Managing malignant wounds in patients receiving palliative care
Intended for healthcare professionals
CPD    

Managing malignant wounds in patients receiving palliative care

Lynn Cornish Tissue viability lead, St Margaret’s Hospice Care, Yeovil, England

Why you should read this article:
  • To enhance your understanding of the physical symptoms and psychosocial effects of malignant wounds

  • To learn about wound management strategies that you could use in your practice to enhance patients’ quality of life

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Malignant wounds are a complication of cancer and usually develop in patients with advanced disease. Physical symptoms associated with these wounds include pain, bleeding, exudate, malodour and pruritus, while patients may also experience various distressing psychosocial effects. The aim for nurses is to manage these physical symptoms and psychosocial effects, thus enhancing quality of life for patients and their families. This article discusses the symptoms and effects associated with malignant wounds, and explains what is involved in a wound assessment. It also outlines strategies that can be used to manage or eliminate wound-related symptoms and enhance patients’ quality of life.

Nursing Standard. doi: 10.7748/ns.2022.e12001

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@cornish_lynn

Correspondence

lynn.cornish@st-margarets-hospice.org.uk

Conflict of interest

None declared

Cornish L (2022) Managing malignant wounds in patients receiving palliative care. Nursing Standard. doi: 10.7748/ns.2022.e12001

Published online: 19 December 2022

Aims and intended learning outcomes

The aim of this article is to equip nurses with an understanding of malignant wounds and their management, and for them to be able to apply this knowledge in practice. After reading this article and completing the time out activities you should be able to:

  • Explain the aetiology of malignant wounds.

  • Discuss the strategies available to manage malignant wounds.

  • Understand the effects that malignant wounds can have on patients and their families and/or carers.

  • Apply the information contained in this article to your clinical practice.

Introduction

Receiving a cancer diagnosis can have a significant effect on a patient’s life, and learning to live with cancer brings challenges for patients, families and carers (Maida et al 2016). The adverse effects of living with cancer can be exacerbated by the presence of a malignant wound, which has been described as an intense, distressing and unforgettable experience (Probst et al 2013). In most cases, malignant wounds occur because of primary skin tumours, tumour cells metastasising from a primary tumour or direct invasion of a primary tumour into the cutaneous structure of the skin (Maida et al 2016). Malignant wounds present as an ulcerative ‘crater’ or a raised lesion of ‘cauliflower’ appearance – or a combination of both (Figure 1) (Starace et al 2022). They may also form a fistula (Maida et al 2016). The physical symptoms of malignant wounds may include any number of those shown in Table 1.

Figure 1.

Malignant wound

ns.2022.e12001_0001.jpg
Table 1.

Physical symptoms of malignant wounds

SymptomPossible cause
Bleeding
  • Fragile and friable (easily broken down) tissue

  • A tumour eroding a large blood vessel

  • Decreased platelet function within the tumour

  • Inappropriate wound care or wound cleansing technique

Excess exudate
  • Abnormal capillary permeability within the wound

  • Infection

Malodour
  • Anaerobic bacteria colonising necrotic tissue within the wound

  • Stale exudate contained in dressings

Pain
  • A tumour pressing on or invading nerves and/or blood vessels

  • Inappropriate wound care or wound cleansing technique

Pruritus
  • A tumour that stretches the skin and irritates the nerve endings

  • The skin being excoriated by exudate

The incidence of malignant wounds is not registered in the UK; however, it is estimated that they occur in around 5% of all patients with cancer (Furka et al 2022), with the most common site being the breast (Probst et al 2013). The absence of accurate incidence data does not encourage the development of specific dressings for malignant wounds, and at the time of writing an ideal dressing for this type of wound was not available (Fromantin et al 2014). Gibson and Green (2013) suggested the introduction of a reporting system for malignant wounds to understand the extent of the issue and to stimulate further research and the development of national guidance.

Malignant wounds are complex, challenging and multidimensional in their characteristics and requirements, so therefore require a multidisciplinary team approach that includes tissue viability nurses, doctors, physiotherapists, occupational therapists, counsellors, spiritual carers and complementary therapists.

Compared with other types of wounds, there is a paucity of research into malignant wounds, resulting in some of the referenced material in this article potentially being dated; however, it includes influential articles, which are still relevant to research and practice.

Time Out 1

Consider a scenario in which a patient with a malignant wound asks you why they are experiencing bleeding, excess exudate and pain. How would you manage this challenging conversation? Would your communication approach differ from that used with a patient with a non-malignant wound? If so, in what way?

