Liver Cancer

Liver cancer starts in the liver, the large organ that sits in the upper right side of your abdomen, under your ribs and next to your stomach. The liver is vital to digestion, so cancer here and its treatments can affect your nutrition, weight, strength, and overall health.

This overview discusses the symptoms, causes, and treatments for primary liver cancer, as well as how nutrition can support your body during treatment and recovery.

Liver cancer starts when abnormal cells grow and form a tumour in your liver. Primary liver cancer differs from secondary liver cancer, which starts somewhere else and spreads to your liver.

Your liver is responsible for hundreds of functions that keep you healthy, including:

• Filtering toxins from your blood
• Making certain blood proteins
• Regulating blood clotting
• Producing bile to help break down fats
• Storing a form of glucose (sugar) for extra energy
• Breaking down and storing many essential nutrients

There are several types of primary liver cancer (1):

• Hepatocellular carcinoma (HCC) is the most common type. It starts in liver cells called hepatocytes and can grow as a single tumour or many nodules throughout the liver.
• Intrahepatic cholangiocarcinoma (bile duct cancer) starts in the bile ducts, which carry bile from the liver to the gallbladder or the small intestine.
• Fibrolamellar carcinoma is a rare type that tends to affect people in their 20s and 30s. Tumours form thick, fibrous bands.
• Angiosarcoma and hemangiosarcoma are also rare and begin in cells that line blood vessels in the liver.

Doctors aren’t certain what causes liver cancer, but these factors can increase your risk (1,2):

• Being male
• Being overweight
• Chronic hepatitis B or C infection
• Non‑alcoholic fatty liver disease (NAFLD), a condition that causes excess fat storage in the liver
• Excessive alcohol use
• Smoking
• Cirrhosis (scarring of the liver from any cause)
• Certain inherited or rare diseases, including Wilson disease, haemochromatosis, or alpha 1-antitrypsin deficiency
• Exposure to certain chemicals and compounds, including aflatoxins, found in mouldy peanuts or grains, and anabolic steroids (used by bodybuilders)

Sometimes, liver cancer develops without a known cause.

Liver cancer symptoms can vary from person to person. It may not cause specific symptoms in the early stages, but as it grows, you may have (1):

• Loss of appetite
• Nausea or vomiting
• Feeling full quickly
• Unexplained weight loss
• Fatigue
• Pain in your upper right belly near your liver
• Jaundice (yellowing of the skin or eyes)
• Itching
• An enlarged liver that you or your doctor may feel on the right side of your belly, under your ribs
• Swelling or fluid build-up in your belly

Your doctor will review your medical history and examine you to learn more about your symptoms. If they suspect liver cancer (or any other liver disease), they’ll order further tests, which might include (1,2):

• Blood tests to check your liver function and measure alpha-fetoprotein (AFP), a blood marker that may be elevated in some people with hepatocellular carcinoma (HCC). AFP results are interpreted together with imaging tests and other clinical information.
• Imaging tests such as ultrasound, CT scan, or MRI to get detailed images of your liver and nearby organs
• A liver biopsy to remove a small amount of liver tissue and check for cancer cells

If liver cancer is confirmed, your doctors will stage the cancer to help guide your treatment. There are various staging systems for liver cancer, including the Barcelona Clinic Liver Cancer (BCLC) staging system and others. They consider the size and spread of the primary cancer, how well your liver is working, and whether your cancer is impacting your health or well-being (1). 

The number staging system is based on the tumour size and whether the cancer has spread to lymph nodes or other parts of your body. This staging also considers how well the remaining liver works:

• Stage I - One tumour in the liver that has not spread to any lymph nodes or invaded blood vessels or other parts of the body.
• Stage II - One tumour larger than 2 cm that has invaded blood vessels but not spread to any lymph nodes, OR two or more tumours, each less than 5 cm, with no spread to lymph nodes.
• Stage III - Two or more tumours (at least one is 5 cm or larger), OR the cancer has grown into the main blood vessels of the liver. The cancer hasn’t spread to any lymph nodes.
• Stage IV - One or more tumours of any size that have spread to lymph nodes or other parts of the body

Liver cancer treatments can vary and depend on the cancer type, stage, and your overall health. Underlying liver disease (especially cirrhosis) often determines the feasibility of treatment more than tumour stage alone. Your doctor may recommend one or more of these treatments:

• Surgery to remove part of your liver (resection). The liver can recover and regrow once the diseased part is removed, however many patients may not be surgical candidates because of underlying cirrhosis or the tumour location.
• A liver transplant removes your entire liver and replaces it with a donor liver.
• Tumour ablation uses radio waves and microwaves to heat and destroy cancer cells.
• Transarterial embolisation treatment (TAE) blocks or reduces blood supply to tumours. You might also have transarterial chemoembolisation (TACE), which is chemotherapy directly to the cancerous section of your liver, before the blood supply is blocked.
• Radiotherapy uses radiation to kill cancer cells.
• Targeted therapy uses medicines that target and destroy specific proteins that the cancer needs to grow.
• Immunotherapy uses drugs that help your immune system kill the cancer.
• Chemotherapy uses strong drugs to kill cancer cells or slow the growth of tumours, however, conventional chemotherapy has a limited role in most hepatocellular cancer cases today. Modern systemic treatment relies more on targeted therapy and immunotherapy.

Every person’s recovery is different, and the long-term outlook depends largely on how much the cancer has spread. Cancers caught early usually have more treatment options available and better odds of recovery. Surveillance with ultrasound and/or an AFP blood test is recommended for high-risk patients (chronic hepatitis or liver cirrhosis) to detect liver cancers earlier.

Some early-stage cancers may be cured. Others may go into remission, meaning the cancer is no longer detectable, but it’s not necessarily cured. In some cases, cancer can recur after a period of remission, which means that it has come back and needs further treatment.

Regular follow-up appointments are important because liver cancer can sometimes return after treatment. Monitoring allows your healthcare team to identify any concerns as early as possible.

Because the liver plays an important role in processing nutrients and supporting metabolism, liver cancer and its treatment can increase the risk of malnutrition, weight loss, and muscle loss.  

Those with underlying cirrhosis may need guidance on protein intake, sodium restriction if fluid is present and monitoring for micronutrient deficiencies. An oncology dietitian can tailor advice to both the cancer and the underlying liver condition as necessary.

Targeted nutritional support can make a big difference in how well you tolerate treatments and in your recovery. Your dietitian can design a personalised nutrition plan to help you meet your calorie, protein, and other nutritional needs and manage eating problems or treatment side effects, which might include: 

• Loss of appetite
• Early fullness
• Taste changes
• Nausea or vomiting
• Diarrhoea

To help manage these, they might recommend that you:

• Eat smaller, more frequent meals and snacks
• Prioritise high-protein foods like scrambled eggs or Greek yoghurt
• Add oral nutritional supplements like shakes, powders, or puddings that provide extra protein and calories in a small volume
• Get your nutrition temporarily through a feeding tube inserted into your small intestine if you’re unable to eat or drink
• Your healthcare team may recommend additional medications or nutritional strategies if treatment or liver disease is affecting digestion or nutrient absorption

Your medical team is available to support you throughout every step, from diagnosis through recovery. Stay in close contact, ask questions, and let them know about any problems or challenges you may encounter.