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Melanoma - Introduction

Approved by the Cancer.Net Editorial Board, 01/2019

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. Use the menu to see other pages. Think of that menu as a roadmap for this complete guide.

About the skin

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

The skin is made up of 3 main layers:

  • Epidermis: the outer layer of skin

  • Dermis: the inner layer of skin

  • Hypodermis: the deep layer of fat

See the Medical Illustrations section for a drawing of these layers.

About melanoma

The deepest layer of the epidermis, located just above the dermis, contains cells called melanocytes. Melanocytes produce the skin’s pigment or color. Melanoma begins when healthy melanocytes change and grow out of control, forming a cancerous tumor. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. Sometimes, melanoma develops from a normal mole a person already has on their skin. When this happens, the mole will undergo changes that usually can be seen, such as changes in shape, size, color, or the border of the mole (see also Symptoms and Signs).

Melanoma can develop anywhere on the body, including the head and neck, the skin under the fingernails, the genitals, and even the soles of the feet or palms of the hands. Melanoma may not be colored like a mole. It may have no color or be slightly red, which is called amelanotic melanoma.

When found early, melanoma can often be cured with surgery. However, melanoma is 1 of the most serious forms of skin cancer. It can grow deep into the skin, called invasive melanoma. It can also invade lymph nodes and blood vessels and spread to distant parts of the body, called metastatic melanoma.

This section focuses on cutaneous melanoma, which is melanoma that first develops in the skin. Melanoma can also develop in the mucous membranes that line the mouth, the gastrointestinal tract, a woman’s vagina, and other locations around the body. Melanoma may also develop in the eye. Learn more about melanoma diagnosed in other parts of the body in these separate sections:

For information about other types of skin cancer, review the section on non-melanoma skin cancers.

Looking for More of an Introduction?

If you would like more of an introduction, explore this related item. Please note that these links will take you to other sections on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a 1-page fact sheet that offers an introduction to melanoma. This free fact sheet is available as a PDF, so it is easy to print.

The next section in this guide is Statistics. It helps explain the number of people who are diagnosed with melanoma and general survival rates. Use the menu to choose a different section to read in this guide.

Melanoma - Statistics

Approved by the Cancer.Net Editorial Board, 01/2019

ON THIS PAGE: You will find information about the number of people who are diagnosed with melanoma each year. You will also read general information on surviving the disease. Remember, survival rates depend on several factors. Use the menu to see other pages.

This year an estimated 96,480 adults (57,220 men and 39,260 women) in the United States will be diagnosed with invasive melanoma of the skin. Melanoma is the fifth most common cancer among men and women.

Before age 50, more women are diagnosed with melanoma than men. However, by age 65, men are 2 times more likely to be diagnosed with melanoma. By age 80, men are 3 times more likely to be diagnosed with melanoma. Although the development of melanoma is more common as people grow older, it also develops in younger people, including those younger than 30 years old. In fact, it is one of the most common cancers diagnosed in young adult women.

Melanoma is 20 times more common in white people than in black people.

The number of people diagnosed with melanoma has risen sharply over the past 3 decades. In men and women ages 50 and older, the number of people diagnosed with melanoma increased 3% per year from 2006 to 2015.

Melanoma accounts for about 1% of all skin cancers diagnosed in the United States, but it causes most of the skin cancer deaths. It is estimated that 7,230 deaths (4,740 men and 2,490 women) from melanoma will occur this year. However, from 2007 to 2016, deaths from melanoma have decreased by 2% in adults older than 50 and by 4% in those younger than 50.

Most people with melanoma are cured by their initial surgery. The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. Among all people with melanoma of the skin, from the time of initial diagnosis, the 5-year survival is 92%.

Overall survival at 5 years depends on the thickness of the primary melanoma, whether the lymph nodes are involved, and whether there is spread of melanoma to distant sites. Lymph nodes are small, bean-shaped organs that help fight infection. For people with "thin melanoma," defined as being less than 1 millimeter in maximal thickness, that has not spread to lymph nodes or other distant sites, the 5-year survival is 98%. However, for people with thicker melanoma, the 5-year survival may be as low as 80%. Survival rates at 5 years for people with melanoma that has spread to the nearby lymph nodes is 64%. However, this number is different for every patient and depends on the number of lymph nodes involved, the amount of tumor in the involved lymph node(s), and the features of the primary melanoma (such as thickness and whether ulceration is present or absent). If melanoma has spread to other, distant parts of the body, the survival rate is lower, about 23%. However, survival varies depending on a number of factors. These factors are explained in detail in the Diagnosis and Stages sections.

It is important to remember that statistics on the survival rates for people with melanoma are an estimate. The estimate comes from annual data based on the number of people with this cancer in the United States.

It is also important to know that these statistics do not yet reflect the effects of newer treatments for metastatic melanoma (see Types of Treatment). The pace of melanoma research is moving quickly, especially over the last 5 years. Experts measure survival statistics every 5 years. So the estimate may not show the results of better diagnosis or newer treatment available for less than 5 years. People should talk with their doctor if they have any questions about this information. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society’s (ACS) publication, Cancer Facts & Figures 2019, and the ACS website (January 2019).

The next section in this guide is Medical Illustrations. It offers a drawing of the structures that make up the skin. Use the menu to choose a different section to read in this guide.

Melanoma - Medical Illustrations

Approved by the Cancer.Net Editorial Board, 01/2019

ON THIS PAGE: You will find a basic drawing of the layers that make up the skin. Use the menu to see other pages.

This illustration shows the many layers of the skin. The thin top layer is the epidermis. Under the epidermis is the dermis, which is the inner layer of skin. Under that is the subcutaneous tissue, which is a deep layer of fat. The dermis is largely made up of elastic fibers. It also contains hair follicles, which are nourished by veins and arteries that run throughout the dermis and subcutaneous tissue. Small muscles, called arrector muscles, are connected to the hair follicle, as are sebaceous glands. The shaft of hair grows up out of the hair follicle and through the epidermis, which also contains pores for sweat glands. Copyright 2004 American Society of Clinical Oncology. Robert Morreale/Visual Explanations, LLC

The next section in this guide is Risk Factors and PreventionIt explains the factors that may increase the chance of developing melanoma and ways to help reduce your risk. Use the menu to choose a different section to read in this guide.

Melanoma - Risk Factors and Prevention

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ON THIS PAGE: You will find out more about the factors that increase the chance of developing melanoma. Use the menu to see other pages.

