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Caution: bevacizumab-based regimens with untreated varices
Immunotherapy plus bevacizumab is standard in liver cancer, but the anti-VEGF part can cause fatal bleeding from swollen veins in the oesophagus unless they are checked first.
IMbrave150 required endoscopy within 6 months and treatment of varices; upper-GI bleeding was 7% with atezolizumab-bevacizumab. STRIDE (HIMALAYA) or nivolumab-ipilimumab are alternatives for patients at high bleeding risk.
Rationale
VEGF blockade impairs mucosal healing and raises portal pressure effects; cirrhotic patients have varices.
Evidence
Trial protocols and label warnings.