Melanoma
Overview
Melanoma is a type of skin cancer. It begins when pigment-producing (color-producing) cells, called melanocytes, begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Melanoma can appear in an area no different from the surrounding skin, or it can develop from or near a mole. It is found most frequently on the back or on a woman’s legs, but melanoma can occur anywhere on the body, including the head and neck. This section describes melanoma of the skin. Learn more about basal cell and squamous cell skin cancers, melanoma of the eye, and anorectal melanoma.
The skin is the body’s largest organ. It protects against infection and injury and helps regulate body temperature. The skin also stores water and fat and produces vitamin D. Skin is made up of two main layers: the epidermis (outer layer of skin) and the dermis (inner layer of skin). The deeper layer of the epidermis contains melanocytes. Melanoma starts in melanocytes and is the most aggressive type of skin cancer. It can grow deep into the dermis, invading lymph and blood vessels. The initial type of treatment is determined by the thickness of the tumor.
Treatment of the primary (initial) melanoma usually involves surgery, which often cures early stage or thin melanoma. After removal of the primary melanoma, additional surgery may be needed to make sure that the melanoma will not come back in the same area and to find out if the melanoma has spread to nearby lymph nodes (tiny, bean-shaped organs that help fight infection). This surgery, using mapping techniques called sentinel lymph node mapping can help estimate risk and help the doctor decide if immunotherapy or radiation therapy, and for the most advanced stages, chemotherapy may be needed. More details can be found in the Treatment section. Researchers are also investigating new ways to treat advanced melanoma, including targeted therapy, gene therapy, and vaccine therapy. For more information on these treatments, read the Current Research section.
Find out more about basic cancer terms used in this section.
Statistics
In 2010, an estimated 68,130 adults (38,870 men and 29,260 women) in the United States will be diagnosed with melanoma. It is estimated that 8,700 deaths (5,670 men and 3,030 women) from this disease will occur this year.
Melanoma accounts for less than 5% of skin cancer cases and a majority of skin cancer deaths. Melanoma is the fifth most common cancer among men and the seventh most common cancer in women. Sometimes, melanoma is found in children and teenagers. Melanoma rates are more than 10 times higher in white people than black people, and has been increasing in young white women (ages 15-39) and in white adults older than 65.
The five-year relative survival rate (percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases) of people with melanoma is 91%. If melanoma is found before it has spread, the five-year relative survival rate is 98%. The five-year relative survival rate if melanoma is found to have regional and distant spread is 62% and 15%, respectively.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with melanoma. Because the survival statistics are measured in five-year intervals, they may not represent recent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.
Statistics adapted from the American Cancer Society’s publication, Cancer Facts & Figures 2010.
Risk Factors and Prevention
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as sunbathing, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
The following factors may raise a person’s risk of developing melanoma:
Individual history. People with many moles or unusual moles called dysplastic nevi (flat, large moles that have irregular color and shape) have a higher risk of developing melanoma. About 50% of people with melanoma have dysplastic nevi. Also, people who have weakened immune systems or use certain medications that suppress immune function have a higher risk of developing skin cancer. In addition, people who have had one melanoma have an increased risk of developing additional new melanomas; overall, in the general population, 3% of people who develop one melanoma develop other new melanomas. People who have had a non-melanoma skin cancer also have a somewhat increased risk of developing melanoma.
Family history. Approximately 10% of people with melanoma have a family history of the disease. Therefore, it is recommended that close relatives (parents, brothers and sisters, and children) of a person with melanoma routinely have their skin examined. Changes in two genes (CDKN2A and CDK4) that may lead to melanoma have been identified. However, only a small number of families with melanoma have changes to these genes. Genetic testing for these two genes is only available through clinical trials (research studies). It is likely that other genes and environmental factors also affect risk of melanoma. Learn more about the genetics of melanoma.
Exposure to ultraviolet (UV) radiation. Ultraviolet B (UVB) radiation from the sun produces sunburn and plays a role in the development of both melanoma and non-melanoma skin cancer. Ultraviolet A (UVA) radiation penetrates skin more deeply and may also play a role in the development of both melanoma and non-melanoma skin cancer. People who live in areas with bright sunlight year-round or at high altitudes have a higher risk of developing skin cancer, as do those who spend a lot of time outside during the midday hours. People who use tanning beds, tanning parlors, or sun lamps have an increased risk of melanoma and other skin cancer. Even people who tan well increase their risk of melanoma with more sun exposure.
