Page 1 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION FOLFOX Name of the regimen and cancer drugs Your care team may refer to your treatment as “FOLFOX”. FOLFOX consists of 3 different anti-cancer therapies. • FOL: Leucovorin (LOO koh VOR in); Folinic Acid • F: 5-FU or fluorouracil (floor oh YOOR uh sil); Adrucil® • OX: Oxaliplatin (ok SA lih pla tin); Eloxatin® Common uses FOLFOX is most commonly used to treat colon cancer and rectal cancer. Treatment schedule Your treatment will be given into your vein through an intravenous (IV) line. This may be into a short, flexible temporary catheter in your arm, or through a central venous catheter. A central venous catheter, or central line is a long, flexible IV tube that empties into a very large vein next to the heart. Talk with your care team to see which will be best for you and your treatment. o Oxaliplatin IV on Day 1 o Leucovorin IV on Day 1 o Fluorouracil (5-FU) IV push on Day 1 o Fluorouracil (5-FU) continuous IV infusion over 46 hours beginning on Day 1 and ending on Day 3 Each FOLFOX treatment is repeated every 14 days. This is known as one cycle. Your treatment may be given for a set number of cycles, or it will keep going until the drug, or drugs, stop working or you have side effects which stop you from continuing treatment. Drug DAY 1 2 3 4 5 6 7 8 9 ... 14 Cycle 2 Day 1 Oxaliplatin X X Leucovorin X X Fluorouracil (5-FU) X X X X Page 2 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Other medications Other medications may be ordered for you to prevent or treat certain side effects. These include: Instructions: Anti-nausea and other medications You will receive medications to prevent nausea and other side effects just before your chemotherapy. You may get prescriptions for other medications to take at home, as below: Possible drug interactions o FOLFOX may interact with other drugs you are taking. Please inform your care providers of all prescription medicine, overthe-counter medications, vitamins, and herbal products that you take. o Talk with your care provider or pharmacist before taking new medications, supplements, or receiving any vaccines. Page 3 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Common Side Effects Common side effects that have been known to happen in patients receiving FOLFOX are listed in the left side of this table. In some instances, the side effects may be reported less often but are still important to discuss. This table does not list all the known side effects for this therapy, only the ones that are experienced most often. Not every patient experiences every known side effect of a drug; even if you are taking the same drug as another patient, you may experience different side effects. Options to help manage any side effects that do occur are included on the right side of this table. These should be discussed with your care provider. If you experience any side effect you cannot manage or that is not listed here, contact your care provider. Possible Side Effect Management Decreased white blood cells (WBCs) and increased risk for infection (neutropenia) Your WBCs should be monitored by a simple blood test. When your WBCs are low, you are at a greater risk of having an in-fection. Take the following precautions to protect yourself from infection. • Wash your hands often, especially before eating and after using the bathroom. • Avoid crowds and people with fevers, flu, or other infection. • Bathe often for good personal hygiene. Contact your care team if you experience any signs or symptoms of an infection such as: • Fever (temperature more than 100.4°F or 38°C) • Chills • Sore throat • Burning when peeing • Tiredness that is worse than normal • A sore that becomes red, is draining, or does not heal. Check with your care team before taking any medicine for a fever or chills. Decreased hemoglobin, part of the red blood cells that carry iron and oxygen Your hemoglobin should be checked by a simple blood test. When your hemoglobin is low, you may notice that you get tired or fatigued more easily. • Try to get 7 to 8 hours of sleep per night • Avoid operating heavy machinery if you feel too tired • Find a balance between “work” and “rest” • Stay as active as possible, but know that it is okay to rest as needed, too • You might notice that you are more pale than usual Let your care team know right away if you have: • Shortness of breath • Dizziness • Fast or abnormal heartbeat Continued on the next page Page 4 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Decreased platelet count and increased risk of bleeding Your platelets should be monitored by a simple blood test. When they are low, you may bruise or bleed more easily than usual. • Use caution to avoid bruises, cuts, or burns. • Blow your nose gently and do not pick your nose • Brush your teeth gently with a soft toothbrush and maintain good oral hygiene • When shaving use an electric razor instead of razor blades • Use a nail file instead of a nail clipper Call your care team if you have bleeding that won’t stop. Examples include: • A bloody nose that bleeds for more than 5 minutes despite pressure • A cut that continues to ooze despite pressure • Gums that bleed a lot when you floss or brush Seek medical help right away if you have any severe headaches, blood in your urine or stool, coughing up blood, or bleeding that you cannot stop or lasts a long time. You may need to take a break or “hold” your medication for medical or dental procedures. Talk to your care team or dentist before any scheduled procedures. Pain of discomfort on hands and/or feet Hand-and-foot syndrome (HFS) is a skin reaction that appears on the palms of the