Liver Cancer: Symptoms, Stages & Treatment Options

Liver cancer can be a tough diagnosis to face, but understanding the basics can help you feel more in control. It’s a disease that can develop quietly, often without early symptoms, so knowing the risk factors and signs is key. From treatment options to lifestyle changes that can lower your risk, being informed can make a huge difference when it comes to taking care of your liver health.

What is Liver Cancer?  

Liver cancer is a type of cancer that starts in the liver or its bile ducts. The American Cancer Society estimates that around 42,000 people are diagnosed with liver cancer each year, with about 30,000 liver cancer deaths annually. Liver cancer is about twice as common in men compared to women.

Primary vs. Secondary  

When liver cancer starts in liver cells or its bile ducts, it is called primary liver cancer. When cancer spreads to the liver from other parts of the body, such as the colon, lungs, or breast, it is called secondary cancer or metastatic cancer.

Types of Liver Cancer

There are 3 main types of primary liver cancer:

• Hepatocellular carcinoma (HCC) is the most common type of liver cancer. It begins in cells called hepatocytes, which are the main types of liver cells.

• Intrahepatic bile duct cancer or intrahepatic cholangiocarcinoma starts in the bile ducts in the liver. It is a less common form.

• Angiosarcoma is a very rare cancer. It begins in the blood vessels in the liver.

Liver cancer can occur in both adults and children. However, the treatment for childhood liver cancer is different.

What Causes Hepatocellular Carcinoma (HCC)?

Liver cancer develops due to unexpected changes in the DNA (genetic material) of healthy liver cells, turning them into cancerous cells. DNA tells cells in the body when to grow and die. Genes called oncogenes tell cells to multiply, while tumor suppressor genes prevent cells from multiplying uncontrolled. DNA mutations (changes in genes or faulty genes) prevent liver cells from getting these instructions, causing cancer cells to multiply unchecked. For example, the changes may turn on oncogenes or turn off tumor suppressor genes. This is the underlying cause of liver cancer and all cancers.

Risk Factors for Liver Cancer

Unlike many other cancers, healthcare professionals have a good understanding of what increases a person’s risk of developing liver cancer. According to the National Cancer Institute, risk factors for primary liver cancer include:

• Chronic hepatitis B or hepatitis C virus infection.

• Cirrhosis—a progressive and permanent scarring of liver tissue. 

• Nonalcoholic fatty liver disease—an accumulation of fat in liver cells.

• Inherited liver diseases such as Wilson’s disease and hemochromatosis.

• Diabetes or high blood glucose levels.

• Excessive alcohol use and associated liver damage are linked to an increased risk of liver cancer.

• Aflatoxin exposure—poisonous substances produced by molds that grow on poorly stored crops like grains and nuts.

Symptoms of Liver Cancer  

Common Liver Cancer Symptoms

Common symptoms of liver cancer include:

• Pain in the right upper abdomen

• Pain near the right shoulder blade

• A hard lump below the rib cage on the right side

• Swelling or bloating of the abdomen

• Jaundice or yellowing of the skin or eyes

• Itching

• Unexplained weight loss

• Nausea or vomiting

• Loss of appetite

• Early satiety (feeling full after a small meal)

• Unusual tiredness

• Dark colored urine

• Pale stools

• Enlarged veins on the belly

• Easy bruising or unusual bleeding

• Feeling worse if you have hepatitis or cirrhosis

First Signs to Watch For

In most people, primary liver cancer does not cause any symptoms in the early stages. When present, the first signs of liver cancer are often non-specific symptoms like unintended weight loss, right upper abdominal pain, and loss of appetite.

Symptoms in Advanced Stages  

People with stage 4 liver cancer who are nearing the end of life can have severe and worsening symptoms, including:

• Extreme fatigue and weakness

• Severe pain

• Significant weight loss

• Jaundice

• Ascites (buildup of fluid in the abdomen)

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Stages of Liver Cancer  

After a liver cancer diagnosis is confirmed, doctors perform a process called staging. This is essentially figuring out how much cancer is in the body, whether it has spread outside the liver, and how far it has spread. Staging helps to determine liver cancer treatment and survival rates. 

