Q & A: What you need to know about liver cancer
September 29, 2020
Liver cancer has become the fastest-increasing cause of cancer death in the United States. Now, several types of cancer can form in the liver. But the good news is there are multiple treatment options. We'll talk about those treatment options, prevention methods, and management of chronic liver diseases with a group of experts who are at the forefront to deliver care. We'll take your questions and answer as many as possible. That's coming up now on At the Forefront Live.
And today on At the Forefront Live, we have Dr. Pillai Dr. Liao. Welcome to the program.
Thanks for having me.
We'll get to your questions in just a moment. But first we need to remind our viewers the program's not designed to it take the place of a visit with your physician. And let's just get started. And we can have each one of you tell us a little bit about yourself and what exactly you do here at UChicago Medicine.
Sure, of course. My name is Anjana Pillai I'm a transplant hematologist with the Transplant Institute. I'm the medical director of our liver tumor program. And I'm also the co-director of our living donor liver transplant program.
And I'm Andy Liao, one of the medical oncologists at University Chicago here. My focus is on liver and bile duct cancers. And together with Dr. Pillai we run our multidisciplinary clinic here.
Dr. Pillai let's start with you and just talk a little bit about the liver in general and the functions that it performs for a person.
Absolutely. So many people may not know this, but your liver is actually your largest internal organ. It's pretty remarkable and can sustain life when only about 10% to 20% of it is working, which is why many people actually don't know that they have advanced liver disease until they have symptoms.
Your liver does-- it actually does most jobs of any organ in your body. It takes food, and it breaks down the nutrients for energy. It stores many of your essential nutrients and minerals. It helps regulate blood sugar and produces blood sugar.
It helps produce as many of your clotting factors so that you heal from surgery or when you get a cut. It produces bile, which helps you metabolize fats. It helps you fight infections. And just as importantly, it also helps detoxify your body. So it helps break down chemicals and drugs you may ingest, as well as alcohol.
Let's talk about liver cancer for just a moment. Is that becoming more common? I mentioned that in my intro, and it's something that I think a lot of people don't think about very much.
Yes, absolutely. So liver cancer is now the fourth-leading cause of cancer-related death in the world. And in the United States, it's the fastest-growing cancer over the last several decades. And so we have definitely noticed a rise in its incidence over all 50 states. It is the number one reason that patients are listed for liver transplant now in the United States. And in our own center, over 50% of our patients that are listed for transplant, it's due to primary liver cancer, HCC.
And Dr. Liao what are the different types of liver cancer?
So there can be many different types of cancer that happen n the liver. There can be primary liver cancer, meaning cancer arising from the liver cells. But inside your liver there are also millions of bile ducts that help drain out the bile to help you digest. And there can be cancer arising from these bile duct cells, and that's what's called bile duct cancer or cholangiocarcinoma. And actually the most common type of cancer that can go to a liver actually comes from somewhere else, for instance, colon cancer that goes to the liver or lung cancer or breast cancer, et cetera.
Dr. Pillai, You mentioned that the cancer death rates, liver cancer death rates are increasing. Why do you think that that's happening? Why are we seeing this?
Yeah, I think there's a few reasons. So just so we all orient ourselves, liver cancer I'll refer to as HCC is a primary liver cancer. As Dr. Liao mentioned, there's several types of cancers that occur in the liver. But HCC often occurs in the background of cirrhosis, which is advanced liver disease.
So about 80% to 90% of cases occur because you have end-stage liver disease. And the most common reasons are alcoholic liver disease, hepatitis C, or fatty liver disease. So the reasons that we're seeing an increase is because there's an increase in cirrhosis.
There's the increase in the number of patients that are now living with hepatitis C that have progressed to cirrhosis. We have better medications available so people with cirrhosis are living longer. And also because of the rise of fatty liver disease, alcohol, and diabetes, which also contribute to cirrhosis, there's an increase in all those different ideologies that all lead to the risk of liver cancer.
Dr Liao, what were some of the symptoms that a person might experience if they do have a liver cancer?
