Haematology R - CEPP Chemotherapy This information is about R-CEPP chemotherapy, which is a treatment for Lymphoma. Lymphoma is a cancer of the lymphatic system a network of glands in the body that helps to defend against infection. Further information on these diseases is available in a separate information sheet. We try to answer most frequently asked questions, but please ask your doctor or nurse when you are attending for treatment if you have any further questions. Drugs that are used R-CEPP is named after the initials of the drugs used R = Rituximab (pronounced ri tucks i mab) C = Cyclophosphamide (pronounced sigh clo fos fa mide) E = Etoposide (pronounced ee top o side) P = Procarbazine (pronounced pro car ba zeen) P = Prednisolone (pronounced pred nis so lone) Rituximab This belongs to a group of drugs called monoclonal antibodies. It is used to treat several different types of NHL that involve cells known as B lymphocytes. This drug is able to target and destroy a specific type of cancer cell while causing little damage to healthy cells. It recognises a specific protein on the cell surface, called CD20, locks onto it and triggers the destruction of the cells. Some healthy cells that have CD20 on their surface will be destroyed, but the body is usually able to replace them quite quickly. CEPP These drugs destroy cancer cells by interfering with the internal workings of the cells. They are known as cytotoxic chemotherapy drugs. Unfortunately these drugs not only target cancer cells we want to get rid of, but also result in a certain amount of damage to normal cells. This causes some of the possible side effects discussed below. Fortunately not all patients get all of the possible side effects, and some may have very few. 1
How is it given? You can usually have this treatment given as a day patient. The first dose of Rituximab has to be given slowly, so the first treatment takes longer than the following ones, and may occasionally mean an overnight stay if you react to the Rituximab (see below). Before each treatment we must be sure that you are well enough for the treatment and this includes a blood test done ideally the day before or sometimes on the day of treatment. The nurse will put a fine tube known as a cannula into a vein on your arm or hand and connect this to an intravenous (i/v) infusion (also known as a drip ). Placing the cannula may be a little uncomfortable or painful but should not take long. You will then be given medicines to reduce the risk of a reaction to Rituximab, and to prevent you being sick. Thirty minutes after these drugs have been given we can start to give the chemotherapy. Rituximab is usually given first, and the first infusion is given over several hours to reduce the risk of a reaction to it. If you tolerate the first treatment with no major reactions, subsequent doses can be given much more quickly usually over about 1½ hours. The CEPP part of the treatment is given as tablets. The Cyclophosphamide is given on day 1. The Etoposide is given on day 1, 2 and 3. The Procarbazine and Prednisolone are both given from day 1 to day 10. How often? The treatment is repeated every 4 weeks. Each 4 week block is known as a cycle. Each cycle has 10 of treatment and then 18 days with no treatment. The number of cycles that you will have varies with several things such as the overall plan for management of your disease, your response to the treatment, and whether or not you have any significant side effects. Six to eight cycles are often given but you may need fewer cycles than this. This should be discussed with your Doctor. Possible side effects Each person s reaction to chemotherapy is unique. Some people have very few side effects while others may experience more. The side effects described here will not affect everyone who is having R-CEPP chemotherapy. We have outlined the most common side effects that may occur, but have not included those that are rare and therefore unlikely to affect you. If you do notice any effects that you think may be due to your treatment but are not listed here, please let your Doctor or Nurse know. 2
Lowered resistance to infection R-CEPP can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect may begin about 4 days into each treatment cycle, reaches its maximum at 10-14 days and then slowly recovers to normal as your next treatment cycle is due to begin. You must contact us immediately if: Your temperature is above 38 C on 2 occasions one hour apart Your temperature is above 38.5 C at any time You suddenly feel unwell, even with a normal temperature While your immunity is low, you cannot fight infection very well yourself and what would usually be minor infections can become serious and in some cases life threatening if they are not treated promptly. You will have a blood test before each cycle of chemotherapy to make sure that your bone marrow cells have recovered. Occasionally it may be necessary to delay your treatment if your blood count is too low. Bruising or bleeding R-CEPP can reduce the production of blood cells known as platelets that help the blood to clot normally. Let us know if you have any unexplained bruising or bleeding. If the platelet count has become low you may need to have a transfusion of platelets. Anemia R-CEPP can reduce the number of red cells in the blood. This is known as anaemia and may make you feel tired and breathless. A blood transfusion may occasionally be needed to correct this. Feeling sick (nausea) and vomiting There are now very effective anti-sickness drugs to prevent or reduce this. If the sickness is not controlled, tell your doctor, as other anti-sickness drugs can be prescribed. Allergic reactions It is not unusual to have a mild allergic reaction to Rituximab. Signs of this include skin rashes and itching, a feeling of swelling in the tongue or throat, irritation of nasal passages, wheezing, a cough and breathlessness. You will be monitored closely during your treatment, but let your nurse or doctor know if you have any of these effects. To reduce the chance of developing an allergic reaction you will be given an antihistamine drug before the infusion. 3
