—Lucinda K. Porter, RN
This year, four friends were diagnosed with liver cancer. One died
in February. Two are not expected to live long. One is doing well after
surgery. None of these friends has hepatitis B or C, although one has a
history of hepatitis C, and was cured more than ten years ago.
The World Health Organization (WHO) just announced that liver
cancer has moved in to second place as the most common cause of cancer
deaths in the world. Second only to lung cancer, liver cancer is
responsible for more than 9% of cancer deaths. The combined number of
deaths from liver cancer and cirrhosis is 1.75 million annually.
In the February 11, 2014 online American Journal of Gastroenterology,
Sean Altekruse and colleagues reported that U.S. liver cancer
mortality rates increased with age in all racial/ethnic groups. Washington DC, Louisiana, Mississippi, and Texas have the most liver
cancer deaths. North Dakota has the lowest liver cancer mortality
rates, followed by Idaho and Utah.
There are two categories of liver cancer—primary and secondary.
Primary liver cancer starts in the liver. Cancerous tumors are called malignant hepatomas, the most common of which is hepatocellular carcinoma (HCC). Secondary liver cancer is more common in the U.S. Also known as metastatic cancer,
it starts in another part of the body and spreads to the liver.
Colorectal cancer is famous for this, with roughly half of all cases
metastasizing to the liver. Because blood filters through the liver, it
is a prime target for metastasis.
More than 90% of HCC occurs in people with risk factors. The more
risk factors, the greater the chances are for developing liver cancer.
Gender and age are the two main risks. Men are more than twice as
likely as women to be diagnosed with liver cancer. Certain ethnic
groups are at increased risk. Asians and Pacific Islanders have the
highest prevalence; African Americans and Latinos have higher liver
cancer rates than Caucasians.
Cirrhosis is linked to more than 80% of all HCC. Anything that
leads to cirrhosis increases liver cancer risk. Alcohol abuse,
chemicals, drugs, parasites, viruses, and autoimmune conditions may all
lead to cirrhosis. Although the majority of primary liver cancers
begin with cirrhosis, the majority of those with cirrhosis will never
get liver cancer.
Hepatitis B and C are the most common risk factors for HCC. Areas
that have a high prevalence of HBV have high liver cancer rates.
Hepatitis C is the next leading cause of liver cancer. In addition to
age, (greater than 60 years old), male gender, and a family history of
liver cancer, other risk factors for HCC are:
- Long-term, heavy alcohol consumption
- Tobacco use
- Obesity or poor diet
- Use of anabolic steroids or male hormones
- Certain inherited diseases, such as hemochromatosis (excess iron storage)
- Ingestion of arsenic, such as in drinking water
- Exposure to certain industrial chemicals
- Aflatoxins (a poison produced by a fungus sometimes
found on peanuts, corn, grains and nuts. In the U.S., most
commercially available grains and nuts are safe.)
Signs and Symptoms
One of the reasons that liver cancer is particularly life threatening
has to do with the liver itself. With over 500 functions, this
resilient organ doesn’t complain. Other parts of the body let us know
when there is trouble. The liver quietly goes about its work and may
not let you know there is a problem until the damage is extensive.
That’s why those with chronic hepatitis C might live with the virus for
decades before realizing that they have it.
The symptoms of liver cancer are similar to other health problems,
such as gall bladder disease. However, since the symptoms of liver
cancer usually don’t show themselves until the later stages of cancer,
it is critical that patients consult their medical providers as soon as
they are even mildly symptomatic. Wait too long and the tumor may grow
too large to treat effectively.
Symptoms of liver cancer:
Pain or discomfort in the upper right side of the abdomen
- Lump on right side or heavy feeling in abdomen
- Pain in the back or right shoulder
- Appetite loss or feeling full after a small meal
- Unexplained weight loss
- Bloated or swollen belly
- Unexplained fatigue or weakness
- Bruising, bleeding
- Nausea or vomiting
- Jaundice (yellow skin and eyes)
- Dark, tea-colored urine
- Pale, clay-colored stools
- Tremors, confusion, disorientation
For those at risk, regular HCC screening is critical. Surveillance is
recommended for those with family history of liver cancer, people with
cirrhosis, Africans, Asians and Pacific Islanders, people with
hepatitis B or C, and those at high risk.
We used to think that hepatitis C without cirrhosis was not a risk
factor. However, a study conducted by a team headed by Anna Lok at the
University of Michigan, identified HCC in a significant number of HCV
patients with advanced fibrosis but no cirrhosis.
We also thought that a sustained virologic response (SVR) to
hepatitis C treatment ensured safety from hepatitis C’s risk of
cirrhosis or liver cancer. However, a study presented by Thierry
Poynard at the 2013 Liver Meeting showed that hepatitis C patients who
had previously developed significant fibrosis, could still continue to
be at risk for fibrosis/cirrhosis and liver cancer despite an SVR.
Another small study presented by Savino Bruno and colleagues at the 2014
European Association for the Study of the Liver (EASL) showed that an
SVR did not reduce HCC risk. However, the numbers of subjects in the
study were too few to make strong conclusions.
Screening helps. In a paper published in the April 2014 Hepatology,
Abbas Mourad and team reported that HCC screening improves survival
rate. The current screening recommendation for hepatitis C patients
with advanced fibrosis is every 6 months. Fortunately, although HCC
rates are increasing, so are the treatment options and success rates.
Early screening leads to higher survival rates.
Everything that prevents hepatitis or cirrhosis reduces liver cancer
risk. Children are now routinely immunized against hepatitis A and B.
Other ways to reduce HCC risk are to maintain a normal weight, quit
smoking, and avoid anabolic steroid use. Abstaining from alcohol is
recommended for those with liver disease. For those whose health allows
it, moderate use of alcohol does not appear to raise the HCC risk.
Many international studies have examined the relationship between
coffee drinking and the risk of primary liver cancer. Patients with
chronic hepatitis C and advanced liver disease who drink three or more
cups of coffee per day have a 53% lower risk of liver disease
progression than non-coffee drinkers, according to a new study led by
Neal Freedman, Ph.D., MPH, from the National Cancer Institute (NCI).
Reduction of disease progression may help to prevent HCC.
No herbs or dietary supplements have been proven to prevent HCC.
Varieties of supplements are being tested in clinical trials. The
National Cancer Institute and the National Institute of Nursing
Research are studying milk thistle for cancer prevention. A large 2007
Chinese study using a variety of dietary supplements for liver cancer
prevention yielded disappointing results. Although liver cancer
mortality remained unchanged, the incidence of cancer was lower for
those under age 55 who took combinations of retinol and zinc or
riboflavin and niacin.
Taking care of our health is the best weapon against all cancer.
Exercise, maintaining a normal body weight and healthy eating habits
are essential. Regular screening for those at risk for HCC and other
forms of cancer is critical. Although HCC is a serious, potentially
life-threatening form of cancer, we are not completely helpless against
it. If you are at risk for HCC, talk to your healthcare provider.
Although the liver is a silent organ, we never have to stay quiet about
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time. Her blog is www.LucindaPorterRN.com