melanoma skin cancer _pdf

8/4/2019 Melanoma Skin Cancer _PDF

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MELANOMA SKIN CANCER

2002 American Cancer Society Melanoma Skin Cancer 1/4/02

What Is Cancer?

Cancer develops when cells in a part of the body begin to grow out of control. Althoughthere are many kinds of cancer, they all start because of out-of-control growth ofabnormal cells.

Normal body cells grow, divide, and die in an orderly fashion. During the early years of aperson's life, normal cells divide more rapidly until the person becomes an adult. Afterthat, cells in most parts of the body divide only to replace worn-out or dying cells and torepair injuries.

Because cancer cells continue to grow and divide, they are different from normal cells.Instead of dying, they outlive normal cells and continue to form new abnormal cells.

Cancer cells often travel to other parts of the body where they begin to grow andreplace normal tissue. This process, called metastasis, occurs as the cancer cells getinto the bloodstream or lymph vessels of our body. When cells from a cancer like breastcancer spread to another organ like the liver, the cancer is still called breast cancer, notliver cancer.

Cancer cells develop because of damage to DNA. This substance is in every cell anddirects all its activities. Most of the time when DNA becomes damaged the body is ableto repair it. In cancer cells, the damaged DNA is not repaired. People can inheritdamaged DNA, which accounts for inherited cancers. Many times though, a persons

DNA becomes damaged by exposure to something in the environment, like smoking.

Cancer usually forms as a tumor. Some cancers, like leukemia, do not form tumors.Instead, these cancer cells involve the blood and blood-forming organs and circulatethrough other tissues where they grow.

Remember that not all tumors are cancerous. Benign (noncancerous) tumors do notspread to other parts of the body (metastasize) and, with very rare exceptions, are notlife-threatening.

Different types of cancer can behave very differently. For example, lung cancer and

breast cancer are very different diseases. They grow at different rates and respond todifferent treatments. That is why people with cancer need treatment that is aimed attheir particular kind cancer.

Cancer is the second leading cause of death in the United States. Half of all men andone-third of all women in the U.S. will develop cancer during their lifetimes. Today,millions of people are living with cancer or have had cancer. The risk of developing mosttypes of cancer can be reduced by changes in a person's lifestyle, for example, by


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quitting smoking and eating a better diet. The sooner a cancer is found and treatmentbegins, the better are the chances for living for many years.

What Is Melanoma Skin Cancer?

About Normal Skin

The skin is the largest organ in your body. It covers the internal organs and protectsthem from injury, serves as a barrier between microbes such as bacteria and internalorgans, and prevents the loss of too much water and other fluids. The skin regulatesbody temperature and helps rid your body of excess water and salts. Certain cells inyour skin communicate with your brain and allow you to feel sensations of temperature,touch, and pain.

The skin has 3 layers called the epidermis, dermis, and subcutis. The top layer is the

epidermis. The epidermis is very thin, averaging only 0.2 mm (about 1/100 of an inch). Itprotects the deeper layers of skin and the organs of the body from the environment.

The outermost part of the epidermis is called the stratum corneum, or horny layer. It iscomposed of dead keratinocytes (the main type of cell of the epidermis) that arecontinually shed. Below the stratum corneum are layers of living keratinocytes, alsocalled squamous cells. These cells form an important protein called keratin. Keratincontributes to the skin's ability to protect the rest of the body. The lowest part of theepidermis, the basal layer, is formed by basal cells. These cells continually divide to


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form new keratinocytes, which replace older keratinocytes that wear off the skin'ssurface.

Melanocytes are also present in the epidermis. These skin cells produce the protectivepigment called melanin. Melanin gives a tan or brown color to the skin and helps protect

the deeper layers of the skin from the harmful effects of the sun. The basementmembrane separates the epidermis from the deeper layers of skin.

The middle layer of the skin is called the dermis. The dermis is much thicker than theepidermis. It contains hair follicles, sweat glands, blood vessels, and nerves that areheld in place by a protein called collagen. Collagen, which is made by skin cells calledfibroblasts, gives the skin its resilience and strength.

The deepest layer of the skin is called the subcutis. The subcutis and the lowest part ofthe dermis form a network of collagen and fat cells. The subcutis conserves heat andhas a shock-absorbing effect that helps protect the body's organs from injury.

Skin Tumors

Skin cancers are divided into 2 general types: melanoma and non-melanoma skincancers.

Non-melanoma skin cancers (usually basal cell and squamous cell cancers) are themost common cancers of the skin. They are called non-melanoma because theydevelop from skin cells other than melanocytes. Because they rarely metastasize(spread elsewhere in the body) they are treated differently. Nonmelanoma skin cancersare discussed in another American Cancer Society document.

Melanoma is a cancer that begins in the melanocytes, the cells that produce the skincoloring or pigment known as melanin. Other names for this cancer include malignantmelanoma, melanoma skin cancer, and cutaneous melanoma. Because mostmelanoma cells still produce melanin, melanoma tumors are often brown or black.Melanoma is much less common than basal cell and squamous cell skin cancers, but itis far more serious.

Melanoma most often appears on the trunk of fair-skinned men and on the lower legs offair-skinned women, but people with other skin types and other areas of the skin arecommonly affected. Having darkly pigmented skin lowers your risk but it is not aguarantee that you will not develop melanoma. People with darker skin can deve lop thiscancer on the palms of the hands, soles of the feet, and under the nails. Rarely,melanomas can form in parts of your body not covered by skin such as the eyes, mouth,vagina, large intestine, and other internal organs.

Melanoma, like basal cell and squamous cell cancers, is almost always curable in itsearly stages. However, melanoma is much more likely than basal or squamous cellcancer to metastasize (spread) to other parts of the body.


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Most tumors of the skin are not cancerous and rarely if ever turn into cancers. Moles arebenign skin tumors that develop from melanocytes. See the section "What are the RiskFactors for Melanoma Skin Cancer?" for more information about moles.

Benign tumors that develop from other types of skin cells include seborrheic keratoses(tan, brown, or black raised spots with a "waxy" texture or rough surface), hemangiomas(benign blood vessel growths often called strawberry spots or port wine stains), lipomas(soft growths of benign fat cells), and warts (rough-surfaced growths caused by a virus).

What Are the Key Statistics About Melanoma Skin Cancer?

Cancer of the skin is the most common of all cancers. Melanoma accounts for about 4%of skin cancer cases, but causes about 79% of skin cancer deaths.

The American Cancer Society estimates that about 53,600 new melanomas will bediagnosed in the United States during 2002. The number of new melanomas diagnosedin the United States is increasing. Since 1973, the incidence rate for melanoma (thenumber of new melanomas diagnosed per 100,000 people each year) has more thandoubled from 5.7 to 14.3.

About 7,400 people in the US are expected to die of melanomas during 2002. Since1973, the mortality rate for melanoma (the number deaths from melanoma per 100,000people each year) has increased by about 44%, from 1.6 to 2.3. The good news is thatmelanoma mortality rates have remained stable during the past 10 years.

What Are the Risk Factors for Melanoma Skin Cancer?

