Effectuez un dépistage du virus de l'hépatite B chez tous les patients cancéreux débutant un traitement systémique. Apprenez-en davantage sur le dépistage et la gestion du virus de l'hépatite B.

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CRBPPEME+PEMB

CRBPPEMEPEMB.pdf

CRBPPEME+PEMB Treatment

This handout gives general information about this cancer treatment.

You will learn:

who to contact for help
what the treatment is
how it is given
what to expect while on treatment

This handout was created by Ontario Health (Cancer Care Ontario) together with patients and their caregivers who have also gone through cancer treatment. It is meant to help support you through your cancer treatment and answer some of your questions.

This information does not replace the advice of your health care team. Always talk to your health care team about your treatment.

Who do I contact if I have questions or need help?

My cancer health care provider is: _____________________________________________

During the day I should contact: _______________________________________________

Evenings, weekends and holidays: _____________________________________________

This page gives general information about this cancer treatment.

You will learn:

who to contact for help
what the treatment is
how it is given
what to expect while on treatment

This information was created by Ontario Health (Cancer Care Ontario) together with patients and their caregivers who have also gone through cancer treatment. It is meant to help support you through your cancer treatment and answer some of your questions.

This information does not replace the advice of your health care team. Always talk to your health care team about your treatment.

What is this treatment?

CRBPPEME+PEMB is the code name of your lung cancer treatment regimen.

A regimen is a combination of medications to treat cancer.

This regimen name is made up of one or more letters from the names of the 3 medications in your treatment.

Here are the name(s) of the medication(s) in this regimen:

CRBP = CaRBoPlatin

PEME = PEMEtrexed

+
PEMB = PEMBrolizumab

For most people, the first part of the treatment (CRBPPEME+PEMB) lasts 12 weeks. The treatment is divided into 4 cycles. Each cycle is 3 weeks long.

Here is a picture of the schedule for CRBPPEME+PEMB treatment:

Cycle 1 

CRBPPEME+
PEMB

(3 weeks)

Cycle 2

CRBPPEME+
PEMB

(3 weeks)

Cycle 3

CRBPPEME+
PEMB

(3 weeks)

Cycle 4

CRBPPEME+
PEMB

(3 weeks)

For some people, treatment may last 18 weeks. The treatment is divided into 6 cycles. Each cycle is 3 weeks long. Your health care team will tell you how many cycles you need.

After CRBPPEME+PEMB is completed, pemetrexed and pembrolizumab alone (PEME+PEMB) continue every 3 weeks for approximately 2 years in total.

During each 3-week cycle, you will have CRBPPEME+PEMB treatment on day 1 at the hospital.

Each cycle looks like this:

Day 1

Treatment Day:
Go to the hospital for CRBPPEME

+PEMB treatment

No CRBPPEME

+PEMB treatment

Remember To:

Tell your health care team about all of the other medications you are taking.
Keep taking other medications that have been prescribed for you, unless you have been told not to by your health care team.

You will have a blood test to check for hepatitis B before starting treatment. See the Hepatitis B and Cancer Medications pamphlet for more information.

How is this treatment given?

The medication(s) in your treatment are given through an IV (injected into a vein) at the hospital.

You will have a blood test before each treatment cycle to make sure it is safe for you to get treatment.

What other medications are given with this treatment?

To Prevent Nausea and Vomiting

You will be given medications to help prevent nausea (feeling like throwing up) and vomiting (throwing up) before they start.

These are called anti-nausea medications and include medications such as ondansetron (Zofran®), granisetron (Kytril®), aprepitant (Emend®), or others.

To Prevent Skin Rash

You will be given a medication to take starting the day before each CRBPPEME+PEMB or PEME+PEMB treatment cycle to prevent skin rashes.

The medication is a corticosteroid such as dexamethasone.

To Protect Healthy Cells and Lower Your Chance of Side Effects

You will be given a prescription for folic acid tablets to take by mouth and vitamin B12 that will be given by a needle.
You will start taking your folic acid and receive vitamin B12 at least 7 days before your first CRBPPEME+PEMB treatment.
Keep taking them during treatment and for at least 21 days after your last pemetrexed treatment (including PEME+PEMB treatment).
Talk to your health care team about exactly how to take these medications.

