Epirubicin, oxaliplatin and fluorouracil (EOF)

EOF is the name of a chemotherapy combination. It includes the drugs below. How to pronounce the drug names are in brackets.

• E - epirubicin (eh-pee-roo-bih-sin)

• O - oxaliplatin (ox-ali-pla-tin)

• F - fluorouracil (floor-oh-yoor-uh-sil) also known as 5FU

It is a treatment for stomach, oesophageal and gastro oesophageal junction (GOJ) cancer.

How does EOF work?

These cancer drugs destroy quickly dividing cells, such as cancer cells.

How do you have EOF?

You have all EOF drugs into your bloodstream (intravenously).

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:

• central line
• PICC line
• portacath

5FU pump

You have the 5FU through a small pump. The pump slowly puts the fluid into your bloodstream (infuses). You can keep the pump in a small bag or attached it to a belt. You'll need to go back to the hospital every 7 days during your treatment to have the pump changed. Or sometimes a chemotherapy nurse may be able to do it for you at home.

How often do you have EOF?

You usually have EOF chemotherapy as cycles of treatment . Each cycle of treatment lasts 21 days (3 weeks). Depending on your situation you may have up to 8 cycles, taking between 4 and 6 months in total.

You have each cycle of treatment in the following way:

You then start your next cycle of treatment.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

Before starting treatment with fluorouracil (5FU) you have a blood test to check levels of an enzyme called dihydropyrimidine dehydrogenase (DPD). A low DPD level means you are more likely to have severe side effects from this chemotherapy, so you may start treatment with a lower amount (dose) of the drug or have a different treatment. Your doctor, nurse or pharmacist will talk to you about this.

What are the side effects of EOF?

Side effects can vary from person to person. They also depend on what other treatment you are having. 

When to contact your team

Your doctor, pharmacist or nurse will go through the possible side effects. They will monitor you closely during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects

• your side effects aren’t getting any better

• your side effects are getting worse

• the side effects are affecting your daily life

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Talk to your healthcare team if you have any new symptoms that you think might be a side effect of your treatment.

Remember it is very unlikely that you will have all of these side effects, but you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Increased risk of infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Bruising, bleeding gums or nose bleeds

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

Less commonly you might also bleed from other areas of the body. For instance, some people might notice their poo is quite dark or they might pass fresh blood.

Breathlessness and looking pale

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Difficulty swallowing or breathing due to cold air

Oxaliplatin can make you more sensitive to the cold. It can affect your throat causing it to feel as though it is difficult to breathe and swallow. This can happen whilst you have oxaliplatin or within a few hours of it finishing. It’s only temporary but can feel quite frightening.

Opening and closing the fridge or freezer, touching metal, eating or drinking cold foods and changes in temperature from the weather can trigger this.

It can help wearing gloves and avoid very cold food and drink before and after oxaliplatin.

Let your nurse know straight away if it's affecting your breathing and swallowing.

Allergic reaction

A reaction may happen during the infusion, causing a skin rash, itching, swelling of the lips, face or throat, breathing difficulties, fever and chills. Your nurse might give you medicines beforehand to try to prevent a reaction.

Difficulty breathing or a cough

It is important to tell your doctor or nurse if you have a cough, tightening of your chest, a wheeze, or are breathless.

More rarely lung changes such as stiffening of the lungs can cause breathing problems too.

Eye problems

You might have eye problems, such as inflammation of the white tissue of your eye (pink eye or conjunctivitis). Symptoms include itchy, watery or gritty eyes. Or you might have inflammation of the clear, dome shaped tissue on the front of your eye (keratitis). Symptoms include pain, blurred vision, watery eyes and sensitivity to light.

Occasionally you may have changes to your vision. More rarely you might get a blocked tear ducts.

Let your doctor or nurse know if you have any problems with your eyes. They can give you eye drops to help.

