PO64 | MANAGEMENT OF BLEEDING RISK IN PATIENTS WITH HEPATOCELLULAR CARCINOMA RECEIVING SYSTEMIC THERAPY: A SURVEY OF CLINICAL PRACTICE

T. Van Broeckhoven^1|9, E. Van Gansewinkel^5|10, J. De Bruijne², F. Eskens³, D. De Groot⁴, K. Hermans⁵, N. Mohammad⁶, F. Van Vilsteren⁷, C. Verslype⁸, W. Moris⁹, M. Roest¹⁰, B. De Laat¹⁰ , J. De Vos-Geelen⁵, M. Kramer^1|9 | ¹Department of Gastroenterology and Hepatology, GROW – Research Institute for Oncology and Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands; ²Department of Gastroenterology & Hepatology, Utrecht University, University Medical Center Utrecht, The Netherlands; ³Department of Medical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands; ⁴Department of Medical Oncology, University Medical Centre Groningen, University of Groningen, the Netherlands; ⁵Department of Internal Medicine, Division of Medical Oncology, GROW – Research Institute for Oncology & Reproduction, Maastricht University Medical Center, Maastricht, The Netherlands; ⁶Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands; ⁷Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands; ⁸Digestive Oncology, University Hospitals Leuven, Belgium; ⁹Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands; ¹⁰Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands, on behalf of the Dutch Hepatocellular & Cholangiocarcinoma Group

Background and Aims. Combination therapy of atezolizumab and bevacizumab is one of the proposed first-line treatment options for patients with advanced hepatocellular carcinoma (HCC). As a vascular endothelial growth factor inhibitor, bevacizumab increases the risk of gastrointestinal bleeding, particularly in HCC patients with cirrhosis and portal hypertension. Although guidelines recommend endoscopic screening for varices, proposed standardized management in this population is lacking. Therefore, this study investigates prevention and treatment strategies based on expert opinion.

Methods. This study encompasses an online survey distributed to hepatologists and medical oncologists in Dutch and Belgian HCC expertise centers. The primary aim was to gather experts’ insights into current clinical practice for the prevention and management strategies of both varices and variceal bleeding in HCC patients receiving systemic therapy.

Results. A total of 35 respondents completed the survey, of whom 97% consider the potential presence of varices before initiating atezolizumab-bevacizumab in patients with underlying cirrhosis, using gastroscopy (55%) or following Baveno VII criteria (36%). In case of low-risk varices, 82% of respondents would start a non-selective beta-blocker (NSBB) before initiating atezolizumab-bevacizumab and 55% before a tyrosine kinase inhibitor. For high-risk varices, 44% opt to start atezolizumab-bevacizumab after NSBB initiation, in combination with complete eradication of varices using endoscopic band ligation. Different approaches among specialists became apparent.

Conclusions. This study demonstrates heterogeneity in variceal screening and prophylactic strategies among HCC specialists. This variability reflects the lack of evidence-based guidance and may affect treatment safety and efficacy, which calls for standardized approaches to optimize bleeding risk management in this population.