DO this while on treatment		DO NOT do this while on treatment
DO tell your health care team about any other medical conditions that you have such as: heart, liver, kidney or lung problems immune conditions (such as Crohn's disease) problems with your nerves (pain, numbness or tingling of your hands or feet) problems with hormone producing glands (such as thyroid, pituitary or adrenal glands) diabetes, or any allergies DO check with your health care team before getting any vaccinations, surgery, dental work or other medical procedures. DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatmen Do moisturize your skin and nails regularly while on treatment and for 2 months after treatment ends. Make sure you use an emollient moisturizer (such as cream or ointment) that is alcohol and fragrance-free. DO tell your health care team about ANY new symptom you develop. You may need urgent medical treatment.		DO NOT take any other medications, such as vitamins, over-the-counter (non-prescription) drugs or substances, or natural health products without checking with your health care team. DO NOT start any complementary or alternative therapies, such as acupuncture or homeopathic products, without checking with your health care team. DO NOT use tobacco products (such as smoking cigarettes or vaping) or drink alcohol while on treatment without talking to your health care team first. Smoking and drinking can make side effects worse and make your treatment not work as well. DO NOT take anti-inflammatory medications (such as ibuprofen (Advil® or Motrin®), naproxen (Aleve®) or Aspirin® for 5 days before and 2 days after your pemetrexed treatment. They can make your side effects worse. DO NOT drive or operate machinery if your vision is blurry or impaired in any way.

DO this while on treatment

DO NOT do this while on treatment

Check Mark Icon

DO tell your health care team about any other medical conditions that you have such as:
- heart, liver, kidney or lung problems
- immune conditions (such as Crohn's disease)
- problems with your nerves (pain, numbness or tingling of your hands or feet)
- problems with hormone producing glands (such as thyroid, pituitary or adrenal glands)
- diabetes, or
- any allergies

DO check with your health care team before getting any vaccinations, surgery, dental work or other medical procedures.
DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatmen

Do moisturize your skin and nails regularly while on treatment and for 2 months after treatment ends. Make sure you use an emollient moisturizer (such as cream or ointment) that is alcohol and fragrance-free.
DO tell your health care team about ANY new symptom you develop. You may need urgent medical treatment.

Stop Icon

DO NOT take any other medications, such as vitamins, over-the-counter (non-prescription) drugs or substances, or natural health products without checking with your health care team.
DO NOT start any complementary or alternative therapies, such as acupuncture or homeopathic products, without checking with your health care team.
DO NOT use tobacco products (such as smoking cigarettes or vaping) or drink alcohol while on treatment without talking to your health care team first. Smoking and drinking can make side effects worse and make your treatment not work as well.
DO NOT take anti-inflammatory medications (such as ibuprofen (Advil® or Motrin®), naproxen (Aleve®) or Aspirin® for 5 days before and 2 days after your pemetrexed treatment. They can make your side effects worse.
DO NOT drive or operate machinery if your vision is blurry or impaired in any way.

DO this while on treatment

Check Mark Icon

DO tell your health care team about any other medical conditions that you have such as:
- heart, liver, kidney or lung problems
- immune conditions (such as Crohn's disease)
- problems with your nerves (pain, numbness or tingling of your hands or feet)
- problems with hormone producing glands (such as thyroid, pituitary or adrenal glands)
- diabetes, or
- any allergies

DO check with your health care team before getting any vaccinations, surgery, dental work or other medical procedures.
DO consider asking someone to drive you to and from the hospital on your treatment days. You may feel drowsy or dizzy after your treatmen

Do moisturize your skin and nails regularly while on treatment and for 2 months after treatment ends. Make sure you use an emollient moisturizer (such as cream or ointment) that is alcohol and fragrance-free.
DO tell your health care team about ANY new symptom you develop. You may need urgent medical treatment.

