Liver Cancer

At a glance

Liver cancer is a malignant tumor that forms in the liver.

There is one thing about liver cancer that is very different from other cancers.
It mostly develops in a liver that is already in poor condition.
The National Cancer Information Center explains that most liver cancer patients also have chronic liver disease.

So liver cancer is "a cancer where you can tell to some degree who will get it".
It mainly develops in people who have hepatitis B or C, or liver cirrhosis.

The reason this matters is that if you know in advance and check regularly, it can be caught early.
This is also why the country supports screening every 6 months for these people only.

The liver is looked at as well

Another unusual thing about liver cancer treatment is that
the cancer is not the only thing looked at, and how well the remaining liver can work is looked at too.

Even if the tumor can be cut out, surgery is not possible if the remaining liver cannot cope.
This is why treatment differs from person to person even for cancers of the same size.

This page is reference information summarized from official sources.
For diagnosis and treatment, always talk to a medical professional.

Liver cancer has almost no symptoms in the early stage.
The liver is called 'the silent organ' because it shows no sign even when fairly damaged.

Below are the symptoms of liver cancer as listed by the National Cancer Information Center.
Most of them appear only after the disease has progressed to some degree.

• Abdominal pain (upper right side of the belly)
• A bloated feeling in the abdomen
• Weight loss
• Tiredness
• Jaundice — the whites of the eyes or the skin turn yellow

Waiting for symptoms is too late.
Liver cancer is a cancer to judge not by symptoms but by whether you are in a high-risk group.

People who must be tested even without symptoms

These are the high-risk groups for liver cancer set by the national cancer screening program (국가암검진).

• People with liver cirrhosis
• People who are hepatitis B antigen positive
• People who are hepatitis C antibody positive
• People with chronic liver disease caused by the hepatitis B or C virus

If this applies to you and you are aged 40 or over,
you can have national cancer screening every 6 months.

The most common of these is being a hepatitis B carrier.
Many people think "I am only a carrier and I am not ill, so I am fine",
but those are exactly the people the screening is for.

Other risk factors

• Drinking alcohol
• Non-alcoholic fatty liver disease

You can get liver cancer even if you never drink at all.
In Korea, hepatitis B and C are the main causes.

Where to go first

For the liver, it is gastroenterology.
At large hospitals it is often set up as a 'liver center' or a 'liver division of gastroenterology'.

If you are already being treated for hepatitis B or C,
you can simply carry on with the screening at the hospital you already attend.
There is no need to look for somewhere new.

After diagnosis

Liver cancer has many treatment methods, and several departments share the work accordingly.

• Gastroenterology — diagnosis and the overall treatment plan, chemotherapy, targeted therapy and immunotherapy
• Hepatobiliary and pancreatic surgery / general surgery — surgery to cut out part of the liver
• Radiology — embolization (treatment that puts medicine in through a blood vessel), radiofrequency ablation
• Radiation oncology — radiation therapy
• Transplant surgery — when a liver transplant is needed

If you ask "which department does this treatment?", the hospital will connect you.

Do I have to go to a large hospital

If liver cancer is confirmed or strongly suspected, you will be sent to a general hospital or a tertiary hospital.
This is because many of the treatments, such as embolization or liver transplant, need equipment and staff.

At a tertiary hospital you need a referral letter (진료의뢰서) for national health insurance (건강보험) to apply,
so it is best to get a referral from the hospital you have been attending.

Things to be sure to bring:

• A CD of your CT and MRI images and the reading report
• Your hepatitis treatment records and the name of the antiviral medicine you take
• Your blood test results so far (changes in liver values and AFP levels matter)

You can look for local clinics and large hospitals together on the map.

The screening stage — every 6 months

In the national cancer screening program, liver cancer has completely different rules from other cancers.

• Who — men and women aged 40 or over who are in a high-risk group for liver cancer
• How often — every 6 months (other cancers are every 1 to 2 years)
• Tests — a liver ultrasound plus a serum alpha-fetoprotein (AFP) test are done together

Here, the high-risk group means
**people with liver cirrhosis, people positive for hepatitis B antigen, people positive for hepatitis C antibody,
and patients with chronic liver disease caused by the hepatitis B or C virus**.

Why every 6 months?
Liver cancer grows relatively fast, so with only one check a year it can grow larger in between.
A short interval is a burden, but it is almost the only way to catch it early.

To see whether you qualify this year, check with the National Health Insurance Service (국민건강보험공단).

The diagnosis stage

• Abdominal ultrasound — the first imaging test done.
• AFP (alpha-fetoprotein) blood test — a tumor marker that can rise in liver cancer.
• CT / MRI — check the size and position of the tumor and how far it has spread. With liver cancer, how the tumor looks over time after contrast dye is given matters, so images are taken several times in stages.
• Tissue biopsy — a piece of tissue is taken for checking when this is needed.

