Multidisciplinary Approach in Managing

Complex Cancer Wounds

SPEAKER: DR.PRATEEK MAURYA

 INTRODUCTION AND CLINICAL RELEVANCE

Prevalence: Malignant or fungating wounds have

been reported to affect up to 15% of

cancer patients in advanced disease stages (during

the last 6–12 months of

life)

Niculescu, AG., Georgescu, M., Marinas, I.C. et al. Therapeutic Management of Malignant Wounds: An Update. Curr. Treat. Options in Oncol. 25, 97–126 (2024).
 Complexity

• MFW s: Non-healing, disfiguring

and complicated (hemorrhage,
infection, and malodor).

• Notoriously resistant to curative

management.

Vardhan M, Flaminio Z, Sapru S, Tilley CP, Fu MR, Comfort C, Li X and Saxena D (2019) The Microbiome, Malignant Fungating Wou nds, and Palliative Care. Front.
Cell. Infect. Microbiol. 9:373. doi: 10.3389/fcimb.2019.00373
 Psychosocial and Emotional Burden

Patients experience significant deterioration in body image, identity, dignity, and

social integration due to visible wounds and persistent symptoms like odor and

bleeding (Robinson & Holloway, 2019).

“Visual metaphors of mortality"

•MFWs (Malignant Fungating Wounds) significantly affect patients' psychological well-being.

•They influence how patients perceive themselves and their illness.

•Patients often experience strong feelings of isolation.

•Specialist and supportive care can help reduce the negative impact on both patients and their families.
 SLO of This Presentation

1.To characterize complex cancer wounds and their clinical burden.

2.To emphasize the value of multidisciplinary collaboration.

3.To propose evidence-based frameworks for optimized care.

4.To highlight patient-centered strategies integrating palliative, oncologic, and surgical goals.
 Definition Complex Cancer Wounds

Malignant Fungating Wounds (MFWs): Skin and subcutaneous lesions caused

by infiltration of malignant cells, typically in advanced stages. Characterized by
necrosis, exudate, and rapid proliferation ( Yasmara et al., 2024).
 Presentation and Progression

•Rapid deterioration with extensive tissue destruction, severe pain, malodor,

bleeding, and psychological trauma.

•In breast cancer, up to 62% of patients in late -stage disease may develop such
wounds, often leading to delayed presentation and management (Robinson &
Holloway, 2019).
 Scope & Challenges

•Infection & Odor: Anaerobic bacterial colonization leads to persistent malodor, frequently
reported as the most socially isolating symptom (Beh & Leow, 2016).

•Hemorrhage: Fragile neovascularization and tumor angiogenesis predispose to catastrophic bleeding events
(Faria et al., 2021).

•Pain: Often under-treated; chronic nociceptive and neuropathic pain contribute to a 'total pain' experience.

•Exudate Management: High-output drainage can require complex dressing regimens and continuous
monitoring.
Impact on: Quality of Life

•MFWs drastically reduce physical, emotional, and existential well -

being—affecting sexuality, independence, and hope (Lo et al., 2012).

•Caregiver burden is also substantial, especially where professional

support is lacking (Probst et al., 2012).
 The Need for a Multidisciplinary Approach

•MFWs: multisymptomatic and multi-systemic

•Integration of oncologic, palliative, surgical, psychosocial, and wound -

care expertise (Merz et al., 2011).

•Isolated interventions (e.g., wound dressing without psychosocial care)

lead to fragmented care and diminished outcomes (Faria et al., 2021).

 Clinical Outcomes Enhanced by Team -Based Models

•Shortens the time to

treatment,

•Reduces symptom
burden and enhances
continuity of care
(Joseph et al., 2017).
 Team Composition

•Oncologists – Drive systemic cancer

control. •Radiation Therapists – Provide tumor-reductive

•Surgeons – Manage tumor debulking and radiotherapy.

local excision. •Dietician – Address catabolic states and cachexia.

•Palliative Care – Address complex

symptom clusters and end -of-life needs •Psychologists/Psychiatrists – Support mental health,
(Tilley et al., 2016).
distress, and adaptation.

