- Liver cancer makes up about 2 percent of cancer cases in the U.S. and is the leading cause of cancer-related deaths worldwide.
- Liver cancer is rarely detected early since many signs and symptoms do not appear until the disease is at an advanced stage.
- Individuals who are suspected to be at high risk of developing liver cancer, including heavy drinkers and those with chronic HBV/HCV infections, should get routine screening tests every 6 to 12 months.
- The general 5-year survival rate is 18% for liver cancer
The Liver and Liver Cancer
The liver is the largest internal organ in the human body that lies just below the ribs in the upper right side of the abdomen. It is the only internal organ capable of natural regeneration of lost tissue. The liver is the powerhouse of the body. It is involved in regulating many different body functions and regulating different aspects of metabolism within the body. One of the most essential functions of the liver is to produce bile, a fluid that is released into the small intestine to aid in digestion and break down lipids. Another important role of the liver is cleansing the blood. The liver cells, called hepatocytes, break down toxic and unnecessary substances, such as alcohol and drugs, found in the blood and discharge them by means of urination or excretion. The liver also manufactures clotting factors needed to stop bleeding, and stores nutrients for the body. With so many functions, the liver is essential for sustaining life, and any damage to the liver can be fatal.
Liver cancer, also referred to as hepatic cancer, is a rare but serious form of cancer in the liver. The disease occurs when hepatocytes develop mutations in their DNA, which causes the cells to grow out of control and form into a tumor. It is difficult to detect liver cancer in its beginning stages since many signs and symptoms are often vague and do not appear until the cancer is at an advanced stage. Liver cancer is often incurable and it is for this very reason why it is important to stay on top of your liver health.
How Common is Liver Cancer?
Liver cancer is relatively rare in the United States, accounting for approximately 2 percent of all cancer cases. Although the condition is rare, the chances of developing liver cancer are high for people with risk factors for the condition. Being that liver cancer is often diagnosed in more advanced stages, treatment options become limited, causing liver cancer to be the leading cause of cancer-related deaths worldwide.
This year, an estimated 40,710 adults (29,200 men and 11,510 women) in the United States will be diagnosed with primary liver cancer. Since 1980, the incidence of liver cancer has tripled. Men are about 3 times more likely than women to be diagnosed with the disease.
It is estimated that 28,920 deaths (19,610 men and 9,310 women) from this disease will occur this year. Liver cancer is the 10th most common cancer and the 5th most common cause of cancer death among men. It is also the 8th most common cause of cancer death among women.
When compared with the United States, liver cancer is much more common in sub-Saharan Africa and Southeast Asia. In some countries, it is the most common cancer type.
What Causes Liver Cancer?
The exact cause of liver cancer is unknown. However, there are a number of factors that can increase one’s risk of developing liver cancer. These include:
Age – although possible, liver cancer is unlikely to develop in people before the age of 40. However, it most commonly afflicts individuals over the age of 60.
Gender – both men and women are at risk of developing liver cancer, yet, men are more likely to develop liver cancer than women by a ratio of 2 to 1.
Ethnic group – liver cancer is present in all populations. However, liver cancer rates are highest in those with Asian or Pacific Islander descent.
Medical conditions – individuals with cirrhosis, the scarring of the liver, have a significantly higher risk of developing liver cancer. Cirrhosis may be caused by chronic hepatitis B or hepatitis C viral infections, or alcoholism. Studies also show that those with diabetes are at a greater risk of developing liver cancer than those who do not have diabetes. In addition, people with non-alcoholic fatty liver disease (NAFLD) are also at an increased risk of developing liver cancer. Inherited metabolic diseases that disrupt the normal metabolism of the body, such as hemochromatosis and Wilson’s disease, have also been shown to increase the risk of developing liver cancer.
Obesity – studies suggest that there is a link between obesity and liver cancer. The higher an individual’s BMI is, the higher the risk of developing liver cancer.
Alcohol – excessive alcohol consumption can significantly increase an individual’s risk of developing liver cancer. Acetaldehyde is a known carcinogen and a product of alcohol metabolism that is more toxic than alcohol itself. Heavy drinking and long-term consumption of alcohol will directly cause irreversible damage to the DNA of the hepatocytes.
