Evaluation of Pressure Ulcers in 202 Patients with Cancer–Do Patients with Cancer Tend to Develop Pressure Ulcers? Once Develope

Since 2003, countermeasure for pressure ulcer development has played an active part in preventing the development of pressure ulcers at the National Nagasaki Medical Center. However, new pressure ulcers continue to develop and it has become clear that half of these patients have cancer as an underlying disease (Figure 1).¹ Terminally ill patients must be treated with consideration of their quality of life and should not be urged to undergo intensive or invasive therapy.
As pressure ulcers tend to develop in patients with cancer despite intensive care, new guidelines and measurements for the prevention of ulcers are desirable. The authors investigated pressure ulcers in patients with cancer and suggest a grading system for countermeasures for pressure ulcers.

Patients and Methods

Patients who had developed pressure ulcers (419) at the authors’ medical center were treated from 2003 through 2005. Of these patients, 202 with cancer and 217 without malignant disease were retrospectively eligible for this study. All pressure ulcers were observed until they had healed or until the patients died as a result of the wound. Among the 202 patients with cancer, 75 died within 2 months after admission, which was thought to be so-called terminal patients. Among the 217 patients without cancer, 35 patients were thought to have a terminal illness.
Changes in primary disease in patients who had developed pressure ulcers for 3 years are shown in Figure 1 and the type of cancer is shown in Figure 2. Patients with cancer (48%) were in the age range from 3 months to 94 years (mean age, 66.2 ± 20.6 years) and patients without cancer (52%) were in the age range from 28 to 92 years (mean age, 68.0 ± 13.8 years). There were no significant differences according to Wilcoxon signed rank test. Data of serum albumin in
cancer- and noncancer groups, which represent their nutritional status are presented in Figure 3. Serum albumin in the cancer group was an average of 2.69 mg/dL, and in the noncancer group there was an average of 2.79 mg/mL. There were no significant differences in serum albumin between the cancer group and noncancer group (P = 0.14, t-tests).
The severity of pressure ulcers at first discovery in patients with and without cancer is shown in Figure 4. In both groups, the pressure ulcer stage showed a close resemblance. Stage I accounted for more than 60% and Stage II accounted for more than 30%, meaning these pressure ulcers were discovered in relatively early stages. The location of the ulcers in patients with and without cancer is shown in Figure 5. Pressure ulcers in the sacral region accounted for more than 75% in both groups.
All patients were evaluated and classified using a scale for preventive measures against pressure ulcers that has been described by Ohura and Hotta² and called the “OH scale.” The physical status of the patients including spontaneous body turning, sacral bony prominences, and edema and joint contraction, were checked and evaluated numerically.² This risk assessment scale indicates that pressure ulcers would develop in less than 25% of patients with a low risk (risk score, 1–3 points), 26% to 65 % of patients with a moderate risk (risk score, 4–6 points), and more than 66 % of patients with a high risk (risk score, 7–10 points).^2–4
To evaluate changes in ulcers, all patients were observed from the time the pressure ulcers developed until the ulcers healed or until a patient died. Patients who were discharged before the pressure ulcers healed and/or died at home or in hospices were excluded from the study.
Several problems were investigated using the following data: 1) when patients developed pressure ulcers, difference in the occurrence of terminal prognoses in patients with or without cancer; 2) when the pressure ulcer healed, differences in pressure ulcer healing times in patients with or without cancer; 3) the differences in survival after pressure ulcer developed in terminally ill patients with or without cancer; 4) difference in risk-assessment scale scores with or without cancer.
Statistical analysis was performed using t-tests.

Results

Outcomes of patients with or without cancer. During the observation of patients who developed pressure ulcers (cancer = 202, noncancer = 217), 36% died in the cancer group, and 15% died in the noncancer group.
Differences in pressure ulcer healing times in patients with or without cancer are shown in Figure 6. The mean healing period for pressure ulcers in patients with cancer was 19.0 days and healing time in patients without cancer was 18.8 days. There was no significant difference between the groups (P = 0.92).
Survival differences in patients with cancer or without cancer whose pressure ulcers failed to heal are shown in Figure 7. The mean survival time after the development of pressure ulcers in patients with cancer was 21.7 days and in patients without cancer was 18.4 days. There was no significant difference between the groups (P = 0.47).
Differences in risk-assessment scale scores in patients with or without cancer are shown in Figure 8. The mean OH scale score in patients with cancer was 3.28 while the mean score for patients without cancer was 3.84. Results demonstrate that there was a significant difference between the groups (P = 0.04).

