How is melanoma skin cancer treated?
This information represents the views of the doctors and nurses serving on the American Cancer Society’s Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.
The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.
Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don’t hesitate to ask him or her questions about your treatment options.
General treatment information
Once melanoma has been diagnosed and staged, your cancer care team will discuss your treatment options with you. Depending on your situation, you may have different types of doctors on your treatment team. These doctors may include:
• A dermatologist: A doctor who treats diseases of the skin
• A surgical oncologist (or oncologic surgeon): A doctor who uses surgery to treat cancer
• A medical oncologist: A doctor who treats cancer with medicines such as chemotherapy, immunotherapy, or targeted therapy
• A radiation oncologist: A doctor who treats cancer with radiation therapy
Many other specialists might be part of your treatment team as well, including physician assistants (PAs), nurse practitioners (NPs), nurses, nutrition specialists, social workers, and other health professionals. To learn more about who may be on your cancer care team, see Health Professionals Associated With Cancer Care.
It’s important to discuss all of your treatment options as well as their possible side effects with your treatment team to help make the decision that best fits your needs. If there is anything you do not understand, ask to have it explained. (See the section “What should you ask your doctor about melanoma skin cancer?” for some questions to ask.)
Based on the stage of the cancer and other factors, your treatment options might include:
• Surgery
• Immunotherapy
• Targeted therapy
• Chemotherapy
• Radiation therapy
Early-stage melanomas can often be treated effectively with surgery alone, but more advanced cancers often require other treatments. Sometimes more than one type of treatment is used. Follow this link to learn more about the most common treatment options based on the stage of the melanoma.
When time permits, getting a second opinion is often a good idea. It can give you more information and help you feel good about the treatment plan that you choose.
Surgery for melanoma skin cancer
Surgery is the main treatment option for most melanomas, and usually cures early stage melanomas.
Wide excision
When a diagnosis of melanoma is made by skin biopsy, the site will probably need to be excised again to help make sure the cancer has been removed completely. This fairly minor surgery will cure most thin melanomas.
Local anesthesia is injected into the area to numb it before the excision. The site of the tumor is then cut out, along with a small amount of normal non-cancerous skin at the edges. The normal, healthy skin around the edges of the cancer is referred to as the margin. The wound is carefully stitched back together afterward. This will leave a scar.
The removed sample is then viewed under a microscope to make sure that no cancer cells were left behind at the edges of the skin that was removed.
Wide excision differs from an excisional biopsy. The margins are wider because the diagnosis is already known. The recommended margins vary depending on the thickness of the tumor. Thicker tumors need larger margins (both at the edges and in the depth of the excision).
Tumor thickness Recommended margins
In situ 0.5 cm
1 mm (about 1/25 of an inch) or less
1 cm
1 to 2 mm 1 to 2 cm
2 to 4 mm 2 cm
Over 4 mm 2 cm
These margins might need to be altered based on where the melanoma is on the body and other factors. For example, if the melanoma is on the face, the margins may be smaller to avoid large scars or other problems. Smaller margins may increase the risk of the cancer coming back, so be sure to discuss the options with your doctor.
Mohs surgery: In some situations, the surgeon may use Mohs surgery. This type of surgery is used more often for some other types of skin cancer, but not all doctors agree on using it for melanoma. In this procedure, the skin (including the melanoma) is removed in very thin layers. Each layer is then viewed under a microscope for cancer cells. If cancer cells are seen, the surgeon removes another layer of skin. The operation continues until a layer shows no signs of cancer. In theory, this allows the surgeon to remove the cancer while saving as much of the surrounding normal skin as possible.
Amputation: If the melanoma is on a finger or toe and has grown deeply, part or all of that digit might need to be amputated.
Lymph node dissection
In this operation, the surgeon removes all of the lymph nodes in the region near the primary melanoma. For example, if the melanoma is on a leg, the surgeon would remove the nodes in the groin region on that side of the body, which is where melanoma cells would most likely travel to first.
Once the diagnosis of melanoma is made from the skin biopsy, the doctor will examine the lymph nodes near the melanoma. Depending on the thickness and location of the melanoma, this may be done by physical exam, or by imaging tests (such as CT or PET scans) to look at nodes that are not near the body surface.