Assessing malignant wounds

Malignant wounds can be challenging to assess because of their complexity, unique presentation and rapidly changing characteristics (Schulz et al 2009). A structured holistic assessment is required, and a validated assessment tool should be used whenever possible when assessing malignant wounds. This will assist the nurse to standardise any subsequent assessments and monitor ongoing treatment. While assessment tools for malignant wounds are available, there is lack of evidence supporting the use of one tool over another. The European Oncology Nursing Society (2015) provides a list of assessment tools that may assist nurses in assessing malignant wounds, including the Malignant Wound Assessment Tool (Schulz et al 2009).

Identifying the tissue type in the wound bed is important, and a malignant wound may include: friable tissue (that which bleeds easily), necrosis (dead tissue), granulation (growth of new connective tissue), tracking or undermining, and/or signs of infection (Wilson 2012).

It is also important to identify the exudate type, colour and consistency, and the condition of the surrounding skin. Malignant wounds can produce up to 1L of fluid per day and therefore nurses should undertake an accurate assessment of the exudate produced, including the volume and viscosity, as well as seeking to understand the aetiology of the exudate (European Oncology Nursing Society 2015). Table 2 details the characteristics of exudate found in malignant wounds.

Table 2.

Characteristics of exudate found in malignant wounds

ElementCharacteristics
Amount
  • Levels of exudate produced vary according to the size, shape and condition of the wound tissue; for example, if the tissue is infected or inflamed the nurse may identify high levels of exudate

Colour
  • In healing wounds, exudate can be yellowish or slightly reddish in colour (serosanguineous)

  • If the exudate is red, this may indicate bleeding

Consistency
  • ‘Healthy’ exudate should be thin, clear and ‘watery’

  • Thick, opaque exudate is more likely to be pus or mixed with necrotic tissue, which could be a sign of infection

Odour
  • May indicate infection

A review or full assessment of the wound should take place at each dressing change and should include the factors listed in Box 1.

Box 1. Factors to review when assessing a wound at each dressing change

  • Allergies and sensitivities

  • Comorbidities

  • Exudate level and/or type

  • Frequency of dressing changes

  • Infection

  • Location and/or size

  • Medicines

  • Odour

  • Pain level, type and frequency

  • Patient’s nutrition status

  • Patient’s priorities and wishes

  • Tissue type in wound bed

(Adapted from Wilson 2012)

Person-centred assessment is essential for developing effective management plans that are acceptable to the patient. Open and honest communication from the nurse can support the patient’s involvement in the planning and implementation of care through shared decision-making (Wilson 2005, Wounds International 2016). It is important to note that the goal of managing a malignant wound in a person with advanced cancer is not always to heal the wound, but to manage the symptoms and make the individual comfortable.

Time Out 2

Review the wound care assessment documentation within your clinical area. Is it suitable for the assessment of malignant wounds? Check this against guidance on assessing malignant wounds from the National Institute for Health and Care Excellence (2021) and European Oncology Nursing Society (2015)

Symptom management

Pain

According to a study by Tamai et al (2016), 77% of patients with a malignant breast wound experienced pain, which was described as a continuous ‘throbbing’ or tender pain. The pathology of pain in malignant wounds includes nerve damage, tissue ischaemia, inflammation and infection (Maida et al 2016). Pain in malignant wounds can be exacerbated by procedural tasks such as dressing changes.

Managing pain in a malignant wound involves first identifying the type of pain. Pain can be classified as nociceptive, neuropathic or mixed (Smith 2018, Freynhagen et al 2020). Nociceptive pain is associated with tissue damage, chemicals or inflammation. Patients have described nociceptive pain as ‘throbbing’ or ‘aching’, or a sense of overall discomfort, and it generally responds well to paracetamol, non-steroidal anti-inflammatory drugs and opioids (European Wound Management Association 2008). Neuropathic pain may occur because of disease, chemotherapy treatment or changes in the peripheral nervous system (Fallon 2013), and is often described as ‘burning’, ‘tingling’, ‘shooting’, ‘numbness’ or a sensation of ‘pins and needles’ (Wilkie et al 2001). Malignant wound pain can present as both neuropathic and nociceptive (Woo et al 2015).

