Primary liver cancer is cancer that begins in the liver. It is more common for the liver to be the site of metastasis (spreading) from other cancers, such as pancreas, colon, stomach, breast, or lung cancer. However, these are not primary liver cancer. For more information about cancer that started in another part of the body and spread to the liver, please see Cancer.Net's information for that type of cancer.
This section deals only with adult primary liver cancer.
The liver is the largest internal organ in the body, and its functions are vital to the digestion of food. No one can survive without a liver. Functions of the liver include:
Collecting and filtering blood from the intestines
Processing and storing needed nutrients absorbed from the intestines
Chemically metabolizing (changing) some nutrients into energy or to repair and build tissue
Producing some of the body's blood clotting factors
Removing toxic wastes from the body
Helping maintain the proper sugar level in the body
The subtypes of adult primary liver cancer are named for the type of cell from which they develop.
Adult Primary Liver Cancers
Type of Liver Cancer
Description
How Common
Hepatocellular carcinoma (HCC)
Hepatocellular carcinoma can follow different growth patterns. Some spread tentacle-like growths through the liver. This pattern is the most common one in the United States. Others start as a single tumor that spreads to other parts of the liver later in the disease. Still others develop as nodules at several different places in the liver. Occasionally, a pattern isn't clear.
Most (about 90%) adult primary liver cancers are hepatocellular carcinomas.
Cholangiocarcinomas grow from cells in the bile duct of the liver. The bile duct is a thin tube that extends from the liver to the small intestine. The bile duct starts inside the liver as several smaller tubes that join together.
About 9% of adult primary liver cancers are cholangiocarcinomas. For more information, please review Cancer.Net's Guide to Bile Duct Cancer
Angiosarcoma
Angiosarcoma starts in the blood vessels of the liver and grows very rapidly.
About 1% of adult primary liver cancers are angiosarcomas. For more information, please read Cancer.Net's Guide to Sarcoma.
Statistics
In 2008, an estimated 21,370 adults (15,190 men and 6,180 women) in the United States will be diagnosed with liver cancer. An estimated 18,410 deaths (12,570 men and 5,840 women) from the disease will occur this year. Liver cancer is the fifth most common cause of cancer death among men, and ninth most common cause of cancer death among women.
The five-year relative survival rate (percentage of patients who survive at least five years after the cancer is detected, excluding those who die from other diseases) of patients with liver cancer is 11%.
Unlike many other forms of cancer, the number of people who develop and die from liver cancer is increasing. Liver cancer is much more common in developing countries within Africa and East Asia. In some countries, it is the most common cancer type.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with liver cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts and Figures 2008.
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
The following factors can raise a person’s risk of developing HCC. The main risks in the United States are chronic liver infection with the hepatitis B or hepatitis C virus or cirrhosis of the liver. HCC usually develops several decades after such an infection starts.
Viral hepatitis. Viral hepatitis is the largest risk factor for this type of cancer. Hepatitis viruses are viruses that infect the liver. Two common types are hepatitis B and hepatitis C. People who are carriers of the hepatitis B virus face up to a 100-fold increased risk of developing adult primary liver cancer.
Viral hepatitis can be transmitted through exposure to another person's blood or bodily fluids through injury, by sharing needles during drug use, or by sexual contact. In the case of hepatitis B, an unborn baby or infant can become infected from an infected mother, although this can be avoided by vaccinating the baby. If you develop acute hepatitis B or C and then "clear the virus," you have no increased risk of liver cancer. Only people who don’t clear the virus (those who become "carriers") are at an increased risk. Your doctor will be able to perform blood tests that tell if you have cleared the virus.
Cirrhosis. Cirrhosis develops when liver cells are damaged and are replaced by scar tissue. Most cirrhosis in the United States is caused by alcohol abuse. Other causes are viral hepatitis (types B and C, as mentioned above), too much iron in the liver from a disease called hemochromatosis, and some other, rare types of chronic liver disease.
