IntroductionMelanoma* is the most serious type of cancer of the skin. Each year in the United States, more than 53,600 people learn they have melanoma.
In some parts of the world, especially among Western countries, melanoma is becoming more common every year. In the United States, for example, the percentage of people who develop melanoma has more than doubled in the past 30 years.
What Is Melanoma?Melanoma is a type of skin cancer. It begins in cells in the skin called melanocytes. To understand melanoma, it is helpful to know about the skin and about melanocytes—what they do, how they grow, and what happens when they become cancerous.
The SkinThe skin is the body’s largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D.
The skin has two main layers: the outer epidermis and the inner dermis.
Melanocytes and MolesMelanocytes produce melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes produce more pigment, causing the skin to tan, or darken.
Sometimes, clusters of melanocytes and surrounding tissue form noncancerous growths called moles. (Doctors also call a mole a nevus; the plural is nevi.) Moles are very common. Most people have between 10 and 40 moles. Moles may be pink, tan, brown, or a color that is very close to the person’s normal skin tone. People who have dark skin tend to have dark moles. Moles can be flat or raised. They are usually round or oval and smaller than a pencil eraser. They may be present at birth or may appear later on—usually before age 40. They tend to fade away in older people. When moles are surgically removed, they normally do not return.
Understanding CancerCancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.
Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor. Not all tumors are cancer.
Tumors can be benign or malignant:
MelanomaMelanoma occurs when melanocytes (pigment cells) become malignant. Most pigment cells are in the skin; when melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma may also occur in the eye (ocular melanoma or intraocular melanoma). Rarely, melanoma may arise in the meninges, the digestive tract, lymph nodes, or other areas where melanocytes are found. Melanomas that begin in areas other than the skin are not discussed in this booklet. The Cancer Information Service (1-800-4-CANCER) can provide information about these types of melanoma.
Melanoma is one of the most common cancers. The chance of developing it increases with age, but this disease affects people of all ages. It can occur on any skin surface. In men, melanoma is often found on the trunk (the area between the shoulders and the hips) or the head and neck. In women, it often develops on the lower legs. Melanoma is rare in black people and others with dark skin. When it does develop in dark-skinned people, it tends to occur under the fingernails or toenails, or on the palms or soles.
When melanoma spreads, cancer cells may show up in nearby lymph nodes. Groups of lymph nodes are found throughout the body. Lymph nodes trap bacteria, cancer cells, or other harmful substances that may be in the lymphatic system. If the cancer has reached the lymph nodes, it may mean that cancer cells have spread to other parts of the body such as the liver, lungs, or brain. In such cases, the cancer cells in the new tumor are still melanoma cells, and the disease is called metastatic melanoma, not liver, lung, or brain cancer.
Melanoma: Who’s at Risk?No one knows the exact causes of melanoma. Doctors can seldom explain why one person gets melanoma and another does not.
However, research has shown that people with certain risk factors are more likely than others to develop melanoma. A risk factor is anything that increases a person’s chance of developing a disease. Still, many who do get this disease have no known risk factors.
Studies have found the following risk factors for melanoma:
Doctors recommend that people take steps to help prevent and reduce the risk of melanoma caused by UV radiation:
People who are concerned about developing melanoma should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor’s advice will be based on the person’s personal and family history, medical history, and other risk factors.
Signs and SymptomsOften, the first sign of melanoma is a change in the size, shape, color, or feel of an existing mole. Most melanomas have a black or blue-black area. Melanoma also may appear as a new mole. It may be black, abnormal, or “ugly looking.”
If you have a question or concern about something on your skin, see your doctor. Do not use the following pictures to try to diagnose it yourself. Pictures are useful examples, but they cannot take the place of a doctor’s examination.
Thinking of “ABCD” can help you remember what to watch for:
A skin examination is often part of a routine checkup by a health care provider. People also can check their own skin for new growths or other changes. (The “How To Do a Skin Self-Exam” section has a simple guide on how to do this skin self-exam.) Changes in the skin, such as a change in a mole, should be reported to the health care provider right away. The person may be referred to a dermatologist, a doctor who specializes in diseases of the skin.
Melanoma can be cured if it is diagnosed and treated when the tumor is thin and has not deeply invaded the skin. However, if a melanoma is not removed at its early stages, cancer cells may grow downward from the skin surface and invade healthy tissue. When a melanoma becomes thick and deep, the disease often spreads to other parts of the body and is difficult to control.
