Treatment - Skin cancer (melanoma)

Surgery is the main treatment for melanoma.

If you have melanoma skin cancer you'll be cared for by a team of specialists that should include a dermatologist, a plastic surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a pathologist and a specialist nurse.

When helping you decide on your treatment, the team will consider:

• the type of cancer you have
• the stage of your cancer (its size and how far it has spread)
• your general health

Your treatment team will recommend what they believe to be the best treatment option, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist. For example, you may want to find out about the advantages and disadvantages of particular treatments.

Treating stage 1 to 2 melanoma

Treating stage 1 melanoma involves surgery to remove the melanoma and a small area of skin around it. This is known as surgical excision.

Surgical excision is usually carried out under local anaesthetic, which means you'll be conscious but the area around the melanoma will be numbed, so you won't feel pain. In some cases, general anaesthetic is used, which means you'll be unconscious during the procedure.

If a surgical excision is likely to leave a significant scar, it may be carried out in combination with a skin graft. However, skin flaps are now more commonly used because the scars are usually much better than those resulting from a skin graft.

In most cases, once the melanoma has been removed there's little possibility of it returning and no further treatment should be needed. Most people (80-90%) are monitored in clinic for 1 to 5 years and are discharged with no further problems.

Sentinel lymph node biopsy

A sentinel lymph node biopsy is a procedure to test for the spread of cancer. It may be offered to people with stage 1B to 2C melanoma. It's carried out at the same time as surgical excision.

You'll decide with your doctor whether to have a sentinel lymph node biopsy. If you decide to have the procedure and the results show no spread to nearby lymph nodes, it's unlikely you'll have further problems with this melanoma.

If the results confirm melanoma has spread to nearby nodes, your specialist will discuss with you whether further surgery is required. Additional surgery involves removing the remaining nodes, which is known as a lymph node dissection or completion lymphadenectomy.

Treating stage 3 melanoma

If the melanoma has spread to nearby lymph nodes (stage three melanoma), further surgery may be needed to remove them.

Stage 3 melanoma may be diagnosed by sentinel node biopsy, or you or a member of your treatment team may have felt a lump in your lymph nodes. The diagnosis of melanoma is usually confirmed using a needle biopsy (fine needle aspiration).

Removing the affected lymph nodes is done under general anaesthetic.

The procedure, called a lymph node dissection, can disrupt the lymphatic system, leading to a build-up of fluids in your limbs. This is known as lymphoedema.

Treating stage 4 melanoma

If melanoma comes back or spreads to other organs it's called stage 4 melanoma.

In the past, cure from stage four melanoma was very rare but new treatments, such as immunotherapy and targeted treatments, show encouraging results.

Treatment for stage 4 melanoma is given in the hope that it can slow the cancer's growth, reduce symptoms, and extend life expectancy.

You may be offered surgery to remove other melanomas that have occurred away from the original site. You may also be able to have other treatments to help with your symptoms, such as radiotherapy and medication.

If you have advanced melanoma, you may decide not to have treatment if it's unlikely to significantly extend your life expectancy, or if you don't have symptoms that cause pain or discomfort.

It's entirely your decision and your treatment team will respect it. If you decide not to receive treatment, pain relief and nursing care will be made available when you need it. This is called palliative care.

Immunotherapy

Immunotherapy is used to treat advanced (stage 4) melanoma, and it's sometimes offered to people with stage 3 melanoma as part of a clinical trial.

Immunotherapy uses medication to help the body's immune system find and kill melanoma cells.

A number of different medications are available, some of which can be used on their own (monotherapy) or together (combination therapy). Medications used include:

• ipilimumab
• nivolumab
• pembrolizumab

Ipilimumab

Ipilimumab is recommended as a treatment for people with previously treated or untreated advanced melanoma that's spread or can't be removed using surgery.

It's given by injection over a 90-minute period, every 3 weeks for a total of 4 doses.

Common side effects include diarrhoea, rash, itching, fatigue, nausea, vomiting, decreased appetite and abdominal pain.

Nivolumab

Nivolumab is recommended for treating advanced cases of melanoma in adults that have spread or can't be removed using surgery.