AFP can rise when it is not liver cancer,
and it can also be normal in someone who does have liver cancer.
So it is judged together with imaging tests such as ultrasound, CT and MRI.
Do not be frightened by one number; listen to your medical team's explanation.

Liver cancer has an unusually large number of treatment methods.
The choice is made by looking at the size, number and position of the cancer along with the condition of the remaining liver.
The National Cancer Information Center describes the following treatments.

Treatments aimed at a cure

• Liver resection — the part of the liver with the cancer is cut out. It is the basic treatment when a cure is the aim.
• Liver transplant — in theory the most ideal treatment, because it replaces the damaged liver along with the cancer. But a donor and the right conditions are needed.
• Radiofrequency ablation (RFA) — a needle is inserted and heat burns the cancer away. It is the most widely used local treatment.
• Microwave ablation (MWA) and cryoablation — local treatments that work on a similar principle.

Treatments that slow the disease down

• Transarterial chemoembolization (TACE) — a tube is passed into the hepatic artery to deliver anticancer drugs and block the vessel. Along with the anticancer effect, it kills the cancer by cutting off its blood supply.
• Transarterial radioembolization (TARE) — very small beads containing a radioactive isotope are put in through a blood vessel.
• External beam radiation therapy — as the technology has improved, the range of cases it is used for has widened.
• Chemotherapy — these days targeted therapy and immunotherapy drugs are at the center of this.

Why it differs from person to person

Even for liver cancers of the same size, the treatment differs.
This is because how much the remaining liver can cope with is looked at as well as the cancer itself.

For someone whose liver is already badly damaged, surgery may be too much to bear,
so embolization or radiofrequency ablation, which are gentler on the body, may be chosen first.
It is not "why won't they operate on me", but choosing the method that suits your body right now.

Which treatments you have, and in what order, differs from person to person.
Talk it through fully with your medical team before deciding.

With liver cancer the process differs a lot by treatment method, so only the main ones are set out here.

If you have embolization (TACE)

1. A thin tube is passed in through a vessel in the groin and up to the hepatic artery.
2. Anticancer drugs are delivered and the vessel is blocked.
3. For a few days after the procedure you may have a fever, stomach pain or nausea. These reactions are common and the hospital will manage them.
4. You usually stay a few days. It often does not end in one session and is done several times in stages.

If you have radiofrequency ablation (RFA)

A needle is inserted while the position is watched on imaging, and heat burns the cancer.
Because the abdomen is not opened, it is gentler on the body and the hospital stay is fairly short.

If you have surgery (liver resection)

1. Tests before surgery — blood tests and an electrocardiogram, along with liver function tests. This step checks whether the remaining liver can cope after part of it is cut out.
2. Surgery
3. Recovery — the liver is an organ that regenerates, so the remaining liver grows to some extent. Meals are increased as recovery is watched.
4. After discharge — CT scans and blood tests are done regularly to see whether the cancer has come back.

Useful things to bring

• Your referral letter, ID and national health insurance card
• A CD of your CT and MRI images and the reading report
• The name of your hepatitis antiviral medicine (it often has to be taken right through treatment)
• A list of the medicines you take (especially blood thinners)

What to keep doing after treatment

Even when liver cancer treatment is over, the liver itself is still there.
So you need to keep having regular tests to check for a return of the cancer,
and you must not stop your hepatitis medicine on your own.

The length of stay and the steps involved differ by hospital and by treatment method.
For exact details, ask at the hospital where you will be treated.

The special cost-sharing program

If you are diagnosed with liver cancer, you can apply for the special cost-sharing program for serious illness (본인일부부담금 산정특례).
Once you are registered, the out-of-pocket rate for care related to that cancer drops sharply,
and it applies for a set period.

The application is usually made for you by the hospital that issued the medical certificate.
If you do it yourself, you submit a registration form to the National Health Insurance Service.

Screening costs

Liver cancer screening (liver ultrasound plus AFP) can be had
through the national cancer screening program every 6 months if you are in a high-risk group.

If you are not sure whether you qualify, ask the hospital you attend
or the National Health Insurance Service whether you are "eligible for liver cancer screening".
If you have a record of being treated for hepatitis B or C, it can usually be confirmed.

Other things

• Depending on your income level, you may qualify for the medical cost support program for cancer patients.
• For targeted therapy and immunotherapy drugs, the conditions under which national health insurance covers them differ from drug to drug. Always check with your medical team.
• For liver transplant, the costs and procedures are set separately. If you come to discuss a transplant, ask the hospital's social work team (사회사업팀) for guidance.

Programmes and out-of-pocket rates change.
What follows is a summary as of the reference date, so before you apply always check
the latest rules with the National Health Insurance Service.