Melanoma: Types of Treatment

Approved by the Lineagotica Editorial Board, 01/2019

ON THIS PAGE: You will learn about the different types of treatments doctors use to treat people with melanoma. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for melanoma. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

The cancer care team

In cancer care, different types of health care professionals often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For a person with melanoma, this team may include these doctors:

  • Dermatologist: A doctor who specializes in diseases and conditions of the skin.

  • Surgical oncologist: A doctor who specializes in treating cancer with surgery.

  • Medical oncologist: A doctor who specializes in treating cancer with medication.

  • Radiation oncologist: A doctor who specializes in treating cancer with radiation therapy.

  • Pathologist: A doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

  • Radiologist: A medical doctor who specializes in using imaging tests to diagnose disease.

Cancer care teams include a variety of other important health care professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Treatment overview

Treatment recommendations depend on many factors, including the thickness of the primary melanoma, whether the cancer has spread, the stage of the melanoma, the presence of specific genetic changes in melanoma cells, rate of melanoma growth, and the patient’s other medical conditions. Other factors used in making treatment decisions include possible side effects, as well as the patient’s preferences and overall health. This section provides an overview of possible treatments and should not be considered treatment recommendations for individuals.

Descriptions of the common types of treatments used for melanoma are listed below. Later in this section, treatments are listed according to the stage of melanoma. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for melanoma because there are different treatment options. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. This procedure is usually performed by a surgical oncologist.

Surgery is the primary treatment for people with local melanoma and most people with regional melanoma. For some people with metastatic melanoma, surgery may also be an option. If surgery is not an option, the melanoma may be called “unresectable.” In recommending a specific treatment plan, doctors will consider the stage of the disease and the person’s individual risk of recurrence.

Types of surgery used to treat local and regional melanoma are wide excision, lymphatic mapping and sentinel lymph node biopsy, and lymph node dissection. Each is described in more detail below.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Wide excision

The main treatment for melanoma is surgical removal, or excision, of the primary melanoma on the skin. The extent of the surgery depends on the thickness of the melanoma. Most melanomas are found when they are less than 1.0 mm thick, and outpatient surgery is often the only treatment needed. A doctor removes the tumor, tissue found under the skin, and some surrounding healthy tissue, called a margin, so that no cancer cells remain. If a sentinel lymph node biopsy is also needed, it is usually done at the same time as the wide excision (see Diagnosis and below).

  • If the melanoma is staged as in situ (stage 0), the doctor may remove a margin of skin at least 5 mm (or 0.5 cm) around the cancer. Overall, the width of the margin increases with the thickness of the melanoma, ranging from a 1-cm margin for melanoma measuring up to 1.0 mm to a 2-cm margin for melanoma measuring over 2 mm.

  • Depending on the site and extent of the surgery, a skin flap or a skin graft may be necessary. A skin flap is created when nearby tissue is moved around to cover the area removed during surgery. A skin graft uses skin from another part of the body to close the wound.

Lymphatic mapping and sentinel lymph node biopsy

During this surgical procedure, the surgeon injects the area of the tumor with a dye and a radioactive tracer. This is to figure out which lymph nodes might be involved and whether the melanoma has spread to the lymph nodes. During these procedures, the surgeon removes 1 or more lymph nodes that take up the dye and/or radioactive tracer, called sentinel lymph nodes, to check for melanoma cells. If melanoma cancer cells are not found in the sentinel lymph node(s), no further lymph node surgery is required. If the sentinel lymph nodes contain melanoma, this is called a positive sentinel lymph node. This means the disease has spread, and lymph node dissection (see below) may be recommended.

These procedures are usually recommended for people with a melanoma that is more than 0.8-mm thick or has ulceration. However, a sentinel lymph node biopsy may also be recommended by a surgical oncologist for some other melanomas that are less than 0.8-mm thick depending on other, associated risk factors.

For non-ulcerated melanomas less than 0.8-mm thick, the likelihood that the cancer has spread to the lymph nodes is low, so sentinel lymph node mapping is not recommended in most cases. However, sometimes the doctor will recommend this procedure for a person with a thin, high-risk melanoma if there are other signs that the melanoma is more aggressive, such as ulceration (see Diagnosis). If the melanoma is less than 0.8 mm, your doctor will discuss whether this approach is recommended based on other features of the primary melanoma and other factors.

