Managing malignant wounds can be challenging for nurses, especially in terms of implications for patients and their quality of care. These wounds can spread rapidly, either as a primary, metastatic, or recurrent malignancy, and are often associated with breast or head and neck cancers.
Skin manifestations of cancer which arise from local progression of a primary tumour or from cutaneous metastases; they are particularly associated with breast cancer, malignant melanoma and mucosal tumours of the head and neck. Malignant wounds may present as proliferative, ulcerative or fistulae.
Approximately 5-10% of people with metastatic cancer develop malignant/fungating wounds. These wounds rarely heal fully, and the focus is often on comfort and reducing their impact on the person’s quality of life.
Nurses have an important role in recognising, assessing, and managing symptoms related to fungating wounds. They can also help patients and families with sensitive and culturally appropriate education and support.
Continually assessing these wounds is important because they can change frequently.
To understand the wound history ask about:
Ask about the associated symptoms: pain, pruritus (itchiness), odour, exudate (drainage), bleeding, lymphoedema, and infection.
To understand the psychological impact of the wound, ask:
Ask family and carers:
A photographic record of the wound, with the person’s consent, can illustrate the progression of the wound. It can be useful for providing the rationale for the choice of local wound management products, the frequency of dressing changes and the volume of products used.
Treatment is generally directed at managing wound-related pain and symptom issues.
Working to develop a care plan with the person and their family is important. Key symptoms requiring management include:
Use of an opioid is widely recommended for pain management including prior to changing a dressing. Establishing if pain is due to infection or the actual wound dressing process is an important first step.
Wounds are often contaminated with bacteria. Management of local infection includes taking a swab to identify the organisms involved and use of appropriate antimicrobial agents to control signs of infection (redness, pain, swelling, increased odour or discharge; fever, chills, and sweats).
Causes of bleeding include changes in blood clotting capacity or blood vessel structure. Medications taken by the person, such as anticoagulants, could contribute to bleeding and should be discussed with prescribers. Wound dressings themselves can also contribute to bleeding through physical abrasion or adhesion.
As the tumour grows, changes to blood vessels and disruption of the lymphatic system often lead to a large volume of exudate at the wound site. This can degrade the extracellular matrix and affect healing.
Management to remove saturated dressings is important and if very moist may require specialist input.
Malodour can be one of the most distressing symptoms of these wounds. It may affect the person’s relationships and interaction with others and be equally distressing for family and carers.
Malodour can be caused by moist necrotic tissue, infection, unchanged or saturated dressings, or old dressings that have not been properly disposed of.
There are many approaches including dressings containing charcoal, medical-grade honey, or silver. If debridement to remove necrotic tissue is considered, then an assessment of how this might impact on the person’s quality of life is essential. Sealing the wound dressing to contain odour or covering the wound with a bag (as with a colostomy) to collect secretions and contain odour may also help.
External odour absorbers (tray of clay kitty litter or activated charcoal) and room ventilation can help reduce the odour. Masking environmental odours using air scents (peppermint oil, vanilla, coffee), an infuser or similar may also be helpful.
Care of the skin surrounding the malignant wound is important. To promote skin hydration, it may help to moisturise the skin with hydrophilic creams and encourage the person to increase their fluid intake where possible.
To care for the skin surrounding a malignant wound it can help to:
The person’s comfort and quality of life remains the goal in managing malignant wounds. This includes finding the dressing that best suits them while minimising any symptoms. It also includes support for quality of life and social interaction where this is important to the person.
Care for staff who provide wound dressings for patients can include sharing care, taking time out and reflecting on practice with colleagues.
A social worker, counsellor, or spiritual care provider can offer counselling and emotional support.
This information was drawn from the following resources:
Read PCNow's factsheet on Malignant Wounds
Read review article: Managing a malignant wound in palliative care (118kb pdf)
Access more Malignant Wounds resources
Last updated 09 November 2023