How common is liver cancer?

The American Cancer Society’s estimates for primary liver cancer and intrahepatic bile duct cancer in the United States for 2018 are:

• About 42,220 new cases (30,610 in men and 11,610 in women) will be diagnosed
• About 30,200 people (20,540 men and 9,660 women) will die of these cancers

Liver cancer incidence has more than tripled since 1980. However, rates in young adults have recently begun to decline. Liver cancer death rates have increased by almost 3% per year since 2000. Liver cancer is seen more often in men than in women.

Where is liver cancer more common?

Liver cancer is much more common in countries in sub-Saharan Africa and Southeast Asia than in the US. In many of these countries it is the most common type of cancer. More than 700,000 people are diagnosed with this cancer each year throughout the world. Liver cancer is also a leading cause of cancer deaths worldwide, accounting for more than 600,000 deaths each year.

Visit the American Cancer Society’s Cancer Statistics Center for more key statistics.

Survival rates tell you what part of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. These numbers can’t tell you how long you will live, but they might help give you a better understanding about how likely it is that your treatment will be successful. 

What is a 5-year survival rate?

Statistics on the outlook for a certain type and stage of cancer are often given as 5-year survival rates, but many people live longer – often much longer – than 5 years. The 5-year survival rate is the percentage of people who live at least 5 years after being diagnosed with cancer. For example, a 5-year survival rate of 50% means that an estimated 50 out of 100 people who have that cancer are still alive 5 years after being diagnosed. Keep in mind, however, that many of these people live much longer than 5 years after diagnosis.

But remember, the 5-year relative survival rates are estimates – your outlook can vary based on a number of factors specific to you.

Relative survival rates are a more accurate way to estimate the effect of cancer on survival. These rates compare people with cancer to people in the overall population. For example, if the 5-year relative survival rate for a specific type and stage of cancer is 50%, it means that people who have that cancer are, on average, about 50% as likely as people who don’t have that cancer to live for at least 5 years after being diagnosed.

But remember, survival rates are estimates – your outlook can vary based on a number of factors specific to you. Your doctor can tell you how these numbers apply to you, as he or she is familiar with your situation.

Cancer survival rates don’t tell the whole story

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they can’t predict what will happen in any particular person’s case. Your doctor can tell you how the numbers below apply to you, as he or she is familiar with the aspects of your particular situation.

Survival rates for liver cancer

The numbers below come from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, and are based on patients who were diagnosed with liver cancer (hepatocellular type) between 2005 and 2011.

The SEER database does not divide liver cancer survival rates by AJCC TNM stages. Instead, it groups cancer cases into summary stages:

• Localized means the cancer is still confined to the liver, and includes stages I, II, and some stage III cancers. This includes a wide range of cancers, some of which are easier to treat than others. The 5-year relative survival rate for people with localized liver cancer is about 31%.
• Regional means the cancer has grown into nearby organs or has spread to nearby lymph nodes, and includes stages IIIC and IVA cancers. For regional stage liver cancer, the 5-year survival rate is about 11%.
• Distant means that the cancer has spread to distant organs or tissues and is the same as stage IVB. The 5-year relative survival rate for distant stage liver cancer is about 3%.

In general, survival rates are higher for people who can have surgery to remove their cancer, regardless of the stage. For example, studies have shown that patients with small, resectable tumors who do not have cirrhosis or other serious health problems are likely to do well if their cancers are removed. Their overall 5-year survival is over 50%. For people with early-stage liver cancers who have a liver transplant, the 5-year survival rate is in the range of 60% to 70%.

Because there are only a few effective ways to prevent or treat liver cancer at this time, there is always a great deal of research going on in the area of liver cancer. Scientists are looking for causes and ways to prevent liver cancer, and doctors are working to improve treatments.

Prevention

The most effective way to reduce the worldwide burden of liver cancer is to prevent it from happening in the first place. Some scientists believe that vaccinations and improved treatments for hepatitis could prevent about half of liver cancer cases worldwide. Researchers are studying ways to prevent or treat hepatitis infections before they cause liver cancers. Research into developing a vaccine to prevent hepatitis C is ongoing. Progress is also being made in treating chronic hepatitis.

Screening

Several new blood tests are being studied to see if they can detect liver cancer earlier than using  AFP and ultrasound. One that is promising is called DKK1.

Surgery

Newer techniques are being developed to make both partial hepatectomy and liver transplants safer and more effective.