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. 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 plays a major role in the development of skin cancer. People who live at high altitudes or in areas with bright sunlight year-round have a higher risk of developing skin cancer. People who spend a lot of time outside during the midday hours also have a higher risk. Avoid recreational sun tanning outdoors to reduce the risk of skin cancer.

    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. While UVB radiation causes sunburn and does not penetrate through car windows or other types of glass, UVA is able to pass through glass and may cause aging and wrinkling of the skin in addition to skin cancer. Therefore, it is important to protect your skin from both UVA and UVB radiation (see “Prevention” below.)

  • Indoor tanning. People who use tanning beds, tanning parlors, or sun lamps have an increased risk of developing all types of skin cancer. Using indoor tanning beds is strongly discouraged.

  • Moles. People with many moles or unusual moles called dysplastic nevi or atypical moles have a higher risk of developing melanoma. Dysplastic nevi are large moles that have irregular color and shape. A doctor may recommend regular photography of the skin to closely watch the skin of 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. This risk is also higher for people whose skin has a tendency to burn rather than tan.

  • Family history. About 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 2 to 3 times higher than the average risk. This risk increases if several family members who 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.

  • Familial melanoma. Although changes, called mutations, in specific genes, such as CDKN2A, CDK4, P53, and MITF, have been identified that may lead to melanoma, these are rare. Only a very small number of families with a history of melanoma actually pass these genetic mutations from generation to generation. Scientists are looking for other genes and environmental factors that might affect a person’s risk of developing melanoma and other cancers. Learn more about familial melanoma.

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

  • Previous skin cancer. People who have already had a 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. Therefore, people who have had previous skin cancer need ongoing, follow-up care to watch for additional cancers. See the Follow-up Care section for more information.

  • Race or ethnicity. Melanoma rates are about 20 times higher in white people than in black people. However, a person of any race or ethnicity can develop melanoma.

  • Age. The median age at which people are diagnosed with melanoma is just above 50 years old. Median is the midpoint, which means that about half of people with melanoma are diagnosed when they are younger than 50 and about half are diagnosed when they are older than 50. Melanoma occurs in young adults more often than in many other types of cancer.

  • Weakened or suppressed immune system. 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

Different factors cause different types of cancer. Researchers continue to look into what factors cause this type of cancer, including ways to prevent it. Although there is no proven way to completely prevent this disease, you may be able to lower your risk. Talk with your health care team for more information about your personal risk of cancer.

Reducing exposure to UV radiation may significantly lower the risk of developing skin cancer. This means reducing exposure to the sun and by avoiding the use of indoor tanning devices. 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 and avoid sunburn:

  • Limit or avoid direct exposure to the sun between 10:00 AM and 4:00 PM.

  • Wear sun-protective clothing, including a wide-brimmed hat that shades the face, neck, and ears. Clothes made from fabric labeled with UV protection factor (UPF) may provide better protection. UV-protective sunglasses are also recommended.

  • Use a broad-spectrum sunscreen throughout the year that protects against both UVA and UVB radiation and has a sun protection factor (SPF) of at least 30. Reapply at least 1 ounce of sunscreen to your entire body every 2 hours or every hour after heavy perspiration or after being in the water.

  • Avoid recreational outdoor sunbathing.

  • Do not use sun lamps, tanning beds, or tanning salons.

  • Examine your skin regularly. This should include examinations by a health care professional, as well as self-examinations. Learn more about melanoma screening.

Learn more about protecting your skin from the sun.

Getting less exposure to the sun may reduce your body’s production of vitamin D. However, some research suggests less than 15 minutes of sunlight exposure 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.

The next section in this guide is Screening. It describes the early warning signs of melanoma and how to perform a self-examination. Use the menu to choose a different section to read in this guide.

Melanoma - Screening

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ON THIS PAGE: You will find out more about the early detection of melanoma. Use the menu to see other pages.

Early detection and recognition of skin cancer are very important. Recognizing the early warning signs of melanoma and doing regular self-examinations of your skin can help find melanoma early, when the disease is more curable. Your doctor may also recommend medical tests based on your risk factors and medical history.

Self-examination

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 face, scalp, trunk or torso (chest, abdomen, back), 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.

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 back of the neck. Include the following steps in a 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 or a dermatologist if your hairdresser or barber has noticed a suspicious skin area, or lesion, on your scalp or beard or if you find any of the following during a self-examination:

  • A growth on the skin that matches any symptom listed in the Symptoms and Signs section of this guide

  • New growth on the skin

  • A suspicious change in an existing mole or spot

  • A sore that doesn't heal within 2 weeks

Medical tests for early detection

A painless medical technique being used for early detection of melanoma is epiluminescence microscopy, or dermoscopy. Using a handheld device, a doctor can evaluate the patterns of size, shape, and pigmentation in pigmented skin lesions. Among trained, experienced medical professionals, dermoscopy may reduce the number of biopsies (see Diagnosis) of pigmented lesions to rule out melanoma, although more research is needed.

Confocal scanning laser microscopy is another new technology that may improve the examination of possible melanoma lesions. Currently, it is only used in research studies and is available in a few major medical centers.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems melanoma can cause. Use the menu to choose a different section to read in this guide.

Melanoma - Symptoms and Signs

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ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. Use the menu to see other pages.

ABCDE rule

Changes in the size, shape, color, or feel of a mole are often the first warning signs of melanoma. These changes can occur in an existing mole, or melanoma may appear as a new or unusual-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) or had grown in size; this is 1/4 inch, about the size of a pencil eraser. Melanoma may be smaller when first detected.

  • Evolving. The mole has been changing in size, shape, color, or appearance, or it is 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 lesion may feel different and may itch, ooze, or bleed, a melanoma skin lesion usually does not cause pain.

When to see a doctor

Many melanomas are dark brown or 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. In addition, the appearance of a new and unusual mole is more likely to be melanoma.

If you are concerned about a new or existing mole, please talk with your family doctor or a dermatologist. 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 figure out the cause of the problem, called a diagnosis.

The next section in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. Use the menu to choose a different section to read in this guide.

Melanoma - Diagnosis

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

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

For melanoma, a biopsy of the suspicious skin area, called a lesion, is the only sure way for the doctor to know if it is cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. The doctor may suggest other tests that will help make a diagnosis and determine the overall stage of the melanoma.

