My recent travels brought me to Ulaanbaatar, the capital of Mongolia, where I visited its National Cancer Centre. Liver cancer is the most common cancer seen at that centre.

That visit brought back a painful memory of a liver cancer patient of mine who died after surgery three years ago. It haunts me still.

Over the years, I have received letters from patients and their family members, many nice and complimentary. Others were scathing, angry ones.

Understandably, the letter from the husband of the patient who died was in the latter category.

She was the wife of a senior member of the legal profession, a pleasant unassuming woman in her 60s. She had a history of chronic hepatitis that eventually developed into cancer of the liver.

Together with her very caring and supportive family, the surgeon and I discussed various treatment options including chemotherapy, which was at best palliative, and surgery, which offered the possibility of a cure.

Informed consent was eventually given and a senior liver surgeon carried out the liver resection - removal of the cancerous segment.

Following what seemed to be a successful surgery, however, the worst case scenario unfolded. Day by day, her jaundice became more and more severe, she lapsed into liver failure and eventually died.

The portion of the liver left behind after the surgery did not have adequate function to sustain life.

Her husband wrote me a scathing letter after her death - admonishing us for killing his beloved wife. He wrote how she berated him just before she died, for putting her through the 'crazy operation'.

'Why did you send me there? I was perfectly all right before all these tough and complicated procedures. Why should I suffer such pain?' she had asked him.

The years have gone by and I'm not sure if he has forgiven us for encouraging her to go through with the surgery.

Although I continue to relate this cautionary tale to liver cancer patients who contemplate surgery, many patients have had liver resections and continue to live happy and healthy lives.

Still, I was reminded of this patient (and the letter) while visiting the Mongolian centre.

Last year, according to the data from its cancer registry, the centre saw 3,521 new cases of cancer of which 1,380 patients had primary liver cancer, also called hepatocellular carcinoma.

In Singapore, liver cancer is ranked the third most common cancer among males but it is less common among females. The National Cancer Registry showed that from 2001 to 2005, there were about 9,000 new cases of cancer each year, of which about 400 were liver cancers.

There are no statistics on the outcome of these patients but it is likely that only a minority would have survived this disease.

Diagnosis is often straightforward - the tumour mass can be imaged through ultrasound or CT (computed tomogram) scans and the majority are found to have a raised cancer marker in the blood called AFP (alpha-feto protein). A biopsy is rarely needed to confirm the diagnosis.

Patients with liver cancer may show symptoms of discomfort or pain over the right upper abdomen, abdominal swelling or yellowing of the skin and eyes (jaundice) and/or tea-coloured urine. The yellowing of the skin is caused by the retention of bilirubin - formed by failing red blood cells - in the blood. Its by-products, excreted in the urine, cause darkening of the urine such that it looks like concentrated Chinese tea.

The problem - in the case of liver cancer - is that the tumour often grows unnoticed in the liver until it is fairly large. By the time the majority of patients are diagnosed, they are in the advanced stage of the disease.

Moreover, it can develop 'satellite' tumours in both lobes of the liver. And once it invades the blood vessels, liver resection is no longer possible.

Chemotherapy is an option but the results are not encouraging.

A novel oral medication has been approved for treatment but the results have been disappointing for many of my liver cancer patients.

The large majority of liver cancer patients in Singapore are Hepatitis B carriers. This is because while most patients with acute Hepatitis B infection recover fully, some go on to a chronic carrier state because the virus is somehow not eradicated.

The good news is that there is a vaccine against Hepatitis B infection. Since 1986, all newborns in Singapore are given this vaccine. I foresee that within another two decades, liver cancer numbers will gradually decline.

Back in Ulaanbaatar, where the average income of people, I was told, was around US$300 (S$410), I was glad to be told its government too has encouraged Hepatitis B vaccination of all newborns since 1993. Soon, hopefully, Mongolia too will see better liver cancer statistics.

angpt@parkwaycancercentre.com

Dr Ang, the medical director of Parkway Cancer Centre, has been treating cancer patients for nearly 20 years. In 1996, he was awarded Singapore's National Science Award for his outstanding contributions to medical research.

This article was first published in Mind Your Body, The Straits Times on June 18, 2008.