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Symptom Management
in Hepatocellular Carcinoma
Virginia Chih-Yi Sun, RN, MSN, ANP,
and Linda Sarna, RN, DNSc, FAAN, AOCN®

Hepatocellular carcinoma (HCC) annually causes about one million deaths. Because of advanced stage at diagnosis, HCC
carries a five-year survival rate of less than 5% in patients diagnosed with unresectable disease. Incidence for HCC is
higher in men and individuals of Asian descent, where viral hepatitis, a leading cause of HCC, is endemic. This article will
provide an overview of the complex symptom management of patients with HCC. The occurrence of multiple symptoms,
including pain, fatigue, weight loss, and obstructive syndromes (e.g., ascites, jaundice) in patients with HCC is common.
Because of limitations in the efficacy of current treatment options, aggressive symptom management is key to preserving
physical functioning and quality of life in patients with HCC. A multidisciplinary team approach to symptom management
of patients with HCC is critical, with oncology nurses playing an integral role.

A
n estimated 21,370 new cases of hepatocellular
carcinoma (HCC) will be diagnosed in the United
States in 2008, and 18,410 individuals will die of
the disease (Jemal et al., 2007). HCC is the fifth-
most common malignancy worldwide, causing
about one million deaths annually (McCracken et al., 2007).
Incidence of HCC is highest in Africa and Asia, where viral
hepatitis is endemic. HCC often is diagnosed at advanced stages
and prognosis generally is poor when the tumor is unresect-
able. The extremely guarded prognosis often is coupled with
severe symptom occurrence, including pain, fatigue, anorexia,
and ascites (Zhu, 2003), impacting patients’ quality of life and
functional status. As a result, this article will describe the cur-
rent state of the science on symptom management in HCC, use
a clinical case presentation to describe the symptoms experi-
enced by patients with HCC while receiving treatment, and
identify nursing implications for the symptom management of
patients with HCC.
Epidemiology
Epidemiologic studies show that HCC (see Figure 1), although
uncommon in the United States and most developed countries,
is one of the world’s most frequent malignancies. This is caused,
in part, by higher incidence rates found in some of the most
populous regions of the world, including Southeast Asia and sub-
Saharan Africa (Seeff, 2004). Chronic viral hepatitis, a critical
risk factor for HCC, also is endemic in those regions. Other com-
mon risk factors for HCC include cirrhosis, aflatoxin exposure,
alcohol or tobacco use, metabolic disorders (e.g., hereditary
hemochromatosis), obesity, diabetes, dietary antioxidants, and
anabolic steroids (Yu & Yuan, 2004) (see Figure 2).
At a Glance
Common signs and symptoms, such as pain, ascites, and

jaundice, are potentially distressing in patients with hepa-
tocellular carcinoma (HCC) because of advanced disease and
guarded prognosis.
Aggressive symptom management using an interdisciplinary

model is key to maintaining quality of life in patients with
HCC and should be initiated at diagnosis.
Oncology nurses must be aware of the impact of multiple

symptoms in patients with HCC.
The global age-adjusted incidence of HCC per 100,000 is 14.67
for men and 4.92 for women (Di Bisceglie, 2002). HCC accounts
for 5.6% of all human cancers worldwide (Bosch, Ribes, Diaz, &
Cleries, 2004). The lowest rates are found in developed coun-
tries, and the highest in developing countries (Di Bisceglie).
