EOX

EOX is a combination treatment used to treat cancers of the gullet (oesophagus) and stomach.

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

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

EOX 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 EOX?

EOX is used to treat cancers of the gullet (oesophagus) and stomach. It is best to read this information with our general information about chemotherapy and the type of cancer you have.

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


The drugs used in EOX

EOX is named after the initials of the drugs used in the treatment. The drugs are:

You might hear the treatment called EEX. This is because the other name for oxaliplatin is Eloxatin®.


How EOX is given

You will be given EOX 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 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) 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.

Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. The chemotherapy drugs can be given through:

  • a short thin tube that the nurse puts 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).

Your nurse will give you epirubicin (a red fluid) as an injection directly into your line or cannula, with a drip (infusion) of fluids to flush it through. Then you have oxaliplatin as a drip. The nurse usually runs the drip through a pump, which gives you the treatment over a set time.

You take capecitabine as tablets, which you take at home.

Your course of EOX chemotherapy

You will have chemotherapy as a course of several sessions (or cycles) of treatment over a few months.

Each cycle of EOX takes 21 days (3 weeks).

On the first day you will have epirubicin and oxaliplatin and you will start the capecitabine tablets. Over the next 3 weeks you continue to take the capecitabine tablets.

When it finishes on day 21, you will 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 that you are likely to have.

Taking your capecitabine tablets

Capecitabine is taken as tablets. The nurse or pharmacist gives you the capecitabine tablets to take at home. Always take your tablets exactly as explained. This is to make sure they work as well as possible for you.

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 then after your evening meal.Tell your doctor if you find it difficult to swallow the tablets. They may suggest that you dissolve the capecitabine tablets in water. In this case, dissolve the tablets 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.If you forget to take a tablet, do not take a double dose. Take your next dose at the normal time and let your doctor or nurse know. Other things to remember about your capsules:

  • 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

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. If you are also having treatment with other cancer drugs, you may 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.

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.

Rarely, capecitabine can cause severe side effects in people who have low levels of an enzyme called DPD. This is called having a DPD deficiency. You will not know before you start treatment whether you have a DPD deficiency as there are no symptoms. There is a test available but it only tests for the more common types of DPD deficiency. This means that the test will detect most cases of DPD deficiency but not all cases. The test is not widely available on the NHS. Talk to your doctor if you are worried about having a DPD deficiency.

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) for more detailed information.


Side effects while treatment is being given

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 while having this treatment. 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 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 can happen a few hours after treatment. If you get any signs or feel unwell after you get home, contact the hospital straight away.

Laryngeal spasm

Rarely, oxaliplatin can affect the area around the voicebox (larynx). This can cause temporary difficulties with swallowing and breathing. This might happen during treatment or in the first few days after treatment. If you have breathing difficulties, take long, deep breaths through your nose. This will have a calming effect and help your breathing return to normal.

This side effect can be brought on by cold temperatures. It is best to avoid cold drinks and ice cubes on the day of your treatment and for a few days afterwards. It can also help to wrap up warmly and cover your nose and mouth with a scarf in cold weather.

It is important to let your doctor know if you have this side effect. They may increase the time taken to give your infusion of oxaliplatin in future cycles. This will reduce the chance of it happening again.

The drug leaks outside the vein

If this happens it can damage the tissue around the vein. This is called extravasation. Extravasation is not common but if it happens it is important that it is dealt with 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 number they gave you.

Pain along the vein

This treatment can cause 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.

Facial flushing

You may suddenly feel warm and your face may get red while the drug is being given. This should only last a few minutes.


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.

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.

Diarrhoea

Capecitabine may cause diarrhoea. This can be severe. Your nurse or doctor may give you anti-diarrhoea drugs to take at home.

If you have diarrhoea:

  • follow any advice you have been given 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 6 times in a day
  • 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 the dose is reduced.

Constipation

This treatment can cause constipation. 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.

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.

Hair loss

Your hair will get thinner or you may lose all the hair from your head. You may also lose your eyelashes, eyebrows or 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. It is important to cover your head to protect your scalp when you are out in the sun.

Hair loss is almost always temporary and your hair will usually grow back after treatment ends.

Skin changes

Capecitabine 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. Capecitabine can 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, a much more serious skin condition can occur. 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 doctors immediately.

Soreness and redness of palms of hands and soles of feet

This is called palmar-plantar or hand-foot syndrome. 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 tight-fitting socks, shoes and gloves. It will start to get better when treatment ends.

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.

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.

Red urine

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.

Eye problems

Your eyes may become watery and feel sore. They may also become red and inflamed, which is called conjunctivitis. Tell your doctor if you have any of these symptoms. You may need antibiotic eye drops.

Headaches

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


Less common side effects of EOX

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 lead to heart failure or a heart attack. The risk of this happening is very low, less than 1 in 100 (1%), 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
  • breathlessness
  • changes to your heartbeat.

If you experience any of these symptoms, you should stop taking the capecitabine tablets until you have spoken to your doctor. If you cannot get through to your doctor or the 24-hour number the hospital has given you then call the NHS urgent advice number which is 111.


Other information

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.