Understanding melanoma treatment options
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There’s more to skin cancer treatment than getting a mole removed. Sometimes a lot more.
A skin cancer diagnosis, especially melanoma, can be complicated and should always be handled by medical professionals that are experienced specifically with melanoma.
Most melanomas only affect the patient’s skin, but more aggressive melanomas can spread to the lymph nodes and other organs including the brain. Very aggressive melanoma and melanomas that are detected at a late stage also can cause death. However, with increasing medical research, good patient education, early detection and major improvements in systemic treatments, melanoma is no longer the death sentence we once considered it.
Melanoma is a type of skin cancer that begins in the melanocytic cells of the skin. These are pigmented cells that get darker when we are exposed to the rays of the sun. Melanomas can develop on any skin surface, but most commonly occur on the back, chest, lower legs, neck, face and scalp.
The skin is made up of three layers. The thin outer layer of the skin is called the epidermis. It consists of squamous, basal and melanocytic cells. Squamous cells are the outermost layer and basal cells are found just under the squamous cells. Melanocytes are found at the base of the epidermis and give skin its color.
Basal cell skin cancer and squamous cell skin cancer are other common cancers. Like melanoma, these types of skin cancers often occur in areas of the body that have endured repeated sun exposure.
Skin cancer is the most common type of cancer in the United States. While melanoma accounts for less than one percent of all skin cancers, it causes the majority of skin cancer deaths. The American Cancer Society estimates that in 2019 more than 96,000 Americans will be diagnosed with a new melanoma and about 7,000 of those patients will die from the disease.
At the Nancy N. and J.C. Lewis Cancer & Research Pavilion, we see a couple hundred cases of melanoma each year, says Howard Zaren, M.D., FACS, Medical Director for the Lewis Cancer & Research Pavilion. The good news: Nearly 80 percent of new melanomas are caught early.
“Melanoma counts for about 80 percent of deaths from skin cancer. It can be an aggressive skin cancer,” Dr. Zaren says. “Most of the skin cancers we see, 80 percent are early stage melanomas. That helps lessen the negative effect of melanoma.”
At the LCRP, a team of oncology experts review each patient’s case to determine the best course of treatment because each case needs individualized treatment.
“One thing I tell my patients is that every patient is different; every patient’s journey is different,” says Cindy Homberger, RN, LCRP oncology patient navigator and melanographer. Homberger also is a melanoma survivor.
“I also tell them that they have a whole team of people here with them. They have someone behind them that can talk them through things.”
While each patient’s case is individualized, it’s important to have a good understanding of melanoma treatment options.
The majority of melanomas begin with changes to an existing mole such as change in shape, borders, color or size. The patient, spouse, primary care physician or dermatologist may recognize a suspicious change in a mole. At that point there is the need for a skin biopsy.
Almost all skin biopsies are performed by a dermatologist. The two most common types are shave biopsies and punch biopsies. During a shave biopsy, the dermatologist uses a sharp blade to shave the top layer off a suspicious area of skin. During a punch biopsy, the dermatologist uses a sharp hollow cylindrical tool to remove a circle of tissue from the suspicious area, Homberger explains.
If melanoma is diagnosed from the biopsy, the next step to determine the stage. Melanoma in situ, or Stage 0 noninvasive, can often be completely removed by a dermatologist, Homberger says. However, for any melanoma that is Stage IA and higher a consult with a surgical oncologist is typically necessary.
The surgical oncologist will review the pathology of the biopsy to help determine the best course of treatment, Dr. Zaren says. Biopsy results include many factors including the thickness of the melanoma, how aggressive it is, if there’s more than one melanoma and how fast it’s growing.
For the majority of melanoma patients, surgery is the main course of treatment with a goal to remove all the cancer. The most common surgical method to remove any remaining melanoma is called wide excision. A wide excision removes the entire melanoma tumor on the skin along with some normal skin around the area of the melanoma. This area is called a margin and the thickness of this margin depends on the stage of the melanoma.
Side effects following wide excision surgery vary from patient to patient and may include short-term pain and swelling and permanent scarring.
For many patients diagnosed with melanoma surgery is often the only course of treatment needed along with close follow-up that includes regular full body skin exams. However, for those patients that are at increased risk of the melanoma spreading, lymph node testing also may also be performed. For accurate results, the lymph node biopsy needs to be completed at the same time as the wide excision surgery.
