Treatment

The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs. Treatment for melanoma depends on the extent of the disease, the patient's age and general health, and other factors.

People with melanoma are often treated by a team of specialists. The team may include a dermatologist, surgeon, medical oncologist, radiation oncologist, and plastic surgeon.
Getting a Second Opinion

Before starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.

There are a number of ways to find a doctor for a second opinion:

• The patient's doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.

• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.

  A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

• The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries.

Preparing for Treatment

People with melanoma often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a melanoma can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor-to take part in the discussion, to take notes, or just to listen.

These are some questions a person may want to ask the doctor before treatment begins: What is my diagnosis? What is the stage of my disease? What are my treatment choices? Which do you recommend for me? Why? What are the benefits of each kind of treatment? What are the risks and possible side effects of each treatment? How will I feel after surgery? If I have pain, how will it be controlled? Will I need more treatment after surgery? Will there be a scar? Will I need a skin graft or plastic surgery? What is the treatment likely to cost? Will treatment affect my normal activities? If so, for how long? How often will I need checkups? Would a clinical trial (research study) be appropriate for me? Can you help me find one?

People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Methods of Treatment

People with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.

At any stage of disease, people with melanoma may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called symptom management, supportive care, or palliative care.

The doctor is the best person to describe the treatment choices and discuss the expected results.

A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.
Surgery

Surgery is the usual treatment for melanoma. The surgeon removes the tumor and some normal tissue around it. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin:

• The doctor may be able to completely remove a very thin melanoma during the biopsy. Further surgery may not be necessary.

• If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas. If the melanoma is thick, the doctor may need to remove a larger margin of tissue.

If a large area of tissue is removed, the surgeon may do a skin graft. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.

Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has also spread to other parts of the body. Two procedures are used to remove the lymph nodes:

• Sentinel lymph node biopsy-The sentinel lymph node biopsy is done after the biopsy of the melanoma but before the wider excision of the tumor. A radioactive substance is injected near the melanoma. The surgeon follows the movement of the substance on a computer screen. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping.) The surgeon removes the sentinel node(s) to check for cancer cells.

  If a sentinel node contains cancer cells, the surgeon removes the rest of the lymph nodes in the area. However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.

• Lymph node dissection-The surgeon removes all the lymph nodes in the area of the melanoma.

Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. The patient may receive biological therapy.

Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods.
Chemotherapy

Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat melanoma. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

People with melanoma may receive chemotherapy in one of the following ways:

• By mouth or injection-Either way, the drugs enter the bloodstream and travel throughout the body.

• Isolated limb perfusion (also called isolated arterial perfusion)-For melanoma on an arm or leg, chemotherapy drugs are put directly into the bloodstream of that limb. The flow of blood to and from the limb is stopped for a while. This allows most of the drug to reach the tumor directly. Most of the chemotherapy remains in that limb.

  The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.

Biological Therapy

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to reduce side effects caused by some cancer treatments. Biological therapy for melanoma uses substances called cytokines. The body normally produces cytokines in small amounts in response to infections and other diseases. Using modern laboratory techniques, scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.
Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. The patient usually has treatment at a hospital or clinic, five days a week for several weeks. Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.
Treatment Choices by Stage

The following are brief descriptions of the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)

Stage 0

People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.

Stage I

People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.

Stage II or Stage III

People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.

Stage IV

People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better-physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.

The patient may have one of the following:

• Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body

• Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

People with advanced melanoma can find helpful information in the National Cancer Institute booklet Pain Control: A Guide for People with Cancer and Their Families.
Recurrent Melanoma

Treatment for recurrent melanoma depends on where the cancer came back, which treatments the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.

The patient may have one of the following:

• Surgery to remove the tumor

• Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

• Heated chemotherapy drugs injected directly into the tumor

Side Effects of Treatment

Because treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" for other sources of information about side effects.
Surgery

The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.

Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can (while still protecting against recurrence). In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, the doctor must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large growths, these scars will still be quite noticeable.

Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, insect bites, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.
Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:

• Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.

• Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.

• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.

Biological Therapy

The side effects of biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also get a skin rash. These problems can be severe, but they go away after treatment stops.

Radiation Therapy The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur in the treated area include red or dry skin and hair loss. Radiation therapy also may cause fatigue. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent. Nutrition People with melanoma may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. Nevertheless, patients should try to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy. The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful ideas and recipes. The "National Cancer Institute Booklets" section tells how to get this publication.

  

Treating melanomas that have spread beyond the skin 

• Surgical removal. It's very difficult to cure melanomas that have spread beyond the skin. But surgically removing a melanoma that has spread (metastatic melanoma) can often provide relief of symptoms — sometimes for years. Whether this is an option for you will depend on where the cancer is located and how severe it is, as well as on your own wishes and overall health. 

• Chemotherapy. This form of treatment uses drugs to destroy cancer cells. Two or more drugs are often given in combination and may be administered intravenously, in pill form or both — usually for four to six months. Melanoma has long been thought to be resistant to most forms of chemotherapy, but new chemotherapy regimens are being studied and developed. In the meantime, chemotherapy is sometimes used to relieve symptoms in people with advanced metastatic melanoma. 

• Radiation therapy. This treatment uses high-energy X-rays to kill cancer cells. It's sometimes used to help relieve symptoms of melanoma that has spread to another organ. Fatigue is a common side effect of radiation therapy, but your energy usually returns once the treatment is completed. 

• Biological therapy (immunotherapy). This form of treatment is designed to help your immune system fight disease. It involves the use of biologic response modifiers (BRMs) — substances your body normally produces in response to infection. BRMs such as interleukin-2 and interferon are now produced in laboratories for use in treating cancer and other diseases. 

• Gene therapy. An area of great interest among researchers, this therapy generally focuses on adding genes to cancer cells. One approach, which has had limited success, is to replace some of the damaged genes that seem to be responsible for abnormal cell growth. 

Once the diagnosis of malignant melanoma has been confirmed, the tumor is staged to determine prognosis and treatment. The staging is based on the tumors thickness, and whether there is ulceration, nodal disease or distant metastases. 

For newly diagnosed cutaneous melanoma, a wide surgical excision is typically used. Regional lymph node removal may also be recommended but the efficacy of this procedure remains controversial. (Some studies demonstrate a survival benefit and some studies do not.) For patients who do not have metastases, but who are at high risk for metastases, adjuvant interferon alpha (2a or 2b) may be capable of improving disease-free and overall survival in some patients. However, this treatment has been associated with severe toxicity. 

Melanomas may spread by the lymph system or the bloodstream. Liver, lung, bone and brain are common sites of metastases. Metastatic melanoma is generally incurable but a number of new approaches are being studied in patients. The Cancer Monthly database currently has the results (survival, side effects, etc.) for 20 recent therapies for melanoma 

   

Notes: National Cancer Institute Katarina G. Chiller, et al., Cancer of the Skin, in HARRISON'S PRINCIPLES OF INTERNAL MEDICINE,

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EditText of this page (last edited August 27, 2008)