Treatment options for melanoma skin cancer

Your specialist is part of a team of health professionals who work with you to decide on the best treatment. This team is called the multidisciplinary team (MDT).

There are 2 levels of MDT for melanoma and other skin cancers. These are the:

• Local Hospital Skin Cancer Multidisciplinary Team (LSMDT)
• Specialist Skin Cancer Multidisciplinary team (SSMDT)

LSMDTs are usually in cancer units in district general hospitals. SSMDTs are more likely to be in larger hospitals that have cancer or plastic surgery centres.

Everyone with suspected melanoma will see a member of one of these teams.

The treatment you have depends on:

• where the cancer is
• how thick the melanoma is and if it has spread (the stage)
• if there are any changes in the cancer's genes
• your general health and level of fitness

Treatment overview

Surgery is the main treatment for early melanoma. This means that it hasn't spread away from the original (primary) cancer. Other treatments for early melanoma include an immunotherapy cream called imiquimod.

If the melanoma has spread, treatment might include one or more of the following:

• surgery
• immunotherapy
• targeted cancer drugs
• radiotherapy to the areas where the melanoma has spread to, such as the bone or brain
• injecting treatment directly into the melanoma (intralesional therapy), for example talimogene laherparepvec (T-VEC)
• chemotherapy directly into the leg or arm where the melanoma is. This can be either isolated limb infusion or isolated limb perfusion
• chemotherapy combined with an electric current (electrochemotherapy)
• chemotherapy into your bloodstream (intravenous)
• imiquimod cream

Treatment for melanoma in situ (stage 0)

The treatments for melanoma in situ are surgery and the immunotherapy cream imiquimod.

Surgery

Surgery is the main treatment for stage 0 melanoma. Your doctor removes an area of healthy tissue around where the melanoma was. The operation is called a wide local excision.

If your doctor is sure they removed enough tissue, this is all the treatment you need. 

Imiquimod cream

Surgery can cause scarring and some people may not be well enough to have an operation. Instead of surgery, you might have treatment with a cream called imiquimod. You put imiquimod on the affected area over a number of weeks. Your doctor, nurse or pharmacist will tell you how long you use it for.

You might have another skin biopsy after you have had imiquimod treatment to see if it has worked.

Treatment for stage 1 and 2 melanoma skin cancer

Stage 1 and 2 melanomas are early cancers. The cancer is only in the skin and hasn’t spread to the lymph nodes or other parts of the body.

A wide local excision is the main treatment. For stage 1A melanoma this is usually all the treatment you need.

Treatment after surgery

Your doctor might offer you treatment after surgery if you have stage 2B or 2C melanoma. This is called adjuvant treatment. The aim is to reduce the risk of the cancer coming back.

You might have targeted cancer drugs or immunotherapy for a year.

Lymph node staging and sentinel lymph node biopsy

Your doctor might offer you a lymph node test for:

• stage 1B melanoma
• stage 2 melanoma
• some stage 1A melanomas

This test is called a sentinel lymph node biopsy (SLNB). It is to check the lymph nodes for melanoma cells.

You usually have it at the same time you have a wide local excision. Knowing if there are cancer cells in your lymph nodes, helps your doctor decide on the best treatment.

If there are cancer cells in the lymph nodes

Most people with melanomas less than 1mm thick don't have cancer cells in the nearby lymph nodes. If your doctor does find them the melanoma is stage 3.

If you decide not to have an SLNB

Some people may decide not to have the test. They normally have regular ultrasounds of their lymph nodes instead. This is called surveillance. But the service may not be available at all hospitals. Ultrasound surveillance is usually for 5 years.

You may need a biopsy if the scans show there may be melanoma cells in your lymph nodes. You may also need a biopsy if your lymph nodes become swollen. Your doctor will take some cells from the lymph nodes using a needle. This is different to a sentinel lymph node biopsy.

Treatment for stage 3 melanoma skin cancer

Stage 3 means that cancer cells have spread to either:

• an area between the melanoma and the nearby lymph nodes
• the lymph nodes near the melanoma

Cancer in the area between the melanoma and the nearby lymph nodes

Melanoma can spread to the area between the primary cancer and the nearby lymph nodes. These are called micro satellite, satellite or in-transit metastases. Which ones they are depend on how far away the cancer cells are from melanoma. Surgery to remove them is the main treatment.

If you can’t have surgery, you might have one of the following:

• an injection directly into the melanoma (intralesional therapy). This is normally a cancer drug called talimogene laherparepvec (T-VEC)

• chemotherapy combined with an electric current (electrochemotherapy)

• chemotherapy directly into the leg or arm where the melanoma is. This can be either isolated limb infusion or isolated limb perfusion

• targeted cancer drugs

• immunotherapy

• chemotherapy into your bloodstream (intravenous)

• radiotherapy

Melanoma in the lymph nodes

If your doctor finds melanoma cells in an SLNB they call this microscopic disease. They might suggest you have:

• regular ultrasound scans
• targeted cancer drugs or immunotherapy

You don’t usually need to have the rest of the lymph nodes in the area removed in this situation.

But sometimes they might recommend you do. The operation is called a completion lymph node dissection or lymphadenectomy. Your doctor might suggest this if:

• the melanoma is on your head or neck
• you can’t have targeted or immunotherapy drugs
• you can’t have regular scans or checks with your doctor to monitor the lymph nodes

If your lymph nodes are swollen, your doctor usually does recommend a completion lymph node dissection.

Treatment after surgery

Your doctor might offer you treatment after surgery. This is called adjuvant treatment. The aim is to reduce the risk of the cancer coming back.

You might have targeted cancer drugs or immunotherapy for a year.

Treatment for stage 4 melanoma skin cancer

Stage 4 means the cancer has spread to other parts of the body, such as the liver. It is also called advanced or metastatic melanoma skin cancer.

Targeted cancer drugs and immunotherapy are the main treatments for stage 4 melanoma. Occasionally you might have surgery if the surgeon thinks they can remove all of the cancer. But this is not an option for everyone.

Other treatments include:

• radiotherapy to specific sites of melanoma spread, for example the bone or brain

• injecting a drug directly into the melanoma (intralesional therapy), for example Talimogene laherparepvec (T-VEC)

• chemotherapy combined with an electric current (electrochemotherapy)

• chemotherapy into your bloodstream (intravenously) – usually you would only have this if you are not able to have targeted cancer drugs or immunotherapy

If the melanoma comes back

Unfortunately, melanoma skin cancer may come back. Any further treatment you have will depend on factors such as:

• where it is
• what treatment you have already had
• your general health and level of fitness

Your doctor will explain what your treatment options are and how they may affect you.

Finding out the cancer has come back can be a shock and devastating news. It's common to feel uncertain and anxious, and it can be difficult to think about anything else.

Take your time to think about the treatment your doctor recommends. You might find it helpful to talk to your specialist nurse about any worries you have about it. This can help you choose what is best for you.

You may also want to talk things over with a close friend or family member. Or there may be a counsellor you can discuss your feelings with.

Clinical trials

Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.

To make sure the research is accurate, each trial has certain entry conditions for who can take part. These are different for each trial. Your doctor may ask you to take part in a trial if you fit the entry conditions. Sometimes you may have new treatments that you wouldn’t be able to have if you weren’t in the trial.