DO NOT do this while on treatment

Stop Icon

DO NOT take any other medications, such as vitamins, over-the-counter (non-prescription) drugs or substances, or natural health products without checking with your health care team.
DO NOT start any complementary or alternative therapies, such as acupuncture or homeopathic products, without checking with your health care team.
DO NOT use tobacco products (such as smoking cigarettes or vaping) or drink alcohol while on treatment without talking to your health care team first. Smoking and drinking can make side effects worse and make your treatment not work as well.
DO NOT take anti-inflammatory medications (such as ibuprofen (Advil® or Motrin®), naproxen (Aleve®) or Aspirin® for 5 days before and 2 days after your pemetrexed treatment. They can make your side effects worse.
DO NOT drive or operate machinery if your vision is blurry or impaired in any way.

Will this treatment interact with other medications or natural health products?

Yes, the medications in this regimen can interact with other medications, vitamins, foods, traditional medicines and natural health products. Interactions can make the treatment not work as well or cause severe side effects.
Tell your health care team about all of your:
- prescription and over-the-counter (non-prescription) medications
- other drugs and substances, such as cannabis/marijuana (medical or recreational)
- natural health products such as vitamins, herbal teas, homeopathic medicines, and other supplements, or traditional medicines
Check with your health care team before starting or stopping any of them.
If you are taking a blood thinner (such as warfarin), your health care team may need extra blood tests and may change your dose.
If you take seizure medications (such as phenytoin), your health care team may monitor your blood levels closely and may change your dose.
If you take anti-inflammatory medications such as ibuprofen (Advil® or Motrin®) or naproxen (Aleve®) or Aspirin®, your health care team will ask you to stop taking them for at least 5 days before and 2 days after your CRBPPEME+PEMB or PEME+PEMB treatment day.

Talk to your health care team BEFORE taking or using these :

Anti-inflammatory medications such as ibuprofen (Advil^® or Motrin^®), naproxen (Aleve^®) or Aspirin^®.
Over-the-counter products such as dimenhydrinate (Gravol^®)
Natural health products such as St. John’s Wort
Traditional medicines
Supplements such as vitamin C
Grapefruit juice
Alcoholic drinks
Tobacco
All other drugs or substances, such as marijuana or cannabis (medical or recreational)

What should I do if I feel unwell, have pain, a headache or a fever?

Always check your temperature to see if you have a fever before taking any medications for fever or pain (such as acetaminophen (Tylenol^®)).
- Fever can be a sign of infection that may need treatment right away.
- If you take these medications before you check for fever, they may lower your temperature and you may not know you have an infection.

How to check for fever:

Keep a digital (electronic) thermometer at home and take your temperature if you feel hot or unwell (for example, chills, headache, mild pain).

You have a fever if your temperature taken in your mouth (oral temperature) is:
- 38.3°C (100.9°F) or higher at any time
OR
- 38.0°C (100.4°F) or higher for at least one hour.

If you do have a fever :

Try to contact your health care team. If you are not able to talk to them for advice, you MUST get emergency medical help right away.
Ask your health care team for the Fever pamphlet for more information.

If you do not have a fever but have mild symptoms such as headache or mild pain:

Ask your health care team about the right medication for you. Acetaminophen (Tylenol^®) is a safe choice for most people.

DO NOT take ibuprofen (Advil^®, Motrin^®), naproxen (Aleve^®) or ASA (Aspirin^®), as they may increase your chance of bleeding and can make side effects worse.

Talk to your health care team if you already take low dose aspirin for a medical condition (such as a heart problem). It may still be safe to take.

How will this treatment affect sex, pregnancy and breast feeding?

Talk to your health care team about:

How this treatment may affect your sexual health
How this treatment may affect your ability to have a baby, if this applies to you.
- One of the medications in your treatment (pemetrexed) may affect your ability to make healthy sperm. You may need to store your sperm before starting treatment, if this applies to you.

This treatment may harm an unborn baby. Tell your health care team if you or your partner are pregnant, become pregnant during treatment, or are breastfeeding.

If there is any chance of pregnancy happening, you and your partner together must use 2 effective forms of birth control at the same time while you are on treatment. Talk to your health care team about which birth control options are best for you, and how long you should use them after your last treatment dose.

Do not breastfeed while on this treatment. Talk to your health care team about how long to wait before you start breastfeeding after your last treatment dose, if this applies to you.

What are the side effects of this treatment?

