Melanoma

ON THIS PAGE: You will find a basic drawing of the layers that make up the skin. Use the menu to see other pages.

Copyright 2004 American Society of Clinical Oncology. Robert Morreale.

The next section in this guide is Risk Factors and Prevention . It describes the factors that may increase the chance of developing melanoma and ways to help reduce your risk. Use the menu to choose a different section to read in this guide.

ON THIS PAGE: You will find out more about the early detection of melanoma. Use the menu to see other pages.

How are people screened for melanoma?

Early detection and recognition of skin cancer are very important. Recognizing the early warning signs of melanoma and doing regular self-examinations of your skin can help find melanoma early, when the disease is more curable. Your doctor may also recommend screenings done by a health care professional and/or medical tests based on your risk factors and medical history.

Self-examination

Melanoma can appear anywhere on the body, even on areas that are not exposed to the sun. The most frequent locations for melanoma are the face, scalp, trunk or torso (chest, abdomen, back), legs, and arms. However, a subtype of melanoma called acral melanoma can develop under the fingernails or toenails, on the palms of hands or soles of feet, or on the tips of fingers and toes. Mucosal melanoma can develop on mucous membranes, such as skin that lines the mouth, nose, vagina, and anus.

Self-examinations should be performed in front of a full-length mirror in a brightly lit room. It helps to have another person check the scalp and back of the neck. Include the following steps in a self-examination:

• Examine the front and back of the entire body in a mirror, then the right and left sides, with arms raised.

• Bend the elbows and look carefully at the outer and inner forearms, upper arms (especially the hard-to-see back portion), and hands.

• Look at the front, sides, and back of the legs and feet, including the soles and the spaces between the toes.

• Part the hair to lift it and examine the back of the neck and scalp with a hand mirror.

• Check the back, genital area, and buttocks with a hand mirror.

• If you suspect that certain areas of skin are changing, take photos of the lesion(s) to look for changes over time.

Talk with your doctor or a dermatologist if your hairdresser or barber has noticed a suspicious skin area, or lesion, on your scalp or beard or if you find any of the following during a self-examination:

• A growth on the skin that matches any symptom listed in Symptoms and Signs

• New growth on the skin

• A suspicious change in an existing mole or spot

• A sore that does not heal within 2 weeks

Learn more about what to expect during a skin cancer screening with a health care professional.

Medical tests for early detection

A painless medical technique being used for early detection of melanoma is epiluminescence microscopy, or dermoscopy. Using a handheld device, a doctor can evaluate the patterns of size, shape, and pigmentation in pigmented skin lesions. Among trained, experienced medical professionals, dermoscopy may reduce the number of biopsies (see Diagnosis ) of pigmented lesions to rule out melanoma, although more research is needed.

Confocal scanning laser microscopy is another new technology that may improve the examination of possible melanoma lesions. Currently, it is only used in research studies, called clinical trials, and is available in a few major medical centers.

The next section in this guide is Symptoms and Signs . It explains what changes or medical problems melanoma can cause. Use the menu to choose a different section to read in this guide.

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find out whether a suspicious lesion or other skin growth is cancerous. Use the menu to see other pages.

Doctors use many tests to find, or diagnose, cancer. They also may perform tests to learn if cancer has spread to another part of the body from where it started, such as imaging tests, which show pictures of the inside of the body. If the melanoma has spread, it is called metastasis. Doctors may also do tests to learn which treatments could work best.

How melanoma is diagnosed

For melanoma, a biopsy of the suspicious skin area, called a lesion, is the only sure way for the doctor to know if it is cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. The doctor may suggest other tests that will help make a diagnosis and determine the overall stage of the melanoma.

There are different tests used for diagnosing melanoma. Not all of the tests described here will be used for every person. Your doctor will consider several factors when choosing diagnostic tests for each person.

Biopsy and pathological examination of a skin lesion

Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. Before a biopsy, a health care provider will usually numb the area with a local anesthetic. Anesthetic is medication that blocks the awareness of pain. Then they will remove a part or all of the suspicious skin growth, typically making sure to preserve the entire lesion so the thickness of the potential cancer and its margin (healthy tissue around the lesion) can be carefully examined.

A pathologist or dermatopathologist analyzes the sample(s) removed during the biopsy to figure out if the lesion is a melanoma. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A dermatopathologist is a pathologist or dermatologist with specialty training in diagnosing skin cancer and other disorders of the skin using a microscope and other laboratory tests.

The pathologist or dermatopathologist will write a report, called a pathology report , that should include the following information:

• Thickness of the melanoma

• Presence or absence of ulceration

• Mitotic rate, which is the frequency with which the cells are dividing

• The type and/or subtype of melanoma

• Presence of immune cells called tumor-infiltrating lymphocytes

• Margin status, which describes whether melanoma cells can be seen at the deep and/or peripheral (side) edges of the biopsy sample

• Presence or absence of certain markers associated with prognosis and/or response to different therapies

• Presence or absence of cancer cells in the lymph vessels or blood vessels, which is called lymphovascular invasion

Additional information is described in detail below.

Types of melanoma of the skin defined by pathologists

The 4 most common types of skin, or cutaneous, melanoma are:

• Superficial spreading melanoma. This is the most common type, making up 70% of melanomas. It usually develops from an existing mole.

• Lentigo maligna melanoma. This type of melanoma tends to occur in older people. It most commonly begins on the face, ears, arms, and other skin that is often exposed to the sun.

• Nodular melanoma. This type accounts for about 15% of melanomas. It often appears rapidly as a bump on the skin. It is usually black, but it may be pink or red.

• Acral lentiginous melanoma. This type of melanoma develops on the palms of the hands, soles of the feet, or under the nail bed. It sometimes occurs on people with darker skin. Acral lentiginous melanoma is not related to sun exposure.

