Newly Diagnosed With Liver Cancer: First Steps

In most cancers, the team assesses the tumor. In liver cancer, they assess the tumor and the liver, and either one can rule out a treatment.

That is why two patients with the same size tumor can be offered completely different plans. One has a liver that can spare a piece. The other does not.

For 2026 the American Cancer Society projects 42,340 new cases of liver and intrahepatic bile duct cancer in the United States, with 30,980 deaths. SEER carries that projection; NCI's PDQ summary still reprints the 2025 version.

NCI lists the main risk factors for hepatocellular carcinoma, the most common primary liver cancer. They are chronic or persistent infection with hepatitis B, hepatitis C, or both, along with cirrhosis, heavy alcohol use, contamination with aflatoxin B1, and nonalcoholic steatohepatitis, shortened to NASH.

NIDDK defines cirrhosis as a liver that is scarred and permanently damaged, with scar tissue replacing healthy tissue so the organ cannot work normally. NIDDK also notes that symptoms may not appear until the liver is badly damaged.

If hepatitis B or C is part of your history, ask whether it is being treated now. That is a separate treatment track that runs alongside cancer care.

Many patients are surprised that a cancer diagnosis was made without taking tissue. There is a reason specific to this disease.

NCI states directly that AFP, alpha-fetoprotein, is insufficiently sensitive or specific for use as a diagnostic test. So a normal AFP does not rule out liver cancer, and a high one does not confirm it.

Imaging carries the weight instead. NCI reports that arterial uptake followed by washout on a single dynamic study is highly specific for hepatocellular carcinoma, at 95% to 100%, in lesions 1 to 3 cm. That pattern allows diagnosis without biopsy confirmation.

If your report describes arterial enhancement and washout, that phrase is the diagnosis.

NCI uses the Child-Pugh classification to grade liver function. StatPearls lays out how the score works.

Five items are scored, each worth 1 to 3 points.

• Encephalopathy, meaning confusion from liver failure.
• Ascites, meaning fluid buildup in the abdomen.
• Bilirubin, a blood marker of liver function.
• Albumin, a protein the liver makes.
• Prothrombin time or INR, a measure of clotting.

Totals run from 5 to 15 points. Child-Pugh A is 5 to 6 points, B is 7 to 9, and C is 10 to 15.

The class carries real weight for surgery. StatPearls reports mortality after abdominal surgery of 10% for class A, 30% for class B, and 70% to 80% for class C.

Ask for your class and your five component values. If someone says surgery is not an option, this score is often why.

NCI names the Barcelona Clinic Liver Cancer system, usually written BCLC, as the most accepted staging system for hepatocellular carcinoma. It combines tumor extent with liver function and performance status, which is why it points toward a treatment rather than only a stage number.

Surgical resection. Removing the tumor with a margin. NCI reports 5-year survival between 27% and 70%, depending on stage and liver function.

Liver transplant. This treats the tumor and the diseased liver at once. NCI describes the Milan criteria as a single lesion under 5 cm, or 2 to 3 lesions each under 3 cm. Five-year survival is approximately 70%.

Ablation. Radiofrequency ablation destroys tumor with heat delivered through a needle. NCI reports 5-year survival as high as 59% in tumors under 3 cm.

Transarterial chemoembolization, or TACE. Chemotherapy is delivered into the artery feeding the tumor, and that artery is then blocked. NCI reports improved survival compared with supportive care alone.

Stereotactic body radiation therapy. NCI reports local control of 70% to 95% at 2 years for smaller tumors.

Systemic therapy. NCI gives head-to-head numbers for first-line options. Atezolizumab with bevacizumab produced overall survival of 19.2 months against 13.4 months for sorafenib, with a hazard ratio of 0.66. Lenvatinib produced 13.6 months, noninferior to sorafenib at 12.3 months. Sorafenib itself produced 10.7 months against 7.9 months for placebo.

Four of the five Child-Pugh items are things you or your family can notice at home. A change in any of them may mean your liver function has shifted, which can change what treatment is possible.

• New or worsening confusion, drowsiness, or personality change. This is encephalopathy. Go to an emergency department, or call 911 if the person cannot be roused. MedlinePlus warns that it can worsen fast and become an emergency. Do not let them drive.
• Abdominal swelling that appears or grows quickly, or sudden weight gain. This is ascites. New ascites, or ascites with fever or belly pain, is an emergency-department visit, not a message left with the clinic.
• Yellowing of the eyes or skin, or urine turning dark. This points to rising bilirubin. Go to an emergency department if it comes on quickly, or comes with fever or confusion.
• Easy bruising, bleeding gums, nosebleeds that will not stop, or black stools. This points to clotting trouble. Black or tarry stools warrant an emergency department the same day.
• Fever of 100.4 degrees F, or 38 degrees C, or higher during chemotherapy. CDC treats this as a medical emergency, so go in rather than waiting. Skip the fever reducer until you are seen, since it can mask what is happening.

• Is this hepatocellular carcinoma, or a different liver cancer such as cholangiocarcinoma?
• Was the diagnosis made on imaging alone, and does my scan show arterial uptake with washout?
• What is my Child-Pugh class, and what are the five component values?
• What is my BCLC stage?
• Am I a transplant candidate under the Milan criteria, and if not, why not?
• Is my hepatitis B or C being treated at the same time?
• Which specialists are on my case: hepatologist, surgeon, interventional radiologist, and medical oncologist?
• Should this go to a liver tumor board before anything starts?

For related reading, see Cancer Staging, Getting a Second Opinion, and Imaging Tests.

• National Cancer Institute — Primary Liver Cancer Treatment (PDQ), Health Professional Version
• StatPearls (NCBI Bookshelf) — Use of the Child Pugh Score in Liver Disease
• NIDDK — Cirrhosis
• National Cancer Institute — Infection and Neutropenia during Cancer Treatment
• CDC — Fever and Cancer Treatment
• MedlinePlus — Hepatic encephalopathy
• American Cancer Society — Cancer Facts & Statistics
• SEER Cancer Stat Facts: Liver and Intrahepatic Bile Duct Cancer