E-CMF (Epi-CMF) chemotherapy
E-CMF is a chemotherapy treatment used to treat breast cancer. It is sometimes called Epi-CMF.
This information should ideally be read with our general information about chemotherapy and your type of cancer.
The drugs used in E-CMF chemotherapy
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E-CMF, which is also known as Epi-CMF, is named after the initials of the chemotherapy drugs involved:
Throughout this information we call fluorouracil by its more common name 5FU.
You have E-CMF in the chemotherapy day unit or during a short stay in hospital. A chemotherapy nurse will give it to you. During treatment you usually see a cancer doctor, a chemotherapy nurse or a specialist nurse. This is who we mean when we mention doctor or nurse in this information.
Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that it is okay for you to have chemotherapy.
You will also see a doctor or nurse before you have chemotherapy. They will ask you about how you have been. If your blood results are alright on the day of your treatment, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse gives you anti-sickness drugs as an injection into a vein or as tablets. They give you the drugs and chemotherapy through one of the following:
a short thin tube (cannula) the nurse puts into a vein in your arm or hand
a fine tube that goes under the skin of your chest and into a vein close by (central line)
a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line).
Your nurse gives you:
Epirubicin (a red fluid) is given by injection directly into your vein with a drip (infusion) to flush it through.
Methotrexate (a clear, yellow fluid) is given by injection directly into your vein with a drip to flush it through.
5FU (a colourless fluid) is given by injection directly into your vein with a drip to flush it through.
Cyclophosphamide (a colourless fluid) is given as an injection into your vein with a drip to flush it through, or as an infusion, or as tablets. Your nurse will explain which is the most suitable for you.
When the chemotherapy is being given
Some people might have side effects while they are having the chemotherapy:
Pain along the vein
If you have this tell your nurse straight away. They will check your drip site and slow the drip to ease the pain.
The drug leaks outside the vein
If this happens when you’re having epirubicin it can damage the tissue around the vein. This is called extravasation. Tell the nurse straight away if you have any stinging, pain, redness or swelling around the vein. Extravasation is not common but if it happens it’s important that it’s dealt with quickly.
If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the number they gave you.
Your course of E-CMF
You have chemotherapy as a course of several sessions (or cycles) of treatment over a few months. E-CMF is usually divided into two parts. Firstly, you have four doses of epirubicin over a few months, then the CMF treatment in the following months. E-CMF can be given in different ways. We describe two ways you might have it. Your doctor or nurse will be able to give you details of your treatment course.
On the first day you have epirubicin. You then have a rest period for the next three weeks. At the end of the three weeks you start your second cycle of epirubicin. This is exactly the same as the first cycle. You have four cycles of epirubicin. CMF treatment is given next.
On the first day you have cyclophosphamide, methotrexate and 5FU and the same drugs again a week later. After this, you have a rest period with no chemotherapy for three weeks before starting your next cycle. This four-week cycle will be repeated four times.
On the first day you have epirubicin. You then have a rest period for the next three weeks. At the end of the three weeks, you start your second cycle of epirubicin. This is exactly the same as the first cycle. You have four cycles of epirubicin. CMF treatment is given next.
On the first day of CMF, you start a two-week course of cyclophosphamide tablets. On the same day you have methotrexate and 5FU. One week later, you have methotrexate and 5FU again. When you finish your cyclophosphamide tablets, you have a rest period with no chemotherapy for two weeks. After the rest period you start the next cycle of CMF treatment. Each cycle lasts four weeks.
Taking your chemotherapy tablets
If you are having cyclophosphamide as tablets, always take them exactly as explained. This is important to make sure they work as well as possible for you. Swallow the tablets whole, preferably on an empty stomach, with a full glass of water.
If you are sick just after taking the tablets, contact the hospital. You may need to take another dose. If you forget to take a tablet, do not take a double dose. Keep to your regular schedule and let your doctor or nurse know.
Other things to remember about your tablets:
keep them in the original package.
store them at room temperature away from heat and direct sunlight.
keep them safe and out of the reach of children.
return any remaining tablets to the pharmacist if your treatment is stopped.
