Physical HealthTaha tinana
Seeking information about the liver and liver cancer can feel overwhelming or frightening, especially if you’re unsure about what’s ahead for you or a loved one. Having the right information can help lessen some of these feelings. Here you will find reliable information about the liver and liver cancer along with diagnosis, symptoms, risks, treatment, side effects, diet and nutrition and some useful websites to visit.
Nau mai rā, rarau mai rā ki tēnei whārangi mō ngā kōrero e pā ana ki te mate pukupuku ate
About the liver
Mō te ate
The liver is one of the largest organs in the body. It is situated in the upper abdomen under the ribcage.
The liver does lots of things to keep our bodies working well. These include:
regulating sugars and fats so they can be used for energy
storing glucose and vitamins so that they can be released into the bloodstream when needed
producing proteins, which are essential for blood clotting and prevent excessive bleeding while other proteins help regulate fluid levels in the body
producing bile which is released into the intestine to break down the fats in food so they can be absorbed in the bowel
processing substances including alcohol, drugs, and by-products of normal metabolism so they can be passed out of the body or broken down into harmless substances.
Click here to view a diagram of the liver.
What is liver cancer | He aha tēnei mea te mate pukupuku ate?
Cancer occurs when abnormal cells grow out of control. There are two types of liver cancer: primary liver cancer and secondary liver cancer. Click on the topics below to learn more.
Primary liver cancer | Mate pukupuku ate mātāmua
Primary liver cancer happens when the cancer arises from the liver cells. The most common type is called hepatocellular carcinoma (HCC). HCC usually arises in people who have had underlying liver disease for many years resulting in liver scarring (cirrhosis).
In New Zealand, the most common causes of the underlying liver disease are hepatitis B, hepatitis C, and alcohol abuse. A rarer sub-type of HCC that is unrelated to liver disease is called fibrolamellar HCC. This usually occurs in younger women.
There are other rarer types of liver cancer, including hepatoblastoma, which affects very young children.
Secondary liver cancer | Mate pukupuku ate mātāmuri
Secondary liver cancer, sometimes called metastatic cancer or advanced cancer, is when a cancer starts somewhere else in the body. The cancer then spreads to the liver via the bloodstream. This is the most common type of cancer in the liver.
Symptoms & Risks
Tohumate & Tūraru
Symptoms of liver cancer | Ngā tohumate o te mate pukupuku ate
Unexplained symptoms can be worrying for anyone. Here you will find information about some common symptoms of liver cancer and how to manage them. It is important to note that having one or more of these symptoms does not necessarily mean that you have cancer, but if you have new or persistent symptoms that are out of the ordinary for you, it’s really important that you contact your GP to get checked out.
Cancer in the liver does not usually cause symptoms until it has reached a more advanced stage. It is important to realise that these symptoms can also arise in other conditions, including liver disease without cancer.
Click here to learn more about the symptoms of liver cancer.
Managing symptoms | Whakahaere i ngā tohumate
You might notice that things change for you physically and emotionally following your diagnosis and you may have even noticed some of these symptoms prior to diagnosis. Understanding them can help you to prepare for them mentally and manage them if they do appear. If you do experience any of these symptoms, let your healthcare team know when you next see them. If they are extreme, or you are worried about them, get in touch with your healthcare team sooner.
Click below to learn about some ways you can manage these changes or symptoms | Pāwhirihia te momo tohumate mō ētahi atu mōhiohio.
Changes in diet | Ngā panonitanga o te whiringa Kai
Many people find that sorting out symptoms related to their diet makes the biggest difference to how they feel. Ask your doctor or nurse for a referral to a dietitian. They can help you with finding food to eat that is gentle on your digestive system.
Nausea | Whakapairuaki
Feeling sick (nauseous) is another common symptom. You may be prescribed anti-sickness medication, or you could try home remedies such as ginger, peppermint, or acupressure bracelets.
Fatigue | Ruha
You are bound to feel tired or exhausted sometimes, so be kind to yourself. Make sure you rest and prioritise what you want or need to do. Give yourself permission to accept offers of help for chores that feel overwhelming. Although you might not feel like it, gentle exercise such as stretching, or a short walk can help combat fatigue.
Intimacy | Mateoha
People of all genders can lose interest in sexual activity during cancer treatment, at least for a time. Although it can feel awkward, talking to your partner about what you find intimate, or soothing can help. There are many ways to be intimate, such as cuddling or gentle touch, or using warmth and comforting language. Your GP may be able to assist with medication or a referral to see a sex and relationship therapist.
Stress, pain, and anxiety | Kohuki, Mamae, Anipā
Simple relaxation techniques can help you cope with stress, pain, and anxiety. Having a warm bath, deep breathing or listening to soothing music are easy things to do at home. You might want to try complementary therapies like reflexology or aromatherapy massage. Talking to others can also help. There are many cancer-specific psychologists available to you in New Zealand – ask your oncologist, nurse, or GP for a referral.
Keep perspective | Kia whakataurite
Each individual will feel and react differently to treatment. What might work for someone else may not always work for you. Acknowledge that not every day will be as easy to manage as the last, and that every day may be different. Focus on what you know works for you and be very gentle with yourself.
Keeping active | Kia kori
Physical activity can also make you feel better, though how much activity will depend on how well you feel. Even a walk round the block or 10 minutes of stretching each day can help.
Risks of developing liver cancer | Ngā tūraru e whanake ai te mate pukupuku
There are some known risk factors that can increase the chance of liver cancer developing. Having a risk factor does not automatically mean that you will develop liver cancer, but they do increase the likelihood of it happening.
Knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.
Some risk factors are environmental and within your control which is why it is important to understand what they are.
Risk factors include:
hepatitis B or C infection: this can lead to long-term (chronic) infection which can cause liver cancer
high alcohol consumption leading to liver cirrhosis
non-alcoholic fatty liver disease
obesity
rare genetic disorders including haemochromatosis and alpha 1-antitrypsin deficiency
type 2 diabetes
smoking tobacco.
Diagnosis
Tautohunga
Diagnosing liver cancer | Te tautohunga mate pukupuku ate
Being diagnosed with cancer can be a scary time for anyone. Here you will find information to help you understand some of the terms you might have heard.
Cancer in the liver is usually diagnosed using special radiology tests, such as ultrasound, CT scan and MRI, and if there is no known primary cancer, a biopsy is required. For primary liver cancer, a blood test is often used to help with diagnosis.
