Carboplatin/paclitaxel, EC + pembrolizumab

Carboplatin/paclitaxel, epirubicin/cyclophosphamide (EC) + pembrolizumab is a combination of cancer drugs. It is used to treat breast cancer.

Carboplatin, paclitaxel, epirubicin and cyclophosphamide are chemotherapy drugs. Pembrolizumab is a type of immunotherapy drug called a checkpoint inhibitor.

It is best to read this information with our general information about chemotherapy, immunotherapy and the type of cancer you have.

Your cancer team will talk to you about this treatment and its possible side effects before you agree (consent) to have treatment.

This information is correct at time of publishing. But sometimes the types of cancer this treatment is used for, or treatment side effects, may change between revision dates.

You can talk to your cancer team if you want more detailed information about this treatment. Or visit the electronic Medicines Compendium (eMC) website, which has patient information leaflets (PIL) for individual drugs.

We explain the most common side effects of this treatment here. We also include some that are less common.

You may get some of the side effects we mention, but you are unlikely to get all of them. And you may have some side effects, including rarer ones, that we have not listed here. 

Always tell your doctor, nurse or pharmacist about any side effects you have. They can give you: 

• drugs to help control some side effects
• advice about managing side effects. 

It is important to take any drugs exactly as explained. This means they will be more likely to work for you. 

Some cancer treatments can cause serious side effects. Sometimes, these may be life-threatening. Your doctor, nurse or pharmacist can explain the risk of these side effects to you.

This treatment may also cause delayed side effects. These can start weeks, months, or sometimes more than a year after you finish treatment.

If you have symptoms or side effects that start during treatment or after treatment ends, contact the hospital straight away on the 24-hour number. Side effects can become serious if they are not treated.

Your doctor, nurse or pharmacist will give you 24-hour contact numbers for the hospital. If you feel unwell or need advice, you can call at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.

They will also give you a card with information about your treatment. It is important to keep the card with you during treatment and after treatment ends. You should show it to any doctor or healthcare professional caring for you.

This treatment can reduce the number of white blood cells in your blood. These cells fight infection. If your white blood cell count is low, you may be more likely to get an infection. A low white blood cell count is called neutropenia.

An infection can be very serious when the number of white blood cells is low. It is important to get any infection treated as soon as possible. If you have any of the following symptoms, contact the hospital straight away on the 24-hour number:

• a temperature above 37.5°C 
• a temperature below 36°C 
• you feel unwell, even with a normal temperature
• you have symptoms of an infection.

Symptoms of an infection include:

• feeling shivery and shaking
• a sore throat
• a cough 
• breathlessness
• diarrhoea
• needing to pass urine (pee) often, or discomfort when you pass urine.

It is important to follow any specific advice your cancer treatment team gives you.

Your white blood cell count will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time, until your cell count increases.

You may be given a drug called G-CSF. This encourages the body to make more white blood cells. You have it as a small injection under the skin.

This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.

If the number of platelets is low, you may bruise or bleed easily. You may have:

• nosebleeds
• bleeding gums
• heavy periods
• blood in your urine (pee) or stools (poo)
• tiny red, brown or purple spots that may look like a rash – these spots can be harder to see if you have black or brown skin. 

If you have any unexplained bruising or bleeding, contact the hospital straight away on the 24-hour number. You may need a drip to give you extra platelets. This is called a platelet transfusion.

This treatment can reduce the number of red blood cells in your blood. Red blood cells carry oxygen around the body. If the number of red blood cells is low, this is called anaemia. You may feel:

• very low in energy
• breathless 
• dizzy and light-headed. 

If you have these symptoms, contact the hospital straight away on the 24-hour number. You may need treatment for anaemia. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.

Your doctor, nurse or pharmacist will prescribe anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as they tell you to, even if you do not feel sick. It is easier to prevent sickness than to treat it after it has started.

If you feel sick, take small sips of fluid often and eat small amounts regularly. It is important to drink enough fluids. If you continue to feel sick, or if you are sick (vomit) 1 to 2 times in 24 hours, contact the hospital on the 24-hour number as soon as possible. They will give you advice. They may change your anti-sickness treatment. Let them know if you still feel sick.

This treatment can cause constipation. Constipation means that you are not able to pass stools (poo) as often as you normally do. It can become difficult or painful. Here are some tips that may help:

• Drink at least 2 litres (3½ pints) of fluids each day.
• Eat high-fibre foods, such as fruit, vegetables and wholemeal bread.
• Do regular gentle exercise, like going for short walks.

