Cancer that starts in the liver is called primary liver cancer. It is relatively uncommon in the United States, but very common in other parts of the world. However, approximately 20,000 cases of primary liver cancer have been diagnosed in the United States each year over the past several years, and the number has increased with each subsequent year.
Primary liver cancer occurs when cancerous tumors grow within liver tissue or in the bile ducts within the liver. The first type of primary liver cancer, called hepatocellular carcinoma, is more common and is discussed in this summary.
Cancer that has started in the liver is different from cancer that has spread to the liver from another part of the body. Advances in treatments for liver cancer in the past several years have given many patients an improved outlook. Even when the cancer is too advanced or you have noncancerous liver disease that is too severe to permit surgical treatment, other treatments may still be possible.
If you have been diagnosed with liver cancer, you probably have many questions and concerns about your disease, how it is likely to be treated, and what happens when treatment is completed. This summary for patients, which is based on the NCCN Clinical Practice Guidelines in Oncology, will help you understand the best available treatments for hepatocellular carcinoma. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.
Background of Advanced Liver Cancer
The liver has many functions. Some of these functions are to produce bile, which helps in the digestion of fat; store sugar as an energy reserve in a form called glycogen; manufacture some of the building blocks of proteins; store certain vitamins and minerals (vitamins A, D, K, and B12, and iron); and produce cholesterol. The liver also helps breakdown certain harmful substances that then pass into the bile or blood and are eliminated from the body in the stool or urine.
There are several risk factors for developing primary liver cancer. Liver cirrhosis is a major risk factor and can be caused by chronic viral hepatitis infection (e.g., hepatitis B or C), alcohol abuse, and other causes. In some cases, chronic infection with hepatitis virus can lead to the development of primary liver cancer even in the absence of liver cirrhosis. However, some type of chronic liver disease is usually present before primary liver cancer begins to develop.
Diagnosing Liver Cancer
Although most people with liver cancer do not have symptoms, some may have symptoms that lead them to contact their doctors. These symptoms can include a hard lump on the right side just below the rib cage, discomfort in the upper abdomen on the right side, pain around the right shoulder blade, unexplained weight loss, jaundice (yellowing of the skin and whites of the eyes), unusual tiredness, nausea, or loss of appetite. These symptoms can also be related to other causes. Because they can be serious, anyone who has any of these symptoms should discuss them with the doctor.
Many people have had a suspicious finding based on screening. To diagnose primary liver cancer, your doctor will perform additional imaging tests to further characterize a nodule or mass found on the screening ultrasound examination. These tests can include contrast-enhanced CT, MRI, and ultrasound (if available).
In some cases, cancer can be confirmed solely on the basis of imaging tests. In other cases, a biopsy is performed. The result of the biopsy can confirm the presence of cancer.
If the mass or nodule is found to be liver cancer, your doctor will recommend another series of tests, including various blood tests and/or chest imaging, to determine how advanced the cancer is, how good your liver function is, and which treatments might be best for you.
The Pathology Report
The results of the biopsy will indicate whether the mass is, in fact, cancer. The pathology report will also assign the tumor a grade from 1 to 4 indicating how aggressive the tumor is based on how similar it is to normal liver tissue. A grade 1 tumor is likely to be less aggressive and a grade 4 is likely to be very aggressive.
Staging of Liver Cancer
Staging is a formal system for identifying how localized or widespread your cancer is. For primary liver cancer, the stages range from stage I (most localized) to stage IV (spread to distant organs in your body). A number of staging systems are available that may be used by your treatment team. Some factors included in some of these systems are how well your liver is functioning (as determined by blood tests and a physical examination) and your overall health.
In general, the lower the stage of disease, the better the chance is that your cancer can be cured. If the cancer has spread to different parts of your body, it is unlikely that your cancer can be cured; however, with appropriate management, it may be controlled and you may live a longer, higher-quality life.
Staging is an important part of developing the best treatment plan for you. Staging is used both to help you and your doctors make the most appropriate treatment decisions and to provide information about what typically happens to patients with cancers most like yours (e.g., your prognosis).
For a more detailed discussion of staging, see the Cancer Staging Guide.
Treatment of Advanced Liver Cancer
Management of advanced liver cancer requires excellent coordination of a team of doctors, including a hepatologist (specialist in liver disease), medical oncologist, interventional radiologist, and surgeon. Treatment often involves a combination of several approaches. In advanced disease, treatments delivered directly to the tumor itself (i.e., locoregional therapies) and systemic treatments that travel throughout your body through the blood system may be combined for the best effect. When one treatment regimen becomes ineffective, your doctor may recommend moving on to another. Often several approaches are used over time.
