What are the treatments for Liver Cancer?
Once the patient is diagnosed to have liver cancer, doctor will consider the stage of the cancer, the malignancy of the cancer cells, and the patient's overall hralth condition to formulate the moste appropriate treatment plan. Generally, doctor will suggest the following treatments to the patient depending on the codition:
(1) Removal by surgery
- Rationale of treatment: To remove the tumor and the surrounding affected tissues.
- Suitable for: Removal by radical surgery is suitable for 20% of liver cancer patients whose tumors affect only one of the liver lobes and their liver functions are normal. 62% of them can survive 3 years while 50% of them can survive 5 years.
(2) Trans-arterial Chemoembolization (TACE)
- Rationale of treatment: This is to block the blood vessels, thus stopping them from providing the tumor with nutrition. This can stop the cancer tumor from growing, which can reduce its size. This can be achieved by injecting drugs into selected blood vessels which are for providing the tumor with nutrition through aorta. This is to block the artery, which monitors the liver cancer, to achieve treatment results and not to affect the normal liver tissues.
- Suitable for: This is suitable for a patient whose tumor has spread to both sides of the liver but has not yet metastasized to other organs, or a patient whose tumor is limited to one side of the liver but whose liver function, tumor location, tumor size, or tumor number is not suitable for surgery or local ablative treatment.
(3) Injection of alcohol
- Rationale of treatment: With the help of ultrasound or computer scan, the location of the tumor is confirmed. Then alcohol with 95% concentration is injected directly into the tumor with a thin needle through the skin. The highly concentrated alcohol will dry up the cells and thus kill them.
- Suitable for: It is suitable for a patient whose tumor is smaller than 3cm or whose number of tumors is less than 3. As the injection can only make the central part of the tumor to wither, which means the neighboring tissues still survive and keep growing, so the patient has to get many injections to ensure the liver cancer cells are killed.
(4) Radiofrequency ablation
- Rationale of treatment: This is to use localized thermal treatment technique, when temperature reaching 60∘C to destroy the tumor tissues. Depending on the location and size of the tumor, the surgery can be performed through percutaneous or laparotomy. Simultaneously ultrasonography is used to guide the electrode and to monitor the ablation level of the tumor.
- Suitable for: This is for those who are infected with primary liver cancer and metastatic liver cancer.
(5) Liver transplant
- Rationale of treatment: It is the best treatment for end-stage liver disease. The patient’s liver is removed and replaced by healthy liver tissue from a donor. Usually, it is suitable for the patient either having a single tumor that is 5cm or smaller or having 3 or fewer tumors, all of which are smaller than 3cm. The liver is the only organ in the body that can replace lost or injured tissue (regenerate). The donor’s liver will grow back to normal size after surgery.
(6) Selective Internal Irradiation (SIRT)
- Rationale of treatment: SIRT is a radio-embolization technique in which radioactive microspheres are injected via intravascular catheters into the hepatic artery that supplies the tumor. These microspheres are tagged with Yttrium-90 which is capable of emitting short-distance radiation. Hence, SIRT allows preferential irradiation of the tumor to a high radiation dose without causing excessive damage to the normal liver function.
- Suitable for: liver cancers that are not eligible for surgery or local ablative therapy. In contrast to TACE, some patients with portal vein thrombosis, a contraindication for TACE, appeared to tolerate SIRT favorably.
- A prospective randomized trial comparison between SIRT and TACE suggested that these two procedures had similar efficacy.
- SIRT is contraindicated in patients who have poor liver function or uncontrolled ascites. Pre-treatment assessment with hepatic angiogram and Technetium MAA scan is necessary to evaluate the amount of microspheres uptake in lung, liver, and gastrointestinal tract. Inadvertent delivery of SIR- microspheres to the gastrointestinal tract or pancreas will cause acute abdominal pain, acute pancreatitis, cholecystitis, or peptic ulceration. Excessive shunting to the lung may lead to radiation pneumonitis. Excessive radiation to the normal liver parenchyma may result in radiation hepatitis.
(7) Stereotactic ablative body radiotherapy (SABR)
- Rationale of treatment: External beam irradiation for HCC was rarely used in the past because of the low radiation tolerance of liver. The risk of radiation induced liver disease (RILD) increases with poor baseline liver function. With growing experience, it is now known that disease control can be possible if high radiation dose can be delivered to the tumor while sparing a sufficient amount of normal liver reserve.
- Suitable for: patients who are not amenable to undergo surgery or local ablative therapies. It is also indicated in patients who have developed recurrence despite multiple courses of TACE. Patients with portal vein thrombosis who are not suitable for TACE can also be treated with SABR.
(8) Targeted therapy & Immunotherapy
- Target therapy is systemic treatment targeting cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. It blocks the growth and spread of cancer cells effectively and limits damage to healthy cells. Side effects may include high blood pressure, back pain, headaches, changes in taste, fatigue, diarrhea, appetite loss, joint and muscle pain, weight loss, abdominal pain, rash, redness, itching or peeling of the skin on the hands and feet, hoarseness, bleeding, change in thyroid hormone levels, and nausea.
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For first-line treatment, for patients with unresectable or metastatic liver cancer, doctors may prescribe bevacizumab (anti-angiogenesis targeted therapy given intravenously) with atezolizumab (immunotherapy, taken as pill), Lenvatinib (anti-angiogenesis targeted therapy, taken as pill) or sorafenib (taken orally as pill).
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For patients who already received sorafenib as previous treatment, cabozantinib (oral pill) or regorafenib (oral pill), may be prescribed
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Immunotherapy fights cancer by improving the immune system's ability. Immune checkpoint inhibitor is a common one, to help the immune system to better find and attack the cancer cells. Immunotherapy can cause side effects. Many side effects happen when the immune system that is revved-up to act against the cancer also acts against healthy cells and tissues in the body. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes from retaining fluid.
- Doctors will choose drugs based on the clinical judgement and patients' condition. Patients may consult the doctor-in-charge for advice on medication treatment. HA has implemented its Drug Formulary with a view to ensuring equitable access by patients to cost effective drugs of proven safety and efficacy through standardization of policies on drugs and drug utilization in all public hospitals and clinics. HA has mechanisms in place to conduct ad hoc and regular reviews of the HA Drug Formulary. The review process follows an evidence-based approach, having regard to the safety, efficacy and cost-effectiveness of drugs while taking into account the latest international practice as well as views of professionals and patient groups.