Liver Cancer – HCC

Key points

• Hepatocellular Carcinoma (HCC) is a type of liver cancer
• It can be cured if you find it at a very early stage
• There is an effective treatment for almost all stages of HCC
• If you already have liver damage or cirrhosis you should be on regular screening for HCC. Talk to your GP or liver specialist
• Some people die of HCC, particularly if it is not found at an early stage

What is HCC?

Cancer can develop in the liver for several reasons. Most often, cancer spreads to the liver from somewhere else in the body, such as the colon, lung or breast. But hepatocellular carcinoma (HCC) is a cancer that starts in the liver.

HCC affects the main type of liver cells, called hepatocytes. The cells start to mutate and divide out of control. The cancer grows as lumps (tumours) throughout the liver and can eventually spread to other parts of the body.

HCC is the most common type of primary liver cancer (cancer that starts in the liver cells). It’s become much more common over the last 40 years. In Australia, around 3,000 people are diagnosed with HCC every year and the rates are increasing. The highest rates are in people aged 60 to 64. It occurs more often in men than in women.

Despite improvements in treatment, because it is often diagnosed late, only 1 in 5 people diagnosed with HCC will survive more than 5 years. Liver cancer is the seventh most common cause of cancer death in Australia.

The earlier HCC is diagnosed the better the chance of having a treatment that can cure it.

What are the symptoms of HCC?

Like other liver cancers, HCC doesn’t usually cause any symptoms in the early stages. When symptoms do eventually appear it usually means the cancer is in an advanced stage. These symptoms may include:

• unexpected weight loss
• losing your appetite
• pain in the upper right of the trunk or in the right shoulder
• feeling sick and vomiting
• feeling tired and weak
• swollen belly
• yellow eyes and skin (jaundice)
• pale poos
• dark urine (wee)

Do I need to screen for liver cancer?

Some people are more at risk of developing HCC. It’s recommended that you have an ultrasound and possibly a blood test to check for HCC every 6 months if:

• you have cirrhosis or have ever been diagnosed with cirrhosis
• you have long standing hepatitis B infection and:
• you are a man of Asian heritage over 40 years or a woman of Asian heritage over 50 years
• you are of African heritage and aged over 20 years
• you are of Aboriginal and Torres Strait Islander heritage and aged 50 years
• you have a family history of liver cancer

How is HCC diagnosed?

Liver ultrasound is the main way doctors find HCC. If you have problems with your liver, you are likely to have regular ultrasounds to check for HCC.

Sometimes your doctor will combine the ultrasound with a blood test. This is to look for levels of alpha-fetoprotein (AFP), a protein that is produced by HCC tumours. AFP levels can be normal even if you have HCC.

A diagnosis of HCC can’t be made from an ultrasound. If an abnormal lump is found, your doctor will then order a CT or an MRI scan to make a diagnosis of HCC.

Sometimes, it’s necessary to look at a small sample of liver tissue taken in a biopsy to confirm the cancer.

Once HCC is confirmed, you may need further tests to work out the stage of the cancer. That means, how far it has spread.

The most common way of staging HCC in Australia is the Barcelona Clinic Liver Cancer (BCLC) staging system:

• Stage 0: Very early stage. There is just one lump in the liver that’s less than 2 cm in diameter
• Stage A: Early stage. There is one lump more than 2 cm or 2 to 3 lumps each less than 3 cm
• Stage B: Intermediate stage. There are more than 3 lumps or 2 to 3 lumps with at least one being bigger than 3 cm
• Stage C: Advanced stage. The cancer has spread into the veins or to other parts of the body
• Stage D: Terminal stage with liver failure

Why did I get HCC?

The risk of developing HCC is higher in people who have long-term liver disease of any cause that has progressed to cirrhosis.

Some people with long standing hepatitis B are at increased risk of developing HCC.

Smoking, drinking unhealthy amounts of alcohol, or having diabetes or obesity increase the chance of developing HCC.

Sometimes, people with no history of liver disease can get an HCC.

How is HCC treated?

The treatment for HCC depends on how far it has spread. It is recommended that the treatment options for someone with HCC should be discussed by a multidisciplinary team – a team of doctors, nurses and other allied health professionals with different areas of expertise.

