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Melanoma - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Melanoma. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

About the skin

The skin is the body’s largest organ. It protects against infection and injury, and it helps regulate body temperature. The skin also stores water and fat and produces vitamin D.

Skin is made up of two main layers: the epidermis, which is the outer layer, and the dermis, which is the inner layer. The deepest layer of the epidermis, located just above the dermis, contains cells called melanocytes, which produce pigment or color.

About melanoma

Melanoma begins when normal melanocytes change and grow uncontrollably, forming a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can spread to other parts of the body. A benign tumor means the tumor will not spread. Melanoma is always cancerous.

Sometimes, melanoma develops from a pre-existing mole. Melanoma occurs most commonly on the skin of men’s backs or on women’s legs, but melanoma can occur anywhere on the body, including the head and neck, the skin under the fingernails, genitals, and even the soles of the feet or palms of the hands. Melanoma may not have the color of a mole. It may have no color or be slightly red, called amelanocytic melanoma.

When found early, melanoma can often be cured with surgery. However, melanoma is the most serious form of skin cancer and can grow deep into the skin, invading lymph and blood vessels. The median age at which people are diagnosed with melanoma is just above 50 years old. Still, melanoma occurs in young adults with greater frequency than many other types of cancer.

This section focuses on cutaneous melanoma, which is melanoma that develops on the skin. Melanoma can also develop in the mucous membranes that line the mouth, gastrointestinal tract, vagina, and other locations around the body. Melanoma may also develop in the eye. You can learn more about melanoma diagnosed in other parts of the body, such as melanoma of the eye, melanoma of the anus, and melanoma of the vagina, in these specific cancer type sections. For information on non-melanoma skin cancer, review the section on basal cell and squamous cell skin cancers.

Looking for More of an Overview?

If you would like additional introductory information, explore these related items. Please note these links take you to other sections on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a one-page fact sheet (available as a PDF) that offers an easy-to-print introduction to this type of cancer.
  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert in this type of cancer that provides basic information and areas of research.

To continue reading this guide, use the menu on the side of your screen to select another section.  

Melanoma - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find information about how many people learn they have this type of cancer each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year an estimated 76,100 adults (43,890 men and 32,210 women) in the United States will be diagnosed with invasive melanoma, which is melanoma that extends deep into the skin. It is estimated that 9,710 deaths (6,470 men and 3,240 women) from melanoma will occur this year.

Melanoma accounts for less than 2% of all skin cancer cases in the United States but a majority of skin cancer deaths, as it is the most serious form of skin cancer. Melanoma is the fifth most common cancer among men and the seventh most common cancer in women. Although more women are diagnosed with melanoma before age 45, by age 60, the rate is more than two times higher in men, and by age 80, the rate in men is nearly three times higher than in women. Melanoma rates are 24 times higher in white people than black people and have been increasing for the last 30 years.

Most people with melanoma are cured by their initial surgery. The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. The five-year survival rate of people with melanoma is 91%. Overall survival depends upon thickness of the primary melanoma, whether lymph nodes (small, bean-shaped organs that help fight infection) are involved, and whether there is spread of melanoma to distant sites. For early-stage melanoma that is only located near where it started, the five-year survival rate is 98%. The five-year survival rates for melanoma that has spread to the nearby lymph nodes or to other parts of the body are 62% and 16% respectively. However, survival rates vary depending on a number of factors. These factors are explained in detail in the Diagnosis and Stages sections.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer in the United States each year, but the actual risk for a particular individual may differ. Also, it is important to know that these statistics are based on data from 14 to 30 years ago and do not reflect the effects of newer treatments for metastatic melanoma (see the Treatment Options section). It is not possible to tell a person how long he or she will live with melanoma. Because the survival statistics are measured in five-year intervals, they may not represent recent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society’s publication, Cancer Facts & Figures 2014.

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Melanoma - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find a basic drawing of the layers that make up the skin. To see other pages, use the menu on the side of your screen.

