PREVENTION
Primary prevention focuses on risk factors for HCC and their preventative measures and treatments. Nowadays, the actions and treatment to prevent HCC consist of universal HBV vaccination and wide implementation of anti-HBV therapy, when indicated, and direct-acting antiviral agents against HCV. They are crucial and likely to change the worldwide etiologic landscape of HCC. However, to prevent the complications of chronic HBV infection, the World Health Organization (WHO) recommends including hepatitis B vaccination in routine immunization services in all countries (universal vaccination starting with the newborn vaccination and particularly vaccination programs for adult people at risk).

Another essential strategy to prevent HCC related to chronic viral hepatitis is testing blood products for HBV and HCV and adopting actions to avoid transmission of HBV and HCV in healthcare settings.

At present, Chronic Alcoholic Liver Disease (ALD) has become one of the leading risk factors for HCC. Since these patients are frequently missed by surveillance programs, when they are diagnosed with HCC, the stage of their tumour is usually advanced. Therefore, it is imperative to carry out early diagnosis of ALD and management of cirrhosis-related complications. Moreover, the increasing incidence of non-alcoholic fatty liver disease (MASLD/MASH), together with metabolic syndrome and obesity, amplifies the risk of liver cancer. The broad implementation of HCC awareness and surveillance in high-risk patients is essential to reduce the high mortality from HCC.

EARLY DETECTION IN PEOPLE WITH RISK FACTORS
The risk of developing HCC is higher in people with cirrhosis due to HBV, HCV, alcohol, or MASLD/MASH. People with liver cirrhosis need abdominal ultrasound with or without analysis with alpha-fetoprotein every 6 months. The risk of HCC in former HCV patients is reduced but does not go away, particularly in patients with advanced fibrosis. Moreover, the risk of HCC is higher if there is obesity and/or diabetes

SURVEILLANCE
The decision to register a patient for a surveillance programme is determined by the risk of having HCC. Different factors such as age, co-morbidities, liver function, etc., should be taken into account. Surveillance is recommended for: patients with cirrhosis (irrespective of the etiology). Patients with hepatitis B or MASLD/MASH but no cirrhosis can develop HCC, although the annual incidence of HCC in these groups is lower than in patients diagnosed with cirrhosis. The preferred test for surveillance is ultrasonography every 6 months. Although specific data in patients with MASLD/MASH are lacking, some authors recommend novel blood tests and imaging-based surveillance strategies. HCC surveillance is underused in clinical practice, highlighting the need for interventions to identify at-risk individuals better and promote HCC surveillance completion.

DIAGNOSIS AND STAGING
Most people don’t exhibit symptoms in the early stages of HCC. However, when signs and symptoms do appear, they might be related to cancer or chronic liver disease. Hepatocellular carcinoma (HCC) is usually diagnosed through screening programs using ultrasounds every 6 months in people with cirrhosis. Once a lesion has been identified by ultrasonography, the diagnosis of HCC must be confirmed with the presence of characteristic features of an HCC using dynamic imaging tests such as CT or/and MRI with contrast that should confirm the diagnosis in a patient deemed to be at risk of the disease.

THE IMPORTANCE OF A MULTIDISCIPLINARY TEAM DURING ALL THE PROCESS
Patients diagnosed with HCC should be managed by a multidisciplinary team involving hepatologists, surgeons, radiologists, interventional radiologists, pathologists, and oncologists. Multidisciplinary experts sharing clinical information and decisions related to management can improve outcomes for patients with HCC.

PROGNOSTIC MODELS AND HCC STRATIFICATION
Barcelona Clinic Liver Cancer (BCLC) is the most used prognostic model for HCC. This classification categorizes the prognosis of HCC in 5 groups and guides the management of hepatocellular carcinoma, considering that, in general, HCC will need a sequential treatment. Barcelona-Clinic Liver Cancer (BCLC) staging gives a risk assessment classification and treatment schedule. Five stages are considered:
◉ Stage 0, Stage A: Patients with early HCC suitable for curative therapies: resection, liver transplantation, or percutaneous treatments (such as RFA).
◉ Stage B: Patients at the intermediate HCC stage may benefit from TACE (Transarterial chemoembolization).
◉ Stage C: Patients at the advanced HCC stage may receive, in selected cases, systemic agents or drugs in the setting of RCT.
◉ Stage D: Those patients with the end-stage disease will receive symptomatic treatment and supportive care.

CURRENT TREATMENT MODALITIES
Treatments of HCC may differ depending on the HCC stage the patient is diagnosed with. In early stages 0 or A, they include:
◉ Resection: removing the cancer and a part of healthy tissue that surrounds it.
◉ Liver transplant surgery: remove the entire liver and replace it with a liver from a deceased or living donor.
◉ Ablation: destroying cancer cells with heat or cold.

If the HCC is classified as an intermediate stage, the locoregional therapy may consist in delivering chemotherapy or radiation directly to cancer cells (TACE, Transarterial chemoembolization, or similar).

In more advanced HCC stages, treatment will be systemic and using targeted drug therapy. Targeted drugs, such as sorafenib, regorafenib, cabozantinib, nivolumab, etc., may help slow the progression of the disease in people with advanced liver cancer. In addition, psychological help in dealing with the burden of end-stage HCC should not be neglected or underestimated.

Due to the HCC characteristics, a patient has two diseases, cirrhosis and cancer, and the treatment is usually sequential and will be escalating through the stages. Patients should be managed by a multidisciplinary team to improve care and outcome.

HCC FROM PATIENTS’ AND FAMILIES’ PERSPECTIVE
Liver cancer might be associated with drug or alcohol abuse, which creates a stigma, although that is no longer the case for a large percentage of people who develop HCC. Patients’ and families’ experiences with HCC are connected to 4 major themes:

1: Illness perceptions. The perceptions of HCC covered a broad spectrum, highlighted by:
◉ Lack of information to prepare them for “the journey ahead,”
◉ Feelings of isolation,
◉ Unrealistic hopes,
◉ Feelings of lack of control.

2: Treatment confusion. Patients may experience:
◉ Uncertainty about treatments over time,
◉ Struggle with symptoms management,
◉ Doubts or regrets for receiving or not receiving treatment.

3: Quality of life. Symptoms affect everyday life, and many patients believe that the side effects compromise their quality of life.

4: Coping strategies. Patients and families experience a range of reactions to their diagnosis and develop their ways of coping.

THE ROLE OF LIVER PATIENTS’ ASSOCIATIONS
The role of Liver Patients’ Associations in HCC is crucial, and it is based on updated, and scientific information mainly focused on prevention since there is no one better than another patient to inform his peers. Patients’ associations are vital in this field since they inform in a simpler way so that patients understand better. The message must be clear, saying that we cannot play with health and cannot rely on news that can be found on the Internet or heard from a neighbour.

It is expected that patients are actively seeking medical knowledge in social media and are exposed to health-related content through these platforms. Based on ELPA’s experience, we are aware of the importance of social media to expand medical information.

Social media present an opportunity for patient education. The intersection of social media and health is unique, given its potential influence on public health. Considering patients’
perspective, social media may provide adequate context to disseminate updated information. Health education on social media could influence public health by improving health literacy, dispelling misconceptions and disinformation from inaccurate sources.