Cancer is the second most common cause of death in the US after cardiovascular disease. According to the American Cancer Society, mortality from cancer in the US has declined steadily over the past two decades, falling 26% from its peak in 1991.1 Reasons for this include a reduction in smoking and advances in early detection and treatment. With these improvements, cancer has become more of a chronic disease and a disease of older adults.2 From 2010 to 2030, the projected cancer incidence will increase from 1.6 million to 2.3 million, with older adults driving much of this increase. A 67% increase in cancer incidence is anticipated for older adults, compared with an 11% increase for younger adults.3
Wounds related to malignancy in postacute/long-term care (PALTC) facilities have not been well studied. With the projected increase in cancer incidence among older adults,3 wound care for these patients is a growing concern. An understanding of wound-related issues is essential for resource allocation and developing clinical programs for improving management, outcomes, and quality of life for patients with cancer.
The postacute care environment has become increasingly important within the healthcare continuum as nursing homes have shifted from custodial care to rehabilitation.4 In 2014, there were nearly 16,000 nursing homes with more than 1.4 million residents, corresponding to 2.6% of the over-65 population and 9.5% of the over-85 population.5 The transformation of the nursing home into a postacute environment has increased acuity levels, causing a surge in demand for complex services including wound care.
Chronic wounds such as pressure injuries are a known occurrence in patients with advanced disease such as cancer.6 To date, there have been no studies of PALTC residents with wounds related to cancer or the consequences of cancer treatment and related debility. Accordingly, this case series aimed to study the epidemiology and characteristics of wounds related to malignancy in a large, academically affiliated PALTC facility.
The authors studied a subset of residents at a 514-bed academically affiliated facility in an urban setting selected from a database consisting of all wound care consultations received in 1 year (October 31, 2017, to October 30, 2018). During this study period, there were 1,515 new admissions and 238 readmissions, and residents came from 34 acute care hospitals and 9 PALTC facilities, mostly within the New York metropolitan area. Consultations were generated by a panel of full- and part-time physicians and NPs.
Prior to study commencement, the investigators received approval from their institutional review board with a waiver of informed consent. Informed consent was waived because this was a retrospective study that did not present more than minimal risk, along with other regulatory criteria. All data were anonymized during the analysis.
Inclusion criteria for the study group included a primary diagnosis of cancer with any type of wound related to malignancy directly or indirectly. Residents with a remote history of cancer that did not impact the PALTC admission in question were not included. Investigators studied the differences between the population that met the inclusion criteria and those who did not.
For residents with cancer, a Karnofsky Performance Status score was determined after initial wound assessment and record review. The Karnofsky Performance Status is a 0- to 100-point scale that classifies patients according to their degree of functional impairment. It is a validated tool for determining prognosis in patients with cancer.7,8 The score is graded with characteristics that include any need for institutional or hospital care, ability to care for self at home, and ability to carry on normal activity and work.8 Scores were determined through chart review, history, and physical examination as recorded during the initial consultation.
Residents were analyzed for age, gender, reason for consultation, type of malignancy, Karnofsky Performance Status, presence of metastases, wound characteristics, presence of infection, and 1-month follow-up. Data on pressure injury stage and location, if any, were collected. Stage 1 pressure injuries were not included in this analysis because they do not qualify as ulcers, and redness is common in residents who are debilitated and therefore introduces a potential error in diagnosis.
There were a total of 190 residents in the sample of residents who received wound care consultations, and researchers compared the characteristics of residents with cancer diagnoses and wounds with those of the remaining residents within this sample using chi-square and independent sample t-tests (SAS, version 9.4; SAS Institute, Inc, Cary, North Carolina).
Researchers reviewed 190 wound care consultations, and 27 (14.2%) met the inclusion criteria. Of these, 20 (74.1%) were female, 7 (25.9%) were male, and the average age was 69.5 years (range, 48.1-86.7 years). Twenty-six residents were admitted from 10 different hospitals, and one was admitted from a home care program. Twenty-five participants (92.6%) resided on the postacute/rehabilitation service; the remainder resided on long-term care units.
The reasons for consult are presented in Table 1. Surgical wounds included recent incisions, dehiscence, and graft donor sites. Infections included abscesses, fungi, and herpes zoster. Of the five residents with malignant wounds, three were from breast cancer, with others secondary to vulvar and rectal tumors. Two breast tumors were fungating, and one was ulcerative. The vulvar wound presented with nodules and induration, and the rectal tumor presented as a nonhealing ulcer.
Residents with malignant wounds had a multiplicity of wound types. For example, one resident had an infected postsurgical breast tumor incision, radiation dermatitis, and herpes zoster. Another resident who consulted for cutaneous metastases had a recent surgical incision from hemipelvectomy and leg amputation related to cancer spread.
A total of eight residents (29.6%) had wounds related to recent surgery. These resulted from grafts related to oral surgery (bone graft donor site and flap reconstruction), hemipelvectomies, and incisions related to abdominal or breast surgery. Two residents had abdominal incisions that dehisced.