So a lot of times it's kind of non-specific, vague symptoms like feeling more tired, fatigued, unexplained weight loss or loss of appetite. Sometimes if the liver function is impaired, patients might notice symptoms like swelling in their legs and having bloating in their abdomen, so fluids fill up inside their abdominal cavity, et cetera.
I'm sorry, but can I just build on what Andy said? That's exactly right. Patients often don't present until they have symptoms. And so by that time, many times we don't have a cure. And I know we're going to talk more in detail about that. So this is where surveillance comes in. And it's important to undergo surveillance and look for risk factors that may potentially put you at risk for liver cancer.
And can we talk about some of those risk factors? What would people need to be aware of? Obviously you mentioned alcohol intake and obesity.
Yeah, absolutely. So 90% of liver cancer happens in the background of cirrhosis. So anyone with cirrhosis, which is advanced liver disease or scarring of the liver, should undergo liver cancer screening. There's guidelines from the US societies, from societies around the world, including Europe, Asia-Pacific, and they all recommend an ultrasound every six months for anyone with cirrhosis.
Also that includes patients with hepatitis B, many of whom, or at least 20% of whom don't necessarily need cirrhosis to have liver cancer. So that subset of patients should also undergo regular screening. And there's guidelines for age related to that and when they should undergo screening.
So Dr. Liao, if we go through the screenings and it's caught early, is it treatable?
Yeah. And in fact, it's curable, if it's caught early. And that's why screening is so important.
What are some of the treatments that people might go through?
So there, we've actually come a long way in how we treat liver cancer, how we treat primary liver cancer and planocellular carcinoma. So for patients with localized disease, options include surgery, or even liver transplant, which we'll talk about in a little bit. And then there are ways to directly treat the liver. For instance, they can go in and burn off with our-- we call it radiofrequency ablation, but burn out small liver tumors.
There are ways to microwave a small liver tumor. And then there's ways to go in directly to the liver with a catheter and plant radiation seeds in there to treat localized liver tumors that way. And then there are a lot of new treatments that treat the whole body for patients with more advanced cancer. As you know, cancer is spread outside the liver. These include targeted therapies and also immunotherapies.
It's interesting. And immunotherapy is one of those areas that we've talked about quite a bit recently. What happens in that case with the patient?
So immunotherapy is a very different way of treating cancer. And it has generated quite a lot of excitement in cancer treatment and not just liver cancer, but in many different other kinds of cancer. And it's actually been approved in liver cancer and other kinds of cancer by the FDA.
So the way, in general, it works is that it tricks your body to go after-- so essentially it's that your body doing the job of attacking the cancer cells. So normally your body's immune system is very good at detecting bad cells. So like if you go out to the beach and get a sunburn, you don't immediately get skin cancer. And that's because your body's immune system recognizes that there are damaged cells and sends those damaged cells to go away.
So for a cancer to grow in your body undetected by your immune system, it must have somehow come up with ways to escape from your immune system surveillance. And so a lot of these new immunotherapy treatments that we have essentially unhides this cancer from your immune system. And then your immune system goes after it. And studies in liver cancer have shown that it's provided significant benefits in our liver cancer patients.
That's fascinating. And I love the sunburn analogy. I've never really thought of it that way. But that makes perfect sense. Your body does do a lot of work to prevent some of these things but can't always. That's fantastic.
So let's talk about some of the other treatment options. You mentioned them briefly. But what are what are the more common treatment options? And what should people expect?
So I think, as Dr. Liao said, it really depends at the stage in which you're diagnosed. So again, just going back to the importance of surveillance, if you present with symptoms, some of the symptoms that actually I described earlier, oftentimes your cancer is advanced. And oftentimes it's not curable.
So this is why we have surveillance for liver cancer because the whole idea of surveillance for any cancer really is if you have the options of curative options, if the cancer is detected early. So if you undergo proper surveillance, if you have cirrhosis or if you have hepatitis B, and you detect a small lesion that's localized, meaning it hasn't spread, it's a certain size or a certain number, curative option includes resection, so taking and removing that tumor, which we work very closely with our transplant surgeons, or our hepatobiliary surgeons, and then transplant. So as I stated earlier, a liver transplant is a curative option and is the number one reason many of our patients-- I'm sorry.
