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Dr. Nguyen, from Stanford Health, in an interview with CURE

What Patients With Liver Cancer Need to Know About Hepatitis B and C

In the world of cancer, liver cancer is unique, as Dr. Mindie H. Nguyen explained to CURE®.

“If you have no underlying chronic liver disease, there should be almost no chance that you would ever get HCC (hepatocellular carcinoma; the most common type of liver cancer). … In my career of almost 30 years, I've never seen a liver cancer patient that did not have a chronic underlying liver disease,” said Nguyen of the division of gastroenterology and hepatology at Stanford University Medical Center and the department of epidemiology and population health at Stanford University in Palo Alto, California.

Nguyen is the lead author of a study recently published in the 

 which showed that while antiviral treatments can play a crucial role in the survival outcomes of patients with either hepatitis B (HBV) or hepatitis C (HCV) viruses and HCC, antiviral therapy is “severely underutilized” among patients with HBV- or HCV-related HCC who undergo curative resection (surgery).

CURE® spoke with Nguyen about HCC and its particular relationship with hepatitis B and C.

Liver cancer is not like, let's say, lung cancer. (With) lung cancer, somebody can get lung cancer because they smoke, but there are also types of lung cancer that are not related to smoking and occur in people who never smoked before. But liver cancer is quite different. If you have no underlying chronic liver disease, there should be almost no chance that you would ever get HCC. There are some (cases due to) exposure to some chemicals, but those are very rare. In my career of almost 30 years, I've never seen a liver cancer patient that did not have a chronic underlying liver disease.

And, 70% of the world's liver cancer is due to either hepatitis B or hepatitis C. ... They both cause liver cancer by two mechanisms. They cause inflammation and the inflammation, the fibrosis or scarring, that (then) causes molecular alterations that lead to cancer. Hepatitis B is a DNA virus. So, it can directly incorporate into our DNA, induces changes in our genes and cause cancer. So, both of them can definitely cause cancer.

What we would really hope is to treat people before they develop cancer, because there is a lot of literature showing that if we treat hepatitis B and hepatitis C patients with antiviral (medication), then their risk of liver cancer decreases dramatically, by about 70%. But what I'm showing (with) this (research) is that even for the people who are unfortunate enough to get liver cancer, getting rid of the virus will stop the inflammation and the damage process.

So, that (means) two things: one is after we treat them for their cancer, the cancer is much less likely to come back. That's one goal. The second goal is stopping the inflammation and fibrosis and the damage also preserves the liver function, so that if the liver cancer were to come back, at least the liver function will be good and the patient can be a candidate for future additional liver cancer treatment. Because one of the great limiting steps for cancer treatment is liver function, there are people who come (for treatment) and we have many things to treat (them with), we can do surgery, you can do this and that, but if the liver function is poor, no treatment can be offered because almost any treatment will have the potential of making the liver function worse, and the patient may die faster than if we (were to) leave them alone.

Transcript edited for length and clarity.

For more news on cancer updates, research and education, don’t forget to 

“In my career of almost 30 years, I've never seen a liver cancer patient that did not have a chronic underlying liver disease,” Dr. Mindie H. Nguyen told CURE®.

At first glance, you wouldn’t think that Alec Guinness (Obi-Wan Kenobi of 

) and Robin Gibb (of the Bee Gees) would have a lot in common. Sadly, these two men both succumbed to liver cancer, a disease that claims roughly 30,000 people in the US annually. Let’s take some time today to talk about liver cancer in its most advanced stage – stage IV – and its symptoms, survival rate, and treatment options.

Liver cancer has a long list of symptoms that could easily be mistaken for other conditions. While some of these symptoms can be benign, it is important to visit your physician if you are experiencing these. The key to survival is early detection – so don’t ignore what your body is trying to tell you! 

 provides us with the following symptoms (directly quoted):

An enlarged liver, felt as a mass under the ribs on the right side

An enlarged spleen, felt as a mass under the ribs on the left side

Pain in the abdomen or near the right shoulder blade

Swelling or fluid build-up in the abdomen

Yellowing of the skin and eyes (jaundice)

Some types of liver tumors can actually produce hormones that affect other body processes. Symptoms of the production of these hormones can include elevated red blood cells, elevated cholesterol, gynecomastia (breast growth in men), low blood sugar, and high levels of calcium in the blood.

