Liver Cancer - the number 1 cancer in men

Liver Cancer - the number 1 cancer in men

Liver cancer is the number 1 cancer found in Thai men (40.5 cases/100,000 population) and is the 3rd most common in Thai women (16.3 cases/100,000 population). The risk of liver cancer increases significantly in patients with cirrhosis, chronic hepatitis B and C virus infections, as well as heavy alcohol consumers. Liver cancer progresses rapidly, and patients often succumb to the disease within 2-4 months after diagnosis.

Types of Liver Cancer

There are two types of liver cancer:

1. Primary liver cancer: Cancer that originates in the liver cells or bile ducts.

2. Secondary liver cancer: Cancer that has spread to the liver from other parts of the body, such as lung cancer or breast cancer.

Hepatocellular carcinoma (HCC), which is a type of primary liver cancer, is the fifth most common cancer worldwide. However, in Thailand, according to data from the National Cancer Institute, it is the most common cancer in males and the second most common in females.

Currently, most cases of HCC are of the classical type, but the infiltrative type is also prevalent. Regardless of the type of cancer or the stage it is in, if it has progressed to stage 4, it is usually found to have spread to the liver, such as in fibrolamellar hepatocellular carcinoma.

Causes

Causes

The causes of liver cancer depend on the region of Asia or Thailand. In most cases, it is caused by chronic hepatitis B virus infection, which can be asymptomatic and transmitted from mother to child. This accounts for 60% of liver cancer cases in Thailand.

Currently, approximately 6 million Thais are infected with chronic hepatitis B virus, and this infection can cause chronic inflammation and liver cirrhosis, eventually leading to liver cancer.

In medical terms, carriers of the virus have a low level of the virus but no symptoms of the disease. However, if the carriers' immune system becomes compromised, the virus can become active and lead to liver cancer.

The main prevention methods are vaccination against hepatitis B and screening for high-risk patients. If diagnosed with the disease, antiviral therapy can help reduce the risk of liver cancer.

Stages and Symptoms

Liver cancer is similar to other types of cancer, where early stages or stages that can be treated usually have no symptoms. Patients often reach a point where treatment is no longer effective. To detect liver cancer, ultrasound and blood tests are recommended for patients with cirrhosis, regardless of the cause, every 6-12 months.

For men aged 40 with chronic hepatitis B infection, liver cancer screening should be done every 6 months. Women should start screening at age 50, but family history should also be taken into account.

If there is a family history, screening should be done earlier than usual. Late-stage symptoms include right upper abdominal pain, loss of appetite, weight loss, yellowing of the skin and eyes, and leg swelling.

Stages of Liver Cancer

Liver cancer has four stages:

Stage 1: The cancerous tumor is small and there is only one tumor present.

Stage 2: The tumor has spread to blood vessels in the liver and/or there are multiple small tumors present.

Stage 3: The tumor has grown larger and/or has spread to nearby tissues and/or large veins in the abdomen and/or nearby lymph nodes.

Stage 4: Cancer has spread through the bloodstream to other organs such as the lungs, brain, or bones, or to distant lymph nodes.

Stages 1 and 2 can be treated successfully, but treatment for stages 3 and 4 is usually aimed at improving quality of life rather than a cure.

The chance of completely curing liver cancer is difficult, so it is recommended to have regular check-ups every 6 months to 1 year for prevention. Generally, these check-ups are included in the general hospital health check-up program. However, in some cases where the patient is not at risk, they may not receive a check-up. The main groups of patients who should receive a check-up are those with a history of liver disease, those infected with hepatitis B virus, and those who are at high risk.

Prevention and Diagnosis

Recommendations for screening in high-risk groups, including patients with cirrhosis, hepatitis B or C, as well as heavy drinkers, include:

1. Blood tests to measure alpha-fetoprotein (AFP) levels. AFP is a substance produced by cancer cells. The cutoff value for diagnosing liver cancer is AFP levels of 400 ng/mL or higher.

2. Imaging tests to detect liver masses, such as ultrasound, CT scan, or MRI. These tests can also help locate the blood vessels that supply the cancerous tumor in the liver.

3. Liver biopsy may be used in cases where the results of blood tests and imaging tests are not clear. This method provides the most accurate diagnosis of liver cancer because it involves examining a sample of liver tissue under a microscope. However, it carries a higher risk of complications and may not be recommended for patients with ascites or other fluid in the abdomen.

Treatment

1. Hepatic resection is the best treatment option for liver cancer with the potential for a complete cure if the tumor size is less than 3 cm and the liver is functioning properly. However, only 5% of liver cancer patients are candidates for surgery.