A risk factor is anything that increases a person's chance of getting a disease such ascancer. Different cancers have different risk factors. Smoking is a risk factor for cancersof the lung, mouth, larynx, bladder, kidney, and several other organs. But having a riskfactor, or even several, does not mean that a person will get the disease.The main risk factors for developing melanoma are:

Moles

A nevus (the medical name for a mole) is a benign (noncancerous) melanocytic tumor.Moles are not usually present at birth, but begin to appear in children and teenagers.Having certain types of moles makes a person more likely to develop melanoma.

One type of mole that increases the risk of melanoma is the dysplastic nevus oratypical mole. Dysplastic nevi (nevi is the plural of nevus) look a little like normalmoles, but also typically look a little like melanoma. Refer to the section "CanMelanoma Skin Cancer be Found Early?" for descriptions of the appearance of


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moles and melanomas. The moles can appear in areas that are exposed to thesun as well as those areas that are usually covered, such as the buttocks andscalp. They are often larger than other moles. Some people have manydysplastic nevi.

Dysplastic nevi often run in families. If you have family members with dysplasticnevi you have about a 50% chance of developing these nevi. Someone with oneor more dysplastic nevi and with at least 2 close relatives with melanoma has a50% or greater risk of developing melanoma. Lifetime melanoma risk isestimated to be between 6% and 10% for those with dysplastic nevi, dependingon age, family, history, the number of dysplastic nevi, and other factors.

Moles present at birth are called congenital melanocytic nevi. The averagelifetime risk of developing melanoma may be about 6% for people with congenitalmelanocytic nevi. However, this risk is affected by the size of a congenital nevus.People with large congenital nevi have a greater risk, while the risk is smaller for

those with small nevi.

The lifetime melanoma risk for the overall United States population is about 1.4%.Moles that are not dysplastic or congenital are not likely to turn into a melanoma.However, people with lots of moles and those who have some large moles have anincreased risk for melanoma.

Fair Skin, Freckling and Light Hair

The risk of melanoma is about 20 times higher for whites than for African Americans.This is due to the protective effect of skin pigment. Whites with red or blond hair and fair

skin that freckles or burns easily are at especially high risk. Darkly pigmented peoplecan also develop melanoma, particularly on the palms of the hands, on the soles of thefeet, under the nails, inside the mouth, and, rarely, in internal organs.

Family History

Risk of melanoma is greater if one or more of a person's first degree relatives (mother,father, brother, sister, child) have been diagnosed with melanoma. Depending on thenumber of affected relatives, the risk can be up to eight times greater than that ofpersons without a family history of melanoma. Around 10% of all people with melanomahave a family history of melanoma.

Immune Suppression

People who have been treated with medicines that suppress the immune system, suchas organ transplant patients, have an increased risk of developing melanoma.

Excessive Exposure to Ultraviolet (UV) Radiation and Sunburn


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The main source of UV radiation is sunlight. Tanning lamps and booths are anothersource. People with excessive exposure to light from these sources are at greater riskfor skin cancer, including melanoma. The amount of UV exposure depends on theintensity of the light, length of time the skin was exposed, and whether the skin wasprotected with clothing and sunscreen. If you have had severe, blistering sunburns,

particularly in you childhood or teenage years, you also have an increased risk ofdeveloping melanoma. Intermittent, intense exposures are more associated withmelanoma risk than lower level, chronic exposures, even if the total dose of UV is thesame.

Age

About half of all melanomas occur in people over the age of 50. However, young people(ages 20 to 30) can also be diagnosed with melanoma. In fact, melanoma is one of themost common cancers in people less than 30 years of age. Familial melanoma occursat a younger age.

Xeroderma Pigmentosum

Xeroderma pigmentosum ( XP) is a rare, inherited condition resulting from a defect in anenzyme that repairs damage to DNA. People with XP have a high risk for bothmelanoma and nonmelanoma skin cancers. Because people with XP are less able torepair DNA damage caused by sunlight, they can develop many cancers on sun-exposed areas of their skin. These facts help explain the connection between sunlightand skin cancer.

Do We Know What Causes Melanoma Skin Cancer?

DNA is the genetic material in our cells. It passes along genetic information to the nextgeneration, making children resemble their parents, for example. In addition toinformation about hair color, facial features, and other aspects of our outwardappearance, DNA also contains information that tells the cells of our body how to growand how to perform the metabolic activities needed for life.

Ultraviolet (UV) radiation can damage DNA. Most melanomas have abnormalities intheir chromosomes, which is where the DNA is found. This damage makes the DNAless able to control how and when cells grow and divide. In some situations, this results

in the formation of a cancer. Most ultraviolet radiation comes from sunlight, but somemay come from artificial sources, such as tanning booths. Some of this exposure mayhave occurred within the few years before the beginning of the cancer. However, muchof it may be due to exposures that happened many years earlier. Children and youngadults often receive a lot of intense ultraviolet sun exposure that may not result in anactual cancer for many years or even decades.


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Scientists continue to study connections between DNA and melanoma. They havefound the DNA of certain genes is often damaged in melanoma cells. Most of theseDNA changes are not inherited. Instead they may be the result of damage caused bysunlight. In the future, better understanding of the way these DNA changes lead tomelanoma might be used in gene therapy to overcome or repair that damage.

DNA changes found in some melanomas may be inherited. Inheriting certain mutant(abnormal) genes from one parent can increase a person's risk of developingmelanoma. Scientists are working on a blood test for one of these genes. Forinformation about current research, see the section "What's New In Research andTreatment of Melanoma Skin Cancer?"

Although most nevi (moles) never turn into a melanoma, some do. Researchers havefound some changes that occur in benign nevus cells can cause transformation intomelanoma cells. However, we still don't know exactly why some nevi become malignantor why having many moles or atypical moles increases your risk of developing

melanoma.

Can Melanoma Skin Cancer Be Prevented?

The most important ways to lower the risk of melanoma are to avoid being outdoors inintense sunlight too long, and to practice sun safety when you are outdoors. You canmaintain your level of physical activity and practice sun safety at the same time.Practicing sun safety includes:

Seeking shade - The simplest and most effective way to limit exposure to

ultraviolet light is to avoid being outdoors in sunlight too long. This is particularly

important in the middle of the day when ultraviolet light is most intense.

Protecting your skin with clothing -You can protect most of your skin withclothing, including a shirt with long sleeves and a hat with a broad brim. Fabricwith a tight weave generally provides the best sun protection.

Using sunscreen - Sunscreens with a SPF factor of 15 or more should be used

on areas of skin exposed to the sun, particularly when the sunlight is strong.Always follow directions when applying sunscreen. To work best, you shouldapply sunscreen before you go outside, use it thickly on all sun-exposed skin,and reapply it every two hours. A one-ounce application (a palmful of sunscreen)

is recommended. Many sunscreens wear off with sweating and swimming andmust be reapplied for maximum effectiveness. Use sunscreen even on hazy daysor days with light or broken cloud cover because the UV light still comes through.

Sunscreen should not be used to gain extra sun exposure time. Sunscreen willnot prevent melanoma, it just reduces the amount of UV light exposure.Researchers have found that many people will use sunscreens to let them stayout in the sun longer. This results in the same amount of UV light exposure as if


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they hadn't used sunscreen at all and doesn't reduce their risk. All excessive sunexposure is unhealthy. Sunscreen should only be used to protect against normalsun exposure.

