While liver cancer continues to present challenges, advances in research and care are increasing treatment options and improving outcomes for many patients. Liver cancer is a rare and complex disease to treat, according to Timothy Pawlik, MD, PhD, MPH, the surgeon-in-chief of The Ohio State University Wexner Medical Center, chair of the Department of Surgery at The Ohio State University College of Medicine and a surgical oncologist who specializes in liver cancer. Recently, Pawlik was recognized as a world leader on liver cancer by Expertscape, which ranks the world’s leading biomedical experts. “Because it’s such a rare and complicated form of cancer, patients should seek treatment at places with a lot of specialists and experience in treating liver cancer and that take a multi-disciplinary approach to treatment,” he says. “What I tell patients is that they have a rare cancer, but it’s not rare for us — we see a lot of liver cancer patients.” The stats There are approximately 42,230 new cases a year (29,890 men and 12,340 women), and around 30,230 deaths (20,300 men and 9,930 women), according to the American Cancer Society. The reason for the high mortality rate is that many patients are diagnosed with advanced, often metastatic, liver cancer because the symptoms are hard to detect. The liver is the body’s largest internal organ. It stores nutrients and filters out and breaks down toxins in the blood. The causes Historically, excessive alcohol consumption (which leads to cirrhosis) along with hepatitis B and hepatitis C have been the leading causes of liver cancer. Though in recent years, obesity has become a leading contributor. “In obese people, fat can be deposited in the liver, and that causes stress and inflammation that can lead to cancer in some people,” Pawlik says. These health issues lead to what Pawlik terms “bad soil” that creates a fertile environment for liver cancer. It also means that Pawlik and his team often have to treat patients who actually have two problems — the cancer and the underlying disease in the liver, such as cirrhosis or chronic hepatitis. Symptoms “The symptoms can be vague and non-specific, and can seem like typical gastrointestinal or stomach issues and not something more serious,” Pawlik says. The symptoms include: A hard lump on the right side, just below the rib cage Discomfort in the upper abdomen on the right side A swollen abdomen Pain near the right shoulder blade or in the back Jaundice Unusual tiredness or fatigue Nausea and vomiting Loss of appetite and weight loss Having one or more of these symptoms does not necessarily mean a person has liver cancer, but it is an indication there could be a medical issue and that you should contact your primary care physician and schedule an examination. Types of liver cancer There are two primary types: Hepatocellular Carcinoma: These cancer cells begin in the liver and is by far the more common form of liver cancer. Cholangiocarcinoma: These cancer cells start in the bile duct. Other cancers that start elsewhere in the body, such as colorectal cancer, can spread to the liver. However, even though these tumors also reside in the liver, they are not categorized as “primary” liver cancer. The treatment for these “secondary” liver tumors is much different than “primary” liver cancers, such as hepatocellular carcinoma or cholangiocarcinoma. Because of this, it is important for patients with liver tumors to be seen at comprehensive cancer centers to ensure they have the correct diagnosis and receive the appropriate treatment. Surgical treatment options Surgery: The benefit of resection surgery that removes the cancerous portions of the liver “is that it’s often not as major a surgery as a transplant. The patient keeps their own liver and doesn’t have to go on immunosuppressants,” Pawlik says. He adds that patients who have liver cancer but otherwise healthy livers are the best candidates to have the tumor removed surgically. Unfortunately, only around 20 percent of liver cancer patients can undergo surgery because many present too late. Transplant: To qualify for a liver transplant, a patient’s cancer can not have spread beyond the liver and must be relatively small. “Because donor livers are such limited resources, the guidelines are relatively strict,” Pawlik says. “If you transplanted someone and they recurred right away, that’s not good for that patient and it’s not good for another patient who was denied that liver. So, we identify the patients who will benefit the most from a transplant.” In general, transplant is used for patients with early-stage liver cancer who may have unhealthy livers that would not allow for resection. Ablation: In this surgical process, a probe connected to a heating device — such as a microwave — is inserted into the tumor and “heats up and destroys the tumor,” Pawlik says. This procedure is most effective for smaller tumors. Non-surgical treatment options Because the majority of liver cancer patients are diagnosed in later stages of the disease, non-surgical treatment is more common. “While surgery offers the best chance for a long-term cure, these types of non-surgical treatments can prolong life, and we continue to make advances,” Pawlik says. Catheter-based treatment: A needle is inserted into the groin area of a patient, and a catheter is threaded up to and into the liver that “delivers a payload,” Pawlik says. The payload can be radiation beads that lodge in the liver and hopefully destroy the cancer cells. Another option is to inject chemotherapy through the catheter. Systematic treatment: Instead of the more targeted catheter method, chemotherapy and/or immunotherapy drugs are delivered through an IV or are taken in pill form. “In the past, there were very few systematic options,” Pawlik says, adding that, 10 years ago, there was only one chemotherapy drug approved for treating liver cancer. “It didn’t provide much of a benefit,” he says. “Now, we have more FDA-approved, targeted immunotherapies demonstrating more effectiveness and more in development in clinical trials we’re working on.” The future Pawlik believes the future of liver cancer treatment will be similar to the advances already made in colorectal cancer. “The hope is that, just like in colorectal cancer, as the chemotherapy options improve, we’ll be better able to keep the liver cancer in check and actually shrink the tumors to the point where we can expand the number of people we can operate on and hopefully cure,” he says. He’s also optimistic that advances in tissue engineering will one day lead to lab-grown livers. “We’re only able to do liver transplants in patients with early-stage cancer because donor livers are such a limited resource,” he says. “In the future, with tissue engineering of livers, we could greatly expand the number of transplants.”