FCR is a chemotherapy treatment used to treat chronic lymphocytic leukaemia (CLL).
This information should ideally be read with our general information about chemotherapy and your type of cancer.
FCR comes from the initials of the drugs used:
Rituximab is not a chemotherapy drug. It belongs to a group of drugs called monoclonal antibodies.
You will have FCR in the chemotherapy day unit or during a short stay in hospital. A chemotherapy nurse will give it to you. During treatment, you will usually see a cancer doctor, a blood specialist (haematologist), 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 will give you paracetamol tablets before you start your treatment. They will then give anti-sickness drugs, a steroid and an antihistamine as injections into a vein or as tablets. They give you the drugs through one of the following (depending if you have a line in or not):
A short thin tube (cannula) that 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).
The nurse gives you rituximab as a drip into your vein. Some people have a reaction to rituximab. The paracetamol, steroid and antihistamine help reduce the chance of this happening. They will usually run the drip through a pump, which gives you the treatment over a set time. You will then be given your first dose of cyclophosphamide and fludarabine tablets.
If you get an upset stomach from the tablets, your nurse can give fludarabine and cyclophosphamide by slow injection or a drip (infusion) into your vein instead. Your doctor, nurse or pharmacist will talk to you about this.
When the treatment is being given
Some people might have the following side effects while having rituximab:
Rituximab may cause an allergic reaction while it’s being given. This is more common with the first treatment, so you have it slowly over a few hours. The nurse will give you drugs to help prevent or reduce this. They will check you for signs of a reaction. If you have one, they will treat it quickly.
Signs of a reaction can include: flu-like symptoms (headaches, high temperature or chills); feeling sick; a rash; feeling itchy; breathlessness; feeling unwell; and/or pain in your back, tummy or chest. Tell your nurse straight away if you have any of these symptoms. Rarely, a reaction can happen a few hours after treatment. If you develop any of these symptoms or feel unwell after you get home, contact the hospital straight away for advice.
Low blood pressure
Some people's blood pressure falls while they are having rituximab. If you usually take medicine to lower your blood pressure, your doctor may ask you not to take it for 12 hours before having rituximab. The nurse will check your blood pressure regularly.
Flushes and blocked nose
Some people may have hot flushes, a feeling of having a blocked nose and a strange taste if having cyclophosphamide into their vein. This doesn’t last for long. But if you notice this, ask the nurse to slow down the drip, which will reduce these symptoms.
Taking your chemotherapy tablets
Before you leave hospital, the nurse or pharmacist will give you chemotherapy tablets to take when you are at home. Always take your tablets exactly as explained. This is important to make sure they work as well as possible for you.
Cyclophosphamide tablets should be swallowed whole with a glass of water on an empty stomach. Fludarabine tablets should be swallowed whole with plenty 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 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.
Your course of FCR
You have chemotherapy as a course of several cycles of treatment over a few months. Each cycle of FCR takes 28 days (four weeks).
On the first day, you have rituximab and start taking a five-day course of fludarabine and cyclophosphamide tablets. At the end of the 28 days, you start your second cycle of FCR. This is exactly the same as the first cycle. You have up to six cycles over six months. Your doctor or nurse will tell you the number of cycles you are likely to have.
If you are having the treatment through a drip, you will have rituximab on day one. Then you will have fludarabine and cyclophosphamide by a slow injection or drip (infusion) into your vein on days one, two and three. At the end of the 28 days, you will start your second cycle of FCR. This is exactly the same as the first cycle. You have up to six cycles over six months. Again, your doctor or nurse will tell you the number of cycles you are likely to have.
Before you go home, the nurse or pharmacist will give you anti-sickness drugs to take. Take all your tablets exactly as explained.
Possible side effects of FCR
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We explain the most common side effects of FCR 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
FCR can reduce the number of white blood cells in your blood. This will make you more likely to get an infection. When the number of white blood cells is low, it’s called neutropenia. Your doctor may give you tablets to help prevent an infection.
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 returns 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
FCR 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)
FCR 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 cells (blood transfusion).
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.
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) during and for 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 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.
Feeling very tired is a common side effect. It’s often worse towards the end of treatment and for some weeks after. Try to pace yourself and get as much rest as you need. It helps to balance this with taking some gentle exercise, such as short walks. If you feel sleepy, don’t drive or operate machinery.
