Bevacizumab (Avastin)

Anti-Angiogenic Targeted Therapy

What is Bevacizumab? Bevacizumab (brand name Avastin) is a targeted therapy drug that starves tumors by blocking the formation of new blood vessels. It works by inhibiting VEGF (vascular endothelial growth factor), a protein that tumors use to grow their own blood supply. Unlike traditional chemotherapy that directly kills cancer cells, bevacizumab is almost always given WITH chemotherapy to make the chemotherapy more effective. It's used for colorectal, lung, kidney, brain, cervical, and ovarian cancers.
Drug Class
Anti-Angiogenic
Target
VEGF-A
Route
IV Infusion
FDA Approved
2004

How Bevacizumab Works

Bevacizumab represents a fundamentally different approach to cancer treatment - instead of attacking cancer cells directly, it attacks their blood supply:

The Angiogenesis Process

  1. Normal blood vessels: Healthy tissues have stable blood vessels that rarely grow new branches
  2. Tumor growth problem: Once a tumor grows beyond 1-2 mm, it needs its own blood supply to get oxygen and nutrients
  3. VEGF production: Tumors produce large amounts of VEGF (vascular endothelial growth factor), a signal protein that tells the body "grow blood vessels here!"
  4. Angiogenesis: VEGF triggers rapid growth of new, abnormal blood vessels into the tumor (this process is called angiogenesis)
  5. Tumor expansion: With their own blood supply, tumors can grow larger and spread (metastasize)

How Bevacizumab Stops This

Bevacizumab Mechanism:
  • VEGF neutralization: Bevacizumab is a monoclonal antibody that binds to VEGF-A in the bloodstream, preventing it from attaching to VEGF receptors on blood vessel cells
  • Blocks new vessel formation: Without VEGF signaling, new blood vessels don't form
  • Normalizes existing vessels: Tumor blood vessels are typically chaotic and leaky. Bevacizumab helps "normalize" them - making them more like normal blood vessels
  • Enhances chemotherapy delivery: Normalized blood vessels may allow better delivery of chemotherapy to the tumor
  • Tumor starvation: Without adequate blood supply, tumor growth slows or stops

Why Bevacizumab is Used WITH Chemotherapy

Bevacizumab is rarely used alone because:

What is Bevacizumab Used For?

FDA-Approved Uses

Colorectal Cancer

Non-Small Cell Lung Cancer (NSCLC)

Glioblastoma (Brain Cancer)

Renal Cell Carcinoma (Kidney Cancer)

Cervical Cancer

Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

Hepatocellular Carcinoma (Liver Cancer)

Common Off-Label Uses

How is Bevacizumab Given?

Standard Dosing by Indication

Colorectal Cancer

Lung Cancer (Non-Squamous NSCLC)

Glioblastoma

Ovarian Cancer

Cervical Cancer

Hepatocellular Carcinoma

Infusion Details

Administration Guidelines:
  • First infusion: Over 90 minutes with close monitoring
  • Second infusion: If first dose tolerated well, give over 60 minutes
  • Subsequent infusions: If 60-minute infusion tolerated, can give over 30 minutes
  • Do NOT give as IV push or bolus
  • Timing with chemotherapy: Give bevacizumab AFTER chemotherapy in the same visit
  • No dose reductions: Unlike chemotherapy, bevacizumab dose is typically not reduced. If toxicity occurs, hold or discontinue

Side Effects and Management

BLACK BOX WARNINGS - Potentially Fatal Side Effects:
  1. Gastrointestinal perforation: Hole in the intestines (2-3% risk, can be fatal)
  2. Surgery/wound healing complications: Impaired healing, dehiscence (wound opening)
  3. Severe or fatal hemorrhage: Bleeding including pulmonary hemorrhage, GI bleeding, CNS bleeding

