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National Collaborating Centre for Cancer (UK). Advanced Breast Cancer: Diagnosis and Treatment. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2009 Feb. (NICE Clinical Guidelines, No. 81.)

Appendix BPosition paper. Management of uncontrolled local disease in patients with advanced breast cancer

A review of this subject was commissioned by the National Collaborating Centre for Cancer in Wales. An expert panel was convened in order to write this position paper. The panel members who drew up the paper were:

Members of the working group

Mrs Samantha Holloway1, Lecturer, Department of Wound Healing, School of Medicine, Cardiff University

Professor Keith Harding2, Head, Wound Healing Research Unit, Professor of Rehabilitation (Wound Healing), Department of Wound Healing, School of Medicine, Cardiff University

Ms Helen McGarrigle2, Clinical Nurse Specialist (Breast Care), Cardiff Breast Unit, Llandough Hospital, Penlan Rd, Llandough, Vale of Glamorgan

Mrs Penny McIlquham2, Palliative Care Clinical Nurse Specialist, Royal Gwent Hospital.

Mrs Sue Scarrott2, Specialist Nurse (Breast Care), Gloucestershire Hospitals NHS Foundation Trust. Cheltenham. Glos

Mrs Kirsty Shilstone2, Clinical Nurse Specialist (Wound Healing), Cardiff and Vale NHS Trust

Acknowledgements

Mrs Nicola West, Consultant Nurse / Lecturer, Cardiff School of Nursing and Midwifery Studies, Cardiff University, Heath Park Campus, Cardiff

Ms Gill Donovan, Director of Patient Services, Cancer Care Cymru, Atlantic House, Cardiff Gate Business Park, Cardiff

Ms Wendy Jones, IT Department, Velindre Hospital, Whitchurch, Cardiff

1.0. Executive Summary

In contrast to other types of disease processes the primary outcome for individuals with uncontrolled disease in advanced local breast cancer is to ensure their quality of life (QoL) as cure may no longer be an option. For the purposes of this paper uncontrolled disease is taken to describe Fungating Breast Wounds (FBW), therefore the remainder of this paper will consider this as the focus.

There are a number of secondary outcomes that should also be taken into consideration to ensure the appropriate local wound management and therefore patient comfort. These will include:

  1. Management of Malodour
  2. Exudate Management
  3. Reduce risk of haemorrhage
  4. Management of pain
  5. Cosmetic appearance
  6. Improve Quality of Life
  7. Tumour containment

This paper will focus on management strategies in relation to the majority of these, however tumour containment is considered to be outside of the scope of this review.

Randomised Controlled Trials (RCT) are viewed as the gold standard for providing evidence, however this is challenging in patients with FBW due to the nature of the disease (Morison et al 1997, Seaman 2006). Therefore the information regarding the assessment and local wound management of patients with (FBW) is primarily derived from literature in nursing which in turn is based on expert opinion and personal experience (Grocott 1995b, Morison et al 1997, Burns and Stephens 2003, Seaman 2006, Lazelle-Ali 2007). Adderley and Smith (2007) suggest that multiple case study designs, such as those by Grocott and Cowley (2001) maybe the highest level of evidence that can be evaluated.

The view of the majority of authors is that such wounds are a particular challenge (Laverty 2003) and require practitioners to be flexible in their approach to managing the patient (Morison et al 1997, Wilson 2005, Bale and Jones 2006). It is not unusual for patients suffering with FBW to be cared for in the community (Young 1997a, Draper 2005) and often in their own home. This obviously requires that the community nursing team caring for the patient be fully converse with the actual and potential problems the patient may have, and also be able to allay the concerns of the patient and family (Wilson 2005).

2.0. Key Recommendations

2.1.

That population – based registers include collection of data related to the incidence of fungating wounds, to include FBW

2.2.

Evidence other than findings from RCTs may need to be considered in terms of developing national guidance. This should include evidence gained from expert opinion, case series and case studies.

2.3.

Patient assessment and subsequent management should take into account presenting problems from the patient’s perspective and existing standards for assessment should be considered to document the progress of interventions and to improve quality of life.

2.4.

Currently best practice advocates the use of existing dressing products to manage patients with FBW. However dressing manufacturers should consider the unique needs of patients with FBW and examine the need for a wider range of products. This should include new developments for exudate and pain management as well as the treatment of malodour. There are systems in place already to carry this forward, i.e. WRAP (Browne et al 2004).

2.5.

In the absence of evidence for the management of patients with FBW current practice indicates that practitioners follow the principles of moist wound healing and wound bed preparation, however such beliefs are based on data that is aimed at wound healing. However in the palliative setting it may be that amelioration rather than healing needs to be considered.

2.6.

Whilst the care of patients with FBW should include a multi-disciplinary approach with MDT clinics where possible, often the physical and psychological problems that a patient faces results in them feeling embarrassed or anxious about having to deal with a number of professionals. Therefore Health Care Professionals should consider the needs of the patient and, where possible and appropriate, limit the number of individuals required to provide direct patient care.