Your mouth may become sore or dry, or you may get ulcers. Look after your mouth by gently cleaning your teeth after meals with a soft toothbrush and drinking plenty of fluids.
Tell your nurse or doctor if you have problems with your mouth. They can prescribe mouthwashes and medicines to prevent or clear any mouth infections.
You may notice food tastes different but this should go back to normal after treatment ends. Try using herbs and spices or strong-flavoured sauces to give your food more taste. Your nurse can give you more advice.
Your hair may thin but you’re unlikely to lose all the hair from your head. 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. Your nurse can give you advice about coping with hair loss.
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. FCR can cause a rash, which may be itchy. 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.
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.
Soreness and redness of palms of hands and soles of feet
This is called palmar-plantar or hand-foot syndrome. It gets better when treatment ends. Your doctor or nurse may prescribe creams to improve the symptoms. It can help to keep your hands and feet cool and to avoid tight-fitting socks, shoes and gloves.
Your nails may become brittle and break easily. They may get darker or discoloured, and 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.
Numb or tingling hands or feet
These symptoms are caused by the effect of FCR on nerves. It’s called peripheral neuropathy. You may also find it hard to fasten buttons or do other fiddly tasks.
Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drugs. The symptoms usually improve slowly after treatment finishes but in some people they may never go away. Talk to your doctor if you are worried about this.
Build up of fluid (oedema)
You may put on weight or your ankles and legs may swell because of fluid building up. Tell your doctor or nurse if fluid builds up. If your ankles and legs swell it can help to put your legs up on a foot stool or cushion. The swelling gets better after your treatment ends.
Your eyes may feel dry and sore. 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. Cyclophosphamide and fludarabine may also cause blurry vision or eye pain. Always tell your doctor or nurse if you have eye pain or notice any change in your vision.
Changes in the way the kidneys and liver work
Treatment can affect how your kidneys and liver work. This is usually mild and goes back to normal after treatment. You will have blood tests before chemotherapy to check how well your kidneys and liver are working.
Raised levels of uric acid in the blood
FCR may cause the leukaemia cells to break down quickly. This releases uric acid (a waste product) into the blood. Too much uric acid can cause swelling and pain in the joints, which is called gout.
Your doctor may give you tablets called allopurinol (zyloric ®) to help prevent this. This is usually just with your first cycle of treatment. Drinking at least two litres of fluid a day will also help. You will have regular blood tests to check the uric acid levels.
Tell your doctor or nurse if you have headaches. They can give you painkillers to help.
Less common side effects of FCR
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Effects on the lungs
FCR can cause changes to the lungs. Always tell your doctor if you develop wheezing, a cough, fever or feel breathless. You should also let them know if any existing breathing problems get worse. If necessary, they can arrange for you to have tests to check your lungs.
Changes in the way the heart works
FCR can affect the way the 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.
Effects on the nervous system
Rarely FCR can affect the nervous system. You may feel anxious or restless, have problems sleeping or experience mood changes. Some people feel drowsy or confused. Tell your doctor or nurse straight away if you notice any of these symptoms. It’s important not to drive or operate machinery if you notice these effects. Rarely, this drug can cause seizures (fits).
It’s important to tell your doctor or nurse straight away if you feel ill or have severe side effects. This includes any we don’t mention here.
Other information about FCR
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After treatment with FCR, any blood and platelets you are given should first be treated with radiation. This lowers the risk of the donated blood cells reacting against your own. It won’t damage the blood or make you radioactive.
Your doctor will record in your medical notes that you should only be given irradiated blood products. They’ll also give you a card to carry in case you’re treated at another hospital. Keep this card with you at all times and remind your hospital team that you need irradiated blood or platelets.
Blood clot risk
Cancer increases the chances 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.
FCR 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.
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.
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.
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. Explain if you are taking chemotherapy tablets that no one should stop or restart them without advice from your cancer doctor. 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 a number of reliable sources, including:
electronic Medicines Compendium (eMC). www.medicines.org.uk (accessed July 2013).
Perry MC. The Chemotherapy Source Book. 5th edition. Lippincott Williams and Wilkins. 2012.
With thanks to Catherine Loughran, Lead Pharmacist Haematology, who reviewed this edition.
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