This section describes options for diagnosing melanoma. Not all of the tests listed below will be used for every person. Your doctor will consider several factors, described below, when choosing diagnostic tests for each person.

Biopsy and pathological examination of a skin lesion

Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. Before a biopsy, a health care provider will usually numb the area with a local anesthetic. Anesthetic is medication that blocks the awareness of pain. Then he or she will remove a part or all of the suspicious skin growth, typically making sure to preserve the entire lesion so the thickness of the potential cancer and its margin (healthy tissue around the lesion) can be carefully examined.

A pathologist then analyzes the sample(s) removed during the biopsy to figure out if the lesion 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 the following information:

  • Thickness of the melanoma

  • Presence or absence of ulceration

  • If the cells are dividing, which is called the mitotic rate, the report will include the type/subtype of melanoma

  • Presence of immune cells called tumor-infiltrating lymphocytes

  • Margin status, which describes whether melanoma cells can be seen at the deep and/or peripheral (side) edges of the biopsy sample

Additional information is described in detail below.

Types of melanoma of the skin described by pathologists

The 4 most common types of skin, or cutaneous, melanoma are:

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

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

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

  • Acral lentiginous melanoma. This type of melanoma 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 defined by gene mutations

Melanoma cells are usually classified by histologic types (listed above), which are based on how the cells appear under a microscope. Recent information has shown that melanoma can also be classified into molecular (genetic) subtypes. These molecular subtypes are based on the distinct genetic changes of the melanoma cells, called mutations. These genetic changes include:

  • BRAF mutations. The most common genetic change in melanoma is found in the BRAF gene, which is mutated in about 50% of cutaneous melanomas.

  • NRAS mutations. NRAS is mutated in the tumors of around 20% of people with melanoma.

  • NF-1 mutations. NF-1 mutations are present in the tumors of around 10% to 15% of people with melanoma.

  • KIT mutations. These mutations occur more commonly in melanomas that develop from mucus membranes, melanomas on the hands or feet, or melanomas that occur in chronically sun-damaged skin, such as lentigo maligna melanoma.

Some melanomas do not have mutations in the BRAF, NRAS, NF-1, or KIT genes. These tumors have other genetic changes that cause them to grow. Researchers are trying to target other mutations found in these tumors in clinical trials.

The classification of melanoma into different subtypes based on genetic changes can have a major effect on the types of treatment used for advanced melanoma. Targeting specific mutated genes is an important new way of treating invasive melanoma, called targeted therapy. Learn more about targeted therapy in the Types of Treatment and Latest Research sections.

Melanoma tumor thickness

The thickness of the primary melanoma tumor is the most reliable characteristic that helps doctors predict the risk that the cancer will spread. To do this, the pathologist will measure the depth of the melanoma from near the top of the skin down to the bottom of the melanoma in the underlying skin.

  • Thin. A melanoma tumor that is less than 1 mm thick is characterized as "thin." A thin melanoma is associated with a low risk of spreading to regional lymph nodes or to distant parts of the body.

  • Intermediate. An intermediate-thickness melanoma is between 1 mm and 4 mm.

  • Thick. A thick melanoma, more than 4 mm thick, is associated with a higher chance of coming back after treatment, called a recurrence. This is because the cancer has sometimes already spread to other parts of the body at the time of diagnosis.

Ulceration

The presence or absence of ulceration of the primary melanoma is defined in the pathology report. Ulceration is the loss of the surface of the skin. If the melanoma is ulcerated, research has shown it significantly increases the risk of spread and recurrence.

Mitotic rate

Another pathological feature of melanoma is the mitotic rate, which is an estimate of the amount of cell growth. It is measured as the number of mitoses per millimeter squared (mm2) Combined with the thickness and the presence of ulceration, the mitotic rate may be used to help determine stage, treatment options, and prognosis (see below).

Additional evaluation after a diagnosis of melanoma

After an 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. 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 on the primary (original) melanoma’s risk of recurrence. For most low-risk melanomas, such as most people with a melanoma that is less than 1 mm thick, no further search for metastases or spread is generally necessary. For people with higher-risk melanoma, more extensive testing, such as radiology tests described below, may be considered, but this usually occurs after surgical management has been completed. Therefore, the extent of the initial evaluation for a person with newly diagnosed melanoma is based 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 takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-dimensional image that shows any abnormalities or tumors. If melanoma has spread, a CT scan can 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 contrast medium can be injected into a patient’s vein or given as a pill or liquid to swallow.

  • Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can 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 is injected into a patient’s vein.

  • Positron emission tomography (PET) or PET-CT scan. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a 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.

Lymphatic mapping and sentinel lymph node biopsy

Lymph nodes are tiny, bean-shaped organs that help fight infection. Melanoma can grow deep into the inner layers of skin and spread to the lymph nodes and other parts of the body.

Sentinel lymph node biopsy -- also called SLNB, sentinel node biopsy, or SNB -- is a surgical procedure that helps the doctor find out whether the cancer has spread to the lymph nodes. When cancer spreads from the place it started to the lymph nodes, it travels through the lymphatic system. A sentinel lymph node is the first lymph node into which the lymphatic system drains. Because melanoma can start anywhere on the skin, the location of the sentinel lymph nodes will be different for each patient, depending on where the cancer started. To find the sentinel lymph node, a dye and a harmless radioactive substance is injected as close as possible to where the melanoma started. The substance is followed to the sentinel lymph node. Then, the doctor removes 1 or more of these lymph nodes to check for melanoma cells, leaving behind most of the other lymph nodes in that area. These are sent to a pathologist who analyzes the lymph nodes and then provides a report.

If melanoma cells are not found in the sentinel lymph node(s), no further lymph node surgery is needed. If the sentinel lymph node contains melanoma, this is called a positive sentinel lymph node. This means the disease has spread, and the removal of more lymph nodes, called lymph node dissection, may be recommended (see Types of Treatment).

Lymphatic mapping and SNB are usually recommended for people with a melanoma that is more than 1.0-mm thick or has ulceration.

For non-ulcerated melanomas less than 0.8-mm thick, sentinel lymph node mapping is not usually recommended. This is because the likelihood that the cancer has spread to the lymph nodes is so low. However, SNB may be considered for melanomas that are between 0.8- and 1.0-mm thick if there are signs that the melanoma is more aggressive, such as ulceration or the number of dividing cells (mitoses). Your doctor will discuss whether this approach is recommended based on this and other features of the primary melanoma and other factors.