Your doctor or liver cancer nurse will talk to you to discuss which treatment is best for you. They will give you information about the treatment. All treatments have a risk of complications or side effects and it is important to discuss these with your healthcare team.

Surgery

Surgery is sometimes recommended to remove the tumour and some of the healthy tissue around it. This surgery is suitable if the tumour has not spread outside the liver and it can be completely removed, leaving enough liver for you to live with.

To decide whether surgery is for you, your doctor will look at the stage of the HCC, your overall health and your liver function.

After surgery, there is a risk of liver failure, complications of surgery or the HCC coming back.

For some people, a liver transplant may give the best chance of cure. This is only an option for people who have early-stage liver cancer. A liver transplant completely removes the HCC along with the liver disease. There is a very good survival rate for people who have liver transplants in Australia.

Radiology-guided therapy

Most people with HCC aren’t suited to surgery or a liver transplant because of their underlying liver disease, age or other medical conditions.

In this case, your doctor may refer you to a doctor called an interventional radiologist for radiology-guided therapy. This is a treatment directed straight to the cancer in the liver. The rest of the body is not affected by the treatment and there is less chance of side effects.

Radiology-guided therapies may completely cure small cancers, or shrink and control larger tumours. They include:

• Ablation – using an ultrasound as a guide, the doctor inserts one or more thin needles through your belly into the liver. When the needles reach the tumour, they are heated with an electric current or microwaves to destroy the cancer cells.
• Chemical injection – ethanol is injected into the tumour to kill the cancer cells.
• Transarterial chemoembolisation (TACE) – chemotherapy (drugs that destroy cells) is injected into arteries that supply blood to the tumour.
• Radioembolisation or Selective internal radiation therapy (SIRT) – tiny beads are inserted into the tumour through the arteries that supply blood to the tumour to provide high doses of internal radiation.

Radiation therapy

Radiation therapy is when energy from X-rays is targeted at the cancer to kill the cells. It is sometimes used in HCC if other treatments aren’t possible or haven’t worked. In people with advanced HCC, radiation can shrink the tumour and relieve some of the symptoms.

Drug therapies

Some patients are suitable to receive drugs therapies that can treat cancer cells wherever they may be in the body. The most commonly used drugs in Australia for HCC are:

• a form of immunotherapy given by infusion into a vein every 3 weeks (combination atezolizumab (Tecentriq) and bevacizumab) that helps the body’s immune system fight tumours, or
• a targeted therapy taken as tablets by mouth (lenvatinib (Lenvima) or sorafenib (Nexavar))

If these drugs don’t work, you doctor will discuss possible second-line treatments.

There’s a lot of research at the moment into new medications that are showing promise to treat HCC and it is likely that treatments will change over time.

Palliative care

Palliative care is care that aims to help with symptoms and let you live your best life possible. It does not mean end-of-life care. People can have palliative care at any stage of their cancer.

Palliative treatments may include radiation therapy or using drugs to manage symptoms.

Your doctor may refer you to a palliative care team to help manage your symptoms and maintain your quality of life.

Living with HCC

If you are diagnosed with HCC, there are some important things you can do to make sure you’re as healthy as you can be.

HCC stops the liver from working properly, so the body uses up fat and muscle to provide energy. This can lead to muscle wasting, weight loss and loss of strength.

If you have HCC, you may need to eat more kilojoules and more protein than you did previously. It’s a good idea to talk to an accredited dietitian about a high protein, high energy eating plan. You can eat small meals often, have extra energy-rich snacks, and avoid salt. You can read more about an eating plan here.

There are other ways you can live well with HCC.

• Look after your overall health by exercising.
• If you are overweight, try to lose weight.
• Avoid all alcohol to protect your liver.
• Avoid anything that is toxic to your liver, including some medications, alternative medicines and liver tonics.
• Look after any other health conditions you may have, such as diabetes.
• Give up smoking if you are a smoker.
• Get support for your mental health if you need it.
• Tell your doctor if symptoms are bothering you, as there are many ways to relieve them.

Additional information and support

• Cancer Council 13 11 20
• Understanding Liver Cancer (Cancer Council, PDF booklet)
• Liver Cancer: Your guide to best cancer care (Cancer Australia and Cancer Council booklet)

What next?

Reviewed November 2022