Unfair priority for HCC: A problem whose ideal solution remains unsolved.

Since the inception of the model for end-stage liver disease (MELD) liver transplant allocation system in 2002, it has been recognized that some diseases exist for which mortality risk is not adequately measured by MELD score. For this reason patients with hepatocellular carcinoma (HCC) have been assigned an exception MELD score. In this issue of AJT (1), Washburn and colleagues attempted to determine whether the current exception score results in an unfair advantage for HCC patients. They used competing risk methods to compare rates of dropout from the waiting list between adults who received an exception for HCC, versus those without HCC who were listed with their laboratory MELD score. They found that HCC patients have substantially lower dropout rates than nonHCC patients: 12% versus 18% at 1 year after listing. The authors also analyzed factors independently associated with dropout among HCC patients, which included tumor size, laboratory MELD score and level of alphafetoprotein.