Sentinel lymph node mapping should be done at the same time as surgery (see Types of Treatment) to remove the melanoma because such surgery can change the lymphatic drainage pattern. This may affect the reliability of the procedure in some situations.

There are few side effects from SNB, but a patient may experience infection, seroma (fluid buildup) near the surgical area, numbness, and re-opening of the surgical area. Rarely, buildup of lymph fluid, called lymphedema, may occur. Talk with your health care team about what to expect and how side effects will be managed.

This information is based on ASCO recommendations for sentinel lymph node biopsy for melanoma. Please note that this link takes you to another ASCO website.

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 in this guide is Stages. It explains the system doctors use to describe the extent of the disease. Use the menu to choose a different section to read in this guide.

Melanoma - Stages

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ON THIS PAGE: You will learn about how doctors describe a melanoma’s growth or spread. This is called the stage. Use the menu to see other pages.

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.

Factors used for staging melanoma

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 the other characteristics described in the Diagnosis section to help determine the disease’s stage.

Doctors also use results from diagnostic tests to answer these questions about the stage of melanoma:

  • How thick or deep is the original melanoma, often called the primary melanoma or primary tumor?

  • Where is the melanoma located?

  • Has the melanoma spread to the lymph nodes? If so, where and how many?

  • Has the melanoma metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of melanoma for each person. The stages of melanoma include: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to create the best treatment plan and understand a patient's prognosis.

Melanoma stage grouping

Stage 0: This refers to melanoma in situ, which means melanoma cells are found only in the outer layer of skin or epidermis. This stage of melanoma is very unlikely to 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 2 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 higher chance of spreading. Stage II is divided into 3 subgroups—A, B, or C—depending on how thick the melanoma is and whether there is ulceration.

Stage III: This stage describes melanoma that has spread locally or through the lymphatic system 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, satellite metastasis, or microsatellite disease.” 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 divided into 4 subgroups—A, B, C, or D—depending on the size and number of lymph nodes involved with melanoma, whether the primary tumor has satellite or in-transit lesions, and if it 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 evaluated based on the location of distant metastasis:

  • M1a: The cancer has only spread to distant skin and/or soft tissue sites.

  • M1b: The cancer has spread to the lung.

  • M1c: The cancer has spread to any other location that does not involve the central nervous system.

  • M1d: The cancer has spread to the central nervous system, including the brain, spinal cord, and/or cerebrospinal fluid, or lining of the brain and/or spinal cord.

Recurrent: Recurrent melanoma is melanoma that has come back after treatment. If the melanoma does return, there will be a round of tests to learn about the extent of the recurrence. These tests and scans may be similar to those done at the time of the original diagnosis.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017), published by Springer International Publishing.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.

Melanoma - Types of Treatment

Approved by the Cancer.Net Editorial Board, 01/2019

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

This section explains the types of treatments that are the standard of care for melanoma. “Standard of care” means the best treatments known. When making treatment plan decisions, you 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. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

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.

Cancer care teams include a variety of other important health care professionals, such as physician assistants, nurse practitioners, oncology nurses, 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 making treatment decisions 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 common types of treatments used for melanoma are listed below. Later in this section, treatments are listed 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. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for melanoma because there are different treatment options. 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, lymphatic mapping and sentinel lymph node biopsy, and lymph node dissection. Each is described in more detail below.

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.

Wide excision

The main treatment for melanoma is surgical removal, or excision, 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 a sentinel lymph node biopsy is also needed, it is usually done at the same time as the wide excision (see Diagnosis and below).

  • 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 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 0.8-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 0.8-mm thick depending on other, associated risk factors.

For non-ulcerated melanomas less than 0.8-mm thick, the likelihood that the cancer has spread to the lymph nodes is low, so sentinel lymph node mapping is not recommended in most cases. However, sometimes the doctor will recommend this procedure for a person with a thin, high-risk melanoma if there are other signs that the melanoma is more aggressive, such as ulceration (see Diagnosis). If the melanoma is less than 0.8 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 ideally 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 biopsy results show that cancer is found in the sentinel lymph nodes, doctors may consider removing the remaining lymph nodes in that area with surgery. This is called completion or complete lymph node dissection (CLND). The number of lymph nodes removed depends on the area of the body. A patient may take longer to recover after CLND and have a higher risk of side effects. 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.

Some research has shown that people who have a CLND after a positive sentinel lymph node biopsy live for the same amount of time as those who are closely watched for signs of cancer and do not receive a CLND unless there are signs that the disease is growing. As a result, some people decide not to have a CLND. Talk with your doctor about the possible risks and benefits of having lymph node dissection.

This information is based on ASCO recommendations for sentinel lymph node biopsy for melanoma. Please note that this link takes you to another ASCO website.

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.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. 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.

Sometimes, radiation therapy is recommended after surgery to prevent the cancer from coming back, called a recurrence. Radiation therapy given in this manner is called adjuvant radiation therapy. 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 which area of the body was treated. 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.

If melanoma that has spread and causes symptoms, such as bone pain or headaches, then radiation therapy may help relieve those symptoms. This is called palliative radiation therapy. For some people, 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.

Learn more about the basics of radiation therapy.

Side effects of radiation therapy

General side effects of radiation therapy include skin irritation and fatigue. These usually get better a few weeks after radiation therapy is finished. 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.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for melanoma include:

  • Immunotherapy

  • Targeted therapy

  • Chemotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with 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. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

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 the basics of immunotherapy.

In recent years, there have been major advances in treating stage III-IV melanoma with immunotherapy. Although immunotherapy can be effective at treating melanoma, there are many possible side effects of the treatment. Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Learn more about the side effects of immunotherapy.

Talk with your doctor about possible side effects for the immunotherapy recommended for you. Different types of immunotherapy are described below.

PD-1 inhibitors

In immunotherapy for melanoma, there are 2 monoclonal antibodies that block a protein called programmed death-1 (PD-1) that have been approved by the FDA to treat stage III or metastatic melanoma: nivolumab (Opdivo) and pembrolizumab (Keytruda). PD-1 is found on the surface of T cells. T cells are a type of white blood cell that directly helps the body’s immune system fight disease. The PD-1 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.