Age. In the United States, adult primary liver cancer occurs most often in people over age 60.
Gender. Men are more likely than women to develop this type of cancer.
Environmental factors. Some environmental factors may increase the risk of liver cancer, such as exposure to certain chemicals or eating foods contaminated with the mold aflatoxin.
Risk factors are cumulative, meaning that having more than one risk factor increases the risk even more. For instance, a person who carries both hepatitis B and C has a higher risk than a person carrying one type of the virus.
Prevention
Most cases of HCC in the United States can be avoided by preventing viral hepatitis and cirrhosis. A vaccine can protect healthy people from contracting hepatitis B. In fact, the U.S. Centers for Disease Control and Prevention recommends that all children should have this vaccination. There is no vaccine against hepatitis C, which is most often associated with present or previous intravenous (IV) drug abuse. Blood banks in the United States check donated blood to make certain that blood infected with hepatitis viruses is not used.
Cirrhosis can be avoided by not abusing alcohol and preventing viral hepatitis. Most industrialized countries have regulations to protect people from cancer-causing chemicals; in the United States, such regulations have virtually eliminated these chemicals as a cause of adult primary liver cancer.
There is increasing evidence that certain medications can control chronic hepatitis B or C infection, and thereby reduce the inflammation they cause in the liver. This may reduce the risk of cancer development, particularly if the medications are taken before cirrhosis develops. It is recommended that information about such treatment come from a hepatologist, a doctor who specializes in diseases of the liver.
If you know you have cirrhosis or other risk factors, it is important to discuss with your doctor whether you should be regularly screened for liver cancer. Early detection, before any symptoms have developed, may increase the likelihood of successful treatment. Hepatologists are the doctors with the most experience in screening for primary liver cancer. You will also see the term "surveillance" used to explain this, but, in effect, this means the same as screening.
People with HCC may experience no symptoms, particularly when the tumor is detected early as part of a screening program. When symptoms do occur, they include:
Pain, especially at the top right of the abdominal area or near the right shoulder blade, or in the back
Weight loss
A hard lump under the ribs on the right side of the body, indicating either the tumor itself or that the liver has increased in size
Weakness or fatigue (tiredness)
At the time of diagnosis of HCC, some people will already know that they have cirrhosis and will already be under the care of a doctor. Some symptoms experienced by patients with HCC may be attributable to the associated cirrhosis rather than the tumor itself, and these include abdominal swelling due to ascites (fluid accumulation), or the individual may find that he or she needs increasing amounts of diuretics (water tablets) to control the abdominal fluid accumulation. Hepatic encephalopathy (mental confusion) and bleeding from the esophagus or stomach, or any worsening of the condition, may also indicate cancer.
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer
Severity of symptoms
Previous test results
The following tests may be used to diagnose HCC:
Physical examination. If a person has symptoms of HCC, the doctor will feel the abdomen to check the liver, spleen, and other nearby organs for lumps, swelling, or other changes. The doctor will also look for an abnormal buildup of fluid in the abdomen and for signs of jaundice (yellowing of the skin and whites of the eyes).
Blood tests. At the same time as the physical examination, the doctor will most likely do a blood test to look for a substance called alpha-fetoprotein (AFP). In the United States, AFP is found in elevated levels in the blood of about 50% to 70% of people who have adult primary liver cancer. The doctor will also test for the presence of hepatitis B or C. Other blood tests can show how well the liver is working.
In addition, other tests are commonly needed to diagnose HCC and to determine the location of the tumor in the liver and if it has spread to other parts of the body. After the physical examination and blood tests, the doctor may order one or more of the following tests:
Imaging tests
Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves bounce off the liver, other organs, and tumors. Each creates a different appearance on a computer monitor.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Usually a special dye is injected into the patient’s vein before the CT scan is done. The dye helps the liver and tumors show up more clearly.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. Sometimes an MRI can distinguish a benign (noncancerous) tumor from a malignant (cancerous) one.
