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Date issued:  September 2022

Review date: September 2024

Ref: A-445/MB/Oncology/The CROSS Regime v2

PDF:  The Cross regime final September 2022 v2.pdf [pdf] 126KB

Introduction

You have recently been diagnosed with cancer of the oesophagus (the long tube that carries food from your throat to the stomach) and have been referred to University Hospitals Plymouth for advice about future treatment. Your consultant oncologist has recommended that the best treatment for you is chemotherapy and radiotherapy prior to an operation.

This information describes your treatment and answers some commonly asked questions. Please read it carefully and make a note of anything you wish to ask your consultant, specialist nurse or radiographer. There are contact telephone numbers at the end of the leaflet. Please ring us if you would like to discuss any aspect of your treatment.

How does radiotherapy and chemotherapy work?

External radiotherapy is invisible x-rays delivered directly onto your chest where the cancer in your oesophagus is situated. Chemotherapy is a type of anti-cancer treatment using drugs, which can be given intravenously, by injection or orally in tablet form. 

Our bodies are made up of cells all of which have the capacity to divide. If radiotherapy and chemotherapy are given to someone with cancer, they hit these dividing cells causing them to be damaged. Cancer cells are much less able than normal cells to repair the damage, so more of the cancer cells will be destroyed.

Giving chemotherapy alongside radiotherapy is known to make the radiotherapy for Oesophageal cancer more effective.

Planning the treatment?

Before starting treatment, you will have to:

• Sign consent

• Blood tests

• Measure of your height and weight

• Outpatient appointment (often by telephone) with the chemotherapy nurse to talk about the practical ‘do’s’ and don’ts’ of having chemotherapy.

• A CT planning scan- everyone with cancer is different. To ensure that the treatment is designed to your particular needs a planning scan is carried out on a CT scanner in the oncology department, on level 2. While you are on the CT scanner, you will need to remove any clothing covering the area being treated. Permanent ink marks will be made on your skin to show where treatment is to be given. These look just like small dots and are barely noticeable but will ensure that you are always in the correct position for the treatment. Your doctors will use this scan to target the radiotherapy to the right place.

When planned the radiotherapy is given once a day (usually Monday to Friday) for a total of 23 sessions and takes about 15 minutes a day. It is given as a day case in the radiotherapy department, level 2 in the Oncology department.

The chemotherapy is combined with radiotherapy to enhance the effectiveness of the treatment. The chemotherapy is given once a week, often on a Monday or Tuesday alongside your radiotherapy. There will be a total of 5 chemotherapy treatments. These will be given, via a drip, as a day case on Fal ward on Level 5.

The chemotherapy used consists of 2 drugs listed below. These are given one after the other on the same day:

• Paclitaxel given via a drip lasting 1 hour

• Carboplatin is given via a drip lasting ½ hour

You will always need to have a routine blood test before the start of each chemotherapy treatment.

The following table shows the timetable for treatment:

 

timetable

Week 1	Week 2	Week 3	Week 4	Week 5
Day case intravenous Chemotherapy Often on a Monday or Tuesday	Day case intravenous Chemotherapy Often on a Monday or Tuesday	Day case intravenous Chemotherapy Often on a Monday or Tuesday	Day case intravenous Chemotherapy Often on a Monday or Tuesday	Day case intravenous Chemotherapy Often on a Monday or Tuesday
Radiotherapy every day Monday - Friday	Radiotherapy every day Monday - Friday	Radiotherapy every day Monday - Friday	Radiotherapy every day Monday - Friday	Radiotherapy every day Monday - Wed

Possible side effects

Chemotherapy can cause many different side effects. Some are more likely to occur than others. Everyone is different and not everyone gets all the side effects. Most side effects are usually temporary, but in some rare cases they can be life-threatening. The team caring for you will discuss the risk of these side effects with you. It is important to tell your hospital doctor or nurse about any side effects so they can be monitored and treated.

Infection

You are vulnerable to infection while you are having chemotherapy. Minor infections can become life-threatening in a matter of hours if left untreated. Symptoms of infection include fever, shivering, sweats, sore throat, diarrhoea, discomfort when you pass urine, cough or breathlessness. We recommend that you use a digital thermometer so you can check your temperature should you feel hot, or cold and shivery. You can buy one from your local chemist.

If you feel unwell, or you have symptoms of an infection or your temperature is 38ºC or above please contact The Chemotherapy Hotline straight away. On Tel: 01752 202082 and ask to speak to the duty oncology nurse on bleep 0023

Blood sugar

You will receive a dose of intravenous steroids before each treatment. If you are diabetic, you should monitor your blood sugar levels during your treatment. If your blood sugar levels are affected, you should speak to your doctor about your diabetic medications.

Allergic reactions

Paclitaxel on rare occasions can cause an allergic reaction. Reactions can include breathlessness, a feeling of dizziness, skin rashes, itching, a high temperature, shivering, redness of the face, headache, anxiety, and a desire to pass urine. You will be monitored throughout your treatment for any signs of an allergic reaction but it is important to tell your nurse or doctor if you have any of these signs, or feel unwell in any way.