Wearing sunglasses - Wrap-around sunglasses with 99%-100% UV absorption

provide the best protection for the eyes and the skin area around the eyes.

Avoiding other sources of UV light - The use of tanning beds and sun lamps ishazardous because the ultraviolet radiation they deliver can damage your skin.Therefore, you shouldnt use them. There is growing evidence that they mayincrease your risk of developing melanoma. This is an area of active research.

Being especially careful about sun protection for children - Children requirespecial attention. Parents should protect them from excess sun exposure byusing the measures described above. Older children need to be cautioned aboutsun exposure as they become more independent. It is important, particularly in

high sun exposure parts of the world, to develop the habit of using sunscreenwhenever you go outdoors and may be exposed to large amounts of sunlight.

Identifying abnormal moles and having them removed - As noted in thesection "What Are The Risk Factors For Melanoma Skin Cancer?" certain typesof moles have an increased risk of developing into a melanoma. Depending onthe appearance of these moles, your doctor may monitor them closely byperiodic examinations or may remove them if they have certain features thatsuggest they may be changing into a melanoma. Routine removal of many molesis not generally recommended as a way to prevent melanoma. If you have manymoles, careful periodic examination by a dermatologist, in combination with

monthly skin self-examination, is recommended. Any changing mole should bechecked by a doctor who is experienced in recognizing skin cancers. See thesection on "Can Melanoma Be Found Early?" for information on how to recognizesuspicious moles and melanoma.

Learning more about skin cancer prevention - Many organizations conduct

skin cancer prevention activities in schools and recreational areas. Othersdistribute informational brochures and public service announcements. For moreinformation, refer to the section "Additional Resources."

Can Melanoma Skin Cancer Be Found Early?

Melanoma can be found early. Everyone can play an important role in finding skincancer early, when it is curable. Part of a routine cancer-related checkup should includea skin examination by a health care professional qualified to diagnose skin cancer.Doctors should be willing to discuss any reservations patients might have about thisexamination. The American Cancer Society recommends a cancer-related checkup,


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including a skin examination, every 3 years for people between 20 and 40 years of age,and every year for anyone age 40 and older.

It's also important to check your own skin, preferably once a month. You should knowthe pattern of moles, blemishes, freckles, and other marks on your skin so that you'll

notice any changes. Self-examination is best done in front of a full -length mirror. Ahand-held mirror can be used for areas that are hard to see.

A spouse or other partner may be able to help you with these examinations, especiallyfor those hard-to-see areas, like the lower back or the back of your thighs. All areasshould be examined, including the palms and soles, the lower back, and the back of thelegs. Be sure to show your doctor any area that concerns you. Friends and familymembers can also help by telling one another about abnormal-appearing areas of skin.Be sure to ask your doctor to look at areas that may be hard for you to see. About 1 ofevery 3 melanomas in men are on the back.

Spots on the skin that are changing in size, shape, or color should be evaluatedpromptly. Any unusual sore, lump, blemish, marking, or change in the way an area ofthe skin looks or feels may be a sign of skin cancer or a warning that it might occur. Theskin might become scaly or crusty or begin oozing or bleeding. It may feel itchy, tender,or painful. Redness and swelling may develop.

Since moles may develop into melanoma or indicate an increased risk for melanoma, itis important to know the difference between melanoma and an ordinary mole.Sometimes this may be difficult to tell -- show your doctor any mole that you are unsureof.

A normal mole is generally an evenly colored brown, tan, or black spot on the skin. Itcan be either flat or raised. It can be round or oval. Moles are generally less than 6millimeters ( inch) in diameter (about the width of a pencil eraser). A mole can bepresent at birth or it can appear during childhood or young adulthood. Several molescan appear at the same time, especially on areas of the skin exposed to the sun.

Once a mole has developed, it will usually stay the same size, shape, and color formany years. Moles may eventually fade away in older people.

Most people have moles, and almost all moles are harmless. But it is important torecognize changes in a mole that can suggest a melanoma may be developing.

Signs and Symptoms of Melanoma

The ABCD rule can help distinguish a normal mole from a melanoma.

Asymmetry: One half of the mole does not match the other half.

Border irregularity: The edges of the mole are ragged or notched.


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Color: The color over the mole is not the same. There may be differing shades of tan,

brown, or black, and sometimes patches of red, blue, or white.

Diameter: The mole is wider than 6 millimeters (about inch) although in recent years

doctors are finding more melanomas between 3 and 6 millimeters.

Other important signs of melanoma include changes in size, shape, or color of a mole.Some melanomas do not fit the ABCD rule described above, so it is particularly

important for you to be aware of changes in skin lesions.

How Is Melanoma Skin Cancer Diagnosed?

If the abnormal appearance of an area of your skin raises the possibility of skin cancer,additional medical examinations and tests will be used to be sure whether this is

melanoma or nonmelanoma skin cancer or some other skin condition.

History and Physical Examination

Usually the first step is for your doctor to take your medical history (questions aboutsymptoms and risk factors). The doctor probably will ask about your age, when the markon the skin first appeared, and whether it has changed in size or appearance. You mayalso be asked about past exposures to known causes of skin cancer, and whetheranyone in your family has had skin cancer.

During the physical examination, your doctor will note the size, shape, color, and texture

of the area in question, and whether there is bleeding or scaling. The rest of your bodywill be checked for spots and moles that may be related to skin cancer. The doctor mayalso examine lymph nodes in the groin, underarm, or neck areas near the abnormalarea of skin. Enlarged lymph nodes might suggest the spread of a melanoma.

Types of Skin Biopsy

If the doctor thinks a melanoma might be present, he or she will take a sample of skinfrom the suspicious area for examination under a microscope. This is called a skinbiopsy. Different methods can be used for a skin biopsy. The choice depends on thesize of the affected area and its location on your body. Any biopsy is likely to leave a

scar. Since different methods produce different types of scars, you should ask thedoctor about biopsies and scarring before the procedure is done.

All skin biopsy samples are examined under a microscope. The skin sample is sent to apathologist, a doctor who has been specially trained in the microscopic examination anddiagnosis of tissue samples. Often, the skin sample is sent to a dermatopathologist, adermatologist or pathologist who has additional training in making diagnoses from skin


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samples and may be more experienced with certain skin cancers than a generalpathologist.

All skin biopsies are performed using a local anesthetic. You will feel a small needlestick and a little burning with some pressure for less than a minute, but no pain.

Shave biopsy: After numbing the area with a local anesthetic, the doctor "shaves" off

the top layers of the skin (the epidermis and the most superficial part of the dermis) witha surgical blade. A shave biopsy is useful in diagnosing many types of skin diseasesand in treating benign moles. But, it is not recommended if a melanoma is suspected,because a shave biopsy sample may not be thick enough for accurate measurement ofthe melanoma depth of invasion.

Punch biopsy: A punch biopsy removes a deeper sample of skin. The doctor uses a

punch biopsy tool that looks like a tiny round cookie cutter. Once the skin is numbedwith a local anesthetic, the doctor rotates the punch biopsy tool on the surface of the

skin until it cuts through all the layers of the skin, including the dermis, epidermis, andthe upper parts of the subcutis. This is usually not recommended for suspectedmelanomas.

