ON THIS PAGE: You will learn about the different treatments doctors use for people with liver cancer. Use the menu to see other pages.
This section tells you the treatments that are the standard of care for HCC. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.
Treatment options and recommendations depend on several factors:
How much of the liver is affected by the cancer
Whether the cancer has spread
The patient’s preferences and overall health
The damage to the remaining cancer-free area of the liver
When a tumor is found at an early stage and the patient’s liver is working well, treatment is aimed at trying to eliminate the cancer. The care plan may also include treatment for symptoms and side effects, an important part of cancer care. When liver cancer is found at a later stage, or the patient’s liver is not working well, the patient and doctor should talk about the goals of each treatment recommendation. At this point, the goals of treatment may focus on slowing growth of the cancer and relieving symptoms to improve quality of life.
Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called "shared decision making." Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your different treatment options. Learn more about making treatment decisions.
The various disease-directed treatment options can be grouped according to whether they may cure the cancer or will improve survival but will most likely not eliminate the cancer. Descriptions of the most common treatment options, both disease-directed and those aimed at managing side effects and symptoms, are listed below.
Disease-directed treatments to eliminate and potentially cure HCC
These treatments are most likely to be recommended when the tumor has been found at an early stage. They may not be recommended to treat later stages of disease. These treatments are surgery, radiofrequency ablation, percutaneous ethanol injection, and radiation therapy.
Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is likely to be the most successful disease-directed treatment, particularly for patients with good liver function and tumors that can be safely removed from a limited portion of the liver. Surgery may not be an option if the tumor takes up too much of the liver, the liver is too damaged, the tumor has spread outside the liver, or the patient has other serious illnesses. A surgical oncologist is a doctor who specializes in treating cancer using surgery. A hepatobiliary surgeon also has specialized training in surgery on the liver and pancreas. Sometimes, liver transplant surgeons are involved in these operations. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.
Two types of surgery are used to treat HCC:
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 in 1 part of the liver and the liver is working well. The remaining section of liver takes over the functions of the entire liver. The liver may grow back to its normal size within a few weeks. A hepatectomy may not be possible if the patient has advanced cirrhosis, even if the tumor is small.
The side effects of a hepatectomy may include pain, weakness, fatigue, and temporary liver failure. The health care team will watch for signs of bleeding, infection, liver failure, or other problems that need immediate treatment.
Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when specific criteria are met, including tumor size and number and whether a suitable donor is found. These criteria usually are a single tumor that is 5 cm or smaller or 3 or fewer tumors, all of which are smaller than 3 cm. It is important to understand that the number of available donor livers is very limited, so transplantation is not always an option.
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 come back. The patient must take medication to prevent rejection. These drugs can cause side effects, such as puffiness in the face, high blood pressure, or increased body hair. Liver transplant has significant risks of serious complications, including death from infection or the body's rejection of the donor liver.
Liver transplantation is a particularly effective treatment for people with a small tumor because transplantation removes the tumor and the damaged liver. However, there are few donors, and people waiting for a liver transplant may have to wait for a long time before a liver becomes available. During this time, the disease may get worse. The transplant center will advise you on how long the wait is likely to be and what rules are used to prioritize people on the waiting list.
Radiofrequency ablation (RFA)
RFA and microwave therapy both use heat to destroy cancer cells. They may be given through the skin, through laparoscopy, or during a surgical operation while a patient is sedated. Sedation is giving medication to become more relaxed, calm, or sleepy. This treatment approach is also called thermal ablation.
Percutaneous ethanol injection
Percutaneous ethanol injection is when alcohol is injected directly into the liver tumor to destroy it. Side effects include fever and pain after the procedure. In general, the procedure is simple, safe, and particularly effective for a tumor smaller than 3 cm. However, if the alcohol escapes from the liver, a person may have brief but severe pain. This option is rarely used and has been largely replaced by RFA (see above).
Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.
