All chronic liver diseases can contribute to the development of hepatocellular carcinoma. Unfortunately, they are very insidious, asymptomatic or they give meager, uncharacteristic symptoms that we do not associate with the liver. The alarming signal is jaundice or ascites. However, we should not underestimate the symptoms, the causes of which we are not able to determine, e.g. fatigue – warns Dr. Ewa Janczewska, hepatologist from the Department of Public Health, Medical University of Silesia.
- Hepatologist: all chronic liver diseases can contribute to the development of hepatocellular carcinoma. Most often, this cancer is associated with infections with hepatitis B and C viruses, alcoholic hepatitis and non-alcoholic steatohepatitis.
- Janczewska: we should not ignore symptoms, the causes of which we are unable to determine, e.g. fatigue, which we cannot justify with our lifestyle
- For some liver diseases, there is no causal treatment and you cannot stop them from developing. In HCV-related liver cirrhosis, even successful elimination of the virus does not guarantee that the cancer will not develop
- The availability of hepatocellular carcinoma treatment in Poland is worse than in other European countries
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Iwona Schymalla: We will talk about liver disease, which is unfortunately the most common primary malignant neoplasm – hepatocellular carcinoma. We often do not realize how important an organ in the human body is the liver, which is responsible for many life functions, e.g. metabolism of nutrients, protein synthesis. We often underestimate certain symptoms, forgetting that the condition of our liver strongly affects the entire body. What causes liver disease, especially hepatocellular carcinoma?
Dr. Ewa Janczewska, hepatologist: The liver is indeed an organ of great importance to our body. It can be likened to a biochemical factory where important chemicals are produced and then transformed that also play a detoxifying role. Therefore, liver diseases of various etiologies, which are characterized initially by inflammation and then by fibrosis, may gradually lead to impairment of its function.
Progressive fibrosis can lead to the development of cirrhosis of the liver, the deposition of collagen fibers that gradually reduce the volume of healthy flesh. In advanced cirrhosis of the liver, we observe biochemical failure. The liver does not produce substances important for the body in sufficient quantities and the development of portal pressure occurs, the manifestation of which may be esophageal varices, which may pose a threat of massive life-threatening bleeding.
Attempts to regenerate, make up for the losses associated with the production of the volume of properly functioning liver parenchyma lead to the so-called regenerative nodules, which may, under unfavorable circumstances, develop into focal lesions of a neoplastic nature. Therefore, hepatocellular carcinoma, with few exceptions, is diagnosed in patients with cirrhosis of the liver.
All chronic liver diseases, whether viral, autoimmune, metabolic, toxic, as well as genetic liver diseases can contribute to the development of this cancer. Most often, this cancer is associated with infections with hepatitis B and C viruses, with alcoholic hepatitis or with a problem that is growing worldwide, i.e. non-alcoholic steatohepatitis.
Why is this cancer diagnosed so late? We know that diagnosis takes a long time. What it comes from?
Unfortunately, liver diseases are very insidious, asymptomatic or with scanty, non-specific symptoms that we do not associate with the liver, e.g. fatigue or joint pain.
A symptom that we clearly associate with liver diseases is jaundice, i.e. yellow discoloration of the skin and whites of the eyes. In chronic liver diseases, this symptom is generally not observed at all until the stage of liver failure. Thus, fibrosis develops completely imperceptibly, and the diagnosis of the disease is completely accidental. For example, viral hepatitis is diagnosed during blood donation at a blood donation station, or we find abnormal liver tests during preventive examinations.
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Sometimes it happens that the first symptom observed by the patient is increasing ascites or bleeding from esophageal varices, i.e. conditions resulting from a significant disturbance of both the structure and function of the liver. In some patients, simultaneously with the diagnosis of the disease, we recognize the already existing cancer, sometimes, unfortunately, in the advanced stage.
Are you worried about the health of your liver? Do you have worrying symptoms? Perform a comprehensive liver test package and consult your doctor about the results.
What symptoms should definitely worry us and what specialist should we go to to rule out hepatocellular carcinoma?
