Melanoma


Treatment for advanced melanoma

Tuesday 1 January, 2019

When melanoma has spread to distant lymph nodes or other internal organs or bones (stage IV), it is known as advanced melanoma or metastatic melanoma.

Treatment may include surgery, systemic treatment with immunotherapy or targeted therapy, and radiation therapy. Palliative treatment may also be offered to help manage your symptoms and improve quality of life.

Since the development of more effective treatments, chemotherapy is rarely used to treat melanoma.

Treatment for advanced melanoma is complex and it is best that you are treated by a specialist melanoma unit.

The team will discuss the best treatment for you based on the thickness of the melanoma and how far the melanoma has spread.

See our information on surgery, targeted therapy, immunotherapy and radiation therapy.

Surgery

In some cases, surgery may be recommended for people with advanced melanoma. Surgery is used to remove melanoma from areas on the skin, lymph nodes, or other organs such as the lung, brain or bowel.

Talk to your treatment team about what is involved and what recovery will be like. Your suitability for surgery will be discussed with a multidisciplinary team.

They will also consider other options including systemic treatment, radiation therapy and other local therapies.

Immunotherapy

There have been several advances in using immunotherapy drugs known as checkpoint inhibitors to treat melanoma.

On the surface of the body's immune cells are proteins called "checkpoints" that stop the immune system from attacking cancer cells.

Checkpoint inhibitors block these proteins so the immune cells can recognise and attack the melanoma.

Checkpoint inhibitors approved for advanced melanoma include ipilimumab, nivolumab and pembrolizumab. These drugs are usually given into a vein (intravenously).

Checkpoint inhibitors do not work for all advanced melanoma, but some people have had very encouraging results. Immunotherapy drugs are sometimes used in combination, and different combinations of drugs work for different people.

Treatments in this area are changing rapidly. Talk to your doctor about whether immunotherapy is appropriate for you.

Side effects of immunotherapy

The side effects of immunotherapy drugs will vary depending on which drugs you are given.

Immunotherapy can cause inflammation in any of the organs in the body, which can lead to side effects such as joint pain, diarrhoea or skin problems such as an itchy rash.

Autoimmune disease may develop and this is generally monitored closely. 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 how long they last. Let your medical team know if you are experiencing side effects that concern you.

Targeted therapy

New types of drugs known as targeted therapy attack specific genetic mutations within cancer cells, 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 surgery.

Several different targeted therapy drugs have been approved for people who have the BRAF mutation.

Drugs are often used together to help block the effects of the BRAF mutation and reduce the growth of the melanoma. Drugs for NRAS and C-KIT mutations may be available through clinical trials – talk to your doctor about whether you are a suitable candidate.

Cancer cells may become resistant to targeted therapy drugs over time. If this happens, your doctor will suggest trying another type of systemic therapy.

Side effects of targeted therapy

The side effects of targeted therapy will vary depending on which drugs you are given. Common side effects include fever, tiredness, loss of appetite, joint aches and pains, nausea, rash and other skin problems, diarrhoea, and high blood pressure.

Ask your treatment team for advice about dealing with any side effects.

It is important to let your doctor know immediately of any side effects. If left untreated, some side effects can become serious.

Radiation therapy

Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply and spread.

Radiation therapy may be offered on its own or in combination with other treatments, and may be recommended:

  • when the cancer has spread to the lymph nodes
  • after surgery to prevent the melanoma coming back
  • as palliative treatment to improve quality of life by relieving pain and other symptoms (see below).

Before starting treatment, you will have a planning appointment where a CT scan is performed. The radiation therapy 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 having an x-ray.

Stereotactic body radiation therapy (SBRT)

This is a way of delivering highly focused radiation therapy to the tumour, while the surrounding tissue receives a low dose. It is delivered from multiple beams that meet at the tumour.

SBRT often involves four treatment sessions over a couple of weeks.

Side effects of radiation therapy

The side effects you experience will depend on the part of the body that receives radiation therapy and how long you receive treatment. Many people will develop temporary side effects, such as skin reactions and tiredness, during treatment.

Skin in the treatment area may become red and sore during or immediately after radiation therapy, and these side effects may build up over time.

Ask your treatment team for advice about dealing with any side effects.

Palliative treatment

In some cases of advanced melanoma, the medical team may talk to you about palliative treatment. Palliative treatment aims to manage symptoms without trying to cure the disease.

It can be used at any stage of advanced cancer to improve quality of life and does not mean giving up hope. Rather, 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 radiation therapy or drug therapies.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs.

The team also supports families and carers. See Understanding Palliative Care and Living with Advanced Cancer.

Key points about treating advanced melanoma

What it is

If melanoma has spread to other parts of your body (distant skin sites, distant lymph nodes or internal organs or bones), it is called advanced or metastatic melanoma.

Choice of treatment

Treatment will depend on test results and whether the cancer has a gene mutation. You may also be able to participate in clinical trials. New developments are occurring all the time.

Treatment options

Treatment for advanced melanoma may include:

  • surgery – removes the melanoma metastasis
  • lymph node dissection (lymphadenectomy) – surgically removes nearby lymph nodes
  • immunotherapy – uses drugs to help stimulate the body's immune system recognise and fight melanoma
  • targeted therapy – uses drugs that attack specific features of cancer cells
  • radiation therapy – uses targeted radiation to damage cancer cells
  • palliative treatment – seeks to improve quality of life without aiming to cure the cancer.

Side effects

  • Immunotherapy drugs can cause inflammation of any organs in the body, and joint pain.
  • Targeted therapy can cause fever, tiredness, and joint aches and pains.
  • Radiation therapy may cause skin redness and fatigue.

Expert content reviewers:

A/Prof Victoria Atkinson, Senior Staff Specialist, Princess Alexandra Hospital, Visiting Medical Oncologist, Greenslopes Private Hospital, and The University of Queensland Clinical School of Medicine, QLD; Adjunct Prof John Kelly AM, Consultant Dermatologist, Victorian Melanoma Service, and Department of Medicine at Alfred Health, Monash University, VIC; Dr Alex Chamberlain, Dermatologist, Glenferrie Dermatology, Victorian Melanoma Service and Monash Univeristy, VIC; Alison Button-Sloan, Melanoma Patients Australia; Peter Cagney, Consumer; Prof Brendon J Coventry, Associate Professor of Surgery, The University of Adelaide, Surgical Oncologist, Royal Adelaide Hospital, and Research Director, Australian Melanoma Research Foundation, SA; Dr David Gyorki, Consultant Surgical Oncologist, Peter MacCallum Cancer Centre, VIC; Liz King, Skin Cancer Prevention Manager, Cancer Council NSW; Shannon Jones, SunSmart Health Professionals Coordinator, Cancer Council Victoria; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Prof Richard Scolyer, Senior Staff Specialist, Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Co-Medical Director, Melanoma Institute Australia and Clinical Professor, The University of Sydney, NSW; Heather Walker, Chair, Cancer Council National Skin Cancer Committee, Cancer Council Australia.

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