LIVER CANCER

( By JASCAP )

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Treating liver cancer

Treatment overview for primary liver cancer

The type of treatment you are offered will depend on thetype of liver cancer you have, the stage of the cancer , its size and your general health.

The main treatments used to treat primary liver cancer are surgery , and chemotherapy . Other treatments, such as tumour ablation , biological therapy , and radiotherapy may occasionally be used.

Planning your treatment

In most hospitals a team of specialists will meet to discuss and agree on the plan of treatment they feel is best for your situation. This multidisciplinary team (MDT) will include:

  • a surgeon experienced in liver surgery
  • a bowel and liver specialist (gastroenterologist/hepatologist)
  • a clinical or medical oncologist (to advise on chemotherapy)
  • a radiologist (who analyses x-rays)
  • a pathologist (who advises on the type and grade of the cancer, and how far it has spread).

The MDT may also include a number of other healthcare professionals such as a:

  • nurse specialist
  • symptom control specialist
  • dietitian
  • physiotherapist
  • occupational therapist
  • psychologist or counsellor.

The MDT will plan your treatment by taking into consideration a number of factors. This will include your age, general health, the type and size of the tumour, what it looks like under the microscope and whether it has spread beyond the liver (the stage).

The benefits and disadvantages of treatment

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Some people ask what would happen if they did not have any treatment.

Although many of the treatments can cause side effects, these can usually be effectively controlled with medicines. Treatment can be given for different reasons, and the potential benefits will vary depending upon each person's situation.

Early-stage liver cancer

In people with early-stage liver cancer, surgery is often done with the aim of curing the cancer.

Advanced liver cancer (metastatic)

If the cancer is at a more advanced stage, the treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. However, for some people, the treatment will have a limited effect upon the cancer and they will get the side effects with little benefit.

Treatment decisions

If you have been offered treatment with the aim of curing your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure isn't possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with treatment.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss in detail with your cancer specialist the possible treatment options.

Giving consent

Before you have any treatment, your doctor will explain its aims to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent. Before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any other treatments that may be available
  • any significant risks or side effects of the treatment.

If you don't understand what you have been told, let the staff know straight away so that they can explain it again. Some cancer treatments are complex, so it's not unusual for people to need repeated explanations.

It's often a good idea to have a friend or relative with you when the treatment is explained.

This can help you remember the discussion more fully.

Patients often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions. You can talk to the liver specialist nurse at the hospital or call our cancer support specialists .

You can always ask for more time to decide about the treatment if you don't feel you can make a decision when it's first explained.

You are also free to choose not to have the treatment. The staff can explain what may happen if you don't have it. It's important to tell a doctor or your nurse if you decide not to have treatment, so that they can record your decision in your medical notes. You don't have to give a reason for not wanting to have treatment, but it can help to let the staff know your concerns so that they can give you the best advice.

Second opinion

Usually a number of cancer specialists work together as a team using national treatment guidelines to decide on the most suitable treatment for you. Even so, you may want to have another medical opinion. Either your specialist or your GP should be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a friend or relative with you, and have a list of questions ready. This way you can make sure your concerns are covered.

Surgery for primary liver cancer

Surgery is the most effective treatment for primary liver cancer, but isn't always possible due to the size and position of the tumour. It's also not possible to operate if the cancer has spread beyond the liver. If the liver is severely damaged by cirrhosis it may not be safe to have surgery. Unfortunately only a small number of people with primary liver cancer will be able to have surgery.

There are different types of surgery, depending on the position and size of the tumour and whether the liver is damaged by cirrhosis. Before any operation it's important to discuss it fully with your doctor so that you understand what it involves.

Liver resection

If only certain areas of the liver are affected by cancer and the rest of the liver is healthy, it may be possible to remove the affected part.

This is called a liver resection. If the operation involves the removal of a whole lobe of the liver, it's called a hemi-hepatectomy .

The liver has an amazing ability to repair itself. Even if up to 80% of the liver is removed it will start to re-grow very quickly, and may be back to normal within a few weeks.

Liver transplant

It may be possible to remove the whole liver and replace it with a liver from another person a donor. In the treatment of Hepatocellular carcinoma (HCC) a liver transplant can only be done if you have:

  • a single tumour that is between 35cm
  • a single tumour that is between 57cm that hasn't changed in size for six months
  • a maximum of five tumours, all smaller than 3cm in size.