Incisional and excisional biopsies: If the doctor has to examine a tumor that hasgrown into the deeper layers of the skin, he or she will perform an incisional orexcisional biopsy. A surgical knife is used to cut through the full thickness of skin. Awedge or ellipse of skin is removed for further examination, and the edges of the woundare sewn together. An incisional biopsy removes only a portion of the tumor. Removal ofthe entire tumor is called an excisional biopsy. Both types of biopsies can be done usinglocal anesthesia. Excisional biopsy is the method usually preferred when melanoma is

suspected.

Diagnosis of Metastatic Melanoma

Although many melanomas are completely cured, some melanomas spread so quicklythat a patient can have large masses of melanoma in the lymph nodes, lungs, brain,gastrointestinal tract, or liver while the original skin melanoma is still small. Melanomathat has spread to other parts of the body may not be detectable until long after theoriginal melanoma was removed from the skin.

When such spread has occurred, the metastatic melanoma in certain organs might beconfused with a cancer starting in that organ. For example, melanoma that has spreadto the lung might be confused with a primary lung cancer (cancer that starts in the lung).There are special tests that can be done on biopsy samples that can tell whether it is amelanoma or some other kind of cancer. This is important because different cancers areoften given different treatments.

How Is Melanoma Skin Cancer Staged?


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Staging is a process of finding out how widespread a cancer is. This includes describingits size as well as if it has spread to any other organs. A staging system is a standardway of summarizing how far a cancer has spread.

The system used most often to stage melanoma is the TNM system. In this system,each cancer is given a T category, an N category, and an M category.

The T category is based on the tumor's thickness and whether it is ulcerated (the

layer of skin covering the melanoma is absent). The N category reflects whether the melanoma has spread to lymph nodes (small

bean-shaped collections of immune system cells that help the body fight infectionsand cancers) near the melanoma. The N category also reflects whether themelanoma cells have begun to spread to lymph nodes and are found in thelymphatic channels connecting to the lymph nodes.

The M category indicates whether there are metastases to distant organs.

In TNM staging, information about the tumor, lymph nodes, and metastasis is combinedaccording to a process called stage grouping to assign a stage. The stage is describedusing 0 and Roman numerals from I to IV.

Several tests and procedures are used to gather information about a melanoma andwhether it has spread to lymph nodes and distant organs. This information is used toassign T, N, and M categories and a grouped stage.

Examination of the Skin Biopsy

It is important to measure the size of a melanoma under a microscope becausemeasuring its thickness is believed to be the best way to determine the patient'sprognosis (the outlook for chances of survival).

The pathologist examining the skin biopsy specimen measures the thickness of themelanoma under the microscope with a device called a micrometer, which is like a smallruler. This technique is called the Breslow measurement. The thinner the melanoma,the better the prognosis. In general, melanomas less than 1 millimeter (mm) in depth(about 1/25 of an inch or the diameter of a period or a comma), have a very smallchance of spreading. As the melanoma becomes thicker, it has a greater chance ofspreading. The thickness of the melanoma also guides the choice of treatment.

Another system describes the thickness of a melanoma in relation to its penetration intothe skin instead of actually measuring it. The Clark level of a melanoma uses a scale ofI to V (with higher numbers indicating a deeper melanoma) to describe:

If the cancer stays in the epidermis (Clark level I)

If the cancer has begun to penetrate to the upper dermis (Clark level II) If the cancer involves most of the upper dermis (Clark level III)

If the cancer has penetrated to the lower dermis (Clark level IV)


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If the cancer has penetrated very deeply, to the subcutis (Clark level V).

In the newest classification, the Breslow measurement of thickness has displaced theClark level of penetration as the first prognostic factor. This is because the thicknessmeasurement is easier and depends less on the pathologist's judgment. Sometimes,

however, the Clark level tells us a melanoma is more advanced than we may think it isfrom the Breslow measurement. Because of this, both systems may be used to describea melanoma.

In either system, the melanoma is said to have a worse prognosis if the pathologist saysit is ulcerated (covering layer of skin is absent).

Procedures and Tests to Detect Metastases

Fine needle aspiration biopsy: A fine needle aspiration (FNA) biopsy uses a syringewith a thin needle to remove very small tissue fragments from a tumor. The needle is

smaller than the needle used for a blood test. A local anesthetic is sometimes used tonumb the area. This test rarely causes much discomfort and does not leave a scar. It isnot used for diagnosis of a suspicious mole, but may be used to biopsy large lymphnodes near a melanoma to find out if the melanoma has metastasized (spread).Sometimes a computed tomography (CT) scan (a special type of x-ray) is used to guidea needle into a tumor in an internal organ, such as the lung or liver. This test can beused if the doctor suspects the melanoma has spread to these organs.

Surgical (excisional) lymph node biopsy: This procedure involves removing anabnormally large lymph node surgically, through a small skin incision. Local anestheticis generally used. This is often done if a lymph node's size suggests spread of

melanoma, but the FNA did not find any melanoma cells.

Sentinel lymph node biopsy: This is a new and very promising procedure. It is not yetstandardized, so different doctors may disagree about when to use the sentinel nodebiopsy. This procedure can find the lymph nodes that drain lymph fluid from the area ofthe skin where the melanoma developed. These lymph nodes will then be checked forany spread of melanoma, because if the melanoma does spread, these lymph nodeswill be the first place it will go.

A surgeon injects a small amount of either a harmless blue dye or radioactive chemicalinto the site of the melanoma. After about an hour, the lymph nodes are checked to find

which one is draining lymph fluid from the skin near the melanoma. If blue dye has beenused, it will be visible. A small Geiger counter will be used if radioactive tracer chemicalhas been injected. When the appropriate lymph node (it will be blue or radioactive),called the sentinel node, has been found, it will be removed for microscopicexamination. If melanoma cells are found in this lymph node, the remaining lymphnodes in this area are surgically removed. If the sentinel node does not containmelanoma cells, further lymph node surgery can be avoided.


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If a lymph node near a melanoma is abnormally large, a sentinel lymph node biopsy isusually not done. Instead, a FNA or surgical biopsy of that lymph node is done.

Imaging Tests

X-rays: Sometimes the doctor will order x-rays of the chest to look for any spread of themelanoma.

Computed tomography (CT): If your doctor suspects there is metastatic melanoma

elsewhere, he or she may order CT scans of the brain or other parts of the body. CTuses multiple x-rays images from various angles, which are combined by a computer toproduce a detailed cross-sectional view of the body.

Magnetic resonance imaging (MRI): MRI is like a CT scan in that it produces cross

sectional images of the body. Unlike CT, MRI also produces longitudinal sections of thebody, and does not use x-rays. Instead, a large magnetic coil is used that energizes

molecules to produce an image.

Nuclear scans: In this procedure a radioactive chemical (in very low doses) is injected

into a vein. The radioactivity over the body or part of the body is detected with a specialtype of camera. If the melanoma has spread to bones or liver, the scan will often detectthis spread.

Descriptions of Grouped Stages

These descriptions are based on current TNM staging definitions. A new staging systemwas proposed for the year 2000 but not yet officially adopted, and is described in

parentheses and Italics.

Stage 0: The melanoma is in situ, meaning that it involves the epidermis but has notspread to the dermis. This is also called Clark level I. (New system -- unchanged.)