Subtypes of melanoma defined by gene mutations

Melanoma cells are usually classified by histologic types (listed above), which are based on how the cells appear under a microscope. Recent information has shown that melanoma can also be classified into molecular (genetic) subtypes. These molecular subtypes are based on the specific genetic changes in the melanoma cells, called mutations. These genetic changes include:

• BRAF mutations. The most common genetic change in melanoma is found in the BRAF gene, which is mutated in about 50% of cutaneous melanomas.

• NRAS mutations. NRAS is mutated in the tumors of around 20% of people with melanoma.

• NF-1 mutations. NF-1 mutations are present in the tumors of around 10% to 15% of people with melanoma.

• KIT mutations. These mutations occur more commonly in melanomas that develop from mucus membranes (mucosal melanoma), melanomas on the hands or feet (acral melanoma), or melanomas that occur in chronically sun-damaged skin, such as lentigo maligna melanoma.

Some melanomas do not have mutations in the BRAF , NRAS , NF-1, or KIT genes. These tumors have other genetic changes that cause them to grow. Researchers are trying to target other mutations found in these tumors in clinical trials.

The classification of melanoma into different subtypes based on genetic changes can have a major effect on the types of treatment used for advanced melanoma. Targeting specific mutated genes is an important way of treating invasive melanoma, called targeted therapy. Learn more about targeted therapy in the Types of Treatment and Latest Research sections.

Melanoma tumor thickness

The thickness of the primary melanoma tumor is the most reliable characteristic that helps doctors predict the risk that the cancer will spread. To do this, the pathologist will measure the depth of the melanoma from near the top of the skin down to the bottom of the melanoma in the underlying skin or fatty tissue below.

• Thin. A melanoma tumor that is less than 1 mm thick is characterized as "thin." A thin melanoma is associated with a low risk of spreading to regional lymph nodes or to distant parts of the body.

• Intermediate. An intermediate-thickness melanoma is between 1 mm and 4 mm.

• Thick. A thick melanoma is more than 4 mm thick and associated with a higher chance of coming back after treatment, called a recurrence. If this occurs, it is because the cancer has already spread to other parts of the body at the time of diagnosis.

It is important to note that tumor thickness applies only to melanomas that invade into the dermis layer of the skin (see Medical Illustrations ). In cases of melanoma in situ (also called MIS), tumor thickness is not measured. Melanoma in situ involves only the epidermal layer of the skin, and tumor thickness is not applicable in this case.

Ulceration

The presence or absence of ulceration of the primary melanoma is defined in the pathology report. Ulceration is the loss of the surface of the skin that lies over the melanoma tumor. If the melanoma is ulcerated, research has shown it significantly increases the risk of spread and recurrence.

Mitotic rate

Another pathological feature of melanoma is the mitotic rate, which is an estimate of the frequency of cell growth. It is measured as the number of dividing cells (mitoses) per millimeter squared (mm ² ). Combined with the thickness and the presence of ulceration, the mitotic rate may be used to help determine prognosis, which is the chance of recovery.

Additional evaluation after a diagnosis of melanoma

After an initial diagnosis of melanoma, you will be referred to a specialist. The doctor will take a complete medical history, noting any symptoms or signs , and perform a complete physical examination, including a total skin examination and lymph node examination. The focus of these examinations is to identify risk factors and signs or symptoms that may indicate melanoma has spread beyond the original site.

The extent of the initial evaluation is based on the primary (original) melanoma’s risk of recurrence. For most people with thin melanoma (less than 1 mm thick), no further search for metastases or spread is generally necessary. For people with higher risk melanoma, more extensive testing, such as the imaging tests described below, may be considered, but this usually occurs after surgical management has been completed. Therefore, the extent of the initial evaluation for a person with newly diagnosed melanoma is based on the stage of melanoma and discussions with the team of doctors.

Depending on the results of the evaluation, including the pathology report of the primary melanoma tumor, further testing for high-risk or later-stage melanoma may include the following:

• Ultrasound. An ultrasound creates a picture of the internal organs, including collections of lymph nodes, called lymph node basins, and soft tissue, using sound waves.

• Computed tomography (CT or CAT) scan. A CT scan takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-dimensional image that shows any abnormalities or tumors. If melanoma has spread, a CT scan can be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This contrast medium can be injected into a patient’s vein or given as a pill or liquid to swallow.

• Magnetic resonance imaging (MRI) . An MRI produces detailed images of the inside of the body using magnetic fields, not x-rays. MRI can be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye is injected into a patient’s vein.

• Positron emission tomography (PET) or PET-CT scan. A PET scan creates pictures of organs and tissues inside the body. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan . However, you may hear your doctor refer to this procedure just as a PET scan. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. However, the amount of radiation in the substance is too low to be harmful. A scanner then detects this substance to produce images of the inside of the body.

Lymphatic mapping and sentinel lymph node biopsy

Lymph nodes are small, bean-shaped organs that help fight infection. Melanoma can grow deep into the inner layers of skin and spread to the lymph nodes and other parts of the body.

Sentinel lymph node biopsy — also called SLNB, sentinel node biopsy, or SNB, or lymphatic mapping — is a surgical procedure that helps the doctor find out whether the cancer has spread to the lymph nodes. When cancer spreads from the place where it started to the lymph nodes, it travels through the lymphatic system. If lymphatic fluid drains from the site of the original melanoma to 1 (or more) lymph node, that node is called the sentinel lymph node. Because melanoma can start anywhere on the skin, the location of the sentinel lymph nodes will be different for each patient, depending on where the cancer started. To find the sentinel lymph node, a dye and a harmless radioactive substance is injected into the dermis of the skin as close as possible to where the melanoma started, which is generally around the biopsy site and/or remaining skin lesion. The substance is followed to the sentinel lymph node. Then, the doctor (typically a surgical oncologist) removes 1 or more of these lymph nodes to check for melanoma cells, leaving behind most of the other lymph nodes in that area. These are sent to a pathologist, who analyzes the lymph nodes and then provides a report.

