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The dreaded “nadir”

Brooklyn_bottom
Posts: 5
Joined: Jan 2018

First post-I am a (reasonably) healthy 47 year old male, who was diagnosed with squamous cell anal cancer in December. I started treatment Dec. 27, flourfouracil and mitomycin with 7 weeks radiation.

2 1/2 weeks in, other than fatigue right after the first round of chemo, and increasing irritation of the “tuchus“ (I prefer to use the medical nomenclature) it has not been that bad so far. Which worries me a bit since I was told this would be a “short but brutal” treatment and to “buckle up,” not sure the the New England Journal of Medicine would tell you to buckle up, but I have a pretty blunt doctor. 

Dr Blunt told me the mitomycin hits it’s “nadir” after week 3, and I can expect the usual suspects (fatigue, nausea, diarrhea etc.) but more severe. 

My questions to anyone who had unfortunately gone though this is:

When do you start to feel the effects of the nadir/mitomycin and do they gradually get worse or hit all at once? And how long does that last?

I‘m just concerned going to bed freeling just crummy and waking up feeling like you can’t get out of bed (expect to run to the bathroom, of course.)

Thanks for any insight.

-BB

 

0626june's picture
0626june
Posts: 73
Joined: Jun 2014

but glad you found this resource. I am 3 1/2 years post-treatment.  I was diagnosed in April of 2014 with stage 3B because lymph nodes were involved.  My mitomycin hit me like an oncoming train the day after my first dose of it.  I did some research on my own (Drs must just hate our internet searches) and found that in The U.K. and in Canada, they had stopped doing the 2nd dose of mitomycin so I decided to follow suit.  I was fortunate to be able to do my FU in pill form.  I believe the lasting effects are mostly from the 7 weeks of radiation.  I found that my bum burns (medical nomenclature) stopped worsening when I began applying aloe vera every day after radiation. It's important to wash it off completely before your next radiation treatment. To answer your question, I don't believe you'll wake up one morning feeling horrid.  (The mornings were actually my best times.) You just may be tolerating the Mitomycin better than I did.  They are so careful about the dosage that I'm certain that you're receiving the correct amount.  I guess my advice to you would be to say that 2 1/2 weeks is no small matter.  You're over 1/3rd of the way done, so enjoy these good days.  After treatment my Dr recommended PETscans every 6 months but in December we decided to make them once a year now even though I'm not yet 5 years out. They keep coming back NED!

Brooklyn_bottom
Posts: 5
Joined: Jan 2018

Thanks for the info and encouragement. It is nice to hear from someone who has been though this. 

-BB

mp327's picture
mp327
Posts: 4459
Joined: Jan 2010

Welcome to this site.  However, I'm sorry you are having to go through treatment for anal cancer.  It's definitely a rough ride, but thank goodness, only for 6 or 7 weeks.  I received treatment in 2008, I'm still here, and doing quite well, so I hope that gives you hope!

Nadir is the point in a chemo cycle where a person's blood counts essentially hit bottom.  The following is a good description of nadir.

"Nadir

 
 

What Is Nadir?

When discussing chemotherapy side effects often you will hear the word nadir, mainly in reference to the blood counts, particularly white blood cell count and platelet count.  Nadir basically means low point, however further explanation may clarify this term in connection with chemotherapy treatment.

Nadir Affects Blood Cell and Platelet Counts

When chemotherapy is given it not only affects the rapidly dividing cancer cells but it also affects some of the normal cells of the body.  These effects particularly occur on normal cells that divide rapidly such as, the hair, the lining of the mouth, the cells lining the intestinal tract and the blood cells (white and red blood cells as well as platelets). 

In the bone marrow, the spongy inner core of the larger bones in the body is where blood cells are made.  There are very immature cells called stem cells, from which the various types of blood cells develop.  These stem cells do not reproduce quickly and are less likely to be affected by chemotherapy.  As cells are maturing there are certain phases in which they divide faster.  It is during these times that the cells are most sensitive to chemotherapy.  The more mature cells can continue to become fully mature cells for several days after chemotherapy is given.  When these cells live out their life span, the circulating supply is depleted and the blood counts fall to a low point, the nadir.