Fair skin. Less pigment (melanin) in the skin offers poorer protection against UV radiation. People with light hair and light-colored eyes who have skin that tans poorly or freckles, or those who burn easily, are two to three times more likely to develop melanoma.
Sunburn. According to many scientific studies, multiple, severe, blistering sunburns increase the risk of developing melanoma.
Prevention
Reducing exposure to UV radiation, particularly through sun exposure, lowers the risk of melanoma. This is important for people of all ages and is especially important for people who have an increased risk of melanoma. Sun damage builds up over time. Steps to reduce sun exposure, avoid sunburn, and help prevent many cases of melanoma include:
• Limiting or avoiding sun exposure between 10:00 AM and 4:00 PM
• Wearing sun-protective clothing, including a hat that shades the face, neck, and ears. Clothes made of fabric labeled with UPF (UV protection factor) may provide better protection. UV-protective sunglasses are also recommended.
• Using sunscreen with a sun protection factor (SPF) of 15 or higher throughout the year and reapplying it often, especially after heavy perspiration or being in the water
• Examining the skin regularly (examinations by a health-care professional and self-examinations)
• Avoiding use of sun lamps, tanning beds, and tanning salons
Symptoms
People with melanoma may experience the following symptoms. Sometimes, people with melanoma do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. The skin features that people with melanoma frequently develop are listed below. If you are concerned about a symptom or skin feature on this list, please talk with your doctor.
Changes in the skin are often the first warning sign of melanoma. An accurate diagnosis by a doctor or other health-care professional is important. Often, the diagnosis can only accurately be made after a lesion is removed and examined under a microscope. Melanoma can appear anywhere on the body, even on areas that are not exposed to the sun, and can appear in a number of different ways:
• A new, possibly large, irregularly shaped, dark brownish spot with darker or black areas
• A simple mole that changes in color (particularly turning darker), size (growing), or texture (becoming firmer), and/or flakes or bleeds
• An unusual lesion with an irregular border and red, white, blue, gray, or bluish-black areas or spots?
• Shiny, firm, dome-shaped bumps that are new, changing, or unusual anywhere on the body
• Dark lesions under the fingernails or toenails, on the palms, soles, tips of fingers and toes, or on mucous membranes (skin that lines the mouth, nose, vagina, and anus)
Early detection of melanoma
The earlier melanoma is detected, the better the chance for successful treatment. Periodic self-examinations of a person’s skin may help find melanoma early.
Self-examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and back of the neck.
Include the following steps in a skin self-examination:
• Examine the front and back of the entire body in a mirror, then the right and left sides, with arms raised.
• Bend the elbows and look carefully at the outer and inner forearms, upper arms (especially the hard-to-see back portion), and hands.
• Look at the front, sides, and back of the legs and feet, including the soles and the spaces between the toes.
• Part the hair to lift it and examine the back of the neck and scalp with a hand mirror.
• Check the back, genital area, and buttocks with a hand mirror.
A doctor should be consulted if you find:
• A growth on the skin that matches any feature on the above list
• New growth on the skin
• A suspicious change in an existing mole or spot
• An unusual sensation in a mole, such as itching or tingling
• A sore that doesn't heal within two weeks
Often, the first sign of melanoma is a change in the size, shape, or color of an existing mole. It also may appear as a new or abnormal-looking mole. The "ABCDE" rule can be used to help remember what to watch for:
Asymmetry: The shape of one half of the mole does not match the other.
Border: The edges are ragged, notched, or blurred.
Color: The color is often uneven. Shades of black, brown, and tan may be present. Areas of white, gray, red, or blue may also be seen.
Diameter: The diameter is usually larger than 6 millimeters (mm) (the size of a pencil eraser) or has grown in size.
Evolving: The mole has been changing in size, shape, color, appearance, or growing in an area of previously normal skin. Also, when melanoma develops in an existing mole, the texture of the mole may change and become hard, lumpy, or scaly. Although the skin may feel different and may itch, ooze, or bleed, melanoma usually does not cause pain.
Diagnosis
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For melanoma, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
• Age and medical condition
• The type of cancer suspected
• Severity of symptoms
• Previous test results
If a person shows signs of melanoma, the doctor will take a complete medical history, noting the symptoms and risk factors. The following tests may be used to diagnose melanoma and/or determine if or where the disease has spread:
Physical examination. A physical examination includes a thorough examination of the person’s skin for lesions.
