Melanoma

Melanoma: Overview

Melanomas: This type of skin cancer can develop in an existing mole or look like a new mole on your skin.

Also called malignant melanoma

Melanoma is the most serious type of skin cancer. Allowed to grow, melanoma can spread quickly to other parts of the body. This can be deadly.

There is good news. When found early, melanoma is highly treatable.

You can find melanoma early by following this 3-step process:

Dermatologist examining woman for skin cancer: If you notice a mole that differs from others on your body or a spot that is changing, bleeding, or itching, see a dermatologist.

1. Learn the warning signs of melanoma.
2. Look for the warning signs while examining your skin.
3. See a dermatologist if you find any of the warning signs.

Images property of the American Academy of Dermatology.

Melanoma: Signs and symptoms

Patients with melanoma: This skin cancer can form on your skin, scalp, genitals, and even under a nail,

Melanoma, the deadliest skin cancer, can show up on your body in different ways. You may see a:

• Change to an existing mole
• New spot or patch on your skin
• A spot that looks like a changing freckle or age spot
• Dark streak under a fingernail or toenail
• Band of darker skin around a fingernail or toenail
• Slowly growing patch of thick skin that looks like a scar
  
  

Warning signs to look for

Dermatologists encourage people of all skin colors to perform skin self-exams. Checking your skin can help you find melanoma early when it’s highly treatable. When examining your skin for melanoma, you want to look for the warning signs, which are called the ABCDEs of melanoma :

If you find anything that looks like it could be melanoma, immediately make an appointment to see a dermatologist. These doctors are the experts at diagnosing skin cancer. Research shows that dermatologists correctly diagnose melanoma more than any other type of doctor.

Symptoms of melanoma

A melanoma may have only 1 or 2 of the ABCDEs.

You can have melanoma without feeling any pain or discomfort. For many people, the only sign is a change to their skin, scalp, or nail.
Sometimes, melanoma causes one of more of the following:

• Itch
• Pain
• Bleeding

When checking your skin, you want to make sure you check everywhere.

Images
Images 1, 3, and 4 used with permission of the Journal of the American Academy of Dermatology:

• Images 1 and 3: J Am Acad Dermatol. 2014;70(4):748-62.
• Image 4 : J Am Acad Dermatol. 2006;55(5):741-60. Courtesy of Calvin McCall, MD.

Images 2, 4, and 5: Images used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
Image 7: Property of the American Academy of Dermatology

References
Agbai ON, MD, Buster K, et al. “Skin cancer and photoprotection in people of color: A review and recommendations for physicians and the public.” J Am Acad Dermatol 2014;70(4):748-62.
Gagnon, L. “Dermatologists better at detecting melanoma
Non-dermatologists would benefit from more training in accurate pigmented lesion diagnosis.” Dermatology Times. Jan 12, 2015:
Gloster HM and Neal K. “Skin cancer in skin of color.” J Am Acad Dermatol 2006;55(5):741-60.
Tsao H, Olazagasti JM, et al. “Early detection of melanoma: Reviewing the ABCDEs.” J Am Acad Dermatol 2015;72:717-23.

Melanoma is one of the most common cancers in females aged 15 to 29 years old. Tanning-bed use contributes to this.

Melanoma: Who gets and causes

Who gets melanoma?

Anyone can get melanoma. Most people who get melanoma have light skin, but people who have brown and black skin also get melanoma.

Your risk of getting melanoma increases if you:

Seek the sun, tanning beds, or sun lamps: The sun, tanning beds, and sun lamps emit ultraviolet light (UV). Scientists have proven that UV light can cause skin cancer in people. Their research also shows you increase your risk of getting melanoma if you:

• Use tanning beds.
  Using indoor tanning beds before age 35 can increase your risk of melanoma by 59%, and the risk increases with each use.
•  Had 5 or more blistering sunburns between ages 15 and 20
  Research shows this increases one's melanoma risk by 80%.
• Live close to the equator.
  Sunlight is more intense there.
• Live in a sunny area of the United States like Florida or Arizona.
• Failed to protect your skin from the sun.
  People older than 65 may experience melanoma more frequently because of UV exposure they've received over the course of their lives. Men older than 50 also have a higher risk of developing melanoma.

