Melanoma

Introduction

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.

The National Cancer Institute (NCI) has written this booklet (NIH Publication No. 02-1563) to help people with melanoma and their families and friends better understand this disease. We hope others will read it as well to learn more about melanoma. This booklet discusses risks and prevention, symptoms, diagnosis, treatment, and followup care. It also has information about resources and sources of support to help patients cope with melanoma. This booklet is about melanoma of the skin. Melanomas arising in areas other than the skin (such as intraocular melanoma, which is melanoma arising in the eye) are not discussed here. Also, two more common and less serious types of skin cancer (squamous cell and basal cell cancer) are discussed in What You Need To Know About Skin Cancer. Research continues to teach us more about melanoma. Scientists are learning more about its causes. They are exploring new ways to prevent, find, and treat this disease. Because of research, people with melanoma can look forward to a better quality of life and less chance of dying from this disease.

What Is Melanoma?

The Skin

The skin has two main layers: the outer epidermis and the inner dermis.

• The epidermis is mostly made up of flat, scalelike cells called squamous cells. Round cells called basal cells lie under the squamous cells in the epidermis. The lower part of the epidermis also contains melanocytes.
• The dermis contains blood vessels, lymph vessels, hair follicles, and glands. Some of these glands produce sweat, which helps regulate body temperature. Other glands produce sebum, an oily substance that helps keep the skin from drying out. Sweat and sebum reach the skin’s surface through tiny openings called pores.

Melanocytes and Moles

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 Cancer

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:

• Benign tumors are not cancer:
• They are rarely life threatening.
• Usually, benign tumors can be removed, and they seldom grow back.
• Cells from benign tumors do not spread to tissues around them or to other parts of the body.
• Malignant tumors are cancer:

• They are generally more serious and may be life threatening.
• Malignant tumors usually can be removed, but they can grow back.
Cells from malignant tumors can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells spread from the original cancer (the primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis. Different types of cancer tend to spread to different parts of the body.

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?

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:

• Dysplastic nevi: Dysplastic nevi are more likely than ordinary moles to become cancerous. Dysplastic nevi are common, and many people have a few of these abnormal moles. The risk of melanoma is greatest for people who have a large number of dysplastic nevi. The risk is especially high for people with a family history of both dysplastic nevi and melanoma.

• Many (more than 50) ordinary moles: Having many moles increases the risk of developing melanoma.

• Fair skin: Melanoma occurs more frequently in people who have fair skin that burns or freckles easily (these people also usually have red or blond hair and blue eyes) than in people with dark skin. White people get melanoma far more often than do black people, probably because light skin is more easily damaged by the sun.

• Personal history of melanoma or skin cancer: People who have been treated for melanoma have a high risk of a second melanoma. Some people develop more than two melanomas. People who had one or more of the common skin cancers (basal cell carcinoma or squamous cell carcinoma) are at increased risk of melanoma.

• Family history of melanoma: Melanoma sometimes runs in families. Having two or more close relatives who have had this disease is a risk factor. About 10 percent of all patients with melanoma have a family member with this disease. When melanoma runs in a family, all family members should be checked regularly by a doctor.

• Weakened immune system: People whose immune system is weakened by certain cancers, by drugs given following organ transplantation, or by HIV are at increased risk of developing melanoma.

• Severe, blistering sunburns: People who have had at least one severe, blistering sunburn as a child or teenager are at increased risk of melanoma. Because of this, doctors advise that parents protect children’s skin from the sun. Such protection may reduce the risk of melanoma later in life. Sunburns in adulthood are also a risk factor for melanoma.

• Ultraviolet (UV) radiation: Experts believe that much of the worldwide increase in melanoma is related to an increase in the amount of time people spend in the sun. This disease is also more common in people who live in areas that get large amounts of UV radiation from the sun. In the United States, for example, melanoma is more common in Texas than in Minnesota, where the sun is not as strong. UV radiation from the sun causes premature aging of the skin and skin damage that can lead to melanoma. Artificial sources of UV radiation, such as sunlamps and tanning booths, also can cause skin damage and increase the risk of melanoma. Doctors encourage people to limit their exposure to natural UV radiation and to avoid artificial sources.

Doctors recommend that people take steps to help prevent and reduce the risk of melanoma caused by UV radiation:

• Avoid exposure to the midday sun (from 10 a.m. to 4 p.m.) whenever possible. When your shadow is shorter than you are, remember to protect yourself from the sun.

• If you must be outside, wear long sleeves, long pants, and a hat with a wide brim.

• Protect yourself from UV radiation that can penetrate light clothing, windshields, and windows.

• Protect yourself from UV radiation reflected by sand, water, snow, and ice.

• Help protect your skin by using a lotion, cream, or gel that contains sunscreen. Many doctors believe sunscreens may help prevent melanoma, especially sunscreens that reflect, absorb, and/or scatter both types of ultraviolet radiation. These sunscreen products will be labeled with “broad-spectrum coverage.” Sunscreens are rated in strength according to a sun protection factor (SPF). The higher the SPF, the more sunburn protection is provided. Sunscreens with an SPF value of 2 to 11 provide minimal protection against sunburns. Sunscreens with an SPF of 12 to 29 provide moderate protection. Those with an SPF of 30 or higher provide the most protection against sunburn.

• Wear sunglasses that have UV-absorbing lenses. The label should specify that the lenses block at least 99 percent of UVA and UVB radiation. Sunglasses can protect both the eyes and the skin around the eyes.

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 Symptoms

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:

• Asymmetry—The shape of one half does not match the other.

  

• Border—The edges are often ragged, notched, blurred, or irregular in outline; the pigment may spread into the surrounding skin.