3.0. Mission Statement

3.1.

People with fungating breast wounds (FBW) require access to health care professionals who have an in-depth understanding of their presenting problems and who have knowledge of the appropriate management options available. Such a service should be able to offer the individual a choice of local treatments and in addition ensure the persons safety, therefore minimising any risks. The management plan must also take into account the individual’s physical and psychological well-being and formulate a plan of care that is consistent with the patient’s priorities and wishes.

4.0. Philosophy of Care

4.1.

There is existing guidance that identifies the systems and services that need to be established in order to provide patients with the required level of care (NICE 2002, WHO 2007).

“Every patient with advanced, recurrent or metastatic disease should be treated by a breast cancer multidisciplinary team (MDT) which includes a specialist oncologist. The team should have close links with a pain specialist and orthopaedic services.”

NICE (2002, pg65)

In addition to those services identified above it would also be advisable to include individuals who have specialist knowledge or experience of wound management in patients with FBW.

4.2.

Patients with locally advanced (T4) tumours are likely to have metastatic disease which affects many organs and tissues, therefore these patients need to be managed jointly by the specialist breast cancer MDT and also palliative care teams (NICE 2002).

Palliative Care is defined as:

“…an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment, and treatment of pain and other problems – physical, psychosocial and spiritual.”

(WHO 2007, pg3)

Therefore it is these that should guide the overriding structure of the services that are provided and include acknowledgement of the range of problems and specialists involved. Cawley and Webber (1995) had previously suggested that palliative care may be required for a considerable length of time because improved methods of treatment mean that patients are surviving for longer. In addition treatments may be considered at fairly advanced stages of the disease process (Cawley and Webber 1995).

5.0. National Context

5.1.

There are existing recommendations that outline service models that should be adopted and in addition provide a framework for developing high quality services for patients with cancer and support for their family / carers (NICE 2004)

5.2.

Previous initiatives outlined in, The NHS Plan, The NHS Cancer Plan and Improving Health in Wales provide recommendations on all aspects of cancer care (NICE 2006).

Therefore this position paper should be considered in conjunction with these standards.

6.0. Extent of the Problem

6.1.

Grocott (2000a, 2000b) has highlighted that the true incidence of FW (to include FBW) is an unknown quantity as there is no formal reporting mechanism currently in terms of population-based cancer registers. This is supported by other authors (Draper 2005, Adderley and Smith 2007). In addition there is a lack of accurate data to establish the extent of FBW (Ivetic and Lyne 1990). Morison et al (1997) highlight the difficulties of applying findings from older studies as changes in screening; prevention and treatment make comparisons difficult.

6.2.

According to the Royal College of Radiologists there are 320 clinical oncologists in the U.K. (RCR 2008). Recent personal communications to try and establish the number of patients with FBW that may present to an oncologist or Breast Care Nurse has identified that there are probably 1–2 patients per month in Cardiff and Vale NHS Trust (Barrett-Lee 2008, McGarrigle 2008). Based on the minimum potential figure of 1 patient presenting every month to each clinical oncologist it could be estimated that there are potentially 3840 patients with FBW seen per year). However what is not so clear is the duration of FBW care in terms of months/weeks. Whilst the overall number of individuals appears small, the impact of having a FBW pervades many aspects of the patient’s day-to-day life.

7.0. Definition

7.1.

Fungating describes a malignant growth which is usually ulcerative and proliferative (Mortimer 2004). They have been described as ‘fungus-like’ or have a ‘cauliflower-like appearance (Collier 2000). However they often vary in their appearance (Grocott 1999).

8.0. Aetiology

8.1. Fungating Wounds: Other terms that are used

8.1.1.

FBW may result from a primary cancer or from metastases that spread to the skin from a local or distant tumour (Bryant 2000, Langemo et al 2007, Naylor 2001, Grocott 2007a). Such wounds are most commonly associated with breast cancer (Wilson 2005). The wound often appears as a cauliflower-like structure as the tumour grows (Collier 1997). Commonly the tumour ulcerates to form craters, sinuses or fistulae. The underlying tissue, capillaries and lymph vessels are often involved and subsequently destroyed. This decrease in vascularity and ulceration often leads to further problems (Grocott 2000a, 2000b) such as infection and friable tissue that can bleed easily or even lead to haemorrhage.

8.1.2.

FBW commonly occur near the end of life (Langemo et al 2007) often in the last 6 months of life (Naylor 2001) and rarely heal. Management is aimed at palliation, symptom control and promoting patient comfort and well-being (Laverty 2000, Naylor et al 2001).

8.1.3.

Patients may also present having had previous radiotherapy with associated ischaemic tissue, complicated by the presence of a FBW. These patients present a particular challenge.

8.4. Staging of breast cancer

The American Joint Committee on Cancer (2001) restaged Fungating Breast Cancer from T3 to T4, where care is defined as being aimed at symptom control rather than curative treatment. Subsequently an additional revision (AJCC 2002) has characterised metastatic disease (T4) in more detail (Ta-Td) (Thor 2004, SIGN 2005b).

