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CION Cancer Clinics
Why you need an endoscopy before starting bevacizumab | CION Cancer Clinics
Before bevacizumab starts, an endoscopy looks for varices, the swollen veins in the food pipe that cirrhosis causes. Bevacizumab can make them more likely to bleed, so large ones are treated first. This page explains why the check matters, what happens between the endoscopy and the first dose, and what the words on the report mean. At CION Cancer Clinics, a multidisciplinary tumour board weighs your liver function and your scans before recommending any treatment.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed October 2026, next review due October 2027
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On this page
- Why is an endoscopy needed before bevacizumab?
- Why does bevacizumab make varices more dangerous?
- What happens between the endoscopy and treatment?
- What do the words on an endoscopy report mean?
- What families often worry about, and what is true
- What this page cannot tell you
- Common questions about the endoscopy before bevacizumab
The short answer
Why is an endoscopy needed before bevacizumab?
An endoscopy is done before bevacizumab to look for varices, swollen veins in the food pipe or stomach that can bleed. Bevacizumab can make bleeding more likely, so large varices are found and treated first, before the first dose. It is a safety check, not a delay for its own sake.
Bevacizumab is given with atezolizumab as the usual first drug treatment for primary liver cancer (hepatocellular carcinoma, or HCC) that cannot be removed. Most people with this cancer also have cirrhosis, which is scarring of the liver. Cirrhosis pushes up the pressure in the vein that carries blood into the liver, called portal hypertension. Blood looks for another way round, and the veins in the food pipe swell. Those swollen veins are varices. The varices explained page covers this in more detail.
Which liver cancer this page is about
This page is about primary liver cancer. If the cancer spread to the liver from the bowel or another organ, the liver is usually not cirrhotic and varices are less common. Your oncologist will tell you whether an endoscopy is needed in your case.
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Go to hospital today
Vomiting blood, vomiting something that looks like coffee grounds, or passing black, sticky, tar-like stools can mean a varix is bleeding. Go to the nearest emergency department today, by ambulance if the person is dizzy or faint. Say they have liver disease and are on, or about to start, cancer treatment. Do not wait to see if it settles.
Not sure whether this applies to you?
Ask an oncologistThe reasoning
Why does bevacizumab make varices more dangerous?
Three things meet in the same person, and together they raise the risk.
The drug
Bevacizumab blocks a signal that tumours use to grow new blood vessels. The same signal helps the body repair small blood vessels. Bleeding is one of its known side effects. Its wider side effects are on the bevacizumab bleeding risk page.
The veins
Varices are thin-walled and under pressure. Large ones, or ones with red marks on their surface, are the most likely to burst. Many people have them without any symptoms at all.
The liver
A scarred liver makes fewer of the proteins that help blood clot. A bleed that a healthy person might stop on their own can become serious quickly in someone with cirrhosis.
What the trials did
The main research on atezolizumab plus bevacizumab required people to have an endoscopy first and to have large varices treated before joining. Guidelines carry that rule forward, which is why your team follows it.
From referral to first dose
What happens between the endoscopy and treatment?
The endoscopy is arranged
CION arranges the endoscopy through a partner hospital. A thin, flexible camera is passed through the mouth into the food pipe and stomach. You are usually asked not to eat beforehand, and a throat spray or sedation keeps it comfortable.
The varices are graded
The doctor doing the endoscopy notes whether there are varices, how large they are and whether they have warning marks. The grades of varices page explains the words on the report.
Large varices are treated
Banding places tiny rubber bands around the veins so they shrink. It often needs a few repeat endoscopies. Some people are given beta-blocker tablets instead of, or as well as, banding.
The tumour board confirms the start
Once the endoscopy report is back and any large varices are treated, the tumour board reviews it with the scans and blood tests. Small or no varices usually mean treatment can begin.
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On your report
What do the words on an endoscopy report mean?
- Oesophageal varices
- Swollen veins in the food pipe. These are the ones most often checked before bevacizumab.
- Gastric varices
- Swollen veins in the stomach. They are treated differently from food pipe varices, and need a specialist's plan.
- Small, medium or large
- The size of the varices. Large ones carry the highest bleeding risk and are usually treated before bevacizumab starts.
- Red wale signs
- Red streaks on the vein wall. They suggest the wall is thin and a bleed is more likely, even if the varix is not large.