If melanoma cells are not found in the sentinel lymph node(s), no further lymph node surgery is needed. If the test finds that the sentinel lymph node contains melanoma, this is called a "positive sentinel lymph node." This means the disease has spread there.

In the past, after a positive sentinel lymph node was found, the removal of more lymph nodes, called lymph node dissection, was typically recommended. However, recent data shows that this procedure does not affect how long patients live. In most instances, close monitoring with regular physical exams and lymph node ultrasounds is recommended in place of a lymph node dissection (see Types of Treatment ).

Lymphatic mapping and sentinel lymph node biopsy 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 risk factors.

There are few side effects from sentinel lymph node biopsy, but a patient may experience infection, seroma (fluid buildup) near the surgical area, numbness, and reopening of the surgical area. Buildup of lymph fluid, called lymphedema , may sometimes occur. Talk with your health care team about what to expect and how side effects will be managed.

This information is based on the ASCO guideline, " Sentinel Lymph Node Biopsy for Melanoma ." Please note that this link takes you to a different ASCO website.

After diagnostic tests are done, your doctor will review the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer. This is called staging.

The next section in this guide is Stages . It explains the system doctors use to describe the extent of the disease. Use the menu to choose a different section to read in this guide.

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, also known as therapies, that are the standard of care for melanoma. “Standard of care” means the best treatments known. Information in this section is based on medical standards of care for melanoma in the United States. Treatment options can vary from one place to another.

When making treatment plan decisions, you are encouraged to discuss with your doctor whether clinical trials offer additional options to consider. A clinical trial is a research study that tests a new approach to treatment. Doctors learn through clinical trials whether a 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 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. Cancer care teams include other important health care professionals, including doctors, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, occupational therapists, and others. Learn more about the clinicians who provide cancer care.

People with melanoma may work with doctors in different specialties. These include:

• 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/Dermatopathologist: A doctor who specializes in interpreting tissue samples and laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A dermatopathologist is a pathologist or dermatologist with additional training who specializes in diseases of the skin.

• Radiologist: A medical doctor who specializes in using and interpreting imaging tests to visualize disease.

How melanoma is treated

Treatment recommendations for melanoma 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, overall health, goals for treatment, and quality of life. This section provides an overview of possible treatments and should not be considered treatment recommendations for individuals.

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 conversations 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 important for melanoma because there are different treatment options. Learn more about making treatment decisions .

The common types of treatments used for melanoma are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

READ MORE BELOW:

• Surgery

• Radiation therapy

• Immunotherapy

• Targeted therapy

• Chemotherapy

• Physical, social, emotional, and financial effects of cancer

• Treatment by stage of melanoma

• Remission and the chance of recurrence

• If treatment does not work

Surgery

Surgery involves 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 main 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.

There are 3 common types of surgery used to treat local and regional melanoma: wide excision, lymphatic mapping and sentinel lymph node biopsy, and lymph node dissection. Each is explained below in more detail.

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 performed, it is preferred to be 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 around the tumor with a dye and a radioactive tracer. This is done to identify the lymph nodes that are most likely to be involved and to figure out whether the melanoma has spread to these 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 discussed.

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, related 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 is done at the same time as wide local excision to remove the melanoma. This is because wide local excision can change the lymphatic drainage pattern and doing both procedures at the same time means the patient only has to have 1 surgery as opposed to multiple surgeries.

Lymph node dissection

If biopsy results show that cancer is found in the sentinel lymph nodes, this is called a positive sentinel lymph node. This means the disease has spread. In the past, the removal of more lymph nodes, called complete lymph node dissection (CLND), was typically recommended. However, recent data shows that this procedure does not affect how long patients live. In most instances, close monitoring with regular physical exams and imaging tests, such as ultrasounds of the lymph node region, are recommended in place of a CLND. The number of lymph nodes removed depends on the area of the body. A patient will take longer to recover after CLND and have a higher risk of side effects. People who have had a CLND around an arm or leg have a higher risk for fluid buildup in that limb, a side effect called lymphedema . If it is recommended, talk with your doctor about the possible risks and benefits of having lymph node dissection.

This information is based on the ASCO guideline, " Sentinel Lymph Node Biopsy for Melanoma ." Please note that this link takes you to a different 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 a biopsy and obtain staging scans. 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.

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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 reduce the risk of the melanoma coming back elsewhere, and it also 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 adjuvant radiation therapy, 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 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 unit. 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, skin infections, 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 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 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.

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Therapies using medication

The treatment plan may include medications to destroy cancer cells. Medication may be given through the bloodstream to reach cancer cells throughout the body. When a drug is given this way, it is called systemic therapy. Medication may also be given locally, which is when the medication is applied directly to the cancer or kept in a single part of the body.

This treatment is generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Medications are often given through an intravenous (IV) tube placed into a vein using a needle or as a pill or capsule that is swallowed (orally). If you are given oral medications to take at home, be sure to ask your health care team about how to safely store and handle them.

The types of medications 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 medication at a time or a combination of medications 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 your 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, causing unwanted side effects or reduced effectiveness. Learn more about your prescriptions by using searchable drug databases .

The information about therapies using medication for melanoma are based on the ASCO guideline, “ Systemic Therapy for Melanoma .” Please note that this link takes you to a different ASCO website.

Immunotherapy

Immunotherapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells. Learn more about the basics of immunotherapy .

In recent years, there have been major advances in treating stage II, stage III and stage 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 fatigue. Learn more about the side effects of immunotherapy .

Talk with your doctor about possible side effects for the immunotherapy recommended for you.