Biopsy. A biopsy is the removal (usually performed with a local anesthetic to numb the area) of a small amount of tissue for examination under a microscope. The suspect lesion is removed using techniques that preserve the entire lesion so that the thickness of the potential cancer and its margin (healthy tissue around the lesion that is removed to make sure no cancer cells remain) can be carefully examined. The tissue sample is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease), who determines if it is a melanoma.
Sentinel lymph node biopsy. This type of biopsy is a surgical procedure and is used to determine if cancer cells have spread to the regional lymph nodes (lymph nodes near the site of the cancer). For a more detailed description of the surgery, read the Treatment section.
X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
Blood tests. The patient’s blood may be tested to help determine if the cancer has spread.
Occasionally, the following tests may be performed to diagnose melanoma and/or help determine if or where the cancer has spread:
Ultrasound. An ultrasound uses sound waves to create pictures of the internal organs, including collections of lymph nodes (called basins) and soft tissue.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.
Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.
Learn more about what to expect when having common tests, procedures, and scans.
Find out more about common terms used during a diagnosis of cancer.
Staging With Illustrations
Our staging illustrations are currently being updated to comply with the new 2010 American Joint Committee on Cancer staging guidelines. We apologize for the inconvenience.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine a cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
To determine the stage of a melanoma, the lesion and some surrounding normal tissue need to be surgically removed and analyzed using a microscope. Doctors use the melanoma’s thickness, measured in millimeters (mm), to help determine the disease’s stage. The original melanoma is often called the primary melanoma or primary tumor.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the regional lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
• How large is the primary tumor and where is it located? (T)
• Has the tumor spread to the regional lymph nodes, or is there evidence of in-transit metastases or satellites (defined below)? (N)
• Has the cancer metastasized to other (distant) parts of the body? (M)
Tumor. Using the TNM system, the "T" plus a letter and/or number (0 to 4) is used to describe the primary melanoma, particularly its size.
If the outer layer of skin (the epidermis) does not appear under a microscope to be overlying the melanoma, that is referred to as ulceration. In addition, the doctor may also refer to the Clark’s level of the tumor, which is a specific classification to describe how deep the melanoma has grown into the layers of skin. The Clark’s level also uses Roman numerals (I, II, III, IV,V; one to five) in its description.
Based on the size, ulceration, and Clark’s level, some T classifications are subdivided into smaller groups that help describe the tumor in even more detail. Tumor classification information is listed below.
TX: The tumor cannot be evaluated.
T0: There is no evidence of cancer.
Tis: Called melanoma in situ, which means that cancer cells are found in only the outer layer of skin (epidermis) and has not grown into any other layers. The cancer cells do not show signs of spreading.
T1: The primary tumor is 1.0 mm or thinner, and one of the following:
T1a: The primary tumor has no ulceration and Clark's level II or III.
T1b: The primary tumor has ulceration or Clark's level IV or V.
T2: The primary tumor’s thickness is between 1.0 mm and 2.0 mm, and one of the following:
T2a: The primary tumor has no ulceration.
T2b: The primary tumor has ulceration.
T3: The primary tumor’s thickness is between 2.0 mm and 4.0 mm, and one of the following:
T3a: The primary tumor has no ulceration.
T3b: The primary tumor has ulceration.
T4: The primary tumor is thicker than 4.0 mm, and one of the following:
T4a: The primary tumor has no ulceration.
T4b: The primary tumor has ulceration.
Node. The "N" in the TNM system stands for regional lymph nodes. In addition, the “N” classification includes whether small deposits of melanoma are found between the primary tumor and the regional lymph nodes (called in-transit metastases or satellites).
NX: The regional lymph nodes cannot be evaluated.
N0: There is no evidence of cancer in the lymph nodes.
N1: The cancer has spread to one lymph node, and one of the following:
N1a: The doctor cannot feel cancer in the lymph nodes but can detect cancer cells in a lymph
node sample when viewed under a microscope (called microscopic metastasis).
N1b: The doctor can feel the cancer in the lymph nodes or see it on a scan (called macroscopic
metastasis).
N2: Cancer has spread to two or three lymph nodes, and one of the following:
N2a: The doctor cannot feel cancer in the lymph nodes but can detect cancer cells in a lymph
node sample when viewed under a microscope.
N2b: The doctor can feel the cancer in the lymph nodes or see it on a scan.
