INTRODUCTION HCC is the fifth most common cancer in the US, and with a 5-year survival rate of 18%, the second most lethal tumor after pancreatic cancer.1 Liver transplantation (LT) is a remarkable therapeutic option for patients with liver cancer. In addition to removing the tumor, LT has the advantage of curing the underlying liver disease. LT within Milan criteria is associated with 60%–80% survival at 5 years and 50% at 10 years.1 For patients with more aggressive disease, however, the treatment options are much more limited and survival time drastically decreases. In an effort to optimize patient selection and allocation policy, the Organ Procurement and Transplant Network (OPTN)2 and United Network for Organ Sharing have developed multiple policy changes in regard to liver transplant for patients with HCC. On February 4, 2020, OPTN/United Network for Organ Sharing implemented a new organ distribution system called the “acuity circles” (AC) model. With this policy change, AC are used where the median Model for End-Stage Liver Disease (MELD) at Transplant (MMaT) is calculated for transplant centers within a 250 nautical mile radius around donor hospitals, and patients with HCC are listed for transplant with a MELD exception score of MMaT-3. Although the policy change is still new and recent, the current available official data released by the OPTN suggest that this new policy places patients with HCC at a disadvantage for 2 main reasons: an increase in the number of liver cancer patients removed from the list due to death or becoming too sick for transplant and fewer patients with HCC receiving transplants after policy. Increased waitlist removal Once a patient is listed for transplant, he or she may be removed for 1 of 3 reasons: transplantation, death, or change in clinical status.3 Waitlist removal is thus an important metric to gauge whether a transplant policy is appropriately providing patients with life-saving organs before their disease progresses to a point beyond transplant or even death. Before the policy change, patients qualifying for HCC exception points comprised 2.5% of those who were removed from the waitlist. Postpolicy overall, that percentage increases to 3.1%. Meanwhile, the waitlist removal rate for patients without HCC exception status remained unchanged.4 In a 2021 retrospective analysis, Bernards and colleagues demonstrate that transplant candidates with HCC were 344% more likely to be removed from the waitlist in the post-AC policy era compared with the prepolicy era in longer waitlist regions (cause-specific hazard ratio (CHR), 1.31, p=0.001). Meanwhile, in shorter waitlist regions, candidates with HCC were 10% more likely to dropout postpolicy compared with those without HCC (CHR, 1.10, p = 0.24).5 Furthermore, while there was concern that compensated patients with HCC were placing decompensated non-HCC patients at a disadvantage with the prior allocation policy systems, the MMaT-3 has now placed decompensated patients with HCC at a significant disadvantage. HCC patients with a MELD-Na score of 21–25 at the time of listing were at higher risk of waitlist dropout compared with those with MELD-Na<15 (CHR, 2.26, 95% CI, 1.99–2.57, p<0.001). Those with a MELD-Na score of >25 were at even higher risk of being removed from the waitlist (CHR, 8.55, 95% CI, 7.54–9.70, p<0.001).5 Decreased liver transplant rates Overall, across all MELD scores, patients with HCC exception points are now being transplanted at a lower rate compared with preceding policy eras. There was a notable drop in transplant rate from the National Liver Review Board system, which immediately preceded the AC model, from 79/100 active person-years (95% CI, 74–85) to 57 (95% CI, 53–61). This point is further solidified with the release of the 12-month report, which demonstrated a clear decrease in number of transplants for HCC patients prepolicy to postpolicy across almost all OPTN regions.6 One particular group of interest is those listed with a MELD/PELD score of 15–28. This population is of utmost importance because it represents the vast majority of HCC patients listed for transplant. The OPTN reports demonstrate that 95% of transplant centers have a MMaT of 31 or less. Therefore, most patients with HCC are listed with MMaT-3 within this 15–28 category. Data from the OPTN again demonstrate a significant decrease in transplant rate from 197 in the National Liver Review Board system to only 126 per 100 active person-years postpolicy without overlapping CIs.4 Although there is a paucity of data available because of the relatively recent implementation of this AC-based allocation policy, the official data presented by the OPTN insofar has demonstrated that this new allocation system clearly puts patients with liver cancer at a disadvantage. But Patients with HCC are already advantaged and overprioritized? Since the onset of MELD exception points for patients with HCC, numerous policy changes have been implemented to appropriately allocate organs for patients awaiting liver transplant. However, the original purpose of the AC policy was not to address any perceived advantages that patients with HCC had in the transplantation allocation process, but rather to respond to concern by the HRSA regarding OPTN Final Rule Section 121.8, paragraph a(8), which states that allocation policies “shall not be based on place of residence or place of listing.”7 In addition, the most recent allocation policy change aimed at patients with HCC was the “cap and delay” policy introduced in 2015, and this substantially reduced any advantages that HCC patients previously had over non-HCC patients in regard to access to transplant. As per Ishaque and colleagues, this policy led to comparable waitlist mortality/dropout for both HCC and non-HCC candidates with the same allocation MELD (9.3% vs. 9.6%). In addition, the rate of waitlist dropout was actually higher for HCC candidates, 1.93-fold over 24 months postpolicy (p<0.001).8 In a large single-study cohort of patients with HCC who dropped out of the liver transplant waiting list due to tumor progression between 2000 and 2016, Gorgen et al9 demonstrated that prognosis after dropout is dismal with a median survival after dropout of 3 months. Role of locoregional therapy Although LT is the gold-standard, curative-intent therapy for patients with unresectable HCC meeting Milan criteria, a role for locoregional therapy (LRT) has emerged as a potential bridging therapy with the goal of slowing tumor progression while the patient awaits curative treatment through transplant. In their official HCC guidelines, the American Association for the Study of Liver Diseases does suggest utilizing LRT to bridge to transplant in those within Milan to decrease progression of disease and subsequent waitlist dropout. However, the quality/certainty of evidence for this recommendation is very low and the strength of Recommendation is Conditional.10 In a multicenter study analyzing 3601 patients with HCC who underwent LT, Agopian and colleagues demonstrated that bridging LRT did not improve survival and did not decrease post-transplant recurrence. In fact, those patients who received both transarterial chemoembolization and ablation had a 52% higher rate of recurrence than those not receiving any therapy. Those who received 3 or more treatments had an inferior 5-year recurrence-free survival rate and an increased risk of post-LT recurrence compared with those receiving 2 or fewer treatments. The only benefit of LRT came to those who received complete pathologic response on explant, but those who did not actually had worse outcomes than with no treatment, including a higher rate of HCC recurrence (HR: 1.32, p = 0.044).11 Additional studies from Xu et al12 and Ravaioli et al13 demonstrated similar findings of higher rates of recurrence in those who received LRT and had only partial necrosis.12,13 Although there may still be a role for bridging LRT, these findings simply highlight that tumors are often unpredictable and dynamic and that prolonged waitlist times, not to mention waitlist dropout, are detrimental to patients with liver cancer. CONCLUSIONS A perfect organ transplant allocation policy remains a moving target. However, the most recently adopted AC policy has led to clear disadvantages for patients with HCC because of increased rates of waitlist removal/dropout and decreased rates of transplantation based on official OPTN data. The benefits and success of bridging LRT in decreasing disease progress remains controversial and does not present a worthy alternative to transplantation in patients with liver cancer.