At the LCRP, we use a technology called lymphoscintigraphy where a radioactive tracer, a blue dye or both are injected into the melanoma tumor in order to locate the position of the sentinel lymph node. The sentinel lymph node is simply the first node that the melanoma would move to if it metastasis, explains Dr. Zaren. The lymph nodes that are detected by the radioactive tracer and/or blue dye are removed and sent to pathology to check for the presence of melanoma cancer cells.
If melanoma is detected in the sentinel lymph node, then this changes the patients’ stage and further treatment beyond surgery may be necessary.
The use of chemotherapy to treat metastatic melanoma patients in the past was common, but is no longer considered the first line of treatment due to advancements in research and the development to new medication. Today most medical oncologists recommend immunotherapy for the treatment of advanced melanoma.
Immunotherapy is a type of treatment that increases the activity of the body’s own immune system. By doing so, these new immunotherapy drugs improve the body’s ability to find and destroy cancer cells. Immunotherapy is typically recommended following surgery in patients where the cancer has spread. However, in some cases immunotherapy may be the primary treatment for patients not deemed for surgery, Homberger says.
Some immunotherapy treatments are similar to chemotherapy in how it’s delivered, typically via an IV. Patients on these drugs will go to an infusion center and receive treatment on average once every three weeks for an hour and a half. These are often given in combination with another class of drugs (targeted therapy) that are designed to specifically target cancer cells and they are often taken in pill form, Homberger says.
Three commonly used drugs in immunotherapy for melanoma patients are Ipilimumab (Yervoy is the brand name), Nivolumab (Opdivo is the brand name) and Pembrolizumab (Keytruda is the brand name).
Keytruda may sound familiar to some as it was the drug taken by Jimmy Carter to treat metastatic melanoma that had spread to his liver and brain. Three months after Carter began receiving immunotherapy treatment, the then 91-year-old former president was informed that is was “cancer free.”
“The treatments we have now are stunning,” Homberger says. “There are so many more treatment options. It’s not nearly as scary as it used to be.”
The side effects of immunotherapy and targeted therapy drugs are considered to be much better tolerated than chemotherapy side effects but may still include skin rash, itchy skin, fatigue, nausea, diarrhea and bone, joint or muscle aches.
Another treatment option that many oncologists recommend as the best treatment option for cancer patients is clinical trials. Clinical trials study how safe and helpful tests and treatments are.
In fact, immunotherapy with drugs like Opdivo and Keytruda were in clinical trial not that long ago. And currently, there are several melanoma trials that involve new immunotherapy drugs with immune checkpoint inhibitors that blocks certain proteins made by immune system cells. This is important because when these proteins can be successfully blocked, it allows immune cells to kill cancer cells, Homberger says.
“If you qualify for a clinical trial, that can be the best way to go because clinicals are the cutting edge of medicine – just like immunotherapy was a couple of years ago,” Homberger says.
Even if current participants in a clinical trial do not benefit directly, they may still make an important contribution by assisting doctors learn more about skin cancer and how to better treat it, Dr. Zaren adds.
Melanoma diagnoses have been on the rise for the last 30 years. Many researchers believe that it is directly related to the indoor tanning industry. But that can’t account for the entire increase, and dermatologists suggest it is partially due to the increase of UV exposure resulting from the ever expanding hole in the planet’s ozone layer. This change in our environment means that we must be diligent in our skin protection routine, Dr. Zaren says. He and Homberger stress the importance of skin protection starting at a very young age.
“Melanoma is common especially where we live because of sun exposure,” Dr. Zaren says. “There are lots of chances to be in the sun. Unless we start to take skin care seriously, skin cancers will continue to be a problem.”
To protect your skin from cancer, always:
- Wear sunblock with at least 30 SPF (Dr. Zaren recommends 50 SPF)
- Apply 30 minutes before sun exposure
- Reapply every two hours or following water contact
- Choose lotions over sprays
- Try to avoid the sun during peak hours – 10 a.m. to 4 p.m.
- Seek shade if you are out, but be aware that sun reflects on water, sand and glass
- Wear protective clothing, including clothing with UPF
- Wear makeup or daily moisturizer with SPF
- Avoid tanning beds and sunlamps
It is also recommended to see a dermatologist regularly, do routine skin checks and examine your own moles and freckles for changes in size and color or any that are itchy and bleeding.
Think you are at high risk for skin cancer? Learn more about our MoleSafe program here.
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