Hot flushes

We have some tips for coping with hot flushes in women and hot flushes in men. This information also includes some of the possible treatments. Talk to your doctor if your hot flushes are hard to cope with. They might be able to prescribe some medicines to help.

Feeling or being sick

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treat it once it has started.

Sore mouth and throat and other parts of the digestive system

It may be painful to swallow drinks or food. Painkillers and mouth washes can help to reduce the soreness and keep your mouth healthy.

Other parts of the digestive system can also be affected. An inflamed food pipe (oesophagus) can cause heartburn. Inflammation of the back passage (rectum) can cause diarrhoea. Other symptoms are pain, bleeding and discharge and the feeling that you want to pass a bowel movement. Speak to your doctor or nurse if you have these symptoms.

Diarrhoea or constipation

Tell your healthcare team if you have diarrhoea or constipation. They can give you medicine to help. 

Skin changes

You might notice skin changes, such as dryness, itching, rashes or areas of skin which differ in appearance and are raised like bumps. Occasionally, these drugs can cause your skin to change colour. So it may get darker or lighter. 

More rarely EOF can cause your skin to get red, crack, blister, ooze, crust and you might develop a sudden rash that’s raised, red and itchy (hives). Your skin might also be sensitive to the sun so you may burn easily. Protect your skin by staying in the shade, covering up and applying a high factor sunscreen.

Tell your healthcare team if you have any rashes or problems with your skin. They might be able to give you something to help like a cream or lotion.

Hair thinning and hair loss

You may have some hair loss or hair thinning. This can be upsetting. Your hair might grow back once treatment has finished.

Red or pink urine

This won't harm you. It’s due to the colour of the chemotherapy and lasts for one or two days.

Periods stopping

Women might stop having periods (amenorrhoea) but this may be temporary.

Feeling generally unwell

Speak to your doctor or nurse if you feel generally unwell after taking this drug.

Liver changes

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Loss of appetite

You might lose your appetite for various reasons while having cancer treatment. Sickness, taste changes or tiredness can put you off food and drinks.

High blood sugar levels

High blood sugar levels can cause headaches, feeling thirsty and blurred vision. You have regular tests to check your blood sugar levels. You may need to check your levels more often if you have diabetes .

Changes to the levels of minerals in your blood

You may have changes in levels of minerals and salts in your blood, such as low potassium and high sodium. You have regular blood tests during treatment to check this.

Numbness or tingling in fingers or toes

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. Tell your healthcare team if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

Taste changes

Taste changes may make you go off certain foods and drinks. You may also find that some foods taste different from usual or that you prefer to eat spicier foods. Your taste gradually returns to normal a few weeks after your treatment finishes.

Headaches

Let your doctor or nurse know if you have headaches. They can give you painkillers such as paracetamol to help.

Pain in different parts of the body

EOF can cause pain in different parts of the body such as your tummy (abdomen) or back. Less commonly you might get joint and bone pain.

Let your healthcare team know if you are in pain.  They can try to find out check the cause and give you medicine to help

Tiredness and weakness

You might feel very tired and as though you lack energy.

Various things can help you to reduce tiredness and cope with it, for example exercise. Some research has shown that taking gentle exercise can give you more energy. It is important to balance exercise with resting.

High levels of enzymes in the blood

You might have higher than usual levels of an enzyme called blood lactate dehydrogenase in your blood. Body tissues release blood lactate dehydrogenase when damaged.

Weight changes

You may gain weight while having this treatment. You may be able to control it with diet and exercise. Less commonly you might lose weight.  

Tell your healthcare team if you are finding it difficult to control your weight. 

Changes in how your heart works

You may have changes to how your heart works that are picked up on a heart trace (electrocardiogram, ECG).

Occasionally people experience chest pain when the heart muscle does not get the blood it needs. Or other symptoms including breathlessness when resting or after an activity, feeling tired and lacking energy most of the time and swollen ankles and legs.

