This information is about a chemotherapy treatment for breast cancer called CAF. It describes the drugs, how they are given and some of the possible side effects. If you have any questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer information nurse specialists.

CAF is named after the initials of the drugs involved. These are:

• cyclophosphamide
• doxorubicin, which was originally called Adriamycin®
• fluorouracil, which is also known as 5FU.

CAF treatment can usually be given to you as a day patient. You will need to have a blood test before you start treatment - either on the same day, or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. This may take a couple of hours.

The nurse will put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful but it should not take long. Some people have their chemotherapy given through a thin plastic tube which is inserted under the skin into a vein near the collarbone (central line), or passed through a vein in their arm (PICC line). Your doctor or nurse will explain more about this to you.

You will be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula, central line or PICC line, which is connected to a drip (infusion). Some anti-sickness medicines may be given as tablets.

The chemotherapy drugs are then given separately, which involves:

• an injection of doxorubicin (a red fluid), given alongside a drip of salt water (saline) into your cannula or line
• cyclophosphamide (a colourless fluid), which can be given as a drip (infusion) or as an injection alongside a drip of saline (unless you are having it as a course of tablets over two weeks - see Schedule B, below)
• followed by an injection of 5FU (a colourless fluid) which is given as an injection into your cannula or line.

If you are having your treatment as a day patient, you can go home when it has finished and the cannula will be removed before you go. If you have a central or PICC line it will usually stay in place, ready for the next cycle of your chemotherapy. You will be shown how to look after the line.

You will be given a supply of anti-sickness drugs to take home with you. It is important to take these as directed even if you aren't feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than stopping it once it starts.

CAF chemotherapy can be given in different ways. Your doctor may use the word 'regimen' (eg the CAF regimen) when talking about your chemotherapy. This means the whole plan or schedule of the particular chemotherapy treatment that you are receiving.

There are two different schedules for giving CAF (see below). You can ask your doctor or nurse to explain which one you are having.

Schedule A

On the first day of your treatment you will be given all three of the drugs (cyclophosphamide, doxorubicin and 5FU) by drip and injection. After this, you will have a rest period with no chemotherapy for the next three weeks. This completes a cycle of your treatment.

After the three-week rest period, the same drugs will be given to you again, which begins the next cycle of your treatment. Usually 4–6 cycles of treatment are given over 3–4 months. This makes up a course of treatment.

Schedule B

On the first day of your treatment, you will start your cyclophosphamide tablets, which you take for two weeks (14 days). On the same day you will also be given injections of doxorubicin and 5FU (as described above). One week later (day 8) you will be given doxorubicin and 5FU again. When you finish your cyclophosphamide tablets (a week after your last injections) you will have a rest period with no chemotherapy for two weeks. This completes a cycle of your chemotherapy.

You will start the next cycle of your treatment after the rest period, which will be four weeks after your first injection. Usually you will be given four cycles of CAF over four months. This makes up a course of treatment.

Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described in this information will not affect everyone who is having CAF chemotherapy.

We have outlined the most common side effects, so that you can be aware of them if they occur. However, we have not included those that are rare and therefore unlikely to affect you. If you notice any effects that you think may be due to the drug, but which are not listed here, please let your nurse or doctor know.

Lowered resistance to infection CAF can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, with your resistance to infection usually reaching its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal levels before your next cycle of chemotherapy is due.

Contact your doctor or the hospital straight away if:

• your temperature goes above 38ºC (100.5ºF)
• you suddenly feel unwell (even with a normal temperature).

You will have a blood test before having more chemotherapy to make sure that your number of white blood cells has returned to normal. Occasionally, it may be necessary to delay treatment if your number of blood cells (blood count) is still low.

Bruising or bleeding CAF can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Anaemia (low number of red blood cells) While having treatment with CAF you may become anaemic. This can make you feel tired and breathless. Let your doctor or nurse know if this is a problem.

Feeling sick (nausea) and being sick (vomiting) Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea and vomiting. If the sickness is not controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness drugs which may be more effective. Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.

Tiredness Many people feel extremely tired (fatigued) during chemotherapy, particularly towards the end of treatment. This is a very common side effect and it is important to try to get as much rest as you need.

Gritty eyes and blurred vision If this happens it is important to tell your doctor as they can prescribe soothing eye drops.

