Skin cancer (melanoma) - Treatment

Treatment-Skin cancer (melanoma)




Surgery is the main treatment for melanoma.
If you have melanoma skin cancer you'll be cared for by a team of specialists that should include a dermatologist, a plastic surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a pathologist and a specialist nurse.
When helping you decide on your treatment, the team will consider:
  • the type of cancer you have
  • the stage of your cancer (its size and how far it has spread)
  • your general health
Your treatment team will recommend what they believe to be the best treatment option, but the final decision will be yours.
Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist.
For example, you may want to find out about the advantages and disadvantages of particular treatments.
Read more about questions to ask your doctor.

Treating stage 1 to 2 melanoma

Treating stage 1 melanoma involves surgery to remove the melanoma and a small area of skin around it. This is known as surgical excision.
Surgical excision is usually carried out under local anaesthetic, which means you'll be conscious but the area around the melanoma will be numbed, so you won't feel pain. In some cases, general anaesthetic is used, which means you'll be unconscious during the procedure.
If a surgical excision is likely to leave a significant scar, it may be carried out in combination with a skin graft. However, skin flaps are now more commonly used because the scars are usually much better than those resulting from a skin graft.
Read more about flap surgery.
In most cases, once the melanoma has been removed there's little possibility of it returning and no further treatment should be needed. Most people (80-90%) are monitored in clinic for 1 to 5 years and are discharged with no further problems.

Sentinel lymph node biopsy

A sentinel lymph node biopsy is a procedure to test for the spread of cancer.
It may be offered to people with stage 1B to 2C melanoma. It's carried out at the same time as surgical excision.
You'll decide with your doctor whether to have a sentinel lymph node biopsy.
If you decide to have the procedure and the results show no spread to nearby lymph nodes, it's unlikely you'll have further problems with this melanoma.
If the results confirm melanoma has spread to nearby nodes, your specialist will discuss with you whether further surgery is required.
Additional surgery involves removing the remaining nodes, which is known as a lymph node dissection or completion lymphadenectomy.

Treating stage 3 melanoma

If the melanoma has spread to nearby lymph nodes (stage 3 melanoma), further surgery may be needed to remove them.
Stage 3 melanoma may be diagnosed by sentinel node biopsy, or you or a member of your treatment team may have felt a lump in your lymph nodes.
The diagnosis of melanoma is usually confirmed using a needle biopsy (fine needle aspiration).
Removing the affected lymph nodes is done under general anaesthetic.
The procedure, called a lymph node dissection, can disrupt the lymphatic system, leading to a build-up of fluids in your limbs. This is known as lymphoedema.
Cancer Research UK has more information about surgery to remove lymph nodes.

Treating stage 4 melanoma

If melanoma comes back or spreads to other organs it's called stage 4 melanoma.
In the past, cure from stage 4 melanoma was very rare but new treatments, such as immunotherapy and targeted treatments, show encouraging results.
Treatment for stage 4 melanoma is given in the hope that it can slow the cancer's growth, reduce symptoms, and extend life expectancy.
You may be offered surgery to remove other melanomas that have occurred away from the original site. You may also be able to have other treatments to help with your symptoms, such as radiotherapy and medication.
If you have advanced melanoma, you may decide not to have treatment if it's unlikely to significantly extend your life expectancy, or if you don't have symptoms that cause pain or discomfort.
It's entirely your decision and your treatment team will respect it. If you decide not to receive treatment, pain relief and nursing care will be made available when you need it. This is called palliative care.

Immunotherapy

Immunotherapy is used to treat advanced (stage 4) melanoma, and it's sometimes offered to people with stage 3 melanoma as part of a clinical trial.
Immunotherapy uses medication to help the body's immune system find and kill melanoma cells.
A number of different medications are available, some of which can be used on their own (monotherapy) or together (combination therapy).
Medications used include:
  • ipilimumab
  • nivolumab 
  • pembrolizumab
  • talimogene laherparepvec

Ipilimumab

Ipilimumab is recommended by NICE as a treatment for people with previously treated or untreated advanced melanoma that's spread or can't be removed using surgery.
It's given by injection over a 90-minute period, every 3 weeks for a total of 4 doses.
Common side effects include diarrhoea, rash, itching, fatigue, nausea, vomiting, decreased appetite and abdominal pain.
Read the NICE guidance about:

Nivolumab

Nivolumab is recommended by NICE for treating advanced cases of melanoma in adults that have spread or can't be removed using surgery.
It's given directly into a vein (intravenously) over a 60-minute period, every 2 weeks. Treatment is continued for as long as it has a positive effect or until it can no longer be tolerated.
Nivolumab can be used either on its own or in combination with ipilimumab.
In clinical trials, the most common side effects were tiredness, rash, itching, diarrhoea and nausea.
Read the NICE guidance about:

Pembrolizumab

Pembrolizumab is recommended by NICE to treat advanced melanoma in adults that's spread or can't be treated with surgery. It's given by injection for 30 minutes, every 3 weeks.
In clinical trials, the most common side effects were diarrhoea, nausea, itching, rash, joint pain and fatigue.
Read the NICE guidance about:

Talimogene laherparepvec

Talimogene laherparepvec is recommended by NICE for treating melanoma that's spread or can't be removed with surgery, where treatment with other immunotherapies isn't suitable.
It's injected directly into the skin, sometimes with the help of ultrasound guidance.
In clinical trials, the most common side effects were flu-like symptoms, reactions at the injection site and cellulitis (infection of the deeper layers of skin and underlying tissue).

