Treatment

If you're taking medicine for another condition when you start treatment for melanoma

You should be able to keep taking any medicines you take for other conditions, unless they're a type of medicine called an immunosuppressant (for example, a corticosteroid or methotrexate). If you're taking an immunosuppressant your doctor may suggest that you reduce the dose or stop the immunosuppressant altogether. Your doctor should discuss with you the possible advantages and disadvantages of reducing or stopping your immunosuppressant treatment.

Treatment for stage 0, stage 1 or stage 2 melanoma

Removal of tissue around the melanoma

You may be offered a second procedure to remove some of the healthy tissue around the area of the melanoma. This is to make sure that all of the cancerous cells have been removed. The amount of healthy tissue that should be removed may be at least half a centimetre if your melanoma was stage 0. If your melanoma was stage 1, this should be increased to at least 1 centimetre, and if your melanoma was stage 2, at least 2 centimetres of surrounding tissue should be removed.

Cream to treat stage 0 melanoma if the tissue can't be removed

Sometimes removal of the tissue around the melanoma would have cosmetic effects that would be unacceptable, or be potentially harmful. You may instead be offered treatment with a cream called imiquimod that you put on the skin. Imiquimod should only be offered to treat stage 0 melanoma in adults. When you finish your imiquimod treatment, you may be offered a skin biopsy (removal of some tissue for testing) to check how well the imiquimod has worked.

Imiquimod to treat melanoma

At the time of publication (July 2015), imiquimod was not licensed specifically to treat stage 0 melanoma or secondary melanomas, or to treat children and young people. Your care team should tell you this and explain what it means for you. For more information about licensing and 'off label' use of medicines visit NHS Choices.

Treatment for stage 3 melanoma

Surgery for stage 3A melanoma

If your melanoma is stage 3, this means it has spread to at least 1 of the nearby lymph nodes.

If you have stage 3A melanoma, you may be offered an operation to remove the rest of the lymph nodes in that part of your body, even if these lymph nodes might not have developed melanoma. This operation is called a completion lymphadenectomy. Your doctor should explain the operation and discuss it with you. They should tell you that there are both possible advantages and possible disadvantages to having the rest of the lymph nodes removed. These are shown in the table below.

Possible advantages of having the rest of your lymph nodes removed (completion lymphadenectomy)

Possible disadvantages of having the rest of your lymph nodes removed (completion lymphadenectomy)

It's less likely that melanoma will come back in that part of your body in the future.

You might develop long‑term swelling (called lymphoedema), which is more likely if the lymph nodes are in your groin than in other parts of your body.

It's safer and less complicated than waiting until melanoma develops in the rest of the lymph nodes before removing them.

Melanoma may not develop in the remaining lymph nodes, so there's a chance that you'll have had them removed unnecessarily. It's been shown that melanoma develops in the remaining lymph nodes in 1 out of every 5 people who don't have them removed.

You may be able to take part in clinical trials of new treatments after having this operation. These trials often can't accept people who haven't had these lymph nodes removed.

Any operation can cause complications.

NICE has also produced a decision aid (called an 'option grid') to help you discuss with your healthcare professional whether to have completion lymphadenectomy.

Surgery for stage 3B or 3C melanoma

If your melanoma is stage 3B or stage 3C, you should be offered an operation to remove the lymph nodes that have developed melanoma together with all the other lymph nodes in that area, in case there are small amounts of melanoma in the other lymph nodes.

Radiotherapy

Radiotherapy (a treatment that uses high‑energy rays to destroy cancer cells) is sometimes used to reduce the risk of the cancer coming back after lymph nodes have been removed. You should not be offered radiotherapy if you have stage 3A melanoma because the disadvantages are likely to outweigh the advantages.

If you have stage 3B or stage 3C melanoma you should only be offered radiotherapy if it's thought that the advantages of radiotherapy for you will outweigh its disadvantages. Your care team should discuss the possible benefits and risks with you.

Treating symptoms of stage 3 melanoma

You may develop small melanomas, called secondary melanomas, on the skin or just under the skin in the same part of the body as your original melanoma. For example, if your original melanoma was in your ankle, you may develop secondary melanomas in your leg. You may be offered surgery to remove these small secondary melanomas.If surgery isn't suitable for you, you may be offered another type of treatment, which might be:

  • Chemotherapy (drugs to destroy the melanoma cells) given directly into the leg or arm (a treatment known as isolated limb infusion or isolated limb perfusion).

  • Radiotherapy.

  • Electrochemotherapy (chemotherapy that uses electrical energy to help the chemotherapy drugs work better). See other NICE guidance for details of our guidance on electrochemotherapy.

  • Laser treatment.

  • Treatments that you apply to your skin, such as imiquimod. For more information see imiquimod to treat melanoma.

Treatment for stage 4 melanoma

Genetic testing and targeted systemic therapy

You might have had a test to examine a sample of tissue from your melanoma to find out whether a type of treatment called targeted systemic therapy would be suitable for you (see genetic testing for stage 2C or stage 3 melanoma).The test can show whether there is a change called a mutation in the cells of your melanoma. The mutation produces a protein that causes melanoma cells to grow more quickly. Targeted systemic therapy uses drugs that can slow the growth of the melanoma by reducing production of this protein. Examples of targeted systemic therapy drugs are dabrafenib and vemurafenib. See other NICE guidance for details of our guidance on dabrafenib and vemurafenib.

Immunotherapy

Immunotherapy is a type of drug treatment that helps the body's immune system to find and destroy melanoma cells. Ipilimumab is an example of an immunotherapy that can be used to treat melanoma. For details of our guidance on ipilimumab see other NICE guidance.

Chemotherapy

If targeted systemic therapy and immunotherapy are not suitable for you, you may be offered chemotherapy with a drug called dacarbazine.

Symptom relief

To relieve symptoms caused by stage 4 melanoma, such as pain or bleeding, you may be offered surgery, radiotherapy, or a treatment called radioembolisation (radiotherapy together with a treatment that blocks the blood vessels to prevent blood flow).

Questions you might like to ask your care team

About surgery to have the melanoma removed (stage 0, stage 1 or stage 2 melanoma)

  • Will there be a scar where the melanoma is removed? How big will it be? Will it fade?

  • Are there any options to having the melanoma removed, for example can it be treated with a cream instead?

  • Will the melanoma come back again?

About surgery to have lymph nodes removed (stage 3 melanoma)

  • Why have you offered me an operation to remove my lymph nodes?

  • What does the operation involve?

  • Can you give me more detailed information about having my lymph nodes removed? Is there any written information, like a leaflet, that I could have?

  • What's likely to happen if I have the lymph nodes removed? What's likely to happen if I don't have them removed?

  • If I decide not to have them removed now, can I change my mind later?

  • What are the side effects of the operation? Are they permanent?

  • How long will I have to wait to have the operation? Will I have any other treatment for my melanoma while I'm waiting?

About drug treatments (stage 4 melanoma)

  • Will I be able to have targeted systemic therapy?

  • What other drug treatments are available for my melanoma?

  • How well are they likely to work? Will they stop the melanoma from spreading further?

  • Information Standard