Signs & Symptoms of Liver Cancer
Initial symptoms of liver cancer are often ambiguous. Common symptoms and signs of individuals with liver cancer experience may include:
- Pain and/or bloating in the abdomen
- Poor appetite
- Feeling full after a small meal
- Unexplained weight loss
- Weakness or fatigue
- Itchy skin
- Dark-colored urine
- White-colored/pale stools
- Jaundice (yellowing of the skin and/or the whites of the eyes)
- Hepatomegaly (enlarged liver)
- Hypercholesterolemia (high cholesterol)
- Hypercalcemia (excessive calcium in the blood)
- Hypoglycemia (low blood sugar)
- Erythrocytosis (excessive red blood cells)
Symptoms will likely vary depending on the stage of the liver cancer. Most individuals do not experience symptoms in the early stages of the condition. Many symptoms are often vague and do not appear until the cancer is at an advanced stage. Thus, it is crucial for individuals to regularly checkup with their general practitioner and reduce their exposure to the known risk factors for the disease.
Types of Liver Cancers
Liver cancer is classified into either of the following two groups: primary liver cancer, when the cancer originates in the liver, or secondary liver cancer, when cancer from another part of the body spreads to the liver.
Primary Liver Cancer – there are several types of primary liver cancers based on the types of cells that become cancerous, which are further broken up into a number of different groups such as the following:
- Hepatocellular carcinoma (HCC) – the most common type of primary liver cancer. Accounts for approximately over 80 percent of primary liver cancers. HCC is a cancer that arises from hepatocytes and occurs most often in individuals with chronic liver diseases, such as cirrhosis caused by alcoholism or hepatitis B or C viral infections.
- Fibrolamellar carcinoma (FLC) – this form of liver cancer is a rare variant of HCC that mainly affects adolescents and young adults with no underlying liver issues.
- Intrahepatic cholangiocarcinoma – also known as bile duct cancer. This type of cancer is an uncommon form of liver cancer that forms in the bile ducts. It accounts for 10 to 20 percent of primary liver cancers.
- Angiosarcoma – originates in the inner lining of blood vessels of the liver. Angiosarcoma is a rare form that accounts for approximately 1 percent of all liver cancers.
- Hepatoblastoma – this is an extremely rare form of liver cancer that develops in children, usually under the age of 5. The cells of this form of cancer are similar to fetal hepatocytes.
Secondary Liver Cancer – also known as liver metastasis. This type of cancer occurs when primary cancer from another part of the body spreads to the liver. For instance, most secondary liver cancers originate from colorectal cancers. In the United States, secondary liver cancers are more common than primary liver cancers.
How to Diagnose Liver Cancer
Physical Examination – a thorough examination by a patient’s general practitioner is the first step to help determine whether a patient may have developed liver cancer. The examination will involve palpating the abdominal area to check for enlargement of the liver. A physical examination will also review any signs or symptoms of the disease the patient may be experiencing, such as dark-colored urine, pale stools, jaundice, etc. An additional factor that may suggest a patient developed the condition is if they previously had an advantaged stage of cancer in another organ in the body, such as the colon – meaning that the cancer may have metastasized to the liver. If symptoms and/or results of physical exams suggest that a patient may have liver cancer, other tests will be done. These may include lab tests, an imaging test, and other procedures.
Lab Tests – patients may get blood work done, which will show if there are any abnormalities that may indicate issues with the liver. This includes examining the alpha-fetoprotein (AFP) levels, calcium and glucose levels, and overall liver function. For instance, since low levels of AFP is normal for healthy individuals, high levels of AFP may be a sign that cancer is present. In addition, blood-clotting tests can help determine if there are problems with the liver since a damaged liver may not be making enough clotting factors. Screening for hepatitis B virus and/or hepatitis C virus in the patient’s blood may also help diagnose liver cancer since these viruses are known to affect the liver. Any alterations in these blood tests may trigger more specific liver function assessments including an ultrasound of the liver.
Imaging Tests – an ultrasound of the liver is often the initial test to visually examine the liver. The ultrasound may show any abnormal growths or tumors in the liver. Individuals who are suspected to be at high risk of developing liver cancer should get ultrasounds of their liver every 6 to 12 months. CT exams of the abdomen help determine the size and location of tumors that may be in the liver. During this exam, a CT may be performed on the chest if metastasis to the lungs is expected. Additional test patients may undergo is an angiogram. An angiogram is an x-ray test used to show if cancer is present in the blood vessels of the liver. In most cases, further tests to check for liver cancer is not usually necessary since most medical professionals can be fairly certain that an individual has the condition based on the results of their imaging tests.
Biopsy – although it is the most accurate method used to detect if cancer is present, biopsies may not be necessary when diagnosing liver cancer. A biopsy is an examination of a sample of tissue to access if there are any abnormalities that are suggestive of a disease; in this case, liver cancer. A major concern with this method is that it could potentially cause the cancer to spread, which may limit possible treatment options.