If the nearby lymph nodes feel abnormally hard or large, and a fine needle aspiration (FNA) biopsy or excisional biopsy finds melanoma in a node or nodes, a lymph node dissection is usually done.
If the lymph nodes are not enlarged, a sentinel lymph node biopsy may be done, particularly if the melanoma is thicker than 1 mm. (See the section “How is melanoma of the skin diagnosed?” for a description of this procedure.) If the sentinel lymph node does not contain cancer, then there is no need for a lymph node dissection because it’s unlikely the melanoma has spread to the lymph nodes. If the sentinel lymph node contains cancer cells, removing the remaining lymph nodes in that area with a lymph node dissection is usually advised. This is called a completion lymph node dissection.
It’s not clear if a lymph node dissection can cure melanomas that have spread to the nodes. This is still being studied. Still, some doctors feel it might prolong a patient’s survival and at least avoid the pain that may be caused by cancer growing in these lymph nodes.
A full lymph node dissection can cause some long-term side effects. One of the most troublesome is called lymphedema. Lymph nodes in the groin or under the arm normally help drain fluid from the limbs. If they are removed, fluid may build up. This can cause limb swelling, which may or may not go away. If severe enough, it can cause skin
problems and an increased risk of infections in the limb. Elastic stockings or compression sleeves can help some people with this condition. For more information, see our document Understanding Lymphedema (for Cancers Other Than Breast Cancer).
Lymphedema, along with the pain from the surgery itself, is a main reason why lymph node dissection is not done unless it is necessary. Sentinel lymph node biopsy, however, is unlikely to have this effect. It is important to discuss the possible risks of side effects with your doctor before having either of these procedures done.
Surgery for metastatic melanoma
If melanoma has spread from the skin to distant organs such as the lungs or brain, the cancer is very unlikely to be curable by surgery. Even when only 1 or 2 metastases are found by imaging tests such as CT or MRI scans, there are likely to be other areas of metastasis that are too small to be found by these scans.
Surgery is sometimes done in these circumstances, but the goal is usually to try to control the cancer rather than to cure it. If 1 or even a few metastases are present and can be removed completely, this surgery may help some people live longer. Removing metastases in some places, such as the brain, might also relieve symptoms and help improve a person’s quality of life.
If you have metastatic melanoma and surgery is offered as a treatment option, talk to your doctor and be sure you understand what the goal of the surgery would be, as well as its possible benefits and risks.
Immunol therapy for melanoma skin cancer
Immunotherapy is the use of medicines to stimulate a patient’s own immune system to recognize and destroy cancer cells more effectively. Several types of immunotherapy can be used to treat patients with melanoma.
Immune checkpoint inhibitors for advanced melanoma
An important part of the immune system is its ability to keep itself from attacking normal cells in the body. To do this, it uses “checkpoints”, which are molecules on immune cells that need to be turned on (or off) to start an immune response. Melanoma cells sometimes use these checkpoints to avoid being attacked by the immune system. But newer drugs that target these checkpoints hold a lot of promise as melanoma treatments.
PD-1 inhibitors
Pembrolizumab (Keytruda) and nivolumab (Opdivo) are drugs that target PD-1, a protein on immune system cells called T cells that normally help keep these cells from attacking other cells in the body. By blocking PD-1, these drugs boost the immune response against melanoma cells, which can often shrink tumors and help people live longer (although it’s not yet clear if these drugs can cure melanoma).
These drugs are given as an intravenous (IV) infusion every 2 or 3 weeks.
Side effects of these drugs can include fatigue, cough, nausea, itching, skin rash, decreased appetite, constipation, joint pain, and diarrhea.
Other, more serious side effects occur less often. These drugs work by basically removing the brakes from the body’s immune system. Sometimes the immune system starts attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, or other organs.
It’s very important to report any new side effects to your health care team promptly. If serious side effects do occur, treatment may need to be stopped and you may get high doses of corticosteroids to suppress your immune system.
CTLA-4 inhibitor
Ipilimumab (Yervoy) is another drug that boosts the immune response, but it has a different target. It blocks CTLA-4, another protein on T cells that normally helps keep them in check.
