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Melanoma


Expert reviewer, Dr Veronique Bataille, Consultant Dermatologist
Next review due September 2020

Melanoma is a type of cancer that starts in cells in your skin called melanocytes. The cancer can often spread to other parts of your body.

Melanoma may start in a mole on your skin, or it may start on normal skin creating a new, abnormal mole.

There are other forms of skin cancer, which tend to be less serious than melanoma. Read our topic on non-melanoma skin cancer for more information on these.

An image showing a diagram of skin cells

About melanoma

Melanoma forms in skin cells called melanocytes. These are a type of cell in the top layer of your skin.

Melanocytes make a pigment called melanin. This pigment gives your skin its colour and helps to protect it from the harmful effects of the Sun. A mole is a group of melanocytes that have clustered together. As melanoma develops in melanocytes, a first sign is often a change in one of your moles.

There are more than 15,000 new cases of melanoma diagnosed every year in the UK. It’s the fifth most common cancer in the UK, with rates having more than doubled since the early 1990s. While the increase has now slowed down, rates of melanoma are still expected to rise in the next 10 years.

Types of melanoma

There are several different types of melanoma. The most common ones are described below.

  • Superficial spreading melanoma. This is the most common type of melanoma. It appears as a flat, coloured lesion and spreads across the surface of your skin. It mainly appears on the back in men, and on the lower legs in women.
  • Nodular melanoma. This usually looks like a dark-coloured lump on your skin. It may ulcerate or bleed easily, although this is uncommon. Nodular melanomas tend to grow vertically into the skin (upwards and downwards) forming a raised lump, rather than flat across the surface. Because of this, they can spread to other areas of your body more rapidly.
  • Lentigo maligna. These often look like freckles at first and then become quite dark with irregular colours such as dark brown, black and blue. They often appear on your face or scalp. They’re most common in older people (over 60 years of age), and grow slowly over time.
  • Acral lentiginous melanoma. These melanomas are most common in people with darker skin types. They often appear on the palms of your hands, soles of your feet, or under a nail.

Symptoms of melanoma

The first sign of melanoma is often the appearance of a new mole or a change in how one of your existing moles looks. If you notice a mole that stands out because it looks different from other moles or marks on your skin, you should get it checked out. This is especially important if the mole is changing in appearance.

The ABCDE checklist (below) includes a few warning signs that might indicate a mole is more likely to be a melanoma. If you have any doubt, it’s always best to check with a doctor.

  • A – asymmetry (one half looks different from the other).
  • B – border irregularity (the edges are uneven and jagged).
  • C – colour variability (the mole is a mixture of different colours, which you don’t usually get in a normal mole, eg, black, grey and pink).
  • D – diameter – the mole is bigger than 6mm across.
  • E – evolution – the mole has changed in size, shape or colour.

It’s also important to get checked out if your mole itches, burns or is painful.

Melanoma can occur anywhere on your body – not just areas that are often exposed to the Sun. In men, melanoma is most common on the trunk; in women, it’s on the legs.

Diagnosis of melanoma

Your GP will examine any suspicious areas of your skin and ask you questions such as when you first noticed any changes. They’ll make an assessment of the mole to decide whether or not you need to be referred for further investigation with a dermatologist. A dermatologist is a doctor who specialises in skin conditions.

Seeing a specialist

If you are referred to a dermatologist, you should get an appointment within a couple of weeks. The dermatologist may first examine your mole with a special tool called a dermatoscope. This is a special, hand-held magnifying glass that your doctor can use to view under the surface of your skin. They may need to apply a liquid to your skin first. Your doctor may also take some photos of the mole, so they can see if it changes over time.

If your dermatologist thinks it could be a melanoma, they’ll ask you to have an excision biopsy. For suspected melanomas, this involves removing the whole mole, along with a narrow margin of normal skin, and sending it to a laboratory for testing. This biopsy is usually carried out under local anaesthesia, which means the skin will be numbed so that you won’t feel anything.

Staging

Once it’s been removed, your mole will be examined to check if it’s a melanoma and, if so, how advanced (what stage) it is. You may be asked to return for further tests to determine if your cancer has spread, although this won’t be necessary for all types of melanoma. Investigations you may have include the following.

