Liver Cancer: Overview

Treatment

How liver cancer is treated will depend on several factors, like what stage you were diagnosed at and your overall health.

“Primary liver cancer is treatable if discovered early — and if discovered early, there are actually several potentially curative options,” says Dr. Robert Brown, chief of division of gastroenterology and hepatology at Weill Cornell Medicine and NewYork-Presbyterian/Weill Cornell Medical Center. ” Increasingly, we are able to to give treatment to get larger tumors down to a size that you can try and manage.”

If your cancer is early stage and contained within the liver, your doctor will likely recommend some type of surgery such as resection, where part of your liver is removed, or a full transplant to replace your diseased liver with a healthy one. This may even lead to a cure.

“Transplant is very successful. And people can live a completely normal life after transplant, with a normal life expectancy, excellent quality of life,” says Dr. Brown.

However, even if your cancer is caught in a more advanced stage where surgery is not an option, there still may be some potential treatments that can help you.

Your treatment plan may include one of the below approaches — or a combination of several.

Early Stage Treatment:

• Surgery (liver resection)
• Liver Transplantation

Later Stage treatment:

• Chemotherapy
• Radiation therapy
• Targeted therapy
• Immunotherapy
• Ablation (using techniques like radiofrequency ablation or microwave ablation to treat small tumors)

The best care takes a multidisciplinary approach — this means you’ll have a team of doctors with different specialties, like surgery or medical oncology.

“I would recommend being seen at a tertiary cancer center, preferably a high volume one where they see a lot of patients with liver cancer and preferably one with an National Cancer Institute designation, because then you know that you’re getting the multidisciplinary care that you need,” Dr. Eskander advises.

Eskander says that because there are so many nuances to liver cancer treatment, you want to make sure you go to a center that can offer you the latest treatments and a diverse group of specialists to ensure you have comprehensive care. She notes that one thing to look for is whether or not the care center offers clinical trials which gives patients access to the latest and most promising treatments available.

Your care team will collaborates to formulate a comprehensive yet tailored strategy. Your specialized team may consist of a:

• Surgical oncologist — a doctor who treats cancer with surgery
• Radiation oncologist — a doctor who treats cancer with radiation therapy
• Medical oncologist — a doctor who treats cancer with medicines such as chemotherapy, targeted therapy, or immunotherapy
• Hepatologist or a gastroenterologist — a doctor who specializes in treating diseases of the digestive system, including the liver
• Interventional radiologist — a doctor who specializes in procedures such as ablations and embolizations

“We kind of individualized treatment based on a few factors. Stage is definitely an important consideration in deciding the best treatment. So an earlier stage cancer may be appropriate for something like surgical resection. However, there’s other factors also such as the patient’s condition, their medical comorbidities and what their goals are in care,” says Dr. Rajiv Kinkhabwala, a clinical assistant professor in the department of medicine at NYU Grossman School of Medicine.

“Someone who may not want to undergo aggressive surgery or transplant can certainly be offered non-surgical techniques that may be less likely to affect their function and allow them to continue to work and perform their daily activities without much interruption,” he adds.

“Other patients who may want a much more aggressive approach to trying to cure their cancer could be candidates for a big operation such as hepatectomy for example,” he says.

Treating Advanced Liver Cancer

Advanced liver cancer means that the disease has progressed beyond the point where it can’t be surgically removed or cured with localized treatments. Instead, the focus shifts to managing symptoms, slowing the progression of the disease, and improving the quality of life for as long as possible.

While the prognosis for advanced liver cancer can be daunting, there is hope. Treatment options are increasing.

Currently, treatment options may include:

• Chemotherapy
• Targeted Therapy
• Immunotherapy
• Radiation Therapy
• Clinical Trials

As doctors learn more about cancer, more drugs that target specific markers that help cancer grow or spread are becoming available.

An example of a targeted drug for advanced liver cancer is Cabometyx. It is a medication that has been successful in helping some liver cancer patients live longer by slowing down the growth of their tumors. It works by blocking special proteins known as enzymes that help cancer cells grow.

Clinical trials are also an important consideration, Dr. Eskander says.

“The National Comprehensive Cancer Network believes that the best management for any patient with cancer is in a clinical trial. So I want to say that upfront,” she says. “But clinical trials are not the last resort – they can actually be a first resort. And so I bring them up early. I include them in the list of treatment options I have for a patient.”

Risk Factors

As Dr. Kinkhalwala noted, there are many factors — both inherited and environmental — that can increase a person’s risk of developing liver cancer.

