Types of Treatment for Melanoma

After the diagnostic tests are done, your cancer care team will recommend one or more treatment options. Consider the options without feeling rushed. If there is anything you do not understand, ask to have it explained. The choice of treatment depends largely on the thickness of the primary tumor and the stage of the disease.

Types of Surgery for Melanoma

Wide local excision

When the diagnosis of melanoma is established by biopsy, a wide local excision is done to decrease the chance of local recurrence. More tissue is removed around the melanoma site, and the tissue from the final excision is examined to make sure that no cancer cells remain in the skin. The size of the margin depends on the thickness of the tumor.

Amputation

If the melanoma is on a finger or toe, the treatment may be to amputate as much of that digit as is necessary to obtain clear margins.

Lymph node evaluation

After the diagnosis of melanoma is made, the doctor will examine the lymph nodes nearest the melanoma. If the lymph nodes are not enlarged, then a sentinel node biopsy procedure may be done. A sentinel lymph node is usually considered if the melanoma is >1 mm thick. If the sentinel lymph node does not show cancer, then it is unlikely the melanoma has spread to the lymph nodes; there is no need for a lymph node dissection. If the sentinel lymph node is positive, removal of the remaining lymph nodes is usually advised.

If the regional lymph nodes feel hard or large, and FNA or biopsy shows metastatic melanoma, a lymph node dissection may be done. This procedure removes most of the lymph nodes in that area, and they will be examined under a microscope to see how many lymph nodes contain cancer.

Lymph node dissection can cause some side effects that may be permanent. The most troublesome is called lymphedema. Lymph nodes in the groin or under the arm help drain fluid from the limbs. Without them, fluid may collect. Most patients do not get lymphedema. Elastic stockings or sleeves can help some people with this condition. Sometimes special devices that squeeze the limbs are used and may be helpful. These side effects, along with the discomfort from the surgery itself, are why this procedure is not done unless the doctor thinks it is necessary. Discuss risks of these side effects with your doctor.

Surgery for Metastatic Melanoma

Once melanoma has spread from the skin to distant organs (such as the lungs or brain), the cancer is unlikely to be curable by surgery. Even when only 1 or 2 metastases are found by imaging studies such as CT or MRI scans, other areas of metastasis are likely to be present that are too small to be found by these scans. Surgery is sometimes done in these circumstances. If one or even a few metastases are present and can be completely removed, this surgery may help some patients to live longer. Also, removing a single metastasis in the brain that might eventually cause symptoms may help improve the patient’s quality of life.

Chemotherapy for Melanoma

Systemic chemotherapy uses anticancer drugs that are usually injected into a vein or given by mouth. These medications travel through the bloodstream to all parts of the body, where they attack cancer cells that have already spread beyond the skin to involve lymph nodes and other organs.

Chemotherapy drugs kill cancer cells but also kill some normal cells, such as the blood-producing cells of the bone marrow, the cells lining the gastrointestinal tract, and cells of hair follicles. Temporary side effects of systemic chemotherapy might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores.

Because chemotherapy can kill normal blood cells, patients may have low blood cell counts, which can result in:

• an increased chance of infection (due to a shortage of white blood cells)
• bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets)
• fatigue (often due to low red blood cell counts but also can be caused by the chemotherapy alone)

Most side effects disappear once treatment is stopped. There are treatments for many of the temporary side effects of chemotherapy, so be sure to discuss side effects with your cancer care team. For example, anti-nausea drugs can be given to prevent or reduce nausea and vomiting.

Only a few chemotherapy drugs are used for stage IV melanoma. Although chemotherapy is usually not as effective in melanoma as in some other types of cancer, it may relieve symptoms or extend survival of some patients with stage IV melanoma.

Chemotherapy drugs often used to treat melanoma include:

DTIC, alone or with other chemotherapy drugs such as BCNU and cisplatin. The combination of these 3 chemotherapy drugs, occasionally together with tamoxifen (a hormonal therapy drug most often used to treat breast cancer) is called the “Dartmouth regimen.”

Cisplatin, vinblastine, and DTIC is another chemotherapy combination for treating melanoma.

Temozolomide is a new drug that works like DTIC, but it can be given in the form of a pill.

These chemotherapy drugs may also be combined with immunotherapy drugs, such as interferon-alpha and/or interleukin-2 (see the section on immunotherapy).

