Liver cancer is one of the most widespread types of tumors, ranking 6th among the most common cancers globally. Statistics show that it is more common in men and is among the top 5 most common cancer types. Around 900,000 new liver cancer cases are detected in the world annually. Meanwhile, the number of deaths is coming closer to the number of new cases. As of 2022, there were more than 750,000 deaths. Although protocol treatments such as surgery and chemotherapy have saved numerous lives, they have shown that they are not enough for a complete cure. Patients at advanced stages of liver cancer still needed therapy, which would be both effective and well-tolerated. As a result of breakthroughs in medicine and technology, a number of innovative minimally invasive interventions are now available for patients with liver cancer.
What is Liver Cancer?
Liver cancer is the sixth most common type of cancer, making it one of the most prevalent worldwide. It arises from liver cells (hepatocytes), causing hepatocellular carcinoma, which is one of the most widespread types of primary liver cancer. Around 900,000 new liver cancer cases are documented in the world annually, which demonstrates the wide spread of the disease. Multiple treatment options are available for patients with liver cancer, which show relatively good results and favourable prognosis. However, there is a list of other tumors that metastasize to the liver, causing multiple metastatic foci that have to be treated effectively. Due to these reasons, standard therapy of liver cancer is being constantly reviewed and novel therapies are being introduced to manage the growing need in more sufficient and life-sparing treatments.
Causes and Risk Factors
Both modifiable and non-modifiable risk factors increase chances of developing primary liver cancer. Non-modifiable risk factors include sex, race, and some inherited metabolic diseases.
Sex is the primary independent risk factor for developing liver cancer. According to statistics, men are diagnosed with this type of cancer at least 2 times more often than women.
Race is another non-modifiable risk factor of acquiring liver cancer. Multiple studies revealed that Asian people and Pacific Islanders have the highest chances of developing liver cancer, followed by Hispanic and Latino individuals.
Inherited metabolic diseases, such as hereditary hemochromatosis, are linked to the disruption of iron distribution, which leads to its accumulation in the liver. This can lead to cirrhosis and, subsequently, liver cancer.
Modifiable risk factors are as follows:
- Liver disease (viral hepatitis and cirrhosis)
- Alcohol abuse
- Tobacco smoking
Persistent infection with hepatitis B (HBV) and hepatitis C (HCV) viruses is a verified cause of liver cancer in the world. Causing persistent damage to the hepatic cells, HBV and HCV lead to the accumulation of alterations in the cell DNA and local and systemic immune responses. All together, it serves as a perfect foundation for liver cancer development. At the same time, alcohol is another risk factor, which is known as the number one reason for liver cirrhosis in the USA. Cirrhosis, which is a process of replacement of healthy liver parenchyma with a scar-like connective tissue, is often observed in patients with first-time diagnosed cancer. Therefore, alcohol increases the chances of acquiring cirrhosis, which may eventually lead to liver cancer. Smoking is another factor, which is associated with increased odds of getting liver cancer.
Diagnosis of Liver Cancer
A timely and precise diagnosis of liver cancer is essential for creating an effective cancer treatment strategy. Hepatocellular carcinoma often develops as a result of pre-existing disorders that cause persistent tissue damage, such as cirrhosis, HBV, or HCV. In this case, given the patient's previous medical history, non-invasive diagnostic procedures are an option. These include:
- Contrast-enhanced CT
- Contrast-enhanced MRI
- Contrast-enhanced ultrasound
Whenever the diagnostic criteria of liver cancer based on the Liver Imaging Reporting and Data System (LI-RADS) version of 2018 are met alongside a previous history of HBV, histopathology may not be considered. However, when the non-invasive criteria are not met, a biopsy of the tumor is required. Histopathology should be performed for all advanced stages of liver cancer as well. If a diagnosis of hepatocellular carcinoma is confirmed, a combined CT scan of the chest, abdomen, and pelvis need to be done for all patients.