Your specialist may suggest a liver transplant if you have cirrhosis of the liver. However, if your cirrhosis is severe you may not be well enough to go through this major operation.

Most liver transplants are taken from people who have died (organ donors). In some situations it may be possible to have a living-donor liver transplant operation. The donor has surgery to remove either the right or the left lobe of their liver, which is immediately transplanted into the patient. This is a newer type of operation and is not available in many hospitals.

Most people with primary liver cancer won't be suitable for a liver transplant. This is because they will not be well enough or because the cancer has already begun to spread beyond the liver. There is also likely to be a wait for a suitable donor to become available, which can take many months. The cancer will continue to grow during this time and you will be given other treatments to control it.

If there is any risk that cancer cells may have spread, a liver transplant won't cure the cancer and usually won't be recommended. After a transplant operation you will need to take drugs so that your body doesn't reject the new liver. These drugs, known as immunosuppressants, dampen down the immune system making it less effective at fighting against any cancer cells. So if the cancer had spread before the surgery you will have gone through a major operation only to have the cancer come back.

Your specialist can discuss if a transplant is suitable for you.

After your operation

For about 24 hours after your operation you may be nursed in the intensive care ward or high-dependency unit, until you have fully recovered from the anaesthetic. The liver has a really good blood supply and there is a risk that it may bleed after surgery so the doctors and nurses will keep a very close check on your blood pressure.

Drips and drains

You will have a dressing over the operation site on your abdomen, and if necessary one or more drainage tubes will drain fluid and blood from the wound site into drainage bags. The nurses will regularly measure the amount of blood (if any) in these bags. When the drainage has almost stopped, the tube(s) will be removed. This usually takes place after a few days.

You will have a drip (intravenous infusion) going into a vein in your arm to give you fluids and essential nutrients. This will be removed once you're drinking and eating again usually within 12 days.

A small tube called a catheter will be put into your bladder to drain urine into a collecting bag. This will save you having to get up to pass urine. It's usually removed after a few days.

Pain

It's normal to have some pain or discomfort after an operation on the liver. You'll be given regular injections of painkillers for several days after the operation to prevent and relieve pain.

Nausea (sickness)

Some people feel sick after an operation. You may be given injections of anti-sickness drugs (anti-emetics) to help prevent and relieve this.

Going home

Most people are able to go home 612 days after their operation and will need painkillers for the next few weeks. It may take up to six weeks before you start getting back to normal.

If you think you might have problems when you go home (for example, if you live alone or have several flights of stairs to climb), let the nurse or social worker know when you are admitted to the ward so that help can be arranged.

Your nurse specialist can offer or arrange support or counselling for you and your family. Social workers are often available to give practical advice. Many are also trained counsellors. If you would like to talk to a social worker you can ask your specialist nurse to arrange it for you.

Before you leave hospital you'll be given an appointment to attend an outpatient clinic for your post-operative check up. This is a good time to discuss any problems you may have. If you have any problems or worries before this time, you can speak with your ward nurses or hospital doctor.

Chemotherapy for primary liver cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.

Chemotherapy is sometimes used to treat primary liver cancers that can't be removed by surgery, although in adults chemotherapy will not usually cure the cancer. It can help to shrink the tumour and slow its progression, which can help to control symptoms.

Chemotherapy drugs are sometimes given as tablets, or more usually, as injections into a vein (intravenously) or by injection directly into the hepatic artery (the main blood vessel that takes blood to the liver). Chemotherapy can sometimes be given as part of a treatment called chemoembolisation .

There is no standard chemotherapy drug for the treatment of hepatocellular carcinoma. The most commonly used chemotherapy drug is doxorubicin . Other chemotherapy drugs that may be used are:

A combination of chemotherapy drugs may be used. Not everyone is suitable for chemotherapy treatment as it can only be given if the liver function is good enough.

How chemotherapy is given

Chemotherapy is usually given as a session of treatment called a cycle. Each cycle lasts a few days and is followed by a rest period of a few weeks to allow the body to recover from any side effects of the treatment. The number of cycles you have will depend on the type of liver cancer you have and how well it is responding to the drugs.

