STAGE 4 MELANOMA
What are the aims of this leaflet?
This leaflet provides some general information on melanoma skin cancer. In particular it tells you what stage 4 melanoma is and what might be the investigations/treatments. This leaflet will be relevant to the majority of patients with stage 4 melanoma but not necessarily all. Details on where to find out more information are provided at the end of the leaflet.
What is melanoma?
Melanoma is a type of skin cancer, which arises from the pigment cells (melanocytes) in the skin. In a melanoma skin cancer the melanocytes become malignant andmultiply excessively. One of the most important causes of melanoma is exposure to too much ultraviolet light in sunlight. The use of artificial sources of ultraviolet light, such as sunbeds, also increases the risk of getting a melanoma.
Melanocytes make a brown/black pigment (known as melanin), and often the first sign of a melanoma developing is a previous mole changing in colour or a new brown/black lesion developing. Most frequently there is darkening in colour but occasionally there is loss of pigmentation with pale areas or red areas developing. This melanoma on the skin is known as the primary melanoma.
Melanoma is considered to be the most serious type of skin cancer because it is more likely to spread (metastasise) from the skin to other parts of the body than other types of skin cancer. If melanoma has spread to other parts of the body, those deposits are known as secondary melanoma (secondaries/metastases).
What is stage 4 melanoma?
Doctors use a staging system for melanoma to indicate both the outcome and the best treatment. The system used in the UK stages melanoma from 1 to 4. Stage 1 is the earliest melanoma and stage 4 is the most advanced. The staging system takes into account if there has been any spread of melanoma from the skin to other parts of the body.
When the melanoma has spread beyond the primary site and the local lymph nodes to other areas in the body, it is known as stage 4 melanoma. Stage 4 melanoma is a form of secondary melanoma where melanoma has spread to distant lymph nodes (glands) or internal organs such as the liver, lungs bones and brain (distant metastases).
What are the symptoms?
When stage 4 melanoma is diagnosed after a scan, there may be no symptoms at all, and it can be difficult to believe the cancer has spread. However, people with stage 4 melanoma may have a very wide range of symptoms.
What tests are carried out for stage 4 melanoma?
These are used to monitor general health and treatment effects. The tests usually include full blood count (to look for anaemia) and tests of liver function.
Scans such asultrasound, CT (computerised tomography), MRI (magnetic resonance imaging), PET (positron emission tomography) and bone scans are used to monitor any further spread of the cancer. Your melanoma team will explain why they have chosen a particular type of scan - each type has particular advantages. Further details on what these scans may involve can be found on the links provided at the end of the leaflet.
These are used to confirm the presence of deposits of melanoma in other parts of the body. A biopsy may involve the removal of a lump or the taking of a sample with a fine needle. The sample is then sent to a laboratory for a doctor called a pathologist to examine under a microscope.
Multidisciplinary Team (MDT) Meetings
Test results will be discussed at a skin cancer multi-disciplinary team (MDT) meeting. Following this you may be referred to a specialist melanoma MDT, which may be at another hospital. The specialist melanoma MDT will include a number of specialists including dermatologists, surgeons, pathologists, radiologists, oncologists and also specialist nurses. Following a diagnosis of stage 4 melanoma, you will be seen in clinic by an oncologist, a doctor who specialises in cancer care. He/she will explain your treatment options and discuss the best treatment plan for you.
What is the treatment for stage 4 melanoma?
The aims of treatment for stage 4 melanoma are to shrink and control the melanoma and to relieve any symptoms. Some of the treatments that may be discussed with you are outlined below. It is possible to remain well for a long time particularly if the melanoma is growing slowly and causing no symptoms. The treatments may cause side effects. The advantages and disadvantages of each treatment, and of having no treatment at all, will be discussed with you. Treatments that may be offered include:
Melanoma lumps in the skin can sometimes bleed or cause discomfort. Similarly, melanoma within lymph nodes can become uncomfortable and painful. It may be possible to remove the lumps or nodes with surgery. If the melanoma has spread to the internal organs, but only as one or two small deposits, it may be possible to remove them with surgery. If melanoma is present in several organs, or there are multiple deposits in one organ, then surgery is not a suitable option.