9.0. Patient Assessment

There are a number of areas that need to be assessed in patients with FBW; these will include those outlined in Table 1.

Table 1. Patient Assessment.

Table 1

Patient Assessment.

Whilst the importance of a MDT approach has been previously identified it must also be recognised that the patient may want to limit the number of health care professionals who are required to provide direct care. Therefore this aspect must be taken into account in the overall management of the patient.

9.1. Presenting Symptoms

A review of the literature has established that the symptoms experienced by patients are multifaceted and distressing (Naylor 2002a {Table 2}, Dowsett 2002, Wilson 2005, Seaman 2006). In addition each patient and their wound are unique in terms of their presentation and symptoms (Barton and Parslow 2001, Young 2005). Morison et al (1997) suggest that the ‘problems’ identified establish the knowledge base that professionals require to care for patients with FBW.

Table 2. Common physical and psychosocial problems.

Table 2

Common physical and psychosocial problems.

These fungating breast wounds are often hidden from family until breast cancer is advanced and terminal. There may have been much secrecy causing many psychosocial problems. This inhibits quality of life and open discussion with loved ones. The patient may experience multiple symptoms (Naylor, Laverty and Mallett 2001, Barton and Parslow 2001) with problems that are often recurring and require sometimes inventive approaches (Carville 1995, Young 1997b). Fletcher (2007) provides a useful guide to dressing awkward areas that may assist the practitioner in utilising the best approach. Assessment should include consideration of these and management should be modified to meet the individual needs of the patient. The subsequent dressing regime needs to be such that both trained and untrained carers can manage the procedure.

Whilst lymphoedema of the arm is a common complication normally associated with treatment of breast cancer (Pain and Purushotham 2000, Soran et al 2006), patients with FBW may present with lymphoedema as a consequence of the tumour blocking the axillary vessels. Therefore practitioners need to be able to manage this symptom in conjunction with other physical problems.

In addition to the physical symptoms there are psychological effects that also require careful attention (Naylor 2002a, Young 2005). Grocott, Browne and Cowley (2005) highlight the findings of Lawton (2000) who undertook an ethnographic study in hospice setting. She identified a theme she termed ‘social death’ which seemed to occur prior to ‘physical death’, which draws attention to the complexity of the situation and the impact of social isolation.

9.2. Wound Assessment

Wound assessment should include an evaluation of; site, location, surface area – where the wound is close to the axilla it can affect movement of the joint or ability to fix a dressing (Collier 2000). Measurement of the size will help to determine the size of dressing required. The type of tissue (i.e. slough, necrosis, signs of infection) and percentage of devitalised tissue (Collier 1997, Collier 2000). The amount and type of exudate, depth of the wound (to include assessment for sinus or fistulae), presence of odour, history of bleeding and pain all need to be assessed. Furthermore the surrounding skin will need to be observed for signs of maceration, excoriation or fragility (Collier 2000, Bates-Jensen, Early and Seaman 2001, Seaman 2006).

A system of note-taking has been developed (TELER) that can assist the practitioner in assessing the wound and provide a means of planning patient centred treatment goals (Grocott 1997, Grocott 1998, Grocott and Cowley 2001), expressed in terms relevant to the patient. Table 3 provides an example of TELER codes for the evaluation of exudate leakage.

Table 3. Example of TELER codes for exudate leakage.

Table 3

Example of TELER codes for exudate leakage.

However there is continued debate about such specific tools and patient self assessment tools such as WoSSAC (Naylor 2002b) which rates the severity of symptoms and interference on everyday activities. The authors highlight the advantages / disadvantages of each, however without further studies to validate these tools it is difficult to draw firm conclusions (Naylor 2002b, Grocott, Browne and Cowley 2005).

There are examples of more generic wound assessment tools such as the WHRU Assessment Form (Wound Healing Research Unit 2001) and those specific to pressure ulcers PSST (Bates-Jensen, 1995, 1997) and PUSH (PUSH Tool 3.0, NPUAP 1998). These tools could be adapted to suit the needs of patients with FBW and furthermore aid the practitioner in making an accurate assessment.

9.3. Pain Assessment

Tissue hypoxia and necrosis occurs as part of the progression of the malignant process, meaning that patients may experience various types of pain or discomfort (Naylor 2001b, Barton and Parslow 2001). Therefore it is important to identify whether the pain is related to the disease i.e. tumour progression, the wound or both (Naylor, Laverty and Mallett 2001, Seaman 2006). Pain can be related to other elements than the disease process, this may include maceration and excoriation from excess exudate levels.

There are a number of validated pain assessment tools that can be used as part of the assessment process; however the practitioner should be aware that not all may be able to differentiate between the various factors that contribute to the overall pain experienced. In addition practitioners should be able to differentiate between the various types of pain, such as nociceptive and neuropathic (Naylor 2001b, Dowsett 2002) to ensure the appropriate management. Pain assessment should be carried out during dressing procedures as well as pre and post to fully appreciate the impact (Dowsett 2002). Table 4 outlines the aspects of pain that need to be assessed and also lists some of the various tools available.