Liver cancer is the number one reason many of our patients are on the liver transplant list nationally. So both those things are 100% curative. And then some of the other treatments that Dr. Liao recommended, such as-- so we call it liver-directed therapy. So unlike most cancers, we're able to direct treatment right into the tumor itself, often through a catheter through your groin area. And that's either radiation seeds, or it's chemotherapy beads.
We can also microwave or ablate that lesion. And then if it's more advanced, that's when the combination of either doing a local or regional therapy or adding systemic therapy, which is where many of the newer medications come into play. For liver cancer, interestingly, until 2008, we only had one systemic therapy.
Right. yeah. The next question from one of viewers, if a lesion can't be biopsied, what are my options?
A lesion can be biopsied. It absolutely can. However, for liver cancer, we don't recommend a biopsy if it's classic because over the years what we've learned is liver cancer has a very characteristic appearance on cross-sectional imaging, which is when you get a CT scan or MRI. But it has to be with contrast. That means there has to be a dye that goes into your IV.
And if you have the right test, it looks very specific. And if it meets all those guidelines, then you do not need to be biopsied. If--
Say so you have an invasive procedure?
Absolutely. And we review all these things. And we have a tumor board, where we review every patient and their case. However, if we are concerned that it might not be classic for liver cancer, or we're concerned that it could be a bile duct cancer, or some cancers are mixed, then we will biopsy it.
And then for patients that we're considering other newer forms of therapy, patients with more advanced disease, nowadays we're getting smarter about personalizing each person's treatment. And so sometimes to consider patients for newer treatments, clinical trials, et cetera, sometimes we would want a biopsy in that setting to see what kind of genetic changes there are in the tumor cells and see if we can find new targeted therapies or clinical trial options for that patient.
Can we talk about the tumor board for just a minute and explain to viewers what that is and what it does? Because I think that's very important in your jobs.
Can we talk about our tumor program first?
So Andy and I are both part of our multidisciplinary liver tumor program. We're very proud of it at the University of Chicago because we are one of the few centers in the Chicagoland area that really have it. And it's one-day clinic, where there's a transplant hepatologist, a transplant-trained surgeon, an oncologist, an interventional radiologist could all see the patient if they need to.
And again, this is because liver cancer often happens in the background of liver disease. So you'd need expertise in liver disease. And you also need expertise in oncology. And so when our patients come, we really try to determine, OK, who do you need to see? And to the best of our ability, we will see patients together in clinic.
Our interventional radiologists will come up, or their nurse practitioner will come up. Our surgeons are almost always available in clinic for us. And it really helps enhance the patient experience because they get quite a lot of time with all of us.
Yeah. It's like one-stop shopping. And it really just highlights because we have so many different treatment options nowadays for liver cancer, it's so important for every specialist to come together and deliver the best treatment plan, individualized treatment plan for each patient.
And so once we have that, once we see that patient in that clinic, then we have all discussed who sees the patient. And then we have a tumor board every Thursday. So all those patients go on that tumor board, where, again, all of us are present.
There's about 15 to 20 physicians that specialize in liver disease from different disciplines that come to the tumor board. And then we make recommendations for treatment, follow up, future treatments, transplant. All of that's done. Then it goes into the medical records. The patients are called. So it's a very step by, streamlined process that we have implemented over the last two years. And we're very proud of it.
So we have another question from a viewer. Is the AFP tumor blood test accurate?
That's a very good question. So the AFP is Alpha-Feto Protein. So it was, up until very recently, part of the surveillance. So we kept talking about surveillance. But I don't think we talked about what that entails.
So surveillance means if you have cirrhosis of the liver, or if you have hepatitis B, and you're an Asian man greater than 40 or if you're an Asian woman greater than 50, or an African, not African-American, Africans with hepatitis B greater than 20, you should be screened for liver cancer. And that includes an ultrasound of your abdomen at minimum every six months. And going back to the AFP, AFP was the tumor marker that was also recommended in addition with the ultrasound.
The issue is not all tumors produce AFP. Only about 60% do. So it is a tumor marker that can help us prognosticate and help us in surveillance. But because it's not seen in all tumors, if you just get an AFP, you may miss 40% of tumors.
