Treating Melanoma: Patient Options Have Gotten Significantly Better

After receiving a diagnosis of melanoma, the most dangerous type of skin cancer, you’ll begin considering treatment options. Several treatments are available, and the best option for a given case depends in large part on how advanced the cancer is.

The treatment process typically begins (and for the most fortunate patients, ends) with surgical removal (excision) of the tumor. This procedure generally takes place at the doctor’s office, under local anesthesia.

But if cancer cells have spread to the lymph nodes or beyond, excision surgery alone is not sufficient to eradicate the cancer. Until recent years, this advanced form of melanoma, called metastatic melanoma, carried a daunting prognosis. It remains a serious diagnosis, but advancements in immunotherapy and targeted therapy have offered tremendous evidence for hope.

Now, some patients with the most severe cases are prolonging their lives by months or years with the help of recently approved treatments.

According to the most recent data from the American Cancer Society, melanoma that has spread to distant regions of the body carries a 36 percent five-year survival rate. As therapies continue to evolve, those numbers may continue to increase.

Surgical Procedures for Treating Melanoma

For most patients, the first step in treating melanoma is usually cutting out the tumor. In some cases, doctors will suggest other subsequent or concurrent surgical procedures.

Tumor Excision

Mohs Micrographic Surgery

Some doctors who are looking to minimize the loss of healthy tissue even more may turn to Mohs micrographic surgery, a method that is more commonly used to treat other types of skin cancer and is not the current standard of care for treating melanoma. During this procedure, a Mohs surgeon will remove the tumor, one thin layer of skin at a time, scrutinizing each section under a microscope for cancer cells before excising the next. The surgery is over as soon as a sample is cancer-free.

Full Lymph Node Dissection

Combination of Immunotherapy and Surgery

Immunotherapy Is Changing the Game

While chemotherapy — a cancer-targeting drug treatment — was once the go-to treatment for metastatic skin cancer, newer approaches have proven to be more effective in most cases. Now, chemo is only very rarely used, and it is not typically used for cutaneous melanoma patients.

Immunotherapy has changed the way oncologists battle advanced melanoma, allowing them to harness the power of the body’s own immune system to fight disease.

Two drugs approved in 2014, pembrolizumab (Keytruda) and nivolumab (Opdivo), have become frontline treatments (either alone or in combination with other drugs) for metastatic melanoma. Both work by blocking the action of a molecule called PD-1 (programmed death-1), which normally keeps the immune system’s T cells in check. By blocking PD-1, the T cells are free to attack the cancer.

For some patients, combining different checkpoint blockade therapies may further increase survival rates and benefits, despite considerable side effects.

Targeted Drugs Exploit Mutations in Some Melanomas

Targeted melanoma drugs work by blocking mutations (DNA defects) in melanoma cells, which then shrink tumors or slow their growth.

About half of all melanomas have mutations (DNA defects) in the BRAF gene that cause out-of-control cellular growth.

The FDA has approved three oral combination therapies targeting this mutation, called BRAF and MEK inhibitors. They work by binding to defective proteins that promote cancer growth and then deactivating them, thereby slowing disease progression and helping some patients live longer.

Since then, this combination of drugs has become a frontline treatment option for metastatic melanoma with the BRAF mutation.

Subsequently, additional combinations of BRAF and MEK inhibitors, including vemurafenib (Zelboraf) with cobimetinib (Cotellic) — and encorafenib (Braftovi) with binimetinib (Mektovi) — were found to be effective and were approved by the FDA in 2015 and 2018, respectively.