While exposure to UV light greatly increases your risk of developing melanoma, your other characteristics also play a role. These include:

Having light-colored skin, hair, or eyes or certain moles: The risk of getting melanoma increases if you have one or more of the following:

• Fair skin
• Red or blond hair
• Blue or green eyes
• Sun-sensitive skin
• You rarely tan or burn easily
• 50 or more moles
• Large moles
• An atypical mole (mole that looks like melanoma)

Taking certain medications or having some medical conditions: Your risk of getting melanoma increases if you have:

• Had melanoma or another type of skin cancer
• Had type of cancer, such as breast or thyroid cancer
• A disease that weakens your immune system, such as acquired immunodeficiency syndrome (AIDS)
• To take medicine to quiet your immune system, such as taking life-saving medicines to prevent organ rejection after transplant surgery

  

  Organ transplant recipients have a three- to fivefold increased risk for melanoma.

Have a history of melanoma in your family: If a close blood relative has or had melanoma, you have a higher risk of getting melanoma.

What causes melanoma?

Ultraviolet (UV) light causes melanoma. We get UV light from the sun and tanning beds. Scientists have shown that UV light from the sun and tanning beds can do two things:

1. Cause melanoma on normal skin.
2. Increase the risk of a mole on your skin turning into a melanoma

Scientists have also found that some people inherit genes that increase their risk of getting melanoma.
Because UV exposure is the leading cause of melanoma, you can greatly reduce your risk of getting melanoma by taking steps to prevent skin cancer.

References
American Academy of Dermatology. Stats and facts: Melanoma. Last accessed April 27, 2016.
Soura E, Eliades PJ, et al. “Hereditary melanoma: Update on syndromes and management Emerging melanoma cancer complexes and genetic counseling.” J Am Acad Dermatol 2016;74:411-20.
Zwald FO and Brown M. “Skin cancer in solid organ transplant recipients: Advances in therapy and management Part I. Epidemiology of skin cancer in solid organ transplant recipients.” J Am Acad Dermatol 2011;65:253-61.

Melanoma: Diagnosis and treatment

How do dermatologists diagnose melanoma?

To diagnose melanoma, a dermatologist begins by looking at the patient’s skin. A dermatologist will carefully examine moles and other suspicious spots. To get a better look, a dermatologist may use a device called a dermoscope. The device shines light on the skin. It magnifies the skin. This helps the dermatologist to see pigment and structures in the skin.

The dermatologist also may feel the patient’s lymph nodes. Many people call these lymph glands.

If the dermatologist finds a mole or other spot that looks like melanoma, the dermatologist will remove it (or part of it). The removed skin will be sent to a lab. Your dermatologist may call this a biopsy. Melanoma cannot be diagnosed without a biopsy.

This biopsy is quick, safe, and easy for a dermatologist to perform. This type of biopsy should not cause anxiety. The discomfort and risks are minimal.

If the biopsy report says that the patient has melanoma, the report also may tell the stage of the melanoma. Stage tells the doctor how deeply the cancer has grown into the skin.

The melanoma stages are:

Sometimes the patient needs another type of biopsy. A type of surgery called a sentinel lymph node biopsy (SLNB) may be recommended to stage the melanoma. When melanoma spreads, it often goes to the closest lymph nodes first. A SLNB tells doctors whether the melanoma has spread to nearby lymph nodes. Other tests that a patient may need include x-rays, blood work, and a CT scan.

How do dermatologists treat melanoma?

The type of treatment a patient receives depends on the following:

• How deeply the melanoma has grown into the skin.
• Whether the melanoma has spread to other parts of the body.
• The patient’s health.

The following describes treatment used for melanoma.

Surgery: When treating melanoma, doctors want to remove all of the cancer. When the cancer has not spread, it is often possible for a dermatologist to remove the melanoma during an office visit. The patient often remains awake during the surgical procedures described below. These procedures are used to remove skin cancer:

• Excision: To perform this, the dermatologist numbs the skin. Then, the dermatologist surgically cuts out the melanoma and some of the normal-looking skin around the melanoma. This normal-looking skin is called a margin. There are different types of excision. Most of the time, this can be performed in a dermatologist’s office.
  
  
• Mohs surgery: A dermatologist who has completed additional medical training in Mohs surgery performs this procedure. Once a dermatologist completes this training, the dermatologist is called a Mohs surgeon.
  