Some of these include:

• Chronic viral hepatitis (having a long-term hepatitis B virus or hepatitis C virus infection)
• Cirrhosis (a disease in which liver cells become damaged and are replaced by scar tissue)
• Significant alcohol use
• Tobacco use
• Being overweight/obese
• Nonalcoholic fatty liver disease (extra fat in the liver that is not caused by alcohol)
• Type 2 diabetes
• Hemochromatosis (a condition where the body takes up and stores more iron than it needs)

In the U.S., liver cancer is also more common among certain races. Asian Americans and Pacific Islanders have the highest rates of liver cancer, followed by Latin Americans, Native Americans, and Black Americans.

The disease is also significantly more common in men than in women.

Dr. Milan Kinkhabwala explains liver cancer risk factors.

“An emerging public health crisis is the development of obesity and diabetes in the population, which causes inflammation in the liver and over time can actually cause liver cancer,” Dr. Kinkhabwala added. “So fatty liver is now becoming much more important in the United States as one of the causes of liver cancer.”

Signs and Symptoms

Symptoms of liver cancer are often very subtle, so many people don’t pick up on them until the disease has progressed, Dr. Kinkhabwala explained.

For example, people with liver cancer may experience abdominal discomfort, typically concentrated on the right side near the rib cage, where the liver is located.

Jaundice, characterized by yellowing of the eyes or darkened urine, can also manifest, stemming from heightened bilirubin levels in the bloodstream. Additionally, abdominal swelling, indicative of liver failure, may arise in some patients. However, these symptoms often signify an advanced stage of the disease.

Here are some symptoms of liver cancer to be aware of:

• Jaundice (yellowing of your skin and the whites of your eyes)
• Intensely itchy skin
• White or clay-like stool (acholia)
• Dark urine (choluria)
• Fatigue
• Abdominal pain on the right side, just below the ribs
• Losing weight without trying
• Fever
• Night sweats

Do I Need Screening?

Screening involves testing for cancer in people who don’t have any symptoms or a history of cancer. Currently, there aren’t widely recommended screening tests for liver cancer in individuals with an average risk.

However, some individuals at higher risk may be advised to undergo testing. People at elevated risk for liver cancer, such as those with long-standing cirrhosis (scar tissue in the liver due to damage), may undergo tests if their condition worsens without an obvious cause.

For those with a higher risk, some experts suggest screening for liver cancer every 6 months using alpha-fetoprotein (AFP) blood tests and ultrasound exams.

Getting Diagnosed

First, it’s important to understand exactly what type of liver cancer you have.

There are two main types:

• Hepatocellular carcinoma (HCC): This is the most common type, starting in the main liver cells called hepatocytes. HCC accounts for the majority of liver cancer cases and can occur in those with chronic liver diseases, like cirrhosis.
• Cholangiocarcinoma: Also known as bile duct cancer, this type begins in the small, tube-like bile ducts within the liver that help to move bile to the gallbladder. It’s less common but can be particularly challenging to treat.
  Liver cancer incidence is steadily rising, and it is the third leading cause of cancer deaths worldwide. There are more than 30,000 new cases of liver and  bile duct cancer diagnosed each yar.

Because liver cancer does not typically cause obvious symptoms, detecting tiny spots on the liver requires special techniques used by skilled specialists.

If you’re experiencing symptoms of liver cancer, your doctor will start with a physical exam.

During this exam, they will:

• Feel your abdomen to check the liver, spleen, and nearby organs
• Look for any fluid buildup in your abdomen (ascites)
• Examine your skin and eyes for signs of jaundice

If liver cancer is suspected, you may need one or more of the following tests to diagnose it and determine if it has spread:

• Blood tests — These can detect substances like alpha-fetoprotein (AFP), which may indicate liver cancer
• Imaging tests — This may include an ultrasound, CAT scan, or MRI scan
• Biopsy — This involves removing a small sample of tissue from the tumor to examine it under a microscope
• Genomic/Molecular Profiling — This testing can identify specific biomarkers that help determine the best treatment options and clinical trials for liver cancer

How is Liver Cancer Staged?

Liver cancer is often staged using the TNM (tumor, nodes, metastasis) system.

• Tumor Size (T): How large has the cancer grown? Is there more than one tumor in the liver? Has the cancer reached nearby structures like the veins in the liver? In general, the higher the number, the larger and/or more invasive the cancer.
• Lymph nodes (N): has the cancer spread to nearby lymph nodes?
• Metastasis (M): has the cancer spread to distant organs such as the bones or lungs?

When your doctor is deciding on your treatment, they also need to consider how effectively your liver is functioning. This is especially important if you have liver damage, like cirrhosis. Doctors use a system called Child-Pugh to rate your liver function.

Unfortunately, if your liver is severely damaged, you might not be healthy enough to undergo cancer treatment.

Doctors commonly rely on the Barcelona Clinic Liver Cancer (BCLC) staging system to guide treatment choices for hepatocellular carcinoma. This system assesses factors such as the number and size of liver tumors, your liver function, and your overall health.