Addressing the Pain: Chronic Wound Pain and Palliative Cancer Care

   Patients with malignant wounds experience distressing complications including pain, odor, exudate, bleeding, edema, emotional distress, social concerns, functional compromise, and complications (ie, infection and fistulas).¹

Life expectancy after developing a cutaneous metastasis is variable but has been shown to be 21.7 months on average. A reproducible assessment of patients with malignant wounds is the cornerstone of treatment² that when obtained in order to implement wound symptom management measures can improve quality of life³ throughout that time period.

Malignant Wound Complications

   Approximately 5% to 10% of patients with internal malignancies develop metastatic cancer that spreads to the skin (cutaneous metastasis).⁴ These wounds can progress despite aggressive oncology care because some patients neglect to seek medical assistance until the wound is advanced. Curative treatment is often not an option, although a range of palliative oncology treatments may be tried, including systemic therapy, radiation therapy, phototherapy, and surgery.⁵ Referrals to oncologists for palliative oncology care can be beneficial. Patients typically have variable responses to treatment, requiring simultaneous and subsequent wound management and various approaches according to assessment (see Table 1). Following the suggested paradigm^6-8 brings a focus to the objectives of any proposed wound care plan.

   Treat the cause. The ability to treat the cause revolves around the correct diagnosis of the wound pain and its potential sources. The pain history begins with active listening to the patient's story, followed by specific questioning to enhance the information gathered. The patient is examined specifically for potential reasons for pain - eg, the tumor pressing on nerve endings and adjacent visceral organs, chemical agents released by tumor cells that irritates nerve endings, ischemia, inflammation, or increased swelling. Chemotherapy, pharmacotherapy, radiation, and surgery may eradicate or reduce the size of the tumor to relieve pain.^9,10

   Patient-centered concerns. The clinician needs to focus on the patient's perspective of pain and its route cause. Because pain is a complex and highly subjective construct comprising multiple dimensions and modulated by the context and meaning in which pain emerges,¹¹ its management must incorporate the impact of body disfigurement, family burden, guilt, and patient shame. In particular, any assessment of patients with fungating wounds should address the immense psychological distress they can cause and highlight key factors critical to managing these complex wounds. Many fungating wounds are heavily exuding, malodorous, and bleed easily. Strategies that focus on managing these symptoms must be explored and recommendations for clinical practice determined accordingly (see Table 2).

   Local wound care. Wound care needs to revolve around debridement, bacterial balance/prolonged inflammation, and moisture balance; it should not necessarily focus on healing. Fungating wounds rarely heal, so the ability to manage their unpleasant symptoms on an ongoing basis is increasingly important. One of the most distressing is malodor; the use of metronidazole preparations in the management of malodorous wounds is becoming more routine.^12-14 Research indicates that topical morphine and other local anaesthetics can be used to alleviate wound pain to promote comfort.¹⁵

Discussion and Suggestions

   Fungating cutaneous metastasis may occur with breast, lung, sarcoma, and head and neck tumors potentially associated with underlying tumor mass invading the skin. Patients may report minimal pain despite the presence of large fungating wounds, provided the dressings are suitable and cancer pain management in general is provided. On the contrary, the most painful malignant lesions tend to be shallow ulcerating malignant wounds that potentially spread through the lymphatics, denuding the overlying epithelium. These can be devastatingly painful lesions, spreading over body surfaces that are awkward to dress. They are commonly found in head and neck squamous cell carcinomas on the scalp. Melanomas tend to metastasize in the extremities and can present with painful ulcers.

   By far, the most common cause of episodic physical pain in patients with malignant wounds occurs during wound dressing changes. It is important to determine if the pain is in the wound, in the periwound skin, or both. Pre-procedural pain medication may be necessary, as well as meticulous attention paid to patient-specific dressing changes.

   Dressing selection. Pain located in the wound bed can be caused by exposure to air and adherent dressings. If exposure to air is painful, the wound should be covered with moist dressing (water, saline soaks) during dressing changes. The clinician should ensure the dressing does not adhere to the wound bed. Appropriate non-adherent dressings vary depending on other wound factors. A silicone mesh contact layer, gels, and skin protectant pastes are effective in reducing pain and bleeding from adherent dressings, particularly in shallow relatively dry wounds. Alginates and hydrofibers can do the same in moist wounds and conform to the typically uneven wound bed in difficult-to-dress areas. Foams are a better second layer in these wound dressings because of the reduced conformity. The pain assessment should be repeated on a regular basis to determine the cause of any discomfort and to select appropriate dressings as the wound changes.

