Melanoma: Treatment Options

Approved by the Cancer.Net Editorial Board, 06/2017

ON THIS PAGE: You will learn about the different treatments doctors use to treat people with this type of cancer. Use the menu to see other pages.

This section tells you the treatments that are the standard of care for this type of cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. To learn more about clinical trials, see the About Clinical Trials and Latest Research sections.

The cancer care team

In cancer care, different types of health care professionals 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 these doctors:

  • Dermatologist: A doctor who specializes in diseases and conditions of the skin.

  • Surgical oncologist: A doctor who specializes in treating cancer with surgery.

  • Medical oncologist: A doctor who specializes in treating cancer with medication.

  • Radiation oncologist: A doctor who specializes in treating cancer with radiation therapy.

  • Pathologist: A doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

  • Radiologist: A medical doctor who specializes in using imaging tests to diagnose disease.

  • Oncology nurse: A nurse who specializes in the care of people with cancer.

Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, social workers, pharmacists, counselors, dietitians, and others.

Treatment overview

Treatment recommendations depend on many factors, 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. This section provides an overview of possible treatments and should not be considered treatment recommendations for individuals.

Descriptions of the most common treatment options for melanoma are listed below according to the stage of melanoma. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and some surrounding healthy 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 people with regional melanoma. For some people with metastatic melanoma, surgery may also be an option. If surgery is not an option, the melanoma may be called “unresectable.” In recommending a specific treatment plan, doctors will consider the stage of the disease and the person’s individual risk of recurrence.

Types of surgery used to treat local and regional melanoma are:

  • Wide excision. The primary treatment for melanoma is excision, or 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 less than 1.0 mm thick, and outpatient surgery is often the only treatment needed. A doctor removes the tumor, tissue found under the skin, and some surrounding healthy tissue, called a margin, so that no cancer cells remain.

    If the melanoma is staged as in situ (stage 0), the doctor may remove a margin of skin at least 5 mm (or 0.5 cm) around the cancer. Overall, the width of the margin increases with the thickness of the melanoma, ranging from a 1-cm margin for melanoma measuring up to 1.0 mm to a 2-cm margin for melanoma measuring over 2.01 mm.

    Depending on the site and extent of the surgery, a skin flap or a skin graft may be necessary. A skin flap is created when nearby tissue is moved around to cover the area removed during surgery. A skin graft uses skin from another part of the body to close the wound.

  • Lymphatic mapping and sentinel lymph node biopsy. During this surgical procedure, the surgeon injects the area of the tumor with a dye and a radioactive tracer. This is to figure out which lymph nodes might be involved and whether the melanoma has spread to the lymph nodes. During these procedures, the surgeon removes 1 or more lymph nodes that take up the dye and/or radioactive tracer, called sentinel lymph nodes, to check for melanoma cells. If melanoma cancer cells are not found in the sentinel lymph node(s), no further lymph node surgery is required. If the sentinel lymph nodes contain melanoma, this is called a positive sentinel lymph node. This means the disease has spread, and lymph node dissection (see below) may be recommended.

    These procedures are usually recommended for people with a melanoma that is more than 1.0-mm thick or has ulceration. However, a sentinel lymph node biopsy may also be recommended by a surgical oncologist for some other melanomas that are less than 1.0-mm thick depending on other, associated risk factors.

    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 recommended. However, sometimes the doctor will recommend this procedure for a person with a thin melanoma if there are other signs that the melanoma is more aggressive, such as ulceration (see Diagnosis). 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.

    Sentinel lymph node mapping should be performed during the same procedure as the wide excision because such surgery can change the lymphatic drainage pattern. This may affect the reliability of the procedure in some situations.

  • Lymph node dissection. If melanoma is found in the sentinel lymph nodes, doctors may recommend removing the remaining lymph nodes in that area with surgery. The number of lymph nodes removed depends on the area of the body. However, some research has shown that people who have a complete lymph node dissection after a positive sentinel lymph node biopsy live for the same amount of time as those who are closely watched for signs of cancer. As a result, some people decide to not have a complete lymph node dissection. People who have had a lymph node dissection around an arm or leg have a higher risk for fluid buildup in that limb, a side effect called lymphedema.

Sometimes an enlarged lymph node is found during a physical exam, after a scan, or during an ultrasound. If this happens, doctors usually perform staging. If no other evidence of spread is found, they may recommend a lymph node dissection. Doctors generally agree it is important to remove all lymph nodes in these situations.  

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy 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, or schedule, with a total number of treatments and dose of radiation.