Stage I: Based on the Breslow measurement, the melanoma is a low-risk tumor (lessthan 1 mm or about 1/16 inch in thickness). Using the Clark system, this can be levelII or III. It appears to be localized in the skin, and has not been found in lymph nodes ordistant organs.

(New system --Breslow thickness is less than 2 mm without ulceration and less than 1mm with ulceration. The melanoma doesn't involve lymph nodes or distant organs.)

Stage II: The melanoma has a Breslow thickness of greater than 1 mm (about 1/16inch), or it can have a Clark level of IV or V. It still appears to be localized to the skinand has not been found in lymph nodes or distant organs.


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(New system -- Breslow thickness can be any thickness greater than 1 mm withulceration or any thickness greater than 2 mm without ulceration and the melanomadoesn't involve lymph nodes or distant organs.)

Stage III: The melanoma has spread to lymph nodes near the affected skin area. There

is no distant spread. The thickness of the melanoma is not considered, although it isusually thick in people with stage III melanoma.

Stage IV: The melanoma has spread beyond the original area of skin and the nearby

lymph nodes to other organs, such as the lung, liver, or brain, or to distant areas of theskin or lymph nodes. Neither the lymph node status nor thickness is considered, but ingeneral, the melanoma will be thick and will have spread to lymph nodes.

Survival Rates by Stage

The 5-year survival rate refers to the percent of patients who live at least 5 years after

their cancer is diagnosed. Many of these patients live much longer than 5 years afterdiagnosis, and 5-year rates are used to produce a standard way of discussingprognosis. Five-year relativesurvival rates for melanoma indicate that the patient diedof the melanoma and not some other disease. This is considered to be a more accurateway to describe the prognosis for people with a particular type and stage of cancer. Ofcourse, 5-year survival rates are based on patients diagnosed and initially treated morethan 5 years ago. Improvements in treatment often result in a more favorable outlook forrecently diagnosed patients.

The 5-year relative survival rate for stage 0 melanoma is 97%. The 5-year survival rate for stage I melanoma is more than 90%.

The 5-year relative survival rates of stages II and III are about 80% and 50%,respectively.

The 5-year survival rate for stage IV melanoma is about 20%.

How Is Melanoma Skin Cancer Treated?

Types of Surgery for Melanoma Skin Cancer

Simple excision: Thin melanomas can be completely cured by a relatively minorsurgery called simple excision. The tumor is cut out, along with a small amount of

normal, noncancerous skin at the edges. This differs from an excisional biopsy in whichthe margins are wider because the diagnosis is already known. The normal, healthyskin around the edges of the cancer is referred to as the margin. The wound is carefullystitched back together. This will leave a scar.

Re-excision (wide excision): When the diagnosis of melanoma is established bybiopsy, the site will need to be excised again. More skin will be cut away from the


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melanoma site and the tissue from the final excision will be examined to make sure thatno cancer cells remain in the skin.

Amputation: If the melanoma is on a finger or toe, the treatment is to amputate as

much of that digit as is necessary. At one time, some melanomas of the arms a nd legs

were also treated by amputation, but this is no longer done. Studies have demonstratedthat wide excision of arm and leg melanomas is as effective as amputation.

Therapeutic lymph node dissection: After the diagnosis of melanoma is made, the

physician will examine the lymph nodes nearest the melanoma. If these lymph nodesfeel abnormally hard or large, a therapeutic lymph node dissection may be performed.This procedure removes most of the lymph nodes in the area of the melanoma, andthey will be examined microscopically to see whether melanoma cells have spreadthere. A fine needle aspiration biopsy (FNA) or excisional lymph node biopsy is oftendone first, and if it shows evidence of melanoma, then a therapeutic lymph nodedissection is performed.

Some doctors recommend a lymph node dissection for all patients who might havemelanoma in their lymph nodes. If the lymph nodes are not enlarged, then a sentinelnode biopsy procedure may be done. If the sentinel lymph node does not show cancer,then it is unlikely the melanoma has spread to the lymph nodes; there is no need for alymph node dissection.

Therapeutic lymph node dissection can cause some important side effects that may bepermanent. The most troublesome is called lymphedema. Lymph nodes in the groin orunder the arm help drain fluid from the limbs. Without them fluid may accumulate.Elastic stockings or sleeves can help some people with this condition. Sometimes

special devices that squeeze the limbs are used and may be helpful. These side effects,along with the discomfort from the procedure itself, are why this procedure is not doneunless the doctor thinks it is absolutely necessary.

Surgery for Metastatic Melanoma

Once there is evidence that melanoma has spread from the skin to distant organs (suchas the lungs or brain), doctors generally assume that the cancer is no longer curable bysurgery. Even when only 1 or 2 metastases are found by imaging studies, such as CTor MRI scans, many other areas of metastasis are likely to be present that are too smallto be found by these scans. Nevertheless, surgery is sometimes performed in thesecircumstances. If one or even a few metastases are present that can be completelyremoved, this surgery may help some patients to live longer. Also, removing metastasesin the brain that might eventually cause symptoms can help improve the patient's qualityof life.

Chemotherapy for Melanoma Skin Cancer


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Systemic chemotherapy uses anticancer drugs that are usually injected into a vein orgiven by mouth. These medications travel through the bloodstream to all parts of thebody and attack cancer cells that have already spread beyond the skin to involve lymphnodes and other organs.

Chemotherapy drugs kill cancer cells but also kill some normal cells. Therefore, yourdoctor will pay careful attention to avoiding or minimizing side effects, which depend onthe type of drugs, the amount taken, and the length of treatment. Temporary side effectsof systemic chemotherapy might include nausea and vomiting, loss of appetite, loss ofhair, and mouth sores.

Because chemotherapy can kill normal blood cells (like the blood-producing cells of thebone marrow, the cells lining the gastrointestinal tract, and hair), patients may have lowblood cell counts, nausea, vomiting, mouth sores, or hair loss.Low blood cell counts result in:

An increased chance of infection (due to a shortage of white blood cells),

Bleeding or bruising after minor cuts or injuries (due to a shortage of bloodplatelets) Fatigue (due to low red blood cell counts).

Most side effects disappear once treatment is stopped. There are remedies for many ofthe temporary side effects of chemotherapy, so be sure to discuss side effects with yourcancer care team. For example, antiemetic drugs to prevent or reduce nausea andvomiting can be given to relieve and sometimes prevent these side effects.

Several types of systemic chemotherapy can be used for stage IV melanoma. Althoughchemotherapy is usually not as effective in melanoma as in some other types of cancer,

it may relieve symptoms or extend survival of some patients with stage IV melanoma.Recent studies have found that combining several chemotherapy drugs with one ormore immunotherapy drugs is much more effective than a single chemotherapy drugalone.

Chemotherapy drugs often used to treat melanoma include: dacarbazine (also called DTIC), carmustine (also known as BCNU), and cisplatin.

The combination of these three chemotherapy drugs, together with tamoxifen (ahormonal therapy drug most often used to treat breast cancer) is called the"Dartmouth regimen."

Cisplatin, vinblastine, and DTIC is another chemotherapy combination for treating

melanoma.

Both of these chemotherapy combinations may also be combined with immunotherapydrugs such as interferon-alpha and/or interleukin-2 (see the section on immunotherapy).