Both nivolumab and pembrolizumab have been shown to shrink melanoma for 25% to 45% of patients, depending on when the treatment is given. Side effects occur less frequently with nivolumab and pembrolizumab compared to ipilimumab (Yervoy, see below). Because of this, nivolumab and pembrolizumab are now being recommended as a first treatment option for people diagnosed with metastatic melanoma.

New PD-1 and PD-L1 inhibitors are being developed and studied.

CTLA4 inhibitors

Ipilimumab (Yervoy) is an immunotherapy that targets a molecule called cytotoxic T-lymphocyte associated molecule-4 (CTLA4). 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. Those responses may last years and are permanent in many patients who benefit.

Ipilimumab 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 closely monitored for diarrhea, rashes, itching, and other side effects. Before treatment begins, be sure to talk to your health care team about potential side effects. Let your health care team know right away if you develop any new symptoms during treatment. It is also important to tell your health care team 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.

Ipilimumab is approved by the FDA for adjuvant treatment of stage III melanoma. In patients with stage III melanoma, ipilimumab has been shown to delay recurrences and lengthen life for some patients, but the rate of severe, life-threatening, or fatal side effects is around 50%. Because this therapy may lengthen life but also has a high rate of severe side effects, it is important for oncologists and people with stage III melanoma to discuss the risks and benefits of ipilimumab and decide together if the risks are worth the benefit.

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

Combining PD-1 and CTLA4 inhibitors

In 2015, the FDA approved the immunotherapy combination of ipilimumab and nivolumab for the treatment of unresectable stage III or stage IV melanoma. This combination is better than either drug alone in reducing the size of tumors 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, where the cancer has spread, and the general health of the person.

Interleukin-2 (IL-2, Proleukin)

Another type of immunotherapy is interleukin-2, which activates T cells. It is sometimes given to people 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 people 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.

Virus therapy

Virus therapy is a type of immunotherapy. The FDA has approved the use of talimogene laherparepvec (T-VEC; Imlygic) for the treatment of unresectable stage III and stage IV melanoma. T-VEC is a herpes virus designed in a laboratory to make an immune-stimulating hormone. This virus can infect and destroy melanoma cells. T-VEC also helps stimulate the immune system to destroy other melanoma tumors.

T-VEC is injected directly into 1 or more melanoma tumors, so it is also called intralesional therapy. Since T-VEC has not been shown to cause significant shrinkage of non-injected tumors in most people, patients with widely 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 tumors or small tumors) elsewhere, such as the lungs or liver. T-VEC is being studied in combination with other medications to improve its effectiveness.

Interferon

High-dose interferon alfa-2b (Intron A). When given over a year, high-dose interferon alfa-2b is an immunotherapy that 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 because it does not lengthen life for most patients who receive this treatment, the use of high-dose interferon is not recommended by all doctors who treat melanoma.

Pegylated interferon alfa-2b (Sylatron). 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 most patients treated with it do not live longer, the use of pegylated interferon is not recommended by all doctors who treat melanoma.

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 here and in Diagnosis, 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 the treatment plan based on the melanoma’s genetic abnormalities or mutations.

A major focus in research is the development of new drugs that block specific biochemical pathways that melanoma cells need to grow. Different types of targeted therapy are described below.

BRAF inhibitors

Dabrafenib (Tafinlar) and vemurafenib (Zelboraf) are FDA-approved targeted therapies 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

Trametinib (Mekinist) is approved as a targeted therapy for unresectable or metastatic melanoma with a BRAF V600E or V600K mutation. This drug, which is taken as a pill, 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 people with stage IIIC or stage 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

The discovery that about 50% of melanomas have a mutated or activated BRAF gene has provided an important new direction in targeted therapy for melanoma. There have been 2 clinical trials showing that the combination of dabrafenib, a BRAF inhibitor, and trametinib, a MEK inhibitor, 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. As a result of these trials, the FDA approved the combination of dabrafenib with trametinib for the treatment of melanoma that cannot be surgically removed or metastatic melanoma with a BRAF V600E or V600K mutation in 2014. Using this combination would not be expected to help people who have melanoma that does not have a detectable BRAF mutation.

In a more recent clinical trial, 1 year of treatment with the combination of dabrafenib and trametinib was shown to improve outcomes in people with stage III melanoma after the completion of surgery. This data led to the approval of this combination, in 2018, as an adjuvant therapy for people with stage III melanoma that has been removed by surgery.

The most common side effects of treatment with trametinib combined 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.

A second BRAF and MEK inhibitor combination is approved by the FDA in 2015. It 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.

In June 2018, the FDA approved a third combination, which includes the BRAF inhibitor encorafenib (Braftovi) and the MEK inhibitor binimetinib (Mektovi). A phase III clinical trial showed that this combination helped people live longer than those treated with vemurafenib alone. The most common side effects of this combination were fatigue, nausea, diarrhea, vomiting, abdominal pain, and joint pain.

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 3 approved combinations when targeted therapy is being offered to patients with tumors that have BRAF mutations.

KIT inhibitors

Researchers are also focusing on the development of targeted therapies for 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).

Tumor-agnostic treatment

Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a certain type of cancer but focuses on a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including melanoma. It is approved as a treatment for melanoma with an NTRK fusion that is metastatic or cannot be removed with surgery and has worsened with other treatments.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

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.

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 a combination of different drugs given at the same time. Dacarbazine (DTIC; available as a generic drug) is the only FDA-approved chemotherapy for melanoma. Temozolomide (Temodar) is essentially an oral version of dacarbazine, 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 help people with melanoma live longer after treatment. Both drugs 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 a generic drug called cisplatin, fotemustine (Muphoran, which is only approved in Europe) lomustine (Gleostine), the taxanes (a group of drugs that includes docetaxel [Taxotere] and paclitaxel [Taxol]), and another generic drug called vinblastine. Combinations of chemotherapy drugs, such as paclitaxel plus carboplatin or cisplatin combined with vinblastine and dacarbazine 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, 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.

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 via a catheter, which typically is placed by the interventional radiology team. The tourniquet keeps the chemotherapy in the arm or leg and prevents it from being transported throughout the body. This therapy typically is administered with general anesthesia.

Around 50% to 80% of tumors located in the area where the chemotherapy is circulated shrink as a result of this treatment. While tumor shrinkage is usually temporary, melanoma may be controlled for a year or more in some people. Researchers are also testing the effectiveness of combining isolated limb infusion therapy with other medicine.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer 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 and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Treatment options by stage of melanoma

This section describes the treatment options that may be recommended for each stage of melanoma. In-depth descriptions of each type of treatment are provided earlier in this page. Remember, clinical trials are also a potential treatment option for each stage of melanoma.