  • A sentinel lymph node biopsy. This is a test to help identify if melanoma has spread to your lymphatic system. The lymphatic system is part of your body’s immune system and includes your lymph nodes. The sentinel lymph node is the first lymph node that cancer cells are most likely to spread to.
  • Scans. These may include CT (computerised tomography) scans, MRI (magnetic resonance imaging) scans and PET (positron emission tomography) scans. These scans can identify cancer that has spread to other parts of your body (metastases).

Melanoma is given a stage using a system of numbers and letters. These describe whether or not it’s spread, how far it’s grown into your skin (its thickness), and if it has broken the skin (ulcered).

  • Stage 0 is the very earliest stage of melanoma, which hasn’t spread.
  • Stage I describes melanomas up to 2mm in thickness.
  • Stage 2 means melanomas thicker than 2mm (or melanomas thicker than 1mm that have ulcerated).
  • Stage 3 means the melanoma has spread to nearby lymph nodes.
  • Stage 4 describes melanomas that have spread to other parts of the body.

Treatment of melanoma

The treatment you’re offered will depend on what stage melanoma you have. This means how far it’s grown into your skin (the thickness) and whether it’s spread.

Surgery

You will already have had your mole removed with an excision biopsy, in order to confirm your diagnosis. If it’s confirmed as a melanoma, you may be asked to come back for a second operation to remove more skin from around the area. This is called a wide local excision. It’s done to try to ensure that all the cancer cells are removed.

You may have a sentinel lymph node biopsy at the same time you have the cancer removed. This is to check if cancer cells have spread to your lymph nodes. If this has happened, you may need to have a procedure called a lymphadenectomy. This involves removing all of your lymph nodes in the affected area, even healthy ones, to prevent the cancer spreading further or coming back.

If you have stage 3 or 4 melanoma that has spread, you might need more surgery to remove additional tumours in other parts of your body.

Non-surgical treatments

Early-stage melanoma

If you have very early stage melanoma, it may be possible to have alternative treatments to surgery. This may also be an option for you if you’re unable to have surgery for any reason. You may also be offered non-surgical treatment if your melanoma is an early stage and is on your face. Treatments you may be offered include radiotherapy, scraping or freezing off the melanoma, or treatment with a cream called imiquimod.

Advanced melanoma

There are a number of treatments that you may be offered if you have stage 3 or 4 melanoma, which has spread. These are listed below.

  • Immunotherapy – this involves treatment with intravenous medicines called ipilimumab, nivolumab or pembrolizumab. These treatments works by stimulating your immune system to fight the melanoma.
  • Targeted therapies – these include the medicines vemurafenib, dabrafenib, and trametinib. The last two are often given together. They work by targeting specific genes in the cancer cells to stop them growing and spreading. You may be able to have this treatment if your melanoma is shown to be positive for a genetic mutation called BRAF.
  • Chemotherapy – you may be offered chemotherapy with a medicine called dacarbazine if other treatments aren’t thought to be suitable. Chemotherapy isn’t used very often in the treatment of melanoma though.
  • Radiotherapy – you may be offered radiotherapy to treat melanoma that has spread to other parts of your body, such as your brain or bones.

Causes of melanoma

Melanoma is caused by a number of genetic and environmental factors. Excessive exposure to sunlight or UV radiation from sunbeds is the main environmental factor for melanoma. You’re at greater risk if you’ve had severe sunburn or intense, intermittent (irregular) exposure to the Sun in the past, particularly as a child or teenager.

The people at the greatest risk of melanoma though, are those with a large number of moles, or larger than average (atypical) moles. In around one in 10 melanomas, there’s a family history of melanoma.

People with pale skin, red or blonde hair, and blue or green eyes, are at greater risk of developing melanoma than those with darker hair and eyes.

If you have any of these factors that put you at greater risk of melanoma, it’s important to regularly check your skin and moles. Try to do this monthly if you can. If you see any changes in your skin, it’s important that you see your GP.

