Treatments
Surgical treatments for liver cancer
Non-surgical treatments for hepatoma
Non-surgical treatments for biliary cancer
Other non-surgical treatments for liver cancer
Emerging treatments and future research
Follow-up and monitoring
Primary and secondary cancer will require different approaches to treatment. The following treatments are used for primary liver cancer. Some of these may also be offered if your liver cancer is secondary, depending on the source of the primary cancer.
A number of treatment options are available. The aim of some treatments (surgery or liver transplant) is to get rid of the cancer to achieve a cure. If this is not possible then treatment will aim to shrink the size of the cancer to relieve symptoms, delay progression or to make surgery possible. Treatments may be used on their own or in combination.
Unfortunately a cure is only possible in a minority of people because liver cancer produces few symptoms and many people are not diagnosed until it is well advanced.
The treatment you receive will depend on a number of factors, including:
- the exact position of the cancer in the liver – sometimes there are several areas
- the stage of the cancer (size and extent of the tumour, whether it has spread to other organs)
- your general health, in particular the general state of your liver function (many people with primary liver cancer have a damaged liver due to cirrhosis).
Surgery is the only treatment which offers a chance of a cure, but may not always be possible. Whether you will be suitable for surgery will depend on a number of different factors, including:
- the size of the cancer and if it is contained in one part of the liver and no major blood vessels are involved
- if the cancer has spread beyond the liver
- whether the rest of your liver would be able to cope after an operation
- other health conditions which could hinder the operation or your recovery.
Resection surgery
The most frequent form of liver surgery is known as resection, where the part of the liver affected by the cancer is cut away and removed. The liver will then re-grow this section.
Resection surgery is only suitable for those who have very good liver function (Child Pugh class A). If you have a hepatoma (HCC) caused by damage to the liver through cirrhosis, then resection is usually not possible. This is because your liver may be too damaged to recover after the operation. A liver transplant may be considered, but only a few people are suitable for this.
Liver surgery is a major operation and there are some risks such as infection, bleeding or bile leakage. Nine out of ten people will recover from the operation however, unfortunately, around one in ten will die as a result of having this operation3.
There is a risk that the cancer may come back as it is not always possible to determine if cancer cells have spread into the blood stream. In around half (50%) of people who have had resection surgery, liver cancer does not recur within five years3.
For those receiving liver resection surgery, the long term success of the operation will depend on the size of the tumour which was removed. For those having a liver resection for cholangiocarcinoma, between one and four out of ten people (10 to 40%) live for more than five years18,19.
For those having liver resection surgery for HCC, overall around one in five (20%) people will live for more than five years20. However, five year outcomes may be considerably better for those who have small, well defined tumours21,22. You should discuss your personal circumstances with your specialist.
Liver transplantation
A liver transplant may be considered if you have:
- a single tumour less than 5cms in diameter or
- up to five tumours, but all less than 3cms in diameter or
- a single tumour greater than 5cms but less than 7cms if there has been no tumour progression for six months23.
Both CT and MRI scans are required to determine the number and size of the tumours, and measurements will be taken from whichever records the largest.
If you meet the criteria your consultant may recommend that you are put on the transplant waiting list. You will need to be assessed by a transplant team to check that you are well enough to go through this major operation. Unfortunately, there is a shortage of donor livers. It may be some time before a suitable liver becomes available and you may need other treatments to slow the growth of the tumour in the meantime.
Overall, about four out of five people (80%) live for at least four years after this type of surgery24.
Liver transplantation is not recommended for those with cholangiocarcinoma as the cancer often returns very quickly18.
If surgery is not an option, there are a number of treatments aimed at reducing the growth of the cancer. In some circumstances these may be effective at halting the cancer for several years.
Ablative therapies
These use a needle to deliver substances directly into cancer cells to kill them, and work best in small tumours which cannot be operated on. Two techniques commonly in use are radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI).
Radiofrequency ablation
Radiofrequency ablation is a way of destroying a cancer tumour using heat. It is done by passing a needle into the tumour. When the needle is inside the tumour a high frequency current heats up and destroys the cancer. You may experience some tiredness or nausea following treatment25.
Radiofrequency ablation is not suitable for all tumours, particularly if they are close to the gallbladder and biliary duct17. Of the people whose small tumours are completely destroyed by this technique, around one in four (25%) live for at least five years.
Ethanol injections
Ethanol is a type of pure alcohol that can be injected into liver cancers to kill the cancer cells by dehydrating them. The ethanol is injected through the skin into the tumour using a very thin needle. You may need more than five sessions of injections to destroy the cancer and this may require a general anaesthetic.
Ethanol injections are often suitable if your tumours are few, well defined and easy to reach. For those people with small tumours and good liver function, five year survival rates are around one in two (50%)17.
Cryotherapy or cryosurgery
This technique uses a metal probe to deliver liquid nitrogen, which is extremely cold, into the tumour to destroy the cells by freezing them. It has been used for tumours up to 4cms where surgery is not suitable or to treat cancer which has recurred after resection surgery, there are uncertainties about how well it works and its use has declined22. NICE (National Institute of Clinical Excellence) has recommended that it should only be used with special arrangement26.
Embolisation
Embolisation is a technique used to cut off the blood supply to the cancer killing the cells. It works best for people who have good liver function.
Transarterial embolisation (TAE) and transarterial chemoembolisation (TACE) Transarterial embolisation involves giving an injection into the main artery of the liver of a substance containing tiny gel-like beads or pieces of a gelatin sponge. This creates a seal that blocks the supply of blood to the tumour to stop it growing.
