Hepatitis C and Liver Cancer —By Alan Franciscus
Did you know…
- Liver cancer is the third-leading cause of death worldwide; hepatocellular carcinoma or HCC is the most common form of liver cancer. – Centers for Disease Control and Prevention
- 29,000 people will die from liver cancer in the United States in 2017. – American Cancer Society
- The most common cause of liver cancer in the United States is hepatitis C. – American Cancer Society
In this article, I will focus on hepatitis C-related liver cancer—the causes, symptoms, diagnosis, prevention, and medications to delay the eventual onset of death from liver cancer.
What is Liver Cancer?
When a cell dies, an abnormal cell can take over the mechanism of the cell and grow out of control. The abnormal cells can form into cancer cells and grow into masses that can develop within an organ, can spread to nearby organs, tissues, lymph nodes and may transport themselves via the bloodstream throughout the body.
Hepatocellular cancer or hepatocellular carcinoma is the most common form of liver cancer.
The common causes of liver cancer in the United States include hepatitis C, fatty liver disease, hepatitis B, alcoholic liver disease, obesity, and diabetes. If you have more than one of these factors, it increases the risk of liver cancer especially once you develop cirrhosis. However, if you have chronic hepatitis B, you can develop liver cancer in the absence of cirrhosis. If infected with hepatitis C, liver cancer develops after severe fibrosis or cirrhosis has developed.
In early stages of liver cancer there are few symptoms. When symptoms appear they may include an ache (where the liver is located), fatigue, fever, and loss of appetite and feeling full (even after eating a small amount of food), vomiting, abnormal bruising or bleeding. Also, there may be some unexplained symptoms.
People with hepatitis C with severe fibrosis or cirrhosis should be monitored on a regular basis for liver cancer. There are three main tests—alpha-fetoprotein test (AFP), liver biopsy, and imaging tests.
The alpha-fetoprotein test (AFP) is a chemical test that may be elevated in some people with cancer. The utility of the AFP is questionable since it is a not a very accurate test for gauging liver cancer. For instance, high levels of AFP are also present in pregnant women, other forms of cancer and may not show up as elevated for liver cancer.
Liver biopsy and imaging tests are better tools for diagnosing liver cancer.
The liver biopsy does have drawbacks because it can cause bleeding and the possibility of the biopsy needle hitting a tumor. A liver biopsy could pose a risk of ‘seeding the tumor’ or spreading cancer to other parts of the liver—although this belief is controversial.
Imaging tests are the preferred way to monitor for liver cancer. The American Association for the Study of Liver Disease (AASLD) recommends two forms of imaging—computed tomography (CT scan) and magnetic resonance imaging (MRI).
CT scan is a computer-generated image of multiple x-rays of the liver that can capture different angles. CT scans use radiation to generate images. MRIs are similar but use a different technology. Both diagnostic tests are safe. Both tests require an injectable contrasting agent (ink) that will highlight blood veins and cancer tumors (if any).
The most widely used liver cancer staging system is the American Joint Committee on Cancer (AJCC) TNM method. The system includes three categories:
- T for tumor – consists of the size and number of the tumor.
- N for lymph node – means the cancer has spread to lymph nodes.
- M for metastasis – cancer has spread to other parts of the body such as the lungs and bones.
The stages are numbered 0 to 4: 0 is the least severe, and four is the most severe when it has spread to other organs.
There are many strategies to prevent liver cancer. For people with hepatitis C, the best option is to treat and cure hepatitis C early before severe fibrosis or cirrhosis; this will eliminate further HCV disease progression and liver cancer. People with severe fibrosis or cirrhosis, who are treated and cured, will have a reduced chance of further HCV disease progression and liver cancer.
Important strategies to further reduce the risk of liver cancer include:
- Avoid alcohol – alcohol is another risk factor for liver cancer.
- Get vaccinated against hepatitis B (HBV) if not already immune – HBV is another risk factor for liver cancer. Get vaccinated against hepatitis A (HAV) to protect the liver from further infection.
- If you have diabetes, keep it under control – diabetes is a risk factor for liver cancer.
- Obesity is another risk factor for liver cancer. Talk with your medical provider about diet and exercise to combat obesity.
- Fatty liver or NASH is another risk factor for liver cancer – diet and exercise may help. Hepatitis C can contribute to fatty liver—get treated and cured.
- Early treatment of hepatitis C will prevent the development of liver cancer.
There are various options to treat liver cancer—this is just a brief overview:
- Resection (hepatectomy): surgery to remove a single tumor in the liver of an otherwise healthy person. A resection will not be performed if the tumor invaded other parts of the liver or blood vessels.
- Tumor ablation: injections (alcohol, freeze or heat) to kill or reduce the size of the tumor.
- Embolization: places medications or synthetic materials into a blood vessel to block the flow of blood into the tumor to starve cancer.
- Liver Transplantation: This can be an option for some people with small liver tumors that have not spread to nearby blood vessels or organs.
FDA Approved Medications
There are three medications approved by the Food and Drug Administration (FDA) to treat HCC – liver cancer:
Sorafenib Tosylate- brand name Nexavar: (pills) in clinical trials Nexavar improved overall survival by 10.7 months compared to 7.9 months for placebo.
Regorafenib-brand name Stivarga: (pills) in clinical trials Stivarga improved overall survival by 10.6 months compared to 7.8 months for placebo. It is approved to treat people who have already been treated with sorafenib (Nexavar).
Nivolumab- brand name Opidivo: (infusion) is approved for patients who had previously been treated with Nexavar. In clinical trials, Opidivo improved overall survival by 3.2 months. The clinical trial was open-label – that is there was no comparator arm. People who continued on therapy for longer periods of time continued to respond to the treatment.
There is no cure for liver cancer unless someone is lucky enough to receive a liver transplant. Liver transplants are costly, and there is a shortage of available livers to provide liver transplants to all who need them.
*Note: There are three SnapShots articles on treating people with direct-acting antivirals (DAAs) and the risk of liver cancer in the October 2017 HCV Advocate newsletter. http://hcvadvocate.org/news/NewsUpdates_pdf/Advocate_2017/advocate1017.pdf
American Cancer Society
AASLD Practice Guidelines Hepatocellular Carcinoma
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