Angiogram. An angiogram is an x-ray picture of the blood vessels. This test may be done in a hospital, and the person may be given a general anesthetic. A dye is injected into the bloodstream, so the blood vessels of the liver show up on an x-ray.
Surgery
Laparoscopy. A laparoscopy uses a thin, lighted tube to look at the liver and other internal organs. The tube is inserted through a small incision in the abdomen. The procedure is usually done under sedation and local anesthetic to numb the area; it doesn’t usually require a general anesthetic.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis (unless the AFP level is extremely high; see Blood Tests above). The sample removed is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluates cells, tissues, and organs to diagnose disease). The type of biopsy performed will depend on the location of the cancer. The biopsy can be taken during a laparoscopy, by fine needle aspiration (cells are removed using a thin needle inserted into the tumor), or by using a thick needle (a core biopsy). Most often it is done by a radiologist who follows the track of the needle using ultrasound to direct him or her to the particular part of the liver he or she wants to obtain the tissue from. The actual biopsy procedure usually lasts for less than one minute. It is typically not painful, and complications only arise in a very small number of cases. Your doctor will test your blood for its ability to clot before this procedure to decrease risk of bleeding after the procedure.
When the AFP test strongly indicates HCC, and the imaging and the clinical picture are typical of HCC, an increasing number of doctors are deciding that a biopsy may not be necessary. Also, if surgical removal of the tumor is being considered, most surgeons will recommend that a biopsy is done as part of the operation, rather than a separate procedure beforehand.
It is also important to note that, with newer imaging technology, very small masses are increasingly being found. However, it is not always possible to identify what these tumors are and determine if they represent a risk to the patient’s health. Under these circumstances, particularly when the mass is one centimeter or less in size, the doctor may recommend a "watch and wait" (also called active surveillance and watchful waiting) approach, repeating the scan in three to six months. If the later scan shows that the size hasn’t changed, the surveillance approach is continued. If it grows, however, the doctor will then do a biopsy.
There are two types of liver cancer: primary and metastatic. Primary liver cancer begins in the liver, whereas metastatic (secondary) liver cancer has spread to the liver from a cancer that started in another part of the body. For information about staging of secondary liver cancer, read the Cancer.Net Guide to Cancer
for the primary cancer, because there are different stage descriptions for different types of cancer. For example, lymphoma that has spread to the liver is still staged as lymphoma.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery).
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the site and location of the tumor. If there is more than one tumor, the lowercase letter "m" (multiple) is added to the "T" category. Specific tumor stage information for HCC is listed below.
TX: The primary tumor cannot be assessed.
T0: There is no evidence of a primary tumor.
T1: The tumor is 2 centimeters (cm) or smaller. It does not involve adjacent blood vessels.
T2: Either of these:
Any tumor that involves adjacent blood vessels is present.
Multiple tumors, none larger than 5 cm, are present.
T3: Either of these conditions:
More than one tumor larger than 5 cm is present.
The tumor involves the veins around the liver.
T4: Either of these conditions:
The tumor has spread to the organs near the liver (except the gallbladder).
The tumor is present with perforation (an abnormal opening) of the visceral peritoneum (layer of tissue that lines the abdomen).
Node. The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the liver are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The regional lymph nodes cannot be assessed.
N0: Cancer has not spread to the regional lymph nodes.
N1: The cancer has spread to the regional lymph nodes.
Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: The tumor cannot be assessed.
M0: The cancer has not metastasized.
M1: There is metastasis to another part of the body.
Cancer stage grouping
Doctors assign the stage of the HCC by combining the T, N, and M classifications.
Stage I: This is the earliest stage of HCC. The tumor has not spread to the blood vessels, lymph nodes, or other parts of the body (T1, N0, M0).
Stage II: The tumor involves nearby blood vessels, but it has not spread to the regional lymph nodes or other parts of the body (T2, N0, M0).
