A Game-Changer in Liver Cancer Management: Atezolizumab-Bevacizumab Combination Extends Liver Cancer Patients' Survival, Promises New Era in Treatment

A first-of-its-kind study in real world setting conducted in India by Asian Institute of Gastroenterology (AIG) and published in the Journal of Clinical and Experimental Hepatology showed immunotherapy Atezolizumab-bevacizumab combination as a breakthrough in liver cancer treatment with a significant number of patients showing promising results in terms of overall and disease-free survival even complete resolution of tumor in certain cases when detected early and with timely treatment.

Immunotherapy Atezolizumab-Bevacizumab uses the immune system of the body and kills the cancer cells. It is found to be safe and effective in unresectable hepatocellular carcinoma (uHCC) in real-world settings. With the right selection of patients, atezolizumab-bevacizumab can achieve a good response in terms of survival period and disappearance of tumor (resolution of tumor).

As part of the study, 67 patients with unresectable hepatocellular carcinoma received Atezolizumab – Bevacizumab combination. The study involved 59 patients from AIG Hospital, Hyderabad and 8 patients from Mahatma Gandhi Medical College, Jaipur. The median age of the 67 patients who received Atezolizumab-Bevacizumab combination therapy was 61 (29–82) years, and 86% were males. The study was conducted across the two centres from November 1, 2020, to July 1, 2022 and was published in July 2023.

Researchers highlighted that 12.9% of patients achieved complete resolution of tumor, and 25.8% achieved partial resolution or shrinking of tumors. Overall, the disease did not progress in 66.12% of the patients studied.

In patients with good liver function, overall survival was 21 months. Most patients with liver cancer present at an advanced stage making treatment a challenge. However, if they have a good liver function and are treated with Atezolizumab-Bevacizumab combination it can improve the chances of survival.

The study also showed that the patients who had received local radiation therapy and Atezolizumab-Bevacizumab combination had better response rates. This shows that Atezolizumab and Bevacizumab combination can be highly effective in patients who have undergone local radiation therapy.

The study also discovered the rising incidence of non-alcoholic steatohepatitis (NASH) as an emerging cause of liver cancer. Dr. Nageshwar Reddy, Chairman & Chief of Gastroenterology, AIG Hospitals said, “Liver cancer is one of the most frequently encountered cancers in the gastrointestinal and liver clinics in recent years. The cause of liver cancer was said to be viral hepatitis B for a long time and the trend is now changing to non-alcoholic steatohepatitis (NASH or fatty liver). The reason for this is a sedentary lifestyle, unhealthy dietary habits, and an increasing incidence of diabetes. Treatment for these patients was limited to oral tablets, but a newer immunotherapy treatment has revolutionized the treatment of advanced liver cancer.”

This study offers renewed hope for liver cancer patients in India, and also highlights the importance of regular check-ups for patients with cirrhosis, Dr Reddy added.

“Immunotherapy such as atezolizumab and bevacizumab can provide a decent survival chance for patients presenting at an advanced stage of liver cancer. It is an excellent therapy for patients with advanced liver cancer. With the conventional line of treatment, it is difficult to achieve complete resolution of the tumor. However, with Atezolizumab and Bevacizumab, we noted that approximately 10-13% of patients achieved complete resolution of tumor, and up to a quarter achieved partial resolution. These drugs must be given under supervision every 3 weeks and are not suitable for all patients, especially patients with jaundice,” says Dr Anand Kulkarni, MD, DM, Senior Consultant from the Department of Hepatology & Liver Transplantation at Asian Institute of Gastroenterology, Hyderabad. Dr Anand is also the lead author of the study.

Dr P N Rao, Director of Hepatology with AIG hospital, Hyderabad said in situations where curative measures like surgery and liver transplant cannot be offered for patients with advanced cancer, immunotherapy represents a significant advancement in the treatment of such patients.

Talking about the major impact of Atezolizumab-Bevacizumab, Prof. Vivek Saraswat, Head of Gastroenterology and Hepatology at Mahatma Gandhi Hospital Jaipur, said at least six major American and European guidelines (AASLD, NCCN, AGA, ASCO, EASL, ESMO) recommend this combination as first-line therapy. The reason is the unprecedented results achieved with this combination which is superior to previously available modes of systemic therapy.

Dr Ashish Kumar, a Senior consultant from Sir Gangaram Hospital, Delhi, who recently authored the Indian Liver Cancer Guidelines, suggested Atezolizumab-Bevacizumab is the first line therapy recommended for patients with advanced liver cancer and has shown to be effective for patients with preserved liver functions.

Dr Akash Shukla, Director of Hepatology at Sir H. N Reliance hospital, Mumbai said that now, there is a treatment for every stage of liver cancer, and a multidisciplinary team approach can have better outcomes for liver cancer.

Globally, liver cancer is the 4th most common cause of cancer-related death worldwide and in India it is 8th most common cause of cancer related death. In India, the age-adjusted incidence rate of liver cancer/hepatocellular carcinoma for men ranges from 0.7 to 7.5 and for women 0.2 to 2.2 per 100,000 of population per year. The age standardized mortality rate for HCC in India for men is 6.8 per 100,000 and for women is 5.1 per 100,000 population per year.