Table 4. Pain Assessment.

Table 4

Pain Assessment.

10. Goals of Management

Grocott (2002) suggests that management should include treatment of the underlying tumour, symptom control, local wound management as well as supportive care to the patient and their family. The concepts regarding management have been drawn from areas of oncology, chronic wound care and palliative care (Grocott 2007a).

The management plan may also include radiotherapy, chemotherapy and hormone therapy as well as more local topical wound treatments to palliate the symptoms (Hallett 1995, Haisfield-Wolfe and Rund 1997, Miller 1998, Naylor, Laverty and Mallett 2001, Seaman 2006). None of the interventions are a cure for advanced cancers however they may extend the patients life, ease the pain and bleeding and improve some aspects of quality of life (Seaman 2006). However the side effects of each have to be considered and balanced with the potential benefits (Morison et al 1997, Grocott 2007a).

Previous authors suggest that the aims of management include minimisation or containment of symptoms (Naylor, Laverty and Mallett 2001) where healing is not usually an achievable outcome (Goldberg and McGinn-Byer 2000, Hampton 2004, Maund 2008) and curative intent is no longer appropriate or effective (Bale and Jones 2006). Table 5 outlines some of the considerations in terms of management.

Table 5. Objectives of management may include.

Table 5

Objectives of management may include.

Naylor (2002a) concurs with previous authors but also adds additional aims of patient comfort, confidence in the professionals providing care and a sense of well-being to maintain or improve their quality of life.

Ultimately there is a reliance on the appropriate dressing being selected, the effectiveness of which should be measured by their ability to meet the required outcome, and will include measures other than ‘healing’. Practitioners must take into account problems as perceived by the patient (Collier 2000) as they are key to judging the effectiveness of treatments (Naylor, Laverty and Mallett 2001). Grocott (2007a) identifies additional skills that the practitioner may need, to include stoma and continence care, as well as being aware of appropriate nutritional intervention and pain relief measures. There is an existing range of guidelines available to help guide assessment and management (Twycross et al 2002, SIGN 2005a, SIGN 2005b, SCHIN 2006).

10.1. Aspects of Management

10.2. Wound Cleansing

Generally normal saline is the solution of choice (Collier 2000, Draper 2005), although showering may be appropriate if the patient’s wishes and can manage this (Wilson 2005, Draper 2005). Whichever method is chosen the fluid should be warm (Langemo et al 2007) and the procedure should be carried out gently so as not to risk bleeding (Seaman 2006). It is also advisable to avoid swabbing the wound as this may also cause damage and risk haemorrhage. Generally topical antiseptics should be avoided because they can cause local reactions and are ultimately inactivated by the devitalised tissue present in FBW (Draper 2005).

10.3. Malodour

It is commonly recognised that offensive odour is a major problem for patients with FBW, it is very distressing and can lead to additional problems of nausea and subsequent loss of appetite (Moody 1998). Ultimately the patient may become socially isolated due to concerns of others being able to smell the wound (Van Toller 1994, Piggin 2003). It is important to try and establish the cause of malodour (Lazelle-Ali 2007) however the difficulties of measuring ‘smell’ have been highlighted (Clark 2002). The assessment of odour should be carried out from the patient’s rather than the professional’s perspective (Morison et al 1997, Dowsett 2002).

There are existing measurement tools such as TELER to help to objectively assess the level of malodour (Grocott 1997, Browne et al 2004). This not only takes into account the level of perceived odour but in addition acknowledges social factors. However existing studies are very few making generalisations difficult.

Such unpleasant odour is generally caused by the type of tissue present, which is often sloughy or necrotic. The presence of this devitalised tissue can lead to the growth of aerobic and anaerobic bacteria which in turn can lead to infection (Hampson 1998, Naylor 2001 Seaman 2006). In addition to the type of tissue odour may also be due to the presence of stagnant exudate (Collier 2000, Barton and Parslow 2001, Draper 2005), hence the need for adequate wound cleansing and timely dressing changes (Draper 2005, Langemo et al 2007). Table 6 outlines the main forms of management.

Table 6. Management of Malodour.

Table 6

Management of Malodour.

In addition to local wound management interventions such as those listed above, Ferris and von Gunten (2001) have suggested that odour absorbers such as cat litter or activated charcoal placed under the bed of the patient may also be an effective method of reducing odour.

If malodour is associated with clinical infection then the patient will require systemic antibiotics (Thomas et al 1998, Wilson 2005, Seaman 2006). Guidelines suggest that oral metronidazole 400mgs three times daily for 2 weeks is appropriate (CREST 1998, SCHIN 2006) however patients may experience gastric disturbances and not be able to tolerate this. An alternative regime of 200mgs twice daily may be considered to be for maintenance purposes and reduces the unpleasant side effects and rectal administration may also be indicated (SCHIN 2006).

