THE LESS TALKED ABOUT, LIVER MALIGNANCY

The one who does not show any signs of trouble and does its job without making much noise is our humble liver. That said, the liver is not to be taken for granted.

Before we delve into this liver cancer awareness blog post, let us briefly recall the vital roles the liver plays in human physiology.   

The liver is located in the upper right section of our abdomen, just behind the lower ribs and inside the rib cage. It is involved in playing several vital functions;

• It helps in digesting food. It especially produces bile that aids in the digestion of fat.
• It helps eliminate the waste products out of our system.
• It acts as the storehouse of nutrients.
• It filters and removes the harmful chemicals present in food, medications and alcohol.
• It produces substance that helps in blood clotting.

Now let us look into what liver cancer is, the steps we can take for prevention and things we need to keep in mind for early detection.

What is liver cancer?

Cancer, as we all know, is a diseased condition wherein there is uncontrolled multiplication of the body cells. Any change or mutation in the deoxyribonucleic acid (DNA, the genetic material) of the liver cells can give birth to liver cancer. The cancer that originates in the liver cells is called primary liver cancer, while the cancer that spreads into the liver from other organs (metastasis) is called secondary liver cancer.

The most common type of primary liver cancer is hepatocellular carcinoma (HCC), accounting for 90% of the cases, followed by intrahepatic cholangiocarcinoma (bile duct cancer).

What do the numbers have to say about liver cancer?

If we have a look at the stats, in 2018, liver cancer was;

• The sixth most commonly diagnosed cancer worldwide
• The third leading cause of cancer related deaths worldwide.
• The second most common cause of premature death from cancer.

Infact, as the world population continues to grow, it is postulated that between 2020 and 2040, the number of new cases of liver cancer could rise by >55% and deaths due to liver cancer by 56.4%.

What is the Indian scenario like?

There is no truly representative data from India on liver cancer. Thus, there is a paucity of information about HCC in our country. That said, the number of new cases are bound to escalate given the predisposition to the risk factors, which are covered in the next section of the blog post. Whatever little data is there, it depicts that for every 1 lakh population, there are 1 to 7.5 new cases of HCC. Deaths due to HCC in India is estimated to be 6.8/1 lakh males.

What are the causes and risk factors of liver cancer?

In India, the most common risk factors for HCC include;

• Chronic hepatitis B virus (HBV) infection
• Chronic hepatitis C (HCV) infection
• Cirrhosis of the liver (scarring of the liver cells)

All of the above factors lead to swelling and scarring of the liver and make it vulnerable for the development of HCC. From what the current evidence states, viral hepatitis with alcohol was the most common risk factor for HCC in India. Infact, the risk for HCC increases exponentially if those with HBV, HCV are obese, diabetic, have human immune deficiency virus, or are into alcohol abuse or exposed to aflatoxin. 

However, owing to the introduction of hepatitis B vaccines and antiviral therapies for HCV, there has been a decline in HBV infections and a stabilisation of HCV infections, respectively. This is going to lead to a shift in the pattern of risk factors for primary liver cancer as the focus will now have to equally be on non-viral risk factors that are becoming too prevalent in India. For instance, now the other prominent risk factors for HCC include;

• Non-alcoholic fatty liver disease (NAFLD) which is now known as metabolic dysfunction associated steatotic liver disease (MASLD). This is a condition marked by unnatural fat deposition in the liver in the absence of significant alcohol intake, that leads to swelling and injury of the liver) has become a major risk factor for chronic liver disease, cirrhosis and HCC in India (read on to learn more about it).
• Obesity
• Diabetes
• History of alcohol abuse.   

The other risk factors for liver cancer include;

• Old age (>60 years)
• Male gender
• Cigarette smoking
• Liver flukes (parasites)
• Human immune deficiency virus
• Prolonged consumption of poorly stored foods (in hot and humid climates) that get contaminated with aflatoxin B1 (a toxic fungus that grows on grains and nuts).
• Hemochromatosis (a genetic condition in which the body stores too much iron that causes liver toxicity)
• Glycogen storage disease (a genetic condition wherein the body cannot properly store or breakdown glycogen – the storage form of carbohydrate in our body)
• Wilson disease (a genetic condition wherein the body stores abnormal amounts of copper)
• Alpha-1 antitrypsin deficiency (a genetic condition that can cause liver damage)
• Primary biliary cirrhosis (bile ducts are damaged leading upto building up of bile inside the liver, which leads to cirrhosis)

Please be wary of the fact that these risk factors may not necessarily lead to the development of liver cancer and those without these risk factors can also develop liver cancer.

What are the subtle signs to watch out for?

The tricky part is, there might be no symptoms during the early stages of liver cancer, which calls for timely screening of those at high risk. Earlier diagnosis would mean better response to treatment.  Many of the below mentioned symptoms might occur due to a multitude of factors caused by different conditions, which is why it is necessary to reach out to your doctor to clear the air to rule out the possibility of liver cancer. Some of the symptoms when they begin to appear include;

• Unusual and unexplained fatigue or lethargy
• Loss of appetite
• Unexplained weight loss
• Dark urine
• Pale stool
• Itchy skin
• Skin and conjunctiva becoming yellow (jaundice)
• A hard lump on the upper right side of your abdomen, just below the rib cage
• Pain or discomfort in the upper right side of your abdomen
• Indigestion (nausea, vomiting)
• Feeling of satiety after eating a small portion of the meal
• Swelling in the abdomen
• Pain in the right shoulder blade
• Easy bruising and bleeding

If your liver has a history of vulnerability, please get yourself checked at the earliest should any of the above symptoms be present along with other risk factors. It is ideal to discuss with your doctor if you might need to undergo screening for liver cancer.

