy.
Caplan agrees with Goldberg’s proposal that the scoring system be changed. “I think what they’re calling for is ethically and medically sensible. You want to use evidence to see who has the greatest need.”
“This is something that a lot of people have recognized on their own but it’s never been put out there,” Goldberg said.
Yet Caplan hopes people remain cognizant of the bigger issues — the lack of livers, the need to have more people sign donor cards and engage in healthier habits and the possibility of building mechanical organs.
“You don’t want to lose sight of solutions to prevent or treat liver failure, although prioritization is important,” he said.