In order to diagnose liver cancer, your oncology specialist will do a range of tests. There might be one test or a mix of tests, some of which are explained below.
Blood Tests | Whakamātau toto
Blood tests are usually taken first to check your blood count and see if your liver and kidneys are working well. Blood tests can also detect tumour markers (chemical substances) that some cancers produce. It is important to note that not all cancers produce these tumour markers, and some other illnesses also produce these markers and so blood tests are often undertaken in combination with other tests.
Alpha-fetoprotein (AFP) is a protein found in your blood. High levels of AFP can be caused by a number of different things, including primary liver cancer. High levels of AFP will indicate that further tests are needed. It is important to note though that not all liver cancers cause high levels of AFP.
Ultrasound | Oro Ikeike
Ultrasound scans can be used to detect growths in the liver.
Ultrasound scans use a microphone (probe) that emits sound waves to provide an image on a computer of the inside of your body. Some gel is applied to your abdomen, and the probe is moved over the gel with slight pressure. Sometimes, you may have a contrast dye injection before your scan to help show any growths clearly.
The scan usually takes place in an outpatient clinic and lasts about 30 minutes. It is not painful, and you can go home afterward.
To prepare for the ultrasound, you may be asked to:
stop eating 6 hours before the scan
drink a litre of water 90 minutes before your appointment
refrain from using the toilet 90 minutes before your appointment to ensure your bladder is full, as this helps provide a clearer image
lie on a bed and adjust your clothes, or put on a hospital gown, so that the Sonographer can apply some gel and the probe onto your abdomen to perform the scan.
Once the scan has been taken, you can go to the bathroom.
Click here for an example of an ultrasound.
Computed tomography (CT) scan | Matawaitanga-ā-rorohiko
A computerised tomography scan (CT scan) combines a series of x-ray images that are taken from different angles around the body. You will lie on a motorised bed that passes through a doughnut-shaped tube. It is important that you lay still for good quality images to be taken, and so a strap and/or pillows may be used to help with this. It isn’t painful and usually takes about 1 hour in an outpatient setting.
To prepare for the scan, you may be asked to:
stop eating or drinking for 4 hours before your scan
take off some or all of your clothing and wear a hospital gown for the scan
remove all objects such as jewellery, piercings, dentures, and glasses as they will interfere with the picture quality.
A CT scan uses small amounts of radiation. This is greater than the amount you would get during a simple x-ray, however, it is still a small amount and so the risk to your health is very low. The low dose of radiation you are exposed to during a CT scan has not been shown to cause harm.
Click here for an example of a CT Scan.
Magnetic resonance imaging (MRI) | Whakaahua ponguru autō
An MRI scan uses magnet fields and radio waves to produce a detailed picture of the body. You will lie on a bed that moves into a tube. It is important that you lay still for good quality images to be taken. It isn’t painful and usually takes between 15 and 90 minutes in an outpatient setting. An MRI scan is very noisy and so you may be given headphones to wear. For those who do not like small spaces it may cause some anxiety. If this is the case, speak to your doctor before your MRI as they may be able to provide you with some relaxation tips or medicine to help you feel calmer.
To prepare for the scan | Hei whakarite i mua i te whakaata roto:
you may be asked to stop eating a few hours before the scan but will be informed beforehand if this is the case
take off some or all of your clothing and wear a hospital gown for the scan
remove all metal objects such as hair clips and piercings and possibly medical patches if you wear one as they may contain metal.
It is important to tell the radiology staff about any metal you have in your body including possible metal fragments in your eye and metal foreign bodies. Objects that have been implanted in your body need to be discussed ahead of the MRI scan as they may cause harm or be damaged. These include pacemakers, aneurysm clips, heart valve replacements, neurostimulators, cochlear implants, magnetic dental implants, and drug infusion pumps.
Click here for an example of an MRI.
Biopsy | Tipako Pītautau
Often liver cancer can be diagnosed without the need for a biopsy. Having a biopsy comes with its own risks as it can cause the cancer to spread along the pathway of the biopsy needle.
There are several ways the biopsy can be taken:
Percutaneous biopsy
This is where a special needle is passed through the skin into the liver to take a small sample of the liver cells. Ultrasound or CT is used to help guide the needle into the correct area. Some anaesthetic is injected into your tummy to numb the area.Transjugular biopsy
This is where a sample of the liver cells are taken through a vein in your neck. The area of the neck is cleaned, and anaesthetic injected to numb the area. You may also be given a sedative to help you relax. A thin tube (catheter) is then passed down the vein in your neck and into your liver. X-Rays are used to help guide the tube.Laparoscopy
This is where keyhole surgery is used to take a small sample of the liver cells using a long thin tube with a camera and light on the end called a laparoscope. This usually occurs under general anaesthetic so you will be asleep. The surgeon makes 2 or 3 small cuts in your tummy through which they can take the sample. The surgeon will also look at the liver and surrounding area as well to see if the cancer has spread.
Click here for a diagram of a biopsy.
It's important to acknowledge that some of these tests can be confronting or sometimes frightening. Taking a friend or whānau member with you can help ease anxiety. Be encouraged to tell staff if you need extra reassurance during the test, you'll find some very compassionate people working in healthcare.
Waiting to have tests carried out | E tāria ana kia whakamātauhia
Even if you have been given an urgent referral for a particular scan or investigation you may have to wait several days or possibly weeks for your appointment. This can be frustrating and worrying, especially if you are already feeling unwell.
Several weeks of testing to confirm a diagnosis or awaiting appointments is relatively common and is unlikely to alter overall outcomes. Cancer growth is considered to be negligible over a period of weeks, and this waiting period is unlikely to cause you harm if your symptoms are stable.
If your symptoms get worse or you start to feel more unwell while you are waiting, it is a good idea to get in touch with your GP or specialist if you already have one. If you cannot get in contact with them, you may need to present to the closest emergency department if your symptoms cannot be controlled at home.
How long will I have to wait for my test results | Ka hia te roa e tatari ai kia puta ngā kitenga whakamātautau?
Depending on which tests you have had it may take from a few days to a few weeks for the results to come through. Waiting for test results can be an anxious time.
It is a good idea to ask how long you may have to wait when you go for tests. If you think you have been waiting too long, then contact your GP or a specialist to follow up on the progress of your results. Usually, the doctor who does the test will write a report and send it to your specialist. If your GP sent you for the test, the results will be sent to the GP clinic.