Stage IIIA: The cancer has not spread beyond the liver, but the area of the cancer is larger than stage I or II, and it often has invaded nearby blood vessels (T3, N0, M0).
Stage IIIB: The cancer has spread to organs near the liver, but the cancer has not spread to nearby lymph nodes or other parts of the body (T4, N0, M0).
Stage IIIC: Any tumor that has spread to the regional lymph nodes but not to other parts of the body (any T, N1, M0).
Stage IV: Any tumor that has spread to other parts of the body (any T, any N, M1).
HCC is different from other types of cancers, in that its treatment is determined not only by the staging (using the TNM system) but also by the degree of liver dysfunction. For example, early stage disease may not always be removable by surgery because the liver is seriously damaged (usually with cirrhosis) and there would not be sufficient liver reserve to support life after an operation. Therefore, sometimes a patient’s condition is described using the four descriptions below as well as the stage.
Localized resectable: Cancer is in one place in the liver, and the other part of the liver is healthy. The cancer is resectable, meaning it can be removed through surgery.
Localized unresectable: Cancer is found in one part of the liver, but it cannot be removed by surgery (unresectable).
Advanced: Cancer has spread throughout the liver and/or to other parts of the body, such as the lungs and bones.
Recurrent: Cancer has recurred (come back) after treatment. It may recur in the liver or another part of the body.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of HCC depends on the size and location of the tumor, whether the cancer has spread, and the patient’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.
Surgery, radiation therapy, and chemotherapy are used to treat HCC. The type of treatment selected for an individual depends on a number of factors:
Whether the cancer is only in the liver
Whether the cancer is only in the area where it started or has spread widely throughout the liver
The patient’s general health
The extent of damage to the remaining (tumor-free) area of the liver
Surgery
Two types of surgery may be used to treat HCC. The affected part of the liver may be removed, or a liver transplantation may be done. Surgery is likely to be the most successful treatment; it is most successful in patients with small tumors (smaller than 5 cm). If the tumor has spread outside the liver, or if the patient has other serious illnesses, surgery may not be an option.
Hepatectomy. When a portion of the liver is removed, the surgery is called a hepatectomy. A hepatectomy can be done only if the cancer is limited to one part of the liver, and the liver is otherwise functioning well. The remaining section of liver takes over the functions of the entire liver and can, in some cases, regrow to its normal size within a few weeks. A hepatectomy may not be possible if the patient has an advanced stage of cirrhosis even if the tumor is small.
The side effects of a hepatectomy may include pain, weakness, and fatigue, and a temporary period of liver failure. The health-care team will watch for signs of bleeding, infection, liver failure, or other problems requiring immediate treatment.
Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when the cancer is confined to the liver, a suitable donor is found, and very specific criteria are fulfilled.
After a transplant, the patient will be watched closely for signs that the body might be rejecting the new liver, or that the tumor has recurred. The patient must take medication to prevent the rejection, and the drugs can have side effects, such as puffiness in the face, high blood pressure, or increased body hair.
Liver transplantation is a particularly effective treatment for people with small tumors, as the transplant removes both the tumor and the liver dysfunction that often accompanies HCC. However, there is only a limited number of donors, and people awaiting a liver transplant may have a long waiting period until a liver becomes available. The disease may continue to advance during the waiting period. The transplant center will advise you as to how long the wait is likely to be, and what rules are used to prioritize people on the waiting list.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. External-beam radiation therapy is radiation given from a machine outside the body. This approach is seldom used for HCC. However, some centers are now using internal radiation therapy for HCC, which is radiation therapy given through an implant inserted in the body.
Internal radiation therapy for HCC involves placing radioactive beads into the artery that supplies the tumor with blood in a manner similar to chemoembolization (see below). Depending on the type of radiation therapy used, your doctor will explain radiation protection issues and the side effects that may be expected.