The TNM Staging System  

The American Joint Committee on Cancer (AJCC) has developed the TNM cancer staging system, which is widely used to stage liver and other cancers. This system is based on three key features of the tumor:

• T: Tumor size and extent within the liver

• N: Spread to nearby lymph nodes 

• M: Metastasis or spread to distant parts of the body, such as the lungs or bones

Numbers or letters after T, N, and M provide additional details about these features. A higher number indicates a more advanced cancer. For example, T1aN0M0 indicates stage 1 liver cancer, where a single tumor is smaller than 2 cm and has not spread to nearby lymph nodes or other parts of the body. Stage 4 liver cancer is one or multiple liver tumors of any size that have spread to other organs, such as the lungs or bones.

Other Staging Systems

The TNM system provides details about the liver tumor but not about liver function. Other staging systems that include these factors are:

• The Barcelona Clinic Liver Cancer (BCLC) system

• The Okuda system

• The Cancer of the Liver Italian Program (CLIP) system

How Do Doctors Diagnose Liver Cancer?

If your healthcare professional suspects liver cancer based on your medical history, symptoms, and physical examination, they may order diagnostic testing, including: 

• Blood tests such as liver function tests to check liver health and alfa-fetoprotein (AFP) which is sometimes high in people with liver cancer.

• Imaging tests such as ultrasound, CT scan, and MRI. 

• An angiogram to look at blood vessels in the liver. 

• A liver biopsy to obtain a sample of liver tissue and examine it in the laboratory for signs of cancer. A biopsy is the gold standard for confirming a diagnosis of liver cancer.

• Additional tests such as endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) if your doctor suspects intrahepatic bile duct cancer. 

Treatment Options for Liver Cancer

Surgery 

Early-stage liver cancer, where the tumor is small and has not invaded nearby blood vessels, may be removable surgically. This is called a partial hepatectomy. The surgery removes the part of the liver that has cancer and leaves the rest of the healthy liver intact.

Liver Transplant  

People with early-stage liver cancer who do not have enough healthy liver remaining after the cancer is removed may be candidates for a liver transplant. A transplant is also an option in people where the tumor is difficult to remove due to its location, for example, near a large blood vessel.

Radiation Therapy and Chemotherapy

Some liver cancers cannot be safely treated with surgery due to the large size of the tumor, multiple tumors, or underlying health conditions in a patient that make surgery unsafe. Treatment options for these liver tumors include chemotherapy, radiation therapy, and other innovative treatments (see below). Chemotherapy drugs kill cancer cells. Radiation uses high-energy waves to kill cancer cells. These treatments may not cure liver cancer but can relieve symptoms and prolong life.

Ablation and Embolization

Interventional oncology treatments are minimally invasive outpatient procedures that are done using imaging guidance. They allow specialists in clinical oncology to target liver tumors using heat (microwave or radiofrequency energy) or extreme cold (cryosurgery). This is called tumor ablation. 

In addition, oncologists can inject medicine into blood vessels that supply blood to the tumor or block the tumor’s blood supply, resulting in shrinking of the tumor and tumor cell death. This is called embolization.

Immunotherapy

Immunotherapy drugs help to boost the body’s immune response against cancer cells. These drugs can shrink some liver tumors or slow their growth. Examples include:

• Atezolizumab (Tecentriq)

• Durvalumab (Imfinzi)

• Pembrolizumab (Keytruda)

• Nivolumab (Opdivo),

• Ipilimumab (Yervoy) 

• Tremelimumab (Imjudo)

Targeted Therapy

Targeted drugs identify specific changes in cancer cells. These drugs reach all parts of the body through the bloodstream and are useful against cancers that have spread from the liver to distant organs in the body. Examples include:

• Sorafenib (Nexavar)

• Regorafenib (Stivarga)

• Lenvatinib (Lenvima)

• Cabozantinib (Cabometyx)

Monoclonal Antibodies 

Monoclonal antibodies are lab-made versions of antibodies (immune system proteins) that attach to a specific target on cancerous cells. They help to treat liver cancer by preventing angiogenesis (the tumor’s ability to make new blood vessels and grow). Examples include bevacizumab (Avastin) and ramucirumab (Cyramza).

