The Royal Marsden ‘Fungating Wounds’ What as Heath Care Professionals can we do to help our patients with this complex side effect? Sonja Hoy Clinical Nurse Specialist Head, Neck Thyroid and Radiation Protection The Royal Marsden Malodourous and fungating wounds are a constant reminder that the body is both infected and rotting (Moyle 1998) Surely this is the ultimate insult to one’s body image (Haughton & Young 1995) The Royal Marsden Aim of the session – A greater understanding of the complexity of fungating wounds in the head and neck setting – Understanding the morbidity for the individual experiencing a fungating lesion – Recognition of the impact the lesion has on carers and HCP – Resource implications for health care professionals – Strategies that may influence management of fungating wounds in our patient population The Royal Marsden ‘Fungating lesions are products of cancerous infiltration of the epithelium resulting in a protruding nodular and often grotesque growth which is at risk of infection, bleeding and producing malodourous exudate’ (Carville 2005 sited in Alexander 2009) Fungating wounds will never heal by the very nature of the pathology The Royal Marsden How many cancer patients will experience this distressing side effect of their disease? – 5-10 percent of cancer patients will experience a fungating wound (Alexander 2009) – Data is normally from cancer registry and we have limited knowledge of the numbers seen in developing countries where health care infra-structure and data collection maybe more limited to identify the extent of the problem The Royal Marsden Cancers known to be associated with fungating wounds in the head & neck region – – – – – – Squamous Cell Carcinoma Basal Cell Carcinoma Merkel Cell Carcinoma’s Melanoma’s Sarcoma’s Anaplastic Thyroid Cancers The Royal Marsden How many of our patients are likely to present or develop fungating disease? Thomas’s work in the UK identified that the most common sites for fungating wounds were: – Breast 62% – Head & Neck 24% – Genitals, groin & back 3% – Others 8%. This data was from radiotherapy and Oncology data (Thomas 1992). Probst and colleagues study identified similar statistics – Breast 49.3% – Neck 20.9% – Chest 17.6% – Extremities 16.6% – Genitalia 16.6 % – Head 13.5 % – Other 1.7% (Probst et al 2009) The Royal Marsden The main physical symptoms of Fungating Wounds – – – – – Malodour Excessive exudate Pain Bleeding Itching (Probst 2010, Lo et al 2008) The Royal Marsden Impact of a fungating wound on the patient Lo and colleagues work in Taiwan identified 5 main themes after studying the impact of a fungating wound on ‘day to day living’ and ‘psychological health’ (Lo et al 2008) – Declining physical wellbeing – Wound related stigma – Need for expert help (limited) – Strategies in wound management (limited) – Living positively with the wound The Royal Marsden The study also identified – Alteration to social behaviours often social isolation due to embarrassment – That wound management was poor with little expertise – Lead to patients adopting practices that caused more harm and exacerbation of problems – Lawton’s work similarly observed a loss of self and social identity (Lawton 1998) The Royal Marsden Impact of fungating wound on carers and health care professionals – Very little literature – Personally distressing to many carers – Nurses often strove to maintain dignity and ensure they kept focused on the person not the wound – The challenges identified by nurses were patient isolation and body image changes – Nurses felt guilty if the wound was unable to be managed successfully (Wilkes et al 2003, Wilkes et al 2001,Saunders 1997) The Royal Marsden What is the way forward? The Royal Marsden Assessment – Always unique presentation – Take the time to listen and gain understanding of what the individual perceives of their experience – Assessment implement and reassess – Needs to be a holistic approach to the person not just about the wound – Assess co-morbidities (diabetes, arthritis, dexterity issues) – Allergies – What is their ability to self care – Main physical issues – Psychosocial issues (body image, depression and sexuality) The Royal Marsden Assessment – – – – – – – – What social support exists Strengths and coping abilities What interventions have they employed to manage their life Spiritual and cultural needs (the meaning of life, impact on relationships and personhood) Laverty 2003 reminds us that we must assess and understand the meaning of the person’s lived experience and identify what their priorities are not ours as HCP Utilising self assessment tools such as WoSSAc and TELER (Anderson 2009 series) Care is patient centred and interventions are acceptable to the patient Care of the carer/s The Royal Marsden The specific issues within Head and Neck Oncology – Site of the Fungating lesion – Is it loco-regional what are the structures at risk – Is there distant disease and has this been properly assessed – Co-morbidities and will they impact on the decision making process – Social class issues and compliance – Smoking status and alcohol status – Life expectancy The Royal Marsden The need to involve the wider MDT in discussions related to management – Utilising the main MDT members – Involving Palliative Care, as well as community colleagues at the outset of identification of a lesion – Utilising wound care specialists (tissue viability) – The patient and their significant others The Royal Marsden What are the four main considerations for a fungating wound? The Royal Marsden Odour – Malignant wounds are polymicrobial, with a wide variety of aerobic and anaerobic bacteria that contribute to the odour (Alexander 2009) – Infection increases odour, exudate, physical and psychological pain – Increasing anxiety and distress which negatively impacts on pain (Probst et al 2012) – Anxiety negatively impacts on the pain experience and is directly associated with increased levels of depression and fatigue (Probst et al 2012, Probst et al 2009, Naylor et al 2001 ) – Frequency of dressing changes had a significant negative correlation on QOL (Piggins and Jones 2009) The Royal Marsden Management of the odour – Treat the cause using microscopy, most often bacterial in nature – Treat the alteration of exudate as this impacts on odour (ostomy bags) – Appropriate use of dressing – Managing the impregnation of smells in the environment (cat litter), absorbent bags and appropriate disposal of waste, charcoal – Aromatherapy burners (Vancouver Wound Care Guidelines Chapter 9 2007) The Royal Marsden Exudate – Comprises water, electroyltes, nutrients, inflammatory mediators, leucocytes, growth factors, enzymes and waste products – Non healing wounds have caustic substances which will degrade the peri-wound tissue and increase the size of the wound – Large fluid loss potential to cause metabolic changes, dehydration due to the fluid loss, electrolyte changes – Can cause anorexia (coping or not) – Anaemia if the wound bleeds Much of the most recent literature clearly identifies the importance of managing exudate and recognising what strategies we need to consider to reduce other physical and psychological consequences The Royal Marsden Exudate Fungating wounds can produce up to a litre of exudate a day which is caused by – disorganisation and permeable tumour vasculature – Catabolism of tissue by bacterial processes – Inflammatory processes at the cellular level (cytokine responses) – Some of the literature reports patient inactivity to prevent leakage Management of this volume of fluid is extremely difficult consider (utilising ostomy bags) anatomically this may be challenging in our patient population Thus impacts on the dressings required, frequency of dressing renewal, availability of dressings, health care resources, experience of the professionals The Royal Marsden Wound management – Honey known for wound healing, inhibitory effect on pathogenic bacteria, highly acidic, and has an osmolarity which inhibits most organism growth, reduces oedema and pain, desloughing and debridement properties, deodorant, maintains moisture, 4% of the cost of commercial dressings and far less clinical evaluation (Udwandia 2011) – Ghee (clarified butter made from cows milk and indigenous to the Indian sub-continent) with Honey (Udwandia 2011) The Royal Marsden – The use of honey or honey and ghee is treated with great scepticism by most, if not all surgeons – In surgery many truths are born of blasphemies, Laporoscopic cholecystectomy was frowned upon by the surgical establishment but is now gold standard without a single RCT (Udwandia 2011) – RCT using honey have good results but are only graded as level II evidence – More trials are needed but Honey and Honey and Ghee potentially offer safe, pain free and low cost treatment for infected wounds The Royal Marsden Wound characteristics Small wound low exudate – Consider silicone (non-adherent, highly absorbent), hydrogel, hydrocolloids Small wound high exudate – Hydrofibre Large size wound and high exudate – Aligates (highly absorbant), foams(trauma free). Absorbant pads (secondary dressing) – Honey Malodourous – Systemic or topical metronidazole – Cadexomer iodine, silver impregnated dressings – Honey Bleeding – Haemostatic alginates, haemostatic surgical sponges, medical referral. (possible use of IV tranzaemic acid solution applied to wound) The Royal Marsden Silver dressings – Reduces malodour – Binds with bacterial DNA and RNA and stops replication of the bacteria – No real studies with Fungating wounds but as it reduces odour and infection theoretically could have a positive effect The Royal Marsden Iodine – Mixed reviews as to its effectiveness and can cause pain – Cadexomer iodine as a dressing, gel sheet or paste are activated by exudate and form a soft foam that maintains a moist environment at wound surface – Can absorb high levels of exudate – No real trials but the ability to absorb exudate strengthens its possible use in FMW The Royal Marsden Activated Charcoal – An area of contention – Need to have a good seal on the dressing – High volume of exudate and inactivation of charcoal – Expense (Hampton 2008) Debridement – Rarely an option in in FMW – Autolytic or enzyme debridement potential to increase exudate while necrotic tissue undergoes liquefaction (Lazelle 2007, Grocott 1999) Larval (maggott) therapy becoming more popular but is also about patient acceptability (Alexander 2009) The Royal Marsden Other products Systemic Metronidazole and topical applications reduces odour – Nausea and vomiting issues, consider PR route – Possible contra-indications with patients who wish to continue alcohol – Known to reduce pain as infection is