N2c: The doctor finds in-transit metastases or satellites.
N3: Any of the following conditions:
• The cancer has spread to four or more lymph nodes.
• Two or more lymph nodes appear joined together (called matted lymph nodes).
• In-transit metastases or satellites are present, with any number of affected lymph nodes.
Distant metastasis. The "M" in the TNM system indicates whether melanoma has spread to other parts of the body, beyond the primary melanoma site and the regional lymph nodes. In melanoma, metastasis may be found in the skin, subcutaneous tissue (under the skin), or in other organs such as the lung, liver or brain. Lymph nodes beyond the primary tumor region are called distant lymph nodes.
MX: Distant metastasis cannot be evaluated.
M0: The melanoma has not spread to distant sites.
M1a: The cancer has spread outside the region where it first started to other parts of the skin, under the skin, or any distant lymph nodes.
M1b: The cancer has spread to the lungs.
M1c: The cancer has spread to any other internal organ in the body. Also, any distant metastasis combined with a blood test result showing an elevated level of a tumor marker called LDH is classified as MIc. A tumor marker is a substance found in a patient’s blood that is produced either by the tumor itself or by the body in response to the cancer.
Melanoma stage grouping
Doctors determine the stage of the melanoma by combining the T, N, and M classifications.
Stage 0: Refers to melanoma in situ (melanoma cells are found only in the outer layer of skin).
Stage IA: The melanoma is 1.0 mm or thinner, has no ulceration, and is Clark's level II or III.
Stage IB: Describes either of these conditions:
• The melanoma is 1.0 mm or thinner, and either has ulceration and/or Clark's level IV or V.
• The melanoma is between 1.0 mm and 2.0 mm and has no ulceration.
Stage IIA: Describes either of these conditions:
• The melanoma is between 1.0 mm and 2.0 mm and has ulceration.
• The melanoma is between 2.0 mm and 4.0 mm and has no ulceration.
Stage IIB: Describes either of these conditions:
• The melanoma is between 2.0 mm and 4.0 mm and has ulceration.
• The melanoma is larger than 4.0 mm and has no ulceration.
Stage IIC: The melanoma is larger than 4.0 mm and has ulceration.
Stage III: The melanoma is of any thickness, and melanoma has spread to one or more regional lymph nodes and/or there is in-transit or satellite involvement. However, the melanoma has not spread to distant parts of the body.
Stage IIIA: The primary melanoma has no ulceration and has spread to up to three lymph nodes in the form of micrometastases.
Stage IIIB: Describes any of these conditions:
• The melanoma has spread to up to three regional lymph nodes in the form of macrometastases and the primary melanoma has no ulceration.
• The melanoma has spread to up to three regional lymph nodes, but is still microscopic and the primary melanoma has ulceration.
• There is in-transit or satellite involvement without regional lymph node spread.
Stage IIIC: Describes any of these conditions:
• The melanoma has spread to up to three regional lymph nodes, the lymph nodes show macrometastases, and the primary tumor has ulceration.
• The melanoma has spread to four or more regional lymph nodes.
• The melanoma has in-transit or satellite involvement and has spread to any of the lymph nodes.
Stage IV: The primary melanoma has spread to other, distant parts of the body beyond the regional lymph nodes. This is regardless of the primary tumor’s thickness and whether it has spread to any of lymph nodes or satellite or in-transit sites.
Recurrent: Recurrent melanoma is melanoma that comes back after treatment.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.cancerstaging.net.
Treatment
The treatment of melanoma depends on the size and location of the tumor, whether the cancer has spread, and the person’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. The team may include a surgical oncologist (a doctor who specializes in treating cancer with surgery), a medical oncologist (a doctor who specializes in treating cancer with medication), a radiation oncologist (a doctor who specializes in giving radiation therapy to treat cancer), a dermatologist (a doctor who specializes in diseases and conditions of the skin), and a pathologist.
This section outlines treatments that are the standard of care (best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section.
Descriptions of the most common treatment options for melanoma are listed below.
Surgery
Melanoma can often be successfully treated if it is diagnosed and treated when the tumor is relatively thin. Most melanomas are found when they are thin (less than 1.0 mm) and when outpatient surgery is often the only treatment needed. A doctor will remove the tumor and some healthy tissue around it to make sure no cancer cells remain. The amount of normal tissue removed depends on the thickness of the melanoma. If the melanoma has grown deep into the skin, lymph nodes near the tumor may be removed and examined for cancer cells. Sometimes, the doctor may recommend a sentinel lymph node biopsy (see below). This may be an outpatient procedure or require an overnight stay in the hospital.