Anatomy of the Skin

Larger image

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Melanoma - Risk Factors and Prevention

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them to your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a person’s risk of developing melanoma:

Sun exposure. Exposure to ultraviolet (UV) radiation from the sun can cause melanoma. Exposure to ultraviolet B (UVB) radiation from the sun appears more closely associated with melanoma, but newer information suggests that ultraviolet A (UVA) may also play a role in the development of melanoma, as well as the development of basal and squamous cell skin cancers. Whereas UVB radiation causes sunburn and does not penetrate through glass (car windows, etc.), UVA is able to pass through glass and may cause aging and wrinkling of the skin in addition to skin cancer.

People who live in areas with bright sunlight year-round or at high altitudes have a higher risk of developing skin cancer, as do those who spend a lot of time outside during the midday hours. The risk of developing melanoma may also be higher in people who have had multiple, severe, blistering sunburns, particularly in childhood. However, there has been some debate about this. Melanoma has also been linked to recreational exposure to intermittent UV, whether from the sun or from indoor tanning facilities. For ways to protect your skin from the sun, see the Prevention section below.

Artificial tanning. People who use tanning beds, tanning parlors, or sun lamps have an increased risk of developing melanoma and other types of skin cancer. Recreational sun tanning should also be avoided to reduce the risk of skin cancer.

Moles. People with many moles or unusual moles called dysplastic nevi or atypical moles have a higher risk of developing melanoma. Dysplastic nevi are flat, large moles that have irregular color and shape. A doctor may recommend photography of the skin to monitor people with many moles.

Fair skin. People with fair complexion, blond or red hair, blue eyes, and freckles are at increased risk for developing melanoma, as are people whose skin has a tendency to burn rather than tan.

Family history. Approximately 10% of people with melanoma have a family history of the disease. If a person has a close relative (parent, brother, sister, or child) who has been diagnosed with melanoma, his or her risk of developing melanoma is two to three times higher than the average risk. This risk increases if several family members that live in different locations have been diagnosed with melanoma. Therefore, it is recommended that close relatives of a person with melanoma routinely have their skin examined

Although changes called mutations in specific genes, such as CDKN2A, CDK4, and MITF, have been identified that may lead to melanoma, these are rare and only a very small number of families with a history of melanoma actually have these genetic mutations. Scientists are looking for other genes and environmental factors that might also affect a person’s risk of developing melanoma, as well as other cancers. Learn more about familial melanoma.

Other inherited conditions. People with specific genetic conditions, including xeroderma pigmentosum, retinoblastoma, Li-Fraumeni syndrome, Werner syndrome, and  hereditary breast and ovarian cancer syndrome, have an increased risk of developing melanoma.

Personal history of skin cancer. People who have had one melanoma have an increased risk of developing other new melanomas. People who have had basal cell or squamous cell skin cancer also have an increased risk of developing melanoma.

Race or ethnicity. Melanoma rates are about 24 times higher in white people than black people; however, it is important to note that melanoma can occur in a person of any race or ethnicity. In fact, the rates of melanoma among Hispanics are rising.

Immune system function. People who have weakened immune systems or use certain medications that suppress immune function have a higher risk of developing skin cancer, including melanoma.

Prevention

Research continues to look into what factors cause melanoma and what people can do to lower their personal risk. There is no proven way to completely prevent this disease, but there may be steps you can take to lower your skin cancer risk. Talk with your doctor if you have concerns about your personal risk of developing this type of cancer.

Reducing exposure to UV radiation, particularly by reducing sun exposure, lowers the risk of developing melanoma. This is important for people of all ages and is especially important for people who have other risk factors for melanoma (see above). Sun damage builds up over time, so it is important to take the following steps to reduce sun exposure, avoid sunburn, and help prevent melanoma:

  • Limiting or avoiding sun exposure between 10:00 AM and 4:00 PM, as well as avoiding recreational sunbathing.
  • Wearing sun-protective clothing, including a hat that shades the face, neck, and ears. Clothes made of fabric labeled with UPF (UV protection factor) may provide better protection. UV-protective sunglasses are also recommended.
  • Using a broad spectrum sunscreen with a sun protection factor (SPF) of at least 30 throughout the year. Reapply at least one ounce of sunscreen to your entire body every two hours or every hour after heavy perspiration or being in the water.
  • Regularly check your skin for irregular moles and other signs of melanoma and have skin examinations by a health care professional. Learn more about the signs and symptoms of melanoma.
  • Avoiding use of sun lamps, tanning beds, and tanning salons.

