Malignant Melanoma

Malignant melanoma is a serious type of skin cancer that begins in cells called melanocytes, which produce the pigment that gives skin its color. While it accounts for only about 1% of all skin cancers, it causes the great majority of skin cancer-related deaths. When detected early, melanoma has a 99% cure rate, but if left untreated, it can spread quickly to other organs.

Table of contents

• What is Malignant Melanoma?
• Causes and Risk Factors
• Warning Signs and Symptoms
• Diagnosis and Testing
• Treatment Options
• Prevention and Skin Protection
• Living With Melanoma

What is Malignant Melanoma?

Melanoma is a type of cancer that develops from melanocytes, which are skin cells found in the upper layer of skin^[1]. These cells produce melanin, the dark pigment that gives skin its color^[2]. The word “melanoma” means “black tumor”^[2].

Most melanomas are black or brown in color, but some can be pink, red, purple, or even skin-colored^[2]. This cancer is particularly dangerous because it grows quickly and has the ability to spread to any organ in the body^[2].

About 30% of melanomas begin in existing moles, but the rest start in normal-looking skin^[2]. This makes it especially important to pay attention to changes in your skin, since the majority of melanomas don’t start as moles^[2].

The incidence of melanoma has increased dramatically over the past 30 years^[2]. According to available data, melanoma accounts for only about 1% of all skin cancers, but it causes the great majority of skin cancer-related deaths^[2]. It’s one of the most common cancers in young people under 30, especially in young women^[2].

• Skin (epidermis)
• Melanocytes
• Eyes (ocular melanoma)
• Mucous membranes

Causes and Risk Factors

Most experts agree that a major risk factor for melanoma is overexposure to sunlight, especially sunburns when you are young^[2]. Statistics show that 86% of melanomas are caused by solar ultraviolet (UV) rays^[2]. UV light is a type of radiation that comes from the sun and from tanning beds^[1].

UV exposure can cause damage to a cell’s DNA, making changes to particular genes that affect how cells grow and divide^[2]. When skin is exposed to UV radiation, it causes skin damage that triggers the melanocytes to produce more melanin^[4]. The potential for problems comes when your skin’s DNA is damaged and those cells start reproducing^[2].

Research suggests that nearly 90% of cutaneous melanoma cases can be linked to exposure to UV rays, either from natural sources like the sun or from artificial sources like indoor tanning beds^[9]. Just one indoor tanning session increases your chance of skin cancer by 75%^[23].

However, since melanoma can occur in all melanocytes throughout the body, even those that are never exposed to the sun, UV light cannot be solely responsible for all diagnoses^[9]. Current research points to a combination of family history, genetics, and environmental factors^[9].

Several factors can increase your risk of developing melanoma^[1]:

• Having fair skin, blonde or red hair, and blue eyes
• A family history of melanoma or skin cancer
• A family history of irregular, prominent moles
• A personal history of previous melanoma
• Lifetime sun exposure and history of sunburns
• Having a large number of moles
• Use of tanning beds

People with darker skin have more of a type of melanin called eumelanin, which has the ability to protect the skin from sun damage, while fair-skinned people have more of a type called pheomelanin, which does not offer protection^[4]. That’s why people with darker skin are at lower risk for developing skin cancer than fair-skinned people^[4].

Warning Signs and Symptoms

Knowing how to spot melanoma is important because early melanomas are highly treatable^[2]. Melanoma can appear as moles, scaly patches, open sores, or raised bumps^[2].

Early melanomas may be identified using the ABCDE rule^[2]:

• A – Asymmetry: One half does not match the other half
• B – Border: The edges are not smooth or are irregular
• C – Color: The color is uneven, with shades of brown, black, gray, red, or white
• D – Diameter: The spot is greater than the tip of a pencil eraser (6.0 mm)
• E – Evolving: The spot is new or changing in size, shape, or color

Some melanomas don’t fit the ABCDE rule, so it’s important to tell your doctor about any sores that won’t go away, unusual bumps or rashes, or changes in your skin or in any existing moles^[2].

Another helpful tool to recognize melanoma is the “ugly duckling” sign^[2]. If one of your moles looks different from the others, it’s the ugly duckling and should be seen by a dermatologist (a doctor who specializes in skin conditions)^[2].

