ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages in this guide, use the colored boxes on the right side of your screen, or click “Next” at the bottom.
This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.
In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For a person with melanoma, this team may include a dermatologist (a doctor who specializes in diseases and conditions of the skin), 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), and a pathologist (see the Diagnosis section for more information).
Treatment recommendations depend on many considerations including: the thickness of the primary melanoma, whether the cancer has spread, the stage of the melanoma, the presence of specific genetic changes in melanoma cells, rate of melanoma growth, and the patient’s other medical conditions. Other factors used in treatment decision making include possible side effects, as well as the patient’s preferences and overall health. Therefore, the following is meant to be an overview and not used as treatment recommendations for specific patients.
Descriptions of the most common treatment options for melanoma are listed below according to the stage of melanoma. Take time to learn about your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.
Surgery is the removal of the tumor and surrounding tissue during an operation. This procedure is usually performed by a surgical oncologist.
Surgery is the primary treatment for people with local melanoma and most patients with regional melanoma. In some patients with metastatic melanoma, surgery may also be considered. In recommending a specific treatment plan, doctors will consider the stage of the disease, as well as the patient’s individual risk of recurrence.
Types of surgery for local and regional melanoma are:
Wide excision. The primary treatment for melanoma is excision (surgical removal) of the primary melanoma on the skin. The extent of the surgery depends on the thickness of the melanoma. Most melanomas are found when they are thin (less than 1.0 mm), and outpatient surgery is often the only treatment needed. A doctor removes the tumor, underlying subcutaneous (under the skin) tissue, and some surrounding healthy tissue (called a margin) to ensure no cancer cells remain.
If the melanoma is staged as in situ (stage 0), the doctor may remove a margin of skin at least 0.5 cm around the cancer. The width of the margin increases with the thickness of the melanoma, ranging from a 1.0 cm margin for melanoma measuring up to 1.0 mm to a 2.0 cm margin for melanoma measuring over 2.01 mm.
Depending on the site and extent of the surgery, a skin flap (a procedure in which neighboring tissue is moved around to cover the area) or 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.
Lymphatic mapping and sentinel lymph node biopsy. This surgical procedure helps determine whether the melanoma has spread to regional lymph nodes. It is generally used for patients with melanomas that are more than 1.0 mm thick or have ulceration.
For non-ulcerated melanomas less than 1.0 mm thick, the likelihood that the cancer has spread to the lymph nodes is so low that, in most cases, sentinel lymph node mapping is not necessary. However, sometimes the doctor will recommend this procedure for a person with a thin melanoma if there are other indications the melanoma is more aggressive, such as ulceration or higher mitotic rate (see the Diagnosis section). If the melanoma is less than 1.0 mm, your doctor will discuss whether this approach is recommended based on other features of the primary melanoma and other factors.
During the procedure, the doctor removes one or a few sentinel lymph nodes to check for melanoma cancer cells. A sentinel lymph node is the first node into which the lymphatic system drains from the primary melanoma site. If melanoma cancer cells are not detected in the sentinel lymph node, no further lymph node surgery is required. However, if the sentinel lymph node does contain melanoma, the disease has spread to regional lymph nodes, and lymph node dissection (see below) is typically recommended. Sentinel lymph node mapping should be performed during the same operative procedure as the wide excision because such surgery can change the lymphatic drainage pattern, which may affect the reliability of the procedure in some situations.
Lymph node dissection. If melanoma has spread to nearby 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. However, it is still unclear whether removing these additional lymph nodes improves the chance of long-term survival. As such, some patients decide not to have a “complete lymph node dissection.” 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. 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 when lymph nodes do not contain disease.
Learn more about cancer surgery.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. The radiation beam produced by this machine can be pointed in different directions and blocked using special techniques to help decrease side effects. The radiation oncologist will recommend a specific radiation therapy regimen (schedule) with a total number of treatments and dose of radiation.
General side effects of radiation therapy include fatigue and skin irritation or infections. These usually get better a few weeks after adjuvant radiation therapy is finished. However, topical corticosteroid creams and antibiotics may also be used to treat and prevent radiation-induced skin reactions. Depending on the area of the body being treated with radiation therapy, other side effects may occur. For example, after treatment of the head and/or neck area, temporary irritation of the mouth or difficulty swallowing could occur. If treatment was directed at the armpit or groin area, 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. Talk with the radiation oncologist to learn more about the possible side effects you may experience and how they can be managed.
