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  • Treatment for melanoma

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    Treatment for early melanoma

    Melanoma that is found early (stages 0–II or localised melanoma) can generally be treated successfully with surgery. If the melanoma has spread to nearby lymph nodes or tissues (stage III or regional melanoma), treatment may also include removing lymph nodes and additional (adjuvant) treatments.

    Surgery

    Surgery to remove the mole is the main treatment for early melanoma, and it can also be the only treatment you need.

    Wide local excision

    Even though the excision biopsy to diagnose melanoma often removes the melanoma, a doctor or surgeon may also do a procedure called wide local excision. This means removing more normal-looking skin from around the melanoma (wider margin).

    Removing more tissue around the melanoma reduces the risk of it coming back (recurring) at that site. In the latest melanoma guidelines, it is recommended that the margin is usually between 5 mm and 1 cm, depending on the type, thickness and site of the melanoma. For thicker tumours, a wider margin of up to 2 cm may be advised.

    A pathologist will check the tissue around the melanoma for cancer cells. If the sample doesn’t contain any cancer cells, it is called a clear margin. If the margins aren’t clear, you may need further surgery.

    A wide local excision is often performed as a day procedure using a local anaesthetic. This means you can go home soon after the surgery, provided there are no complications. People with a melanoma thicker than 1 mm will usually be offered a sentinel lymph node biopsy at the same time.

    For more information about surgery, call Cancer Council 13 11 20 or you can download the booklet Understanding Surgery.

    Repairing the wound

    Most people will be able to have the wound closed with stitches. You will have a scar but this will become less noticeable with time.

    If a large area of skin is removed, the wound may be too big to close with stitches. In this case, the surgeon may repair it using skin from another part of your body. This can be done in two ways:

    Skin flap – nearby skin and fatty tissue are lifted and moved over the wound from the edges and stitched.

    Skin graft – a layer of skin is taken from another part of your body (usually the thigh or neck) and placed over the area where the melanoma was removed. The skin grows back quickly over a few weeks.

    The decision about whether to do a skin flap or graft will depend on many factors, such as where the melanoma is, how much tissue has been removed and your general health. In either case, the wound will be covered with a dressing. After several days, it will be checked to see if the wound is healing properly. If you had a skin graft, you will also have dressings on any area that had skin removed for the graft.

    Removing lymph nodes

    If your doctor’s examination, ultrasound or lymph node biopsy shows that the melanoma has spread to your lymph nodes (regional melanoma or stage III), you will have scans regularly and, in some cases, may be offered immunotherapy or targeted therapy (systemic treatment). If melanoma has spread to lymph nodes and caused a lump, the lymph nodes will be removed in an operation called a lymph node dissection or lymphadenectomy. This is performed under a general anaesthetic and requires a longer stay in hospital. Usually only the lymph nodes near the melanoma are removed.

    Side effects of lymph node dissection

    Having your lymph nodes removed can cause side effects, such as:

    Wound pain – Most people will have some pain after the operation, which usually improves as the wound heals. For some people, the pain may be ongoing, especially if lymph nodes were removed from the neck. Talk to your medical team about how to manage your pain.

    Neck/shoulder/hip stiffness and pain – These are the most common problems if lymph nodes in your neck, armpit or groin were removed. You may find that you cannot move the affected area as freely as you could before the surgery. It may help to do gentle exercises or see a physiotherapist.

    Seroma/lymphocele – This is a collection of fluid in the area where the lymph glands have been removed. It is a common side effect of lymph node surgery. Sometimes this fluid is drained by having a needle inserted into the fluid-filled cavity after surgery.

    Lymphoedema

    If lymph nodes have been surgically removed, your neck, arm or leg may swell. This is called lymphoedema. It happens when lymph fluid builds up in the affected part of the body because the lymphatic system is not working as it should.

    The chance of developing lymphoedema following melanoma treatment depends on the extent of the surgery and whether you’ve had radiation therapy that has damaged the lymph nodes. It can develop a few weeks, or even several years, after treatment. Although lymphoedema may be permanent, it can usually be managed, especially if treated at the earliest sign of swelling or heaviness.

