Treatment Update
Liver Cancer
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Treatment Update
Liver Cancer Table of Contents Introduction
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Treatments for Liver Cancer
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Surgery
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Treating the Liver Directly
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Treating the Liver Systemically
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Managing Side Effects
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Your Support Team
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Frequently Asked Questions
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Resources
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Editors Ghassan K. Abou-Alfa, MD
Medical Oncologist, Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan-Kettering Cancer Center
Carolyn Messner, DSW, MSW
Director of Education and Training, CancerCare © 2013 Cancer Care, Inc. All rights reserved. 2/13 All people depicted in the photographs in this booklet are models, used for illustrative purposes only.
As treatments improve, people with liver cancer are living longer and with a better quality of life. Liver cancer affects nearly 29,000 people in the United States each year. The major type of liver tumor is hepatocellular carcinoma, a cancer that forms in the main cells of the liver, called hepatocytes. If these cells are stressed by alcohol or the hepatitis B or C virus, they are at increased risk for cancer. Hepatocellular carcinoma accounts for about 90 percent of all liver cancers.
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Hepatocellular carcinoma is a primary tumor––that is, it begins in the liver. This organ is a common site of metastatic tumors––tumors that have spread from a cancer in another part of the body. Almost any type of cancer can spread to the liver, including breast cancer, colorectal cancer, lung cancer and melanoma.
Your Health Care Team Liver cancer is usually treated by a multidisciplinary team of experts. Working together, your team will set up a personalized treatment plan for you. The doctors treating your liver cancer may include a: • Hepatologist—an expert in the treatment of liver disease • Surgeon—an expert in surgical procedures of the liver • Medical oncologist—to coordinate all aspects of cancer care, especially chemotherapy and other drug treatments • Radiologist—to locate the tumors in the liver and determine whether they have spread to other organs, using CT scanning or MRI • I nterventional radiologist—to perform radioembolization, chemoembolization or radiofrequency ablation or to take tissue samples from tumors in the liver or elsewhere Other health care professionals, such as oncology nurses, pain specialists, registered dietitians, psychologists and social workers, may also form part of your health care team.
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Treatments for Liver Cancer Before deciding how to treat your liver cancer, your team of experts will go over all the information it has gathered about your health. One of the most important factors in determining the best treatment (or combination of treatments) for you is the current status of your liver. The factors your team will consider are: • Whether there are tumors in more than one section of the liver; • Whether the cancer has spread beyond the liver to other parts of the body; • Whether blood vessels are involved; • How much the liver has been damaged by the cancer; • How much, if any, underlying damage is present, such as cirrhosis (a long-term disease in which liver cells are replaced by scar tissue).
Surgery Standard surgery, or hepatectomy, is the surgical removal of the part of the liver affected by cancer. This procedure can only be performed in people who do not have severe liver damage and whose cancer has not spread to the blood vessels of the liver or other parts of the body. Liver transplants are done most often in people whose tumors are very small, few in number, do not involve blood vessels and have not spread outside the liver. These tumors usually cannot be removed by surgery because of advanced cirrhosis. To receive a transplant, a suitable donor with a healthy liver must be found.
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Treating the Liver Directly Embolization or chemoembolization may be used as options to treat liver tumors that cannot be removed by surgery. In these cases, doctors may use a procedure called transarterial embolization (TAE, without chemotherapy) or transarterial chemoembolization (TACE, with chemotherapy). In these procedures, a catheter (a small plastic tube) is placed into the liver’s artery. An inactive substance, with or without chemotherapy, is injected directly into the liver tumor to control and kill the cancer cells. Although TAE and TACE may not destroy all the cancer cells, they can slow the growth of the tumor and perhaps stop it from growing. Radiofrequency ablation (RFA) kills cancer cells with heat. An imaging technique such as ultrasound or CT scan is used to help guide a needle into the liver tumor. High-frequency electrical currents are then passed through the needle, creating heat, which destroys the cancer cells.
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Cryoablation is similar to RFA, but this technique uses cold instead of heat to freeze tumors and kill them. Radiation is sometimes used when a liver cancer cannot be removed by surgery. Although radiation kills liver cancer cells, very high doses can damage healthy liver tissue as well. So now, doctors use devices that deliver radiation beams more directly to the tumor, helping to spare healthy tissue. Intensity-modulated radiation therapy (IMRT) is a technique that uses advanced computer technologies to map and plan a precise dose of radiation to the liver. The dose is based on the tumor’s size, shape and location. IMRT modulates, or controls, very thin beams of radiation at different intensities and angles. This allows the radiation beams to conform to, or fit, the three-dimensional shape of the tumor for a custom-tailored dose.
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Radioembolization is a technique used by the radiation specialist to inject small radioactive beads into the main artery of the liver. This allows concentrated amounts of radiation to attack the tumor. Radioembolization delivers an intense dose of radiation to the cancer cells with less damage to healthy tissue. Patients remain awake during this procedure, which is usually performed in a hospital’s radiology suite.