The general side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. For internal radiation therapy, there may be such side effects as damage to the stomach and lungs. However, these can often be avoided by special pre-treatment preventive measures.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. The patient may receive one drug or a combination of drugs. Two types of delivery are used to treat HCC:
Systemic chemotherapy treatment. Systemic chemotherapy is typically injected into a vein, so that it travels through the bloodstream to the whole of the body with the aim of killing cancer cells both inside and outside the liver.
Regional chemotherapy treatment. A small pump is surgically placed in the body to deliver anticancer drugs directly to the blood vessels that feed the tumor.
Common side effects include nausea and vomiting, loss of appetite, diarrhea, fatigue, low blood count, bleeding or bruising after minor cuts or injuries, numbness and tingling in the hands or feet, headaches, hair loss, and darkening of the skin and fingernails. Side effects usually go away when treatment is complete.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Targeted therapy
Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Anti-angiogenic drugs block the formation of new blood vessels that are needed for a tumor to grow and spread. Sorafenib (Nexavar, Nexovar) is an anti-angiogenic drug that is being studied for HCC. Sorafenib is administered orally (by mouth). In current research, significant improvements were seen in survival in people with advanced HCC (from about 8 months to 10.5 months), with only modest side effects that include diarrhea and certain skin complications. In November 2007, the Food and Drug Administration (FDA) approved sorafenib for the treatment of patients with advanced HCC.
Other options
All treatment is more effective when the tumor is small; many doctors will not use these treatments if the tumor is larger than 5 cm in diameter.
Radiofrequency ablation (RFA) and microwave therapy both use heat to kill the cancer cells. It may be applied under sedation through the skin, through laparoscopy, or during a surgical operation.
Percutaneous ethanol injection uses alcohol injected directly into the liver tumor to kill it. Side effects include fever and pain following the procedure, but the procedure is generally very simple, safe, and particularly effective for tumors smaller than 3 cm in diameter. If the alcohol escapes from the liver, however, there may be a brief episode of severe pain.
Cryosurgery uses extreme cold to freeze and kill cancer cells.
Hepatic arterial infusion uses an anticancer drug injected into a catheter that has been placed in the major artery supplying blood to the liver. This treatment is a type of chemotherapy, but it does not have as many side effects.
Chemoembolization is a procedure similar to hepatic arterial infusion. However, with this method, the flow of blood through the artery is blocked for a short time, so the anticancer drug stays in the tumor longer. The blocking of the blood supply to the tumor also kills cancer cells. Recently, two clinical trials (research studies) have provided evidence that this form of treatment can prolong survival in some patients. In addition to being used for primary treatment of the HCC, chemoembolization may be used to slow down the growth of a tumor in people who are on the waiting list for liver transplantation.
Biologic therapy (also called immunotherapy) uses the body's own immune system to fight cancer. Materials (made by the body or in the laboratory) enhance or restore the body's natural defenses against cancer. Side effects of biologic therapy are similar to the flu and can include fatigue, fever, chills, muscle pain, and headache.
In addition to the treatment options described above, the doctor may suggest that the patient enroll in a clinical trial, which is a research study that evaluates new treatments.
Advanced HCC
Advanced HCC is cancer that has spread throughout the liver and to other parts of the body. At this stage, the goal of treatment is typically not to cure the cancer, but to slow the disease’s growth and make the patient more comfortable. Treatment for advanced HCC may include chemotherapy (including sorafenib, see above), radiation therapy, or both. Palliative care can reduce pain, control symptoms, and make the patient’s quality of life better.
Cancer and cancer treatment can cause a variety of side effects; some are easily controlled and others require specialized care. Below are some of the side effects that are more common to HCC and its treatments. For more detailed information on managing these and other side effects of cancer and cancer treatment, visit the Cancer.Net's Managing Side Effects section.
Diarrhea. Diarrhea is frequent, loose, or watery bowel movements. It is a common side effect of certain chemotherapeutic drugs or of radiation therapy to the pelvis, such as in women with uterine, cervical, or ovarian cancers. It can also be caused by certain tumors, such as pancreatic cancer.