•Wound Care Nurses – Lead local wound

assessment, dressing protocols, and
•Social Workers – Assist with home care, resources, and
infection control.
caregiver coordination.
 Role of the Surgical Team

•Surgery is often palliative, aiming to:

• Reduce wound burden

• Control hemorrhage

• Facilitate dressing application (Kondra et al., 2022).

•Inappropriate excision can worsen tissue necrosis; hence collaboration with radiology,
pathology, and palliative teams is essential.
Niculescu, AG., Georgescu, M., Marinas, I.C. et al. Therapeutic Management of Malignant Wounds: An Update. Curr. Treat. Options in Oncol. 25, 97–126 (2024).
https://doi.org/10.1007/s11864-023-01172-2
 Oncology & Radiation Therapy Contributions

Chemotherapy/Radiotherapy in Wound Modulation

•Systemic therapy can temporarily stabilize tumor proliferation at the wound site but must be
balanced against immunosuppression and wound healing inhibition (Rupert & Fehl, 2020).

Radiation-Specific Considerations

•Palliative radiation is particularly effective in:

• Controlling bleeding

• Decreasing tumor mass

• Reducing odor-producing necrosis (O'Neill et al., 2022).

 Wound Care & Nursing Interventions

Complex Wound Management Requires:

•Standardized frameworks like PEBO (Pain, Exudate, Bleeding, Odor) to guide dressing
selection (Janowska et al., 2021).

•Advanced dressings ( hydrofiber, silver-infused, foam dressings, alginates).

•Topical metronidazole and charcoal for odor control.

Nursing Expertise is Crucial

•Nurses are frontline responders in managing wound exudate, malodor, and hemorrhage
and play a central role in patient education and psychosocial monitoring (Grocott, 2007).
 Palliative & Psychosocial Care

Holistic Suffering Needs Holistic Solutions

•The “total pain” paradigm integrates physical, emotional, spiritual, and existential distress
(Faria et al., 2021).

Psychosocial Role

•Patients with MFW s face:

• Body image deterioration

• Social isolation

• Chronic anticipatory grief

•Support groups, counselling, and dignity therapy enhance resilience and end -of-life planning
(Probst et al., 2012).
 Assessment Framework

Multidimensional Assessment Domains

•Clinical: Lesion size, exudate, necrosis, bleeding, malodor.

•Psychological: Patient distress, body image, depression.

•Social/Functional: Caregiver support, dressing logistics, hygiene capacity.

Evidence-Based Tools

•Use of the W ound Assessment Tool and PEBO framework (Pain, Exudate, Bleeding, Odor) for
standardized wound symptom grading (Janowska et al., 2021).
 Treatment Planning Algorithms

Stepwise Care Protocol

1.Primary oncologic control (chemo/radiotherapy when feasible)

2.Palliative debridement or surgical stabilization

3.Topical and systemic symptom control

4.Psychosocial and spiritual support

Transitioning Goals of Care

•Early integration of palliative principles is essential as wounds shift from curative

potential to symptom-focused management (Qiu & Good, 2020).
 Pain and Symptom Control

Pharmacologic Strategies

•W HO analgesic ladder - Basic

Consider opioid titration, ketamine, tricyclics, and gabapentinoids for neuropathic
components (Niculescu et al., 2024).

Non-Pharmacologic Measures

•Regular repositioning, wound cooling, distraction therapy.

 Infection Control & Odor Management

•MFW s are often colonized but not truly infected —hence antibiotic stewardship is key
(O’Neill et al., 2022).

Evidence-Based Interventions

•Topical metronidazole is a gold standard for malodor (Adderley & Smith, 2007).

•Charcoal dressings, silver -releasing foams, and iodine dressings are useful adjuncts.
 Nutrition and Healing

Role of Nutrition in Wound Physiology

•Chronic wounds are associated with catabolic states; protein -energy malnutrition impairs
collagen synthesis and angiogenesis.

•Key micronutrients: Vitamin C, zinc, glutamine etc

Clinical Recommendations

•Registered dietitian consultation is imperative.

•Early enteral nutrition for those with oral intake limitation is associated with better
wound scores (Dutta et al., 2021).
 Technology and Innovation

Emerging T herapies

•Nanotechnology-based antimicrobial dressings and plant -extract infused films are in

early clinical testing (Niculescu et al., 2024).

•Bacteriocins and honey -derived bioactives showing promise for resistant microbial
biofilms.

