Treatment for advanced melanoma

Sunday 1 January, 2017

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On this page: Surgery | Radiotherapy | Targeted therapy | ImmunotherapyPalliative treatment | Key points


Advanced melanoma (stage 4 or metastatic melanoma) means the cancer has spread to distant skin sites, lymph nodes, internal organs or bones. Treatment may include surgery, radiotherapy, targeted therapy or immunotherapy. Palliative treatment may also be offered to help you manage your symptoms. Due to the development of more effective treatments, chemotherapy is now rarely used to treat melanoma. Your medical team will discuss the best treatment for you based on the thickness of the melanoma and how far the melanoma has spread.

Surgery

In some cases the surgeon will be able to do a wide local excision to treat metastatic melanoma that involves other parts of the skin. The surgeon will also remove nearby lymph nodes if they are cancerous. This procedure is called a lymph node dissection or lymphadenectomy.

If the melanoma has spread to internal organs, surgery may still be possible, but this will depend on a number of factors. The type of operation you have will depend on the part of your body that is affected. Talk to your medical team for more information or call Cancer Council 13 11 20.

See more information on surgery or call Cancer Council 13 11 20.

Radiotherapy

Radiotherapy uses x-rays to damage or kill cancer cells so they cannot multiply. Radiotherapy for melanoma might be used:

  • when the cancer has spread to the lymph nodes and may not be controlled by surgery without help
  • after surgery to prevent the melanoma coming back
  • in combination with other treatments or, in special circumstances, on its own
  • as palliative treatment when the melanoma has spread to other parts of the body, such as the bones or brain, to control cancer growth or relieve symptoms.

Before starting treatment, you will have a planning appointment where a CT (computerised tomography) scan is performed. The radiotherapy team will use the images from the scan to plan your treatment. The technician may make some small permanent tattoos or temporary marks on your skin so that the same area is targeted during each treatment session.

During treatment, you will lie on a table under a machine that aims radiation at the affected part of your body. Treatment sessions are usually given daily over one to four weeks. The number of treatment sessions will depend on the size and location of the tumour, and your general health. Each session takes about 20–30 minutes and is painless – similar to an x-ray.

Side effects

Many people will develop temporary side effects, such as skin reactions and tiredness, during their treatment. Skin in the treatment area may become red and sore during or immediately after treatment, and may build up over time. The side effects you experience will depend on the part of the body that receives radiotherapy and how long you receive treatment. Ask your treatment team for advice about dealing with any side effects.

External radiotherapy will not make you radioactive. It is safe for you to be with other people, including children, after your treatment.

See more information on radiotherapy or call Cancer Council 13 11 20.

Targeted therapy

Targeted therapy drugs attack specific genetic changes (mutations) within cells that allow melanomas to grow and spread, while minimising harm to healthy cells. They are generally taken as tablets (orally). Targeted therapy is most commonly used for advanced melanoma that has spread to other organs or if the melanoma has come back after treatment.

Types of targeted therapy drugs approved for use for patients with BRAF-mutated advanced melanoma include dabrafenib and trametinib. These drugs aim to block the effects of the BRAF mutation and reduce the growth of the melanoma. Other drugs may be available through clinical trials – talk to your doctor about whether you are a suitable candidate.

Cancer cells often become resistant to targeted therapy drugs. If this happens, your doctor will change your treatment and may suggest trying another type of targeted therapy.

Some cancer treatments can affect your fertility permanently or temporarily. If having children is important to you, talk to your doctor before starting treatment.

Side effects

The side effects of targeted therapy will vary depending on which drug you are given. Common side effects include fever, tiredness, joint aches and pains, nausea, rash and other skin problems, diarrhoea, liver inflammation, and high blood pressure. Ask your treatment team for advice about dealing with any side effects.

It is important to discuss any side effects with your doctor immediately, including changes to your mood. If left untreated some symptoms can become life-threatening. For more information about targeted therapy and immunotherapy call Cancer Council 13 11 20.