Topical metronidazole (TM) can also be used, a method delivery which avoids effects such as nausea or vomiting (SCHIN 2006). Thomas and Hay (1991) have suggested that 0.8% TM is active against a range of microrganisms that may be implicated in such wound types. In a later study by Finlay et al (1996) 0.75% TM was used in a sample of 47 patients with a variety of malodorous benign and malignant lesions. No placebo treatment was included because of the ethical issues of not treating malodour raised by the authors. Their findings indicated that by day fourteen 95% (n=41) reported a decrease in smell. The study also outlined that topical administration is a more expensive treatment than oral. Unfortunately there is no sub-group analysis to examine the effects of treatment for patients with FW.

To date there is still debate about the optimal dose of metronidazole (Draper 2005, Lazelle-Ali 2007) however previous research has suggested that 1g of metronidazole is required per cm2 (Bower et al 1992). This dosage would be applied to the wound surface once or twice daily following wound cleansing and is usually effective in 2–3 days (Draper 2005, SCHIN 2006) with the length of treatment being 5–7 days (Naylor, Laverty and Mallett 2001). However current evidence is based on small studies making generalisations difficult. Furthermore it has been suggested that largely exuding wounds can make the gel ineffective by diluting the concentration (Grocott 1999). Also practitioners need to consider that the use of TM can exacerbate the problem of exudate management. Clark (2002) suggests that further studies into its effectiveness are required.

11. Use of Dressings

Grocott (2002) undertook a review of the key published work from 1991–2001 regarding the management of FW, she concluded that the numbers of studies remains small. Some of the judgements made were that the use of metronidazole still needs further research, dressing usage needs additional evaluation and objective patient / wound assessment tools require more investigation.

More recently Adderley and Smith (2007) undertook a systematic review of topical agents and dressings for FW; however they were unable to provide any conclusive evidence of the role of many of the topical products that are used in the day-to-day management of patients. This was related to methodological considerations that precluded certain levels of evidence. Therefore they suggested that further research is required to establish guidance for practice.

There is a general acceptance that many of the wound dressings currently available are appropriate to use in the management of patients with FBW. The guiding principle of modern wound management being based Winter’s work on moist wound healing in the 1960’s (Harding et al 2000, Cutting and White 2002). This is based on beliefs that the wound healing process generally requires such an environment for cells to work effectively (Jones et al 2006). However whilst there are hundreds of research studies that have examined the myriad of products in a variety of wound types the inclusion of patients with FBW in such trials are minimal.

Recently experts in the management of patients with FW have questioned confidence in the principle of moist wound healing (Grocott and Cowley 2001, Grocott 2007a, 2007b) as the management of excess moisture is in fact a challenge which potentially requires an alternative theoretical framework. Recent developments such as the WRAP collaboration are attempting to bridge this gap (Browne, Grocott, Cowley et al 2004). Such progress has the potential to have an impact on other groups of patients where exudate management is an issue.

Generally the criteria on which to base dressing choice are:

  1. Tissue involved
  2. State of healing
  3. Aetiology of the wound
  4. Condition of the wound
  5. Environment and Carer
  6. Healthcare System

Harding et al (2000)

In addition whilst concepts such as Wound Bed Preparation (WBP) may be appropriate for healing wounds, the aims for patients with FBW are different (Grocott 2007a). Table 7 outlines the principles of wound bed preparation according to Grocott (2007a).

Table 7. Principles of wound bed preparation for FW.

Table 7

Principles of wound bed preparation for FW.

In addition practitioners need to consider issues of re-establishing body symmetry and the cosmetic acceptability of the dressing to the patient (Grocott 1995a, 2000a).

Whereas generally the principle consideration when choosing a dressing is efficacy, attention to local availability, number of applications, complexity of procedure and additional patient care needs also need to be thought about (Goldberg and McGinn-Byer 2000). Dowsett (2002) suggests that practitioners need to be flexible in their approach, taking into account the patient’s concerns as the main focus. See Appendix 1, Table 1 which outlines the current dressings available (BNF 2007). Consideration also needs to be given dressings included in the Drug Tariff as not all the dressings are available in the community. This often presents a challenge to community practitioners who then find it difficult to obtain the most appropriate products.

11.1. Dressings for the management of malodour

11.1.1. Charcoal Dressings

Such dressings usually contain activated charcoal which acts as a filter to adsorb volatile chemicals. However their ability to maintain this effect relies on them not getting wet (Draper 2005), therefore frequent dressing changes may be required. The practitioner also needs to be aware that whilst some charcoal dressings can be cut to size others should not be (Wilson 2005, Draper 2005, Seaman 2006). One of the difficulties is finding a large enough dressing to cover the wound and contain the exudate (Lazelle-Ali 2007).