PD-1 and PD-L1 inhibitors

Two monoclonal antibodies that block a protein called PD-1 that have been approved by the U.S. Food and Drug Administration (FDA) to treat stage II, stage III, or stage IV (metastatic) melanoma: nivolumab (Opdivo) and pembrolizumab (Keytruda). PD-1 is found on the surface of T cells and interacts with a protein called PD-L1. T cells are a type of white blood cell that directly helps the body’s immune system fight disease. The PD-1/PD-L1 protein interaction keeps the immune system from destroying the cancer. Drugs that stop PD-1 and PD-L1 from working allow the immune system to better target and destroy melanoma cells.

Both nivolumab and pembrolizumab have been shown to shrink melanoma for 25% to 45% of patients with unresectable (which means surgery is not an option) or stage IV melanoma, depending on when the treatment is given. Both drugs also have been shown to reduce the risk of the cancer coming back after surgery for stage III melanoma. More recently, pembrolizumab has been shown to reduce the risk of cancer coming back after surgery for higher risk stage II melanoma (stage IIB and stage IIC). Side effects occur less frequently with nivolumab and pembrolizumab compared to ipilimumab (Yervoy, see below). ASCO recommends either nivolumab or pembrolizumab as options for the adjuvant treatment of high-risk stage II or stage III melanomas, or for treatment of unresectable melanoma or metastatic melanoma, whether or not the melanoma has a BRAF mutation.

Atezolizumab (Tecentriq) is a PD-L1 inhibitor that can be used to treat advanced melanoma with a BRAF V600 mutation. Atezolizumab was approved by the FDA in 2020 to be given in combination with 2 targeted therapies: cobimetinib (Cotellic), a MEK inhibitor, and vemurafenib (Zelboraf), a BRAF inhibitor. These targeted therapies are described below.

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

CTLA-4 inhibitors

Ipilimumab (Yervoy) is an immunotherapy that targets a molecule called CTLA-4. There have been 2 clinical trials that showed that people with unresectable or metastatic melanoma 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 may be permanent in many patients.

Ipilimumab is approved by the FDA to treat unresectable melanoma and metastatic melanoma. It is also approved for adjuvant treatment of stage III melanomas after surgery. However, past studies have shown that, when used by itself, ipilimumab is not as effective as the PD-1/PD-L1 inhibitors and can cause more immune-related side effects, as well as immune-related side effects that are more severe. As a result, adjuvant ipilimumab is no longer recommended for routine use. For unresectable and metastatic melanoma, it is often recommended to be combined with nivolumab as an aggressive treatment option.

Ipilimumab and other CTLA-4 inhibitors continue to be studied in clinical trials. See the Latest Research section for more information.

Combining different immunotherapies

A combination of ipilimumab and nivolumab may be used 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 tumor growth, and 58% of people on this combination have their tumors shrink. However, combining these drugs causes far more side effects. 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. ASCO recommends giving this combination followed by nivolumab alone as an option to treat unresectable stage III or metastatic melanoma whether or not the melanoma has a BRAF mutation.

A combination of nivolumab and relatlimab, called Opdualag, may also be used to treat unresectable stage III or stage IV melanoma in people aged 12 and older. Relatlimab is an immune checkpoint inhibitor that targets lymphocyte-activation gene 3 (LAG-3). LAG-3 is a protein found on the surface of T cells that helps control how the immune system responds.

Interleukin-2 (IL-2, Proleukin)

Interleukin-2 is a type of immunotherapy that 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.

Treatment with IL-2 has helped some patients, but it can cause many serious side effects that may require being monitored in the hospital. Newer immunotherapies and targeted therapies have been shown to be more effective and to cause fewer serious side effects. If IL-2 is part of the treatment plan, it should be given by an experienced health care team familiar with its side effects.

Virus therapy

Virus therapy, also called oncolytic viruses or intralesional therapy, is a type of immunotherapy that includes talimogene laherparepvec (T-VEC; Imlygic). T-VEC may be used to treat 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. T-VEC may be offered to patients with unresectable or metastatic melanoma who cannot or choose not to receive any other recommended treatments. T-VEC is being studied in combination with other medications to improve its effectiveness.

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Targeted therapy

Targeted therapy is a type of 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 and limits 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 have allowed 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.

BRAF inhibitors

The discovery that about 50% of melanomas have a mutated or activated BRAF gene has provided an important direction in targeted therapy for melanoma. BRAF inhibitors approved to treat unresectable stage III and stage IV melanoma include:

• Dabrafenib (Tafinlar)

• Encorafenib (Braftovi)

• Vemurafenib (Zelboraf)

These drugs, taken by mouth as pills, 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. The addition of a MEK inhibitor to BRAF inhibitors has been shown in multiple studies to increase tumor shrinkage rate as well as delay tumor growth (see below).

Vemurafenib may be given in combination with atezolizumab (see “PD-1 and PD-L1 inhibitors” above) and the MEK inhibitor cobimetinib to treat advanced melanoma with a BRAF V600 mutation.

Talk with your doctor about what side effects may occur before your specific treatment begins.

MEK inhibitors

Trametinib (Mekinist), cobimetinib (Cotellic), and binimetinib (Mektovi) are approved as a targeted therapy for unresectable or metastatic melanoma with a BRAF V600E or V600K mutation. These drugs, which are taken as a pill, specifically target the MEK protein, which is involved in cancer growth and survival. While trametinib originally 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, these medications (trametinib, cobimetinib, and binimetinib) are almost always given in combination with a BRAF inhibitor. These combinations are described in more detail below.

Cobimetinib may also be given in combination with atezolizumab (see “PD-1 and PD-L1 inhibitors,” above) and the BRAF inhibitor vemurafenib to treat advanced melanoma with a BRAF V600 mutation.