People who have had melanoma have a high risk of developing a new melanoma. People at risk for any reason should check their skin regularly and have regular skin exams by a health care provider.
Dysplastic NeviSome people have certain abnormal-looking moles (called dysplastic nevi or atypical moles) that are more likely than normal moles to develop into melanoma. Most people with dysplastic nevi have just a few of these abnormal moles; some people have many. People with dysplastic nevi and their health care provider should examine these moles regularly to watch for changes.
Dysplastic nevi often look very much like melanoma. Doctors with special training in skin diseases are in the best position to decide whether an abnormal-looking mole should be closely watched or removed and checked for cancer.
In some families, many members have a large number of dysplastic nevi, and some have had melanoma. Members of these families have a very high risk of melanoma. Doctors often recommend that they have frequent checkups (every 3 to 6 months) so that any problems can be detected early. The doctor may take pictures of a person’s skin to help show when changes occur.
DiagnosisIf the doctor suspects that a spot on the skin is melanoma, the patient will need to have a biopsy. A biopsy is the only way to make a definite diagnosis. In this procedure, the doctor tries to remove all of the suspicious-looking growth. This is an excisional biopsy. If the growth is too large to be removed entirely, the doctor removes a sample of the tissue. The doctor will never "shave off" or cauterize a growth that might be melanoma.
A biopsy can usually be done in the doctor’s office using local anesthesia. A pathologist then examines the tissue under a microscope to check for cancer cells. Sometimes it is helpful for more than one pathologist to check the tissue for cancer cells.
A person who needs a biopsy may want to ask the doctor the following questions:
StagingIf the diagnosis is melanoma, the doctor needs to learn the extent, or stage, of the disease before planning treatment. Staging is a careful attempt to learn how thick the tumor is, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. The doctor may remove nearby lymph nodes to check for cancer cells. (Such surgery may be considered part of the treatment because removing cancerous lymph nodes may help control the disease.) The doctor also does a careful physical exam and, if the tumor is thick, may order chest x-rays, blood tests, and scans of the liver, bones, and brain.
Stages of MelanomaThe following stages are used for melanoma:
The melanoma cells have not spread to nearby lymph nodes.
The melanoma cells have not spread to nearby lymph nodes.
TreatmentThe doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient’s needs. Treatment for melanoma depends on the extent of the disease, the patient’s age and general health, and other factors.
People with melanoma are often treated by a team of specialists. The team may include a dermatologist, surgeon, medical oncologist, radiation oncologist, and plastic surgeon.
Getting a Second OpinionBefore starting treatment, the patient might want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient or doctor requests it.
There are a number of ways to find a doctor for a second opinion:
Preparing for TreatmentPeople with melanoma often want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a melanoma can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor—to take part in the discussion, to take notes, or just to listen.
These are some questions a person may want to ask the doctor before treatment begins:
People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Methods of TreatmentPeople with melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy. Patients may have a combination of treatments.
At any stage of disease, people with melanoma may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional and practical problems. This kind of treatment is called symptom management, supportive care, or palliative care.
The doctor is the best person to describe the treatment choices and discuss the expected results.
A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. The section on “The Promise of Cancer Research” has more information about clinical trials.
SurgerySurgery is the usual treatment for melanoma. The surgeon removes the tumor and some normal tissue around it. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin:
If a large area of tissue is removed, the surgeon may do a skin graft. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.
Lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has also spread to other parts of the body. Two procedures are used to remove the lymph nodes:
Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant therapy. The patient may receive biological therapy.
Surgery is generally not effective in controlling melanoma that has spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods.
ChemotherapyChemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat melanoma. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor’s office, or at home). However, depending on which drugs are given and the patient’s general health, a short hospital stay may be needed.
People with melanoma may receive chemotherapy in one of the following ways:
The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.
Biological TherapyBiological therapy (also called immunotherapy) is a form of treatment that uses the body’s immune system, either directly or indirectly, to fight cancer or to reduce side effects caused by some cancer treatments. Biological therapy for melanoma uses substances called cytokines. The body normally produces cytokines in small amounts in response to infections and other diseases. Using modern laboratory techniques, scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.
Radiation TherapyRadiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the body. The patient usually has treatment at a hospital or clinic, five days a week for several weeks. Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.