Sentinel lymph node mapping ideally should be performed during the same procedure as the wide excision because such surgery can change the lymphatic drainage pattern. This may affect the reliability of the procedure in some situations.

Lymph node dissection

If biopsy results show that cancer is found in the sentinel lymph nodes, doctors may consider removing the remaining lymph nodes in that area with surgery. This is called completion or complete lymph node dissection (CLND). The number of lymph nodes removed depends on the area of the body. A patient may take longer to recover after CLND and have a higher risk of side effects. People who have had a lymph node dissection around an arm or leg have a higher risk for fluid buildup in that limb, a side effect called lymphedema.

Some research has shown that people who have a CLND after a positive sentinel lymph node biopsy live for the same amount of time as those who are closely watched for signs of cancer and do not receive a CLND unless there are signs that the disease is growing. As a result, some people decide not to have a CLND. Talk with your doctor about the possible risks and benefits of having lymph node dissection.

This information is based on ASCO recommendations for sentinel lymph node biopsy for melanoma. Please note that this link takes you to another ASCO website.

Sometimes an enlarged lymph node is found during a physical exam, after a scan, or during an ultrasound. If this happens, doctors usually perform staging. If no other evidence of spread is found, they may recommend a lymph node dissection. Doctors generally agree it is important to remove all lymph nodes in these situations.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. The radiation beam produced by this machine can be pointed in different directions and blocked using special techniques to help decrease side effects. The radiation oncologist will recommend a specific radiation therapy regimen, or schedule, with a total number of treatments and dose of radiation.

Sometimes, radiation therapy is recommended after surgery to prevent the cancer from coming back, called a recurrence. Radiation therapy given in this manner is called adjuvant radiation therapy. Research has shown that although this may reduce the risk of the melanoma coming back in the area that received radiation, it does not increase how long a person lives. People who receive adjuvant radiation therapy experience side effects based on which area of the body was treated. In general, a person’s overall quality of life is similar to that of people who do not receive it, according to the results of recent clinical trials. However, in those studies, some patients who received adjuvant radiation therapy had worse symptoms in the first year.

If melanoma that has spread and causes symptoms, such as bone pain or headaches, then radiation therapy may help relieve those symptoms. This is called palliative radiation therapy. For some people, palliative radiation therapy is given to an entire organ with several small doses of radiation, such as to the entire brain using whole-brain radiation therapy. Other times, 1 or just a few high doses of radiation therapy are given using a linear accelerator (or "linac," for short), Gamma Knife, CyberKnife, or TomoTherapy units. This is called stereotactic radiosurgery, stereotactic ablative radiation therapy, or stereotactic body radiation therapy. It usually works best for just 1 or a few tumors in the brain or elsewhere in the body.

Radiation therapy may be used when cancer has extensive spread to the lymph nodes or skin and cannot be removed by surgery. Researchers also are testing the effectiveness of combining radiation therapy and medicines for melanoma.

Learn more about the basics of radiation therapy.

Side effects of radiation therapy

General side effects of radiation therapy include skin irritation and fatigue. These usually get better a few weeks after radiation therapy is finished. Topical corticosteroid creams and antibiotics may be used to help prevent and treat radiation-induced skin reactions.

Depending on the area of the body being treated with radiation therapy, other side effects may develop. For example, after treatment to the head and/or neck region, temporary irritation of the mouth or difficulty swallowing can occur. If treatment was directed at the armpit or groin area, the person may have higher risk of fluid buildup in that limb, a side effect called lymphedema. Lymphedema can be a long-term, ongoing side effect. Talk with the radiation oncologist to learn more about the possible side effects that you may experience and how they can be managed.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for melanoma include:

  • Immunotherapy

  • Targeted therapy

  • Chemotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Learn more about the basics of immunotherapy.

In recent years, there have been major advances in treating stage III-IV melanoma with immunotherapy. Although immunotherapy can be effective at treating melanoma, there are many possible side effects of the treatment. Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Learn more about the side effects of immunotherapy.

Talk with your doctor about possible side effects for the immunotherapy recommended for you. Different types of immunotherapy are described below.

PD-1 inhibitors

In immunotherapy for melanoma, there are 2 monoclonal antibodies that block a protein called programmed death-1 (PD-1) that have been approved by the FDA to treat stage III or metastatic melanoma: nivolumab (Opdivo) and pembrolizumab (Keytruda). PD-1 is found on the surface of T cells. T cells are a type of white blood cell that directly helps the body’s immune system fight disease. The PD-1 protein keeps the immune system from destroying the cancer. Because these drugs stop PD-1 from working, the immune system is able to better target melanoma cells.

