This information is about ECX chemotherapy. ECX is used as a treatment for cancers of the gullet (oesophagus), the stomach (gastric cancer) and of the gastro-oesophageal junction (where the gullet and the stomach join together). This information 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 information nurse specialists.

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

• epirubicin
• cisplatin 
• capecitabine, which is also known as Xeloda®.

Your chemotherapy treatment can usually 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 your treatment you will need 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. 

Before treatment starts the nurse will put a thin, flexible tube (cannula) into a vein in your arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a fine plastic tube, which is inserted under the skin and into a vein near the collarbone  (central line), or passed through a vein in the crook of their arm (PICC line).

Once your chemotherapy is ready you will be given anti-sickness (anti-emetic) medication, either by injection through your cannula or line, or in tablet form. You will then be given epirubicin (a red fluid), along with a drip of salt water (saline). After this you will be given cisplatin (a colourless fluid), which is also given as a drip (infusion). Before and after treatment with cisplatin you will be given plenty of fluid through the drip to keep your kidneys working normally. This may mean that you will need to stay in hospital overnight, especially if your treatment has started in the afternoon or evening.

Capecitabine is given as tablets twice a day. They should be swallowed whole with a glass of water and within half an hour of starting or finishing a meal. You should take them in the morning just before or after breakfast, and again in the evening just before or after your evening meal, so that the doses are spaced at least eight hours apart.

Capecitabine tablets are available as 500mg peach coloured tablets, and 150mg light-peach coloured tablets. Your doctor may want you to take a combination of 500mg and 150mg tablets, depending on the dose you need.

You may hear your doctor use the word 'regimen' (eg The ECX 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. On the same day, you will also start your capecitabine tablets. The capecitabine is usually taken twice a day for 21 days. The first dose of capecitabine is often taken on the evening of day one of your treatment and the last dose in the morning of day 22 (just before you start the next cycle of the treatment). Check with your doctor or nurse how long you will need to take your capecitabine tablets for before you leave hospital. Always follow the prescribed dose.

Three weeks after the first day of treatment, you will have completed what is called a cycle of chemotherapy. The treatment will then be repeated. On day one of the next cycle, the epirubicin and cisplatin will be given and you will start another 21-day course of the capecitabine tablets. You will usually take capecitabine tablets twice a day throughout the whole course of your chemotherapy treatment. This is because each cycle takes three weeks (21 days) and the capecitabine tablets are taken for 21 days of each cycle.

You can have up to eight cycles of ECX chemotherapy over a 24-week period. Your doctor will advise you about the number of cycles you will have.

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 section won't affect everyone who is having ECX 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 chemotherapy, but that are not listed here, please let your nurse or doctor know.

Lowered resistance to infection Epirubicin, cisplatin and capecitabine can all 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 38 °C (100.4 °F)
• 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 Epirubicin, cisplatin and capecitabine can all 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 ECX, you may become anaemic. This can make you feel tired and breathless. Let your doctor or nurse know if these effects are a problem.

Diarrhoea This can be quite severe, but can usually be controlled with medicines. It is important to drink plenty of fluids and you may be given medicine to take. Follow the instructions and take it immediately. If you have diarrhoea more than 4−6 times a day, or if you have it at night, contact your specialist for advice immediately. You may be advised to stop taking capecitabine. However, once the diarrhoea has eased your doctor will tell you if you can restart the treatment, perhaps at a lower dose.

Nausea (feelings of sickness) and vomiting Sickness is most likely in the few days after treatment with cisplatin and epirubicin, and less likely during the time you are taking capecitabine. Your doctor can prescribe very effective anti-sickness (antiemetic) drugs to prevent or reduce nausea and vomiting. If the sickness isn't 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.

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 might notice that your food tastes different. Normal taste will usually come back after the treatment finishes.

Skin changes Your skin may become itchy and dry. Your doctor can prescribe treatment to help to reduce this. You may experience soreness and redness on the palms of your hands and soles of your feet, (known as hand-foot syndrome or palmar-plantar syndrome). It is temporary and improves when the treatment is finished. If you get hand-foot syndrome, stop the capecitabine tablets immediately and contact your chemotherapy clinic for advice. Your doctor may prescribe a vitamin called pyridoxine (vitamin B6), which some people find helpful.

