INTRODUCTION In February 2020, a liver transplant allocation policy based on acuity circles was implemented. This included the conversion of each transplant hospital’s median Model for End-stage Liver Disease (MELD) score at transplant (MMaT) to reflect transplants performed at hospitals within a radius of 250 nautical miles. The simulation modeling suggested that this policy would reduce pretransplant deaths and geographic variation in MELD scores at the time of transplant. Liver cancer is an indication for liver transplant. In the new system, patients with HCC were eligible for the standardized MELD exception of MMaT minus 3. We believe this new liver allocation system is appropriate for patients with HCC. In the early 2000s, the mandate by the Department of Health and Human Services to allocate livers to the sickest patients prompted the implementation of the MELD. However, it was apparent early on that the MELD model did not incorporate the likelihood of HCC disease progression. This increased the risk of waitlist dropout for patients with HCC whose cancer progressed beyond the acceptable criteria for transplant.1 This prompted the allotment of MELD exception points to patients with HCC. Although the addition of exception points had good intentions, it gave HCC patients an unnecessary and unfair advantage. With these changes, liver transplantation for HCC skyrocketed from 5% in 2001 to 30% in 2020 (Figure 1).2 The pendulum had swung too far in the opposite direction, and there have been consistent efforts to balance it for the last 20 years. From 2002 to 2005, the exception points for T2 lesions went from 29 to 22, and T1 lesions were no longer granted the exception points. In 2015, a mandatory 6-month delay was implemented, after which 28 exception points were granted. Despite this, still >30% of liver transplants were for HCC.FIGURE 1: The percentage of liver transplantation for HCC from year 1987 to 2017. After the addition of MELD exception points, liver transplantation for HCC has increased from 5% in 2001 to 30% in 2020.Although these changes were instituted to make allocation more equitable, the MELD exception system continued to give an unnecessary and unfair advantage to patients with HCC.3 A major reason for this is the advancement of treatment options. The treatment landscape that existed in 2001 is drastically different from the treatment landscape in 2021. Locoregional therapy is readily available and has been proven to be not only effective as bridging therapy to transplant but is also curative in some cases. For patients receiving radiation segmentectomy for a solitary lesion <5 cm, the 1-year survival ranges from 96% to 100%, which is better than reported 1-year survival rates for liver transplant (Figure 2).4 Furthermore, the 3- and 5-year survival for lesions under 3 cm is comparable to the survival rates of patients who undergo transplantation for HCC within Milan criteria (Figure 3). These data show that granting HCC patients the artificial exception points is simply unnecessary and unfair.FIGURE 2: Overall 1-year survival in all the patients treated with radiation segmentectomy as reported in Lewandowski and colleagues.FIGURE 3: One-, 3-, and 5-year survival for lesions under 3 cm is comparable to survival rates of patients who undergo transplantation for HCC within Milan criteria.In fact, Mehta and colleagues clearly showed that the patients with HCC ≤3 cm in size have a waitlist dropout rate of <10% over 2 years (Figure 4A).5 From 2005 to 2011, across all United Network for Organ Sharing regions, the waitlist dropout was lower for patients with any HCC compared with patients without HCC (Figure 4B).6 Patients with small tumors clearly have excellent survival and should not be prioritized over patients with a high natural meld and, more importantly, a higher 90-day mortality.FIGURE 4: (A) Cumulative incidence of waitlist dropout of patients based on tumor size and number of lesions. (B) Waitlist dropout for patients with any HCC compared with patients without HCC.For example, consider 2 patients: 1 patient has HCC with a lesion <3 cm with a natural MELD of 18 one year ago. On the basis of the previous allocation system, this patient will accumulate a MELD score of 34 after 1 year. This puts them at equal prioritization as a patient with decompensated cirrhosis with a MELD score of 34, whose 90-day survival is <50%. In contrast, patient with HCC has a 1-year survival of 100% and a 5-year survival of 75%, even in the absence of transplant. We believe that we should follow the mandate of the Department of Health and Human Services to prioritize liver allocation to the sickest patients with the highest risk of short-term mortality, which in this case is not the patient with HCC. The most recent change in the HCC-related MELD exception rules not only attempts to address the inappropriate granting of MELD exception points but also inequities that exist between United Network for Organ Sharing organ allocation regions.7 By giving all HCC patients the same MELD exception score regardless of the region, the system created equality whereby patients were treated equally but failed to achieve equity, where all patients were granted the same chance for a transplant. Given this geographic inequity, an acuity circle model was implemented in February 2020. The implementation of this model led to a significant decrease in the variance of MMAT among different regions. The variance in median allocation meld at transplant decreased by 50% (9.97–4.33) with the implementation of acuity circles (Figure 5).8FIGURE 5: Variance in median allocation meld at transplant decreased by 50% (9.97–4.33) with implementation of acuity circles.Patients with HCC were previously overprioritized and given unnecessary and unfair exception points. The prior systems disadvantaged non-HCC patients, as they have far higher waitlist dropout rates when compared with HCC patients.9 We believe this new allocation system allows for the appropriate prioritization of liver transplant donor organs for patients with liver cancer. TEACHING POINTS Patients with HCC were previously overprioritized for transplant, as they were given an unnecessary and unfair advantage to receive liver transplant as evidenced by lower waitlist dropout rates when compared with non-HCC patients. Locoregional therapy in 2021 is not what it was in 2021. Radiation segmentectomy can be curative in select patient populations with survival rates comparative to liver transplantation, thus precluding the need to overprioritize this patient population. Implementation of acuity circles has decreased the variance in median meld scores at transplant, significantly reducing regional disparities.