Bleeding

Acute Oncology Guidelines
NHS Lothian
  • 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. 

Management of bleeding

  • 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. 

Editorial Information

Last reviewed: 05/01/2024

Next review date: 05/01/2027

Author(s): Edinburgh Cancer Centre.

Version: 1.1

Approved By: Authorised by CTAC. Refer to Q-Pulse for approval details.

Reviewer name(s): Stewart J.