For example, China has the highest incidence rates overall, ap-
proaching 35 per 100,000 people (Di Bisceglie). Incidence rates
Virginia Chih-Yi Sun, RN, MSN, ANP, is a senior research specialist in the
Department of Nursing Research and Education in the Division of Popu-
lation Sciences at City of Hope National Medical Center in Duarte, CA;
and Linda Sarna, RN, DNSc, FAAN, AOCN®, is a professor in the School
of Nursing at the University of California, Los Angeles. This article was
supported by a National Institute of Health/National Institute of Nursing
Research Predoctoral Fellowship (T32 NR007077). (Submitted February
2008. Accepted for publication April 5, 2008.)
Digital Object Identifier:10.1188/08.CJON.759-766

Clinical Journal of Oncology Nursing • Volume 12, Number 5 • Symptom Management in Hepatocellular Carcinoma 759

Figure 1. Hepatocellular Carcinoma, a Malignant
Tumor of the Epithelial Cells in the Liver
Note. Copyright by ISM/Phototake. All rights reserved. Used with
permission.
of HCC in the United States prior to the 1980s were relatively low
(2.1%–2.5%); however, the annual incidence rate has increased
about 80% since the late 1980s (El-Serag & Mason, 1999). Overall,
HCC tends to occur earlier in life (20–35 years of age) for those
in countries with the highest incidence (Di Bisceglie). Mortality
rates follow a pattern consistent with incidence rates; the yearly
fatality ratio is about one, indicating that most patients do not
survive more than a year (Bosch et al.).
Incidence rates in the United States are lowest in Caucasians,
but increasing rates are found in Japanese, African American,
Hispanic, Filipino, Chinese, and Korean populations (Bosch et al.,
2004). In the United States, HCC occurs more frequently in males,
with incidence rates among African American men twice as high
as Caucasian men (Monto & Wright, 2001). In North America and
Europe, Asian males have a 1.3–10.9-fold increase in HCC mortal-
ity, which is the highest compared to all other ethnicities (Hanley,
Choi, & Holowaty, 1995; Rosenblatt, Weiss, & Schwartz, 1996).
Current Management
Most treatments for HCC (e.g., surgical resection, chemo-
embolization, percutaneous ethanol injection, radiofrequency
ablation, cryosurgery) are palliative in nature and require
extensive follow-up patient care. To date, the only potentially
curative treatment for HCC is partial hepatectomy, but only 20%
of patients are considered eligible for surgical resection (Zhu,
2003). For more advanced and unresectable diseases, overall
median survival is about eight weeks (Leung & Johnson, 2001).
In addition, local recurrence will occur despite curative intent
resection (Little & Fong, 2001). Although the perioperative
mortality for partial hepatectomy is less than 5% in specialized
centers because of advances in surgical technologies (Carr,
2004), potential postoperative complications (e.g., portal hy-
pertension, ascites) warrant extensive postoperative monitor-
ing (Little & Fong). Complications associated with other local
ablative therapies include hemorrhage, acute cholecystitis, liver
infarction, bile duct necrosis, abscess formation, pleural effu-
sions, and acute pancreatitis (Song, Ip, & Fong, 2004).
Surgical resections of varying degrees remain the standard
treatment for HCC. Although postsurgical recurrence rates
760 October 2008 • Volume 12, Number 5 • Clinical Journal of Oncology Nursing
have decreased and survival has increased since the late 1980s,
most patients still have only a 50% five-year survival rate (Carr,
2004). The most important parameter to consider when choos-
ing patients for partial hepatectomy is baseline hepatic func-
tion (Song et al., 2004). The most common evaluation tool for
patients being considered for partial hepatectomy remains
the Child-Pugh Classification (Child & Turcotte, 1964; Pugh,
Murray-Lyon, Dawson, Pietroni, & Williams, 1973) (see Table
1). The prognostic tool is useful in predicting perioperative
and postoperative mortality in abdominal surgery patients with
cirrhosis (Garrison, Cryer, Howard, & Polk, 1984; Mansour, Wat-
son, Shayani, & Pickleman, 1997). A numeric score is assigned
for patients in each parameter (albumin, bilirubin, prothrombin
time, ascites, encephalopathy); then patients are categorized
into Child A (5–6 points), B (7–9 points), or C (10–15 points),
with class C patients presenting the most abnormalities within
each parameter. Other factors that dictate resectability include
absence of extrahepatic lesions, size of residual liver, and exper-
tise of the surgical team (Song et al.). Perioperative mortality
and postoperative morbidity largely depend on the presence or
absence of cirrhosis. Patients with HCC and cirrhotic livers have
thrombocytopenia, coagulopathy, and varices, which increase
the likelihood of operative bleeding. An increasing array of lo-
calized semisurgical treatments has become accepted wildely,
including percutaneous ethanol injection, radiofrequency abla-
tion, and cryotherapy (Carr). Local ablative therapies generally
are useful in patients with multiple lesions and as a method to
preserve residual liver function when used with surgery. Liver
transplantation is a final option for patients with inoperable
HCC, but rigorous eligibility criteria must be fulfilled for pa-
tients with HCC to compete for healthy livers.
