FCR
FCR is used to treat chronic lymphocytic leukaemia (CLL) and some types of non-Hodgkin lymphoma (NHL).
What is FCR?
FCR is used to treat chronic lymphocytic leukaemia (CLL) and some types of non-Hodgkin lymphoma (NHL). It may sometimes be used to treat other cancers. It is best to read this information about FCR with our general information about chemotherapy, targeted therapy and the type of cancer you have.
FCR is named after the initials of the drugs used:
- F – fludarabine
- C – cyclophosphamide
- R – rituximab.
Fludarabine and cyclophosphamide are types of chemotherapy. Rituximab is a type of targeted therapy called a monoclonal antibody.
Your cancer doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.
More information about this treatment
This information is correct at time of publishing. But sometimes the types of cancer this treatment is used for, or treatment side effects, may change between revision dates.
You can talk to your cancer team if you want more detailed information about this treatment. Or visit the electronic Medicines Compendium (eMC) website, which has patient information leaflets (PIL) for individual drugs.
How FCR is given
You will be given FCR in the chemotherapy day unit or during a stay in hospital. A chemotherapy nurse will give it to you.
During a course of treatment, you usually see a:
- cancer doctor
- chemotherapy nurse or a specialist nurse
- specialist pharmacist.
This is who we mean when we mention doctor, nurse or pharmacist in this information.
Before or on the day of each treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that it is safe for you to have chemotherapy.
You will speak to a doctor, nurse or pharmacist before you have chemotherapy. They will talk to you about your blood results and ask how you have been feeling. If your blood results are okay, the pharmacy team will prepare your chemotherapy.
Your nurse usually gives you anti-sickness (anti-emetic) drugs before the treatment. You will have rituximab through:
- a cannula – a short, thin tube the nurse puts into a vein in your arm or hand
- a central line – a fine tube that goes under the skin of your chest and into a vein close by
- a PICC line – a fine tube that is put into a vein in your arm and goes up into a vein in your chest
- an implantable port (portacath) – a disc that is put under the skin on your chest or arm and goes into a vein in your chest.
If you are having treatment for non-Hodgkin lymphoma, you may have rituximab as an injection under the skin (sub-cutaneous) instead of a drip into a vein. This will only be from the second cycle of treatment. Your doctor, nurse or pharmacist can tell you more.
You may be given fludarabine and cyclophosphamide as a drip or injection into a vein, or as tablets that you take by mouth (oral).
Your course of chemotherapy
You usually have a course of several cycles of treatment over a few months. It may be given in different ways, including:
- FCR – oral over 3 days
- FCR – oral over 5 days
- FCR – as a drip (intravenous) over 3 days.
Each cycle takes 28 days (4 weeks). Each cycle is the same. You may have up to 6 cycles. Your nurse or doctor will talk to you about how the treatment will be given. They may give you a copy of a treatment plan to take home with you.
The following are examples of how you might have your treatment:
FCR – oral over 3 days
Day 1
You will be given:
- an infusion of rituximab
- fludarabine and cyclophosphamide tablets.
For the first cycle only, you may have rituximab on day 1 and day 2.
Days 2 and 3
You take fludarabine and cyclophosphamide tablets.
Days 4 to 28
You will have no chemotherapy for the next 25 days. At the end of the 28 days, you start your second cycle of FCR.
FCR – oral over 5 days
Day 1
You will be given:
- an infusion of rituximab
- fludarabine and cyclophosphamide tablets.
For the first cycle only, the rituximab may be repeated on day 2.
Days 2 to 5
You take fludarabine and cyclophosphamide tablets.
Days 6 to 28
You will have no chemotherapy for the next 23 days. At the end of the 28 days, you start your second cycle of FCR.
FCR – as a drip (intravenous) over 3 days
Day 1
You will be given fludarabine, cyclophosphamide and rituximab into a vein. For the first cycle only, the rituximab may be repeated on day 2.
Days 2 and 3
You are given fludarabine and cyclophosphamide into a vein.
Days 4 to 28
You will have no chemotherapy for the next 25 days. At the end of the 28 days, you start your second cycle of FCR.