Treating the Liver Systemically Medicines given systemically go through the bloodstream to reach cancer cells throughout the body. These medicines include chemotherapy and targeted treatments. They are given when tumors have spread beyond the liver and surgery is not an option. In treating liver cancer, chemotherapy is not used as commonly as targeted treatments. Targeted treatments are more likely than chemotherapy to spare healthy tissues, but they may still cause side effects. Sorafenib (Nexavar) has been approved by the U.S. Food and Drug Administration (FDA) for treating hepatocellular carcinoma since 2007. It works by blocking the action of proteins that promote the growth of new blood vessels. These blood vessels carry oxygen, minerals and other nutrients that tumors need to grow. Sorafenib also blocks a protein called RAF kinase, which helps signal cancer cells to grow and multiply. So far, sorafenib is the standard of care for liver cancer. But clinical trials continue to search for ways to treat liver cancer that does not respond, or no longer responds, to sorafenib. Ongoing studies are combining sorafenib with a number of different treatments, including doxorubicin, a standard chemotherapy.
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The Importance of Clinical Trials Clinical trials are the standard by which we measure the worth of new treatments and their effect on the quality of life as patients go through those treatments. For this reason, doctors and researchers urge people with cancer to take part in clinical trials. Your doctor can guide you in making a decision about whether a clinical trial is right for you. Here are a few things you should know: • Often, people who take part in clinical trials gain access to (and may be the first to benefit from) new treatments. • Before you participate in a clinical trial, you will be fully informed about the possible risks and benefits. • Some studies show that patients get higher quality care simply by taking part in a clinical trial, because most trials require that doctors and nurses watch patients extremely carefully, and this extra attention may be beneficial all by itself. • You can choose to stop taking part in a clinical trial at any time for any reason––you are always in control of your voluntary participation.
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Managing Side Effects As you are being treated for liver cancer, it’s important that you let your health care team know about any side effects you experience. The more detailed and precise you can be, the more it will help your team treat you quickly and effectively. Consider keeping a journal of your symptoms—when they occur, how severe they are, how they feel and whether you get relief from prescribed medications. Some of the side effects you may experience when taking sorafenib include: Skin rash Developing a rash can actually mean the treatment is working effectively. Rash may cause itching, redness or
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peeling skin on the hands or feet, but it can also spread to other parts of the body. Here are some tips to help reduce hand and foot rash: • Where possible, avoid extremes in temperature, pressure or friction on the hands and feet. • Carefully moisturize the hands and feet with thick ureabased creams that your doctor can prescribe. • Wear socks at night after applying the moisturizer. You can also wear thin cotton gloves. Usually, a rash develops within the first six weeks of starting a targeted treatment. (If it occurs right away, it is probably an allergic reaction.) It’s important to tell your health care team
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about any changes to your skin or nails, whenever they occur. If a rash becomes severe, it may be necessary to temporarily stop cancer treatment or change the dose. Mild rashes can be treated with a steroid cream applied to the skin. A steroid cream may help reduce the inflammation, pain and discomfort of a rash. Although you can buy some of these creams without a doctor’s prescription, it’s best to consult with a skin doctor (dermatologist). Anyone who is taking a targeted treatment would be wise to use a sunscreen daily. Sun exposure can aggravate sensitive skin, especially if a rash has developed. The ingredient called Helioplex keeps a sunscreen from breaking down the way other products do. This ingredient is gentle on sensitive skin. Diarrhea Take this symptom seriously. Severe diarrhea can lead to an imbalance in the body’s salts (electrolytes), which can affect functioning. Talk to your doctor about the right medication for you. Loperamide (Imodium A-D, for example) may be used. Do not treat yourself with any other drugs without talking to your doctor first. There are a number of changes you can make to your diet that will help as well. For example, limit or avoid lactose (found in milk or cheese), insoluble fiber such as wheat bran or whole grain products, alcohol and sugary drinks. Increase your use of active yogurt culture, soluble fibers such as oats, high-potassium foods such as bananas and drinks such as Gatorade to replace lost electrolytes. Your doctor may also reduce your dose of sorafenib. Fatigue A common side effect of cancer treatments, fatigue can be a challenge to manage. Talk to your health care team to explore what can be done. Medications such as
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stimulants may help, although they have their own side effects. Exercising regularly may help you cope with fatigue. Taking naps throughout the day can also make a difference in your energy level. It is very important to communicate with your health care team about how you feel in order to manage fatigue. High blood pressure This side effect can be managed with diet and medication. Your doctor and a registered dietitian can advise you on how to manage high blood pressure. Pain People being treated for liver cancer may experience pain in the liver or any other place in the body where the cancer has spread. Effective treatments are available and can make a big difference in your quality of life. Because certain pain relievers such as acetaminophen (Tylenol and others) may damage the liver, it is important that you tell your health care team about any pain you are experiencing rather than
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treat yourself with over-the-counter drugs. Don’t hesitate to report this (or any) side effect. There is no need for you to put up with pain. Encephalopathy is an impairment in brain function. It is due to the liver’s inability to remove toxins from the body. Doctors usually treat encephalopathy with medication. While it is important to eat enough protein every day, your doctor may ask you to spread out evenly throughout the day the amount of protein you eat. Your doctor can prescribe the right drug, and a registered dietitian can advise you on the right amount of protein for you. Because of cirrhosis, some patients may experience fluid in the abdomen (ascites). If you develop this symptom, reducing the sodium in your diet will help decrease the buildup of fluid in the stomach and legs.