To prevent this happening, we will give you pre-medication before starting the Paclitaxel treatment.

Extravasation

Extravasation is when chemotherapy leaks outside the vein. If you develop redness, soreness or pain at the injection site at any time please let us know straight away. Paclitaxel can cause pain where the injection is given, or along the vein. If you feel pain, tell your doctor or nurse as they can slow the drip to reduce the reaction.

Muscle and joints pains

Sometimes you may experience pain in the muscles in your legs. A simple painkiller will help such as paracetamol. Ask your doctor for advice on this.

Sore mouth

Your mouth may become sore or dry, or you may notice small mouth 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. We can prescribe a mouthwash for you to use during treatment. You can dilute this with water if your mouth is sore. Ask your doctor or nurse for further advice. There is also general mouth care information in the chemotherapy booklet.

If you continue to have a sore mouth, please contact The Chemotherapy Hotline on 01752 202082 and ask to speak to the Duty Oncology Nurse on bleep 0023.

Skin

The skin in the treated area might become a little pink or even red. It may itch a little or become dry. You may shower or bathe during your treatment period but be careful about the water temperature. Don’t have the water too hot and don’t soak the skin for long periods. Use mild baby soap or Simple soap and avoid rubbing the area, especially if the skin is already red or itchy. It is best to pat the area dry with a soft towel. If your skin is very sore, mention it to the radiographers. They may recommend a suitable cream. Men may find that chest hair can fall out in the treated area, this usually happens 2 to 3 weeks after treatment starts and it will grow back once the treatment is finished.

Low blood pressure

Your blood pressure will be checked during your treatment. Let the doctor know if you feel faint or dizzy.

Tiredness

Radiotherapy and chemotherapy can both make you feel tired. This can last for a number of weeks after the treatment is finished. Whilst you should pace yourself, it is also important to continue daily gentle exercise such as walking. This can lessen the amount of tiredness you experience and help prepare you for surgery. 

Nausea and vomiting (sickness)

Chemotherapy and radiotherapy can both make you feel nauseous, particularly if the lower part of your oesophagus is being treated with radiotherapy. We will give you anti-sickness drugs to take before and after the chemotherapy and your doctor or nurse clinician can prescribe additional tablets which you can take as needed. Ginger has natural anti-sickness properties and is available in different forms such as biscuits, tea and ginger ale. If you continue to feel or be sick, contact your GP or this hospital, because your anti-sickness medication may need to be changed or increased.

Swallowing problems

The lining of the gullet becomes irritated during the treatment. You may feel as if you have a lump in your throat when you swallow. In some cases this can be painful. Your doctor or nurse can prescribe soothing medicines such as liquid paracetamol or Oxcetacaine elixir to help you, so let us know as soon as swallowing becomes difficult. Cool drinks or ice cream and jellies might help and it is advisable not to take hot drinks or eat spicy food. You may need a soft or liquidised diet as a temporary measure.

Occasionally, if you cannot swallow at all, a temporary feeding tube will need to be inserted. At first, you will have to stay in hospital as an inpatient for this and to establish your feeding pattern, but you may be allowed to go home with the feeding tube once you have had training on how to do this. If you need help with your nutrition, you can meet a dietitian for advice. You can ask your specialist nurse to arrange this for you.

Kidney function

Some chemotherapy such as carboplatin can affect your kidneys. It is important to monitor how your kidneys are working while you are having treatment. We do this by a blood test, but a more accurate assessment with a special kidney test called Glomerular Filtration Rate (GFR) can be arranged if there are concerns about your kidney function. It is important to drink plenty of fluids, at least 8 cups (a cup = 250mls) the day before and for a few days after chemotherapy.

Hair loss

Hair loss is usually minimal. The hair may thin over your course of treatment. The time scale varies from person to person. Please remember that this is a temporary side effect and your hair will grow back when your treatment is completed. It is very rare for hair loss to be permanent. If you would like an appointment with the wig service, this can be arranged for you either by asking your specialist nurse or via your local hospital Cancer Support Centre.

Anaemia (low number of red blood cells)

While having this treatment you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if these symptoms are a problem.

Bruising or bleeding

This treatment can reduce the production of platelets which help the blood clot. Let your doctor know if you have any unexplained bruising or bleeding, such as nose bleeds, bloodspots or rashes on the skin.

Diarrhoea

If this becomes a problem while you are having treatment, anti-diarrhoea tablets can be bought from a pharmacy or prescribed by your GP for a temporary period until this resolves. If the problem persists contact this hospital. If you develop severe diarrhoea, it is important to contact the chemotherapy helpline straight away on 01752 202082 and ask to speak to the duty oncology nurse on bleep 0023.

Constipation

You may become constipated during this treatment. Try to drink plenty of fluids and eat foods high in fibre. Tell your doctor who may prescribe a suitable laxative.

Changes in heart rate

Paclitaxel can sometimes cause a temporary slowing of the heart rate known as bradycardia. This usually does not cause any harm.

Liver function

Your liver function may be temporarily affected. Paclitaxel may cause changes in the way that your liver works. Before each treatment your liver function will be reviewed.