Important information about your tablets
The nurse or pharmacist will give you anti-sickness tablets to take home. Always take any tablets you are given exactly as explained. This is important to make sure they work as well as possible for you.
Your tablets should be swallowed whole with a glass of water. They should not be chewed or crushed.
Fludarabine can be taken at lunchtime with or without food.
Cyclophosphamide can be taken in the morning with or without food.
Other things to remember:
- Wash your hands after taking your tablets.
- Other people should avoid direct contact with the chemotherapy drugs.
- Keep them in the original package and at room temperature, away from heat and direct sunlight.
- Keep them safe, somewhere children cannot see or reach them
- If you are sick just after taking the tablets, contact the hospital. Do not take another dose.
- If your treatment is stopped, return any unused tablets to the pharmacist.
About side effects
We explain the most common side effects of this treatment here. We also include some that are less common.
You may get some of the side effects we mention, but you are unlikely to get all of them. And you may have some side effects, including rarer ones, that we have not listed here.
Always tell your doctor, nurse or pharmacist about any side effects you have. They can give you:
- drugs to help control some side effects
- advice about managing side effects.
It is important to take any drugs exactly as explained. This means they will be more likely to work for you.
Serious and life-threatening side effects
Some cancer treatments can cause serious side effects. Sometimes, these may be life-threatening. Your doctor, nurse or pharmacist can explain the risk of these side effects to you.
Contact the hospital
Your doctor, nurse or pharmacist will give you 24-hour contact numbers for the hospital. If you feel unwell or need advice, you can call at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
Side effects while treatment is being given
Allergic reaction
Some people have an allergic reaction to rituximab or cyclophosphamide while they are having it. A reaction is most likely with the first rituximab infusion, so it is given slowly over a few hours. Before treatment, you will be given medicines to help prevent or reduce any reaction.
Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- itching
- shivering
- feeling dizzy
- a headache
- feeling breathless
- swelling of your face or mouth
- pain in your back, tummy or chest.
Your nurse will check you for signs of a reaction during your infusion. If you feel unwell or have any of these signs, tell them straight away. If you do have a reaction, it can be treated quickly.
Sometimes a reaction can happen a few hours after treatment. If you develop any signs or feel unwell after you get home, contact the hospital straight away on the 24-hour number.
Low blood pressure
Some people have low blood pressure 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. Sometimes, rituximab can make your blood pressure go up. The nurse will check your blood pressure regularly.
Flushes and blocked nose
Some people may have hot flushes, or a feeling of having a blocked nose and a strange taste while they are having cyclophosphamide into a vein. This does not last for long. But if you notice this, tell your nurse. They may slow the drip to reduce these symptoms.
Tumour pain
During the infusion, you may have mild pain in the parts of the body where you have cancer. You may be given painkillers to help with this.
Common side effects
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If your white blood cell count is low, you may be more likely to get an infection. A low white blood cell count is called neutropenia.
An infection can be very serious when the number of white blood cells is low. It is important to get any infection treated as soon as possible. If you have any of the following symptoms, contact the hospital straight away on the 24-hour number:
- a temperature above 37.5°C
- a temperature below 36°C
- you feel unwell, even with a normal temperature
- you have symptoms of an infection.
Symptoms of an infection include:
- feeling shivery and shaking
- a sore throat
- a cough
- breathlessness
- diarrhoea
- needing to pass urine (pee) often, or discomfort when you pass urine.
It is important to follow any specific advice your cancer treatment team gives you.
Your white blood cell count will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time, until your cell count increases.
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.
If the number of platelets is low, you may bruise or bleed easily. You may have:
- nosebleeds
- bleeding gums
- heavy periods
- blood in your urine (pee) or stools (poo)
- tiny red, brown or purple spots that may look like a rash – these spots can be harder to see if you have black or brown skin.
If you have any unexplained bruising or bleeding, contact the hospital straight away on the 24-hour number. You may need a drip to give you extra platelets. This is called a platelet transfusion.
Anaemia (low number of red blood cells)
This treatment can reduce the number of red blood cells in your blood. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may feel:
- very low in energy
- breathless
- dizzy and light-headed.
