What is FCR?

FCR is used to treat chronic lymphocytic leukaemia (CLL) and some types of non-Hodgkin lymphoma. It is best to read this information with our general information about chemotherapy and the type of cancer you have. 

FCR comes from the initials of the drugs used:

Your doctor will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment. 

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 treatment you usually see a haematologist (specialist in blood disorders) or 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 first day of your treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that your blood cells are at a safe level to have chemotherapy. 

You will see a doctor or nurse before you have chemotherapy. They will 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. 

Before you have the treatment your nurse will give you anti-sickness drugs. Some people have a reaction to rituximab, so you will also be given drugs to reduce the chance of this happening.

The nurse will give you rituximab as a drip into your vein. It can be given through:

  • a short, thin tube (cannula) that they put 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)

You may be given cyclophosphamide and fludarabine as a drip or injection into a vein, or as tablets that you take by mouth.

Your course of FCR

FCR is given as 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 doctor, nurse or pharmacist will tell you how many cycles you will have. 
We describe these in more detail here. Your doctor or nurse can tell you more about your treatment course.

FCR – oral over 3 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.

Day 2 and 3

You take fludarabine and cyclophosphamide tablets.

Day 4 to 28

You will then 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.

Day 2 to 5 

You take fludarabine and cyclophosphamide tablets.

Day 6 to 28

You will then 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.

Day 2 and 3

You are given fludarabine and cyclophosphamide into a vein.

Day 4 to 28

You will then have no chemotherapy for the next 25 days. At the end of the 28 days, you start your second cycle of FCR. 

Going home

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. 

If you have chemotherapy tablets to take at home.

  • 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 capsules or tablets, contact the hospital. Do not take another dose.
  • If your treatment is stopped return any unused tablets to the pharmacist.

About side effects

About side effects

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 or nurse can explain the risk of these side effects to you.

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.

More information

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.

Side effects while given

Allergic reaction

Some people have an allergic reaction to rituximab while they are having it. A reaction is most likely with the first 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.

Blood pressure

Your blood pressure may fall when you 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. Your 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 in their mouth when cyclophosphamide is given.

This does not last for long. But if you notice this, tell your nurse. They can give the treatment more slowly, which will reduce these symptoms.

Tumour pain

During the infusion, some people have mild pain in the parts of the body where they have cancer. Painkillers can be given 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 the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is called neutropenia.

If you have an infection, it is important to treat it as soon as possible. Contact the hospital straight away on the 24-hour contact number you have 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.

Symptoms of an infection include:

  • feeling shivery
  • a sore throat
  • a cough
  • diarrhoea
  • needing to pass urine often.

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.

Bruising and bleeding

This treatment 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 that you cannot explain. This includes:

  • nosebleeds
  • bleeding gums
  • tiny red or purple spots on the skin that may look like a rash.

Some people may need a drip to give them 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. 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. This is called a blood transfusion.

Feeling sick

You may feel sick in the first few days after this treatment. Your doctor will give you anti-sickness drugs to help prevent or control sickness. 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 and eat small amounts often. If you continue to feel sick, or if you vomit more than once in 24-hours, contact the hospital as soon as possible. They will give you advice and may change the anti-sickness drug to one that works better for you.

Bladder irritation

Cyclophosphamide may irritate your bladder and cause discomfort when you pass urine (pee). Drink plenty of fluids, at least 2 litres (3 ½ pints) during the first 24 hours after chemotherapy. It is also important to empty your bladder regularly and to try to pass urine as soon as you feel you need to. Contact the hospital straight away if you find it difficult to pass urine. Or contact the hospital if you feel any discomfort or stinging when you pass urine. If you notice any blood in your urine tell your doctor straight away.

Diarrhoea

This treatment may cause 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.

If you have diarrhoea:

  • try to 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 for advice.

Feeling tired

Feeling tired is a common side effect. 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 operate machinery.

Sore mouth

You may get a sore mouth or mouth ulcers. This can make you more likely to get a mouth infection.

Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.

If your mouth 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.

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.

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 and at least 4 or 5 UVA stars. 

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.

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.

