Liver Cancer

Overview

Liver cancer means cancer that starts in the liver. Your liver is a large organ in the upper right part of your belly. It filters your blood, helps you digest food, stores energy, and clears away waste and toxins. When cells in the liver start to grow out of control, they can form a lump called a tumour. The most common type that begins in the liver is called hepatocellular carcinoma (say: hep-uh-toh-SELL-yoo-lur kar-sih-NOH-muh), or HCC. It is worth knowing that cancer which starts somewhere else, such as the bowel or the breast, and then spreads to the liver is a different illness. Doctors call that 'secondary liver cancer' or 'liver metastases', and it is treated based on where the cancer first began.

Liver cancer is one of the more common cancers worldwide, but how common it is varies a great deal from place to place. It is much more frequent in parts of East Asia and sub-Saharan Africa, largely because hepatitis B infection is more common there. In the UK and many other Western countries it is less common, though rates have been slowly rising over recent decades. Overall, it is an uncommon cancer in the UK.

Liver cancer mostly affects adults, and it is more common in men than in women. It is usually diagnosed in people in their 60s and 70s, but it can happen at any age. Most people who develop it already have some form of liver damage, such as cirrhosis, long-standing hepatitis B or C, or a fatty liver condition. A rare type of liver cancer called hepatoblastoma affects very young children, usually under the age of three.

Symptoms

Common symptoms

• Feeling very tired and lacking energy
• Losing weight without trying
• Losing your appetite, or feeling full after only a small amount of food
• Pain or discomfort in the upper right part of your belly, sometimes felt in the right shoulder
• Feeling or being sick
• Yellowing of the skin or the whites of the eyes (this is called jaundice)
• Itchy skin
• Swelling or bloating in the belly
• Bruising or bleeding more easily than usual
• Dark urine or pale, chalky stools
• A mild fever or feeling generally unwell

Symptoms in children

• A swollen or firm belly, sometimes with a lump you can feel
• Poor feeding or refusing feeds
• Weight loss or failing to gain weight
• Being unusually sleepy, fussy or irritable
• Yellowing of the skin or eyes
• A fever that does not settle

Symptoms in older adults

• Tiredness or low energy that is put down to getting older
• Poor appetite and gradual weight loss
• Symptoms that overlap with an existing liver condition, making them easy to miss
• New confusion or drowsiness, which can happen when the liver is not clearing waste products properly
• Feeling unsteady or generally weaker than usual

Causes

Main causes

• Long-term damage and scarring of the liver, called cirrhosis, from any cause
• Long-standing hepatitis B or hepatitis C infection
• Heavy alcohol use over many years
• Fatty liver disease that is not caused by alcohol, now often called metabolic dysfunction-associated steatotic liver disease
• Exposure to aflatoxin, a toxin made by mould that can grow on poorly stored grains, nuts and seeds
• Some inherited liver conditions, such as haemochromatosis (too much iron stored in the body) or Wilson disease (too much copper)
• In some parts of the world, infection with a liver fluke parasite

Risk factors

• Having cirrhosis of any cause
• Chronic hepatitis B or C infection
• Drinking a lot of alcohol over many years
• Being very overweight, especially with fat around the middle, or having type 2 diabetes
• Smoking
• A family history of liver cancer
• Being male
• Being older, usually over 60
• Certain inherited liver conditions
• Long-term exposure to aflatoxin in food

When to see a doctor

See a doctor urgently if:

• You notice yellowing of your skin or the whites of your eyes
• You are vomiting blood or passing black, tarry stools — call your local emergency number straight away
• You have severe or sudden belly pain
• Your belly has swollen up quickly
• You feel confused, very drowsy or unusually sleepy, especially if you already have liver disease

Book a routine appointment if:

• You have lost weight without trying
• You feel very tired all the time and it is not getting better
• You have ongoing pain or discomfort under your ribs on the right side
• Your appetite has changed or you feel full after small meals
• You feel sick or are being sick regularly
• Your skin is itchy for no clear reason
• Your urine has become dark or your stools look pale
• You have liver disease and your usual symptoms are changing

Diagnosis

Your doctor will start by asking about your symptoms, your health history, your alcohol use and any liver conditions you or your family have had. They will examine you, feeling your belly and checking your skin and eyes. From there, they may arrange blood tests and scans. Often a scan alone can strongly suggest liver cancer, and a small sample of tissue (a biopsy) is only needed in some cases. If you have cirrhosis or chronic hepatitis B, you may already be having regular ultrasound scans to look for changes early, before symptoms appear.

