Primary liver cancer is cancer that forms in the tissues of the liver. The liver, one of the largest organs in the human body, is located on the right side of the abdomen and is protected by the rib cage. The liver has three important functions: it filters and removes waste and toxins from the blood; it makes bile which breaks down fats in the digestive process; and it stores energy in the form of glycogen, a type of sugar.
Secondary liver cancer is when the cancer begins in another part of the body and then spreads to the liver. In the U.S., cancer affecting the liver is most commonly secondary cancer, and it most often spreads from colon, lung, and breast cancers. When this happens, the disease is not liver cancer. It is named for the organ where it began, and the cancer in the liver is secondary.
Primary liver cancer is rarely diagnosed early, and it often doesn’t respond to current treatments, making the prognosis poor. Treatments can help pain and other symptoms of liver cancer and improve quality of life. The following information is about primary liver cancer. Chances of developing primary liver cancer can be greatly reduced by protection from hepatitis and cirrhosis, which are the leading causes of the disease.
Risk Factors, Signs and Symptoms
Research is increasing regarding what we know about liver cancer. Scientists are learning more about its causes. Following are common risk factors for the disease:
- Viral Hepatitis - Viral hepatitis is one of the largest risk factors for this type of cancer. Hepatitis viruses are viruses that infect the liver. Two common types are Chronic Hepatitis B (HBV) and Chronic Hepatitis C (HCV.) Carriers of Hepatitis B virus face up to a 100-fold increased risk of developing adult primary liver cancer.
- Cirrhosis - Cirrhosis is a disease in which liver cells become damaged and are replaced by scar tissue. People with cirrhosis have an increased risk of liver cancer. Most (but not all) people who develop liver cancer already have some evidence of cirrhosis. There are several possible causes of cirrhosis. Most cases in the United States occur in people who abuse alcohol or have chronic HBV or HCV infections.
- Age and Gender - Liver cancer is much more common in males than in females. The fibrolamellar subtype of HCC occurs in about equal numbers in both sexes. In the United States, adult primary liver cancer occurs most often in people over age 60.
- Race/Ethnicity - In the United States, Asian Americans and Pacific Islanders have the highest rates of liver cancer, followed by American Indians/Alaska Natives and Hispanics/Latinos, African Americans, and whites.
- Inherited Metabolic Diseases - Certain inherited metabolic diseases can lead to cirrhosis. People with hemochromatosis absorb too much iron from their food. They are more likely to develop cirrhosis because of the high levels of iron in their liver. Other rare diseases that increase the risk of liver cancer include tyrosinemia, alpha1-antitrypsin deficiency, porphyria cutanea tarda, glycogen storage diseases, and Wilson disease.
- Diabetes and Obesity - Diabetes can also increase the risk of liver cancer, usually in patients who have other risk factors such as heavy alcohol consumption and/or chronic viral hepatitis. Obesity may increase the risk of developing liver cancer, probably because it can result in fatty liver disease and cirrhosis.
- Anabolic Steroids - Anabolic steroids are male hormones used by some athletes to increase their strength. Long-term anabolic steroid use can slightly increase the risk of hepatocellular cancer. Cortisone-like steroids, such as hydrocortisone, prednisone, and dexamethasone, do not carry this same risk.
- Arsenic - Chronic exposure to drinking water contaminated with naturally occurring arsenic, such as that from some wells, increases the risk of some types of liver cancer. This is more common in parts of East Asia but may be a concern in some areas of the United States.
Signs and Symptoms
Because signs and symptoms of liver cancer do not usually appear until it is in its later stages, it is seldom diagnosed early.
Many patients who develop liver cancer have long-standing cirrhosis. If a patient with cirrhosis becomes worse without any known reason, doctors will probably suspect that liver cancer is the cause and do appropriate tests.
The increasing size of the liver and its inability to perform its functions as cancer cells multiply can cause warning signs in people with liver cancer.
Following are the most common health problems experienced by people with liver cancer or liver disease:
- A hard lump or swelling found on the right side of the abdomen, just below the ribs
- Pain or discomfort on the upper side of the abdomen or by the right side of the shoulder blade
- Jaundice, or the yellowing of the skin or the whites of the eyes or dark-colored urine
- Nausea, loss of appetite or feeling full shortly after you begin to eat
- Unexplained weight loss
- Swollen abdomen, bleeding (the symptoms of cirrhosis)
Diagnosis and Staging
Liver cancer is sometimes referred to as a “silent disease” because early liver cancer often doesn’t cause symptoms. As it grows, symptoms may include pain on the right side of the upper abdomen, swollen abdomen, weight loss and loss of appetite, weakness, fatigue, nausea and vomiting, jaundice, and fever.
If a patient has symptoms of liver cancer, a doctor may perform one or more of the following procedures:
- Physical Exam
- Serum Alpha Feto-Protein (AFP) Test
- Blood Test
- CT Scan
The doctor feels the abdomen to check the liver, spleen, and nearby organs for any lumps or changes in shape or size. The doctor also checks for ascites, abnormal buildups of fluid in the abdomen. The doctor checks the skin and eyes for signs of jaundice.
This test shows if there is an increased level of protein in the blood which may indicate the presence of a tumor. However, AFP may also be elevated by a different cancer or non-cancerous condition, so other tests are offered.
Samples of blood are used to check for liver problems. One test detects alpha-fetoprotein (AFP). High levels of AFP could be a sign of liver cancer. Other tests also show how well the liver is functioning.
This procedure allows the physician to view the abdominal organs through a laparoscope (small camera.)
An X-ray machine takes detailed pictures of the liver and other organs and blood vessels in the abdomen. From the CT scan, the doctor may see tumors in the liver or other parts of the abdomen.