Treatment Choices by StageThe following are brief descriptions of the treatments most often used for each stage. (Other treatments may sometimes be appropriate.)
People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.
People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.
Stage II or Stage III
People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.
People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better—physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.
The patient may have one of the following:
Recurrent MelanomaTreatment for recurrent melanoma depends on where the cancer came back, which treatments the patient has already received, and other factors. As with Stage IV melanoma, treatment usually cannot cure melanoma that recurs. Palliative care is often an important part of the treatment plan. Many patients have palliative care to ease their symptoms while they are getting anticancer treatments to slow the progress of the disease. Some receive only palliative care to improve their quality of life by easing pain, nausea, and other symptoms.
The patient may have one of the following:
Side Effects of TreatmentBecause treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.
The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may have some pain during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.
Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can (while still protecting against recurrence). In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, the doctor must remove more surrounding skin and other tissue (including muscle). Although skin grafts reduce scarring caused by the removal of large growths, these scars will still be quite noticeable.
Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymphatic fluid in the arm or leg. Lymphatic fluid may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, insect bites, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.
The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:
The side effects of biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also get a skin rash. These problems can be severe, but they go away after treatment stops.
The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur in the treated area include red or dry skin and hair loss. Radiation therapy also may cause fatigue. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.
NutritionPeople with melanoma may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different. Nevertheless, patients should try to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.
The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet.
Followup CareMelanoma patients have a high risk of developing new melanomas. Some also are at risk of a recurrence of the original melanoma in nearby skin or in other parts of the body.
To increase the chance of detecting a new or recurrent melanoma as early as possible, patients should follow their doctor’s schedule for regular checkups. It is especially important for patients who have dysplastic nevi and a family history of melanoma to have frequent checkups. Patients also should examine their skin monthly (keeping in mind the “ABCD” guidelines in the “Signs and Symptoms” section, and the skin self-exam described in “How To Do a Skin Self-Exam”). They should follow their doctor’s advice about how to reduce their chance of developing another melanoma. General information about reducing the risk of melanoma is described in the “Melanoma: Who’s at Risk?” section.
The chance of recurrence is greater for patients whose melanoma was thick or had spread to nearby tissue than for patients with very thin melanomas. Followup care for those who have a high risk of recurrence may include x-rays, blood tests, and scans of the chest, liver, bones, and brain.
A person who has been treated for melanoma may want to ask the doctor the following questions:
Support for People with MelanomaLiving with a serious disease such as melanoma is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group. Groups may offer support in person, over the telephone, or on the Internet.
People living with melanoma may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills also are common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, or emotional support.
The Cancer Information Service at 1-800-4-CANCER can send publications and provide information to help patients and their families locate programs and services.
The Promise of Cancer ResearchDoctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new ways to treat melanomas. Research already has led to advances, and researchers continue to search for more effective approaches.
Patients who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.
Researchers are testing new anticancer drugs. They are looking at combining chemotherapy with radiation therapy. Other studies are combining chemotherapy with biological therapy. Scientists also are studying several cancer vaccines and a type of gene therapy designed to help the immune system kill cancer cells.
How To Do a Skin Self-ExamYour doctor or nurse may recommend that you do a regular skin self-exam. If your doctor has taken photos of your skin, comparing your skin to the photos can help you check for changes.
The best time to do a skin self-exam is after a shower or bath. You should check your skin in a well-lighted room using a full-length mirror and a hand-held mirror. It’s best to begin by learning where your birthmarks, moles, and blemishes are and what they usually look and feel like.
Check for anything new:
Check yourself from head to toe. Don’t forget to check all areas of the skin, including the back, the scalp, between the buttocks, and the genital area.
1. Look at your face, neck, ears, and scalp. You may want to use a comb or a blow dryer to move your hair so that you can see better. You also may want to have a relative or friend check through your hair because this is difficult to do yourself.
2. Look at the front and back of your body in the mirror, then raise your arms and look at your left and right sides.
3. Bend your elbows and look carefully at your fingernails, palms, forearms (including the undersides), and upper arms.
4. Examine the back, front, and sides of your legs. Also look between your buttocks and around your genital area.
5. Sit and closely examine your feet, including the toenails, the soles, and the spaces between the toes.
By checking your skin regularly, you will become familiar with what is normal for you. It may be helpful to record the dates of your skin exams and to write notes about the way your skin looks. If you find anything unusual, see your doctor right away.