Both nivolumab and pembrolizumab have been shown to shrink melanoma for 25% to 45% of patients, depending on when the treatment is given. Side effects occur less frequently with nivolumab and pembrolizumab compared to ipilimumab (Yervoy, see below). Because of this, nivolumab and pembrolizumab are now being recommended as a first treatment option for people diagnosed with metastatic melanoma.

New PD-1 and PD-L1 inhibitors are being developed and studied.

CTLA4 inhibitors

Ipilimumab (Yervoy) is an immunotherapy that targets a molecule called cytotoxic T-lymphocyte associated molecule-4 (CTLA4). There have been 2 clinical trials that showed that people taking ipilimumab had a better chance of survival than people who only received traditional chemotherapy (see below). Ipilimumab has been shown to shrink melanoma for 10% to 15% of patients. Those responses may last years and are permanent in many patients who benefit.

Ipilimumab works by taking the brakes off the immune system. Because this drug activates the immune system, it can trigger “autoimmune” side effects in which the patient’s own immune system attacks healthy cells in the body. These side effects can be serious and even life threatening.

These side effects include significant colon inflammation (colitis), liver problems, skin reactions, nerve and hormone gland inflammation, and eye problems. Patients are closely monitored for diarrhea, rashes, itching, and other side effects. Before treatment begins, be sure to talk to your health care team about potential side effects. Let your health care team know right away if you develop any new symptoms during treatment. It is also important to tell your health care team about all other medications you are taking, including over-the-counter drugs and dietary or herbal supplements, to avoid possible side effects from drug interactions with ipilimumab. Learn more about this medication and its side effects in this Lineagotica podcast.

Ipilimumab is approved by the FDA for adjuvant treatment of stage III melanoma. In patients with stage III melanoma, ipilimumab has been shown to delay recurrences and lengthen life for some patients, but the rate of severe, life-threatening, or fatal side effects is around 50%. Because this therapy may lengthen life but also has a high rate of severe side effects, it is important for oncologists and people with stage III melanoma to discuss the risks and benefits of ipilimumab and decide together if the risks are worth the benefit.

Ipilimumab and other CTLA4 inhibitors continue to be studied in clinical trials. See the Latest Research section for more information.

Combining PD-1 and CTLA4 inhibitors

In 2015, the FDA approved the immunotherapy combination of ipilimumab and nivolumab for the treatment of unresectable stage III or stage IV melanoma. This combination is better than either drug alone in reducing the size of tumors and delaying growth of tumors. However, combining these drugs causes far more side effects and does not necessarily help people live longer. The decision to give this combination therapy is often based on how fast the cancer is growing, where the cancer has spread, and the general health of the person.

Interleukin-2 (IL-2, Proleukin)

Another type of immunotherapy is interleukin-2, which activates T cells. It is sometimes given to people with metastatic melanoma. The number of people for whom this treatment works is similar to that of ipilimumab (about 16%), with fewer than 10% of people experiencing a complete response. A complete response is defined as the disappearance of all signs of cancer as a result of treatment.

This treatment often has multiple and significant side effects. The most common side effects of IL-2 are low blood pressure, fever, chills, and a condition known as capillary leak syndrome. Capillary leak syndrome occurs when fluids and proteins leak from blood vessels, which can cause very low blood pressure and other dangerous effects. Patients treated with high-dose IL-2 require intensive monitoring by the health care team. IL-2 should be given by an experienced health care team familiar with the side effects of IL-2 treatment.

Virus therapy

Virus therapy is a type of immunotherapy. The FDA has approved the use of talimogene laherparepvec (T-VEC; Imlygic) for the treatment of unresectable stage III and stage IV melanoma. T-VEC is a herpes virus designed in a laboratory to make an immune-stimulating hormone. This virus can infect and destroy melanoma cells. T-VEC also helps stimulate the immune system to destroy other melanoma tumors.

T-VEC is injected directly into 1 or more melanoma tumors, so it is also called intralesional therapy. Since T-VEC has not been shown to cause significant shrinkage of non-injected tumors in most people, patients with widely metastatic disease are not usually offered this treatment. It may be offered, for example, to patients who have a tumor that can be felt during an exam and who have limited metastatic disease (a small number of tumors or small tumors) elsewhere, such as the lungs or liver. T-VEC is being studied in combination with other medications to improve its effectiveness.

