Melanoma (Skin Cancer)

Introduction

Melanoma is a rare and serious type of cancer that begins in the skin and can spread to other organs in the body.

The most common sign of melanoma is the appearance of a new mole or a change in an existing mole. This can happen anywhere on the body, but most often on the back, legs, arms and face.

In most cases, melanomas have an irregular shape and more than one colour. They may also be larger than normal moles and can sometimes be itchy or bleed.

Why does melanoma happen?

Melanoma happens when some cells in the skin begin to develop abnormally. It is not known exactly why this happens, although it is thought that exposure to ultraviolet (UV) light from natural or artificial sources may be partly responsible.

Aa number of factors can increase your chances of developing melanoma, such as having:

Pale skin that burns easily
Red or blonde hair
Lots of moles or freckles
A family member who has had melanoma

Diagnosis

Dr. B C Shah if you notice any change to your moles. Dr. B C Shah can often diagnose melanoma after an examination.

In most cases, a suspicious mole will be surgically removed and studied to see if it is cancerous. This is known as a biopsy.

You may also have what’s known as a sentinel node biopsy to check if melanoma has spread elsewhere in your body.

How is melanoma treated?

The main treatment for melanoma is surgery, although your treatment will depend on your circumstances.

If melanoma is diagnosed and treated at an early stage surgery is usually successful, although you may need follow-up care to prevent melanoma recurring.

If melanoma isn’t diagnosed until an advanced stage, treatment is mainly used to slow the spread of the cancer and reduce symptoms. This usually involves medicines, such as chemotherapy.

Who is affected

Melanoma is relatively rare, but it is becoming more common.

Melanoma is one of the most common cancers in people aged 15-34 and is also responsible for most skin cancer deaths.

Recurrent melanoma

If you have had melanoma in the past, there is a chance it may return. This risk is increased if your previous cancer was widespread and severe.

If your cancer team feels there is a significant risk of your melanoma returning, you will probably need regular check-ups to monitor your health. You will also be taught how to examine yourself for any tumours on your skin.

Can melanoma be prevented?

Melanoma is not always preventable, but you can reduce your chances of developing the condition by avoiding overexposure to UV light.

You can help protect yourself from sun damage by using sunscreen and dressing sensibly in the sun.

Sunbeds and sunlamps should also be avoided.

Regularly checking your moles and freckles can help lead to an early diagnosis and increase your chances of successful treatment.

Symptoms of melanoma

The first sign of a melanoma is often the appearance of a new mole or a change in appearance of an existing mole.

Normal moles are usually a single colour, round or oval in shape and not larger than 6mm (1/4 inch) in diameter. Melanomas are more likely to have an irregular shape, be more than one colour, and often larger than 6mm (1/4 inch) in diameter. A melanoma may also be itchy and may bleed.

A good way to tell the difference between a normal mole and a melanoma is to use the ABCDE checklist:

A stands for asymmetrical – melanomas have two very different halves and are an irregular shape.
B stands for (irregular) border – unlike a normal mole, melanomas have a notched or ragged border.
C stands for (two or more) colours – melanomas will be a mix of two or more colours.
D stands for (large) diameter – unlike most moles, melanomas are larger than 6mm (1/4 inch) in diameter.
E stands for enlargement or evolution – a mole that changes characteristics and size over time is more likely to be a melanoma.

Melanomas can appear anywhere on your body, but the back, legs, arms and face are the most common locations. Sometimes, they may develop underneath a nail.

If you are concerned about one of your moles, see Dr. B C Shah as soon as possible.

Causes of melanoma

The exact cause of melanoma is not known, although most cases are closely linked to the effect of ultraviolet (UV) light on the skin.

What is cancer?

The body is made up of millions of different types of cells. Cancer happens when some cells multiply in an abnormal way. When cancer affects organs and solid tissues, it causes a growth called a tumour to form. Cancer can occur in any part of the body.

It is not clear why cells sometimes multiply abnormally.

How does cancer spread?

Left untreated, cancer can quickly grow and spread, either in the skin or the blood, or to other parts of the body. This usually happens through the lymphatic system.

The lymphatic system is a series of glands that spread throughout your body and link together in a similar way to the blood circulation system. The lymph glands produce many of the cells needed by your immune system.