Chemotherapy is usually given in the hospital outpatient department or chemotherapy unit. Sometimes the chemotherapy is injected slowly into a vein (intravenously), or it may be given as a drip (infusion) over a few hours. You may need to stay a few days in hospital. Occasionally it is given as a continuous infusion through a small pump that you take home with you. Your doctor or nurse will explain all about your chemotherapy.

A number of research trials are being carried out to try to improve the results of treatment for primary liver cancer. You may be asked to take part in a trial. See our clinical trials section for more information.

Side effects

Chemotherapy can sometimes cause unpleasant side effects, but it can also make you feel better by relieving the symptoms of the cancer. Most people have some side effects, but these can often be well controlled with medicines. The possible side effects are described here, along with some of the ways in which they can be reduced.

Lowered resistance to infection (neutropenia)

While the chemotherapy is acting on the cancer cells in your body, it also temporarily reduces the number of white blood cells. When there are fewer white blood cells, you're more likely to get an infection. During chemotherapy, your blood will be tested regularly and, if necessary, you'll be given antibiotics to treat any infection.

Bruising or bleeding (thrombocytopenia)

Chemotherapy can reduce the production of platelets, which help the blood to clot and stop any bleeding. Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Low number of red blood cells (anaemia)

You may become anaemic. This can make you feel tired and breathless. Our section on coping with fatigue may be helpful.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause small ulcers. Regular mouthwashes are important and your nurses will show you how to do these properly. If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet.

Our section about eating well has some useful tips on coping with eating problems.

Feeling sick

Some of the drugs may make you feel sick (nauseated) and you may be sick. There are now very effective anti-sickness drugs (anti-emetics) to prevent or greatly reduce nausea and vomiting . Your doctor can prescribe these for you. Let your doctor or nurse know if your anti-sickness drugs aren't helping, as they can change it to a different type. Some anti- emetics can cause constipation. Let your doctor or nurse know if this is a problem.

Tiredness

You are likely to find that you become very tired and have to take things much more slowly. Just do as much as you feel like and try not to overdo it. Our section on coping with fatigue may be helpful.

Hair loss

Ask your doctor whether the drugs you are taking are likely to make your hair fall out. Not all drugs cause hair loss . If your hair does fall out, it will start to grow back once your treatment is over.

Diarrhoea

Some drugs used to treat cancer of the liver can irritate the lining of the digestive system and cause diarrhoea for a few days. Your doctor can give you medicine to slow down the bowel and reduce the diarrhoea. You may also be able to help to control it by eating a low-fibre diet, avoiding wholemeal bread and pasta, raw fruit, cereals and vegetables for a few days after each treatment. There are more tips and recipes in our eating well section.

Skin

Chemotherapy can affect the skin and nails, causing dryness and flaking. Some drugs make your skin more sensitive to the sun, so it is important to cover up and use a high-factor sun cream (SPF 15 or greater).

Numbness or tingling in hands or feet

Some chemotherapy drugs can affect the nerves causing numbness and tingling. This is known as peripheral neuropathy. Tell your doctor if you notice these side effects. This problem usually improves slowly a few months after the treatment has finished.

Your kidneys may be affected

Some chemotherapy drugs can affect the way your kidneys work. Usually this does not cause any symptoms and the effect is normally mild. Rarely, it may cause permanent damage to the kidneys unless the treatment is stopped. Before and after each treatment, your kidneys will be checked by a blood test and you'll be given plenty of fluid through a drip to keep your kidneys working normally. It is important that you also drink plenty of fluids during and after your treatment. Your urine may also be measured (to check that your kidneys are working properly).

Changes in hearing

Chemotherapy can cause ringing in the ears (tinnitus) and you may be unable to hear some high-pitched sounds. This usually improves when the treatment is over. Tell your doctor if you notice any loss of hearing or ringing in your ears.

Although these side effects may be hard to bear at the time, they will gradually disappear over a few weeks once your treatment has finished.

Chemoembolisation

Chemoembolisation treatment aims to get rid of the cancer by giving chemotherapy directly into the affected part of the liver and by cutting off the blood supply to the tumour (a process known as embolisation).

Chemotherapy drugs are injected directly into the tumour in the liver. The chemotherapy drugs will be mixed with a substance called lipiodol that helps the chemotherapy stay in the liver for longer. This makes the treatment more effective.

