Atezolizumab plus bevacizumab versus sorafenib or atezolizumab alone for unresectable hepatocellular carcinoma:A systematic review

BACKGROUND Despite the use of current standard therapy,the prognosis of patients with unresectable hepatocellular carcinoma(HCC)is poor,with median survival times of 40 mo for intermediate HCC(Barcelona Clinic Liver Cancer[BCLC]stage B)and 6-8 mo for advanced HCC(BCLC stage C).Although patients with earlystage HCC are usually suitable for therapies with curative intention,up to 70% of patients experience relapse within 5 years.In the past decade,the United States Food and Drug Administration has approved different immunogenic treatment options for advanced HCC,the most common type of liver cancer among adults.Nevertheless,no treatment is useful in the adjuvant setting.Since 2007,the multikinase inhibitor sorafenib has been used as a first-line targeted drug to address the increased mortality and incidence rates of HCC.However,in 2020,the IMbrave150 trial demonstrated that combination therapy of atezolizumab(antiprogrammed death-ligand 1[PD-L1])and bevacizumab(anti-vascular endothelial growth factor[VEGF])is superior to sorafenib,a single anti-programmed death 1/PD-L1 antibody inhibitor used as an anti-cancer monotherapy for HCC treatment.AIM To conduct a systematic literature review to evaluate the evidence supporting the efficacy and safety of atezolizumab/bevacizumab as preferred first-line drug therapy over the conventional sorafenib or atezolizumab monotherapies,which are used to improve survival outcomes and reduce disease progression in patients with unresectable HCC and non-decompensated liver disease.METHODS A comprehensive literature review was conducted using the PubMed,Scopus,ScienceDirect,clinicaltrials.gov,PubMed Central,Embase,EuropePMC,and CINAHL databases to identify studies that met the inclusion criteria using relevant MeSH terms.This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and risk of bias(RoB)were assessed using the Cochrane RoB 2 tool and Sevis.RESULTS In the atezolizumab/bevacizumab group,an improvement in overall tumor response,reduction of disease progression,and longer progression-free survival were observed compared to monotherapy with either sorafenib or atezolizumab.Hypertension and proteinuria were the most common adverse events,and the rates of adverse events were comparable to those with the monotherapy.Of the studies,there were two completed trials and two ongoing trials analyzed using high quality and low bias.A more thorough analysis was only performed on the completed trials.CONCLUSION Treatment of HCC with atezolizumab/bevacizumab combination therapy was confirmed to be an effective first-line treatment to improve survival in patients with unresectable HCC and non-decompensated liver disease compared to monotherapy with either sorafenib or atezolizumab.

Virtual patient education for hypertension: The truth about behavioral change

Anti-hypertensive education is an important public health intervention to decrease the mortality and burden of the disease.Using digital technologies for education as a part of preventive measures for hypertension is a cost-effective approach and helps low-income communities and vulnerable populations overcome barriers to healthcare access.The coronavirus disease 19 pandemic further highlighted the need of new health interventions to address health inequalities.Virtual education is helpful to improve awareness,knowledge,and attitude toward hypertension.However,given the complexity of behavioral change,educational approaches do not always provide a change in behavior.Some of the obstacles in online hypertensive education could be time limitations,not being tailored to individual needs and not including the different elements of behavioral models to enhance behavior change.Studies regarding virtual education should be encouraged and involve lifestyle modifications emphasizing the importance of Dietary Approaches to Stop Hypertension diet,salt restriction,and exercise and should be used adjunct to in-person visits for the management of hypertension.Additionally,to stratify patients according to hypertension type(essential or secondary)would be useful to create specific educational materials.Virtual hypertension education is promising to increase awareness regarding risk factors and most importantly motivate patients to be more compliant with management helping to decrease hypertension related complications and hospitalizations.