Acute Oncology Guidelines
- When red cell transfusion or major intervention is required (Grade 3 or 4), VEGF-i should be discontinued.
- Bevacizumab has a half-life of about 20 days (range 11-50) so its effect may be long-lasting.
- If source of bleeding has been identified and managed and bleeding has stopped, careful consideration can be given to re-starting VEGF-i therapy.
Bleeding
Warning
- It is common to have bleeding from the mucocutaneous membranes eg epistaxis (usually stops within 5 minutes) and longer /heavier uterine bleeding during the menses. In these instances VEGF-i can continue.
- Tumour-associated haemorrhage can also occur.
- Prescribe with caution when primary colorectal cancer still in situ (5% risk of bleeding), if inherited or acquired coagulopathy or on full-dose anticoagulant therapy for thrombosis prior to starting.
- Avoid with brain metastases, unless specialist advice, as risk of intracranial haemorrhage is not known
- Patients commencing atezolizumab and bevacizumab for hepatocellular carcinoma (HCC) may be at increased risk of variceal haemorrhage. Endoscopic assessment +/- treatment of varices of high-risk patients is required prior to initiation of bevacizumab therapy – see HCC protocols for risk assessment.