Typically, the complete surgical removal of the melanoma requires the removal of 1.0 centimeters (cm) (3/8 of an inch) to 2.0 cm (3/4 of an inch) of normal-appearing skin surrounding the melanoma in all directions, called the margin. In addition, the underlying fat tissue is removed. The specific size of the margin taken depends on the size, stage, and possibility that the melanoma may grow and spread. If it is staged as melanoma in situ (Stage 0), a margin of between 0.5 cm to 1.0 cm may be recommended. In general, a thin melanoma (measuring 1.0 mm or smaller in thickness) can be safely removed with a 1.0 cm margin of skin, while a thicker melanoma requires a 2.0 cm margin of skin.
Depending on the site of the surgery, a skin graft (a procedure using the skin from another part of the body to both close the wound and reduce scarring) may be necessary. Since melanoma surgery for primary melanoma is usually limited to the removal of the skin and subcutaneous tissues, rehabilitation is rarely necessary for this procedure.
Lymphatic mapping and sentinel lymph node biopsy. This surgical procedure is used to determine if the melanoma has spread to regional lymph nodes. During the procedure, the doctor removes one or a few sentinel lymph nodes to check for cancer cells. A sentinel lymph node is the first node into which the lymph system drains from the primary melanoma site. If cancer cells are detected in the sentinel lymph node, it means that the disease has spread to the regional lymph nodes. Other lymph nodes in the region are also at risk for spread.
Lymph node dissection. When melanoma has spread to lymph nodes, surgical removal of the remaining lymph nodes in that region is usually recommended. The number of lymph nodes removed depends on the area of the body, and the likelihood of finding additional lymph nodes that contain melanoma is determined based on the stage of the melanoma. People who have had a lymph node dissection around an arm or leg have higher risk for fluid build-up in that limb, a side effect called lymphedema (see Side Effects). In general, the risk of spread to areas of the body beyond the regional lymph nodes is greater for patients who have lymph nodes containing melanoma than for patients whose lymph nodes do not contain disease.
If the melanoma has spread to distant organs (Stage IV) or recurs (comes back after treatment), surgery may be a treatment option to help control the disease.
After surgery, the surgeon or medical oncologist may also recommend adjuvant treatment (treatment given after the primary treatment) based on the information that was learned about the disease during surgery. This may include immunotherapy, chemotherapy, and/or radiation therapy; see more information below on each treatment.
Learn more about cancer surgery.
Immunotherapy
Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune function. Immunotherapy works well to treat melanoma, particularly to reduce the risk that the melanoma will come back. Immunotherapy may be used in combination with surgery and/or chemotherapy, or as part of a clinical trial. Many immunotherapies are being evaluated for melanoma in clinical trials.
Only one adjuvant therapy has been shown to consistently reduce the likelihood of a recurrence of melanoma. This treatment is called high-dose interferon alfa-2b. It is given intravenously (injected into a vein) in the doctor’s office for 20 doses (five days a week, for four weeks) in the first month, and then under the skin three times a week at home for 11 months. It has been shown to reduce recurrence and, in two clinical trials, has greatly increased survival. This is the only therapy that is currently approved as adjuvant therapy, except as part of a clinical trial. Adjuvant therapy for melanoma is often recommended when the primary melanoma is found at a later stage or if it has spread to the lymph nodes.
Interleukin-2 (IL-2) is another type of immunotherapy used to treat melanoma. High-dose IL-2 treatment is used for patients when cancer has spread where it cannot be removed with surgery. In clinical trials, the therapy does not significantly increase a patient's life span, but it delays the time it takes for cancer to come back after treatment. A few patients have had long-term disappearance of detectable melanoma with this approach.
Some cancer centers offer experimental vaccines to treat melanoma. These are now being tested for advanced disease, in the hopes that a vaccine could help prevent melanoma recurrence similar to treatment with interferon alfa-2b. The vaccines are made using certain proteins found only on a melanoma tumor and are given as an injection. The person's immune system then recognizes these proteins and destroys the cancer cells. Another type of experimental immunotherapy involves altering the patient’s lymphocytes (white blood cells) in the laboratory to increase their ability to fight the tumor. The changed cells are given back to the patient, often in combination with chemotherapy. These types of treatments are only available as part of a clinical trial.