Once cancer has been detected, the next step would be to stage the cancer. The stage refers to how extent the liver cancer is. Identifying the cancer’s stage allows medical professionals to develop optimal treatment plans for patients. Lab tests and imaging tests help to clearly demonstrate the liver cancer’s stage.
Liver Cancer Staging
Cancer staging takes place after the initial diagnosis. A liver cancer stage is a way of describing how far cancer has progressed and what form that progress has taken. Judging a liver cancer stage is more complex than judging stages for other types of cancers since liver cancer patients may also have liver damage. This makes a difference in determining the prognosis and treatment possibilities. The lower the stage, the more likely it is that treatment will lead to a positive outcome. The judgment of a stage depends on the size of the tumor, the location, and the extent of the cancerous cells. Using these criteria to judge the stage of liver cancer, the stages of liver cancer are as follows:
Stage I – the cancer occupies a single area and has not grown into any blood vessels or has not spread to any lymph nodes or other organs. This stage of liver cancer can be surgically removed. Stage I liver cancer can be further classified as the following:
- Stage IA – a single tumor is 2 centimeters or smaller
- Stage IB – the tumor is 2 centimeters or larger
Stage II – at this stage, the cancer has not spread to the lymph nodes or any other part of the body. Stage II liver cancer can be a single tumor larger than 2 centimeters that have grown into a blood vessel, or several tumors smaller than 5 centimeters that have not yet grown into any blood vessels.
Stage III – this stage of liver cancer is further categorized into the following three stages:
- Stage IIIA – multiple tumors 5 centimeters or larger are present, but have not yet grown in any blood vessels, and have not spread to the lymph nodes or distant sites.
- Stage IIIB – at least one tumor of any size has grown into a major blood vessel of the liver, such as the portal vein or hepatic vein. There are no cancer cells present in the lymph nodes or in other parts of the body.
- Stage IIIC – either the cancer has spread into a nearby organ, other than the gallbladder, or the tumor has grown into the outermost layer of the liver. The cancer has not yet reached lymph nodes or distant sites in the body.
Stage IV – stage IV liver cancer is the most advanced form of the disease. This stage is further classified as the following two sub-stages:
- Stage IVA – one or several tumors of any size has grown into blood vessels and/or nearby sites, and cancer spread to nearby lymph nodes but has not spread to distant sites.
- Stage IVB – one or several tumors of any size may are present and may have grown into blood vessels and/or nearby organs. The tumor(s) may or may not have spread into lymph nodes, but the cancer has spread to distant organs, such as the lungs or bones.
How to Treat Liver Cancer
Any form of liver cancer is difficult to cure. As with many cancers, treatment depends on the type of cancer, its location, and the stage of the disease. Patients and their cancer care team will review all treatment options, including their goals and possible side effects, which will lead to the most optimal treatment plan.
First treatment if liver cancer is Chemotherapy. Chemotherapy is a potent remedy to kill cancer cells. Chemotherapy is not effective in some cases of liver cancer but the type of chemotherapy is known as chemoembolization plays a key role in management for HCC. chemoembolization causes many of the same side effects as other means of chemotherapy, including abdominal anguish, nausea. Second management is surgery. Surgery is an excellent management for localized resectable cancer is often an operation known as surgical resection. In some disputes, the region of the liver where the cancer is located can be completely removed. Alcohol injection has been shown to improve survival in people with small-time hepatocellular tumors. It may also be used to help reduce manifestations in situations of metastatic liver cancer.
Chemotherapy – Chemotherapy is the use of drugs to help kill cancer cells. Chemotherapy drugs may be administered orally in the form of a pill, or intravenously; either approach spreads the medicine throughout the body. This treatment can be used but is not a popular option to treat liver cancer as there are more effective treatments available.
Surgery – the best chance for successful treatment of liver cancer is with surgery. Surgery is a popular treatment for primary liver cancer. If all of the cancer can be removed, the possibility of successful treatment is higher. If the tumor is not too large and the remaining liver tissue is healthy, surgical removal is often possible. After the excision, the liver can regenerate to full size within several months. Yet, complete removal of liver cancer often is not possible because the cancer is large or has spread to other parts of the liver or the body by the time it is detected. In addition, the liver may be damaged because of other underlying medical conditions, such as cirrhosis. Surgeons attempt to remove as much of the tumor as possible while keeping enough of the liver to function. Common surgeries to treat liver cancer include the following:
Liver Transplant – this surgery involves the complete removal of the diseased liver and replacing it with a healthy liver from a donor. Liver transplants are recommended for those with cirrhosis or a large tumor.
Partial Hepatectomy – part of the liver where the tumor is located is surgically removed. As much as 80 percent of the liver may be removed, and since the liver can regenerate, it will rebuild itself within a matter of weeks.