One of the medications in your treatment (pembrolizumab) makes your immune system work harder. Your immune system is what fights infections and your cancer.

When your immune system is working harder, you may have side effects in your bowels, liver, lungs, skin, kidneys, and other organs. You may also have changes in hormone levels in your body.

These side effects may be mild or may become serious or life-threatening in rare cases.

They may happen during your treatment or weeks to months after your treatment ends.

Some things to watch for are:

diarrhea
a new cough
problems with breathing
rash
any other new symptom

If you have side effects, you must talk to your health care team right away. You may need urgent treatment.

The following table lists side effects that you may have when getting CRBPPEME+PEMB treatment. The table is set up to list the most common side effects first and the least common last. It is unlikely that you will have all of the side effects listed and you may have some that are not listed.

After the CRBPPEME+PEMB treatment is completed, pemetrexed and pembrolizumab alone (PEME+PEMB) continue for approximately 2 years in total. You may have less side effects with this treatment. The side effects that you are less likely to have with PEME+PEMB are outlined in the table below.

Read over the side effect table so that you know what to look for and when to get help. Refer to this table if you experience any side effects while on CRBPPEME+PEMB and PEME+PEMB treatment.

Very Common Side Effects (50 or more out of 100 people)
Nausea and vomiting (Less likely with PEME+PEMB) What to look for? Nausea is feeling like you need to throw up. You may also feel light-headed. You may feel nausea within hours to days after your treatment. What to do? To help prevent nausea: It is easier to prevent nausea than to treat it once it happens. If you were given anti-nausea medication(s), take them as prescribed, even if you do not feel like throwing up. Drink clear liquids and have small meals. Get fresh air and rest. Do not eat spicy, fried foods or foods with a strong smell. Limit caffeine (like coffee, tea) and avoid alcohol. If you have nausea or vomiting: Take your rescue (as-needed) anti-nausea medication(s) as prescribed. Ask your health care team for the Nausea & Vomiting pamphlet for more information. Talk to your health care team if: nausea lasts more than 48 hours vomiting lasts more than 24 hours or if it is severe	Contact your healthcare team if nausea lasts more than 48 hours or vomiting lasts more than 24 hours.

Very Common Side Effects (50 or more out of 100 people)

Side effects and what to do

When to contact health care team

Nausea and vomiting

(Less likely with PEME+PEMB)

What to look for?

Nausea is feeling like you need to throw up. You may also feel light-headed.
You may feel nausea within hours to days after your treatment.

What to do?

To help prevent nausea:

It is easier to prevent nausea than to treat it once it happens.
If you were given anti-nausea medication(s), take them as prescribed, even if you do not feel like throwing up.
Drink clear liquids and have small meals. Get fresh air and rest.
Do not eat spicy, fried foods or foods with a strong smell.
Limit caffeine (like coffee, tea) and avoid alcohol.

If you have nausea or vomiting:

Take your rescue (as-needed) anti-nausea medication(s) as prescribed.
Ask your health care team for the Nausea & Vomiting pamphlet for more information.
Talk to your health care team if:
- nausea lasts more than 48 hours
- vomiting lasts more than 24 hours or if it is severe

Contact your healthcare team if nausea lasts more than 48 hours or vomiting lasts more than 24 hours.

