This information is about a chemotherapy treatment called EOX, which is used to treat cancers of the gullet (oesophageal cancer), the stomach (gastric cancer) and of the gastro-oesophageal junction (where the gullet and the stomach join together).
You'll see your doctor regularly while you have this treatment so they can monitor the effects of the chemotherapy.
EOX is named after the initials of the drugs used. These are:
EOX is sometimes called EEX because oxaliplatin is also known as Eloxatin®.
How the treatment is given
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EOX 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 will need a blood test - on the same day or a few days beforehand. You will 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.
Before treatment starts, the nurse will put a thin, flexible tube (cannula) into a vein in your 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, which is inserted under the skin and into a vein near the collarbone (central line), or passed through a vein in the crook or their arm (PICC line).
Once your chemotherapy is ready you will be given anti-sickness (anti-emetic) medicines, either by injection through your cannula or line, or in tablet form.
You will then be given epirubicin (a red fluid) along with a drip (infusion) of salt water (saline) into the line. After this you'll have oxaliplatin (a clear fluid), which is also given as an infusion. This is usually given over a period of two hours.
Capecitabine is given as tablets twice a day. The tablets should be swallowed whole with a glass of water. They should be taken within half an hour of finishing a meal, as capecitabine works best if it's broken down in the stomach with food. You should take capecitabine in the morning just after breakfast, and then again just after your evening meal, so that the doses are spaced at least eight hours apart.
If you have trouble swallowing capecitabine tablets, they can be dissolved in a 200ml glass of warm water. The mixture should be stirred with a spoon until the tablets are completely dissolved and then drunk immediately. You can add some blackcurrant juice just before swallowing to help disguise the taste. The glass and spoon should be washed and kept separate from your other crockery and cooking utensils.
Capecitabine tablets are available as 500mg peach coloured tablets and 150mg light-peach coloured tablets. Your doctor may want you to take a combination of 500mg and 150mg tablets, depending on the dose you need. It is important to take the tablets as directed by your doctor, specialist nurse or pharmacist.
How often treatment is given
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You may hear your doctor use the word 'regimen' (eg the EOX regimen) when talking about your chemotherapy. This just means the whole plan or schedule of the particular treatment that you are receiving.
On the first day of your treatment, you'll be given epirubicin and oxaliplatin (as described). On the same day, you will also start your capecitabine tablets, which are usually taken twice a day for 21 days. The first dose of capecitabine is often taken on the evening of day one of your treatment and the last dose in the morning of day 22 (just before you start the next cycle of the treatment). Before you leave hospital, check with your doctor or nurse how long you will need to take your capecitabine tablets for. Always follow the prescribed dose.
Three weeks from the first day of treatment, you will have completed what's called a cycle of chemotherapy. The treatment will then be repeated. On day one of the next cycle, the epirubicin and oxaliplatin will be given and you'll start another 21 day course of the capecitabine tablets. You will usually take capecitabine tablets twice a day throughout the whole course of your chemotherapy treatment. This is because each cycle takes three weeks (21 days) and the capecitabine tablets are taken for 21 days in each cycle.
You can have up to eight cycles of EOX chemotherapy over a 24-week period. Your doctor will advise you about the number of cycles you're likely to 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 has EOX chemotherapy.
We have outlined the most common side effects but haven't included those that are rare and unlikely to affect you. If you do notice any effects that aren't listed here, discuss them with your doctor, chemotherapy nurse or pharmacist.
Risk of infection
EOX 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 will be more prone to infections. A low white blood cell count is called neutropenia. This 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 your number of blood cells (blood count) is still low.
Bruising and bleeding
EOX 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 can have a platelet transfusion if your platelet count is low.
EOX 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.
Capecitabine can cause diarrhoea. This can be quite severe, but can usually be controlled with medicines. It's important to drink plenty of fluids, and you may be given medicine to take. Follow the instructions and take it immediately. If you have diarrhoea more than 4-6 times a day, or if you have it at night, contact your specialist for advice immediately. You may be advised to stop taking capecitabine. However, once the diarrhoea has eased your doctor will tell you if you can restart the treatment, perhaps at a lower dose.
Feeling sick (nausea) and being sick (vomiting)
Sickness is most likely in the few days after treatment with epirubicin and oxaliplatin but less likely during the time you are taking capecitabine. 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.
