After diagnosis and staging, the doctor develops a treatment plan to fit each patient's needs. Treatment for melanoma depends on the extent of the disease, the patient's age and general health, as well as other factors.

People with melanoma are often treated by a team of specialists, which may include a dermatologist, surgeon, medical oncologist, and plastic surgeon. The standard treatment for melanoma is surgery; in some cases, doctors may also use chemotherapy, biological therapy, or radiation therapy. The doctors may decide to use one treatment method or a combination of methods.

Some patients take part in a clinical trial, which is a research study using new treatment methods. Such trials are designed to improve cancer treatment.

Getting a Second Opinion

Before starting treatment, the patient may want a second doctor to review the diagnosis and treatment plan. It may take a week or two to arrange for a second opinion. A short delay will not reduce the chance that treatment will be successful. Some insurance companies require a second opinion; many others will cover a second opinion if the patient requests it.

There are a number of ways to find a doctor who can give a second opinion:

• One doctor may refer the patient to another who has special interest and training in treating melanoma.
• Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their background. This resource is in most public libraries.

Preparing for Treatment

Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

These are some questions a patient may want to ask the doctor before treatment begins:

• What is my diagnosis?
• What is the stage of the disease?
• What are the treatment choices? Which do you recommend? Why?
• What are the chances that the treatment will be successful?
• How will we know if the treatment is working?
• How long will the treatment last?
• What can I do to take care of myself during treatment?
• What new treatments are being studied? Would a clinical trial be appropriate for me?
• What are the risks and possible side effects of each treatment? ? How will I feel after the operation?
• If I have pain, how can it be controlled?
• Will I need more treatment after surgery?
• Will I need a skin graft or plastic surgery? Will there be a scar?
• Will treatment affect my normal activities? If so, for how long?
• How often will I need checkups?
• What is the treatment likely to cost?

Patients do not need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

Methods of Treatment

Surgery

Surgery to remove (excise) a melanoma is the standard treatment for this disease. It is necessary to remove not only the tumor but also some normal tissue around it in order to minimize the chance that any cancer will be left in the area.

The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin. In cases in which the melanoma is very thin, enough tissue is often removed during the biopsy, and no further surgery is necessary. If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is necessary, even for thin melanomas. For thick melanomas, it may be necessary to do a wider excision to take out a larger margin of tissue.

If a large area of tissue is removed, a skin graft may be done at the same time. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.

Lymph nodes near the tumor may be removed during surgery because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has spread to other parts of the body.

Surgery is generally not effective in controlling melanoma that is known to have spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods. When therapy is given after surgery (primary therapy) to remove all cancerous tissue, the treatment is called adjuvant therapy. The goal of adjuvant therapy is to kill any undetected cancer cells that may remain in the body.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. It is generally a systemic therapy, meaning that it can affect cancer cells throughout the body. In chemotherapy, one or more anticancer drugs are given by mouth or by injection into a blood vessel (intravenous). Either way, the drugs enter the bloodstream and travel through the body.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

One method of giving chemotherapy drugs currently under investigation is called \l "limb perfusion". It is being tested for use when melanoma occurs only on an arm or leg. In limb perfusion the flow of blood to and from the limb is stopped for a while with a tourniquet. Anticancer drugs are then put into the blood of the limb. The patient receives high doses of drugs directly into the area where the melanoma occurred. Since most of the anticancer drugs remain in one limb, limb perfusion is not truly systemic therapy.

Biological therapy

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen side effects caused by some cancer treatments. Biological therapy is also a systemic therapy and involves the use of substances called biological response modifier (BRMs). The body normally produces these substances in small amounts in response to infection and disease. Using modern laboratory techniques, scientists can produce BRMs in large amounts for use in cancer treatment. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon and interleukin-2 (also called aldesleukin) may be recommended after surgery. Colony-stimulating factors and tumor vaccine are examples of other BRMs under study.

Radiation therapy

In some cases, radiation therapy (also called radiotherapy) is used to relieve some of the symptoms caused by melanoma. Radiation therapy is the use of high-energy rays to kill cancer cells. Radiation therapy is a local therapy; it affects cells only in the treated area. Radiation therapy is most commonly used to help control melanoma that has spread to the brain, bones, and other parts of the body.

Clinical Trials

Many people with melanoma take part in clinical trials (research studies). Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of melanoma. Each achievement brings researchers closer to the eventual control of melanoma.

A new procedure under study, called sentinel lymph node biopsy, may eventually reduce the number of lymph nodes that need to be removed for biopsy and possibly prevent or lessen the severity of lymphedema (build up of excess lymph in tissue that causes swelling). In this procedure, either a blue dye or a small amount of radioactive material is injected near the area where the tumor was. This material flows into the sentinel lymph node(s) (the first lymph node(s) that the cancer is likely to spread to from the primary tumor). A surgeon then looks for the dye or uses a scanner to find the sentinel lymph node(s) and removes it for examination by a pathologist. If the sentinel lymph node(s) is positive for cancer cells, then the rest of the surrounding lymph nodes are usually removed; if it is negative, the remaining lymph nodes may not need to be removed.