- Portal hypertensive gastropathy
- A fragile, reddened stomach lining caused by the same high pressure. It can ooze blood slowly and cause a low blood count.
- Band ligation, or EVL
- Banding: tying off the swollen veins with small rubber bands during an endoscopy.
Commonly believed
What families often worry about, and what is true
"The endoscopy is just a delay. The cancer is growing while we wait."
The wait is usually short, and the check is there to stop a dangerous bleed in the middle of treatment. A serious bleed could stop cancer treatment for much longer than the endoscopy takes.
"He has never vomited blood, so he has no varices."
Most varices cause no symptoms until they bleed. The only reliable way to know is to look, which is why the endoscopy is done even in people who feel well.
"If varices are found, bevacizumab is off the table."
Usually not. Small varices often need nothing more than watching or tablets. Large ones are treated, and once they are controlled, treatment can usually go ahead.
"A recent endoscopy for something else is enough."
It may be. Bring the report. Your team will decide whether it is recent enough and detailed enough, or whether a fresh look is needed.
Being straight with you
What this page cannot tell you
It cannot tell you whether your varices are safe enough for bevacizumab. That depends on what the endoscopy shows, how well your liver is working, whether you have bled before and what other medicines you take. Your oncologist and the doctor who did the endoscopy decide this together.
Who this does not apply to
If you are being offered a treatment without bevacizumab, such as durvalumab plus tremelimumab or a tablet like lenvatinib, the endoscopy may still be advised for your general liver care, but not for the same reason. People who cannot have bevacizumab at all are covered on who cannot have atezolizumab plus bevacizumab.
It cannot replace the emergency plan
Even after banding, varices can return and bleed. Keep the warning signs in mind for as long as you are on treatment, and make sure everyone at home knows them.
If you are unsure whether the endoscopy has been done or what it showed, ask your team for the report before the first dose.Questions we are asked
Common questions about the endoscopy before bevacizumab
Does the endoscopy hurt?
Most people find it uncomfortable rather than painful. A spray numbs the throat, and sedation is often offered so you are drowsy and relaxed. You may have a sore throat for a short while afterwards. Someone should take you home if you had sedation.
How recent does the endoscopy need to be?
The trials asked for a recent one, and most teams follow that. Exactly how recent is a judgement your oncologist makes, based on how stable your liver has been. If you already had one, bring the report and let the team decide whether to repeat it.
Can I start treatment while the varices are being banded?
Usually the team waits until the large varices are controlled. Some situations allow a start alongside, for example when the cancer is growing fast. This is a decision for your oncologist and the doctor doing the banding, made together.
Will I need another endoscopy during treatment?
Sometimes. People who had large varices banded usually have check endoscopies to make sure they have not come back. Your team will plan these alongside your scans and blood tests while you are on treatment.
What if I cannot have an endoscopy?
If an endoscopy is not possible or not safe for you, the team may treat you as if large varices are present, or choose a drug without bevacizumab. The bevacizumab and bleeding risk page explains the trade-offs.
Do beta-blockers interfere with cancer treatment?
They are commonly used together. Beta-blockers lower the pressure in the varices and can also lower blood pressure, which bevacizumab can raise. Your doctors will check your pulse and blood pressure and adjust them. Never stop them on your own.
Does the endoscopy cost extra?
The endoscopy and any banding are quoted separately from cancer treatment, and the cost varies by hospital and by what is needed. Ask for a written, itemised estimate. Schemes and insurance may cover part of it; check the details at the time.
Who can explain my endoscopy report?
The doctor who did the endoscopy, or your oncologist at CION. Bring the report and the photographs if you have them. Call the CION helpline and the team will arrange a consultation to go through it with you and your family.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- Cleveland Clinic — Esophageal Varices: Symptoms, Causes & Treatment
- MedlinePlus — Bleeding esophageal varices
- American Cancer Society — Immunotherapy for Liver Cancer
- Merck Manual Consumer Version — Portal Hypertension
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Who cannot have atezolizumab plus bevacizumabThe other reasons the combination may not suit youBevacizumab and bleeding risk with varicesHow the bleeding risk is weighed in detailBanding: tying off the veinsWhat happens if large varices are foundAtezolizumab plus bevacizumab for liver cancerThe treatment this check prepares you for
Talk to us
Waiting on an endoscopy before treatment?
We can arrange the endoscopy through a partner hospital and have the tumour board review the report with your scans. One helpline serves every CION centre.