Changes of taste

You may notice that food tastes different. Normal taste usually comes back after treatment finishes.

Nail changes

You may notice nail changes and discolouration of the nail bed. These changes should be temporary and the condition of your nails should improve when treatment finishes.

Cough

Sometimes you might start to cough and bring up phlegm (spit) during the course of treatment. Let your doctor, nurse, or GP know if you find this troublesome or the phlegm becomes discoloured.

Tingling and numbness in the fingers or toes

This is due to the effect of the chemotherapy on the nerves and is known as peripheral neuropathy. You may also notice that you have difficulty doing up buttons or similar tasks. Tell your doctor if you notice any numbness or tingling in your hands or feet.

Other medicines

Some medicines can be harmful to take when you are having chemotherapy. Let your doctor know about any medications you are taking, including non-prescribed medicines such as complementary therapies and herbal remedies.

Sex, contraception & fertility

Protecting your partner and contraception:

We recommend that you or your partner use a condom during sexual intercourse while you are undergoing chemotherapy. Chemotherapy is dangerous to unborn babies and this will also protect you and your partner from any chemotherapy drugs that may be present in semen and in the vagina. You should continue to use protection for up to 72 hours after chemotherapy regime is completed.

Radiation can be harmful to the unborn child. It is important to let the radiographers know if you have missed a period, or suspect that you may be pregnant before any radiation exposure is given.

Fertility: This chemotherapy may affect your ability to have children. Your doctor or nurse should have discussed this with you. If not, please ask them before you start treatment.

Late side effects of radiotherapy

Narrowing of the gullet: Scarring caused by the radiotherapy might cause a narrowing in the gullet. Sometimes you will need a minor procedure to stretch the gullet. But this does not necessarily mean that your cancer has come back.

Breathlessness: Radiotherapy may leave the lungs with some scarring (fibrosis). Although every effort is made to minimise the radiation dose to lungs, sometimes you might notice a slight increase in shortness of breath. If this becomes a problem, tell your doctor as sometimes medicine or breathing exercises may help.

Chest or rib pain: Rarely, radiotherapy can cause inflammation of the ribs leading to thinning of the bones. It is possible that a rib can break particularly after a bout of coughing or mild injury.

Radiotherapy may in extremely rare cases lead to injury to the spinal cord which can cause permanent difficulties in walking and loss of sensation in the lower body. Every effort is made to plan your treatment carefully to avoid this problem.

Late side effects of chemotherapy

Tingling and numbness in the fingers or toes normally recovers between each treatment, but occasionally this can become permanent.

Some rare side effects may not appear for a number of years. In reaching any decision with you about treatment, the potential benefit you receive from treatment will be weighed against the risks of long term side effects to the heart, lungs, kidneys and bone marrow.

With some drugs there is also a small but definite risk of developing another cancer. If any of these problems specifically applies to you, the doctor will discuss these with you and note this on your consent form.

What can I do to help myself?

It is very important that you try to keep your weight stable before and during the treatment. Try to eat small frequent meals or snacks throughout the day. Ask the radiotherapy or nursing staff for advice and dietary information leaflets. You may need nutritional supplements if you are losing weight, or you are not eating very well. They are available on prescription from your doctor or dietitian. If you have any questions you can contact the dietetic department for general advice 01752 432243.

Take things easy whilst you are having treatment. Don’t push yourself too hard.

How will I be followed up after treatment?

Following completion of treatment you will have a month to recover. During this time you will have a CT scan to assess you response to treatment and confirm the plan for surgery to proceed. Your scan will be reviewed by all the team of specialists who look after you. You will then meet with the surgeons to discuss scan results and surgery.

Who can I contact for advice or support?

We hope that this information will help you to understand your proposed treatment. You will already have been offered a cancer nurse specialist (key worker) who has been responsible for co-ordinating your care. For ongoing care and support (should you have any worries or concerns during or after treatment has completed) you can contact your nurse specialists and Dietitians on the numbers listed below.

Cancer Specialist Nurses

Jen O’Reilly, Marilyn Bolter, Lizzie Bevan:

Tel: 01752 431528

Cancer support worker Angela Bleasdale

Tel: 01752 431528

Dietitians: Tel: 01752 432253

The Mustard Tree, Macmillan Cancer Support Centre

If you would value the opportunity to talk to someone about how you feel, or just need a break from the usual routine you can visit the Mustard Tree. The centre is available to anyone affected by cancer at any stage of the illness and offers a comfortable space where you can share your concerns, ask questions and receive support. It is staffed by professionals and trained volunteers many of whom have a personal experience of cancer.

The centre is open Monday – Friday 09.00 am – 5.00pm See number listed below.

The Mustard Tree Support Centre: Tel:01752 763672

Where can I find further help or information?

NHS Choices web page

www.cancerinfo.nhs.uk

Macmillan Cancer Support

www.Macmillan.org.uk

(0808 808 0000)

Oesophageal Patients Association

www.opa.org.uk

(0121 7049860)

Cancer Research UK

www.cancerresearchuk.org

(0300 123 1022)