Emerging from the Nadir and Returning to Normal

The blood counts will return to normal within three to four weeks, after the body's feedback system has told the stem cells in the bone marrow to increase production and begin making new cells.   If chemotherapy is given at the time that the stem cells in the bone marrow are increasing their production this could cause permanent bone marrow damage.  The timing of chemotherapy cycles takes this process into account.  For example some chemotherapy drugs are given on day 1 and day 8 of a 28-day cycle.  The second dose of chemotherapy, one week after the first, is tolerated because the stem cells have not yet increased their production (they are still at the nadir).  They have not increased their production because the second treatment is given before the count of the circulating blood has reached its nadir.

The nadir time is usually about 10 days after treatment, although this may vary depending on the drugs given.  The concern during the nadir time is that the body's first line of defense against infection, white blood cells (WBC) and the platelets, which help to clot the blood, are low leaving a person more susceptible to infection and bleeding.  The next dose of chemotherapy is given only after a person's blood counts have left the nadir and recovered to a safe level."

As stated in the above information, this is a time when you need to be careful about infection and bleeding.  Some people choose to wear a mask in certain situations, especially when in public in places where germs may abound.  That might be something to consider.  During this time, a minor infection or bug can suddenly become serious, as your body's defenses may be compromised.  This is also the time of year for the flu, which is going around.  If you are concerned, I would definitely consider a mask.  Also, hand washing is important.

I remember hitting bottom around day 14 during both cycles of chemo.  I seemed very weak for about 7 days, then began feeling better.  By the time my second round of chemo was administered, I was feeling better (except for the ongoing diarrhea and burning from radiation).  For me, those two side effects were the worst and I attribute them to the radiation, not the chemo.

I'm glad you've found this site.  You will likely have more questions as you continue to move forward in your treatment, so please ask us here.  There's lots of smart people on this forum who have been through this who can offer suggestions that helped them and may help you.  Speak up and let us know what you need.  Hang in there--this treatment is definitely a difficult thing to get through, but so many of us have done it and you will too.  I wish you all the best.  Take it one day at a time and soon you'll be crossing the finish line!

 

Brooklyn_bottom
Posts: 5
Joined: Jan 2018

Thank you for the information, that was the best explanation I read about how Chemo works and why it causes certain side effects (And That One to Grow On!)

I‘m still waiting for my aunt Nadir to drop in, but right now, still feeling good.  Thanks for the support!

-BB

mp327's picture
mp327
Posts: 4459
Joined: Jan 2010

You are most welcome.  I hope things continue to go well for you.

StruTanToot
Posts: 122
Joined: Aug 2012

For me, that last week and the two weeks after were the hardest. Radiation seemed to have the hardest effect on me. 

I' male also. The ladies on this site are wonderful and incredible. I will say conversing with a male though is welcomed, but make no mistake, I'm sorry you are going through this battle. Stay strong, stay on this site...again, the ladies...can't say enough good about them. We guys need to do better.

 

Mollymaude
Posts: 431
Joined: Nov 2016

Martha gave you a great explaination about nadir, I don't have anything to add to that except personal experience. I didn't feel too bad at the point you are at either- don't worry about it- just enjoy it while it lasts. Some of us got very sick and had to be hospitalized at the end of treatment like I was, others have been able to work during almost the entire treatment course, so it is pretty variable. What I remember was seeing a substitute radiation oncologist one week ( I think week 2) and him asking if I had radiation burns. When I told him I didn't, he seemed disappointed and said something like "well just wait, you will".  Two years later thinking about that it still makes me mad, and worse yet he was right, I did get terrible burns. I think men get by a bit better skin breakdown-wise just because of anatomy- not as much mucus membrane in the genital area so mens' skin is a little tougher. Best of luck in treatment, don't be afraid to ask anything on this site.

