Scoop of Practice Episode 3: Cancer Prevention and Control in Wound Medicine

From my early years as a medical student, I saw the value of promoting preventive medicine and protecting the health and well-being of humanity. Ironically, I was criticized by an admissions committee member that preventing disease and injury was a sure way of putting myself out of a job. I did not have a good rebuttal at that time, but now I could easily persuade this official why prevention practices are important.
 
We physicians are all healers, but I want to heal through improving systems and processes of our medical practice that will not just affect one patient but will affect an entire population. As previously described the wounded population is rapidly growing due to the aging population and its rising prevalence of related comorbidities like obesity, diabetes, cardiovascular disease and not surprisingly mental health. While our incident numbers are growing, so too are our prevalence numbers which mean the risk of secondary malignant degeneration of wounds will follow. The easy solution is to heal the hole and restore wholeness in a timely fashion, but unfortunately despite the many diagnostics and regenerative therapeutics the system is not reaching this goal.
 
As time goes on, malignant degeneration of chronic non-healing, inflamed wounds is a daily risk. Secondary malignant wounds include: Marjolin's ulcers, squamous cell cancer associated with chronic osteomyelitis and skin manifestations of metastatic cancers (breast, prostate, ovarian, etc). Other atypical wounds with pseudo-malignant tendencies are heterotopic ossification, hidradenitis suppurativa and pyoderma gangrenosum.
 
Wound specialists must have a keen eye on whether an incident wound is in fact malignant, and be open to utilizing tissue biopsy as a diagnostic modality at time zero of presentation. Full thickness punch biopsy is the standard of care to obtain a sample containing the entire architecture of the layers of skin for full staging, however a tangential shave can give providers a diagnostic lens for the presence or absence of atypia (in situ cancers) vs. dysplasia (fulminant cancer). For a more compassionate approach, providers can use a novel nylon based hand held tool that can be used to obtain particulate sections of the wound base tissue and cytological evaluation. This device contains no steel and offers a less painful, less invasive utility to obtain cytology. No reason to remove sheets of cells when we are simply looking for malignant degeneration which would ultimately require a wide local excision and lymph node staging depending o which will inform the care team and patient about next steps.

Traci A. Kimball, MD, CWSP, aka The Wound Wizard, is affiliated with WISH Expert Consulting LLP. Her direct contact is tkimball0525@gmail.com.