This information is about a chemotherapy treatment for advanced cancer of the stomach or oesophagus (gullet) called ELF. 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 support service nurses.

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

• etoposide
• leucovorin, which is also known as folinic acid. This is a drug that makes 5FU more effective.
• fluorouracil, also known as 5FU.

ELF chemotherapy can usually be given to you as an outpatient. Before you start treatment you will need to have a blood test (on the same day or a few days before) and will 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 are given as tablets.

The chemotherapy drugs are then given separately:

• Etoposide (a colourless fluid) is given as an infusion into your cannula or line, over 30–60 minutes.
• Leucovorin (a pale-yellow fluid) is given as a slow injection along with a drip of salt water (saline) or an infusion, over 15 minutes.
• 5FU (a colourless fluid) is given as an infusion, over an hour.

Once the treatment is finished you can go home. The cannula will be removed and you will be given a supply of anti-sickness drugs to take with you. It is important to take these as directed even if you are not feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than at stopping it once it starts.

Your doctor may use the word ‘regimen’ (eg the ELF regimen) when talking about your chemotherapy. This means the whole plan or schedule of your particular chemotherapy treatment. The following is a description of a commonly-used schedule for giving ELF.

On the first day of your treatment you will be given all three drugs (etoposide, leucovorin and 5FU) as described above. On the second and third days all three drugs are repeated.

After this you will have a rest period, with no chemotherapy, for 25 days. This completes a cycle of your treatment. Each cycle takes four weeks (28 days).

Following the rest period, the same drugs will be given to you again, beginning the next cycle of your treatment. Usually six cycles of treatment are given over six 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 ELF 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 ELF chemotherapy 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, and your resistance to infection usually reaches 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 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 ELF treatment 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 ELF chemotherapy, you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if you experience these problems.

Feeling sick (nausea) and being sick (vomiting) There are now very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea & vomiting. If the sickness is not controlled, or 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 and get as much rest as you need.

Sore mouth and taste change 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 do have a sore mouth or ulcer, as they can give you special mouthwashes and medicine to prevent or clear any mouth infection.

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

Hair loss Hair loss may be total with ELF chemotherapy, and usually starts about 3–4 weeks after you first have chemotherapy. You may also experience thinning and loss of eyelashes, eyebrows and other body hair. Hair loss is temporary and all your hair will start to grow again once treatment is finished.

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

Diarrhoea This can usually be easily controlled with medicine, but tell your doctor if it is severe or continues. It is important to drink plenty of fluids if you have diarrhoea.

Loss of appetite A dietitian or specialist nurse at your hospital can give advice and tips on boosting appetite, coping with eating difficulties and maintaining weight.

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 can happen when 5FU is given. It is temporary and improves when the treatment is finished. You may be prescribed vitamin B6 (pyridoxine), which can help to reduce this.

Skin changes 5FU and etoposide can cause a rash, which may be itchy. Your doctor can prescribe medicine to help. Your skin may darken, due to excess production of pigment. It usually returns to normal a few months after treatment.

The skin over the vein used for injection may become discoloured, but this is only temporary.

Sensitivity of the skin to sunlight During treatment with 5FU, and for several months afterwards, you will be more sensitive to the sun, and your skin may burn more easily than normal. You can still go out in the sun, but always wear a high protection-factor sun cream and protective clothing.

Allergic reaction You will be monitored for any signs of an allergic reaction during the treatment. Signs include skin rashes and itching, a high temperature, shivering, redness of the face, a feeling of dizziness, headache, breathlessness, anxiety and a need to pass urine. Tell your doctor or nurse if you have any of these signs, as medicine can be given to reduce them.

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 medicines can be harmful to take when you are having chemotherapy. Always tell your doctor about any medicine you are taking. This includes any that you may have bought from a pharmacy or supermarket, and any herbal or complementary therapies.

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 father a child while taking this treatment as it may harm the developing foetus. It is important to use effective contraception whilst taking this drug, and for some time afterwards. Again, discuss this with your doctor.

Loss of periods 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 ELF chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:

• Martindale: The Complete Drug Reference (33rd edition). Eds Sweetman et al. Pharmaceutical Press, 2002.
• British National Formulary (54th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, March 2007.
• The Chemotherapy Source Book (3rd edition).  Eds Perry, Lippincott Williams and Wilkins, 2001.

For further references, please see the general bibliography.