Fatigue (tiredness). Fatigue is extreme exhaustion or tiredness, and is the most common problem that people with cancer experience. More than half of patients experience fatigue during chemotherapy or radiation therapy, and up to 70% of patients with advanced cancer experience fatigue. Patients who feel fatigue often say that even a small effort, such as walking across a room, can seem like too much. Fatigue can seriously impact family and other daily activities, can make patients avoid or skip cancer treatments, and may even impact the will to live.
Hair loss (alopecia). A potential side effect of radiation therapy and chemotherapy is hair loss. Radiation therapy and chemotherapy cause hair loss by damaging the hair follicles responsible for hair growth. Hair loss may occur throughout the body, including the head, face, arms, legs, underarms, and pubic area. The hair may fall out entirely, gradually, or in sections. In some cases, the hair will simply thin-sometimes unnoticeably-and may become duller and dryer. Losing one's hair can be a psychologically and emotionally challenging experience and can affect a patient's self-image and quality of life. However, the hair loss is usually temporary, and the hair often grows back.
Infection. An infection occurs when harmful bacteria, viruses, or fungi (such as yeast) invade the body and the immune system is not able to destroy them quickly enough. Patients with cancer are more likely to develop infections because both cancer and cancer treatments (particularly chemotherapy and radiation therapy to the bones or extensive areas of the body) can weaken the immune system. Symptoms of infection include fever (temperature of 100.5°F or higher); chills or sweating; sore throat or sores in the mouth; abdominal pain; pain or burning when urinating or frequent urination; diarrhea or sores around the anus; cough or breathlessness; redness, swelling, or pain, particularly around a cut or wound; and unusual vaginal discharge or itching.
Nausea and vomiting. Vomiting, also called emesis or throwing up, is the act of expelling the contents of the stomach through the mouth. It is a natural way for the body to rid itself of harmful substances. Nausea is the urge to vomit. Nausea and vomiting are common in patients receiving chemotherapy for cancer and in some patients receiving radiation therapy. Many patients with cancer say they fear nausea and vomiting more than any other side effects of treatment. When it is minor and treated quickly, nausea and vomiting can be quite uncomfortable but cause no serious problems. Persistent vomiting can cause dehydration, electrolyte imbalance, weight loss, depression, and avoidance of chemotherapy.
Pain. Depending on the stage of disease, 30% to 75% of all patients experience pain from cancer. About 85% to 95% of cancer pain can be treated successfully. Pain can make other aspects of cancer seem worse, such as fatigue, weakness, sleep disturbance, and confusion. Pain can come from the tumor itself or may be a result of cancer treatment. Pain from a tumor can be a result of the tumor growing and spreading to the bones or other organs and putting pressure on and damaging nerves. Pain from surgery is normal and may persist for months or years. Common procedures that cause pain afterward include mastectomy (removal of the breast and, occasionally, the surrounding tissue), chest surgery, neck surgery, and amputation of a limb (stump pain). Phantom pain is perceived pain in an organ or limb that has been removed. Pain may develop after radiation therapy and go away on its own. It can also develop months or years after treatment, especially after radiation therapy to the chest, breast, or spinal cord. Certain chemotherapeutic drugs can cause pain along with numbness in the fingers and toes. Usually this pain goes away when treatment is finished, but sometimes the damage can be permanent.
Skin problems. The skin is an organ system that contains many nerves. Because of this, skin problems can be very painful. Because the skin is on the outside of the body and visible to others, many patients find skin problems especially difficult to cope with. Because the skin protects the inside of the body from infection, skin problems can often lead to other serious problems. As with other side effects, prevention or early treatment is best. In other cases, treatment and wound care can often improve pain and quality of life. Skin problems can have many different causes, including chemotherapeutic drugs leaking out of the intravenous (IV) tube, which can cause pain or burning; peeling or burned skin caused by radiation therapy; pressure ulcers (bed sores) caused by constant pressure on one area of the body; and pruritus (itching) in patients with cancer, most often caused by leukemia, lymphoma, myeloma, or other cancers.