Combining BRAF and MEK inhibitors

Clinical trials have shown that there are improved outcomes and reduced side effects when a BRAF and MEK inhibitor are combined compared with giving a BRAF or MEK inhibitor alone. It has become standard practice to recommend 1 of the 3 following approved combinations when targeted therapy is being offered to patients with tumors that have BRAF mutations.

ASCO recommends dabrafenib plus trametinib as an option to treat stage III melanoma with a BRAF mutation after surgery. For unresectable or metastatic melanoma with a BRAF mutation, ASCO recommends dabrafenib plus trametinib, encorafenib plus binimetinib, or vemurafenib plus cobimetinib as options.

Dabrafenib and trametinib. 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 unresectable advanced melanoma and metastatic melanoma with a BRAF V600E or V600K mutation. This combination is not 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 this combination 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.

Vemurafenib and cobimetinib. In 2015, the FDA approved the combination of vemurafenib and cobimetinib. 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.

Encorafenib and binimetinib. In 2018, the FDA approved the combination of encorafenib and binimetinib. A phase III clinical trial showed that this combination helped people live longer than those treated with vemurafenib alone.

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) and entrectinib (Rozlytrek) are targeted therapies that are not specific to a certain type of cancer but instead focus on a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including very rarely in melanoma. These medications are approved for the treatment of unresectable or metastatic melanoma with an NTRK fusion that has worsened with other treatments.

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Chemotherapy

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

Because immunotherapy and targeted therapy have become more effective at treating melanoma, chemotherapy is used much less often.

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 that may be 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 may be used, such as paclitaxel plus carboplatin or cisplatin combined with vinblastine and dacarbazine. Some chemotherapy 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. Depending on the overall extent and pattern of spread of the tumors, 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. In isolated limb infusion, the interventional radiology team places a catheter to deliver the chemotherapy. In isolated limb perfusion, thin tubes called cannulae are placed surgically to deliver the chemotherapy. 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 in the operating room.

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.

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Physical, emotional, social, and financial effects of cancer

Melanoma and its treatment may cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative and 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 and supportive 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 and supportive care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that 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, such as medications, surgery, or radiation therapy, to improve symptoms.

Before treatment begins, talk with your doctor about the goals of each treatment in the recommended treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative and supportive care options. Many patients also benefit from talking with a social worker and participating in support groups. Ask your doctor about these resources, too.

Cancer care is often expensive, and navigating health insurance can be difficult. Ask your doctor or another member of your health care team about talking with a financial navigator or counselor who may be able to help with your financial concerns .

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 and supportive care in a separate section of this website.

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Treatment by stage of melanoma ( updated 08/2023)

Different treatments may be recommended for each stage of melanoma. The general options by stage are described below. For more detailed descriptions, see “How melanoma is treated,” above. Your doctor will work with you to develop a specific treatment plan based on your specific diagnosis and needs. Clinical trials may also be a treatment option for each stage.

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, lymphatic mapping and sentinel lymph node biopsy may also be done. For people with stage IIB and stage IIC melanoma, discuss with your medical oncologist whether adjuvant treatment with 1 year of pembrolizumab or nivolumab is an option for you. Treatment in a clinical trial for stage II melanoma may also be an option. Ask your doctor about what clinical trials may be available for you.

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 or to a skin site on the way to a lymph node. If the stage III melanoma can be removed with surgery, this will play an important role in how the melanoma is managed. An important part of the treatment plan will also center on whether adjuvant or neoadjuvant therapy is recommended.

• Adjuvant therapy. Adjuvant therapy is when medication is given after surgery to prevent the cancer from coming back, which is called a recurrence. Typically, surgery will be recommended to remove the primary melanoma site, and lymph nodes will be checked for cancer and removed. After surgery, adjuvant treatment with immunotherapy or targeted therapy for 1 year may be recommended to help prevent the cancer from coming back.

• Neoadjuvant therapy. Neoadjuvant therapy is when medication is given before surgery to try to improve treatment outcomes. Immunotherapy or targeted therapy may be recommended before surgery. Recent research has shown that giving pembrolizumab both before and after surgery for patients with stages IIIB to IV melanoma can reduce the risk of disease recurrence compared to giving pembrolizumab after surgery alone.

Treatment in a clinical trial for stage III melanoma also may be an option. Ask your doctor about what clinical trials may be available for you.

Advanced/unresectable melanoma

Advanced melanoma is a stage III melanoma that cannot be treated with surgery or stage IV melanoma. Stage IV melanoma has spread to distant parts of the body, such as distant lymph nodes or the liver, lung, brain, bone, gastrointestinal tract, or other organs. 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. Talk with your doctor to learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Unresectable stage III melanoma and stage IV melanoma are often treated the same way, with immunotherapy, targeted therapy, or combinations of immunotherapies and/or targeted therapies. For certain patients, T-VEC may be offered as an option. In rare cases, chemotherapy may be recommended. Palliative and supportive treatments intended to relieve symptoms may also be recommended, such as surgery or radiation therapy to treat affected lymph nodes and tumors that have spread elsewhere in the body. And, surgery may be recommended to remove 1 or 2 tumors if there are few sites of disease. 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 and goals of care

• How treatment is to be given and how that affects the patient's quality of life

If the recommended treatment does not work, stops working, or causes serious side effects, your doctor may suggest changing the treatment plan.

For many people, a diagnosis of advanced cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of your health care team. It may also be helpful to talk with other patients, such as through a support group or other peer support program.

Surgery to remove metastatic tumors

There are times when it may be appropriate to remove one or more metastatic tumors (a surgery called metastatectomy) in people with stage IV melanoma. While the development of more effective therapies has reduced the use of surgery to be the main treatment for metastatic melanoma, surgery may be used to remove 1 or more tumors that are causing symptoms or tumors that are growing while a person is receiving systemic therapy. This is most commonly done when other tumors have shrunk or gone away or if there are only a few tumors in the body.