Sound waves and a computer are used to create a picture of the liver and other organs inside the abdomen, which can show tumors and abnormalities.
This uses magnets and radio waves to produce detailed images of areas of the body. A doctor injects dye into the bile and pancreatic ducts, and X-rays can help determine blockages, which may be caused by tumors.
A doctor injects dye into an artery so that the blood vessels in the liver show up in an X-ray. This can reveal a tumor in the liver.
A pathologist looks at a sample of tissue from the pancreas under a microscope to check for cancer cells. The doctor may obtain tissue by fine needle aspiration, or inserting a thin needle into the liver. Sometimes the doctor does a core biopsy, using a thick needle, or a thin tube called a laparoscope through a small incision in the abdomen.
Stages of Liver Cancer
Staging is the process of finding out how widespread a cancer is. The stage of liver cancer is one of the most important factors in considering treatment options.
Staging is a standardized way for the cancer care team to summarize information about the primary tumor size (T), number of lymph nodes that contain tumor (N) and if it has spread (metastasized) to another part of the body (M). These factors comprise the TNM Staging system. Numbers or letters that appear after T, N, and M provide more details about each of these factors:
- Numbers 0-4 indicate increasing severity (0 begin less severe than 4)
- The letter X means “cannot be assessed” because information is not available
Liver cancer is unique in that it occurs mostly in people who have some liver damage. The degree of liver damage plays a very important role in determining what treatment options are possible for an individual patient. As a result, several other liver cancer staging systems have been developed that take into account a variety of factors including:
- Liver function
- Tumor spread
- Tumor invasion into blood vessels (which is very common in liver cancer)
- Overall health of the individual
Currently, most cancer treatment centers use a team approach in evaluating patients with liver cancer. The multi-disciplinary team reviews all of the information and determines if the patient is eligible for liver transplantation, surgical resection, intrahepatic or regional therapy, systemic targeted therapy, or a clinical trial.
There are several treatment options for liver cancer, depending on the cancer stage and the patient’s age and general health. Patients have time for second opinions and to talk through all of their options with their doctors and develop a treatment plan that best fits their needs.
Treatment for liver cancer has the most favorable outcome when detected and treated in early stages, before it has spread. Cancer of the liver is very hard to control with current treatments. Treatments other than surgery can help control liver cancer and help patients live longer and alleviate symptoms.
Follow-up care for patients with liver cancer depends on the stage of the disease and the treatments they have received. It is very important after surgery because the cancer can return in the liver or in another part of the body.
People who have had liver cancer surgery may wish to discuss the chance of recurrence with their doctor. Follow-up care may include blood tests, x-rays, ultrasound tests, CT scans, angiograms, or other tests. For patients who have had a liver transplant, the doctor will test how well the new liver is functioning. The doctor will watch the patient closely to make sure the new liver is not being rejected.
Coping With Stigma
Many people living with liver cancer feel that they must explain the cause of their condition to others. You may feel that you are unfairly judged because of the perceived links between liver cancer and alcohol or drug misuse. The feeling that society has these thoughts about you, even when they go unsaid, is called stigma. It is unfortunate that these ideas are often based on stereotypes and promoted by the media.
The stigma of liver cancer is especially unique because liver cancer is often associated with lifestyle or personal choices. These include smoking, drinking alcohol, and other conditions, like HCV, which can be transmitted sexually or through IV drug use, and alcohol-related cirrhosis. Stigma can affect how you feel about yourself or how you think others feel about you. Anyone can be diagnosed with liver cancer.
Stigma can be especially harmful as it can discourage people from seeking medical help. This may be because they fear discrimination from healthcare professionals, friends, family, or others. Stigma often delays diagnosis and, in turn, leads to poorer outcomes. Even early diagnosis and treatment of liver cirrhosis or hepatitis infections can greatly reduce the risk of developing liver cancer.
What You Can Do
Dealing with a liver cancer diagnosis and treatment can be difficult to manage. The added feelings of stigma, shame, and blame will not help you heal. Focus on identifying what you can do to find support after a liver cancer diagnosis.
Talk About Stigma
In some cases, you may feel like you are being treated differently because of your diagnosis. You deserve good care regardless of your medical condition or possible history with alcohol or drug use. If your care team does ask about your history, they may be asking because it could impact treatment options.
It is important to find a care team that you trust and can be open and honest with. They should treat you with dignity and respect. If this is not happening, advocate for yourself. Talk to your care team about your concerns. You do not need to continue working with a care team if you are being mistreated. Consider seeing a different provider if you are uncomfortable. To change the narrative, consider the following:
- Talk to your care team about the emotional impact of their questions
- Advocate for yourself by sharing information about liver cancer from trusted resources
- Remind your care team that you can never know exactly why you got liver cancer, but you do need their support and empathy
Regardless of if you have a history of drug or alcohol use or not, questions about these topics and others’ assumptions can be frustrating. All these feelings are valid.
The stigma of living with liver cancer can contribute to many negative emotional impacts. This can include distress, grief, stress, depression, and/or anxiety. These symptoms should be taken as seriously as cancer itself.
Cancer care teams are prepared to help you and your loved ones after a cancer diagnosis. Throughout your care, they may check in with you specifically about your mental health. Your care team can connect you with social workers, psychologists, and other mental health specialists. These professionals can help you talk through your feelings, understand what you are experiencing, and develop coping skills. Coping skills are things you can do in the moment and over time to feel more in control when you are feeling stressed, anxious, or uncomfortable.
Some people may think that only someone experiencing severe mental health challenges should seek help. This is not true. Everyone deserves to have good mental health. You do not need to wait for your mental health to reach a certain severity before getting help.