The assessment of malignant wound pain is a vital component of a holistic assessment (World Union of Wound Healing Societies 2004, Gardner et al 2017). There are several validated self-report pain tools that can assist nurses, including the Visual Analogue Scale, the Numerical Pain Rating Scale and faces pain scales (The British Pain Society and The Faculty of Pain Medicine of the Royal College of Anaesthetists 2019, Walker et al 2019). These tools assess pain occurrence and intensity. It is essential that the nurse identifies the factors that lead to any deterioration or improvement in the patient’s pain, or if it is experienced as background, constant, procedural or incidental pain, so that they can gain a full overview of the patient’s pain experience (World Union of Wound Healing Societies 2004). The choice of self-report pain tool depends on the patient; for example, in patients who are unable to use a numerical scale to rate their pain it may be more appropriate to use a faces pain scale.

In patients with cancer who have a malignant wound, it can be challenging to differentiate cancer pain from wound pain, particularly when the underlying cancer and the wound are in the same location. When a malignant wound has caused nerve damage and the patient is displaying neuropathic symptoms, opioids administered for cancer pain may be ineffective in managing the wound pain. In such cases, medicines such as amitriptyline hydrochloride, gabapentin or pregabalin may prove beneficial (Fallon 2013).

When infection within a malignant wound is thought to be the cause of a patient’s pain, treatment should include oral or topical antibiotics and antibacterial dressings (International Wound Infection Institute 2022).

Patients with a malignant wound whose pain is related to dressing changes should be managed by using (World Union of Wound Healing Societies 2004, Woo et al 2015):

  • Pre-dressing-change analgesia.

  • A rapid-onset, short-acting analgesic such as nitrous oxide or fentanyl.

  • Lidocaine hydrochloride 5% patches placed topically near to the wound.

  • Dressings containing ibuprofen.

  • Hydrogel sheet dressings, which maintain moisture balance in the malignant wound bed, and have a cooling and soothing effect.

  • Conformable dressings that mould to contours of the patient’s skin. These should also be non-adherent, soft and sufficiently large to cover the wound area without stretching.

  • Dressings with sufficient wicking (ability to draw fluid away from the wound) and absorbent capabilities to prevent maceration and excoriation to the skin, which may also cause pain and bleeding.

  • Appropriate application and removal techniques.

For persistent wound pain, a topical application of injectable morphine or diamorphine hydrochloride mixed with amorphous gel has proven effective (Graham et al 2013). The mixture is applied to gauze and then to the wound for 10-15 minutes. The gauze should then be removed and the wound redressed. Nurses should be aware that this technique is used off-licence, and therefore care should be taken when prescribing and documenting its use.

Key points

  • In most cases, malignant wounds occur because of primary skin tumours, tumour cells metastasising from a primary tumour or direct invasion of a primary tumour into the cutaneous structure of the skin

  • Physical symptoms of malignant wounds may include bleeding, excess exudate, malodour, pain and pruritus

  • As a result of the physical symptoms of malignant wounds, patients may experience psychosocial effects such as social isolation, depression, embarrassment and impaired sexuality

  • Holistic assessments are essential to the effective care of malignant wounds, and nurses should focus on managing patients’ physical symptoms and psychosocial effects to enhance quality of life

Transcutaneous electric nerve stimulation (TENS) with pads applied either side of the wound has proved effective in alleviating pain in malignant wounds (Grocott 2000). In addition, complementary therapy, distraction techniques and relaxation techniques have achieved positive outcomes in managing patients’ anxiety during clinical procedures, for example before, during and after dressing changes (Au and Assavarittirong 2021). Nurses should also consider referral to specialist pain management teams.

Exudate

Large volumes of exudate affect the management of malignant wounds and contribute to the sense of shame, embarrassment and disgust experienced by patients (Merz et al 2011). Larger and deeper wounds may produce higher levels of exudate, as can wounds in certain parts of the body, for example the lower leg (World Union of Wound Healing Societies 2019). The production of high levels of exudate in malignant wounds is also associated with (Alexander 2009):

  • Catabolism (breakdown) of tissues provoked by bacterial proteases, which may be related to wound infection.

  • Inflammatory process associated with infection.

  • High blood vessel permeability, where pressure in the capillaries forces them to release protein-rich fluid and results in increased exudate levels within the tumour.

High levels of exudate can result in significant damage to the surrounding skin, causing pain and bleeding. Nurses should use barrier products such as gels and films to prevent moisture-associated skin damage (Romanelli et al 2010). Dressings should have the required absorbency and wicking capabilities to manage the level of exudate (Merz et al 2011). However, this can prove challenging and may result in the need for increasingly frequent dressing changes, which in turn may have a negative effect on the patient’s quality of life.

