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Treatment Name: ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel)

ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel) is a Treatment Regimen for Lung Cancer, Non-Small Cell Lung Cancer (NSCLC)

How does ABCP work?
Both carboplatin and paclitaxel are chemotherapy drugs designed to kill and slow the growth of cancer cells.

Bevacizumab is an immunotherapy drug designed to slow the growth of cancer cells by decreasing the spread of blood vessels carrying nutrients to cancer cells.

Atezolizumab is an immunotherapy drug designed to enhance your immune system’s ability to target and specifically kill lung cancer cells. Sometimes cancer cells have the ability to escape discovery from specific cancer-fighting cells known as T-cells. By attaching to lung cancer cells, atezolizumab helps your body’s T-cells recognize the cancer and kill it.

AAtezolizumab (Tecentriq®)
BBevacizumab (Avastin®)
CCarboplatin
PPaclitaxel (Taxol®)

Goals of therapy:
ABCP is given as a first-line treatment to patients with metastatic NSCLC who do not have an EGFR or ALK mutation. ABCP is designed to kill or slow the growth of cancer cells. It may help relieve symptoms of NSCLC and slow the progression of lung cancer, but it is not commonly given with the goal of cure.

Schedule

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Induction:

  • Atezolizumab intravenous (I.V.) infusion over 60 minutes on Day 1
    • If the first infusion is well tolerated, subsequent doses may be given over 30 minutes
  • Bevacizumab I.V. infusion over 90 minutes on Day 1 of Cycle 1
    • Then over 60 minutes for Cycle 2, if no infusion reactions occur
    • Then over 30 minutes for Cycles 3 and on, if no infusion reactions occur
  • Carboplatin I.V. infusion over 30 minutes on Day 1
  • Paclitaxel I.V. infusion over 3 hours on Day 1

The induction phase of ABCP is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to 4 to 6 times. Duration of therapy may last up to five months, depending upon response, tolerability, and number of cycles prescribed.

Maintenance:

  • Atezolizumab I.V. infusion over 30 minutes on Day 1
    • The infusion may be given over 60 minutes for history of infusion reactions
  • Bevacizumab I.V. infusion over 30 minutes on Day 1 of Cycle 1
    • The infusion may be given over 60 or 90 minutes for history of infusion reactions

Atezolizumab and Bevacizumab may both be given during the maintenance phase or only one of them may be given.

The maintenance phase of ABCP is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated until the treatment no longer works or until unacceptable side effects occur. Duration of therapy depends upon response, tolerability, and number of cycles prescribed.

Estimated total infusion time for this treatment:

  • For induction treatment, infusion time may take up to 7 hours for Cycle 1, Day 1; Up to 6 hours for Cycle 2, Day 1; as short as 5 hours for the first day of Cycles 3 and on
  • For maintenance treatment, infusion time may take up to 2 hours for Day 1 of each Cycle
  • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time

ABCP is usually given in an outpatient infusion center, allowing the person to go home afterwards. On occasion, it may be given in the hospital if someone is too sick for outpatient treatment.

Click here for the common ABCP starting doses.

Side Effects

In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most commonly reported side effects of ABCP are shown here:

  • Hair loss (47%)
  • Tingling or numbness in fingers or toes (39%)
  • Nausea (34%)
  • Fatigue (26%)
  • Anemia [low red blood cells] (24%)
  • Decreased appetite (22%)
  • Diarrhea (20%)
  • High blood pressure (19%)
  • Neutropenia [low white blood cells] (18%)
  • Joint pain (17%)
  • Constipation (17%)
  • Weakness (15%)
  • Nose bleed (14%)
  • Muscle pain (14%)
  • Thrombocytopenia [low platelets] (13%)
  • Protein in urine (13%)
  • Skin rash (13%)
  • Mouth sores (12%)
  • Tingling or burning sensation on skin (11%)
  • Neutropenic fever (9%)

Approximately 33% of patients discontinue treatment due to unacceptable side effects at some point during therapy with ABCP.

Side effect videos Side Effect Videos
Hair LossHair LossNausea and VomitingNausea and VomitingFatigue Fatigue AnemiaAnemiaDiarrheaDiarrheaPainPainConstipationConstipationBleedingBleedingNeutropenic FeverNeutropenic Fever

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before each treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), urine protein levels, thyroid function, blood amylase levels, blood lipase levels, plus any others your doctor may order.