Interferon

High-dose interferon alfa-2b (Intron A). When given over a year, high-dose interferon alfa-2b is an immunotherapy that has been shown to delay recurrences for some patients. However, it has not been shown to lengthen how long most people live. There are substantial and common side effects to this treatment, including flu-like symptoms, such as fatigue, fever, chills, nausea, vomiting, and headache; rashes; hair thinning; and depression. Because of the side effects and because it does not lengthen life for most patients who receive this treatment, the use of high-dose interferon is not recommended by all doctors who treat melanoma.

Pegylated interferon alfa-2b (Sylatron). This immunotherapy is given by weekly injection for up to 5 years and has been shown to delay recurrences for some patients. However, it has not been shown to lengthen how long people live. The side effects are very similar to those of high-dose interferon alfa-2b. Because of the side effects and most patients treated with it do not live longer, the use of pegylated interferon is not recommended by all doctors who treat melanoma.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. Learn more about the basics of targeted treatments.

As explained here and in Diagnosis, ongoing research has identified several key pathways and genes involved in the growth and spread of melanoma. These advances now allow doctors to tailor or personalize the treatment plan based on the melanoma’s genetic abnormalities or mutations.

A major focus in research is the development of new drugs that block specific biochemical pathways that melanoma cells need to grow. Different types of targeted therapy are described below.

BRAF inhibitors

Dabrafenib (Tafinlar) and vemurafenib (Zelboraf) are FDA-approved targeted therapies for people with both stage IV and stage III melanoma that cannot be surgically removed. These drugs, taken as a pill, are specifically used when the melanoma tumors have a V600E or V600K mutation in the BRAF gene (see Diagnosis). These drugs should not be used by patients without the mutation because it can actually be harmful for them.

In clinical trials for people with metastatic melanoma having the mutated BRAF gene, both drugs shrank the tumors in the majority of those patients. Vemurafenib was shown to extend patients’ survival by nearly a year, on average. Dabrafenib’s effect on overall survival was not formally tested. Based on these clinical trials, both drugs are approved for use for patients with locally advanced stage III melanoma that cannot be removed by surgery and for patients with stage IV melanoma, if the melanoma has the mutated BRAF gene.

Side effects of vemurafenib included skin problems, including rashes, hair thinning, thick or dry skin, sun sensitivity, and a less aggressive form of skin cancer called squamous cell carcinoma that can often be treated with minor surgery. Other side effects included joint pain, fatigue, nausea, fever, and hair thinning and curling. Talk with your doctor about what side effects may occur before treatment begins. Dabrafenib seems to have fewer side effects like thick or dry skin and hair thinning, and it only rarely causes sun sensitivity.

MEK inhibitors

Trametinib (Mekinist) is approved as a targeted therapy for unresectable or metastatic melanoma with a BRAF V600E or V600K mutation. This drug, which is taken as a pill, specifically targets the MEK protein, which is involved in cancer growth and survival. Trametinib was approved based on the results of a clinical study that showed people with stage IIIC or stage IV melanoma who took this targeted therapy lived longer without the cancer getting worse than those who received chemotherapy. The side effects of trametinib include an acne-like rash, nail inflammation, itching, dry skin, and diarrhea.

Combining BRAF and MEK inhibitors

The discovery that about 50% of melanomas have a mutated or activated BRAF gene has provided an important new direction in targeted therapy for melanoma. There have been 2 clinical trials showing that the combination of dabrafenib, a BRAF inhibitor, and trametinib, a MEK inhibitor, is associated with better tumor shrinkage rates, delay in tumor growth, and longer life compared to vemurafenib alone, in 1 study, and dabrafenib alone, in the other study. As a result of these trials, the FDA approved the combination of dabrafenib with trametinib for the treatment of melanoma that cannot be surgically removed or metastatic melanoma with a BRAF V600E or V600K mutation in 2014. Using this combination would not be expected to help people who have melanoma that does not have a detectable BRAF mutation.

In a more recent clinical trial, 1 year of treatment with the combination of dabrafenib and trametinib was shown to improve outcomes in people with stage III melanoma after the completion of surgery. This data led to the approval of this combination, in 2018, as an adjuvant therapy for people with stage III melanoma that has been removed by surgery.

