Melanoma treatment depends on the stage of the disease. In early melanoma, it is aimed at the original site (primary tumor), but if the cancer has spread, systemic treatments are often used, with specific therapies being tailored to each patient.
“As with every cancer, each patient is different and should be treated individually, not with a ‘one size fits all’ therapy,” says Isabella C. Glitza Oliva, M.D., Ph.D., assistant professor of melanoma medical oncology at the University of Texas MD Anderson Cancer Center in Houston. Treatments may entail surgery, lymph node biopsy and dissection, radiation, medications, or combinations of these. Chemotherapy is seldom used, due to the availability of much better options.
Surgery is the primary treatment for all stages of melanoma. Very successful, its cure rate is as high as 98 percent when the cancer is found early and treated before spreading to the lymph nodes, according to the American Academy of Dermatology. “This is often minor surgery done in a dermatology office,” says Robert M. Conry, M.D., associate professor of hematology and oncology at the University of Alabama at Birmingham. “People shouldn’t be afraid of finding a melanoma. They should only be afraid of missing it.”
Radiation is typically reserved for previously treated, advanced melanoma. It can be used to kill residual cancer cells after surgery, to treat disease that cannot be removed with surgery, or to control symptoms of cancer pain. Highly focused radiation may be applied to specific areas, such as the brain.
Targeted therapies and immunotherapies
Several big advances in drug therapy for melanoma have occurred recently. Conry calls the progress “an explosion of innovation.”
Targeted therapies are medications tailored to specific features of melanoma cells, such as gene mutations; this type of treatment is typically used for advanced melanoma. Imatinib (Gleevec) targets a mutation in the c-kit gene. About half of all melanomas have a mutation in a gene called BRAF. Four new oral drugs are used to treat such tumors, including vemurafenib (Zelboraf ), dabrafenib (Tafinlar), trametinib (Mekinist), and cobimetinib (Cotellic)—this last one is used in combination with vemurafenib. Says Conry, “BRAF targeted therapy is very effective early on—70 percent of patients rapidly get much better.”
Immunotherapies, or biological therapies, boost the body’s immune system to help it destroy cancer cells. The most promising ones with regard to melanoma are the “checkpoint inhibitors,” which act as “on switches” to allow immune system cells (called T-cells) to kill a tumor.
Older systemic immunotherapies include interferon alfa-2b (Intron A) and interleukin-2 (Proleu- kin). Three new checkpoint inhibitors have been approved in the past five years: ipilimumab (Yervoy), pembrolizumab (Keytruda), and nivolumab (Opdivo). Robert Andtbacka, M.D., associate professor of surgical oncology at the University of Utah School of Medicine in Salt Lake City, is researching a newly approved melanoma drug called talimogene laherparepvec, or T-VEC (Imlygic), which uses a herpes simplex virus that has been genetically altered. That virus is injected into tumors, where it reproduces and eventually causes the tumor cell to burst open, triggering an immune response.
Another type of immunotherapy is T-cell therapy, which involves taking immune system cells out of the patient’s body, growing them in a lab to increase the numbers, and infusing them back into the patient.
Mixing it up
Stages III to IV are usually treated with a mix of strategies. “Our goal is to find the best treatment for each patient with the least amount of side effects, and not just the treatment that works initially, but treatment that is long-lasting so that the tumor goes away completely and never comes back,” says Andtbacka.
Your doctor may recommend enrolling in a clinical trial for access to a new and possibly effective therapy, says Conry. Also, oncologists often combine treatments from each category, and this is often done as part of a clinical trial.
Melanoma care is a group effort, Conry adds. “We believe that patients are best served in a multidisciplinary approach, where surgeons, oncologists, and radiation oncologists work together to provide the best possible care for the patient. A good network of support is also very important, and I consider the family members of my cancer patients as one unit with the patient.” Be sure to understand the goals of each melanoma treatment you’re receiving, and remember that other options are available if one stops working.
Doctors expect even more innovations, such as cancer vaccines, as well as many new drug approvals in the near future. “The hope,” Conry says, “is that we’ll have a three-drug cocktail or four-drug cocktail that will be so effective, the vast majority of patients with melanoma will be cured on the basis of immune response.”