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.

Hair loss This usually starts 3−4 weeks after the first course of treatment. Hair usually falls out 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. Your nurse can give you advice about coping with hair loss.

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

Your kidneys may be affected Usually this does not cause any symptoms and any effect on your kidneys is mild. If the effect is severe the kidneys can be permanently damaged unless the treatment is stopped. For this reason your kidneys will be checked by a blood test before each treatment.

Plenty of fluid will be given into the vein before and after treatment to keep your kidneys working normally.

You may be asked to measure and record what you drink and the amount of urine that you pass. If you pass less urine than you usually do, it is important to tell your nurse or doctor.

If necessary, you may be given medicine to help you to pass urine. If you are asked to drink extra fluid it is essential to do this. Let your doctor know if this is difficult – for example, if you are feeling sick.

Tiredness Many people feel extremely tired (fatigued) during chemotherapy, particularly towards the end of treatment. It is important to try to get as much rest as you need.

Abdominal pain and constipation It may help to drink plenty of fluids, eat a high-fibre diet and take gentle exercise. Sometimes you may need to take laxatives (medicines to stimulate your bowel). These can be prescribed by your doctor.

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

Changes in your heart function This is very rare with regular 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.

Capecitabine may also affect the way your heart works. Some people can experience chest pain and tightening across the central chest while taking capecitabine. This pain is called angina. Chest pain can be caused by many different things other than chemotherapy. If you develop any of these symptoms, you should contact your doctor immediately.

Numbness or tingling in hands or feet This is due to the effect of cisplatin on nerves and is known as peripheral neuropathy. You may notice that you have difficulty doing up buttons or similar fiddly tasks. Tell your doctor if you notice any numbness or tingling in your hands or feet. This side effect usually disappears slowly, a few months after the treatment ends.

Changes in hearing You may have ringing in the ears (tinnitus) and may lose the ability to hear some high-pitched sounds. Again, this effect usually decreases when the treatment ends although in a small number of cases it may be permanent. Tell your doctor if you notice any loss of hearing or tinnitus.

Increased production of tears This may be caused by capecitabine and is temporary.

Headaches and dizziness Tell your doctor if you have headaches or feel dizzy and lightheaded while taking capecitabine.

Allergic reaction Signs of an allergic reaction include skin rashes and itching, a high temperature, shivering, redness or darkening of the face, dizziness, a headache, breathlessness, anxiety and a need to pass urine. You will be monitored for any signs of an allergic reaction during treatment. Tell the doctor or nurse if you have any of these symptoms while you are having the drip.

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, including some you can buy from a shop or chemist.

Capecitabine is known to react with the drugs phenytoin (Epanutin®), allopurinol (Zyloric®) and interferon (IntronA®, Roferon-A®). It may also affect the action of some medicines given to thin the blood (anti-coagulants), such as warfarin. You should let your doctor know if you are taking any of these.

It's a good idea to tell your doctor about other medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.

Let your doctor know if you are taking folic acid because it might increase the side effects of capecitabine.

Leakage into the tissue around the vein If this happens with epirubicin it can damage the tissue in that area. If you notice any stinging or burning around the vein while the drug is being given, tell the doctor or nurse immediately. This is unlikely to happen if the chemotherapy is given through a central line or PICC line. If the area around the injection site becomes red or swollen at any time, you should tell your doctor or nurse.

Fertility Your ability to become pregnant or father a child 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 or to father a child while taking this treatment as it may harm the developing foetus. It is important to use effective contraception whilst 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.

• It is important to take your tablets at the right times. You must take them as directed by your doctor.
• Keep your tablets in their original packaging, at room temperature and away from direct sunlight.
• Keep the tablets in a safe place out of the reach of children as capecitabine could harm them.
• If your doctor decides to stop the treatment, return any remaining tablets to the hospital pharmacy. Do not flush them down the toilet or throw them away.
• If you are sick just after taking the tablets, let your doctor know. Do not take an extra dose.
• If you forget to take a tablet do not take a double dose. Inform your doctor and keep to your regular dose schedule.

This section is based upon our ECX 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 (56th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2008.
• The Chemotherapy Source Book (4th edition). Ed. Perry, M. Lippincott, Williams and Wilkins, 2007.

For further references, please see general bibliography.