Prevention of melanoma

Most cases of melanoma could be prevented by following steps to be safe in the Sun. The following tips may help to protect your skin from burning and reduce your risk of skin cancer.

  • Cover up with suitable clothing, including a wide-brimmed hat and ultraviolet-protective sunglasses.
  • Stay in the shade or cover up between 11am and 3pm, when the sunlight is most intense, rather than relying on sunscreens alone.
  • Use high-factor sunscreen if you are out in strong sunlight, with a Sun protection factor (SPF) of at least 30, and high UVA protection (at least 4 stars).
  • Don’t use sunbeds, unless you have been advised to for a skin condition. The intensity of the UV rays in sunbeds can be stronger than those of the Sun at midday. If you use sunbeds for a skin condition, the medical team will make sure they are not exceeding safe doses.

Frequently asked questions

  • Doctors don’t tend to use the term ‘cured’ because there is always the chance that a melanoma can return, even if the chance is very small. Instead, they refer to 5-year survival rates. This describes the number of people who live for at least 5 years after their diagnosis (this is an average and many people live much longer).

    How likely you are to survive your cancer for at least 5 years really depends on the stage melanoma you have when you’re diagnosed. This means how deep into the skin it has grown, and whether or not it has spread.

    Nine in 10 people with melanoma survive their disease for 5 years or more. This number is higher for people diagnosed at the earliest stage (almost everyone diagnosed with stage 1 survives for 5 years or more). Fewer people survive when melanoma is diagnosed at a later stage. For more advanced stage 4 melanoma, only around a quarter of women and one in 10 men survive for 5 years or more. However, it takes time to collect the data and these figures are for people who were treated around 10 years ago. Treatments are improving all the time – so the outlook today will be better.

    Being aware of the signs of melanoma and seeking treatment early, will give you the best chance of surviving the disease.

  • When you have melanoma surgically removed, some of your healthy skin is removed from around the tumour. Usually, the wound from surgery can be closed with stitches. But if the area is too large to close this way, you may need to have the skin replaced with a skin graft or skin flap.

    Skin graft

    A skin graft is a thin layer of skin taken from another area of your body and placed over the area where the melanoma was removed. The area where your skin is taken from depends on factors such as the colour and texture of your skin and the skin thickness that’s needed. A graft is usually held in place with stitches and a dressing will be placed over it.

    The area that the healthy skin was taken from will either be closed with stitches or left to heal by itself under a special dressing. The area where your skin is replaced will be delicate as it heals, so you will need to take special care of it. You can take paracetamol if you need pain relief. After it has healed, the skin may look different from your surrounding skin and may be a slightly different colour.

    Skin flap

    A skin flap is a thicker layer of skin than a graft. It’s taken from an area close to where your melanoma has been removed. The blood supply to the skin flap is left intact – this will help it to heal. The flap is held in place with stitches and a dressing will be placed over it. Skin flaps may give a better cosmetic result because they use skin that is similar to the colour, type and thickness of the skin that has been removed.

    Your surgeon will discuss which option is best for you.

  • You won’t usually get skin cancer just from having been sunburned on the odd occasion. But getting sunburned regularly, especially if you have very fair skin or lots of moles, does increase your risk of skin cancer later on. This is because even once your skin has healed after sunburn, the DNA in your skin’s cells has been damaged and these changes can stay in the skin for many years.

    Research shows that melanoma is more common in people who expose their skin to the Sun intermittently. For example, at weekends or when they are on holiday, rather than spending regular time in sunlight every day. However, this may be partly due to other factors affecting these people. Melanoma is more likely to develop on areas of your body that are exposed to the Sun intermittently – such as your back or legs. This is different from non-melanoma skin cancer, which is more likely to occur on parts of your body that get a lot of exposure to the Sun, such as your face.

    Because the effects of the Sun can be so damaging over the long term, it’s really important that you take steps in the future not to let your skin redden and get burned by the Sun.


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  • Reviewed by Pippa Coulter, Specialist Health Editor, Bupa Health Content Team, September 2017
    Expert reviewer, Dr Veronique Bataille, Consultant Dermatologist
    Next review due September 2020



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