Treating melanoma

By NHS Choices 35

Staging melanoma

Health professionals use a staging system to describe how far melanoma has grown into the skin (the thickness) and whether it has spread. The type of treatment you receive will depend on what stage the melanoma has reached.

The stages of melanoma can be described as:

  • Stage 0 – the melanoma is on the surface of the skin 
  • Stage 1A – the melanoma is less than 1mm thick 
  • Stage 1B – the melanoma is 1-2mm thick or the melanoma is less than 1mm thick and the surface of the skin is broken (ulcerated)
  • Stage 2A – the melanoma is 2-4mm thick or the melanoma is 1-2mm thick and is ulcerated
  • Stage 2B – the melanoma is thicker than 4mm or the melanoma is 2-4mm thick and ulcerated
  • Stage 2C – the melanoma is thicker than 4mm and ulcerated
  • Stage 3A – the melanoma has spread into one to three nearby lymph nodes but they are not enlarged. The melanoma is not ulcerated and has not spread further
  • Stage 3B – the melanoma is ulcerated and has spread into one to three nearby lymph nodes but they are not enlarged, or the melanoma is not ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread to small areas of skin or lymphatic channels but not to nearby lymph nodes
  • Stage 3C – the melanoma is ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread into four or more lymph nodes nearby
  • Stage 4 – the melanoma cells have spread to other areas of the body, such as the lungs, brain or other parts of the skin

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Stage 1 melanoma

Treating stage 1 melanoma will involve surgically removing the melanoma and a small area of skin around it. This is known as surgical excision and is usually carried out by a plastic surgeon.

Surgical excision is usually carried out under local anaesthetic. This means that you will be awake, but the area around the melanoma will be numbed and you won’t feel pain. In some cases, general anaesthetic is used, which means you will be asleep during the procedure.

If a surgical excision is likely to leave a significant scar, it may be done in combination with a skin graft. A skin graft involves removing a patch of healthy skin, usually taken from a part of your body where scarring cannot be seen, such as your back. It is then connected, or grafted, to the affected area.

Once the melanoma has been removed, there is little possibility it will return and no further treatment should be required. You will probably be asked to come for follow up appointments before being discharged. 

Stage 2 and 3 melanoma

As with stage 1 melanomas, any affected area of skin will be removed and a skin graft carried out if necessary.

If the melanoma has spread to nearby lymph nodes, you may need further surgery to remove them. This is known as a block dissection and is carried out under a general anaesthetic.

While the surgeon will try to ensure the rest of your lymphatic system can function normally, there is a risk that the removal of lymph nodes will disrupt the lymphatic system, leading to a build-up of fluids in your limbs. This is known as lymphoedema.

Once the melanoma has been removed, you will need follow-up appointments to see how you are recovering and to watch for any sign of the melanoma returning.

You may be offered treatment to try to prevent the melanoma returning. This is called adjuvant treatment. Currently, there is not much evidence that adjuvant treatment helps prevent melanoma from coming back. However, ongoing clinical trials are looking into this and you may be asked to join one. These trials investigate whether drug treatment could be used to reduce the risk of the melanoma returning.

Stage 4 melanoma

If melanoma is diagnosed at its most advanced stage, or if the melanoma has spread to another part of your body (metastasis) or has come back in another part of your body after treatment (recurrent cancer), it may not be possible to cure it.

Treatment is available and given in the hope it can slow the growth of the cancer, reduce any symptoms you may have and possibly extend your life expectancy.

You may be able to have surgery to remove other melanomas that have occurred away from the original site.

You may also be able to have other treatments to help with symptoms. These include:

  • radiotherapy
  • drug treatments

Radiotherapy

Radiotherapy may be used after an operation to remove your lymph nodes and also used to help relieve the symptoms of advanced melanoma.

Radiotherapy uses controlled doses of radiation to kill cancer cells. It is given at the hospital as a series of 10-15 minute daily sessions with a rest period over the weekend.

The side effects of radiotherapy include:

  • tiredness
  • nausea
  • loss of appetite
  • hair loss
  • sore skin

Many side effects can be prevented or controlled with medicines your doctor can prescribe, so let them know about any you experience. After treatment has finished, the side effects of radiotherapy should gradually reduce.

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Drug treatment

Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill the cancer. Chemotherapy is normally used to treat melanoma that has spread to parts of the body beyond its original site. It is mainly given to help relieve symptoms of advanced melanoma.