If you have constipation, contact the hospital on the 24-hour number for advice. They can give you drugs called laxatives to help. 

If you have not been able to pass stools for over 2 days and are being sick, contact the 24-hour number straight away. 

This treatment may cause a sore mouth and throat. You may also get mouth ulcers. This can make you more likely to get a mouth or throat infection. Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.

Contact the hospital straight away on the 24-hour number, if:

• a sore mouth or throat affects how much you can drink or eat 
• your mouth, tongue, throat or lips have any blisters, ulcers or white patches. 

They can give you advice, and mouthwash or medicines to help with the pain or to treat any infection. Follow their advice and make sure you:

• drink plenty of fluids
• avoid alcohol and tobacco
• avoid food or drinks that irritate your mouth and throat.

You usually lose all the hair from your head. You may also lose your eyelashes and eyebrows, as well as other body hair. Hair loss usually starts after your first or second treatment.

Scalp cooling is a way of lowering the temperature of your scalp to help reduce hair loss. Your nurse can tell you whether this is an option for you.

If you want to cover up hair loss, there are different ways to do this. Your nurse can give you information about coping with hair loss. Remember to protect your skin from the sun. Use suncream with a sun protection factor (SPF) of at least 30 on your scalp. Or cover up with a hat or scarf.

Hair loss is usually temporary. Your hair will usually grow back after treatment ends. Very rarely, hair may not grow back. Or it may grow back thinner than before. If you are worried about this, talk to your doctor, nurse or pharmacist.

This treatment can affect your nails. They may grow more slowly or break more easily. You might notice ridges or white or dark lines across your nails. These changes usually disappear as the nails grow out after treatment. Sometimes nails can become loose or fall out.

If the skin around your nails becomes sore and swollen, contact the hospital straight away on the 24-hour number. These might be signs of an infection.

Tips to look after your nails:

• Keep your nails clipped short and clean. 
• Avoid using very hot water when washing your hands or bathing.
• Moisturise your nails and cuticles regularly.
• Avoid false nails, gels or other acrylics during treatment – it is okay to use water-based nail polish. 
• Wear gloves to protect your nails when working in the house or garden.
• If your toenails are affected, wear well-fitting shoes, or shoes with open toes to cushion them.

Tell your doctor or nurse about any changes to your nails. They can give you advice or arrange for you to see a podiatrist. They are a foot care specialist.

Cyclophosphamide may irritate your bladder. This can cause discomfort when you pass urine (pee). Make sure you drink plenty of fluids during the 24 hours after chemotherapy. Try to drink at least 2 litres (3½ pints).

It is also important to empty your bladder regularly. Try to pass urine as soon as you feel the need to go.

Contact the hospital straight away if you feel any discomfort or stinging when you pass urine, or if you notice any blood in it.

Your urine may be a pink-red colour for up to 48 hours after you have your treatment. This is caused by epirubicin and is not harmful.

This treatment may cause hearing changes, including hearing loss. You may have ringing in the ears. This is called tinnitus. You may also become unable to hear some high-pitched sounds. Hearing changes may get better after this treatment ends. But this does not always happen. If you notice any changes in your hearing, tell your doctor, nurse or pharmacist.

Pembrolizumab can make the immune system too active. This can cause the following side effects. Some of them are rare. But it is important to know about them.

Side effects can become serious if they are not treated. They can start weeks, months, or sometimes more than a year after you finish treatment.

Do not try to treat these side effects yourself. If you have these side effects during treatment or after it ends, always contact the hospital straight away on the 24-hour number.

Your patient alert card has information about your pembrolizumab treatment. Remember to keep the card with you during treatment and after treatment ends. You should show it to any doctor or healthcare professional caring for you.

This treatment can cause inflammation of the lungs. This is called pneumonitis. Contact the hospital straight away on the 24-hour number if you notice any of these changes during treatment or after it ends:

• breathlessness
• a cough that does not go away
• wheezing
• a fever, with a temperature over 37.5°C.

You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs. You may need steroids or other treatments.

You may have diarrhoea or tummy (abdominal) pain. This treatment can also cause inflammation of the bowel (colitis) which can be very serious. 

Diarrhoea means passing more stools (poo) than is normal for you, or having watery or loose stools. If you have a stoma, it may be more active than usual.

Contact the hospital straight away on the 24-hour number if you have any of the following symptoms during treatment, or after treatment ends:

• You have diarrhoea 4 or more times in a day. 
• You have a moderate increase in stoma activity. 
• You have uncomfortable tummy cramps. 
• You have diarrhoea at night. 
• Your temperature is over 37.5°C.
• There is blood or mucus in your stool.