Common Side Effects (25 to 49 out of 100 people)
Side effects and what to do	When to contact health care team
Fatigue What to look for? Feeling of tiredness or low energy that lasts a long time and does not go away with rest or sleep. What to do? Be active. Aim to get 30 minutes of moderate exercise (you are able to talk comfortably while exercising) on most days. Check with your health care team before starting any new exercise. Pace yourself, do not rush. Put off less important activities. Rest when you need to. Ask family or friends to help you with things like housework, shopping, and child or pet care. Eat well and drink at least 6 to 8 glasses of water or other liquids every day (unless your health care team has told you to drink more or less). Avoid driving or using machinery if you are feeling tired. Ask your health care team for the Fatigue pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe.
Constipation (Less likely with PEME+PEMB) What to look for? Having bowel movements (going poo) less often than normal. Small hard stools (poo) that look like pellets. The need to push hard and strain to have any stool (poo) come out. Stomach ache or cramps. A bloated belly, feeling of fullness, or discomfort. Leaking of watery stools (poo). Lots of gas or burping. Nausea or vomiting. What to do? To help prevent constipation: Try to eat more fiber rich foods like fruits with skin, leafy greens and whole grains. Drink at least 6 to 8 cups of liquids each day unless your health care team has told you to drink more or less. Be Active. Exercise can help to keep you regular. If you take opioid pain medication, ask your health care team if eating more fibre is right for you. To help treat constipation: If you have not had a bowel movement in 2 to 3 days you may need to take a laxative (medication to help you poo) to help you have regular bowel movements. Ask your health care team what to do. Ask your health care team for the Constipation Pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe.
Low neutrophils (white blood cells) in the blood (neutropenia) (Less likely with PEME+PEMB) When neutrophils are low, you are at risk of getting an infection more easily. Ask your health care team for the Neutropenia (Low white blood cell count) pamphlet for more information. What to look for? If you feel hot or unwell (for example if you have chills or a new cough), you must check your temperature to see if you have a fever. Do not take medications that treat a fever before you take your temperature (for example, Tylenol® (acetaminophen). Do not eat or drink anything hot or cold right before taking your temperature. You have a fever if your temperature taken in your mouth (oral temperature) is: 38.3°C (100.9°F) or higher at any time OR 38.0°C (100.4°F) or higher for at least one hour. What to do? If your health care team has told you that you have low neutrophils: Wash your hands often to prevent infection. Check with your health care team before getting any vaccines, surgeries, medical procedures or visiting your dentist. Keep a digital thermometer at home so you can easily check for a fever. If you have a fever: If you have a fever, try to contact your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.	If you have a fever, try to contact your health care team. If you are unable to talk to the team for advice, you MUST get emergency medical help right away.
Low platelets in the blood (Less likely with PEME+PEMB) When your platelets are low, you are at risk for bleeding and bruising. Ask your health care team for the Low Platelet Count pamphlet for more information. What to look for? Watch for signs of bleeding: bleeding from your gums unusual or heavy nosebleeds bruising easily or more than normal black coloured stools (poo) or blood in your stools (poo) coughing up red or brown coloured mucus dizziness, constant headache or changes in your vision heavy vaginal bleeding red or pink coloured urine (pee) What to do? If your health care team has told you that you have low platelets: Tell your pharmacist that your platelet count may be low before taking any prescriptions or over-the-counter medication. Check with your healthcare team before you go to the dentist. Take care of your mouth and use a soft toothbrush. Try to prevent cuts and bruises. Ask your health care team what activities are safe for you. Your treatment may have to be delayed if you have low platelets. Your health care team may recommend a blood transfusion. If you have signs of bleeding: If you have a small bleed, clean the area with soap and water or a saline (saltwater) rinse. Apply pressure for at least 10 minutes. If you have bleeding that does not stop or is severe (very heavy), you must get emergency medical help right away.	Talk to your health care team if you have any signs of bleeding. If you have bleeding that doesn’t stop or is severe (very heavy), you MUST get emergency help right away.