If you have these symptoms, contact the hospital straight away on the 24-hour number. You may need treatment for anaemia. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
Feeling sick
Your doctor, nurse or pharmacist will prescribe anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as they tell you to, even if you do not feel sick. It is easier to prevent sickness than to treat it after it has started.
If you feel sick, take small sips of fluid often and eat small amounts regularly. It is important to drink enough fluids. If you continue to feel sick, or if you are sick (vomit) 1 to 2 times in 24 hours, contact the hospital on the 24-hour number as soon as possible. They will give you advice. They may change your anti-sickness treatment. Let them know if you still feel sick.
Bladder irritation
Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine. Drink plenty of fluids – at least 2 litres (3½ pints) during chemotherapy and in the 24 hours after having it. It is also important to empty your bladder regularly and to try to pass urine as soon as you feel the need to go.
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 your urine.
Diarrhoea
This treatment may cause diarrhoea. Diarrhoea means passing more stools (poo) than is normal for you, or having watery or loose stools. You may also have stomach cramps. If you have a stoma, it may be more active than usual.
If you are passing loose stools 3 or more times a day and this is not normal for you, contact the hospital as soon as possible on the 24-hour number. Follow the advice they give you about:
- taking anti-diarrhoea medicines
- drinking enough fluids to keep you hydrated and to replace lost salts and minerals
- any changes to your diet that might help.
They might also ask you for a specimen of your stool to check for infection.
Sore mouth and throat
This treatment may cause a sore mouth and throat. You may also get mouth ulcers. This can make you more likely to get a mouth or throat infection. Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.
Contact the hospital straight away on the 24-hour number, if:
- your mouth or throat is sore, or affecting how much fluid you can drink or food you can eat
- your mouth, tongue, throat or lips have any blisters, ulcers or white patches.
They can give you advice, and mouthwash or medicines to help with the pain or to treat any infection. Follow their advice and make sure you:
- drink plenty of fluids
- avoid alcohol and tobacco
- avoid food or drinks that irritate your mouth and throat.
Changes to your taste
Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. You may also get a bitter or metallic taste in your mouth. Your doctor, nurse or pharmacist can give you advice. It might help to try:
- sucking sugar-free sour or boiled sweets
- eating cold foods
- eating sharp-tasting fresh fruit.
Taste changes usually get better after treatment ends. We have more information about coping with changes to taste.
Feeling tired
Feeling tired is a common side effect of this treatment. It is often worse towards the end of treatment and for some weeks after it ends. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can help you feel less tired.
If you feel sleepy, do not drive or use machinery.
Hair loss
Your hair may get thinner. But you are unlikely to lose all the hair from your head. Hair loss usually starts after your first or second treatment. It is almost always temporary, and your hair will usually grow back after treatment ends.
Your nurse can talk to you about ways to cope with hair loss.
Skin changes
FCR 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 and for some months after treatment you will be more sensitive to the sun and your skin may burn more easily. Cover up with clothing and a hat. Use a sun cream with a sun protection factor (SPF) of at least 30.
If you have had radiotherapy (either recently or in the past), the area that was treated may change colour, or become red or sore.
Always tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Rarely, a much more serious skin condition can develop. You may have:
- a skin rash which then blisters
- peeling skin
- flu-like symptoms, such as a high temperature and joint pain.
If you have any of these symptoms, contact your doctor or hospital straight away.
Hand-foot (palmar-plantar) syndrome
This treatment can affect the palms of your hands and the soles of your feet. This is called palmar-plantar or hand-foot syndrome.
If you have white skin these areas may become red. If you have black or brown skin, these areas might get darker.
The skin on the palms of your hands and the soles of your feet may:
- be sore
- be painful, tingle, or swell
- peel, crack or blister.
If you have any of these symptoms, contact the hospital straight away on the 24-hour number. They can give you advice. This is especially important if you have any broken skin or if walking is difficult. They can prescribe creams and painkillers to help.
You can care for your hands and feet by:
- keeping your hands and feet cool by washing in cool water
- gently moisturising your hands and feet regularly
- wearing gloves to protect your hands and nails when working in the house or garden
- wearing loose cotton socks and avoiding tight-fitting shoes and gloves.