As soon as the diagnosis is verified, additional tests are administered for precise tumor staging, which consequently helps to guide cancer treatment. These include:
- Serum biomarkers such as AFP, AFP-L3, and DCP
- Gadoxetic acid-enhanced MRI (when curative treatments such as ablation and liver resection are considered)
Noteworthy, doctors recommend assessing the biomarkers before and after curative treatments, as high levels of these substances are linked to cancer treatment resistance and lower survival rates. Consequently, staging of liver cancer is based on both liver function and the patient's overall functioning by ECOG PS scale, which are perfectly summarized in a Barcelona Clinic Liver Cancer (BCLC) Staging System. According to it, there are 5 stages of liver cancer:
- Very early stage (0)
- Early stage (A)
- Intermediate stage (B)
- Advanced stage (C)
- Terminal stage (D)
The treatment choice is then recommended based on the stage of the disease, with ability to mediate treatment towards managing more advanced disease stages.
Source: European Association for the Study of the Liver
Liver Cancer Treatment Methods
The treatment of liver cancer is commonly guided by the specific type of the tumor, but, most importantly, it depends on the stage of the disease. Surgery is the foundation of therapy, whereas systemic therapies are reserved for advanced liver cancer.
Standard Treatment Methods
For early-stage hepatocellular carcinoma (HCC), surgical resection or liver transplantation remain the preferred curative options. Resection is suitable for patients with good liver function and localized disease, while transplantation is considered when underlying cirrhosis limits resection.
Hepatic resection involves removing the portion of the liver, which contains the tumor. It is generally indicated for patients with:
- Preserved liver function (Child-Pugh A)
- Absence of significant portal hypertension
- No major vascular invasion or extrahepatic tumor spread
- A single tumor or, in select cases, limited multifocal disease
Outcomes have improved thanks to innovations in imaging and 3D surgical planning, while techniques such as laparoscopic or robotic resection are gaining traction for select cases. However, according to new information, recurrence rates remain high, with 5-year recurrence observed in up to 70% of cases, underscoring the need for novel therapies.
Liver Transplantation
For patients with underlying cirrhosis, liver transplantation (LT) is often the most appropriate curative option. It not only removes the tumor, but also treats the underlying liver disease. Eligibility criteria for LT are most commonly based on the Milan Criteria and include:
- A single tumor ≤5 cm
- Up to 3 tumors, each ≤3 cm
- No vascular invasion or extrahepatic metastasis
Transplantation candidates must undergo comprehensive evaluation and are typically placed on a long waiting list, which significantly reduces survival chances.
Systemic treatments, such as radiotherapy and chemotherapy, are not among the first-line treatments for early-stage liver cancer. Nevertheless, they become the most valuable options for patients with advanced stages of the disease.
Innovative Therapies
Doctors are actively introducing novel medical techniques into multidisciplinary liver cancer management strategies. The most prominent of these minimally invasive techniques are transarterial chemoembolization (TACE), thermal ablation, dendritic cell therapy, electrochemotherapy, and cryotherapy.
Transarterial Chemoembolization (TACE)
Once a breakthrough in medicine, now TACE is a cornerstone for intermediate-stage hepatocellular carcinoma treatment. The technique delivers chemotherapy directly to the tumor while simultaneously obstructing its blood supply. As a result, it maximizes local chemotherapeutic effect on the tumor without systemic exposure. Recent studies have shown that by combining chemoembolization with systemic therapies, such as monoclonal antibodies or dendritic cells, doctors can significantly improve progression-free survival. One of the recent studies informed that this combination nearly doubled the median progression-free survival to 15 months compared to TACE alone. Above that, TACE is an invaluable option for advanced stages of the disease, especially accompanied by systemic treatments like radiotherapy and chemotherapy.