Clinical Implementation Tools

•Telewound platforms and AI -powered wound imaging are helping extend access to
specialty care, especially in resource-constrained settings (Starace et al., 2022).
 Case 1 – Breast Fungating Wound in Advanced Palliative Care

 Study on 25 cancer patients with malignant fungating wounds.

 Day 15 showed symptom improvement after palliative care.

 Pain, exudate, malodor, and bleeding were key symptoms.

 Statistical improvement noted in all symptom scores.

 Palliative care effective in reducing wound-related distress.

 Latest Evidence Supporting Multidisciplinary Care

Clinical Outcom es Enhanced by Collaborati on

•Multidiscip linar y m odels incorp orating oncolog ists , nurses, and p alliativ e care sp ecialists sig nif icantly
im p rov e sym p tom m anag em ent and continuit y of care in MFW p atients (Qiu & Good, 2020).

•Early integ ration of p alliativ e care reduces hosp italizatio ns , p rocedural ov eruse, and existenti al
distress (Faria et al., 2021).

Patient and Nurse -Focus ed Outcom es

•New b est p ractice m odels hav e dem onstrat e d:

• A 70% im p rov em ent in com p rehensiv e w ound assessm ents

• 90% adherenc e to ev idence -b as e d dressing and p ain control g uidelines af ter structured nurse
training (Chang et al., 2024).
 Global Best Practices in Multidisciplinary Cancer Wound Care

1.Multi-center review analyzed 44 patients with 45 fungating malignant wounds over 11 years.

2.Breast cancer was the leading cause, responsible for over half the cases (54.5%).

3.Tumor size had no clear link to survival, highlighting other prognostic factors.

4.Palliative surgery helped manage wounds and supported dignified end-of-life care.

5.Holistic palliative approaches enhanced quality of life for patients and families alike.
 Gaps in Current Practice

1. Lack of Standardized Clinical Guidelin es

•Desp ite g row ing ev idence, care p ractices rem ain larg ely exp loratory, w ith sub stantial v ariation across
institution s and countries (Pram od et al., 2023).

2. Underrepre s ent at ion in Clinical Trials

•Most nov el therap eu tic ap p roaches ( e.g ., silv er-f oam , honey-b a se d dressing s ) lack rob ust RCT-lev el
v alidation. Only 1 p ub licly av ailab le clinical trial result exists f or MFW s (Niculescu et al., 2024).

3. Unm et Needs in Sym ptom Assessm e nt

•No univ ersally accep ted tool f or com p rehensiv e sym p tom p rof iling . Existing tools f ail to adeq uatel y
cap ture f unctional lim itations, w ound -induc e d stig m a, and sp iritual distress (Tilley et al., 2020).
 Future Perspectives

1. Biotechnologi c a l Innov ations

•Em erg ing therap ies include:

• Nanotech n ol og y-b as e d dressing s (dual antim icrob ial & drug -deliv ery f unctions)

• Plant-b ase d and b acteriocin -i nf u se d ag ents show ing anti -inf lam m ator y and deb riding p rop erties
in p reclinical trials (Niculescu et al., 2024).

2. Artifici a l Intelligen c e & Digital Monitoring

•Pilot studies p rop osing AI -driv en im ag e analysis f or:

• W ound p rog ression tracking

• Sym p tom p rediction

• Enhance d triag e in telew ound care setting s

 Key Takeaways

1. Complex Cancer Wounds Are a Multidimensional Burden

•Malignant fungating wounds (MFW s) represent one of the most distressing

complications in advanced cancer, impacting physical, psychological, social, and

existential domains.
 Key Takeaways

2. Multidisciplinary Management Is Essential

•Integration of oncology, palliative care, surgery, wound care nursing, psychology, and social

support ensures comprehensive and compassionate care.

•Transitioning from curative to palliative goals must be proactively managed by the entire

care team (Qiu & Good, 2020).

 Key Takeaways

3. Evidence-Guided Frameworks Improve Outcomes

•Symptom-oriented protocols (pain, odor, bleeding, exudate) reduce suffering and caregiver

burden.

•Nurse-led innovations and structured assessment tools are powerful levers for

standardization and quality care (Chang et al., 2024).

THANKYOU