Survival rates for stage 4 liver cancer are quite low. As with most cancers, liver cancer staging is described with the TNM system. There are two TNM combinations that fall under stage 4: 1) any T, N1, and M0 and 2) any T, any N, and M1. What this means is that there are no restrictions on the number of and size of the tumors in both cases and there can be spread to one lymph node with no metastases, or vice versa. Survival rate for stage 4 liver cancer depends on the extent of the spread of the disease. If the spread is only local – local lymph nodes, blood vessels, or other close by structures, the five-year survival rate is roughly 11%; however, with distant metastases, the five-year survival rate drops to as low as 3%.

Treatment Options for Stage 4 Liver Cancer

With advanced stage liver cancer, treatment options can be limited. Disease at this stage is considered unresectable, so treatments depend upon pharmaceutical and radiation treatments, focusing on pain control and extending the time and quality of life. Chemoembolization of the tumor(s) is an option, as well as targeted therapies with drugs such as sorafenib (Nexavar®) can be utilized in order to shrink the tumor. Other drugs that can be used to help slow the growth, or shrink, the tumor(s) include immunotherapies. You can read more about immunotherapy in “

”. Clinical trials may also be an option for you, so visit with your doctor about these options. See our page on 

 for information on how to search for studies that may be enrolling in your area.

For those going through late stage cancers, as well as their families and caregivers, finding support is vital. Always know that you are not alone. We encourage your to find 

 both in your area and online. We have found that “

” offer a great community of patients and caregivers that can offer you care, love, and support from those that have been in your shoes.

As always, much love, many prayers, and abundant blessings to all of the warriors out there!

https://www.ranker.com/list/famous-people-who-died-of-liver-cancer/reference

https://www.cancer.org/cancer/liver-cancer.html

https://www.cancercenter.com/liver-cancer/stages/tab/stage-4/

Stage 4 liver cancer has a long list of symptoms that can easily be mistaken for something else which is why many are initially diagnosed at late stage 4

Stage 4 Liver Cancer

Liver Cancer: Overview

Liver cancer starts in the liver, the largest internal organ, when cells mutate in their DNA.

Signs and symptoms of liver cancer may include losing weight without trying, loss of appetite, upper abdominal pain, nausea and vomiting, general weakness and fatigue, abdominal swelling, yellow discoloration of your skin and the whites of your eyes, or white, chalky stools.

Risk factors for the disease include chronic infection with HBV or HCV, cirrhosis, inherited liver diseases (hemochromatosis or Wilson's disease), diabetes, nonalcoholic fatty liver disease, exposure to aflatoxins and excessive alcohol consumption.

Diet & Exercise

Bladder Cancer: Overview

Bladder cancer is also known as urothelial carcinoma. Urothelial cells line the urinary tract, including the urethra, bladder, and ureters and renal pelvis in the kidneys. These urothelial or transitional cells are in contact with urine. Bladder cancer happens when those cells in the bladder start to grow out of control.

Smoking and being exposed to secondhand smoke increases the risk of developing bladder cancer. In addition, people exposed to occupational or environmental chemicals may have a higher risk of developing bladder cancer. White people are twice as likely to develop bladder cancer as are Black people or Hispanic people, and older age is another risk factor. Health history also matters, with chronic bladder inflammation, such as urinary tract infections or kidney stones, as well as a personal or family history of bladder cancer, associated with risk of the disease.

Many people are unaware of the common signs of bladder cancer, such as blood in the urine, known as hematuria. If blood in the urine can be seen, this is called gross hematuria. When a physician runs a urinalysis test as part of a routine checkup, tiny amounts of blood may be detected. This is microscopic hematuria. Any blood seen in the urine should be checked by a physician. Irritation when urinating, urgency and frequency are other warning signs. These signs may also be from other causes, such as a urinary tract infection, kidney stones or aging.

