E-CMF (Epi-CMF) chemotherapy
This information is about a chemotherapy treatment for breast cancer called E-CMF.
You'll see your hospital doctor regularly while you have this treatment so they can monitor the effects of the chemotherapy.
The drugs that are used
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E-CMF, which is also known as Epi-CMF, is named after the initials of the four chemotherapy drugs involved:
Throughout this section we'll refer to fluorouracil by its more common name 5FU.
How treatment is given
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E-CMF 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. All of 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 fine, plastic tube that is 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.
The nurse will attach a drip (infusion) to your cannula and make sure that it is flowing freely. The drip will normally contain a sterile salt water (saline) solution. If you have a PICC or central line this may not be necessary.
The nurse will give you some anti-sickness (anti-emetic) drugs as an injection or sometimes as tablets.
The chemotherapy drugs are given separately.
An injection of epirubicin (a red fluid) is given along with an infusion of salt water (saline) into your cannula or line.
Methotrexate (a clear, yellow fluid) is given either as a slow injection alongside an infusion of saline or through your central or PICC line.
5FU (a colourless fluid) is given in the same way as methotrexate.
Cyclophosphamide can be given in a number of ways:
as an infusion of colourless fluid through your cannula or line
as a slow injection alongside an infusion of saline, or through your central or PICC line
as tablets, which should be swallowed whole.
Your doctor or nurse will explain which is the most suitable for you.
If you're having your treatment as a day patient, you can go home when it's finished and 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, as some anti-sickness drugs are much better at preventing sickness than stopping it once it has started.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the E-CMF regimen) when talking about your chemotherapy. This refers to the whole plan or schedule of your particular chemotherapy treatment.
Usually treatment with E-CMF is divided into two parts: the E part and the CMF part. Four doses of epirubicin are given during the first few months, followed by the CMF over the next few months. The following are descriptions of two different schedules for giving E-CMF. You can ask your doctor or nurse to explain which one you're having.
During the first three months of your chemotherapy you'll be given four cycles of epirubicin. This is given once every three weeks. You'll have a total of four injections over this time. The CMF part of the regime is given next.
Cyclophosphamide, methotrexate and 5FU are given on the first day (day one) and again a week later (day eight). After this, you'll have a rest period with no chemotherapy for the next three weeks before starting your next cycle. This four-week cycle will be repeated four times over a four-month period.
As in schedule A, the epirubicin is given for the first four cycles, once every three weeks. Then the CMF part of the regimen is given for the last four cycles. On the first day of the CMF treatment, you'll start a two-week course of cyclophosphamide tablets. On the same day you'll also be given injections of methotrexate and 5FU.
One week later, you'll be given injections of methotrexate 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 the next two weeks. After the rest period you'll start the next cycle of the CMF part of the treatment. Each cycle lasts four weeks.
Each person's reaction to chemotherapy is different. Some people have very few side effects while others may experience more. The side effects described below won't affect everyone who is having E-CMF 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 below, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
E-CMF 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
E-CMF 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.
E-CMF 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.
This usually starts 3-4 weeks after starting treatment, although it may occur earlier. 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. Your nurse can give you advice about coping with hair loss.
Scalp cooling 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.
E-CMF 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.
This treatment 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 side effect tends to happen more during the CMF part of treatment.
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.
Epirubicin 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.
Epirubicin and CMF can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this. Areas of skin that have previously been treated with radiotherapy may become red and sore. Let your doctor know if this happens.
The skin over the vein used for the injection may become discoloured. Your skin may darken because of excess production of pigment. It usually returns to normal a few months after the treatment has finished.
During treatment with E-CMF 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. You might find our section on taking care in the sun helpful.
Pain along the vein
Epirubicin can cause pain at the place where the injection is given or along the vein. If you feel pain, tell your nurse or doctor straight away so that they can check the site. They may give the drug more slowly or flush it through with more fluid to reduce pain.
Less common side effects
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Changes in the way your heart works
This is very rare with standard doses of epirubicin but may occasionally occur with high-dose treatment. The muscle of the heart may be affected, usually temporarily. Tests to see how well your heart is working may be carried out before the drug is given and sometimes before each treatment.
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 any of these symptoms, contact your doctor immediately.
The colour of your nails may change. They may become darker and white lines may appear on them. These usually grow out over several months once the treatment has finished.
Treatment with E-CMF may cause changes in the way your liver works, although it will return to normal when the treatment finishes. You're very unlikely to notice any problems, but your doctor will take regular blood samples to check your liver is working properly.
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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Effects when treatment is given
Some people have hot flushes, dizziness, a strange taste and a feeling of having a blocked nose when cyclophosphamide is being given. If you have any of these symptoms, ask the doctor or nurse to slow down the drip as this should reduce these effects.
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.
Leakage into the tissue around the vein (extravasation)
If this happens when epirubicin is being given, the tissue in thatarea 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.
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.
Some painkillers, such as ibuprofen, can make the side effects of methotrexate worse. Before taking any painkillers, check with your chemotherapy nurse, pharmacist or doctor.
Folinic acid tablets
If you have bad side effects from the methotrexate, such as a very sore mouth and gritty eyes, your doctor may give you folinic acid tablets to take 24 hours after having the methotrexate.
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 E-CMF, 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 are 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 cyclophosfamide 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 E-CMF 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). www.medicines.org.uk (accessed October 2011).