Less Common Side Effects (10 to 24 out of 100 people)
Diarrhea What to look for? Loose, watery, unformed stool (poo) that may happen days to weeks after you get your treatment. What to do? If you have diarrhea: Take anti-diarrhea medication if your health care team prescribed it or told you to take it. Do not eat foods or drinks with artificial sweetener (like chewing gum or ‘diet’ drinks), coffee and alcohol, until your diarrhea has stopped. Eat many small meals and snacks instead of 2 or 3 large meals. Drink at least 6 to 8 cups of liquids each day, unless your health care team has told you to drink more or less. Talk to your health care team if you can’t drink 6 to 8 cups of liquids each day when you have diarrhea. You may need to drink special liquids with salt and sugar, called Oral Rehydration Therapy. Ask your health care team for the Diarrhea pamphlet for more information. In rare cases, your diarrhea may be severe due to inflammation of the intestines if: You have blood in your stool (poo) or You have more than 4 bowel movements (going poo) a day (if that is not normal for you) If this happens, talk to your health care team or go to the emergency room right away.	Talk to your health care team for advice. Talk to your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.
Low appetite What to look for? Loss of interest in food or not feeling hungry. Weight loss. What to do? Try to eat your favourite foods. Eat small meals throughout the day. You may need to take meal supplements to help keep your weight up. Talk to your health care team if you have no appetite. Ask your health care team for the Loss of Appetite pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe.
Cough and feeling short of breath What to look for? You may have a cough and feel short of breath. Symptoms that commonly occur with a cough are: wheezing or a whistling breathing runny nose sore throat heartburn weight loss fever and chills Rarely this may be severe with chest pain, trouble breathing or coughing up blood. What to do? Check your temperature to see if you have a fever. Read the above section "What should I do if I feel unwell, have pain, a headache or a fever?". If you have a fever, try to talk to your health care team. If you are not able to talk to them for advice, you MUST get emergency medical help right away. If you have a severe cough with chest pain, trouble breathing or you are coughing up blood, get medical help right away.	Talk to your health care team. If you are not able to talk to your health care team for advice, and you have a fever or severe symptoms, you MUST get emergency medical help right away.
Rash (May be severe) What to look for? Your skin may look red and feel warm, like a sunburn. Your skin may have bumps, itch, burn, sting or feel very tender when touched. The rash may be seen in areas where you have had radiation before. What to do? To prevent and treat dry skin: Use fragrance-free skin moisturizer. Protect your skin from the sun and the cold. Use sunscreen with UVA and UVB protection and a SPF of at least 30. Avoid perfumed products and lotions that contain alcohol. Drink 6 to 8 cups of non-alcoholic, non-caffeinated liquids each day, unless your health care team has told you to drink more or less. In rare cases, rash may be severe if: The rash covers more than a third of your skin (for example your whole trunk, or an arm AND a leg) or The rash causes your skin to blister or peel. If this happens, talk to your health care team or go to the emergency room right away.	Talk to your health care team for advice. Talk to your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.
Mild swelling What to look for? You may have mild swelling or puffiness in your arms and/or legs. Rarely, this may be severe. What to do? To help prevent swelling: Eat a low-salt diet. If you have swelling: Wear loose-fitting clothing. For swollen legs or feet, keep your feet up when sitting.	Talk to your health care team if it does not improve or if it is severe.
Mouth sores What to look for? Round, painful, white or gray sores inside your mouth that can occur on the tongue, lips, gums, or inside your cheeks. In more severe cases they may make it hard to swallow, eat or brush your teeth. They may last for 3 days or longer. What to do? To help prevent mouth sores: Take care of your mouth by gently brushing and flossing regularly. Rinse your mouth often with a homemade mouthwash. To make a homemade mouthwash, mix 1 teaspoonful of baking soda and 1 teaspoonful of salt in 4 cups (1L) of water. Do not use store-bought mouthwashes, especially those with alcohol, because they may irritate your mouth. If you have mouth sores: Avoid hot, spicy, acidic, hard or crunchy foods. Your doctor may prescribe a special mouthwash to relieve mouth sores and prevent infection. Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow. Ask your health care team for the Oral Care (Mouth Care) pamphlet for more information.	Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow.
Too much or too little salt in your body (with CRBPPEME+PEMB) What to look for? Muscle spasms, cramping, weakness, twitching, or convulsions. Irregular heartbeat, confusion or blood pressure changes. What to do? Get emergency medical help right away for severe symptoms.	Get emergency medical help right away for severe symptoms.
Liver problems Your health care team may check your liver function with a blood test. Liver changes do not usually cause any symptoms. What to look for? Rarely, you may develop yellowish skin or eyes, unusually dark pee or pain on the right side of your belly. This may be severe. What to do? If you have any symptoms of liver problems, get emergency medical help right away.	Get emergency medical help right away.
Mild joint, muscle pain or cramps What to look for? New pain in your muscles or joints, muscle cramps, or feeling achy. What to do? Take pain medication (such as acetaminophen) as needed, or opioids such as codeine, morphine, hydromorphone, oxycodone) as prescribed. Read the above section: "What should I do if I feel unwell, have pain, a headache or a fever?" before taking acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), naproxen (Aleve®) or Aspirin. These medications may hide an infection that needs treatment or they may increase your risk of bleeding. Rest often and try light exercise (such as walking) as it may help. Ask your health care team for the Pain pamphlet for more information.	Talk to your health care team if it does not improve or if it is severe.