Stage 0 melanoma

Stage 0 melanoma is almost always treated with surgery alone, usually a wide excision.

Stage I melanoma

Stage I melanoma is usually treated with surgical removal of the tumor and some of the healthy tissue around it. The doctor may recommend lymph node mapping, and some lymph nodes may be removed.

Stage II melanoma

The standard treatment for stage II melanoma is surgery to remove the tumor and some of the healthy tissue around it. While this surgery is being done, lymph node mapping and sentinel lymph node biopsy may also be done. In some people with stage II melanoma, treatment with interferon may be recommended after surgery to lower the chances of the cancer coming back.

Stage III melanoma that can be removed with surgery

Stage III melanoma has spread locally or through the lymphatic system to a regional lymph node located near where the cancer started or to a skin site on the way to a lymph node. If the stage III melanoma can be removed with surgery, then that will be the first treatment option. The lymph nodes may be checked for cancer and removed. After surgery, treatment with immunotherapy or targeted therapy may be recommended to prevent the cancer from coming back.

Advanced melanoma

Advanced melanoma is a stage III melanoma that cannot be treated with surgery or stage IV melanoma. Stage IV 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 may refer to this as metastatic melanoma. If this happens, it is a good idea to talk with doctors who have experience treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Stage III melanoma that cannot be removed with surgery, sometimes called unresectable stage III, and stage IV melanoma are often treated the same way, with immunotherapy, targeted therapy, and chemotherapy. Palliative treatments intended to relieve symptoms may also be recommended, such as surgery or radiation therapy to treat affected lymph nodes and smaller tumors that have spread elsewhere in the body. The treatment plan will also depend on a number of factors:

  • 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

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel 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.

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 poor prognosis. Prognosis is the chance of recovery. Traditionally, less than 50% of people with melanoma that has spread to the brain live 6 months, although this is changing in recent years. 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. Read this fact sheet to learn more about cancer that has spread to the brain.

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 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 and commonly causes problems with thinking clearly (cognition).

  • 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 treated with these medications shrink around 40% to 50% of the time.

  • Immunotherapy. Ipilimumab, nivolumab, and pembrolizumab have recently been studied in in clinical trials to treat people with melanoma that has spread to the brain. These trials have shown that these treatments can help patients with melanoma and brain metastases. In particular, the combination of ipilimumab and nivolumab appears to be the most effective therapy for such patients, although due to the high rate of side effects, this treatment may not be the right choice for everybody.

Learn about caring for someone with cancer that has spread to the brain.

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 is 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 returns 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 the 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. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not 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 health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider 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. Use the menu to choose a different section to read in this guide.

Melanoma - About Clinical Trials

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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. Use the menu to see other pages.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for people with melanoma. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the FDA was tested in clinical trials.

Clinical trials are used for all types and stages of melanoma. Many focus on new treatments to learn if a new treatment is safe, effective, and possibly better than the existing treatments. These types of studies evaluate new drugs, different combinations of treatments, new approaches to radiation therapy or surgery, and new methods of treatment.

People who participate in clinical trials can be some of the first to get a treatment before it is available to the public. However, there are some risks with a clinical trial, including possible side effects and the chance that the new treatment may not work. People are encouraged to talk with their health care team about the pros and cons of joining a specific study.

Some clinical trials study new ways to relieve symptoms and side effects during treatment. Others study ways to manage the late effects that may happen a long time after treatment. Talk with your doctor about clinical trials for symptoms and side effects.

Deciding to join a clinical trial

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

Insurance coverage and the costs of clinical trials differ by location and by study. In some programs, some of the expenses from participating in the clinical trial are reimbursed. In others, they are not. It is important to talk with the research team and your insurance company first to learn if and how your treatment in a clinical trial will be covered. Learn more about health insurance coverage of clinical trials.

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

Patient safety and informed consent

To join a clinical trial, people must participate in a process known as informed consent. During informed consent, the doctor should:

  • Describe all of the treatment options so that the person understands how the new treatment differs from the standard treatment.

  • List all of the known or expected risks of the new treatment, which may or may not be different from the risks of standard treatment.

  • Explain what will be required of each person in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Clinical trials also have certain rules called “eligibility criteria” that help structure the research and keep patients safe. You and the research team will carefully review these criteria together.

People who participate in a clinical trial may stop participating at any time for personal or medical reasons. This may include that the new treatment is not working or there are serious side effects. It is important that people 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 they choose to leave the clinical trial before it ends.

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for melanoma, learn more in the Latest Research section.

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.

PRE-ACT, Preparatory Education About Clinical Trials

In addition, you can find a free video-based educational program about cancer clinical trials in another section of this website.

The next section in this guide is Latest Research. It explains areas of scientific research for melanoma. Use the menu to choose a different section to read in this guide.

Melanoma - Latest Research

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ON THIS PAGE: You will read about the scientific research being done to learn more about melanoma and how to treat it. Use the menu to see other pages.

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 clinical trials because this field is changing rapidly. Always talk with your doctor about the best diagnostic and treatment options 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, such as reducing exposure of ultraviolet (UV) radiation from the sun and avoiding the use of indoor tanning devices. 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 Types of Treatment, targeted therapy is a treatment that targets specific genes or proteins. Research has identified a number of molecular pathways and activated or mutated genes 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 new schedules of giving drugs to patients.

  • Immunotherapy. Researchers are studying new checkpoint inhibitors and immunotherapies directed at other parts of the immune system. These include TIM3 inhibitors, LAG3 inhibitors, OX40 agonists, CD137 agonists, GITR agonists, and IDO inhibitors. Also, a number of combinations of immunotherapies are being looked at, including all of the above agents with anti-PD-1 or anti-PD-L1 antibodies, as well as combinations of targeted therapies with anti-PD-1 or anti-PD-L1 antibodies.

  • Chimeric antigen receptor T-cell (CAR-T) therapy and T-cell receptor (TCR) therapy. Another type of experimental immunotherapy involves altering a person’s white blood cells, known as lymphocytes, in a laboratory. This is done to increase their ability to fight the tumor. The changed cells are given back to the patient, often in combination with chemotherapy, interleukin-2, and/or other immunotherapies.

