context: Hepatocellular carcinoma is a cancer that starts in your liver. It's different from "secondary" liver cancers, which have spread to the liver from other organs. If caught early, it can sometimes be cured with surgery or transplant. In more advanced cases it can't be cured, but treatment and support can help you live longer and better. It's important to remember that you still have control over the decisions you make about your treatment and your life. Make sure you have people you can talk to about your plans, your fears, and your feelings. Ask your doctor about support groups, where you can meet people who know what you're going through. Your doctor can help you understand your treatment options. Surgery, radiation, and chemotherapy are some of your choices. Immunotherapy and targeted therapy are also options. Doctors aren't sure exactly what causes all cases of hepatocellular carcinoma, but they've identified some things that may increase your risk for getting it: Hepatitis B or hepatitis C. Hepatocellular cancer can start many years after you've had one of these liver infections. Both are passed through blood, such as when drug users share needles. Blood tests can show whether you have hepatitis B or C. Cirrhosis. This serious disease happens when liver cells are damaged and replaced with scar tissue. Many things can cause it: hepatitis B or C infection, alcohol drinking, certain drugs, and too much iron stored in the liver. Heavy drinking. Having more than two alcoholic drinks a day for many years raises your risk of hepatocellular cancer. The more you drink, the higher your risk. Obesity and diabetes. Both conditions raise your risk of liver cancer. Obesity can lead to nonalcoholic fatty liver disease, which can lead to hepatocellular carcinoma. The higher risk from diabetes may be due to high insulin levels in people with diabetes or from liver damage caused by the disease. Iron storage disease. This causes too much iron to be stored in the liver and other organs. People who have it may develop hepatocellular carcinoma. Aflatoxin. This harmful substance, which is made by certain types of mold on peanuts, corn, and other nuts and grains, can cause hepatocellular carcinoma. The U. S. has safety measures that limit aflatoxin in the food supply. You might not have any symptoms when hepatocellular carcinoma is in an early stage. As the cancer grows, you may have one or more of these: Pain in the upper right part of your belly A lump or feeling of heaviness in your upper belly Bloating or swelling in your belly Loss of appetite and feelings of fullness Weight loss Weakness or deep fatigue Nausea and vomiting Yellow skin and eyes Pale, chalky bowel movements and dark urine Fever Your doctor will give you a physical exam and may ask you questions like: Have you had any pain in your belly? Are you feeling weak or tired? Is your appetite down? Have you lost weight? Your doctor may use tests to help diagnose hepatocellular carcinoma: Blood test. Your doctor takes a sample of your blood and checks to see if it has a protein called AFP. : Unborn babies have high levels of AFP, but it decreases in most people right after birth. If your blood has a high amount of AFP, it could be a sign of liver cancer. Imaging tests. Your doctor may ask you to get an ultrasound, CT scan, or MRI to look for tumors in your liver. An ultrasound creates images of your liver with sound waves. A CT scan is a powerful X-ray that makes detailed pictures inside your body. An MRI uses strong magnets and radio waves to make an image of your liver. Liver biopsy . Your doctor may want to remove a sample of your liver tissue and check it under a microscope for cancer cells. This can be done several ways. In one method, your doctor removes some liver tissue with a needle that he places through your skin and into your liver. He numbs the area first so you won't feel pain. Your doctor may also do a biopsy by making a small cut in your belly and putting a needle into the liver to pull out a sample of tissue. You'll get anesthesia first, so you won't be awake while this is going on. Has my liver cancer spread? What treatment do you recommend? What are the side effects? What can help my pain and treatment side effects? What kind of follow-up care will I need? There are many treatments for hepatocellular carcinoma. It's a big decision, so work closely with your doctor to make the right plan for you. Your choices may include: Radiation. This uses high-energy rays to kill your cancer cells. Two types of radiation therapy can treat hepatocellular carcinoma: External: You'll lie on a table while a large machine aims beams of radiation at specific spots on your chest or belly. Internal: A doctor injects tiny radioactive particles into the artery that sends blood to your liver. These block or destroy the blood supply to the tumor in your liver. Radiation therapy can cause side effects, including nausea, vomiting, or tiredness, but these symptoms go away when treatment is done. Chemotherapy. To treat cancer, doctors often place chemotherapy drugs directly into your liver. It's a process called "chemoembolization." Your doctor puts a thin, flexible tube into the artery that supplies blood to