# Atezolizumab Plus Bevacizumab for Advanced Hepatocellular Carcinoma with Macroscopic Vascular Invasion: An Inverse Probability of Treatment Weighted Analysis

## TL;DR

A drug combination delayed liver cancer growth as effectively as traditional treatments, with similar safety and survival rates in patients with advanced disease.

## Contribution

This study provides real-world evidence comparing drug therapy and locoregional treatments for advanced liver cancer with vascular invasion.

## Key findings

- The drug combination delayed cancer progression more effectively than locoregional therapy.
- Overall survival and serious side effect rates were similar between the two treatment approaches.
- Objective response rates and major adverse events were comparable across both treatment groups.

## Abstract

Patients with liver cancer that grows into major blood vessels typically have a poor outlook and limited treatment options. Clinicians often choose between two very different approaches: a modern drug combination (atezolizumab plus bevacizumab) or locoregional treatments such as targeted chemotherapy delivered into the liver, sometimes combined with radiation. However, it has not been clear which option works better for these high-risk patients. In this study, we examined real-world outcomes from nearly 500 patients to compare these two strategies fairly. We found that the drug combination delayed cancer progression for a longer period, while overall survival and rates of serious side effects were similar between the two approaches. These findings provide practical evidence to help guide treatment decisions and support more personalized care for patients with advanced liver cancer involving major blood vessels.

Background/Objectives: Management of hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) varies between systemic immunotherapy and locoregional approaches. We compared atezolizumab plus bevacizumab (Atezo–Bev) with locoregional therapy in treatment-naïve patients. Methods: We conducted a retrospective cohort study of patients with image- or biopsy-proven HCC and MVI, Child–Pugh A/B, and ECOG 0–1 who received first-line Atezo–Bev or locoregional therapy (transarterial chemoembolization [TACE] with or without external-beam radiotherapy [RT]). Inverse probability of treatment weighting (IPTW) minimized baseline imbalances. Primary outcomes were overall survival (OS) and progression-free survival (PFS). Modified RECIST assessed radiologic response, and major adverse events were classified using Society of Interventional Radiology criteria. Results: We analyzed 475 patients (Atezo–Bev, n = 191; locoregional therapy, n = 284). Baseline characteristics were similar, and IPTW achieved covariate balance. Median OS was 9.3 months with Atezo–Bev and 10.8 months with locoregional therapy; after IPTW, OS remained comparable (hazard ratio [HR] 0.95; 95% CI 0.76–1.19; p = 0.635). Median PFS was 6.0 versus 4.1 months, favoring Atezo–Bev; this persisted after IPTW (HR 0.64; 95% CI 0.52–0.79; p < 0.001). Objective response rates were similar (45% vs. 48%; p = 0.49). Major adverse events occurred in 11% of patients in both groups. Subgroup analyses showed no OS differences and a consistent PFS advantage with Atezo–Bev. Conclusions: In HCC with MVI, first-line Atezo–Bev achieved longer PFS than locoregional therapy, with comparable OS and safety, supporting Atezo–Bev as a valid and effective first-line option for disease control while locoregional modalities remain relevant within multidisciplinary care.