The most common side effects of treatment with trametinib combined with dabrafenib include fever, chills, tiredness, rash, nausea, vomiting, diarrhea, abdominal pain, swelling in the hands and feet, cough, headache, joint pain, night sweats, decreased appetite, constipation, and muscle pain. Interestingly, the combination of dabrafenib and trametinib reduces some side effects when compared to either of the medicines taken separately, including a lower rate of secondary skin cancers and rash.

A second BRAF and MEK inhibitor combination is approved by the FDA in 2015. It consists of the BRAF inhibitor vemurafenib and the MEK inhibitor cobimetinib (Cotellic). A clinical trial has shown that the combination of vemurafenib and cobimetinib is associated with better tumor shrinkage rates, delay in tumor growth, and longer life compared to vemurafenib alone. The common side effects with this combination include tiredness, nausea, diarrhea, joint aches, sun sensitivity, rash, fever, liver irritation, and swelling in the hands and feet.

In June 2018, the FDA approved a third combination, which includes the BRAF inhibitor encorafenib (Braftovi) and the MEK inhibitor binimetinib (Mektovi). A phase III clinical trial showed that this combination helped people live longer than those treated with vemurafenib alone. The most common side effects of this combination were fatigue, nausea, diarrhea, vomiting, abdominal pain, and joint pain.

Because of the improved outcomes and reduced side effects of BRAF and MEK inhibitor combinations compared to BRAF or MEK inhibitors alone, it is standard practice to recommend 1 of these 3 approved combinations when targeted therapy is being offered to patients with tumors that have BRAF mutations.

KIT inhibitors

Researchers are also focusing on the development of targeted therapies for the KIT gene, which is mutated or present in increased numbers (extra copies of the gene) in some tumors in certain subtypes of melanoma, including lentigo maligna melanoma, mucosal melanoma, and acral lentiginous melanoma. Drugs currently being tested in clinical trials for people with stage IV, mutated KIT melanoma include dasatinib (Sprycel), imatinib (Gleevec), and nilotinib (Tasigna).

Tumor-agnostic treatment

Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a certain type of cancer but focuses on a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including melanoma. It is approved as a treatment for melanoma with an NTRK fusion that is metastatic or cannot be removed with surgery and has worsened with other treatments.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

Traditional types of chemotherapy are still used to treat melanoma, but they are usually no longer used as first-line therapy. First-line therapy is the initial treatment recommended after a cancer diagnosis.

A chemotherapy regimen, or schedule, usually consists of a set number of cycles given over a specific time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. Dacarbazine (DTIC; available as a generic drug) is the only FDA-approved chemotherapy for melanoma. Temozolomide (Temodar) is essentially an oral version of dacarbazine, and it is used for the treatment of stage IV melanoma.

Both DTIC and temozolomide have been shown to shrink melanoma for about 12% to 15% of patients. However, no clinical trials have tested whether these drugs help people with melanoma live longer after treatment. Both drugs have a limited number of side effects. Talk with your doctor about possible side effects of these drugs.

Other chemotherapies used to treat melanoma include a generic drug called cisplatin, fotemustine (Muphoran, which is only approved in Europe) lomustine (Gleostine), the taxanes (a group of drugs that includes docetaxel [Taxotere] and paclitaxel [Taxol]), and another generic drug called vinblastine. Combinations of chemotherapy drugs, such as paclitaxel plus carboplatin or cisplatin combined with vinblastine and dacarbazine may be used. Some chemotherapy drug combinations may have a higher chance of causing melanoma to shrink, but they also cause more side effects.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, nail changes, loss of appetite, diarrhea, some nerve damage causing changes in sensation, and hair loss. These side effects usually go away after treatment is finished.

Learn more about the basics of chemotherapy.

Isolated limb infusion therapy

Sometimes melanoma may spread and appear as a number of tumors that develop in the leg or arm. In these situations, there are too many tumors for surgery to be possible or helpful. A doctor may recommend isolated limb infusion or perfusion with chemotherapy.

During this treatment, a tourniquet is placed on the arm or leg before high doses of chemotherapy are given via a catheter, which typically is placed by the interventional radiology team. The tourniquet keeps the chemotherapy in the arm or leg and prevents it from being transported throughout the body. This therapy typically is administered with general anesthesia.

