Increasing Age and Survival after Orthotopic Liver Transplantation for Patients with Hepatocellular Cancer Joseph Kim, MD, FACS, Michelle E Ko, BA, Rebecca A Nelson, PhD, Amanda Arrington, MD, Carrie Luu, MD, Ann E Falor, MD, Nicholas N Nissen, MD, FACS, Steven Colquhoun, MD, FACS, Arti Hurria, MD, Gagandeep Singh, MD, FACS BACKGROUND: Orthotopic liver transplantation (OLT) is the gold standard treatment for patients with early hepatocellular carcinoma (HCC). There are concerns about the efficacy of OLT for HCC in older patients, who we hypothesized might have poorer outcomes. Therefore, we sought to examine advanced age and its impact on OLT outcomes. STUDY DESIGN: The United Network for Organ Sharing database was queried for patients who underwent OLT for HCC from 1987 to 2009. Patients were divided into 3 age groups: 35 to 49 years old, 50 to 64 years old, and 65 years or older, and patient characteristics were compared. Univariate and multivariate analyses were performed to assess the impact of age on OLT outcomes. RESULTS: Of 10,238 patients with OLT for HCC, 16.5% (n ¼ 1,688) of patients were 35 to 49 years old, 67.8% (n ¼ 6,937) were 35 to 49 years old, and 15.8% (n ¼ 1,613) were 65 years and older. By Kaplan-Meier method, the 50- to 64-year-old age group had the highest overall survival, despite having one of the highest rates of hepatitis C positivity (70%), but this group also had the lowest rate of diabetes mellitus (8.7%). The lowest overall survival was observed in the 65-year or older age group (p < 0.001). Finally, there was no difference in disease- specific survival among the age groups (p ¼ 0.858), and patients aged 65 years and older had the highest rate of death from nonhepatic causes (17.5%). CONCLUSIONS: Although OS was prolonged in younger patients who underwent OLT for HCC, there was no observed difference in disease-specific survival among the age groups. Our results suggest that carefully selected patients 65 years of age and older can derive equal benefit from OLT for HCC when compared with their younger counterparts. (J Am Coll Surg 2014;218: 431e438. Ó 2014 by the American College of Surgeons) Hepatocellular carcinoma (HCC) remains a major cause of morbidity and mortality worldwide. 1 Although the inci- dence of HCC remains relatively low in the United States, it is one of the few cancers that is rising, with incidence rates that have nearly tripled during the past 2 decades. 1 Impor- tantly, this increase coincides with the aging of the US pop- ulation. Estimates show that by the year 2020, at least 20% of the United States will be 65 years of age or older. 2 Considering the median age of HCC diagnosis (ie, 64 years) and the peak age of HCC incidence (ie, 70 years), the aging of the US population is an important public health concern. 1,3 Such concerns are compounded by investiga- tions reporting inferior outcomes in older compared with younger patients with HCC. 4 With advancing age, physical deterioration is inevitable and is accompanied by increased rates of age-related med- ical comorbidities, eg, coronary artery disease and dia- betes mellitus. 5,6 Not surprisingly, older cancer patients have exhibited inferior outcomes, including shorter sur- vival, when compared with younger patients diagnosed with the same cancers. 4,7-11 This disparity is particularly CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Received October 7, 2013; Revised November 25, 2013; Accepted December 3, 2013. From the Division of Surgical Oncology, Department of Surgery (Kim, Ko, Arrington, Singh), Department of Biostatistics (Nelson), and Department of Medical Oncology and Experimental Therapeutics (Hurria), City of Hope Comprehensive Cancer Center, Duarte, Department of Surgery, Har- bor-UCLA Medical Center (Luu, Falor), Division of Transplant Surgery, Department of Surgery (Nissen, Colquhoun), Cedars-Sinai Medical Center, Los Angeles, CA. Correspondence address: Joseph Kim, MD, FACS, Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Rd, Duarte, CA 91010. email: jokim@coh.org 431 ª 2014 by the American College of Surgeons ISSN 1072-7515/13/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.001