I've just been reminded by our director and producer that we do have a video that we would like to show, too, that kind of shows the care that is available UChicago Medicine. This one really struck a chord with me and John. If you want to just go ahead and roll that, we'll watch that real quick.
I had some unusual symptoms in my home state of South Carolina. And I went to the emergency room. And as part of the evaluation, they got a CAT scan of my chest to make sure I hadn't passed a blood clot up into my lung area.
And that was fine. But they noted something that didn't look quite right. So two days later, an MRI confirmed that I had a tumor in my liver that was, in all likelihood, a cancer.
So Richard was fortunate in that he was able to pick up the diagnosis of primary liver cancer relatively early in his course. It hadn't spread to the lymph nodes. It hadn't spread outside of his liver into the lungs, for example.
He put forth taking the liver out completely to get better access to this tumor. This tumor, in and of itself, was not very large. But it was in a very tricky part of the liver, close to some very big and small blood vessels.
The first part was what I call the donor operation. We had to do skeletonize the liver, as if we were going to take it out for transplant. Then came the second part of the operation, which was a resection part, which is what we did in the basin. It was a ex-vivo liver resection.
So the liver now is outside of the body. The body's being maintained on a bypass pump. The liver is now taken and chilled at 4-degrees centigrade, almost freezing, to flush out the blood so that it doesn't clot.
And then we resected the central tumor and all the blood vessels around it. And then we reconstructed it using Gore-Tex, which is a plastic. And then the third part of operation was doing a transplant because we had to put it back in. So it was really three operations rolled into one full day. And true to form, it actually worked exactly as we had planned.
The operating room team was great. The anesthesia group was great. Nursing was fabulous. I couldn't have said anything better or hope for a better outcome. So we're optimistic that we have a good starting point. He may need some additional therapy. But we'll decide that now that we have the tissue that we can send out for specific genomic analysis, for mutation analysis, and then do individualized therapy for that tumor.
I'm glad I did it. And I feel like I've been cured at this point in time. I'm very optimistic. And I feel like my chances to be victorious with this situation were the best here at the University of Chicago. I don't think there's any other facility that I can think of that would've done a better job than John Fong and the University of Chicago.
So I like that one because it just kind of illustrates a very complex situation. And that was a doctor that came to us for help, which was kind of neat too. So one of the questions we had on the list was, how long can you live with liver cancer before you actually need a liver transplant? You don't obviously always need a transplant.
Yeah, again, I think it really depends on the stage at which you present. So if you undergo surveillance and it's caught before symptoms, it's caught early, of course you are going to be more amenable to curative options, like we said, taking the tumor out or the transplant. Now, of course, that depends on the health of your background liver and your overall functional health yourself.
Now, if you have more advanced cancer, there's a lot of timelines. I'd say once it's metastasized, or it goes outside the liver or goes into any of your major blood vessels, your five-year survival is lower. It's about 10%. However, that's before many of these new treatments came out. And keep in mind, these treatments just came out really in the last two years.
So now we are seeing people that live longer. And so if they live longer, there's also newer treatments coming out. So that's where the idea of sequential therapy-- meaning you start one treatment. If they fail, there's a second-line treatment. There's a third-line treatment. Or we go back, and we reconsider the local regional therapy.
We didn't have any of those options just even two years ago, which is why these statistics were so poor. Now, I'm not saying that we're anywhere close to where we would like to be to cure advanced liver cancer. But I do think that we have many more options than we did just a few years ago.
And Dr. Liao, one of the advantages that we have here as an academic medical center, we do a lot of research and clinical trials. Can you talk to us a little bit about some of the clinical trials and research that may be happening in this area?
Yeah. So as I said, immunotherapy has generated a lot of excitement. And there are a few drugs that already have been FDA approved for liver cancer. But we're always trying to improve upon current standards in immunotherapy.
So a lot of the next generation in clinical trials that are coming up are focusing on these next-generation immunotherapy approaches, where they're combining immunotherapy with a different kind of immunotherapy or combining immunotherapy with targeted therapy or using immunotherapy in an earlier setting, for instance, starting patients on immunotherapy right after surgery. And some of the trials we have here, one of them we have is very cool. It's called a oncolytic virus.