  

• Color—The color is uneven. Shades of black, brown, and tan may be present. Areas of white, grey, red, pink, or blue also may be seen.

  

• Diameter—There is a change in size, usually an increase. Melanomas are usually larger than the eraser of a pencil (1/4 inch or 5 millimeters).

  

• Melanomas can vary greatly in how they look. Many show all of the ABCD features. However, some may show changes or abnormalities in only one or two of the ABCD features.

  

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 Nevi

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.

Diagnosis

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:

• Why do I need a biopsy?
• How long will it take? Will it hurt?
• Will the entire tumor be removed?
• What side effects can I expect?
• How soon will I know the results?
• If I do have cancer, who will talk to me about treatment? When?

Staging

Stages of Melanoma

• Stage 0: In stage 0, the melanoma cells are found only in the outer layer of skin cells and have not invaded deeper tissues.
• Stage I: Melanoma in stage I is thin:
• The tumor is no more than 1 millimeter (1/25 inch) thick. The outer layer (epidermis) of skin may appear scraped. (This is called an ulceration).
• Or, the tumor is between 1 and 2 millimeters (1/12 inch) thick. There is no ulceration.

The melanoma cells have not spread to nearby lymph nodes.

• Stage II: The tumor is at least 1 millimeter thick:
• The tumor is between 1 and 2 millimeters thick. There is ulceration.
• Or, the thickness of the tumor is more than 2 millimeters. There may be ulceration.

The melanoma cells have not spread to nearby lymph nodes.

• Stage III: The melanoma cells have spread to nearby tissues:
• The melanoma cells have spread to one or more nearby lymph nodes.
• Or, the melanoma cells have spread to tissues just outside the original tumor but not to any lymph nodes.
• Stage IV: The melanoma cells have spread to other organs, to lymph nodes, or to skin areas far away from the original tumor.
• Recurrent: Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may have come back in the original site or in another part of the body.

Treatment

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 Opinion

There are a number of ways to find a doctor for a second opinion:

• The patient’s doctor may refer the patient to one or more specialists. At cancer centers, several specialists often work together as a team.

• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about nearby treatment centers.

• A local or state medical society, a nearby hospital, or a medical school can usually provide the names of specialists.

• The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries. Also, ABMS offers this information on the Internet(Click on "Who's Certified.").

Preparing for Treatment

These are some questions a person may want to ask the doctor before treatment begins:

• What is my diagnosis?
• What is the stage of my disease?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• How will I feel after surgery?
• If I have pain, how will it be controlled?
• Will I need more treatment after surgery?
• Will there be a scar? Will I need a skin graft or plastic surgery?
• What is the treatment likely to cost?
• Will treatment affect my normal activities? If so, for how long?
• How often will I need checkups?
• Would a clinical trial (research study) be appropriate for me? Can you help me find one?

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 Treatment

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.

Surgery

• The doctor may be able to completely remove a very thin melanoma during the biopsy. Further surgery may not be necessary.
• If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is often necessary, even for thin melanomas. If the melanoma is thick, the doctor may need to remove a larger margin of tissue.

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:

• Sentinel lymph node biopsy—The sentinel lymph node biopsy is done after the biopsy of the melanoma but before the wider excision of the tumor. A radioactive substance is injected near the melanoma. The surgeon follows the movement of the substance on a computer screen. The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy. The procedure to identify the sentinel node(s) is called sentinel lymph node mapping.) The surgeon removes the sentinel node(s) to check for cancer cells.

  If a sentinel node contains cancer cells, the surgeon removes the rest of the lymph nodes in the area. However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.

• Lymph node dissection—The surgeon removes all the lymph nodes in the area of the melanoma.

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.

Chemotherapy

People with melanoma may receive chemotherapy in one of the following ways:

• By mouth or injection—Either way, the drugs enter the bloodstream and travel throughout the body.
• Isolated limb perfusion (also called isolated arterial perfusion)—For melanoma on an arm or leg, chemotherapy drugs are put directly into the bloodstream of that limb. The flow of blood to and from the limb is stopped for a while. This allows most of the drug to reach the tumor directly. Most of the chemotherapy remains in that limb.

The drugs may be heated before injection. This type of chemotherapy is called hyperthermic perfusion.

Biological Therapy

Radiation Therapy

Treatment Choices by Stage

Stage 0

People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.

Stage I

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.

Stage IV

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:

• Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body
• Radiation therapy, biological therapy, or chemotherapy to relieve symptoms

Recurrent Melanoma

The patient may have one of the following:

• Surgery to remove the tumor
• Radiation therapy, biological therapy, or chemotherapy to relieve symptoms
• Heated chemotherapy drugs injected directly into the tumor

Side Effects of Treatment

Surgery

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.

Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs and the dose. In general, anticancer drugs affect cells that divide rapidly, especially:

• Blood cells: These cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When drugs affect blood cells, patients are more likely to get infections, may bruise or bleed easily, and may feel very weak and tired.
• Cells in hair roots: Chemotherapy can lead to hair loss. The hair grows back, but the new hair may be somewhat different in color and texture.
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Many of these side effects can be controlled with drugs.

Biological Therapy

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.

Radiation Therapy

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.

Nutrition

The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet.

Followup Care

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:

• How often should I have checkups?
• What special precautions should I take to avoid sun exposure?
• Are my family members at risk of melanoma? Should they schedule an appointment with their doctor for an examination?

Support for People with Melanoma

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 Research

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-Exam

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:

• A new mole (that looks abnormal)
• A change in the size, shape, color, or texture of a mole
• A sore that does not heal

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.