Nail changes

Your nails may grow more slowly or break more easily. You may notice white lines across your nails, or other changes to their shape or colour. Once the treatment has ended, any changes usually take a few months to grow out.

There are things you can do to look after your nails:

  • Keep your nails and hands moisturised.
  • Wear gloves to protect your nails when you are doing things in the house or garden.
  • Do not use false nails during this treatment. It is fine to wear nail varnish.
  • If your toenails are affected, wear well-fitted shoes to cushion them.

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.

Build-up of fluid

You may put on weight, or your ankles and legs may swell. This is because of fluid building up. It is caused by steroids and is more common if you are taking them for a long time. Tell your doctor or nurse if this happens. If your ankles and legs swell, it can help to put your legs up on a foot stool or cushion. The swelling will go down after your treatment ends.

Eye problems

Your eyes may become watery and feel sore. They may also become more sensitive to light. 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. Methotrexate 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.

Eye problems

This treatment may make your eyes feel sore, red and itchy (conjunctivitis). Your doctor will prescribe eye drops to help prevent this. 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.

Raised levels of uric acid (tumour lysis syndrome)

This treatment may cause the cancer cells to break down quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid, but may not be able to cope with large amounts. Too much uric acid can cause swelling and pain in the joints, which is called gout.

Your doctor may give you drugs to help prevent this. Drinking at least 2 litres (3 ½ pints) of fluid a day will also help. You will have regular blood tests to check the uric acid levels.

Headaches

This treatment may cause headaches. If this happens, tell your doctor or nurse. They can give you painkillers.

Less common side effects

Effects on the lungs

This treatment can cause changes to the lungs. Tell your doctor if you develop:

  • a cough
  • wheezing
  • a fever (high temperature)
  • 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

Chemotherapy can affect the way the heart works. You may have tests to see how well your heart is working. These may be done before, during and sometimes after treatment. If the treatment is causing heart problems, your doctor can change the type of chemotherapy you are having.

Contact a doctor straight away if you:

  • have pain or tightness in your chest
  • feel breathless or dizzy
  • feel your heart is beating too fast or too slowly.

Other conditions can cause these symptoms, but it is important to get them checked by a doctor.

Effects on the nervous system

Rarely, this treatment can affect the nervous system. You may:

  • feel anxious or restless
  • have problems sleeping
  • have mood changes
  • feel drowsy or confused.

Rarely, this treatment can cause seizures (fits). 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.

Second cancer

This treatment can increase the risk of developing a second cancer years later. This is rare. The benefits of treatment usually far outweigh this risk. Your doctor can talk to you about this.

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 transfusion irradiation

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 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.

Blood clot risk

Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:

  • pain, redness or swelling in a leg or arm
  • breathlessness
  • chest pain.

If you have any of these symptoms, contact a doctor straight away.

A blood clot is serious, but can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.

Other medicines and food

Some medicines can affect chemotherapy or be harmful when you are having it. This includes medicines you can buy in a shop or chemist. Tell your cancer doctor about any medicines you are taking, including vitamins, herbal drugs and complementary therapies.

It is important to avoid eating grapefruit or drinking grapefruit juice during your course of chemotherapy. This is because a chemical in grapefruit can affect how well the treatment works or can make side effects worse.

Vaccinations

Your doctor or nurse may talk to you about vaccinations. These help reduce your risk of getting infections.

Doctors usually recommend that you have a flu jab, which is an inactivated vaccination. People with weak immune systems can have this type of vaccination.

If your immune system is weak, you need to avoid live vaccinations such as shingles. Your cancer doctor or GP can tell you more about live vaccinations.

Contraception

Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment. The drugs may harm a developing baby. It is important to use contraception during your treatment and for a while after treatment finishes. Your doctor, nurse or pharmacist can tell you more about this.

Breastfeeding

Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.

Fertility

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.

There may be ways to preserve fertility for men and women. If you are worried about fertility, it is important to talk with your doctor before you start treatment.

Sex

If you have sex during this course of chemotherapy, you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluids.

Medical and dental treatment

If you need medical treatment for any reason other than cancer, always tell the doctors and nurses that 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.

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