1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

These recommendations cover suspected and diagnosed melanoma. All recommendations relate to children, young people and adults unless specified otherwise.

1.1 Communication and support

1.1.1 To help people make decisions about their care, follow the recommendations on communication, information provision and support in NICE's guideline on improving outcomes for people with skin tumours including melanoma, in particular the following 5 recommendations:

  • 'Improved, preferably nationally standardised, written information should be made available to all patients. Information should be appropriate to the patients' needs at that point in their diagnosis and treatment, and should be repeated over time. The information given must be specific to the histopathological type of lesion, type of treatment, local services and any choice within them, and should cover both physical and psychosocial issues.'

  • 'Those who are directly involved in treating patients should receive specific training in communication and breaking bad news.'

  • 'Patients should be invited to bring a companion with them to consultations.'

  • 'Each LSMDT [local hospital skin cancer multidisciplinary team] and SSMDT [specialist skin cancer multidisciplinary team] should have at least one skin cancer clinical nurse specialist (CNS) who will play a leading role in supporting patients and carers. There should be equity of access to information and support regardless of where the care is delivered.'

  • 'All LSMDTs and SSMDTs should have access to psychological support services for skin cancer patients.'

1.1.2 Follow the recommendations on follow‑up in NICE's guideline on improving outcomes for people with skin tumours including melanoma, in particular the following 2 recommendations:

  • 'All patients should be given written instruction on how to obtain quick and easy access back to see a member of the LSMDT/SSMDT when necessary.'

  • 'All patients should be given both oral and written information about the different types of skin cancer and instruction about self‑surveillance.'

1.1.3 Give people with melanoma and their families or carers advice about protecting against skin damage caused by exposure to the sun while avoiding vitamin D depletion.

1.1.4 Carry out a holistic needs assessment to identify the psychosocial needs of people with melanoma and their needs for support and education about the likelihood of recurrence, metastatic spread, new primary lesions and the risk of melanoma in their family members.

1.1.5 Follow the recommendations on communication and patient‑centred care in NICE's guideline on patient experience in adult NHS services.

1.2 Assessing melanoma

Dermoscopy and other visualisation techniques

See implementation: getting started for information about putting recommendation 1.2.1 into practice.

1.2.1 Assess all pigmented skin lesions that are either referred for assessment or identified during follow‑up in secondary or tertiary care, using dermoscopy carried out by healthcare professionals trained in this technique.

1.2.2 Do not routinely use confocal microscopy or computer‑assisted diagnostic tools to assess pigmented skin lesions.

Photography

1.2.3 For a clinically atypical melanocytic lesion that does not need excision at first presentation in secondary or tertiary care:

  • use baseline photography (preferably dermoscopic) and

  • review the clinical appearance of the lesion, and compare it with the baseline photographic images, 3 months after first presentation to identify early signs of melanoma.

Assessing and managing atypical spitzoid lesions

1.2.4 Discuss all suspected atypical spitzoid lesions at the specialist skin cancer multidisciplinary team meeting.

1.2.5 Make the diagnosis of a spitzoid lesion of uncertain malignant potential on the basis of the histology, clinical features and behaviour.

1.2.6 Manage a spitzoid lesion of uncertain malignant potential as melanoma.

Taking tumour samples for genetic testing

1.2.7 If targeted systemic therapy is a treatment option, offer genetic testing using:

  • a secondary melanoma tissue sample if there is adequate cellularity or

  • a primary melanoma tissue sample if a secondary sample is not available or is of inadequate cellularity.

Genetic testing in early‑stage melanoma

1.2.8 Do not offer genetic testing of stage IA–IIB primary melanoma at presentation except as part of a clinical trial.

1.2.9 Consider genetic testing of stage IIC primary melanoma or the nodal deposits or in‑transit metastases for people with stage III melanoma.

1.2.10 If insufficient tissue is available from nodal deposits or in‑transit metastases, consider genetic testing of the primary tumour for people with stage III melanoma.

1.3 Managing suboptimal vitamin D levels

See implementation: getting started for information about putting recommendations 1.3.1 and 1.3.2 into practice.

