Makes a grown man writhe
January 31, 2008 § 6 Comments
On most occasions I know exactly what to expect when I’m heading out to film some procedure or other. Operations are routine work and I know how patients tend to react to different biopsies, infusions etc. But one recent assignment really caught me off guard.
There is a treatment option for skin cancer which sounds easy and gentle. Most cancers can only be treated with major surgery, radiation or massive chemotherapy schedules. But for skin cancer patients, a treatment involving light has emerged the last 15 years.
Superficial and nodal basal cell carcinoma can be cured or controlled effectively with this treatment. It is called photodynamic therapy, or PDT for short.
Skin lesions are first scraped with a dermal curette. The raw skin is then rubbed with a special medical cream (methyl aminolevulinate) that acts as a photosensitizer. Molecules that react to light are accumulated in the tumor cells. When this tissue is exposed to red light the cancer cells are killed. The surrounding healthy tissue is not affected. One of the creams that are used was actually invented and developed at the hospital were I’m working.
The whole treatment takes about 4 hours, including 3 hours of waiting after the cream is applied before exposing it to red light. It is an outpatient procedure.
As I said, this all sounds easy and gentle. You put on some cream and bathe in light. Just like a tanning bed session. Except that for some this can be extremely painful.
I was scheduled to document the procedure some days ago. To get different localisations and sizes of lesions I followed four patients at the outpatients clinic. Two with minor lesions (< 1 cm) of the facial region. One with several small lesions on the back. And one with one small and one large (> 5 cm) lesion of the back. The first step went well with all four patients. The curretage of the patient with the larger lesions looked painful, but he didn’t seem to be bothered.
While the patients were waiting for the cream to do its work, I chatted with the nurses. One of them was very concerned about the last patient. She told us there was not yet any good analgesics to use with PDT. Some patients don’t feel any discomfort during the treatment, while others experience severe pain. Exactly what is causing the pain and how to kill it is apparently still a mystery. The only option available is spraying the lesion with water to reduce the painful effects of the light. For patients with large lesions local anesthetics like lidocaine can be used, but they have no substantial effect.
The patients came back for light treatment. The first three all wanted to be sprayed with water, but none of them reported experiencing any real pain. So I was not in any way prepared for the reaction of the last patient.
The dressings were removed and a light was placed above his small lesion. So far he acted just as the others. But when another light was placed over his large lesion, he suddenly and without warning started to writhe and scream. The nurses desperately tried to sooth him with water, but it didn’t work. He was in serious pain, like his skin was on fire.
As the nurses were on the phone trying to get the doctor, I silently withdrew from the room. Thinking to myself that “cancer” and “easy and gentle” just don’t go together.
The Sterile Eye 
Interesting post. I didn’t know anything about this type of treatment. The larger lesion seems to be the only one that caused so much pain. Perhaps more nerve tissue involved?
Both lesion size and location seemed to matter. Lesions in the face (even small ones) tended to cause more pain than lesions on the back, according to the nurses. But the individual differences were huge. Some don’t feel anything, while others “burn”.
Pain is indeed difficult stuff!
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