Isolated limb perfusion is an experimental type of chemotherapy sometimes used fortreating melanomas on arms or legs. This method temporarily separates the circulationof the involved limb from the rest of the body and injects high doses of chemotherapy


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into the artery feeding the limb. This allows high doses to be given to the area of thetumor without exposing internal organs to these doses that would otherwise causesevere side effects. So far, this treatment has not helped people with melanoma to livelonger and is not recommended outside of a clinical trial (see section on "ClinicalTrials").

Radiation Therapy

Radiation therapy uses high-energy rays or particles to kill cancer cells. External beamradiation therapy focuses radiation from outside the body on the skin tumor. This type ofradiation therapy is used for treating some patients with melanoma.

Radiation therapy is not commonly used to treat the primary tumors of melanoma (theoriginal melanoma that developed on the skin). The main role of radiation therapy formelanoma is palliation (to relieve symptoms) of metastases to the brain or perhapsbone. Palliative radiation therapy is not expected to cure the cancer. For example, a

brain metastasis from melanoma might cause partial paralysis, severe dizziness, orother symptoms that can be temporarily relieved by radiation therapy.

Immunotherapy

Immunotherapy enhances and encourages a patient's immune system to recognize anddestroy cancer cells more effectively. There are several types of immunotherapy used intreating patients with advanced melanoma.

Cytokine therapy: Cytokines are proteins that activate the immune system in a generalway. Two cytokines, interferon-alpha and interleukin-2, can help boost immunity in

patients with melanoma. Both drugs can help shrink metastatic (stage III and IV)melanomas in about 10% to 20% of patients.

Patients with deeply invasive stage II melanomas often have cancer cells that breakaway from their primary melanoma and travel to other parts of the body. But these cellshave not yet grown into metastatic tumors that are large enough to be detected byroutine tests. Some researchers feel that giving cytokines to these patients will helpprevent growth of melanoma cells in other organs. This is called adjuvantimmunotherapy.

Side effects of cytokine therapy may include fever, chills, aches, and severe tiredness.Interleukin-2, particularly in high doses, can cause fluid to accumulate in the body sothat the person swells up and can feel quite sick. Some patients may need to behospitalized because of this problem.

Vaccine therapy: Antimelanoma vaccines are, in some ways, similar to the vaccinesused to prevent diseases caused by viruses such as polio, measles, and mumps.Antivirus vaccines usually contain weakened viruses or parts of a virus that cannot


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cause the disease. The vaccine stimulates the body's immune system to destroy themore harmful type of virus.

In the same way, weakened melanoma cells or certain chemical substances found inmelanoma cells can be injected into a patient in an attempt to stimulate the body's

immune system to selectively destroy melanoma cells. Usually, the melanoma cells aremixed with substances that help stimulate the body's immune system. However,developing a vaccine against a tumor like melanoma is more difficult than developing avaccine to fight a virus. Clinical trials are in progress to test the value of treating stage IIIor stage IV melanoma patients with vaccines, sometimes combined with cytokinetherapy as well.

Clinical Trials

The purpose of clinical trials: Studies of promising new or experimental treatments inpatients are known as clinical trials. A clinical trial is only done when there is some

reason to believe that the treatment being studied may be valuable to the patient.Treatments used in clinical trials are often found to have real benefits. Researchersconduct studies of new treatments to answer the following questions:

Is the treatment helpful? How does this new type of treatment work?

Does it work better than other treatments already available? What side effects does the treatment cause?

Are the side effects greater or less than the standard treatment? Do the benefits outweigh the side effects? In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are three phases of clinical trials in which a treatment isstudied before it is eligible for approval by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a Phase I study is to find the best way to give anew treatment and how much of it can be given safely. Physicians watch patientscarefully for any harmful side effects. The treatment has been well tested in laboratoryand animal studies, but the side effects in patients are not completely known. Doctorsconducting the clinical trial will start by giving very low doses of the drug to the firstpatients and increasing the dose for later groups of patients until side effects appear.Although doctors are hoping to help patients, the main purpose of a phase I study is totest the safety of the drug.

Phase II clinical trials: These are designed to see if the drug works. Patients are given

the highest dose that doesnt cause severe side effects (determined from the phase Istudy) and closely observed for an effect on the cancer. The doctors will also look forside effects.

Phase III clinical trials: These Phase III studies involve large numbers of patients.

Some clinical trials may enroll thousands of patients. One group (the control group) will


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receive the standard (most accepted) treatment. The other groups will receive the newtreatment. Usually doctors study only 1 new treatment to see if it works better than thestandard treatment, but sometimes they will test 2 or 3. All patients in Phase III studiesare closely watched. The study will be stopped if the side effects of the new treatmentare too severe or if one group has had much better result than the others.

If you are in a clinical trial, you will receive excellent care. You will have a team ofexperts looking at you and monitoring your progress very carefully. The study isespecially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whetherthe treatment will work or exactly what side effects will occur. That is what the study isdesigned to discover. While most side effects will disappear in time, some can bepermanent or even life threatening. Keep in mind, though, that even standardtreatments have side effects. Depending on many factors, you may decide to enroll in aclinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up toyou. Your doctors and nurses will explain the study to you in detail and will give you aform to read and sign indicating your desire to take part. This process is known asgiving your informed consent. Even after signing the form and after the clinical trialbegins, you are free to leave the study at any time, for any reason. Taking part in thestudy will not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questionsyou should ask are:

What is the purpose of the study?

What kinds of tests and treatments does the study involve?

What does this treatment do?

What is likely to happen in my case with, or without, this new researchtreatment?

What are my other choices and their advantages and disadvantages? How could the study affect my daily life?

What side effects can I expect from the study? Can the side effects becontrolled?

Will I have to be hospitalized? If so, how often and for how long? Will the study cost me anything? Will any of the treatment be free?

If I am harmed as a result of the research, what treatment would I be entitled to?

What type of long-term follow-up care is part of the study? Has the treatment been used to treat other types of cancers?

You can get a list of current clinical trials by calling the National Cancer Institute'sCancer Information Service toll free at 1-800-4-CANCER or visiting the NCI clinical trialsWeb sites for patients (cancertrials.nci.nih.gov) or health care professionals(cancernet.nci.nih.gov/prot/protsrch.shtml).


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Treatment of Melanoma Skin Cancer by Stage

Stage I: Treatment of stage I melanoma consists of surgical removal of the melanomaand removal of a margin of normal skin. The amount of normal skin removed dependson the thickness of the melanoma. When the thickness is less than 1 mm, wide excision

with 1 cm margins is recommended. For stage I melanomas between 1 mm and 1.5 mmthick, the tumor and 1 cm to 2 cm of surrounding normal-appearing tissue are removed.One cm and 2 cm are about 3/8 inch and 3/4 inch, respectively. No more than 2 cm ofnormal skin needs to be removed from all sides of the melanoma in stage 1. In the past,wider margins were used but healing was more difficult and the wider margins did nothelp people live longer. Removal of lymph nodes near the cancer does not improvesurvival of patients with stage I melanoma.

