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 explains the treatments, also known as therapies, that are the standard of care for hepatocellular carcinoma (HCC). “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to discuss with your doctor whether clinical trials are an option. A clinical trial is a research study that tests a new approach to treatment. Doctors learn through clinical trials whether a 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. Clinical trials are an option for all stages of cancer. 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.
How liver cancer is treated
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, nurse practitioners, 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 the 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 care. Shared decision-making is particularly important for liver cancer because there are different treatment options. Learn more about making treatment decisions.
The various disease-directed treatment options for liver cancer can be grouped according to whether they may cure the cancer or if they 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 of the liver, or if 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 is a surgery in which the patient's liver is removed and replaced by healthy liver tissue from a donor. This procedure is possible only when specific criteria are met, including having a certain tumor size and number of tumors and whether a suitable donor is found. These criteria are usually either having a single tumor that is 5 cm or smaller or having 3 or fewer tumors, all of which are smaller than 3 cm. It is important to note 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, the body's rejection of the donor liver, and the possibility of an increased risk of other unrelated cancers.
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.
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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.
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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).
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Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. 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 of SBRT 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.
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Disease-directed treatments to help patients live longer
If the doctor feels the cancer cannot be cured using the treatments listed above or if the cancer is at a more advanced stage, the doctor may recommend one 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 extend 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 (see "Surgery," above).
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.
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Systemic therapy for advanced HCC
The treatment plan for later stage HCC may include medications to destroy cancer cells. Medication may be given through the bloodstream to reach cancer cells throughout the body. When a drug is given this way, it is called systemic therapy. Medication may also be given locally, which is when the medication is applied directly to the cancer or kept in a single part of the body.
This treatment is generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. Medications are often given through an intravenous (IV) tube placed into a vein using a needle, an injection into a muscle or under the skin, or as a pill or capsule that is swallowed (orally). If you are given oral medications, be sure to ask your health care team about how to safely store and handle them.
The types of medications 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 therapy” 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 medication at a time or a combination of medications 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, causing unwanted side effects or reduced effectiveness. 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 and limits damage to healthy cells.
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. Unlike many anti-angiogenesis therapies, which are taken as pills, bevacizumab is given intravenously.
Lenvatinib. In 2018, the FDA approved an anti-angiogenesis targeted therapy called lenvatinib. This drug is approved as a first treatment for HCC that cannot be removed by surgery. It is taken as a pill that is swallowed (orally).
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).
Ramucirumab. Ramucirumab is another anti-angiogenesis therapy approved for treating HCC that has high levels of the tumor marker alpha-fetoprotein (AFP) for patients who have already received sorafenib. It is given intravenously.
Cabozantinib. In 2019, the FDA approved the use of cabozantinib to treat HCC for people who have previously received sorafenib. It is taken as a pill that is swallowed (orally).
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. It is taken as a pill that is swallowed (orally).
Side effects of targeted therapy can vary but may include high blood pressure, back pain, headaches, changes in taste, fatigue, diarrhea, appetite loss, joint and muscle pain, weight loss, abdominal pain, rash, redness, itching or peeling of the skin on the hands and feet, hoarseness, bleeding, change in thyroid hormone levels, and nausea. Talk with your doctor about the possible side effects for a specific medication and how they can be managed.
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.
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Immunotherapy (updated 10/2022)
Immunotherapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells. 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.
Immunotherapies for HCC include:
Nivolumab. 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 a type of immunotherapy called immune checkpoint inhibitors, which means they work to block the pathways that would otherwise allow the cancer to hide from the immune system. 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. Atezolizumab is an immune checkpoint inhibitor, and bevacizumab is an anti-angiogenesis therapy (see "Targeted therapy" above).
Tremelimumab (Imjudo) and durvalumab (Imfinzi). In 2022, the FDA approved the combination of 2 immunotherapy drugs, tremelimumab and durvalumab, for the treatment of people with HCC that cannot be removed with surgery. Both tremelimumab and durvalumab are immune checkpoint inhibitors.
Other immunotherapy drugs, including durvalumab (Imfinzi) and tremelimumab, are still being studied in clinical trials but have shown promise in treating HCC. 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.
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In addition to the treatment options described above, your 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 the Latest Research areas in HCC.
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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 that 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 surgery or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the recommended treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options. Many patients also benefit from talking with a social worker and participating in support groups. Ask your doctor about these resources, too.
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.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
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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 surgery, 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 people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of your health care team. It may also be helpful to talk with other patients, such as through a support group or other peer support program.
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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).
If a recurrence happens, a new cycle of testing will begin again to learn as much as possible about it. 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 recurrent liver cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer sometimes experience emotions such as disbelief, fear, or disappointment that the first treatment did not entirely eliminate the cancer. You are encouraged to talk with your health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.
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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 some 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 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.
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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.