Treatments

Overview of Treatment Options

There are many different treatment options for melanoma, the treatment recommendations made by your cancer care team will depend on the stage of the disease and the thickness of the primary tumor. Your cancer care team may recommend standard treatment (the currently used treatment) or a clinical trial. It is important that you understand your treatment options and the recommendations being made and always ask for an explanation of anything that you don’t understand. Below is a brief overview of standard treatment options, which include: surgery, chemotherapy, radiation therapy, and immunotherapy. There are also numerous clinical trials studying the use of vaccine therapy and chemo immunotherapy (please refer to our page on clinical trials).

Surgery: Generally, surgery is done to remove the tumor as part of the primary treatment for all stages of melanoma. Surgery options include the following: local excision, wide local excision, lymphadenectomy and sentinel lymph node biopsy.

• Local excision takes out the melanoma and some of the normal tissue surrounding it.
• Wide local excision is an excision of a larger area of tissue and may involve removal of lymph nodes.
• Lymphadenectomy involves removing the lymph nodes to see if they contain cancer cells.
• Sentinal lymph node biopsy is when they remove the first lymph node (that the cancer is likely to spread to) during surgery, this is determined by injecting either a radioactive substance and/ or a blue dye near the tumor and following where the dye travels.

Radiation Therapy: Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation can be external or internal. External radiation uses a machine outside the body to deliver the treatment, whereas, internal radiation uses needles, seeds, wires, or catheters placed directly into or near the cancer (inside the body) to deliver the treatment.

Chemotherapy: Part of the treatment may include chemotherapy with anti-cancer drugs given by injection into the vein or taken orally, this is considered systemic therapy. With systemic therapy the medications travel through the body via the bloodstream to try and attack cancer cells that have already spread beyond the skin. Some chemotherapy drugs used in the treatment of melanoma include but are not limited to: DTIC, BCNU, Cisplatin, Vinblastine, and Temozolide. These drugs can be given alone or in different combinations, depending on what your cancer care team recommends.

Immunotherapy: Immunotherapy encourages a patient’s immune system to recognize and destroy cancer cells. One type of immunotherapy is cytokine therapy. Specifically, cytokines (proteins) are used to activate the immune system and help shrink melanoma cancer cells. The two cytokines used are interferon-alpha and interleukin-2. In addition, interferon-alpha-2b can be used in the adjuvant setting, which means treatment after surgery.

Experimental Therapy: Currently, melanoma vaccines are being given experimentally. The weakened melanoma cells or parts of cells, called antigens, can be injected into a patient in an attempt to stimulate the immune system to destroy melanoma cells.

Currently NIH and other institutes are aggressively seeking new therapies to find a cure for melanoma.

April 2011 Media News: The U.S. Food and Drug Administration today approved the use of ipilimumab for the treatment of previously treated metastatic melanoma. It is the first drug approved for metastatic, or advanced, melanoma in more than a decade. "Ipilimumab is the first in a new class of drugs that has been shown to offer a survival benefit for metastatic melanoma, which is often a fatal disease, and hopefully, this will lead to the development of related treatments for other cancers," said F. Stephen Hodi, MD, director of the melanoma treatment center at Dana-Farber Cancer Institute and a lead investigator of the national clinical study of ipilimumab. The number of cases of metastatic melanoma, considered to be one the most serious form of skin cancer, has increased during the past 30 years, and its death rate is rising faster than most other cancers. The American Cancer Society estimated that the disease was diagnosed in more than 68,000 Americans and be responsible for 8,700 deaths in this country in 2010.

Ipilimumab, developed by Bristol-Myers Squibb and Medarex, is a monoclonal antibody that consists of millions of copies of a human antibody that binds to CTLA-4 protein molecule on T cells – white blood cells that patrol the body for signs of illness. CTLA-4 serves as a control switch for the immune system’s response to disease. With no antibody attached, CTLA-4 suppresses the immune response. Ipilimumab reverses that condition, unleashing the immune attack on abnormal cells, including cancer cells.

Last year, Hodi reported at the annual meeting of the American Society of Clinical Oncology and in the New England Journal of Medicine findings from a phase III trial involving 676 patients with advanced (stage III or IV), inoperable melanoma that had worsened during prior therapy for metastatic disease. Patients were randomly assigned to receive one of three treatment regimens: ipilimumab and the gp100 vaccine (which seeks to spark an immune response by presenting the immune system with a protein fragment associated with cancer); ipilimumab alone; or gp 100 alone. The median survival period for patients receiving ipilimumab plus gp100 was 10 months, compared with 6.4 months for those receiving gp100 alone. The median survival for participants receiving ipilimumab alone was 10.1 months. In the ipilimumab-alone group, nine of 15 patients continued to benefit from the therapy for at least two years, as did four of 23 patients in the combination therapy group.

About 60 percent of the patients treated with ipilimumab experienced adverse side effects to the therapy, as did 32 percent of the patients treated with gp100. The complications were generally immune system-related and most often affected the skin and gastrointestinal tract. The most common included diarrhea, nausea, constipation, fatigue, decreased appetite, and rash. While the adverse effects could be severe and long-lasting, most of them were reversible with appropriate treatment.

"While ipilimumab, on average, extended the lives of patients by four months, there is also a group of patients who experienced a greater benefit and lived many months while being treated with this drug," said Hodi. "This is a big step in the right direction because it demonstrates that this class of drugs can benefit cancer patients."

References

National Cancer Institute http://www.cancer.gov
National Cancer Comprehensive Network http://www.nccn.org