Adding other treatments to surgery

An active area of research uses adjuvant therapies – treatments given right after surgery – to try to reduce the chances that the cancer will return. Most of the studies so far using chemotherapy or chemoembolization after surgery have not shown that they help people live longer. Research studies are also looking into newer drugs, like targeted therapy and may prove to be more effective. Some promising results have also been seen with radioembolization, but these need to be confirmed in larger studies. Another area of study has been the use of anti-viral therapy in people with liver cancer related to having viral hepatitis to see if it improves outcomes after surgery.

Doctors are also studying ways to make more liver cancers resectable by trying to shrink them before surgery. Studies are now looking at different types of neoadjuvant therapies (therapies given before surgery), including targeted therapy, chemotherapy, ablation, embolization, and radiation therapy. Early results have been promising but have only looked at small numbers of patients.

Laparoscopic surgery

In laparoscopic surgery, several small incisions are made in the abdomen, and special long, thin surgical instruments are inserted to view and cut out the diseased portion of the liver. It does not require a large incision in the abdomen, which means there is less blood loss, less pain after surgery, and a quicker recovery.

At this time, laparoscopic surgery is still considered experimental for liver cancer. It is being studied mainly in patients with small tumors in certain parts of the liver that can be easily reached through the laparoscope.

Determining recurrence risk after surgery

After a partial hepatectomy, one of the biggest concerns is that the cancer might come back (recur). Knowing someone's risk for recurrence after surgery might give doctors a better idea of how best to follow up with them, and may someday help determine who needs additional treatment to lower this risk.

Various researchers are studying ways to predict if the cancer may come back by testing the liver cells in the surgery sample through genetic profiling. . These studies are promising but will need to be confirmed in other larger studies before it is widely used.

Liver transplant

Only a small portion of patients with liver cancer are candidates for a liver transplant because of the strict criteria they need to meet (based mainly on the size and number of tumors). Some doctors are now looking to see if these criteria can be expanded, so that people who are otherwise healthy but have slightly larger tumors might also be eligible.

Radiation therapy

The main problem with using radiation therapy against liver cancer is that it also damages healthy liver tissue. Researchers are now working on ways to focus radiation therapy more narrowly on the cancer, sparing the nearby normal liver tissue. One approach being studied is called brachytherapy. In this treatment, catheters (thin tubes) are placed in the tumor and then pellets that give off radiation are put into the catheters for a short time. After the treatment, both the pellets and the catheters are removed. This allows radiation to be targeted to the cancer with less harm to the normal liver.

Targeted therapy

New drugs are being developed that work differently from standard chemotherapy drugs. These newer targeted drugs act on specific parts of cancer cells or their surrounding environments.

Tumor blood vessels are the target of several newer drugs. Liver tumors need new blood vessels to grow beyond a certain size. The drug sorafenib (Nexavar), which is already used for some liver cancers that can't be removed surgically, works in part by hindering new blood vessel growth. This drug is now being studied for use earlier in the course of the disease, such as after surgery or trans-arterial chemoembolization (TACE). Researchers are also studying whether combining it with chemotherapy may make it more effective.

Regorafenib (Stivarga) is a targeted drug that has shown promise in treating liver cancers that are no longer responding to sorafenib.

Cabozantinib is another targeted drug that has been shown to reduce tumor growth and stop new blood vessel growth in some studies.

Chemotherapy

New forms of chemotherapy combined with other treatments are being tested in clinical trials. A small number of tumors respond to chemotherapy, although it has not yet been shown to prolong survival.

Chemotherapy drugs, such as oxaliplatin, capecitabine, gemcitabine, and docetaxel, are being tested against liver cancer in clinical trials. Oxaliplatin has shown promising results in early studies when given in combination with doxorubicin and also when given with gemcitabine and the targeted therapy drug cetuximab (Erbitux).

Virus therapy

A newer approach to treatment is the use of a virus, known as JX-594. This started as the same virus that was used to make the smallpox vaccine, but it has been altered in the lab so that it mainly infects cancer cells and not normal cells. A solution containing the virus is injected into liver cancers, and the virus can enter the cancer cells, where it causes them to die or to make proteins that result in them being attacked by the body’s immune system. Early results of this treatment against advanced liver cancer have been promising, even in patients who have already had other treatments.

