Although the exact cause of liver cancer is unknown, it has been linked to damage and scarring of the liver (cirrhosis).

Cancer is a condition where cells in a specific part of the body grow and reproduce uncontrollably, producing a lump of tissue known as a tumour.

Increased risk

In cases of liver cancer, it is uncertain why and how the cells of the liver are affected. However, it appears that damage to the liver, such as the condition cirrhosis, can increase the risk of liver cancer.

Cirrhosis

Cirrhosis is a medical term which means the tissue of the liver has become scarred and cannot perform many of its usual functions. However, it is important to point out most cases of cirrhosis do not lead to liver cancer.

In England, the main causes of cirrhosis are:

• prolonged alcohol misuse – usually over many years
• non-fatty alcoholic liver disease
• hepatitis C

These are discussed in more detail below.

Alcohol abuse

The liver is a tough and resilient organ. It can endure a high level of damage that would destroy other organs. It is also capable of regenerating itself. But despite the liver’s resilience, prolonged alcohol misuse over many years can damage it.

Every time you drink alcohol, your liver filters out the poisonous alcohol from your blood and some of the liver cells die. The liver can regenerate new cells, but if you drink heavily for many years, your liver will lose the ability to do this.

It is estimated that one in three cases of liver cancer are related to alcohol misuse.

Read more about alcohol misuse and alcoholic liver disease.

Non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease occurs when small deposits of fat build up inside the tissue of the liver. It’s a common condition and causes no noticeable symptoms in most people. However, in some people high levels of fat can make the liver inflamed. Over time, the inflammation will scar the liver.

The exact cause of non-alcoholic fatty liver disease is unclear, but it is associated with obesity and type 2 diabetes.

Hepatitis C

A long term infection of hepatitis C can cause inflammation and scarring of the liver. In England, most people infected by hepatitis C develop the infection by using contaminated needles or other drug equipment, such as mixing spoons when injecting drugs like heroin.

If you smoke and have hepatitis C, your risk of developing liver cancer further increases.

Other risk factors

Other risk factors for liver cancer include:

Hepatitis B

Hepatitis B is a virus that can be spread via contaminated blood and other types of bodily fluids, such as saliva, semen and vaginal fluids. Hepatitis B is uncommon in England and other western European countries.

A small number of people have severe symptoms similar to those of liver cancer, and can develop extensive scarring of their liver.

The risk of someone with a hepatitis B infection developing liver cancer appears to be influenced by ethnicity. People of Asian origin infected with hepatitis B have a higher-than-average chance of developing liver cancer, regardless of whether they have also developed cirrhosis of the liver.

People of other ethnic backgrounds only seem to have an increased risk of liver cancer if they also develop cirrhosis or another related liver condition, such as hepatitis C.

If you smoke and have hepatitis B, your risk of developing liver cancer further increases.

Haemochromatosis

Haemochromatosis is a genetic condition where the body stores too much iron from food. The excess levels of iron have a poisonous effect on the liver and cause scarring. 

People with haemochromatosis-related cirrhosis have a 1 in 10 chance of developing liver cancer. This risk decreases to 0.1 in 10 once treatment to remove the excess iron from the body begins.

Autoimmune hepatitis

Autoimmune hepatitis is a rare, genetic condition thought to affect 1 in every 7,150 people.

In autoimmune hepatitis, your immune system (the body’s natural defence against infection) attacks the cells of the liver as if they are a ‘foreign’ infection. Exactly what triggers the attack is unknown.

If you have autoimmune hepatitis, the risk of developing liver cancer is smaller than if you have cirrhosis from one of the other common causes. This may be because most cases of autoimmune hepatitis can be treated with immunosuppressant drugs that help prevent your immune system from damaging your liver. 

Primary biliary cirrhosis

Primary biliary cirrhosis is a rare and poorly understood liver condition. In England, an estimated 1 in 4,150 people is affected.