Nurses managing patients with malignant wounds should also attempt to treat the underlying cause of elevated exudate levels, which is often infection. This may be achieved with antibiotics and antimicrobial cleansers, along with wound dressings that contain antibacterial substances such as honey (providing that the patient does not experience adverse effects such as pain or an allergic reaction) or silver (Molan and Rhodes 2015, Lin et al 2016).

Superabsorbent dressings including foams, alginates and hydrofibres, as well as wound management pouches and bags, may also be required to manage excess exudate. Leakage of exudate from dressings can be an issue due to the size, shape and location of the malignant wound and the volume of exudate. Therefore, any dressings should conform to the patient’s body, with an effective seal preventing any leaks. Wound dressing adhesives that adhere to the skin should be avoided, particularly when the skin is damaged from radiotherapy, chemotherapy, trauma or excoriation. The nurse should also consider applying topical treatments to alleviate any skin irritation (Wounds UK 2013).

Malodour

Malodour in the malignant wound can be caused by anaerobic or aerobic organisms (McMurray 2003), necrotic, suboptimally vascularised tissue and exudate (Gethin 2011). Patients rarely become desensitised to malodour (West 2007), and constant odour may cause patients to stop eating or socialising, which in turn can result in social isolation and depression (Probst et al 2009). Wound malodour can also permeate into the environment and lead to families and friends avoiding spending time with the patient (Naylor 2002, Morris 2008).

Strategies to reduce or eliminate odour from malignant wounds include:

  • Low-pressure showering with warm water (not aimed at the wound), which assists the patient to feel clean (Wilson 2005). Using a low-pressure shower will also prevent trauma and bleeding to the wound.

  • Cleansing the wound using a wound irrigation solution.

  • Topical antimicrobials such as dressings that incorporate an antiseptic agent such as silver, honey or iodine. These products have a broad-spectrum action and can be effective in killing microorganisms, but some may compromise healthy tissue (Punjataewakupt et al 2019).

  • Topical antibiotics such as metronidazole gel. These products target specific microorganisms and should only be given if there is a host response (symptoms of infection), or spreading infection is noted in the periwound area (Wounds UK 2013).

  • Debriding the wound, for example using a technique such as autolytic debridement (the breakdown of necrotic tissue by the body’s natural moisture and enzymes) (Ramundo and Gray 2008).

  • Dressings that absorb and trap odour such as those containing charcoal.

It should be noted that some topical treatments are used off-licence in palliative care, and optimal documentation is essential to ensure that any treatment provided is in accordance with professional and legal requirements (Wilcock et al 2022).Some substances, such as deodorisers and aromatherapy oils, can be used to mask wound malodour in the patient’s environment (European Oncology Nursing Society 2015). Substances used for managing environmental odour should be placed in unobtrusive bowls and containers in a discreet location. Due to the sensitive nature of living with malodour, the nurse would need to discuss any strategies with the patients and their families and carers to ensure that no offence is caused.

Bleeding

Bleeding is a significant challenge in malignant wounds and can be distressing and frightening for patients, their families and carers (Probst et al 2013). Generally, bleeding occurs when tumour cells erode blood vessels. Furthermore, tissue within malignant wounds is friable and fragile, and has a tendency to bleed (Woo and Sibbald 2010). Wound bleeding may also be caused by inappropriate dressing choice or suboptimal dressing application and removal techniques.

When the tumour has eroded into a major blood vessel, this may cause a fatal haemorrhage (Woo and Sibbald 2010). Any patient who is at risk of bleeding should have a management plan in place to limit their distress as much as possible (Yorkshire Palliative Medicine Clinical Guidelines Group 2008). Such a plan would involve (European Oncology Nursing Society 2015):

  • Use of non-adherent dressings with haemostatic properties.

  • Use of appropriate dressing application and removal techniques. Any dressings that have adhered to the wound should be soaked before removal.

  • Use of topical agents such as tranexamic acid (an antifibrinolytic agent). If topical application does not have the desired effect, oral tranexamic acid tablets should be considered.

  • Use of adrenaline (epinephrine)-soaked gauze, which causes vasoconstriction in arterioles and capillaries. Adrenaline should be used with caution because it can cause ‘rebound’ bleeding and necrosis (Watret 2011).

  • Use of haemostatic granules or bandages, which were developed for use on battlefields and are now used by emergency and palliative care services to stop bleeding wounds.

  • Discontinuation of anticoagulants and any antiplatelet medicines if and when appropriate.