You will need an appointment with your specialist or GP to discuss the test results and how they might affect your treatment. Usually, your specialist will discuss your results and plan your subsequent care.
All these tests will give the specialist more information about the cancer such as where it is, if it is growing, and if it has spread. This is called staging. Staging helps to work out the best treatment plan for you.
Liver cancer stages | Ngā tūātupu mate pukupuku ate
You may have heard people talk about the stages of cancer. Staging provides an indication of the size of the cancer and if it has spread to other areas of the body and contributes to the treatment planning.
There are two ways in which the stage of cancer can be described. One uses numbers (stage 1, 2 etc) and the other uses letters and numbers (T1, N0 M0 etc) also known as TNM (Tumour-Nodes-Metastases) staging. The cancer may be described in one or both ways by your healthcare team.
Click here to learn more about the stages of cancer | Pāwhirihia kia whai mōhiotanga mō ngā tūātupu mate pukupuku.
TNM (Tumour-Nodes-Metastases) staging
The TNM gives a number according to tumour size (T), how many lymph nodes are affected (N), and how far the cancer has spread, or metastasised, to distant parts of the body (M). This may be expressed as, for example, T1, N0, M0. This information is used to help decide the best treatment.
Stage No. | TNM Stage | Description |
|---|---|---|
IA | T1a | A single tumour 2 cm (4/5 inch) or smaller that hasn't grown into blood vessels (T1a). |
IB | T1b | A single tumour larger than 2cm (4/5 inch) that hasn't grown into blood vessels (T1b). |
II | T2 | Either a single tumour larger than 2 cm (4/5 inch) that has grown into blood vessels, OR more than one tumour but none larger than 5 cm (about 2 inches) across (T2). |
IIIA | T3 | More than one tumour, with at least one tumour larger than 5 cm across (T3). |
IIIB | T4 | At least one tumour (any size) that has grown into a major branch of a large vein of the liver (the portal or hepatic vein) (T4). |
IVA | Any T | A single tumour or multiple tumours of any size (Any T) that has spread to nearby lymph nodes (N1) but not to distant sites (M0). |
IVB | Any T | A single tumour or multiple tumours of any size (any T). |
Prognosis (Life expectancy) | Matapaenga (Te wā ora)
Like any cancer there are many things that can impact on survival rates, so it is best to talk to your cancer specialist for guidance about your own care and outcomes. Remember, even with a diagnosis, no one can know for certain how long anyone will live. Estimates of life expectancy are based on historical data, however treatments are becoming more effective over time which changes these estimates.
Prognosis is usually improved the earlier the cancer is detected. Your doctor will be able to give you the best idea of prognosis.
Often, statistics talk about survival rates which are taken from an average of other patients. These are usually described in 1, 5 and 10-year survival rates. A 10-year survival rate is the proportion (or percent) of people who have not died 10 years after having cancer, however many people live much longer than this.
Click here to view primary liver cancer statistics related to morbidity (number of diagnoses) and mortality (survival rate). Remember that everyone is different, and statistics are only a guide.
The prognosis for liver cancer depends on many factors, including whether it is primary or secondary, the stage of disease (how advanced it is at the time of diagnosis), and whether it is possible to remove all the cancer with surgery. In the best circumstances, cure can be possible for both primary and other cancers that have spread to the liver.
Overall, the survival rate for liver cancer is 36% at year one, 16.1% at year 5, and 13.9% at year 10. Around 281 New Zealanders die from liver cancer each year.
Remember that everyone is different, and statistics are only a guide.
Seeking a second opinion | E rapu ana i te whakaaro kē atu
Following diagnosis, some people choose to request a second opinion because they want to have peace of mind that they have explored all options and opinions available to them before starting treatment.
If you would like to know more about your care team and how to seek a second opinion, click here.
Treatment
Ngā momo rongoā
Treatment options | Ngā kōwhiringa rongoā
There are a number of treatment options available, and it may feel confusing and unsettling not knowing which will be the best for you.
Treatment of liver cancer depends on its location, the stage of the cancer (how advanced it is at the time of diagnosis), and whether the person is otherwise medically fit.
The choice of treatments will be discussed with you and your whānau and your preferences will be considered. Your treatment will be discussed by a multidisciplinary team (MDT), which means that experts in different areas of cancer treatment (e.g., surgeons, gastroenterologists, radiologists, oncologists, and nurses) come together to share their expertise in order to provide the best patient care.
It is also important to note that more than one treatment may be needed to get the best results.
The treatment often depends on whether the cancer is primary liver cancer (cancer that started in the liver) or secondary liver cancer (cancer that started somewhere else and spread to the liver).
See below to read more about the treatment options. | Tirohia atu ētahi kōwhiringa rongoā ki raro nei.
*Not all the options below will be applicable to everyone's situation. Some treatments listed may not be funded and would require the patient to pay directly. It is important to discuss all your options with your specialist team.
Surgery | Poka tinana
Treatment may include surgery to remove part of the liver (liver resection) or removal and replacement of the whole liver with a donor liver (liver transplantation).
When only part of the liver needs to be removed this is called a partial hepatectomy. The liver can then slowly repair and regrow over time if it is not too damaged. If two parts of the liver need to be replaced it is usually done so over two operations to allow the first to heal and regrow before replacing the second part.
When the whole liver needs to be replaced, it can be done so either from a live donor or someone who had passed away. In both cases, there are some factors to be considered first. These include:
the overall health and lifestyle of the person receiving a liver transplant and whether the cancer has spread elsewhere
the compatibility of the donor organ with the person receiving the donor organ
the availability of a liver for donation. The rate of organ donation is relatively small in New Zealand compared to other countries, so it may take a long time for an organ to become available.
Complications during and after surgery are always a risk. Remember that if you have surgery, your medical team will be monitoring you closely and will have ways of treating any complications that might arise.
Click here to learn more about potential complications of partial liver removal (liver resection).
Click here to learn more about potential complications of liver transplant.
Thermal ablation
This involves using extreme heat (microwave ablation) or cold (cryoablation) to kill the cancer cells. It is usually used for small primary cancers of the liver and if surgery is not an option or the cancer isn’t responding to other forms of treatment. It is less invasive than other forms of cancer treatment.
