Liver cancer in 2007 is one of the most significant problems that a person with hepatitis C can develop. The medical term for the main cancer that begins in the liver is hepatocellular carcinoma (pronounced "HEP-a-toe-SEL-yoo-ler KAR-sih-NOH-muh"), or HCC for short. We will refer to HCC as "liver cancer" here.

People with long-standing hepatitis C who develop cirrhosis are at increased risk of developing liver cancer. Those who do not develop cirrhosis usually do not develop liver cancer. Among people with both hepatitis C and cirrhosis living in the United States, about 1-4% per year will develop liver cancer.

Other groups of people also can develop liver cancer, including people with cirrhosis resulting from long-term heavy alcohol use and people with chronic hepatitis B. Those with hepatitis B have an increased risk even if cirrhosis has not developed. The risk of developing liver cancer is higher for people living in Asia and Africa than it is for people living the United States.

Experts recommend that persons with hepatitis C who have developed cirrhosis be tested regularly for signs of liver cancer, even if they have no symptoms. Testing for the presence of a disease before there are any symptoms is called "screening." Repeat testing, such as every 6 or 12 months, is called "surveillance."

A diagnosis of liver cancer can be made if a mass is seen in the liver and a blood test reveals high levels of a substance called alpha-fetoprotein (AFP). Radiologists can take images of the liver to check for any mass. That can be done with:

• ultrasound
• a computed tomography (CT) scan
• magnetic resonance imaging (MRI)

An extremely high level of AFP alone can indicate that liver cancer is present, but it is especially likely if a mass is seen in the liver images as well. A high level of AFP and the appearance of a mass in the liver sometimes are sufficient for making a diagnosis of liver cancer, without doing a biopsy. If not, further testing can be done by taking a small sample of the mass with a hollow needle or by removing the mass and examining the tissue for cancer.

The benefit of screening and surveillance for liver cancer is that it can be detected in its early stages, when there are more options for treatment. When liver cancer is found at a more advanced stage, involving either a large tumor or symptoms such as abdominal pain, fewer treatment options are available.

• Liver cancer can cause death in a person with cirrhosis.
• Patients with cirrhosis resulting from any cause, including hepatitis C, hepatitis B, and alcohol use, have a greater risk of developing liver cancer.
• Liver cancer is one of the most common cancers in the world, especially in Asia and Africa, and it is becoming increasingly common in the United States.
• Biopsy refers to extracting a small sample of tissue with a hollow needle and testing it for liver cancer. A biopsy is sometimes needed to make a diagnosis, but imaging and blood tests can usually determine whether liver cancer is present. Biopsies of liver masses can be difficult to perform and there are some risks involved.
• Liver cancer can be treated if it is detected early, but the treatment is very specialized. Patients should discuss the details thoroughly with their health care providers.
• One excellent treatment for early-stage liver cancer is a liver transplant. This is a complicated form of treatment, because a patient first needs to be a good candidate for a liver transplant, then be evaluated at a liver transplant center and placed on a waiting list, and finally, be well enough to undergo a transplant when a donated liver becomes available.

There are several different kinds of treatment:

• Alcohol injection
• Radiofrequency ablation
• Embolization or chemoembolization of arteries in the liver
• Surgical resection
• Chemotherapy or radiation therapy
• Liver Transplant

Read more about each of these treatments in the following pages.

Alcohol injection

This is the most limited form of direct therapy currently available. With this technique, surgeons or interventional radiologists figure out exactly where a tumor is located within the liver, often with an ultrasound scan, and pass a needle into it. Through the needle, they inject a liquid containing a high concentration of alcohol. The alcohol is so concentrated that it kills whatever cells it contacts, ideally, mostly liver cancer cells. This form of treatment is most effective in treating small liver tumors (less than 3 centimeters in size). Occasionally, more than one small tumor can be treated at the same time, which places less stress on the rest of the liver.

Radiofrequency ablation (RFA)

With this technique, surgeons or interventional radiologists place metal wires directly into a tumor and super-heat it, killing the cancer cells. This may be done through an operation in the abdomen where the liver can be examined directly, or it may be done through the skin. This form of treatment can kill either small or medium-size liver tumors (often, up to 5 centimeters in size). This treatment can cause stress to the liver, and sometimes patients are kept in the hospital for a day or longer after RFA for observation.