If you have some of the signs and symptoms of liver cancer, your doctor will try to find if they are caused by liver cancer or something else.

Medical history and physical exam

Your doctor will ask about your medical history to check for risk factors and learn more about your symptoms. Your doctor will also examine you for signs of liver cancer and other health problems, probably paying special attention to your abdomen and checking your skin and the whites of your eyes looking for jaundice (a yellowish color).

If symptoms and/or the results of the physical exam suggest you might have liver cancer, other tests will probably be done. These might include imaging tests, lab tests, and other procedures.

Imaging tests

Imaging tests use x-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Imaging tests are done for a number of reasons, including:

• To help find suspicious areas that might be cancerous
• To help diagnose liver cancer
• To help a doctor guide a biopsy needle into a suspicious area to take a sample
• To learn how far cancer might have spread
• To help guide certain treatments in the liver
• To help determine if treatment has been effective
• To look for a possible recurrence of the cancer

People who have (or may have) liver cancer may get one or more of the following tests.

Ultrasound

Ultrasound is often the first test used to look at the liver.

Ultrasound (ultrasonography) is the use of sound waves to create an image on a video screen. This test can show masses (tumors) growing in the liver, which then can be tested for cancer, if needed.

Computed tomography (CT)

The CT scan is an x-ray test that produces detailed cross-sectional images of your body. A CT scan of the abdomen can help identify many types of liver tumors. It can provide precise information about the size, shape, and position of any tumors in the liver or elsewhere in the abdomen, as well as nearby blood vessels. CT scans can also be used to guide a biopsy needle precisely into a suspected tumor (called a CT-guided needle biopsy). If you are found to have liver cancer, a CT of your chest may also be done to look for possible spread to the lungs.

Magnetic resonance imaging (MRI)

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body.

MRI scans can be very helpful in looking at liver tumors. Sometimes they can tell a benign tumor from a malignant one. They can also be used to look at blood vessels in and around the liver, and can help show if liver cancer has spread to other parts of the body.

Angiography

An angiogram is an x-ray test that looks at blood vessels. Contrast medium, or dye, is injected into an artery to outline blood vessels while x-ray images are taken.

Angiography can be used to show the arteries that supply blood to a liver cancer, which can help doctors decide if a cancer can be removed and to help plan the operation. It can also be used to help guide some types of non-surgical treatment, such as embolization (see the section Embolization Therapy for Liver Cancer).

Angiography can be uncomfortable because a small catheter (a flexible hollow tube) must be put into the artery leading to the liver to inject the dye. Usually the catheter is put into an artery in your groin and threaded up into the liver artery. You have to stay very still while the catheter is in place. A local anesthetic is often used to numb the area before inserting the catheter. Then the dye is injected quickly to outline all the vessels while the x-rays are being taken.

Angiography may also be done with a CT scanner (CT angiography) or an MRI scanner (MR angiography). These techniques are often used instead of x-ray angiography because they can give information about the blood vessels in the liver without the need for a catheter in the artery. You will still need an IV line so that a contrast dye can be injected into the bloodstream during the imaging.

Bone scan

A bone scan can help look for cancer that has spread (metastasized) to bones. Doctors don't usually order this test for people with liver cancer unless you have symptoms such as bone pain, or if there's a chance you may be eligible for a liver transplant to treat your cancer. .

For more information about imaging tests see the section Exams and Tests to Find and Diagnose Cancer.

Other tests and procedures

Other types of tests may be done if your doctor thinks you might have liver cancer but the imaging test results aren’t conclusive.

Laparoscopy

Laparoscopy can be used for liver cancer:

• To help doctors confirm a diagnosis of cancer through biopsy
• To confirm the stage or (extent) of the cancer
• To help plan surgery or other treatments

Laparoscopy is usually done at an outpatient surgery center. In this procedure, a doctor inserts a thin, lighted tube with a small video camera on the end through a small incision (cut) in the front of the abdomen to look at the liver and other internal organs. (Sometimes more than one cut is made.) This procedure is done in the operating room. Usually you are under general anesthesia (in a deep sleep), although sometimes the person may just be sedated (made sleepy) and the area of the incision will be numbed.

Because the surgeon only makes a small incision to insert the tubes, you should not have much pain after surgery. You should be able to go home after you recover from the anesthesia.

Biopsy

A biopsy is the removal of a sample of tissue to see if it is cancer. Sometimes, the only way to be certain that liver cancer is present is to take a biopsy and look at it under a microscope.

