14. WHAT ARE SOME OF THE TREATMENTS AVAILABLE FOR MELANOMA?

Some treatments available for patients in stage 0, I or II.

Surgery for a primary melanoma

For patients in stage 0, I or II, surgery will be the main treatment undertaken. Surgery of a primary melanoma includes, but may not be limited to, the removal of the primary tumour with excision margins.  Excision margins involve the removal of skin and flesh from around the primary tumour with the aim of improving the prognosis of the patient.

The treatment of the primary lesion will also be influenced by the site of the original melanoma and various prognosis features.  For example, the treatment of a primary melanoma situated 3mm from a patients eye would require different treatment to that of a melanoma situated on the back of a patients leg.  Furthermore, prognosis factors such as the invasiveness of the primary tumour may effect the excision margins removed.

Sentinal Node biopsy

Although a sentinel node biopsy is not a treatment per-say it deserves mention here due to its role as a staging tool.  A sentinel node biopsy is an experimental treatment sometimes used, usually in case of a deep invasive primary melanoma, to determine whether metastases to lymph nodes have taken place.  It involves the injection of a radioactive blue tracer dye around the site of the primary lesion and then examination of the first lymph node to take up the dye.  A biopsy of the involved lymph node is taken and examined to determine if the node tests positive for melanoma.  If the node tests positive the patient is regarded as being in stage III and appropriate further treatment is undertaken. It is still debateable whether sentinel node biopsy improves the overall prognosis of the patient.       

Some treatments available for patients in stage III      

Surgery to remove lymph nodes

Again for patients in stage III, surgery is the main treatment prescribed.  A removal or block dissection of lymph nodes surrounding the node/s that tested positive to melanoma is undertaken and has been shown to increase the prognosis of the patient. 

Radiotherapy

Radiotherapy may be used as an alternative to surgery in patients who are medically unfit for surgery or who have unresectable disease because it is too extensive.  Post-operative radiotherapy is also considered in patients who have positive or close margins following surgery or where there were metastases to lymph nodes raising the risk of regional recurrence. While there is evidence that radiotherapy may reduce the risk of recurrence, there is a lack of randomised evidence (post-operative radiotherapy versus no radiotherapy) demonstrating a significant benefit and therefore there is an ongoing national study addressing this question.

http://www.ranzcr.edu.au/affiliatedgroups/trog/index.cfm

Biological Therapy

Biological therapies work with or enhance the immune system to fight cancer.  Biological therapies include treatments such as; interferons, interleukins, colony stimulating factors, monoclonal antibodies, gene therapies and cancer vaccines.  For the treatment of stage III melanoma, a biological treatment using high dose Interferon Alpha 2b is sometimes administered.  Interferons are types of cytokines which are produced by white blood cells.  Interferons are produced naturally in the body and help regulate the intensity and duration of the immune response.    

This treatment is standard care in the United States for stage III melanoma and is available at the discretion of the patient in most circumstances in Australia.  The research on high dose alpha interferon 2b is not yet conclusive. Some doctors claim there is a survival advantage in the treatment while others are not convinced.  The three academic papers written on high dose alpha interferon most commonly sighted are as follows:

• Kirkwood J. M., et al., High-Dose Interferon Alfa-2b significantly prolongs relapse-free and overall survival compared with the GM2-KLH/QS-21 vaccine in patients with resected stage IIb-III melanoma: Results of intergroup trial E1694/s9512/c509801. Journal of Clinical Oncology, Vol 19, No 9 (May 1), 2001: pp 2370-2380.
• Kirkwood J. M., et al., High and Low-Dose Interferon Alfa-2b in high risk melanoma: First analysis of intergroup trial E1690/s9111/c9190. Journal of Clinical Oncology, Vol 18, No 12 (June) 2000: pp2444-2458
• Kirkwood J. M., et al., Interferon alfa-2b Adjuvant therapy of High-risk resected cutaneous melanoma: The Eastern Cooperative Oncology Group Trial EST 1684. Journal of Clinical Oncology, Vol 14, No 1 (January), 1996: pp 7-17.

Clinical Trials

Clinical trials are experimental treatments undertaken to determine whether a new technology or drug offers health benefits to patients.  Involvement in a clinical trial would be a worthwhile consideration for patients diagnosed with stage III melanoma.  Information regarding clinical trials can be obtained by talking with your doctor.

Some Treatments available to patients in Stage IV

Chemotherapy

Chemotherapy is a treatment which affects the whole body or systemic treatment.  While chemotherapy is a systemic treatment, it focuses on killing cancer cells by targeting rapidly dividing cells.  Unfortunately cancer cells are not the only rapidly dividing cells; the digestive system cells, hair cells and other healthy cells are also rapidly dividing cells.  It is the damage to healthy cells that cause the side effects of chemotherapy. Common side effects include hair loss, nausea and fatigue.

Currently the standard treatment for stage four melanoma is a chemotherapy drug called dacarbazine or DTIC.  While other chemotherapy drugs like lomustine and futemusane are approved for the treatment of melanoma, dacarbazine remains the main drug used in the treatment of melanoma (stage 4). 

The National Cancer Institute of America states that the use of dacarbazine results in response in approximately 10-20% of cases.  However, these responses are usually short lived (3-6mths) and long term remissions are rare.  A response can be defined as either disease stabilisation or the reduction in the size of tumours13. 

Radiotherapy

Radiation therapy is a localised treatment that uses high energy radiation to kill cancer cells.  It does this by damaging the DNA of cells that are dividing.  Radiotherapy is commonly used to palliate (relieve symptoms) symptomatic metastases from sites such as the brain, bones or lungs.

Clinical Trials

Many patients participate in clinical trials as a means of gaining access to new experimental treatments for melanoma.  At any one time there are numerous clinical trials taking place that aim to improve upon the current treatment protocol for melanoma. 

Current standard treatment modules for advanced melanoma are not associated with great outcomes. Therefore, it seems reasonable for patients with advanced melanoma to consult as many appropriately qualified doctors as possible in order to explore their clinical trial options.  It is also a good idea for the patients in conjunction with doctors to put together a treatment plan. 

An example of a treatment plan is as follows; patient B with stage four melanoma should be eligible to undertake trial X as a front line treatment and then if needed should be eligible (assuming there is no significant change in the patient's condition) to participate in either trial Y or Z as a second line treatment.