Epirubicin, cisplatin and capecitabine (ECX)

ECX is a combination of chemotherapy drugs that includes epirubicin, cisplatin and capecitabine. It is a treatment for stomach, oesophageal and gastro oesophageal junction cancer.

What is ECX?

 ECX chemotherapy combination is made up of:

• E - epirubicin
• C - cisplatin
• X - capecitabine (also known and Xeloda)

It is a treatment for:

• stomach cancer
• food pipe (oesophageal) cancer
• cancer that develops at the point where your food pipe (oesophagus) joins your stomach, this is called gastro oesophageal junction cancer

How does ECX work?

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

How do you have ECX?

You have epirubicin and cisplatin as a drip into your bloodstream (intravenously). 

Capecitabine comes as a tablet that you swallow whole, with plenty of water. You should take the tablets within 30 minutes after eating a meal.

Into the bloodstream

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

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

Taking your tablets

You should take the right dose, not more or less.

Talk to your healthcare team before you stop taking a cancer drug, or if you miss a dose.

How often do you have ECX?

You have ECX chemotherapy as cycles of treatment. This means you have the drugs and then a rest to allow your body to recover.

Each cycle is 21 days (3 weeks). You might have up to 8 cycles, the number of cycles depends on your individual situation. Your doctor, nurse or pharmacist can let you know how many cycles you will be having.

You usually have each cycle of treatment in the following way:

You then start a new cycle of treatment.

Tests during treatment

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

You might also have tests to check how well your heart is working. Epirubicin can weaken the heart. This isn’t very common, but doctors need to know how well your heart is working before you start treatment.

Before starting treatment with capecitabine 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 these drugs. So you may start treatment with a lower amount (dose) of the drug or have a different treatment. Your doctor, pharmacist or nurse will talk to you about this.

What are the side effects of ECX?

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. 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 getting an 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 nosebleeds

This treatment can cause bleeding and bruising. This could be 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, bleeding gums after brushing your teeth, lots of tiny red spots or bruises on your arms or legs (known as petechiae). Or you might bleed for another reason.

Occasionally, you might notice bleeding from other areas of the body. Although rare, you may pass fresh blood in your poo or dark poo, or you might have abnormal bleeding from your vagina, or pass blood when you wee.

Contact your team know if you notice any bleeding.

Breathlessness and looking pale

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

Less commonly you might develop a cough or shortness of breath. This could be a sign of infection or more rarely lung problems such as asthma or a collapsed lung (pneumothorax)

Hearing changes

You might have ringing in the ears (called tinnitus) or some hearing loss.

Let your team know if you have hearing changes.

Tiredness and weakness (fatigue)

Tiredness and weakness (fatigue) can happen during and after treatment. Doing gentle exercises each day can keep your energy up. Don't push yourself, rest when you start to feel tired and ask others for help.

You might feel generally unwell (malaise).

Sore mouth

Mouth sores and ulcers can be painful. It helps to keep your mouth and teeth clean, drink plenty of fluids and avoid acidic foods such as lemons. Chewing gum can help to keep your mouth moist. Tell your doctor or nurse if you have ulcers.

Less commonly, you might have a dry mouth.

Diarrhoea

Contact your advice line if you have diarrhoea. For example, in one day you have 2 or more loose bowel movements than usual. If you have a stoma , you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

Eye problems

You might get inflammation and irritation of the clear dome shaped layer of the front of the eye that covers the pupil and coloured part of the eye. This is the cornea. Symptoms can include a red, painful or watery eye. Less commonly your eye might feel gritty, itch or form a sticky discharge making your eyes crust or stick together. Rarely you may have eyesight changes including double or blurred vision.

It’s important to contact your healthcare team if you have any problems with your eyes, they might be able to give you a medicine to help ease the symptoms.

Red or pink urine

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

Redness, soreness and peeling on hands or soles of the feet

The skin on your hands and feet may become sore, red, or may peel. You may also have tingling, numbness, pain and dryness. This is called hand-foot syndrome or palmar plantar syndrome.

Moisturise your skin regularly. Your healthcare team will tell you what moisturiser to use.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. 

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.

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.

Tummy (abdominal) pain and pain in other areas of the body

You might get tummy pain or less commonly you may have pain in other parts of your body such as your joints, arms, legs and back. Rarely this might also affect your bones and face.