  • Vaccines. Therapeutic vaccines that may improve the specific immune response to melanoma have been the focus of multiple clinical trials. 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. To date, no vaccines have shown a clinical benefit in patients. Learn more about cancer vaccines.

  • Palliative care/supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current melanoma treatments to improve comfort and quality of life for patients.

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 recent scientific meetings about advances in the treatment of melanoma on the Cancer.Net Blog.

  • Listen to a podcast from an ASCO expert in melanoma discussing highlights from the 2018 and 2019 ASCO Annual Meetings.

  • Visit the website of ASCO's Conquer Cancer Foundation to find out how to help support cancer research. Please note that this link takes you to a separate ASCO website.

The next section in this guide is Coping with Treatment. It offers some guidance in how to cope with the physical, emotional, social, and financial changes that cancer and its treatment can bring. Use the menu to choose a different section to read in this guide.

Melanoma - Coping with Treatment

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ON THIS PAGE: You will learn more about coping with the physical, emotional, social, and financial effects of cancer and its treatment. Use the menu to see other pages.

Every cancer treatment can cause side effects or changes to your body and how you feel. For many reasons, people do not experience the same side effects even when they are given the same treatment for the same type of cancer. This can make it hard to predict how you will feel during treatment.

As you prepare to start cancer treatment, it is normal to experience anxiety related to treatment-related side effects. It may help to know that your health care team will work to prevent and relieve both physical and emotional side effects. Doctors call this part of cancer treatment “palliative care" or "supportive care.” It is an important part of your treatment plan, regardless of your age or the stage of disease.

Coping with physical side effects

Common physical side effects from each treatment option for melanoma are listed in the Types of Treatment section. Learn more about side effects of cancer and its treatment, along with ways to prevent or control them. Changes to your physical health depend on several factors, including the cancer’s stage, the length and dose of treatment, and your general health.

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

Talk with your health care team regularly about how you are feeling. It is important to let them know about any new side effects or changes in existing side effects. If they know how you are feeling, they can find ways to relieve or manage your side effects to help you feel more comfortable and potentially keep any side effects from worsening.

You may find it helpful to keep track of your side effects so it is easier to explain any changes with your health care team. Learn more about why tracking side effects is helpful.

Sometimes, physical side effects can last after treatment ends. Doctors call these long-term side effects. They call side effects that occur months or years after treatment late effects. Treating long-term side effects and late effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

Coping with emotional and social effects

You can have emotional and social effects as well as physical effects after a cancer diagnosis. This may include dealing with difficult emotions, such as sadness, anxiety, depression, fear, or anger, or managing your stress level. Sometimes, patients have problems expressing how they feel to their loved ones. These loved ones may also have a hard time supporting or responding to your emotions.

Patients and their families are encouraged to share their feelings with a member of their health care team. Care teams can connect you with a mental health professional who specializes in helping people with cancer. Mental health professionals can help patients and their families manage and cope with their feelings related to cancer. You can also find coping strategies for emotional and social effects in a separate section of this website. This section includes many resources for finding support and information to meet your needs.

Coping with financial effects

Cancer treatment can be expensive. It is often a major source of stress and anxiety for people with cancer and their families. In addition to treatment costs, many people find they have extra, unplanned expenses related to their care. For some people, the high cost of medical care stops them from following or completing their cancer treatment plan. This can put their health at risk and may lead to higher costs in the future. Patients and their families are encouraged to talk about financial concerns with a member of their health care team. There may be resources available to help with cancer-related costs. Learn more about managing financial considerations in a separate part of this website.

Caring for a loved one with cancer

Family members and friends often play an important role in taking care of a person with melanoma. This is called being a caregiver. Caregivers can provide physical, practical, and emotional support to the patient, even if they live far away.

Caregivers may have a range of responsibilities on a daily or as-needed basis, including:

  • Providing support and encouragement

  • Talking with the health care team

  • Giving medications

  • Helping manage symptoms and side effects

  • Coordinating medical appointments

  • Providing a ride to and from appointments

  • Assisting with meals

  • Helping with household chores

  • Handling insurance and billing issues

Learn more about caregiving.

Talking with your health care team about side effects

Before starting treatment, talk with your doctor about possible side effects. Ask:

  • Which side effects are most likely?

  • When are they likely to happen?

  • What can we do to prevent or relieve them?

Be sure to tell your health care team about any side effects that happen during treatment and afterward, too. Tell them even if you do not think the side effects are serious. This discussion should include physical, emotional, and social effects of cancer.

Also, ask how much care you may need at home and with daily tasks during and after treatment. This can help you make a caregiving plan. Create a caregiving plan with this 1-page fact sheet that includes an action plan to help make caregiving a team effort. This free fact sheet is available as a PDF, so it is easy to print out.

Looking for More on How to Track Side Effects?

Cancer.Net offers several resources to help you keep track of your symptoms and side effects. Please note that these links will take you to other sections of Cancer.Net:

  • Cancer.Net Mobile: The free Cancer.Net mobile app allows you to securely record the time and severity of symptoms and side effects.

  • ASCO Answers Managing Pain: Get this 36-page booklet about the importance of pain relief that includes a pain tracking sheet to help patients record how pain affects them. The free booklet is available as a PDF, so it is easy to print out.

  • ASCO Answers Fact Sheets: Read 1-page fact sheets on diarrhea and rash that provide a tracking sheet to record the timing and severity of the side effect. These free fact sheets are available as a PDF, so they are easy to print out.

The next section in this guide is Follow-up Care. It explains the importance of checkups after melanoma treatment is finished. Use the menu to choose a different section to read in this guide.

Melanoma - Follow-Up Care

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ON THIS PAGE: You will read about your medical care after cancer treatment is completed and why this follow-up care is important. Use the menu to see other pages.

Care for people diagnosed with melanoma does not end when active treatment has finished. Your health care team will continue to check that the cancer has not come back, manage any side effects, and monitor your overall health. This is called follow-up care or surveillance and monitoring.

Your follow-up care 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 look for a recurrence or spread of the disease, as well as a new primary melanoma. 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. The most important parts of this surveillance are your medical history and physical exams.

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence, which means that the cancer has come back. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will ask specific questions about your health. Some people may have blood tests or imaging tests done as part of regular follow-up care, but testing recommendations depend on several factors, including the type and stage of cancer originally diagnosed and the types of treatment given.