Radiotherapy involves the use of high energy X-rays to destroy cancer cells. This can be helpful for melanoma in the bones or brain. Unfortunately the radiotherapy will not cure the melanoma but it may reduce or remove symptoms. For melanoma that has spread to the brain steroid tablets may also be given, reducing any swelling around the tumour.
Certain melanomas contain an altered gene. This gene makes a protein called BRAF that makes the melanoma grow. When the melanoma is tested, the pathology lab will look for this gene. If it is present then a targeted therapy, a drug called Vemurafenib (a BRAF inhibitor) may be suitable for you. This is not a cure but may help to shrink down or slow the growth of the melanoma cells.
Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. There are several drugs that can be used to treat melanoma cancer cells such as dacarbazine (also known as DTIC) and temozolamide. As with surgery these treatments will not cure the melanoma but can help control it.
The body’s own defences, the immune system, may act on the melanoma cells to slow their growth. Immunotherapy is treatment that encourages this action of the body to fight against the melanoma. Ipilimumab is a medicine used for melanoma that allows the cells in the body’s immune system to work more effectively. This medicine, like others used for melanoma, may cause side effects so the doctors will discuss with you whether it will be helpful.
Significant progress is being made in the treatment of metastatic melanoma. Ask your melanoma team what clinical trials are available in your area.
Self care (What can I do?)
Top sun safety tips:
Protect your skin with clothing, and don’t forget to wear a hat that protects your face, neck and ears, and a pair of UV protective sunglasses.
Spend time in the shade between 11am and 3pm when it’s sunny. Step out of the sun before your skin has a chance to redden or burn.
When choosing a sunscreen look for a high protection SPF (SPF 30 or more) to protect against UVB, and the UVA circle logo and/or 4 or 5 UVA stars to protect against UVA. Apply plenty of sunscreen 15 to 30 minutes before going out in the sun, and reapply every two hours and straight after swimming and towel-drying.
Keep babies and young children out of direct sunlight.
The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole or patch of skin. If your GP is concerned about your skin, make sure you see a Consultant Dermatologist – an expert in diagnosing skin cancer. Your doctor can refer you for free through the NHS.
Sunscreens should not be used as an alternative to clothing and shade, rather they offer additional protection. No sunscreen will provide 100% protection.
It may be worth taking Vitamin D supplement tablets (available from health food stores) as strictly avoiding sunlight can reduce Vitamin D levels.
Vitamin D advice
The evidence relating to the health effects of serum Vitamin D levels, sunlight exposure and Vitamin D intake remains inconclusive. Avoiding all sunlight exposure if you suffer from light sensitivity, or to reduce the risk of melanoma and other skin cancers, may be associated with Vitamin D deficiency.
Individuals avoiding all sun exposure should consider having their serum Vitamin D measured. If levels are reduced or deficient they may wish to consider taking supplementary vitamin D3, 10-25 micrograms per day, and increasing their intake of foods high in Vitamin D such as oily fish, eggs, meat, fortified margarines and cereals. Vitamin D3 supplements are widely available from health food shops.
Having had a melanoma does have some practical disadvantages. It can be difficult to obtain life or health insurance, particularly for the first five years after your diagnosis.
Where can I get more advice, support & information about melanoma?
Coping with stage 4 melanoma can be a tremendous challenge for you as well as your family and friends. The website links below contain interviews with melanoma patients talking about their experiences having been diagnosed with stage 4 melanoma and how they have coped. You may find this helpful.
When you are diagnosed with stage 4 melanoma, you will be given a lot of information. All this information at once can be hard to take in. If you are not clear about anything during your treatment, please don’t be afraid to ask.
Web links to detailed leaflets:
British Association of Dermatologists
Cancer Research UK (CRUK)
GenoMEL: The Melanoma Genetics Consortium
Macmillan Cancer Support
For details of source materials used please contact the Clinical Standards Unit (firstname.lastname@example.org).
This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: its contents, however, may occasionally differ from the advice given to you by your doctor.
This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel
BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED APRIL 2013
REVIEW DATE APRIL 2016