Transarterial chemoembolization is the localized intra-arterial
delivery of chemotherapeutic agents that are emulsified in an
oily medium and combined with embolic material. The rationale
behind this localized treatment arose from the observation that
healthy liver tissue receives as much as 80% of its blood supply
from the portal vein, whereas liver tumors receive blood en-
tirely from the hepatic artery. Therefore, the hepatic artery is
a logical means to target liver tumors while preserving normal
liver function (Ramsey, Kernagis, Soulen, & Geschwind, 2002).
The partial or complete occlusion of the hepatic artery induces
tumor necrosis but will not affect normal liver tissue because
of the different blood supply route. The goal of chemoemboliza-
tion treatment is to deliver a highly concentrated dose of che-
motherapy directly to the tumor cells. A second objective is to
preserve as much functional liver tissue as possible. Significant
Aflatoxin exposure Excessive alcohol consumption
Anabolic steroids (> 80 g per day or 6–7 drinks
Chronic hepatitis B per day for 10 years)
Chronic hepatitis C Heavy smoking (≥ 40 cigarettes
Chronic liver disease (cirrhosis) per day for 10 years)
Diabetes Hereditary hemachromatosis
Dietary antioxidants Obesity
Figure 2. Causes of Treatment Uncertainty
in Men With Prostate Cancer
Note. Based on information from Yu & Yuan, 2004.

Table 1. Child-Pugh Classificationa
Points
Variable 1 2 3 demonstrated statistically significant improvements in survival
Albumin level > 35 30–35 < 30
Bilirubin level < 50 50–75 > 75
Prothrombin time > 60 40–60 < 40
Ascites None Mild Tense
Encephalopathy stage None I–II III–IV
a
Child-Pugh grade is the sum of individual points for the five variables.
A: 5-6, B: 7-9, C: 10-15
Note. Based on information from Kadry et al., 2004.
improvements in long-term survival have been demonstrated
but are not supported by randomized trials. A meta-analysis
demonstrated that four randomized clinical trials comparing
patients undergoing transarterial chemoembolization with un-
treated controls have failed to show an effect on patient survival
(Geschwind, Ramsey, Choti, Thuluvath, & Huncharek, 2003).
Systemic chemotherapy has been studied extensively in HCC,
but limited published data have shown a response rate higher
than 20% with no survival benefit compared to supportive care
alone (Carr, 2004).
Selective internal radiation therapy using radiolabeled mi-
crospheres is a current therapeutic option for patients with
HCC. The microspheres are administered intra-arterially,
resulting in high radiation doses delivered to the arterial-fed
tumors while sparing normal liver parenchyma (Geschwind
et al., 2004). The one-year survival rate for patients treated
with the microspheres is about 63%, which is similar to rates
reported in patients receiving transarterial chemoembolization
(Geschwind et al., 2004). The side-effect profile is similar to
those seen in other localized procedures such as transarterial
chemoembolization, including mild abdominal pain, nausea,
and fever (Popperl et al., 2005).
To date, the search for novel agents in the treatment of HCC
has focused on targeted therapies. One agent, sorafenib, is an
oral multikinase inhibitor of the Raf kinase and receptor ty-
rosine kinases that has been approved for renal cell carcinoma.