Around 50% to 80% of tumors located in the area where the chemotherapy is circulated shrink as a result of this treatment. While tumor shrinkage is usually temporary, melanoma may be controlled for a year or more in some people. Researchers are also testing the effectiveness of combining isolated limb infusion therapy with other medicine.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Treatment options by stage of melanoma

This section describes the treatment options that may be recommended for each stage of melanoma. In-depth descriptions of each type of treatment are provided earlier in this page. Remember, clinical trials are also a potential treatment option for each stage of melanoma.

Stage 0 melanoma

Stage 0 melanoma is almost always treated with surgery alone, usually a wide excision.

Stage I melanoma

Stage I melanoma is usually treated with surgical removal of the tumor and some of the healthy tissue around it. The doctor may recommend lymph node mapping, and some lymph nodes may be removed.

Stage II melanoma

The standard treatment for stage II melanoma is surgery to remove the tumor and some of the healthy tissue around it. While this surgery is being done, lymph node mapping and sentinel lymph node biopsy may also be done. In some people with stage II melanoma, treatment with interferon may be recommended after surgery to lower the chances of the cancer coming back.

Stage III melanoma that can be removed with surgery

Stage III melanoma has spread locally or through the lymphatic system to a regional lymph node located near where the cancer started or to a skin site on the way to a lymph node. If the stage III melanoma can be removed with surgery, then that will be the first treatment option. The lymph nodes may be checked for cancer and removed. After surgery, treatment with immunotherapy or targeted therapy may be recommended to prevent the cancer from coming back.

Advanced melanoma

Advanced melanoma is a stage III melanoma that cannot be treated with surgery or stage IV melanoma. Stage IV melanoma has spread to other distant parts of the body, such as distant lymph nodes or the liver, lung, brain, bone, or gastrointestinal tract. Doctors may refer to this as metastatic melanoma. If this happens, it is a good idea to talk with doctors who have experience treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Stage III melanoma that cannot be removed with surgery, sometimes called unresectable stage III, and stage IV melanoma are often treated the same way, with immunotherapy, targeted therapy, and chemotherapy. Palliative treatments intended to relieve symptoms may also be recommended, such as surgery or radiation therapy to treat affected lymph nodes and smaller tumors that have spread elsewhere in the body. The treatment plan will also depend on a number of factors:

  • The person’s age and overall health

  • The locations and number of metastases

  • How fast the disease is spreading

  • The presence of specific genetic mutations in the tumor

  • The patient’s preferences

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Treating brain metastases

The brain is one of the most common places to which melanoma spreads. Unfortunately, the presence of brain metastases is linked with a poor prognosis. Prognosis is the chance of recovery. Traditionally, less than 50% of people with melanoma that has spread to the brain live 6 months, although this is changing in recent years. Because of this poor prognosis and because of the perceived difficulty in getting chemotherapy drugs into brain tissue (called the blood-brain barrier), people with melanoma that has spread to the brain have typically not been allowed into clinical trials. Fortunately, this is beginning to change, and there are clinical trials for patients with melanoma and brain metastases. Read this fact sheet to learn more about cancer that has spread to the brain.

Currently, the following treatments may be recommended for melanoma that has spread to the brain:

  • Radiation therapy. High-dose radiation therapy given using stereotactic techniques is often used when there are only a few metastatic tumors in the brain. These techniques are highly effective for getting rid of existing tumors. However, they do not prevent new tumors from developing. The entire brain can be treated with radiation therapy, called whole-brain radiation therapy. However, because the dose of radiation used to treat the entire brain is lower, this type of treatment usually does not shrink tumors and commonly causes problems with thinking clearly (cognition).

  • BRAF inhibitors. For people with melanoma that has a BRAF mutation, drugs such as dabrafenib and vemurafenib may be recommended. These drugs easily penetrate into the brain. Clinical trials have shown that melanoma tumors in the brain treated with these medications shrink around 40% to 50% of the time.

  • Immunotherapy. Ipilimumab, nivolumab, and pembrolizumab have recently been studied in in clinical trials to treat people with melanoma that has spread to the brain. These trials have shown that these treatments can help patients with melanoma and brain metastases. In particular, the combination of ipilimumab and nivolumab appears to be the most effective therapy for such patients, although due to the high rate of side effects, this treatment may not be the right choice for everybody.

Learn about caring for someone with cancer that has spread to the brain.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the melanoma returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another part of the body (distant recurrence).

When this occurs, a new cycle of testing will begin to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, chemotherapy, immunotherapy, targeted therapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.