Learn more about radiation therapy.
Adjuvant therapy (stage II and stage III)
After surgery, the surgeon or medical oncologist may also recommend adjuvant therapy for patients who are at higher risk for recurrence of melanoma. Adjuvant therapy is treatment given after the initial treatment (surgery) to reduce the risk of melanoma recurrence. People who might consider adjuvant therapy are those whose melanomas are more than 4.0 mm thick (stage IIB) or have spread to regional lymph nodes (stage III). Adjuvant treatment options may include immunotherapy, radiation therapy, participation in a clinical trial (see Latest Research section), or observation/active surveillance, which includes regular check-ups with your doctor.
On the other hand, if the melanoma is thinner and no lymph nodes are involved, your doctor may not recommend adjuvant therapy.
Adjuvant radiation therapy
Sometimes, radiation therapy is considered after surgery to prevent recurrence. A recent randomized trial showed that, although this can slightly decrease the risk of a local recurrence (melanoma that comes back after treatment at or near the same place), it does not increase the amount of time a person lives. Patients who received adjuvant radiation therapy also experienced a worse quality of life compared to patients who did not receive it.
Immunotherapy (also called biologic therapy) is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Learn more about immunotherapy.
Interferon. The one FDA-approved adjuvant immunotherapy for this stage of melanoma is high-dose interferon alfa-2b. High-dose interferon alfa-2b given over a year has been shown to delay recurrences in some patients; however, it has not been shown to increase overall survival. There are substantial and common side effects to this treatment, including flu-like symptoms (such as fatigue, fever, chills, nausea, vomiting, and headache), rashes, hair thinning, and depression. High dose interferon is not universally used in the United States.
Vaccines. Vaccines that may improve the specific immune response to melanoma have been the focus of multiple clinical trials and are currently being explored as adjuvant therapy for melanoma (see the Latest Research section for additional details). However, to date, vaccines must still be considered experimental as none have shown clinical benefit in patients. Learn more about cancer vaccines.
New immunotherapies. There are a number of new immunotherapies currently being tested in the adjuvant setting. This includes ipilimumab (Yervoy) and inhibitors of mutated BRAF. See Stage IV: Immunotherapy (below) and the Latest Research section for more information.
Systemic treatment options for stage IV (metastatic) melanoma
If melanoma has spread beyond draining lymph nodes, it is considered stage IV or metastatic melanoma. The most common sites of spread beyond the skin include the lung, liver, and brain. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion usually includes clinical trials, which are the preferred option for certain patients with stage IV melanoma.
Treatment recommendations for patients with metastatic melanoma depends on multiple factors, including the patient’s age and overall health, the locations and number of metastases, how fast the disease is spreading, and the patient’s preferences. Treatment options include chemotherapy, immunotherapy, biochemotherapy (the combination of immunotherapy with chemotherapy), targeted therapy, radiation therapy, surgery for isolated and/or limited metastases, and participation in a clinical trial. (Some of the treatments described below are available only through clinical trials.) For patients with brain metastases, surgery or radiation therapy (see below) may be considered based upon symptoms, number of lesions, and location of metastases in the brain. Supportive care will also be important to help relieve symptoms and side effects.
For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
Common treatment options for stage IV metastatic melanoma are described below.
Stage IV: Immunotherapy
As explained above, immunotherapy is aimed at boosting the body’s natural defenses to fight the cancer. In recent years, there have been major advances in treating Stage IV melanoma with immunotherapy. Current options for patients include:
Anti-CTLA4 antibodies. Ipilimumab is a monoclonal antibody approved by the FDA for the treatment of stage IV melanoma, as well as stage III melanoma that cannot be surgically removed (unresectable). It is the first of two drugs approved in 2011 that was shown to extend survival for such patients (the second is a targeted therapy called vemurafenib, see below).
Ipilimumab targets cytotoxic T-lymphocyte associated molecule-4 (CTLA-4) and works by taking the brakes off the immune system. Because this drug activates the immune system, it can trigger “autoimmune” side effects in which the patient’s own immune system attacks normal cells in their body. These side effects can be serious, even life-threatening. Such side effects can include significant colon inflammation (colitis), liver problems, skin reactions, nerve and hormone gland inflammation, and eye problems. Due to these potentially significant side effects, the drug’s manufacturer has created an FDA-approved wallet card for patients (PDF) being given this therapy to carry with them for emergency reference. Patients are also closely monitored for diarrhea, rashes, itching, and other side effects. Learn more about this medication and its side effects in this Cancer.Net podcast.