Side effects of these treatments vary widely. They can include fatigue, fever, chills, headache and some memory difficulties, muscle ache, and skin irritation. Occasionally, immunotherapy can cause a change in blood pressure or increased fluid in the lungs. Side effects of immunotherapy can be greater than or less than side effects from other types of treatment. Patients should discuss the benefits and risks of each treatment option with their doctors.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. It is given by a medical oncologist. Some people may receive chemotherapy in their doctor’s office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.
For melanoma, chemotherapy is typically used to control advanced disease, although the cure of widespread melanoma is rare. Systemic chemotherapy used for melanoma include dacarbazine (DTIC-Dome), carboplatin (Paraplat, Paraplatin), cisplatin (Platinol), and temozolomide (Methazolastone, Temodar).There are several combinations of chemotherapy that are currently being tested in clinical trials, and new drugs that specifically stop melanoma from growing are also being studied.
In addition to systemic chemotherapy, there are also chemotherapy techniques that focus on a specific region. If melanoma has spread only on one limb (an arm or a leg), isolated limb perfusion (ILP) is an approach that uses surgery and chemotherapy. First, a surgeon separates the limb’s blood circulation from the rest of the body. Then, a high dose of chemotherapy is injected into the limb’s bloodstream to kill cancer cells. Isolated limb infusion (ILI) is similar to ILP, but in order to isolate the limb’s blood circulation from the rest of the body, pressure is applied above the area using a tourniquet. Then, a high dose of chemotherapy is injected into the major blood vessels entering and leaving the limb. ILP/ILI may use melphalan (Alkeran).
The side effects of chemotherapy depend on the individual and the dose used but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, diarrhea, some nerve damage causing changes in sensation, and hair loss. These side effects usually go away once treatment is finished.
Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body.
Radiation therapy for melanoma can be used in several ways. Radiation therapy is most commonly used to relieve symptoms caused by melanoma that has spread, especially to the brain and bones. It may also be used when cancer has spread to the lymph nodes, following a lymph node dissection (see above). Radiation therapy is also used when the amount of melanoma that can be removed with surgery is limited by the location of the tumor. And, research is being done to test the effectiveness of chemoradiation, a combination of radiation therapy and chemotherapy, to treat melanoma.
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. A patient may experience hair loss if radiation therapy is used on the scalp. If radiation therapy is used around the head and neck, side effects, such as a change in taste and dry mouth, may occur. Most side effects go away soon after treatment is finished. If lymph nodes near an arm or leg were affected, the person may have higher risk of fluid build-up in that limb, a side effect called lymphedema. Lymphedema can be a long-term, ongoing side effect. Learn more about radiation therapy and managing side effects.
Find out more about common terms used during cancer treatment.
Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat patients with melanoma. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a new combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating melanoma. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with melanoma.
Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill”. The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.
To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
For specific topics being studied for melanoma, learn more in the Current Research section.
Side Effects
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatment you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them.
In addition to physical side effects, you may experience psychosocial (emotional and social) effects as well. Learn more about the importance of addressing such needs, including concerns about managing the cost of your medical care.
Learn more about late effects or long-term effects by reading the After Treatment section or talking with your doctor.
After Treatment
After treatment for melanoma ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.
Routine screening for new melanoma (and non-melanoma skin cancer) is necessary as part of follow-up care, as is sun protection. Screening for melanoma and other skin cancer may include mole mapping (photography of the moles) by a doctor. If possible, the patient should receive copies of their photographs and education in skin self-examination. There is growing evidence that individuals followed using photographs have melanomas diagnosed at an earlier stage.
Sun protection is essential to help prevent second skin cancers, either melanoma or non-melanoma skin cancer. Many people who are treated for melanoma lead an active, outdoor lifestyle, but it is essential that they take steps to protect themselves from further skin damage. Participating in outdoor activities before 10:00 AM or after 4:00 PM and wearing long sleeves, pants, sunscreen, and a hat help protect against further skin damage. A major consideration following diagnosis and treatment of melanoma is adjusting a person’s lifestyle to use sun protective measures at all times. In addition, if a person is working in an area where there is high UV exposure, there may be occupation-related issues. Learn more about protecting your skin from the sun.
For an early-stage, thin melanoma, the surgery is most often outpatient surgery with little need for rehabilitation. With a thicker melanoma and possible skin grafts, depending on the location, there may be some need for rehabilitation.
