Here's how doctors usually treat this dangerous form of skin cancer

By Seraphina Seow
June 23, 2021
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Though only responsible for around 1% of skin cancers, melanoma is widely considered to be one of the most dangerous forms of the disease, Sowmya Ravi-Jeyamohan, MD, board-certified dermatologist and Mohs Surgeon of North Sound Dermatology, tells Health. And, as with any type of cancer, early detection and appropriate treatment is essential to positive outcomes.

In early and late stages of melanoma, the treatment varies, says Dr. Kendra Bergstrom, MD, board-certified dermatologist at University of Washington Medical Center's Roosevelt Dermatology Clinic, tells Health. Dermatologists or primary care physicians usually collaborate with oncologists to devise a treatment plan that ensures the melanoma is eradicated. Here's what you need to know about each type of melanoma treatment available, and when they're most likely to be used.

Melanoma-Treatment-GettyImages-1211808593
Credit: Getty Images

What is melanoma?

Melanoma is a type of skin cancer in that happens when skin cells called melanocytes, which give skin its tan or brown color, begin to grow out of control. Though it's not the most common form of skin cancer, rates of melanoma have been on the rise for the past 30 years, and actually doubled between 1982 and 2011, according to the American Academy of Dermatology (AAD).

While it is more frequently seen in non-Hispanic white individuals, research shows that melanoma is often diagnosed in its later, more dangerous stages in Black, Hispanic, Asian, Pacific Islander, Native Americans, and Alaska Natives populations, and their survival rates are lower.

While other skin cancers, like basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), tend to stay confined to one location, melanoma works a bit differently. "The melanocytes grow and appear in places and structures that they don't necessarily belong to," says Dr. Ravi-Jeyamohan. That's what makes it more threatening than other skin cancers. "Melanomas tend to move around, metastasize, go to lymph nodes, and go to places like the brain a lot more commonly and quickly than other types of skin cancers," says Dr. Bergstrom.

For this reason, the AAD recommends performing a melanoma self-exam on a monthly basis to alert yourself to any concerning skin signs, so that you can head to the doctor as early as possible for a thorough examination. The best way to confirm if you have melanoma is to visit a dermatologist or primary care physician. This is because melanoma is difficult to diagnose visually, as it isn't only linked to moles, but also found on skin without lesions.

To confirm a diagnosis, the doctor performs a biopsy, which is the removal of a sample of the suspicious tissue, and sends this to the lab for testing, says Dr. Ravi-Jeyamohan. If the lab results indicate the presence of cancer-and if other imaging tests are needed-the melanoma will be classified as stage 0, I, II, III, or IV (these can also be written as stage 0, 1, 2, 3, or 4).

  • Stage 0 and Stage 1: These are considered early stages of melanoma, according to the Skin Cancer Foundation (SCF). Both stages are localized, meaning stage 0 melanoma is confined to the epidermis, the top layer of the skin, while stage 1 melanoma has spread to the dermis and is at most 2 millimeters thick (in depth), and may or may not be ulcerated (have breakdown of skin over the melanoma).
  • Stage 2: This refers to intermediate or high-risk melanomas, melanomas that are more invasive and have an increased chance of spreading to lymph nodes or other organs. Stage 2 melanomas range from being more than 1 millimeters thick to more than 4 millimeters thick, though they are still considered to be localized. They may or may not be ulcerated.
  • Stage 3: This is advanced melanoma that has spread to nearby lymph nodes, lymph vessels, or skin. Stage 3 melanomas may range from being less than 2 millimeters in thickness to more than 4 millimeters in thickness, and may or may not be ulcerated.
  • Stage 4: Also known as metastatic skin cancer, this means the cancer has spread to distant lymph nodes, bones, or organs. Stage 4 melanomas can be at any thickness and may or may not be ulcerated.

As with all cancers, staging matters in a melanoma diagnosis-it helps doctors decide how best to treat the cancer and which type of therapy or surgical procedure (or both) to use.

How is melanoma treated? ­

According to the National Comprehensive Cancer Network (NCCN) guidelines for patients, melanoma is treated using surgery, targeted therapy drugs, immunotherapy, chemotherapy, or radiation therapy. A person may require only one of these, or a few, and this is decided by the dermatologist and oncologist. Here's what each type of treatment entails:

Wide excision surgery

Wide excision surgery is generally used as the main treatment for stage 0, 1, and early stage 2 melanomas, says Dr. Bergstrom. Stage 3 melanomas may need wide excision surgery to remove the tumor first before receiving other therapies to halt the cancer which has spread to nearby lymph nodes, lymph vessels, or skin.

Stage 0 and Stage 1 melanoma excision surgeries are often done under local anesthesia, and later stage melanomas may require general anesthesia depending on how deep the melanoma tumor is. Once the skin is numbed, the dermatologist would remove the melanoma along with a safety margin of tissue around the melanoma tumor. The removed safety margin of tissue is checked to ensure it does not contain any cancerous cells, then the wound is stitched back together.