But in some cases, doctors can be fairly certain that a person has liver cancer based on the results of imaging tests such as CT and MRI scans. In these cases, a biopsy may not be needed. Doctors are often concerned that sticking a needle into the tumor or otherwise disturbing it without completely removing it might help cancer cells spread to other areas. This is a major concern if a liver transplant might be an option to try to cure the cancer, as any spread of the cancer might make the person ineligible for a transplant. That is why some experts recommend that patients who could be transplant candidates only have biopsies done at the center where the transplant will be done.

If a biopsy is needed, it can be done in several ways. For more information about biopsies and how they are tested, see Testing Biopsy and Cytology Specimens for Cancer

Needle biopsy: A hollow needle is placed through the skin in the abdomen and into the liver. The skin is first numbed with local anesthesia before the needle is placed. Different-sized needles may be used.

Laparoscopic biopsy: Biopsy specimens can also be taken during laparoscopy. This lets the doctor see the surface of the liver and take samples of abnormal-appearing areas.

Surgical biopsy: An incisional biopsy (removing a piece of the tumor) or an excisional biopsy (removing the entire tumor and some surrounding normal liver tissue) can be done during an operation.

Lab tests

Your doctor could order lab tests for a number of reasons:

• To help diagnose liver cancer
• To help determine what might have caused your liver cancer
• To learn how well your liver is working, which can affect what types of treatments you can have
• To get an idea of your general health and how well your other organs are working, which also could affect what types of treatments you can have
• To see how well treatment is working
• To look for signs that the cancer has come back after treatment

Alpha-fetoprotein blood (AFP) test

AFP is normally present at high levels in the blood of fetuses but drops to low levels shortly after birth. Levels in adults can go up from liver disease, liver cancer, or other cancers.

If AFP levels are very high in someone with a liver tumor, it can be a sign that liver cancer is present. But because liver cancer isn’t the only reason for high AFP levels and many patients with early liver cancer have normal levels of AFP, it isn’t very helpful in determining if a liver mass might be cancer.

This test is sometimes useful in people already diagnosed with liver cancer. The AFP level can help determine what treatment might be an option. During treatment, the test can be used to help give an idea of how well it is working, as the AFP level should go down if treatment is effective. The test can be used after treatment as well, to look for possible signs that the cancer has come back (recurred).

Other blood tests

Liver function tests (LFTs): Because liver cancer often develops in livers already damaged by hepatitis and/or cirrhosis, doctors need to know the condition of your liver before starting your treatment. A series of blood tests can measure levels of certain substances in your blood that show how well your liver is working.

If the part of your liver not affected by cancer isn’t working well, you might not be able to have surgery to try to cure the cancer, as the surgery might require removal of a large part of your liver. This is a common problem in people with liver cancer.

Blood clotting tests: The liver also makes proteins that help blood clot when you bleed. A damaged liver might not make enough of these clotting factors, which could increase your risk of bleeding. Your doctor may order blood tests such as a prothrombin time (PT) to help assess this risk.

Tests for viral hepatitis: Your doctor might order blood tests to check for hepatitis B and C.

Kidney function tests: Tests of blood urea nitrogen (BUN) and creatinine levels are often done to assess how well your kidneys are working.

Complete blood count (CBC): This test measures levels of red blood cells (which carry oxygen throughout your body), white blood cells (which fight infections), and platelets (which help the blood clot). It gives an idea of how well the bone marrow (where new blood cells are made) is functioning.

Blood chemistry tests and other tests: Blood chemistry tests check the levels of a number of substances in the blood, some of which might be affected by liver cancer. For example, liver cancer can raise blood levels of calcium, while blood glucose levels may fall. Liver cancer can also sometimes raise cholesterol levels, so this may be checked as well.

Signs and symptoms of liver cancer often do not show up until the later stages of the disease, but sometimes they may show up sooner. If you go to your doctor when you first notice symptoms, your cancer might be diagnosed earlier, when treatment is most likely to be helpful. Some of the most common symptoms of liver cancer are:

• Weight loss (without trying)
• Loss of appetite
• Feeling very full after a small meal
• Nausea or vomiting
• An enlarged liver, felt as a mass under the ribs on the right side
• An enlarged spleen, felt as a mass under the ribs on the left side
• Pain in the abdomen or near the right shoulder blade
• Swelling or fluid build-up in the abdomen
• Itching
• Yellowing of the skin and eyes (jaundice)

Some other symptoms can include fever, enlarged veins on the belly that can be seen through the skin, and abnormal bruising or bleeding.

