Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team. 

Treatment for melanoma depends on:^[7] 

• the stage of the disease 
• the location of the cancer 
• the severity of symptoms 
• the possible side effects 
• the risk of the cancer returning after treatment 
• if the cancer cells have certain gene changes 
• your general health and wishes. 

Treatment may involve the following. 

Surgery

Surgery is the main initial treatment for melanoma. 

Thin, early-stage melanomas can be removed by minor surgery (under local anaesthetic) that excises the tumour and some normal skin tissue around it. A wide margin of healthy skin around the edge of the tumour is removed to ensure that no cancer cells were left behind. This is called wide local excision. The thicker the tumour, the wider the margin required, in terms of both area and depth. This minor surgery will leave a scar. 

You may also have a sentinel lymph node biopsy at the same time as the wide local excision. This is where a lymph node near the melanoma is identified by injecting a radioactive substance and/or dye into the skin near the melanoma. The lymph node is then removed so that a pathologist can test it for melanoma cells.  

If the melanoma has spread to nearby lymph nodes, these lymph nodes are usually removed by surgery under general anaesthetic. This is called lymph node dissection. It will not necessarily cure the cancer, but it might prolong survival and avoid the pain resulting from the cancer growing in the lymph nodes. Removal of lymph nodes that drain fluid (lymph) from the arms or legs can cause side effects, including a buildup of fluid in the limbs or neck. This is called lymphoedema. 

Chemotherapy

Along with surgery, some people may receive chemotherapy. 

Chemotherapy may be less effective for melanoma than for some other types of cancer. For this reason, immunotherapy and targeted therapy may be preferred. However, chemotherapy may be used to prolong survival or relieve symptoms. 

Radiation therapy

Along with surgery, some people may receive radiation therapy. 

Radiation therapy is not usually used to treat the original melanoma in the skin. It may be used to treat melanoma that has come back (recurred) or to kill any cancer cells remaining after surgery. It can also be used to relieve symptoms caused by spread of the melanoma, especially to the brain or bones. 

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells. 

Medicines used for targeted therapy of melanoma include vemurafenib, cobimetinib,^[8] dabrafenib and trametinib, which attack cells that have a damaged BRAF gene. About half of all melanomas have mutations in the BRAF gene that cause the cells to grow and divide more rapidly. 

Targeted medicines for melanoma with NRAS and C-KIT mutations may be available through clinical trials. Talk to your doctor to work out if a clinical trial is right you.^[9]  

Immunotherapy

Immunotherapy uses medicines to stimulate the immune system to attack cancer cells. In recent years, there have been major advances in the treatment of melanoma with the use of immunotherapy leading to improved outcomes for patients with advanced melanoma. These medicines include: 

• pembrolizumab, nivolumab and ipilimumab, which block proteins on immune system cells that stop these cells from attacking other cells in the body. These treatments are called immune checkpoint inhibitors. This boosts the immune system’s response against melanoma cells but can also produce side effects, including causing the immune system to attack other parts of the body. Checkpoint inhibitors can be given as single agents, or a combination, however, this can have increased side effects. 
• cytokines, including interferon-alpha and interleukin-2, which boost the immune system generally; they can also cause side effects, some of which are serious 
• talimogene laherparepvec (T-VEC), which is a type of virus made in a lab to infect and kill mainly cancer cells and also boosts the immune system; a common side effect is flu-like symptoms^[10] 
• Bacille–Calmette–Guerin (BCG) vaccine, which is used to vaccinate against tuberculosis and boosts the immune system generally 
• imiquimod cream, which boosts the immune system’s response against skin cancer cells for stage 0 melanoma.^[11] 

Immunotherapy may be used after surgery to attack remaining cancer cells, or it may be used to treat tumours that can’t be removed by surgery. 

Follow-up

After treatment, you will need regular examination of the skin and lymph nodes. Depending on the stage of the melanoma when it was diagnosed and treated, you might also need imaging tests. You should also regularly examine your own skin and lymph nodes for lumps or other changes. 

Advanced disease

Stage IV melanoma, when the cancer has spread to distant organs such as the lungs or brain, is unlikely to be treatable with surgery alone. However, surgery might still be used at this stage to prolong survival and relieve symptoms. Metastases that cannot be removed by surgery may be treated with radiation therapy, immunotherapy, targeted therapy or chemotherapy. These types of treatment may shrink the tumours or slow their growth, as well as relieving symptoms. 

Recurrent cancer

Melanoma may recur (come back) after treatment. The cancer can recur in the skin or somewhere else in the body, and is classified as being local, in-transit or distant. Secondary cancer is when the cancer spreads to another part of the body. 

Treatment options for recurrent and secondary melanoma depend on where the cancer comes back, the stage of the original melanoma and the treatments that have already been tried. Treatment can include surgery (especially if the melanoma comes back in the skin near the original tumour), radiation therapy, immunotherapy, targeted therapy or chemotherapy. When the cancer comes back in organs such as the lungs, brain, bones or liver, the treatment is usually the same as for stage IV melanoma.