A phase II study tested the efficacy of sorafenib (400 mg BID)
in patients with HCC, inoperable disease, no prior systemic
treatments, and Child-Pugh class A or B. Sorafenib showed mod-
est efficacy, with 33.6% of patients (n = 137) achieving stable
disease for at least 16 weeks and median overall survival of 9.2
months (Abou-Alfa et al., 2006). In the study, grade 3 or 4 toxici-
ties included fatigue (9.5%), diarrhea (8%), and hand-foot skin
reactions (5.1%) (Abou-Alfa et al.). A subsequent randomized,
placebo-controlled phase III study called the Sorafenib HCC As-
sessment Randomized Protocol was conducted to evaluate the
efficacy and safety of sorafenib (400 mg BID) versus placebo.
Inclusion criteria were patients with advanced measurable HCC
and no prior systemic treatments, Eastern Cooperative Oncol-
ogy Group performance status of 0–2, and Child-Pugh class A.
Results suggested that sorafenib was superior in median over-
all survival (10.7 versus 7.9 months), presenting a 44% overall
survival improvement (Llovet, Ricci, & Mazzaferro, 2007). The
most frequent grade 3 or 4 toxicities included diarrhea (11%
Clinical Journal of Oncology Nursing • Volume 12, Number 5 • Symptom Management in Hepatocellular Carcinoma 761
versus 2%), hand-foot skin reactions (8% versus 1%), and fatigue
(10% versus 15%) (Llovet et al.). The placebo group had higher
percentages of fatigue (15% versus 10%) and bleeding (9% versus
6%). Although sorafenib was the first agent in decades to have
for patients with advanced HCC, nurses must take caution. The
agent was tested only in patients with Child-Pugh class A and
high performance status; therefore, the agent’s efficacy for
patients with lower performance status and higher Child-Pugh
scores is unknown.
Signs, Symptoms, and Management
Table 2 provides a list of the common HCC symptoms and
treatment strategies. Patients with HCC usually are asymptomatic
during the early stages of disease. However, 80% of patients with
HCC will be diagnosed with advanced-stage disease (Cahill &
Braccia, 2004). About 90%–95% of patients with HCC will present
with the triad of right upper-quadrant pain, palpable mass, and
weight loss (Bartlett, Carr, & Marsh, 2005). Patients typically pres-
ent with an enlarged, irregular, and nodular liver. Other physical
findings include hepatic bruits (25%), ascites, splenomegaly, jaun-
dice, wasting, and fever. Liver function tests and jaundice may not
appear until late in the disease trajectory because of the organ’s
functional reserve capability (Cahill & Braccia).
Patients with terminal HCC may present with various symp-
toms related to decompensated cirrhosis, including ascites, va-
riceal bleeding, peripheral edema, and hepatic encephalopathy
(Lin et al., 2004). In a cohort of Taiwanese patients with HCC, the
most common symptom was abdominal pain (75.5%), originating
from an enlarged tumor mass and characterized by dull visceral
pain (Lin et al., 2004). Other common symptoms included fa-
tigue or weakness, peripheral edema, cachexia, ascites, dyspnea,
anorexia, and vomiting (Lin et al.). Patients diagnosed with HCC
had the third-highest level of psychiatric distress among patients
with eight other types of cancer (Zabora, BrintzenhofeSzoc,
Curbow, Hooker, & Piantadosi, 2001).
Patients with cancer experience a significant number of
symptoms as a direct or indirect result of disease, treatment,
and comorbidities that are often complex, multifactorial, and
challenging to manage. To date, the majority of symptom-related
research focuses on a single symptom. However, symptom
presentation includes multiple symptoms, and the relationship
among those symptoms, their underlying mechanisms, and
impact on patient outcomes still are being explored. In addi-
tion, unrelieved symptoms have a negative effect on patient
outcomes, including functional status, mood states, and quality
of life (Miaskowski, Dodd, & Lee, 2004).