It helps to know what your skin normally looks like^[8]. Only 20-30% of melanomas are found in existing moles, while 70-80% arise on normal-looking skin^[4].

In men, melanoma is often found on the trunk, particularly the upper back^[2]. In women, melanoma forms most often on the arms and legs^[2]. You can get melanoma on any area of your body, including your eyes and internal organs^[2].

Diagnosis and Testing

If you have symptoms of melanoma, your doctor will examine your skin and ask questions about your health history^[11]. Tests that examine the skin are used to diagnose melanoma^[10].

The most common way to diagnose melanoma is through a biopsy, which is a procedure to remove a sample of tissue for testing in a laboratory^[11]. An excisional biopsy is the preferred method, where the entire growth is removed when possible^[11].

One common technique is called a punch biopsy, which is done with a circular blade that’s pressed into the skin around the suspicious mole^[11]. Another technique is an excisional biopsy, which uses a scalpel to cut away the entire mole and some of the healthy tissue around it^[11].

Once a biopsy confirms melanoma, your doctor will need to determine how far the cancer has spread^[11]. To assign a stage to your melanoma, your healthcare team will determine the thickness of the melanoma by looking at it under a microscope^[11]. In general, the thicker the melanoma, the more serious the disease^[11].

Additional tests may be performed if your doctor suspects the melanoma has spread^[11]. These can include:

• Blood tests, including lactate dehydrogenase levels
• Chest radiography (X-ray)
• Computed tomography (CT) scans of the chest, abdomen, or pelvis
• Magnetic resonance imaging (MRI) of the brain
• Positron emission tomography (PET) scans
• Sentinel lymph node biopsy to check if cancer has spread to nearby lymph nodes

The 5-year relative survival rate for patients with stage 0 melanoma is 97%, compared to 30% for those with stage IV disease^[3]. This highlights the critical importance of early detection and diagnosis.

Treatment Options

Surgery is the main treatment for melanoma, especially if it’s found early^[12]. The type of treatment depends on where the cancer is, if it has spread to other areas of your body, and your general health^[5].

Several types of surgery can be used to treat melanoma^[12]:

• Removing the melanoma and an area of healthy skin around it (called wide local excision) to help lower the chances of it coming back
• Removing swollen lymph nodes if the cancer has spread to them
• Removing melanoma that has spread to other areas of your body

If the melanoma is in a visible area, such as on your face, a plastic surgeon may carry out the surgery to ensure the best possible appearance^[12]. If a large area of skin is removed, skin may need to be taken from another part of your body and used to cover the area where the melanoma was, which is known as a skin graft^[12].

For more advanced melanoma, additional treatment options include^[12]:

Targeted medicines aim to stop the cancer from growing. These medicines work on melanomas with certain genetic changes. A sample of the melanoma is usually tested before starting targeted medicines to check for changes in certain genes and help doctors decide if this type of treatment is likely to work^[12].

Immunotherapy medicines help your immune system find and kill the cancer cells^[12]. These treatments have dramatically improved the quality of life and overall survival of patients with metastatic melanoma^[3].

Radiotherapy is sometimes used to reduce the size of large melanomas and help control and relieve symptoms^[12]. You may have one or several sessions of radiotherapy, depending on the area of your body being treated and if you’re also having other types of treatment^[12].

Chemotherapy uses medicines to kill cancer cells. It’s sometimes used to treat advanced melanoma where the cancer has spread to another part of the body^[12]. However, chemotherapy doesn’t work as well for melanoma as other treatments like targeted medicines and immunotherapy^[12].

Melanoma was once considered a very aggressive cancer that was resistant to traditional therapies^[3]. However, a dramatic improvement in outcomes has resulted after the development of various new combinations of targeted therapies and different types of immunotherapies^[3].

Treatment success is directly related to the depth of the cancerous growth^[2]. Because of the fast growth rate of melanomas, a treatment delay sometimes may mean the difference between life and death^[2]. Melanoma has a 99% cure rate if caught in the earliest stages^[2].

Prevention and Skin Protection

It’s often possible to prevent skin cancer by being careful in the sun^[5]. If you’ve had one melanoma, it means you’re at risk for more, but you can protect your skin with some basic sun-safety measures^[20].