One of the main functions of the liver is to create a fluid called bile, used by the body to help break down fat. The bile is transported to the digestive system via a series of tubes called bile ducts.

For reasons that are unclear, in cases of primary biliary cirrhosis, the bile ducts are gradually damaged. This eventually leads to a build-up of bile inside the liver, which damages the liver and causes cirrhosis.

People with advanced primary biliary cirrhosis are estimated to have a 1 in 20 chance of developing liver cancer in any given year.

For many people, the first stage of diagnosing liver cancer is a consultation with a GP, although people at risk are usually tested regularly for the condition.

If you visit your GP, they will ask about your symptoms, when they started, and when they are noticeable, as well as examining you. If they feel you need further tests, they will refer you to a hospital specialist.

See below for information about these tests.

Surveillance for liver cancer

If you are in a high-risk group for developing liver cancer, regular screening, known as surveillance, is recommended. This is because the earlier the cancer is diagnosed, the greater the chance of curing it.

Surveillance is usually carried out every six months and is a two-stage process. These stages are:

• blood tests – a little over half of people with primary liver cancer produce a protein in their blood called alphafetoprotein (AFP). This can be detected by regular testing.
• ultrasound scans – high-frequency sound waves are used to create an image of your liver, which can highlight any abnormalities

Surveillance is usually recommended if you have cirrhosis, although there are other factors that can also affect your risk of liver cancer. The potential benefits of surveillance should be discussed with you before you enter any screening programme.

Further testing

There are several tests that can be used to confirm a diagnosis of liver cancer, although it would be unusual for someone to need all the tests to confirm the diagnosis. The tests are:

• a computer tomography (CT) scan – a series of X-rays of your liver are taken, and a computer assembles them into a more detailed three-dimensional image.
• a magnetic resonance imaging (MRI) scan uses a strong magnetic field and radio waves to build up a picture of the inside of your liver.
• biopsy – a needle is used to remove a small sample of liver tissue, which is then tested in a laboratory for cancerous cells.
• laparoscopy – a test performed under general anaesthetic (you will be asleep during the procedure and will not feel pain). During a laparoscopy, a small incision is made in your abdomen (tummy) and a flexible camera called an endoscope is used to examine your liver.

Staging

Staging is a term used to describe how far a particular cancer has spread. There are a number of different systems used to stage liver cancer. Many liver cancer specialists use combination staging systems that include features of both the cancer and the underlying liver function to stage a person’s condition.

This is because the length of time a person lives, and how well they tolerate potential treatments, will be determined not only by how advanced their cancer is, but also by their level of health and how good their underlying liver function is.

One combination system for staging liver cancer is known as the Barcelona Clinic Liver Cancer (BCLC) staging system. The BCLC staging system consists of five stages. These are:

• Stage 0 – the tumour is less than 2cm (20mm) in diameter and the person is very well and has normal liver function
• Stage A – a single tumour has grown but is less than 5cm (50mm) in diameter, or there are three or fewer smaller tumours less than 3cm (30mm) in diameter and the person is very well with normal liver function
• Stage B – there are multiple tumours in the liver, but the person is well and their liver function is unaffected
• Stage C – any of the above circumstances, but the person is not so well and their liver function is not so good; or where the cancer has started to spread into the main blood vessel of the liver, into nearby lymph nodes or other parts of the body
• Stage D – where the liver has lost most of its functioning abilities and the person begins to have symptoms of end-stage liver disease, such as a build-up of fluid inside their abdomen (tummy)

Primary liver cancer is a rare but serious type of cancer that begins in the liver. It mostly affects older people.

Symptoms are often vague and don’t appear until the cancer is at an advanced stage. They include:

• unexplained weight loss
• nausea (feeling sick)
• vomiting
• tiredness
• jaundice – yellowing of the skin and the whites of the eyes

Read more about the symptoms of liver cancer.

