This information is about EEX chemotherapy, which 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). 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.

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

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

Your chemotherapy treatment can be given to you as a day patient, or during a short stay in hospital, and is then continued at home. Before you start 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 a little uncomfortable or a little painful but it should not take long. Some people have their chemotherapy given through a fine, plastic tube that is inserted under the skin and into a vein near the collarbone (central line), or passed through a vein in their arm (PICC line).

Once your chemotherapy is ready you will be given anti-sickness (anti-emetic) medicine, 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) into the line. After this you will have oxaliplatin (a clear fluid), which is given as a drip (infusion). This is usually given over a period of 1−2 hours.

Capecitabine is given as tablets twice a day. They should be swallowed whole with a glass of water and within half an hour of the end of a meal. You should take them in the morning after breakfast, and again in the evening 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. The first dose is taken on the evening of day one and the last dose is taken in the morning of day 22.

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

When your treatment begins, you will be given epirubicin and oxaliplatin. You will also start your capecitabine tablets on the same day. Capecitabine is usually taken everyday for 21 days. Before you leave hospital, check with your doctor, nurse or pharmacist how long you will need to take your capecitabine tablets for. Always follow the prescribed dose.

Three weeks from the first day of treatment, you will have completed what is called a cycle of chemotherapy. Your treatment with epirubicin and oxaliplatin will then be repeated to begin your next cycle. You can have up to eight cycles of chemotherapy over a 24-week period. Your doctor will advise you about the number of cycles you are likely to have.

Some people have very few side effects while others may experience more. The side effects described in this section will not affect everyone who is having EEX 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 which you think may be due to the chemotherapy, but which are not listed here, please let your nurse or doctor know.

Lowered resistance to infection Epirubicin, oxaliplatin 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 straightaway if:

• your temperature goes above 38 °C (100.5 °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, oxaliplatin 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 EEX you may become anaemic. This may 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 it can usually be controlled with medicines. It is important to drink plenty of fluids if you have diarrhoea. You may be given medicine to take and it’s important to follow the instructions and take the medicine straight away. If you have diarrhoea more than 4−6 times a day, or at night-time, 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.

Feeling sick (nausea) and being sick (vomiting) If you feel sick, this effect may begin a few hours after the treatment is given and may last for a few days. Your doctor can prescribe very effective anti-sickness (anti-emetic) medicines to prevent or greatly reduce nausea and vomiting. If the sickness is not controlled, 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 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 of the palms of the hands and soles of the 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.

Numbness or tingling in hands or feet Oxaliplatin can have an effect on the nerve endings, which is known as peripheral neuropathy. This may result in feelings of numbness or tingling, especially in the hands and feet. For some people, these symptoms can be triggered by anything cold, such as cold air. If you notice that your symptoms are related to the cold, you should wrap up warmly in chilly weather. It is important to report your symptoms to your doctor as they may be controlled by slightly lowering the dose of the oxaliplatin.

Sometimes the tingling or numbness may not happen until you have had several treatments. This is known as a cumulative effect and should improve after the treatment has finished.

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.

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 is finished.

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.

Discoloured urine Your urine may become a pink-red colour following 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. This is harmless.

Laryngeal spasm The area around the voice box (larynx) can be affected by oxaliplatin, resulting in severe breathing problems and a sensation of difficulty in swallowing. This can be very frightening but should only be a temporary side effect. This symptom may be triggered by cold and it is advisable to avoid very cold drinks for a few days after treatment. It is important to let the doctor know if you have this side effect.

Changes in the way your heart works This is very rare with standard 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.

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.

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.

When oxaliplatin is given it may cause pain along the vein, especially if it is given through a cannula. Let the nurse or doctor know if you experience any pain.

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. Let your doctor know about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal medicines. Avoid multivitamins containing folic acid as these may interact with 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.

Hot flushes Some people experience hot flushes when epirubicin is being given.

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 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 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 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 EEX 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, M. Lippincott, Williams and Wilkins, 2001.

For further references, please see general bibliography.