This information is about a chemotherapy treatment for breast cancer called CAF.
The drugs that are used
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CAF is named after the initials of the chemotherapy drugs used, which are:
How treatment is given
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CAF treatment can usually be given to you as a day patient. Before you start treatment you'll need to have a blood test, either on the same day or a few days beforehand. You'll also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. This may take a couple of hours.
The nurse will insert a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a thin, plastic tube inserted under the skin and into a vein near the collarbone (central line) or passed through a vein in the crook of their arm (PICC line).
Your doctor or nurse will explain more about this to you.
You'll be given some anti-sickness drugs (anti-emetic) drugs. These are usually given by injection through the cannula, central line or PICC line, which is connected to a drip (infusion). Some anti-sickness medicines may be given as tablets.
The chemotherapy drugs are then given separately, which involves:
an injection of doxorubicin (a red fluid) given alongside a drip (infusion) of salt water (saline) into your cannula or line
an infusion or injection of cyclophosphamide (a colourless fluid)given alongside a drip of saline – it can also be given as a course of pink or white tablets over two weeks (see Schedule B)
followed by an injection of 5FU (a colourless fluid) given into your cannula or line.
If you're being treated as a day patient, you can go home when it has finished. The cannula will be removed before you go. If you have a central or PICC line it will usually stay in place, ready for the next cycle of your chemotherapy. You'll be shown how to look after the line.
You'll be given a supply of anti-sickness drugs to take home with you. It's important to take these as directed even if you aren't feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than stopping it once it starts.
How often treatment is given
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CAF chemotherapy can be given in different ways. Your doctor may use the word 'regimen' (eg the CAF regimen) when talking about your chemotherapy. This refers to the whole plan or schedule of the particular chemotherapy treatment you are receiving.
There are two different schedules for giving CAF. You can ask your doctor or nurse to explain which one you're having.
On the first day of your treatment you'll be given all three of the drugs (cyclophosphamide, doxorubicin and 5FU) by drip (infusion) and injection.
After this, you'll have a rest period with no chemotherapy for the next three weeks. This completes a cycle of your treatment.
After the three-week rest period, the same drugs will be given to you again. This begins the next cycle of your treatment. Usually 4–6 cycles of treatment are given over 3–4 months. This makes up a course of treatment.
On the first day of your treatment, you'll start your cyclophosphamide tablets, which you take for two weeks (14 days). On the same day you will also be given injections of doxorubicin and 5FU (as described above).
One week later (day eight) you'll be given doxorubicin and 5FU again. When you finish your cyclophosphamide tablets (a week after your last injections) you'll have a rest period with no chemotherapy for two weeks. This completes a cycle of your chemotherapy.
You'll start the next cycle of your treatment after the rest period, which will be four weeks after your first injection. Usually you'll be given four cycles of CAF over four months. This makes up a course of treatment.
Each person’s reaction to chemotherapy is different. Some people have very few side effects while others may experience more. The side effects described here won't affect everyone who is having CAF chemotherapy.
We have outlined the most common side effects but haven't included those that are rare and therefore unlikely to affect you. If you notice any effects that aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
CAF can reduce the number of white blood cells, which help fight infection. White blood cells are produced by the bone marrow. If the number of your white blood cells is low you'll be more prone to infections. A low white blood cell count is called neutropenia.
Neutropenia begins seven days after treatment, and your resistance to infection is usually at its lowest 10–14 days after chemotherapy. The number of your white blood cells will then increase steadily and usually return to normal before your next cycle of chemotherapy is due.
Contact your doctor or the hospital straight away if:
your temperature goes above 38°C (100.4°F)
you suddenly feel unwell even with a normal temperature.
You'll have a blood test before having more chemotherapy to check the number of white blood cells. Occasionally, your treatment may need to be delayed if the number of your blood cells (blood count) is still low.
Bruising or bleeding
CAF can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. You may need to have a platelet transfusion if your platelet count is low.
CAF can reduce the number of red blood cells, which carry oxygen around the body. A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Feeling sick (nausea) or being sick (vomiting)
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea or vomiting. If the sickness isn't controlled, or if it continues, tell your doctor; they can prescribe other anti-sickness drugs that may be more effective.
Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.
Feeling tired is a common side effect of chemotherapy, especially towards the end of treatment and for some weeks after it’s over. It’s important to try to pace yourself and get as much rest as you need. Try to balance this with some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
CAF may cause an inflammation of the lining of the eyelids (conjunctiva) that makes your eyes feel sore, red and itchy. Let your doctor know so they can prescribe soothing eye drops if necessary.
This usually starts about 10–14 days after you first have treatment. Hair usually falls out completely. You may also have thinning and loss of eyelashes, eyebrows and other body hair. This is temporary, and your hair will start to grow again once the treatment has finished. Your hair may grow back straighter, curlier, finer or a slightly different colour than it was before treatment. Your nurse can give you advice about coping with hair loss.
is a method of reducing hair loss that may be helpful for some people. You can ask your doctor or nurse if it's available at your hospital.
Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help reduce the risk of this happening. Some people find sucking on ice soothing. Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicine to prevent or clear mouth infections.
You may notice that food tastes different. Normal taste usually comes back after treatment finishes. A dietitian or specialist nurse at your hospital can give you advice about ways of coping with this side effect.
CAF can cause diarrhoea. This can usually be easily controlled with medicine, but tell your doctor if it's severe or continues. It's important to drink plenty of fluids if you have diarrhoea.
Cyclophosphamide may irritate your bladder. It’s important to drink as much fluid as you can (at least two litres) during the 24 hours following chemotherapy to help prevent this.
Doxorubicin is red and, as a result, your urine may become a pink-red colour. This is normal and can last up to 48 hours after your treatment. Let your doctor know if you have any discomfort when you pass urine or if you notice any blood in it.
Your nails may become darker, brittle, chipped or ridged. These changes usually grow out slowly over a few months once the treatment has ended.
Less common side effects
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A skin rash can sometimes occur while you're having treatment with CAF. It’s important to let your doctor know if this happens. Your doctor can prescribe medicine to help with this. Rarely, your skin may darken. If it does, it usually goes back to normal a few months after the treatment has finished.
During treatment and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than normal. You can still go out in the sun but should wear a suncream with a high sun protection factor (SPF) and cover up with clothing and a hat.
Changes in the way your heart works
5FU may affect the way your heart works. Some people can experience chest pain and tightening across the centre of the chest while taking it. Chest pain can be caused by many different things other than chemotherapy. If you develop chest pain, shortness of breath, fatigue or leg swelling, contact your doctor immediately.
It’s important to let your doctor know straight away if you feel unwell or have any severe side effects, even if they’re not mentioned above.
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Risk of developing a blood clot
Cancer can increase the risk of developing a blood clot (thrombosis), and chemotherapy may increase this risk further.
A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it’s important to tell your doctor straight away if you notice any of these symptoms. Most clots can be treated with drugs that thin the blood. The doctor or nurse can give you more information.
Some medicines, including those you can buy in a shop or chemist, can be harmful to take when you're having chemotherapy. Tell your doctor about any medicines you're taking, including over-the-counter drugs, complementary therapies and herbal drugs.
Leakage into the tissue around the vein (extravasation)
If this happens when doxorubicin is being given, the tissue in that area can be damaged. Tell the doctor or nurse immediately if you notice any stinging or burning around the vein while the drug is being given. This is unlikely to happen if the chemotherapy is given through a central or PICC line.
If the area around the injection site becomes red or swollen at any time, you should tell the doctor or nurse on the ward. If you're at home, ring the clinic or ward and ask to speak to the doctor or nurse.
Your ability to become pregnant or father a child may be affected by having this treatment. It's important to discuss fertility with your doctor before starting treatment.
It's not advisable to become pregnant or father a child while having CAF, as it may harm the developing baby. It’s important to use effective contraception while having this chemotherapy and for at least a few months afterwards. You can discuss this with your doctor.
It’s not known whether chemotherapy drugs can be present in semen or vaginal fluids. To protect your partner, it’s safest to either avoid sex or use a barrier form of contraception for about 48 hours after chemotherapy.
Loss of periods in women
Because of the effect of chemotherapy on the ovaries, women may find that their periods become irregular and may eventually stop. In some women this may be temporary, but for others it will be permanent. This will result in menopausal symptoms, such as hot flushes, sweats and vaginal dryness.
There's a potential risk that chemotherapy drugs may be present in breast milk. Women are advised not to breastfeed during chemotherapy and for a few months afterwards.
If you’re admitted to hospital for a reason not related to the cancer, it’s important to tell the doctors and nurses looking after you that you're having chemotherapy treatment. You should tell them the name of your cancer specialist so that they can ask for advice.
It’s a good idea to know who you should contact if you have any problems or troublesome side effects when you’re at home. Your chemotherapy nurse or doctor will give you details of who to contact for advice. This should include ‘out-of hours’ contact details if you need to call someone at evenings, overnight or at the weekend.
Things to remember about cyclophosphamide tablets
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Swallow your tablets whole with a glass of water.
It’s important to take your tablets at the right times as directed by your doctor.
Always tell any doctors treating you for non-cancerous conditions that you're taking a course of chemotherapy tablets that should not be stopped or restarted without advice from your cancer specialist.
Keep the tablets in their original packaging, and store them at room temperature away from heat and direct sunlight.
Keep the tablets in a safe place and out of the reach of children.
If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Don't flush them down the toilet or throw them away.
If you're sick just after taking the tablets tell your doctor as you may need to take another dose. Don't take another tablet without telling your doctor first.
If you forget to take a tablet, don't take a double dose. Let your doctor know and keep to your regular dose schedule.
This section is based upon our CAF chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
British National Formulary. 62nd edition. 2011. British Medical Association and Royal Pharmaceutical Society of Great Britain.
electronic Medicines Compendium (eMC). (accessed October 2011).
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.