Chemoembolisation is a type of chemotherapy (see below) that directly targets a tumour. This reduces the side effects of using anti-cancer (chemotherapy) drugs directly in the patient’s bloodstream. In chemoembolisation a drug (such as doxorubicin) is mixed with an oily dye (lipiodol) and injected before the embolising substance. The drug is sealed in to make it attack only the tumour, and for a longer time. This therapy is given under local anaesthetic and requires a stay of up to two days in hospital. New methods aimed at improving delivery of the drug in this way are emerging. Your medical advisor can provide more information about these treatments.
Biological therapies
For those with advanced hepatoma but good liver function, and where other treatments are not suitable, sorafenib (a drug used to treat kidney cancer) has been shown to slow tumour growth, relieving symptoms and giving people some extra months.
NICE has issued guidance that sorafenib should not be prescribed on the NHS as it is not considered to be cost effective27. However, if your cancer specialist believes you would benefit from a treatment not routinely available through the NHS they can apply to the local Primary Care Trust for exceptional funding. There are also proposals for other initiatives through which the Department of Health will cover the costs of cancer drugs, such as a Cancer Drugs Fund. Talk to your cancer specialist to see if any of these would be options for you.
You may also be able to receive sorafenib as part of a clinical trial in combination with other therapies (see below).
Stents
In order to relieve symptoms of bile duct cancer your consultant may suggest inserting a stent. Biliary stenting is used to treat obstructions that occur in the bile ducts in order to allow bile to drain away and relieve symptoms. When there is a narrowing (stricture) in the bile duct the doctor can insert a small, thin wire-mesh or plastic tube, called a stent, to open up the duct to keep it from collapsing. The stent can be inserted using endoscopic retrograde cholangiopancreatography (ERCP) and can remain in place permanently to help to drain away bile into the duodenum. Another common method of stent insertion is percutaneous transhepatic cholangiography (PTC) in which a hollow needle is inserted through the skin (after local anaesthetic and a sedative) into the obstructed duct area to guide and place the stent.
This may very occasionally be used prior to surgery but is not routinely recommended18.
Radiotherapy
Radiotherapy may be used to treat bile duct cancer, either externally (using a machine to target the cancer with radioactive beams) or internally (using a wire inside your bile duct).
As well as damaging the cancerous cells, radiotherapy may also damage healthy cells causing side effects such as nausea and fatigue.
Photodynamic therapy (PDT)
PDT is a relatively new technique that aims to destroy cancer cells while minimising damage to normal tissue. Patients are given a ‘photosensitising’ drug intravenously that makes cells more sensitive to light. A low power red light, usually from a laser, is then directed onto the treatment area at the time of biliary stenting, up to two days after the photosensitising drug has been given. This activates the drug to attack the nearby cancerous tissue and thus improve the drainage of bile from the liver.
NICE has not recommended PDT as standard treatment on the NHS, however it may be available as part of a clinical trial28.
Chemotherapy
Chemotherapy is a treatment which uses drugs to kill cancer cells, or to stop them from multiplying. It aims to shrink the tumour down and slow the development of the disease. Drugs are given by injection or tablet form.
Chemotherapy will not cure your cancer, but it may control the cancer or even reduce its size. This can help to reduce symptoms and may also extend your life. In a very small number of cases chemotherapy may shrink a cancer sufficiently to make it possible to operate on it29.
Not everyone will be able to have chemotherapy. Chemotherapy is not often used for HCC as this type of cancer does not respond well, but it is standard treatment for biliary tree cancer. However, if you have biliary cancer you may not be able to have chemotherapy if you have any signs of jaundice (yellow skin or eyes). This is because your liver may not be able to cope with the toxicity of the chemotherapy drugs. Other treatments, such as the use of a stent, may be needed to treat the jaundice before chemotherapy can begin.
Possible problems of chemotherapy include:
- anaemia
- increased risk of infections
- increased risk of bruising.
After receiving chemotherapy, you will need to have regular blood tests to monitor the effect of the drugs and to see how you are responding to treatment.
Radioembolisation/ Selective Internal Radiation Therapy (SIRT)
Like chemoembolisation, this technique uses tiny beads to block the supply of blood to the cancer. The beads contain a radioactive substance called yttrrium-90, which helps to kill the cells using radiation. A course of chemotherapy may also be given at the same time. This may be an option if you have good liver function but resection is not suitable. Research is being undertaken to further evaluate the safety and effectiveness of the technique30,31. You may be able to take part in the research as part of a clinical trial. The technique is available through the NHS with the condition that uncertainties, benefits and risks are fully discussed with patients before they consent, and outcomes of treatment are monitored32.
Microwave ablation
This is a procedure, similar to radiofrequency ablation, which uses heat from microwave energy to destroy cancer cells. It can be used to treat primary liver cancer. Like other ablative therapies, it is not aimed at curing your cancer. NICE has approved this procedure for use in the NHS under the condition that patients fully understand what is involved and the results of treatment are recorded to provide more information on how well the procedure works33.
Your specialist team will be able to advise whether these treatments are suitable for you and the possible risks and benefits compared with the other treatment options available.
Biological therapies and tumour characterisation
An area of active research is focussing on identifying elements in the process of tumour development which can be targeted with new drugs, used alone or in combination. Alongside this, work is ongoing to identify differences in the genetic make up of HCC tumours so that these can be grouped into types (characterised). Certain types of HCC tumours respond better to certain drugs. By characterising tumours in this way it should be possible to individualise a person’s treatment to maximise the effect on the tumour and minimise side effects34,35,36.
Following treatment you will receive ongoing monitoring which usually involves the following:
- imaging tests every three to six months for two years and once a year thereafter
- alpha-fetoprotein (AFP) measurement every three months for two years and then every six months17.