EOX is used to treat cancers of the stomach and gullet (oesophagus).
Before starting this treatment, you should have a blood test to check whether you have low levels of an enzyme called DPD. This is called DPD deficiency. People who have low DPD levels can develop serious or life-threatening side effects if they have capecitabine. If you have DPD deficiency, this can affect the treatments that are available for you.
You will not know without a test if you have DPD deficiency, as there are no symptoms. Testing can detect most cases of DPD deficiency, but not all cases. You can talk to your cancer doctor about your risk of having DPD deficiency before you start treatment.
You have EOX in the chemotherapy day unit or during a stay in hospital. A chemotherapy nurse gives it to you.
During treatment you usually see a cancer doctor, a chemotherapy nurse or a specialist nurse, and a specialist pharmacist. This is who we mean when we mention doctor, nurse or pharmacist in this information.
Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) takes a blood sample from you. This is to check that your blood cells are at a safe level to have chemotherapy.
You see a doctor or nurse before you have chemotherapy. They will talk to you about your blood results and ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. The chemotherapy drugs can be given:
- through a short, thin tube the nurse puts into a vein in the arm or hand (cannula)
- through a fine tube that goes under the skin of the chest and into a vein close by (central line)
- through a fine tube that is put into a vein in the arm and goes up into a vein in the chest (PICC line).
- as tablets that you swallow.
For this treatment, your nurse injects a red fluid called epirubicin directly into your line or cannula. They give it with a drip (infusion) of fluids to flush it through. You then have oxaliplatin as a drip.
You have capecitabine as tablets, which you take at home.
Your course of chemotherapy
You usually have a course of several cycles of treatment over a few months. Each cycle of EOX takes 21 days (3 weeks).
On the first day you have epirubicin and oxaliplatin and you start the capecitabine tablets. Over the next 3 weeks you continue to take the capecitabine tablets.
When it finishes on day 21, you start the next cycle of EOX. This is the same as the first cycle. Your doctor or nurse will tell you the number of cycles you are likely to have. They may give you a copy of a treatment plan to take home with you.
Your nurse or pharmacist may also give you anti-sickness (anti-emetic) drugs and other medicines to take home.
Taking your capecitabine tablets
You take capecitabine as tablets. The nurse or pharmacist gives you the tablets to take at home. Always take your tablets exactly as they tell you to. This is to make sure they work as well as possible for you. You may be given tablets of different strengths.
You take capecitabine tablets twice a day. Swallow them whole with a glass of water within half an hour after eating a meal. Take the tablets in the morning after breakfast and after your evening meal.
If you find it difficult to swallow the tablets, tell your doctor. They may suggest dissolving them in a 200ml glass of warm water. Stir the water with a spoon until the tablets are completely dissolved and then drink it immediately. The glass and spoon should be washed and kept separate from your other crockery and cooking utensils. Do not crush or cut capecitabine tablets.
If you forget to take a tablet, do not take a double dose. Take your next dose at the normal time and tell your doctor or nurse.
Other things to remember about your tablets:
- Wash your hands after taking them.
- Other people should avoid direct contact with your chemotherapy drugs.
- Keep them in the original package and at room temperature, away from heat and direct sunlight.
- Keep them safe and out of sight and reach of children.
- 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.
We explain the most common side effects of this treatment here. We also include some less common side effects. You may get some of the side effects we mention, but you are unlikely to get all of them.
You may also have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.
Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.
Serious and life-threatening side effects
Some cancer treatments can cause severe side effects. Rarely, these may be life-threatening. Your cancer doctor, nurse or pharmacist can explain the risk of these side effects to you.
If you have low levels of an enzyme called DPD (DPD deficiency), you may have a higher risk of severe or life-threatening side effects.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) to download a Patient Information Leaflet (PIL) for these drugs. The leaflet lists all known side effects.
Some people have an allergic reaction while having this treatment. Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- feeling dizzy
- a headache
- feeling breathless or wheezy
- 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 treatment. 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 happens a few hours after treatment. If you develop any signs or feel unwell after you get home, contact the hospital straight away.
Rarely, oxaliplatin can cause a spasm in the throat area around the voice box (larynx). This can make swallowing and breathing difficult. Throat spasm may happen during treatment or in the first few days after treatment. It can be frightening, but it should not last long. If you have breathing difficulties, take long, deep breaths through your nose. This will help calm you and help your breathing return to normal.
Throat spasm may be worse in cold temperatures. It is best to avoid cold drinks and ice cubes during treatment and for a few days afterwards. It might also help to wrap up warm and cover your nose and mouth in cold weather.
It is important to let your doctor know if you have this side effect. Your doctor may increase the time of your infusion to 4 to 6 hours in future cycles. This will reduce the chance of it happening again.