How often is imaging needed?
Imaging may be checked before treatment and during cancer treatment if there are concerns for disease progression or side effects. Imaging may include: X-rays, magnetic resonance imaging (MRI), computerized tomography (CT) scans, or positron emission tomography (PET) scans.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue ABCP as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

ChemoExperts Tips

  • Because atezolizumab (Tecentriq®) enhances your immune system response to cancer, it may cause unintended side effects that are caused by the immune system and affect healthy cells as well. Some organs that can be affected include the thyroid, pituitary gland, adrenal glands, pancreas, gastrointestinal tract, liver, lungs, skin and eyes. A corticosteroid (e.g., prednisone) may be prescribed by your doctor to decrease symptoms if the immune system attacks healthy tissues during treatment
  • Paclitaxel tends to cause infusion reactions that can be related to the cremophor that is used in the IV formulation. Patients may receive several medications prior to receiving paclitaxel (this is known as "pre-medication") to decrease the risk of infusion reactions. Common pre-medications given are a histamine-2 blockers such as famotidine (Pepcid®) or ranitidine (Zantac®), a histamine-1 blocker such as diphenhydramine (Benadryl®), and a corticosteroid such as dexamethasone
  • Bevacizumab may lead to increases in blood pressure after starting therapy. If you currently are taking medications to control blood pressure, the doses of these medications may need to be adjusted or you may need to take additional medications to help control blood pressure
  • Tell your doctor if you plan on having any surgeries while on therapy with bevacizumab as it can delay wound healing from the surgery and possibly lead to complications
  • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
  • Clinical trials may exist for NSCLC (Non-Small Cell Lung Cancer). Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering study medications

Patient Assistance & Co-payment Coverage

Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel), we have provided links that may help.

Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel). Depending upon your income, they may be able to help cover the cost of:

  • Atezolizumab
  • Bevacizumab
  • Paclitaxel
  • Carboplatin

For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

  • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel) and are the best source to help you understand drug cost.

  • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

Emotional Wellness

What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.

Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.

Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.

Learn more about pursuing emotional wellness while receiving treatment with ABCP (Atezolizumab (Tecentriq®) + Bevacizumab (Avastin®) + Carboplatin + Paclitaxel)

Individual Drug Label Information

Atezolizumab (Tecentriq®)

  • Atezolizumab (Tecentriq®) is an intravenous infusion
  • Doses may need to be delayed due to lung, liver, intestine, adrenal gland, thyroid, pituitary, eye, or other treatment-related problems
  • Inflammation of the lungs is rare, but serious if it occurs. Call your doctor immediately if you notice change in breathing, worsening cough, or chest pain as immediate treatment may be necessary
  • Liver inflammation may occur and is usually found through blood tests and may not cause any symptoms early in treatment. Atezolizumab therapy may need to be put on hold if this occurs, or steroid treatment may be started to help the liver recover. It may be possible to restart atezolizumab treatment if the liver fully recovers. Signs of liver problems may include yellowing of eyes or skin, pain on right side of abdomen, or easy bruising or bleeding
  • Intestine (colon) inflammation is relatively common and often causes diarrhea, with or without abdominal pain. Atezolizumab therapy may need to be put on hold if this occurs, or steroid treatment may be started to help the intestines recover. It may be possible to restart atezolizumab treatment if the intestines recover
  • Thyroid, adrenal gland, pancreas, or pituitary gland inflammation may occur, although all are relatively rare and occur in roughly 4% or fewer patients (1 out of every 25 patients)
  • Symptoms of thyroid problems may include: extreme tiredness, hair loss, weight loss or weight gain, feeling cold
  • Symptoms of adrenal gland problems may include: Dizziness, fatigue, low blood pressure, low blood sugar, difficulty with walking
  • Symptoms of pancreas problems may include: blood sugars that are difficult to control or abdominal pain, or frequent urination
  • Symptoms of pituitary gland problems may include: headache, vision problems, changes in hair, nails, or skin, and problems with other glands such as adrenals
  • Atezolizumab may be unsafe to receive if you are pregnant or breastfeeding. If you are a woman of child-bearing potential, tell you doctor immediately if you become pregnant while receiving atezolizumab. Women should not breastfeed for at least five months after the last dose of therapy
  • Women should also use effective contraception during treatment and for at least five months after the last dose
General side effects from atezolizumab (Tecentriq®)
  • Fatigue is the most common side effect reported with atezolizumab
  • Decreased appetite
  • Nausea
  • Infection, such as urinary tract infections or others. Report any fever, chills, flu-like symptoms, cough, or pain when urinating to your doctor immediately
  • Constipation
  • Skin reactions, such as itching or rash
  • Diarrhea is most often mild, but in some cases it can become severe when the digestive tract becomes inflamed. Watch for blood in stool or black tarry stools
  • Pain in joints
  • Vision problems
  • Click on the atezolizumab (Tecentriq®) package insert below for all reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaFatigue Fatigue ConstipationConstipationPainPainAnemiaAnemia

