Etoposide and cisplatin chemotherapy (EP/PE)
This information is about a chemotherapy treatment called etoposide and cisplatin that is used to treat several different types of cancer. It's also known as EP or PE.
The drugs that are used
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The treatment involves two chemotherapy drugs: etoposide and cisplatin, which contains platinum.
How treatment is given
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Etoposide and cisplatin chemotherapy can usually be given to you as a day patient. Before you start treatment, you'll need a blood test on the same day or several days beforehand. You'll also be seen by a doctor, specialist nurse or pharmacist. You'll also have tests to check how well your kidneys are working as the chemotherapy can affect them. These may include collecting your urine for 24 hours or having a specific blood test known as an EDTA test. If the results of your tests are normal, the pharmacy will prepare your chemotherapy drugs. All this may take a couple of hours.
The nurse will then 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 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 this to you.
Once your chemotherapy is ready, you'll be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula or central/PICC line, which is connected to a drip (infusion). Some anti-sickness medicines may also be given as tablets.
Before having the chemotherapy, you'll be given an infusion of sterile salt water (saline) to keep your kidneys working normally. This is because cisplatin can affect how the kidneys work and taking the fluids can help prevent any damage. This infusion is sometimes called pre-hydration.
You'll then be given the chemotherapy drugs:
Etoposide (a colourless fluid) is given as an infusion taking about an hour, or as capsules that are taken by mouth. It's available as 50mg and 100mg pale pink capsules, which should be swallowed whole with plenty of water. The 50mg capsules are smaller than the 100mg ones. If you have trouble swallowing the 100mg capsules tell your doctor so that you can be given the smaller ones.
Cisplatin (a colourless fluid) is given as an infusion.
Etoposide may be given first or following the pre-hydration. After the chemotherapy has finished you'll be given more saline through the drip for about one hour (post-hydration).
If you're having your treatment as a day patient you can go home after it's 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 some 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 medicines are much better at preventing sickness than at stopping it once it has started.
How often treatment is given
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You may hear your doctor use the word 'regimen' (eg the EP regimen) when talking about your chemotherapy. This refers to the whole plan or schedule of your particular chemotherapy treatment.
There are different ways of giving etoposide and cisplatin chemotherapy. You can ask your nurse or doctor to explain your particular regimen. A typical way of giving this chemotherapy regimen is as follows:
On day 1 of your treatment you'll be given infusions of both etoposide and cisplatin, as described. You'll then be given etoposide capsules to take at home over the next two days (days 2 and 3). The etoposide given on days 2 and 3 may sometimes be given by infusion, which will mean that you have to return to the hospital each day.
After this, you'll have a rest period for 18 days. This completes a cycle of your treatment. Each cycle takes 21 days (three weeks). After the rest period the treatment will be repeated. This is the next cycle of your chemotherapy. Up to six cycles of treatment may be given, over a period of 4–5 months.
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 etoposide and cisplatin 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
Etoposide and cisplatin 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 and bleeding
Etoposide and cisplatin 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.
Etoposide and cisplatin 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)
This is common and may begin soon after the treatment is given and last for a few days. Occasionally, it may last longer. 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.
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 to 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.
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.
Less common side effects
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Numbness or tingling in 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 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.
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.
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.
Etoposide and cisplatin 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.
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.
Etoposide can cause a rash, which may be itchy. Your doctor can prescribe medicine to help with this. Your skin may darken due to excess production of pigment. It usually returns to normal a few months after the treatment has finished.
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'll be monitored for any signs of an allergic reaction during the treatment. Tell your doctor or nurse about any side effects you have.
Pain at injection site
Etoposide can cause pain at the place where the injection is given, or along the vein. Tell your doctor or nurse if you experience pain.
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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Very rarely, etoposide may cause a second cancer (usually a type of acute leukaemia) to develop years later. Your nurse or doctor can discuss this with you.
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.
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 EP 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 or nurse.
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.
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 etoposide capsules
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It's important to take your tablets at the right times as directed by your doctor.
Take the capsules whole with water. Don't open the capsules.
If the capsules leak, it's important not to touch their contents.
Always tell any doctors treating you for non-cancerous conditions that you’re taking a course of chemotherapy tablets that shouldn’t be stopped or restarted without the advice of your cancer specialist.
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 capsules to the pharmacist. Don't flush them down the toilet or throw them away.
If you're sick just after taking the capsules, let your doctor know. You may need to take another dose. Don't take another tablet without telling your doctor first.
If you forget to take a capsule don't take a double dose. Let your doctor know and keep to your regular dose schedule.
This section is based upon our etoposide and cisplatin chemotherapy fact sheet, which has been compiled using information from a number of reliable sources including:
Sweetman, et al. Martindale: The Complete Drug Reference. 36th edition. 2009. Pharmaceutical Press.
British National Formulary. 58th edition. 2009. British Medical Association and Royal Pharmaceutical Society of Great Britain.
Perry MC. The Chemotherapy Source Book. 4th edition. 2007. Lippincott Williams and Wilkins.