Discussion

Countermeasure for pressure ulcer association has served a critical role in preventing pressure ulcer development at the authors’ facility. This action reduced the incidence of pressure ulcers and shortened healing times. It appears the incidence of pressure ulcers in patients with malignant neoplasms has increased over the past 3 years, yet has remained the same or has reduced in patients with other diseases (Figure 1).^1,3
An effective way to prevent pressure ulcers is to pay close attention to patients with risk factors for pressure ulcers.⁵ Fortunately, the OH scale has been shown to be a simple, reliable, and effective method for predicting pressure ulcer development and is used throughout Japan.^2–4 For patients at the authors’ facility who are thought to be at moderate or high risk by the OH scale (scoring more than 4 points), air mattresses or extra-soft mattresses must be prepared. In spite of these preventive efforts, patients with cancer and pressure ulcer(s) accounted for 48% of all patients. In 2004, patients with cancer accounted for only 6% of inpatients (various cancers = 655 patients; other diseases = 9898 patients). This result suggests that patients whose underlying disease is cancer are more likely to develop pressure ulcers.
Many investigators have demonstrated the relation of skin disturbances and cancer. In advanced cancer, skin disturbances may be caused by common conditions, including anorexia, cachexia, malnutrition, anemia, impaired mobility, old age, circulation disturbance, and neurological disorders.^6,7 All of these conditions produce general alterations of the skin, such as thinning, loss of elasticity and resistance, dehydration, deepening of sores and wrinkles, and dermal atrophy, which may allow pressure ulcers to develop.⁸ Furthermore, anticancer treatment may induce skin toxicity. Some chemotherapeutic agents cause edema, desquamation vesicles, ulceration, and skin necrosis.⁹ In addition, radiation therapy can produce skin alterations due to arteriolar damage and inhibition of mitosis in the epidermal basal layer.¹⁰ The treatments for cancer varied greatly—anti-cancer medications, radiation, operation, immune-therapy, and combination and adjuvant therapy were usually chosen. It is desirable to categorize all aforementioned circumstances including all incidence data to study the relationship between each type of cancer treatment and pressure ulcer development.
It is commonly believed that pressure ulcer prevention may be related to the patients’ spontaneous movements.¹¹ In this line of reasoning, the use of opiates and other sedatives should be limited. However, insufficient analgesics and sedatives can produce pain and distress for a patient, which runs counter to proper cancer treatment. Terminal care for example, focuses on the elimination of each specific symptom including pain via comfort-oriented therapy.¹² Seiler and Stahelin¹³ have demonstrated that pressure ulcers can be prevented with extra-soft mattresses and 30-degree oblique positioning, which should be changed every 2 hours. This investigation showed that there was no difference in the time to heal pressure ulcers between patients with cancer and patients without cancer. Moreover, there was also no difference between the groups in the time from pressure ulcer development to death with an ulcer. These results were unexpected because the authors had believed that patients with cancer would be more likely to develop pressure ulcers, that the ulcers would be difficult to heal, and patients would have the ulcers for a longer time. These results also demonstrated that adequate preventive care and proper treatment would be equally effective for patients with and without cancer as an underlying disease. Adequate amounts of analgesics and sedatives are indispensable for patients with cancer. Pain control allows frequent position changes, proper skin hygiene, and discovery of early skin disturbances; both are the most effective means for preventing and healing pressure ulcers.
The risk assessment scores in patients with or without cancer show that patients with cancer tend to develop pressure ulcers more often than patients without cancer, even though their risk scores are not high. Therefore, the results emphasize that pressure ulcers in patients with cancer need to be cared for more attentively through preventive measures. It is necessary to modify risk assessment measures (eg, risk assessment scores of patients with cancer should be increased by 0.5 on the OH scale), because cancer is a risk factor for pressure ulcers.