Learn more about protecting your skin from the sun in this additional article on Cancer.Net.

Limiting your sun exposure may reduce your body’s production of vitamin D, although some research suggests only brief exposure to sunlight (less than 15 minutes) may be enough for most people to produce an adequate amount of vitamin D. People with limited sun exposure should talk with their doctor about how to include good sources of vitamin D in their diet, including the use of supplements. Your levels of vitamin D can be checked through a simple blood test by your doctor.

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Melanoma - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

Melanoma can appear anywhere on the body, even on areas that are not exposed to the sun. The most frequent locations for melanoma are the trunk (torso), legs, and arms. However, melanoma can also develop under the fingernails or toenails; on the palms, soles, or tips of fingers and toes; or on mucous membranes, such as skin that lines the mouth, nose, vagina, and anus.

Melanoma can appear in a number of different ways. Many melanomas are dark brown/black and are often described as changing, different, unusual, or “ugly looking.” However, any skin abnormality that is growing or changing quickly and does not go away, whether colored or not, should be examined by a doctor. Bleeding may be a sign of more advanced melanoma.

Changes in the size, shape, color, or feel of a mole is often the first warning sign of melanoma. These changes can occur in an existing mole, or melanoma may appear as a new or abnormal-looking mole. The "ABCDE" rule is helpful in remembering the warning signs of melanoma:

Asymmetry. The shape of one half of the mole does not match the other.

Border. The edges are ragged, notched, uneven, or blurred.

Color. Shades of black, brown, and tan may be present. Areas of white, gray, red, or blue may also be seen.

Diameter. The diameter is usually larger than 6 millimeters (mm) (1/4 inch; the size of a pencil eraser) or has grown in size. Melanoma may be smaller when first detected.

Evolving. The mole has been changing in size, shape, color, or appearance, or growing in an area of previously normal skin. Also, when melanoma develops in an existing mole, the texture of the mole may change and become hard or lumpy. Although the skin may feel different and may itch, ooze, or bleed, melanoma usually does not cause pain.

In addition, the appearance of a new and unusual mole is more likely to be melanoma.

If you are concerned about a symptom or sign on this list, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Early detection of melanoma

Earlier detection and recognition of melanoma is the key to improving the chance for successful treatment and overall survival. Recognizing early warning signs of melanoma and doing regular self-examinations of your skin will help find melanoma early when the disease is highly curable.

Self-examination of skin. Self-examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and the back of the neck. Include the following steps in a skin self-examination:

  • Examine the front and back of the entire body in a mirror, then the right and left sides, with arms raised.
  • Bend the elbows and look carefully at the outer and inner forearms, upper arms (especially the hard-to-see back portion), and hands.
  • Look at the front, sides, and back of the legs and feet, including the soles and the spaces between the toes.
  • Part the hair to lift it, and examine the back of the neck and scalp with a hand mirror.
  • Check the back, genital area, and buttocks with a hand mirror.

Talk with your doctor if you find any of the following:

  • A growth on the skin that matches any feature on the ABCDE rule list (see above)
  • New growth on the skin
  • A suspicious change in an existing mole or spot
  • An unusual sensation in a mole, such as itching or tingling

Medical tests for early detection. A painless medical technique being used for early detection of melanoma is epiluminescence microscopy, or dermoscopy, which allows a doctor to evaluate the patterns of size, shape, and pigmentation in pigmented skin lesions using a handheld device. Among trained, experienced medical professionals, the use of dermoscopy may reduce the number of biopsies (see the Diagnosis section) of pigmented lesions to rule out melanoma, although more research is needed. Meanwhile, confocal scanning laser microscopy is another new technology to better examine possible melanoma lesions, but it is only available in a few major facilities.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.

Melanoma - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out whether a suspicious mole or other skin growth is cancerous. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has spread to another part of the body, called metastasis. For melanoma, a biopsy of the suspicious skin area, called a lesion, is the only way to make a definitive diagnosis. The doctor may suggest other tests that will help make a diagnosis and determine the overall stage of the melanoma. Imaging tests may be used to find out whether the cancer has spread. This list describes options for diagnosing this type of cancer, but not all of the tests listed will be used for every person.