Thermal Ablation Techniques
Thermal ablation, including radiofrequency (RFA) and microwave ablation (MWA), is a novel minimally invasive intervention that is suggested for individuals with early-stage HCC. Having proved their significance in multiple clinical settings, RFA and MWA are now officially part of liver cancer treatment guidelines. Advancements in imaging, particularly MRI-guided techniques, have additionally enhanced their precision. One of the decade-long studies reported a median overall survival of 73.8 months for patients undergoing MRI-guided thermal ablation, with 1-, 3-, and 5-year survival rates of 98.3%, 87.8%, and 62.9%, respectively.
Source: Ruers T et al. Local Treatment of Unresectable Colorectal Liver Metastases: Results of a Randomized Phase II Trial. J Natl Cancer Inst. 2017 Sep 1;109(9)
It is also the preferred option for centrally located tumors up to 2 cm, regardless of whether they are metastatic or primary. This is crucial for preserving critical structures. Both MWA and RFA, when accompanied by systemic treatments, have demonstrated superior efficacy as opposed to systemic treatment alone. This is especially promising for patients with advanced liver cancer, for whom therapeutic options are limited.
Electrochemotherapy (ECT)
Electrochemotherapy (ECT) offers a novel approach for liver tumors. It is a breakthrough technique that combines chemotherapy with electric pulses to increase drug uptake by malignant cells. Above that, electrochemotherapy is known to have one of the best local tumor control rates compared to other ablation techniques.
*Data of Prof. Dr. med. Attila Kovács
Clinical studies have demonstrated high complete response rates, with one phase II study reporting an 84% complete response per treated lesion in HCC patients. ECT is particularly beneficial for tumors located near large blood vessels, where traditional ablation methods are less effective. Noteworthy, ECT can enhance the immune response, which makes it a perfect companion for immunotherapy.
*Data of Prof. Dr. med. Attila Kovács
An additional benefit of this treatment option is its radiosensitizing effect. This is especially valuable for advanced liver cancer, as ECT can significantly improve the response to radiotherapy.
Cryoablation
Cryoablation is a minimally invasive technique that is based on a targeted freezing, which leads to tumor necrosis. It is particularly valuable for liver tumors, which are located near large blood vessels and in patients with impaired liver function. Cryoablation is indicated for very early and early stage liver cancer patients. Clinical studies have demonstrated that cryoablation has comparable local control rates to radiofrequency ablation, with lower post-procedural pain and a favorable safety profile. A 2023 meta-analysis found 1-year and 3-year survival rates of 89% and 62%, respectively, in early-stage HCC patients undergoing cryoablation. Due to such promising results, cryoablation is being increasingly used both as a standalone therapy and in combination with other tissue-sparing interventions such as TACE.
Dendritic Cell Therapy
Dendritic cell therapy is a subtype of immunotherapy that represents a promising frontier in liver cancer treatment. Dendritic cells are so-called "guards" of the immune system, which are called to recognize malignant cells and initiate a full-scale immune response towards them. For such a breakthrough in medicine, the discoverer of dendritic cells Ralph Steinmann was awarded with a Nobel Prize in medicine. Clinical trials have demonstrated that dendritic cell-based vaccines can elicit targeted, tumor-specific immune responses, which improve survival rates in liver cancer patients up to 60% in some cases. As a part of a comprehensive medical approach, dendritic cell therapy is exceptionally well tolerated by patients. Multiple research reported little to no adverse effects after administering a dendritic cell vaccine, which highlights its promising role in the treatment of advanced and intermediate stages of liver cancer.
