Systemic therapies are medicines that travel all through the body to kill cancer cells or slow their growth. They may be given right into your blood (as an I.V.), as a shot, or as pills you take at home.

There are three main systemic therapies used to treat liver cancer:

• Chemotherapy (chemo) uses strong medicines to kill cancer cells. The medicines affect and kill cells that grow quickly, like cancer cells. But some normal cells also grow quickly. Because of this, chemo can harm those cells. This can cause side effects.
• Targeted therapy medicines target specific proteins and genetic changes in cancer cells. They kill cancer cells or stop the cells from growing. They tend to have fewer effects on normal cells. As a result, they may cause fewer and different side effects than chemo.
• Immunotherapy medicines help the immune system find and kill cancer cells.

Systemic therapies are medicines that can reach all parts of the body. They're used mainly to treat liver cancers that can't be treated with surgery or other local treatments. These include cancers that have spread to other parts of the body.

Most liver cancers are not very sensitive to chemo, so targeted therapy is often tried first. But chemo might be used if targeted or immunotherapy is no longer working.

Targeted therapy may be the first treatment used when surgery can't be done or when the cancer has spread to other organs.

Immunotherapy may be the first treatment in some cases.

Sometimes, you may have targeted therapy and immunotherapy together.

Before treatment starts, you'll meet with a medical oncologist. This is a doctor who specializes in treating cancer with medicines. The doctor will discuss your treatment choices with you and explain what you might expect.

Depending on which chemo medicines you're getting, you may get them in one of these ways:

• I.V. (intravenous). The medicine goes right into your blood through a small tube (catheter) that's been put into a vein. The medicine may drip in slowly over several hours. Or it may be given more quickly over a few minutes.
• Pills. Some chemo medicines can be taken as a pill you swallow.

Sometimes two or more chemo medicines are used together. Chemo is often given as an outpatient treatment. That means that you get it at a clinic, doctor's office, or hospital. You can go home after the treatment is given. Less often, you may need to stay in the hospital during treatment. Your doctor will watch you for reactions during your treatments.

Chemo treatments may last for a while. So you may want to take something that is comforting to you, such as music to listen to. You may also want to bring something to keep you busy, such as a book or mobile device.

To reduce the damage to healthy cells and to give them a chance to recover, chemo is given in cycles. Each cycle consists of one or more days of treatment, followed by some time to rest. Cycles normally last 3 or 4 weeks. Your doctor will discuss your chemo schedule with you.

Some targeted therapy medicines for liver cancer are taken as pills at home. Other targeted therapy medicines such as bevacizumab and ramucirumab are given through an I.V. They are strong medicines that can sometimes have serious side effects.

These medicines are liquids that are put into your blood through an I.V. They're given once every few weeks. You may get immunotherapy in your doctor's office or an infusion clinic.

These are some of the chemo medicines that might be used to treat liver cancer:

• Capecitabine
• Cisplatin
• Doxorubicin or pegalated liposomal doxorubicin
• 5-fluorouracil (5-FU)
• Gemcitabine
• Oxaliplatin
• Mitoxantrone

Targeted medicines are the main medicines used to treat liver cancer. Those most often used are sorafenib and lenvatinib. Others that might be used are:

• Regorafenib.
• Cabozantinib.
• Larotrectinib.
• Entrectinib.
• Selpercatinib.
• Bevacizumab.
• Ramucirumab.

Immunotherapy medicines that might be used for some people with liver cancer include:

• Atezolizumab.
• Pembrolizumab.
• Nivolumab.
• Ipilimumab.
• Durvalumab.
• Tremelimumab.
• Dostarlimab-gxly.

Side effects of these medicines are different for everyone. They vary based on the medicines you get. Below are some of the most common side effects of these treatments. All the treatments also can cause less common but serious side effects. Be sure to ask your doctor what side effects you could have and what you should watch for.

Many side effects can be treated to keep them from getting worse. There may even be things you can do to help prevent some of them. Most side effects go away over time after treatment ends.

• Hair loss
• Nausea and vomiting
• Mouth sores
• Diarrhea
• Loss of appetite
• Changes in the way things taste
• Low blood cell counts
  • Low white blood cell counts can put you at a high risk for infection.
  • Low red blood counts can cause tiredness (fatigue).
  • Low platelet counts can make you bruise and bleed easily.

• Tiredness (fatigue)
• High blood pressure
• Skin rashes
• Loss of appetite
• Weight loss
• Diarrhea
• Skin redness or blistering on your hands or feet (hand-foot syndrome)
• Low blood cell counts
• Hair loss
• Belly (abdomen) pain

• Tiredness (fatigue)
• Fever
• Cough
• Skin rashes
• Itching
• Loss of appetite and nausea
• Diarrhea or constipation
• Muscle pain, joint pain, or both

It's important to know which medicines you're taking. Write down the names of your medicines. Ask your health care team how they work and what side effects they might cause.

Talk with your doctors about what symptoms to watch for and when to call them. For instance, targeted therapy can cause skin changes that can make you more likely to get infections. Make sure you know what number to call with questions, including after hours and on holidays.

It may be helpful to keep a diary of your side effects. A written list will make it easier for you to remember your questions when you go to your appointments. It will also make it easier for you to work with your health care team to make a plan to manage your side effects.