The liver

The liver is one of the most complex organs in the human body. It performs more than 500 functions. Some of the liver’s most important functions include:

• digesting proteins and fats
• removing toxins (poisons) from the body
• helping to control blood clotting (thickening)
• releasing bile, a liquid that breaks down fats and aids digestion

Liver cancer is a serious condition because it can disrupt these functions or cause them to fail completely.

Why does liver cancer happen?

Although the exact cause of liver cancer is unknown, it is thought to be related to damage to the liver, such as cirrhosis.

Cirrhosis can be caused by:

• alcohol misuse – drinking more than the recommended amount of alcohol
• hepatitis B or hepatitis C viral infections 

It is also believed that obesity may increase the risk of liver cancer due to its links with non-alcoholic fatty liver disease.

Read more about the causes of liver cancer.

How common is liver cancer?

Liver cancer is rare in England, but much more common in other parts of the world.

In the UK, almost 4000 new cases of liver cancer are diagnosed each year. Around 60% of cases affect men and 40% affect women. The number of people affected by liver cancer rises sharply with age, about 70% of cases involve people 65 years of age or older.

Over the past few decades, rates of liver cancer in the UK have risen sharply as a result of  increased levels of alcohol misuse and obesity. 

Diagnosis and screening

Liver cancer is usually diagnosed after a consultation with a GP and a referral to a hospital specialist for further tests.

However, regular check-ups for liver cancer (known as ‘surveillance’) are recommended for people known to have a high risk of developing the condition, such as those with a confirmed hepatitis C infection or those who have had cirrhosis.

If you are in a high-risk group for developing liver cancer, having regular check-ups will help ensure the condition is diagnosed early. The earlier liver cancer is diagnosed, the more effective treatment is likely to be.

Read more about diagnosing liver cancer.

How is liver cancer treated?

Treatment for liver cancer depends on the stage the condition is at. If diagnosed early, it may be possible to treat.

Treatment options include:

• surgical resection – surgery is used to remove a section of liver
• liver transplant – the liver is replaced with a donor liver
• radiofrequency ablation – a small electrical current is used to destroy the cancerous cells

If liver cancer is only discovered at an advanced stage, treatment is only used to relieve pain and discomfort.

Currently, only 1 in 10 people is diagnosed for liver cancer at an early stage. In most people who are diagnosed with liver cancer, the cancer has advanced too far to be cured. As a result, only 1 in 5 people live for at least a year after being diagnosed with liver cancer. Just 1 in 20 people live for at least five years.

Read more about treating liver cancer.

Preventing liver cancer

Many cases of liver cancer are preventable. Most steps to reduce the chances of liver cancer involve having a healthy lifestyle.

The risk of liver cancer can be reduced by:

• avoiding alcohol or excessive drinking
• eating healthily and keeping fit to avoid obesity
• reducing the chances of being infected by hepatitis B or hepatitis C

Read more about preventing liver cancer.

Lifestyle and self-care measures are the most effective ways to reduce the chances of liver cancer developing.

These include:

• drinking alcohol in moderation
• eating healthily and exercise regularly to avoid obesity-related illnesses, such as cardiovascular disease (disease of the heart or blood vessels)
• avoiding exposing yourself to risk factors such as hepatitis C and hepatitis B

Alcohol

Giving up drinking alcohol altogether is the most effective way of reducing your risk of developing liver cancer, particularly if you have been drinking for many years.

As a minimum preventative measure, you should not regularly drink more than the recommended daily amounts:

• 3-4 units a day for men
• 2-3 units a day for women

A unit of alcohol is approximately half a pint of normal-strength lager, a small glass of wine or a single measure (25ml) of spirits.

Visit your GP if you are finding it difficult to moderate your alcohol consumption. Counselling services and medication are available to help you reduce your alcohol intake.

Read more about alcohol and treating alcohol misuse.