After treatment for HCC ends, talk with your doctor about developing a follow-up care plan. This plan will include regular physical examinations, imaging tests (such as ultrasound), and blood tests to monitor your recovery for the coming months and years.
Careful follow-up care is crucial after all treatment approaches. Follow-up care will not only measure how effective the treatment has been, but also allow early detection of any recurrence (return) of the disease. This is particularly important because there is always a risk that the tumor will recur after treatment, or that another tumor will develop.
The prevention of second cancers and recurrence of HCC is an area of active research, but at the present time, there is no standard preventive treatment. Patients recovering from HCC are encouraged to follow established guidelines for good health, such as avoiding alcohol, maintaining a healthy weight, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help you rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
General questions
Am I a carrier of hepatitis B or C? What does this mean?
Do I have cirrhosis of the liver? What does this mean?
What is my diagnosis? What is the exact type of liver cancer?
What is the stage of my cancer? What does this mean?
What are my treatment options?
What clinical trials are open to me?
What treatment do you recommend? Why?
What is the goal of this treatment?
Do I need treatment right away?
For patients who need surgery
Will my liver be removed?
Will I need a liver transplantation?
If I need a liver transplant, am I likely to be prioritized on the transplant waiting list because I have cancer? How long should I expect to wait?
What are the possible side effects of my surgery, in the short term and the long term?
Will I need to stay in the hospital for this surgery? If so, for how long?
For patients who need chemotherapy/immunotherapy
What type of therapy will I be receiving?
How will it be delivered (through an IV, a catheter, or a pill)?
What does the preparation for this treatment involve?
What side effects can I expect from this treatment?
What can be done to relieve the side effects?
For patients who need radiation therapy
What type of radiation therapy is recommended?
What is the goal of the radiation therapy?
How long will it take to give the radiation therapy?
What side effects can I expect from this treatment?
What can be done to relieve the side effects?
After treatment
What are the chances that the tumor will return?
What follow-up tests do I need, and how often do I need them?
Research involving more advanced diagnostic procedures and treatment for HCC is ongoing. The following advancements may still be under investigation in clinical trials and may not be approved or available at this current time. Always discuss all diagnostic and treatment options with your doctor.
Cancer vaccines. These are experimental treatments that may help the patient's immune system recognize and attack HCC cells. Sometimes, the vaccine is given with an immune system stimulant, such as GM-CSF (sargramostim).
Combination chemotherapy. Different drugs kill cancer cells in different ways. Using a combination of drugs increases the chance that the tumor will be destroyed; many times the first drug will help the second drug work better.
Gene therapy. This new treatment changes a gene to fight cancer. Although gene therapy is in the very early stages of development, some clinical trials are already underway. In one example, the new gene makes an anticancer drug work better. In this therapy, a gene can be directly injected into the tumor. The doctor then gives the patient the inactive drug; this new gene helps activate the drug at the site of the tumor.
Anti-angiogenesis drugs. The formation of new blood vessels that feed tumors is known as angiogenesis. Some scientists think that by cutting off a tumor’s blood supply, it may be possible to starve the tumor to stop it from growing. Several anti-angiogenic agents are being extensively tested in clinical trials, and the agent sorafenib, which in part may be active by a pathway that inhibits angiogenesis has recently undergone a successful clinical trial that suggested improvement in survival. Sorafenib is discussed in the Treatment section. Several other "targeted treatments" are currently being investigated for treatment of HCC.
Combining therapies. Several centers are looking into whether combining treatments, such as RFA and chemoembolization, is more effective than single treatments.
Greater use of liver transplantation. The possibility of expanding the criteria for liver transplantation (allowing more patients to be eligible) is being actively investigated for HCC.
Doctors and scientists are always looking for better ways to treat patients with HCC. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating HCC. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with HCC.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
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