People who have chronic hepatitis or cirrhosis may feel worse than usual or just have changes in lab test results, such as alpha-fetoprotein (AFP) levels.

Some liver tumors make hormones that act on organs other than the liver. These hormones may cause:

• High blood calcium levels (hypercalcemia), which can cause nausea, confusion, constipation, weakness, or muscle problems
• Low blood sugar levels (hypoglycemia), which can cause fatigue or fainting
• Breast enlargement (gynecomastia) and/or shrinkage of the testicles in men
• High counts of red blood cells (erythrocytosis) which can cause someone to look red and flushed
• High cholesterol levels

Many of the signs and symptoms of liver cancer can also be caused by other conditions, including other liver problems. Still, if you have any of these problems, it's important to see your doctor right away so the cause can be found and treated, if needed.

A risk factor is anything that affects your chance of getting a disease, such as cancer. Different cancers have different risk factors. Some risk factors, like smoking, can be changed. Others, like a person's age or family history, can't be changed.

But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And some people who get the disease may have few or no known risk factors.

Scientists have found several risk factors that make a person more likely to develop hepatocellular carcinoma (HCC).

Gender

Hepatocellular carcinoma is much more common in males than in females. Much of this is probably because of behaviors affecting some of the risk factors described below. The fibrolamellar subtype of HCC is more common in women.

Race/ethnicity

In the United States, Asian Americans and Pacific Islanders have the highest rates of liver cancer, followed by American Indians/Alaska Natives and Hispanics/Latinos, African Americans, and whites.

Chronic viral hepatitis (Hep-B or Hep-C)

Worldwide, the most common risk factor for liver cancer is chronic (long-term) infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). These infections lead to cirrhosis of the liver (see above) and are responsible for making liver cancer the most common cancer in many parts of the world.

In the United States, infection with hepatitis C is the more common cause of HCC, while in Asia and developing countries, hepatitis B is more common. People infected with both viruses have a high risk of developing chronic hepatitis, cirrhosis, and liver cancer. The risk is even higher if they are heavy drinkers (at least 6 standard drinks a day).

HBV and HCV can spread from person to person through sharing contaminated needles (such as in drug use), unprotected sex, or childbirth. They can also be passed on through blood transfusions, although this is very rare in the United States since the start of blood product testing for these viruses. In developing countries, children sometimes contract hepatitis B infection from prolonged contact with family members who are infected.

HBV is more likely to cause symptoms, such as a flu-like illness and a yellowing of the eyes and skin (jaundice). But most people recover completely from HBV infection within a few months. Only a very small percentage of adults become chronic carriers (and have a higher risk for liver cancer). Infants and small children who become infected have a higher risk of becoming chronic carriers.

HCV, on the other hand, is less likely to cause symptoms. But most people with HCV develop chronic infections, which are more likely to lead to liver damage or even cancer.

Other viruses, such as the hepatitis A virus and hepatitis E virus, can also cause hepatitis. But people infected with these viruses do not develop chronic hepatitis or cirrhosis, and do not have an increased risk of liver cancer.

Cirrhosis

Cirrhosis is a disease in which liver cells become damaged and are replaced by scar tissue. People with cirrhosis have an increased risk of liver cancer. Most (but not all) people who develop liver cancer already have some evidence of cirrhosis.

There are several possible causes of cirrhosis. Most cases in the United States occur in people who abuse alcohol or have chronic HBV or HCV infections.

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease, a condition in which people who consume little or no alcohol develop a fatty liver, is common in obese people. People with a type of this disease known as non-alcoholic steatohepatitis (NASH) might go on to develop cirrhosis.

Primary biliary cirrhosis

Some types of autoimmune diseases that affect the liver can also cause cirrhosis. For example, there is also a disease called primary biliary cirrhosis (PBC). In PBC, the bile ducts in the liver are damaged and even destroyed which can lead to cirrhosis. People with advanced PBC have a high risk of liver cancer.

Inherited metabolic diseases

Certain inherited metabolic diseases can lead to cirrhosis.

People with hereditary hemochromatosis absorb too much iron from their food. The iron settles in tissues throughout the body, including the liver. If enough iron builds up in the liver, it can lead to cirrhosis and liver cancer.

