This information is about a chemotherapy treatment for stomach cancer called ECF. This treatment may also be used to treat cancer of the gullet (oesophagus), stomach, breast, ovary and other less common cancers.
The drugs that are used
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ECF is named after the initials of the chemotherapy drugs used, which are:
Throughout this fact sheet we'll refer to fluorouracil by its more common name, 5FU.
How treatment is given
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ECF treatment can usually be given to you as a day patient or during a short stay in hospital. The treatment is then continued at home. Before you start treatment you'll need to have a blood test 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.
Most people who have ECF will have their chemotherapy given through a thin, 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.
You'll be given an anti-sickness (anti-emetic) drug as tablets or by injection through your central/PICC line.
The chemotherapy drugs are then given separately:
Epirubicin (a red fluid) is given as an injection along with a drip (infusion) of salt water (saline) into the line. It may sometimes be given as an infusion.
Cisplatin (a colourless fluid) is given as an infusion.
Before and after treatment with cisplatin, you'll be given plenty of fluid through your drip to keep your kidneys working normally. This may mean that you'll need to stay in hospital overnight.
Once your infusion is finished you'll start treatment with 5FU, which is usually given through a small portable pump. The pump is used to give a controlled amount of the drug into your bloodstream over a set period of time. There are several different types of pump, but all of them are small enough to be carried in a belt or holster so that you can continue doing the things you normally do.
Once the pump is connected to your line, you can go home with it. Before you go you should be given instructions on how to look after the pump. Your nurse should explain how to care for it and what to do if something goes wrong.
When the infusion is finished there may be some fluid left in the pump. This may be normal as some types of pump need to be overfilled to get the correct dose. You can check with your nurse or pharmacist whether you have this type of pump.
The 5FU treatment is given continuously over the whole time that you have your chemotherapy. You'll need to have the drug reservoir or the entire pump replaced as it empties; usually on a weekly basis. This may be done at the hospital, or you may be taught to change the pump yourself. Alternatively, arrangements may be made for a district nurse to come to your home to change the pump.
When you go home you'll be given a supply of anti-sickness tablets to take with you. You should take these regularly as directed by your doctor even if you aren't feeling sick. This is because some medicines are much more effective at preventing sickness than stopping it once it has started. However, the 5FU in the pump is very unlikely to make you feel sick and it's unlikely that you'll need anti-sickness medicines for more than a few days after your visit to the hospital.
If you don't have a central line or PICC line, 5FU can be given to you as a drip into your arm through a small tube known as a cannula, which is inserted into a vein in your arm. This is given over a shorter period, often for four days every three weeks. You'll need to stay in hospital for the four days of treatment.
How often treatment is given
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Your doctor may use the word 'regimen' (eg the ECF regimen) when talking about your chemotherapy. This refers to the whole plan, or schedule, of the particular treatment you are receiving.
On the first day of your treatment you'll be given epirubicin and cisplatin as described. On the same day you'll start your treatment with 5FU through the pump, which will be given continuously over the whole time that you have your chemotherapy. If you don't have a pump, you may be given 5FU through a drip into your arm, which usually takes a few days. Three weeks after the first day of treatment you'll complete what is called a cycle of your chemotherapy.
Your treatment with epirubicin and cisplatin will then be repeated to begin the next cycle of your chemotherapy.
If you don't have a pump you'll have another short treatment with 5FU through a drip as before.
You can have up to eight cycles of ECF chemotherapy over a 24-week period. Sometimes, four cycles of ECF chemotherapy can be given before surgery followed by four cycles after surgery. Your doctor will advise you about the number of cycles you'll have.
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 ECF chemotherapy.
We have outlined the most common side effects but haven't included those that are rare and 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
ECF chemotherapy 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 you'll 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 38ºC (100.4ºF)
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 and bleeding
ECF chemotherapy 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 have a platelet transfusion if your platelet count is low.
ECF chemotherapy 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) and being sick (vomiting)
Sickness is most likely in the few days after treatment with cisplatin and epirubicin and less likely during the time you're taking 5FU. Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or reduce these effects. 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 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.
5FU 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.
Your urine may become a pink-red colour. This may last for up to two days after you’ve had your treatment. It is normal and is due to the colour of the epirubicin.
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 may 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.
Your kidneys may be affected
Cisplatin can affect your kidneys. This doesn't usually cause any symptoms and the effect is generally mild. Rarely, it may cause permanent damage to the kidneys unless the treatment is stopped.
Before each treatment, your kidneys will be checked by a blood test. You’ll be given fluid through a drip (infusion) before and after the treatment to keep your kidneys working normally. You may be asked to measure and record what you drink and the amount of urine you pass. It’s important to tell your nurse or doctor if you pass less urine than usual.
If necessary, you may be given medicine to help you pass urine. You may be asked to drink extra fluid before and after treatment. It's important to do this, so let your doctor know if this is a problem – for example, if you're feeling sick.
Less common side effects
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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.
Numbness or tingling in the hands or feet
This is due to the effect of Cisplatin on nerves and is known as peripheral neuropathy. You may also notice that you have difficulty doing up buttons or similar fiddly tasks.
Tell your doctor if you notice any numbness or tingling in your hands or feet. It's important to report your symptoms to your doctor as they may be controlled by slightly lowering the dose of the drug.
This side effect usually improves slowly over a few months after the treatment has finished. Sometimes symptoms can persist; talk to your doctor if this happens.
Changes in hearing
Cisplatin may cause ringing in the ears (tinnitus) and you may lose the ability to hear some high-pitched sounds. Hearing loss can be more severe with higher doses and longer courses of treatment. Very occasionally your sense of balance may be affected. Any hearing loss, and balance changes if they occur, may be permanent. However, tinnitus usually improves when treatment ends. Tell your doctor if you notice any loss of hearing or tinnitus.
Increased production of tears
This may be caused by 5FU and is temporary. You may also notice that your eyes become sore and inflamed (conjunctivitis). Let your doctor know so they can prescribe soothing eye drops if necessary.
Epirubicin can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this. Areas of skin which 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 due to excess production of pigment. It usually returns to normal a few months after the treatment has finished.
Soreness and redness of the palms of the hands and soles of the feet
This is sometimes known as palmar plantar or hand-foot syndrome. It can happen when 5FU is given. It's usually temporary and improves when the treatment is finished.
Your doctor may prescribe creams or a vitamin called pyridoxine (vitamin B6), which some people find helpful. It can also help to keep your hands and feet cool and to avoid tight-fitting clothing, such as socks, shoes and gloves.
During treatment with ECF chemotherapy 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.
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. Some people have pain in the nail bed at the base of the nail, but this is rare.
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.
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 epirubicin is being given, the tissue in that area can become 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 this treatment as it may harm the developing baby. It’s important to use effective contraception while having this drug 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
Due to the effect of chemotherapy on the ovaries, women may find that their periods become irregular and they 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.
This section is based upon our ECF 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. 62th 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.