We recently spoke with several experts in the management of advanced hepatocellular carcinoma (HCC), each from a different specialty, to get their perspectives on the use of bevacizumab in this setting. Evidence indicates some hesitancy, historically, in prescribing the agent to patients with advanced disease, as bevacizumab is a relatively aggressive agent. However, The latest guidelines from NCCN recommend that the “combination of atezolizumab plus bevacizumab is the preferred category 1 first-line systemic therapy option for patients with Child Pugh A liver function based upon significant survival improvement in the IMBrave150 trial.” Also, the latest ASCO guidelines state that “atezolizumab + bevacizumab (atezo + bev) may be offered as first-line treatment of most patients with advanced HCC, Child-Pugh class A liver disease, Eastern Cooperative Oncology Group Performance Status (ECOG PS) 0-1, and following management of esophageal varices, when present, according to institutional guidelines.”

Following are responses from the physicians we spoke with regarding whether hesitancy to prescribe bevacizumab in patients with advanced HCC is warranted and what those who care for this patient population should know about the role of this agent in combination with atezolizumab.

Bassam Estfan, MD – Oncologist

With good optimization, I don’t believe the hesitancy to prescribe bevacizumab is warranted. One of the main concerns regarding bevacizumab is bleeding risk, especially in a cirrhotic population at risk for esophageal varices bleeding. All patients should have an upper endoscopy done to rule out or treat esophageal varices if found. Working with hepatologists on the team can mitigate some of the concerns regarding starting bevacizumab with atezolizumab. It is important to remember that there are patients in whom bevacizumab use may be contraindicated and other first line treatments can be sought (eg, sorafenib, levenatinib, or durvalumab/tremilimumab).

Amit Singal, MD, MS, FAASLD – Hepatologist

Bevacizumab can be well tolerated in well-selected patients. For example, we typically order an upper endoscopy to assess bleeding risk prior to starting bevacizumab and those at higher risk of bleeding are treated with alternative agents. Overall, the risk–benefit ratio of bevacizumab in combination with atezolizumab is favorable, underscoring its role as a preferred first-line therapy in the advanced stage setting.

Nadine Abi-Jaoudeh, MD, FSIR, CCRP – Interventional Radiologist

The risk/benefit must be considered. If it is indicated and the patient has no contraindications, then it should be prescribed. It has been shown in combination with atezolizumab to improve overall survival in patients with advanced HCC. The results of IMbrave 150 speak for themselves. On the one hand, bevacizumab has consequences that are not benign, including bleeding and hypertension. In interventional radiology, patients on bevacizumab have friable vessels that dissect and bleed. Therefore, it should not be given to every patient just because they have HCC. I especially get worried if it is given early, because it will interfere with locoregional therapies.