your liver. The tube delivers a chemo drug combined with another drug that helps to block the artery. The goal is to kill the tumor by starving it of blood. Your liver still gets the blood it needs through another blood vessel. You usually get chemotherapy on an outpatient basis, which means you don't need to stay overnight in a hospital. It can cause side effects, such as nausea and vomiting, loss of appetite, fever and chills, headache, and weakness. You may also be more likely to get infections, bruising, bleeding, and fatigue. Medicine can ease some of these side effects. Alcohol injection. This is also called "percutaneous ethanol injection." An ultrasound, which uses sound waves to see structures in your body, helps your doctor guide a thin needle into the tumor. Then he injects ethanol (alcohol) to destroy the cancer. You usually have this procedure under local anesthesia, which means you won't feel pain but you're awake while this is going on. Targeted therapy. The cancer is treated with drugs that target specific changes in cells that cause cancer. Some targeted therapies block new blood vessel growth in tumors. Others target certain proteins found on cancer cells that help tumors grow. Side effects can include: fatigue, rash, decreased appetite, diarrhea, pain, bleeding, blistering of hands and feet, and holes in the stomach or intestine. Immunotherapy. This treatment uses drugs that help stimulate your immune system to find and kill cancer cells. Immunotherapy drugs called immune checkpoint inhibitors are sometimes used to treat liver cancer. Side effects can include: fatigue, fever, rash, decreased appetite, pain, and an autoimmune reaction involving the lungs, liver, intestine, kidneys, and other organs. Cryoablation and radiofrequency ablation. In cryoablation, your doctor destroys your tumor by freezing it with a thin metal probe. While you're under anesthesia, your doctor puts the probe into the tumor and delivers a cold gas that kills the cancer cells. A similar method, called radiofrequency ablation, uses an electric current to kill the cancer with heat. Surgery to remove part of your liver. Your surgeon may take out the part of your liver that has the cancer, an operation called "partial hepatectomy." Healing time varies, but you might have pain and discomfort for the first few days. Medicine can help control it. You may also feel weak or tired for a while. Some people also have diarrhea and a sense of fullness in the stomach. Liver transplant . If your doctor can't remove your cancer through a partial hepatectomy, he may suggest a liver transplant. A liver transplant is major surgery. First, you'll need to get on a waiting list for a donor. Your new liver will come from someone who recently died and has the same blood type and a similar body size as yours. When donor livers are available, they go to the sickest people on the waiting list. Since you may have to wait a long time for a new liver, your doctor may suggest that you keep up with other treatments in the meantime. You may need to stay in the hospital for up to 3 weeks after your surgery. It could take you 6 months to a year before you can return to your regular lifestyle. After your transplant, you'll need to take drugs that prevent your body from rejecting the new liver. If you're considering a transplant, you'll need a lot of emotional support. Ask your doctor about support groups that have people facing the same concerns as you. Also ask about educational workshops that can explain what to expect before and after a transplant. While you're getting treatment, there are lots of things you can do to manage side effects and stay healthy. Since chemotherapy can sometimes upset your stomach, you can try changing some of your eating habits. For instance, stay away from fried or spicy foods. You can also try eating five or six small meals a day rather than the traditional three meals. If your treatment makes you tired, you can try to take short naps. You also might find that short walks can help boost your energy. If you're stressed about your treatment, sometimes deep breathing and meditation might help you relax. Reach out to family and friends who can give you emotional support when you need it. For some people, treatment makes the cancer go away. For others, the cancer may not go away completely or may return. If that's the case, you may need regular treatment to keep it in check for as long as possible. Your treatment to fight liver cancer may stop working. If that happens, you may want to focus on making sure you're as comfortable as possible, known as palliative care. You may not be able to control your cancer, but you control choices about how you'll live your life. You don't have to face things alone. Consider joining a support group, where you can you share your feelings with others who understand what it's like. For more information on hepatocellular cancer, go to the web site of the American Cancer Society. You can find out how to join support groups in your area. You can also learn how to take part in a clinical trial, which tests new drugs to see if they are safe and if they work. It's often a way for people to try new medicine that isn't available to everyone.