Most Common Side Effects

1. Hypertension (High Blood Pressure) - VERY COMMON

Incidence and Management:
  • Incidence: 25-40% develop new or worsening hypertension; 5-15% severe
  • Mechanism: VEGF normally helps keep blood vessels dilated; blocking it causes vasoconstriction
  • Monitoring: Check blood pressure before EVERY infusion. Home monitoring recommended
  • Target: Keep BP <140/90 mmHg (or <130/80 if diabetic/kidney disease)
  • Treatment:
    • Usually managed with standard BP medications (ACE inhibitors, calcium channel blockers, diuretics)
    • May need multiple medications
    • Hold bevacizumab if BP >150/100 despite medications
    • Discontinue if hypertensive crisis or hypertensive encephalopathy
  • Home monitoring: Check BP twice weekly at home, keep a log

2. Proteinuria (Protein in Urine)

3. Bleeding and Hemorrhage

Ranges from Minor to Life-Threatening:
  • Minor bleeding (common 20-40%): Nosebleeds, bleeding gums, easy bruising
  • Serious bleeding (1-5%): GI bleeding, pulmonary hemorrhage (coughing blood), CNS bleeding
  • Highest risk groups:
    • Squamous cell lung cancer (why it's contraindicated)
    • Brain metastases
    • Recent hemoptysis (coughing blood)
    • On anticoagulation
  • Call doctor immediately for: Any significant bleeding, coughing blood, black tarry stools, severe headache

4. Gastrointestinal Perforation - MEDICAL EMERGENCY

Rare but Potentially Fatal (2-3% overall risk):
  • What it is: Hole in the stomach or intestines → abdominal infection (peritonitis)
  • Risk factors: Prior abdominal surgery, diverticulitis, inflammatory bowel disease, bowel obstruction, intra-abdominal tumor
  • Timing: Can occur any time but median ~6 months into treatment
  • Symptoms:
    • Severe abdominal pain (new or worsening)
    • Nausea and vomiting
    • Fever
    • Constipation or inability to pass gas
  • Treatment: Emergency surgery, discontinue bevacizumab permanently
  • Action: Severe abdominal pain while on bevacizumab = GO TO ER

5. Wound Healing Complications

VEGF is Essential for Normal Wound Healing:
  • Problem: Bevacizumab impairs wound healing, increasing risk of wound dehiscence (opening), infections, fistulas
  • Critical timing rules:
    • Before surgery: Stop bevacizumab at least 4 weeks (preferably 6-8 weeks) before elective surgery
    • After surgery: Do not resume bevacizumab until surgical incision fully healed (typically 4+ weeks)
    • For minor procedures: Discuss with oncologist and surgeon
  • If wound dehiscence occurs: Discontinue bevacizumab permanently

6. Arterial Thromboembolic Events (Blood Clots in Arteries)

7. Reversible Posterior Leukoencephalopathy Syndrome (RPLS)

Common but Less Serious Side Effects

Special Considerations

Monitoring During Treatment

Before EVERY Infusion

Test/Check Purpose Action if Abnormal
Blood pressure Detect hypertension Hold if >150/100; start/adjust BP meds
Urine protein (dipstick) Detect proteinuria If ≥2+, get 24-hour urine; hold if ≥2g/24h
Recent surgeries/procedures Wound healing assessment Ensure 4+ weeks from surgery, wound healed
New symptoms Detect complications early Address bleeding, pain, neurologic changes

Periodic Monitoring

How Well Does Bevacizumab Work?

Colorectal Cancer - Most Robust Evidence

First-Line Metastatic Colorectal Cancer:
  • E3200 Trial: IFL + bevacizumab vs. IFL alone
    • Median survival: 20.3 vs. 15.6 months (nearly 5-month improvement)
    • Progression-free survival: 10.6 vs. 6.2 months
    • Response rate: 45% vs. 35%
  • With modern regimens (FOLFOX/FOLFIRI): Median survival now 24-30 months with bevacizumab
  • Impact: Bevacizumab became standard first-line therapy for metastatic colorectal cancer

Lung Cancer (Non-Squamous NSCLC)

E4599 Trial:
  • Carboplatin/paclitaxel + bevacizumab vs. chemo alone:
  • Median survival: 12.3 vs. 10.3 months
  • 1-year survival: 51% vs. 44%
  • Note: Excluded squamous cell due to bleeding risk

Ovarian Cancer

Glioblastoma

Hepatocellular Carcinoma

IMbrave150 Trial - NEW Standard of Care:
  • Atezolizumab + bevacizumab vs. sorafenib:
  • Median survival: 19.2 vs. 13.4 months
  • 1-year survival: 67% vs. 55%
  • PFS: 6.8 vs. 4.3 months
  • Impact: Replaced sorafenib as first-line standard

Important Limitation

Bevacizumab typically improves progression-free survival consistently but overall survival benefit is more variable and often modest (2-5 months). Quality of life and symptom control can also be important benefits.

