Assessing Bleeding and Variceal Risk Before Anti-VEGF Therapy in HCC

This segment focuses on assessing bleeding and variceal risk before initiating anti-VEGF therapy with atezolizumab plus bevacizumab in advanced hepatocellular carcinoma (HCC). The panel reviews how IMbrave150 required esophagogastroduodenoscopy (EGD) within 6 months of treatment, and the experts emphasize that many patients with advanced HCC are simultaneously diagnosed with cirrhosis and need variceal optimization before and during therapy. They discuss how grade 3 varices clearly argue against bevacizumab and grade 1 varices clearly permit it, while grade 2 varices represent a genuine gray zone. The physicians note that the availability of dual immunotherapy now offers an alternative when bleeding risk is uncertain, allowing clinicians to choose tremelimumab plus durvalumab rather than push the envelope with anti-VEGF therapy. They also highlight collaboration with hepatology to medically optimize higher-risk patients. The conversation reinforces variceal screening, ongoing surveillance, and bleeding-risk stratification as essential steps in frontline regimen selection for advanced HCC.