  • Use of the benzodiazepine midazolam to sedate the patient and keep them comfortable in cases of catastrophic bleeding.

  • Collection of dark towels stored close to the patient in case of bleeding.

  • Potential use of radiotherapy and electrochemotherapy to manage repetitive bleeds (Gehl and Geertsen 2006).

Families and carers should be prepared for potentially catastrophic and distressing bleeding. Patients living in the community should have the necessary medicines in a ‘just-in-case box’ at home, along with a collection of dark towels and haemostatic dressings, granules and bandages. In addition, carers should agree with the nurse what their role should be and informed of who to call in the event of bleeding. Whatever the setting, patients and their families require support and reassurance from nurses.

Pruritus

Pruritis or itching in malignant wounds is thought to be caused by the tumour stretching the skin and irritating the nerve endings (European Oncology Nursing Society 2015). Pruritus may not respond to oral antihistamines; in such situations, gabapentin, pregabalin or amitriptyline may provide relief (Maida et al 2016). Dressings designed to keep the skin cool and well-hydrated, such as hydrogel sheets, should be considered. Cool compresses, baths and showers may also provide relief, as can garments and bed linen made from cotton, silk and bamboo. Furthermore, TENS machines can prove beneficial, along with menthol creams, bath additives and oils applied to intact skin (European Oncology Nursing Society 2015).

Dressing selection

Malignant wounds are often located on difficult-to-dress areas of the body and they can be challenging to apply dressings to because of their shape. Patients often become experts on their wound and can inform nurses about what dressings are or are not effective, so they should therefore be involved in shared decision-making. Malignant wounds may require several layers of dressings, and dressings that optimally manage the wound bed conditions should be used. Input from tissue viability nurses may be required. Based on the author’s clinical experience, dressings should be:

  • Non-adherent.

  • Soft, conformable and comfortable.

  • Sufficiently large to cover the wound without rubbing.

  • Occlusive.

  • Manufactured using fibres that do not shed into the wound bed.

  • Manufactured to wick away exudate.

  • Able to contain odour.

  • Aesthetically acceptable to the patient.

  • Pain free.

Consideration should also be given to the weight of dressing when wet.

Time Out 3

Reflect on your workplace dressing formulary. Do you have access to dressings that would optimally manage a malignant wound? Contact your local hospice and discuss the dressings and topical treatments that the staff there find effective, and consider whether these should be introduced in your workplace

Psychosocial effects

Malignant wounds are a visible reminder of advanced, incurable disease and impending death (Alexander 2010, Watret 2011). Research conducted by Lo et al (2008) found that while patients may have felt able to share their cancer diagnosis, they would often hide their malignant wound due to what they perceived as its repugnant nature.

Research data from a small study involving nine participants with a breast wound demonstrated that feelings of shame and blame meant that many patients delayed seeking medical advice until their wound became unmanageable (Probst et al 2013). Patients with a malignant wound can experience a sense of vulnerability as a result of living with a continually changing body, particularly since the wound means that their cancer is visible.

As a result of the physical symptoms of malignant wounds, patients may experience one or many of the psychosocial effects detailed in Box 2.

Box 2. Psychosocial effects of malignant wounds

  • Challenges in managing the cost of dressings

  • Communication – for example, facial malignant wounds can impair a patient’s speech. Furthermore, patients can become withdrawn and isolated due to the distressing symptoms of malignant wounds

  • Denial

  • Depression

  • Embarrassment

  • Fear

  • Guilt

  • Impaired sexuality – for example, due to wound malodour or concerns regarding pain and discomfort during sex

  • Information needs – for example, patients may not receive sufficient information about malignant wounds and their treatment

  • Negative body image

  • Negative effects on family members

  • Restrictions due to dressing changes

  • Revulsion and disgust

  • Shame

  • Social isolation

(Adapted from Naylor 2002)

For the nurse, the aim of care is to manage the patient’s wound symptoms and thereby alleviate any psychosocial effects and enhance their quality of life. Research conducted by Lo et al (2008) identified that patients with a malignant wound required assistance from wound care specialists in the early stage of their cancer, but reported enhanced quality of life after the specialists’ input. The psychosocial effects of malignant wounds can be managed by complementary therapy, counselling, addressing the physical symptoms of the wound, social support, spiritual care and working in partnership with patients and their families (Naylor 2002).