How Long is Treatment?

Duration Varies by Cancer Type

Drug Interactions and Precautions

Important Interactions

Contraindications and Cautions

DO NOT use bevacizumab if:
  • Recent hemoptysis (>2.5 mL blood)
  • Serious/untreated infection
  • Recent surgery (<28 days) or planned surgery (<28 days)
  • Uncontrolled hypertension
  • Recent GI perforation or fistula
  • Active GI bleeding

Cost and Insurance Coverage

Medication Cost

Insurance Coverage

Financial Assistance

Biosimilars

Biosimilar Options Available:
  • Mvasi (bevacizumab-awwb): FDA-approved 2017
  • Zirabev (bevacizumab-bvzr): FDA-approved 2019
  • What are biosimilars? Highly similar to Avastin with no clinically meaningful differences in safety or effectiveness
  • Benefits: Lower cost (though still expensive); same clinical outcomes
  • Interchangeability: Can be substituted for Avastin; insurance often prefers biosimilars

Frequently Asked Questions

Q: How is bevacizumab different from chemotherapy?
A: Bevacizumab is a targeted therapy, NOT traditional chemotherapy. Chemotherapy directly kills rapidly dividing cells (including cancer cells and some normal cells like hair follicles). Bevacizumab is a monoclonal antibody that specifically blocks VEGF, starving tumors by preventing blood vessel formation. Because it targets a specific protein rather than all dividing cells, it has a different side effect profile - no hair loss, no bone marrow suppression, but unique issues like hypertension, proteinuria, and bleeding risk. It's almost always used WITH chemotherapy, not instead of it.
Q: Why is my blood pressure suddenly high?
A: Hypertension is one of the most common side effects of bevacizumab, occurring in 25-40% of patients. VEGF normally helps blood vessels stay dilated (relaxed). When bevacizumab blocks VEGF, blood vessels constrict, raising blood pressure. This is actually somewhat expected and manageable. Your oncologist will monitor your BP before every infusion and may prescribe BP medications. Monitor your BP at home twice weekly and report values >140/90. The good news: BP usually returns to normal or near-normal after stopping bevacizumab.
Q: I'm scheduled for dental work. Should I tell my dentist I'm on bevacizumab?
A: YES, always tell your dentist and any doctor performing procedures that you're on bevacizumab. For minor dental work (cleaning, fillings), usually okay to proceed with caution. For extractions or oral surgery, there's increased risk of bleeding and poor wound healing. Your dentist and oncologist should coordinate timing - ideally schedule dental work between infusions when drug levels are lower, or consider holding bevacizumab for 4+ weeks before major dental surgery. The wound healing concern is real but manageable with proper planning.
Q: Can I have surgery while on bevacizumab?
A: Elective surgery requires careful timing. Stop bevacizumab at least 4 weeks (preferably 6-8 weeks) before surgery. The drug impairs wound healing because VEGF is essential for healing. After surgery, wait until the incision is completely healed (typically 4+ weeks, but surgeon's assessment is critical) before restarting. For emergency surgery, understand there's increased risk of wound complications. Always coordinate between your surgeon and oncologist. Minor procedures (port access, skin biopsies) are generally okay with shorter intervals.
Q: I have protein in my urine. Is this serious?
A: Proteinuria (protein in urine) is common with bevacizumab (20-40%). Most cases are mild and not concerning. Your team monitors with urine dipstick before each infusion. If you have 2+ or more on dipstick, they'll do a 24-hour urine collection to measure exact protein amount. Bevacizumab is held if protein ≥2 grams/24 hours and discontinued if nephrotic syndrome develops (protein >3.5 g/day with swelling). The good news: proteinuria usually improves or resolves after stopping bevacizumab. Kidney damage from bevacizumab is typically reversible.
Q: What's the difference between Avastin and the biosimilars (Mvasi, Zirabev)?