General side effects of radiation therapy include skin irritation and fatigue. These usually get better a few weeks after adjuvant radiation therapy is finished. Adjuvant therapy is treatment after the first treatment. Topical corticosteroid creams and antibiotics may be used to help prevent and treat radiation-induced skin reactions.

Depending on the area of the body being treated with radiation therapy, other side effects may develop. For example, after treatment to the head and/or neck region, temporary irritation of the mouth or difficulty swallowing can occur. If treatment was directed at the armpit or groin area, the person may have higher risk of fluid buildup 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 that you may experience and how they can be managed.

Learn more about the basics of radiation therapy.

Adjuvant therapy for stage II and stage III melanoma

After surgery, the surgeon or medical oncologist may recommend adjuvant therapy for patients who are at higher risk for recurrence. Adjuvant therapy is treatment given after the initial treatment to reduce the risk of the melanoma coming back.

Adjuvant treatment options after melanoma surgery may include radiation therapy, immunotherapy, or joining a clinical trial that is researching new drug treatments (see below and the Latest Research section.)

Adjuvant radiation therapy

Sometimes, radiation therapy is considered after surgery to prevent recurrence. Research has shown that although this may reduce the risk of the melanoma coming back in the area that received radiation, it does not increase how long a person lives.

People who receive adjuvant radiation therapy experience side effects based on the area treated (see above). In general, a person’s overall quality of life is similar to that of people who do not receive it, according to the results of recent clinical trials. However, in those studies, some patients who received adjuvant radiation therapy had worse symptoms in the first year.

Adjuvant immunotherapy

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. Different types of immunotherapy can cause different side effects. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

The U.S. Food and Drug Administration (FDA) has approved 3 adjuvant immunotherapies for stage II and stage III melanoma: high-dose interferon alfa-2b (Intron A), pegylated interferon alfa-2b (Sylatron), and ipilimumab (Yervoy).

  • High-dose interferon alfa-2b. When given over a year, high-dose interferon alfa-2b has been shown to delay recurrences for some patients. However, it has not been shown to lengthen how long most people live. 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. Because of the side effects and lack of a lengthening of life for most patients who receive this treatment, the use of high-dose interferon is not recommended by all doctors who care for melanoma patients.
  • Pegylated interferon alfa-2b. This immunotherapy is given by weekly injection for up to 5 years and has been shown to delay recurrences for some patients. However, it has not been shown to lengthen how long people live. The side effects are very similar to those of high-dose interferon alfa-2b. Because of the side effects and lack of a lengthening of life for most patients treated, the use of pegylated interferon is not recommended by all doctors who care for melanoma patients.
  • Ipilimumab. Adjuvant ipilimumab for stage III melanoma was approved by the FDA in October 2015. In patients with stage III melanoma, ipilimumab has been shown to delay recurrences and lengthen life for some patients. The side effects of ipilimumab in patients with stage III melanoma are significant, however, and the rate of severe, life-threatening, or fatal side effects is around 50%. Because this therapy may lengthen life yet has a high rate of severe side effects, it is important for oncologists and patients with stage III melanoma to discuss the risks and benefits of ipilimumab and decide together if the risks are worth the benefit.

    Ipilimumab targets a molecule called cytotoxic T-lymphocyte associated molecule-4 (CTLA4). It 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 healthy cells in the body. These side effects can be serious and even life threatening. These side effects include significant colon inflammation (colitis), liver problems, skin reactions, nerve and hormone gland inflammation, and eye problems. Patients are also closely monitored for diarrhea, rashes, itching, and other side effects. 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 that 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. Learn more about this medication and its side effects in this Cancer.Net podcast.

New adjuvant drug treatments

There are many clinical trials testing targeted therapies and other immunotherapies after surgery. These include anti-PD1 antibodies and inhibitors of the mutated BRAF protein. See stage IV treatment options (below) and the Latest Research section for more information about these treatment options that may be open for those with stage II or stage III disease.

Systemic treatment options for stage III that cannot be treated with surgery and stage IV melanoma

Melanoma that has spread to the lymph nodes or developed other skin lesions nearby is called stage III melanoma. If melanoma has spread to other, distant parts of the body, such as distant lymph nodes or the liver, lung, brain, bone, or gastrointestinal tract, doctors call it stage IV melanoma. The most common distant places melanoma spreads to include the lung, liver, and brain. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Treatment recommendations for people with stage III melanoma that cannot be removed with surgery, called unresectable stage III, and stage IV melanoma are often the same and depend on a number of factors, including:

  • The person’s age and overall health

  • The locations and number of metastases

  • How fast the disease is spreading

  • The presence of specific genetic mutations in the tumor

  • The patient’s preferences

Since 2011, several new drugs have become available for metastatic melanoma. These drugs help shrink melanoma for 12% to nearly 70% of patients and help them live longer. These new drugs are generally divided into 2 groups: immunotherapy and targeted therapy. Immunotherapy, targeted therapy, and other common treatment options for stage IV melanoma are described below. Some of these treatments are available only through clinical trials. See the Latest Research section for more information.

