The first 60 days: Hepatocellular carcinoma
Liver cancer almost always grows in a liver already damaged by hepatitis, alcohol or fatty liver disease. It is one of the most preventable cancers, and since 2020 immunotherapy combinations have roughly doubled how long people with advanced disease live. Below, week by week, is what OnCo's record of Hepatocellular carcinoma says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Advanced, Advanced (BCLC C), first line.
- RadiologistNamed in the standard of care for: Surveillance, Adjuvant after resection/ablation.
- SurgeonNamed in the standard of care for: Early, Very early / early (BCLC 0-A), Intermediate (BCLC B).
- Medical oncologistNamed in the standard of care for: Intermediate, Advanced, Intermediate (BCLC B), Advanced (BCLC C), first line and 3 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Intermediate, Very early / early (BCLC 0-A), Intermediate (BCLC B), Portal vein tumour thrombosis.
- Transplant and cell therapy teamNamed in the standard of care for: Early, Very early / early (BCLC 0-A), Advanced (BCLC C), first line.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Universal HBV vaccination; antiviral suppression of HBV; direct-acting antiviral cure of HCV; alcohol and metabolic risk reduction.
Resection, ablation, transplant.
TACE/TARE ± systemic therapy.
Ablation (RFA/microwave) for ≤3 cm; resection for preserved liver function; transplantation within Milan or downstaged criteria; radiation segmentectomy as an alternative.
TACE (conventional or DEB-TACE) or TARE; systemic therapy for high tumour burden or TACE-refractory disease; TACE + durvalumab-bevacizumab or STRIDE + lenvatinib prolong PFS (OS unproven).
No approved adjuvant therapy; IMbrave050 benefit not sustained. Surveillance imaging every 3-6 months.
Atezolizumab-bevacizumab, durvalumab-tremelimumab, or nivolumab-ipilimumab.
- 8.Advanced (BCLC C), first lineNCCN category Category 1 (preferred) for all three IO regimens, ESMO-MCBS IMbrave150 grade 5
Atezolizumab + bevacizumab (IMbrave150), STRIDE tremelimumab + durvalumab (HIMALAYA), or nivolumab + ipilimumab (CheckMate 9DW); lenvatinib or sorafenib if immunotherapy is contraindicated (transplant, active autoimmune disease).
Systemic immunotherapy; Y-90 radioembolisation where TACE is contraindicated; radiotherapy to the thrombus in selected patients.
After immunotherapy: lenvatinib, sorafenib, cabozantinib or regorafenib by extrapolation (no dedicated phase 3); ramucirumab if AFP ≥400 ng/mL; clinical trials.
Six-monthly ultrasound ± AFP in cirrhosis and high-risk HBV carriers; abbreviated MRI where ultrasound is inadequate.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example AFP, GPC3, Child-Pugh / ALBI liver function, AFP, BCLC stage and performance status), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include ViralHCC, Alcohol-related HCC, MASLD/MASH-related HCC.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Early
- For my situation (early), which of the standard options do you recommend and why?Guideline options include: Resection, ablation, transplant.
Intermediate
- For my situation (intermediate), which of the standard options do you recommend and why?Guideline options include: TACE/TARE ± systemic therapy.
Advanced
- For my situation (advanced), which of the standard options do you recommend and why?Guideline options include: Atezolizumab-bevacizumab, durvalumab-tremelimumab, or nivolumab-ipilimumab.
- Am I a candidate for Atezolizumab, Durvalumab, Nivolumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Prevention
- For my situation (prevention), which of the standard options do you recommend and why?Guideline options include: Universal HBV vaccination; antiviral suppression of HBV; direct-acting antiviral cure of HCV; alcohol and metabolic risk reduction.
Surveillance
- For my situation (surveillance), which of the standard options do you recommend and why?Guideline options include: Six-monthly ultrasound ± AFP in cirrhosis and high-risk HBV carriers; abbreviated MRI where ultrasound is inadequate.
Very early / early (BCLC 0-A)
- For my situation (very early / early (bclc 0-a)), which of the standard options do you recommend and why?Guideline options include: Ablation (RFA/microwave) for ≤3 cm; resection for preserved liver function; transplantation within Milan or downstaged criteria; radiation segmentectomy as an alternative.
Intermediate (BCLC B)
- For my situation (intermediate (bclc b)), which of the standard options do you recommend and why?Guideline options include: TACE (conventional or DEB-TACE) or TARE; systemic therapy for high tumour burden or TACE-refractory disease; TACE + durvalumab-bevacizumab or STRIDE + lenvatinib prolong PFS (OS unproven).
- How do the results of EMERALD-1 and LEAP-012 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Advanced (BCLC C), first line
- For my situation (advanced (bclc c), first line), which of the standard options do you recommend and why?Guideline options include: Atezolizumab + bevacizumab (IMbrave150), STRIDE tremelimumab + durvalumab (HIMALAYA), or nivolumab + ipilimumab (CheckMate 9DW); lenvatinib or sorafenib if immunotherapy is contraindicated (transplant, active autoimmune disease).
