Treatment
Many people with liver cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may want to take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.
At this time, liver cancer can be cured only when it is found at an early stage (before it has spread) and only if the patient is healthy enough to have an operation. However, treatments other than surgery may be able to control the disease and help patients live longer and feel better. When a cure or control of the disease is not possible, some patients and their doctors choose palliative therapy. Palliative therapy aims to improve the quality of a person's life by controlling pain and other problems caused by the disease.
The doctor may refer patients to doctors who specialize in treating cancer, or patients may ask for a referral. Specialists who treat liver cancer include surgeons, transplant surgeons, gastroenterologists, medical oncologists, and radiation oncologists.
Getting a Second Opinion
Before starting treatment, a patient may want to get a second opinion about the diagnosis, the stage of cancer, and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it.
There are a number of ways to find a doctor for a second opinion:
The doctor may refer patients to one or more specialists. At cancer centers, several specialists often work together as a team.
The Cancer Information Service (1-800-4-CANCER) can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute, and can send printed information about finding a doctor.
A local medical society, a nearby hospital, or a medical school can usually provide the names of specialists.
The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries.
Treatment Choices
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs.
Cancer of the liver is very hard to control with current treatments. For that reason, many doctors encourage patients with liver cancer to consider taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for people with all stages of liver cancer. The section called "The Promise of Cancer Research" has more information about clinical trials.
The choice of treatment depends on the condition of the liver; the number, size, and location of tumors; and whether the cancer has spread outside the liver. Other factors to consider include the patient's age, general health, concerns about the treatments and their possible side effects, and personal values.
Usually, the most important factor is the stage of the disease. The stage is based on the size of the tumor, the condition of the liver, and whether the cancer has spread. The following are brief descriptions of the stages of liver cancer and the treatments most often used for each stage. For some patients, other treatments may be appropriate.
Localized resectable cancer
Localized resectable liver cancer is cancer that can be removed during surgery. There is no evidence that the cancer has spread to the nearby lymph nodes or to other parts of the body. Lab tests show that the liver is working well.
Surgery to remove part of the liver is called partial hepatectomy. The extent of the surgery depends on the size, number, and location of the tumors. It also depends on how well the liver is working. The doctor may remove a wedge of tissue that contains the liver tumor, an entire lobe, or an even larger portion of the liver.
In a partial hepatectomy, the surgeon leaves a margin of normal liver tissue. This remaining healthy tissue takes over the functions of the liver.
For a few patients, liver transplantation may be an option. For this procedure, the transplant surgeon removes the patient's entire liver (total hepatectomy) and replaces it with a healthy liver from a donor. A liver transplant is an option only if the disease has not spread outside the liver and only if a suitable donated liver can be found. While the patient waits for a donated liver to become available, the health care team monitors the patient's health and provides other treatments, as necessary.
Localized unresectable cancer
Localized unresectable liver cancer cannot be removed by surgery even though it has not spread to the nearby lymph nodes or to distant parts of the body. Surgery to remove the tumor is not possible because of cirrhosis (or other conditions that cause poor liver function), the location of the tumor within the liver, or other health problems.
Patients with localized unresectable cancer may receive other treatments to control the disease and extend life:
Radiofrequency ablation -- The doctor uses a special probe to kill the cancer cells with heat. The probe contains tiny electrodes that destroy the cancer cells. Sometimes the doctor can insert the probe directly through the skin. Only local anesthesia is needed. In other cases, the doctor may insert the probe through a small incision in the abdomen or may make a wider incision to open the abdomen. These procedures are done in the hospital with general anesthesia.
Other therapies that use heat to destroy liver tumors include laser or microwave therapy.
Percutaneous ethanol injection -- The doctor injects alcohol (ethanol) directly into the liver tumor to kill cancer cells. The doctor uses ultrasound to guide a small needle. The procedure may be performed once or twice a week. Usually local anesthesia is used, but if the patient has many tumors in the liver, general anesthesia may be needed.
Cryosurgery -- The doctor makes an incision into the abdomen and inserts a metal probe to freeze and kill cancer cells. The doctor may use ultrasound to help guide the probe.
Hepatic arterial infusion -- The doctor inserts a tube (catheter) into the hepatic artery, the major artery that supplies blood to the liver. The doctor then injects an anticancer drug into the catheter. The drug flows into the blood vessels that go to the tumor. Because only a small amount of the drug reaches other parts of the body, the drug mainly affects the cells in the liver.
Hepatic arterial infusion also can be done with a small pump. The doctor implants the pump into the body during surgery. The pump continuously sends the drug to the liver.
Chemoembolization -- The doctor inserts a tiny catheter into an artery in the leg. Using x-rays as a guide, the doctor moves the catheter into the hepatic artery. The doctor injects an anticancer drug into the artery and then uses tiny particles to block the flow of blood through the artery. Without blood flow, the drug stays in the liver longer. Depending on the type of particles used, the blockage may be temporary or permanent. Although the hepatic artery is blocked, healthy liver tissue continues to receive blood from the hepatic portal vein, which carries blood from the stomach and intestine. Chemoembolization requires a hospital stay.
Total hepatectomy with liver transplantation -- If localized liver cancer is unresectable because of poor liver function, some patients may be able to have a liver transplant. While the patient waits for a donated liver to become available, the health care team monitors the patient's health and provides other treatments, as necessary.