  Mohs surgery begins with the Mohs surgeon removing the visible part of the melanoma. Next, the surgeon begins removing the cancer cells. Cancer cells are not visible to the naked eye, so the surgeon removes skin that may contain cancer cells one layer at a time. After removing a layer, it is prepped so that the surgeon can examine it under a microscope and look for cancer cells. This layer-by-layer approach continues until the surgeon no longer finds cancer cells. In most cases, Mohs surgery can be completed within a day or less. Mohs has a high cure rate.

When caught early, removing the melanoma by excision or Mohs may be all the treatment a patient needs. In its earliest stage, melanoma grows in the epidermis (outer layer of skin). Your dermatologist may refer to this as melanoma in situ or stage 0. In this stage, the cure rate with surgical removal is nearly 100%.

When melanoma grows deeper into the skin or spreads, treatment becomes more complex. It may begin with one of the surgeries described above. A patient may need more treatment. Other treatments for melanoma include:

• Lymphadenectomy: Surgery to remove lymph nodes.

• Immunotherapy: Treatment that helps the patient’s immune system fight the cancer.
• Targeted therapy: Drugs that can temporarily shrink the cancer; however, some patients appear to be fully cured. 

• Chemotherapy: Medicine that kills the cancer cells (and some normal cells).

• Radiation therapy: X-rays that kill the cancer cells (and some normal cells).

Other treatment that may be recommended includes:

• Clinical trial: A clinical trial studies a medicine or other treatment. A doctor may recommend a clinical trial when the treatment being studied may help a patient. Being part of a medical research study has risks and benefits.
  
  Before joining a clinical trial, patients should discuss the possible risks and benefits with their doctor. The decision to join in a clinical trial rests entirely with the patient.
  
  
• Adoptive T-cell therapy: This treatment uses the patient's immune system to fight the cancer. Instead of receiving medicine, the patient has blood drawn. The blood is sent to a lab so that the T cells (cells in our body that help us fight cancers and infections) can be removed. These T cells are then placed in a culture so that they can multiply. 
  
  Once the T cells are ready, they are injected back into the patient. Some patients with advanced melanoma have had long-lasting remission. This therapy, however, is not widely available. 
  
  
• Palliative care: This care can relieve symptoms and improve a patient’s quality of life. It does not treat the cancer. Many patients receive palliative care, not just patients with late-stage cancer.
  
  When melanoma spreads, palliative care can help control the pain and other symptoms. Radiation therapy is a type of palliative care for stage IV (has spread) melanoma. It can ease pain and other symptoms.

Outcome

This depends on how deeply the melanoma has grown into the skin. If the melanoma is properly treated when it is in the top layer of skin, the cure rate is nearly 100%. If the melanoma has grown deeper into the skin or spread, the patient may die.

Melanoma: Tips for talking with your dermatologist

A dermatologist meets with his patient and her daughter. Having someone you trust at your appointments can be helpful and comforting.

Have you been diagnosed with melanoma? Are you going through treatment?

If you feel stressed about your diagnosis or treatment, it can be difficult to listen. Too often, our minds just wander. This can make it challenging to understand medical information and instructions.

Good two-way communication, however, is important. Studies show that effective communication between a patient and doctor during cancer care can improve results.

The following tips can help you get the information you need. These tips can also help make sure you give your dermatologist essential information.

What to tell your dermatologist

You can improve communication by telling your dermatologist the following about yourself.

1. How much information you want. Some people want details like the risks and benefits of treatment, expected results, and how treatment will affect their everyday life.
   
   Other patients feel overwhelmed with so much information and just want to know what treatment the dermatologist recommends.
   
   Think about how much detail you want, and tell your dermatologist.
2. Honest answers to questions that may seem embarrassing or irrelevant, such as:

Tips to help you understand — and remember — what your dermatologist tell you

When we're stressed, it can be difficult to remember what we hear. The following tips can help you get the information you need.

3. Bring a laptop or pad of paper to your appointments. Even if you just want basic information, it can be hard to remember what your dermatologist says. Taking notes can help you know what you need to do next and make informed decisions about your cancer care.
   
   Keeping notes also gives you a place to jot down questions that you may think of after the appointment so that you can ask them later.
4. Take a family member or close friend with you. It's understandable that you feel shaken. You may feel too stressed to listen well or take notes. Having a trusted family member or close friend take notes and ask questions can be very helpful.
5. Ask for an explanation if anything your dermatologist says seems unclear. Medical jargon lets doctors communicate very specific information clearly to other doctors and medical professionals. For example, saying that a patient has melanoma in a certain stage can give another doctor important information.
   