Immunotherapy

Some drugs can stimulate the body’s immune system to recognise and fight melanoma cancer cells. There have been a number of new developments in the use of immunotherapy to treat melanoma. Ipilimumab, nivolumab and pembrolizumab are three immunotherapy drugs that are approved for the treatment of advanced melanoma. These drugs are known as checkpoint inhibitors because they block proteins that suppress the immune response, helping the immune system to recognise and attack melanoma cancer cells. These drugs are usually administered into a vein (intravenously). If the melanoma comes back on the skin, it may be treated using an immunotherapy cream or with an injection of an immunotherapy drug directly into the recurrence.

Around one in three people with advanced melanoma will respond to immunotherapy drugs. However, melanoma can become resistant to these drugs and tumours can start to regrow. Immunotherapy drugs are sometimes used in combination and different combinations of drugs suit different people. Treatments in this area are changing rapidly. It is important to talk to your doctor about your particular circumstances to see what therapies are appropriate for you.

Side effects

The side effects of immunotherapy drugs will vary depending on which drugs you are given. They can include tiredness, inflammation, joint pains, diarrhoea, low hormone levels, and skin problems such as rash and itch. It’s important to discuss any side effects with your medical team as soon as they appear so they can be managed appropriately. Early treatment for side effects is likely to shorten their duration. Contact your medical team if you are experiencing side effects which concern you.

Because immunotherapy drugs stimulate the immune system, they can cause major inflammatory reactions such as dermatitis, hepatitis and colitis. Consider wearing a medical alert bracelet to ensure that medical staff know you are undergoing immunotherapy treatment.

Many of the current treatments for advanced melanoma have come from testing in clinical trials. New treatments are continually being developed and you may be asked to participate in a clinical trial to help improve therapies for melanoma.

Palliative treatment

In some cases of advanced melanoma, the medical team may talk to you about palliative treatment. Palliative treatment aims to manage symptoms and improve people’s quality of life without trying to cure the disease.

Many people think that palliative treatment is for people at the end of their life; however it may be beneficial for people at any stage of advanced melanoma. It is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiotherapy or drug therapies.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. The team also provides support to families and carers.

See more information about palliative care or living with advanced cancer or call Cancer Council 13 11 20.

Key points

  • If melanoma has spread to other parts of your body (distant skin sites, lymph nodes or internal organs), it is called advanced or metastatic melanoma.
  • Treatment options for metastatic melanoma include surgery, radiotherapy, targeted therapy or immunotherapy. You may also be able to participate in clinical trials. New developments are occurring all the time.
  • The surgeon will often be able to remove the melanoma metastasis and the skin around it (wide local excision).
  • Nearby lymph nodes may also be removed in a surgical procedure called lymph node dissection (lymphadenectomy).
  • Radiotherapy uses x-rays to kill or damage cancer cells so they cannot multiply.
  • Side effects of radiotherapy may include skin redness and soreness, and fatigue.
  • Targeted therapy targets specific mutations within skin cells that signal the melanoma to grow.
  • Common side effects of targeted therapy drugs include fever, tiredness, and joint aches and pains.
  • Immunotherapy drugs stimulate the body’s immune system to recognise and fight melanoma cancer cells.
  • Common side effects of immunotherapy drugs include tiredness, inflammation of a range of organs, and joint pains.
  • Palliative treatment seeks to improve quality of life without aiming to cure the cancer.

Reviewed by: Prof Brendon J Coventry, Associate Professor of Surgery, University of Adelaide, Surgical Oncologist, Royal Adelaide Hospital, and Research Director, Australian Melanoma Research Foundation, SA; A/Prof Victoria Atkinson, Senior Medical Oncologist, Princess Alexandria Hospital and Greenslopes Private Hospital, QLD; Prof Diona Damian, Dermatologist, University of Sydney at Royal Prince Alfred Hospital, and Melanoma Institute Australia, NSW; Sharon Dei Rocini, Consumer; Prof Gerald Fogarty, Director, Radiation Oncology, St Vincent’s Hospital, NSW; Chantal Gebbie, 13 11 20 Consultant, Cancer Council NSW; Miklos Pohl OAM, Plastic and Reconstructive Surgeon, Peter MacCallum Cancer Centre and Epworth Healthcare, VIC; Julie Teraci, Clinical Nurse Consultant, Western Australian Melanoma Advisory Service, St John of God Subiaco Hospital, WA.

Updated: 01 Jan, 2017