Doctors are also studying new ways of giving chemotherapy, biological therapies, and radiation therapy; new drugs and drug combinations; and new ways of combining various types of treatment. Some trials are designed to explore ways to reduce the side effects of treatment and to improve the quality of life.
People who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science. While clinical trials may pose some risks for the people who take part, each study takes steps to protect patients. Patients who are interested in taking part in a clinical trial should talk with their doctor.

Side Effects of Treatment

Doctors plan treatment to keep side effects to a minimum, but it is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend mainly on the type and extent of the treatment. Side effects may not be the same for everyone, and they may change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment, and they can help relieve symptoms that may occur during and after treatment.

Surgery

The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may be uncomfortable during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for awhile. The length of time it takes to recover from an operation varies for each patient.

Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can without increasing the chance of recurrence. In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was located, how well the person heals, and whether the person develops raised scars called keloid. When a tumor is large and thick, more surrounding skin and other tissue (including muscle) are removed. Although skin grafts reduce scarring from the removal of large growths, these scars will still be quite noticeable.

Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymph in the arm or leg. Lymph may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs and the doses received. In addition, as with other types of treatment, side effects vary from person to person. Generally, anticancer drugs affect cells that divide rapidly. In addition to cancer cells, these include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected, people are more likely to get infections, may bruise or bleed easily, and may feel unusually weak or tired. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, people may lose their hair and may have other side effects, such as poor appetite, nausea and vomiting, or mouth and lip sores.

Biological therapy

The side effects caused by biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also bleed or bruise easily, get a skin rash, or have swelling. These problems can be severe, but they go away after treatment stops.

Radiation therapy

The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur during treatment include fatigue and hair loss in the treated area. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.

Causes, Risk Factors, and Prevention

Researchers at hospitals and medical centers all across the country are studying melanoma. They are trying to learn what causes the disease and how to prevent it.

At this time, the causes of melanoma are not fully understood. It is clear, however, that this disease is not contagious; no one can "catch" cancer from another person.

By studying patterns of cancer in the population, researchers have found certain risk factor that are more common in people who develop melanoma than in people who do not get this disease. It is important to know, however, that most people with these risk factors do not get melanoma, and many who do get this disease have none of these risk factors.

The following are some of the factors associated with this disease:

• Family history of melanoma--Having two or more close relatives who have had this disease is a risk factor because melanoma sometimes runs in families. About 10 percent of all patients with melanoma have family members who also have had this disease. When melanoma runs in a family, the family members should be checked regularly by a doctor.
• Dysplastic nevi--Dysplastic nevi are more likely than ordinary moles to become cancerous. Many people have only a few of these abnormal moles; the risk of melanoma is greater for people with a large number of dysplastic nevi. The risk is especially high for people who have a family history of both dysplastic nevi and melanoma.
• History of melanoma--People who have been treated for melanoma are at a high risk for developing a second melanoma.
• Weakened immune system--People whose immune system is weakened by certain cancers, by drugs given following organ transplants, or by AIDS are at increased risk of developing melanoma.
• Many ordinary moles (more than 50)--Because melanoma usually begins in the melanocytes of an existing mole, having many moles increases the risk of developing this disease.
• Ultraviolet radiation--Experts believe that much of the worldwide increase in melanoma is related to an increase in the amount of time people spend in the sun. This disease is also more common in people who live in areas that get large amounts of UV radiation from the sun. In the United States, for example, melanoma is more common in Texas than it is in Minnesota, where the sun is not as strong. UV radiation from the sun causes premature aging of the skin and skin damage that can lead to melanoma. (Two types of ultraviolet radiation--UVA and UVB--are explained in the Glossary.) Artificial sources of UV radiation, such as sunlamps and tanning booths, also can cause skin damage and probably an increased risk of melanoma. To help prevent and reduce the risk of melanoma caused by UV radiation, people should avoid exposure to the midday sun (from 10 a.m. to 3 p.m.) whenever possible. Another simple rule is to protect yourself from the sun when your shadow is shorter than you are. Wearing a hat and long sleeves offers protection. Also, lotion, cream, or gel that contains sunscreen can help protect the skin. Many doctors believe sunscreens may help prevent melanoma, especially those that reflect, absorb, and/or scatter both types of ultraviolet radiation. Sunscreens are rated in strength according to a sun protection factor. The higher the SPF, the more sunburn protection is provided. Sunscreens with an SPF value of 2 to 11 provide minimal protection against sunburns. Sunscreens with an SPF of 12 to 29 provide moderate protection. Those with an SPF of 30 or higher provide high protection against sunburn. Sunglasses that have UV-absorbing lenses should also be worn. The label should specify that the lenses block at least 99 percent of UVA and UVB radiation.
• Severe, blistering sunburns--People who have had one or more severe, blistering sunburns as a child or teenager are at increased risk for melanoma. Because of this, doctors advise protecting children's skin from the sun, which they hope will help prevent, or at least reduce the risk of, melanoma later in life. Sunburns in adulthood are also a risk factor for melanoma.
• Fair skin--Melanoma occurs more frequently in people who have fair skin that burns or freckles easily (these people also usually have red or blond hair and blue eyes) than in people with dark skin. White people get melanoma far more often than do black people, probably because light skin is more easily damaged by the sun.

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