Different types of specialists frequently collaborate in cancer care to develop a patient’s overall treatment plan, including a variety of treatments. A multidisciplinary team is what this is referred to as. Physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counsellors, nutritionists, and other health care professionals are part of cancer treatment teams.
Several factors influence treatment options and recommendations:
- How much of the liver is cancer-affected?
- Whether or not cancer has progressed
- The patient’s preferences as well as their overall health
- The damage to the liver’s remaining cancer-free area
When a tumour is discovered early on, and the patient’s liver is functioning normally, treatment is directed at eradicating cancer. Treatment for symptoms and side effects, an important element of cancer care, may be included in the treatment plan. When liver cancer is discovered later, or the patient’s liver isn’t functioning properly, the patient and doctor should discuss the aims of the treatment recommendations. At this time, the treatment goals may be to delay cancer’s progression and relieve symptoms to improve quality of life.
Take the time to learn about all of your treatment options, and don’t be afraid to ask questions if you have any concerns. Discuss the aims of each treatment with your doctor and what to expect during treatment. “Shared decision-making” is the term for these types of discussions.
When you and your doctors work together to identify treatments that match your care objectives, this is known as shared decision-making. Because there are several treatment choices for liver cancer, shared decision-making is vital.
The different disease-directed treatment options for liver cancer can be divided into two categories: those that may cure cancer and those that will likely enhance survival but not eliminate the malignancy. Below are descriptions of the most frequent treatment choices, both disease-specific and managing side effects and symptoms.
Treatments that target certain diseases to remove and maybe cure them HCC
When a tumour is discovered early, these treatments are most likely to be prescribed. Later stages of the disease may not be treated with them. Surgery, radiofrequency ablation, percutaneous ethanol injection, and radiation therapy are all options.
During an operation, the tumour and some surrounding healthy tissue are removed. It’s expected to be the most effective disease-directed treatment, especially for patients who have strong liver function and tumours that can be safely removed from only a small section of the liver. If the tumour takes up too much of the liver, the liver is too damaged, the tumour has spread outside the liver, or the patient has other significant conditions, surgery may not be an option. A surgical oncologist is a physician who specializes in the surgical treatment of cancer. A hepatobiliary surgeon gets further training in liver and pancreas surgery. Liver transplant surgeons are sometimes involved in these procedures. Before surgery, talk to your doctor about the potential adverse effects of the procedure you’ll be having.
HCC is treated with two types of surgery:
Hepatectomy: A hepatectomy is a procedure that involves removing a piece of the liver. A hepatectomy can be performed only if the cancer is limited to one portion of the liver and the liver is otherwise healthy. The remaining part of the liver takes over the full liver’s duties. Within a few weeks, the liver may return to its original size. Even if the tumour is tiny, a hepatectomy may not be possible if the patient has severe cirrhosis. Pain, weakness, exhaustion, and transient liver failure are all possible adverse effects of a hepatectomy. The medical team will be on the lookout for signs of bleeding, infection, liver failure, or other issues that require rapid attention.
Transplantation of the liver: A liver transplant is possible in some cases. This operation is only possible if certain conditions are met, such as the presence of specified tumour size and quantity, as well as the availability of a suitable donor. Having a single tumour that is 5 cm or smaller, or having three or fewer tumours that are all smaller than 3 cm, are usually the criteria. It’s crucial to remember that donors’ livers are in short supply, so transplantation isn’t always possible.
After a transplant, the patient will be constantly monitored for signals that the body rejects the new liver or that the tumour has returned. To avoid rejection, the patient must take medicine. Side effects of these medicines include puffiness in the face, elevated blood pressure, and increased body hair. A liver transplant carries a high risk of major consequences, such as death from infection, rejection of the donor liver by the body, and an increased chance of other malignancies.
Because liver transplantation eliminates both the tumour and the damaged liver, it is a particularly effective treatment for those with a tiny tumour. However, because there are a limited number of donors, persons who need a liver transplant may have to wait a long time until one becomes available. The condition may worsen at this time.
Microwave therapy and radiofrequency ablation (RFA)
They both employ heat to kill cancer cells. They can be administered through the skin, via laparoscopy, or while the patient is anaesthetized during a surgical procedure. Sedation is the administration of drugs to make a person feel more relaxed, tranquil, or sleepy. Thermal ablation is another name for this therapeutic method.
