FCR chemotherapy

FCR is a combination treatment used to treat chronic lymphocytic leukaemia (CLL) and some types of non-Hodgkin lymphoma (NHL). It includes the three drugs:

  • fludarabine
  • cyclophosphamide
  • rituximab

It is best to read this information with our general information about chemotherapy and the type of cancer you have.

FCR is usually given into a vein and as tablets. You usually have it as an outpatient or during a hospital stay. Your cancer doctor or nurse will tell you how often you will have it.

FCR can cause side effects. Some of the side effects can be serious, so it is important to read the detailed information below.

Your healthcare team can give you advice on how to manage any side effects. Tell your doctor or nurse straight away if you:

  • have a temperature
  • feel unwell
  • have severe side effects, including any we do not mention here.

Rarely, side effects may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.

If you need medical attention for any reason other than cancer, always tell the healthcare staff that you are having this treatment.

What is FCR?

Chemotherapy

This video provides a brief overview of chemotherapy treatment, how it can be given, how it works and possible side effects.

About our cancer information videos

Chemotherapy

This video provides a brief overview of chemotherapy treatment, how it can be given, how it works and possible side effects.

About our cancer information videos


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 cancer doctor, a blood specialist (haematologist), and a chemotherapy or 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 a 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 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.

Your nurse will give you paracetamol tablets before you start your treatment. They will then give you anti-sickness drugs, a steroid and an anti-histamine as injections into a vein or as tablets. Some people have a reaction to rituximab. The paracetamol, steroid and anti-histamine help reduce the chance of this happening.

The chemotherapy drugs can be given through:

  • a short, thin tube that they put into a vein in your arm or hand (cannula)
  • 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 nurse gives you rituximab as a drip into your vein. They will usually run the drip through a pump, which gives you the treatment over a set time.

You will then be given your first dose of cyclophosphamide and fludarabine tablets. If you get an upset stomach from the tablets, your nurse can give fludarabine and cyclophosphamide as a slow injection or a drip into your vein instead. Your doctor, nurse or pharmacist will talk to you about this.

Your course of FCR

You have chemotherapy as a course of several cycles of treatment over a few months. FCR may be given in different ways, including:

  • FCR – oral three-day
  • FCR – oral five-day
  • FCR – intravenous three-day.

We describe these in more detail here. Your doctor or nurse can tell you more about your treatment course.

FCR – oral three-day

Each cycle takes 28 days (four weeks).

On day one, you will be given an infusion of rituximab. You will also take the fludarabine and cyclophosphamide tablets. For the first cycle only, the rituximab may be repeated on day two.

On days two and three, you will take more fludarabine and cyclophosphamide tablets.

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. This is exactly the same as the first cycle. You have up to six cycles over six months. Your doctor or nurse will tell you the number of cycles you are likely to have.

FCR – oral five-day

Each cycle takes 28 days (four weeks).

On day one, you will be given an infusion of rituximab. You will also take the fludarabine and cyclophosphamide tablets. For the first cycle only, the rituximab may be repeated on day two.

On days two to five, you will take more fludarabine and cyclophosphamide tablets.

You will then have no chemotherapy for the next 22 days. At the end of the 28 days, you start your second cycle of FCR. This is exactly the same as the first cycle. You have up to six cycles over six months. Your doctor or nurse will tell you the number of cycles you are likely to have.

FCR – intravenous three-day

Each cycle takes 28 days (four weeks).

On day one, you will be given infusions or slow injections of fludarabine and cyclophosphamide. You will also be given an infusion of rituximab. For the first cycle only, the rituximab may be repeated on day two.

On days two and three, you have infusions or injections of fludarabine and cyclophosphamide.

If you are being treated as a day patient, you can usually go home after each day's chemotherapy. If you are an inpatient, you can usually go home after the chemotherapy on the third day.

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. This is exactly the same as the first cycle. You have up to six cycles over six months. Your doctor or nurse will tell you the number of cycles you are likely to have.

Going home

Before you go home, the nurse or pharmacist will give you anti-sickness drugs to take. Take all your tablets exactly as explained.

Having your central line put in

This is a short animation about how you can have a central line (or skin-tunnelled venous catheter) put in.

About our cancer information videos

Having your central line put in

This is a short animation about how you can have a central line (or skin-tunnelled venous catheter) put in.

About our cancer information videos

Having your PICC line put in

This is a short animation about having a PICC line (Peripherally inserted central catheter) put in.

About our cancer information videos

Having your PICC line put in

This is a short animation about having a PICC line (Peripherally inserted central catheter) put in.

About our cancer information videos


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 haven’t 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.


Side effects during treatment

Some people may have side effects while they are being given the chemotherapy or shortly after they have it:

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

Some people's blood pressure falls 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. 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 while they are having cyclophosphamide into a vein. This doesn’t last for long. But if you notice this, ask the nurse to slow down the drip. This will reduce these symptoms.


Common side effects of FCR

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 (99.5F)
  • 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 chemotherapy. If your white blood cell count is low, your doctor may delay your treatment for a short time.

Bruising and bleeding

Chemotherapy can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot. Tell your doctor or nurse if you have any bruising or bleeding that you can’t 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)

Chemotherapy 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 chemotherapy. 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.

Drink plenty of fluids – at least two litres (three and a half 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 it.

Diarrhoea

If you have diarrhoea, contact the hospital for advice. Try to drink at least two litres (three and a half pints) of fluids every day. It can help to avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.

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 bad 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

Cyclophosphamide 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 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 it.

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 can give you advice and prescribe creams to improve the symptoms. It can help to keep your hands and feet cool and to avoid heat, hot water and 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.
  • Don’t 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 or delay treatment for a short time. 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, because of fluid building up. Tell your doctor or nurse if fluid builds up. 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 your treatment ends.

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 causes 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 they 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 allopurinol (Zyloric®) tablets to help prevent this. Drinking at least two litres (three and a half 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.

A photo of Stuart talking about neutropenic sepsis

Neutropenic sepsis

Stuart talks about he how coped with neutropenic sepsis, an infection which can be a side effect of chemotherapy.

About our cancer information videos

Neutropenic sepsis

Stuart talks about he how coped with neutropenic sepsis, an infection which can be a side effect of chemotherapy.

About our cancer information videos

Watch our hair loss video playlist

In these videos, people with experience of cancer and hair loss share their stories. You can also watch tutorials on wigs, headwear and eye make up.

Watch our hair loss video playlist

In these videos, people with experience of cancer and hair loss share their stories. You can also watch tutorials on wigs, headwear and eye make up.

Coping with fatigue

Denton describes how he coped with fatigue (tiredness) during his treatment for prostate cancer.

About our cancer information videos

Coping with fatigue

Denton describes how he coped with fatigue (tiredness) during his treatment for prostate cancer.

About our cancer information videos


Less common side effects of FCR

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

This treatment 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 treatment 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, FCR 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.

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.

Second cancer

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


Other information about FCR

Blood 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

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 drugs you are taking, including vitamins, herbal drugs and complementary therapies.

Contraception

Your doctor will advise you not to get pregnant or father a child while having this treatment. The drugs may harm the developing baby. It is important to use effective contraception.

Breastfeeding

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

Fertility

Some chemotherapy drugs can affect whether you can get pregnant or father a child.

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 chemotherapy 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.