Before you go home the nurse or pharmacist will give you anti-sickness drugs to take. They may also give you anti-diarrhoea tablets if you need them. Take all your tablets exactly as they have explained to you.
Possible side effects of E-CMF
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We explain the most common side effects of your treatment here. But we don’t include all the rare ones that are unlikely to affect you.
You may get some of the side effects we mention, but you are very unlikely to get all of them. Always tell your doctor or nurse about the side effects you have. Your doctor can prescribe drugs to help control some of these. It is very important to take the drugs exactly as your nurse or pharmacist has explained. This means they will be more likely to work better for you. Your nurse will give you advice about managing your side effects. After your treatment is over, the side effects will start to improve.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. You can call them if you feel unwell or need advice any time of day or night. Save these numbers in your phone or keep them somewhere safe.
Risk of infection
E-CMF can reduce the number of white blood cells in your blood. This will make you more likely to get an infection. Your white blood cells start to reduce seven days after treatment and are usually at their lowest 10-14 days after. When the number of white blood cells is low, it’s called neutropenia. Your nurse may give you injections of a drug called GCSF under the skin. It encourages the bone marrow (where blood cells are made) to make more white blood cells.
Contact the hospital straight away on the contact number you’ve been given if:
your temperature goes over 37.5°C (99.5°F) or over 38°C (100.4°F), depending on the advice given by your chemotherapy team
you suddenly feel unwell, even with a normal temperature
you have symptoms of an infection – this can include feeling shaky, a sore throat, a cough, diarrhoea or needing to pass urine a lot.
The number of white blood cells usually increases steadily and return to normal before your next treatment. You will have a blood test before having more chemotherapy. If your white blood cells are still low, your doctor may delay your treatment for a short time.
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot. Tell your doctor if you have any bruising or bleeding you can’t explain. This includes nosebleeds, bleeding gums, blood spots or rashes on the skin. Some people may need a drip to give them extra platelets.
Anaemia (low number of red blood cells)
E-CMF can reduce the number of red blood cells in your blood. These cells carry oxygen around the body. If the number of red blood cells is low, you may be tired and breathless. Tell your doctor or nurse if you feel like this. If you are very anaemic, you may need a drip to give you extra red blood cells (blood transfusion).
This may happen in the first few days after chemotherapy. Your doctor will prescribe anti-sickness (anti-emetic) drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist explains to you. It’s easier to prevent sickness than to treat it after it has started.
If you still feel sick or are vomiting, contact the hospital as soon as possible. They can give you advice and change the anti-sickness drug to one that works better for you.
Feeling very tired is a common side effect. It’s often worse towards the end of treatment and for some weeks after it’s finished. Try to pace yourself and get as much rest as you need. It helps to balance this with some gentle exercise, such as short walks. If you feel sleepy, don’t drive or operate machinery.
You usually lose all the hair on your head. Your eyelashes, eyebrows and other body hair may also thin or fall out. This usually starts after your first or second cycle of chemotherapy. It is almost always temporary and your hair will grow back after chemotherapy ends. It is important to cover your head to protect your scalp when you are out in the sun until your hair grows back. Your nurse can give you advice about coping with hair loss.
Scalp cooling is a way of lowering the temperature of the scalp to help reduce hair loss. Your nurse can tell you if this is an option for you.
Your mouth may become sore and you may get ulcers. This can make you more likely to get an infection in your mouth. Gently clean your teeth and/or dentures morning and night and after meals. Use a soft-bristled or children’s toothbrush. Your nurse might ask you to rinse your mouth regularly or use mouthwashes. It’s important to follow any advice you are given and to drink plenty of fluids.
Tell your nurse or doctor if you have any problems with your mouth. They can prescribe medicines to prevent or treat mouth infections and reduce any soreness.
You may get a bitter or metallic taste in your mouth or find that food tastes different. This should go away when your treatment finishes. Try using herbs and spices (unless you have a sore mouth or ulcers) or strong-flavoured sauces to give your food more flavour. Sucking boiled sweets can sometimes help get rid of a bitter or metallic taste. Your nurse can give you more advice.
Your doctor can prescribe drugs to control diarrhoea. Let them know if it is severe or if it doesn’t get better. Make sure you drink at least two litres (three and a half pints) of fluids every day if you have diarrhoea.