Tests that may be done

• Blood tests to check how well your liver is working
• A blood test for a marker called alpha-fetoprotein (AFP), which can be raised in some liver cancers
• An ultrasound scan of the liver
• A CT scan or an MRI scan to look at the liver in more detail
• A biopsy, where a tiny sample of liver tissue is taken with a thin needle and looked at under a microscope
• Blood tests for hepatitis B and hepatitis C
• Tests to see how well your liver is working overall, which helps plan treatment
• Scans of the chest and other areas to check whether the cancer has spread

What to expect at your appointment

Being investigated can feel like a lot of waiting. Some results come back within days, but scans and biopsy results can take a week or two. You will usually be seen by a team of specialists, including liver doctors, cancer doctors, surgeons and specialist nurses, who meet to agree on the best plan for you. It helps to write down your questions beforehand and to bring someone with you if you can — two sets of ears are better than one, and it can be hard to take everything in when you are anxious.

Treatment

Treatment for liver cancer is planned for you as an individual. The team considers the size and number of tumours, where in the liver they are, whether the cancer has spread, how well your liver is working, and your general health and preferences. Some treatments aim to remove or destroy the cancer completely. Others aim to control it, slow it down and keep you as well as possible for as long as possible. Often more than one approach is used together. You should always be told the pros and cons of each option so you can take part in the decision.

Self-care at home

• Keep a note of your symptoms and side effects so you can describe them clearly at appointments
• Ask your team before starting any new medicine, herbal remedy or supplement, because some can affect the liver
• Avoid alcohol, as it puts extra strain on your liver
• Rest when you need to, and ask for help with everyday tasks on low-energy days
• Try small, frequent meals if your appetite is poor
• Stay as active as feels comfortable for you
• Keep up with recommended vaccinations, and ask your team which ones you need
• Tell your team about pain, sickness or sleep problems — there is usually something that can help
• Ask about who to contact between appointments if something changes

Medical treatments

Several kinds of treatment are used, depending on your situation. Surgery can remove the part of the liver containing the cancer, and in selected cases a liver transplant may be an option. Other treatments destroy the tumour in place without a big operation, using heat, cold or an injection directly into the tumour, or by blocking the blood supply that feeds it. Some people have treatments that deliver radiation precisely to the tumour. There are also newer medicines that target cancer cells or help your immune system recognise and fight the cancer; these are usually given as tablets or through a drip, often for cancer that cannot be removed or has spread. Alongside all of this, supportive care is important — it means treating pain, sickness, tiredness and other symptoms so you can live as fully as possible. You may also be offered the chance to join a clinical trial. Your specialist team will explain which options fit your situation, and you can ask for a second opinion if you would like one.

When is surgery considered?

Surgery may be possible when the cancer is in one part of the liver, has not spread beyond it, and the rest of your liver is healthy enough to keep working after part of it is removed. Only a small number of people are suitable for this, usually because the liver is already damaged by cirrhosis. In some cases a liver transplant is considered, again for a carefully selected group. If surgery is not an option for you, that does not mean nothing can be done — other treatments can still control the cancer and help you feel better.

Living with this condition

Living with liver cancer usually means a mix of appointments, treatment and quieter days at home. Many people find it helps to keep a simple routine, plan around their good hours of the day, and keep a diary of symptoms, medicines and questions. Practical help — with shopping, childcare, housework or travel to hospital — can make a real difference, and it is fine to accept it. If you work, ask your team or employer about flexible hours or time off. It is also worth asking your specialist nurse who to call when something worries you between appointments.