Hyperthermic isolated limb perfusion is a type of chemotherapy sometimes used for treating metastatic melanomas confined to the arm or leg. This method temporarily separates the circulation of the involved limb from the rest of the body and injects high doses of chemotherapy into the artery feeding the limb. This allows high doses to be given to the area of the tumor without exposing internal organs to these doses that would otherwise cause severe side effects. Usually the fluid is warmed to 102° to 104° Fahrenheit. Melphalan is the drug most often used in this chemo­therapy procedure. Limb perfusion is done to help control disease in the affected extremity and is not thought to improve survival.

Radiation Therapy

Radiation therapy uses high-energy rays or particles to kill cancer cells. External beam radiation therapy focuses radiation from outside the body on the skin tumor. This type of radiation therapy is used for treating some patients with melanoma.

Radiation therapy is not commonly used to treat the primary tumors of melanoma (the original melanoma that developed on the skin). But it may be considered in some patients and in patients whose melanoma has come back.

Immunotherapy

Immunotherapy enhances and encourages a patient’s immune system to recognize and destroy cancer cells more effectively. Several types of immunotherapy are used in treating patients with melanoma. Some are being studied as adjuvant therapy. Adjuvant therapy is treatment given after surgery, either chemo­therapy or radiation therapy, with the intent of destroying any cancer cells that may not have been removed by the surgery.

Cytokine therapy

Cytokines are proteins that activate the immune system in a general way. Two cytokines, interferon-alpha and interleukin-2, can help boost immunity in patients with melanoma. Both drugs can help shrink metastatic (stage III and IV) melanoma in about 10% to 20% of patients.

Side effects of cytokine therapy may include fever, chills, aches, depression, and severe tiredness. Interleukin-2, particularly in high doses, can cause fluid to accumulate in the body, so the person swells up and can feel quite sick. Some patients may need to be hospitalized because of this problem.

Interferon-alpha-2b

Patients with deeper melanomas often have cancer cells that break away from the primary melanoma and travel to other parts of the body. Interferons are immune substances produced by the body in response to infection. Interferon-alpha-2b can be used as an adjuvant therapy. Side effects include fever, chills, aches and severe tiredness. Interferon-alpha-2b can also have effect on the heart and liver, and patients should be followed by an oncologist who is experienced with this treatment. Interferon-alpha-2b given to patients with stage III melanoma following surgery can delay the recurrence of melanoma but may not prolong patients’ lives. Decisions about adjuvant therapy by patients and their doctors should take into account the potential benefits and side effects of this treatment.

Vaccine therapy

Melanoma vaccines are experimental therapies that are being tested in patients with stage III or stage IV melanoma. Anti­melanoma vaccines are, in some ways, similar to the vaccines used to prevent diseases caused by viruses such as polio, measles, and mumps. Antivirus vaccines usually contain weakened or killed viruses or parts of a virus that cannot cause the disease. The vaccine stimulates the body’s immune system to destroy the more harmful type of virus.

In the same way, weakened melanoma cells or parts of melanoma cells called antigens can be injected into a patient in an attempt to stimulate the body’s immune system to destroy melanoma cells. Usually, the melanoma cells are mixed with substances that help stimulate the body’s immune system.

Direct tumor injections

Sometimes melanomas will shrink and go away if they are injected with certain substances. The substances used most often are interferon and BCG, a form of killed tuberculosis that is used to immunize people against tuberculosis. This treatment is not used often.

CO2 laser ablation

This treatment may be used in some patients with several small skin metastatic melanomas. The CO2 laser is a type of laser used for skin problems. It emits a very high energy beam that destroys superficial skin lesions.

Supportive Care

Most of this document discusses ways to cure people with melanoma or to help them live longer by removing or destroying melanoma cancer cells. However, another important goal is to help you feel as well as you can and to continue to do the things in life that you want to do. Don’t hesitate to discuss your symptoms or how you are feeling with your cancer care team. There are effective and safe ways to treat symptoms you may be having, as well as most of the side effects caused by treatment for melanoma.