    How to prevent and/or manage lymphoedema

    • Keep the skin healthy and unbroken to reduce the risk of infection.
    • Wear a professionally fitted compression garment if recommended by your doctor or lymphoedema practitioner.
    • Always wear gloves for gardening, outdoor work and housework.
    • Moisturise your skin daily to prevent dry, irritated skin.
    • Protect your skin from the sun
    • Don’t pick or bite your nails, or cut your cuticles.
    • Try to avoid scratches from pets, insect bites, thorns, or pricking your fingers.
    • Do regular exercise to help the lymph fluid flow, such as swimming, bike riding or yoga.
    • Massage the affected area to help move lymph fluid.
    • Avoid having blood taken or blood pressure done on the arm on the affected side.
    • Visit lymphoedema.org.au to find a lymphoedema practitioner or ask your doctor for a referral.
    • If your skin feels swollen or hot, see your doctor as soon as possible as these may be signs of infection.

    For more information about lymphoedema, call Cancer Council 13 11 20 or download our fact sheet Understanding Lymphoedema.

    Adjuvant treatment

    If there’s a risk that the melanoma could come back (recur) after surgery, other treatments are sometimes used to reduce that risk. These are known as adjuvant (or additional) treatment. They may be used alone or together.

    Some treatments enter the bloodstream and travel throughout the body. This is known as systemic treatment, and includes:

    • immunotherapy – drugs that help the body’s immune system to recognise and fight some types of cancer cells
    • targeted therapy – drugs that attack specific features within cancer cells known as molecular targets to stop the cancer growing and spreading.

    In some cases, people may be offered radiation therapy (also known as radiotherapy). This is the use of targeted radiation to damage or kill cancer cells.

    For more information call Cancer Council 13 11 20 or download Understanding Immunotherapy, Understanding Targeted Therapy or Understanding Radiation Therapy.

    Treatment for advanced melanoma

    When melanoma has spread to distant lymph nodes or other internal organs or bones (stage IV), it is known as advanced melanoma or metastatic melanoma. Treatment may include surgery, systemic treatment with immunotherapy or targeted therapy, and radiation therapy. Palliative treatment may also be offered to help manage your symptoms and improve quality of life.

    Since the development of more effective treatments, chemotherapy is rarely used to treat melanoma.

    Treatment for advanced melanoma is complex and it is best that you are treated by a specialist melanoma unit. The team will discuss the best treatment for you based on the thickness of the melanoma and how far the melanoma has spread.

    Surgery

    In some cases, surgery may be recommended for people with advanced melanoma. Surgery is used to remove melanoma from areas on the skin, lymph nodes, or other organs such as the lung, brain or bowel.

    Talk to your treatment team about what is involved and what recovery will be like. Your suitability for surgery will be discussed with a multidisciplinary team. They will also consider other options including systemic treatment, radiation therapy and other local therapies.

    For more information about surgery, call Cancer Council 13 11 20 or you can download the booklet Understanding Surgery.

    Immunotherapy

    There have been several advances in using immunotherapy drugs known as checkpoint inhibitors to treat melanoma. On the surface of the body’s immune cells are proteins called “checkpoints” that stop the immune system from attacking cancer cells. Checkpoint inhibitors block these proteins so the immune cells can recognise and attack the melanoma. Checkpoint inhibitors approved for advanced melanoma include ipilimumab, nivolumab and pembrolizumab. These drugs are usually given into a vein (intravenously).

    Checkpoint inhibitors do not work for all advanced melanoma, but some people have had very encouraging results. Immunotherapy drugs are sometimes used in combination, and different combinations of drugs work for different people. Treatments in this area are changing rapidly. Talk to your doctor about whether immunotherapy is appropriate for you.

    Side effects of immunotherapy

    The side effects of immunotherapy drugs will vary depending on which drugs you are given. Immunotherapy can cause inflammation in any of the organs in the body, which can lead to side effects such as joint pain, diarrhoea or skin problems such as an itchy rash.

    Autoimmune disease may develop and this is generally monitored closely. It’s important to discuss any side effects with your medical team as soon as they appear so they can be managed appropriately. Early treatment for side effects is likely to shorten how long they last. Let your medical team know if you are experiencing side effects that concern you.

    For more information about immunotherapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Immunotherapy.

    Targeted therapy

    New types of drugs known as targeted therapy attack specific genetic mutations within cancer cells, while minimising harm to healthy cells. They are generally taken as tablets (orally). Targeted therapy is most commonly used for advanced melanoma that has spread to other organs or if the melanoma has come back after surgery.