Ethanol injection under the skin
When alcohol is injected directly into the liver tumour to kill it, it is known as percutaneous ethanol injection. Fever and soreness following the operation are common side effects. In general, the treatment is straightforward, safe, and particularly effective when the tumour is less than 3 cm in diameter. However, if the alcohol escapes from the liver, the person may experience significant discomfort for a short period. RFA has essentially supplanted this option, which is rarely used.
The use of high-energy x-rays or other particles to eliminate cancer cells is known as radiation therapy. A radiation therapy regimen, often known as a schedule, comprises a defined number of treatments administered over a set amount of time. A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy.
Stereotactic body radiation therapy (SBRT) is a type of radiation therapy that refers to several techniques for providing high doses of radiation therapy to a tumour while reducing the quantity of radiation delivered to neighbouring healthy tissue. This is significant because radiation can harm healthy liver tissue. SBRT is an effective treatment for tumours that are 5 cm or smaller. However, compared to RFA, it is still deemed experimental because there is little data on its long-term usefulness.
SBRT may cause harm to the stomach and lungs as a side effect. These adverse effects, on the other hand, are frequently avoidable. Consult your doctor about how to avoid and manage potential side effects.
If the doctor believes cancer cannot be cured with the treatments indicated above or if cancer has progressed, one of the following alternatives may be recommended to decrease the tumour and slow tumour growth. While these treatments are unlikely to cure cancer, they have increased the length of time patients can live.
Chemoembolization and radioembolization
Chemoembolization, which is comparable to hepatic arterial infusion, is a method of chemotherapy treatment (see below). Chemotherapy uses medications to kill cancer cells by preventing them from growing, dividing, and producing new ones. Drugs are injected into the hepatic artery, and blood flow via the artery is temporarily restricted to keep the chemotherapy in the tumour for longer. Cancer cells are also killed when the tumor’s blood supply is cut off.
Chemoembolization can be used to reduce tumour growth in persons waiting for a liver transplant and be utilized as a primary treatment for HCC. Radioembolization is identical to chemoembolization, except that radioactive beads are inserted into the artery that provides blood to the tumour during radioembolization. When the beads become stuck in the tumor’s tiny blood arteries, they give radiation therapy directly to the tumour.
Medication-based treatments are used to kill cancer cells. Medication can be injected directly into the bloodstream to reach cancer cells throughout the body. Systemic therapy refers to the administration of medicine in this manner. Medication can also be provided locally, which is applied directly to cancer or stored in one location on the body. A medical oncologist, a doctor who specializes in using medications to treat cancer, is most likely to prescribe this sort of treatment. Medications are commonly administered via an intravenous (IV) tube inserted into a vein with a needle, an injection into a muscle or beneath the skin, or a pill or capsule eaten (orally).
The following drugs are used to treat advanced HCC:
- Target Therapy
The first-line treatment is the treatment that is given first. The following are some of the first-line treatments for advanced HCC:
Some individuals with advanced HCC may be given a combination of bevacizumab (Avastin) and atezolizumab (Tecentriq).
People who cannot receive atezolizumab with bevacizumab may be provided targeted therapy with sorafenib (Nexavar) or lenvatinib (Lenvima).
If the first-line treatment fails, second-line treatment is offered. For advanced HCC, second-line treatment options include:
- Cabozantinib is a drug that is used to treat cancer (Cabometyx; a targeted therapy)
- Regorafenib is a drug that is used to treat cancer (Stivarga; a targeted therapy)
- Ramucirumab Ramucirumab Ramucirumab Ramuci (Cyramza; a targeted therapy)
- Atezolizumab and bevacizumab in combination
- Immune checkpoint inhibitors include pembrolizumab (Keytruda) and nivolumab (Opdivo).
The next sections go over targeted treatments and immunotherapies in further depth. One type of drug may be administered at a time, or a combination of medications may be given simultaneously. They can also be used with surgery and radiation therapy. The drugs used to treat cancer are being tested all the time. Your doctor may recommend that you participate in clinical studies researching novel ways to treat HCC.
The best approach to learn about the medications that can be given for you, their purpose, and any potential adverse effects is to speak with your doctor. It’s also crucial to inform your doctor if you’re taking any additional medications or supplements, prescription or over-the-counter. Herbs, vitamins, and other pharmaceuticals can interact with cancer therapies, resulting in unpleasant side effects or decreased efficacy.
Targeted therapy is a medication treatment that specifically targets the genes, proteins, or tissue environment that contribute to cancer growth and survival. This treatment method stops cancer cells from growing and spreading while limiting damage to healthy cells.
