Liver Cancer

Liver cancer is among the more common cancers in Singapore and the wider region, and is seen substantially more often in men — driven largely by chronic hepatitis B infection, which has historically affected a significant proportion of the Asian population. Unlike many other cancers, liver cancer very often develops on a background of pre-existing liver disease. This matters because it means the people most at risk can usually be identified in advance, monitored closely, and in many cases protected through regular surveillance.

Liver cancer occurs when cells within the liver — the body's largest internal organ, responsible for filtering the blood, metabolising nutrients and medications, and producing bile and essential proteins — begin to grow and divide abnormally. The most common form, hepatocellular carcinoma (HCC), typically arises in a liver already affected by cirrhosis or chronic viral hepatitis. Liver cancer can also arise from the bile ducts within the liver, or spread to the liver from a cancer elsewhere in the body.

What Is the Liver, and How Does Cancer Develop Here?

The liver sits beneath the ribcage on the right side of the abdomen and performs several hundred functions essential to life — filtering toxins from the blood, metabolising medications and nutrients, producing bile for digestion, and manufacturing the proteins that regulate blood clotting. It is also one of the few organs in the body capable of regenerating damaged tissue.

Liver cancer develops when liver cells accumulate genetic changes that cause them to grow uncontrollably. In the great majority of cases, this occurs against a backdrop of long-standing liver injury — chronic hepatitis B or C infection, cirrhosis from any cause, or fatty liver disease — in which repeated cycles of liver cell damage and regeneration create the conditions for cancerous change to take hold. Because of this relationship, the presence of underlying liver disease is itself one of the strongest predictors of liver cancer risk, independent of any symptoms a patient may or may not have.

Types of Liver Cancer

Several distinct cancers can affect the liver, and distinguishing between them matters for treatment planning.

• Hepatocellular Carcinoma (HCC): the most common type of primary liver cancer, beginning in hepatocytes — the liver's main functional cells. HCC is strongly linked to cirrhosis and chronic viral hepatitis.
• Intrahepatic Cholangiocarcinoma: a less common cancer that begins in the small bile ducts within the liver. It behaves differently from HCC and often calls for a different treatment approach.
• Hepatoblastoma: a rare form of liver cancer that occurs almost exclusively in young children.
• Secondary (Metastatic) Liver Cancer: cancer that has spread to the liver from another organ, most commonly the colon, breast, lung, or pancreas. This is distinct from primary liver cancer and is managed according to the original cancer type, though liver-directed treatments such as ablation are often part of its management too.

Symptoms of Liver Cancer

Early liver cancer, like many cancers arising deep within the abdomen, is frequently silent. Because the liver itself has few pain-sensing nerve endings, tumours can grow to a significant size before any warning sign appears — a key reason surveillance for high-risk patients is so important.

Early or non-specific symptoms

• Mild fatigue or reduced appetite
• Vague discomfort or a sense of fullness in the upper right abdomen
• Unintentional weight loss
• Mild, persistent nausea

Symptoms of more advanced disease

• Persistent abdominal pain, particularly in the upper right side
• Jaundice — yellowing of the skin and eyes
• Abdominal swelling caused by fluid build-up (ascites)
• Pale, chalky stools and unusually dark urine
• Easy bruising or bleeding
• A noticeable lump or fullness beneath the right ribcage

Symptoms requiring urgent assessment

• Sudden worsening of abdominal pain or swelling
• New or rapidly worsening jaundice
• Vomiting blood, or passing black, tarry stools
• New confusion or unusual drowsiness

Any of the symptoms above — particularly in a patient with known chronic liver disease — should prompt urgent medical assessment rather than a routine appointment

Risk Factors for Liver Cancer

Several factors increase the risk of developing liver cancer. Many relate to chronic liver disease, and several can be reduced through vaccination, treatment, or lifestyle change.

Underlying disease and non-modifiable risk factors

• Chronic hepatitis B infection — the leading cause of liver cancer in Singapore and across Asia; risk is present even without cirrhosis
• Chronic hepatitis C infection
• Cirrhosis of any cause
• Inherited or metabolic liver conditions, including haemochromatosis and Wilson's disease
• Family history of liver cancer
• Sex — men are affected substantially more often than women

Modifiable risk factors

• Excessive alcohol consumption — a leading cause of cirrhosis and liver cancer
• Non-alcoholic fatty liver disease, increasingly common alongside rising rates of obesity and diabetes
• Type 2 diabetes
• Obesity
• Aflatoxin exposure — a toxin from mould that can contaminate improperly stored grains and nuts
• Smoking

Hepatitis B and Liver Cancer in Singapore

Chronic hepatitis B infection is the single most important cause of liver cancer in Singapore, reflecting historically high rates of hepatitis B carriage in the region before universal infant vaccination was introduced. Patients with chronic hepatitis B are at increased risk of liver cancer even without cirrhosis, which is why hepatitis B status is checked as part of liver cancer risk assessment, and why patients with chronic hepatitis B require lifelong monitoring regardless of how well they feel. Antiviral treatment reduces, but does not eliminate, this risk — surveillance remains essential.

How is Liver Cancer Diagnosed?

Diagnosis combines blood tests, imaging, and — in selected cases — tissue sampling. Unusually among cancers, liver cancer can sometimes be diagnosed from its appearance on contrast imaging alone, without a biopsy, when a patient with known cirrhosis or chronic hepatitis B shows a typical pattern on scanning.

• Blood Test: Measures a protein often elevated in liver cancer, used alongside imaging for both surveillance and diagnosis. AFP can be normal even with confirmed liver cancer, so it is never relied on alone.
• Ultrasound: Often the first imaging test used, both for routine surveillance in at-risk patients and for initial assessment of a suspected liver mass. Painless and does not use radiation.
• CT / MRI: Contrast dye is injected and images are taken at several timed phases. The distinctive way liver cancer takes up and releases contrast allows a confident diagnosis in patients with cirrhosis, sometimes without a biopsy.
• Biopsy: A sample of the suspicious liver tissue is taken, usually guided by ultrasound or CT, and examined under the microscope. Used when imaging findings are inconclusive.
• Liver Function Tests & Hepatitis Screening: Blood tests assessing how well the liver is functioning, and confirming or excluding chronic hepatitis B or C — both essential for staging and treatment planning.
• Interventional Radiology: Supports image-guided biopsy as well as many of the liver-directed treatments described below, performed by specialists trained in minimally invasive, catheter-based techniques.

Living with Liver Cancer and Chronic Liver Disease

Because liver cancer so often accompanies chronic liver disease, ongoing management extends well beyond the tumour itself.

• Attend all scheduled surveillance appointments — liver cancer can develop between visits even when you feel entirely well
• Continue antiviral treatment for hepatitis B or C exactly as prescribed
• Avoid alcohol completely if you have cirrhosis or chronic liver disease
• Manage diabetes and body weight, both of which influence fatty liver disease progression
• Ensure household members are screened and vaccinated for hepatitis B where relevant
• Report any new abdominal symptoms promptly rather than waiting for the next scheduled review
• Discuss nutrition with your care team — maintaining adequate protein intake matters for patients with cirrhosis

Listen as Dr. Mark Fernandes discusses the purpose and benefits of liver screening: