Bowel cancer that has spread to the liver: what happens next?

TL;DR

• When bowel cancer spreads to the liver, the spots in the liver are bowel cancer cells, not a new liver cancer. The liver is the most common place for bowel cancer to spread.
• Many people have no symptoms. Spread to the liver is often found on a routine scan after bowel cancer treatment.
• A team of specialists (an MDT) looks at how many spots there are and where they sit. That detail decides which treatments are possible.
• The main options are surgery, chemotherapy, heat treatment (ablation) and very precise radiotherapy (SABR), used alone or together.
• No one can tell you exactly what the future holds. Cancer Research UK figures give a general picture, and your own team can explain what applies to you.

When bowel cancer spreads to the liver, it means some cancer cells have travelled from the bowel and started to grow in the liver. What happens next depends on how many spots there are, where they sit and how well you are. A team of specialists will look at all of this before suggesting a plan, and for some people there are several treatment options to choose between.

This article explains what liver metastases are, how they are found, the main treatments and how those decisions are made. It is general information, not advice about your own care, which your own team is best placed to give.

What does it mean when bowel cancer spreads to the liver?

It means bowel cancer cells have reached the liver and formed one or more new spots there. A spot of cancer that has spread from where it started is called a metastasis, so doctors call these liver metastases, or secondary liver cancer.

This is not the same as liver cancer. Cancer Research UK explains that a secondary cancer is made of the same type of cells as the original one. The spots in your liver are bowel cancer cells, and they are treated as bowel cancer that has spread.

Bowel Cancer UK describes the liver as the most common place for bowel cancer to spread. Spread can be found at the same time as the bowel cancer itself, or months or years after the first treatment. The timing matters, because it can affect which treatments are suitable.

What are the signs that bowel cancer has spread to the liver?

Often there are none. Macmillan Cancer Support notes that secondary liver cancer may not cause any symptoms for a long time, and may only be found during routine tests, such as a follow-up scan.

When there are symptoms, Macmillan lists:

• loss of appetite, or feeling full soon after starting to eat
• weight loss
• feeling sick or being sick
• tiredness (fatigue)
• aching or pain on the right side of the tummy, near the ribs, and sometimes in the right shoulder
• a high temperature and flu-like symptoms
• a swollen tummy from fluid build-up (called ascites)
• yellowing of the skin and the whites of the eyes (jaundice)
• bruising and bleeding easily

These symptoms often have other causes. If you notice any of them, tell your doctor or specialist nurse so they can be checked.

How are liver metastases found and measured?

Liver metastases are found and measured with scans, blood tests and sometimes a biopsy. Cancer Research UK lists the tests you might have:

• Blood tests that show how well the liver is working.
• Ultrasound, which uses sound waves to build a picture of the liver.
• CT and MRI scans, which show the size and position of each spot in detail.
• PET-CT, which can show whether cancer is anywhere else in the body.
• A biopsy, where a small sample of tissue is taken with a needle, if the team needs to be certain what a spot is.

The aim is to count the spots and see exactly where they sit. That detail, more than anything else, decides which treatments are possible.

Who decides on treatment, and how?

Treatment is decided by a multidisciplinary team, or MDT: a group of specialists who meet to plan care together, and who then talk the options through with you. For spread to the liver, Bowel Cancer UK describes a team of liver experts working with your oncologist or surgeon.

NICE, which sets guidance for the NHS in England, says liver surgery should be considered after discussion by a team with expertise in this kind of operation, and that other local treatments should be discussed by a specialist team when surgery is not suitable.

The team looks at:

• how many spots there are, and how big they are
• where they sit in the liver, and what is next to them
• whether there is cancer anywhere else in the body
• how the cancer has behaved over time, and how it has responded to treatment so far
• your general health, and what matters to you

It helps to write your questions down before the appointment. Useful ones include: which treatments are possible for me, and why; what each would involve; what the side effects are; and what happens if I wait.

What are the treatment options for liver metastases?

There is no single treatment for liver metastases. Several approaches can be used alone or together, and each has limits and side effects.

Treatment	What it involves	When it may be considered
Surgery (liver resection)	Removing the part of the liver that contains the cancer	When the spots can be removed safely and enough healthy liver would be left
Chemotherapy and targeted drugs	Medicines that travel through the bloodstream	As the main treatment, or to shrink spots so another treatment becomes possible
Ablation	Destroying a spot with heat, delivered through a needle	Usually for small spots when surgery is not suitable
SABR	A short course of very precise, high-dose radiotherapy	For a small number of spots when surgery is not possible or not the right choice
SIRT or chemoembolisation	Tiny beads delivered into the liver’s blood supply	In particular situations, not as a first choice for most people

Surgery. NICE guidance says liver resection should be considered where it is possible, sometimes with chemotherapy before or after the operation. Bowel Cancer UK notes that surgery is not suitable for every bowel cancer patient. Recovery takes around six to eight weeks after open surgery, and around three to four weeks after keyhole surgery.

Chemotherapy and targeted drugs. These reach cancer wherever it is in the body. They may be the main treatment, or they may be used to shrink the spots so that surgery or another local treatment becomes possible. More is on the chemotherapy page.

Ablation. Cancer Research UK describes microwave and radiofrequency ablation. Radiofrequency ablation is usually used for tumours under 3cm, though it can treat tumours up to 5cm. The main side effects are pain and a high temperature for a few days. NICE says chemotherapy combined with ablation can be considered when surgery is not suitable.

SABR (stereotactic ablative radiotherapy). The beams come from many different angles and meet at the tumour, so the tumour receives a high dose and the tissue around it much less, as Cancer Research UK explains. More on how it works is on the SABR page.

SIRT and chemoembolisation. In SIRT, tiny radioactive beads are delivered into the blood vessels that feed the cancer. In chemoembolisation, beads coated with chemotherapy cut off much of the blood supply to the cancer. NICE says SIRT should not be offered as a first treatment for liver metastases that are unsuitable for local treatment.

Where does SABR fit for liver metastases?

SABR is one way to treat spots in the liver directly when surgery is not possible or not the right choice. It is part of a wider approach to oligometastatic cancer, meaning cancer that has spread to only a small number of places.

In England, a 2020 NHS England policy makes SABR routinely available on the NHS for people whose:

• first (primary) cancer is under control
• cancer has come back in up to three places, in organs that include the liver and lung
• spread appeared at least six months after the first cancer was treated

The same policy describes SABR as given in one, three, five or eight treatments, far fewer than a standard course of radiotherapy.

The evidence is still growing. NICE’s bowel cancer guidance recommends considering surgery for spots in the liver and, where surgery is not suitable, chemotherapy with ablation. It names stereotactic radiotherapy as an option for spots in the lung, but makes no specific recommendation about it for the liver. That is part of why the choice between surgery, ablation and SABR is made case by case, by a team that knows all of them.

The liver sits close to the stomach and bowel, which are sensitive to radiation and move from day to day. MR-Linac SABR uses a treatment machine with an MRI scanner built in, so the team can see the liver and the tissue around it during treatment and adjust the plan that day. It is one of the treatments Dr Harinarayanan plans and oversees, described on the MR-Linac SABR page. It is not needed for everyone: for many people, SABR on a standard machine, or a different treatment altogether, is the better fit.

What is the life expectancy when bowel cancer spreads to the liver?

No one can tell you exactly how long you will live. Figures can give a general picture, but your own outlook depends on things the numbers cannot capture.

Cancer Research UK figures show that around 10 in 100 people with stage 4 bowel cancer in England survive their cancer for 5 years or more after diagnosis. Stage 4 means the cancer has spread to another part of the body. This figure includes people whose cancer has spread widely, as well as those with a few spots in the liver.

For the smaller group of people who can have surgery to remove spread in the liver, the picture is different. Cancer Research UK reports a 2010 UK study in which around 45 in 100 people survived 5 years or more after the operation. That figure applies only to people who were well enough, and whose spots were suitable, for surgery.

Keep in mind that:

• statistics describe large groups of people, often diagnosed years ago, before some of today’s treatments were in use
• your outlook depends on how many spots you have, whether they can be treated directly, how your cancer responds and how well you are
• the best person to talk this through with is your own oncologist, who knows your scans

How can you get a second opinion?

You can ask your current team to refer you for a second opinion, or arrange one privately. Some people want their scans and options looked at again by another specialist, particularly when deciding between treatments. A second opinion does not mean leaving your current team.

Dr Harinarayanan is a consultant clinical oncologist in Southampton with a special interest in bowel cancer and in cancer that has spread to a few places. The second opinion page explains how a consultation or second opinion with him works, alongside your existing team.