It's given directly into a vein (intravenously) over a 60-minute period, every 2 weeks. Treatment is continued for as long as it has a positive effect or until it can no longer be tolerated.

Nivolumab can be used either on its own or in combination with ipilimumab.

In clinical trials, the most common side effects were tiredness, rash, itching, diarrhoea and nausea.

Pembrolizumab

Pembrolizumab is recommended to treat advanced melanoma in adults that's spread or can't be treated with surgery. It's given by injection for 30 minutes, every 3 weeks.

In clinical trials, the most common side effects were diarrhoea, nausea, itching, rash, joint pain and fatigue.

Targeted treatments

Around 40 to 50 in every 100 people with melanoma have changes (mutations) in certain genes, which cause cells to grow and divide too quickly.

If gene mutations have been identified, medication can be used to specifically target these gene mutations to slow or stop cancer cells growing.

Possible targeted treatments include:

• vemurafenib
• dabrafenib
• trametinib

Vemurafenib

Vemurafenib is a medication that blocks the activity of a cancerous gene mutation known as BRAF V600.

It's recommended  as a treatment for people who've tested positive for the mutation and have locally advanced melanoma or melanoma that's spread.

Common side effects include joint pain, tiredness, rash, sensitivity to light, nausea, hair loss and itching.

Vemurafenib can also be used with another medication called cobimetinib for treating people with the BRAF V600 mutation melanoma that's spread or can't be removed with surgery.

Dabrafenib

Dabrafenib also blocks the activity of BRAF V600.

It's recommended for treating adults with the BRAF V600 mutation who have melanoma that's spread or can't be removed with surgery.

Common side effects include decreased appetite, headache, cough, nausea, vomiting, diarrhoea, rash and hair loss.

Trametinib

Trametinib blocks the activity of the abnormal BRAF protein, slowing the growth and spread of the cancer.

It's recommended for use on its own or with dabrafenib for treating people with melanoma with a BRAF V600 mutation that's spread or can't be removed with surgery.

Common side effects include tiredness, nausea, headache, chills, diarrhoea, rash, join pain, high blood pressure and vomiting.

Radiotherapy and chemotherapy

You may have radiotherapy after an operation to remove your lymph nodes, and it can also be used to help relieve the symptoms of advanced melanoma. Controlled doses of radiation are used to kill the cancerous cells.

If you have advanced melanoma, you may have a single treatment or a few treatments. Radiotherapy after surgery usually consists of a course of 5 treatments a week (one a day from Monday to Friday) for a number of weeks. There's a rest period over the weekend.

Common side effects associated with radiotherapy include:

• tiredness
• nausea
• loss of appetite
• hair loss
• sore skin

Many side effects can be prevented or controlled with prescription medicines, so tell your treatment team if you experience any. The side effects of radiotherapy should gradually reduce once treatment has finished.

Chemotherapy is now rarely used to treat melanoma. Targeted treatments and immunotherapy (as described above) are the preferred treatment options.

Follow up

After your treatment, you'll have regular follow up appointments to check whether:

• there's signs of the melanoma coming back
• the melanoma has spread to your lymph nodes or other areas of your body
• there's signs of any new primary melanomas

Your doctor or nurse will examine you, they'll ask about your general health and whether you have any questions or concerns.

You may be offered treatment to try to prevent the melanoma returning. This is called adjuvant treatment. There's not much evidence that adjuvant treatment helps prevent melanoma coming back, so it's currently only offered as part of a clinical trial.

Help and support

Being diagnosed with melanoma can be difficult to deal with. You may feel shocked, upset, numb, frightened, uncertain and confused. These types of feelings are natural.

You can ask your treatment team about anything you're unsure about.

Your family and friends can be a great source of support. Talking about your cancer and how you're feeling can help both you and members of your family cope with the situation.

Some people prefer to talk to people outside their family. There are a number of Irish charities that have specially trained staff you can speak to:

• Irish Cancer society – Freephone 1800 200 700 (Monday to Friday, 9am to 5pm)
• Irish Skin Foundation - 01 486 6280 (Monday to Friday, 10am to 4.30pm)
• Marie Keating Foundation– 01 628 3726 (Monday to Friday, 9am to 8pm)