1.3.1 Measure vitamin D levels at diagnosis in secondary care in all people with melanoma.

1.3.2 Give people whose vitamin D levels are thought to be suboptimal advice on vitamin D supplementation and monitoring in line with local policies and NICE's guideline on vitamin D.

1.4 Managing concurrent drug treatment

1.4.1 Do not withhold or change drug treatment for other conditions, except immunosuppressants, on the basis of a diagnosis of melanoma.

1.4.2 Consider minimising or avoiding immunosuppressants for people with melanoma.

1.5 Staging investigations

Sentinel lymph node biopsy

See implementation: getting started for information about putting recommendation 1.5.2 into practice.

1.5.1 Do not offer imaging or sentinel lymph node biopsy to people who have stage IA melanoma or those who have stage IB melanoma with a Breslow thickness of 1 mm or less.

1.5.2 Consider sentinel lymph node biopsy as a staging rather than a therapeutic procedure for people with stage IB–IIC melanoma with a Breslow thickness of more than 1 mm, and give them detailed verbal and written information about the possible advantages and disadvantages, using the table below.

Possible advantages of sentinel lymph node biopsy

Possible disadvantages of sentinel lymph node biopsy

The operation helps to find out whether the cancer has spread to the lymph nodes. It is better than ultrasound scans at finding very small cancers in the lymph nodes.

The purpose of the operation is not to cure the cancer. There is no good evidence that people who have the operation live longer than people who do not have it.

The operation can help predict what might happen in the future. For example, in people with a primary melanoma that is between 1 and 4 mm thick:

  • around 1 out of 10 die within 10 years if the sentinel lymph node biopsy is negative

  • around 3 out of 10 die within 10 years if the sentinel lymph node biopsy is positive.

The result needs to be interpreted with caution. Of every 100 people who have a negative sentinel lymph node biopsy, around 3 will subsequently develop a recurrence in the same group of lymph nodes.

People who have had the operation may be able to take part in clinical trials of new treatments for melanoma. These trials often cannot accept people who haven't had this operation.

A general anaesthetic is needed for the operation.

The operation results in complications in between 4 and 10 out of every 100 people who have it.

Imaging

1.5.3 Offer CT staging to people with stage IIC melanoma who have not had sentinel lymph node biopsy, and to people with stage III or suspected stage IV melanoma.

1.5.4 Include the brain as part of imaging for people with suspected stage IV melanoma.

1.5.5 Consider whole‑body MRI for children and young people (from birth to 24 years) with stage III or suspected stage IV melanoma.

1.6 Managing stages 0–II melanoma

Excision

1.6.1 Consider a clinical margin of at least 0.5 cm when excising stage 0 melanoma.

1.6.2 If excision for stage 0 melanoma does not achieve an adequate histological margin, discuss further management with the multidisciplinary team.

1.6.3 Offer excision with a clinical margin of at least 1 cm to people with stage I melanoma.

1.6.4 Offer excision with a clinical margin of at least 2 cm to people with stage II melanoma.

Imiquimod for stage 0 melanoma

1.6.5 Consider topical imiquimod[1] to treat stage 0 melanoma in adults if surgery to remove the entire lesion with a 0.5 cm clinical margin would lead to unacceptable disfigurement or morbidity.

1.6.6 Consider a repeat skin biopsy for histopathological assessment after treatment with topical imiquimod for stage 0 melanoma, to check whether it has been effective.

1.7 Managing stage III melanoma

Completion lymphadenectomy

See implementation: getting started for information about putting recommendation 1.7.1 into practice.

1.7.1 Consider completion lymphadenectomy for people whose sentinel lymph node biopsy shows micro‑metastases and give them detailed verbal and written information about the possible advantages and disadvantages, using the table below.

Possible advantages of completion lymphadenectomy

Possible disadvantages of completion lymphadenectomy

Removing the rest of the lymph nodes before cancer develops in them reduces the chance of the cancer returning in the same part of the body.

Lymphoedema (long‑term swelling) may develop, and is most likely if the operation is in the groin and least likely in the head and neck.

The operation is less complicated and safer than waiting until cancer develops in the remaining lymph nodes and then removing them.