Hair loss This is often total with CAF chemotherapy, with the hair usually starting to fall out about 10–14 days after you first have treatment. You may also experience thinning and loss of eyelashes, eyebrows and other body hair. The hair loss is temporary and your hair will start to grow again once treatment is finished. Your nurse can give you advice about coping with hair loss.

Scalp cooling is a method of reducing hair loss that may be helpful for some people. You can ask your doctor or nurse if it is available at your hospital.

Sore mouth and ulcers Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids and cleaning your teeth regularly and gently with a soft toothbrush can help to reduce the risk of this happening. Tell your nurse or doctor if you have any of these problems, as they can give you special mouthwashes and medicine to prevent or clear any mouth infection.

Taste changes You may notice that your food tastes different. Normal taste will return when treatment ends.

Diarrhoea If you have diarrhoea it can usually be controlled easily with medicine. Let your doctor know if it is severe or if it continues. Try to drink as much as 2–3 litres of fluid a day to replace the fluid you are losing. 

Irritation of the bladder Cyclophosphamide may irritate your bladder. To help prevent this it is important to drink as much fluid as you can (up to two litres a day) on the days when you are given cyclophosphamide. Tell your doctor if you have any discomfort when you pass urine.

You may also notice that your urine becomes a pink-red colour. This is caused by the red colour of the doxorubicin and may last up to 24 hours after your treatment. It is quite normal.

Skin changes You may develop an itchy rash. Your doctor can prescribe medicine to help with this. Rarely, your skin may darken. If it does, it usually goes back to normal a few months after treatment has finished.

During treatment, and for several months afterwards, you will be more sensitive to the sun and your skin may burn more easily. You can still go out in the sun, but always wear a high protection factor suncream and cover up with clothes and a hat.

Changes to nails Your nails may become brittle, chipped and ridged. These changes grow out slowly over a few months once the treatment has ended.

Soreness and redness of the palms of the hands and soles of the feet (sometimes known as palmar plantar or hand and foot syndrome) This is temporary and improves when the treatment is finished. You may be prescribed vitamin B6 (pyridoxine), which may help to reduce this.

Change in the way your heart works This is very rare with usual doses of CAF chemotherapy, but may occasionally happen when high doses are used. You may have tests to see how well your heart is working before you start treatment.

Always let your doctor or nurse know about any side effects that you have. There are usually ways in which they can be controlled or improved.

Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straight away if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs to thin the blood. Your doctor or nurse can give you more information.

Other medicines Some other medicines can be harmful to take when you are having chemotherapy (including those you can buy in a shop or chemist). Let your doctor know about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.

Leakage into the tissue around the vein If this happens while doxorubicin is being given, the tissue in that area can be damaged. If you notice any stinging or burning around the vein while the drug is being given, tell your doctor or nurse immediately.

Fertility Your ability to become pregnant may be affected by this treatment. It's important to discuss fertility with your doctor before starting treatment.

Contraception It's not advisable to become pregnant while taking this treatment, as the developing foetus may be harmed. It is important to use effective contraception while taking these drugs, and for at least a few months afterwards. Again, discuss this with your doctor or nurse.

Loss of periods Due to the effect of chemotherapy on your ovaries, you may find that your periods become irregular and may eventually stop. In younger women this may be temporary, but if you are closer to your menopause it may be permanent. This will result in menopausal symptoms such as hot flushes, sweats and vaginal dryness.

• It is important to take your tablets at the right times. You must take them as directed by your doctor.
• Keep the tablets in the original packaging and store them at room temperature, away from heat and direct sunlight.
• Keep the tablets in a safe place where children cannot reach them, as cyclophosphamide could harm them.
• If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
• If you are sick just after taking the tablet tell your doctor or chemotherapy nurse as you may need to take another dose. Do not take another tablet unless told to do so.
• If you forget to take a tablet do not take a double dose. Let your doctor know and keep to your regular dose schedule.

This section is based upon our CAF chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:

• Martindale: The Complete Drug Reference (35th ed). Eds. Sweetman et al. Pharmaceutical Press, 2007.
• British National Formulary (56th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2008.
• The Chemotherapy Source Book (4th edition). Ed. Perry. Lippincott, Williams and Wilkins, 2007.

For further references, please see general bibliography.