Microwave ablation:
Microwave ablation is seen as a curative treatment for small areas of primary liver cancer. A small probe is placed through the skin into the cancerous cells and delivers microwave energy to heat up and kill the cells. The probe is guided into place using ultrasound or CT. The procedure usually takes about 2 hours and may take place either in a radiology clinic or in hospital under general anaesthetic depending on how the probe is inserted through the skin.
If the probe is inserted using a needle through the skin (percutaneously) it will likely occur in the radiology suite.
If the probe is inserted using keyhole surgery (laparoscopic surgery) or during open surgery (laparotomy) it will take place in hospital under general anaesthetic (you will be asleep).
Cryoablation:
Cryoablation takes place under general anaesthetic (you will be asleep) in the hospital. A probe is passed through the skin into the cancer cells. Liquid nitrogen is injected through the probe into the cancerous cells and freezes them. If there is more than one area of cancer the procedure may need to be repeated. The dead cancerous cells are then absorbed and passed out of the body in the same way as other waste products. This therapy is less common than microwave ablation. It is used to prolong life and is not seen as a cure for cancer. As a relatively new form of therapy, the effectiveness is not yet fully known.
Irreversible electroporation (IRE)
This procedure uses high-current electrical pulses to cause death in the liver cancer cells. Electrodes in the form of needles are inserted through the skin and placed around the tumour. Electrical pulses are then directed at the tumour to destroy the membrane of the cancerous cells.
The probe is guided into place using ultrasound or CT. The procedure usually takes about 2 hours and may take place either in a radiology clinic or in hospital under general anaesthetic depending on how the probe is inserted through the skin. If the probe is inserted using a needle through the skin (percutaneously) it will likely occur in the radiology suite. If the probe is inserted using keyhole surgery (laparoscopic surgery) or during open surgery (laparotomy) it will take place in hospital under general anaesthetic (you will be asleep).
Transarterial chemoembolisation (TACE)
This involves delivering chemotherapy directly to cancer cells using a catheter that is passed through your blood vessels and into your liver.
The catheter is either inserted through the groin or through the wrist. The procedure requires you to be sedated, takes about 2 hours, and occurs in the radiology department of the hospital. If the catheter has been inserted into the groin you will need to stay overnight in hospital. If the catheter has been inserted through the wrist you may be able to go home the same day or you may need to stay overnight.
Selective internal radiation therapy (SIRT)
SIRT is used to deliver radiation to the cancer cells by delivering particles containing the radiation directly to the liver. This is possible through a catheter which is passed into the blood vessels of the liver. SIRT is usually used when surgery to remove the tumour/s is not an option.
It is a 2-step procedure with the second occurring about 1-2 weeks after the first.
Both procedures involve angiograms to map the pathway of the vessels by inserting a catheter through either in your groin (femoral approach) or your wrist (radial approach) and into your liver.
in the first procedure, the blood vessels to the cancerous cells will be blocked. Additionally, a small ‘test’ amount of tiny glass spheres containing radiation are passed through the catheter to check that these spheres stay in the liver and do not go into the lungs
in the second procedure, a larger amount of tiny glass spheres containing radiation are then passed through the catheter and into the cancer cells to block the blood supply to them and kill them.
Each procedure usually takes 2 hours and occurs in the hospital radiology department. You will be given a sedative and will need to stay in hospital at least overnight.
This treatment option is not funded in New Zealand but available privately.
Click here to view a diagram of SIRT
Targeted therapy | Haumanu heipū
Targeted therapy uses drugs to attack specific features of cancer cells and stop the cancer growing. It may be used if surgery is not an option, or the cancer has spread.
This treatment option is not funded but is available privately.
Targeted therapy involves blocking the processes that change normal cells into cancer cells. As the therapy treats only the cancer cells, healthy cells are not affected, and fewer side effects occur. Targeted therapies can be delivered intravenously, injected directly into tumors or via oral tablets.
Click here to view a diagram of targeted therapy | Pāwhirihia ki kōnei kia tirohia te hoahoa haumanu heipū
Endoscopic retrograde cholangiopancreatography (ERCP) | Tūkanga tiro oranga whēkau huri kōaro
ERCP is a procedure to help unblock the bile ducts leading from the liver or gallbladder that have become blocked following cancer treatment.
Bile ducts are tubes that allow bile to travel from the liver or gallbladder into the duodenum to help break down fats during digestion. Sometimes, cancer and cancer treatments can cause bile ducts to become blocked through the cancer itself or scarring from the treatment. ERCP is a procedure that opens up the bile ducts to release the blockage.
An ERCP is when a long thin flexible tube with a camera on the end is passed through your mouth and stomach to be able to see the bile ducts to detect any blockages. You will be given a sedative and anaesthetic throat spray to numb your throat and a mouth guard is then put into your mouth before the tube is inserted.
Sometimes a contrast dye is inserted into the catheter and gas pumped into the area to allow better images to be produced on X-Ray of where the blockages are.
Metal or plastic stents are placed into the ducts to open them up and clear the blockage.
The procedure usually takes 30-60 minutes and is not painful, but you will have to stay in hospital for about 4 hours afterwards or overnight until the sedative has worn off. Due to the effects of the sedative, you will need someone to drive you home and stay with you for the rest of the day.
In preparation for the procedure, you may be asked to:
refrain from eating for 6-8 hours beforehand
remove your clothes and put on a hospital gown.
The risks from an ERCP vary depending on your circumstances. Complications can include:
pancreatitis
bleeding
infection.
Click here to for a diagram of an ERCP
Clinical trials | Whakamātau haumanu
You may be eligible to take part in a clinical trial, which is a type of research study that investigates new or specialised therapies or treatments. While you are discussing therapy options with your care team, it is a good idea to ask about clinical trials that may be suitable for your condition and discuss whether participating may be right for you.
Being involved in a clinical trial may be beneficial in that you may access the latest treatments before they become generally available. Additionally, clinical trial participation is often associated with closer monitoring of your care and condition and potentially improved outcomes.
Click here to learn more about clinical trials
Palliative care | Pairuri
A specialist may refer a patient to palliative care services, but this doesn’t always mean end-of-life care. Today people can be referred to these services much earlier if they’re living with cancer. Palliative care can help one to live as well as possible including managing pain and symptoms. This care may be at home, in a hospital or at another location one prefers. Additional supportive care (treatment or services that support you through a cancer experience) are also available.
