Establish intent of treatment

• Curative
• Loco-regional control
• Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• Symptom palliation

Full skin assessment is a preliminary treatment option to assess the risk of further melanomas, for surveillance planning and to detect synchronous primaries, and/or other keratinocytic skin cancers that may require intervention.

Surgery with direct primary closure can be undertaken in a primary care setting for excision biopsy and selected re-excision for in situ and early-stage melanomas. Surgery for all other excisions (including sentinel lymph node biopsy and regional lymphadenectomy) should be undertaken by a surgeon with adequate training and experience.

Radiation therapy may benefit in the following circumstances: definitive treatment for in situ melanoma in medically inoperable areas or for patients where a complete resection would be prohibitively morbid; adjuvant radiation therapy following surgical resection for invasive melanoma with a high risk of recurring if potentially effective systemic therapy is not available; and for palliative treatment.

Systemic therapy should be considered for select patients with stage III melanoma (confined to regional lymph nodes) and all patients with advanced melanoma (stage IV) given their potential improvement in progression-free survival and overall survival. Options include immunotherapy and targeted therapy.

Palliative care:

For patients who are not responding to treatment or with very advanced disease, early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more, visit the Palliative Care Australia website.

Communication

The lead clinician and team’s responsibilities include:

• discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
• discussing advance care planning with the patient and/or carer where appropriate
• communicating the treatment plan to the patient’s GP
• helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.

Checklist

Timeframe

Surgery in a primary care setting should occur within 2 weeks of the decision that it is necessary.

If not urgent, radiation therapy should begin within 4 weeks of the MDM.

Systemic therapy: as adjuvant therapy, should occur within 12 weeks of definitive surgery; and to treat stage IV disease, should begin as soon as clinically relevant, ideally within 4 weeks.