Malignant Fungating Wounds in Advanced Cancer: Pathophysiology, Odor Control, and Dignity-Centered Management

Malignant fungating wounds (MFWs) represent a profoundly distressing complication of advanced cancer, affecting an estimated 5-10% of patients with solid tumors and imposing a disproportionate burden on quality of life, caregiver wellbeing, and therapeutic engagement. Despite their clinical significance, MFWs remain a systematically neglected domain within oncology and palliative medicine. Existing literature addresses wound odor, wound myiasis, and dignity-related dimensions as isolated topics; a unified clinical framework integrating these three domains from both biological and ethical perspectives has been conspicuously absent. This review was designed to address that gap. The review introduces and applies a triple-framework approach to MFW management: (1) a Biological Dimension encompassing anaerobic microbial metabolism and volatile organic compound (VOC) generation; (2) a Clinical Dimension operationalizing evidence-based strategies for odor control and wound myiasis management; and (3) an Ethical Dimension centering dignity-conserving care as an indispensable component of oncologic wound management. This tripartite integration constitutes the primary conceptual contribution of this article.

Wound microbiome profiling using 16S rRNA sequencing has identified anaerobic genera including Bacteroides, Prevotella, Peptostreptococcus, and Fusobacterium as principal contributors to the VOC profile responsible for MFW malodor, providing a mechanistic basis for targeted antimicrobial therapy. Biofilm-forming organisms, particularly Pseudomonas aeruginosa and Staphylococcus aureus, create recalcitrant wound environments that resist conventional topical therapies. Topical metronidazole remains the most robustly supported intervention for odor control, with emerging evidence for cadexomer iodine and Manuka honey as biofilm-disrupting adjuncts. Wound myiasis, increasingly reported in tropical and resource-limited settings, benefits from stepwise management combining mechanical debridement, larval asphyxiation techniques, and systemic ivermectin for severe cases. Electronic nose (e-nose) technology and volatile compound analysis represent emerging diagnostic tools for objective odor quantification. Palliative radiotherapy-using hypofractionated regimens such as 20 Gy in 5 fractions or single-fraction schedules in frail patients-offers biologically rational tumor cytoreduction with sustained improvement in odor and exudate. Community-based palliative care models, particularly those adapted for India and sub-Saharan Africa, demonstrate that dignified, evidence-informed MFW care is achievable within low-resource frameworks using trained community health workers and locally compounded or accessible wound care agents. Malignant fungating wounds demand a comprehensive, dignity-centered clinical response that is simultaneously evidence-based, culturally sensitive, and globally implementable. This review synthesizes the pathophysiology, evidence base, and ethical imperatives of MFW care into a unified clinical framework, providing oncologists and palliative care teams with practical algorithms for odor management and myiasis control, and reinforcing the imperative for equitable access to palliative wound care worldwide.