Melanoma: A Patient’s Guide
What Treatment Should I Receive?

Treatment of melanoma is based on many factors including the patient's age, general health, type of melanoma and the stage of the disease. There are four basic forms of treatment for melanoma: surgery, radiation therapy, chemotherapy and biotherapy. A brief summary of each type of treatment is listed. If you need additional information on the type your physician recommends for you, ask your physician or nurse. Your physician may recommend one or possibly several of these therapies in order to best treat your disease.

Surgery
Surgery is used in the treatment of about 95 percent of melanoma cases. When the tumor is thin and has not spread beyond its point of origin, it is usually curable with surgery alone. The physician will usually remove the tumor plus a border area of normal tissue around it to prevent the tumor from recurring. A skin graft may be needed if a wider surgical removal is done. In some cases, the physician may recommend removing nearby lymph nodes to help reduce the chance of the melanoma recurring. In more advanced cases, a combination of surgery and other therapies may be used to help relieve a symptom such as pain. Surgery is considered a local treatment and is usually not effective alone if the melanoma is widespread or present in more than one area of the body.

Radiation Therapy
Radiation therapy is another form of local treatment which uses X-rays, cobalt, electrons or other radiation sources to damage or kill the melanoma cells. In general, melanoma is not considered to be very responsive to radiation therapy. However, there are times when it may be used to treat local recurrences or melanoma that has spread to distant organs like the lungs, liver or brain to provide relief from symptoms such as pain.

Chemotherapy
Chemotherapy is a common term for anti-cancer drugs. It can be administered in a variety of ways to treat melanoma. One way it can be given is topically. This method uses a cream or lotion form of chemotherapy which is applied directly to a lesion to treat cancer. Agents used for this include 5-fluorouracil or psoralen.

Chemotherapy may also be given directly into a limb. This is called isolated limb perfusion. Isolated limb perfusion, which is still under investigation, enables high doses of chemotherapy to be delivered directly into the affected arm or leg. Since the chemotherapy does not go into the main bloodstream, the patient does not experience the side effects common with systemic (IV or oral) chemotherapy. In this method, blood circulation is temporarily stopped by the use of a tourniquet. Blood is withdrawn from the patient and pumped through a machine that adds oxygen, chemotherapy and sometimes heat to enhance the effect of the chemotherapy drugs. The blood is then pumped back into the patient through the main artery that supplies blood to that limb. The drugs most commonly used for this include melphalan, dacarbazine (DTIC) or cisplatin.

The most common way to give chemotherapy for melanoma is intravenously (by vein). When given this way, it is considered a form of systemic therapy because it travels throughout the body. Currently, chemotherapy has not been proven effective in preventing recurrences in patients with early stages of melanoma; therefore, it is usually used only in people with widespread melanoma.

The single most effective agent for metastatic melanoma is dacarbazine (DTIC). Since most drugs seen to work better together than alone, usually more than one drug is used to treat metastatic melanoma. The drugs most commonly used in combination include cisplatin (CDDP), dacarbazine (DTIC), carmustine (BCNU), and tamoxifen. Many patients' tumors do get smaller while receiving chemotherapy, but these responses are of short duration. This problem has led researchers to look at other options for treating melanoma. One option includes biologic therapy.

Biologic Therapy
Biologic therapy (also called biotherapy or immunotherapy) works either directly against the cancer or indirectly to change the way the body reacts to the cancer. Several forms of biotherapy are under investigation for treating melanoma including vaccines, interferon-a and interleukins.

• Vaccines are being studied for the treatment of melanoma. The use of vaccines has stimulated a lot of interest. Vaccines are intended to stimulate a patient's immune system to react against melanoma and hence increase resistance to further tumor progression or even destroy existing tumor cells. Although no vaccine has been shown to be effective in treating melanoma, several types of vaccines are being tested. One technique uses whole tumor cells or cellular extracts to prepare the vaccine. Often, the patient's own tumor is used to develop these types of vaccines. A second way to prepare a vaccine is to use highly purified melanoma antigens from many patient's tumors. The third method uses peptide vaccines designed to stimulate immune responses to specific melanoma antigens.

  Vaccines are used in a variety of ways to treat persons with melanoma. They may be used after primary surgical treatment of melanoma to prevent the melanoma from recurring. Vaccines may also be used to treat melanoma once it has spread to distant organs. Sometimes, vaccines are combined with other agents like chemotherapy, interferon or interleukins.

• Interferons are proteins normally produced in the body that appear to both boost the body's immune reaction to cancer cells and to act directly against the cancer.

  There are three types of interferon, alpha, beta and gamma interferon. Only alpha interferon (Interferon-a) is approved to treat melanoma. Interferon-a is now being used "adjuvantly" after surgery to prevent the cancer from reappearing. People who may benefit from receiving interferon adjuvantly include those with a primary >4mm in depth or have disease that has spread to the nearby lymph nodes. The treatment lasts for one full year. The first month you will need to come to your doctor's office every day, Monday-Friday to receive Interferon-a intravenously. Then for 11 months you will give yourself Interferon-a injections three times a week at home, usually in the evenings. Interferon may also be used alone or in combination with other agents to treat melanoma that has spread to distant sites. The days and times you will receive interferon-a vary depending on the treatment plan your doctor recommends for you.

• Interleukins are hormone-like substances produced by the body. To date, more than 13 interleukins have been identified. In general, interleukins stimulate the immune system to fight cancer cells. Only interleukin-2 is FDA-approved at this time. However, many are under investigation as possible treatments for metastatic melanoma. Often interleukins are used in combination with chemotherapy and other biologic agents to treat melanoma.

What is combination or sequential therapy?

Melanoma - A Guide For Patients

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