The concept of symptom clusters has gained momentum in
current symptom-related research. Although the occurrence of
multiple symptoms has been studied previously (Sarna, 1993),
the phenomenon was not labeled “symptom clusters” until
the 2000s. To date, several working definitions for symptom
clusters exist in nursing research. Dodd, Miaskowski, and Paul
(2001) defined symptom clusters as three or more concurrent,
related symptoms that may not share a common etiology. Kim,
McGuire, Tulman, and Barsevick (2005) developed a more com-
prehensive definition by reviewing the research and ultimately
defining symptom clusters as two or more related symptoms

Table 2. Management of Common Symptoms
in Hepatocellular Carcinoma
Symptom treatment
Abdominal pain Opioid analgesics (moderate to severe), non-
steroidal anti-inflammatory drugs (mild)
Fatigue Treatment of contributing factors, if indicat-
ed: anemia (erythropoietin), depression (an-
tidepressants), sleep disturbance, nutritional
deficiencies, deconditioning (exercise), and
decreased energy level (psychostimulants)
Anorexia Treatment of contributing factors, if indicated:
or cachexia chronic nausea (antiemetics), constipation
(laxatives), and depression (antidepressants)
Pharmacologic: megestrol acetate
Others: dietary counseling and artificial
nutrition
Ascites Pharmacologic: diuretics (potassium-sparing
and loop)
Procedural: paracentesis
Jaundice secondary Percutaneous drainage and biliary stent
to biliary obstruction
For cholestatic pruritus: cholestyramine and
self-care measures (emollients and perfume-
free soaps)
Note. Based on information from Del Fabbro et al., 2006; Greenway
et al., 1982; Jones & Bergasa, 2000; National Comprehensive Cancer
Network, 2007a, 2007b.
that occur together (Kim et al.). The clusters are composed of
stable symptom groups, are relatively independent from other
clusters, and may uncover specific underlying symptom dimen-
sions. Symptoms within a cluster may or may not share a com-
mon etiology, and the relationship among symptoms within a
cluster is associative rather than causal (Kim et al.).
The exploration of potential symptom clusters is critical to
the development of effective symptom management strategies
for patients with HCC, particularly those with unresectable,
metastatic disease. The identification of clusters specific to
therapies (e.g., surgery, chemotherapy, liver-directed therapies)
contributes to the specific symptom management needs of pa-
tients with HCC based on treatment modalities.
Pain
Pain is one of the most common and distressing symptoms
in patients with cancer. Abdominal pain is common in HCC
because of visceral involvement that originates from a pri-
mary or metastatic lesion in the abdominal or pelvic viscera
(Mercadante, 2002). Treatment-related pain also is common
in patients with HCC. Postembolization syndrome occurs
in 80%–90% of patients with HCC treated with transarterial
chemoembolization (Ramsey et al., 2002). Postembolization
syndrome often includes abdominal pain, ileus, fever, nausea,
and vomiting, and can last from hours to days (Ramsey et al.).
762 October 2008 • Volume 12, Number 5 • Clinical Journal of Oncology Nursing
Pain can occur during and after transarterial chemoemboliza-
tion, and patients who did not experience distressing pain levels
during the procedure are vulnerable to postprocedural pain
(Lee, Hahn, & Park, 2001).
Pain treatment in patients with HCC begins with a compre-
hensive assessment of the clinical characteristic of visceral pain.
Referred visceral pain in HCC often is found in the right shoul-
der (Mercadante, 2002). Opoid analgesics remain the standard
treatment for severe pain. Several options exist for the delivery
of opioids (oral, parenteral, transdermal, transmucosal or sub-
lingual, rectal, and spinal). The route of administration must
be determined based on the patient’s ability to use the specific
route, efficacy of the route in delivering adequate analgesia, ease
of use for the patient and family, associated complications, and
cost (Mercadante). In visceral pain, nonsteroidal anti-inflamma-
tory drugs produce an analgesic effect similar to opioids and are
particularly useful when pain is mild (Mercadante et al., 1999).