A biopsy and pathologic examination of a skin lesion for melanoma

A biopsy is the removal of a small amount of tissue for examination under a microscope. During this procedure, the suspected skin lesion is removed, usually after a local anesthetic has been used to numb the area, using techniques to preserve the entire lesion so that the thickness of the potential cancer and its margin (healthy tissue around the lesion) can be carefully examined. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis.

The sample removed during the biopsy is analyzed by a pathologist who determines if it is a melanoma. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

The pathologist will write a report, called a pathology report, that should include at least the following information:

  • Type/subtype of melanoma
  • Thickness of melanoma
  • Presence or absence of ulceration (loss of the surface of the skin)
  • Mitotic rate (how rapidly the cells are dividing)
  • Presence of immune cells (tumor infiltrating lymphocytes)
  • Margin status (whether melanoma cells can be seen at the edges of the biopsy specimen)

Each of these items is described in detail below.

Types of skin melanoma

There are four types of skin or cutaneous melanoma:

Superficial spreading melanoma. This is the most common type, accounting for 70% of melanomas. It usually develops from an existing mole.

Lentigo maligna melanoma. This type tends to occur in older people. It most commonly begins on the face, ears, and arms on skin that is chronically exposed to the sun. 

Nodular melanoma. This type accounts for about 15% of melanomas, and it often appears rapidly as a bump on skin. It is usually black, but it may also be pink or red.

Acral lentiginous melanoma. This type develops on the palms of the hands, soles of the feet, or under the nail bed. It sometimes occurs on people with darker skin. Acral lentiginous melanoma is not related to sun exposure.

Subtypes of melanoma

Recent information has shown that melanoma can also be classified into molecular (genetic) subtypes based upon distinct genetic changes in the melanoma rather than histologic types, which are based on how the tissue appears under a microscope. The most common genetic change in melanoma is found in the BRAF (V600E) gene, which is mutated in about 50% of cutaneous melanomas. Another gene, NRAS, is mutated in the tumors of approximately 20% of patients with melanoma. KIT mutations occur more commonly in melanomas that develop from the mucosal lining, acral lentiginous melanoma, or melanoma that occur in chronically sun damaged skin, such as lentigo maligna melanoma, and may influence a patient’s treatment options. It is likely that additional molecular subtypes of melanoma will be described in the near future.

The classification of melanoma into different subtypes based upon genetic alterations can have a major effect on treatment options, since targeting specific mutated genes is an important new way of treating advanced melanoma. Learn more about this approach, called targeted therapy, in the Treatment Options and Latest Research sections.

Thickness of melanoma

The pathologist will measure the “thickness” of the melanoma in millimeters (or fraction of a millimeter) from the top of the skin down to the underlying skin because it is the most reliable characteristic that reflects the risk of spread. A melanoma tumor that is less than 1 mm thick is characterized as "thin" and is associated with low risk of spread to regional lymph nodes or to distant sites. An intermediate-thickness melanoma is between 1 mm and 4 mm. A thicker melanoma, greater than 4 mm thick, is associated with a greater chance of recurrence, which is the chance the cancer will return following initial treatment, presumably because the cancer has already spread to other parts of the body at the time of diagnosis.

Mitotic rate and ulceration

Another pathologic feature of melanoma is the mitotic rate, which is an estimate of the speed at which tumor cells are dividing. It is measured as the number of mitoses per millimeter squared (mm2). In combination with the thickness and the presence of ulceration, the mitotic rate is used to help determine the stage, treatment approach, and prognosis of melanoma (see below).

Finally, the presence or absence of ulceration of the primary melanoma is defined in the pathology report. If there is ulceration, research has shown it significantly increases the risk of spread and recurrence.

Additional patient evaluation after a diagnosis of melanoma

After the initial diagnosis of melanoma, you will be referred to a specialist. The doctor will take a complete medical history, noting any symptoms or signs, and perform a complete physical examination, including a total skin examination. This could also include a sentinel lymph node biopsy (see the Treatment Options section). The focus of these examinations is to identify risk factors and signs or symptoms that may indicate melanoma has spread beyond the original site.