Traditional Māori Healing | Rongoā Māori
Rongoā Māori is a body of knowledge that takes a holistic view to wellbeing and treatment. In particular, it focuses on hinengaro (mind), wairua (soul), mauri (life essence), ngā atua (Gods) and te taiao (the environment).
There are many providers who are able to provide rongoā services. Your Māori Health team at the hospital will be able to connect you with one nearest to where you live.
See the below websites for more information on rongoā Māori
Other complementary therapies
Complementary therapies are treatments that are used alongside standard treatments. They are often used to boost the immune system, relieve symptoms, and enhance the effectiveness of standard treatments.
Speak to your doctor if you intend to use complementary therapies to ensure that they will work well alongside your treatment.
Some examples of complementary therapies are:
acupuncture
meditation and mindfulness
music therapy
massage
aromatherapy
naturopathy
tai chi
pilates
visualisation or Guided Imagery
spirituality.
Click here to find out more about complementary therapies
Side Effects from Treatment
Ngā mate āpiti
Side effects of liver cancer treatment | Ngā mate āpiti o te rongoā mate pukupuku repetaiaki huka
As with any medical treatment, you may experience side effects from your cancer treatment. This is perfectly normal and can be a sign that the treatment is working, although it may feel unpleasant. Side effects vary from person to person and depend on the type of treatment, the part of the body treated, and the length and dose of treatment. Most side effects are temporary and go away after treatment ends. Below you can find information on some common side effects of treatments and how you can manage them to improve your daily well-being.
You may experience side effects other than those discussed here.
If you experience side effects, let your healthcare team know when you next see them. If the symptoms feel extreme or are worrying you, get in contact with your oncology team sooner.
Common side effects of liver cancer treatments
Click on each treatment to learn more about the side effects of that treatment | Pāwhirihia i ia momo rongoā kia tirohia i ngā mate āpiti e hāngai ana
Surgery | Poka tinana
Liver surgery is major abdominal surgery and so you may experience a variety of side effects.
Liver resection
Liver resection usually takes about 4-8 weeks to recover from and side effects may include:
nausea
vomiting
dizziness
agitation
fatigue
pain at the site of the surgery which usually lasts 1-2 weeks
diarrhoea
constipation
gas
headache
low fever
numbness where the incision was made.
Liver transplant
Liver transplant can take up to a year to recover fully from, but you will usually start to notice improvements after a few weeks.
Your body will naturally recognise the new liver as a foreign organ and will try to attack it. This is a natural part of organ donation and is called ‘rejection’. To prevent rejection of the new liver, you will be required to take immunosuppressants for the rest of your life.
In addition to side effects from the surgery and disruption to your digestive system, you may also experience side effects from the immunosuppressants.
Side effects from surgery and disruption to the digestive system may include:
nausea
vomiting
dizziness
agitation
fatigue
pain at the site of the surgery
diarrhoea
constipation
gas
headache
low fever
numbness where the incision was made.
Side effects from the immunosuppressants may include:
headaches
high blood pressure
tremor (uncontrollable shaking or trembling)
increased risk of infections
kidney failure
mood swings
muscle weakness
increased appetite and weight gain – care will need to be taken to avoid overeating after the transplant
changes to your mental state, such as confusion, hallucinations, and suicidal thoughts – contact your GP or a member of your care team as soon as possible if you experience these.
Thermal ablation
Side effects of microwave ablation may include:
pain in the area that was treated
fever / chills however these need to be closely monitored to make sure that you do not have an infection
nausea / vomiting / abdominal bloating which should resolve within a week
lethargy / tiredness may last for several weeks following the procedure.
Some side effects of cryoablation may include:
abdominal pain
infection in the liver
bleeding in the chest cavity and/or abdomen
Irreversible electroporation (IRE)
Side effects of irreversible electroporation may include:
pain in the area that was treated
fever / chills however these need to be closely monitored to make sure that you do not have an infection
nausea / vomiting / abdominal bloating which should resolve within a week
lethargy / tiredness may last for several weeks following the procedure.
Transarterial chemoembolisation (TACE)
Side effects from transarterial chemoembolisation may include:
pain in the area that was treated
fever / chills however these need to be closely monitored to make sure that you do not have an infection
nausea / vomiting / abdominal bloating which should resolve within a week
lethargy / tiredness may last for several weeks following the procedure.
loss of appetite
feeling full quickly
diarrhoea and constipation
fatigue
weight loss
sore mouth or throat
taste changes.
Selective internal radiation therapy (SIRT)
Side effects of SIRT may include:
nausea and vomiting
loss of appetite
feeling full quickly
diarrhoea and constipation
fatigue
weight loss.
Targeted therapy | Haumanu Heipū
Side effects of targeted therapy are usually due to the drugs that inhibit the cancer cells from growing. Common side effects of these drugs can include:
fatigue
loss of appetite
hand-foot syndrome (redness and irritation of the hands and feet)
high blood pressure
weight loss
diarrhoea
abdominal pain
low white blood cell counts (with increased risk of infections)
headaches
mouth sores.
Less common but more serious side effects can include:
problems with blood flow to the heart
bleeding
abnormal thyroid tests
perforations (holes) in the stomach or intestines.
blood clots
slow wound healing.
Endoscopic retrograde cholangiopancreatography (ERCP) | Tūkanga tiro oranga whēkau huri kōaro
Side effects of ERCP may include:
abdominal pain or bloating due to the gas pumped into the abdomen during the procedure. This should settle quickly after the procedure. Severe pain may indicate pancreatitis and so you should let your doctor know immediately if you experience this.
Managing symptoms and side effects | Whakahaere tohumate me ngā mate āpiti
Click on the symptoms below to find information on how to manage symptoms and side effects | Pāwhirihia i ia momo tohumate mō ngā mōhiohio kia whakahaere ai ngā tohumate me ngā mate āpiti
Fatigue | Ruha
A common side effect of treatment is feeling constant tiredness (fatigue). Treatment or the cancer itself can reduce the number of red blood cells in your body, resulting in anaemia, which can make you feel very tired.
Tips to manage fatigue | Ngā kupu āwhina mō te whakahaere i te ruha:
Use your energy wisely
plan ahead for when you feel too tired to cook
shop online for groceries
bulk cook meals you can store in the freezer
cook when you have more energy
ask and accept offers of help with shopping and cooking from whānau and friends
use home delivery services such as Meals on Wheels or other companies that bring pre-prepared food to you. You can ask for help to access these via your social worker
keep snacks handy in your bag or car.