If the cancer reaches your lymphatic system, it can spread to any other part of your body, including your bones, blood and organs.

Melanomas

In most cases, it is thought melanomas are caused by exposure to sunlight. Sunlight contains UV light that can affect the skin.

There are two main types of UV – ultraviolet A (UVA) and ultraviolet B (UVB). Both UVA and UVB damage skin over time, making it more likely for skin cancers (including melanomas) to develop.

Artificial sources of light, such as sunlamps and tanning beds, may also increase your risk of developing melanoma skin cancer.

However, not all melanomas are linked with exposure to UV light and they can appear on areas of skin that are rarely exposed.

Increased risk

Factors that increase your risk of developing melanoma include:

Pale skin that tends to burn and not tan easily
A family member who has had melanoma
Red or blonde hair
Blue eyes
Increased age
A large number of moles
A large number of freckles
A condition that suppresses your immune system, such as HIV
Medicines that suppress your immune system (immunosuppressants), commonly used after organ transplants

All the above risk factors make your skin more sensitive to the effects of the sun.

Diagnosing melanoma

A diagnosis of melanoma will usually begin with a visit to Dr. B C Shah who will examine your skin and decide if you need further assessment.

Biopsy

If Dr. B C Shah decides a suspicious looking mole could be the result of melanoma, you will be referred to a skin specialist (dermatologist) or specialist plastic surgeon for further testing.

The dermatologist or plastic surgeon may do a biopsy. This is a small operation where a suspect mole is removed from your skin to be studied under a microscope. This shows whether the mole is cancerous.

A biopsy is usually carried out under local anaesthetic. The area around the mole will be numbed and you won’t feel any pain.

If cancer is confirmed, you will usually need a further operation, most often carried out by a plastic surgeon, to remove a wider margin of skin.

Further tests

If there is a concern the cancer could have spread into other organs, bones or your blood stream, further testing will be carried out.

Sentinel lymph node biopsy

If melanoma spreads, it will usually begin spreading in a predictable way through channels in the skin (called lymphatics) to the nearest group of glands (called lymph nodes).

These are the same glands that come up in your neck when you have a cold or sore throat, but they are found everywhere in the body. They are part of the body’s immune system, and they act as a sort of way-station for fluid in the skin as it circulates slowly around the body.

Microscopic amounts of melanoma can spread through the lymphatics to the lymph nodes. A melanoma on the arm will most often spread to lymph nodes in the armpit, while a melanoma on the leg will most often spread to glands at the groin.

Sentinel lymph node biopsy is a test to determine whether microscopic amounts of melanoma (less than would show up on any X-ray or scan) might already have spread to the lymph nodes.

The plastic surgeon injects a combination of blue dye and a weak radioactive chemical around your scar. This will usually be done just before the wider margin of skin is removed. This dye and the radioactivity will follow the same channels in the skin as any melanoma, and the first lymph node that they get to would, logically, be the first lymph node that any cancer would reach – the “sentinel” lymph node.

Using first the radioactivity and then the blue dye, can locate and remove the sentinel node (or sometimes nodes), leaving all the others intact. The node is then given to a pathologist who will be asked to examine it to identify or exclude a single microscopic speck of melanoma (this process can take several weeks).

If the sentinel lymph node is clear of melanoma, it is extremely unlikely (although not impossible) that any other lymph nodes are involved. This can be reassuring, since patients whose melanoma has spread to the lymph nodes are much more likely to have their melanoma spread elsewhere.

If the sentinel lymph node contains melanoma, there is around a 20% risk that at least one other lymph node in the same group will contain melanoma. Under these circumstances, you are usually recommended to have a much bigger operation to remove all the remaining lymph nodes in the affected group.

This is recommended because patients whose lymph nodes are involved and left to grow do less well than those whose affected lymph nodes are removed at an early stage. This bigger operation is often called a completion lymph node dissection or completion lymphadenectomy.

Other tests you may have include:

An X-ray
A magnetic resonance imaging (MRI) scan
A computerised tomography (CT) scan
Blood tests

Treating melanoma

Surgery is the main treatment for melanoma, although it often depends on your individual circumstances.