So basically we hijack the virus to infect a tumor. So it's a kind of immunotherapy now. We've seen some pretty dramatic responses to that. We also have trials combining current immunotherapies with what's called targeted therapies.
So these are drugs, in general, pills, that target different ways that the cancer uses to grow. For instance, a lot of these target how cancer cells make new blood vessels, so prevents them from growing or spreading by inhibiting their ability to make new blood vessels. We also have studies looking at what's called metabolic therapy, meaning depleting key nutrients into the liver tumor microenvironment to make them more responsive to conventional treatments and make the immune environment more favorable. So lots of exciting things going on.
Yeah, it sounds like the research is really booming on this, just very exciting things happening in the world of science when it comes to liver tumor and prostate cancer. So that's good news for all of us. So interesting question, a colonoscopy, can that help detect?
We get this all the time. I do colonoscopies. I'm a gastroenterologist that sub-specializes in transplant medicine, but, no. So a colonoscopy looks at your colon. And many people always ask me if their liver looks OK. And I say, you never want me to see your liver while I'm doing a colonoscopy because that means I went through your perineum.
So no, I don't see your liver when I do a colonoscopy. What it can tell us is if there's any masses. So colon cancer, of course, is the reason we do colonoscopies, colon cancer surveillance. And that is one of the cancers that do go to the liver. And we do see those types of patients in our clinic. And we're seeing these patients present younger.
So colonoscopy is important. You should get colon cancer surveillance as well, which we have guidelines for. So in that regard, it's very important. But it's not a way to detect primary liver cancer.
Interesting. Is there such thing as a benign liver tumor? And if so, does it hurt you at all? Can you live with them?
Yes. So, no, it does not hurt you. And yes, there are benign liver tumors. So I actually give this lecture quite often. And the way that I look at liver tumors is benign lesions that never need follow up, benign lesions that need follow up, and then malignant things, like what we're talking about, liver cancer and bile duct cancer.
So because we get cross-sectional imaging or a CT scan for so many reasons, we see all these things pop up in the liver that you may have had your whole life that never will have any impact. So hemangiomas are the most common things, which is abnormal collection of blood vessels. You can see cysts. You can see focal nodular hyperplasia or adenomas. All of these are-- they're different subsets of benign tumor.
Some never need to be followed. And some need to be followed or your lifestyle modified a little bit. But absolutely, you don't need to chase every lesion that you see in the liver.
So if you do have liver cancer, are you automatically added to the transplant list? And if so, how long does that usually take?
Yeah. Thank you for that question, too, because then I can plug this Donate Life, which is very important to--
That is very important, yes.
--all of us. So you don't automatically get on the transplant list no matter what. There is a pretty extensive work-up our patients go through. So in addition to an indication which is often the advanced liver disease, or in this case, as you say, a liver cancer, we have to make sure the liver cancer is not too advanced, because then we can't offer cure with a liver transplant.
But we also have to make sure you fit all the other criteria for liver transplant, that you're medically otherwise stable, that surgically the surgeons can do it, that you have good support system, that you don't have any psychological issues that bar treatment, that you don't have substance abuse issues. These are all just as important to get on that list. And once you get on the list, the time is very variable. The United States is divided into 11 regions by the United Network of Organ Sharing, which kind of controls this.
And we're region seven. And so for our region, it can go anywhere from 6 to 18 months once you're put on the list for liver cancer as to when you would get a liver. And so for that reason, we also have a living donor program at the University of Chicago Medicine.
So if you have relatives that could potentially donate or close friends or community members, altruistic donors, that is also an option. And I know we're over time. But I just think that purpose of organ donation, the issue is we want to give livers to our patients. The problem is there's about only 6,000 to 8,000 livers that we do a year. And there's about 16,000 patients waiting on the liver transplant list, so just not enough supply for the demand that we have.
Well, you guys were fantastic.
Thank you. This was so much fun.
Thanks so much.
And both so young.
Thank you. Thank you.