You may need to go into hospital to have fluids through a drip or treatments such as steroids.

This treatment can cause kidney inflammation and may affect how the kidneys work. This is called nephritis. This is not common, but if it is not treated it can become serious. You will have regular blood tests to check how your kidneys are working. If tests show kidney changes, you may have steroids or other treatments.

Contact the hospital straight away on the 24-hour number during treatment, or after it ends, if you either:

• have blood in your urine (pee) 
• are passing less urine or peeing less often than usual.

This treatment can cause liver inflammation and may affect how your liver works. This is called hepatitis. You will have regular blood tests to check this. If the blood tests show liver changes, you may have steroids.

Sometimes liver changes can be serious. Contact the hospital straight away on the 24-hour number if you have any of these symptoms during treatment or after it finishes:

• yellow skin or eyes
• feeling very sleepy
• dark urine (pee)
• unexplained bleeding or bruising
• pain in the right side of your tummy (abdomen)
• loss of appetite.

This treatment may cause inflammation in the skin. This is usually mild, but can if it is not treated it can become serious. You may need creams, steroids or other medicines to treat skin problems. If you notice skin changes during treatment, or after treatment ends, contact the hospital on the 24-hour number as soon as possible. Skin changes can include: 

• a rash or bumps on the skin
• dry or itchy skin
• patches of white or paler skin.

To protect your skin from the sun, use suncream with of at least SPF 30. SPF stands for sun protection factor. Cover up with clothing and a hat. 

Contact the hospital straight away on the 24-hour number if you have any of these symptoms:

• a rash that is spreading
• blistering or peeling skin
• flu-like symptoms, such as a high temperature and joint pain. 

These symptoms can be a sign of a serious skin reaction that needs to be treated immediately in hospital.

This treatment can cause sore or weak muscles. Your joints may also be stiff, sore or swollen (arthritis). If you already have problems with joint pain, this may become worse. Contact the hospital on the 24-hour number if you have any of these symptoms during treatment or after it ends:

• new or worsening aches or pains
• new or worsening stiffness in a joint
• swollen joints.

You may need steroids or other treatments, such as painkillers.

Rarely, this treatment can affect the brain and nerves. These effects may be mild at first, but can become serious if they are not treated. Contact the hospital straight away on the 24-hour number if you have any of these symptoms during treatment or after it ends:

• any weakness, numbness or tingling in your arms, legs or face
• a headache that does not get better
• dizziness
• drowsiness or confusion
• problems with moving or speaking
• any unexplained pain in other parts of your body.

You may need steroids and other treatments.

This treatment may affect your hormones. Hormones control many different processes in the body. You will have regular blood tests to check some of your hormone levels. Contact the hospital on the 24-hour number if you have any of these side effects during treatment or after it ends:

• increased sweating
• weight gain or weight loss
• dizziness or fainting
• feeling more hungry or thirsty than usual
• loss of sex drive
• passing urine (peeing) more often than usual
• headaches that do not go away
• feeling more tired than usual (fatigue)
• mood changes.

You may need drugs to control your hormone levels.

This treatment may raise your blood sugar levels and increase the risk of diabetes. 

You will have regular blood tests to check this. 

Signs of raised blood sugar include:

• feeling thirsty
• needing to pass urine (pee) more often than usual
• feeling more tired than usual.

Contact the hospital on the 24-hour number if you have these symptoms during treatment or after it ends.

If you already have diabetes, your blood sugar levels may be higher than usual. You may need advice and support from your GP or diabetes team about managing this.

This treatment can affect your eyes and eyesight. Contact the hospital straight away on the 24-hour number if you have any of these symptoms during treatment or after it ends:

• sore, painful, or swollen eyes
• eyes that are sensitive to light
• changes to your eyesight.

You may need steroids or other treatments. A specialist eye doctor (ophthalmologist) may also need to check your eyes.

This treatment can affect how the heart works. This is not common, but it can be serious. You may have tests to check how well your heart is working. These may be done before, during and after treatment.

Contact the hospital straight away on the 24-hour number if you have any of these symptoms during or after treatment:

• breathlessness
• dizziness
• changes to your heartbeat
• swollen feet and ankles.

Other conditions can cause these symptoms, but it is important to get them checked by a doctor. 

Always call 999 if you have:

• chest pain, pressure, heaviness, tightness or squeezing across the chest
• difficulty breathing.

If your symptoms are caused by this treatment, you may need steroids. You may be monitored in hospital for a time.

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