Less Common Side Effects (10 to 24 out of 100 people)

Side effects and what to do

When to contact health care team

Diarrhea

What to look for?

Loose, watery, unformed stool (poo) that may happen days to weeks after you get your treatment.

What to do?

If you have diarrhea:

Take anti-diarrhea medication if your health care team prescribed it or told you to take it.
Do not eat foods or drinks with artificial sweetener (like chewing gum or ‘diet’ drinks), coffee and alcohol, until your diarrhea has stopped.
Eat many small meals and snacks instead of 2 or 3 large meals.
Drink at least 6 to 8 cups of liquids each day, unless your health care team has told you to drink more or less.
Talk to your health care team if you can’t drink 6 to 8 cups of liquids each day when you have diarrhea. You may need to drink special liquids with salt and sugar, called Oral Rehydration Therapy.

Ask your health care team for the Diarrhea pamphlet for more information.

In rare cases, your diarrhea may be severe due to inflammation of the intestines if:

You have blood in your stool (poo) or
You have more than 4 bowel movements (going poo) a day (if that is not normal for you)

If this happens, talk to your health care team or go to the emergency room right away.

Talk to your health care team for advice.

Talk to your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.

Low appetite

What to look for?

Loss of interest in food or not feeling hungry.
Weight loss.

What to do?

Try to eat your favourite foods.
Eat small meals throughout the day.
You may need to take meal supplements to help keep your weight up.
Talk to your health care team if you have no appetite.

Ask your health care team for the Loss of Appetite pamphlet for more information.

Talk to your health care team if it does not improve or if it is severe.

Cough and feeling short of breath

What to look for?

You may have a cough and feel short of breath.
Symptoms that commonly occur with a cough are:
- wheezing or a whistling breathing
- runny nose
- sore throat
- heartburn
- weight loss
- fever and chills
Rarely this may be severe with chest pain, trouble breathing or coughing up blood.

What to do?

Check your temperature to see if you have a fever. Read the above section "What should I do if I feel unwell, have pain, a headache or a fever?".
If you have a fever, try to talk to your health care team. If you are not able to talk to them for advice, you MUST get emergency medical help right away.
If you have a severe cough with chest pain, trouble breathing or you are coughing up blood, get medical help right away.

Talk to your health care team. If you are not able to talk to your health care team for advice, and you have a fever or severe symptoms, you MUST get emergency medical help right away.

Rash

(May be severe)

What to look for?

Your skin may look red and feel warm, like a sunburn.
Your skin may have bumps, itch, burn, sting or feel very tender when touched.
The rash may be seen in areas where you have had radiation before.

What to do?

To prevent and treat dry skin:

Use fragrance-free skin moisturizer.
Protect your skin from the sun and the cold.
Use sunscreen with UVA and UVB protection and a SPF of at least 30.
Avoid perfumed products and lotions that contain alcohol.
Drink 6 to 8 cups of non-alcoholic, non-caffeinated liquids each day, unless your health care team has told you to drink more or less.

In rare cases, rash may be severe if:

The rash covers more than a third of your skin (for example your whole trunk, or an arm AND a leg) or
The rash causes your skin to blister or peel.

If this happens, talk to your health care team or go to the emergency room right away.

Talk to your health care team for advice.

Talk to your health care team. If you are unable to talk to the team for advice, you must get emergency medical help right away.

Mild swelling

What to look for?

You may have mild swelling or puffiness in your arms and/or legs. Rarely, this may be severe.

What to do?

To help prevent swelling:

Eat a low-salt diet.

If you have swelling:

Wear loose-fitting clothing.
For swollen legs or feet, keep your feet up when sitting.

Talk to your health care team if it does not improve or if it is severe.

Mouth sores

What to look for?

Round, painful, white or gray sores inside your mouth that can occur on the tongue, lips, gums, or inside your cheeks.
In more severe cases they may make it hard to swallow, eat or brush your teeth.
They may last for 3 days or longer.

What to do?