Jewlz's picture
Jewlz
Posts: 14
Joined: Aug 2017

When I read this, it reminded me of the radiation techs (whom I knew by name by the end of treatment). I  remember after week three of radiation, if I was uncomfortable or had trouble laying down on the machine bed the tech would ask if I was okay or if I had bad burns. They always looked a little disappointed when I didn't complain about burning.  Then, I did become severely burned and when I told the tech I picked up on that "yup she finally burned " vibe. My husband and I joked that after week three they were taking bets on what day I would crash. I will also add that the techs were very kind and were never rude about the burns...but they were definitely waiting.

Brooklyn_bottom
Posts: 5
Joined: Jan 2018

Three weeks into treatment and my white blood count dropped below normal, 3.1, (my doctor said it would drop at 3 weeks, and this is 3 weeks to the day. I’ll have to ask who he likes in the Vikings/Eagles game.) I’m told if it drops much more I’ll need to get a shot to boost the WBC. 

Anyone else get a shot to boost their white blood count? What can I look forward too?

B.B. 

(Thank you Mollymaude and Strutsntoot for the support.)

mp327's picture
mp327
Posts: 4459
Joined: Jan 2010

I received a Neupogen injection during my first round of chemo when my WBC got very low.  My WBC did the same thing during the second round, but my doctor decided not to give me an injection at that time, perhaps because I was already so miserable with diarrhea and other side effects, I don't know.  When I got the injection, it made my bones ache for a couple of days.  That's the only side effect from Neupogen that I had. 

eihtak
Posts: 1467
Joined: Oct 2011

Hi, 

I was initially treated almost 7 years ago and I do not remember if I was given a shot for this at that time but if it was available I assume I was. I was very sick going in and do remember getting Iron infusions though. Three years ago I had a recurrance of my anal cancer with mets to my lung and "yes" I do remember getting Neupogen shots to boost my white cell count at that time. I think another popular shot is Neulasta, for the same thing. The shots may cause some bone ache, but nothing of great significance at least for me and sent my white count through the roof so worth it if so.

Hang in there, and keep us updated, we're right here with you...

katheryn

Ohmy's picture
Ohmy
Posts: 102
Joined: Aug 2017

I had chemo and radiation the first week and I felt fine.  My husband says they removed the pump on Friday and Saturday morning I woke up with horrible mouth sores.  I gargled with salt and baking soda.  I used magic mouth wash  and nothing helped.  I felt like my esophagus was raw when I swallowed.  The doctor prescribed lidocaine liquid and that finally helped.  I received IV fluids but my blood work was always good.  The doctor lowered my chemo for week five.  I did not get mouth sores but I did have nausea on that round.  Took lots of anti nausea medication.  I think my white count never crashed because I always forced myself to eat and drink no matter how bad I felt.  I stayed home from work and I got plenty of rest.  I didn't get radiation burns until week five.  I kept worrying i wasn't getting enough but I guess I did.  My husband says I don't remember how sick I was.  He took good care of me.  The important thing is to avoid infection during Nadir.  Keep the anal area clean. Avoid being around people who may be sick.  I wore a mask to the treatment center waiting room. I pretty much stayed at home for months but it was all worth it.  One year later and I am still here.

Mollymaude
Posts: 431
Joined: Nov 2016

my WBC count got very low, after second round of chemo I got sepsis from a urinary tract infection. My doctor felt neupogen would not help and the explaination made sense at the time but I don't remember what it was. It obviously isn't a universal opinion though since others in this thread have gotten the shot. Your WBCs have dropped but you are nowhere near a panic situation. The cell counts do come back very quickly too so hopefully at your next lab you will see improvement. If you do end up getting the shot take a benedryl to lessen the bone pain that comes as a side effect. My aunt with breast cancer got those shots and said she learned that trick from a friend and the care team didn't tell her about it but it sure helped. You might want to google "absolute neutrophils" because that calculation was what my doctor used to determine just how serious the low white count was. 

Mollymaude
Posts: 431
Joined: Nov 2016

Thanks for sharing your story about the radiation techs waiting for your burns to show up! My techs were great too. One day I just lost it and started crying and one of the techs was just so kind to me. I don't remember what she said, just how empathic she was. Some good memories in the experience!

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