See DailyMed package insert.

Bevacizumab (Avastin®)

  • Bevacizumab is an intravenous (I.V.) drug
  • Use extreme caution in patients with a history of stomach and intestine perforations or disorders
  • Do not use 28 days before or after any surgery
  • Bleeding is more likely in patients taking this drug
  • Bevacizumab treatment may be delayed or stopped for: surgery, high blood pressure, protein in urine, severe infusion reactions
General Bevacizumab Side Effects
  • Infusion reactions: usually does not happen after first successful dose
  • Bleeding
  • Blood clots
  • Stomach and intestinal problems
  • Poor wound healing
  • High blood pressure
  • Protein leaking from kidneys into urine
  • Avoid during pregnancy, Bevacizumab is known to cause fetal harm
  • Ovarian failure
  • Click on the bevacizumab (Avastin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
BleedingBleedingBlood ClotsBlood Clots

See DailyMed package insert.

Paclitaxel (Taxol®)

  • Paclitaxel is an intravenous infusion
  • There is a risk for serious infusion reactions such as trouble breathing, low blood pressure, severe swelling, or hives. These reactions are due to a component in the solution called Cremophor. You will receive several medications before receiving paclitaxel to decrease the risk of experiencing an infusion related reaction that include: a corticosteroid, diphenhydramine (Benadryl), and histamine-2 antagonists (Zantac or Pepcid).Patients who experience these type of severe reactions should not be rechallenged with paclitaxel.
  • This drug can cause low white blood cell counts. Complete blood counts (CBC) will be checked before each treatment to make sure your white blood cells are at a safe enough to use this drug
  • Dosage adjustments may be required for liver dysfunction, nerve pain or toxicity, low white blood cells, or low blood platelets
  • Nerve pain usually starts as tingling or a "pins and needles" feeling in the fingers or toes, but can worsen over time and lead to numbness. It is important to notify the doctor if there are any signs of nerve damage. If caught early, this is typically reversible but can become permanent if not addressed
  • Interacts with certain antifungal, blood pressure, cholesterol, erectile dysfunction, sedative, antibiotic, and anti-seizure medications.  Ask your doctor or pharmacist to review your medications for any possible interactions
  • Known interaction with grapefruit or grapefruit juice. Avoid eating grapefruit and drinking grapefruit juice as they may increase your risk of experiencing side effects
  • Avoid the natural supplement St. John’s Wort as this can possibly decrease the effectiveness of paclitaxel
  • Injection site skin reactions can occur:  itching, skin infection, skin falling off, skin death, and redness. Report any of these to your physician, even if this occurs several days after an infusion
  • Can cause fetal harm; this drug should not be used during pregnancy.  Women should avoid becoming pregnant while on this drug
General Paclitaxel (Taxol) Side Effects
  • Low blood neutrophil count (neutropenia)
  • Low white blood cells
  • Nerve pain and general pain
  • Low red blood cells and related fatigue
  • Infusion reactions - hypersensitivity
  • Hair loss
  • Nausea
  • Diarrhea
  • Mouth sores
  • Low blood pressure
  • Liver problems
  • Constipation
  • Fever and infection
  • Bleeding
  • Injection site reactions
  • Nail discoloration; usually reversible once paclitaxel is stopped
  • Click on the paclitaxel (Taxol) package insert below for all manufacturer reported side effects and possible drug interactions

Side Effect Videos
DiarrheaDiarrheaHair LossHair LossFatigue Fatigue BleedingBleedingConstipationConstipationPainPainAnemiaAnemiaNeutropenic FeverNeutropenic Fever

See DailyMed package insert.