Stage II: Treatment of stage II melanoma also depends on the thickness of the

melanoma. When the thickness is greater than 1.5 mm but less than 4 mm, excisionwith 2 cm margins is recommended. When thickness is equal to or greater than 4 mm,

wide excision with margins of at least 2 cm is recommended. Doctors will oftenrecommend adjuvant therapy (additional medical treatment after surgery) withinterferon-alpha. Other drugs, in addition, may also be recommended as part of aclinical trial to try to reduce the chance the melanoma will come back.

Some doctors recommend removing lymph nodes near stage II melanomas. Thesedoctors feel this will reduce the chance the melanoma will come back. Other doctorsfeel the value of this surgery has not been proven. A second opinion may be useful. Insome patients, a sentinel lymph node biopsy may be helpful in deciding whether lymphnodes should be removed. This procedure is explained earlier in this section under"Types of surgery for melanoma skin cancer."

Stage III: In addition to excision of the primary tumor as in stage II, surgical treatment

for stage III melanoma requires therapeutic lymph node dissection. Immunotherapy withinterferon may help some patients with stage III melanomas to live longer. However, thistreatment may cause severe side effects. Newer treatments being evaluated in clinicaltrials may benefit some patients. Because current treatments do not cure most patientswith stage III melanoma, participation in clinical trials should be considered.

Stage IV: No current treatment is able to cure stage IV melanoma. Skin tumors orlymph node metastases causing symptoms can be removed by surgery. Metastases tointernal organs are sometimes removed, depending on how many are present, theirlocation and likelihood of causing symptoms. Metastases that cause symptoms butcannot be removed surgically may be treated with radiation or chemotherapy.

Chemotherapy drugs available at this time are of limited value in most people with stageIV melanoma. Even when chemotherapy can shrink these cancers, the effect is onlytemporary, usually 3 to 6 months.


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Immunotherapy using interferon or interleukin-2 can help some patients with stage IVmelanoma to live longer. No particular program has been very successful. Each seemsto benefit some patients. The patient should carefully evaluate the benefits and sideeffects of any program that is recommended.

Because of the poor prognosis of stage IV melanoma, patients should considerparticipation in a clinical trial. Clinical trials of new chemotherapy drugs, new methods ofimmunotherapy or vaccine therapy, and combinations of different types of treatmentsmay benefit some of these patients.

Recurrent melanoma: Treatment of recurrent melanoma depends on the stage of theoriginal melanoma, the initial treatment, and the type of recurrence. In general, local(skin) recurrence is treated by surgery similar to that recommended for a primarymelanoma. Lymph node recurrence is treated by therapeutic lymph node dissection.Patients with distant recurrences have the same treatment options as those with stageIV melanoma.

What Should You Ask Your Doctor About Melanoma Skin Cancer?

It is important for you to have honest, open discussions with your cancer care team.They want to answer all of your questions, no matter how trivial you might think theyare. Some questions to consider:

What type of skin cancer do I have?

How far has my melanoma spread within or beneath the skin? How thick is mymelanoma?

What are my treatment options? What do you recommend? Why?

What are the risks or side effects that I should expect? What is my expected prognosis, based on my cancer as you view it? Will a scar remain after treatment?

What should I do to be ready for treatment? What are the chances of my cancer recurring (coming back) with the treatment

programs we have discussed? Should I take special precautions to avoid sun exposure? Do I need follow-up appointments to check for recurrence or formation of a new

cancer? How can I arrange to have my family members screened?

In addition to these sample questions, be sure to write down your own questions. Forinstance, you might want more information about recovery times so you can plan yourwork schedule. Or, you may want to ask about second opinions or about clinical trialsfor which you may qualify.


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What Will Happen After Treatment For Melanoma Skin Cancer?

Even when a melanoma skin cancer has been completely removed and is consideredcured, follow-up examinations are needed to see if the cancer recurs (comes back).This includes examination of skin by the patient and by the cancer care team. Your

doctor will also check for lymph node swelling and do a general physical examination.How often a patient needs follow-up visits depends on the stage of the patient'smelanoma when they were diagnosed. In addition to the examinations, blood andimaging tests are recommended for some patients.

For example, a typical follow-up schedule for melanomas thinner than 1 mm generallycalls for physical exams every 6 months for 2 years. If these exams are normal, thepatient then returns for a checkup once a year. Your doctor may recommend morefrequent exams if you have many moles or a few atypical moles.

For thicker melanomas that have not spread to lymph nodes, physical exams are done

every 3 to 6 months for 3 years, then every 6 to 12 months for the next 2 years. Afterthat, exams are done once a year. Some doctors also recommend chest x-rays (todetect lung metastases) and certain blood tests (to detect liver or bone metastases)every 6 to 12 months.

If the melanoma has spread to regional lymph nodes (stage III), the usual examschedule is every 3 to 6 months for 3 years, every 4 to 12 months for the following 2years, and once a year thereafter. Chest x-rays and blood tests may be done every 3 to12 months for some patients in this group.

It is also important for a melanoma skin cancer survivor to regularly examine him or

herself. You should see your doctor if you find any new lump or change in your skin.You should also report any new symptoms (for example, pain, cough, fatigue, loss ofappetite) that persist to your doctor.

Patients with stage IV melanoma whose cancer has been completely removed ordisappeared after treatment usually have the same follow-up schedule as for stage III.Patients with persistent stage IV melanoma have a follow-up schedule that isindividualized based on their specific medical situation.

In addition, someone who has had one melanoma may still be at risk for developinganother melanoma or a non-melanoma type of skin cancer. People cured of one

melanoma should continue to examine their skin every month for new skin cancers andshould avoid overexposure to the sun, and use protection when in the sun.


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Whats New in Research and Treatment of Melanoma Skin Cancer?

Gene Therapy

One of the most promising new approaches to treating melanoma adds certain genes to

the cancer cells. Gene therapy can be used in 3 general ways. In the first way,scientists attempt to replace some of the damaged genes in the melanoma cells thatscientists believe are causing the cells to grow and spread abnormally. This approachhas had limited success, perhaps because most melanoma cells have several abnormalgenes that all contribute together to their malignant behavior.

Another approach is to add a specific gene to melanoma cells. This gene can make themelanoma sensitive to a drug that would otherwise not affect the cancer. Augmerosenis an example of a drug that uses this approach. It is an antisense drug, made up ofshort strands of DNA that can neutralize the melanoma cells ability to make certainproteins. This particular drug prevents the cells from producing the BCL2 protein, which

is found at high levels in most melanoma cells, and preventing the cancer cells fromdying. In preliminary studies, the combination of this drug plus chemotherapy withdacarbazine caused some metastatic melanoma tumors to shrink, even in patientswhose cancers had not responded to chemotherapy alone.

The third strategy adds certain genes to melanoma cells, which are then used forvaccine therapy. Addition of these genes to melanoma cells can help the immunesystem start to attack the altered cells as well as the unaltered cells remaining in thepatient. Many researchers feel that progress in the third strategy is the farthest along.Several clinical trials testing these gene therapy approaches are currently in progress.

Melanoma DNA Research

Scientists have made considerable progress during the past few years in understandinghow ultraviolet light damages DNA, and how changes in DNA cause normal skin cells tobecome cancerous.

