Preventive care is a crucial aspect of chronic liver disease management, and liver cancer screening is a top priority. Liver cancer (hepatocellular carcinoma) is the third-leading cause of cancer-related deaths worldwide, and its incidence is expected to rise in the United States in coming years.
The majority of patients with liver cancer are asymptomatic, only manifesting signs or symptoms at very late stages. For this reason, liver cancer often is referred to as a “silent killer.” Historically, rates of liver cancer screening have been poor, and a greater emphasis on early detection is needed to improve patient outcomes.
Why should we screen for liver cancer?
The goal of liver cancer screening, or surveillance, is to identify liver cancers in at-risk patients as early as possible. This is incredibly important, because when diagnosed at early stages, liver cancer is a very treatable condition and the overall outlook (prognosis) is far better than for patients with more advanced liver cancer at the time of diagnosis.
Indeed, early-stage liver cancer is curable. But treatment options for patients with advanced tumors are limited, and the opportunity to prolong patient survival is greatly diminished. Liver cancer patients are often asymptomatic until the late stages of the disease, and routine screening is the only way to identify small liver lesions that are easier to treat.
Who is at risk?
The vast majority of liver cancers are a result of chronic infection with the hepatitis B and C viruses. Also at risk for liver cancer are patients with advanced liver disease due to causes such as heavy alcohol use, non-alcoholic fatty liver disease, primary biliary cirrhosis and hereditary hemochromatosis.
While having cirrhosis (severe scarring) is the major risk factor for liver cancer, it is important to note that some patients may be at a heightened risk even without cirrhosis, particularly hepatitis B-infected Asian men over the age of 50 and Asian women over the age of 40. The development of liver cancer also has been described in some patients with non-alcoholic fatty liver disease who do not have cirrhosis, but more research is needed before routine screening can be recommended for this patient population.
How do we screen for liver cancer?
Current guidelines recommend an abdominal ultrasound every six months to screen for liver cancer in at-risk patients. Measurement of the tumor marker alpha-fetoprotein (AFP) can be used as an adjunct screening test, but it should not be used alone, given its limited reliability as a screening test (poor sensitivity and specificity). Abnormal findings on an abdominal ultrasound should prompt further evaluation with a dedicated multi-phase CT or MRI of the abdomen. The diagnosis of liver cancer is largely based on the presence of characteristic features on dynamic imaging, and a biopsy of liver lesions is seldom necessary.
How do we treat liver cancer?
The treatment of liver cancer requires a multi-disciplinary team approach incorporating the input of hepatologists, liver surgeons, oncologists, pathologists and radiologists. Surgical resection (removing the tumor) can be considered for patients with good liver function, while radiofrequency ablation and liver transplantation are the main curative options for patients who are not candidates for resection due to advanced liver disease.
Outcomes following liver transplantation for appropriately selected candidates are excellent, with high long-term survival rates similar to those for patients who have transplants for causes unrelated to cancer. Transarterial chemoembolization (TACE) has emerged as a mainstay of treatment and a “bridge therapy” for patients awaiting liver transplantation. TACE is a minimally invasive procedure done to block the flow of blood to a tumor and deliver local chemotherapy.
Radiation therapies, including stereotactic body radiation therapy (SBRT) and Y-90 radioembolization, are also playing a greater role in the management of non-resectable liver cancer. The role of conventional cytotoxic chemotherapy in the treatment of liver cancer is limited. Patients with advanced liver cancer that is not amenable to surgery or locoregional treatments by radiologists should be considered for systemic therapy with sorafenib, though the survival benefit is limited.
Take-away message
Liver cancer is a universally fatal condition when diagnosed in late stages. Given that patients are often asymptomatic, regular screening of at-risk individuals to detect liver cancer as early as possible is the key to promoting a good outcome.
Patients, loved ones and healthcare providers should feel empowered by the growing number of treatment options for liver cancer, and I encourage all patients with chronic liver disease to take an active role in ensuring they receive appropriate liver cancer screening.
Additional Information
For a consultation about managing chronic liver disease or liver cancer, please contact the Swedish Organ Transplant and Liver Center at 206-386-3660.
Find more information about liver cancer at MedlinePlus, a website of the National Institutes of Health.