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Your Support Team When you are diagnosed with liver cancer, you’re faced with a series of choices that will have a major effect on your life, and you may not be sure where to turn. But help is available. Your health care team, family members and friends will likely be an invaluable source of support. It’s important to share your feelings with people close to you. Sometimes, caregivers and people with cancer feel as if they are a burden to their loved ones by “complaining” about their problems. You are entitled to every emotion you have. Don’t hesitate to tell your doctor and nurse about your feelings. Doctors understand that patients are concerned about good quality of life as they go through treatment. If needed, your doctor can refer you to a professional who can counsel you or offer medical treatment for anxiety or depression. It can also be helpful to talk with other people who are having a similar experience. Support groups help you feel less isolated. They provide reassurance, suggestions and insight, allowing you to share similar concerns with your peers in a safe and supportive environment. CancerCare ® provides free support groups over the telephone, online and face-to-face. All support groups are led by a professional oncology social worker. Oncology social workers also can help you and your loved ones cope with the challenges of a liver cancer diagnosis and guide you to resources. CancerCare offers free counseling from oncology social workers on staff who can work with you one-on-one to develop strategies for coping with liver cancer. To learn more about how CancerCare helps, call us at 800-813-HOPE (4673) or visit www.cancercare.org.
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More
about liver cancer
Frequently Asked Questions
Q. Is liver cancer hereditary? Can it run in the family?
A.
Most liver cancers are caused by chronic (long-term) damage from hepatitis or alcohol. Damage to the liver, in the form of cirrhosis, also raises the risk of bile duct cancer. Some people inherit conditions that can lead to liver cancer. One of the most common is a disorder of iron metabolism. Bile duct cancer also may be inherited, but it is rare. People who have Lynch syndrome, which involves gene mutations, are at an increased risk of liver cancer, among other types of cancer. This genetic syndrome is also linked to cancers of the stomach, small intestine, gallbladder ducts, upper urinary tract, brain, skin and prostate. Women with Lynch syndrome also have a high risk of cancer of the endometrium (lining of the uterus) and ovaries.
had hepatitis C. Should I be tested for liver Q. I’ve cancer? What is my risk of developing it?
A.
Anyone who has had the hepatitis C virus should be monitored, especially if cirrhosis has already developed. The risk of eventually developing a liver tumor is high in such situations. It’s important to realize that, depending on the type of infection, nowadays we often can cure hepatitis C with interferon (Intron A, Roferon-A and others), ribavirin (Rebetol and others) and a drug called a protease inhibitor such as boceprevir (Victrelis) or, in some cases, telaprevir (Incivek).
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the treatments the same for primary tumors Q. Are (those that begin in the liver) as they are for metastatic tumors (those that spread to the liver from cancers in other parts of the body)?
A.
The most common cancer in the liver is in fact a tumor that has come from another site such as the colon, stomach or breast. These metastatic tumors are treated with the specific drugs used when they are in their original place in the body. For primary liver tumors, there are different specific drugs used to treat them. Surgery is used for both primary and metastatic tumors. For primary tumors, having the option to do surgery depends on how much liver damage exists and whether the primary tumors have themselves spread to other parts of the body. In the case of tumors that have spread to the liver from different sites, surgery may be an option, depending upon the type of cancer and the number of tumors.
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Resources CancerCare ® 800-813-HOPE (4673) www.cancercare.org
American Cancer Society 800-227-2345 www.cancer.org
American Liver Foundation 800-465-4837 www.liverfoundation.org
Cancer.Net Patient information from the American Society of Clinical Oncology 888-651-3038 www.cancer.net
National Cancer Institute 800-422-6237 www.cancer.gov
National Coalition for Cancer Survivorship 877-622-7937 www.canceradvocacy.org
National Organization for Rare Disorders 800-999-6673 www.rarediseases.org To find out about clinical trials:
Coalition of Cancer Cooperative Groups www.CancerTrialsHelp.org
EmergingMed 877-601-8601 www.emergingmed.com
National Cancer Institute www.cancer.gov/clinicaltrials
This program was made possible by an educational grant from Daiichi Sankyo, Inc. and by a charitable contribution from Bayer HealthCare Pharmaceuticals and Onyx Pharmaceuticals.
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