How to Treat Melanoma Stage by Stage

Melanoma is a type of skin cancer that forms in the cells (called melanocytes) that control the pigment, or color, in your skin. It’s less common than other skin cancers, like basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but melanoma is more dangerous because of its ability to quickly spread to other organs, or metastasize, if it’s not treated early.

Over time, exposure to ultraviolet (UV) rays, either from the sun or from artificial lights like those in indoor tanning beds, can damage the DNA in skin cells. These damaged genes cause the cells to divide and grow uncontrollably, eventually becoming a tumor—which looks like a mole. Melanoma can form a brand-new mole or change the appearance of an existing mole (which is why knowing how to do a skin self-exam is so important).

The best treatment for melanoma depends mostly on what stage it’s in, or how advanced it is. To determine the stage, your doctor will first measure the melanoma’s thickness or depth (called Breslow depth) and check to see if the skin is broken (called ulceration), says Lisa Zaba, M.D., dermatologic oncologist at Stanford Medical Center in San Jose, CA. Then, they’ll test to see if the melanoma has spread to the lymph nodes or to another area of the body. Your doctor will also note the location of the tumor—less invasive treatments are typical if melanoma is on your face—and any other health conditions you have.

Stage 0 is also referred to as melanoma in situ, says David Polsky, M.D., dermatologist at NYU Langone Medical Center in New York City. In this stage, the cancer cells are only in the epidermis, the outermost layer of your skin. To treat stage 0 melanoma, doctors will simply remove the mole and a small amount of normal skin surrounding it, a procedure called wide excision. If cancer cells are still present on the edges, they’ll go back and remove a little bit more until they’re sure they’ve got it all.

In stage 1, cancer cells are in the layer of skin just below the epidermis, called the dermis. The tumor is up to 2 millimeters (mm) thick and may or may not be broken on the surface, according to the American Cancer Society (ACS). Just like stage 0, wide excision is used to remove stage 1 melanoma. Your doctor may want to test the nearest lymph nodes (called sentinel nodes) for cancer cells, though at this point, the risk of spreading to lymph nodes is still pretty low, Dr. Zaba says.

In stage 2, the melanoma is still only as deep as the dermis, but it’s slightly deeper than in stage 1. The tumor may be up to 4 mm thick and may or may not be broken, according to the ACS. Once again, the melanoma will be removed by wide excision. At this point, it’s more likely that the cancer has spread to the nearby lymph nodes, Dr. Zaba says, so many doctors will want to test the lymph nodes to be safe. They do this with a procedure called a sentinel-node biopsy, which involves identifying the closest lymph node (sentinel node), removing it, and testing it for melanoma cells.

If a lymph-node biopsy comes back negative, that’s great. It means the melanoma hasn’t spread beyond the skin. You won’t need to be treated further, but your doctor will want to schedule regular follow-ups to make sure the melanoma doesn’t come back. With early-stage melanoma that hasn’t spread, that typically means scheduling a checkup every six to 12 months for a couple of years.

If the lymph-node biopsy finds melanoma cells, there are two options. If many cancer cells are present in many lymph nodes, then all the lymph nodes in that area may be surgically removed. If there are only a few cancer cells, your doctor may instead opt to monitor the lymph nodes through ultrasound every few months and start you on immunotherapy or targeted therapy, says Melinda L. Yushak, M.D., assistant professor in the department of hematology and medical oncology at Emory University School of Medicine in Atlanta.

Immunotherapy treatments help the immune system kill melanoma cells at any stage. Melanoma knows how to manipulate immune cells to survive, Dr. Polsky explains, so immunotherapy drugs basically help the immune system do its job as it should. There are a handful of drugs that target the immune system in slightly different ways. Your doctor will choose the best one for you based on the stage of your melanoma, risks, side effects, and more. Immunotherapy is usually given when excision isn’t possible, when melanoma has spread to other parts of the body, or to prevent the cancer from coming back after lymph node removal.

Targeted melanoma drugs can be used if there are specific genetic mutations in the melanoma cells—which is true for about 40% of people who have melanoma, Dr. Yushak says. These mutations help the cancer cells grow and spread, so the goal of targeted therapy is to shut down the mutated molecules to slow or stop that growth. Targeted therapies are taken as daily pills and are usually given if melanoma can’t be removed surgically, has spread to other parts of the body, or after lymph-node surgery to prevent recurrence.

Melanoma is stage 3 if it’s already traveled to the lymph nodes when it’s first diagnosed. Treatment for stage 3 melanoma usually requires wide excision, along with lymph-node biopsy and removal. After the surgery, you’ll likely be put on either immunotherapy or targeted therapy to fight any cancer cells that are left and prevent recurrence. Your doctor may prescribe multiple immunotherapy drugs at once, Dr. Yushak says. “We think the response rate is a little higher when you combine two types of immunotherapy drugs together.” This increases the risk of side effects, so it may not be an option for everyone.

Stage 4 melanoma, the most advanced form, is when cancer cells have already spread, or metastasized, to distant lymph nodes or to other areas of the body, like the brain, liver, lungs, or bones. At this stage, your doctor may choose to remove the primary tumor (mole) if it isn’t large enough to cause disfigurement, but treatment is mainly focused on using immunotherapy and/or targeted therapies to shrink tumors and prevent melanoma from spreading further. Tumors that have developed in other organs may be surgically removed depending on their size, location, risk, and if they cause symptoms.

While radiation and chemotherapy are often used to treat other cancers, they’re not common treatments for melanoma. That’s because immunotherapy and targeted therapy have proven to be much more effective at fighting melanoma, Dr. Polsky says. Radiation may be used in areas where lymph nodes were removed if there’s a high risk of recurrence or a chance that some cancer cells were left behind. It’s also a consideration for targeting cancer cells that have spread to other organs, like the brain. But Dr. Polsky notes that radiation is mostly used to shrink a tumor and relieve symptoms, not to actually cure the patient.

In stage 0 melanoma, a topical cream called imiquimod may be tried in cosmetically sensitive areas—which usually means on the face, Dr. Polsky says. “It does not have the cure rate of surgery by any means, but if you’re a poor candidate for surgery, we might consider using it.”

As for vaccines for melanoma? They’re in development, Dr. Yushak says. “We do use them in clinical trials—there are several that have been done in the past and some ongoing trials looking at vaccine therapies. But there’s no current standard vaccine that we give people,” she says.