They have also found that DNA damage affecting certain genes is important in causingmelanocytes to change into a melanoma. Often, this damage is due to sun exposure.On the other hand, some people may inherit mutated (damaged) genes from theirparents. Inherited genes not only cause us to look like our parents, they can make uslikely to get the same diseases as our parents. Scientists recently discovered a gene

that causes some melanomas that run in certain families. This is called the p16 gene.

People who have a strong family history of melanoma should speak with a cancergenetic counselor or a physician with experience in cancer genetics to discuss thebenefits, limitations, and potential disadvantages of this test.

Molecular Staging


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Advances in melanoma DNA research are also being applied to molecular staging. Inordinary staging, a lymph node removed from a patient is examined under a microscopeto see if melanoma cells have spread to the lymph node.

In molecular staging, RNA (a chemical related to DNA) is extracted from the lymph

node. Certain types of RNA are made by melanoma cells but not by normal lymph nodecells. A very sensitive and sophisticated test called a reverse transcription polymerasechain reaction (RTPCR) is used to detect these types of RNA.

Preliminary studies have found that RTPCR is more sensitive than routine microscopictesting in detecting the spread of melanoma to lymph nodes. In fact, RTPCR can detect1 melanoma cell among a million normal cells. This test may help identify some patientswho might benefit from additional treatment (such as immunotherapy) after surgery.

Immune Therapy

New ways of manipulating the immune system are being developed. This may be themost promising area of melanoma therapy research. As we learn more about how theimmune system works, immune treatments will become more effective.

Public Education

Most skin cancer is preventable. The greatest reduction in the number of skin cancercases and a reduction in the pain and loss of life from this disease will come frompreventive strategies. This involves educating the public, especially parents, about skincancer risk factors. It is important for health care professionals and skin cancersurvivors to remind everyone else about the dangers of excessive sun exposure and

about how easy it can be to protect your skin against ultraviolet radiation.

Melanoma should be detected early, when it is most likely to be completely cured.Monthly skin self-examination and awareness of the warning signs of melanomas maybe helpful in detecting melanoma at an early, curable stage.

The American Academy of Dermatology (AAD) sponsors annual free skin cancerscreenings throughout the country. The American Cancer Society works closely withAAD to provide volunteers for registration, coordination, and education efforts related tothese free screenings. Look for information locally about these screenings or call theAmerican Academy of Dermatology for more information. Their telephone number andinternet address are listed in the section "Additional Resources."

A slogan popularized in Australia, and now used in the United States, focuses thepublic's attention on skin cancer prevention. The American Cancer Society's skin cancer

prevention message is "Slip Slop Slap! Wrap!TM Slip on a Shirt! Slop on Sunscreen!Slap on a hat! Look for shade in the middle of the day and Wrap around sunglasseswhen outdoors to protect eyes and sensitive skin around them.


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It is important to remember that sunscreen is used to protect from the sun's rays duringnormal activity. It should not be used to spend more time exposed to the sun thannecessary.

Additional Resources

National Organizations and Web Sites*

American Academy of DermatologyTelephone: 1-847-330-0230; Automated Information Center 888-462-DERM (3376)Internet Address: www.aad.org

Environmental Protection AgencyTelephone: 1-800-296-1996Internet Address: www.epa.gov/sunwise

National Cancer InstituteTelephone: 1-800-4-CANCERInternet Addresses: www.nci.nih.gov and cancernet.nci.nih.gov

Skin Cancer FoundationTelephone: 1-800-754-6490Internet Address: www.skincancer.org

*Inclusion on this list does not imply endorsement by the American Cancer Society

Additional American Cancer Society Information

Books

American Cancer Societys Guide to Pain Control(Book; Code #9438)

Cancer in the Family: Helping Children Cope with a Parents Illness(Book; Code #9435)

Caregiving: A Step-By-Step Resource for Caring for the Person with Cancer at Home(Book; Code #9422)

Coming to Terms with Cancer: A Glossary of Cancer-RelatedTerms (Book: Code#9505)

Consumers Guide to Cancer Drugs(Book; Code #9436)

Informed Decisions, Second Edition: The Complete Book of Cancer Diagnosis,Treatment, and Recovery(Book; Code #9449.02)


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Brochures

After Diagnosis: A Guide for Patients and Families (Booklet; Code #9440)

Caring for the Patient with Cancer at Home (Booklet; Code #4656)

It's Your Skin. Wear It Well! (Information Card; Code# 2085.01)

It's Your Skin. Wear It Well! (Spanish version; Code# 2087)

Questions and Answers About Pain Control (Booklet; Code #4518)

Why You Should Know About Melanoma (Booklet; Code# 2619)

Other Publications*

*Inclusion on this list does not imply endorsement by the American Cancer Society

Capossela, Cappy, Warnock, Sheila. Share the Care: How to Organize a Group forSomeone Who Is Seriously Ill. New York, Ny: Simon and Schuster; 1995.

Dollinger, Malin, Ernest H. Rosenbaum, and Greg Cable. Everyone's Guide to CancerTherapy. Kansas City, Mo: Somerville House Books; 1994.

Holland Jimmie C, and Sheldon Lewis. The Human Side of Cancer. New York,HarperCollins Publishers. 2000.

Morra, Marion and Eve Potts. Choices. New York, Ny: Avon Books; 1994.

References

American Cancer Society. Cancer Facts and Figures 2002. Atlanta, GA: AmericanCancer Society; 2002.

American Joint Committee on Cancer.AJCC Cancer Staging Manual. 5th ed.Philadelphia, PA: Lippincott-Raven; 1997: 157-160.

Brash DE, Safai B. Cancer of the skin. In: DeVita VT, Hellman S, Rosenberg SA, eds.Cancer: Principles and Practice of Oncology. Philadelphia, PA: Lippincott-Raven; 1997:1879-1933.

Gilchrest BA, Eller MS, Geller AC, Yaar M. Mechanisms of disease: The pathogenesisof melanoma induced by ultraviolet radiation. New Engl J Med. 1999; 340:1341-1348.


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Houghton A, et al. NCCN melanoma practice guidelines. National ComprehensiveCancer Network. Oncology. 1998; 12(7A): 153-177.

Morton DL, Essner R, Kirkwood JM, Selch MT. Malignant melanoma. In: Bast RC, KufeDW, Pollock RE, Weischselbaum RR, Holland JF, Frei E, eds. Cancer Medicine.

Hamilton, Ontario:.BC Decker Inc.: 2000: 1849-1869.

National Cancer Data Base. Cancer Statistics by Disease Site: Relative Survival ofPatients Diagnosed with Malignant Melanoma of the Skin by AJCC Stage of Disease atDiagnosis, 1985-1989 Cases. American Cancer Society & American College ofSurgeons; 1999. Available at www.facs.org/dept/cancer/ncdb/melano4.html.

PDQ database. Skin cancer, melanoma. Bethesda, Md: National Cancer Institute; 2001.Available at cancernet.nci.nih.gov/Cancer_Types/Melanoma.shtml.

Rigel DS, Carucci JA. Malignant melanoma: Prevention, early detection, and treatment

in the 21st century. CA Cancer J Clin2000; 50: 215-236.

Urist MM, Heslin MJ, Miller DM. Malignant melanoma. In: Clinical Oncology. LenhardRE Jr, Osteen RT, Gansler T eds. Atlanta, GA: The American Cancer Society; 2001:553-561.

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