Wide excision surgery is generally able to be done in the doctor's office, says Dr. Ravi-Jeyamohan. To facilitate wound healing, you may need to restrict your activity in the area for seven to 14 days, depending on how deep the wound is and which part of the body it is located, says Dr. Ravi-Jeyamohan.

Mohs surgery

"We may sometimes use a specialized form of surgery called Mohs micrographic surgery to treat melanomas," says Dr. Ravi-Jeyamohan. "There is a growing body of practitioners that may use it for early invasive melanoma, which is melanoma that has grown just beyond the epidermis [what is known as Stage I melanoma]."

After the patient is anesthetized, the melanoma and some healthy skin around it is removed layer by layer, and examined after each layer is removed. This process is repeated until no more cancer cells can be detected.

Lymph node removal

If the doctor finds during the wide excision surgery that the melanoma is thicker than 1 millimeter in depth, they may perform a sentinel lymph node biopsy at the time of the excision surgery ('sentinel' means the indicator of presence of disease). This is because a melanoma at this thickness is likely to spread to local lymph nodes, per the NCCN.

The biopsied sentinel lymph node tissue is sent to the lab to check whether the cancer has spread to nearby lymph nodes. The doctor may also physically palpate the lymph nodes for any abnormal enlargement and order additional imaging, like PET or CT scans, to examine the spread of cancer to lymph nodes nearby.

According to the American Cancer Society, a biopsied sentinel lymph node tissue showing the presence of cancer cells may indicate that the lymph nodes around the area are to be surgically removed under general anesthesia. But the NCCN guidelines advise doctors to reserve complete lymph node removal for those that are palpably enlarged. Lymph node removal may be advised for Stage 1, 2, 3, or 4 melanomas.

Targeted therapy

Targeted therapy is usually an adjuvant (aka additional) therapy. Targeted therapy is used if there is cancer in nearby lymph nodes, distant lymph nodes, or distant areas and organs of the body, so it could be recommended for Stage 1, 2, 3, or 4 melanomas. It uses drugs that target the mutated genes and molecules in melanoma cells to halt their action, and slow or stop the growth and proliferation of melanoma cells.

Targeted therapy drugs inhibit the growth of melanoma that posess mutated BRAF, MEK, or C-KIT genes. Not all melanoma cells exhibit these mutated genes, so targeted therapy will only be used if the tested melanoma tissue has these.

Immunotherapy

"One of the reasons melanomas are so insidious is because they're very good at evading detection by the immune system and they're very good at modifying themselves and adapting to your body's immune environment," says Dr. Ravi-Jeyamohan. "That way, your immune system may not detect them, respond to them, or attempt to clear them."

Immunotherapy agents boost the immune system's effectiveness in destroying cancer cells and are usually administered intravenously. The most common types currently used are: immune checkpoint inhibitors, interleukin-2 (IL-2), oncolytic virus therapy, Bacille Calmette-Guerin (BCG) vaccine, and imiquimod cream.

Immunotherapy may be used alone to treat melanomas that are unable to be surgically removed or as an adjuvant therapy. Like targeted therapy, immunotherapy can be used if there is cancer in nearby lymph nodes, distant lymph nodes, or distant areas and organs of the body, so it is usually recommended in Stage I, II, III, or IV melanomas.

Chemotherapy

Chemotherapy involves using a drug that kills any rapidly-growing cell, whether they are cancerous or not. The chemotherapy drug is given either as an infusion or a pill, and travels throughout the body or to an isolated limb to perform its role.

Chemotherapy is often used as a last resort if other therapies are ineffective, or may be used as an adjuvant therapy to immunotherapy or targeted therapy. It is usually recommended in Stage 3 or 4 melanomas.

The patient will be treated with the drug for a few weeks at a time, then the body will get a few weeks of no treatment to recover. This repeats over a few cycles, depending on the oncologist's prescription.

Radiation therapy

In radiation therapy, high-energy ray beams are directed to tumors to shrink cancer cells. It is mostly used for melanomas in Stage 3 or 4 that have spread to distant lymph nodes or organs, mainly to slow down and relieve symptoms of advanced melanoma, which may have spread to the brain or bones. Radiation therapy may also be used to prevent or destroy recurring melanoma.

Clinical trials

Sometimes, patients may consider enrolling in a clinical trial for a new therapy, especially when they are diagnosed with Stage IV melanoma. This is usually done after careful discussions with the oncologist to weigh up the risks and benefits.

While melanoma treatment is advancing through scientific research, experts emphasize the utmost importance of prevention and routine screening to ensure early detection.

"Based on our years of research and findings, typically we recommend patients to see a dermatologist every one to two years, to be screened for melanoma and for other forms of skin cancer, or to [ensure they] have these screenings done with their primary care doctor at their annual [check-up] visit," says Dr. Ravi-Jeyamohan. "A lot of patients do not know that these are the recommendations." In between these doctor examinations, make it your routine to perform a melanoma self-exam once a month so you can catch the cancer at the earliest stage.

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