Effects of malignant wound management on nurses

A study conducted by Wilkes et al (2003) included a sample population of 26 nurses, many of whom emphasised the challenges involved in applying dressings to malignant wounds, such as hiding their disgust at the odour. The nurses also reported that patients’ isolation and changed body image meant that caring for such patients was often emotionally challenging (Wilkes et al 2003).

Nurses require education and training to manage malignant wounds, as well as developing an understanding of the effect that malignant wounds can have on patients and their families. Nurses also require access to the most effective dressings and support from experts such as tissue viability nurses who have experience in managing malignant wounds. Those caring for patients with malignant wounds also require support that enables them to express their feelings and reflect on their management of these wounds. This will assist them in managing any feelings of helplessness, failure and inadequacy, as well as preventing them from becoming emotionally overwhelmed (Alexander 2010).

Time Out 4

George is a 70-year-old man with a malignant melanoma on his left shoulder. The wound has bled significantly and frequently, but it is not painful. The wound is large, measuring 14cm by 13.5cm, and is covered with a combination of slough and necrotic tissue, which is highly odorous. The surrounding skin is discoloured and painful due to radiotherapy treatment, with skin-stripping visible where tape has previously been used to fix dressings. The medical consultant has given George a prognosis of 2-3 weeks to live. George has become socially isolated and wants his symptoms to be managed so that he is not apprehensive about going out with his family members during his final weeks of life. Consider how you could manage George’s wound. For example, what specific wound care techniques would you consider? Would you refer George to a specialist? Formulate a management plan using the knowledge that you have gained from reading this article

Conclusion

Malignant wounds are a result of tumour infiltrating the skin and can occur anywhere on the body. Their presence can cause patients intense distress and act as a visible reminder of incurable disease. Holistic assessments are essential for the effective management of these wounds, and management plans should be discussed and implemented in partnership with the patient. For nurses, wound management should focus on addressing patients’ physical symptoms and psychosocial effects to enhance their quality of life.

Time Out 5

Identify how managing malignant wounds applies to your practice and the requirements of your regulatory body