The drug leaks outside the vein
If the drug leaks outside the vein, it can damage the surrounding tissue. This is called extravasation. Extravasation is not common but if it happens it is important to treat it quickly. Tell your nurse straight away if you have any stinging, pain, redness or swelling around the vein.
If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the contact telephone number they gave you.
Pain along the vein
You may get pain at the place where the injection is given or along the vein. If you feel pain, tell your nurse or doctor straight away so that they can check the site. They may give the drug more slowly or flush it through with more fluid to reduce pain.
You may suddenly feel warm and your face may get red while the drug is being given. This should only last a few minutes.
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is sometimes 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. Contact the hospital straight away on the 24-hour contact number you have been given if:
- your temperature goes over 37.5°C (99.5°F)
- you suddenly feel unwell, even with a normal temperature
- you have symptoms of an infection
- your temperature goes below 36°C (96.8°F).
Symptoms of an infection include:
- feeling shivery and shaking
- a sore throat
- a cough
- needing to pass urine (pee) a lot, or discomfort when you pass urine.
It is important to follow any specific advice your cancer treatment team gives you.
The number of white blood cells 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:
- bleeding gums
- heavy periods
- blood in your urine (pee) or stools (poo)
- tiny red or purple spots on the skin that may look like a rash.
Tell your doctor if you have any unexplained bruising or bleeding. 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 have symptoms such as:
- pale skin
- lack of energy
- feeling breathless
- feeling dizzy and light-headed.
Tell your doctor or nurse if you have these symptoms.
If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
Your doctor will give you anti-sickness drugs to help prevent or control sickness during your treatment. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.If you feel sick, take small sips of fluids often and eat small amounts regularly. It is important to drink enough fluids. If you continue to feel sick, or are sick (vomit) more than once in 24 hours, contact the hospital as soon as possible. They will give you advice. Your doctor or nurse may change the anti-sickness drug to one that works better for you.
Capecitabine may cause severe diarrhoea. Diarrhoea means passing more stools (poo) than is usual for you, or having watery or loose stools. If you have a stoma, it will be more active than usual.
Your hospital team may give you anti-diarrhoea drugs to take at home.
If you have diarrhoea or an increase in stoma activity:
- follow any advice from your hospital team about taking anti-diarrhoea drugs
- drink at least 2 litres (3½ pints) of fluids each day
- avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.
Contact the hospital straight away if:
- you have diarrhoea at night
- you have diarrhoea more than 4 times in a day
- you have a moderate or severe increase in stoma activity
- the anti-diarrhoea drugs do not work within 24 hours.
Your doctor may ask you to stop taking capecitabine. When the diarrhoea is better, they will tell you if you can start taking it again. Sometimes they reduce the dose.
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 for advice. Your doctor can give you drugs called laxatives to help.
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 has finished. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy.
If you feel sleepy, do not drive or use machinery.
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.
If your mouth or throat is sore:
- tell your nurse or doctor – they can give you a mouthwash or medicines to help
- try to drink plenty of fluids
- avoid alcohol, tobacco, and foods that irritate your mouth and throat.
Sucking ice chips may sometimes help relieve mouth or throat pain. But if you are having radiotherapy to the head or neck, do not suck on ice. It can cause damage.
Changes to your taste
You may get a bitter or metal taste in your mouth. Sucking sugar-free sweets may help with this. Some foods may taste different or have no taste. Try different foods to find out what tastes best to you. Taste changes usually get better after treatment finishes. Your nurse can give you more advice.
Helpful hints to improve taste
- Season food or add spices and herbs to add flavour when cooking.
- Use strong, flavoured sauces or gravies to make food tastier.
- Eat sharp-tasting fresh fruit and juices or try sugar-free sweets to leave a pleasant taste in your mouth.
- Try cold foods as they may have a stronger taste than hot foods.
Your hair will get thinner. Or you may lose all the hair from your head. You may also lose your eyelashes and eyebrows, as well as other body hair. Hair loss usually starts after your first or second treatment.
Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. Your scalp may be sensitive. It is important to cover your head to protect your skin when you are out in the sun.
Hair loss is almost always temporary. Your hair will usually grow back after treatment finishes.
This treatment 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. This treatment can also cause a rash, which may be itchy. 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.
Very rarely, capecitabine may cause a much more serious skin condition. You may have a skin rash which then blisters and your skin can peel. You may also feel unwell with flu-like symptoms such as a high temperature and joint pain. If you have these symptoms, you must stop taking the capecitabine and contact your doctor immediately.
Soreness and redness of palms of hands and soles of feet
Numb or tingling hands or feet (peripheral neuropathy)
This treatment affects the nerves, which can cause numb, tingling or painful hands or feet. You may 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 drug. The symptoms usually improve slowly after treatment finishes, but for some people they may never go away. Talk to your doctor if you are worried about this.
