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 number of Australians with liver cancer is going up.

Your liver is the largest organ in your body. It sits under your 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. Secondary liver cancer is more common than primary liver cancer in Australia.

Primary liver cancer

Most people with primary liver cancer have 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 your 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.

Read the Cancer Council fact sheet about secondary liver cancer.

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

Symptoms 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

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 scarring and liver damage called cirrhosis.

Cirrhosis of the liver can be caused by drinking excessive amounts of alcohol. Some types of liver disease also cause cirrhosis:

• long-term hepatitis B or hepatitis C infection
• metabolic-associated fatty liver disease (MAFLD)
• haemochromatosis (having very high iron levels in the blood)

People living with obesity or type 2 diabetes are more likely to develop MAFLD.

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

If you regularly drink a lot of alcohol and also have diabetes or hepatitis, you are more likely to get HCC.

Other risk factors for primary liver cancer are:

• smoking
• having a family history of hepatocellular carcinoma (HCC)
• being male
• being older than 60 years
• being Aboriginal and/or Torres Strait Islander

When should I see my doctor?

If you have symptoms of cirrhosis or liver cancer see a doctor. Tell your doctor if you have:

• pain in the upper right side of your belly, or upper right back, or around your right shoulder blade
• a hard lump in the right side of your belly, below your ribs
• lost weight without meaning to
• noticed your skin or the whites of your eyes look yellow
• been feeling extremely tired or weak
• itchy skin
• fluid build-up in your abdomen (tummy)

Your doctor can talk to you and work out the possible causes.

You may have been screened for liver cancer if you have some of the risk factors. Screening helps to find cancer earlier, before symptoms are noticeable.

How is liver cancer diagnosed?

Your doctor will start by examining you and asking about your symptoms.

If your doctor thinks you may have liver cancer, they will refer you for tests including:

• blood tests
• 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 done using 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 or oncologist (cancer specialist).

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. Knowing the stage of your cancer helps your doctors plan the best treatment for you.

Your doctor may use the Barcelona Clinic Liver Cancer (BCLC) system to stage primary liver cancer. 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.
• How well you are doing in daily life and how active you are.
• How well your liver is working.

Secondary cancers are staged using the system for the primary cancer. Because the cancer has spread from another part of your body, secondary liver cancer is an advanced cancer. For example, if the secondary cancer spread from your bowel, your doctor will use the bowel cancer staging system.

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 surgery or ablation (using heat or extreme cold to damage cells).

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

Ask your doctor questions so that you understand your options. It is your choice to have treatment.

Surgery

The aim of surgery is to remove the part of your liver that is affected by the cancer. Surgery is most suitable if your liver cancer has clear edges and your liver is otherwise working well.

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. You will need to prepare for surgery and give informed consent.

Liver transplant

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

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 a more targeted form of chemotherapy. Your 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.

If you have secondary liver cancer which spread from your breast or prostate, you may have chemotherapy combined with hormone therapy.

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. They must be prescribed by a specialist oncologist.

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 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.

Living with liver cancer

Being diagnosed with cancer is difficult. You may feel unwell and struggle emotionally.

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 with the physical and emotional difficulties you are experiencing. Relaxation techniques can reduce anxiety and improve your mood.

Who provides liver cancer treatment?

Your medical team will include many different health professionals, such as:

• your local doctor
• a gastroenterologist (specialist in diseases of the digestive system and liver)
• a radiologist
• a medical oncologist
• a surgeon
• a cancer care nurse
• allied health professionals, such as counsellors and dietitians

Having a team of people means you receive the best care possible. You may need to visit a large hospital for specialised treatment.

You may also have a friend or family member who helps care for you.

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 person who coordinates your care, helps you communicate with all the health professionals involved in your treatment, and supports you and your family.

What are the complications of liver cancer?

If your liver is badly damaged by cancer or cirrhosis, it may not be able to cope with some of the medicines used to treat cancer.

You may also have portal hypertension. This is an increase in blood pressure in the vein between your digestive organs and your liver.

Some other complications of liver cancer are:

• jaundice
• extreme weight loss known as cachexia
• very low blood sugar levels
• diarrhoea
• low calcium levels
• internal bleeding

Can liver cancer be prevented?

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

There are things you can do to lower your chance of getting liver cancer.

You can take steps to avoid or treat 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
• practising safe sex
• avoiding needle sharing, if you inject medicines or drugs
• 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. Medicines to treat hepatitis B and hepatitis C are available.

You can reduce how much alcohol you drink. This will lower your chance of liver cirrhosis.

You can reduce your chance of metabolic-associated fatty liver disease (MAFLD) by:

• eating plenty of fruit and vegetables, whole grains and healthy fats
• maintaining a healthy weight
• being physically active on most days of the week
• taking medicines for high cholesterol if you have it
• managing diabetes
• limiting how much sugar and alcohol you have

Resources and support

Cancer Council Australia provides services and support to people affected by any type of cancer. You can reach them on 13 11 20.

Call the Liver Foundation's free support line on 1800 841 118 to speak to a liver nurse.

Information about cancer in many community languages is provided by the Cancer Institute of NSW.

Read cancer information for Aboriginal and/or Torres Strait Islander peoples provided by Cancer Council NSW.

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with you 24 hours a day, 7 days a week.