Tell your treatment team if you have this. They can check the cause and give you medicine to help. 

Periods stopping

This might only be temporary.

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.

Inflammation of the vein (phlebitis)

Tell your nurse straight away if you have any pain, redness, or if you notice a hard lump.

Skin problems

Your skin might look different or have an area of abnormal growth. Other less common skin problems include a skin rash, dry skin and itching, and changes in skin colour. You might also develop some reddening, but this is rare.

This usually goes back to normal when your treatment finishes. Your nurse will tell you what products you can use on your skin to help.

Liver problems

You might have liver changes that are usually mild. It is very rare for your liver to stop working (liver failure) symptoms might include yellowing of the skin and whites of the eyes.

You have regular blood tests to check for any changes in the way your liver is working. These tests usually go back to normal when treatment finishes.

Changes in levels of minerals in the blood

It’s quite common for your levels of sodium to drop. Rarely other minerals can get too low, these are called potassium and magnesium.

You usually have potassium or magnesium as a drip into your bloodstream (intravenously) before and after cisplatin. This helps to keep these levels of minerals at the right level.

Your healthcare team will do regular blood tests to check for any changes in your mineral levels.

High temperature (fever)

If you get a high temperature, let your health care team know straight away. Ask them if you can take paracetamol to help lower your temperature.

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:

• heart problems such as changes to your hearts rate and rhythm, angina or heart attack
• difficulty pooing (constipation)
• passing wind (flatulence)
• indigestion, symptoms include heartburn, bloating or burping
• taste changes
• low level of fluid in the body (dehydration)
• blood clots that can be life threatening; signs are pain, redness and swelling where the clot is. Feeling breathless can be a sign of a blood clot in the lung. Contact your advice line or doctor straight away if you have any of these symptoms
• weight loss
• difficulty sleeping (insomnia)
• feeling low (depression)
• headaches 
• dizziness, rarely it may feel like the area around you is spinning and you may lose your balance (vertigo)
• fluid build up in different parts of the body
• nail changes - your nails may become brittle, dry, change colour or develop ridges
• runny nose
• numbness and tingling sensation on the skin
• shivering and shaking (chills)
• pain or burning in the digestion system

Rare side effects

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

• second cancers such as leukaemia
• an allergic reaction that can cause a rash, shortness of breath, redness or swelling of the face and dizziness - some allergic reactions can be life-threatening, alert your nurse or doctor if notice any of these symptoms
• very rarely you may develop a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish and your eyes may be more sensitive to light. This is serious and could be life threatening
• your skin being more sensitive to sunlight or previously treated areas of skin with radiation can become irritated and inflamed
• blood pressure changes
• numbness or tingling in fingers or toes that can make it difficult to do fiddly things such as doing up buttons (peripheral neuropathy)
• changes in blood sugar levels (diabetes)
• loss of interest in sex
• confusion or memory changes 
• inflammation or blockage in the bowel
• changes to how well your kidneys are working- you will have regular blood tests to check for any changes  
• problems with passing urine such as going very often overnight or being unable to control when you pass urine
• flu-like symptoms such as a fever, chills and muscle aches
• difficulty swallowing
• fainting
• lumps under the skin (lipoma)
• high levels of a type of fat in your blood
• cold limbs
• muscle weakness and stiffness

Coping with side effects

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

What else do I need to know?

Other medicines, foods and drinks

Cancer drugs can interact with some other medicines and herbal products. Tell your doctor or pharmacist about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies.

Lactose intolerance

This drug contains lactose (milk sugar). If you have an intolerance to lactose, contact your doctor before taking this medicine.

Pregnancy and contraception

This treatment might harm a baby developing in the womb. It is important not to become pregnant or father a child while you're having treatment and for 6 to 7 months afterwards. Talk to your doctor or nurse about effective contraception before starting treatment.

Breastfeeding

Don’t breastfeed during this treatment and for 2 weeks after your final treatment. This is because the drug may come through into your breast milk.

Loss of fertility

You may not be able to become pregnant or get someone pregnant after treatment with this drug. 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.    

Treatment for 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 about this treatment

For further information about this treatment and possible side effects go to the electronic Medicines Compendium (eMC) website. You can find the patient information leaflet 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.