That's all the time we have for the program. Thank you for being on the show. And thank you for your wonderful questions. If you want more information, you can visit our website, uchicagomedicine.org, or you can call 888-824-0200. And also remember to keep an eye on our Facebook page for more events and live programs that will be coming up soon. Thanks for watching and have a great week.
What is liver cancer?
This is a type of cancer that starts in the liver. Primary liver cancer typically affects individuals who already have advanced liver disease or cirrhosis (usually as a result of hepatitis B or C), alcoholic liver disease or fatty liver disease. Because patients are battling two competing diseases — advanced liver disease and liver cancer — care and treatment is complex and requires an experienced, multidisciplinary team.
How does UChicago Medicine approach treatment?
The UChicago Medicine Liver Tumor Program brings together specialists from our cancer and digestive disease programs — two programs ranked among the best in the nation by U.S. News & World Report. Transplant hepatologists, transplant and hepatobiliary surgeons, medical and radiation oncologists, interventional and body radiologists, pain specialists and others offer personalized care for patients with primary liver cancer, bile duct cancer and other benign and malignant tumors of the liver. Transplant hepatologists on our team are experts in determining which liver cancer patients may benefit from liver transplant. This includes patients with other types of cancer that has spread to the liver, including colorectal and bile duct cancer (cholangiocarcinoma).
Why is there a need for a specialized liver tumor program?
A unique thing about liver cancer is that there are often two competing illnesses: end-stage liver disease and the cancer itself. You're not dealing with just one thing, or cancer in an otherwise healthy organ. Our liver tumor program offers a comprehensive, individualized treatment approach to these patients by utilizing the expertise of multiple specialists who treat both liver disease and liver cancer.
Depending on the stage of the cancer and overall liver function, patients have a multitude of options. Ideally, the ultimate goal for many of these patients would be liver transplantation, as it would cure the cancer and remove the diseased liver. So instead of seeing one physician in a silo, you're able to see several specialists in one visit, which is very unique. It makes sense for something this complex.
Why has liver cancer been increasing in the past several decades?
It largely stems from people with advanced liver disease or cirrhosis. The No. 1 cause for that has been infection with the hepatitis C virus. Although the peak of the HCV epidemic occurred in the early 2000s, the downstream detrimental effects — including liver decompensation and liver cancer — will continue and peak around 2030. People with hepatitis C have somewhere between a 2% and 8% risk of developing liver cancer. The other very pertinent issue is the rise of nonalcoholic fatty liver disease, or NAFLD. As people have become more sedentary and obese, putting them at higher risk for metabolic syndrome, there is an increase in NAFLD-associated cirrhosis, and thus liver cancer.
How is liver cancer treated?
We've come a long way in how we treat liver cancer, and the treatment strategy will depend on the specific diagnosis. For patients with localized disease, options include surgery, treatments offered by interventional radiologists or even a liver transplant. We can directly treat the lesion(s) in the liver with several different treatment options, including inserting a catheter to deliver radiation or chemotherapy beads to localized liver tumors. Another treatment involves heating small liver tumors via radio frequency/microwave ablation.
There is also a wide range of newer treatments for patients with more advanced liver cancer, especially if it has spread outside the liver. These include targeted therapies and also immunotherapies. FDA approved in May 2020, atezolizumab and bevacizumab is the first of these combination therapies to treat advanced liver cancer.
What types of research are underway?
Multiple phase 3 clinical trials are showing promise for treating patients with advanced liver cancer using a combination of chemotherapies. That includes some of the seven new chemotherapy agents approved in the past three years.
Anjana Pillai, MD
Anjana Pillai, MD, is a board-certified gastroenterologist and transplant hepatologist who specializes in the management of chronic liver diseases. Dr. Pillai is the medical director of the multidisciplinary liver tumor program, which encompasses multiple specialists with expertise in benign and malignant tumors of the liver.See Dr. Pillai's profile
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Anjana Pillai, MD: On a relentless quest to find answers to liver cancer
Transplant hepatologist Anjana Pillai's commitment to patients, research and social justice issues has been shaped by her physician father as well as her childhood in India and the U.S.
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