    Several different targeted therapy drugs have been approved for people who have the BRAF mutation. Drugs are often used together to help block the effects of the BRAF mutation and reduce the growth of the melanoma. Drugs for NRAS and C-KIT mutations may be available through clinical trials – talk to your doctor about whether you are a suitable candidate.

    Cancer cells may become resistant to targeted therapy drugs over time. If this happens, your doctor will suggest trying another type of systemic therapy.

    Side effects of targeted therapy

    The side effects of targeted therapy will vary depending on which drugs you are given. Common side effects include fever, tiredness, loss of appetite, joint aches and pains, nausea, rash and other skin problems, diarrhoea, and high blood pressure. Ask your treatment team for advice about dealing with any side effects.

    It is important to let your doctor know immediately of any side effects. If left untreated, some side effects can become serious.

    For more information about targeted therapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Targeted Therapy.

    Radiation therapy

    Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply and spread. Radiation therapy may be offered on its own or in combination with other treatments, and may be recommended:

    • when the cancer has spread to the lymph nodes
    • after surgery to prevent the melanoma coming back
    • as palliative treatment to improve quality of life by relieving pain and other symptoms.

    Before starting treatment, you will have a planning appointment where a CT scan is performed. The radiation therapy team will use the images from the scan to plan your treatment. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.

    During treatment, you will lie on a table under a machine that aims radiation at the affected part of your body. Treatment sessions are usually given daily over one to four weeks. The number of treatment sessions will depend on the size and location of the tumour, and your general health. Each session takes about 20–30 minutes and is painless – similar to having an x-ray.

    Stereotactic body radiation therapy (SBRT)

    This is a way of delivering highly focused radiation therapy to the tumour, while the surrounding tissue receives a low dose. It is delivered from multiple beams that meet at the tumour. SBRT often involves four treatment sessions over a couple of weeks.

    Side effects of radiation therapy

    The side effects you experience will depend on the part of the body that receives radiation therapy and how long you receive treatment. Many people will develop temporary side effects, such as skin reactions and tiredness, during treatment. Skin in the treatment area may become red and sore during or immediately after radiation therapy, and these side effects may build up over time. Ask your treatment team for advice about dealing with any side effects.

    For more information about radiation therapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Radiation Therapy.

    Palliative treatment

    In some cases of advanced melanoma, the medical team may talk to you about palliative treatment. Palliative treatment aims to manage symptoms without trying to cure the disease. It can be used at any stage of advanced cancer to improve quality of life and does not mean giving up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

    As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiation therapy or drug therapies.

    Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs. The team also supports families and carers.

    For more information about palliative care, call Cancer Council 13 11 20 or you can download the booklets Understanding Palliative Care and Living with Advanced Cancer.

    This website page was last reviewed and updated November 2019.

    Information reviewed by: : A/Prof Victoria Atkinson, Senior Staff Specialist, Princess Alexandra Hospital, Visiting Medical Oncologist, Greenslopes Private Hospital, and The University of Queensland Clinical School of Medicine, QLD; Adjunct Prof John Kelly AM, Consultant Dermatologist, Victorian Melanoma Service, and Department of Medicine at Alfred Health, Monash University, VIC; Dr Alex Chamberlain, Dermatologist, Glenferrie Dermatology, Victorian Melanoma Service and Monash Univeristy, VIC; Alison Button-Sloan, Melanoma Patients Australia; Peter Cagney, Consumer; Prof Brendon J Coventry, Associate Professor of Surgery, The University of Adelaide, Surgical Oncologist, Royal Adelaide Hospital, and Research Director, Australian Melanoma Research Foundation, SA; Dr David Gyorki, Consultant Surgical Oncologist, Peter MacCallum Cancer Centre, VIC; Liz King, Skin Cancer Prevention Manager, Cancer Council NSW; Shannon Jones, SunSmart Health Professionals Coordinator, Cancer Council Victoria; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Prof Richard Scolyer, Senior Staff Specialist, Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Co-Medical Director, Melanoma Institute Australia and Clinical Professor, The University of Sydney, NSW; Heather Walker, Chair, Cancer Council National Skin Cancer Committee, Cancer Council Australia.

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