Explaining Liver Cancer Treatment Options
Dr. Amit Singal didn't always know medicine would be his path. Growing up, his father was a physician. He saw the long hours and wondered if that kind of life was right for him. He thought about other jobs where he could still help people, like teaching. In the end, he returned to medicine. He found it challenging but also deeply rewarding and unlike any other field. The chance to make a real difference drew him in.
Choosing Hepatology
Dr. Singal's path to hepatology — the study of the liver — wasn't straightforward. He considered other specialties. Then he went into gastroenterology (GI). He liked the appeal of quickly solving urgent problems. In GI, one can treat a patient with bleeding with an endoscopy and send them home the next day.
But as he learned more about hepatology, he became fascinated. The liver is a unique organ. Doctors had made progress in studying it, but there was still so much left to learn and improve.
Today, Dr. Singal splits his time between clinical practice and research. This allows him to care for patients one-on-one in the clinic while he works on larger public health improvements.
How He Decides on Treatment for Liver Cancer
When liver cancer patients come to him, Dr. Singal begins with one central question: Is it curable?
The most aggressive curative option is often a liver transplant. This removes the cancer while treating the underlying liver disease, such as cirrhosis. Doctors use guidelines like the Milan criteria to decide who is eligible.
Sometimes patients have cancer that is too advanced for transplant under these criteria. In those cases, doctors can try downstaging. Downstaging involves shrinking the tumor to meet transplant requirements. This might include treatments like:
Chemoembolization: injecting chemotherapy-loaded beads into the liver
Radioembolization: injecting radiation-loaded beads into the liver
If the tumor responds well, the cancer has better biology, and the patient has a better prognosis. Patients who respond well to downstaging can get a transplant. Their chances of survival are about the same as those who qualified immediately.
The biggest problem happens when patients are not sent to a transplant center in time. By the time they are, their cancer may be too advanced for surgery. Dr. Singal stresses the importance of using a center that offers all possible treatment options from the start.
Curative and Non-Curative Options
If a transplant is not possible, there are other curative approaches:
Surgical resection, which involves cutting out the tumor. It's suitable for patients with good liver function and limited tumor size.
Ablation, which is burning the tumor directly.
If curative options are not possible, local or systemic therapies can still help:
Local therapies like chemoembolization or radioembolization
Systemic treatments, like immunotherapy, can shrink the cancer in about one out of three patients.
Risk of Cancer Coming Back
One couple Dr. Singal cared for was surprised to learn that liver cancer can come back after surgery. After a transplant, it returns in about 10% of patients. This is the lowest risk, since both the cancer and the damaged liver are removed.
With surgical resection or ablation, the risk jumps to 50–70% within five years. This happens because the liver disease is still there, creating conditions where new tumors can grow.
For years, trials aimed at reducing recurrence risk have failed. But a new trial has shown success. To lower the risk of cancer coming back, doctors can now give a mix of two drugs — atezolizumab and bevacizumab — for about a year after surgery or ablation. These drugs are already used to treat advanced liver cancer.
The Power of the Multidisciplinary Team
Treating HCC involves many specialists:
Transplant hepatologists
Surgeons
Interventional radiologists
Medical oncologists
Radiation oncologists
These teams meet in special groups called multidisciplinary tumor boards. There, all the doctors discuss the best plan for each patient. Research shows that this approach improves survival, increases curative options, and improves communication.
Who leads the team varies between centers. Dr. Singal says the best doctor is someone who knows the full range of HCC care, not just one area. Often, a transplant hepatologist is the best choice because liver disease affects every step of treatment.
Understanding the National Transplant List
The United Network for Organ Sharing (UNOS) handles organ allocation in the United States. UNOS ranks patients based on how urgent their need is, not on how long they've been waiting. Doctors use the MELD score to measure urgency for most people. But this score doesn't show how serious liver cancer really is. Liver function can look normal even when the cancer is life-threatening.
To fix this, UNOS gives liver cancer patients extra points to raise their priority. Changes to this policy sometimes give liver patients too much advantage and sometimes too little, causing significant differences in transplant access across regions. Now, UNOS is revising the system again. Their goal is to make it fair across the country while still giving liver cancer patients the right level of priority.
Final Advice
Dr. Singal's key message for liver cancer patients is simple:
Get evaluated early at a center that offers the full range of treatments
Seek care from experts who understand both the cancer and the underlying liver disease
Understand that liver cancer treatment is a team effort and that having the right team can make all the difference
