What is liver cancer?

Liver cancer is a cancer in the cells of the liver. It is the seventh leading cause of cancer deaths in Australia.

The liver is the largest organ in the body. It sits under the ribs, on the right side of the abdomen. It has many important functions, including:

• making and storing sugars and fat to be used for energy
• making bile to help digest your food
• making important proteins for use in the body
• breaking down harmful chemicals

Liver cancer can be ‘primary’, which means the cancer started in the liver or ‘secondary’ (metastatic), which means the cancer has spread into the liver from another part of the body.

Primary liver cancer

Most people with primary liver cancer have a hepatoma, also known as hepatocellular carcinoma (HCC). This begins in the main type of liver cell, known as a hepatocyte.

Other types of primary liver cancer include:

• cholangiocarcinoma — or bile duct cancer, which starts in the cells lining the bile ducts
• angiosarcoma — a rare liver cancer that starts in the blood vessels
• hepatoblastoma – a rare liver cancer that occurs in young children

If primary liver cancer is not treated early or treatment is unsuccessful, it can spread (metastasise) to other parts of the body.

Secondary cancer in the liver

Most cancers that affect the liver have spread from other parts of the body. These are known as secondary cancers (metastases). These secondary cancers are named after the part of the body in which they started. Colon, breast, ovarian, kidney, oesophageal, stomach and lung cancers, as well as melanomas, are all cancers that can spread to the liver.

What are the symptoms of liver cancer?

You may not have symptoms in the early stages of liver cancer.

If you do have symptoms, you may feel generally unwell and notice symptoms such as:

• feeling weak and tired
• unexplained weight loss
• loss of appetite
• nausea and vomiting

They may also be more specific to the function and location of the liver:

• pain or swelling in your upper right abdomen
• pain below your right shoulder blade
• swelling of your abdomen due to fluid buildup (ascites)
• yellowing your skin and eyes (jaundice)
• dark urine
• pale, chalky bowel motions

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

What causes liver cancer?

Doctors do not always know what causes primary liver cancer. The risk of getting primary liver cancer is increased if you already have permanent scarring to your liver, so that scar tissue replaces many healthy liver cells. This damage to your liver is called cirrhosis.

Cirrhosis of the liver is caused by excessive alcohol use, or by some types of liver disease, for example:

• long-term hepatitis B or hepatitis C infection
• metabolic-associated fatty liver disease (MAFLD) from living with obesity or type 2 diabetes
• haemochromatosis (having very high iron levels in the blood)

Some people develop liver cancer without first having cirrhosis. This can happen if you have a long-term hepatitis B infection or MAFLD.

Other risk factors for primary liver cancer are:

• smoking
• having a family history of hepatocellular carcinoma (HCC)
• being Aboriginal and/or Torres Strait Islander, as this increases your risk of hepatitis B infection
• being born in an area with a high rate of hepatitis B infection (such as Asia, the Pacific Islands and Africa)

How is liver cancer diagnosed?

Your doctor will start by examining you and asking about your physical symptoms. If your doctor thinks you may have liver cancer, they will refer you for tests including blood tests and imaging (such as magnetic resonance imaging (MRI) or computerised tomography (CT) scans, or a PET-CT scan). You may have a biopsy to remove a sample of liver tissue for testing. This is performed with a thin needle under local anaesthetic.

If you have secondary liver cancer, you may have other tests to find out where the primary cancer is, if this isn’t clear. This could involve blood tests, endoscopy and urine tests.

If liver cancer is confirmed, you are likely to be referred to a specialist doctor or a team of specialists which may include a gastroenterologist, surgeon and/or oncologist (cancer specialist).

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Stages of liver cancer

The stage of a cancer describes its size and location, and whether it has spread in the body. This is known as ‘staging’ the cancer, and can help your doctors plan the best treatment in your situation.

Staging primary liver cancer

Staging of primary liver cancer uses a system called the Barcelona Clinic Liver Cancer (BCLC) staging system. The system has 5 stages:

• 0 — very early
• A — early
• B — intermediate
• C — advanced
• D — end-stage

Your doctor will consider these things when staging the cancer:

• The size of the tumour.
• The number of tumours.
• If the cancer has spread to blood vessels, lymph nodes or other organs.
• How well you are functioning in daily life and how active you are.
• How well your liver is working using this scale:
  • A: some damage but is working normally
  • B: moderate damage, affecting how well the liver is working
  • C: very damaged and not working well.

Staging secondary liver cancer

Secondary cancers are staged using the system for the primary cancer. For example, if it started in the bowel, it will often be staged using a system called TNM (tumour–nodes–metastasis).

How is liver cancer treated?

A team of medical specialists, nurses and other health professionals will be involved in your liver cancer treatment.

