This information is about a chemotherapy treatment for breast cancer called EC. 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.

EC is named after the initials of the chemotherapy drugs used in the treatment, which are:

• epirubicin
• cyclophosphamide.

EC treatment can usually be given to you as a day patient. 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.

The nurse will then 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 the arm (PICC line). Your doctor or nurse will explain more about this.

You will be given some anti-sickness (anti-emetic) drugs, either as tablets, or more usually by injection through the cannula, central line or PICC line, which is often connected to a drip (infusion) to flush the drugs in.

The chemotherapy drugs are then given separately:

• An injection of epirubicin (a red fluid) is given along with a drip of salt water (saline) into your cannula.
• An injection of cyclophosphamide (a colourless fluid) is given in the same way. Cyclophosphamide can also be given as a drip.

This will usually take an hour or more.

Although the epirubicin is often given first, the order in which the drugs are given will not alter their effectiveness.

If you are having your treatment as a day patient you can then 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 regularly as directed even if you are not feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than stopping it once it starts.

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

You will be given epirubicin and cyclophosphamide (as described) at the start of your treatment. After this you will have a rest period with no chemotherapy for the next three weeks. This completes what is called a cycle of your treatment.

After the rest period the same drugs will be given to you again, which begins the next cycle of your treatment. Usually 4–6 cycles are given over a period of 3–4 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 here will not affect everyone who is having EC 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 below, please let your nurse or doctor know.

Lowered resistance to infection EC 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 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 the number of white blood cells in your body (blood count) has returned to normal. Occasionally, it may be necessary to delay treatment if your blood count is still low.

Bruising or bleeding EC 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 EC you may become anaemic. This may make you feel tired and breathless. Let your nurse or doctor know if these effects are a problem.

Feeling sick (nausea) and being sick (vomiting) There are 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 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 and 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 all 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.

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 do 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 usually come back after the treatment finishes.

Skin changes You may develop an itchy rash. Your doctor can prescribe medicine to help with this. Sometimes areas which have been treated with radiotherapy may become red and sore. Let your doctor know if this happens. The skin over the vein used for the injection may become discoloured. Rarely, your skin may darken. If it does it usually goes back to normal a few months after the treatment has finished.

Irritation of the bladder Cyclophosphamide may irritate your bladder. It is important to drink as much fluid as possible (up to two litres) during the 24 hours after chemotherapy to help prevent this.

Epirubicin is red and it may cause your urine to become a pink-red colour. This may last up to 24 hours after your treatment and is quite normal.

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.

Changes in nails Some people may find that their nails become darker or ridged. White lines may appear on them. These changes usually grow out over a few months once the treatment has finished.

Changes in the way your heart works This is very rare with usual doses of these drugs, 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 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 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 nonprescribed drugs such as complementary therapies and herbal drugs.

Leakage into the tissue around the vein If epirubicin leaks into the tissue around the vein it can damage the cells 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.

Fertility Your ability to become pregnant 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 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 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 EC 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.