FAQ: The link between hepatitis C and liver cancer

By Paul Hansen, M.D, director, Providence Hepatobiliary and Pancreatic Cancer Program and Providence Liver Cancer Clinic, Providence Cancer Center; and Ken Flora, M.D., medical director of Providence Digestive Health Institute and consulting physician to Providence Liver Cancer Clinic.
I heard recently that liver cancer is on the rise. Why is that?
Primary liver cancer — cancer that starts in the liver, rather than spreading to the liver from somewhere else — is increasing rapidly right now. This increase is linked mainly to the spread of hepatitis C infection in the ’60s, ’70s and ’80s. Hepatitis C, a virus that inflames the liver, is one of the main causes of primary liver cancer, or “hepatocellular” cancer. It wasn’t until the late 1980s that we began to understand hepatitis C and how it was spread — through blood. Until then, blood donations weren’t screened for hepatitis C, so a lot of people were exposed to the virus through transfusions, as well as other ways, such as using shared needles used to inject drugs.  Since the hepatitis C virus progresses very slowly, we’re just now starting to see complications arise among this large population that was exposed 20, 30 or 40 years ago. Liver cancer is one of the potential complications.

Does everyone with hepatitis C eventually develop liver cancer?
No — in fact, most don’t. Only people who develop cirrhosis as a complication of hepatitis C have a higher risk of developing liver cancer. About 20 percent of people with hepatitis C develop cirrhosis — advanced liver scarring caused by decades of inflammation. Of those who do develop cirrhosis, about 20 percent eventually develop liver cancer. So overall, among all people with hepatitis C, the chance of developing liver cancer at some point in your life is about 4 percent.

What makes some people with hepatitis C more or less likely to get liver cancer?
If you don’t develop cirrhosis, then you are at no higher risk of liver cancer than the general public. Having cirrhosis is what raises the risk, so anything that increases your risk of developing cirrhosis will also increase your risk of developing liver cancer. Alcohol consumption is the key risk factor here. People with hepatitis C should not drink alcohol, since it can accelerate liver damage. Certain prescription and non-prescription drugs also can damage the liver, so people with hepatitis C should review their medications with their physician to make sure they aren’t taking anything that could put further stress on their liver. Finally, smoking increases the risk of all cancers, including liver cancer, so people with hepatitis C should not smoke.

How does hepatitis C lead to liver cancer?
Hepatitis C inflames the liver, and over the course of many years, this inflammation can lead to scarring. Most people with hepatitis C never experience significant scarring or complications, but about 20 percent develop cirrhosis, which is advanced scarring throughout the liver. Because hepatitis C is a slowly progressive virus, it can take 30 or 40 years for cirrhosis to develop. Meanwhile, the liver is resilient — when damage occurs, the liver goes to work to regenerate itself. We believe that cancer occurs during this ongoing cycle of injury and regeneration. The more cells the liver regenerates, the higher the chances that a mutation will occur in one of those cells, and it’s these mutations that can lead to hepatocellular cancer.

Is there a way to screen people with hepatitis C to check for liver cancer?
Yes. Ultrasound is the main screening tool used to check for tumors in the liver. Ultrasound is non-invasive and can detect tumors when they are quite small.

Should everyone with hepatitis C get ultrasound screenings?
Since liver cancer is a complication of cirrhosis, people who don’t have cirrhosis don’t need to be monitored closely for liver cancer. But people who do have cirrhosis should definitely get regular ultrasound screenings to check for liver tumors.

How often should a person with cirrhosis get screened for liver cancer?
At Providence Liver Cancer Clinic, we recommend that people with cirrhosis get an ultrasound screening twice a year. The more vigilant you are about getting these screenings regularly, the better your chances of catching cancer early, when treatment is most likely to be successful.

Are there any symptoms of liver cancer that a person should watch for?
Liver cancer usually doesn’t present any outward symptoms in its early stages, which is why regular screening is so important. Signs of advanced liver cancer may include pain, tenderness or a lump on the upper right side of the abdomen; enlargement of the abdomen; jaundice (yellowing of the skin and whites of the eyes); easy bruising or bleeding; nausea; fatigue; loss of appetite; unexplained weight loss; or pain around the right shoulder blade.

Can liver cancer be treated?
In many cases, yes. The treatment options generally depend on the size and the number of tumors in the liver. That’s why we say that the best treatment for liver cancer is appropriate surveillance, which means keeping your ultrasound appointments so we can catch cancer when it is most treatable.

What are the options for a person whose cancer is caught early?
If tumors are found when they are small and there aren’t many of them, we can remove them either through surgery (“resection”) or through radiofrequency ablation. Advances in minimally invasive surgery are making it possible to perform many tumor resections through tiny half-inch incisions, rather than opening up a large incision. These “laparoscopic” techniques minimize trauma to surrounding tissues and leave patients with just two or three tiny scars. While resection involves cutting tumors out, radiofrequency ablation involves zapping or burning tumors with localized electrical energy, which destroys the tumor and a small margin of tissue around the outside of it. This procedure can be performed laparoscopically, as well. Both tumor resection and radiofrequency ablation have the potential to cure a patient of liver cancer.

What if a person has a large tumor, or a large number of tumors?
In this case, we can’t cut out or burn out the tumors, because a person with cirrhosis wouldn’t have enough healthy liver tissue left in reserve to tolerate it. Instead, we use interventional therapies, such as radiation and chemotherapy, to try to slow the growth or reduce the size of the tumors. One of the most promising new interventional therapies is yttrium-90 bead implantation. This non-invasive procedure uses millions of tiny beads coated with a radioactive element — yttrium-90 — to deliver radiation directly to tumors. The beads are inject into a catheter leading to the main blood vessel that feeds the tumors. Once they reach the tumors, they stay there, blocking the blood supply that feeds tumor growth and destroying the tumor cells with radiation. The treatment is extremely effective at slowing down cancer growth, and can shrink tumors in many cases, as well. In some cases, tumors shrink so much that they become small enough for resection or ablation.

What if a patient isn’t a candidate for these therapies. Are there any other options?
The final treatment option is a liver transplant. A person whose primary tumor is less than five centimeters in diameter, or who has no more than three small tumors (each less than three cm), can get on the transplant list. However, only about 7,000 livers become available for transplant each year, and there are about 55,000 people on the waiting list in the United States. Preference is given to people who will have the best prognosis after transplantation.

What is the prognosis after a liver transplant? Even if it cures the liver cancer, doesn’t the patient still have hepatitis C?
A transplant won’t cure hepatitis C, but it will remove the cancer and the cirrhosis. Remember that hepatitis C is a slowly progressing virus, and it can take decades to lead to cirrhosis — the main risk factor for liver cancer. After a transplant, the new liver will become infected with hepatitis C, but it will take at least 10 or 15 years for cirrhosis to develop. That gives patients an extra 10 or 15 years of health and hope, during which time scientists will continue to develop more effective therapies.