What does screening for liver cancer involve?

Screening (also known as surveillance) means to test to diagnose a condition even when there might be no symptoms. However, this makes sense given the fact that vulnerable or at-risk people may not show any symptoms during the early stages of liver cancer but early diagnosis is the key to a better prognosis. There are no standard routine tests for liver cancer screening. You might need to undergo the following tests;

• A detailed physical examination with medical history is mandatory.
• Blood work: Alpha fetoprotein tumour marker, liver function tests and other routine blood parameters
• Imaging scans: An abdominal ultrasound or a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan
• Liver biopsy

A grim reality check: Unfortunately, in India, by the time HCC is usually diagnosed it is often too late because it is at a later and at an advanced stage. Regular screening for liver cancer is recommended bi-annually for those at high risk of developing liver cancer. The five year survival rate of HCC is very low (18%) because most of the cases are diagnosed late wherein cancer would have widely spread and are not suitable for curative treatments.

What are the odds of a favourable prognosis upon liver cancer diagnosis?

Early detection helps to improve the response to treatment. Upon liver cancer diagnosis, there is concurrent staging. Determining the extent of the cancer is called staging of the cancer. Staging HCC helps to decide on the treatment options and prognosis.

• How big is the tumour
• Type of tumour
• Precise location of the tumour
• Whether it is localized or if it has spread
• Primary or secondary liver cancer
• Liver function
• General health

Your doctor will recommend a positron emission tomography (PET) scan to check for secondary liver cancer or to determine the spread of the cancer beyond liver. There are different staging systems available but the most commonly used is The Barcelona Clinic Liver Cancer (BCLC) Staging System.

What are the treatment options once liver cancer has been diagnosed?

A multidisciplinary team will look into the treatment of HCC as it is complex in nature and does not involve the conventional oncological intervention. The standard treatment of HCC can broadly be put into two categories; curative and non-curative.

• Curative treatments (in the early stage where a complete cure maybe possible)
  • Ablation – Microwave or radiofrequency waves are used to kill the cancerous cells
  • Surgical resection – surgical removal of the affected section of the liver
  • Liver transplantation – a healthy donor’s liver replaces the liver
• Non-curative treatments (in later stages where complete cure is not possible) which aim to kill or slow down the cancer cells, relieve symptoms of pain and discomfort and ultimately prolong the life
  • Trans-arterial chemoembolization
  • Transarterial radioembolization
  • Stereotactic body radiation therapy
  • Systemic chemotherapy
  • Targeted medicines
  • Immunotherapy

Since most of the cases of HCC are detected at a late stage in India, sadly, there is no room for curative treatment under those circumstances. That said, there is certainly hope for the future as several clinical trials are underway aimed at effectively treating the malignancies to improve the survival rate. But this also calls for timely screening of those most vulnerable to HCC.

What steps can I take to prevent liver cancer?

While there are no means through which one can completely prevent the occurrence of liver cancer, we can certainly take some preventive steps, the factors in our control, to lower the chance of getting liver cancer.

• Take steps to prevent HBV and HCV infection
• Seek timely treatment for HBV and HCV infection
• Take the hepatitis B vaccine
• Modify your lifestyle to eat healthy and engage in routine physical activity to maintain a healthy body weight
• Maintain a normal body mass index (less than or equal to 22.9)
• Keep a tab on your waist line. An increased waist line (>80 cms in women and >90 cms in men) is an open invitation to all the lifestyle disorders.
• Abstain from alcohol
• Quit smoking  
• Avoid consuming foods stored for long periods in hot and humid conditions.
• Ensure timely screening if you are in the high risk group

Lowering the risk of liver cancer through nutrition – what does the evidence say?

Nutrition and a healthy diet are one of the modifiable risk factors that we can work on to try to keep lifestyle disorders at bay, cancer being one among them. Evidence is emerging as to what can protect and what can increase our risk for HCC.

• Frequent consumption of processed meats and processed fish might increase the risk of getting HCC, on the other hand, consuming fresh fish (a source of good fats) and white meat might reduce the risk of HCC.
• Red meat, which is always red flagged, owing to its saturated fat content and known carcinogens, is another risk factor.
• Dietary sugar in any form is turning out to be another factor that increases the risk of HCC.
• Consuming fresh fruits and vegetables (a rich source of vitamins and minerals, dietary fibre, flavonoids), milk and yogurt (source of retinol), consumption of coffee in moderation (no more than 4 cups a day), high intake of whole grains (dietary fibre, resistant starch, B complex, vitamin E, zinc, copper, selenium, magnesium, phytochemicals) and dietary fibre reduces the risk of HCC.

To consult Dr. Roy for a personalized nutrition plan, register here or write to her at info@nafldnutrition.in

Disclaimer: The information shared in the blog is aimed at increasing your awareness and is not a substitute for professional medical advice.  

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