Stereotactic body radiation therapy (SBRT). SBRT is a term that describes several methods of delivering high doses of radiation therapy to a tumor while limiting the amount of radiation to nearby healthy tissue. This is important because healthy liver tissue can be damaged by radiation. SBRT effectively treats tumors that are about 5 cm or smaller. However, it is still considered investigational compared to RFA (see above) because there is not much available information about its long-term effectiveness.
Side effects may include damage to the stomach and lungs. However, these side effects can often be prevented. Talk with your health care team about avoiding and managing possible side effects. Learn more about the basics of radiation therapy.
Disease-directed treatments to help patients live longer (updated 11/2020)
If the doctor feels the cancer cannot be cured using the treatments listed above or the cancer is at a more advanced stage, the doctor may recommend 1 of the following options to shrink the tumor and/or slow tumor growth. While these treatments will most likely not eliminate the cancer, they have been shown to improve how long patients can live.
Chemoembolization and radioembolization for disease confined to the liver
Chemoembolization is a type of chemotherapy treatment that is similar to hepatic arterial infusion (see below). Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. During this procedure, drugs are injected into the hepatic artery, and the flow of blood through the artery is blocked for a short time so the chemotherapy stays in the tumor longer. Blocking the blood supply to the tumor also destroys cancer cells.
In addition to being used as a primary treatment for HCC, chemoembolization may be used to slow tumor growth for people who are on the waiting list for liver transplantation.
Radioembolization is similar to chemoembolization, except that during radioembolization, a doctor places radioactive beads into the artery that supplies the tumor with blood. The beads deliver radiation therapy directly into the tumor when they become trapped in the small blood vessels of the tumor.
Systemic therapy for advanced HCC (updated 11/2020)
Systemic therapy is the use of medication to slow the growth of or kill cancer cells. Medications circulate through the body and therefore can reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle, an injection into a muscle or under the skin, or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for advanced HCC include:
The first-line treatment is the initial treatment given. First-line therapy options for advanced HCC include:
The combination of bevacizumab (Avastin, see “Targeted therapy” below), with atezolizumab (Tecentriq, see "Immunotherapy" below) may be offered to some patients with advanced HCC.
Targeted therapy with sorafenib (Nexavar) or lenvatinib (Lenvima) may be offered to people who are unable to receive atezolizumab with bevacizumab. See more under “Targeted therapies” below.
A second-line treatment is given if the first-line treatment does not work. Second-line therapy options for advanced HCC include:
Cabozantinib (Cabometyx; a targeted therapy)
Regorafenib (Stivarga; a targeted therapy)
Ramucirumab (Cyramza; a targeted therapy)
The combination of atezolizumab and bevacizumab
Pembrolizumab (Keytruda) or nivolumab (Opdivo), which are a type of drug called immune checkpoint inhibitors (see “Immunotherapy” below)
This information is based on the ASCO guideline, “Systemic Therapy for Advanced Hepatocellular Carcinoma.” Please note that this link takes you to another ASCO website.
Targeted therapies and immunotherapies are discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy. The medications used to treat cancer are continually being evaluated. Your doctor may suggest clinical trials that are studying new ways to treat HCC.
Talking with your doctor is often the best way to learn about the medications that can be prescribed for you, their purpose, and their potential side effects. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.
Targeted therapy is drug treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.
For HCC, anti-angiogenesis drugs are the most common type of targeted therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor.
Some anti-angiogenesis therapies are for people with unresectable HCC. Unresectable means that surgery is not an option.
Anti-angiogenesis therapies include:
Bevacizumab with atezolizumab. In 2020, the U.S. Food and Drug Administration (FDA) approved the combination of the anti-angiogenesis targeted therapy, bevacizumab, with atezolizumab, an immunotherapy drug (see "Immunotherapy" below), for people with unresectable or metastatic HCC who have not received previous cancer treatment using medications. Side effects of bevacizumab include high blood pressure, back pain, headaches, and changes in taste. Unlike many anti-angiogenesis therapies, which are taken as pills, bevacizumab is given intravenously.