Embolization or chemoembolization

With this technique, interventional radiologists pass special plastic tubes (called catheters) into the arteries of the liver, directly cutting off the blood supply to liver tumors. The catheters are usually passed up to the liver through one of the main arteries in the groin or upper thigh. This technique is excellent for killing several small tumors in the same area or tumors that cannot be treated effectively by any other method. One advantage of this technique is that liver tumors get almost all their blood supply from arteries, but healthy areas of the liver get most of their blood from veins. This treatment can involve simply cutting off blood from arteries (embolization) or putting chemotherapy medications directly into the arteries going to the tumors (chemoembolization). The technique is sometimes used immediately before a liver transplant, in an attempt to kill all the tumor cells so that they do not move into the new liver.

Surgical resection

Surgical resection involves surgeons cutting out the tumors from the liver directly. The procedure is performed with the patient unconscious in an operating room. This is a very effective treatment for liver cancer, but the surgery can be performed only if the patient's liver is functioning well enough to allow a portion of it to be removed. Surgical resection can be quite stressful to the liver because it is cut directly. Patients often remain in the hospital for monitoring for several days after receiving this treatment.

Chemotherapy or radiation therapy

Chemotherapy is treatment in which medications that are toxic to tumors are given to patients by intravenous infusion or in pill form. It has not been found to be very effective against liver cancer. Studies have not shown that chemotherapy effectively kills liver tumor cells or gives patients a better chance for survival. Using radiation is not effective either, as that damages the rest of the liver as much as cancerous areas. As these techniques are improved, chemotherapy and radiation may be used more frequently in treating liver tumors, but currently they are not as effective as the other treatments described.

Liver transplant

Liver transplant is an effective treatment for liver cancer as long as the tumors are very small and are located in only a few areas of the liver. Once cancer has spread to blood vessels within the liver or has moved outside the liver, it is too late to control the cancer with a transplant. The advantage of performing a transplant when liver cancer is still in the early stage is that more tumors can form in the liver over time, and replacing the entire liver with a transplanted one lowers the risk of that happening. Transplantation is the most complex form of treatment for liver cancer. The section on Liver Transplant (http://www.hepatitis.va.gov/trans-00-00) provides more details about the process of being referred to a transplant center and possibly being placed on a transplant waiting list. Patients with liver cancer who are good candidates for a transplant and who want to pursue this option are often given priority for receiving a donated liver in the current U.S. national system.

For patients with hepatitis C, the treatments against the virus are pegylated interferon and ribavirin. If the virus is cleared, that will reduce the chance of developing cirrhosis. For patients who already have cirrhosis, the treatment can sometimes reduce the risk that liver cancer will develop.

For patients who have cirrhosis resulting from hepatitis C or alcohol use, the risk of further damage to the liver can be reduced by avoiding alcohol.

Patients with advanced cirrhosis can be evaluated for a liver transplant before liver cancer develops.

Patients with hepatitis B and a high hepatitis B viral load can be treated with medications for hepatitis B. Reducing the hepatitis B viral load will reduce the chance of developing liver cancer.

Liver cancer is becoming more common as a late complication of chronic hepatitis C infection among patients who have developed cirrhosis. Patients who are concerned about their risk of cancer should discuss with their medical care providers how they can protect themselves from it. Tests that take images of the liver (e.g., ultrasound, CT, MRI scans), together with measurements of AFP levels in the blood, can detect liver cancer early much of the time.

Once liver cancer is diagnosed, a patient should discuss the options for treatment with health care professionals who have experience managing this type of cancer. This often involves liver specialists, surgeons, interventional radiologists, cancer specialists (called oncologists), and other professionals. Within the VA health care system, this may involve care at larger facilities where more management options are available.

Treatment of liver cancer can involve a lot of discussions and information. Sometimes a number of treatments are required over time to control the cancer. The most important thing for patients with cancer to do is continue discussing plans for treatment with their health care providers, so that they have the widest range of options available and can decide with their providers which options are best for them

• American Liver Foundation
  (http://www.liverfoundation.org)
  Nonprofit organization promoting liver disease prevention and liver wellness
• American Cancer Society
  (http://www.cancer.org/docroot/cri/content/cri_2_2_1x_what_is_liver_cancer_25.asp)
  Click-through tutorial on liver cancer
• National Library of Medicine
  (http://www.nlm.nih.gov/medlineplus/livercancer.html)
  Web links on liver cancer