The effectiveness of your treatment depends on how localized your cancer is, whether or how far it has spread in your body, and whether you have underlying liver disease and its severity.
When the cancer is too advanced or you have noncancerous liver disease that is too severe to permit surgical treatment, other treatments may still be possible. These treatments are designed to slow the progression of the disease and reduce symptoms to provide you with the longest, best possible quality of life.
Talk with your doctor about what to expect from your treatment and how side effects can be prevented, reduced, managed, or eliminated. Some side effects can be anticipated and you can receive treatment to reduce their severity. Generally, reducing side effects does not affect the effectiveness of treatment.
Your doctor should provide you with a written care plan explaining what treatments you will have, when and how often (if you will have targeted therapy) they will occur, and what side effects you may experience.
You will also be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect.
It is very important that you ask your doctor or nurse every question you have. Liver cancer and its treatment are complicated, and most patients have questions.
Locoregional Therapies
Ablation, Embolization, and Radiation Therapy
Locoregional therapies are used to destroy or reduce the size of a tumor and help alleviate symptoms associated with the disease. If your cancer is localized but you cannot have surgery or undergo a liver transplant, locoregional therapies such as ablation, embolization, or radiation therapy may be recommended. They may also be used in combination with systemic treatments to control the tumor and improve quality of life.
Ablation destroys the tumor by focusing the treatment directly in it. This treatment is usually reserved for small tumors (≤ 3 cm), but it may be used in combination with embolization if larger tumors are present.
Some types of ablation use changes in temperature to destroy the tumor. For example, radiofrequency ablation uses radiowaves to heat the tumor, and cryoablation freezes the tumor. Chemoablation involves injection of a chemical substance, usually ethanol or acetic acid, directly into the tumor.
Embolization uses small particles injected into the arteries supplying blood to the liver tumor to block the flow of nutrients and oxygen to the tumor. Embolization is often the preferred locoregional therapy to treat larger tumors (> 5 cm).
With chemoembolization, chemotherapy drugs are injected into the artery to help kill the tumor cells.
Radioembolization uses the same principle except that radioactive substances are embedded in small particles to deliver radioisotopes directly to the tumor through the artery. Tumor cells are selectively destroyed by radiation.
Radiation therapy, which uses high-energy beams to destroy the tumor, is another option for people who cannot undergo surgery. Because the healthy portion of the liver and its surrounding blood vessels that supply it with nourishment are delicate structures that must be protected, specific and very targeted techniques are used to direct the radiation to the tumor.
Systemic Therapy
Systemic (drug) therapy to slow the progress of the cancer may be used to treat localized liver cancer that cannot be surgically removed or to treat a person with disease that has spread beyond the liver.
Sorafenib, a newer targeted therapy, is directed toward certain processes occurring in tumor cells. It interferes with the growth of liver cancer cells and blocks the development of blood vessels that supply nutrients to the tumor. Sorafenib has improved the outlook for some people with liver cancer, especially if they have good liver function. Because it is not clear how much patients with worse liver function will benefit from or be able to tolerate this drug, NCCN recommends using it with caution in patients with less than good liver function.
Managing Symptoms of Liver Cancer
Treatment for advanced liver cancer can help alleviate some of the symptoms of the disease. However, even if you and your doctor agree that you are too sick to undergo treatment for the liver cancer, your doctor still may be able to treat your symptoms and improve your quality of life. Common symptoms are pain, fatigue, and loss of appetite, and each of these can be helped with proper care. There is no reason to suffer needlessly. Let your doctor or nurse know if you have troublesome symptoms so that together you can decide how they should be addressed.
Prognosis
In determining a prognosis—the likely course or outcome of a disease and its treatment—your doctor may look at survival statistics taken from studies of large groups of liver cancer patients. However, such statistics:
- Are estimates only and cannot be used to predict outcomes for a particular person
- Can vary widely with each stage of liver cancer
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment options
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health, including other diseases you have
- The stage and grade of your liver cancer
- Your response to the treatment(s) being used
Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life.
New therapies and combinations of therapies are enabling people with liver cancer to live longer, with better-quality lives than ever before. You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental therapies are used and may be compared with standard treatments. More information is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.