This drug is given as an intravenous (IV) infusion, usually once every 3 weeks for 4 treatments. In patients with melanomas that can’t be removed by surgery or that have spread to other parts of the body, this drug has been shown to help people live an average of several months longer, although it’s not clear if it can cure the melanoma.
The most common side effects from this drug include fatigue, diarrhea, skin rash, and itching.
Serious side effects seem to happen more often with this drug than with the PD-1 inhibitors. Like the PD-1 inhibitors, this drug can cause the immune system to attack other parts of the body, which can lead to serious problems in the intestines, liver, hormone-making glands, nerves, skin, eyes, or other organs. In some people these side effects have been fatal.
It’s very important to report any new side effects during or after treatment to your health care team promptly. If serious side effects do occur, you may need to stop treatment and take high doses of corticosteroids to suppress your immune system.
Cytokines for advanced melanoma
Cytokines are proteins in the body that boost the immune system in a general way. Man- made versions of cytokines, such as interferon-alfa and interleukin-2 (IL-2), are sometimes used in patients with melanoma. They are given as intravenous (IV) infusions, at least at first. Some patients or caregivers may be able to learn how to give injections under the skin at home. Both drugs can help shrink advanced (stage III and IV) melanomas in about 10% to 20% of patients when used alone. These drugs may also be given along with chemotherapy drugs (known as biochemotherapy) for stage IV melanoma.
Side effects of cytokine therapy can include flu-like symptoms such as fever, chills, aches, severe tiredness, drowsiness, and low blood cell counts. Interleukin-2, particularly in high doses, can cause fluid to build up in the body so that the person swells up and can feel quite sick. Because of this and other possible serious side effects, high-dose IL-2 is given only in the hospital, in centers that have experience with this type of treatment.
Interferon-alfa as adjuvant therapy
Patients with thicker melanomas often have cancer cells that have spread to other parts of the body. Even if all of the cancer seems to have been removed by surgery, some of these cells may remain in the body. Interferon-alfa can be used as an added (adjuvant) therapy after surgery to try to prevent these cells from spreading and growing. This may delay the recurrence of melanoma, but it is not yet clear if it improves survival.
High doses must be used for the interferon to be effective, but many patients can’t tolerate the side effects of high-dose therapy. These can include fever, chills, aches, depression, severe tiredness, and effects on the heart and liver. Patients getting this drug need to be closely watched by a doctor who is experienced with this treatment.
When deciding whether to use adjuvant interferon therapy, patients and their doctors should take into account the potential benefits and side effects of this treatment.
Bacille Calmette-Guerin (BCG) vaccine
BCG is a germ related to the one that causes tuberculosis. BCG does not cause serious disease in humans, but it does activate the immune system. The BCG vaccine works like a cytokine by enhancing the entire immune system. It is not directed specifically at melanoma cells. It is sometimes used to help treat stage III melanomas by injecting it directly into tumors.
Imiquimod cream
Imiquimod (Zyclara) is a drug that is applied as a cream. It stimulates a local immune response against skin cancer cells. For very early (stage 0) melanomas in sensitive areas on the face, some doctors may use imiquimod if surgery might be disfiguring. It can also be used for some melanomas that have spread along the skin. Still, not all doctors agree it should be used for melanoma.
The cream is applied anywhere from once a day to 2 times a week for around 3 months. Some people have serious skin reactions to this drug. Imiquimod is not used for more advanced melanomas.
Newer treatments
Some other types of immunotherapy have shown promise in treating melanoma in early studies. At this time they are available only through clinical trials (see “What’s new in research and treatment of melanoma skin cancer?”).
To learn more about this type of treatment, see our document Cancer Immunotherapy.
Targeted therapy for melanoma skin cancer
As doctors have found some of the gene changes that make melanoma cells different from normal cells, they have begun to develop drugs that attack these changes. These targeted drugs work differently from standard chemotherapy drugs, which basically attack any quickly dividing cells. Sometimes, targeted drugs work when chemotherapy doesn’t. They can also have less severe side effects. Doctors are still learning the best way to use these drugs to treat melanoma.