If you have melanoma, you may see one or several of the following professionals who work together as a team:

Dermatologist (skin specialist)
Plastic surgeon (surgeon who specialises in skin problems)
Clinical oncologist (cancer doctor specialising in using radiotherapy)
Medical oncologist (cancer doctor specialising in using drug treatments)
Specialist nurse

Other members of the team include:

Pathologist (who studies samples under the microscope to diagnose cancer)
Radiologist (who reads and interprets X-rays and scans)

This team of specialists, known as a multidisciplinary team or MDT, work together to provide the best treatment and care.

When helping you decide on your treatment, the team will consider:

The type of cancer you have
the stage of your cancer (how big it is and how far it has spread)
Your general health

Dr. B C Shah will recommend what he believes to be the best treatment option, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask Dr. B C Shah. For example, you may want to find out what the advantages and disadvantages of particular treatments are.

Preventing melanoma

The best way to prevent all types of skin cancer is to avoid overexposure to the sun.

This is especially important for people who have already been treated for melanoma, as it can help prevent recurrence of the condition.

However, it is not recommended you completely avoid the sun, as it can be a good source of vitamin D, essential for healthy bones. A few minutes in the sun can help maintain healthy levels of vitamin D.

Some simple steps to manage your sun exposure are outlined below.

Avoid the sun when it is at its hottest

The sun is usually at its hottest between 11am and 3pm, but it can also be strong and have potentially damaging effects at other times. Do not spend long periods in the sun during the day and make sure you spend time in the shade and cover up with clothes as well as sunscreen.

Dress sensibly

If you cannot avoid spending long periods of time in the sun – for example, if you have a job that requires you to work outside – wear clothes that provide protection from the sun. This should include a hat to protect your face and scalp and sunglasses to protect your eyes.

Use sunscreen

When buying sunscreen, make sure it is suitable for your skin type and blocks both ultraviolet A (UVA) and ultraviolet B (UVB) radiation. A sun protection factor (SPF) of at least 15 is recommended.

Sunscreen should be applied around 15 minutes before you go into the sun and reapplied every two hours. If you are planning to spend time in the water, use a waterproof sunscreen and reapply regularly.

Take extra care to protect babies and children. Their skin is much more sensitive than adult skin and repeated exposure to sunlight could lead to skin cancer developing in later life. Before going out into the sun, make sure your children are dressed appropriately and are wearing a hat and high protection factor sunscreen.

Avoid burning

If you spend time in the sun, avoid getting sunburnt. Once you are burnt, the damage has already been done to your skin as your skin has received a dangerous level of radiation. Every time the skin is exposed to radiation, this increases the chance of a cancer occurring, possibly many years in the future.

Tan sensibly

Avoid sunbathing altogether because even a tan can increase your risk of developing skin cancer. However, if you are determined to get a tan, do it gradually by limiting the amount of time you spend in the sun each day and by wearing sunscreen. When you begin to tan, limit your exposure to the sun to 30 minutes, then gradually increase it by 5 or 10 minutes a day.

Sunbeds and sunlamps

Sunbeds and lamps can be more dangerous than natural sunlight because they use a concentrated source of ultraviolet (UV) radiation.

UV radiation can increase your risk of developing melanomas – the most dangerous type of skin cancer. Sunbeds and sunlamps can also cause premature skin ageing.

If you insist on using sunbeds or sunlamps, the Health and Safety Executive (HSE) has issued advice on health risks linked to UV tanning equipment, such as sunbeds, sunlamps and tanning booths. They recommend you do not use UV tanning equipment if:

You have fair, sensitive skin that burns easily or tans slowly or poorly.
You have a history of sunburn, particularly in childhood.
You have lots of freckles or red hair.
You have lots of moles.
You are taking medicines or using creams that make your skin sensitive to sunlight.
You have a medical condition that is made worse by sunlight.
You have had skin cancer or someone in your family has had skin cancer.
Sunlight has already badly damaged your skin.

Check your moles

As well as staying safe in the sun, you should regularly check any moles for signs of melanoma. See Dr. B C Shah if you notice any changes to your moles or freckles as this can help lead to an early diagnosis and improve the chances of successful treatment.