Treating brain metastases

The brain is one of the most common places to which melanoma spreads. The presence of brain metastases is linked with a poor prognosis. Prognosis is the chance of recovery. Historically, less than 50% of people with melanoma that has spread to the brain live 6 months, although this has changed in recent years. Because of this poor prognosis and because of the perceived difficulty in getting cancer medications 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 changing, and there are recently completed and ongoing clinical trials for patients with melanoma and brain metastases that have helped to improve prognosis in these patients. 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 (see "Radiation therapy," above) 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 is not as effective as stereotactic radiation and commonly causes problems with thinking clearly (cognition) .

• BRAF and MEK inhibitors. For people with melanoma that has a BRAF V600 mutation, combinations of a BRAF and a MEK inhibitor may be recommended. These drugs penetrate into the brain metastases. Clinical trials have shown that melanoma tumors in the brain treated with these medications shrink around 40% to 50% of the time. For those with a BRAF V600 mutation, with or without symptoms from the brain metastases, the doctor may recommend treatment with a combination of a BRAF and a MEK inhibitor.

• Immunotherapy. Ipilimumab, nivolumab, and pembrolizumab have recently been studied in clinical trials to treat people with melanoma that has spread to the brain. These studies have shown that these treatments can help patients with melanoma and brain metastases. For those with no symptoms from the brain metastases, with or without a BRAF mutation, the doctor may recommend treatment with ipilimumab plus nivolumab. Although this combination of ipilimumab and nivolumab has been shown to be an effective treatment for patients with melanoma that has spread to the brain, it has a high rate of side effects and may not be the right choice for everybody.

• Surgery. Surgery may be offered to some people to remove tumors in the brain, especially if they are causing symptoms.

Below is a general summary of when and how surgery and radiation therapy are used to treat brain metastases:

• People with relatively few brain metastases generally receive stereotactic radiosurgery. If the brain metastases are large or causing symptoms due pressure on the brain and the person is in general good health, they often receive surgery followed by stereotactic radiosurgery.

• Treatment for people in relatively good health and with more than 4 tumors that cannot be removed with surgery or more than 2 tumors that were removed surgically may include stereotactic radiosurgery or whole brain radiation therapy.

• People who also have metastatic cancer in parts of the body other than the brain usually continue their treatment regimen if the disease outside the brain is not worsening. If the disease is worsening, the treatment plan may be changed based on the recommendations for metastatic melanoma.

The information in this section is based on a joint guideline from ASCO, the Society for Neuro-Oncology (SNO), and the American Society for Radiation Oncology (ASTRO), “ Treatment for Brain Metastases .” Please note that this link takes you to a different ASCO website.

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

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Remission and the chance of recurrence

Being in remission means that the cancer can no longer be detected in the body. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty may cause 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).

If a recurrence happens, a new cycle of testing will begin to learn as much as possible about it. 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 recurrent melanoma. Whichever treatment plan you choose, palliative and supportive care will be important for relieving symptoms and side effects.

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

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If treatment does not work

Recovery from melanoma 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 some 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.

Planning for your future care and putting your wishes in writing is important, especially at this stage of disease. Then, your health care team and loved ones will know what you want, even if you are unable to make these decisions. Learn more about putting your health care wishes in writing.

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 your doctor or a member of your palliative 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 .

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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.

ON THIS PAGE: You will read about the scientific research being done to learn more about melanoma and how to treat it. Use the menu to see other pages.

Doctors are working to learn more about melanoma, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. This section is not meant to be a complete list of new clinical trials because this field is changing rapidly. Always talk with your doctor about the best diagnostic and treatment options for you.

• Enhanced prevention and early detection methods. There is ongoing research on better prevention and early detection strategies for melanoma. Both primary and secondary prevention are important. Primary prevention involves keeping melanoma from developing, such as reducing exposure of ultraviolet (UV) radiation from the sun and avoiding the use of indoor tanning in any form. Secondary prevention includes methods of early detection. One promising area is the screening of people with a high risk of developing melanoma, as described earlier in this guide .

• Targeted therapy. As discussed in Types of Treatment , targeted therapy is a treatment that targets specific genes or proteins. Research has identified a number of molecular pathways and activated or mutated genes in melanoma. Clinical trials are testing new drugs to inhibit the MAP kinase pathway and other pathways that melanoma might use to grow and spread. Strategies to prevent the melanoma from becoming resistant to treatment are also being tested, such as using combinations of drugs or exploring new schedules of giving drugs to patients.

• Immunotherapy. As explained in Types of Treatment , immunotherapy is an important treatment option for melanoma. Researchers are studying new checkpoint inhibitors and immunotherapies directed at other parts of the immune system. These include TIM3 inhibitors, LAG3 inhibitors, OX40 agonists, CD137 agonists, GITR agonists, and IDO inhibitors. Also, a number of combinations of immunotherapies are being looked at, including all of the above drugs with PD-1 or PD-L1 inhibitors, as well as combinations of targeted therapies with PD-1 or PD-L1 inhibitors. Recently, the combination of a LAG3 inhibitor, called relatlimab, and nivolumab was shown to delay tumor growth when compared with nivolumab alone in people with newly diagnosed, unresectable stage III or metastatic melanoma. A fixed-dose combination of these 2 drugs, called Opdualag, has been approved to treat unresectable stage III or stage IV melanoma in people aged 12 and older. It is considered an alternative standard of care treatment to using a single PD-1 inhibitor and to using a combination of ipilimumab and nivolumab.