The extent of the initial evaluation is based upon the risk of recurrence associated with the primary (original) melanoma. In general, for most low-risk melanomas, such as those less than 1 mm thick, no further search for metastases or spread is necessary. In patients with higher-risk melanoma, more extensive testing, such as lymph node assessment and the other tests described below, may be considered. Therefore, the extent of the initial evaluation for a patient with newly diagnosed melanoma depends upon on the stage of melanoma and discussions with the team of doctors.

Depending on the results of the evaluation, including the pathology report of the primary melanoma tumor, further testing for high-risk or later-stage melanoma may include the following:

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs, including collections of lymph nodes, called lymph node basins, and soft tissue.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. If melanoma has spread, a CT scan can also be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a pill to swallow.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

There are advantages and disadvantages to each of these tests. Depending on your situation, your doctor may feel that one is more appropriate for you than others. Your doctor may also feel you don’t need any of these tests. Talk with your doctor about which test(s) will provide the most useful information about your condition.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.

Melanoma - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will learn about how doctors describe a melanoma’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctors decide what type of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

To determine the stage of a melanoma, the lesion and some surrounding healthy tissue needs to be surgically removed and analyzed using a microscope. Doctors use the melanoma’s thickness, measured in millimeters (mm), and other characteristics to help determine the disease’s stage. These factors are explained in the Diagnosis section.

In addition, doctors use the following factors to determine the stage of melanoma:

  • How large is the original melanoma, often called the primary melanoma or primary tumor, and where is it located?
  • Has the melanoma spread to the lymph nodes?
  • Has the melanoma metastasized to other parts of the body?

The results are combined to determine the stage of melanoma for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatment plan and understand a patient's prognosis when diagnosed.

Here are more details about each stage of melanoma.

Stage 0: This refers to melanoma in situ, which means melanoma cells are found only in the outer layer of skin, called the epidermis. This stage of melanoma has virtually no metastatic potential, which means it is very unlikely that it will spread to other parts of the body.

Stage I: The primary melanoma is still only in the skin and is very thin. Stage I is divided into two subgroups, IA or IB, depending on the thickness of the melanoma and whether a pathologist sees ulceration under a microscope.

Stage II: Stage II melanoma is thicker than stage I melanoma, extending through the epidermis and further into the dermis, the dense inner layer of the skin. It has a slightly higher chance of spreading. Stage II is divided into three subgroups—A, B, or C—depending on how thick the melanoma is and whether or not there is ulceration.

Stage III: This stage describes melanoma that has spread through the lymphatic system either to a regional lymph node located near where the cancer started or to a skin site on the way to a lymph node, called “in-transit metastasis.” The lymphatic system is part of the immune system and drains fluid from body tissues through a series of tubes or vessels. Stage III is also divided into subgroups—A, B, or C—depending on the size and number of lymph nodes involved with melanoma and whether the primary tumor appears ulcerated under a microscope. 

Stage IV: This stage describes melanoma that has spread through the bloodstream to other parts of the body, such as distant locations on the skin or soft tissue, distant lymph nodes, or other organs like the lung, liver, brain, bone, or gastrointestinal tract. Stage IV is further divided into M1a, which means the cancer has only spread to distant skin and/or soft tissue sites; M1b, which involves metastasis to the lung; and M1c, which describes distant metastasis at any other location or an elevated serum lactate dehydrogenase (LDH) blood test.

Recurrent: Recurrent melanoma is melanoma that has come back after treatment. If there is a recurrence, the cancer may need to be staged again (re-staging).

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a treatment plan. The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.

Melanoma - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best known 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 approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

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. 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. 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

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, tissue found under the skin, 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. Overall, 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 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 both close the wound and reduce scarring.

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; however, it may also be recommended by a surgical oncologist for some other melanomas that are less than 1.0 mm thick.

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. 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.

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 area 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. The only randomized clinical trial that has looked into the value of this procedure for people with stage I or II melanoma found that people who had a complete lymph node dissection after a positive sentinel lymph node biopsy had the same overall survival as those who were closely observed after the biopsy. As a result, 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.

Talk with your health care team about the possible side effect that may develop based on the specific type of surgery. Learn more about 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 (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 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 IIC) 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 the melanoma coming 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 experienced side effects; however, their overall quality of life was the same as patients who did not receive it.