If the person’s treatment included lymph node dissection and/or radiation therapy under the arm or in the groin, fluid build-up in the affected limb, called lymphedema, is possible. Graduated support garments and other therapies may help manage the condition.
If the person treated for melanoma has pain from surgery, he or she should speak with the surgeon or other health-care team member. Although rare, some individuals have post surgical long-term pain. If needed, a pain management specialist can also help find ways to manage pain.
People recovering from melanoma are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer.
Find out more about common tests used after cancer treatment is complete.
Current Research
Research for melanoma is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all prevention, diagnostic, and treatment options with your doctor.
Enhanced prevention and early detection methods. Both primary prevention (keeping melanoma from developing) and secondary prevention (early detection of melanoma) are important. One promising area is the screening of people with a high-risk of developing melanoma. A melanoma risk calculator has been developed for use by health-care professionals to estimate a person’s five-year risk of melanoma. This risk calculator needs to be tested in other groups of patients to confirm its effectiveness. Other tools being used for early detection of melanoma include epilluminescence microscopy or dermoscopy, which evaluates patterns of size, shape, and pigmentation in pigmented skin lesions. Among trained, experienced examiners, the use of dermoscopy may reduce the number of biopsies of pigmented lesions to rule out melanoma, although more research is needed. Another new technology to better examine possible melanoma lesions is called confocal scanning laser microscopy, but this is only available in a few major facilities.
Vaccines. Vaccines aim to stimulate the body's own defenses to destroy melanoma cancer cells. Research has shown that vaccination can cause the immune system to fight melanoma, even in advanced disease, but these therapies are still considered experimental.
Chemotherapy. There are several new types of chemotherapy and combinations of drugs being evaluated in clinical trials.
Gene therapy. Gene therapy is a targeted form of treatment that is able to change bits of genetic code in a person's cells. Although gene therapy is relatively new, it shows potential for treating melanoma. Although there are several approaches to gene therapy, one goal is to make the cancer cells "look" different, so the immune system can recognize them as cancer and attack them.
Targeted therapy. Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Targeted therapies are already available for some cancers, and research is underway to determine how this approach may be useful in treating melanoma.
Questions to Ask the Doctor
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
For patients with primary melanoma (initial diagnosis of a skin lesion):
• What stage of melanoma do I have? What is the size, in millimeters, of the melanoma? Is the melanoma ulcerated? What is the depth of the melanoma (the Clark’s level)?
• Can you explain my pathology report (laboratory test results) to me?
• Is it likely the melanoma has spread? Why or why not?
• What stage of melanoma do I have?
• What are my treatment options?
• What clinical trials are open to me?
• What treatment plan do you recommend? Why?
• What are the goals of this treatment?
• Will surgery be able to remove all of the cancer? Do I need additional surgery?
• After the surgical removal of the melanoma, will I need a skin graft?
• Should I have a sentinel lymph node biopsy to find out if there is spread to the lymph nodes?
• Should I have another type(s) of treatment following surgery?
• What are the possible side effects of this treatment, both in the short term and the long term?
• How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
• If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
• Is the cancer likely to recur?
• What is my prognosis?
• What follow-up test will I need, and how often will I need them?
• What steps can I take to reduce the risk of additional new melanomas?
• Are my family members at a higher risk of melanoma?
• What support services are available to me? To my family?
For patients with stage III melanoma (when the sentinel lymph node biopsy indicates cancer is present or when cancer is found in the lymph nodes):
• Will the remainder of the lymph nodes be removed?
• What are the potential complications of lymph node surgery?
• How many lymph nodes are affected?
• Is there any extracapsular extension of the melanoma (that is, has the melanoma spilled out of the lymph node)? What does this mean?
• Is radiation therapy recommended after surgery?
• Do recommend other types of treatment after surgery? What are the risks and benefits of each treatment?
• What are the goals of treatment?
• What are the side effects of each treatment?
• What clinical trials are open to me?
• What is my prognosis?
• What follow-up care is necessary?
For patients with stage IV (advanced) melanoma:
• Where has the disease spread? Is a brain scan or PET scan necessary to determine where it has spread?
• What are the treatment options?
• What are the goals of treatment?
• Is surgical removal of the metastases an option (especially if one or two tumors are present)? If so, what are the benefits and risks?
• What clinical trials are open to me?
• What is my prognosis?
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease.
View organizations that offer information on this specific type of cancer.