hands and soles of the feet. It can appear as a rash, peeling skin, or a “pins and needles” sensation. Let your care provider know right away if you experience this side effect. To prevent HFS, you can: • Keep hands and feet moisturized with a non-fragranced moisturizing cream • Urea 10% or 20% cream may be helpful • Avoid exposure to hot water on the hands and feet, in showers, baths or doing dishes • Avoid tight shoes or socks • Avoid excess rubbing on hands and feet unless putting on lotion • Wear gloves when working with your hands Mouth irritation or sores (stomatitis or mucositis) Practice good mouth care. • Rinse your mouth after meals and at bedtime, and more frequently if you develop sores in your mouth • Brush your teeth with a soft toothbrush or cotton swab after meals • Use a mild non-alcohol mouth rinse at least 4 times a day (after eating and at bedtime). One example is a mixture of 1/8 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of warm (not hot) water • Avoid acidic, hot or spicy foods and beverages, and rough foods that might irritate the mouth • If you have sores in your mouth, avoid using tobacco products, alcohol, and mouthwashes that contain alcohol Call your care team if you experience pain or sores in your mouth or throat. Continued on the next page Page 5 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Nausea or vomiting • Take all medications as prescribed to help prevent and lessen symptoms of nausea and vomiting • Eat and drink slowly • Drink 8-10 (8-ounce) glasses of water and/or fluid (soup or broth) each day unless your care team has instructed you to limit your fluid intake • Eat small, frequent meals throughout the day rather than a few large meals • Eat bland foods; avoid spicy, fried, and greasy foods • Avoid intense exercise immediately after eating • Don’t lay down right away after eating • Wear loose fitting clothing for comfort • Avoid strong odors. Consider getting fresh air and try deep breathing. Let your care team know if you have nausea or vomiting. Your care team may prescribe medication to help with the symptoms. Diarrhea (loose and/ or urgent bowel movements) Monitor how many bowel movements you have each day. • Drink 8-10 (8-ounce) glasses of water or fluid each day unless your care team has asked you to limit your fluid intake. • Eat small, frequent meals throughout the day rather than a few large meals. • Eat bland, low-fiber foods (such as bananas, applesauce, potatoes, chicken, rice, and toast). • Avoid high fiber foods, such as raw vegetables and fruits and whole grains. • Avoid foods that cause gas, such as broccoli and beans. • Avoid foods with lactose, such as yogurt and milk. • Avoid spicy, fried, and greasy foods. Contact your care team if: • The number of bowel movements you have in a day increases by 4 or more • You feel dizzy or lightheaded Talk with your care team if you believe you have diarrhea. They may recommend an over-thecounter medication or prescribe something to help keep it under control. Sensitivity to cold Oxaliplatin can cause you to be VERY sensitive to cold for 3-7 days after treatment. • Avoid exposure to cold temperatures or touching cold objects • Avoid cold drinks, ice, and cold food. Use a straw when drinking cool liquids • Wear gloves when reaching into the freezer or handling cold objects Wear gloves and cover mouth with a scarf during cold weather Continued on the next page Page 6 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Possible Side Effect Management Numbness or tingling in your hands and feet (peripheral neuropathy) Report changes in your sense of touch, such as a burning feeling, pain on the skin or weakness. Fatigue You may be more tired than usual or have less energy. • Stay as active as possible, but know it is okay to rest as needed. • Try to do some type of moderate activity every day. • Conserve your energy. Plan your activities and do them at a time of day when you feel a bit more energetic. • Follow a healthy diet and stay hydrated. • Accept help from family and friends • Find healthy ways to manage stress, such as meditation, journaling, yoga, and guided imagery • Develop good sleeping habits, limit napping during the day to help you sleep better at night. • Avoid operating heavy machinery if you feel too tired. Contact your care team if you experience extreme fatigue that prevents you from doing your normal daily activities. Sun sensitivity Your skin will be more sensitive to the sun. • Avoid excess sun exposure to decrease the risk of sunburn • Wear a broad-brimmed hat • Apply broad-spectrum sunscreen (UVA/UVB) with SPF 30 or higher and use a lip balm with at least SPF 30 • Avoid tanning beds Page 7 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Rare but serious side effects Tell your care provider if you experience any symptoms of these problems: o Interstitial Lung Disease: Oxaliplatin may be harmful to your lungs. Inform your care team of any new difficulty breathing, cough, or fever. Your provider may stop treatment with oxaliplatin if your lungs are affected. o Hypersensitivity Reactions: Severe allergic reactions are a rare but serious side effect of oxaliplatin. Right away seek medical attention if you notice difficulty breathing, swelling of the mouth or tongue, or a serious rash. o Cardiotoxicity: See medical attention right away if you have any chest pain or tightness. o Cardiomyopathy: Fluorouracil can make your heart work harder to pump blood to the rest of your body. Notify your care team if you experience shortness of breath or chest pain. o Dihydropyrimidine dehydrogenase (DPD) deficiency is a rare genetic condition where the body cannot break