Judicious organ matching for older liver transplant candidates with hepatocellular carcinoma (HCC) leads to survival outcomes similar to those in younger recipients, a case review suggests.
Overall survival (OS) rates among transplant recipients included in a prospective institutional database were 85.5% and 84% at 3 years after liver transplant in patients aged 65 years and under and those over 65 years, respectively. The 5-year survival rates were 73.9% and 77%, respectively (P = .26), Ola Ahmed, MD, of the department of abdominal organ transplantation surgery at Washington University, St. Louis, and colleagues found.
The investigators looked at 1,629 patients diagnosed with HCC between Jan. 1, 2002, and Dec. 31, 2019 of whom 700 were considered for curative surgery, including transplant in 538, and resection in 162.
The patients had a mean age of 62.8 years. Those older than 65 years were less likely to be considered or listed for transplant (27% vs. 73%, P < .01), although oncologic staging and delisting rates were similar in both groups. “This observation still holds true after controlling for other variables, including viral hepatitis and gender in the multivariable analysis (adjusted odds ratio, 0.365),” the investigators reported in the Journal of the American College of Surgeons.
The findings were also reported at the 2020 virtual Western Surgical Association 128th Scientific Session in November.
The issue of resection
Surgical intervention occurred in 597 patients, including 392 and 205 aged 65 years and younger and over 65 years, respectively.
OS was lower among patients who underwent resection, compared with the liver transplant recipients, but was similar in the older and younger age groups (3-year OS, 59% vs. 64.8% and 5-year OS, 44.8% vs. 49%; P = .13). No differences were noted in the development of local or distant metastatic disease after transplant or resection.
The two age groups had comparable ICU stays (2 days) and total hospital length of stay (6 days). There were no differences in 30- and 90-day hospital readmissions, they noted.
“On additional age analysis, 65% of transplanted patients over 65 years are currently alive and were disease free at the end of the study period, compared to only 18% of their resected counterparts (P < .01),” they wrote.
Justifying transplant
The findings are notable because despite the effectiveness of transplant as an alternative treatment for unresectable HCC, older patients are often excluded from consideration for transplant. Most studies over the past 15 years have focused on patients aged under 60 years and the ability to extrapolate results to older patients has been limited. Further, results have been conflicting in older patients, the authors explained.
“This is particularly apposite at this time with prolonged life expectancy and the growing interest in improving cancer survivorship,” they noted, adding that “there is logic in challenging existing gold standards and traditional norms with real-life medical practice.
Indeed, the current findings suggest – perhaps contrary to common perceptions – that transplant in carefully selected patients “can be justified in older age groups and provide clinically meaningful and longer survival benefits,” they said, adding that “discussions should be guided by the potential for unfair age discriminations and precise terminology of physiologic rather than actual age.
“Such insights highlight the continued need for quality improvement in the surgical management of older patients, raising questions regarding current resource utilization among different age groups and how age can influence patterns of cancer care,” they concluded.
The authors reported having no disclosures.