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. 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 used everywhere 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 drug treatments

With a number of new drugs available for stage IV melanoma and stage III melanoma that cannot be removed with surgery, there are many clinical trials underway looking at using targeted therapies and other immunotherapies after surgery. These include ipilimumab (Yervoy) and inhibitors of the mutated BRAF protein. See Stage IV: Immunotherapy (below) and the Latest Research section for more information about these treatment options.

Systemic treatment options for stage IV melanoma

If melanoma has spread through the bloodstream, it is considered stage IV or metastatic melanoma. The most common sites of distant spread 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 stage IV 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, the presence of specific genetic mutations in the tumor, and the patient’s preferences. Treatment options include immunotherapy, targeted therapy, chemotherapy, biochemotherapy (the combination of immunotherapy with chemotherapy), radiation therapy, surgery for isolated and/or limited metastases, and participation in a clinical trial. For patients with brain metastases, surgery or radiation therapy (see below) may be considered based upon symptoms, number and size 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 melanoma are described below. Some of these treatments are currently available only through clinical trials.

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, called unresectable melanoma. Ipilimumab targets cytotoxic T-lymphocyte associated molecule-4 (CTLA-4) and works by taking the brakes off the immune system. Two clinical trials showed that people taking ipilimumab had a better chance of survival than people who only received chemotherapy. Some people with melanoma may benefit from ipilimumab treatment for years. Complete disappearance of melanoma has been observed in some patients, and it seems to be permanent.

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 for more information.

PD-1/PDL-1 pathway inhibitors. Drugs that block interactions between a protein called PD-1 (programmed death-1) on T-cells and PD-L1 on tumor cells have shown promise in clinical trials. PD-1 is found on the surface of T-cells, which are a type of white blood cell that directly helps body’s immune system fight disease, 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.

In September 2014, the FDA approved pembrolizumab (Keytruda) as a treatment for patients with unresectable or metastatic melanoma whose disease has progressed after ipilimumab and a BRAF inhibitor (if the tumor was BRAF V600 mutation positive). Research of PD-1 and PD-L1 inhibitors alone and in combination continues, especially for patients with later-stage melanoma, and other anti-PD-1 antibodies are expected to be approved by the FDA in the near future.

Interleukin-2 (IL-2, aldesleukin, Proleukin). This is a drug that 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. A complete response is defined as the 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.

Combination therapies. 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. Another approach is to combine immunotherapy with targeted therapy (see below).

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, dabrafenib (Tafinlar) and vemurafenib (Zelboraf), 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 used by patients with melanoma whose tumors have a V600E or V600K mutation in the BRAF gene (see the Diagnosis section). These drugs should not be used by patients without the mutation as it can actually be harmful for them.

In randomized clinical trials for patients with metastatic melanoma whose tumors had the mutated BRAF gene, both drugs resulted in tumor shrinkage 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 trials, both drugs are 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, 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 and almost never causes sun sensitivity.

MEK inhibitors. In May 2013, the FDA approved trametinib (Mekinist) for patients with a BRAF V600E or V600K mutation 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. However, trametinib is rarely used alone for the treatment of BRAF-mutated melanoma. The side effects of trametinib include an acne-like rash, nail inflammation, dry skin, diarrhea, and lymphedema.

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. However, a more recent phase III study showed the combination provided only a minor benefit in overall survival. The most common side effects of this combination therapy 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. Because of the side effects and cost, the dabrafenib + trametinib combination is not universally accepted. More research into combining BRAF and MEK inhibitors is ongoing.

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 dasatinib (Sprycel), imatinib (Gleevec), and nilotinib (Tasigna). 

Other targeted therapies. There are many targeted therapies being researched in clinical trials for melanoma, both alone and in combination. See the Latest Research section for more information.

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 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, 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, one 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 and usually works 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 may sometimes be 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, hair loss, headaches, and nausea. Radiation therapy directed at other parts of the body can cause other specific side effects, such as skin irritation and infections. 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 or a few distant organs (stage IV) or has come back after treatment, the surgical removal of cancer that has spread to an internal organ may help control the disease.

Stage IV: Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. 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 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.