resolved – Odour reduces and positively impacts on physical and psychological wellbeing alters – Clearing of infection reduces exudate and reduces dressing changes and wound trauma The Royal Marsden Pain – Pain is complex and in this setting maybe associated with pressure on surrounding structure (Naylor 2002) – Nerve damage from advancing disease and exposure of dermal nerve endings (Naylor 2001) – Recurrent infections (Grocott 1999) – Alteration to fluid due to impaired capillary function and lymphatic drainage – The actual ritual of wound care and dressing changes (Grocott 1999) The Royal Marsden Management of pain – Recognition that pain is multidimensional – Total pain recognises the psychological factors that affect the pain experience identified in most of the literature – Specifically anger, fear, anxiety and depression – Pain was also linked to malodour and in some studies the use of Metronidazole to reduce the odour saw reduced pain scores (Bale et al 2004) – Use of palliative care teams to manage both the pain and the wound – Topical and systemic analgesics work from St Christopher’s Hospice with topical diamorphine and morphine with hydrogels (Naylor 2002) The Royal Marsden Bleeding Caused by clotting irregularities from the abnormal vasulature, peri tumour angiogenesis and coagulopathy which cause thin walled vessels and susceptibility to bleeding In head and neck the other real issue is location of major blood vessels and the risk of a catastrophic bleed. It is essential that plans are in place to ensure optimal management of this potential risk should it arise Ensuring that wound changes do not cause trauma to the wound increasing the risk of localised bleeding through trauma – Use of anti-fibrinolytics (adrenaline 1mg in 1ml, tranexamic acid – Vasoconstrictors – Correct any systemic clotting issues – Radiotherapy – Ligation and cauterisation The Royal Marsden Key considerations – – – – – Contain exudate, prevent leaks Control the malodour Maintain moisture balance in the wound Reduce pain especially during wound care and dressing changes Try not to cause any further trauma to the wound or peri-wound skin potential to use barrier creams to protect the surrounding skin (Grocott 2003, Alexander 2009) – Maintain body symmetry and aesthetics as much as is possible – Timings of dressing changes and consider any complicating factors (Alexander 2009) The Royal Marsden Role of palliative radiotherapy – Possibility of help with bleeding and potentially disease progression – Reduces pain – Will it slow the growth of disease but cause other morbidity such as fistulae – Palliating pain has a positive impact on the patient – Need to consider the benefits versus the risks – Time spent on treatment and away from family and friends, is it justified and acceptable to the patient The Royal Marsden Role of palliative chemotherapy – Is there a positive benefit expected – Side effects versus potential benefit – Disease regression and management of potential side effects that may be minor or major – Is it acceptable with time in hospital versus time at home – Sepsis and side effect risk – The mixture of cytotoxic chemotherapy and a fungating wound The Royal Marsden Role of palliative surgery Assessing – The surgical morbidity – Time spent in hospital versus predicted life expectancy – Expected recovery time – Will the surgical intervention positively impact on the individuals quality of life? – Is the proposed intervention acceptable to the individual? The Royal Marsden Fungating disease into the epithelium and extending to the orbital region The Royal Marsden The Royal Marsden Palliative Surgery Underwent a total Laryngectomy and Total Glossectomy Lived for 2 years post this procedure The Royal Marsden The Royal Marsden Palliative Surgery not offered: in hindsight would he have been better served by surgery? Living with a fungating wound and unable to talk or swallow The Royal Marsden Palliative Surgery: Died within 3 months of distant disease not pre assessed The Royal Marsden The Royal Marsden Lived for 3 years with few symptoms The Royal Marsden Again palliative surgery lived for 3 years again with few symptoms The Royal Marsden The Royal Marsden Considerations Those individuals living with advanced cancer can live for long periods; their quality of life is directly influenced by supportive care and management of symptoms. Grocott (2007) advocates integration of cancer services and palliative care to facilitate good symptom support through national guidelines and accredited standards especially in the area of complex wound management Further research into Fungating Malignant Wounds is required Collaboration with Tissue viability teams is essential Utilise the expertise out there Know when to ask for help Highlighting this uncommon but complex side effect of advanced cancer The Royal Marsden Fungating wounds remain a challenging area for patients, carers and health care professionals alike. Collaboration is essential to positively impact upon the individual who is faced with the daily reminder of their disease and destiny The Royal Marsden What are the possible interventions Wound management and palliation of symptoms – Is there a role for: – palliative surgery? – palliative chemotherapy? – re-irradiation What are we as health care professionals trying to achieve for this individual?