1. What is E-CMF? 
2. Who might be offered E-CMF? 
3. How E-CMF works 
4. How E-CMF is given 
5. Common side effects of E-CMF 
6. Less common side effects of E-CMF 
7. Vaccinations 
8. Blood clots

What is E-CMF?

E-CMF is a combination of four chemotherapy drugs used to treat breast cancer.

It takes its name from the initials of these drugs:

  • E – epirubicin
  • C – cyclophosphamide
  • M – methotrexate
  • F – 5 fluorouracil (5FU) 

You may also hear it called Epi-CMF.

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Who might be offered E-CMF?

E-CMF can be used to treat primary breast cancer – breast cancer that has not spread beyond the breast or the lymph nodes (glands) under the arm. Chemotherapy is given to reduce the risk of breast cancer returning or spreading.

E-CMF is usually started a few weeks after surgery, known as adjuvant (additional) therapy. If you’re going to have radiotherapy or hormone therapy, you’ll usually complete the E-CMF first. 

It may also be given to people with:

  • local recurrence – breast cancer that has come back in the chest/breast area or in the skin near the original site or scar, but has not spread to other parts of the body
  • locally advanced breast cancer (also called regional recurrence) – breast cancer that has come back and has spread to the tissues and lymph nodes around the chest, neck and under the breastbone
  • secondary breast cancer – breast cancer that has spread to other parts of the body

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How E-CMF works

Chemotherapy drugs interfere with how cancer cells develop and grow, and different drugs do this in different ways.

E-CMF works by stopping the cancer cells from dividing and multiplying, which blocks the growth of the cancer.

Different chemotherapy drugs attack the cancer cells at different phases of their growth. This is why a combination of drugs is often used instead of one single drug.

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How E-CMF is given

E-CMF is usually given as a drip into a vein (intravenously) in the hand or arm, although there are other ways of giving it depending on factors such as how easy it is to find suitable veins.

Cyclophosphamide can be given as a tablet.

You’ll have your chemotherapy as an outpatient so you’ll be able to go home the same day.

How long treatment lasts

E-CMF is usually divided into two parts. First, you’ll have four cycles of epirubicin (E) every three weeks over a few months. Then you’ll have the other three drugs (CMF) over the next few months.

The total length of E-CMF chemotherapy treatment is usually about seven months.

The time between each cycle of treatment gives your body time to recover. This may vary depending on whether the number of blood cells has returned to normal between each cycle.

Before starting E-CMF

Before starting your treatment many hospitals will arrange a chemotherapy information session. A nurse will discuss how and when your chemotherapy will be given and how side effects can be managed. Contact numbers will also be given so you know who to phone if you have any questions or concerns.

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Common side effects of E-CMF

Like any treatment, E-CMF can cause side effects. Everyone reacts differently to drugs and some people have more side effects than others. These can usually be controlled and those described here will not affect everyone.

If you’re worried about any side effects, even if they’re not listed here, talk to your chemotherapy nurse or cancer specialist (oncologist).

Effects of giving E-CMF

While the drug cyclophosphamide is being injected, you may feel hot or flushed and slightly dizzy, and have an itchy nose or a metallic taste in your mouth. These feelings usually go away when the injection is finished, but tell your nurse if you experience any of them. Asking to have the drug given more slowly can sometimes help. Some people also find sucking a boiled sweet helps.

If the drug epirubicin leaks out of the vein, it can damage the surrounding soft tissue. Tell the chemotherapy nurse immediately if you experience pain, stinging or a burning sensation near the cannula (small plastic tube) while the drug is being given.

Effects on the blood

E-CMF can temporarily affect the number of healthy blood cells in the body.

You’ll have regular blood tests to check your blood count. If the number of blood cells is too low, your next course of treatment may be delayed or the dose of chemotherapy reduced.

Not having enough white blood cells can increase the risk of getting an infection.

Contact your hospital immediately if at any time:

  • your temperature goes over 37.5°C or whatever temperature has been advised by your chemotherapy team
  • you suddenly feel unwell, even with a normal temperature
  • you have any symptoms of an infection, for example a sore throat, a cough, a need to pass urine frequently or feeling shivery

Having too few red blood cells is called anaemia. If you feel particularly tired, breathless or dizzy, let your specialist team know.

You may also bruise more easily, have nosebleeds or your gums may bleed when you brush your teeth. Tell your specialist team if you have any of these symptoms.

Hair loss

E-CMF causes total hair loss in most people. For some people, scalp cooling may be possible to try to prevent or lessen hair loss. It’s not available in all areas so ask your specialist or chemotherapy nurse if this treatment is available and suitable for you.

You can read more about hair loss, scalp cooling and looking after your hair in our Breast cancer and hair loss booklet.

Nausea and vomiting

You may experience nausea (feeling sick) and vomiting (being sick), but many people are not actually sick. You’ll be given anti-sickness medication into your vein before the chemotherapy is given, and you’ll be prescribed anti-sickness drugs to take home to reduce nausea or stop it happening.

Diarrhoea or constipation

If you  have diarrhoea or constipation, your specialist or GP can prescribe medicine to help control it. Contact your specialist chemotherapy team if you have four or more episodes of diarrhoea within a 24-hour period.