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.

Unresectable stage III and stage IV: Immunotherapy

As explained above, immunotherapy helps boost 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 include:

  • Anti-CTLA4 antibody. As described above, ipilimumab is approved by the FDA for the treatment of stage IV melanoma, as well as stage III melanoma that cannot be surgically removed, called unresectable melanoma, and as adjuvant therapy for stage III melanoma.

    There have been 2 clinical trials that showed that people taking ipilimumab had a better chance of survival than people who only received traditional chemotherapy (see below). Ipilimumab has been shown to shrink melanoma for 10% to 15% of patients. Some people with melanoma may benefit from ipilimumab treatment for years. Complete disappearance of melanoma has been seen in some patients, and it seems to be permanent in many such patients.

    Ipilimumab and other anti-CTLA4 antibodies continue to be studied in clinical trials. See the Latest Research section for more information.

  • Anti-PD-1 antibodies. There are 2 monoclonal antibodies that block a protein called programmed death-1 (PD-1) that have been approved by the FDA: nivolumab (Opdivo) and pembrolizumab (Keytruda). PD-1 is found on the surface of T-cells, which are a type of white blood cell that directly helps the body’s immune system fight disease. This protein keeps the immune system from destroying the cancer. Because these drugs stop PD-1 from working, the immune system is able to better target melanoma cells. New anti-PD-1 and anti-PD-L1 antibodies are currently being developed.

    Both nivolumab and pembrolizumab have been shown to shrink melanoma for 25% to 45% of patients, depending on when the treatment is given. They also cause fewer side effects than ipilimumab. Because of this, nivolumab and pembrolizumab are now being recommended as a first treatment option for people diagnosed with metastatic melanoma.

  • Combining anti-PD-1 and anti-CTLA4 antibodies. In September 2015, the FDA approved the immunotherapy combination of ipilimumab and nivolumab for patients with unresectable stage III or stage IV melanoma. This combination is better than either drug alone in reducing the size and delaying growth of tumors. However, combining these drugs causes far more side effects and does not necessarily help people live longer. The decision to give this combination therapy is often based on how fast the cancer is growing and where the cancer has spread.

  • Interleukin-2 (IL-2, aldesleukin, Proleukin). This drug activates T-cells, and it is sometimes given to patients with metastatic melanoma. The number of people for whom this treatment works is similar to that of ipilimumab (about 16%), with fewer than 10% of patients experiencing a complete response. A complete response is defined as the disappearance of all signs of cancer as a result of treatment.

    This treatment often has multiple and significant side effects. The most common side effects of IL-2 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 treated with high-dose IL-2 require intensive monitoring by the health care team. IL-2 should be given by an experienced health care team familiar with the side effects of IL-2 treatment.

Unresectable stage III and 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. Learn more about the basics of targeted treatments.

As explained above and in the Diagnosis section, ongoing research has identified several key pathways and genes involved in the growth and spread of melanoma. These advances now allow doctors to tailor or personalize a patient’s treatment plan based on the melanoma’s genetic abnormalities or mutations.

A major research focus is the development of new drugs that block specific biochemical pathways that melanoma cells need to grow. Currently, targeted therapy for melanoma includes:

  • BRAF inhibitors. The discovery that about 50% of melanomas have a mutated or activated BRAF gene has provided an important new direction in the treatment of melanoma. There are 2 drugs that inhibit BRAF. Dabrafenib (Tafinlar) and vemurafenib (Zelboraf) have been FDA approved for people with both stage IV and stage III melanoma that cannot be surgically removed. These drugs, taken as a pill, are specifically used when the melanoma tumors have a V600E or V600K mutation in the BRAF gene (see Diagnosis). These drugs should not be used by patients without the mutation because it can actually be harmful for them.

    In clinical trials for people with metastatic melanoma having the mutated BRAF gene, both drugs shrank the tumors in the majority of those patients. Vemurafenib was shown to extend patients’ survival by nearly a year, on average. Dabrafenib’s effect on overall survival was not formally tested. Based on these clinical trials, both drugs are approved for use for patients with locally advanced stage III melanoma that cannot be removed by surgery and for patients with stage IV melanoma, if the melanoma has the mutated BRAF gene.