Here are important steps to protect your skin^[20][23]:

• Don’t spend much time outside between 10 a.m. and 4 p.m., when the sun and its UV rays are strongest. Between the hours of 10 a.m. and 2 p.m., UV light is the strongest and your chance of skin cancer and skin aging increases significantly
• Every time you go outside, wear a broad-spectrum sunscreen with an SPF of at least 30. Apply about one ounce (a shot-glassful) 15 minutes before sun exposure and reapply at least every 2 hours, and more often if you’re swimming or sweating
• Cover your skin with long-sleeved pants and shirts, and wear a wide-brimmed hat that shades your face and neck
• Wear UV-protective sunglasses outside to protect your eyes
• Seek shade when possible
• Never use a sun bed or tanning lamp

Be extra careful if you’re taking “photosensitive” drugs, which make you more sensitive to the sun, including some chemotherapy drugs^[20].

There is no such thing as a safe or healthy tan^[23]. Skin damage is cumulative, and for every tan, the risk of melanoma increases substantially^[23].

Check every part of your skin at least once a month, looking for any new or changing marks^[20]. You are most likely to first spot melanoma on your skin^[23]. Routinely examine your skin and any moles to identify any changes early on. Put your selfie skills to good use and photograph your moles or use a mole mapping app to keep track of any changes in your skin^[23].

Make sure you have regular check-ups with your doctor^[20]. If you notice any changes in your skin or moles, prioritize seeing your primary care provider or dermatologist for a full body skin exam^[23].

Some people who have had melanoma may need to take vitamin D supplements, since covering up and using sunscreen helps reduce the risk of melanoma but can also reduce the amount of vitamin D in your body^[22]. Your doctor can test your vitamin D levels and recommend supplements if needed^[22].

Living With Melanoma

There’s no doubt that your life will change when you get a diagnosis of melanoma^[20]. From the moment you learn that you or someone you love has melanoma, you will face a variety of challenging decisions and at times, overwhelming circumstances^[16]. Learning to live and manage this new normal will take time^[16].

Many people find that knowing more about their situation can make it easier to cope^[17]. It’s common to experience a range of feelings, including anxiety, fear, guilt, doubt, hesitation, and insecurity, as well as relief and pride once you’ve achieved certain milestones^[18]. When everything feels like it’s swirling out of control, it’s important to know there are factors under your control, and focusing on those things can help^[18].

Throughout your journey with melanoma, it’s important to listen to your body, give yourself some slack, and remember that you are more than any diagnosis^[16].

Here are some strategies for coping:

Practice self-care. Redefining and recommitting to self-care is important as you manage your diagnosis and treatment^[16]. After learning you have melanoma, self-care might begin to look different, such as gentle yoga instead of marathon training, or it may stay exactly the same^[16]. Making time and space in your life to take care of yourself is more important now than ever^[16].

Talk to others. You might find it helpful to talk to other people about how you are feeling^[17]. Specialist nurses can help if you’re finding it difficult to cope or if you have any problems. They can give you information and connect you with support in your local area^[17]. Some people find great comfort in talking to family and friends, while others may prefer to speak to a counselor or join a support group^[17].

Set boundaries. There may come a time when your friends and family or coworkers invite you somewhere, ask for help, or just want to see you^[16]. Remember that you should not feel obligated to say yes. While often easier said than done, politely declining can be a way to reclaim control over what is happening and give you the time and space you need to heal, process, and take care of yourself^[16].

Stay active when possible. Exercise is one of the best things anyone can do for their health, and people with melanoma are no exception^[20]. Just follow a few commonsense guidelines: don’t do any really taxing exercise right after surgery, keep in mind that treatment may affect your energy levels, and always protect your skin when exercising outdoors^[20].

Get practical help. If you have physical difficulties that make it hard to cope at home, your specialist nurse or a district nurse can talk to you about what may help^[17]. It is also important that you feel as well as you possibly can. Tell your doctor or nurse if you have any symptoms so they can help you get the treatment you need to relieve them^[17].

You’ll have regular check-ups during and after any treatments^[5]. You do not need to wait for your next check-up if you have any symptoms or side effects you’re worried about^[5].

Finding out you have advanced melanoma can be a shock, and it’s common to feel uncertain and anxious^[17]. Treatment may be able to shrink the melanoma or stop it from growing for a time^[17]. Many organizations and support groups are available to help you, your family, and friends throughout your journey^[9].