Sore mouth and taste changes

You’ll be given mouthwash to try to reduce soreness of the mouth and gums and to try to stop mouth ulcers developing. Good mouth hygiene is very important during treatment. It’s advisable to see your dentist for a dental check-up before chemotherapy begins. If you do need dental treatment during chemotherapy you can talk to your oncologist about the best time to have this.

E-CMF can make your taste change and some food may taste different, for example more salty, bitter or metallic. This usually returns to normal once you have finished treatment.

Our information on diet during breast cancer treatment includes tips on dealing with taste changes.

Tiredness (fatigue)

It’s common to feel extremely tired during your treatment. For some people, fatigue can last for several weeks or even months after the treatment has finished, but your energy levels will gradually return.

There are different ways of coping with fatigue.

Bladder irritation and pink or red urine

Drink plenty of fluids around the time you have your treatment because chemotherapy drugs (particularly cyclophosphamide) can irritate the lining of the bladder. Try to empty your bladder regularly, as soon as you feel the urge. Tell your specialist if you notice any irritation or a burning/stinging sensation when passing urine.

Epirubicin can cause your urine to become pink or red for a couple of days. This is because of the colour of the drug and is completely normal.

Effects on fertility

E-CMF causes changes in the ovaries, which may lead to infertility in women who haven’t been through the menopause. The likelihood of you becoming infertile will also depend on whether you have had chemotherapy in the past and your age.

If you’re concerned about your fertility, talk to your specialist team before treatment begins to discuss options for preserving fertility and to ask for a referral to a fertility specialist.

Menopausal symptoms

If E-CMF affects the ovaries, which produce oestrogen, this can cause women who haven’t been through the menopause to experience menopausal symptoms.

Common symptoms can include:

  • hot flushes and night sweats
  • mood changes
  • joint aches and pains
  • vaginal dryness

Effects on your concentration (cognitive impairment)

Your ability to concentrate or think clearly can also be affected, which can be very frustrating. This is sometimes referred to as ‘chemo-brain’ or ‘chemo-fog’ but is more commonly known as cognitive impairment. It usually improves over time after treatment has finished.

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Less common side effects of E-CMF

Heart changes

Epirubicin can affect the way your heart works and may not be suitable for people with existing heart conditions. 5FU can also affect your heart.

Heart problems as a result of epirubicin and 5FU are not common. However, because they can happen, before you start chemotherapy your specialist may arrange a heart (cardiac) function test to check your heart is working normally.

Skin reactions

E-CMF may cause your skin to become red and sore, especially if you’ve had radiotherapy recently. Let your specialist team know if this happens.

Your skin may darken due to extra pigment (colour) being produced. Any darkening usually returns to normal a few months after the treatment ends.

During E-CMF treatment, and for several months afterwards, your skin will be more sensitive. You’ll be more likely to get sunburnt so wear sunscreen with a high sun protection (SPF) if you’re out in the sun.

Sore eyes

Your eyes may feel sore or gritty. Sometimes eye drops will be prescribed to ease discomfort. Your eyes may also water. This can happen more frequently during CMF cycles and it usually improves over time. Let your specialist team know about any eye problems you have.

Nail changes

Your fingernails or toenails may become discoloured (darker) or more ridged. These effects generally grow out over the months following the end of treatment.

Sex and contraception

You can still have sex during treatment. It’s not known if chemotherapy drugs can pass into vaginal fluids (or semen). Most hospital specialists advise using barrier methods of contraception, such as condoms, for a few days after chemotherapy is given.

Having E-CMF while pregnant may be harmful to a developing baby. Some women can still become pregnant even if their periods are irregular or have stopped, so effective barrier contraception such as a condom should be used.

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Travel vaccinations

Vaccines may be less effective if given during treatment, and live vaccines can cause serious infections.

You shouldn’t have any live vaccines while having chemotherapy. These include vaccines that protect against measles, rubella, yellow fever and typhoid.

It’s usually safe to have these vaccinations six months after your treatment finishes.

If you’re planning a trip and need vaccinations, discuss this with your specialist team.

Flu vaccination

Anyone with a reduced immunity to infection should have a flu vaccine. This includes people having or due to have chemotherapy.

The flu vaccine is not a live vaccine, which means there are no active viruses in it.

It’s best to have the vaccination at least two weeks before your chemotherapy starts. If you’re already having chemotherapy, talk to your chemotherapy specialist or breast care nurse about the best time to have your flu jab to ensure you gain the greatest possible effect from it. This will usually be at a point in your chemotherapy cycle when your white blood cell count is recovering.

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Blood clots

People with breast cancer have a higher risk of blood clots. Their risk is higher because of the cancer itself and some treatments for breast cancer. Having E-CMF increases the risk of blood clots such as deep vein thrombosis (DVT). People with a DVT are at risk of developing a pulmonary embolism. This is when part of the blood clot breaks away and travels to the lung.

If the cancer has spread to other parts of the body (secondary breast cancer), this also increases the risk.

Blood clots can be harmful but are treatable so it’s important to report symptoms as soon as possible.

If you experience any of the following symptoms contact your local A&E department, GP or specialist team straight away:

  • pain, redness/discolouration, heat and swelling of the calf, leg or thigh
  • swelling, redness or tenderness where a central line is inserted to give chemotherapy, for example in the arm, chest area or up into the neck
  • shortness of breath
  • tightness in the chest
  • unexplained cough (may cough up blood)

Find out more about blood clots.

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Last reviewed: July 2017
Next planned review begins 2019

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