Carboplatin (Paraplatin®)

  • Carboplatin is an intravenous infusion 
  • This medication is dosed based on your kidney function. If your kidney function improves or worsens during therapy, your dose may need to be adjusted
  • This drug should not be used during pregnancy, it may cause fetal harm
General Carboplatin (Paraplatin) Side Effects:  
  • Low red blood cells, low white blood cells, and most commonly, low platelets can be occur
  • Nausea and vomiting is common but can be prevented by taking certain pre-medications
  • Hair loss
  • Constipation and/or diarrhea
  • Pain
  • Allergic reactions to carboplatin can occur. These typically are not seen until after the 6th dose of carboplatin is given 
  • Can cause liver damage at high doses 
  • May cause kidney damage or hearing loss if combined with other medications that also cause these side effects 
  • Click on the carboplatin (Paraplatin) package insert below for reported side effects and possible drug interactions

Side Effect Videos
Nausea and VomitingNausea and VomitingDiarrheaDiarrheaHair LossHair LossBleedingBleedingConstipationConstipationPainPainAnemiaAnemia

See DailyMed package insert.

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References

Socinski MA, Jotte RM, Cappuzzo F, et al. Atezolizumab for First-Line Treatment of Metastatic Nonsquamous NSCLC. N Engl J Med. 2018;378:2288-2301.

Created: August 14, 2019 Updated: August 14, 2019

What is Lung Cancer, Non-Small Cell Lung Cancer (NSCLC)?

What is Non-Small Cell Lung Cancer?
A disease of the tissue found in the lung.  Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Known causes include smoking and exposure to environmental toxins.  The stage of NSCLC can vary at diagnosis and throughout treatment.  Stages include stage I, II, III, and IV.  The effectiveness of the treatment may depend upon the stage at diagnosis.

NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

Common ABCP starting doses

Induction:

  • Atezolizumab 1,200 mg intravenous (I.V.) infusion over 60 minutes on Day 1
    • If the first infusion is well tolerated, subsequent doses may be given over 30 minutes
  • Bevacizumab 15 mg/kg I.V. infusion over 90 minutes on Day 1 of Cycle 1
    • then over 60 minutes for Cycle 2, if no infusion reactions occur
    • then over 30 minutes for Cycles 3 and on, if no infusion reactions occur
  • Carboplatin (AUC 6) I.V. infusion over 30 minutes on Day 1
  • Paclitaxel 200 mg/m2 I.V. infusion over 3 hours on Day 1

Maintenance:

  • Atezolizumab 1200 mg I.V. infusion over 30 minutes on Day 1
    • The infusion may be given over 60 minutes for history of infusion reactions
  • Bevacizumab 15 mg/kg I.V. infusion over 30 minutes on Day 1 of Cycle 1
    • The infusion may be given over 60 or 90 minutes for history of infusion reactions

Note 1: Atezolizumab and Bevacizumab may both be given during the maintenance phase or only one of them may be given.

Note 2: Individual doses may vary based upon your Doctor's recommendation, or drug availability.

What does Cure mean?

The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.

Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.

What is a CBC?

A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

Common uses:
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

What is a CMP?

A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

Kidney Function:
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

Liver Function:
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

Blood sugar:
13) Serum glucose

Calcium:
14) Serum calcium

What is amylase?

Amylase is an enzyme that is produced by the pancreas that helps the body break down and digest carbohydrates. When the pancreas is injured, amylase is leaked out into the blood. 

Amylase, along with lipase, can be monitored to check for possible injury to the pancreas, indicated by elevated levels of the enzymes in the blood.

What is Lipase?

Lipase is an enzyme that is produced by the pancreas that helps the body break down fats. When the pancreas is injured, lipase is leaked out into the blood. Lipase, along with amylase, can be monitored to check for possible injury to the pancreas, indicated by elevated levels of the enzymes in the blood.