This information is about a chemotherapy treatment for stomach cancer called ECF. This treatment may also be used to treat cancer of the gullet (oesophagus), breast, ovary and other less common cancers. It describes the drugs used, 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 support service nurses.

ECF is named after the initials of the chemotherapy drugs used, which are:

• epirubicin
• cisplatin 
• fluorouracil, which is also known as 5FU.

Your chemotherapy treatment can be given to you as a day patient or during a short stay in hospital. The treatment is then continued at home. Before you start treatment you will need to have a blood test 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. All of this may take a couple of hours.

Most people who have ECF will 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 the arm (PICC line). Your doctor or nurse will explain more about this to you.

You will be given an anti-sickness (anti-emetic) drug, either as tablets or by injection through your central line or PICC line. The chemotherapy drugs are then given separately:

• epirubicin (a red fluid) is given as an injection along with a drip of salt water (saline) into the line. It may sometimes be given as a drip
• after this you will be given cisplatin (a colourless fluid) which is given as a drip (infusion).

Before and after treatment with cisplatin, you will be given plenty of fluid through your drip to keep your kidneys working normally. This may mean that you will need to stay in hospital overnight.

Once your drip is finished you will start treatment with 5FU, which is usually given through a small portable pump. The pump is used to give a controlled amount of the drug into your bloodstream over a set period of time. There are several different sorts of pump, though all are small enough to be carried in a belt or holster so that you can continue doing the things you normally do.

Once the pump is connected to your line, you can go home with it. Before you go you should be given instructions on how to look after the pump. Your nurse should explain how to care for it and what to do if something goes wrong.

When the infusion is finished there may be some fluid left in the pump. This may be normal as some types of pump need to be overfilled to get the correct dose. You can check with your nurse or pharmacist whether you have this type of pump.

The 5FU treatment is given continuously over the whole time that you have your chemotherapy. You will need to have the drug reservoir or the entire pump replaced as it empties, usually on a weekly basis. This may be done at the hospital or you may be taught to change the pump yourself. Otherwise, arrangements may be made for a district nurse to come to your home to change the pump.

When you go home you will be given a supply of anti-sickness tablets to take with you. You should take these regularly if you have been told to do so, even if you are not feeling sick. This is because some medicines are much more effective at preventing sickness than stopping it once it has started. However, the 5FU in the pump is very unlikely to make you feel sick and it is unlikely that you will need anti-sickness medicines for more than a few days after your visit to the hospital.

If you do not have a central line or PICC line, 5FU can be given to you as a drip into your arm (through a small tube known as a cannula which is inserted into a vein in your arm). This is given over a shorter period, often for four days every three weeks. You will need to stay in hospital for the four days of treatment.

Your doctor may use the word 'regimen' (eg the ECF regimen) when talking about your chemotherapy. This means the whole plan, or schedule, of the particular treatment that you are receiving.

When your treatment begins you will be given epirubicin and cisplatin (as described above) for one day only. On the same day you will start your treatment with 5FU through the pump, which will continue until your chemotherapy is over. If you do not have a pump you may be given 5FU through a drip into your arm, which usually takes a few days. Three weeks from the first day of treatment you will have completed what is called a cycle of your chemotherapy.

Your treatment with epirubicin and cisplatin will then be repeated (three weeks after you first had it), to begin the next cycle of your chemotherapy. If you do not have a pump you will have another short treatment with 5FU through a drip as before. Usually 4–6 cycles of chemotherapy are given over a period of 3–5 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 below will not affect everyone who is having ECF 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 in this information, please let your nurse or doctor know.

Lowered resistance to infection ECF can reduce the production of white blood cells by the bone marrow, making you more prone to infection. During the period when you are not having chemotherapy (or while you are only having the 5FU through the pump) your blood count will begin to recover. It will usually have returned to normal before your next cycle of chemotherapy is due.

Contact your doctor or the hospital straightaway 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 ECF 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, and bleeding gums.

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

Feeling sick (nausea) and being sick (vomiting) Sickness is most likely in the few days after treatment with cisplatin and epirubicin. 5FU is unlikely to make you feel sick. 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, who can prescribe other anti-sickness drugs that 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.

Hair loss This usually starts 3–4 weeks after the first course of treatment. Hair is usually lost completely. You may also have thinning and loss of eyelashes, eyebrows and other body hair. Hair loss is temporary and your hair will start to grow again once the treatment has finished.

Sore mouth and ulcers Your mouth may become sore or dry, or you may notice small ulcers during this treatment. 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. You may find it helpful to use a soft toothbrush.

Taste changes You may notice that your food tastes different. Normal taste will usually come back after the treatment finishes.

Your kidneys may be affected Usually this does not cause any symptoms, and any effect on your kidneys (due to cisplatin) is usually mild. Rarely, cisplatin may cause permanent damage to the kidneys unless the treatment is stopped. Before each treatment your kidneys will be checked by a blood test. You may be asked to drink more than normal during the day after the cisplatin treatment and it is important to tell your doctor or chemotherapy nurse if you are not able to drink enough. Before and after the treatment you will be given plenty of fluid through a drip to keep your kidneys working normally.

Numbness or tingling in hands or feet This is due to the effect of cisplatin on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. This problem usually improves slowly a few months after the treatment is over.

Changes in hearing You may have ringing in the ears (tinnitus) and you may not be able to hear some high-pitched sounds. This is due to cisplatin and, again, it usually improves when the treatment is over. Tell your doctor if you notice any loss of hearing or ringing in your ears.

Gritty eyes and blurred vision If this happens let your doctor know. They can prescribe some soothing eye drops.

Skin changes Your skin may become itchy and dry. Your doctor can prescribe treatment to help to reduce this. You may also have soreness and redness on the palms of your hands and soles of your feet (known as hand-foot syndrome or palmar-plantar syndrome). This is temporary and improves when the treatment is finished. Your doctor can prescribe a vitamin called pyridoxine (vitamin B6) which some people find helpful.

Your skin may darken but this will slowly return to normal a few months after the 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.

Changes in nails Your nails may become darker and white lines may appear on them. These changes usually grow out over a few months once the treatment has finished.

Diarrhoea If you have diarrhoea it can usually be easily controlled 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.

Discoloured urine Your urine may become a pink-red colour after epirubicin treatment. This is due to the colour of the drug and may last for up to a day after you have had the treatment.

Changes in the way your heart works This is very rare with usual doses of epirubicin but may occasionally happen when high doses are used. Tests to see how well your heart is working may be carried out before you start treatment.

Always let your doctor or nurse know about any side effects you are having. There are usually ways 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 straightaway if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs which 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. 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 epirubicin is being given, it can damage the tissue in that area. Tell the doctor or nurse immediately if you notice any stinging or burning around the vein while the drug is being given. This is unlikely to happen if the chemotherapy is given through a central line or PICC line.

Fertility Your ability to become pregnant or father a child may be affected by this treatment. It is important to discuss fertility with your doctor before starting treatment.

Contraception It is not advisable to become pregnant or to father a child 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.

Loss of periods in women Due to the effect of chemotherapy on the 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.

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

• Martindale: The Complete Drug Reference (35th edition). Eds. Sweetman et al. Pharmaceutical Press, 2007.
• British National Formulary (54th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2007.
• The Chemotherapy Source Book (3rd edition). Ed. Perry. Lippincott, Williams and Wilkins, 2001.

For further references, please see the general bibliography.