Pain is a concern for patients with advanced cancer. Growth of the cancer around certain nerves may cause severe pain. It is important that patients not hesitate to tell their doctors if they have pain. For most patients, treatment with morphine or other opioids (prescription medicines that are the strongest pain relievers available) will reduce the pain considerably. For more information on the treatment of cancer pain, please click here or contact the ACS or NCCN to request a copy of the Cancer Pain Treatment Guidelines for Patients.

Complementary and Alternative Therapies

Complementary and alternative medicines are a group of different types of health care practices, systems, and products that are not part of your usual medical treatment. They may include Chinese herbs, special supplements, acupuncture, massage, and a host of other types of treatment. You may hear about different treatments from your family and friends. People may offer all sorts of things, such as vitamins, herbs, stress reduction, and more as a treatment for your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit.

The American Cancer Society defines complementary medicine or methods as those that are used in addition to your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative therapies re defined as those that are used instead of your regular medical care. Some of them have been proven harmful, but are still promoted as “cures.” If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying or replacing regular cancer treatment.

There is a great deal of interest today in complementary and alternative treatments for cancer. Many are being studied to find out if they are truly helpful to people with cancer.

Before changing your treatment or adding any of these methods, it is best to discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it's important to talk with your doctor. More information about complementary and alternative methods of cancer treatment is available through the American Cancer Society’s toll-free number at 1-800-ACS-2345 or on our Web site at www.cancer.org.

About Clinical Trials

Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?

There are 3 phases of clinical trials in which a treatment is studied before it can be approved by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. Doctors watch patients carefully for any harmful side effects. The treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The doctors also look for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patients. Some clinical trials enroll thousands of patients. One group (the control group) receives the standard (most accepted) treatment. The other groups receive the new treatment. Usually doctors study only 1 new treatment to see if it works better than the standard treatment, but sometimes they test 2 or 3. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had a much better result than the others.

If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial

Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study in detail to you and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study will not prevent you from getting other medical care you may need.

To find out more about clinical trials, talk to your cancer care team. Among the questions you should ask are:

• Is there a study I would be eligible for?
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do?
• Will I know which treatment I will receive?
• What is likely to happen in my case with, or without, this new research treatment?
• What are my other choices and their advantages and disadvantages?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side effects be controlled?
• Will I have to be hospitalized? If so, how often and for how long?
• Will the study cost me anything? Will any of the treatment be free?
• If I am harmed as a result of the research, what treatment would I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can gain access to this service through the ACS cancer information center (1-800-ACS-2345) or their Web site (www.cancer.org). Based on the information you provide about your cancer type, stage, and previous treatments, this service compiles a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll free at 1-800-4-CANCER, or by visiting the NCI clinical trials Web site www.cancer.gov/clinical_trials/.

Participating in a clinical trial may help you directly, and it may help other people with melanoma in the future. For these reasons, the NCCN and the ACS are committed to conducting clinical trials and helping people with cancer learn more about these studies.

Other Things to Consider During and After Treatment

During and after treatment, you may be able to hasten your recovery and improve your quality of life by taking an active role in your care. Learn about the benefits and disadvantages of each of your treatment options, and ask questions of your cancer care team if there is anything you do not understand. Learn about and look out for side effects of treatment, and report these promptly to your cancer care team so that they can take steps to help relieve them.

Remember that your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about your treatment options can help predict what health problems you may face, no one can say precisely how you will respond to cancer or its treatment.

You may have special strengths such as a history of good nutrition and being physically active, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer. In fact, behavioral scientists have recently found that some people who took advantage of a social support system, such as a cancer support group, survived with a better quality of life. There are also experienced professionals in mental health services, social work services, and pastoral services who may assist you in coping with your illness.

You can also help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, stop now. Quitting will improve your overall health, and the full return of the sense of smell may help you enjoy a healthy diet. If you use alcohol, limit how much you drink. Have no more than 1 drink per day if you are a woman or 2 drinks per day if you are a man. Good nutrition can help you get better after treatment. Eat a nutritious and balanced diet, with plenty of fruits, vegetables, and whole grain foods. Ask your cancer care team if you could benefit from a special diet. They may have specific suggestions for people who have had radiation therapy, chemotherapy, or surgery.

If you are in treatment for cancer, be aware of the battle that is going on in your body. Radiation therapy, cytokine therapy, and chemotherapy all add to the fatigue that can be caused by the disease itself if it has spread. Give your body the rest it needs so that you will feel better as time goes on. Exercise once you feel rested enough. Ask your cancer care team whether your cancer or its treatments might limit your exercise program or other activities.