Hepatitis C

If you regularly inject drugs, such as heroin, the best way of avoiding a hepatitis C infection is to not share any of your drug-injecting equipment with other people. This does not just apply to needles but to anything that could come into contact with other people’s blood, such as:

• mixing spoons
• filters
• water used to dissolve drugs
• tourniquets – the belt that drug users sometimes tie around their arm to make it easier to inject their veins

Hepatitis C does not cause noticeable symptoms for several years, so many people may be unaware they are infected. It is therefore safer to assume anyone may have the infection.

Even if you are not a drug user, it is important to take common-sense precautions to minimise your exposure to other people’s blood. This includes avoiding sharing any object that could be contaminated with blood, such as razors or toothbrushes.

There is less risk of getting hepatitis C by having sex with someone who is infected. However, as a precaution, it is recommended you use a barrier method of contraception during sex, such as a condom.

It may also be possible to get hepatitis C by sharing banknotes or ‘snorting tubes’ to snort drugs, such as cocaine or amphetamine with an infected person. These types of drugs can irritate the lining of your nose and small particles of contaminated blood could be passed on to the note or tube which you could then inhale.

Read more about getting tested and treated for hepatitis C and preventing hepatitis C.

Hepatitis B

There is a vaccine that protects against hepatitis B. However, because hepatitis B is relatively rare in England, the vaccination does not form part of the routine childhood vaccination schedule.

Vaccination is usually only recommended for people in high-risk groups, such as:

• injecting drug users (including their partners, children and others living with them)
• people who change sexual partners frequently (including men who have sex with men, and male and female sex workers)
• close family contacts of someone with a chronic hepatitis B infection
• people who receive regular blood products and their carers
• people who have chronic kidney failure
• people who have chronic liver disease
• prisoners and some prison service staff
• people who live in residential accommodation for those with learning difficulties
• families that foster or adopt children who may have been at increased risk of developing a hepatitis B infection
• people travelling to, or going to live in, areas where there is a high or moderate incidence of hepatitis B, such as China

People who have an occupation that increases their exposure to hepatitis B should also be vaccinated. These occupations include:

• healthcare workers
• laboratory staff
• staff who work in residential care homes for people with learning difficulties
• morticians and embalmers
• some emergency services personnel

Contact your GP for advice if uncertain about whether you should be vaccinated against hepatitis B. 

Read more about preventing hepatitis B.

The Map of Medicine is used by doctors throughout the NHS to determine the best treatment options for their patients. NHS Choices offers everyone in England exclusive and free access to this cutting-edge internet resource, which lets you see exactly what your doctor sees.

The information in the Map has been approved by the UK’s leading clinical experts, is based on the best available clinical evidence, and is continually updated. To take advantage of this unique resource go to:

Map of Medicine: hepatocellular cancer

 

Cancer of the liver does not usually cause  noticeable symptoms until it has reached an advanced stage.

These symptoms include:

• unexplained weight loss
• loss of appetite that lasts longer than a week
• feeling very full after eating, even if the meal was small
• feeling sick (nausea) and vomiting
• swelling of your abdomen (tummy)
• jaundice – yellowing of your skin and the whites of your eyes
• itchy skin
• feeling very tired and weak

When to seek medical advice

Visit your GP if you are notice any of the symptoms listed above. Although they are more likely to be the result of a more common condition, such as an infection, rather than liver cancer, it’s best to have them checked.

Also, you should contact your GP if you have previously been diagnosed with a condition known to affect the liver, such as cirrhosis or a hepatitis C infection, and your health suddenly deteriorates.

The treatment for liver cancer depends on the stage of the condition. Treatment can include surgery and medication.

Cancer treatment teams

Many hospitals use multidisciplinary teams (MDTs) to treat liver cancer. MDTs are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Deciding what treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Your treatment plan

Your recommended treatment plan will depend on the stage your liver cancer is at (see diagnosing liver cancer for more information about staging).