    Side effects of vemurafenib included skin problems, including rashes, hair thinning, thick or dry skin, 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, fever, and hair thinning and curling. Talk with your doctor about what side effects may occur before treatment begins. Dabrafenib seems to have fewer side effects like thick or dry skin and hair thinning, and it only rarely causes sun sensitivity.

  • MEK inhibitors. In May 2013, the FDA approved trametinib (Mekinist) for people with melanoma having a BRAF V600E or V600K mutation and who have been diagnosed with unresectable or metastatic melanoma. This drug, which is taken as a tablet, specifically targets the MEK protein, which is involved in cancer growth and survival. Trametinib was approved based on the results of a clinical study that showed patients with stage IIIC or IV melanoma who took this targeted therapy lived longer without the cancer getting worse than those who received chemotherapy. The side effects of trametinib include an acne-like rash, nail inflammation, itching, dry skin, and diarrhea.

  • Combining BRAF and MEK inhibitors. In May 2014, the FDA approved the combination of trametinib with dabrafenib (see above) for melanoma that cannot be surgically removed or metastatic melanoma with a BRAF V600E or V600K mutation. There have now been 2 clinical trials showing that the combination of dabrafenib and trametinib is associated with better tumor shrinkage rates, delay in tumor growth, and longer life compared to vemurafenib alone, in 1 study, and dabrafenib alone, in the other study.

    The most common side effects of treatment with trametinib with dabrafenib include fever, chills, tiredness, rash, nausea, vomiting, diarrhea, abdominal pain, swelling in the hands and feet, cough, headache, joint pain, night sweats, decreased appetite, constipation, and muscle pain. Interestingly, the combination of dabrafenib and trametinib reduces some side effects when compared to either of the medicines taken separately, including a lower rate of secondary skin cancers and rash.

    In the fall of 2015, the FDA approved a second BRAF and MEK inhibitor combination, which consists of the BRAF inhibitor vemurafenib and the MEK inhibitor cobimetinib (Cotellic). A clinical trial has shown that the combination of vemurafenib and cobimetinib is associated with better tumor shrinkage rates, delay in tumor growth, and longer life compared to vemurafenib alone. The common side effects with this combination include tiredness, nausea, diarrhea, joint aches, sun sensitivity, rash, fever, liver irritation, and swelling in the hands and feet.

    Because of the improved outcomes and reduced side effects of BRAF and MEK inhibitor combinations compared to BRAF or MEK inhibitors alone, it is standard practice to recommend 1 of these 2 approved combinations when targeted therapy is being offered to patients whose tumors have BRAF mutations.

  • 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 some tumors in certain subtypes of melanoma, including lentigo maligna melanoma, mucosal melanoma, and acral lentiginous melanoma. Drugs currently being tested in clinical trials for people with stage IV, mutated KIT melanoma include dasatinib (Sprycel), imatinib (Gleevec), and nilotinib (Tasigna).

Unresectable stage III and stage IV: Intralesional therapy

In late 2015, the FDA approved the use of talimogene laherparepvec (TVEC) for the treatment of unresectable stage III and stage IV melanoma. TVEC is a herpes virus designed in a laboratory to make an immune-stimulating hormone. This virus can infect and destroy melanoma cells. TVEC also helps stimulate the immune system to destroy other melanoma tumors. During intralesional therapy, TVEC is injected directly into 1 or more melanoma tumors. Since TVEC has not been shown to cause significant shrinkage of non-injected tumors in most people, patients with metastatic disease are not usually offered this treatment. It may be offered, for example, to patients who have a tumor that can be felt during an exam and who have limited metastatic disease (a small number of or small tumors) elsewhere, such as the lungs or liver. TVEC is being studied in combination with other medications to improve its effectiveness.

Unresectable stage III and stage IV: Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide.

Traditional types of chemotherapy are still used to treat melanoma, but they are usually no longer used as first-line therapy. First-line therapy is the initial treatment recommended after a cancer diagnosis. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen, or schedule, usually consists of a set number of cycles given over a specific time. A patient may receive 1 drug at a time or combinations of different drugs given at the same time. Common drugs used for melanoma include 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 used for the treatment of stage IV melanoma.

Both DTIC and temozolomide have been shown to shrink melanoma for about 12% to 15% of patients. However, no clinical trials have tested whether these drugs increase how long people with melanoma live after treatment. Both DTIC and temozolomide have a limited number of side effects. Talk with your doctor about possible side effects of these drugs.