down certain cancer treatments, leading to severe side effects. Talk to your doctor to see if you should be tested. If you experience ANY new, worsening, or uncontrolled side effects, call your care team immediately. Page 8 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Handling body fluids and waste Some of the drugs you receive may be present in urine, stool, sweat, or vomit for many days after treatment. Many cancer drugs are toxic, your bodily waste may also be toxic and can be dangerous to come into contact with. Once you have started FOLFOX, follow the instructions below for at least two days after your treatment. This is to keep you, your loved ones, and the environment as safe as possible. o Pregnant women should avoid touching anything that may be soiled with body fluids from the patient. o Toilet and septic systems • You may use the same toilet, septic tank, and/or sewer that you usually use. If you have a low-flow toilet, close the lid and flush twice to ensure that all waste has been discarded. o If the toilet or toilet seat becomes soiled with urine, stool, or vomit, clean the surface after every use before other people use the toliet. o Wash hands with soap and water after using the toilet for at least 20 seconds. o If you need a bedpan, be sure your caregiver knows to wear gloves to assist with cleanup and to wash the bedpan with soap and water every day. o If you do not have good control of bladder or bowels, use a disposable pad with a plastic back, a diaper, or a sheet to absorb body waste. o Wash any skin that has been exposed to body waste with soap and water. o Linens or clothing that are soiled with body fluids or body waste should be washed separately from other linens and clothing. If you do not have a washer, place the soiled linens in a plastic bag until they can be washed. o Wash hands with soap and water after touching linens or clothing that may be soiled with body fluids. Intimacy, sexual activity, contraception, and fertility This treatment may cause changes that can affect intimacy and sexuality, including desire and body image. Maintaining physical closeness and/or intimacy with loved ones can be continued during treatment. Holding hands, hugging, and kissing can be done safely. It is recommended that you talk to your care team about any restrictions or questions you may have. Some treatments can influence the ability to have children, also known as fertility. If you’re interested in preserving fertility, talk to your care team before treatment. Ask your healthcare provider to determine when it is safe to become pregnant after your treatment. Patients of reproductive ability should not become pregnant or get their partners pregnant while receiving Some of the drugs you receive may be present in semen and vaginal secretion for many days after treatment. You should use barrier devices, such as condoms, during sexual activity to limit exposure to body fluids. o Talk to your care team about birth control. Not all options may be right for your treatment or cancer. Effective contraception could include one or more of the following: barrier methods (e.g. condoms), hormone methods (e.g. birth control pills), or surgery. o Tell your care team if you become pregnant or plan to breastfeed. Page 9 FOLFOX INTRAVENOUS CANCER TREATMENT EDUCATION Additional resources Prescribing information links: Leucovorin: https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/040347s010lbl.pdf Oxaliplatin (Eloxatin): https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/021759s012lbl.pdf Fluorouracil or 5-FU (Adrucil): https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/012209s040lbl. pdf Updated – January 4, 2022 Additional instructions Important notice: The Association of Community Cancer Centers (ACCC), Hematology/Oncology Pharmacy Association (HOPA), National Community Oncology Dispensing Association, Inc. (NCODA), and Oncology Nursing Society (ONS) have collaborated in gathering information for and developing this patient education guide. This guide represents a brief summary of the therapy derived from information provided by the drug manufacturer and other resources. This guide does not cover all existing information related to the possible uses, directions, doses, precautions, warnings, interactions, adverse effects, or risks associated with this therapy and should not substitute for the advice of a qualified healthcare professional. Provision of this guide is for informational purposes only and does not constitute or imply endorsement, recommendation, or favoring of this therapy by ACCC, HOPA, NCODA, or ONS, who assume no liability for and cannot ensure the accuracy of the information presented. The collaborators are not making any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual receiving therapy. All decisions related to receiving this therapy should be made with the guidance and under the direction of a qualified healthcare professional. Permission: Intravenous Cancer Treatment Education (IVE) sheets are provided as a free educational resource for patients with cancer in need of concise, easy-to-understand information about intravenous cancer therapy. Healthcare providers are permitted to copy and distribute the sheets to patients as well as direct patients to the OCE website for information. However, commercial reproduction or reuse, as well as rebranding or reposting of any type, are strictly prohibited without permission of the copyright holder. Please email permission requests and licensing inquiries to This email address is being protected from spambots. You need JavaScript enabled to view it.. Copyright © 2021 by NCODA. All rights reserved.