This study demonstrates the feasibility and acceptability of using innovative dressings requiring specific resources for managing tumor wounds in difficult context such as the Malian actual situation (low-income country, lack of medical equipment, lack of human resources, political instability, security concerns). The majority of caregivers and patients found the dressing easy to use, including for repeated applications every 24 to 48 h. There was a significant reduction in odors and good acceptance of the dressing, as the majority of patients continued to use it after the study. Despite reductions in unpleasant odor, there was no impact on appetite seen in this cohort. Most of these patients, however, were also undergoing palliative chemotherapy at an advanced stage of disease, which may account for this result.

Tumor wounds are difficult to manage. They are often progressive and require careful, repeated, and communicated evaluation (report, treatment plan, and photo). The management of tumor wounds is based on three principles: symptom management, wound treatment, and treatment of the underlying cancer. This management combines local treatments, cancer-specific systemic treatments, and supportive care. The primary goal is to relieve pain and reduce odors to lessen the stigma suffered by the patient. The risk of bleeding must be considered, as it is increased by the aggressive care sometimes necessary (debridement), especially in certain locations where a vital prognosis may be at stake (head and neck). The often-abundant exudates determine the frequency of dressing changes. In case of infection, antibiotics are necessary, especially since patients are often immunocompromised. The diagnosis of infection is primarily clinical (increase in exudates and pain, peri-lesional redness, rapid change in the wound, general symptoms). These signs can sometimes be misleading in tumor wounds due to the cutaneous infiltration of the tumor and the progression of the disease.

Odor control usually relies on a two steps treatment: manage the biocontamination (by cleaning, debriding, controlling exudate and using antibacterial treatment) and mask or adsorb odors. The most commonly used anti-odor solutions are silver dressings, activated charcoal dressings, and honey [14,15,16]. Activated charcoal is a porous material that provides a large adsorption surface for gases, bacteria, and liquids. It traps VOCs responsible for fetid odors. Honey has antibacterial properties and also serves as an alternative nutrient for the bacteria present in the wound, leading to the production of lactic acid as a bacterial waste product instead of sulfur compounds responsible for bad odors. Silver has antimicrobial and anti-inflammatory activity. It indirectly reduces odors by destroying bacteria. However, the literature is limited, results are controversial with negative studies, and there are very few controlled studies comparing different types of dressings. Tumor wounds occur at advanced stages that are rare in high-income countries, and research in this area is poor. The most recent reviews report barely a dozen studies with correct methodology, with very small samples [17,18,19]. According to these publications, silver dressings and topical metronidazole use seem to reduce odors compared to a placebo. There is no evidence for other types of dressings, but studies are rare, with small patient samples and varying evaluation criteria. Quality of life is never assessed in these publications. Odor can also cause therapeutic issues, especially the excessive prescription of antibiotics. Inappropriate antibiotic use increases the risk of drug interactions and selection pressure, which lead to antibiotic resistance and destabilization in the bacterial colonization equilibrium, as well as other possible side effects [20]. In countries where cancer is a scary and taboo subject, the appearance of foul odors can also rapidly worsen a patient’s isolation. It is therefore essential to develop new solutions to control odors emanating from tumor wounds.

Another interesting result of our study is the patient’s perception of tumor wounds odor as smelling like “rotten meat,” a nearly universal description across Africa, Asia, and Europe, where the three most commonly used terms by patients to describe the wound odor are: garbage, rotten meat, or corpse-like. Hedonic valence and olfactory empathy are determined by an individual’s experience and culture, but also by the structure of the odor molecule. Despite the lack of cultural proximity to cinnamon in our specific cohort, this dressing was well accepted by the patients and caregivers in our study. Not all spices are adsorbent [21]. All cinnamons are, but the particularity of Cinesteam® cinnamon is its stability and sterility. Using other cinnamons would not necessarily be reproducible.

Our study is a pilot feasibility study and therefore has limitations: it was a non-comparative observational study with a small sample in a humanitarian medical context with very impaired patients. This led to significant loss of follow-up and missing data. Nevertheless, we show that cinnamon dressing is acceptable and provides a significant reduction of odor intensity using it every other day. The cost of this strategy was not evaluated in our study. The dressing we tested is not currently marketed in Sub-Saharan Africa; we were able to benefit from a donation. The price in Europe is 5.4 euros per unit. This price would obviously not be affordable for low-income countries, but we cannot extrapolate a cost study as the market does not yet exist. Nevertheless, demonstrating the feasibility and acceptability of this medical device for the treatment of tumor wounds in a highly constrained humanitarian context may make the case for market access.