Embolization – small plastic pellets are injected into the blood vessels that carry blood to the tumor. These pellets block blood flow and make it difficult for the liver cancer to grow.
Ablation – a treatment in which heat (radiofrequency ablation) or extreme cold (cryosurgery or cryotherapy) is used to burn or freeze the liver cancer away. Ablation may be used when surgical removal of the tumor is not possible.
Any type of surgery may have risks and side effects, so it is important to speak with your surgeon about what can be expected.
Being that liver cancer is most commonly detected at advanced stages, the disease may have grown into blood vessels and/or infected other parts of the body, often making surgical treatment impossible. When the stage of liver cancer is advanced, or if the cancer is secondary liver cancer, treatments other than surgery are considered. The liver cancer may not be cured, but the following treatments may alleviate symptoms and prolong life:
Radiation Therapy – radiation therapy uses high-energy x-rays or particles to help destroy the DNA of cancerous cells or help control the cancer in patients who do not qualify for surgery. This treatment may shrink the tumor in the liver and help relieve symptoms.
Chemoembolization – with this treatment, chemotherapy medication is directly inserted into the blood vessel feeding the tumor in the liver. Afterward, the hepatic artery is blocked to prevent it from feeding blood to the liver. Chemoembolization reduces the side effects of normal chemotherapy while killing the tumor.
Hepatic Artery Infusion (HAI) – this procedure directly delivers chemotherapy medication to the liver through a pump that is implanted in the abdomen. HAI is a common option for treating secondary liver cancer where the disease metastasized from the colon or rectum.
Targeted Therapy – unlike chemotherapy medication, the innovative drugs in targeted therapy, called biologics, stop the growth of cancer cells by interfering with proteins and receptors. They can also stop tumor cells from replicating and can disrupt the flow of blood to a tumor. In some cases, biologic drugs are combined with chemotherapy to improve the effectiveness of treatment.
The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. The general 5-year survival rate is 18%. Survival rates depend on several factors, including the stage of the disease. For the 43% of people who are diagnosed at an early stage, the 5-year survival rate is 31%. If the liver cancer has spread to surrounding tissues or organs and/or the regional lymph nodes, the 5-year survival rate is 11%. If the cancer has spread to a distant part of the body, the 5-year survival rate is 3%. However, even if the cancer is found at a more advanced stage, treatments are available that help many people with liver cancer experience a quality of life similar to that of before their diagnosis, at least for some time.
After Liver Cancer Treatment
Completing liver cancer treatment can both a stressful and exciting experience for many people. A very common concern for many individuals is whether the liver cancer may return or worsen. It is important that patients who receive treatment for their liver cancer follow up with their cancer care team, preferably every 3 to 6 months. Regular exams, like lab tests and imaging tests, should be done to monitor the patient’s health. It is also crucial for these individuals to stay on top of their liver health and reduce any risk factors for liver cancer.
Although it is a rare form of cancer, liver cancer is something to be taken seriously as it is the leading cause of cancer-related deaths worldwide. As with most cancers, early detection is key. However, it is difficult to diagnose liver cancer in its early stages as symptoms do not appear until later stages. Routine screening tests, such as blood work and ultrasounds of the liver, should be done on patients who may be at increased risk, including heavy drinkers and those with chronic hepatitis B or hepatitis C viral infections. Liver cancer may be either primary or secondary. Primary liver cancer is when the cancer begins in the liver. The most common form of primary liver cancer is hepatocellular carcinoma (HCC), as it accounts for approximately 85 percent of primary liver cancers. However, the most common type of liver cancer is secondary liver cancer. Secondary liver cancer is when cancer has spread from another part of the body and to the liver. Most secondary liver cancers metastasize from the colon or rectum. If diagnosed with liver cancer, determining the type and stage of the cancer will affect a patient’s outlook. Patients diagnosed with early stages of liver cancer generally have the highest survival rate. However, treatments are available for all stages of liver cancer. Primary liver cancer is mainly treated by surgery. However, depending on whether it is secondary liver cancer or how advanced the cancer is, other therapies, such as hepatic artery infusion therapy or targeted therapy, may be a more ideal treatment option.
The information in this document does not replace a medical consultation. It is for personal guidance use only. We recommend that patients ask their doctors about what tests or types of treatments are needed for their type and stage of the disease.
American Cancer Society
The National Cancer Institute
National Comprehensive Cancer Network
American Academy of Gastroenterology
National Institute of Health
MD Anderson Cancer Center
Memorial Sloan Kettering Cancer Center
American Academy of Hematology