To get a broader perspective on the main indicators of different treatments, feel free to look through the table of comparison for liver cancer treatments. The table offers survival and response rates, potential side effects, and the approximate cost of treatment.
| Characteristics/Therapy type | 2-Year Survival Rate | Response Rate | Duration | Side Effects |
|---|---|---|---|---|
| Standard Treatment | ~25% for advanced cancer | Less than 10% | Several cycles | Severe (nausea, fatigue, hair loss, immunosuppression, skin irritation) |
| Innovative Methods | ~60% for advanced cancer | 45-65% | Up to 4 sessions | Mild (localized discomfort) |
*Booking Health data
Comparison of Cost for Standard vs Innovative Treatments
| Treatment Method | GERMANY* | GB | USA |
|---|---|---|---|
| Standard Treatment | €80,000 - €150,000 full course | €90,000 - €165,000 full course | €100,000 - €180,000 full course |
| Innovative Methods | €25,000 - €60,000 full course | €70,000 - €120,000 full course | €100,000 - €150,000 full course |
*Cost may vary depending on the type and duration of treatment, as well as the combinations of methods used for each individual clinical case
Rehabilitation After Treatment
Standard treatments for patients with liver cancer are commonly quite exhausting. A whole list of adverse effects have a notable negative impact on a patient's life and already compromised health. Cancer rehabilitation is a supportive therapy program that is part of comprehensive liver cancer management. This program addresses mobility problems, as well as cognitive and memory disorders. Cancer rehab specialists can help manage a variety of health issues that arise during systemic treatment. These include:
- Pain
- Swelling
- Neuropathy
- Limited range of motion
- Troubles chewing and/or swallowing food
Above that, cancer rehabilitation helps to overcome mobility challenges resulting from liver cancer treatment. This is crucial because it helps patients deal with day-to-day activities, such as climbing the stairs, walking, or even dressing and showering. All of that is possible due to a large team of medical professionals, including:
- Physiotherapists
- Dietarians
- Psychologists and psychiatrists
- Speech therapists
- Occupational therapists and others
Cancer rehabilitation may also be suggested prior to undergoing systemic treatment (the so-called prerehab). This allows doctors to assess the patient's health state and functional capacity before the treatment starts and offer procedures to prepare for the upcoming chemo- or radiotherapy.
Innovative therapies, on the contrary, do not usually require any prior preparation. Though a standard examination or a number of diagnostic tests may be required, novel treatments are usually patient-friendly due to their generally favorable profile. The few side effects that occur after treatment usually do not require special rehabilitation. With dendritic cell therapy, for example, patients can leave the hospital on the day of the injection. Minimally invasive procedures, such as transarterial chemoembolization or thermal ablation, require small cuts, which can produce some discomfort or swelling on the site. Nonetheless, these are moderate and resolve within a couple of days. Created to be patient-friendly, novel liver cancer treatment options generally have shorter and easier recovery with little to no need for a hospital stay.
Advanced Liver Cancer Management: When Hope Means Looking Forward
A stage 4 liver cancer diagnosis may feel like a moment when all the options are narrowing dangerously. Oftentimes, the focus shifts to managing symptoms rather than actively treating the disease. This is the time when you may be led to believe that there's little left to be done. However, this stage does not have to mark the end of your fight. In fact, it can be the start of a broader, more determined and mindful approach to care.
While curing advanced liver cancer completely may not yet be possible in many cases, it doesn't mean treatment stops here, especially not at your country's borders. Leading cancer centers, including those in Germany, are expanding the frontiers of care. From novel systemic therapies to highly targeted interventions like thermal ablation, the treatment of liver cancer abroad offers new hope to patients seeking options beyond what is locally available.
Focused on prolonging survival, standard treatment options do not prioritize the patient's comfort and quality of life. Meanwhile, access to global oncology expertise and next-generation therapies can indeed transform life and bring back the life you deserve. Emerging treatment protocols, personalized therapy, and participation in clinical trials launched by the best international cancer clinics in Germany may provide a path forward once lost.
Choosing to explore treatment options internationally doesn't mean giving up. It's expanding the possibilities for living. By seeking second opinions and remaining open to innovative cancer treatment solutions, patients with advanced liver cancer can take back a measure of control. A diagnosis is not a conclusion, but rather a call to explore every opportunity wherever they may be found.