• Adoptive cell therapy (ACT), chimeric antigen receptor T-cell (CAR-T) therapy, and T-cell receptor (TCR) therapy. Another type of experimental immunotherapy involves altering a person’s white blood cells, known as lymphocytes, in a laboratory. In ACT, this may involve a surgical procedure to remove a tumor, isolate the white blood cells, and expand them outside the body. In CAR-T therapy and TCR therapy, white blood cells are removed from the body using a procedure called pheresis. The white blood cells are modified to better recognize cancer cells. This is done to increase their ability to fight the tumor. Then, the cells are given back to the patient, often in combination with chemotherapy, interleukin-2, and/or other immunotherapies.

• Vaccines. Therapeutic vaccines that may improve the specific immune response to melanoma have been the focus of multiple clinical trials. Melanoma peptide vaccines are being evaluated in clinical trials for patients with both localized and advanced melanoma. Research has shown that vaccination can cause the immune system to fight melanoma, even in advanced disease, but these treatments are still considered experimental. The vaccines are made using certain proteins found only on a melanoma tumor and are given as an injection. The person’s immune system then recognizes the proteins and destroys melanoma cancer cells. To date, no vaccines have shown a clinical benefit in patients. Learn more about the basics of cancer vaccines .

• Palliative and supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current melanoma treatments to improve comfort and quality of life for patients.

Looking for More About the Latest Research?

If you would like more information about the latest areas of research in melanoma, explore these related items that take you outside of this guide:

• To find clinical trials specific to your diagnosis, talk with your doctor or search online clinical trial databases .

• Visit the Cancer.Net Blog to review news and information about melanoma, including research announced at recent scientific meetings or in ASCO’s peer-reviewed journals, including highlighted studies from 2022 and 2021 .

• Listen to a podcast from an ASCO expert in melanoma discussing highlights from the 2021 ASCO Annual Meeting.

• Get updates from Cancer.Net delivered right to your inbox. Subscribe to the Inside Cancer.Net email newsletter.

• Visit the website of Conquer Cancer, the ASCO Foundation , to find out how to help support cancer research. Please note that this link takes you to a different ASCO website.

The next section in this guide is Coping with Treatment . It offers some guidance on how to cope with the physical, emotional, social, and financial changes that cancer and its treatment can bring. Use the menu to choose a different section to read in this guide.

ON THIS PAGE: You will read about your medical care after cancer treatment is completed and why this follow-up care is important. Use the menu to see other pages.

Care for people diagnosed with melanoma does not end when active treatment has finished. Your health care team will continue to check that the cancer has not come back, manage any side effects, and monitor your overall health. This is called follow-up care or surveillance and monitoring.

Your follow-up care plan may include regular physical and dermatologic (skin) examinations and/or medical tests to monitor your recovery for the coming months and years. The purpose of monitoring is to look for a recurrence or spread of the disease, as well as a new primary melanoma. The follow-up and surveillance program for a person with a history of melanoma is based on a person’s risk of recurrence, is highly individualized, and can vary from person to person. The most important parts of this surveillance are your medical history and physical exams.

Cancer rehabilitation may be recommended, and this could mean any of a wide range of services, such as physical therapy, occupational therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent as possible. Learn more about cancer rehabilitation.

Learn more about the importance of follow-up care .

Watching for recurrence

One goal of follow-up care is to check for a recurrence, which means that the cancer has come back. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will ask specific questions about your health. Some people may have blood tests or imaging tests done as part of regular follow-up care, but testing recommendations depend on several factors, including the type and stage of cancer first diagnosed and the types of treatment given.

In general, physical and skin examinations are performed every 3 to 6 months for at least the first 2 to 3 years and then once a year after that. However, your doctor may recommend a different follow-up schedule. A chest x-ray, computed tomography (CT) scan, magnetic resonance imaging (MRI), and/or positron emission tomography (PET)-CT scan may be recommended if the melanoma has a higher chance of coming back. For people treated for early-stage melanoma, scans are not generally recommended during follow-up care.

The anticipation before having a follow-up test or waiting for test results may add stress to you or a family member. This is sometimes called “scanxiety.” Learn more about how to cope with this type of stress .

Preventing and detecting second skin cancers

Routine screening with a skin examination for a new melanoma and non-melanoma skin cancer is a necessary part of follow-up care, as is sun protection and sun avoidance. Screening for melanoma and other skin cancers by a doctor or other health care professional may be recommended. Regular photography of the skin to closely watch your skin may be recommended. If possible, you should ask your doctor for copies of your photographs and learn how to perform a skin self-examination . There is growing evidence that individuals who are followed using photographs are diagnosed at an earlier stage of melanoma.

Protecting your skin from ultraviolet (UV) radiation is important to help prevent second skin cancers, both melanoma and non-melanoma skin cancer. Many people who are treated for melanoma lead an active, outdoor lifestyle. It is important to take steps to protect yourself from further skin damage. You can protect against further sun damage by:

• Participating in outdoor activities before 10:00 AM or after 4:00 PM

• Wearing long sleeves and pants

• Using a broad-spectrum sunscreen with an sun protection factor (SPF) of 30 or more. Please remember to reapply sunscreen every 2 hours or, if you are sweating or in the water, every hour.

• Wearing UV-protective sunglasses

• Wearing a hat

• Avoiding all use of indoor tanning devices

A major consideration following diagnosis and treatment of melanoma is adjusting a person’s lifestyle to use sun-protective or sun-avoidance measures at all times, as well as avoiding indoor tanning devices. In addition, if a person works in an area where there is high UV exposure, there may be job-related issues to consider. Learn more about protecting your skin from the sun .

Managing long-term and late side effects

Most people expect to have side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. Other side effects called late effects may develop months or even years after treatment has ended. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on your diagnosis, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may have certain physical examinations, scans, or blood tests to help find and manage them.