In 4 out of 5 people, cancer will not develop in the remaining lymph nodes, so there is a chance that the operation will have been done unnecessarily.

People who have had the operation may be able to take part in clinical trials of new treatments to prevent future melanoma. These trials often cannot accept people who have not had this operation.

There is no evidence that people who have this operation live longer than people who do not have it.

Having any operation can cause complications.

Lymph node dissection

1.7.2 Offer therapeutic lymph node dissection to people with palpable stage IIIB–IIIC melanoma or nodal disease detected by imaging.

Adjuvant radiotherapy

1.7.3 Do not offer adjuvant radiotherapy to people with stage IIIA melanoma.

1.7.4 Do not offer adjuvant radiotherapy to people with stage IIIB or IIIC melanoma unless a reduction in the risk of local recurrence is estimated to outweigh the risk of significant adverse effects.

Palliative treatment for in‑transit metastases

1.7.5 Refer the care of all people with newly diagnosed or progressive in‑transit metastases to the specialist skin cancer multidisciplinary team (SSMDT).

1.7.6 If palliative treatment for in‑transit metastases is needed, offer palliative surgery as a first option if surgery is feasible.

1.7.7 If palliative surgery is not feasible for people with in‑transit metastases, consider the following options:

Palliative treatment for superficial skin metastases

1.7.8 Consider topical imiquimod[2] to palliate superficial melanoma skin metastases.

1.8 Managing stage IV melanoma

Management of oligometastatic stage IV melanoma

1.8.1 Refer the care of people who appear to have oligometastatic melanoma to the specialist skin cancer multidisciplinary team (SSMDT) for recommendations about staging and management.

1.8.2 Consider surgery or other ablative treatments (including stereotactic radiotherapy or radioembolisation) to prevent and control symptoms of oligometastatic stage IVmelanomain consultation with site‑specific MDTs (such as an MDT for the brain or for bones).

Brain metastases

1.8.3 Discuss the care of people with melanoma and brain metastases with the SSMDT.

1.8.4 Refer people with melanoma and brain metastases that might be suitable for surgery or stereotactic radiotherapy to the brain and other central nervous system tumours MDT for a recommendation about treatment.

Systemic anticancer treatment

Targeted treatments

1.8.5 For adults, see NICE's technology appraisal guidance on dabrafenibfor treating unresectable or metastatic BRAF V600 mutation-positive melanoma[3].

1.8.6 For adults, 'Vemurafenib is recommended as an option for treating BRAF V600 mutation‑positive unresectable or metastatic melanoma only if the manufacturer provides vemurafenib with the discount agreed in the patient access scheme'[4]. [This recommendation is from NICE's technology appraisal guidance on vemurafenib for treating locally advanced or metastatic BRAF V600 mutation-positive malignant melanoma.]

Cytotoxic chemotherapy

1.8.8 Consider dacarbazine for people with stage IV metastatic melanoma if immunotherapy or targeted therapy are not suitable[6].

1.8.9 Do not routinely offer further cytotoxic chemotherapy for stage IV metastatic melanoma to people previously treated with dacarbazine except in the context of a clinical trial.

1.9 Follow-up after treatment for melanoma

Follow-up for all people who have had melanoma

1.9.1 Perform a full examination of the skin and regional lymph nodes at all follow‑up appointments.

1.9.2 Consider personalised follow‑up for people who are at increased risk of further primary melanomas (for example people with atypical mole syndrome, previous melanoma, or a history of melanoma in first‑degree relatives or other relevant familial cancer syndromes).

1.9.3 Consider including the brain for people having imaging as part of follow‑up after treatment for melanoma.

1.9.4 Consider imaging the brain if metastatic disease outside the central nervous system is suspected.

1.9.5 Consider CT rather than MRI of the brain for adults having imaging as part of follow‑up or if metastatic disease is suspected.

1.9.6 Consider MRI rather than CT of the brain for children and young people (from birth to 24 years) having imaging as part of follow‑up or if metastatic disease is suspected.

1.9.7 Provide psychosocial support for the person with melanoma and their family or carers at all follow‑up appointments.