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. 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 find our section on mouth care during chemotherapy helpful.
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.
Capecitabine can cause a rash or dry skin, which may be itchy. Your doctor can prescribe medicine to help with this.
Soreness and redness of the palms of hands and soles of feet
This is sometimes known as palmar plantar or hand-foot syndrome. It can happen when capecitabine 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 EOX chemotherapy and for several months afterwards, you will 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 page on taking care in the sun useful.
Numbness or tingling in the hands or feet
Oxaliplatin can have an effect on the nerve endings, which is known as peripheral neuropathy. This may result in feelings of numbness or tingling, especially in the hands or feet. You may also notice that you have difficulty doing up buttons or similar fiddly tasks.
For some people, these symptoms can be triggered by anything cold, such as iced drinks and cold air. If you notice that your symptoms are related to the cold, you should avoid cold drinks and wrap up warmly in the cold weather. It is important to report your symptoms to your doctor as they may be controlled by slightly lowering the dose of the drug.
Sometimes the tingling or numbness may not happen with the first treatment, but after several treatments. This is known as a ‘cumulative effect’ and should improve after the treatment has finished. However, for some people, the tingling and numbness can last for several months or persist - tell your doctor if this is the case for you.
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 taking some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
Hair loss 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.
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.
Less common side effects
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Oxaliplatin can affect the area around the voicebox (larynx), causing a sensation of difficulty swallowing and severe breathing difficulties.
This symptom may be made worse by cold temperatures, so it’s advisable to avoid cold drinks and ice cubes for a few days after treatment. You might find our section on breathing more easily useful.
This side effect can be very frightening although it should only be temporary. If you have breathing difficulties, take long deep breaths through your nose. This will have a calming effect and help your breathing return to normal. It’s important to let your doctor know if you have this side effect. Your doctor may increase the time of your oxaliplatin infusion to 4-6 hours in future cycles to reduce the chance of this happening.
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.
Capecitabine 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 things other than chemotherapy. If you develop any of these symptoms, contact your doctor immediately.
Abdominal pain and constipation
EOX chemotherapy can cause pain in your tummy (abdomen) and constipation. Let your doctor know if you develop pain. It can usually be controlled with mild painkillers. Constipation can usually be helped by drinking plenty of fluids, eating more fibre and doing gentle exercise. You may need to take medicine (laxative) to help. Your doctor can prescribe these or you can buy them at a pharmacy.
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.
Increased production of tears
This may be caused by capecitabine 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.
Some people find that EOX chemotherapy causes headaches. Let your doctor or nurse know. They can give you painkillers to relieve this.
Signs of an allergic reaction include skin rashes and itching, a high temperature, shivering, reddening of the face, dizziness, a headache, breathlessness, anxiety, and a feeling that you want to pass urine. You will be monitored for any signs of an allergic reaction during the treatment. Tell your doctor or nurse about any side effects you have.
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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Pain along the vein
Oxaliplatin can cause pain along the vein that's used to give you your chemotherapy. If you feel any pain, tell your doctor or nurse straight away so that they can check the infusion site. They may slow the infusion down to reduce pain.
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.
Capecitabine interacts with the drugs phenytoin (Epanutin®), allopurinol (Zyloric®) and interferon alpha (IntronA®, Roferon-A®). It may also affect the action of some medicines given to thin the blood (anti-coagulants) such as warfarin. Let your doctor know if you are taking any of these.
You should also tell your doctor if you’re taking folic acid because it might increase the side effects of capecitabine.
Some other medicines, including those you can buy in a shop or chemist, can be harmful to take when you are having chemotherapy. Tell your doctor about any medicines you are 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 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 line 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 are at home, ring the clinic or ward and ask to speak to the doctor or nurse.
Some people have hot flushes when epirubicin is being given.
Your ability to become pregnant or father a child may be affected by 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 EOX chemotherapy, 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
Because of 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 risk that chemotherapy drugs may be present in breast milk so 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 capecitabine tablets
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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 are taking a course of chemotherapy tablets that should not be stopped or restarted without advice from your cancer specialist.
Keep the tablets in the original packaging and store them at room temperature away from heat and direct sunlight.
Keep the tablets in a safe place, out of the reach of children.
If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
If you are 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 EOX chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
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).
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.
Sweetman, et al. Martindale: The Complete Drug Reference. 37th edition. 2011. Pharmaceutical Press.