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. Other chemotherapies used to treat melanoma include carmustine (BiCNU), 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, also may be given to patients with stage IV melanoma. Combinations of new drugs that may reduce melanoma's resistance to chemotherapy are being researched in clinical trials.

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 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.

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 “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 loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.

Melanoma - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with melanoma. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.  

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that it is the only way to make progress in treating melanoma. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with melanoma.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for melanoma, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trials ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.

Melanoma - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about melanoma, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. This section is not meant to be a complete list of new trials as this field is changing rapidly. Always talk with your doctor about the diagnostic and treatment options best for you.

Enhanced prevention and early detection methods. There is ongoing research on better prevention and early detection strategies for melanoma. Both primary and secondary prevention are important. Primary prevention involves keeping melanoma from developing, while secondary prevention includes methods of early detection. One promising area is the screening of people with a high risk of developing melanoma.

Targeted therapy. As discussed in the Treatment Options section, targeted therapy is a treatment that targets specific genes or proteins. It is a major area of research for melanoma. Ongoing research has identified a number of molecular pathways and activated or mutated genes in melanoma. This includes the most commonly mutated gene BRAF as well as activation of the MAP kinase pathway. Ongoing laboratory and clinical research confirms the importance of these genes and pathways in melanoma.

Clinical trials are testing new drugs to inhibit the MAP kinase pathway and other pathways that melanoma might use to grow and spread. Strategies to prevent the melanoma from becoming resistant to treatment are also being tested such as using combinations of drugs or exploring novel drug administration schedules (see the Treatment Options section).

Immunotherapy. Immunotherapy, which boosts the immune system to fight cancer, is also a major focus in melanoma research. An active area of research is blocking PD1/PD-L1 interactions to allow the immune system to destroy melanoma. Several clinical trials have shown that anti-PD1 antibody treatments can cause significant shrinkage of melanoma in more than 30% of patients. Some of these responses have been complete, which means the melanoma is no longer detectable. Combinations of anti-PD1 antibody treatment and ipilimumab are also being tested. 

Another type of experimental immunotherapy involves altering a person’s white blood cells, known as lymphocytes, in a laboratory to increase their ability to fight the tumor. The changed cells are given back to the patient, often in combination with interleukin-2 or other immunotherapies. These types of treatments are known as adoptive cell transfer (ACT).

A variety of new agents are being developed to inject directly into melanoma tumors. Some of these are chemicals, others are viruses. Although the injected tumors often respond to treatment, other distant tumors that are not injected with the agent usually don’t.

Melanoma peptide vaccines are being evaluated in clinical trials for patients with both localized and advanced melanoma. Research has shown that vaccination can cause the immune system to fight melanoma, even in advanced disease, but these therapies are still considered experimental. The vaccines are made using certain proteins found only on a melanoma tumor and are given as an injection; the person’s immune system then recognizes the proteins and destroys melanoma cancer cells. Learn more about vaccines.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current melanoma treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding melanoma, explore these related items that take you outside of this guide:

  • To find clinical trials specific to your diagnosis, talk with your doctor or search online clinical trial databases now.
  • Review research announced at ASCO’s recent scientific meetings about advances in the treatment of melanoma, especially for metastatic disease, by reading these easy-to-understand summaries or by listening to a short podcast led by an ASCO expert in melanoma.
  • Visit ASCO’s CancerProgress.Net website to learn more about the historical pace of research for melanoma. Please note this link takes you to a separate ASCO website.

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.

Melanoma - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for melanoma are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

If your treatment included lymph node dissection and/or radiation therapy under the arm or in the groin, fluid build-up in the affected limb, called lymphedema, is possible. Graduated support garments, special massages, and other therapies help manage the condition.

If you have pain from surgery, you should talk with the surgeon or another health care team member. Although rare, some people have post-surgical long-term pain, called chronic pain. If needed, a pain management specialist can also help find ways to manage pain.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with melanoma. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.

Melanoma - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After active treatment for melanoma ends, talk with your doctor about developing a follow-up care plan, called surveillance and monitoring. This plan may include regular physical and dermatologic (skin) examinations and/or medical tests to monitor your recovery for the coming months and years. The purpose of monitoring is to detect a recurrence or spread of the disease, as well as a new primary melanoma. The most important parts of surveillance are your medical history and physical exams.

