Key Points
➤ HCC is the fourth leading cause of cancer deaths worldwide, accounting
for approximately 670,000 new cases and 625,000 deaths in 2018.
➤ Atezolizumab + bevacizumab (atezo + bev) may be offered as first-line
treatment for most patients with advanced HCC, following management of
esophageal varices, when present.
➤ Second-line therapy with a tyrosine kinase inhibitor may be recommended
for appropriate candidates.
Treatment
First-Line Therapy
➤ Recommendation 1.1: Atezolizumab-bevacizumab (atezo + bev) may
be offered as first-line treatment for most patients with advanced
HCC, Child-Pugh class A, ECOG PS 0-1, and following management of
esophageal varices, when present, according to institutional guidelines
(Strong recommendation; EB-B-M/H).
Qualifying statements:
▶ Recommendation 1.1 is based on results from the IMbrave150 phase III RCT comparison
of atezo + bev to sorafenib (HR for OS, 0.58; 95% CI, 0.42 to 0.79; P = 0.0006) in Child-
Pugh class A patients. Caution should be exercised when applying these results to patients
with more advanced liver disease who have a greater likelihood of portal hypertension
because of the risk of bleeding complications associated with bevacizumab.
▶ Due to risk of bleeding, patients in this trial were required to have undergone
esophagogastroduodenoscopy (EGD) within 6 months of trial initiation and to have received
treatment of esophageal varices when necessary. The Expert Panel recognizes that some
patients may have been evaluated for varices outside the 6-month window, are receiving
treatment (eg, adequately dosed nonselective β-blockers), and/or are deemed to be low risk
for variceal bleed by a hepatolog y specialist. In these patients, the decision to forgo an EGD
prior to initiation of therapy with atezo + bev may be carefully considered.
▶ Patients who had a myocardial infarction or stroke within the previous 3 months, had a
history of autoimmune disease, were on therapeutic anticoagulation, or had coinfection with
HBV and HCV were also excluded from the IMbrave150 RCT.