Lifestyle tips

• Stop drinking alcohol, and ask for help if that feels hard — support is available and effective
• If you smoke, ask about ways to stop; your team can point you to free local support
• Aim for a healthy weight in a gentle, steady way rather than strict dieting
• Get plenty of rest, and try to keep regular sleep and wake times
• Stay as physically active as feels comfortable, even if that is just short walks
• Ask your team about vaccines you may need, such as flu and hepatitis B
• Keep a list of all your medicines and bring it to every appointment
• Protect your liver: check with your team before taking any new medicine, supplement or herbal product

Diet and exercise

Eating well can help you keep your strength and cope better with treatment. Try small meals and snacks more often if big portions feel like too much. Include some protein at each meal — eggs, beans, lentils, fish, chicken, dairy or tofu — and choose wholegrain foods, fruit and vegetables where you can. If your appetite is poor or food tastes different, ask to see a dietitian; they can suggest practical changes and, if needed, high-energy drinks. Gentle movement such as walking, stretching or light housework helps with tiredness, mood and muscle strength. Start small, build up slowly, and stop if you feel unwell or very tired. Your team or a physiotherapist can help you find a safe level of activity.

Mental health and emotional wellbeing

A diagnosis like this can bring shock, fear, anger and sadness, and those feelings are completely normal. Some people feel numb at first, or find that worry comes in waves around scan results. You do not have to cope alone, and talking about how you feel is a sign of strength, not weakness. Ask your team about psychological support or counselling, which is often available through cancer services. If you are having thoughts of harming yourself, or feel you cannot keep going, please contact your local emergency number or a crisis support line in your country straight away — help is available at any hour. If you are in the UK and struggling to cope, you can also contact your GP or NHS 111 for urgent advice.

Prevention

Not all liver cancer can be prevented, and it is important to say that no one is to blame if it happens. But many of the things that damage the liver over time can be reduced or avoided, and that lowers the risk. The most important steps are protecting against hepatitis B and C, being careful with alcohol, and looking after your liver if you already have a liver condition. If you have cirrhosis, or long-standing hepatitis B, regular follow-up is a powerful form of prevention because it can catch problems early.

Vaccines

There is a safe and effective vaccine against hepatitis B, and it is now given routinely to babies in many countries, including the UK. Adults who may be at risk can also ask their doctor about it. There is no vaccine against hepatitis C, but modern treatment can cure it in most people — ask your doctor about testing if you think you could have been exposed. Your team can advise which other vaccines are sensible for you.

Screening programmes

There is no national screening programme for liver cancer for the general population in the UK. However, people at higher risk — for example those with cirrhosis or chronic hepatitis B — are often offered a regular ultrasound scan of the liver, usually every six months, sometimes with a blood test. This is called surveillance, and its aim is to find any cancer early, when treatment works best. If you have a liver condition, ask your specialist whether you should be having regular scans.

Complications

If left untreated

• The tumour can grow larger and spread to other parts of the body, such as the lungs or bones
• The liver can stop working properly, which is called liver failure
• Yellowing of the skin and eyes (jaundice) and itchy skin can get worse
• Fluid can build up in the belly and cause swelling and discomfort
• Bleeding can happen more easily, sometimes from swollen veins in the food pipe
• Waste products can build up in the blood and cause confusion or drowsiness
• Pain, tiredness and weight loss can increase, affecting everyday life

Long-term outlook

The outlook for liver cancer varies a lot from person to person, and no one can predict exactly what will happen for you. When the cancer is found early and can be removed with surgery or treated with a transplant, some people are cured. For many others, treatment can control the cancer and keep it from growing for months or even years, and new treatments are being developed all the time. Even when a cure is not possible, good supportive care can help you feel better and live as well as possible. Your specialist team can talk honestly with you about what to expect in your own situation, and it is always fine to ask questions or to ask again later.

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