Tumor types are presented in Table 2. Of the studied residents, 19 (70.4%) received chemotherapy, radiotherapy, or surgery in the month prior to the wound consultation. Four were undergoing chemotherapy at the time of consultation. One month following wound consultation, 13 (48.2%) were still in the facility, 6 (22.2%) were discharged to home, 6 (22.2%) had died, and 3 (11.1%) were hospitalized.
A total of 14 residents (51.9%) had pressure injuries. Two of these residents received consultation for wounds other than pressure injury, but a pressure injury was found on examination. Of the 14 residents, 12 had a pressure injury on the sacrum, buttocks, or ischium, and the remainder had pressure injuries to the lumber area and thoracic spine. One resident had both ischium and heel wounds. When recording the severity of the residents' pressure injuries, six (42.9%) were Stage 2, one (7.1%) was Stage 3, one (7.1%) was Stage 4, five (35.7%) were unstageable, and one (7.1%) was a deep tissue injury. Of the residents with pressure injuries, 12 (85.7%) were present on admission, and 2 (15.3%) were facility-acquired. Further, 14 residents (51.9%) had metastatic cancer; 13 of these (92.9%) had pressure injuries.
The distribution of Karnofsky Performance Status scores of residents with cancer who received a wound consultation is shown in the Figure. There was a significant relationship between a lower Karnofsky score and mortality at 1 month after initial consultation (P = .002). There was a nonsignificant trend for lower Karnofsky scores in residents with cancer and pressure injuries compared with the group of residents with cancer and no pressure injuries (P = .01).
Study authors compared the characteristics of the residents with wounds and cancer (n = 27) to those with wounds but without an active cancer diagnosis (n = 163). Although the group with cancer included a larger percentage of female residents, there was no statistically significant difference in sex between the cancer and noncancer groups (P = .12). The mean age of patients with cancer and wounds was 69.5 years, whereas the mean age of the group without cancer was 77.1 years. This age difference was statistically significant (P = .003).
To the authors’ knowledge, this is the first study to explore the epidemiology of wounds related to cancer in the PALTC setting. Postacute care is a critical component of the healthcare continuum for persons with cancer; however, the challenges of this population need to be better understood to provide a comprehensive array of services. These findings expand provider knowledge of expected care burdens for persons with malignancy, underscore the importance of a wound care skill set for providers, and demonstrate the continued need for pressure injury prevention measures. Because of the scope and complexity of wounds in residents with cancer, these findings also reflect the importance of maintaining a facility-wide system of care as required by Federal regulations.9
Pressure injuries are a known consequence of advanced cancer, but little has been reported on other types of wounds and no data are available for residents with cancer and wounds in PALTC. Pressure injuries in patients with cancer have been reported in a variety of acute care settings.10–13 Similarly, pressure injuries and other wounds are noted to occur in persons with advanced cancer in palliative care settings, but PALTC-specific data are lacking.6,14,15 This study's data suggest a wide array of serious wounds that include but are not limited to pressure injuries in patients with cancer admitted to PALTC facilities.
The distribution of Karnofsky scores in the Figure demonstrates that PALTC residents with both cancer and wounds were quite debilitated. Overall mortality at 1 month after initial wound consultation was 22.2%. Not surprisingly, there was a significant relationship between a low Karnofsky score and mortality. There was also a nonsignificant trend for residents with cancer and pressure injuries to have lower Karnofsky scores than those who had malignancy but no pressure injuries.
According to Maida et al,16 malignant wounds may be classified into four principal classes: nodules and induration, fungating, malignant ulcers, and other (including zosteriform and mixed). Three residents had fungating wounds (all of which involved breast cancer), one presented with nodules and induration (squamous cell cancer of the vulva), and one had a nonhealing ulcer (rectal cancer).
Of the residents with both cancer and pressure injuries, 79% were admitted from an acute care setting, indicating the need to critically examine prevention efforts in hospitals for these patients. The distribution of malignant wounds is similar to that previously reported, with breast cancer being the most common cause.14 This sample is notable for the high prevalence of surgical wounds (21.4%), including recent incisions, dehiscence, and graft donor sites. One could speculate that this is attributable to the authors’ affiliation with major tertiary care facilities in the New York metropolitan area that perform many surgical procedures. Study authors found that residents with cancer and wounds were younger than residents with no cancer and wounds, which is also similar to previously published data.14
There is controversy surrounding the preventability of pressure injuries and whether these lesions are justifiable reflections of care quality, particularly in light of the increasingly recognized concept of skin failure.17–19 These data on PALTC residents with metastatic cancer add to this discussion. Of the residents with pressure injuries in this data set, 92.9% occurred in patients with known metastases. The preventability of pressure injuries often depends on irremediable risk factors such as poor nutrition status, immobility, and end-of-life situations.17 These conditions apply to many residents with cancer and wounds, particularly in light of the low Karnofsky scores, which are established predictors of mortality.7 Metastatic cancer is associated with weight loss and anorexia, as well as pain that limits mobility. Further, cancer treatment can induce anorexia and immune compromise, both of which confer increased risk for pressure injuries and impaired wound healing. Pressure injuries in this population may be an unavoidable consequence of skin failure and therefore unsuitable as a quality measure. This does not, however, mitigate the need to maintain preventive measures for those persons at risk for skin breakdown.
