Chemotherapy for bowel cancer

The drugs most commonly used to treat colon cancer or rectal cancer are:

• fluorouracil (5FU) usually given with folinic acid (leucovorin)
• capecitabine (Xeloda^®)
• oxaliplatin (Eloxatin^®)
• irinotecan (Campto^®)
• trifluridine and tipiracil (Lonsurf^®)
• raltitrexed (Tomudex®).

Often, 2 or more chemotherapy drugs are given in combination. The most common combinations are:

• FOLFOX (folinic acid, fluorouracil and oxaliplatin)
• CAPOX (XELOX) (capecitabine and oxaliplatin)
• FOLFIRI (folinic acid, fluorouracil and irinotecan)
• FOLFOXIRI (folinic acid, fluorouracil, oxaliplatin and irinotecan).

Chemotherapy drugs can cause different side effects. Many of these can be managed with different medicines and most of them will get better after treatment ends. Chemotherapy affects everyone differently. Some people may have only a few side effects whereas others may have more.

Your cancer doctor or nurse will tell you more about what to expect. Tell them about any side effects you have, as they can usually be well controlled with medicines.

Although they can be hard to cope with, side effects usually get better after your treatment finishes.

We describe some of the common side effects here. We have more information about chemotherapy side effects.

Chemotherapy 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 you have been given:

• 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) a lot, 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.

Chemotherapy 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 on the skin that may look like a rash.

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.

Chemotherapy 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 lightheaded.

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.

Some chemotherapy drugs can cause diarrhoea. Diarrhoea means passing more stools than is usual for you, or having watery or loose stools. If you have a stoma, it will be more active than usual.

Sometimes diarrhoea can be severe. Your hospital team may give you anti-diarrhoea drugs to take at home. It is important to follow any advice from them about taking anti-diarrhoea drugs. Contact the hospital on the 24-hour number straight away if:

• you have diarrhoea at night
• you have uncomfortable stomach cramps
• you have diarrhoea 4 or more times in a day
• you have a moderate increase in stoma activity
• the anti-diarrhoea drugs do not work within 24 hours.

If you are taking capecitabine tablets, the hospital may ask you to stop taking them. They will tell you when you can start taking them again.

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

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:

• your mouth or throat is sore, or affecting how much fluid you can drink or food you can eat
• your mouth, tongue, throat or lips have any blisters, ulcers or white patches.

Feeling tired is a common side effect. It is often worse towards the end of treatment and for some weeks after it ends. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy. If you feel sleepy, do not drive or use machinery.

Rarely, oxaliplatin can cause a spasm in the throat area around the voicebox (larynx). This can cause difficulties with swallowing and breathing. This might happen during treatment, or in the first few days after treatment.

This side effect can be frightening, but it should only be temporary. If you have breathing difficulties, take long, deep breaths through your nose. This will have a calming effect and help your breathing return to normal.

This symptom may be worse in cold temperatures. It may help to avoid cold drinks during treatment, and for a few days afterwards. It may also help to wrap up warm and cover your nose and mouth in cold weather.

It is important to tell your doctor if you have this side effect. They may give the next doses of oxaliplatin over 4 to 6 hours to reduce the chance of throat spasms.

Some chemotherapy drugs can affect the nerves in your fingers and toes. This can cause numbness, tingling or pain in your hands or feet. This side effect is called peripheral neuropathy. You might find it hard to do fiddly tasks such as fastening buttons or tying shoe laces. If you have these symptoms, always tell your doctor, nurse or pharmacist. They sometimes need to change the drug or the dose of the drug.

Many of the chemotherapy drugs for colon and rectal cancer do not cause hair loss, but you may still get some hair thinning. The chemotherapy drug irinotecan can cause hair loss. Your hair may get thinner or you may lose all the hair from your head.

Your nurse can talk to you about ways to cope with hair loss. Hair loss is almost always temporary. Your hair will usually grow back after treatment ends.

This treatment can affect the palms of your hands and the soles of your feet. This is called palmar-plantar or hand-foot syndrome.

If you have white skin these areas may become red. If you have black or brown skin, these areas might get darker.

The skin on the palms of your hands and the soles of your feet may:

• be sore
• be painful, tingle, or swell
• peel, crack or blister.

If you have any of these symptoms, contact the hospital straight away on the 24-hour number. They can give you advice. This is especially important if you have any broken skin or if walking is difficult. They can prescribe creams and painkillers to help.

Fluorouracil and capecitabine can affect the way the heart works. You may have tests to see 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. 

Always call 999 if you have:

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

Having chemotherapy can sometimes affect your sex life. Side effects like tiredness and feeling sick can reduce your sex drive and make having sex difficult.

If you have a partner, try to tell them how you feel. It can also help to talk with your doctor or specialist nurse about your concerns. They can reassure you and support you with any problems. We have more information about cancer and your sex life.

Your doctor, nurse or pharmacist will advise you not to get pregnant or make someone pregnant while having this treatment and for some time afterwards. The drugs may harm a developing baby. It is important to use contraception to prevent pregnancy. Follow their advice about:

• what types of contraception to use
• how long after treatment you should continue to use contraception.

Some cancer drugs can affect whether you can get pregnant or make someone pregnant. If you are worried about this, it is important to talk with your doctor before you start treatment.

We have more information about fertility and cancer.