Activity can help with fatigue
regular, gentle exercise can help improve fatigue and your appetite
activity can mean many things – walking, stretching, even vacuuming!
set small goals. Set a timer for five minutes and see what you can manage in this time
eat with others.
Loss of appetite | Kore hiakai
It can be discouraging to lose your appetite. You may lose your appetite because of the effects of cancer itself, the treatment, or other side effects, such as feeling sick, not enjoying the smell of food, or feeling upset. To help you can:
eat small amounts often, e.g., every 2–3 hours. Keeping to a regular eating pattern rather than waiting until you are hungry will mean your body gets the nourishment it needs to
use a smaller plate – a big plate of food may put you off
eat what you feel like when you feel like it. Have cereal for dinner or a main meal at lunch
include a variety of foods in your diet
sip fluids throughout the day
replace water, tea and coffee with drinks or soups that add energy (kilojoules/calories), such as milk, milkshake, smoothies, replacement drinks or soup
relax dietary restrictions – maintaining your weight or regaining weight you have lost is more important than avoiding full-fat and other high-energy foods
gentle physical activity can stimulate appetite – take a short walk around the block
eat with others
keep snacks handy e.g., in your bag or car so you can eat on the go
talk to your dietitian about liquid meal replacements that might be easier to digest.
Taste or smell changes | Rongo kakara me te hā
Some treatments such as chemotherapy can change the way food and/or drink taste or smell. It may taste bland or metallic.
Tips on managing changes in taste include:
add extra flavour to food if it tastes bland – like fresh herbs, lemon, lime, ginger, garlic, soy sauce, honey, chilli, or pepper
experiment with different food, as your tastes may change
if meat tastes bad during treatment, replace it with other protein sources like cheese, eggs, nuts, dairy foods, baked beans, lentils, or chickpeas
add small amounts of sugar to food if it tastes bitter or salty
use a straw when drinking
change from using metal cutlery to plastic or bamboo cutlery.
Tips on managing changes in smell include | Ngā kupu āwhina mō te whakahaere i ngā panoni rongo kakara:
eat cold food or food at room temperature (hot food smells more)
reheat pre-prepared meals in the microwave so the cooking smell doesn’t put you off
stay out of the kitchen, if possible, when food is being prepared
ask family or friends to cook
use the exhaust fan, open the kitchen window, or cook outside to help reduce cooking smells.
Nausea and vomiting | Whakapairuaki me te ruaki
Feeling sick and vomiting are often side effects of cancer, its treatment, or some medicines. They often occur together, but not always.
Nausea | Whakapairuaki
Nausea is stomach discomfort and the sensation of wanting to vomit. Nausea can be a precursor to vomiting the contents of the stomach and may be caused by treatment, stress, food odours, gas in the gastrointestinal tract, motion sickness or even the thought of having treatment.
Tips on how to cope with nausea | Ngā kupu āwhina ki te morimori i te whakapairuaki:
have a light snack before treatment and wait a few hours before eating again
eat small meals 5–6 times during the day. Going without food for long periods can make nausea worse
snack on dry or bland foods, e.g., crackers, toast, dry cereals, bread sticks or pretzels
choose cold foods or foods at room temperature instead of hot, fried, greasy, or spicy foods
eat and drink slowly and chew your food well
try foods with ginger, e.g., ginger biscuits, or ginger beer
avoid foods that are overly sweet, fatty, fried, spicy, or oily, or that have strong smells
brush teeth regularly to help reduce unpleasant tastes that may make you feel nauseated
do not eat your favourite food when feeling nauseated to avoid developing a permanent dislike
suck on hard lollies – flavoured with ginger, peppermint, or lemon
try ginger food and drink items, such as candied ginger, ginger beer, ginger ale, or ginger tea. Talk to your dietitian doctor or pharmacist about ginger supplements
take anti-nausea medicines as prescribed. Let the doctor know if the medicines don’t seem to be working.
Vomiting | Ruaki
Vomiting is the forcible emptying (“throwing up”) of stomach contents through the mouth. Vomiting can follow nausea and may be caused by treatment, stress, food odours, gas in the gastrointestinal tract, motion sickness or even the thought of having treatment.
Vomiting is more serious than nausea. Vomiting can cause dehydration and increase the risk of malnutrition. See a doctor if you are vomiting for more than one day, especially if you cannot keep water down as you may become dehydrated.
Tips on how to cope with vomiting | Ngā kupu āwhina ki te morimori i te ruaki:
Take small sips of water or clear liquids, such as ginger ale, soda water or sports drinks like Gatorade or Hydrolyte. Dilute sweet drinks. If you feel like a fizzy drink, open it, and let it sit for 10 minutes or so, and drink it when it’s a bit flat
sucking on crushed ice cubes or an ice block can be soothing
once you can keep clear liquids down try some different drinks, such as consommé and clear broths, weak tea, herbal tea, fruit drinks, beef, and chicken stocks
have small, frequent meals and snacks throughout the day
introduce bland, starchy foods, such as plain biscuits, bread or toast with honey or jam, peanut butter, rice, yoghurt, or fruit. Attempt small, frequent servings at first
consume a little bit more each time until you are eating a well-balanced diet.
Chewing and swallowing | Ngaungau me te horomi
After treatment chewing and swallowing may be difficult and painful. Surgery, radiotherapy, and chemotherapy can cause temporary problems. People with dentures who have lost weight may also find their teeth become loose, which can make eating difficult.
Signs that you are having problems with chewing and swallowing include taking longer to chew and swallow, coughing or choking while eating or drinking, or food sticking in your mouth or throat like a ball.
Tips on chewing and swallowing | Ngā kupu āwhina mō te ngaungau me te horomi:
change how you prepare your food by chopping food up into smaller pieces or pureeing
let your doctor know that you are having issues and get a referral to see a speech pathologist and dietitian
a speech pathologist can monitor your ability to swallow and suggest modifications to the texture of your food once your ability to swallow and chew begins to improve. A dietitian can ensure you are meeting your nutritional needs.
Mouth changes | Ngā panonitanga o te waha
Some chemotherapy drugs and some pain medicines can make your mouth dry, cause mouth ulcers, or change the amount of saliva in your mouth. A dry mouth can increase the risk of tooth decay and infections such as oral thrush, which will make eating harder.
Ulcers may also be present in your digestive tract, causing discomfort in the stomach or bowel and diarrhoea.