Benefits of Treatment Abroad
Searching for the best treatment option for advanced stages of cancer is extremely time-consuming and draining. The lack of options offered by conventional medicine, insurance limitations, huge queues, and high cost of therapy are just a few of the issues you need to deal with while looking for the best clinic for your case. It is easy to get lost or to agree to the first-hand option just to avoid extra stress. However, it often turns out to be less than you expected, especially in terms of how much time and money it takes. Instead of wasting precious time or compromising quality for cost, utilize Booking Health services.
As a renowned medical tourism operator, Booking Health has helped to find the most appropriate treatment options for over 100,000 patients in 10 years. The company offers no standard all-to-one methods, but rather personalized cancer management strategies that will be effective in your specific case. Treatment abroad seems to be way more complex to organize, without even mentioning the taxes international patients may have to pay. With Booking Health, you may save 40-70% of your money and much of your time. Moreover, the Booking Health experts may organize urgent (within 48h) access to the best clinics in Germany.
High-quality services and top innovations in the field of advanced cancer management are indisputable features of the Booking Health policy. Organizational challenges no longer seem troublesome because everything is organized, starting from visas and transfers to accommodations and personal translations all the way through the treatment process. By selecting Booking Health as your trusted partner, you are securing your money and time, while gaining access to the most recent medical advancements in the top hospitals for advanced cancer management.
Do not waste your time searching for the options all alone. Instead, invest that time in quality services and innovations offered by Booking Health. Only the most reputable hospitals and top experts in the field of advanced cancer management are readily available upon request. Get a consultation now and start your treatment tomorrow.
Fighting Cancer Together: Treatment Journeys with Booking Health
Frequently Asked Questions of Our Patients About Liver Cancer Treatment
Send request for treatmentThe main types of liver cancer are hepatocellular carcinoma (HCC), which is the most common form, and intrahepatic cholangiocarcinoma or bile duct cancer. Less common types of liver cancer include angiosarcoma and hepatoblastoma (in children).
Common symptoms include:
- abdominal pain
- swelling
- unexplained weight loss
- fatigue
- jaundice (yellowing of skin and eyes)
- loss of appetite
- nausea
Diagnosis involves imaging tests such as ultrasounds, CT scans, and MRI scans. Laboratory tests also play an important role and typically include blood tests (including alpha-fetoprotein or AFP levels) and a liver biopsy to confirm the specific cancer type.
Standard treatment methods for liver cancer include:
- surgery (liver resection)
- local ablation
- embolization therapy like TACE
- radiation therapy
- systemic treatments like chemotherapy
- targeted therapy or immunotherapy
Innovative therapy is represented by immunotherapy, personalized medicine like dendritic cell vaccines, and radioembolization. Clinical trials are also available for novel drug combinations to expand the treatment landscape.
Survival rates typically depend on the disease stage and liver function. Localized HCC has a 5-year survival rate of 30-35%, while advanced stages may drop below 10%.
Non-surgical options for liver cancer include radiofrequency ablation, transarterial chemoembolization (TACE), radiotherapy, and systemic therapies such as immunotherapy.
A complete cure is rare in advanced stages, but treatment can significantly extend survival and improve quality of life. Innovative treatments, such as targeted therapy or immunotherapy, can improve survival rates.
Seeking treatment abroad can offer access to the latest advancements in cancer therapy, clinical trials, and cost-effective care, which are not available locally. Specialized centers in Germany offer comprehensive treatment strategies, including a combination of standard and innovative therapies, to boost treatment effect.
Choose treatment abroad and you will for sure get the best results!
Authors:
This article was edited by medical experts, board-certified doctors Dr. Nadezhda Ivanisova, and Dr. Vadim Zhiliuk. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!
Our editorial policy, which details our commitment to accuracy and transparency, is available here. Click this link to review our policies.
Sources:
Clinical and Molecular Hepatology
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Treatment of stage 4 liver cancer in Germany
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