If your cancer is at Stage A when diagnosed, a complete cure may be possible. The three main ways this can be achieved are:

• removing the affected section of liver – known as a resection
• having a liver transplant – an operation to remove the liver and replace it with a healthy one
• using heat to kill cancerous cells – known as radiofrequency ablation (RFA)

If your cancer is at Stage B or C, a cure is not usually possible. However, chemotherapy can slow the progression of the cancer, relieve symptoms and prolong life for months or, in some cases, years.

There is also a medication called sorafenib, which can help prolong life.

If your cancer is at Stage D when diagnosed, it is usually too late to slow down the spread of the cancer. Instead, treatment focuses on relieving symptoms of pain and discomfort you may have.

Each treatment option is discussed in more detail below.

Surgical resection

If damage to your liver is minimal and the cancer is contained in a small part of your liver, it may be possible to remove the cancerous cells during surgery. This procedure is known as surgical resection.

As the liver can regenerate itself, it may be possible to remove a large section of it without seriously affecting your health. However, in the majority of people with liver cancer, their liver’s regenerative ability may be significantly impaired and resection may be unsafe.

Whether or not a resection can be performed is often determined by estimating the severity of the cirrhosis.

If a liver resection is recommended, it will be carried out under a general anaesthetic, which means you will be asleep during the procedure andnot feel any pain.

Most people are well enough to leave hospital six to 12 days after surgery. However, depending on how much of your liver was removed, it may take up to three or four months for you to fully recover.

Liver resection is a complicated surgery and can have a considerable impact on your body. There is a one in four chance of complications after surgery.

Possible complications of liver resection include:

• infection at the site of the surgery
• bleeding after the surgery
• blood clots that develop in your legs – the medical term for this is deep vein thrombosis (DVT)
• bile leaking from the liver – further surgery may be required to stop the leak
• jaundice 
• liver failure

Liver resection can sometimes cause fatal complications, such as a heart attack. It is estimated that 1 in every 30 people who have liver resection surgery will die during or shortly after the operation.

One type of liver resection surgery, which involves the temporary removal of the liver (ex-vivo hepatic resection), is a possible treatment for liver cancer.

However, the National Institute for Health and Clinical Excellence (NICE) has recently released guidance about this procedure which raises concerns about how safe and effective this treatment is.

Your doctor should discuss the benefits and dangers of this surgery before any decision is made.

Liver transplant

If you only have a single tumour less than 5cm (50mm) in diameter, you may be suitable for a liver transplant. However, if you have multiple tumours, or a tumour larger than 5cm, the risk of the cancer returning is usually so high a liver transplant will be of no benefit.

Some people who have three or fewer small tumours, each less than 3cm (30mm) in diameter may be offered a transplant. Occasionally, if a person has a tumour that responds exceptionally well to treatment, with no evidence of tumour growth for a six-month period, they may also be offered a transplant.

There can be a long time until a suitable liver becomes available, so you may be put on a waiting list.

In some cases, a small part of the liver of a living relative can be used. This is known as a living donor liver transplant.

The advantage of using a living donor liver transplant is that the person receiving the transplant can plan the procedure with their medical team and relative, and will not usually have to wait very long. 

However, there are also disadvantages, such as higher complication rates. Research has also found results of live donor liver transplants tend not to be as good as transplants using a liver from someone who has died.

Read more about liver transplants.

Radiofrequency ablation

Radiofrequency ablation (RFA) may be recommended as an alternative to surgery to treat liver cancer at an early stage, ideally when the tumour or tumours are smaller than 5cm (two inches) in diameter. RFA can also be used to treat tumours larger than this, but the treatment may need to be repeated in such cases.

RFA usually involves heating the tumours with an electric current produced by small, needle-like electrodes. This heat kills the cancer cells and causes the tumours to shrink. Similar procedures using microwaves, lasers or freezing can also be performed to achieve the same result.