Anti-angiogenesis medicines are the most prevalent targeted therapy for HCC. Anti-angiogenesis therapy aims to halt the process of angiogenesis or the formation of new blood vessels. Anti-angiogenesis therapies aim to “starve” a tumour of nutrients given by blood vessels, which are required for it to develop and spread. People with unresectable HCC may benefit from anti-angiogenesis therapy. Surgery is not an option if the tumour is unresectable.
Bevacizumab and atezolizumab: The combination of bevacizumab, an anti-angiogenesis targeted therapy, and atezolizumab, an immunotherapy drug (see “Immunotherapy” below), was approved by the US Food and Drug Administration (FDA) in 2020 for people with unresectable or metastatic HCC who have not received previous cancer treatment using medications. High blood pressure, back discomfort, headaches, and changes in taste are all side effects of bevacizumab. Bevacizumab is given intravenously, unlike many anti-angiogenesis medications taken as pills.
Lenvatinib: The FDA authorized lenvatinib, a new anti-angiogenesis targeted medication, in 2018. This medicine has been approved as a first-line treatment for HCC resistant to surgery. High blood pressure, exhaustion, diarrhoea, appetite loss, joint and muscle discomfort, 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 are the most prevalent adverse effects of this medicine.
Sorafenib: Sorafenib is a drug used to treat advanced HCC that is resistant to surgery. It comes in the form of a pill that must be swallowed (orally). Sorafenib’s most common adverse effects include diarrhoea, exhaustion, and some skin disorders, as well as a few others.
Ramucirumab: For patients who have already had sorafenib, ramucirumab is another anti-angiogenesis medication approved for treating HCC with high levels of the tumour marker AFP. Fatigue, stomach pain, and nausea are the most prevalent ramucirumab side effects.
Cabozantinib: The FDA approved cabozantinib for treating HCC in persons who have previously undergone sorafenib in 2019. Cabozantinib has several adverse effects, including diarrhoea, lethargy, decreased appetite, and nausea.
Regorafenib: The FDA approved the use of regorafenib, a targeted treatment, to treat persons with HCC who had previously been treated with sorafenib in 2017. Regorafenib is already being used to treat colorectal cancer and gastrointestinal stromal tumours because it suppresses angiogenesis. It comes in the form of a pill that must be swallowed (orally). Diarrhoea and skin issues are two common side effects.
Please consult your doctor about the potential side effects of a particular medicine and how to deal with them. According to recent research, not all cancers have the same objectives. Your doctor may do tests to determine the genes, proteins, and other variables in your tumour to find the most effective treatment. This allows doctors to better match each patient with the most appropriate treatment when possible. Furthermore, numerous research projects are currently underway to learn more about specific molecular targets and potential treatments aimed at them.
Immunotherapy, also known as biologic therapy, is a cancer treatment that boosts the body’s natural defences. It improves, targets, or restores immune system function by using materials created by the body or laboratory. Immune checkpoint inhibitors are a frequent kind of immunotherapy. Immune checkpoint inhibitors operate by preventing cancer from hiding from the immune system by blocking the mechanisms that would otherwise allow it to do so.
Nivolumab: The FDA authorized nivolumab, immunotherapy, to treat HCC in 2017. Nivolumab is a sort of targeted therapy that can treat persons who have already been treated with sorafenib.
Pembrolizumab: The immunotherapy pembrolizumab was licensed by the FDA in 2018 to treat HCC patients. Pembrolizumab, like nivolumab, can be used to treat persons who have already received sorafenib treatment. Pembrolizumab is an inhibitor of the immune system’s checkpoints.
Nivolumab in combination with ipilimumab (Yervoy): In 2020, the FDA approved the use of nivolumab in conjunction with ipilimumab (Yervoy), an immunotherapy medication, to treat patients with HCC who had previously been treated with sorafenib. Both nivolumab and ipilimumab are immune checkpoint inhibitors, which means they block the pathways that would otherwise allow cancer to hide from the immune system. Ipilimumab and nivolumab are both immune checkpoint inhibitors.
Atezolizumab in combination with bevacizumab: In 2020, the FDA approved the use of atezolizumab, an immunotherapy drug, in combination with bevacizumab, a targeted therapy drug, for persons with unresectable or metastatic HCC who had not previously received cancer treatment with drugs. Bevacizumab is an anti-angiogenesis treatment, and atezolizumab is an immune checkpoint inhibitor.
Clinical trials for various immunotherapy medicines are also ongoing. Various forms of immunotherapy can have a variety of adverse effects. Skin rashes, flu-like symptoms, diarrhoea, and weight fluctuations are common adverse effects. Consult your doctor about the potential adverse effects of the immunotherapy you’ve been prescribed.