1.9.8 All local follow‑up policies should include reinforcing advice about self‑examination (in line with recommendation 1.1.2), and health promotion for people with melanoma and their families, including sun awareness, avoiding vitamin D depletion (in line with recommendation 1.1.3), and NICE guidance on smoking cessation.

1.9.9 Continue to manage drug treatment for other conditions in line with recommendations 1.4.1 and 1.4.2 after treatment for melanoma.

Follow-up after stage 0 melanoma

1.9.10 Discharge people who have had stage 0 melanoma after completion of treatment and provide advice in line with recommendation 1.9.8.

Follow-up after stage IA melanoma

1.9.11 For people who have had stage IA melanoma, consider follow‑up 2–4 times during the first year after completion of treatment and discharging them at the end of that year.

1.9.12 Do not routinely offer screening investigations (including imaging and blood tests) as part of follow‑up to people who have had stage IA melanoma.

Follow-up after stages IB–IIB melanoma or stage IIC melanoma (fully staged using sentinel lymph node biopsy)

1.9.13 For people who have had stages IB–IIB melanoma or stage IIC melanoma with a negative sentinel lymph node biopsy, consider follow‑up every 3 months for the first 3 years after completion of treatment, then every 6 months for the next 2 years, and discharging them at the end of 5 years.

1.9.14 Do not routinely offer screening investigations (including imaging and blood tests) as part of follow‑up to people who have had stages IB–IIB melanoma or stage IIC melanoma with a negative sentinel lymph node biopsy.

Follow-up after stage IIC melanoma with no sentinel lymph node biopsy or stage III melanoma

1.9.15 For people who have had stage IIC melanoma with no sentinel lymph node biopsy, or stage III melanoma, consider follow‑up every 3 months for the first 3 years after completion of treatment, then every 6 months for the next 2 years, and discharging them at the end of 5 years.

1.9.16 Consider surveillance imaging as part of follow‑up for people who have had stage IIC melanoma with no sentinel lymph node biopsy or stage III melanoma and who would become eligible for systemic therapy as a result of early detection of metastatic disease if:

  • there is a clinical trial of the value of regular imaging or

  • the specialist skin cancer multidisciplinary team agrees to a local policy and specific funding for imaging 6‑monthly for 3 years is identified.

Take into account the possible advantages and disadvantages of surveillance imaging and discuss these with the person, using the table below.

Possible advantages of surveillance imaging (having regular scans)

Possible disadvantages of surveillance imaging (having regular scans)

If the melanoma comes back (recurrent melanoma), it is more likely to be detected sooner. It is possible that this could lead to a better outcome by allowing treatment with drugs (such as immunotherapy drugs) to start earlier.

Although early drug treatment of recurrent melanoma might improve survival, there is currently no evidence showing this.

Some people find it reassuring to have regular scans.

Some people find that having regular scans increases their anxiety.

Scans expose the body to radiation, which can increase the risk of cancer in the future.

Scans of the brain and neck increase the risk of developing cataracts.

Scans of the chest cause a very small increase in the risk of thyroid cancer.

Scans may show abnormalities that are later found to be harmless, causing unnecessary investigations and anxiety.

Follow‑up after stage IV melanoma

1.9.17 Offer personalised follow‑up to people who have had stage IV melanoma.



[1] At the time of publication (July 2015) topical imiquimod did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[2] At the time of publication (July 2015) topical imiquimod did not have a UK marketing authorisation for this indication or for use in children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[3] Dabrafenib has a marketing authorisation in the UK in monotherapy for the treatment of adult patients with unresectable or metastatic melanoma with a BRAF V600 mutation.

[4] Vemurafenib has a UK marketing authorisation for 'the treatment of adult patients with BRAF V600 mutation-positive unresectable or metastatic melanoma'.

[5] Ipilimumab has a UK marketing authorisation for 'the treatment of advanced (unresectable or metastatic) melanoma in adults'.

[6] Although this use is common in UK clinical practice, at the time of publication (July 2015), dacarbazine did not have a UK marketing authorisation for this indication or for use in children and young people. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

  • National Institute for Health and Care Excellence (NICE)