Your eyes may feel dry and sore and may become more sensitive to light. Your doctor can prescribe eye drops to help with this. If your eyes get red and inflamed (conjunctivitis), tell your doctor. This is because you may need antibiotic eye drops. This side effect tends to happen more during the CMF cycles.
Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine. Drink plenty of fluids - at least two litres (three and a half pints) - especially during the 24 hours following chemotherapy. It is also important to empty your bladder regularly and to try to pass urine as soon as you feel the need to go.
Contact the hospital straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in it.
Your urine may be a pink-red colour for up to 48 hours after you’ve had your treatment. This is due to the colour of epirubicin.
Chemotherapy may affect your skin. Your doctor or nurse can tell you what to expect. If your skin feels dry, try using an unperfumed moisturising cream every day. During treatment and for several months afterwards, you'll be more sensitive to the sun and your skin may burn more easily than usual. You can still go out in the sun, but use a suncream with a sun protection factor (SPF) of at least 30, and cover up with clothing and a hat.
Your skin may darken. It will return to its normal colour after you finish treatment. If you’ve had radiotherapy (either recently or in the past), the area that was treated may become red or sore.
Always tell your doctor or nurse about any skin changes. They can give you advice and may prescribe creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Less common side effects of E-CMF
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Changes in the way the heart works
Epirubicin can affect the way the heart works but only occasionally when it’s given in high doses, and is usually temporary. 5FU may also affect the way your heart works. You may have tests to see how well your heart is working before, during and sometimes after treatment.
If you have pain or tightness in your chest or feel breathless or notice changes to your heartbeat at any time during or after treatment, tell a doctor straight away. These symptoms can be caused by other conditions but it’s important to get them checked by a doctor.
Your nails may become brittle and break easily. They may get darker or discoloured, and/or you may get lines or ridges on them. These changes grow out after treatment finishes. Wearing gloves when washing dishes or using detergents will help protect your nails during treatment.
Changes in the way the liver works
E-CMF may affect how your liver works. This is usually mild and goes back to normal after treatment. You will have blood tests to check how well your liver is working.
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 here.
Additional information about E-CMF
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Blood clot risk
Cancer increases the chance of a blood clot (thrombosis) and chemotherapy can add to this. A clot can cause symptoms such as pain, redness and swelling in a leg, breathlessness and chest pain. Contact your doctor straight away if you have any of these symptoms. A blood clot is serious but your doctor can treat it with drugs that thin the blood. Your doctor or nurse can give you more information.
Some medicines can interact with chemotherapy or be harmful when you are having chemotherapy. This includes medicines you can buy in a shop or chemist. Tell your doctor about any medicines you are 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.
E-CMF may affect your fertility (being able to get pregnant or father a child). If you are worried about this, you can talk to your doctor or nurse before treatment starts.
Your doctor will advise you not to become pregnant or to father a child during treatment. This is because the drugs may harm a developing baby. It’s important to use effective contraception during and for a few months after chemotherapy. You can talk to your doctor or nurse about this.
If you have sex within the first couple of days of having chemotherapy you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluid
Changes to your periods
Chemotherapy can sometimes stop the ovaries working. You may not get a period every month and they may eventually stop. In some women, this is temporary, but for others it is permanent and they start the menopause.
Women are advised not to breastfeed during treatment and for a few months after. This is in case there is chemotherapy in their breast milk.
Medical and dental treatment
If you need to go into hospital for any reason other than cancer, always tell the doctors and nurses that you are having chemotherapy. Give them contact details for your cancer doctor.
Talk to your cancer doctor or nurse if you think you need dental treatment. Always tell your dentist you are having chemotherapy.
This section has been compiled using information from a number of reliable sources, including:
British National Formulary. 66th edition. 2013. British Medical Association and Royal Pharmaceutical Society of Great Britain.
electronic Medicines Compendium (eMC). medicines.org.uk (accessed December 2013).
Perry MC. The Chemotherapy Source Book. 5th edition. 2012. Lippincott Williams and Wilkins.
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.
With thanks to Christine Clarke, Lead Pharmacist Oncology & Haematology, who reviewed this edition.
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