Before treatment begins, be sure to talk to your doctor about potential side effects, and let your doctor know right away about any side effects you experience during treatment. It is also important to tell your doctor about all other medications you are taking, including over-the-counter drugs and dietary or herbal supplements, to avoid possible side effects from drug interactions with ipilimumab.
Ipilimumab and other anti-CTLA-4 antibodies continue to be evaluated in clinical trials (see the Latest Research section).
PD-1 inhibitors. Drugs that block interactions between a protein called PD-1 (programmed death-1) on T-cells (a type of white blood cell that directly helps body’s immune system fight infection) and PD-L1 on tumor cells have shown promise in clinical trials; however, they are currently not FDA-approved treatment options. PD-1 is found on the surface of T-cells and keeps the immune system from destroying the cancer. Because these drugs stop PD-1 from working, the immune system is able to better fight against the cancer. Research of PD-1 inhibitors alone and in combination is ongoing, especially for patients with later-stage melanoma.
Cytokines. Interleukin-2 (IL-2, aldesleukin, Proleukin) activates T-cells and is sometimes given to patients with this stage of melanoma. The current FDA-approved IL-2 regimen consists of two five-day courses of IL-2, separated by a rest period of seven to 10 days. Typically, two or three courses are given when the melanoma responds well to treatment. However, response rates are quite low, with less than 10% of patients experiencing a complete response (disappearance of all signs of cancer in response to treatment).
The most common side effects are low blood pressure, fever, chills, and a condition known as “capillary leak syndrome.” Capillary leak syndrome occurs when fluids and proteins leak from blood vessels, which can cause very low blood pressure and other dangerous effects. Patients being treated with high dose IL-2 require intensive monitoring by the health care team, and IL-2 should be given by an experienced health care team familiar with the side effects of IL-2 treatment.
Other clinical trials are investigating newer immunotherapy approaches, including adoptive immunotherapy, vaccine studies, treatment with GM-CSF (such as sargramostim [Leukine]), and treatment with other anti-CTLA-4 monoclonal antibodies (such as tremelimumab). Doctors are also looking into combining immunotherapy and chemotherapy as a way to treat metastatic melanoma. This approach is called biochemotherapy. However, there are many side effects, and evidence has not yet shown survival benefit over standard treatment. See the Latest Research section for further discussion of some of these approaches.
Stage IV: Targeted therapy
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
As explained above and in the Diagnosis section, ongoing research has identified several key pathways and genes involved in melanoma. These advances now allow doctors to begin to classify melanoma into specific subtypes based upon the melanoma’s genetic abnormalities or mutations. As a result, a patient’s treatment plan can be tailored or personalized based upon each subtype of melanoma.
A major research focus is the development of new drugs that target specific molecular pathways and genes that are abnormal or activated in melanoma. Currently there are two specific types of targeted therapy for melanoma:
BRAF inhibitors. The discovery that approximately 50% of melanomas have a mutated or activated BRAF gene has provided an important new direction in the treatment of melanoma. Two drugs that inhibit BRAF, vemurafenib (Zelboraf) and dabrafenib (Tafinlar), have been approved for people with both stage IV and stage III melanoma that cannot be surgically removed. These drugs, which are taken as a pill, are specifically indicated for patients with melanoma whose tumors have V600E mutation in the BRAF gene (see the Diagnosis section). The drug is not indicated for use in patients without the mutation as it can actually be harmful for them.
In a clinical trial for patients with metastatic melanoma whose tumors had the mutated BRAF gene, vemurafenib resulted in tumor shrinkage in the majority of those patients, and it extended patients’ survival by nearly a year (on average). Based on those findings, it is now approved for standard use for patients with locally advanced stage III melanoma that cannot be removed by surgery or for patients with stage IV melanoma, if the melanoma has the mutated BRAF gene.
Side effects of vemurafenib included skin problems, including rashes, sun sensitivity, and a less aggressive form of skin cancer called squamous cell carcinoma that can often be treated with minor surgery. Other side effects included joint pain, fatigue, nausea, and hair thinning and curling. Talk with your doctor about what side effects may affect you before treatment begins.