A: Biosimilars (Mvasi and Zirabev) are highly similar to brand-name Avastin with no clinically meaningful differences in safety, purity, or effectiveness. Think of them like generic versions, though technically they're "biosimilars" not "generics" because they're made from living cells (more complex than chemical drugs). They work the same way, have the same side effects, and same clinical outcomes. Main difference: cost is somewhat lower (though still very expensive). Insurance companies often prefer biosimilars. All three are FDA-approved and medically appropriate.
Q: I'm getting nosebleeds. Should I stop bevacizumab?
A: Minor nosebleeds are very common with bevacizumab (happens in 20-40%). Usually they're not dangerous and don't require stopping treatment. Management: use saline nasal spray or gel to keep nasal passages moist, humidifier at night, avoid nose-picking. However, tell your doctor about any bleeding. STOP treatment and call immediately if: coughing up blood (hemoptysis), severe/uncontrollable nosebleeds, blood in stool (black/tarry stools or bright red blood), severe bruising, or any significant bleeding. The distinction between minor expected bleeding and serious hemorrhage is important.
Q: Does bevacizumab cure cancer?
A: For metastatic cancer, bevacizumab does not cure but helps control the disease and extend life. It slows tumor growth by cutting off blood supply and makes chemotherapy work better. In colorectal cancer, adding bevacizumab extends median survival by 2-5 months (from ~20 to ~24-25 months on average). Some patients respond very well and live much longer. Benefits vary by cancer type. In glioblastoma, it improves progression-free survival and symptoms but hasn't shown overall survival benefit. The goal is disease control, prolonging life, and maintaining quality of life.
Q: I have severe abdominal pain. What should I do?
A: Severe abdominal pain while on bevacizumab is a RED FLAG for possible GI perforation (hole in intestines), which is a medical emergency. GO TO THE EMERGENCY ROOM immediately. Don't wait. GI perforation occurs in 2-3% of patients and can be fatal if not treated urgently. Other warning signs: fever, nausea/vomiting, inability to pass gas or stool. Even if it turns out to be something else (constipation, gas, unrelated issue), severe abdominal pain needs immediate evaluation. Better safe than sorry with this particular side effect.
Q: Will bevacizumab cause hair loss?
A: No, bevacizumab itself does NOT cause hair loss. It's a targeted therapy that doesn't affect hair follicles. However, bevacizumab is almost always given WITH chemotherapy, and many chemotherapy drugs DO cause hair loss (like docetaxel, paclitaxel, doxorubicin, irinotecan). So if you're experiencing hair loss, it's from the chemotherapy component of your treatment, not the bevacizumab. When bevacizumab is used alone (like maintenance therapy after stopping chemo), you won't lose hair from it.

Living with Bevacizumab Treatment

Home Blood Pressure Monitoring

Preventing Complications

When to Call Your Doctor

Contact your oncology team or go to ER immediately for:
  • Severe abdominal pain
  • Coughing up blood
  • Blood in stool (black/tarry or bright red)
  • Severe headache, confusion, vision changes, seizures
  • Chest pain or sudden shortness of breath
  • Sudden weakness, numbness, speech problems (stroke symptoms)
  • Uncontrolled bleeding from any source
  • Signs of wound dehiscence (surgical wound opening)

Support Resources

Medical Disclaimer: This information is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Bevacizumab has serious risks including potentially fatal complications (GI perforation, severe bleeding, arterial blood clots). Every patient's situation is unique. Always consult your oncologist and healthcare team about your specific condition, treatment plan, and any questions or concerns you have. If you have a medical emergency, call 911 or go to the nearest emergency room immediately.
Sources: This guide is based on FDA prescribing information for Avastin and biosimilars, National Comprehensive Cancer Network (NCCN) guidelines, landmark clinical trials (E2100, E4599, GOG-218, AURELIA, IMbrave150), peer-reviewed medical literature on anti-angiogenic therapy, and clinical practice guidelines from major cancer centers. Content reviewed for medical accuracy and updated to reflect current standards of care as of 2025.