There are three main ways RFA can be carried out:

• where the needles are passed through the skin (percutaneously)
• during “keyhole” surgery (laparoscopy) – where the needles are inserted through small incisions in your abdomen
• during “open” surgery – where the needles are inserted through a single large incision made in your abdomen

Continuous ultrasound or computerised tomography (CT) scans are used to make sure the needles are guided into the correct position.

RFA can be carried out under general anaesthetic or local anaesthetic (where you are awake but the area being treated is numbed), depending on the technique used and the size of the area that needs to be treated.

How long it takes for perform RFA depends on the size and number of tumours that need to be treated, but it usually takes between one and three hours in total. Most people need to stay overnight in hospital.

You may experience some minor discomfort and flu-like symptoms, such as chills and muscle pains, for a few days after the procedure.

The risk of complications occurring with RFA is low, but possible problems can include bleeding, infection, minor burns and damage to nearby organs.

Chemotherapy

Chemotherapy involves using a combination of powerful cancer-killing medications to slow the spread of liver cancer.

A type of chemotherapy called transcatheter arterial chemoembolisation (TACE) is usually recommended to treat cases of stage B and C liver cancer. This is a palliative treatment that can prolong your life but is not curative. TACE is not recommended for Stage D liver cancer because it can make the symptoms of liver disease worse.

TACE may also be used to help prevent cancer spreading out of the liver in people waiting for a liver transplant.

TACE uses a combination of two techniques:

• chemotherapy medications are injected directly into your liver
• gel or small plastic beads are injected into the blood vessels supplying the tumours with blood; this should help slow down the speed at which the tumours grow

TACE usually takes one to two hours to complete. After the procedure, you will stay in hospital overnight before returning home. Your response to the treatment will be assessed a month or so after the procedure, usually by having a CT scan. If you remain well, further TACE treatment may be requested for you.

People who have TACE often receive three to four sessions, with a period of about one month in between each session.

Injecting chemotherapy medications directly into the liver, rather than into the blood, has the advantage of avoiding the wide range of side effects associated with ‘traditional chemotherapy’, such as hair loss and fatigue.

However, the procedure is not free of side effects and complications. The most common being post-chemoembolisation syndrome, which occurs in around one in three cases.

Post-chemoembolisation syndrome can cause the following symptoms:

• abdominal (tummy) pain
• high temperature (fever) of 38ºC (100.4ºF) or above
• nausea (feeling sick)
• vomiting
• loss of appetite

These symptoms may last for one to two weeks after having a session of TACE.

Less common complications of TACE include:

• worsening of liver function, which is usually temporary
• swelling of the abdomen due to a build-up of fluid – this occurs in around 1 in 20 cases
• liver abscess
• damage to the biliary tract or gall bladder

Alcohol injections

If you only have a few small tumours, alcohol injections may be used as a treatment. This involves using a needle that passes through the skin to inject alcohol into the cancerous cells. This dehydrates the cells and stops their blood supply.

In most cases, this is carried out under a local anaesthetic, meaning you will be awake, but the  affected area is numbed so you won’t feel any pain.

Sorafenib

Sorafenib is a tablet sometimes used to treat liver cancer. Whether or not you are eligible for sorafenib will be decided by your medical team and will depend on whether it is likely to do you more good than harm.

In cases of advanced liver cancer, NICE does not recommend the use of sorafenib because the cost is high for the limited benefit it brings.

Common side effects include:

• diarrhoea
• nausea (feeling sick)
• vomiting
• hair loss
• itchy skin
• pain, such as headaches, abdominal (tummy) pain or bone pain

Advanced liver cancer

Treatment for advanced liver cancer focuses on relieving the symptoms of pain and discomfort, rather than attempting to slow down the progression of the cancer.

Some people with advanced liver cancer require strong painkillers, such as codeine or possibly morphine. These will be given to you if they are needed. Nausea and constipation are common side effects of these types of painkillers, so you may also be given an anti-sickness tablet and a laxative.

Read more about end of life care.