It is rare but these drugs can cause other side effects like a heart attack, lack of oxygen to the heart, an enlarged heart muscle or the heart not being able to pump enough blood.

You will have regular heart checks during and after the treatment. Tell your doctor or nurse straight away if you have any chest pain.

Inflammation around the drip or injection site

Tell your nurse straight away if you have any pain, redness, swelling or leaking around your drip site.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• not enough fluid in your body (dehydration) – make sure you drink plenty of fluids

• reddening (flushing) of the skin

• brittle, chipped and ridged nails that change colour. More rarely you might have thickening of the nail bed, inflammation, pain and changes in the colour of the nail bed

• mood changes such as feeling very low (depressed). Some people may have an intense feeling of happiness (euphoria), but this is rare. Tell your doctor or nurse if you are struggling with your moods

• sleep changes - you might find it more difficult to get to sleep or you might find it difficult to stay awake (somnolence)

• dizziness

• damage to the nerves that control your muscles causing weakness, cramping or twitching

• inflammation of the membranes covering the brain and spinal cord (meninges) causing symptoms similar to meningitis (stiff neck, unable to look at bright light and headache)

• blood clots that are life threatening; signs are pain, swelling and redness where the clot is. Feeling breathless can be a sign of a blood clot on the lung. Contact your advice line or doctor straight away if you have any of these symptoms

• Changes in your blood pressure. If it goes up you may get headaches, changes to your eyesight, nosebleeds or shortness of breath. If it drops you may feel lightheaded or dizzy. You have your blood pressure is checked regularly while having treatment

• hiccups

• indigestion and heartburn - ask your doctor or nurse for anti heartburn medicines if you need them

• an increase in sweating

• high levels of a waste chemical called creatinine in your blood – you will have regular blood tests to check this

• a risk of falls

• weeing problems such as going too often or too little. It may burn, be painful or sting. You might notice blood when you wee. Let your healthcare team know of any problems

Rare side effects

These side effects happen in fewer than 1 in 100 people (fewer than 1%). You might have one or more of them. They include:

• a serious reaction to an infection (sepsis). Signs can include feeling very unwell, not passing urine, being sick, a very high or very low temperature or shivering - contact your advice line straight away if you have any of these symptoms

• a second cancer such as acute leukaemia

• a blood disorder that causes your red blood cells to be destroyed faster than they can be made. You might have symptoms such as feeling tired, dizzy, headache and confusion

• an imbalance of chemicals in your body that affects the pH of the blood

• feeling nervous

• feeling confused and disorientated, and having problems with walking or speaking due to changes in the brain

• hearing changes such as loss of hearing

• slowing down or blockage of your gut

• shaking and trembling, stiffness and slow movement (symptoms of Parkinson's disease)

• changes in the brain that are usually reversible, causing a sudden onset of symptoms including headaches, dizziness, confusion, fits (seizures) and changes to your vision

Other side effects

If you have side effects that aren't listed on this page, you can look at the individual drug pages:

• epirubicin
• oxaliplatin
• fluorouracil (5FU)

Coping with side effects

We have more information about side effects and tips on how to cope with them.

What else do you need to know?

Other medicines, foods and drink

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Pregnancy and contraception

This treatment may harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you are having treatment. Women must not become pregnant for at least 7 months after the end of treatment. Men should not get someone pregnant for at least 6 months after treatment. 

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner become pregnant while having treatment.

Loss of fertility

You may not be able to become pregnant or father a child after treatment with these drugs. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Men might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Breastfeeding

Don’t breastfeed during this treatment and for 1 week after your last dose, because the drug may come through into your breast milk.

Other conditions

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and one of the shingles vaccines called Zostavax.

You can have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine - talk to your doctor or pharmacist about the best time to have it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system recovers from treatment.

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

More information

For further information about each drug and the possible side effects go to the electronic Medicines Compendium (eMC) website. You can find patient information leaflets for each drug on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.