Nurses should refer to the Oncology Nursing Society’s ([ONS’s],
2008b) Putting Evidence Into Practice® card for pain, which
provides detailed evidence-based information on the assessment
and management of pain.
Fatigue
Fatigue, a common and distressing symptom in patients with
cancer, is caused by advanced disease and treatment. Fatigue
is part of the postembolization syndrome associated with tran-
sarterial chemoembolization. Patients usually experience mild
to moderate levels of fatigue that peak on the second day after
transarterial chemoembolization (Shun et al., 2005). Although
fatigue level gradually decreases two days after treatment, the
level is still higher than pretreatment at six days after treatment
(Shun et al.). The pattern of fatigue in patients undergoing tran-
sarterial chemoembolization with doxorubicin is similar to the
pattern following systemic administration of the same agent
(Lai et al., 2007).
Fatigue management in patients with HCC should begin
with an in-depth assessment of contributing factors, including
pain, emotional distress, sleep disturbance, anemia, nutritional
deficiencies, deconditioning, and comorbidities (Mock, 2004).
Treating the factors as an initial approach may increase the
tolerability of fatigue. Pharmacologic interventions targeted
toward the contributing factors associated with fatigue include
erythropoietin for chemotherapy-induced anemia, antidepres-
sants for depression-related fatigue, and psychostimulants for
increasing energy level. Evidence in the literature also supports
the use of methylphenidate for reducing fatigue in advanced
cancer (Bruera et al., 2006). In addition, considerable evidence
shows the efficacy of nonpharmacologic interventions (e.g.,
aerobic exercise) on fatigue reduction (Courneya et al., 2003;
Dimeo, Stieglitz, Novelli-Fischer, Fetscher, & Keul, 1999; Mock
et al., 1997; Schwartz, Mori, Gao, Nail, & King, 2001; Segal et al.,
2003). Proper sleep hygiene and energy conservation are help-
ful self-care strategies that patients can use at home. A careful
review of patients’ medications also may identify adverse ef-
fects that aggravate fatigue. In addition, ONS’s (2008a) Putting
Evidence Into Practice® card for fatigue is a comprehensive
resource for accessing evidence-based information on the as-
sessment and management of fatigue.

Case Study
Mr. S, an insurance agent, lived with his wife and had two grown
children. Mr. S was a member of the local Greek Orthodox Church,
and he reported no history of tobacco, alcohol, or drug use. He was
an otherwise healthy 67-year-old man who presented with diarrhea
and abdominal bloating following a course of antibiotics for treat-
ment of a tooth abscess. He complained of persistent abdominal pain
and swelling after completion of antibiotics; computed tomography
scan and ultrasound confirmed a liver mass. A subsequent biopsy
revealed well-differentiated hepatocellular carcinoma (HCC). The tu-
mor was about 6 cm in size and located in the center of the left lobe.
At the time of diagnosis, Mr. S also had moderate ascites. He did not
have a history of viral hepatitis, although his antibody titers were
positive on screening. Comorbidities included diabetes, which was
well controlled with insulin. Mr. S had moderate bilateral peripheral
edema of the lower extremities. On further evaluation, Mr. S had a
Child-Pugh C (elevated prothrombin time, elevated total bilirubin,
lowered albumin, and moderate ascites) classification. Based on its
size and location, the tumor was surgically resectable, but Mr. S’s
Child-Pugh classification made surgery unsafe. Mr. S was referred for
chemoembolization. Spironolactone and furosemide were prescribed
for his ascites. He also needed frequent paracentesis. No family his-
tory of hepatitis or HCC was present.