The follow-up and surveillance program for a person with a history of melanoma is based on a person’s risk of recurrence, is highly individualized, and can vary from person to person. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

In general, physical and dermatologic examinations are performed every three to six months for the first two to three years and then once a year after that. However, your doctor may recommend a different follow-up schedule. A chest x-ray, CT scan, MRI, and/or PET/CT scan can be considered for screening of patients with higher risk melanoma. For people treated for early-stage disease, scans are not generally recommended for routine surveillance.

Routine screening with a skin examination for a new melanoma and non-melanoma skin cancer is a necessary part of follow-up care, as is sun protection and sun avoidance. Screening for melanoma and other skin cancers may include mole mapping (photography of the moles) by a doctor or other health care professional. If possible, the patient should receive copies of their photographs and education in skin self-examination. There is growing evidence that individuals followed using photographs have melanomas diagnosed at an earlier stage.

Protecting your skin from UV radiation is important to help prevent second skin cancers, either melanoma or non-melanoma skin cancer. Many people who are treated for melanoma lead an active, outdoor lifestyle, but it is important to take steps to protect yourself from further skin damage. Participating in outdoor activities before 10:00 AM or after 4:00 PM and wearing long sleeves, pants, a broad-spectrum sunscreen with an SPF of at least 30, UV-protective sunglasses, and a hat help protect against further sun damage. A major consideration following diagnosis and treatment of melanoma is adjusting a person’s lifestyle to use sun protective or sun avoidance measures at all times, as well as avoiding artificial tanning. In addition, if a person is working in an area where there is high UV exposure, there may be occupation-related issues. Learn more about protecting your skin from the sun.

For an early-stage, thin melanoma, the surgery is most often outpatient surgery, with little need for rehabilitation. With a thicker melanoma and possible skin grafts, depending on the location, there may be some need for rehabilitation following treatment. As explained in the Side Effects section, some patients experience lymphedema or chronic pain; talk with your doctor about how these can be managed. 

People recovering from melanoma are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.

Melanoma - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

For patients with newly diagnosed skin melanoma

  • Can you explain my pathology report to me?
  • What stage of melanoma do I have? What is the depth, in millimeters, of the melanoma? Is the melanoma ulcerated? Does my melanoma have mitotic activity?
  • Is it likely that the melanoma has spread? Why or why not?
  • What are my treatment options?
  • Will surgery be able to remove all of the cancer? Will I need additional surgery?
  • After the surgical removal of the melanoma, will I need a skin graft?
  • Should I have a sentinel lymph node biopsy to find out if there is spread to the lymph nodes?
  • What clinical trials are open to me? Where are they located, and how do I find out more about them?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of each treatment option, both in the short term and the long term? Is there anything we can do to prevent them?
  • How will each treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • Is the cancer likely to recur following treatment? What steps can I take to reduce the risk of additional new melanomas?
  • What follow-up tests will I need, and how often will I need them?
  • What support services are available to me? To my family?
  • Whom should I call for questions or problems?
  • Are my family members at a higher risk of melanoma?

Additional questions for patients with stage III melanoma

  • How many lymph nodes are affected with melanoma?
  • Will the remainder of the lymph nodes be removed? If yes, what are the potential complications of lymph node surgery?
  • Is there any extracapsular extension of the melanoma (that is, has the melanoma spilled out of the lymph node)? What does this mean?
  • Is radiation therapy or other treatment recommended after surgery?
  • What are the goals of each treatment? What is my prognosis?

Additional questions for patients with stage IV melanoma

  • Where has the melanoma spread? Is a brain scan or PET scan necessary to determine where it has spread?
  • Is surgical removal of the metastases an option, especially if one or two tumors are present? If so, what are the benefits and risks?
  • What are the goals of each treatment? What is my prognosis?
  • How will side effects and symptoms be prevented and managed, to reduce my discomfort and increase my quality of life?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.

Melanoma - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2014

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Melanoma. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

This is the end of Cancer.Net’s Guide to Melanoma. Use the menu on the side of your screen to select another section, to continue reading this guide.