Lenvatinib. In 2018, the FDA approved another anti-angiogenesis targeted therapy, called lenvatinib. This drug is approved as a first treatment for HCC that cannot be removed by surgery. The most common side effects of this drug include high blood pressure, fatigue, diarrhea, and thyroid abnormalities.
Sorafenib. Sorafenib is used to treat advanced HCC that cannot be completely removed with surgery. It is taken as a pill that is swallowed (orally). The most common side effects of sorafenib include diarrhea, fatigue, and certain skin problems, along with other less common ones.
Ramucirumab. Ramucirumab is another anti-angiogenesis therapy approved for treating HCC that has high levels of the tumor marker AFP for patients who have already received sorafenib. The most common side effects of ramucirumab include fatigue, abdominal pain, and nausea.
Cabozantinib. In 2019, the FDA approved the use of cabozantinib to treat HCC for people who have previously received sorafenib. The side effects of cabozantinib include diarrhea, fatigue, decreased appetite, and nausea.
Regorafenib. In 2017, the FDA approved the use of another targeted therapy, regorafenib, to treat people with HCC that was previously treated with sorafenib. Regorafenib also inhibits angiogenesis, and it is also used to treat colorectal cancer and gastrointestinal stromal tumors. It is taken as a pill that is swallowed (orally). Side effects include diarrhea and skin problems.
Talk with your doctor about the possible side effects for a specific medication and how they can be managed.
Immunotherapy (updated 11/2020)
Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. One common type of immunotherapy is called an immune checkpoint inhibitor. Immune checkpoint inhibitors work by blocking the pathways that would otherwise allow the cancer to hide from the immune system.
Nivolumab (Opdivo). In 2017, the FDA approved an immunotherapy called nivolumab for the treatment of HCC. Nivolumab can be used to treat people who have already been treated with sorafenib, which is a type of targeted therapy.
Pembrolizumab. In 2018, the FDA approved the immunotherapy pembrolizumab for the treatment of people with HCC. Like nivolumab, pembrolizumab can be used to treat people who have previously been treated with sorafenib. Pembrolizumab is an immune checkpoint inhibitor.
Nivolumab with ipilimumab (Yervoy). In 2020, the FDA approved the use of the combination of nivolumab with another immunotherapy drug called ipilimumab (Yervoy) to treat patients with HCC who have already been treated with sorafenib. Both nivolumab and ipilimumab are immune checkpoint inhibitors.
Atezolizumab with bevacizumab. In 2020, the FDA approved the use of the combination of atezolizumab, an immunotherapy drug, with bevacizumab, a targeted therapy drug, for people with unresectable or metastatic HCC who have not received previous cancer treatment using medications. Unresectable means surgery is not an option. Atezolizumab is an immune checkpoint inhibitor, and bevacizumab is an anti-angiogenesis therapy (see "Targeted therapy" above).
Other immunotherapy drugs are still being studied in clinical trials. Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your health care team about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.
Other clinical trials
In addition to the treatment options described above, the doctor may suggest participating in a clinical trial that is evaluating a new treatment approach for HCC. This is particularly important for a disease like HCC, where options for treating advanced disease are very limited and there is ongoing research to find more treatment options. Learn more about Latest Research areas in HCC.
Physical, emotional, and social effects of cancer
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
If HCC has spread to another location in the body, it is called metastatic cancer. People with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan and cancer care team. This discussion may include clinical trials studying new treatments.
Your treatment plan may include a combination of chemotherapy, targeted therapy, radiation therapy, and/or other options. At this stage, the goal of treatment is typically to slow the cancer’s growth. Palliative care will also be important to help relieve symptoms and side effects.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Remission and the chance of recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above, such as surgery and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.
If treatment does not work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.