Liver Decompensation in Patients With Hepatocellular Carcinoma Treated With Atezolizumab Plus Bevacizumab: A Real-life Study

Background & Aims: Atezolizumab plus bevacizumab (atezobeva) has changed the treatment landscape of advanced hepatocellular carcinoma, but its efficacy and safety in patients with impaired liver function are still debated. This study aimed to evaluate the prognostic impact of baseline liver function and liver decompensation during treatment on clinical outcomes. Methods: In this multicenter study, we included 247 patients with advanced or unresectable hepatocellular carcinoma treated with atezobeva. We analyzed data on survival, tumor progression, and liver decompensation and introduced time to decompensation as a new safety endpoint. Results: The reported overall survival (OS) was 18.30 months, time to progression 13.07 months, and progression-free survival (PFS) 9.83 months. Although OS was better in Child Pugh A compared with Child Pugh B patients (20.20 vs 9.83 months; P = .0008), no differences were observed in time to progression and treatment safety. Liver decompensation occurred in 63 patients (25.51%), specifically 27.89% Child Pugh A and 51.16% Child Pugh B patients; in 41.26% of patients, atezobeva was resumed after decompensation, achieving an OS comparable to those who never decompensated (20.87 vs 20.2 months; P = .77), and better than those who permanently stopped treatment (8.07 months; P = .02). Time to decompensation was similar for patients with albumin-bilirubin score 2 regardless of Child Pugh class, and the probability of recovery from decompensation was similar for Child Pugh A and B patients. Conclusion: Atezobeva is effective in both Child Pugh A and B patients. The possibility to resume treatment after an episode of decompensation underscores the importance of integrated hepato-oncological management.