Staging melanoma

Health professionals use a staging system to describe how far melanoma has grown into the skin (the thickness) and whether it has spread. The type of treatment you receive will depend on what stage the melanoma has reached.

The stages of melanoma can be described as:

• Stage 0 – the melanoma is on the surface of the skin.  
• Stage 1A – the melanoma is less than 1mm thick.
• Stage 1B – the melanoma is 1-2mm thick, or the melanoma is less than 1mm thick and the surface of the skin is broken (ulcerated) or its cells are dividing faster than usual (mitotic activity).
• Stage 2A – the melanoma is 2-4mm thick, or the melanoma is 1-2mm thick and is ulcerated.
• Stage 2B – the melanoma is thicker than 4mm, or the melanoma is 2-4mm thick and ulcerated.
• Stage 2C – the melanoma is thicker than 4mm and ulcerated.
• Stage 3A – the melanoma has spread into one to three nearby lymph nodes, but they are not enlarged; the melanoma is not ulcerated and has not spread further.
• Stage 3B – the melanoma is ulcerated and has spread into one to three nearby lymph nodes but they are not enlarged, or the melanoma is not ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread to small areas of skin or lymphatic channels, but not to nearby lymph nodes.
• Stage 3C – the melanoma is ulcerated and has spread into one to three nearby lymph nodes and they are enlarged, or the melanoma has spread into four or more lymph nodes nearby.
• Stage 4 – the melanoma cells have spread to other areas of the body, such as the lungs, brain or other parts of the skin.

Want to know more?

• Cancer Research UK: Treating melanoma.
• Cancer Research UK: Stages of melanoma.
• Macmillan: Malignant melanoma.

Stage 1 melanoma

Treating stage 1 melanoma will involve surgically removing 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. This means you will be awake 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 will be asleep during the procedure.

If a surgical excision is likely to leave a significant scar, it may be done in combination with a skin graft. A skin graft involves removing a patch of healthy skin, usually taken from a part of your body where scarring cannot be seen, such as your back. It is then connected, or grafted, to the affected area. Skin grafts or flaps are used when the area of skin being removed is too big to close using a direct method.

Once the melanoma has been removed, there is little possibility it will return and no further treatment should be required. You will probably be asked to come for follow-up appointments before being discharged. 

Stage 2 and 3 melanoma

As with stage 1 melanomas, any affected areas of skin will be removed. The remaining skin is either closed directly, or a skin graft or flap may be carried out if necessary.

Sentinel node biopsy

Sentinel node biopsy, which is not a mandatory procedure, will be discussed with you. If you decide to go ahead with the procedure and the results show no spread to nearby lymph nodes, it is unlikely you will have further problems with this melanoma.

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

Lymph nodes

If the melanoma has spread to nearby lymph nodes, you may need further surgery to remove them. Your doctor will have felt a lump in your lymph nodes and the diagnosis of melanoma is usually confirmed using a needle biopsy (fine needle aspiration). Removing the affected nodes requires a procedure called a block dissection, performed under general anaesthetic.

While the surgeon will try to ensure the rest of your lymphatic system can function normally, there is a risk that the removal of lymph nodes will disrupt the lymphatic system, leading to a build-up of fluids in your limbs. This is known as lymphoedema.

Follow-up

Once the melanoma has been removed, you will need follow-up appointments to see how you are recovering and to watch for any sign of the melanoma returning.

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

Stage 4 melanoma

It may not be possible to cure melanoma if it has:

• been diagnosed at its most advanced stage
• spread to another part of your body (metastasis)
• come back in another part of your body after treatment (recurrent cancer)

Treatment is available and given in the hope that it can slow the cancer's growth, reduce any symptoms you may have and possibly extend your life expectancy.

You may be able to have 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 symptoms. These include:

• radiotherapy 
• drug treatments

Radiotherapy

Radiotherapy may be used after an operation to remove your lymph nodes, and can also be used to help relieve the symptoms of advanced melanoma.

Radiotherapy uses controlled doses of radiation to kill cancer cells. It is given at the hospital as a series of 10-15 minute daily sessions, with a rest period over the weekend.

The side effects of radiotherapy include:

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

Many side effects can be prevented or controlled with medicines your doctor can prescribe, so let them know about any that you experience. After treatment has finished, the side effects of radiotherapy should gradually reduce.

Want to know more?

• Cancer Research UK: Radiotherapy for melanoma.

Drug treatment

In recent years there have been major advancements in treating melanoma. The medications used to treat melanoma are changing as new formulations are being introduced into clinics.

The medications currently being used include:

• vemurafenib
• ipilimumab
• nivolumab

However, not everyone is suitable for these drugs. Your specialist will discuss an appropriate treatment with you, and many people are entered into clinical trials (see clinical trials, below).

