Liver cancer risk factors: hepatitis, cirrhosis, alcohol and fatty liver

What liver cancer is

Primary liver cancer starts in the liver. Metastatic liver cancer starts somewhere else in the body and spreads to the liver (MedlinePlus). This guide is about primary liver cancer in adults.

The most common type in adults is hepatocellular carcinoma (HCC). It typically develops in people with chronic (long-lasting) liver disease caused by hepatitis virus infection or cirrhosis (NCI risk factors).

Worldwide, liver cancer is the sixth most common cancer and the third leading cause of cancer death. In the United States it is the sixth leading cause of cancer deaths, and rates are highest in American Indian or Alaska Native people (NCI risk factors).

Risk factors

Not everyone with one or more risk factors gets liver cancer, and some people with no known risk factor do. People with several risk factors have an even higher risk, and men are more likely than women to develop HCC (NCI risk factors).

• Hepatitis B. The hepatitis B virus spreads through blood, semen and other body fluids: from mother to child at birth, through sex or by sharing needles to inject drugs. It can inflame the liver in a way that leads to cancer. Chronic hepatitis B is the leading cause of liver cancer in Asia and Africa (NCI risk factors).
• Hepatitis C. The hepatitis C virus spreads through blood, mostly by sharing needles to inject drugs and less often through sex. Before donated blood was tested for it, it also spread through blood transfusions and organ transplants. It can cause cirrhosis that may lead to liver cancer. Chronic hepatitis C is the leading cause of liver cancer in North America, Europe and Japan (NCI risk factors).
• Cirrhosis from any cause. In cirrhosis, scar tissue replaces healthy liver tissue and keeps the liver from working as it should. Long-term heavy drinking and chronic hepatitis are common causes. Cirrhosis linked to hepatitis C carries a higher liver cancer risk than cirrhosis linked to hepatitis B or alcohol (NCI risk factors).
• Heavy alcohol use. Heavy drinking can cause cirrhosis, but liver cancer can also occur in heavy drinkers without cirrhosis. Heavy drinkers who have cirrhosis are ten times more likely to develop liver cancer than heavy drinkers who do not. Heavy drinking also raises the risk in people with hepatitis B or C (NCI risk factors).
• Fatty liver disease. Nonalcoholic steatohepatitis (NASH), the most severe form of nonalcoholic fatty liver disease, can cause cirrhosis that may lead to liver cancer. Liver cancer has also been found in people with NASH who do not have cirrhosis (NCI risk factors). The newer names for these conditions are MASLD and MASH (NIDDK).
• Obesity and diabetes. MedlinePlus lists obesity and diabetes among the risk factors for primary liver cancer (MedlinePlus).
• Cigarette smoking. Smoking has been linked to a higher risk of liver cancer. The risk grows with the number of cigarettes a day and the number of years smoked (NCI risk factors).
• Aflatoxin B1. This poison comes from a fungus that can grow on foods such as corn and nuts stored in hot, humid places. Eating foods that contain it may raise the risk. It is most common in sub-Saharan Africa, Southeast Asia and China (NCI risk factors).
• Rare inherited and other conditions. Untreated hereditary hemochromatosis (an iron storage disease), alpha-1 antitrypsin deficiency, glycogen storage disease, porphyria cutanea tarda and Wilson disease may raise the risk (NCI risk factors) (MedlinePlus).

What can lower the risk

• Hepatitis B vaccine. Preventing hepatitis B by vaccinating newborns has been shown to lower the risk of liver cancer in children. It is not yet known whether vaccination lowers the risk in adults (NCI risk factors).
• Treating chronic hepatitis B. Treatments for chronic hepatitis B include interferon and nucleos(t)ide analog drugs, and they may reduce the risk of liver cancer (NCI risk factors).
• Less aflatoxin B1. Replacing foods high in aflatoxin B1 with foods much lower in it can reduce the risk (NCI risk factors).

Because hepatitis B and C, heavy drinking, smoking and fatty liver disease are on the risk factor list, the checks below can help you see where you stand. They do not measure liver cancer risk:

• the hepatitis B screening check and the hepatitis C screening check
• the FIB-4 calculator, which estimates liver scarring from a routine blood test, and the fatty liver index
• the AUDIT-C alcohol check and the quit smoking help check
• the guides to fatty liver disease and alcohol and cancer risk

Signs to check with a doctor

These can be caused by liver cancer or by other conditions. Check with your doctor if you have any of them (NCI):

• a hard lump on the right side just below the rib cage, or discomfort in the upper right part of the abdomen
• a swollen abdomen
• pain near the right shoulder blade or in the back
• jaundice (yellowing of the skin and whites of the eyes)
• easy bruising or bleeding
• unusual tiredness or weakness
• nausea and vomiting, loss of appetite or feeling full after a small meal
• weight loss for no known reason
• pale, chalky bowel movements and dark urine
• fever

You may have no symptoms until the cancer is advanced, which makes it harder to treat (MedlinePlus).

Screening: what NCI says

There is no standard or routine screening test for liver cancer. Ultrasound, CT scans and the alpha-fetoprotein (AFP) blood test are being used or studied for it. AFP can also be raised by pregnancy, hepatitis and other cancers (NCI screening).

Screening can give false-negative results, which may delay care, and false-positive results, which cause worry and lead to more tests such as a liver biopsy. A biopsy can rarely cause serious problems such as bleeding. NCI advises that your doctor can tell you about your risk and whether you need screening tests (NCI screening).

Common questions

I do not drink. Can I still get liver cancer?

Yes. Hepatitis B and C, fatty liver disease, smoking, aflatoxin and some inherited conditions also raise the risk (NCI risk factors), as do obesity and diabetes (MedlinePlus). Some people with no known risk factor get liver cancer too (NCI risk factors).

Does fatty liver disease turn into cancer?

The most severe form, NASH (now MASH), can lead to cirrhosis and then liver cancer, and liver cancer has been found in some people with NASH without cirrhosis (NCI risk factors). The fatty liver disease guide explains how doctors check for scarring.

Should I get a liver cancer screening test?

NCI says there is no standard or routine screening test for liver cancer, and that your doctor can advise you about your risk and whether you need screening (NCI screening).