Tips to lessen discomfort with mouth sores | Ngā kupu āwhina ki te whakamauru i ngā harehare waha:
suck on ice cubes
eat soft foods – stews, soups, scrambled eggs, and smoothies
cold foods and fluids may be more comfortable than hot ones
avoid ‘coarse’ foods that can irritate your mouth, such as crackers, toast, nuts, and seeds
avoid spicy or very hot foods
use a straw and direct liquids away from the areas where mouth sores are most painful
talk to your doctor about medication or mouth washes to help manage the pain and allow you to eat more comfortably.
Tips to relieve a dry mouth | Ngā kupu āwhina ki te whakamauru i te waha maroke:
suck on ice cubes
keep your mouth clean with regular mouthwashes to prevent infections
gargle with 1⁄2 tsp salt or 1 tsp bicarbonate of soda in a glass of water
choose an alcohol-free mouthwash to avoid irritating your mouth further
use a soft toothbrush when cleaning your teeth
ask your dentist or health care team about suitable mouth rinses or oral lubricants
limit alcohol and coffee as these are dehydrating fluids and avoid smoking
avoid ‘coarse’ foods that can irritate your mouth, such as crackers, toast, nuts, and seeds
avoid spicy or very hot foods
soften food by dipping it into milk, soup, tea, or coffee
moisten with sauce, gravy, cream, custard
sip fluids with meals and throughout the day
chew sugar-free gum to stimulate the flow of saliva.
Changes in bowels- constipation and diarrhoea | Ngā panonitanga o ngā kōpiro
Living with cancer and its treatments can result in changes to your bowel habits. This could be differences in the appearance, consistency, and/or the smell of your stools. If your bowel motions change colour (pale or black) contact your medical team.
Constipation | Kōroke
This is when your bowel motions are infrequent and difficult to pass. It can be caused by different factors including regularly taking opioid medicines; having a diet low in fibre; not getting enough exercise; not having enough fluids to drink (dehydration); or having a low overall food intake.
Tips on how to manage constipation | Ngā kupu āwhina mō te whakahaere kōroke:
soften stools by drinking 8–10 glasses of fluid a day, e.g., water, herbal tea, milk-based drinks, soup, prune juice
eat foods high in fibre, e.g., wholegrain breads, cereals, or pasta; raw and unpeeled fruits and vegetables; nuts and seeds; legumes and pulses
if you are increasing the amount of fibre in your diet, increase fluids to prevent the extra fibre making constipation worse
ask your doctor about using a laxative, stool softener and/or fibre supplement
exercise – check with your doctor, exercise physiologist or physiotherapist about the amount and type of exercise that is right for you.
Diarrhoea | Kotere
This means your bowel motions are watery, urgent, and frequent. You may also get abdominal cramping, wind, and pain. Frequent loose stools can occur because you are not digesting food or absorbing nutrients properly. Cancer treatment, medicines, infections, reactions to certain foods and anxiety can all cause diarrhoea.
Diarrhoea can result in dehydration, so it’s important to stay hydrated by drinking extra fluids. Every time you have a loose bowel movement you should drink an extra cup of non-caffeinated fluid. If you have diarrhoea for several days, see your doctor so he/she can determine the cause and help to manage your diarrhoea. Your doctor may decide to prescribe you anti-diarrhoea or over-the-counter medication.
Tips on how to manage diarrhoea | Ngā kupu āwhina mō te whakahaere kōtere:
drink plenty of fluids to avoid becoming dehydrated. Water and diluted cordials are better than high-sugar drinks, alcohol, or caffeinated fluids – remember signs of dehydration are smaller amounts of dark urine
choose low-fibre foods, e.g., bananas, mashed potato, rice, pasta, white bread, oats, steamed chicken without the skin, white fish
avoid foods that increase bowel activity, e.g., spicy, fatty, or oily foods, caffeine, alcohol, or artificial sweeteners
try soy milk or lactose-free milk if you develop a temporary intolerance to milk (lactose)
don’t eat too many raw fruit and vegetable skins and wholegrain cereals as they may make diarrhoea worse
avoid foods and drinks that are high in sugar, such as cordial, soft drinks and lollies
avoid foods sweetened with artificial sweeteners such as sorbitol, mannitol, and xylitol. These are often marketed as ‘sugar-free’
it may also help to eat small, frequent meals throughout the day, rather than three large meals
Heartburn (Indigestion) | Tokopā
Some cancers and treatments can cause heartburn, which is a burning sensation in the upper chest, oesophagus and/or throat. It is caused by the contents of the stomach coming back up into the oesophagus (reflux).
Heartburn may make you feel too uncomfortable to eat much, which could lead to weight loss. If the tips below do not relieve heartburn, let your doctor know as medication may help to prevent or manage these side effects.
Tips to manage heartburn | Ngā kupu āwhina mō te whakahaere tokopā:
avoid large meals; try to eat 3 small meals and 3 small snacks throughout the day
eat slowly and take the time to enjoy your meal
avoid wearing tight clothing while eating, especially belts
sip fluids between meals, rather than drinking large amounts at mealtimes
limit or avoid foods that may make heartburn worse, e.g., chocolate, highly seasoned spicy foods, high-fat foods (e.g., fried food, pastries, cream, butter, and oils), tomato and tomato products, citrus fruits, coffee (including decaf), strong tea, soft drinks, and alcohol
straight after eating, sit upright for at least 30 minutes and avoid lying down or activities that involve bending over (e.g., gardening).
Peripheral neuropathy | Pūtau Iotaiaki mōwaho
Peripheral neuropathy is caused by damage to the peripheral nerves. These are the nerves in the body outside the brain or spinal cord. Peripheral neuropathy may be caused by cancer, cancer treatments or other health problems. It most commonly affects the hands and feet. Peripheral neuropathy caused by cancer treatment will get better over time with proper treatment and care.
The most common symptoms of peripheral neuropathy can include | Ngā kōrero tōkau mō te Pūtau Iotaiaki Mōwaho:
tingling, burning, numbness or pain in the hands or feet
difficulty doing up buttons and picking up small items
loss of feeling especially in the hands and feet
problems with balance or walking, and clumsiness
be safe. If you notice changes in your walking, stance, fine and gross motor skills, or balance speak to your doctor as soon as possible and ask for a referral to an occupational therapist, exercise physiologist or physiotherapist.