Heavy alcohol use

Alcohol abuse is a leading cause of cirrhosis in the United States, which in turn is linked with an increased risk of liver cancer.

Obesity

Being obese (very overweight) increases the risk of developing liver cancer. This is probably because it can result in fatty liver disease and cirrhosis.

Type 2 diabetes

Type 2 diabetes has been linked with an increased risk of liver cancer, usually in patients who also have other risk factors such as heavy alcohol use and/or chronic viral hepatitis. This risk may be increased because people with type 2 diabetes tend to be overweight or obese, which in turn can cause liver problems.

Certain rare diseases

Diseases that increase the risk of liver cancer include:

• Tyrosinemia
• Alpha1-antitrypsin deficiency
• Porphyria cutanea tarda
• Glycogen storage diseases
• Wilson disease

Aflatoxins

These cancer-causing substances are made by a fungus that contaminates peanuts, wheat, soybeans, ground nuts, corn, and rice. Storage in a moist, warm environment can lead to the growth of this fungus. Although this can occur almost anywhere in the world, it is more common in warmer and tropical countries. Developed countries such as the United States and those in Europe regulate the content of aflatoxins in foods through testing.

Long-term exposure to these substances is a major risk factor for liver cancer. The risk is increased even more in people with hepatitis B or C infections.

Vinyl chloride and thorium dioxide (Thorotrast)

Exposure to these chemicals raises the risk of angiosarcoma of the liver (see What is liver cancer?). It also increases the risk of developing cholangiocarcinoma and hepatocellular cancer, but to a far lesser degree. Vinyl chloride is a chemical used in making some kinds of plastics. Thorotrast is a chemical that in the past was injected into some patients as part of certain x-ray tests. When the cancer-causing properties of these chemicals were recognized, steps were taken to eliminate them or minimize exposure to them. Thorotrast is no longer used, and exposure of workers to vinyl chloride is strictly regulated.

Anabolic steroids

Anabolic steroids are male hormones used by some athletes to increase their strength and muscle mass. Long-term anabolic steroid use can slightly increase the risk of hepatocellular cancer. Cortisone-like steroids, such as hydrocortisone, prednisone, and dexamethasone, do not carry this same risk.

Arsenic

Drinking water contaminated with naturally occurring arsenic, such as that from some wells, over a long period of time increases the risk of some types of liver cancer. This is more common in parts of East Asia, but it might also be a concern in some areas of the United States.

Infection with parasites

Infection with the parasite that causes schistosomiasis can cause liver damage and is linked to liver cancer. This parasite is not found in the US, but infection can occur in Asia, Africa, and South America.

Tobacco use

Smoking increases the risk of liver cancer. Former smokers have a lower risk than current smokers, but both groups have a higher risk than those who never smoked.

Factors with unclear effects on liver cancer risk

Birth control pills

In rare cases, birth control pills, also known as oral contraceptives, can cause benign tumors called hepatic adenomas. But it is not known if they increase the risk of hepatocellular cancer. Some of the studies that have looked at this issue have suggested there may be a link, but most of the studies were not of high quality and looked at types of pills that are no longer used. Current birth control pills use different types of estrogens, different estrogen doses, and different combinations of estrogens with other hormones. It is not known if the newer pills increase liver cancer risk.

Although several risk factors for hepatocellular cancer are known (see Liver Cancer Risk Factors), exactly how these may lead normal liver cells to become cancerous is only partially understood.

Cancers develop when a cell’s DNA is damaged. DNA is the chemical in each of our cells that makes up our genes – the instructions for how our cells function. Some genes have instructions for controlling when cells grow, divide into new cells, and die.

• Some genes that tell cells to grow and divide are called oncogenes.
• Genes that slow down cell division or cause cells to die at the right time are called tumor suppressor genes.

Cancers can be caused by DNA changes that turn on oncogenes or turn off tumor suppressor genes. Several different genes usually need to have changes for a cell to become cancerous.

Certain chemicals that cause liver cancer, such as aflatoxins, are known to damage the DNA in liver cells. For example, studies have shown that aflatoxins can damage the TP53 tumor suppressor gene, which normally works to prevent cells from growing too much. Damage to the TP53 gene can lead to increased growth of abnormal cells and formation of cancers.