In May 2013, the FDA approved another drug, trametinib (Mekinist), for patients with a BRAF V600E or V600K mutation who have been diagnosed with unresectable (cancer that cannot be removed with surgery) or metastatic melanoma. This drug, which is taken as a tablet, was approved based on the results of a clinical study that showed patients with Stage IIIc or IV melanoma who took trametinib lived longer without the cancer getting worse than those who had chemotherapy. The side effects of trametinib include an acne-like rash, nail inflammation, dry skin, diarrhea, and lymphedema.
There are several other drugs being researched in clinical trials that target BRAF. See the Latest Research section for more information.
KIT inhibitors. Researchers are also focusing on the development of treatments that target the KIT gene, which is mutated or present in increased numbers (extra copies of the gene) in certain subtypes of melanoma, including lentigo maligna melanoma, mucosal melanoma, and acral lentiginous melanoma. Drugs currently being tested in clinical trials for patients with stage IV, mutated KIT melanoma include imatinib (Gleevec), nilotinib (Tasigna), and dasatinib (Sprycel).
Learn more about targeted therapy.
Stage IV: Radiation therapy
As described above, radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Radiation therapy may be used to treat melanoma that has spread in several ways.
Sometimes melanoma that has spread causes symptoms, such as bone pain, that radiation therapy can help relieve. This is called palliative radiation therapy. For some patients, palliative radiation therapy is given to an entire organ with several small doses of radiation, such as to the entire brain (whole brain radiation therapy). Other times, one or just a few high doses of radiation therapy are given, which is known as stereotactic radiosurgery, stereotactic ablative radiation therapy, or stereotactic body radiation therapy. This type of treatment may be given with different types of radiation machines, such as a linear accelerator (or "linac" for short), Gamma Knife, CyberKnife, or TomoTherapy units. These types of treatment work best for just one or a few tumors in the brain.
Radiation therapy may be used when cancer has extensive spread to the lymph nodes, following a lymph node dissection (see above, under Adjuvant therapy). Radiation therapy is also used when the amount of melanoma that can be removed with surgery is limited by the location of the tumor. In addition, researchers are testing the effectiveness of chemoradiation, a combination of radiation therapy and chemotherapy.
The side effects of radiation therapy depend on the type of radiation therapy given and the area of the body that is being treated. Radiation therapy to the brain can cause fatigue, headaches, and nausea. A patient may experience hair loss if radiation therapy is used on the scalp. Radiation therapy directed at other parts of the body can cause other specific side effects. See the Adjuvant radiation therapy section above and talk with your radiation oncologist for more information.
Learn more about radiation therapy.
Stage IV: Surgery
If the melanoma has spread to a single distant organ (stage IV) or has recurred (come back after treatment), the surgical removal of cancer that has spread to an internal organ may help control the disease.
Stage IV: Chemotherapy
As explained above, chemotherapy is the use of drugs to kill cancer cells. A chemotherapy regimen usually consists of a set number of cycles given over a specific time. A patient may receive one drug at a time or combinations of different drugs at the same time.
Systemic chemotherapy is delivered through the bloodstream (by vein; called an “IV”) or as a pill to reach cancer cells throughout the body. Systemic chemotherapy used for melanoma includes dacarbazine (DTIC-Dome), which is the only FDA-approved chemotherapy for melanoma. Temozolomide (Methazolastone, Temodar) is essentially an oral version of DTIC, and it is frequently used for the treatment of stage IV melanoma. Other chemotherapies used to treat melanoma include cisplatin (Platinol), the taxanes (a group of drugs that includes paclitaxel [Taxol] and docetaxel [Taxotere]), carmustine (BiCNU), fotemustine (Muphoran), lomustine (CeeNU), and vinblastine (Velban, Velsar). Combinations of chemotherapy drugs, such as paclitaxel plus carboplatin, also may be given to patients with stage IV melanoma. Combinations of new drugs that may reduce melanoma's resistance to chemotherapy are now under exploration.
The side effects of chemotherapy depend on the individual and the dose used but they can include fatigue, risk of infection, nausea and vomiting, hair loss, 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.
Getting care for symptoms and side effects
Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.
Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.
Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. Learn more about palliative care.
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.
A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
If the melanoma does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another part of the body (distant recurrence).
When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, immunotherapy, targeted therapy, and radiation therapy), but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.
People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.
If treatment fails
Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.
This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.
Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and bereavement.
Choose “Next” (below, right) to continue reading to learn more about clinical trials, which are research studies. Or, use the colored boxes located on the right side of your screen to visit any section