As long as the liver is efficient, even in the cirrhosis stage, the body may not be giving us signals. Of course, the alarming symptoms are jaundice or ascites, because the likelihood of cancer increases with the advancement of liver cancer. However, we should not ignore non-specific symptoms, the causes of which we are unable to determine, e.g. fatigue, which we cannot justify with our lifestyle.
If we already have a diagnosed liver disease, it would be best to stay under the care of a hepatologist, monitor the form of this disease and try to stop it.
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Can we talk about risk groups in this cancer? Is prevention possible at all? Can we protect ourselves from this cancer?
I observe the highest risk of developing this cancer in patients with cirrhosis, regardless of its cause. For some conditions, such as hepatitis B or nonalcoholic fatty liver disease, the cancer can develop in the liver where cirrhosis has not yet developed.
As for prophylaxis, the most effective is to prevent the development of liver disease. We can eliminate the risk of getting hepatitis B completely by vaccination. Since the 90s of the last century, this vaccination has been included in the calendar of compulsory vaccinations (administration already in newborns), so this cause of cancer – chronic HPV infection will be eliminated in future generations.
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In the case of already existing viral chronic hepatitis B and C, we have the option of implementing effective drugs that inhibit or even reduce liver fibrosis, which significantly reduces the risk of cancer.
In turn, the prevention of fatty liver diseases is primarily a healthy lifestyle, preventing the development of obesity and appropriate correction of possible metabolic disorders. However, if we are already dealing with advanced fibrosis, especially with cirrhosis, then we can no longer talk about the prevention of cancer development, because our impact becomes quite limited.
For some liver diseases, we do not have causal treatment and we cannot stop them from developing. In HCV-related liver cirrhosis, even successful elimination of the virus does not guarantee that the cancer will not develop. In these patients, it is necessary to implement a monitoring program consisting in performing imaging tests (the recommended frequency is once every six months) in order to detect the already developing cancer at its earliest possible stage, because if this happens, we may have a chance for radical therapy. The basic examination here is ultrasound of the abdominal cavity, and if a suspicious focal lesion is detected, verification by CT or MRI is necessary. And they must necessarily be tests with multiphase contrast. These six-monthly imaging tests can be combined with levels of alpha-fetoprotein, which is a marker of hepatocellular carcinoma. However, it should be remembered that in some patients the concentration of this protein is normal.
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People who have already been diagnosed with hepatocellular carcinoma require the involvement of a whole team of specialists in various fields. Why is it so important and necessary?
Unlike most other neoplasms, usually developing in organs that do not show any lesions apart from the tumor, hepatic cancer arises in an organ with limited efficiency or even in an ineffective organ. Hence, we have limited possibilities of both surgical and surgical management as well as the use of drugs, in which the liver generally plays a key role in metabolism.
In the case of drugs used in chemotherapy of various cancers, an increase in parameters indicating liver damage is sometimes an indication of treatment discontinuation or modification. On the other hand, in patients with hepatocellular carcinoma, such elevated parameters are sometimes found at the very beginning, before starting treatment. Therefore, the cooperation of oncologists and hepatologists may play an important role here. Drugs used in the treatment of hepatocellular carcinoma can also cause disorders of other organs, such as the thyroid gland or abnormalities in the blood picture. Here, therefore, cooperation with an endocrinologist or hematologist is necessary.
Medicines influencing the functioning of the immune system, used in the so-called immunochemotherapy. These drugs, in turn, can cause autoimmunity in almost all organs and systems, which may require the cooperation of doctors of various specialties. Fortunately, these autoimmune phenomena are not common, and it must be recognized here that the benefits of greater efficacy of these drugs outweigh the risks.
Are these therapies financed by the National Health Fund and can they be used by a Polish patient suffering from hepatocellular carcinoma?
When it comes to treatment options in advanced stages of hepatocellular carcinoma, a Polish patient has access to only one drug. In addition, the eligibility criteria for this single drug are too restrictive, therefore patients with localized lesions outside the liver cannot be eligible for this treatment. It can therefore be said that the availability of treatment for hepatocellular carcinoma in Poland seems to be worse than in the case of other cancers and certainly worse than in other European countries.