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. Sometimes nails can become loose or fall out. When treatment finishes, any changes usually disappear as the nails grow out.There are things you can do to look after your nails:
- Moisturise your nails and cuticles regularly.
- Keep your nails clipped short.
- Wear gloves to protect your nails when you are doing things in the house or garden.
- Keep your hands and nails clean to help avoid infection, but avoid bathing in very hot water.
- Do not use false nails, gels or other acrylics during this treatment, as they may increase the risk of infection.
- It is fine to wear nail varnish, but try to use a water-based polish. Avoid using harsh chemicals, such as acetone, when taking off the polish.
- If your toenails are affected, wear well-fitted shoes to cushion them.
Tell your doctor or nurse if you notice changes to your nails. They can give you advice or arrange for you to see a podiatrist for foot care advice if needed.
Your urine may be a pink-red colour for up to 48 hours after you have your treatment. This is caused by epirubicin and is not harmful.
Your eyes may become watery and feel sore. Your doctor can prescribe eye drops to help with this. If your eyes get red and inflamed, tell your doctor. This is because you may need antibiotic eye drops to treat conjunctivitis.
This treatment may cause headaches. If you have headaches, tell your doctor. They may give you painkillers to help.
Changes in the way the liver works
Chemotherapy may affect how your liver works. This is usually mild and goes back to normal after treatment. You will have blood tests to check how well your liver is working.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
Changes in the way the heart works
Capecitabine can affect the way your heart works. You may have tests to see how your heart is working before, during and sometimes after treatment. But it is still possible for your heart to be affected even if these tests are normal. Very rarely, this can cause heart failure or a heart attack. The risk of this happening is less than 1 in 100 (1%). This risk is very low but it is important that you know about it.
Tell a doctor immediately if you have any of these symptoms at any time during treatment:
- pain or tightness in your chest
- changes to your heartbeat.
If you have any of these symptoms, you should stop taking the capecitabine tablets until you have spoken to your doctor. Call your doctor or the 24-hour number the hospital has given you. If you cannot get through, call the NHS urgent advice number which is 111.
This treatment may cause hearing changes, including hearing loss. Some people may have pain or ringing in their ears (tinnitus) and become unable to hear some high-pitched sounds. Tinnitus usually gets better after treatment ends. Some hearing changes can be permanent. Tell your doctor if you notice any changes in your hearing.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- throbbing pain, redness or swelling in a leg or arm
- suddenly feeling breathless or coughing
- sharp chest pain, which may be worse when you cough or take a deep breath.
If you have any of these symptoms, contact the hospital straight away on the 24-hour contact number you have been given. If you cannot get through to your doctor, call the NHS urgent advice number on 111.
A blood clot is serious, but it can be treated with drugs that thin the blood (anticoagulants). Your doctor or nurse can give you more information.
You can help reduce the risk of developing a blood clot by:
- staying active during treatment
- drinking plenty of fluids, especially water.
You may be given anticoagulants to help prevent a clot.
Capecitabine contains a small amount of lactose. If you have a lactose intolerance, talk to your doctor before you start taking this.
Some medicines can affect how this treatment works or be harmful when you are having it. Always tell your cancer doctor about any drugs you are taking or planning to take, such as:
- medicines you have been prescribed
- medicines you buy in a shop or chemist
- vitamins, herbal drugs and complementary therapies.
Tell other doctors, pharmacists or dentists who prescribe or give you medicines that you are having this cancer treatment.
You can visit the electronic Medicines Compendium (eMC) for more detailed information about your treatment.
Vaccinations can reduce your risk of getting certain infections. Your doctor or nurse may talk to you about having vaccinations.
Doctors usually recommend that people with cancer have a flu vaccination and a coronavirus vaccination. These are both inactivated vaccinations that can help reduce the risk of infection. People with weak immune systems can have these, as they are not live vaccinations.
If your immune system is weak, you need to avoid live vaccinations. This is because they can make you unwell. Live vaccines, such as shingles, contain a very weak version of the illness they are vaccinating you against. Your cancer doctor or GP can tell you more about live and inactivated vaccinations.
Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment and for some time afterwards. The drugs may harm the developing baby. It is important to use effective contraception.
You are advised not to breastfeed while having this treatment, or for some time after treatment finishes. This is because the drugs could be passed to the baby through breast milk.
Your doctor or nurse can give you more information.
Some cancer drugs can affect whether you can get pregnant or make someone pregnant.
If you are a woman, your periods may become irregular or stop. This may be temporary, but for some women it is permanent. Your menopause may start sooner than it would have done.
If you have sex during a course of this treatment, you should use barrier protection such as a condom or dental dam. This will protect your partner if any of the drug is in your semen or vaginal fluid.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the doctors and nurses you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.
If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.