To help prevent mouth sores:

Take care of your mouth by gently brushing and flossing regularly.
Rinse your mouth often with a homemade mouthwash.
To make a homemade mouthwash, mix 1 teaspoonful of baking soda and 1 teaspoonful of salt in 4 cups (1L) of water.
Do not use store-bought mouthwashes, especially those with alcohol, because they may irritate your mouth.

If you have mouth sores:

Avoid hot, spicy, acidic, hard or crunchy foods.
Your doctor may prescribe a special mouthwash to relieve mouth sores and prevent infection.
Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow.

Ask your health care team for the Oral Care (Mouth Care) pamphlet for more information.

Talk to your health care team as soon as you notice mouth or lip sores or if it hurts to eat, drink or swallow.

Too much or too little salt in your body

(with CRBPPEME+PEMB)

What to look for?

Muscle spasms, cramping, weakness, twitching, or convulsions.
Irregular heartbeat, confusion or blood pressure changes.

What to do?

Get emergency medical help right away for severe symptoms.

Get emergency medical help right away for severe symptoms.

Liver problems

Your health care team may check your liver function with a blood test. Liver changes do not usually cause any symptoms.

What to look for?

Rarely, you may develop yellowish skin or eyes, unusually dark pee or pain on the right side of your belly. This may be severe.

What to do?

If you have any symptoms of liver problems, get emergency medical help right away.

Get emergency medical help right away.

Mild joint, muscle pain or cramps

What to look for?

New pain in your muscles or joints, muscle cramps, or feeling achy.

What to do?

Take pain medication (such as acetaminophen) as needed, or opioids such as codeine, morphine, hydromorphone, oxycodone) as prescribed.
Read the above section: "What should I do if I feel unwell, have pain, a headache or a fever?" before taking acetaminophen (Tylenol®), ibuprofen (Advil®, Motrin®), naproxen (Aleve®) or Aspirin. These medications may hide an infection that needs treatment or they may increase your risk of bleeding.
Rest often and try light exercise (such as walking) as it may help.

Ask your health care team for the Pain pamphlet for more information.

Talk to your health care team if it does not improve or if it is severe.

Other rare, but serious side effects are possible with this treatment.

If you have any of the following, talk to your cancer health care team or get emergency medical help right away:

irregular heartbeat, shortness of breath or chest pain
new cough, or coughing up blood
severe headache, passing out (fainting) or seizure
any changes to your vision, unusual or increased tearing or new sensitivity to light
changes in your hearing (for example not being able to hear as well as before, new noise or ringing sounds in your ears).
sudden confusion, trouble speaking, thinking or problems with your memory
severe numbness or tingling of your fingers or toes that is painful (sometimes feels like burning), or makes it hard for you do tasks like doing up buttons, writing, or moving
signs of an allergic reaction, such as rash, swollen lips, face or tongue, chest or throat tightness that happen during or shortly after your treatment is given
peeing less than usual
weight gain that is not normal for you
severe muscle pain, weakness or twitching
difficulty moving your arms or legs
sudden, severe pain in your lower back, belly, or arm

For more information on how to manage your symptoms ask your health care provider, or visit: https://www.cancercareontario.ca/symptoms.

Notes

February 2026 New patient medication information sheet

For more links on how to manage your symptoms go to www.cancercareontario.ca/symptoms.

The information set out in the medication information sheets, regimen information sheets, and symptom management information(for patients) contained in the Drug Formulary (the "Formulary") is intended to be used by health professionals and patients for informational purposes only. The information is not intended to cover all possible uses, directions, precautions, drug interactions or side effects of a certain drug, nor should it be used to indicate that use of a particular drug is safe, appropriate or effective for a given condition.

A patient should always consult a healthcare provider if he/she has any questions regarding the information set out in the Formulary. The information in the Formulary is not intended to act as or replace medical advice and should not be relied upon in any such regard. All uses of the Formulary are subject to clinical judgment and actual prescribing patterns may not follow the information provided in the Formulary.

Certaines de ces informations ou toutes, dans certains cas, n’apparaissent qu’en Anglais. Vous pouvez demander la version française

CRBPPEME+PEMB

Gestion des symptômes

Sécurité et administration des médicaments