Several different chemotherapy drugs are used to treat melanoma and are occasionally given in combination. The drugs most commonly used for melanoma are dacarbazine and temozolomide. However, many different types of drugs could be used. Your specialist can discuss which drugs are best for you.

Chemotherapy is usually given as an outpatient treatment, which means you will not have to stay in hospital overnight. Dacarbazine is given through a drip and temozolomide is given as tablets. You would probably receive chemotherapy sessions once every three to four weeks, with gaps between treatment intended to give your body and blood time to recover.

The main side effects of chemotherapy are caused by their influence on the rest of the body. Side effects include infection, nausea and vomiting, tiredness and sore mouth. Many side effects can be prevented or controlled with medicines that your doctor can prescribe.

Immunotherapy

Immunotherapy uses drugs (often derived from substances that occur naturally in the body) that encourage your body’s immune system to work against the melanoma. Two such treatments in regular use for melanoma are interferon-alpha and interleukin-2. Both are given as an injection (into the blood, under the skin or into lumps of melanoma). Side effects include flu-like symptoms, such as chills, a high temperature, joint pain, and fatigue.

Vaccines

There is ongoing research into producing a vaccine for melanoma, either to treat advanced melanoma or to be used after surgery in patients who have a high risk of the melanoma coming back. Vaccines are designed to focus the body’s immune system so that it recognises the melanoma and can work against it. Vaccines are usually given as an injection under the skin repeated every few weeks, often over a period of months.

As more research is needed into vaccines, you would only have them as part of a clinical trial.

Monoclonal antibodies

Our immune systems make antibodies all the time, usually as a way of controlling infections. They are substances that recognise something which doesn’t belong in the body and help to destroy it. Antibodies can be produced in the laboratory, and can be made to recognise and lock onto specific targets, either in the cancer or in specific parts of the body.

Antibodies produced in the laboratory are usually called monoclonal antibodies. Two types of monoclonal antibody treatments are bevacizumab and ipilimumab.

Bevacizumab is currently licensed as a treatment for advanced bowel cancer. Research is continuing to see if it can reduce the risk of melanoma returning once it has been removed from the skin or lymph nodes. Your doctor can advise you whether you would be eligible to enter the clinical trial exploring this.

Ipilimumab is a monoclonal antibody that has been licensed for use in the UK since 2011. It works like an accelerator for the immune system, allowing the body to work against all sorts of conditions, including cancer. In December 2012, NICE recommended ipilimumab as a possible treatment for people with previously treated advanced melanoma that has spread or cannot be surgically removed.

Signalling inhibitors

Signalling inhibitors are drugs that work by disrupting the messages (signals) that a cancer uses to co-ordinate its growth. There are hundreds of these signals, and it is difficult to know which ones need to be blocked. Most of the signals have short, technical names. Two that are of current interest in melanoma are BRAF and MEK.

There are drugs available that can interfere with these signals, but most are only widely available as part of clinical trials at present.

In December 2012, NICE recommended a signalling inhibitor called vemurafenib as a possible treatment for melanoma that has spread or cannot be surgically removed.

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Clinical trials

All new treatment for cancer (and other diseases) is first given to patients in a clinical trial. A clinical trial or study is an extremely rigorous way of testing a drug in real people, with patients monitored both for an effect of the drug on the cancer, and for any side effects. Many patients with melanoma are offered entry into clinical trials, but some people are suspicious of the process.

There are a few key things to know about clinical trials:

  • Overall, patients in clinical trials do better than those on routine treatment, even when receiving a drug that would be given routinely. 
  • All clinical trials are highly regulated.
  • All new treatments will first become available through clinical trials.
  • Even where a new drug fails to offer any benefits over existing treatment, the knowledge that we gain from the trial is valuable for future patients. 

If you are asked to take part in a trial, you will be given an information sheet and, if you want to take part, you will be asked to sign a consent form. You can refuse or withdraw from a clinical trial without it affecting your care.

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Deciding against treatment for Stage 4 melanoma

As many treatments above have unpleasant side effects that can affect your quality of life, you may decide against having treatment, particularly if it is unlikely to significantly extend your life expectancy or if you do not have symptoms causing you pain or discomfort.

This is entirely your decision and your healthcare team will respect it. If you decide not to receive treatment, pain relief and nursing care will be made available as and when you need it. This is called palliative care.

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