Nail changes
This treatment can affect your nails. They may grow more slowly or break more easily. You might notice ridges or white or dark lines across your nails. These changes usually disappear as the nails grow out after treatment. Sometimes nails can become loose or fall out.
If the skin around your nails becomes sore and swollen, contact the hospital straight away on the 24-hour number. These might be signs of an infection.
Tips to look after your nails:
- Keep your nails clipped short and clean.
- Avoid using very hot water when washing your hands or bathing.
- Moisturise your nails and cuticles regularly.
- Avoid false nails, gels or other acrylics during treatment – it is okay to use water-based nail polish.
- Wear gloves to protect your nails when working in the house or garden.
- If your toenails are affected, wear well-fitting shoes, or shoes with open toes to cushion them.
Tell your doctor or nurse about any changes to your nails. They can give you advice or arrange for you to see a podiatrist. They are a foot care specialist.
Numb or tingling hands or feet (peripheral neuropathy)
This treatment may affect the nerves in your fingers and toes. This can cause numbness, tingling or pain in your hands or feet. This is called peripheral neuropathy. You might find it hard to do fiddly tasks such as fastening buttons or tying shoelaces.
If you have these symptoms, always tell your doctor, nurse or pharmacist. They sometimes need to change the drug or the dose of the drug. The symptoms usually improve slowly after treatment ends. But for some people they continue and are a long-term side effect of treatment.
Build-up of fluid (oedema)
If fluid builds up in your body:
- you may put on weight
- your ankles and legs may swell.
If this happens, tell your doctor or nurse. 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 treatment ends.
Eye problems
This treatment may make your eyes feel sore, red and itchy. If this happens, your doctor will prescribe eye drops to help treat it. It is important to use these as you are told to.
This treatment may also make your eyes more sensitive to light and cause blurry vision. If you have pain or notice any change in your vision, always tell your doctor or nurse.
Changes in the way your liver or kidneys work
This 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 to check how well your kidneys and liver are working.
Tumour lysis syndrome (TLS)
Some people are at risk of developing a condition called tumour lysis syndrome (TLS) during this treatment. When treatment makes large numbers of cancer cells die and break down quickly, they release lots of waste products into the blood. This can affect how well the kidneys work. It may also cause problems with the heart rhythm.
TLS can be prevented. You will have regular blood tests to check for TLS. If you are at risk of TLS, you may have:
- extra fluids through a drip
- medicines such as rasburicase through a drip, or allopurinol as tablets.
Drinking at least 2 litres (3½ pints) of fluid a day will also help.
Headaches
This treatment may cause headaches. If you have headaches, tell your doctor, nurse or pharmacist. They can give you advice about painkillers that may help. Tell them if the headache does not get better, or gets worse.
Less common side effects
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor, nurse or pharmacist if you develop:
- a cough that does not go away
- wheezing
- breathlessness.
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
Effects on the heart
This treatment can affect how the heart works. You may have tests to check how well your heart is working. These may be done before, during and after treatment.
If the treatment is causing heart problems, your doctor may change the type of treatment you are having.
Contact the hospital straight away on the 24-hour number if you have any of these symptoms during or after treatment:
- breathlessness
- dizziness
- changes to your heartbeat
- swollen feet and ankles.
Other conditions can cause these symptoms, but it is important to get them checked by a doctor.
Always call 999 if you have:
- chest pain, pressure, heaviness, tightness or squeezing across the chest
- difficulty breathing.
Effects on the nervous system
Rarely, FCR can affect the nervous system. This can be serious. If you notice any of the following symptoms, contact your doctor straight away on the 24-hour number the hospital has given you. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
The symptoms include:
- trouble with your speech or vision
- confusion or memory loss
- changes in your personality
- weakness in your arms and legs
- poor balance or coordination
- fits (seizures).
Other nervous system side effects can include:
- feeling anxious or restless
- having problems sleeping.
It is important not to drive or operate machinery if you notice these effects.
