Skin cancer: Treatment and follow-up
Part of our GP resources on tumour types, here we focus on treatment and follow-up of skin cancer, including developments in treatments and detecting recurrence
Primary melanoma is usually treated with surgery. Once the Breslow thickness is determined a wide local excision is usually undertaken. The width of excision size will be determined by the depth and stage of the melanoma. It is important this is performed by a team experienced in melanoma excision that is part of the skin cancer Multi-Disciplinary Team (MDT) team.
Dependent on stage, a patient may also be offered a Sentinel Lymph Node Biopsy to check if the cancer has spread to local nodes. This is carried out under general anaesthetic at the same time as the wider excision. A positive result means that cancer has started to spread and the treating consultant will discuss further treatment options with the patient.
Radiotherapy is not commonly used to treat melanoma which generally is not radiosensitive but there are some instances when it can be useful; including treatment of brain metastases and bony metastases. It is generally only used for advanced disease. Radiotherapy does have side effects and these vary depending on the site of the treatment. Patients may experience reddening of the skin or feel sore and fatigued during the treatment period but this usually starts to disappear within a fortnight of treatment ending.
Chemotherapy for melanoma is rarely curative and aims instead to control symptoms in cases of advanced melanoma. The most common chemotherapy drug used to treat melanoma is dacarbazine (DTIC).
Isolated limb perfusion
Isolated limb perfusion (ILP) is a specialised surgical technique for the treatment of cancers in limbs, commonly melanomas and sarcomas. Melanoma can spread with multiple outbursts of tumour progressing gradually higher up the limb before progressing to the lymph nodes.
ILP delivers high doses of a combination of anti-cancer drugs directly to a limb at concentrations too high for the vital organs to tolerate. To prevent organ damage, the limb’s blood supply is isolated from the rest of the body during the operation via a tourniquet. The limb is connected by the main artery and vein to a cardiac bypass machine to oxygenate the blood while the chemotherapy is delivered, together with a protein called Tumour Necrosis Factor which interacts with both the drugs and the cancer cells to make the treatment more effective. This combination circulates through the limb for an hour, before the drugs are washed out and the limb is reconnected to the normal circulation.
This can be curative in some cases but usually offers extension of life and improved quality of life by avoiding amputation. The Royal Marsden is the only centre in the UK to offer this technique.
Immunotherapy is an emerging treatment that harnesses the body’s immune response to target and destroy cancer cells.
Two immunotherapy drugs developed at The Royal Marsden, Nivolumab and ipilimumab, have been successful in treating melanoma when used in combination.
A trial led by Dr James Larkin, a Consultant Medical Oncologist specialising in melanoma at The Royal Marsden, showed that in 58 per cent of patients, the two drugs combined shrank tumours and stopped the cancer advancing for nearly a year on average. The drugs are available to eligible NHS patients with advanced melanoma as of July 2016.
In another Royal Marsden trial, a genetically engineered herpes simplex virus was shown to halt the progression of melanoma. T-VEC is a modified form of the virus that multiplies inside cancer cells and bursts them from within, and stimulates the immune system to destroy the tumour. Responses to treatment were most pronounced in patients with less advanced cancers and those who had yet to receive any treatment – showing the potential benefits of T-VEC as a first-line treatment for metastatic melanoma that cannot be removed surgically. T-VEC immunotherapy is currently available to private patients or through clinical trials.
Follow-up appointments are vital to detect recurrence or spread of melanoma as early as possible. The frequency and longevity of follow-up appointments varies according to the stage of melanoma. Early stage melanomas may only require a year’s follow-up but later stage cancers may require follow-up for up to five years. Regular imaging scans may also be required to detect spread of the melanoma in more advanced patients so that treatments can be started early.
Patients are taught what signs and symptoms to look out for and it is vital that they return to their specialist if they experience:
- Skin changes or changes to a mole
- Swollen or painful lymph nodes
- Persistent bone pain
- Frequent headaches
- General symptoms of feeling unwell such as fatigue, unexplained weight loss or loss of appetite.