Bevacizumab and trifluridine-tipiracil (Lonsurf®)

You usually have bevacizumab in a chemotherapy day unit or clinic as an outpatient. You usually take Lonsurf as tablets at home.

During your course of treatment, you will meet someone from your cancer team, such as a:

• cancer doctor
• chemotherapy nurse or 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, you will have a blood test. This is to check that it is safe for you to have treatment. 

You will meet with a doctor, nurse or pharmacist before you have treatment. 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 cancer drugs. 

You have bevacizumab as a drip (infusion) into a vein. You have it through 1 of the following: 

a cannula – a short, thin tube the nurse puts into a vein in the arm or hand

• 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.

You have the first treatment of bevacizumab slowly over 90 minutes. If you do not have any problems, you have the next treatment over 60 minutes. After this, you usually have it over 30 minutes.

You take Lonsurf as tablets. 

Your cancer team may also give you anti-sickness drugs and other medicines to take home. Take all your capsules or tablets exactly as they tell you to.

Your cancer team will discuss your treatment plan with you. They may give you a copy of the plan to take home. Follow any instructions your cancer team gives you.

Bevacizumab and Lonsurf is a 28-day (4-week) cycle. 

You have an infusion of bevacizumab on day 1 of the cycle. You have this in the chemotherapy day unit or clinic.

You usually take Lonsurf tablets at home every day on days 1 to 5 of the cycle. You then have a break for 2 days on days 6 and 7. You take Lonsurf again on days 8 to 12. 

On day 15 you have another infusion of bevacizumab at the chemotherapy day unit or clinic.

You then have 13 days without any cancer treatment before starting the next cycle of bevacizumab and Lonsurf. 

Your cancer team will give you the tablets to take home. They may give you tablets of different strengths. Always take the tablets exactly as explained. This is important to make sure they work as well as possible for you.

The dose of Lonsurf may change each cycle. This may be because of side effects or changes to your weight. It is very important that you know how many tablets to take each time you start a new cycle. 

Make sure you:

• take the tablets twice a day 
• take them within 1 hour of eating your breakfast and evening meal
• swallow them whole with a glass of water
• do not chew, break or crush them.

If you forget to take the tablets, take the next dose at the usual time. Do not take a double dose to make up for the missed dose. 

Other things to remember about your tablets:

• Wash your hands after taking them.
• Other people should avoid direct contact with them. 
• Keep them in the original package and at room temperature, away from moisture, heat and direct sunlight.
• Keep them safe, where children cannot see or reach them.
• If you are sick (vomit) just after taking them, contact the hospital. Do not take an extra dose. Take your next dose at the usual time. 
• Do not throw away unused tablets. Return them to your cancer team at the hospital.

Some people may have side effects while they are having this treatment or shortly after they have it:

Some people have an allergic reaction while having bevacizumab. The first infusion is the most likely to cause a reaction, so it is usually given more slowly than later infusions. Before treatment, you will have medicines to help prevent or reduce any reaction.

Signs of a reaction include:

• feeling hot or flushed
• shivering
• itching
• a skin rash
• feeling dizzy or sick
• a headache
• feeling breathless or wheezy
• swelling of the face or mouth
• pain in the 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, they can treat it quickly.

Sometimes a reaction happens a few hours after treatment. If you develop any of these signs or feel unwell after you get home, contact the hospital straight away on the 24-hour number.

Always call 999 if swelling happens suddenly or you are struggling to breathe.

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.

We have more information about coping with changes to taste.

You may get pain in your tummy (abdomen), or have indigestion. Your doctor, nurse or pharmacist can give you advice or treatment to help. Contact the hospital straight away on the 24-hour number if your symptoms do not go away, or get worse.

Bevacizumab may cause a hole (perforation) in the bowel. This is more likely if you have also had radiotherapy to the pelvis (lower part of the tummy).

Contact the hospital on the 24-hour number straight away if the tummy pain is severe or is not getting better.

 It is also very important to let them know if:

• you have bleeding from the back passage (rectum) or black stools
• you are vomiting up blood
• your vomit looks like coffee grounds.

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.

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.

This treatment can cause constipation. Constipation means that you are not able to pass stools (poo) as often as you normally do. It can become difficult or painful. Here are some tips that may help:

• Drink at least 2 litres (3½ pints) of fluids each day.
• Eat high-fibre foods, such as fruit, vegetables and wholemeal bread.
• Do regular gentle exercise, like going for short walks.

If you have constipation, contact the hospital on the 24-hour number for advice. They can give you drugs called laxatives to help. 

If you have not been able to pass stools for over 2 days and are being sick, contact the 24-hour number straight away. 

Your hair may get thinner but you are unlikely to lose all the hair from your head. Hair loss 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.

Cancer treatment can affect your skin. If your skin feels dry, try using soap-free cleansers and unperfumed moisturising cream every day.

This treatment can also:

• cause a rash, which may be itchy 
• make your skin darker in some areas
• make you more sensitive to the sun. 

If you have had radiotherapy, the treated area may become sore. If you have white skin, the area may become red. If you have black or brown skin, the area may become darker. 

Your skin may burn more easily during treatment and for several months after. Use a suncream of at least SPF 30. SPF stands for sun protection factor. Cover up with clothing and wear a hat. 

Always tell your doctor, nurse or pharmacist about any skin changes. They can give you advice or prescribe creams or medicines to help. 

You may get pain in your muscles or joints with this treatment. If this happens, tell your doctor, nurse or pharmacist. They can give you painkillers and advice. They can also tell you if any of the painkillers you usually take are suitable. 

This treatment can affect how your liver works. This is usually mild. 

You will have blood tests to see how well your liver is working. 

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 dose of the drug. 

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.

This treatment may affect the heart. Contact the hospital on the 24-hour number if:

• you feel that your heart is beating too fast
• you have ankle swelling.

These could be signs that bevacizumab is affecting your heart.

Always call 999 if you have:

• chest pain, pressure, heaviness, tightness or squeezing across the chest
• difficulty breathing.

Wounds may take longer to heal while you are being treated with bevacizumab. If you have any wounds that are not healing or look infected, speak to your doctor or nurse straight away.

If you need to have surgery or invasive dental work, you will stop having bevacizumab about 4 to 6 weeks before the operation. You can start it again when the wound is fully healed.

Rarely, bevacizumab can cause a fistula. A fistula is an abnormal opening that connects 2 or more parts of the body. If this happens, it is more likely to be in the part of the body affected by the cancer.

Rarely, bevacizumab may cause osteonecrosis of the jaw. This is when bone tissue in the jaw becomes damaged and dies. Symptoms of osteonecrosis include:

• pain
• swelling
• redness of the gums
• loose teeth.

Tell your cancer doctor and dentist straight away if you have any of these symptoms.

Sometimes fluid builds up in the legs and ankles. This is called oedema. Fluid may also build up in the linings of the lungs. This is called a pleural effusion.

Oedema and pleural effusion may be treated with drugs that help you to you pass more urine (pee). These drugs are called diuretics. Always tell your doctor if you notice any swelling. It is important to contact your doctor or the hospital straight away if you:

• develop a cough
• have chest pain
• feel more breathless than usual
• gain weight suddenly.

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.

Rarely, this treatment causes a brain condition that can be serious. You can make a full recovery from this. But it must be diagnosed and treated quickly.

This condition can cause:

• a headache that does not get better
• drowsiness or confusion
• changes in eyesight
• fits (seizures).

If you have any of these symptoms, it is important to either:

• contact the hospital straight away on the 24-hour number 
• go to the hospital straight away. 

You should not drive yourself to hospital.