Mr. S was scheduled for chemoembolization using doxorubicin,
mitomycin C, and cisplatin. However, the procedure was considered
unsuccessful because of significant intratumoral arteriovenous
shunting. He tolerated the procedure well with no severe postem-
bolization syndrome except for mild transient abdominal pain
and mild fatigue. After chemoembolization, his ascites gradually
returned, and Mr. S began to experience mild abdominal disten-
tion and pain. Liver function tests also were increasing two days
after the procedure. After discharge, the patient had increasing
abdominal distension refractory to medications and dyspnea, so
paracentesis was performed. Because of decreasing performance
status and worsening liver function, Mr. S was not a candidate for
further treatment.
Anorexia-Cachexia
Weight loss is a frequent complication in patients with HCC.
The incidence of weight loss is greater than 54% in most patients
with cancer and reaches 80% in the terminal stage (Strasser &
Bruera, 2002). Cachexia can be separated into primary (meta-
bolic) and secondary (starvation) stages. Anorexia, a leading
symptom of the metabolic cachexia syndrome, is separate from
weight loss; therefore, a common term for cancer-wasting syn-
drome is anorexia-cachexia syndrome (Strasser & Bruera). The
diagnosis of anorexia-cachexia syndrome is based on simple as-
sessment of weight loss and anorexia, but no established tools or
guidelines are available that distinguish primary and secondary
cachexia. Other parameters (e.g., hypoalbuminemia, asthenia,
chronic nausea, reduced caloric intake, clinical judgment of
reduced muscle and fat mass) can serve as additional criteria
for the presence of cachexia (Strasser & Bruera). The criteria
can help patients with HCC with relevant fluid retention (e.g.,
ascites, edema) in which the accumulation of excess fluid masks
the extent of weight loss (Strasser, 2000).
The management of anorexia-cachexia syndrome in patients
with HCC begins with a thorough assessment of potential con-
tributors, including chronic nausea, constipation, early satiety,
Clinical Journal of Oncology Nursing • Volume 12, Number 5 • Symptom Management in Hepatocellular Carcinoma 763
taste alterations, and depression (Del Fabbro, Dalal, & Bruera,
2006). Pharmacologically, at least 15 randomized clinical trials
have demonstrated that megestrol acetate (doses ranging from
160–1,600 mg per day) significantly improves appetite when
compared to placebo (Pascual Lopez et al., 2004). Artificial nutri-
tion (e.g., total parenteral nutrition) is used frequently but does
not increase lean body mass (Muscaritoli, Bossola, Aversa, Bellan-
tone, & Rossi Fanelli, 2006). Individualized dietary counseling in
recent randomized clinical trials in patients with cancer has been
effective in improving food intake, nutritional status, and quality
of life (Ravasco, Monteiro-Grillo, Vidal, & Camilo, 2005).
Obstructive Syndromes
About 19%–40% of patients with HCC present with jaundice
at the time of diagnosis, and the condition usually occurs in later
stages (Qin & Tang, 2003). Only 1%–12% of patients with HCC
present with obstructive jaundice as the initial clinical symptom
(Lai & Lau, 2006). Obstructive jaundice occurs secondary to
diffuse tumor invasion of the liver parenchyma or progressive
liver failure. Intraductal tumor growth may occur in the com-
mon hepatic duct and common bile duct, causing obstructive
jaundice (Qin & Tang). Jaundice is not necessarily a harbinger
of advanced disease nor a contraindication for aggressive treat-
ment (e.g., surgery).
Obstructive jaundice in patients with HCC can be managed
with percutaneous drainage or the placement of a biliary stent.
Cholestatic pruritus associated with obstructive jaundice can
be treated using cholestyramine to decrease the enterohepatic
circulation of bile acids (Jones & Bergasa, 2000). Other self-care
measures include the use of emollients to maintain skin mois-
ture and mild, fragrant-free soaps to prevent skin irritation that
may exacerbate pruritus (Cherny, 2002).