- Am I a candidate for Atezolizumab, Durvalumab, Tremelimumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of IMbrave150 and HIMALAYA apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Advanced, second line and beyond
- For my situation (advanced, second line and beyond), which of the standard options do you recommend and why?Guideline options include: After immunotherapy: lenvatinib, sorafenib, cabozantinib or regorafenib by extrapolation (no dedicated phase 3); ramucirumab if AFP ≥400 ng/mL; clinical trials.
- Am I a candidate for Cabozantinib, Regorafenib, Ramucirumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of RESORCE and CELESTIAL apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Adjuvant after resection/ablation
- For my situation (adjuvant after resection/ablation), which of the standard options do you recommend and why?Guideline options include: No approved adjuvant therapy; IMbrave050 benefit not sustained. Surveillance imaging every 3-6 months.
- How do the results of IMbrave050 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Portal vein tumour thrombosis
- For my situation (portal vein tumour thrombosis), which of the standard options do you recommend and why?Guideline options include: Systemic immunotherapy; Y-90 radioembolisation where TACE is contraindicated; radiotherapy to the thrombus in selected patients.
Any stage
- Are there clinical trials I could join, for example of FAPI PET, PF-08634404, Budigalimab, Livmoniplimab?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Liver function limits therapy”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Surveillance uptake in cirrhosis is poor”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- A Phase III Study of AK104 as Adjuvant Therapy in HCC With High Risk of Recurrence After Curative ResectionPhase 3 · recruiting · NCT05489289A Randomized, Double-blind, Phase III Clinical Study on the Efficacy and Safety of AK104 Versus Placebo as Adjuvant Therapy for Hepatocellular Carcinoma With High Risk of Recurrence After Curative Resection
- A Study Evaluating Atezolizumab and Bevacizumab, With or Without Tiragolumab, in Participants With Untreated Locally Advanced or Metastatic HepatocellPhase 3 · active · NCT05904886A Phase III, Randomized, Double-blind, Placebo-controlled Study Evaluating Atezolizumab and Bevacizumab, With or Without Tiragolumab, in Patients With Untreated Locally Advanced or Metastatic Hepatocellular Carcinoma
- A Study of AK104+Lenvatinib in Combination With Transarterial Chemoembolization (TACE) Versus TACE in Participants With Incurable/Non-metastatic HepatPhase 3 · recruiting · NCT06371157A Phase III, Randomized, Double-blinded, Multicenter Study of Cadonilimab (AK104) + Lenvatinib in Combination With Transarterial Chemoembolization (TACE) Versus TACE in Participants With Incurable/Non-metastatic Hepatocellular Carcinoma
- A Study of Nivolumab in Participants With Hepatocellular Carcinoma Who Are at High Risk of Recurrence After Curative Hepatic Resection or AblationPhase 3 · active · NCT03383458A Phase 3, Randomized, Double-blind Study of Adjuvant Nivolumab Versus Placebo for Participants With Hepatocellular Carcinoma Who Are at High Risk of Recurrence After Curative Hepatic Resection or Ablation
- A Study of Nofazinlimab (CS1003) in Subjects With Advanced Hepatocellular CarcinomaPhase 3 · active · NCT04194775A Multi-Center, Double-Blind, Randomized, Phase III Study to Investigate the Efficacy and Safety of Nofazinlimab (CS1003) in Combination With Lenvatinib Compared to Placebo in Combination With Lenvatinib as First-Line Therapy in Subjects With Advanced Hepatocellular Carcinoma (HCC)
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Hepatocellular carcinoma: the full pageLiver cancer almost always grows in a liver already damaged by hepatitis, alcohol or fatty liver disease. It is one of the most preventable cancers, and since 2020 immunotherapy combinations have roughly doubled how long people with advanced disease live.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Guidelines comparedNCCN, ESMO and NICE side by side for this cancer.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- BCLC staging: The liver-cancer staging system that combines tumour size, liver function and fitness to recommend treatment: ablation or surgery, transplant, TACE, or drugs.
- Hepatitis B and C as cancer causes: Two viruses cause most liver cancer worldwide.
- Child-Pugh score: A score of how well a damaged liver is still working, from five simple measures (bilirubin, albumin, clotting, fluid in the abdomen, confusion).
- Cirrhosis: Permanent scarring of the liver after years of damage from hepatitis B or C, alcohol or fatty liver disease.
- Child-Pugh and ALBI liver-function scores: Scores for how well the liver still works; in liver cancer they decide whether a patient can tolerate treatment at all.
- Dosimetry: Measuring how much radiation dose each organ and tumour actually received from a radioactive drug.
- TACE (transarterial chemoembolisation): Threading a catheter into the artery feeding a liver tumour and injecting chemotherapy plus particles that block the blood supply, starving and poisoning it at once.
- Portal vein tumour thrombus (macrovascular invasion): Liver cancer growing into the main vein that brings blood from the gut to the liver.
- Microwave ablation (MWA): Like radiofrequency ablation but using microwaves, which heat faster and larger volumes and are less affected by nearby blood vessels.
- Microenvironment and inflammation: tumours as wounds that do not heal: A tumour is not a lump of cancer cells but a tissue: fibroblasts, vessels and immune cells, recruited by the signals a wound uses and never told to stop.
Every term links to the glossary.