Some of the available medications are discussed below.

Chemotherapy

Chemotherapy involves using anti-cancer (cytotoxic) drugs to kill the cancer. It is normally used to treat melanoma that has spread to parts of the body and is mainly given to help relieve symptoms of advanced melanoma.

Several different chemotherapy drugs are used to treat melanoma and are occasionally given in combination. The drugs most commonly used for melanoma are dacarbazine and temozolomide. However, many different types of drugs can be used. Your specialist can discuss with you which drugs are the most suitable.

Chemotherapy is usually given as an outpatient treatment, which means you will not have to stay in hospital overnight. Dacarbazine is given through a drip and temozolomide is given in tablet-form. Chemotherapy sessions are usually given once every three to four weeks, with gaps between treatment intended to give your body and blood time to recover.

The main side effects of chemotherapy are caused by their influence on the rest of the body. Side effects include infection, nausea and vomiting, tiredness and sore mouth. Many side effects can be prevented or controlled with medicines that your doctor can prescribe.

Immunotherapy

Immunotherapy uses drugs (often derived from substances that occur naturally in the body) that encourage your body's immune system to work against the melanoma. Two such treatments in regular use for melanoma are interferon-alpha and interleukin-2. Both are given as an injection (into the blood, under the skin, or into lumps of melanoma).

Side effects include flu-like symptoms, such as chills, a high temperature, joint pain and fatigue.

Vaccines

There is ongoing research into producing a vaccine for melanoma, either to treat advanced melanoma or to be used after surgery in patients who have a high risk of the melanoma coming back.

Vaccines are designed to focus the body’s immune system so it recognises the melanoma and can work against it. Vaccines are usually given as an injection under the skin every few weeks, often over a period of months.

As more research is needed into vaccines, they are only given as part of a clinical trial.

Monoclonal antibodies

Our immune systems make antibodies all the time, usually as a way of controlling infections. They are substances that recognise something which doesn’t belong in the body and help to destroy it. Antibodies can be produced in the laboratory and can be made to recognise and lock onto specific targets, either in the cancer or in specific parts of the body.

Antibodies produced in the laboratory are usually called monoclonal antibodies.

Ipilimumab

Ipilimumab is a monoclonal antibody that has been licensed for use in the UK since 2011. It works like an accelerator for the immune system, allowing the body to work against all sorts of conditions, including cancer.

In December 2012, NICE recommended ipilimumab as a possible treatment for people with previously treated advanced melanoma that has spread or cannot be surgically removed.

Signalling inhibitors

Signalling inhibitors are drugs that work by disrupting the messages (signals) a cancer uses to co-ordinate its growth. There are hundreds of these signals, and it is difficult to know which ones need to be blocked. Most of the signals have short, technical names. Two that are of current interest in relation to melanoma are BRAF and MEK.

There are drugs available that can interfere with these signals, but most are currently only widely available as part of clinical trials.

NICE recommends a signalling inhibitor called vemurafenib as a possible treatment for melanoma that has spread or cannot be surgically removed.

Want to know more?

• Cancer Research UK: Biological therapy for melanoma.
• Cancer Research UK: Chemotherapy for melanoma.
• Clinical trials for melanoma.

Clinical trials

All new treatment for cancer (and other diseases) is first given to patients in a clinical trial.

A clinical trial or study is an extremely rigorous way of testing a drug on people. Patients are monitored for any effects of the drug on the cancer, as well as side effects. Many people with melanoma are offered entry into clinical trials, but some people are suspicious of the process.

There are a few key things to know about clinical trials:

• Overall, patients in clinical trials do better than those on routine treatment, even when receiving a drug that would be given routinely.
• All clinical trials are highly regulated.
• All new treatments will first become available through clinical trials.
• Even where a new drug fails to offer any benefits over existing treatment, the knowledge that we gain from the trial is valuable for future patients.

If you are asked to take part in a trial, you will be given an information sheet and, if you want to take part, you will be asked to sign a consent form. You can refuse or withdraw from a clinical trial without it affecting your care.

Want to know more?

• Clinical trials and medical research.
• Cancer Research UK: Melanoma research.
• Clinical trials for melanoma.

Deciding against treatment for Stage 4 melanoma

Many of the treatments described above have unpleasant side effects that can affect your quality of life. You may decide against having treatment if it is unlikely to significantly extend your life expectancy, or if you do not have symptoms causing you pain or discomfort.

This is entirely your decision and your healthcare 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.

Want to know more?

• Accessing palliative care.
• Macmillan: About advanced melanoma. 
• Cancer Research UK: Advanced melanoma (Stage 4).