Infection of liver cells with hepatitis viruses can also damage DNA. These viruses have their own DNA, which carries instructions on how to infect cells and produce more viruses. In some patients, this viral DNA can insert itself into a liver cell's DNA, where it may affect the cell's genes. But scientists still don't know exactly how this might lead to cancer.

Liver cancer clearly has many different causes, and there are undoubtedly many different genes involved in its development. It is hoped that a more complete understanding of how liver cancers develop will help doctors find ways to better prevent and treat them.

Many liver cancers could be prevented by reducing exposures to known risk factors for this disease.

Avoiding and treating hepatitis infections

Worldwide, the most significant risk factor for liver cancer is chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV). These viruses can spread from person to person through sharing contaminated needles (such as in drug use) and through unprotected sex, so some of these cancers may be prevented by not sharing needles and by using safer sex practices (such as consistent use of condoms).

A vaccine to help prevent HBV infection has been available since the early 1980s. The US Centers for Disease Control and Prevention (CDC) recommends that all children, as well as adults at risk get this vaccine to reduce the risk of hepatitis and liver cancer.

There is no vaccine for HCV. Preventing HCV infection, as well as HBV infection in people who have not been immunized, is based on understanding how these infections occur. These viruses can be spread through sharing contaminated needles (such as in drug use), unprotected sex, and through childbirth.

Blood transfusions were once a major source of hepatitis infection as well. But because blood banks in the United States test donated blood to look for these viruses, the risk of getting a hepatitis infection from a blood transfusion is extremely low.

People at high risk for HBV or HCV should be tested for these infections so they can be watched for liver disease and treated if needed.

According to the CDC, you are at risk of having hepatitis B if you:

• Have sex with someone who is infected
• Have multiple sex partners
• Have a sexually transmitted disease
• Are a man who has sex with other men
• Inject drugs
• Live with a person who has chronic HBV
• Travel to countries where many people have HBV
• Are exposed to blood on the job
• Get long-term hemodialysis

A baby born to a mother that is infected with HBV is also at risk for being infected.

The CDC recommends that you get tested for HCV if any of the following are true:

• You were born from 1945 through 1965 (this is because most of the people in the US that are infected with HCV were born in these years)
• You ever injected drugs (even just once or a long time ago)
• You needed medicine for a blood clotting problem before 1987
• You received a blood transfusion or organ transplant before July 1992 (when blood and organs started being screened for HCV)
• You are on long-term hemodialysis
• You are infected with HIV

Treatment of chronic HCV infection can eliminate the virus in many people.

A number of drugs are used to treat chronic HBV. These drugs reduce the number of viruses in the blood and lessen liver damage. Although they do not cure the disease, they lower the risk of cirrhosis and might lower the risk of liver cancer, as well.

Limiting alcohol and tobacco use

Drinking alcohol can lead to cirrhosis, which in turn, can lead to liver cancer. Not drinking alcohol or drinking in moderation could help prevent liver cancer.

Since smoking also increases the risk of liver cancer, not smoking will also prevent some of these cancers. If you smoke, quitting will help lower your risk of this cancer, as well as many other cancers and life-threatening diseases.

Getting to and staying at a healthy weight

Avoiding obesity might be another way to help protect against liver cancer. People who are obese are more likely to have fatty liver disease and diabetes, both of which have been linked to liver cancer.

Limiting exposure to cancer-causing chemicals

Changing the way certain grains are stored in tropical and subtropical countries could reduce exposure to cancer-causing substances such as aflatoxins. Many developed countries already have regulations to prevent and monitor grain contamination.

Most developed countries also have regulations to protect consumers and workers from certain chemicals known to cause liver cancer. For example, the US Environmental Protection Agency (EPA) limits the allowable level of arsenic in drinking water in the United States. But this may continue to be a problem in areas of the world where naturally occurring arsenic commonly gets into drinking water.

Treating diseases that increase liver cancer risk

Certain inherited diseases can cause cirrhosis of the liver, increasing a person’s risk for liver cancer. Finding and treating these diseases early in life could lower this risk. For example, all children in families with hemochromatosis should be screened for the disease and treated if they have it. Treatment regularly removes small amounts of blood to lower the amount of excess iron in the body.

It is often hard to find liver cancer early because signs and symptoms often do not appear until it is in its later stages. Small liver tumors are hard to detect on a physical exam because most of the liver is covered by the right rib cage. By the time a tumor can be felt, it might already be quite large.