Time Out 6

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

References

  1. Alexander SJ (2009) Malignant fungating wounds: managing malodour and exudate. Journal of Wound Care. 18, 9, 374-382. doi: 10.12968/jowc.2009.18.9.44305
  2. Alexander SJ (2010) An intense and unforgettable experience: the lived experience of malignant wounds from the perspectives of patients, caregivers, and nurses. International Wound Journal. 7, 6, 456-465. doi: 10.1111/j.1742-481X.2010.00715.x
  3. Au TY, Assavarittirong C (2021) The overview of utilizing complementary therapy to relieve stress or anxiety in emergency department patients: animal-assisted therapy, art therapy, and music therapy. Mental Health: Global Challenges Journal. 4, 2. doi: 10.32437/mhgcj.v4i2.125
  4. European Oncology Nursing Society (2015) Care and Recommendations for the Care of Patients with Malignant Fungating Wounds. European Oncology Nursing Society, London.
  5. European Wound Management Association (2008) Hard-to-Heal Wounds: A Holistic Approach. MEP, London.
  6. Fallon MT (2013) Neuropathic pain in cancer. British Journal of Anaesthesia. 111, 1, 105-111. doi: 10.1093/bja/aet208
  7. Freynhagen R, Rey R, Argoff C (2020) When to consider ‘mixed pain’? The right questions can make a difference! Current Medical Research and Opinion. 36, 12, 2037-2046. doi: 10.1080/03007995.2020.1832058
  8. Fromantin I, Watson S, Baffie A et al (2014) A prospective, descriptive cohort study of malignant wound characteristics and wound care strategies in patients with breast cancer. Ostomy Wound Management. 60, 6, 38-48.
  9. Furka A, Simkó C, Kostyál L et al (2022) Treatment algorithm for cancerous wounds: a systematic review. Cancers. 14, 5, 1203. doi: 10.3390/cancers14051203
  10. Gardner SE, Abbott LI, Fiala CA et al (2017) Factors associated with high pain intensity during wound care procedures: a model. Wound Repair and Regeneration. 25, 4, 558-563. doi: 10.1111/wrr.12553
  11. Gehl J, Geertsen PF (2006) Palliation of haemorrhaging and ulcerated cutaneous tumours using electrochemotherapy. European Journal of Cancer Supplements. 4, 11, 35-37. doi: 10.1016/j.ejcsup.2006.07.007
  12. Gethin G (2011) Management of malodour in palliative wound care. British Journal of Community Nursing. 16, Suppl 9, S28-S36. doi: 10.12968/bjcn.2011.16.Sup9.S28
  13. Gibson S, Green J (2013) Review of patients’ experiences with fungating wounds and associated quality of life. Journal of Wound Care. 22, 5, 265-275. doi: 10.12968/jowc.2013.22.5.265
  14. Graham T, Grocott P, Probst S et al (2013) How are topical opioids used to manage painful cutaneous lesions in palliative care? A critical review. Pain. 154, 10, 1920-1928. doi: 10.1016/j.pain.2013.06.016
  15. Grocott P (2000) The palliative management of fungating malignant wounds. Journal of Wound Care. 9, 1, 4-9. doi: 10.12968/jowc.2000.9.1.25942
  16. International Wound Infection Institute (2022) Wound Infection in Clinical Practice: Principles of Best Practice. Third Edition. http://societyoftissueviability.org/wp-content/uploads/2022/03/IWII-Wound-Infection-in-Clinical-Practice-International-Consensus-1.pdf (Last accessed: 21 November 2022.)
  17. Lin YH, Hsu WS, Chung WY et al (2016) Silver-based wound dressings reduce bacterial burden and promote wound healing. International Wound Journal. 13, 4, 505-551. doi: 10.1111/iwj.12467
  18. Lo SF, Hu WY, Hayter M et al (2008) Experiences of living with a malignant fungating wound: a qualitative study. Journal of Clinical Nursing. 17, 20, 2699-2708. doi: 10.1111/j.1365-2702.2008.02482.x
  19. Maida V, Alexander SJ, Case AA et al (2016) Malignant wound management. Public Health and Emergency. 1, 12. doi: 10.21037/phe.2016.06.15
  20. McMurray V (2003) Managing patients with fungating malignant wounds. Nursing Times. 99, 13, 55-57.
  21. Merz T, Klein C, Uebach B et al (2011) Fungating wounds – multidimensional challenge in palliative care. Breast Care. 6, 1, 21-24. doi: 10.1159/000324923
  22. Molan P, Rhodes T (2015) Honey: a biologic wound dressing. Wounds. 27, 6, 141-151.
  23. Morris C (2008) Wound odour principles and management and the use of Clinisorb. British Journal of Nursing. 17, Suppl 6, S38-S42. doi: 10.12968/bjon.2008.17.Sup3.28914
  24. National Institute for Health and Care Excellence (2021) Palliative Care – Malignant Skin Ulcer. http://cks.nice.org.uk/topics/palliative-care-malignant-skin-ulcer (Last accessed: 21 November 2022.)
  25. Naylor W (2002) Part 1: Symptom Control in the Management of Fungating Wounds. http://www.worldwidewounds.com/2002/march/Naylor/Symptom-Control-Fungating-Wounds (Last accessed: 21 November 2022.)
  26. Punjataewakupt A, Napavichayanun S, Aramwit P (2019) The downside of antimicrobial agents for wound healing. European Journal of Clinical Microbiology & Infectious Diseases. 38, 1, 39-54. doi: 10.1007/s10096-018-3393-5
  27. Probst S, Arber A, Faithfull S (2009) Malignant fungating wounds: a survey of nurses’ clinical practice in Switzerland. European Journal of Oncology Nursing. 13, 4, 295-298. doi: 10.1016/j.ejon.2009.03.008