You will be given a local anaesthetic and possibly a mild sedative to make you feel relaxed. The doctor then puts a fine tube called a catheter into a main blood vessel in your groin (femoral artery). The catheter is passed along the femoral artery until it reaches the main blood vessel that carries blood to the liver (hepatic artery).

The chemotherapy and lipiodol mixture is then injected into the liver through the catheter. Sometimes the doctor will also inject something to block the blood flow to the tumour, such as a gel or some tiny plastic beads. Blocking the blood supply (embolisation) will starve the tumour of oxygen, which can help to destroy it.

Chemoembolisation is carried out in the x-ray department at the hospital. You will usually need to stay in hospital overnight and possibly longer.

The treatment can be repeated several times.

Chemoembolisation is sometimes combined with radiofrequency ablation and your doctor can explain if this would be helpful for you.

Chemoembolisation can cause side effects such as sickness, pain and a raised temperature. You will be given anti-sickness (antiemetic) drugs and painkillers to help control any side effects.

Tumour ablation for primary liver cancer

Ablation means to destroy. There are two different ways of ablating primary liver tumours, using either alcohol or heat.

Percutaneous ethanol injection

This type of treatment is used for tumours less than 5cm (2in) in size. Alcohol (ethanol) is injected through the skin and into the tumour in the liver. The alcohol can destroy the cancer cells. This procedure is usually done in the scanning department so that ultrasound can be used to guide the needle directly into the tumour. You will be given a local anaesthetic. If the tumour grows again, the treatment can be repeated.

Side effects of percutaneous ethanol injection are usually mild and include pain and fever. Let your doctor know if you develop any side effects as they can usually be controlled with medication.

Radiofrequency ablation (RFA)

This treatment uses laser light or radio waves to destroy the cancer cells by heating them to a very high temperature. A fine needle is passed through the skin into the tumour in the liver. Powerful laser light or radio waves are then passed through the needle and into the tumour.

These heat the cancer cells.

Like percutaneous ethanol injection, radiofrequency ablation is done in the scanning department using ultrasound or CT (computerised tomography) scanning so that the doctor can guide the needle directly into the tumour. You may be given a local anaesthetic or a general anaesthetic.

Side effects of RFA include pain and fever, but they are usually very mild and can be controlled with medicines.

The National Institute for Health and Clinical Excellence (NICE), which advises doctors about treatment, has issued guidance on the use of RFA for primary liver cancer. The guidance states that RFA can be helpful at destroying hepatocelullar carcinoma, which may improve survival. The guidance also recommends that RFA is given using ultrasound or CT scanning, and that people having the treatment are cared for by a multidisciplinary team that includes a liver surgeon.

Biological therapies for primary liver cancer

Biological therapies use substances that are produced naturally in the body, to destroy cancer cells. A biological therapy called sorafenib (Nexavar®) may be used to treat hepatocellular carcinoma.

Sorafenib is a cancer growth inhibitor. In order to grow and divide cancer cells 'communicate' with each other using chemical signals. Cancer growth inhibitors interfere with this process and so affect the cancer's ability to develop.

Sorafenib is a tablet that is usually taken twice a day. Side effects include tiredness, diarrhoea, feeling sick (nausea), high blood pressure and muscle pains.

Although sorafenib is licensed and can be prescribed in the UK, it has not yet been assessed by the National Institute for Health and Clinical Excellence (NICE). NICE gives advice on which new drugs or treatments should be available on the NHS. As a result, sorafenib may not be widely available on the NHS.

Radiotherapy for primary liver cancer

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy is not often used to treat primary liver cancer because the liver can't tolerate very high doses of radiotherapy. It's sometimes used to treat cholangiocarcinoma, but not usually hepatocellular cancers.

Our section about radiotherapy gives more details about this treatment and its side effects.

Other treatments for primary liver cancer

The following treatment is still being evaluated as part of research trials. Your cancer specialist will be able to discuss with you whether it may be helpful in your situation, and can refer you to a hospital that carries out this treatment.

Cryosurgery or cryotherapy

This treatment may be possible if you can't have surgery. A device called a cryoprobe is inserted into the centre of the tumour. Liquid nitrogen is then passed through the probe. This freezes the surrounding area and destroys the cancer cells. The treatment may be done during an operation or a laparoscopy.

Cryotherapy can be painful and you can be given painkillers if you need them. Some people also develop a fever. Let your doctor know if you notice any side effects.

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