If you do have a reaction the infusion will be stopped, further medication given to reduce the reaction and then the infusion will be restarted once you have fully recovered. Flushing You may have a sudden feeling of warmth and some reddening of your face. This may happen for a short time during the Rituximab infusion. Flu like symptoms Some people find that Rituximab causes a high temperature, chills, weakness, muscle aches, tiredness, dizziness and headache. These can occur while the drug is being given, but do not usually last long. Low blood pressure This may happen during the Rituximab infusion, so your blood pressure will be checked regularly. People who normally take drugs to lower their blood pressure may be advised by their doctor to take this at least 12 hours before the Rituximab begins. It is important not to alter your blood pressure tablets without first discussing it with your doctor. Irritation of the stomach lining Prednisolone may irritate the lining of your stomach. Tell your doctor if you have indigestion or other stomach problems, as they can prescribe medicine to relieve these symptoms. If your prednisolone tablets are red, they are coated to protect the stomach, but the white ones are not and should not be taken with a meal or a glass of milk. Increased appetite You may notice that you feel hungrier than usual while you are taking prednisolone. This will stop when you are no longer taking the drug. Irritation of bladder Cyclophosphamide may irritate your bladder. It is useful to drink plenty of fluid (up to about 2 litres) during the day following chemotherapy to help prevent this. If you notice any blood in your urine tell your doctor or nurse. Numbness of tingling in hands and feet This is known as peripheral neuropathy and may occur as a side effect. Tell you doctor or nurse if you notice these symptoms. This problem usually improves slowly over the few months once treatment is completed. 4
Changes in the level of sugar in your blood Occasionally prednisolone may make your blood sugar levels rise. Tell your doctor or nurse if you are very thirsty or are passing more urine than usual, as you may need to have a blood test to check the level of sugar in the blood. Fluid retention Prednisolone may affect the salt and water balance in your body, leading to fluid retention and swelling of ankles and fingers. This is usually only a problem with long-term treatment, but tell your doctor or nurse if this happens. Alcohol Avoid alcohol while you are taking the Procarbazine tablets as there may be an interaction that would make you very sick and unwell. Raised levels of Uric acid in the blood A drug called Allopurinol may be given to stop this happening, as it can result in gout and rarely kidney damage. It may also help to drink plenty of fluids. Tiredness Many people feel very 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 There may be some hair loss or thinning with this treatment, but often it is not severe. This usually starts about 3-4 weeks after your first treatment. As well as scalp hair loss, you may have thinning or loss of eyebrows, eyelashes and other body hair. This is temporary and your hair will start to grow again once your treatment is finished. If hair loss is significant then speak to your nurse who will give you information about a wig. Sore mouth Your mouth may become sore or dry, or you may develop small ulcers during this treatment. Drink plenty of fluids and clean teeth regularly and gently with a soft toothbrush to help reduce the risk of this happening. Tell your nurse if you have a problem with a sore mouth. You may be given mouthwashes or medicines to prevent or treat mouth soreness and ulcers. Constipation Your treatment may cause constipation, as can some of the anti-sickness drugs. Let your doctor or nurse know if this is a problem. 5
Taste You may notice that your food tastes different, but normal taste will return once your treatment is finished. Skin changes During treatment and for several months afterwards you will be more sensitive to the sun and your skin will burn more easily than usual. You can still go out in the sun but wear a high protection factor sun cream and cover up with clothes. Rarely your skin may darken during treatment. If it does it will usually return to normal over a few months once treatment is completed. Many people find that their skin becomes drier than usual during treatment. Simple moisturising creams can help this. Nail changes Your nails may become darker and white lines may appear on them. They may also become dry. These changes grow out with the nails over a few months once treatment is finished. Additional information Some medicines can be harmful to take when you are having chemotherapy. Let your doctor know about any medicines you are taking, including nonprescribed drugs such as complementary therapies and herbal drugs. Fertility Your ability to become pregnant or father a child may be affected by this treatment. It is important to discuss this with your doctor before starting treatment if this is of concern to you. Contraception It is not advisable to become pregnant or father a child while having this treatment as the developing baby may be harmed. It is important to use effective contraception while taking these drugs, and for at least 6 months afterwards, and it may be advisable to delay starting a family for about 12 months after your treatment to make sure that you are fully recovered. Discuss this with your nurse or doctor if you have any concerns. Loss of periods in women Due to the effect of chemotherapy on the ovaries you may find that your periods become irregular or stop. In younger women this is often temporary but if you are closer to your menopause it may be permanent. This will result in menopausal symptoms such as hot flushes and sweats and vaginal dryness. 6
Second cancers For people treated with chemotherapy there is a small increase in the risk of developing other cancers at a later date. With this treatment this risk is very low and after about 10 years falls back towards the background risk shared by the whole population. Reviewer: Dr John Davies Review Date: March 2012 7