Bladder Cancer: Living with Cancer

Bladder cancer has a high rate of recurrence, which implies the need for regular surveillance with cystoscopy over the course of a patient’s lifetime. For some patients, the new normal after bladder removal surgery is adjusting to life with a urinary diversion. A patient should always feel comfortable talking with their health care team about any issues or questions. If the team can’t help, they can usually find someone who can.

Bladder Cancer: Types of Disease

Doctors usually describe and treat bladder cancer by how far it has grown into the bladder wall.

NMIBC (non-muscle invasive bladder cancer) is cancer that remains in the urothelial cells that line the bladder.

MIBC (muscle-invasive bladder cancer) is cancer that has grown into the deeper layers of bladder muscle.

If bladder cancer has spread to other parts of the body outside the urinary tract, it is advanced disease, or metastatic.

Types of bladder cancer include urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, small cell carcinoma and sarcoma.

Urothelial carcinoma, the most common type of bladder cancer, is also known as transitional cell carcinoma. Transitional cell carcinoma begins in the part of the kidney, called the renal pelvis, where urine collects before moving to the bladder.

Squamous cell carcinoma comprises 1% to 2% of bladder cancers, according to the American Cancer Society. Most squamous cell carcinomas of the bladder are invasive.

Adenocarcinoma, which are also mostly invasive, occur in only 1% of bladder cancers.

Small cell carcinoma, which occurs in less than 1% of bladder cancers, start in the neuroendocrine cells. This subtype of the disease can grow quickly.

Sarcoma of the bladder is rare, and start in the muscle cells of the organ.

Bladder Cancer: Diagnosis

A urologist will make a bladder cancer diagnosis. Urologists use a cystoscope to examine the lining of the bladder and the tube that carries urine out of the body (urethra).

If bladder cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall or spread beyond that, and, if so, to what parts of the body. Grade refers to how abnormal the cancer cells look and how many cells are multiplying. A higher grade means the cells are more uneven and are multiplying more. Knowing the grade can help your doctor predict how quickly the cancer will grow and spread.

Bladder Cancer: Treatment

When bladder cancer is classified as NMIBC, surgery to remove the tumor is often the first step. A transurethral resection of the bladder tumor uses a special instrument inserted through the urethra to remove the tumor. If the tumor is low risk/grade and has not invaded the muscle wall of the bladder, it may not require more treatment. Unfortunately, bladder cancer has a high rate of recurrence so most of those who receive diagnoses must return to their urologist at regular intervals for surveillance using cystoscopy to see if the tumors return.

If the tumor cells appear aggressive under the microscope and the pathologist determines that the cancer is high risk/grade, it is more likely to return or worsen. In these cases, further treatment to keep the cancer from returning or worsening is required. Most often, patients with high-grade NMIBC receive intravesical (inside the bladder) treatments. Bacillus Calmette-Guérin (BCG) is an early form of immunotherapy that uses a weakened form of bacteria. When these bacteria are put into the bladder, the immune system goes on alert. It responds by killing cancer cells on the bladder lining. Though BCG is very effective, it doesn’t work for all tumors. If BCG doesn’t work, there are other options such as mitomycin C, an antibiotic that helps fight tumors.

When bladder cancer grows into the deeper layers of the bladder (MIBC), it is more difficult to treat. In many cases, a urologist may suggest radial cystectomy, which is surgery to remove your bladder. Removing the bladder also involves removing lymph nodes around the organ. As part of the surgery, it will be necessary to create a urinary diversion, a new way for urine to leave your body.

Systemic chemotherapy is medicine that treats cancer throughout the whole body. Neoadjuvant chemotherapy is chemotherapy patients get before bladder removal surgery. Clinical trials have shown that cisplatin chemotherapy before bladder removal improves survival for patients with MIBC because it helps kill bladder cancer cells that may be outside the bladder. Adjuvant chemotherapy is the chemotherapy patients get after surgery.