Other chemotherapies used to treat melanoma include cisplatin (Platinol), fotemustine (Muphoran), lomustine (CeeNU), the taxanes (a group of drugs that includes docetaxel [Taxotere] and paclitaxel [Taxol]), and vinblastine (Velban, Velsar). Combinations of chemotherapy drugs, such as paclitaxel plus carboplatin or cisplatin combined with vinblastine and DTIC may be used. Some chemotherapy drug combinations may have a higher chance of causing melanoma to shrink, but they also cause more side effects.

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, nail changes, loss of appetite, diarrhea, some nerve damage causing changes in sensation, and hair loss. These side effects usually go away after treatment is finished.

Learn more about the basics of 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.

Unresectable stage III or stage IV: Isolated limb infusion therapy

Sometimes melanoma may spread and appear as a number of tumors that develop in the leg or arm. In these situations, there are too many tumors for surgery to be possible or helpful. A doctor may recommend isolated limb infusion or perfusion with chemotherapy.

During this treatment, a tourniquet is placed on the arm or leg before high doses of chemotherapy are given. The tourniquet keeps the chemotherapy in the arm or leg and prevents it from being transported throughout the body. Around 50% to 80% of tumors located in the area where the chemotherapy is circulated respond to this type of treatment. While tumor shrinkage is usually temporary, melanoma may be controlled for a year or more in some patients. Researchers are also testing the effectiveness of combining isolated limb infusion therapy with other medicine.

Stage IV: Radiation therapy

As described above, radiation therapy is the use of high-energy x-rays or other particles to destroy 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 or headaches, 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 using whole-brain radiation therapy. Other times, 1 or just a few high doses of radiation therapy are given using a linear accelerator (or "linac," for short), Gamma Knife, CyberKnife, or TomoTherapy units. This is called stereotactic radiosurgery, stereotactic ablative radiation therapy, or stereotactic body radiation therapy. It usually works best for just 1 or a few tumors in the brain or elsewhere in the body.

Radiation therapy may be used when cancer has extensive spread to the lymph nodes or skin and cannot be removed by surgery. Researchers also are testing the effectiveness of combining radiation therapy and medicines for melanoma.

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, hair loss, headaches, and nausea. Radiation therapy directed at other parts of the body can cause other specific side effects, such as skin irritation. See “Adjuvant radiation therapy” above and talk with your radiation oncologist for more information.

Stage IV: Surgery

If the melanoma has spread to a single or a few distant parts of the body or has come back after treatment, the surgical removal of cancer may help control the disease. However, if there are too many tumors, surgery may not be helpful.

Stage IV: Treating brain metastases

The brain is one of the most common places to which melanoma spreads. Unfortunately, the presence of brain metastases is linked with a very poor prognosis. Prognosis is the chance of recovery. Less than 50% of people with melanoma that has spread to the brain live 6 months. Because of this poor prognosis and because of the perceived difficulty in getting chemotherapy drugs into brain tissue (called the blood-brain barrier), people with melanoma that has spread to the brain have typically not been allowed into clinical trials. Fortunately, this is beginning to change, and there are clinical trials for patients with melanoma and brain metastases.

Currently, the following treatments may be recommended for melanoma that has spread to the brain:

  • Radiation therapy. High-dose radiation therapy given using stereotactic techniques (see “Stage IV: Radiation therapy” above) is often used when there are only a few metastatic tumors in the brain. These techniques are highly effective for getting rid of existing tumors. However, they do not prevent new tumors from developing. The entire brain can be treated with radiation therapy, called whole-brain radiation therapy. However, because the dose of radiation used to treat the entire brain is lower, this type of treatment usually does not shrink tumors.

  • BRAF inhibitors. For people with melanoma that has a BRAF mutation, drugs such as dabrafenib and vemurafenib may be recommended. These drugs easily penetrate into the brain. Clinical trials have shown that melanoma tumors in the brain shrink around 40% to 50% of the time.

  • Immunotherapy. Ipilimumab, nivolumab, and pembrolizumab (see “Unresectable stage III and stage IV: Immunotherapy” above) are currently being used in clinical trials to treat people with melanoma that has spread to the brain.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatments intended 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 is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer at the same time that they receive treatment to ease side effects. In fact, patients who receive both at the same time 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, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or 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 palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it can be addressed as quickly as possible. Learn more about palliative care.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry 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 your 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 new cycle of testing will begin to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments 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 suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

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 doesn’t work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. 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 6 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 talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option 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 loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. You may use the menu to choose a different section to read in this guide.