Towards a rational approach to priority in liver transplant oncology

Introduction In the last two decades, the number of oncological “exceptions” equated or even exceeded the number of non-oncological indications to liver transplantation (LT) in many countries. However, the prioritization of oncological patients within common waiting lists (WL) is still an unmet need. Aim The aim of this study is to define and grade the factors that influence WL priority amongst all oncologic indications to liver transplant. Material and Methods A literature search was made to define which factors influence urgency, utility and transplant benefit principles in oncologic indications to LT. Those factors found to be shared by all oncological indications were then defined and qualitatively graded. For each grade, an evaluation of priority according to the three allocation principles was assessed, and priority for each grade (from 1 to 5) was given according to a blended principle. Results The following factors were identified: time on treatment before WL, response to therapy, availability of maintenance therapies while on WL, presence of alternative curative treatments, expected progression-free survival on WL, tumor burden with respect to transplant criteria, age and liver function. Each factor was graded according to a blended principle that takes into account urgency, utility and transplant benefit. A scale was then derived, summing a minimum of 15 and a maximum of 36 points, that allows for grading priority within oncologic indications to LT and with non-oncologic indications. Conclusions We propose a prioritization scheme of oncologic indications to LT according to the principle of transplant benefit blended with those of urgency and utility. Its feasibility should be discussed within the transplant community and prospectively tested.