11.1.2. Silver

Silver is known to be antibacterial (Demling and DeSanti 2001 Thomas and McCubbin 2003) and when combined with charcoal can help with deodorising in addition to its antimicrobial action (Draper 2005). However there are no studies that compare the effectiveness of activated charcoal dressings with silver and plain charcoal to draw any firm conclusions in relation to FBW (Draper 2005). Furthermore, dressings that contain hydrofibre or foam technology in combination with silver can have a substantial capacity to absorb large amounts of exudate. These can also be cut to size.

11.1.3. Foams

There a number of foam dressings that have the ability to absorb large amounts of exudate. These have also now been combined with silver to have an added antimicrobial benefit. They can be left in place for longer periods of time, depending on the amount of exudate. They also have the ability to vent moisture away from the wound bed, although the risk of maceration may only be avoided with frequent dressing changes.

11.1.4. Combination dressings

There are dressings available that combine the benefits of charcoal and hydrofibre or silver and foam as well as low-adherence, however it is often the amount of dressings required that influences the final choice.

11.1.5. Honey and Yogurt

Whilst there are reports of honey being used because of its antibacterial action (Wilson 2005), caution must be employed in view of its additional debriding action where bleeding may result. A review of the literature established use in FBW is not common practice.

11.2. Management of Exudate

Whilst in normal wound healing exudate can assist healing, its presence in excessive amounts can prevent or delay wound healing ((WUWHS 2007). FBW often produce moderate to large amounts of exudate, this in part due to the increased permeability of vessels in the tumour (Haisfield-Wolfe and Rund 1997) although the presence of infection and associated bacterial enzymes may also be implicated (Naylor 2002a). Current guidance suggests that practitioners should aim to assess all the factors that may be contributing to exudate formation and evaluate the interaction between this and dressing performance (WUWHS 2007).

Uncontrolled exudate can lead to soiling of dressings and clothing, peri-wound maceration and odour (Draper 2005, Grocott 2007a). Therefore the aim of management should be to conceal and collect the exudate produced (Seaman 2006), as well as achieve an acceptable cosmetic effect (Naylor, Laverty and Mallett 2001). Grocott (2007a) also suggests that exudate control can help patients regain control over their lives as this often the most limiting and debilitating symptom.

For moderate to heavy exudate a number of dressing products can be used, to include; alginates; hydrofibre; and foams (Draper 2005).

11.2.1. Alginates

There are two distinct types that absorb different amounts of exudate. Some are classified as haemostatic alginates and therefore can assist arrest minor bleeding. They are available in flat sheets and ribbon so are able to conform to the shape of a wound so can be useful for awkward shaped wounds. The composition of the dressing is such that the fibres are designed to breakdown; however the dressings rely on exudate being present to do this. Therefore if the wound is dry alginates should be avoided as they may adhere and cause trauma on removal (Jones et al 2006).

11.2.2. Hydrofibre

As previously stated these have been shown to absorb large amounts of exudate with the additional benefit of limiting the risk of maceration by vertical wicking. The dressing is available with added silver and is produced as flat sheets and ribbon, which is useful for conforming to cavities. The dressing maintains its integrity reducing the risk of fibres being incorporated into the wound.

Both hydrofibre and alginate dressings need to be secured by a secondary dressing to prevent leakage.

11.2.3. Foams

These dressings as available as polyurethane foam or silicone foam. Their properties are such that they transmit moisture vapour and oxygen and provide thermal insulation (Jones et al 2006). There is a wide range of dressings of this type which have varying absorbencies. They are available in a variety of sizes and some are designed for use in cavity wounds.

Currently there is a best practice statement available that provides a consensus based on expert opinion with regards to the role of exudate, its assessment and management (WUWHS 2007). Therefore practitioners should be encouraged to use this as a resource.

11.2.4. Prevention of Trauma

There is a risk of bleeding if any of the dressing types adhere to the wound bed. Therefore the dressing will need to be soaked off to prevent the risk of bleeding. In view of this adhesive dressings and those that contain petroleum should be avoided.

Grocott (2000a, 2000b) evaluated a number of dressing regimes for the management of exudate and has suggested the following:

  1. 2 layer permeable system – which comprises a non-adherent contact layer and an absorbent outer layer
  2. 2 layer controlled permeability – highly absorbent alginate /hydrofibre and a secondary foam dressing with a high MVTR.

Grocott (2000a, 2000b) highlights that currently the range of dressing sizes currently available does not meet the requirements of patients with FBW. In addition manufacturers need to consider how the MVTR can be improved.

Where dressings are being changed frequently and the wound shape allows practitioners may want to consider the use of stoma products to assist with exudate management.

11.2.5. Stoma appliances / Wound Managers

The use of ostomy products, ointments and skin sealants may be appropriate as an alternative to dressings where exudate management is of paramount importance. If the wound is small then stoma bags can be used, therefore referral to a stoma nurse may be appropriate. If however the wound is larger and the dressing is being changed 2 – 3 times per day then alternative pouches may be an option, again liaison with stoma therapists is advisable. At present there are no studies examining the effectiveness of this system for patients with FBW.