There are no widely recommended screening tests for liver cancer in people who are not at increased risk. (Screening is testing for cancer in people without any symptoms.) But testing might be recommended for some people at higher risk.

Many patients who develop liver cancer have long-standing cirrhosis (scar tissue formation from liver cell damage). Doctors may do tests to look for liver cancer if a patient with cirrhosis gets worse for no apparent reason.

For people at higher risk of liver cancer due to cirrhosis (from any cause) or chronic hepatitis B infection (even without cirrhosis), some experts recommend screening for liver cancer with alpha-fetoprotein (AFP) blood tests and ultrasound exams every 6 to 12 months. In some studies, screening was linked to improved survival from liver cancer.

Ultrasound uses sound waves to take pictures of internal organs.

AFP is a protein that can be present at increased levels in patients with liver cancer. But looking at AFP levels isn’t a perfect test for liver cancer. Many patients with early liver cancer have normal AFP levels. Also, AFP levels can be increased from other kinds of cancer as well as some non-cancerous liver conditions.

The American Cancer Society does not have recommendations for liver cancer screening.

Some amount of feeling depressed, anxious, or worried is normal when liver cancer is a part of your life. Some people are affected more than others. But everyone can benefit from help and support from other people, whether friends and family, religious groups, support groups, professional counselors, or others. Learn more in Coping with Cancer or Distress in People with Cancer.

Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer growing or coming back. (When cancer comes back after treatment, it is called a recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives.

For others, liver cancer may never go away completely. You may still get regular treatments to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty. Learn more in Managing Cancer as a Chronic Illness.

Ask your doctor for a survivorship care plan

Talk with your doctor about developing a survivorship care plan for you. This plan might include:

• A suggested schedule for follow-up exams and tests
• A schedule for other tests you might need in the future, such as early detection (screening) tests for other types of cancer, or tests to look for long-term health effects from your cancer or its treatment
• A list of possible late- or long-term side effects from your treatment, including what to watch for and when you should contact your doctor
• Diet and physical activity suggestions

Follow-up care

Even after you have completed liver cancer treatment, your doctors will want to watch you closely. It is very important to go to all follow-up appointments. During these visits, your doctors will ask you if you are having any problems , do physical exams and blood tests, such as alpha-fetoprotein (AFP) levels, liver function tests (LFTs). Imaging tests, such as ultrasound, CT, or MRI scans might also be ordered.

If you have been treated with a surgical resection or a liver transplant and have no signs of cancer remaining, most doctors recommend follow-up with imaging tests and blood tests every 3 to 6 months for the first 2 years, then every 6 to 12 months. Follow-up is needed to check for cancer recurrence or spread, as well as possible side effects of certain treatments.

Almost any cancer treatment can have side effects. Some might only last a few weeks or months, but others can last a long time. . Don't hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them effectively.

It is important to keep health insurance. Health care costs a lot, and even though no one wants to think of their cancer coming back, this could happen.

Follow-up after a liver transplant

A liver transplant can be very effective at treating the cancer and replacing a damaged liver. But this is a major procedure that requires intense follow-up after treatment. Along with monitoring your recovery from surgery and looking for possible signs of cancer recurrence, your medical team will watch you closely to make sure your body is not rejecting the new liver.

You will need to take strong medicines to help prevent the rejection. These medicines can have their own side effects, including weakening your immune system, which can make you more likely to get infections.

Your transplant team should tell you what to watch for in terms of symptoms and side effects and when you need to contact them. It is very important to follow their instructions closely.

Anti-viral treatment

If you have hepatitis B or C that may have contributed to your liver cancer, your doctor may want to put you on medicines to treat or help control the infection.

Keeping health insurance and copies of your medical records

Even after treatment, it’s very important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

At some point after your cancer diagnosis and treatment, you might find yourself seeing a new doctor who does not know about your medical history. It’s important to keep copies of your medical records to give your new doctor the details of your diagnosis and treatment.

Can I lower my risk of liver cancer progressing or coming back?

If you have (or have had) liver cancer, you probably want to know if there are things you can do that might lower your risk of the cancer coming back, or of getting a new skin cancer.

Adopting healthy behaviors such as not smoking, eating well, being active, and staying at a healthy weight might help as well, but no one knows for sure. However, we do know that these types of changes can have positive effects on your health that can extend beyond your risk of liver or other cancers.