  28. Probst S, Arber A, Faithfull S (2013) Coping with an exulcerated breast carcinoma: an interpretative phenomenological study. Journal of Wound Care. 22, 7, 352-360. doi: 10.12968/jowc.2013.22.7.352
  29. Ramundo J, Gray M (2008) Enzymatic wound debridement. Journal of Wound, Ostomy, and Continence Nursing. 35, 3, 273-280. doi: 10.1097/01.WON.0000319125.21854.78
  30. Romanelli M, Vowden K, Weir D (2010) Exudate Management Made Easy. http://www.wounds-uk.com/uploads/resources/63eff19562a3f132b4f2ad297fdcd3f4.pdf (Last accessed: 21 November 2022.)
  31. Schulz V, Kazell K, Biondo PD et al (2009) The malignant wound assessment tool: a validation study using a Delphi approach. Palliative Medicine. 23, 3, 266-273. doi: 10.1177/0269216309102536
  32. Smith ES (2018) Advances in understanding nociception and neuropathic pain. Journal of Neurology. 265, 2, 231-238. doi: 10.1007/s00415-017-8641-6
  33. Starace M, Carpanese MA, Pampaloni F et al (2022) Management of malignant cutaneous wounds in oncologic patients. Supportive Care Cancer. 30, 9, 7615-7623. doi: 10.1007/s00520-022-07194-0
  34. Tamai N, Mugita Y, Ikeda M et al (2016) The relationship between malignant wound status and pain in breast cancer patients. European Journal of Oncology Nursing. 24, 8-12. doi: 10.1016/j.ejon.2016.05.004
  35. The British Pain Society, The Faculty of Pain Medicine of the Royal College of Anaesthetists (2019) Outcome Measures. http://www.britishpainsociety.org/static/uploads/resources/files/Outcome_Measures_January_2019.pdf (Last accessed: 21 November 2022.)
  36. Walker BJ, Polaner DM, Berde CM (2019) Acute pain. In Coté CJ, Lerman J, Anderson BJ (Eds) A Practice of Anaesthesia for Infants and Children. Sixth edition. Elsevier, London, 1023-1062.
  37. Watret L (2011) Management of a fungating wound. Journal of Community Nursing. 25, 2, 31-36.
  38. West D (2007) A palliative approach to the management of malodour from malignant fungating tumours. International Journal of Palliative Nursing. 13, 3, 137-142. doi: 10.12968/ijpn.2007.13.3.23276
  39. Wilcock A, Howard P, Charlesworth S (2022) Palliative Care Formulary. Eighth edition. Royal Pharmaceutical Society, London.
  40. Wilkes LM, Boxer E, White K (2003) The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difficult. Journal of Wound Care. 12, 2, 76-80. doi: 10.12968/jowc.2003.12.2.26468
  41. Wilkie D, Huang H, Reilly N et al (2001) Nociceptive and neuropathic pain in patients with lung cancer: a comparison of pain quality descriptors. Journal of Pain and Symptom Management. 22, 5, 899-910. doi: 10.1016/S0885-3924(01)00351-7
  42. Wilson M (2012) Understanding the Basics of Wound Assessment. http://www.wounds-uk.com/resources/details/wound-essentials-72-understanding-the-basics-of-wound-assessment (Last accessed: 21 November 2022.)
  43. Wilson V (2005) Assessment and management of fungating wounds: a review. British Journal of Community Nursing. 10, Suppl 1, S28-S34. doi: 10.12968/bjcn.2005.10.Sup1.17627
  44. Woo KY, Sibbald RG (2010) Local wound care for malignant and palliative wounds. Advances in Skin and Wound Care. 23, 9, 417-428. doi: 10.1097/01.ASW.0000383206.32244.e2
  45. Woo KY, Krasner DL, Kennedy B et al (2015) Palliative wound care management strategies for palliative patients and their circles of care. Advances in Skin and Wound Care. 28, 3, 130-140. doi: 10.1097/01.ASW.0000461116.13218.43
  46. World Union of Wound Healing Societies (2004) Minimising Pain at Wound Dressing-Related Procedures: A Consensus Document. http://www.werner-sellmer.de/files/Reduzierung-von-Schmerz-Englisch-WUWHS.pdf (Last accessed: 21 November 2022.)
  47. World Union of Wound Healing Societies (2019) Consensus Document. Wound Exudate: Effective Assessment and Management. Wounds International, London.
  48. Wounds International (2016) International Best Practice Statement: Optimising Patient Involvement in Wound Management. http://www.woundsinternational.com/uploads/resources/9fccd1d852f5fc23b853a0a00066c5b9.pdf (Last accessed: 21 November 2022.)
  49. Wounds UK (2013) Best Practice Statement: Effective Exudate Management. http://tv4nh.co.uk/files/TVS_effective_exudate_management.pdf (Last accessed: 21 November 2022.)
  50. Yorkshire Palliative Medicine Clinical Guidelines Group (2008) Guidelines on the Management of Bleeding for Palliative Care Patients with Cancer. http://www.palliativedrugs.com/download/090331_Final_bleeding_guideline.pdf (Last accessed: 21 November 2022.)

Share this page

Related articles

An overview of non-Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma is a heterogeneous group of...

Supporting delivery of the recovery package for people living with and beyond cancer
Survivorship is an important issue in cancer care in the UK....

How play specialists can reduce use of anaesthesia during radiotherapy
Radiotherapy practice is complex and daunting for children....

Impact of genome sequencing on cancer research and treatment
Since the sequence of the human genome was first published...

Managing patients with metastatic breast cancer and experience of eribulin
Management of patients with metastatic breast cancer (MBC)...