   When speaking with you, though, your dermatologist should use everyday language. Still, if something is unclear, be sure to tell your dermatologist.

If something is unclear, ask questions. It's important to understand what you need to do.

What to do at the end of each appointment

Before leaving, it's important to know what you need to do next. Taking a minute to do the following can help.

6. Quickly summarize the important points that you heard. It can be helpful to end your appointment by:
7. If you need to make a decision, request time to decide. You want to feel comfortable with the decisions you make. Ask how long you can have to make the decision.
8. Ask whom you can contact if you have questions later. Most patients say they wish they had asked certain questions during the appointment but thought of the questions later.

Bookmark or print this page

You probably have a lot on your mind now. By bookmarking or printing this page, you'll be able to refer to these tips during your appointments. (7.8, 598)

Reference
National Cancer Institute. “Communication in Cancer Care (PDQ®)–Patient Version.” Last update March 27, 2015. Last accessed June 27, 2016

Melanoma: Treatment news

Treatment for advanced melanoma continues to improve

March 2015: Treatment for advanced melanoma is changing rapidly. Breakthroughs in medical research are giving hope to patients who have melanoma that has spread.

Fueling this change is a type of treatment called targeted therapy. This therapy uses new drugs that can temporarily shrink the cancer. 

Breakthroughs in another type of treatment called immunotherapy, which helps the patient’s immune system fight cancer, also are helping some patients live longer.

The following explains how these new drugs, approved by the U.S. Food and Drug Administration (FDA) between 2011 and 2014, are helping patients. All have been approved to treat adults (18 years or older) who have melanoma that has spread.

Help the patient’s immune system fight the cancer

Ipilimumab (Yervoy®), which was FDA approved in 2011, is helping some people with advanced melanoma live longer. 

How ipilimumab works: This drug helps the patient’s immune system to recognize, target, and attack cancer cells. Healthy cells are left alone.

Patient responses to ipilimumab: In studies, patients had the following response:

• This drug shrank tumors for about 11% of patients with advanced melanoma. 
• Patients who respond often have a long-lasting response.
• In patients who survive 7 years, the likelihood of a long-lasting response increases. No deaths have been reported in patients who live for 7 years after the first treatment.
• It has been effective in patients when melanoma spreads to the brain. In 18% of these patients, the tumor(s) cleared, shrank, or did not progress.

Encouraging news: Giving patients ipilimumab and another drug that boosts the immune system can increase a patient’s response. In clinical trials, the patients receiving such combinations live longer and have fewer toxic side effects than patients who receive only ipilimumab. 

How to take ipilimumab: Patients receive IV drips at a hospital or cancer treatment center. 

Note: A medical oncologist (doctor who specializes in treating cancer) usually treats patients when melanoma spreads. This doctor can tell you how often you would take this drug and possible side effects. 

Pegylated interferon: Another advance in immunotherapy is the FDA approval of pegylated (or peg) interferon to treat melanoma that has spread to nearby lymph nodes. Peg-interferon causes fewer side effects than interferon given in the past. This may help patients take the drug for a longer time. The recommended treatment period is 5 years.

Target therapy can temporarily stop cancer from spreading

Cancer begins when changes take place within our genes. Your doctor may call these changes “gene mutations.” 

Some people with melanoma have changes to a specific gene called BRAF. Doctors often refer to this change as a “BRAF gene mutation.”

Researchers have developed drugs that can target a BRAF gene mutation. The following drugs are FDA approved to treat melanoma driven by a BRAF gene mutation:

• Vemurafenib (Zelboraf®) approved in 2011
• Dabrafenib (Tafinlar®) approved in 2013
• Trametinib (Mekinist®) approved in 2013 
• Dabrafenib + trametinib, approved 2014 

How these drugs works: If a patient has a certain BRAF gene mutation, these drugs can temporarily block the specific pathway that melanoma uses to grow. Because dabrafenib and trametinib block different parts of the same pathway, they can be more effective when taken together. 

Patient must have BRAF gene mutation: For a patient to receive this type of targeted therapy, the melanoma tumor must have a specific mutation in the BRAF gene. A tumor biopsy, which involves removing some of the melanoma and testing it, can tell your doctor whether you have a BRAF gene mutation.