   Periwound skin. Periwound skin requires special attention because it is often compromised. Oncology treatments include surgery and radiation, which can alter blood flow, and cancer progression can occur subcutaneously in the periwound skin. Preventing wound development in the periwound skin is the easiest way to manage pain. Although dressings must be changed regularly, this should be minimized as much as possible. Prevention and management of pain in the periwound skin includes skin sealants (eg, alcohol-free, film-forming acrylate barrier),^16,17 monitored use of tape, and using elastic mesh or bandaging to hold dressings or tape onto thin hydrocolloids (only use hydrocolloids on periwound skin).

   Infection. Wound infection should be considered if the pain changes, especially in association with increased erythema, heat, odor, exudate, bleeding, and wound bed friability. Wound infections often have significant odor; however, cellulites may not have an odor. Wound cultures and antibiotics are important, particularly for patients receiving chemotherapy.

Conclusion

   The total pain experience involves social and emotional contributions to pain and the impact of the pain phenomenon on quality of life. Emotional responses such as depression, anger, and frustration are related to the degree of acceptance of the situation and the potential for tumor reduction through oncology. Patient withdrawal from society and social rejection by family, friends, and healthcare providers may occur. Social acceptance is heavily dependent on appearance and symptom control. Cosmetically acceptable dressings that control odor, exudate, and bleeding are fundamental in forestalling social isolation.

   The wound and the patient's response to it must be part of a thorough assessment. The most important principle in pain management is to listen to the patient and provide care accordingly, including dressing changes, oncology care, and pain medication.

   As part of the assessment, the clinician should ask the patient, What bothers you most about this wound? The answer will provide a starting point for improving quality of life.

   Addressing the Pain is made possible through the support of Molnlycke Health Care.

1. Schulz VN, Triska O, Tonkin K. Malignant wounds: caregiver determined clinical problems. J Pain Symptom Manage. 2002;24(6):572-577.

2. Schulz VN. The development of a malignant wound assessment tool. Unpublished thesis. University of Alberta, Edmonton, Alberta; 2001.

3. Haisfield-Wolfe ME (1997). Malignant cutaneous wounds: a management protocol. Ostomy/Wound Management. 1997;43(1):56-66.

4. Lookingbill D, Spangler N, Helm K. Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients. J Am Acad of Derm. 1993;29: 228-236.

5. Schulz, Nocent V. Cutaneous metastasis and malignant wounds. In: Nabholtz JM, Tonkin K, Reese D, et al (eds). Breast Cancer Management Application of Clinical and Translational Evidence to Patient Care, 2nd ed. Philadelphia, Pa.: Lippincott, Williams & Wilkins;2002:475-488.

6. Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the wound bed - debridement, bacterial balance, and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.

7. Reddy M, Kohr R, Queen D, Keast D, Sibbald RG. Practical treatment of wound pain and trauma: a patient-centered approach. An overview. Ostomy/Wound Management. 2003;49(4A suppl):2A-15A.

8. Reddy M, Keast D, Fowler E, Sibbald RG. Pain in pressure ulcers. Ostomy/Wound Management. 2003;49(4A suppl):30-35.

9. Mercandante S. Malignant bone pain: pathophysiology and treatment. Pain. 1997;69(1-2):1-18.

10. Regaard A. The principles of pain management in advanced cancer. British Journal of Community Nursing. 2000;5(8):382-388.

11. Melzack R. Pain - an overview. Acta Anaesthesiol Scand. 1999;43(9):880-884.

12. Hampson JP. The use of metronidazole in the treatment of malodorous wounds. Journal of Wound Care. 1996;5(9):421-426.

13. Moody M. Metrotop: a topical antimicrobial agent for malodorous wounds. British Journal of Nursing. 1998;12-25;7(5):286-289.

14. Clark J. Metronidazole gel in managing malodorous fungating wounds. British Journal of Nursing. 2002;11(6 Suppl):S54-S60.

15. Mercandante S, Villari P, Ferrera P, Arcuri E. Local anesthetic switching for intrathecal tachyphylaxis in cancer patients with pain. Anesth Analg. 2003;97(1):187-189.

16. Sibbald RG, Campbell K, Coutts P, Queen D. Intact skin--an integrity not to be lost. Ostomy/Wound Management. 2003;49(6):27-33.

17. Coutts P, Queen D, Sibbald RG. Peri-Wound skin protection: a comparison of a new skin barrier versus traditional therapies in wound management. Canadian Wound Journal. In press.

18. Portenoy RK. Definitions and principles of assessment. In: Portenoy RK (ed). Pain in Oncology and AIDS Patients. Phildelphia, Pa.: Handbooks in Health Care Co., a Division of AMM Co., Inc.;1997:14-43.

19. Spitzer WO, Dobson AJ, Chesterman E, et al. Measuring the quality of life of cancer patients. J Chron Dis. 1981;34:585-597.