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KEY CONCEPTS
Cutaneous melanoma is an increasingly common malignancy that can be cured if detected early. Public education about screening and early detection is one strategy to control the increase in incidence and the mortality associated with cutaneous melanoma.
Surgical resection can cure patients with early-stage melanoma.
Adjuvant therapy should be considered in patients with locally advanced disease; recommended options include IFN-α2b, ipilimumab, nivolumab, pembrolizumab, BRAF/MEK inhibitors, and clinical trial.
Chemotherapy and biochemotherapy offers limited benefit in the treatment of metastatic melanoma.
Advances in immunotherapy with ipilimumab, nivolumab, the combination of ipilimumab/nivolumab and pembrolizumab have led to durable responses in patients with metastatic melanoma and have significantly influenced overall survival.
Immune-related toxicities associated with immunotherapy can be severe and life-threatening. Consequently, the use of these agents warrants appropriate patient selection, close monitoring and toxicity management by an experienced healthcare team.
As the biology of melanoma has been further delineated, a growing number of potential targets for drug therapy have been identified. BRAF mutations occur in up to 70% of melanoma patients. The use of combination BRAF and MEK inhibitors improves overall survival in patients with this mutation.
Treatment of melanoma is determined by many factors. As the number of treatment options for patients with metastatic melanoma grows, it will be important to consider disease- and patient-related aspects when determining appropriate therapy.
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Patient Care Process for Melanoma
Collect
Patient characteristics (eg, age, sex, physical features)
Patient medical history (personal/family) including autoimmune diseases
Social history (eg, history of blistering sunburns; intermittent, intense sun exposure; tanning bed use)
Current medications including OTC products, herbal products, dietary supplements, current or past use of immunosuppressants
Objective data
Type of biopsy performed
Pathology report: Breslow thickness, presence or absence of ulceration, mitotic rate
Routine imaging and labs not recommended for early stage/localized disease. Perform for baseline staging in stage IIIB or higher (can be considered for stage IIIA)
Labs: serum creatinine (SCr), liver function (AST, ALT, total bilirubin), lactate dehydrogenase (LDH), complete blood count (CBC), thyroid function (TSH, free T4) for regional/metastatic disease
Assess
Appropriate primary treatment (wide excision, need for sentinel lymph node biopsy)
Status of sentinel lymph node biopsy, if performed; if positive sentinel lymph node, appropriateness of nodal basin ultrasound surveillance versus complete lymph node dissection
Mutational analysis, if appropriate
Presence of active autoimmune disease
Ability/willingness to complete one year of adjuvant treatment, if recommended
Ability/willingness to pay for treatment options
Ability/willingness to obtain laboratory monitoring tests and imaging to evaluate signs and symptoms
Emotional status (eg, presence of anxiety, depression)
Plan
Wide excision for all stages. Consider sentinel lymph node biopsy for stage IB; offer to stage II
Adjuvant treatment with either PD-1 inhibitor or BRAF/MEK inhibitor combination for patients with fully resected stage III or stage IV disease that are appropriate for therapy
Drug therapy regimen including specific drug(s) dose, route, frequency, and duration (see Tables 156-8 and ...