Patient responses to these drugs: These drugs can shrink melanoma tumors and slow the progression of melanoma. In clinical trials, patients had the following response rates:

• Dabrafenib: 54% have a positive response (tumors shrink or clear completely), which lasts about 5.6 months before the melanoma progresses. 
• Trametinib: When a patient has a positive response, it lasts about 4.8 months before the melanoma progresses.
• Dabrafenib + trametinib: 76% of patients have a positive response, which lasts about 9.4 months. 
• Vemurafenib: More than half the patients had a positive response, which lasted about 6.7 months, and 6% of patients achieved a complete response (no sign of melanoma).

While these drugs can be effective, they tend to stop working in time. When the drug stops working, the melanoma can progress. At that time, other treatment options can be considered.

How to take these drugs: All of these drugs are pills. 

Note: A medical oncologist usually prescribes the pills and monitors patients. 

Since some of the side effects can occur in the skin, patients taking one of these drugs usually see a dermatologist for one year. 

Patients taking vemurafenib: Patients taking this drug must protect their skin from the sun because vemurafenib causes the skin to become extremely sensitive to sunlight. Spending just 5 minutes outdoors in the sun can cause sunburn. Patients also burn when they are outdoors in the shade.

Drugs that offer hope when other treatments fail 

In 2014, the FDA approved two drugs that can be considered when other treatments fail or stop working. Both nivolumab (Opdivo®) and pembrolizumab (Keytruda®) are FDA approved for patients who have:

• Tried the drug ipilimumab 
• A BRAF gene mutation 

Because some patients experience serious side effects, the FDA approved these drugs only for patients who have tried other treatment first. 

How nivolumab and pembrolizumab work: Like ipilimumab, these drugs enable the body’s immune system to attack the melanoma cells.

Research breakthroughs occurring at a rapid pace

Other treatments for advanced melanoma are being studied in clinical trials. More therapies are expected to be approved by the FDA.

More information about the newer FDA-approved therapies

If you are interested in exploring treatment options, you should ask your doctor which treatment might be a good fit for you.

Researchers continue to study the drugs discussed in this article. You can learn more about these drugs and look for clinical trials (run to improve drugs) that are accepting patients with advanced melanoma by clicking on the following pages:

• Dabrafenib
• Ipilimumab
• Nivolumab
• Pembrolizumab
• Trametinib
• Vemurafenib

References
Fox MC, Lao CD, et al. “Management options for metastatic melanoma in the era of novel therapies: a primer for the practicing dermatologist: part I: Management of stage III disease.” J Am Acad Dermatol. 2013 Jan;68(1)1.e1-1.e8.

Fox MC, Lao CD, et al. “Management options for metastatic melanoma in the era of novel therapies: a primer for the practicing dermatologist: part II: Management of stage IV disease.” J Am Acad Dermatol. 2013 Jan;68(1):13.e1-13e12.

Hinrichs CS, Rosenberg SA. “Exploiting the curative potential of adoptive T-cell therapy for cancer.” Immunol Rev. 2014 Jan;257(1):56-71.

Hodi FS, Lee S, et al. “Ipilimumab plus sargramostim vs ipilimumab alone for treatment of metastatic melanoma: A randomized clinical trial.” JAMA. 2014 Nov 5; 312(17):1744-53.

Hodi FS, Corless CL, et. al. “Imatinib for melanomas harboring mutationally activated or amplified KIT arising on mucosal, acral, and chronically sun-damaged skin.” J Clin Oncol. 2013 Sep 10;31(26):3182-90.

Robert C, Long GV, et. al. “Nivolumab in previously untreated melanoma without BRAF mutation.” N Engl J Med. 2014 Nov 16. [Epub ahead of print.]

Thompson JF, Agarwala SS, et al. “Phase 2 Study of Intralesional PV-10 in Refractory Metastatic Melanoma.” Ann Surg Oncol. 2014 Oct 28. [Epub ahead of print]

U.S. Food and Drug Administration, “FDA approves Opdivo for advanced melanoma.” FDA news release issued December 22, 2014.

Van Voorhees AS, “From the editor: Dermatology is sitting at an interesting juncture.” Dermatology World. 2014; 24(5):2.

Wolchok JD, Kluger H, et al. “Nivolumab plus ipilimumab in advanced melanoma.” N Engl J Med 2013; 369:122-133. (Funded by Bristol-Myers Squibb and Ono Pharmaceutical; ClinicalTrials.gov number, NCT01024231.)

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