Grocott (2007b) suggested that it may be preferable to promote the formation of a natural scab in patients with FBW, which may in turn reduce the levels of exudate and perhaps the risk of bleeding occurring from traumatic injury. Although products that address this issue are not widely available, some manufacturers are evaluating the use of materials that may enhance this process.

11.3. Management of Maceration

Maceration is a common problem and is linked to the amount of exudate produced. Inadequate management can lead to further skin breakdown and enlargement of the wound (Cutting and White 2002). Therefore dressings that absorb exudate are of paramount importance (see previous section – Management of Exudate). Practitioners must be able to gauge the most appropriate dressing based on the proposed characteristics (Cutting and White 2002).

In conjunction with exudate management the surrounding skin requires protection, products known as ‘barrier films’ or ‘barrier creams’ are most commonly used. These should be alcohol free to avoid further stinging or discomfort. In addition to their barrier function they can also help to provide a surface to which tapes and adhesives can adhere (Wilson 2005).

11.4. Management of Surrounding Skin

The peri-wound area can be extremely fragile due to a number of reasons (Seaman 2006); the patient may have had previous radiation, or there may be an ongoing inflammation due to the tumour, adhesive dressings can cause skin stripping or there may be maceration from uncontrolled exudate. Therefore barrier films should be used for protection, adhesive products should generally be avoided, however thin hydrocolloids or semi-permeable films may help to protect vulnerable skin if used in conjunction with a barrier (Cutting and White 2002, Draper 2005).

Patients may also report pruritis or itching which may be related to excoriation; therefore prevention is preferable, with the use of skin barriers (Naylor, Laverty and Mallett 2001). However progression of the tumour should also be considered as a cause of itching and irritation (Twycross et al 2002). If there are signs of infection, the practitioner should consider both bacterial and fungal origins (Goldberg and McGinn-Byer 2000) and treat accordingly.

Beynon, Laverty, Baxter et al (2003) have reported on the use of a thermoreversible gel which was used on a small sample of patients as a barrier to prevent excoriation. The gel seemed to ameliorate soreness (as measured using a TELER scale) in patients with gynaecological related malignancies. However the authors suggest that further research comparing this with other skin barriers is required before any recommendations can be made.

11.5. Management of bleeding

Patients may be at risk of bleeding due to coagulation defects as a consequence of cancer and its treatment or from progression of the disease. Some lesions have the potential to erode into major blood vessels therefore careful planning is required (Barton and Parslow 2001). In addition the wound bed can be extremely delicate; one of the main ways of reducing the risk of bleeding is by careful dressing changes that minimise trauma (Wilson 2005, Seaman 2006, SCHIN 2006). Therefore practitioners must avoid inappropriate dressing choices. The patient can be prone to acute or chronic anaemia if bleeding presents as a problem so consideration should be given as to the most appropriate treatment.

A number of treatments can be employed depending on the degree of bleeding:

  1. Initial first aid may be through applying compression to the area (Naylor, Laverty and Mallett 2001, Seaman 2006), or if severe adrenaline can be used under close medical supervision in an emergency situation.
  2. For minimal bleeding, silver nitrate can be applied to bleeding points (Seaman 2006) (although this can cause minor irritation). Haemostatic alginates can also be used (Seaman 2006).
  3. The patient may require radiotherapy treatment as this has the effect of occluding small vessels which decreases neovascularisation and may help to decrease exudate levels as well as ameliorate pain and bleeding (Bale and Jones 2006).

11.5.1. Role of wound debridement

Many of the authors reviewed discuss the role of debridement (Naylor, Laverty and Mallett 2001, Draper 2005, Wilson, Seaman, Langemo et al 2007). However only a few debate the risks of different methods of debridement in terms of the risk of bleeding or haemorrhage. Most agree that surgical debridement is not an option and advocate gentle debridement. Grocott (2007a) suggests that there is a potential role for autolytic debridement, however there should be judicious assessment of the clinical benefit of removing dead tissue.

Methods that are considered inappropriate for debridement are:

  1. larvae,
  2. surgical / sharp

This is because of the risk of bleeding (SCHIN 2006). Therefore clear guidance is required for practitioners if risks to the patient are to be minimised.

11.5.2. Silicone Dressings

This type of dressing can reduce the risk of bleeding and pain associated with dressing removal when tissue is very friable and fragile. This type of dressing is normally coated with a non-adherent surface which helps to keep the dressing in place, and also allows exudate to pass through. The advantage of using this is that in kept in place for 6–7 days with the secondary dressing being changed as required.

12. Management of Pain

12.1.

The World Health Organisation have suggested an analgesic ladder (WHO 1996) therefore this should be considered when attempting to plan the appropriate intervention for pain relief (Naylor 2001, SIGN 2005a). There is a well established role for opiates in the management of pain, which can be administered orally, intravenously and intra-muscularly.

12.2.