The limitations of this study include the small number of patients and the retrospective nature of the design. This study includes only a single facility, which may not be representative of facilities elsewhere because of its large size, academic affiliation, urban location, and admissions from multiple hospitals. The residents studied represent a select group who were deemed appropriate for wound consultation by an in-house panel of providers and therefore may have greater burden of illness and severity of wounds than other similar patients. Finally, the fact that all primary care providers were full- or part-time renders this facility unique when compared with most PALTC facilities.
These findings begin to fill a gap in understanding the spectrum of wounds in residents with cancer admitted to PALTC and reinforce the importance of the wound care skill set.9 Geriatrics has embraced pressure injuries as a geriatric syndrome; however, wound care entails much more than pressure injuries.20 This is clearly demonstrated by the high level of medical complexity of residents with cancer admitted to PALTC. Efforts focused on delivering quality cancer care to older adults must anticipate severe skin complications not only from the tumor itself, but also from the long-term sequelae of multiple comorbidities, immobility, immune compromise, malnutrition, and skin failure. The close association between metastatic disease and pressure injuries underscores the importance of recognizing terminal ulceration and skin failure and casts doubt on the use of pressure injuries for quality measurement in this population.
1. Noone AM, Howlader N, Krapcho M, et al, eds. SEER Cancer
Statistics Review, 1975-2015. Bethesda, MD: National Cancer
2. Simon S. Facts & Figures 2018: Rate of Deaths from Cancer
Continues Decline. American Cancer
. Last accessed October 18, 2019.
3. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer
incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 2009;27(17):2758–65.
4. Burke RE, Cumbler E, Coleman EA, Levy C. Post-acute care reform: implications and opportunities for hospitalists. J Hosp Med 2017;12(1):46–51.
6. DeConno F, Ventafridda V, Saita L. Skin problems in advanced and terminal cancer
patients. J Pain Symptom Manage 1991;6(4):247–56.
7. Crooks V, Waller S, et al. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. J Gerontol 1991;46:M139–44.
8. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncology 1984;2:187–93.
9. 42 CFR § 483.25, F-Tag 684, Quality of Care (2016).
10. Flood KL, Carroll MB, Le CV, Ball L, Esker DA, Carr DB. Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit. J Clin Oncol 2006;24(15):2298–303.
11. Tan HJ, Saliba D, Kwan L, Moore AA, Litwin MS. Burden of geriatric events among older adults undergoing major cancer
surgery. J Clin Oncol 2016;34(11):1231–8.
12. Chan JK, Gardner AB, Mann AK, Kapp DS. Hospital-acquired conditions after surgery for gynecologic cancer
—an analysis of 82,304 patients. Gynecol Oncol 2018;150(3):515–20.
13. Aljezawi M, Tubaishat A. Pressure injuries among hospitalized patients with cancer
: prevalence and use of preventive interventions. J Wound Ostomy Continence Nurs 2018;45(3):227–32.
14. Maida V, Corbo M, Dolzhykov M, Ennis M, Irani S, Trozzolo L. Wounds in advanced illness: a prevalence and incidence study based on a prospective case series. Int Wound J 2008;5(2):305–14.
15. Hendrichova I, Castelli M, Mastroianni C, et al. Pressure ulcers in cancer
palliative care patients. Palliat Med 2010;7(24):669–773.
16. Maida V, Ennis M, Kuziemsky C, Trozzolo L. Symptoms associated with malignant wounds: a prospective case series. J Pain Sympt Manage 2009;37(2):206–211.
17. Edsberg LE, Langemo D, Baharestani MM, et al. Unavoidable pressure injury
: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs 2014;41(4):313–34.
18. Ayello EA, Levine JM, Brennan M, Kennedy-Evans K, Langemo D, Sibbald G. Reexamining the literature on skin changes at the end of life including terminal ulcers/injuries, skin failure and unavoidable pressure injuries. Adv Skin Wound Care 2019;32(3):109–21.
19. Baker MW, Whitney JD, Lowe JR, Liao S, Zimmerman D, Mosqueda L. Full-thickness and unstageable pressure injuries that develop in nursing home residents despite consistently good quality care. J Wound Ostomy Continence Nurs 2016;43(5):464–70.
20. Levine JM. Pressure injuries and wound care. In: Harper GM, Lyons WL, Potter JF, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 10th ed. New York, NY: American Geriatrics Society; 2019.