Clinical Trials

People with liver cancer may qualify for enrollment in clinical trials that are studying new and experimental treatments. 

Prognosis and Survival Rates  

Prognosis By Stages

Stage 1 or stage 2 liver cancer has a good prognosis (outlook). These tumors can be cured with surgery such as partial hepatectomy or liver transplant to remove the cancer from the body. However, only a small number of patients with liver cancer are candidates for curative surgery. 

Overall, the prognosis for the majority of people with liver cancer is poor. Inoperable liver cancer is generally not curable, but treatments can reduce symptoms and increase life expectancy by 6 to 18 months.

Life Expectancy 

Life expectancy in liver cancer depends on many factors, including the type of cancer stage, liver function, available treatments, and individual response to treatment. The median survival based on the BCLC system is as follows:

• Stage B: 16 months, may increase to 40 months with embolization treatment.

• Stage C: 11 to 13 months with treatment and 6 to 8 months without treatment.

• Stage D: 3 to 4 months.

Survival Rates of Hepatocellular Carcinoma  

The 5-year relative survival rate is the percentage of people with cancer that are, on average, likely to live for 5 years after being diagnosed.

The relative 5-year survival rates for people with the most common type of primary liver cancer (hepatocellular carcinoma) are as follows:

• Localized cancer: 37%

• Regional spread: 13%

• Distant spread: 3%

• All stages combined: 22%

Does Liver Cancer Spread Fast?

Like many cancers, liver cancer develops slowly and silently in the early stages without causing any noticeable liver cancer symptoms. Most people find out they have liver cancer when it is in the advanced stages and is growing and spreading more quickly.

How Aggressive Is Liver Cancer?

Liver cancer is often aggressive and can spread quickly, particularly in people with pre-existing liver disease.

Can You Fully Recover from Liver Cancer?

Yes, people who are diagnosed with liver cancer in the early stages may be able to fully recover. 

Is Liver Cancer Curable?

Early-stage liver cancer is curable with surgery or liver transplantation.

Living with Liver Cancer  

Managing Symptoms and Side Effects  

Treating the cancer often improves symptoms in people with primary liver cancer or secondary liver cancer. Other supportive treatments can also help to keep you comfortable. This is called palliative care.

For example, your doctor may give you prescription pain medications for liver pain or medications such as water pills to remove excess fluid from the body if you have ascites (fluid collection in the abdomen). A paracentesis procedure can also be done to remove ascites fluid. Radiofrequency ablation may help to relieve signs and symptoms of liver cancer by shrinking a tumor. Treatments are available for other symptoms, such as jaundice, loss of appetite, and fatigue.

Support for Patients and Caregivers  

• American Liver Foundation (ALF)

• National Comprehensive Cancer Network (NCCN)

• American Cancer Society (cancer.org)

• National Cancer Institute (cancer.gov)

• National Coalition for Cancer Survivorship (NCCS)

Lifestyle Changes for Liver Cancer Prevention  

You cannot 100% prevent liver cancer, but the following can help to lower your risk:

• Drink alcohol in moderation or not at all. Avoid excessive alcohol consumption.

• Eat a healthy diet and maintain a healthy weight.

• Get vaccinated. Talk to your doctor about getting the hepatitis B vaccine and hepatitis A vaccine.

• Avoid hepatitis C by practicing safe sex, avoiding unhygienic tattoos, and not abusing injectable illegal drugs.

• Talk to your healthcare provider about liver cancer screenings if you have risk factors such as liver disease, obesity, diabetes, or heavy drinking.