Second cancer
Hepatitis B reactivation
If you have had hepatitis B (a liver infection) in the past, rituximab can make it active again. Your doctor or nurse will talk to you about this and test you for hepatitis B. If you have active hepatitis B, you will not have treatment with rituximab.
Other information
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Contact the hospital straight away on the 24-hour number if you have any of these symptoms during or after treatment:
- throbbing pain or swelling in a leg or arm
- reddening of the skin in the area – if you have black or brown skin, this can be harder to notice, but the skin might become darker
- suddenly feeling breathless or coughing.
Always call 999 if you have:
- chest pain
- difficulty breathing.
A blood clot is serious, but it can be treated with drugs called anticoagulants. These thin the blood. Your doctor, nurse or pharmacist can give you more information about preventing and treating blood clots.
Other medicines
Some medicines can affect how this treatment works or be harmful while you are having it. Always tell your cancer doctor, nurse or pharmacist about any drugs you are taking or planning to take, such as:
- medicines you have been prescribed
- medicines you buy in a shop, pharmacy or online
- vitamins or supplements
- herbal drugs and complementary or homeopathic therapies
- recreational drugs – for example, cannabis.
Avoiding grapefruit and grapefruit juice
Alcohol
Lactose
Blood transfusion irradiation
Your doctor will record in your medical notes that you should only be given irradiated blood products. They will also give you a card to carry in case you are treated at another hospital. Keep this card with you at all times and remind your hospital team that you need irradiated blood or platelets.
Vaccinations
Doctors usually recommend that people with cancer have vaccinations for flu and for coronavirus (covid). These help reduce your risk of serious illness from these infections. Most people can have these vaccines, including people with weak immune systems.
If your immune system is weak, you should not have live vaccinations. Live vaccines can make you unwell because they contain a very weak version of the illness they will protect you against. Live vaccines include Zostavax®, which is a shingles vaccine, and the yellow fever vaccine.
It is important to ask your doctor, nurse or pharmacist for advice about having vaccinations. They can explain what vaccines are right for you and when it is best to have them.
Contraception
Your doctor, nurse or pharmacist will advise you not to get pregnant or make someone pregnant while having this treatment and for some time afterwards. The drugs may harm a developing baby. It is important to use contraception to prevent pregnancy. Follow their advice about:
- what types of contraception to use
- how long after treatment you should continue to use contraception.
Breastfeeding
You are advised not to breastfeed while having this treatment, or for some time after treatment ends. This is because the drugs could be passed to the baby through breast milk.
Your doctor, nurse or pharmacist can give you more information.
Fertility
Some cancer drugs can affect whether you can get pregnant or make someone pregnant. If you are worried about this, it is important to talk with your doctor before you start treatment.
Sex
It is possible that small amounts of chemotherapy may be passed on through vaginal fluids or semen. If you have sex during this treatment, your cancer team will usually advise using condoms or a dental dam to protect your partner.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the healthcare professional that you are having cancer treatment. Give them the contact details for your cancer doctor or cancer team so they can ask for advice.
If you have appointments with a dentist, always tell them you are having cancer treatment. Talk to your cancer team before you have any dental treatment.
About our information
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References
Visit the electronic Medicines Compendium (eMC) to download a Patient Information Leaflet (PIL) for more detailed information. The leaflet lists all known side effects.
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Reviewers
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert health professionals and people living with cancer.
Our cancer information has been awarded the PIF TICK. Created by the Patient Information Forum, this quality mark shows we meet PIF’s 10 criteria for trustworthy health information.
The language we use
We want everyone affected by cancer to feel our information is written for them.
We want our information to be as clear as possible. To do this, we try to:
- use plain English
- explain medical words
- use short sentences
- use illustrations to explain text
- structure the information clearly
- make sure important points are clear.
We use gender-inclusive language and talk to our readers as ‘you’ so that everyone feels included. Where clinically necessary we use the terms ‘men’ and ‘women’ or ‘male’ and ‘female’. For example, we do so when talking about parts of the body or mentioning statistics or research about who is affected.
You can read more about how we produce our information here.
Date reviewed
Our cancer information meets the PIF TICK quality mark.
This means it is easy to use, up-to-date and based on the latest evidence. Learn more about how we produce our information.