The type of treatment your doctor recommends will depend on:

• the stage of your cancer
• your general health
• your medical history
• your age
• your personal preferences

Often different therapies are used together. For HCC, your doctor may recommend treating your cancer with ablation (using heat or extreme cold to damage cells) or surgery.

Your doctors may also recommend chemotherapy or radiotherapy to shrink the cancer, or destroy any cancer cells left after surgery.

Tumour ablation

During tumour ablation, a specialist doctor will insert thin needles into the tumour and apply different methods to destroy cancer cells. In most cases, imaging (such as CT scans) is used to help your doctor place the needles in the right place.

Your doctor can apply a range of methods to ablate (destroy) a liver cancer, including:

• high frequency radio waves and/or microwaves (radiofrequency) — more commonly used for small primary tumours
• pure alcohol
• heat
• liquid nitrogen (cryotherapy)

Radiation therapy

There are 2 types of radiation therapy (also known as radiotherapy) that can be used to treat liver cancer. This is usually done if surgery is not possible, or to shrink the tumour before surgery or while you wait for a liver transplant.

Selective internal radiation therapy (SIRT or radioembolisation) involves a specialist doctor inserting a thin tube into an artery, through which they release tiny radioactive beads (microspheres) into the liver. These beads block the blood supply to the tumour and deliver high-dose radiation.

Stereotactic body radiation therapy (SBRT) uses a machine to target beams of radiation to the tumour from outside.

Chemotherapy and TACE

Chemotherapy uses medicines to destroy, shrink or slow the growth of cancer. If your liver cancer has spread or you have secondary cancer, your doctors may prescribe chemotherapy, which you will take through a vein (intravenous or IV) to treat your whole body.

If you have primary liver cancer, you may be offered ‘transarterial chemoembolisation’ (TACE), which is more targeted form of chemotherapy. The doctor inserts a tube into an artery supplying the liver to deliver a high dose of anti-tumour medicines. A substance is also used to partly block the artery, starving the cancer cells of their blood supply.

Surgery

Surgery is only suitable for some people with liver cancer. Your doctor is more likely to recommend surgery if you don’t have cirrhosis and the tumour hasn’t spread to blood vessels. The type of surgery will depend on the size and location of the liver cancer.

Surgery to remove part of the liver is called partial hepatectomy or segmentectomy, depending on what part and how much is removed. The liver can still work well even if most of it has been surgically removed. If your liver is working well before the surgery, your liver can recover and grow again after surgery.

Liver transplant

If you only have one tumour or a few small tumours in the liver, you may be eligible for a liver transplant. There are also other criteria you must meet to receive a liver transplant. It can take months or years for suitable donor liver to become available. You will usually need to have other treatment such tumour ablation or TACE while you wait.

Immunotherapy and targeted therapy

Immunotherapy and targeted therapy are medicines that stop cancer cells growing or spreading, or help the body’s own immune system to destroy them. These medicines can be used for both primary and secondary liver cancers.

Palliative care

Palliative care aims to help reduce your symptoms, relieve pain, control the spread of the cancer and improve your quality of life. If you have advanced or late-stage liver cancer, you may choose to have palliative care.

Radiotherapy, pain management, draining of fluid in your abdomen (ascites) can all be part of palliative of care. If there is a build-up of bile in the liver, because the cancer is blocking a bile duct, a thin tube (stent) placed in the liver can help relieve the blockage and drain the bile.

Looking after yourself

If you have liver cancer, maintaining a healthy diet and staying active during treatment can help your wellbeing. Complementary therapies such as remedial massage may also help the physical and emotional concerns you are experiencing. Relaxation techniques can reduce anxiety and improve your mood.

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Who provides liver cancer treatment?

Your medical team will include many different health professionals. It may include a GP, a radiologist, an medical and radiation oncologist, a cancer care nurse, a surgeon and allied health professionals such as counsellors and dietitians. Having a multi-disciplinary team means you receive the best care possible.

Sometimes, understanding the role of each health professional in your care team can be confusing. Ask your doctor if a cancer care coordinator is available. A cancer care coordinator is a health professional who coordinates your care, helps you communicate with all the health professionals involved in your treatment, and supports you and your family throughout your cancer experience.

Can liver cancer be prevented?

Unfortunately, there is no way to completely prevent liver cancer.

You can reduce your risk by addressing any risk factors, for example avoiding hepatitis B or C infection. As these infections are spread through contact with body fluids of an infected person, you reduce your chance of infection by:

• getting vaccinated against hepatitis B
• practicing safe sex
• if you inject medicines or drugs, avoiding needle sharing
• avoiding blood-to-blood contact

If you may have been exposed to hepatitis B or C, see your doctor to check if you were infected, as there are some treatments available.

Resources and support

• Cancer Council Australia provides services and support to all people affected by cancer. Call on 13 11 20.
• General information from NSW Health about cancer is available online in many community languages.
• Read all about cancer for Aboriginal and/or Torres Strait Islander peoples.