ICE chemotherapy for lymphoma
ICE is a chemotherapy treatment used to treat lymphoma.
This information should ideally be read with our general information about chemotherapy and your type of cancer.
ICE is named after the initials of the drugs used:
Some people may also have a drug called rituximab with their ICE chemotherapy. This is called R-ICE chemotherapy.
This information is about ICE chemotherapy.
You will have ICE during a short stay in hospital. A chemotherapy nurse will give it to you. During treatment, you will usually see a cancer doctor, a haematologist (blood specialist), 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 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 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 drugs are given to you as three separate drips (infusions). They usually run each drip through a pump, which gives you the treatment over a set time. Ifosfamide can irritate the bladder lining and cause bleeding (see information under 'Possible side effects' below). To help prevent this, you are given infusions of a drug called mesna (Uromitexan ®). Occasionally mesna is given as tablets.
When the chemotherapy is being given
Some people might have side effects while they are having the chemotherapy:
Rarely, ICE may cause an allergic reaction while it’s being given. Your nurse will check you for this. If you have a reaction, they will treat it quickly. Signs of a reaction can include: a rash; feeling itchy, flushed or short of breath; swelling of your face or lips; feeling dizzy; having pain in your tummy, back or chest; or feeling unwell. Tell your nurse straight away if you have any of these symptoms.
The drug leaks outside the vein
If this happens when you’re having etoposide 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 rare 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 ICE
You have chemotherapy as a course of several sessions (or cycles) of treatment over a few months. Each cycle of ICE usually takes 21 days but it may also be given over 28 days. Your doctors and nurses can tell you which cycle you are going to have.
On day 1 your nurse will give you a one-hour infusion of etoposide.
On day 2 your nurse will give you a one-hour infusion of etoposide and a one-hour infusion of carboplatin. You are also given an infusion of mesna over about 15 minutes, followed by a 24-hour infusion of ifosfamide and mesna.
On day 3 your nurse will give you a one-hour infusion of etoposide. And, when the 24-hour infusion of ifosfamide and mesna from day 2 has finished, you are given a 12-hour infusion of mesna.
After this, you have a rest period with no chemotherapy for 18 or 25 days. Then the same drugs will be given to you again, beginning the next cycle of your treatment. Usually, two to four cycles of treatment are given over two to four months. This makes up a course of treatment.
Before you go home, the nurse or pharmacist will give you tablets to take. These will include anti-sickness tablets and tablets to help prevent infections. Take all your tablets exactly as they have explained to you.
While you are having ICE treatment you will have injections of a drug called G-CSF (granulocyte-colony stimulating factor). This is a type of protein that stimulates the bone marrow to make white blood cells. The injections may be given at the hospital or you may have them at home. They are given under the skin (subcutaneously). Your doctor or nurse will tell you which days you will have them.
Possible side effects of ICE
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We explain the most common side effects of ICE 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, 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
ICE 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 nurse may give you injections of a drug called G-CSF 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 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
ICE 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)
ICE 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.
Ifosfamide 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 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.
You will be given fluids through a drip (infusion) and a drug called mesna (Uromitexan ®) as an infusion. This helps to prevent bladder irritation.
Tell your nurse or doctor straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in it.
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.
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 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.
We have more information about mouth care during chemotherapy.
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.
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. 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.
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.
Loss of appetite
You may lose your appetite during your treatment. Try to eat small meals regularly. Don’t worry if you don’t eat much for a day or two. If your appetite doesn’t improve after a few days, let your nurse or dietitian know. They can give you advice on getting more calories and protein in your diet. They may give you food supplements or meal replacement drinks to try. Your doctor can prescribe some of these and you can buy them from chemists.
Less common side effects of ICE
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Changes in the way the heart works
Some of the drugs 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, 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.
Changes in the way the kidneys and liver work
ICE 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.
Effects on the nervous system
Ifosfamide can affect the nervous system. You may feel very drowsy or confused, or you may have hallucinations. You may feel dizzy or unsteady. Rarely, this treatment can cause seizures (fits). You may be given medication to prevent this. Tell your doctor or nurse straight away if you notice any of these symptoms. They may make some changes to your treatment if they become a problem for you.
It’s important not to drive or operate machinery if you have these side effects.
Tumour lysis syndrome (TLS)
ICE may cause the cancer cells to break down very quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid but they may not be able to cope with large amounts. This can cause chemical imbalances in the blood that affect the kidneys and the heart. This is called tumour lysis syndrome (TLS).
To reduce the risk of TLS, your doctor may give you a drug called rasburicase. You will have this as a drip. You will also be given fluid through your drip to help protect your kidneys. You may only need rasburicase with the first treatment. After that, you can have tablets called allopurinol (Zyloric ®) instead.
Rarely, ifosfamide can increase the risk of developing a second cancer, usually leukaemia, years later. But the benefits of treatment usually far outweigh this risk. Your doctor can talk to you about this.
It is 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 ICE
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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. Etoposide and ifosfamide may affect the way some drugs work. Tell your doctor about any medicines you are taking, including over-the-counter drugs, complementary therapies and herbal drugs. You may be advised to avoid eating grapefruit or drinking grapefruit drinks.
ICE can affect your fertility (being able to get pregnant or father a child). If you are worried about this, you can talk to your doctor before treatment starts.
Your doctor will advise you not to become pregnant or father a child during treatment. This is because the drugs may harm a developing baby. It’s important to use 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. 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.
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.
This section has been compiled using a number of reliable sources, including:
electronic Medicines Compendium (eMC). medicines.org.uk (accessed July 2013).
Perry MC. The Chemotherapy Source Book. 5th edition. 2012. Lippincott Williams and Wilkins.
Medicines and Healthcare products Regulatory Agency (MHRA) mhra.gov.uk (accessed December 2013)
With thanks to Man-Chie Chow, Lead Pharmacist Haemato-Oncology, who reviewed this edition.
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