In addition to the treatment choices listed above, your doctor may recommend that you take part in a clinical study exploring a novel HCC therapy technique. This is especially crucial for a disease like HCC, where therapy choices for advanced disease are limited and continuing research is underway to develop new therapeutic alternatives.
Physical, emotional, and societal consequences
Physical symptoms and side effects and emotional, social, and financial impacts are all caused by cancer and its treatment. Palliative care, also known as supportive care, is the process of coping with all of these side effects. It’s a vital aspect of your treatment, and it’s included with medicines aimed at slowing, stopping, or eliminating cancer.
Palliative care focuses on treating symptoms and assisting patients and their families with non-medical needs while undergoing treatment. This treatment is available to everybody, regardless of age, cancer type, or stage. And it’s most effective when started soon after a cancer diagnosis. People who receive palliative care in addition to cancer therapy frequently have fewer symptoms, a higher quality of life, and are more satisfied with their treatment.
Medication, nutritional adjustments, relaxation techniques, emotional and spiritual support, and other therapies are common palliative treatments. You may also receive palliative treatments like surgery or radiation therapy, comparable to those used to treat cancer. Before starting treatment, discuss the aims of each treatment in the recommended treatment plan with your doctor.
You should also discuss the treatment plan’s potential negative effects as well as palliative care options. Many patients find that chatting with a social worker and attending support groups are beneficial. Inquire with your doctor about these options as well.
During therapy, your health care provider may ask you to detail each problem and answer questions about your symptoms and side effects. If you have a problem, make sure to alert your healthcare staff. This enables the medical team to treat any symptoms or adverse effects as soon as feasible. It may also aid in preventing more significant issues in the future.
Metastatic cancer occurs when HCC has spread to another part of the body. People who have received this diagnosis are recommended to speak with doctors familiar with treating this stage of cancer because treatment options may change.
Surgery, targeted therapy, radiation therapy, and other alternatives may be used in your treatment strategy. The purpose of treatment at this stage is usually to slow cancer’s progression. Palliative care will be crucial in reducing discomfort and side effects.
A diagnosis of metastatic cancer is distressing and unpleasant for most people. Doctors, nurses, social workers, and other members of the health care team encourage you and your family to talk about how you’re feeling. Talking with other patients, such as in a support group or other peer support programme, may also be beneficial.
The chances of recurrence and remission
When cancer is undetectable in the body and there are no symptoms, it is in remission. This is also known as NED, or “no evidence of disease.” Remission may be temporary or permanent. Many individuals are concerned that cancer will return due to this uncertainty. While many remissions are durable, it’s crucial to discuss the potential of cancer returning with your doctor. Knowing your recurrence risk and treatment options will help you feel better prepared if cancer returns.
Recurrent cancer occurs when cancer returns after the initial treatment. It may reoccur in the same location (called a local recurrence), in a nearby area (called a regional recurrence), or in a different location (called a regional recurrence) (distant recurrence). When this happens, a new testing cycle will begin to understand as much as possible about the recurrence. After completing this testing, you and your doctor will discuss your treatment options.
The treatments outlined above, such as surgery and radiation therapy, are frequently included in treatment plans, but they may be performed in a different order or at a different pace. Your doctor may refer you to clinical studies looking for novel ways to treat recurring cancer. Palliative care will be vital for alleviating symptoms and side effects regardless of the treatment option you choose.
People with recurring cancer may feel shocked, worried, or disappointed when the previous treatment failed to eliminate the malignancy. You are urged to discuss these feelings with your health care provider and inquire about support options to assist you in coping.
If the treatment fails, It is not always feasible to recover from cancer. Cancer may be classified as advanced or terminal if it cannot be cured or controlled. This is a traumatic diagnosis, and advanced cancer is difficult to discuss for some people. It is, nevertheless, critical to have open and honest discussions with your doctor and healthcare team about your feelings, choices, and concerns. The healthcare staff has specialized skills, expertise, and experience to assist patients and their families. Ensuring that a person is physically comfortable, pain-free, and emotionally supported is critical.
Patients with advanced cancer and a life expectancy of less than six months may benefit from hospice care. Hospice care aims to give those nearing the end of their lives the best quality of life possible.
You and your family are invited to discuss hospice care alternatives with the health care team, including hospice at home, a particular hospice centre, or other health care facilities. For many families, remaining at home with nursing care and appropriate equipment is a viable alternative.