For an early-stage, thin melanoma, the surgery is most often outpatient surgery with little need for rehabilitation. For those with a thicker melanoma and possible skin grafts, depending on the location, there may be some need for rehabilitation following treatment. As explained in Coping With Treatment , some patients experience lymphedema or chronic pain . Talk with your health care team about how these or other side effects can be managed.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to discuss any concerns you have about your future physical or emotional health. The American Society of Clinical Oncology (ASCO) offers forms to help keep track of the cancer treatment you received and develop a survivorship care plan after treatment is completed.

This is also a good time to talk with your doctor about who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the care of their primary care doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, treatments received, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with them and with all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

The next section in this guide is Survivorship . It describes how to cope with challenges in everyday life after a cancer diagnosis. Use the menu to choose a different section to read in this guide.

ON THIS PAGE: You will find some questions to ask your doctor or other members of the health care team to help you better understand your diagnosis, treatment plan, and overall care. Use the menu to see other pages.

Talking often with the health care team is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for a digital list and other interactive tools to manage your care. It may also be helpful to ask a family member or friend to come with you to appointments to help take notes.

Questions to ask after getting a diagnosis

• What type or subtype of melanoma do I have?

• Can you explain my pathology report to me?

• What stage is the melanoma? What does this mean?

• What is the depth of the melanoma in millimeters?

• Is the melanoma ulcerated?

• Does the melanoma have mitotic activity? If yes, how much and what does that mean?

• Is it likely that the melanoma has spread? Why or why not?

Questions to ask about choosing a treatment and managing side effects

• What are my treatment options?

• What types of research are being done for melanoma in clinical trials? Do clinical trials offer additional treatment options for me?

• What treatment plan do you recommend? Why?

• What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?

• What are the possible side effects of each treatment option, both in the short term and the long term? Is there anything we can do to prevent or manage them?

• Who will be part of my health care team, and what does each member do?

• Who will be leading my overall treatment?

• How will each treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

• Could this treatment affect my sex life? If so, how and for how long?

• Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?

• If I’m worried about managing the costs of cancer care, who can help me?

• What support services are available to me? To my family?

• If I have questions or problems, who should I call?

Questions to ask about having surgery

• Do you recommend that I get surgery for my melanoma? If so, what type of surgery?

• Should I have a sentinel lymph node biopsy to find out if there is spread to the lymph nodes?

• Will surgery be able to remove all of the cancer? Will I need additional surgery?

• How long will the operation take?

• How long will I be in the hospital?

• After the surgical removal of the melanoma, will I need a skin graft?

• Can you describe what my recovery from surgery will be like?

• Who should I contact about any side effects I experience? And how soon?

• What are the possible long-term effects of having this surgery?

• Will I need to have additional treatment after surgery?

Questions to ask about therapies with medication before surgery (neoadjuvant therapy)

• Do you think I would benefit from neoadjuvant therapy? Why or why not?

• What medication would you recommend that I get before surgery?

• Does my melanoma have a BRAF genetic mutation? Will the BRAF status affect which neoadjuvant medication you recommend?

• How long will my neoadjuvant treatment be?

• When will my first imaging scan to restage the cancer be done?

• When will my surgery be done?

• What side effects can I expect during treatment?

• Who should I contact about any side effects I experience? And how soon?

• What are the possible long-term or late effects of having this treatment?

• What can be done to prevent or manage these side effects?

• Will my insurance cover the recommended treatments? Is there someone I can talk to if insurance does not cover all of the costs of treatment?

Questions to ask about systemic treatment with medication after surgery (adjuvant therapy)

• What type of treatment with medication is recommended?

• Does my melanoma have a BRAF genetic mutation or other known mutation? Is targeted therapy or immunotherapy an option?

• What is the goal of this treatment?

• How long will it take to have this treatment?

• Will I receive this treatment at a hospital or clinic? Or will I take it at home?

• What side effects can I expect during treatment?

• Who should I contact about any side effects I experience? And how soon?

• What are the possible long-term or late effects of having this treatment?

• What can be done to prevent or manage these side effects?

• Will my insurance cover the recommended treatments? Is there someone I can talk to if insurance does not cover all of the costs of treatment?

Questions to ask about stage II melanoma

• What, if any, treatment is recommended after surgery?

• Will my insurance cover the recommended treatments? Is there someone I can talk to if insurance does not cover all of the costs of treatment?

Questions to ask about stage III melanoma

• Do I have lymph nodes that are involved with melanoma?

• Will the rest of the lymph nodes be removed? If yes, what are the potential complications of lymph node surgery?

• Has the melanoma spilled out of the lymph node? This is called extranodal extension of the melanoma. What does this mean for my treatment?

• What, if any, treatment is recommended after my surgery?

• What are the goals of each treatment? What is my prognosis?

• How will I be followed to watch for a recurrence?

• Will my insurance cover the recommended treatments? Is there someone I can talk to if insurance does not cover all of the costs of therapy?

Questions to ask about stage IV melanoma

• Where has the melanoma spread? Do I need a brain scan or body imaging (such as PET-CT or CT scan) to find where it has spread?

• Is surgical removal of the metastases an option, especially if 1 or 2 tumors are present? If so, what are the benefits and risks?

• What are the goals of each treatment? What is my prognosis?

• How will side effects and symptoms be prevented and managed to reduce my discomfort and increase my quality of life?

Questions to ask about planning follow-up care

• What is the chance that the cancer will come back? Should I watch for specific signs or symptoms?

• What steps can I take to reduce the risk of developing a new melanoma or other type of skin cancer?

• What long-term side effects or late effects are possible based on the cancer treatment I received?

• What follow-up tests will I need, and how often will those tests be needed?

• How do I get a treatment summary and survivorship care plan to keep in my personal records?

• When should I return to my primary care doctor for regular medical care?

• Who will be leading my follow-up care?

• What survivorship support services are available to me? To my family?

• Are my family members at a higher risk for developing melanoma?

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