Tips to manage peripheral neuropathy | Ngā kupu āwhina mō te whakahaere Pūtau Iotaiaki Mōwaho:
use a night light so that you don’t trip or bang into anything if you need to go to the toilet at night
keep clutter and rugs off the floors
have clear paths to the toilet and bedroom
use handrails where possible
use nonslip mats in the shower and bathroom
be careful on slippery and wet floors
do not walk around bare footed as you may not notice if you stand on something that could damage your feet
wear shoes and slippers that fit well
use a walking stick if you need to
wear gloves when washing up, cleaning and gardening
test water temperature with your elbow
take care when cutting food and opening cans or jars
keep your skin moisturised to prevent cracking
check your hands and feet daily for signs of injury, rubbing, redness or infection
ask for help if you need it, e.g., to do up buttons and shoes
find clothes and shoes that are easy to put on and take off
avoid driving if symptoms are severe.
Alerting your healthcare team of side effects | Whakaohititia tō rōpu tiaki hauora ki ngā mate āpiti
Your health care team wants to hear about your side effects. Your questions and concerns are important. Do not be afraid to share them. Ask your health care team who you should contact if you feel that your side effects need assessing right away.
Treatment changes | Ngā pānonitanga maimoa
Occasionally, if you have severe side effects, your doctor may discuss delaying or changing your treatment to prevent further discomfort.
Start a symptom diary | Tīmatahia he rātaka tohumate
Keeping track of your symptoms can help you and your cancer care team to manage them better.
Know who to contact if you have a problem | Me mōhio hoki ki te whakapā atu ki a wai mēnā he raru tāu
Ask your doctor or nurse:
when you should call for help or advice
who you should contact
how to contact them (including at night or weekends).
Keep this information where you can easily find it.
Our partners at the Pancare Foundation have created a webinar to help patients manage these side effects and help you navigate each day and experience greater quality of life. Pancare's experts share their knowledge surrounding common side effects such as nausea, peripheral neuropathy, fatigue, mouth sores, abdominal discomfort and more. Practical ways to manage these side effects are explored along with information regarding the support and care available for you and your family.
*NB - The PanSupport service mentioned is not available to patients in New Zealand
Diet & Nutrition
Whiringa kai me te taioranga
Why is diet and nutrition important? | He aha e whaitikanga ai te whiringa kai me te taioranga?
You may be feeling that some things are out of your control, however there are a number of actions that you can take to make sure your body is in the best condition to cope with, and heal from, the symptoms and side effects of the cancer and cancer treatments.
Below you will find detail about why diet and nutrition can make a big difference to the healing process and how you feel.
Why does liver cancer affect nutrition? | He aha e pāngia ai te mate pukupuku ate i te taioranga?
Liver cancer, and cancer treatments place extra demands on your body. They can also cause you to lose your appetite and energy, putting you at an increased risk of malnutrition. It is important to ensure that your body is receiving the right nutrition before, during and after treatment to be able to cope with these extra demands.
Your food choices when you have cancer and are undergoing treatment may be very different from what you are used to eating.
The main goal is to try to keep your weight constant, maintain muscle strength, maintain a healthy weight, and have more energy, all of which help your body to heal properly, improve your quality of life and give you the energy to cope with all the new challenges treatment may bring.
Liver cancer and the treatments for liver cancer may impact | Ka pāngia pea e te mate pukupuku ate me ngā maimoatanga e hāngai ana:
your nutritional requirements and what you need to eat
how much you eat
your appetite
your ability to digest food
your ability to maintain your weight and muscle mass
your energy levels and general wellbeing.
Good nutrition can help to | He mea āwhina te taioranga pai:
manage the side effects of treatment
speed up recovery after treatment
heal wounds and rebuild damaged tissues after surgery, radiotherapy, chemotherapy, or other treatment
improve the body’s immune system and ability to fight infections.
Overall, try to make food choices that provide you with enough | Heoi, kia whakamātau koe ki te whiriwhiri i ngā kai e ratoa ai:
calories (to maintain your weight)
protein (to help rebuild tissues that cancer treatment may harm)
nutrients such as vitamins and minerals
fluids (essential for your body’s functioning).
Exercise can also help with appetite and digestion issues related to treatment.
Nutritional tips during treatment | He kupu āwhina taioranga e koke ai te maimoatanga
Click here to learn more about nutritional tips during treatment | Pāwhirihia ki kōnei mō ētahi atu whakamōhiotanga
To maintain good nutrition | Kia mau roa ki te taioranga pai:
you may need more energy (kilojoules/calories)
eat small, frequent meals or snacks, rather than three large meals a day
ask for a referral to a dietitian – discuss eating issues, weight issues, muscle loss
do some light physical activity, such as walking, to improve appetite and mood, reduce fatigue, help digestion, and prevent constipation
check with your doctor or dietitian before taking vitamin or mineral supplements or making other changes to your diet
relax dietary restrictions, e.g., choose full-cream rather than low-fat milk
consider using nutritional supplements if you cannot eat enough – discuss options with your doctor, palliative care specialist or dietitian.
Nutritional tips following surgery | Ngā kōrero āwhina taioranga whai muri i te pokanga
Click here to learn more about nutritional tips following surgery | Pāwhirihia ki kōnei mō ētahi atu kupu āwhina taioranga
Surgeries used to treat cancer may result in a variety of side effects, including weight loss and diarrhoea. The side effects usually only last for a short period of time, but you may have to make some changes to your diet to ensure that you are getting enough nutrition and maintaining your weight.
Your body needs good nutrition after surgery, and it is an important part of your recovery process. If you are struggling to eat or drink, the hospital may prescribe nutrition supplements, or recommend tube feeding, to help you to maintain weight and provide you with the nutrients you need for speedy recovery.
Tips on maintaining weight after surgery | Ngā kupu āwhina ki te whakataki taumaha whai muri i te pokanga:
monitor your weight – weigh yourself once or twice a week to monitor for any weight loss
if you are losing weight, tell your doctor and get a referral to see a dietitian
eat small, frequent meals after surgery so your digestive system only has to deal with a small amount of food at a time.
We recognise that dietary changes have a huge impact on everyone with cancer. It can take a while to get used to changes to your diet and lifestyle but finding ways to manage your diet and symptoms can help you feel more in control. It can also be helpful to speak to your dietitian, doctor or nurse.
Living well with cancer
Kia ora pai ai
Learn more about living with cancer.
Read about other people’s cancer journeys see our personal journeys page.