Recently approved targeted therapies can block the growth and spread of cancer. They focus on stopping the cancer-driving activity caused by specific genetic mutations that are found in some bladder cancers.

Some patients may benefit from combined modality therapy, which uses surgery to remove the tumor, plus chemotherapy and radiation to help kill the cancer while keeping the bladder intact. This option can be used for some patients who are ineligible for bladder removal surgery. Those with advanced or metastatic disease may benefit from chemotherapy and a variety of immunotherapies that can help the body fight off the cancer.

There are many talented researchers and clinicians working to improve the diagnosis and treatment of the disease. Clinical trials are an essential part of bladder cancer research. They may provide treatment alternatives to patients who have not had success with standard and approved therapies.

Breast Cancer: Living with Cancer

Similar to other cancers, there is often a fear breast cancer will return, and in some individuals, the cancer will never go away completely. Therefore, it is key to maintain follow-up appointments for physicians to watch closely. These include consistent doctor appointments, mammograms, pelvic exams, bone density tests, as well as we blood and imaging tests.

Survivorship care plans, comprised of a suggested schedule for follow-ups, a list of long-term effects, lifestyle modification suggestions and a summary of ones diagnosis, may be very helpful for long-term care and to aid individuals in transitioning back to a primary care provider.

Breast Cancer: Types of Disease

The type of breast cancer that is diagnosed is determined by specific cells.

Ductal carcinoma in situ, or DCIS, also known as intraductal carcinoma, is when the abnormal cells have not spread through the ducts into surrounding breast tissue. It is a non-invasive breast cancer that has not spread outside of the breast; however, it can become invasive.

Lobular carcinoma in situ, also called lobular neoplasia, is when the abnormal cell growth starts in the lobules of the breast and has likely not spread to surrounding tissues. This subtype can be an indicator for the likeliness of developing invasive cancer in either breast.

Invasive ductal carcinoma, also known as infiltrating ductal carcinoma, is the most common type of breast cancer that occurs when the cancer starts in the ducts of the breast, then grows into fatty breast tissue. This type of breast cancer may spread to other parts of the body.

Invasive lobular carcinoma, also known as infiltrating lobular carcinoma, starts in the lobules of the breast. As one of the less common types, invasive lobular carcinoma may be difficult to detect via mammogram.

Inflammatory breast cancer, an uncommon type of invasive breast cancer, occurs when the cancer cells block the lymph vessels in the skin, causing inflammation, redness, pitted appearance, itchiness or tenderness. In this instance, a lump may not be detected

Paget disease, also rare, starts in the ducts and spreads to the skin of the nipple. Symptoms include crusted, scaly, red, bleeding, oozing, burning or itchy nipples.

Lastly, there are subtypes of breast cancer driven by hormones that will drive treatment decisions: hormone receptor-positive, HER2-positive and triple-negative breast cancer.

Breast Cancer: Diagnosis

After a biopsy or surgery to remove the breast cancer, a pathologist examines the tissue and may run additional tests to create a pathology report to help create an appropriate treatment plan for the patient. In addition, the use of an Oncotype Dx® Recurrence Score results may also be considered and used to determine certain treatment.

Stage 0, carcinoma in situ, is the earliest stage of breast cancer, followed by:

Stage 1: The tumor is 2 centimeters or smaller; the cancer has not spread outside of the organ; or small clusters of cancer cells are found in the lymph nodes.

Stage 2: There is no tumor, or the tumor is smaller than 2 centimeters, but the cancer is also found in the lymph nodes or the breast; or the tumor is larger than 2 to 5 centimeters, but the cancer has not spread to lymph nodes.

Stage 3: There is no tumor, or the tumor can be any size, but the cancer has spread to the lymph nodes; the tumor is larger than 5 centimeters and small clusters of cancer cells are found in the lymph nodes or the breast; or the tumor is larger than 5 centimeters and the cancer has spread to the lymph nodes.

Stage 4: The cancer has spread to other parts of the body, often in the bones, lungs, brain or liver.

Liver Cancer

OVERVIEW

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