Targeted treatments

Around 40 to 50 in every 100 people with melanoma have changes (mutations) in certain genes, which cause cells to grow and divide too quickly.
If gene mutations have been identified, medication can be used to specifically target these gene mutations to slow or stop cancer cells growing.
Possible targeted treatments include: 
  • vemurafenib
  • dabrafenib
  • trametinib

Vemurafenib

Vemurafenib is a medication that blocks the activity of a cancerous gene mutation known as BRAF V600.
It's recommended by NICE as a treatment for people who've tested positive for the mutation and have locally advanced melanoma or melanoma that's spread.
Common side effects include joint pain, tiredness, rash, sensitivity to light, nausea, hair loss and itching.
Vemurafenib can also be used with another medication called cobimetinib for treating people with the BRAF V600 mutation melanoma that's spread or can't be removed with surgery.
Read the NICE guidance about:

Dabrafenib

Dabrafenib also blocks the activity of BRAF V600.
It's recommended by NICE for treating adults with the BRAF V600 mutation who have melanoma that's spread or can't be removed with surgery.
Common side effects include decreased appetite, headache, cough, nausea, vomiting, diarrhoea, rash and hair loss.

Trametinib

Trametinib blocks the activity of the abnormal BRAF protein, slowing the growth and spread of the cancer.
It's recommended by NICE either for use on its own or with dabrafenib for treating people with melanoma with a BRAF V600 mutation that's spread or can't be removed with surgery.
Common side effects include tiredness, nausea, headache, chills, diarrhoea, rash, join pain, high blood pressure and vomiting.

Radiotherapy and chemotherapy

You may have radiotherapy after an operation to remove your lymph nodes, and it can also be used to help relieve the symptoms of advanced melanoma. Controlled doses of radiation are used to kill the cancerous cells.
If you have advanced melanoma, you may have a single treatment or a few treatments. Radiotherapy after surgery usually consists of a course of 5 treatments a week (1 a day from Monday to Friday) for a number of weeks. There's a rest period over the weekend.
Common side effects associated with radiotherapy include:
  • tiredness
  • nausea
  • loss of appetite
  • hair loss 
  • sore skin
Many side effects can be prevented or controlled with prescription medicines, so tell your treatment team if you experience any. The side effects of radiotherapy should gradually reduce once treatment has finished.
Chemotherapy is now rarely used to treat melanoma. Targeted treatments and immunotherapy (as described above) are the preferred treatment options.

Melanoma vaccines

Research is under way to produce vaccines for melanoma, either to treat advanced melanoma or to be used after surgery in people with a high risk of the melanoma returning.
They're currently only given as part of a clinical trial.
Cancer Research UK has more information about melanoma vaccines.

Follow-up

After your treatment, you'll have regular follow-up appointments to check whether:
  • there's signs of the melanoma coming back
  • the melanoma has spread to your lymph nodes or other areas of your body
  • there's signs of any new primary melanomas
Your doctor or nurse will examine you, they'll ask about your general health and whether you have any questions or concerns.
You may be offered treatment to try to prevent the melanoma returning. This is called adjuvant treatment.
There's not much evidence that adjuvant treatment helps prevent melanoma coming back, so it's currently only offered as part of a clinical trial.
There's evidence that checkpoint therapies, which boost the body's immune responses to cancer, may be used in the future if clinical trials provide evidence that they're effective.
Cancer Research UK has more information about follow-up appointments.

Help and support

Being diagnosed with melanoma can be difficult to deal with. You may feel shocked, upset, numb, frightened, uncertain and confused. These types of feelings are natural.
You can ask your treatment team about anything you're unsure about.
Your family and friends can be a great source of support. Talking about your cancer and how you're feeling can help both you and members of your family cope with the situation.
Some people prefer to talk to people outside their family. There are a number of UK-based charities that have specially trained staff you can speak to on their free helplines:
  • Cancer Research UK – 0808 800 4040 (Monday to Friday, 9am to 5pm)
  • Macmillan – 0808 808 0000 (Monday to Friday, 9am to 8pm)
  • Melanoma UK – 0808 171 2455 or you can use their online form
Cancer Research UK also has a section about living with melanoma.

Clinical trials

Any new cancer treatment is first given to patients in a clinical trial.
A clinical trial is a rigorous way of testing new treatments on people. Patients are closely monitored for any effects the medicine has on the cancer as well as any side effects.
Many people with melanoma are offered entry into clinical trials.
If you're asked to take part in a clinical trial, you'll be given an information sheet, and if you decide to take part you'll be asked to sign a consent form.
You can withdraw from a clinical trial at any time without it affecting your care.
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