2. Transarterial oily chemoembolization (TOCE) is a treatment that can be used in combination with surgery. It shrinks the liver tumor and is effective for tumors smaller than 5 cm. The average survival rate with this treatment is about 9 months, with a minority of patients surviving up to 5 years.

3. Percutaneous ethanol injection (PEI), which involves injecting alcohol into the tumor through the skin, is no longer popular because it often causes severe pain at the injection site.

4. Systemic chemotherapy is used to alleviate symptoms of liver cancer, but the treatment results are still unsatisfactory.

Prevention and Screening

• Vaccination for Hepatitis B can help reduce the risk of chronic hepatitis B infection leading to liver cancer. However, there is currently no vaccine for hepatitis C, which still remains a risk factor for future development of liver cancer worldwide.

• Avoiding alcohol consumption in patients with cirrhosis and chronic hepatitis B or C virus infection is recommended. Studies have shown that alcohol can accelerate the progression of these conditions to liver cancer.

• Screening for liver cancer should be performed in high-risk groups aged 35 and older every 6-12 months using blood tests to detect alpha-fetoprotein (AFP) levels in combination with ultrasound.

Fatty liver disease and its progression to liver cancer

Currently, the risk of fatty liver disease progressing to liver cancer or cirrhosis is high. There are two methods for screening for fatty liver disease. If the condition is present in 30% of the liver, it can be detected with an ultrasound. For a more detailed examination, a Fibro Scan can be used to measure the amount of fat in the liver, as well as to check for fibrosis in the liver.

What are the treatment options for early-stage fatty liver disease?

Treatment currently does not focus on medication. For patients with fatty liver disease, weight loss of approximately 7-10% is recommended, as it can help reduce inflammation and fibrosis of the liver. However, the main recommendation by liver disease associations worldwide is to encourage patients to exercise and change their lifestyle habits by eating a healthy diet.

If the tumor is small, surgery may be the first option, which can increase the chances of the patient being cured. However, certain conditions need to be met, such as the size of the tumor should not exceed 5 centimeters, there should be no spread of cancer to nearby blood vessels, and the remaining liver should function properly.

If the remaining liver cannot function adequately or cannot support the patient's survival, surgery may not be an option. In these cases, surgeons will assess whether a liver transplant is feasible.

If the patient has cirrhosis, late-stage liver disease, and accompanying liver cancer, the best treatment option is liver transplantation if the tumor is not too large, has not spread too far, and meets the required criteria. This involves removing the diseased liver and replacing it with a healthy liver. However, currently, this is not a widely available option and is mainly performed in large hospitals or medical schools. A major problem at present is the shortage of organ donors, which limits the number of patients who can undergo liver transplantation. The average cost of a liver transplant is around 1,000,000 baht.

Surgical treatment is currently covered by the government only for civil servants and those with social security. Patients with golden card coverage are not fully covered yet, but plans are being made to expand access to treatment. Currently, only 100-200 surgeries can be performed annually due to limited resources.

Another method for treating small tumors that are less than 2 centimeters in size and require a relatively large amount of resources is to use high-frequency electric waves. High-frequency waves convert to thermal energy to destroy liver cancer cells. Studies have shown that this method is just as effective as surgery in treating tumors that are not larger than 2 centimeters. This method is preferred in many countries because hospitalization and surgical costs are relatively expensive, and some patients do not want to undergo surgery or are at a high risk of complications.

However, the choice of treatment method must be assessed on a case-by-case basis, as the position of the tumor affects the treatment. In cases where the cancer has spread too far, treatment by liver transplantation or electrical stimulation is not possible. Another treatment method, known as "TACE," involves directly injecting chemotherapy drugs into the cancerous tumor while also injecting Gelfoam to block the blood vessels that supply the tumor. This treatment does not cure cancer, but it can improve the quality of life for patients and allow them to live longer.

Additional advice for self-care to prevent developing liver cancer

Focus on prevention, as prevention is better than cure. In general, individuals should try to reduce their risk factors, such as screening for hepatitis B and C viruses, avoiding risky behaviors such as unprotected sex, intravenous drug use, and tattoos, and avoiding excessive or inappropriate alcohol consumption. Lastly, it is essential to maintain a healthy weight, as fatty liver is a significant cause of liver cancer. For patients who do not have immunity to hepatitis B, vaccination is recommended to prevent the disease.

Best wishes from the Gastrointestinal Disease Center, Vibhavadi Hospital.