Surgery and radiation therapy may sometimes affect your feelings about your body and may lead to specific physical problems that affect sexuality. Your cancer care team can help with these issues, so don’t hesitate to share your concerns.

A cancer diagnosis and its treatment are major life challenges, affecting you and everyone who cares for you. Before you reach the point of feeling overwhelmed, consider attending a meeting of a local support group. If you need assistance in other ways, contact your hospital’s social service department or the American Cancer Society for help in contacting counselors or other services.

Protecting Your Skin From Sun Exposure

Everyone needs to protect his or her skin from the harmful effects of the sun. Sunlight contains ultraviolet radiation (UV), which can damage the genes in your skin cells. Tanning lamps and booths are another source of ultraviolet radiation. Excessive exposure to light from these sources can increase the risk to skin cancer, including melanoma. The amount of UV exposure depends on the intensity of the radiation, length of time the skin was exposed, and whether the skin was protected with clothing and sunscreen.

The most important ways to protect your skin is by avoiding being outdoors in intense sunlight too long and to protect your skin when you are outdoors. You can maintain your level of physical activity and protect your skin at the same time with the following:

Seeking shade: The simplest and most effective way to limit exposure to ultraviolet (UV) light is to avoid being outdoors in sunlight too long. This is most important in the middle of the day when UV light is most intense.

Protecting your skin with clothing: You can protect most of your skin with clothing, including a shirt with long sleeves and a hat with a broad brim. Tightly woven and darkly colored (especially blue) fabrics generally provide the best sun protection.

Using sunscreen: Sunscreens with an SPF (Sun Protection Factor) of 15 or more should be used on areas of skin exposed to the sun, particularly when the sunlight is strong. Always follow directions when applying sunscreen. You should apply sunscreen before you go outside, use it thickly on all sun-exposed skin, and reapply it every 2 hours. A 1-ounce application (a palmful of sunscreen) is recommended. Many sunscreens wear off with sweating and swimming and must be reapplied for maximum effectiveness. Use sunscreen even on hazy days or days with light or broken cloud cover because the UV light still comes through.

Sunscreen should not be used to gain extra sun exposure time. Sunscreen will not prevent melanoma; it just reduces the amount of UV light exposure. Researchers have found that many people use sunscreens so that they can stay out in the sun longer. However, by extending their time in the sun, they end up receiving the same amount of UV light exposure as if they hadn’t used sunscreen at all. All excessive sun exposure is unhealthy. Sunscreen should not be used to increase a person’s sun exposure.

Wearing sunglasses: Wrap-around sunglasses with 99% to 100% UV absorption provide the best protection for the eyes and the skin area around the eyes.

Avoiding other sources of UV light: The use of tanning beds and sun lamps is not safe because the UV radiation they deliver can damage your skin. Their use may increase your risk of developing melanoma.

Checking Your Skin

As part of your follow-up care, your doctor may talk to you about checking your skin on a regular basis. You should know the pattern of your existing moles, blemishes, freckles, and other marks on your skin so that you’ll notice any changes. Self-examination is best done in front of a full-length mirror. A handheld mirror can be used for areas that are hard to see.

A spouse or other partner may be able to help you with these examinations, especially for those hard-to-see areas, like the back of your thighs. All areas should be inspected, including the palms and soles, the lower back, and the back of the legs. Friends and family members can also help by pointing out areas of skin that appear abnormal. Be sure to show your doctor any spots that concern you. Your doctor will also examine your skin on your follow-up visits.

Spots on the skin that are changing in size, shape, or color should be evaluated promptly. Any unusual sore, lump, blemish, marking, or change in the way an area of the skin looks or feels should be looked at by your doctor.

It is important to know the difference between a normal mole and a melanoma. A normal mole is generally an evenly colored brown, tan, or black spot on the skin. It can be either flat or raised. It can be round or oval. Moles are generally less than 6 mm (1/4 inch) in diameter (about the width of a pencil eraser). A mole can be present at birth, or it can appear during childhood or young adulthood. Several moles can appear at the same time, especially on areas of the skin exposed to the sun. Moles may fade away in older people.

STAGES OF MELANOMA

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

© 2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.