Advanced cancer
Advanced cancer is cancer that is found in both lobes of the liver or that has spread to other parts of the body. Although advanced liver cancer cannot be cured, some patients receive anticancer therapy to try to slow the progress of the disease. Others discuss the possible benefits and side effects and decide they do not want to have anticancer therapy. In either case, patients receive palliative care to reduce their pain and control other symptoms.
Treatment for advanced liver cancer may involve chemotherapy, radiation therapy, or both:
Chemotherapy uses drugs to kill cancer cells. The patient may receive one drug or a combination of drugs. The doctor may use chemoembolization or hepatic arterial infusion. Or the doctor may give systemic therapy, meaning that the drugs are injected into a vein and flow through the bloodstream to nearly every part of the body. The doctor may call this intravenous or IV chemotherapy.
Usually chemotherapy is an outpatient treatment given at the hospital, clinic, or at the doctor's office. However, depending on which drugs are given and the patient's general health, the patient may need to stay in the hospital.
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Radiation therapy is local therapy, meaning that it affects cancer cells only in the treated area. A large machine outside the body directs radiation to the tumor area.
Recurrent cancer
Recurrent cancer means the disease has come back after the initial treatment. Even when a tumor in the liver seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Most recurrences occur within the first 2 years of treatment. The patient may have surgery or a combination of treatments for recurrent liver cancer.
These are some questions a person may want to ask the doctor before treatment begins: Is there any evidence the cancer has spread? What is the stage of the disease? Do I need any more tests to determine whether I can have surgery? What are my treatment choices? Which do you recommend for me? Why? What are the expected benefits of each kind of treatment? What are the risks and possible side effects of each treatment? Will I need to stay in the hospital? How will you treat my pain? What is the treatment likely to cost? Is this treatment covered by my insurance plan? How will treatment affect my normal activities? Would a clinical trial (research study) be appropriate for me?
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People do not need to ask all of their questions or understand all of the answers at once. They will have other chances to ask the health care team to explain things that are not clear and to ask for more information.
Side Effects of Treatment
Because cancer treatment may damage healthy cells and tissues, unwanted side effects often occur. Side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. The health care team will explain the possible side effects of treatment and how they will help the patient manage them.
The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Chemotherapy and You, Radiation Therapy and You, and Eating Hints for Cancer Patients. See the "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" sections for other sources of information about side effects.
Surgery
It takes time to heal after surgery, and the time needed to recover is different for each person. Patients are often uncomfortable during the first few days. However, medicine can usually control their pain. Patients should feel free to discuss pain relief with the doctor or nurse. It is common to feel tired or weak for a while. Also, patients may have diarrhea and a feeling of fullness in the abdomen. The health care team watches the patient for signs of bleeding, infection, liver failure, or other problems requiring immediate treatment.
After a liver transplant, the patient may need to stay in the hospital for several weeks. During that time, the health care team checks for signs of how well the patient's body is accepting the new liver. The patient takes drugs to prevent the body from rejecting the new liver. These drugs may cause puffiness in the face, high blood pressure, or an increase in body hair.
Cryosurgery
Because a smaller incision is needed for cryosurgery than for traditional surgery, recovery after cryosurgery is generally faster and less painful. Also, infection and bleeding are not as likely.
Percutaneous Ethanol Injection
Patients may have fever and pain after percutaneous ethanol injection. The doctor can suggest medicines to relieve these problems.
Chemoembolization and Hepatic Arterial Infusion
Chemoembolization and hepatic arterial infusion cause fewer side effects than systemic chemotherapy because the drugs do not flow through the entire body. Chemoembolization sometimes causes nausea, vomiting, fever, and abdominal pain. The doctor can give medications to help lessen these problems. Some patients may feel very tired for several weeks after the treatment.
Side effects from hepatic arterial infusion include infection and problems with the pump device. Sometimes the device may have to be removed.
Systemic Chemotherapy
The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives. As with other types of treatment, side effects are different for each patient.
Systemic chemotherapy affects rapidly dividing cells throughout the body, including blood cells. Blood cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When anticancer drugs damage blood cells, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is complete. The health care team can suggest ways to relieve side effects.
Radiation Therapy
The side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
Radiation therapy to the chest and abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. Radiation therapy also may cause a decrease in the number of healthy white blood cells, cells that help protect the body against infection. Although the side effects of radiation therapy can be distressing, the doctor can usually treat or control them.
When cancers are detected before symptoms appear surgery alone can provide survival rates of 28% at 3 years. The course of clinically apparent disease is rapid if untreated. In selected cases, therapy may prolong life.
Treatment options include liver transplantation, hepatic artery embolization and chemotherapy (also called chemoembolization), radiofrequency ablation, and cryoablation. For potentially respectable HCC the 5 year survival rate can be over 50%. However, even after "curative" resection of HCC, the predisposing primary liver disorder (e.g. cirrhosis, hepatitis B) persists and new cancers can arise in the residual liver.
Treatment options for unresectable disease are limited. The liver cannot tolerate doses of radiation and the disease is not responsive to chemotherapy. Immunotherapy, biological therapy, and gene therapy techniques are being tested.
Treatment Results
The Cancer Monthly database currently has the results (survival, side effects, etc.) for 15 recent therapies for liver cancer including immunotherapy, hormone therapy, chemotherapy, radiation, and alternative therapy.