In addition topical application has been used (Back and Finlay 1995, Krajnik and Zylicz 1997). These studies have suggested that 10mgs of diamorphine in 15g of a hydrogel can help to some degree. Topical applications should be administered once or twice a day (SCHIN 2006); however the duration of treatment has not been clearly identified to date. A disadvantage of using a hydrogel carrier is that they are 70–90% water-based therefore fluid handling can be a problem which has the potential to exacerbate maceration.

12.3.

Zeppetella and colleagues have examined the analgesic efficacy and bioavailability of topical morphine in patients with ‘painful ulcers’ (mainly pressure ulcers) and found a reduction in VAS scores (Zeppetella, Paul and Ribeiro 2003). It works by local mediation of pain relief, rather than systemic absorption (Ribiero, Joel and Zeppetella 2004). Furthermore they examined the stability or morphine prepared in advance and stored under different conditions (Zeppetella, Joel and Ribiero 2005). They concluded that morphine was stable for 28 days if prepared in a sterile environment; however it should be used within 7 days if not sterile.

12.4.

MacGregor et al (1994) examined the use of a local anaesthetic gel for analgesia to treat pain experienced from skin excoriation, although in a review of the current literature there is limited further evidence of the use of this.

12.5.

Although approved for the use on patients with postherpatic neuralgia pain (Popescu and Salcido 2004, DTB 2008) the use of lidocaine as a patch or a solution has been reported in the management of patients with acute and chronic wounds. The use of Lidocaine solution has been previously reported as a topical method of pain relief at dressing change (Krasner 2002, Doughty 2006), allowing 15–20 minutes before then changing the dressing or undertaking debridement. Davis and Adams (2006) report using a topical 5% lidocaine patch in the management of local pain associated with leg ulcers (although the aetiology is not stated), whilst Lockhart (2006) reports the use of lidocaine 10% patches on surgical wounds post –operatively with good effect. However there is limited evidence to support its use as a patch or solution for patients with FBW.

12.6.

Previous authors have discussed the use of local anaesthetic creams as a method of reducing pain prior to debridement of a wound (Krasner 2002, Popescu and Salcido 2004). A review of topical agents for pain in venous leg ulcers suggests that such creams applied 30–45 minutes before wound debridement may provide some pain relief (Briggs and Nelson 1999). Whilst previous authors have called for further research into it’s affects on wound healing (Popescu and Salcido 2004) it must be remembered that for patients with FBW healing is not usually a priority. Therefore it may be appropriate to re-examine the use in this particular patient population.

12.5.

Adjuvant analgesics such as anti-depressants, anti-convulsants, non-steroidal anti-inflammatories (NSAIDS) and steroids may also be required to treat pain. It has also been suggested that Entonox can be used pre/peri dressing change (Evans 2003), although the evidence for its effect in wound management procedures is limited (Naylor, Laverty and Mallett 2001). Furthermore it is not available in the community setting where most patients are cared for.

12.6.

As well as pharmacological interventions, non-pharmocological measures should also be considered (Naylor 2001). These will include wound cleansing technique, choice of wound dressing and protection of the surrounding skin. Thus the importance of an accurate assessment of the patient and their wound cannot be over emphasised.

12.7.

Recently hydrogel sheets have been reported as providing a topical means of pain relief (Young and Hampton 2005, Maund 2008).

12.8.

Although not reported for use on patients with FBW, a recent advancement of a foam dressing with added Ibuprofen has been reported as decreasing wound pain in patients with venous leg ulcers (Jorgensen et al 2006, Sibbald et al 2007, Gottrup et al 2007). Therefore further research into its use on patients with FBW should be evaluated.

13. Communication

13.1.

Establishing a good relationship with the patient, family and/or carers is very important. The practitioner needs to show compassion, and be able to reduce any anxieties. What is of equal importance is to try and maintain a consistent team of individuals to care for the patient (Wilson 2005). The patient should feel able to communicate their problems to the practitioner and feel able to contribute to a management plan that takes into account their problems.

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15. Appendix 1

Table 1Current generic groups of dressings available (BNF 2007)

GENERIC GROUP
Alginates
Calcium Alginates
Alginate with hydrocolloid
Calcium Alginate (with silver)
Calcium Alginate (with honey)
Foams
Polyurethane Foam
Polyurethane Foam Film with adhesive border
Polyurethane Foam Film without adhesive border
Foams with silver
Hydrogels

With alginate
With honey
Hydrocolloids
Potentially used as a border for FW
Hydrocolloid and Alginate with silver
Hydrocolloid Fibre
Hydrocolloid Fibre with silver
Hydrocolloid with silver
Low Adherent
With silver
Odour Absorbent with silver
Odour Absorbent
Skin Protectives
Surgical Absorbents
Topical Metronidazole

Any dressing should be removed with caution in case of adherence to the wound bed which might precipitate bleeding.

Author

Reviewers

Footnotes

1

Author

2

Reviewers

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Cover of Advanced Breast Cancer
Advanced Breast Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 81.
National Collaborating Centre for Cancer (UK).

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