In general, physical and skin examinations are performed every 3 to 6 months for the first 2 to 3 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 may be recommended if the melanoma has a higher chance of coming back. For people treated for early-stage melanoma, scans are not generally recommended during follow-up care.

The anticipation before having a follow-up test or waiting for test results can add stress to you or a family member. This is sometimes called “scan-xiety.” Learn more about how to cope with this type of stress.

Preventing and detecting second skin cancers

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, you should ask your doctor for copies of your photographs and learn how to perform a skin self-examination. There is growing evidence that individuals who are followed using photographs are diagnosed at an earlier stage of melanoma.

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. It is important to take steps to protect yourself from further skin damage. You can protect against further sun damage by:

  • Participating in outdoor activities before 10:00 AM or after 4:00 PM

  • Wearing long sleeves and pants

  • Using a broad-spectrum sunscreen with an SPF of at least 30. Please remember to reapply sunscreen every 2 hours or, if you are sweating or in the water, every hour.

  • Wearing UV-protective sunglasses

  • Wearing a hat

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 indoor tanning devices. In addition, if a person works in an area where there is high UV exposure, there may be job-related issues to consider. Learn more about protecting your skin from the sun.

Managing long-term and late side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. Other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may have certain physical examinations, scans, or blood tests to help find and manage them.

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 Coping With Treatment, some patients experience lymphedema or chronic pain. Talk with your health care team about how these can be managed.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to discuss any concerns you have about your future physical or emotional health. ASCO offers forms to help keep track of the cancer treatment you received and develop a survivorship care plan after treatment is completed.

This is also a good time to talk with your doctor about who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her and with all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship. It describes how to cope with challenges in everyday life after a cancer diagnosis. Use the menu to choose a different section to read in this guide.

Melanoma - Survivorship

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ON THIS PAGE: You will read about how to cope with challenges in everyday life after a cancer diagnosis. Use the menu to see other pages.

What is survivorship?

The word “survivorship” means different things to different people. Common definitions include:

  • Having no signs of cancer after finishing treatment.

  • Living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

Survivorship is one of the most complicated parts of having cancer. This is because it is different for everyone.

Survivors may experience a range of feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain about coping with everyday life.

Survivors may feel some stress or anxiety when their treatment ends and their visits to the health care team become less frequent. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true when new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexual health and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing

  • Thinking through solutions

  • Asking for and allowing the support of others

  • Feeling comfortable with the course of action you choose

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the place where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make lifestyle changes.

People recovering from melanoma are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, managing stress, and protecting your skin from the sun. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

It is important to have recommended medical checkups and tests (see Follow-up Care) to take care of your health. Cancer rehabilitation may be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your health care team to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note that these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: Get this 44-page booklet that helps people transition into life after treatment. It includes blank treatment summary and survivorship care plan forms. The free booklet is available as a PDF, so it is easy to print out.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes after finishing treatment.

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for those in different age groups.

The next section offers Questions to Ask the Health Care Team to help start conversations with your cancer care team. Use the menu to choose a different section to read in this guide.

Melanoma - Questions to Ask the Health Care Team

Approved by the Cancer.Net Editorial Board, 01/2019

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

Talking often with the health care team 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 a digital list and other interactive tools to manage your care. It may also be helpful to ask a family member or friend to come with you to appointments to help take notes.

Questions to ask after getting a diagnosis

  • What type or subtype of melanoma do I have?

  • Can you explain my pathology report to me?

  • What stage is the melanoma? What does this mean?

  • What is the depth of the melanoma in millimeters?

  • Is the melanoma ulcerated?

  • Does the melanoma have mitotic activity?

  • Is it likely that the melanoma has spread? Why or why not?

Questions to ask about choosing a treatment and managing side effects

  • What are my treatment options?

  • What clinical trials are available for 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?

  • 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?

  • Who will be part of my health care team, and what does each member do?

  • Who will be leading my overall treatment?

  • 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 of cancer care, who can help me?

  • What support services are available to me? To my family?

  • If I have questions or problems, who should I call?

Questions to ask about having surgery

  • What type of surgery do you recommend?

  • Should I have a sentinel lymph node biopsy to find out if there is spread to the lymph nodes?

  • Will surgery be able to remove all of the cancer? Will I need additional surgery?

  • How long will the operation take?

  • How long will I be in the hospital?

  • After the surgical removal of the melanoma, will I need a skin graft?

  • Can you describe what my recovery from surgery will be like?

  • Who should I contact about any side effects I experience? And how soon?

  • What are the possible long-term effects of having this surgery?

  • Will I need to have additional treatment after surgery?

Questions to ask about having adjuvant or systemic treatment

  • What type of treatment is recommended?

  • Does my melanoma have a BRAF genetic mutation or other known mutation? Is targeted therapy or immunotherapy an option?

  • What is the goal of this treatment?

  • How long will it take to have this treatment?

  • What side effects can I expect during treatment?

  • Who should I contact about any side effects I experience? And how soon?

  • What are the possible long-term effects of having this treatment?

  • What can be done to prevent or manage these side effects?

Questions to ask about stage III melanoma

  • How many lymph nodes are affected with melanoma?

  • Will the rest of the lymph nodes be removed? If yes, what are the potential complications of lymph node surgery?

  • Has the melanoma spilled out of the lymph node? This is called extranodal extension of the melanoma. What does this mean for my treatment?

  • Is radiation therapy or other treatment recommended after surgery?

  • What are the goals of each treatment? What is my prognosis?

Questions to ask about stage IV melanoma

  • Where has the melanoma spread? Do I need a brain scan or PET-CT scan to find where it has spread?

  • Is surgical removal of the metastases an option, especially if 1 or 2 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?

Questions to ask about planning follow-up care

  • What is the chance that the cancer will come back? Should I watch for specific signs or symptoms?

  • What steps can I take to reduce the risk of developing a new melanoma or other type of skin cancer?

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

  • What follow-up tests will I need, and how often will I need them?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be leading my follow-up care?

  • What survivorship support services are available to me? To my family?

  • Are my family members at a higher risk for developing melanoma?

The next section in this guide is Additional Resources. It offers some more resources on this website that may be helpful to you. Use the menu to choose a different section to read in this guide.

Melanoma - Additional Resources

Approved by the Cancer.Net Editorial Board, 01/2019

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. Use the menu to go back and see other pages.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer 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 links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to Melanoma. Use the menu to choose a different section to read in this guide.