Ascites accumulate as a result of an imbalance in the normal
state of influx and efflux of fluid from the peritoneal cavity. The
decreased rate of efflux may be caused by lymphatic blockage
from tumor invasion (Keen & Fallon, 2002). Symptoms related
to ascites include increased intra-abdominal pressure, abdomi-
nal wall discomfort, dyspnea, anorexia, early satiety, nausea
and vomiting, esophageal reflux, pain, and peripheral edema
(Keen & Fallon).
Diuretics remain the standard for managing ascites in pa-
tients with cancer, with response rates ranging from 38%–86%
(Gough & Balderson, 1993; Greenway, Johnson, & Williams,
1982). A potassium-sparing diuretic combined with a loop di-
uretic helps treat ascites secondary to hepatic cirrhosis (Keen
& Fallon, 2002). Abdominal paracentesis remains the most
common procedure for treating ascites. The procedure affords
quick symptomatic relief and is useful in patients with HCC
when diuretics are either ineffective or require a significant lag
period prior to efficacy.
Managing the Side Effects of Sorafenib
In pivotal clinical trials for HCC, common side effects from
sorafenib include fatigue, diarrhea, and hand-foot skin reactions.
The drug should be taken on an empty stomach one hour before
meals or two hours after (Wood, 2006). For fatigue manage-
ment, healthcare providers and patients should communicate
openly regarding assessment and follow-up. Nurses should
encourage patients to stay as active as possible and maintain a
balanced diet with adequate fluid intake. Detailed assessment
of baseline bowel habits and stool consistencies will aid in the
selection of proper treatment for diarrhea. If needed, loper-
amide or diphenoxylate can be initiated on a PRN basis. Der-
matologic reactions associated with sorafenib include dry skin,
rash, pruritus, blistering, desquamation, and calluses (Wood).
Areas of hyperkeratosis commonly are found on the soles of
the feet and may result in thick calluses (Wood). Although no
empirical evidence supports the use of topical ointments to
control dermatologic toxicities, anecdotal reports suggest that
ointments may help minimize the effects of skin reactions.
Nurses should advise patients to use nonfragrant lotions and
soaps and to maintain skin moisture. Treatment interruption
or dose reductions are warranted in more severe cases, but
discontinuation of treatment is rare (Wood).
Nursing Implications
HCC is a leading cause of cancer-related mortality worldwide,
primarily because of the high incidence of unresectable, meta-
static disease in patients with HCC, which inevitably leads to
poor prognosis. Therefore, aggressive symptom management of
disease-related and treatment-related symptoms is critical in pre-
serving functional status and quality of life in patients with unre-
sectable, advanced HCC. Oncology nurses can impact the care of
patients with HCC by using several methods. First, nurses should
become familiar with the established guidelines for managing
common cancer-related symptoms (e.g., pain, fatigue, weight
loss). The guidelines are based largely on evidence presented in
the literature and should aid in developing individualized strate-
gies for symptom management based on patient preferences,
physical status, and disease condition. In addition, nurses can
provide counseling and education for patients with HCC on
disease-related and treatment-related symptoms commonly seen
in that population. Finally, nurses can bridge the communication
of symptoms between patients and clinicians through advocacy
and thorough symptom assessment. Early identification of symp-
tom burden can facilitate the prompt referral of patients with
HCC to experts in supportive care services (nutrition, rehabilita-
tion, and pain specialist) for symptom control.
The complex interplay of physical, psychological, social,
spiritual, existential, medical, financial, and social burdens
experienced by patients with HCC make an integrative team
approach imperative. Quality symptom management is best
delivered in a collaborative environment that integrates the
skills of medicine, nursing, and supportive care professionals.
Nurses must foster collaborative, multidisciplinary methods of
symptom management to improve the physical functioning and
quality of life in patients with HCC.
Author Contact: Virginia Chih-Yi Sun, RN, MSN, ANP, can be reached at
vsun@coh.org, with copy to editor at CJONEditor@ons.org.
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