STEP 4: Treatment

Step 4 describes the optimal treatments for melanoma, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for melanoma. For detailed clinical information on treatment options refer to these resources:

The intent of treatment can be defined as one of the following:

  • curative
  • loco-regional control
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

A full skin assessment should be considered as a preliminary treatment option for assessing the risk of further melanomas, surveillance planning and for detecting synchronous primaries and/or other keratinocytic skin cancers that may require intervention.

The definitive treatment of a primary melanoma involves an adequate margin of skin and subcutaneous fat. For a melanoma in situ, this is 5–10 mm. For an invasive melanoma, the margins of 10 mm or 20 mm will be considered depending on its thickness and specific type of melanoma (Cancer Council Australia Melanoma Guidelines Working Party 2019).

Surgery in a primary care or dermatology centre

Surgery under local anaesthetic with direct primary closure for excision biopsy and selected re-excision for in situ and early-stage melanomas can be undertaken in the primacy care setting by a dermatologist or a general practitioner with adequate training and experience.

Surgery by a specialist team

Surgery for all other excisions (including sentinel lymph node biopsy and regional lymphadenectomy) should be undertaken by a surgeon with adequate training and experience.

Resection of regional and distant metastatic melanoma may be appropriate in selected cases.

Timeframe for starting treatment

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

Training and experience required of the surgeon

Fellow of the Royal Australian College of Surgeons, or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice in melanoma (ACSQHC 2015).

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with melanoma and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having more advanced surgery, health services should have these features:

  • critical care support
  • 24-hour medical staff availability
  • 24-hour operating room access and intensive care unit
  • diagnostic imaging
  • pathology
  • nuclear medicine imaging

Radiation therapy may benefit patients in the following circumstances:

  • definitive treatment for in situ melanoma in special circumstances such as, where surgery needs to be avoided for medical reasons, and sites on the body where complete resection would be prohibitively morbid
  • adjuvant radiation therapy following surgical resection for invasive melanoma at high risk of recurrence if potentially effective systemic therapy is not available – at primary sites this includes recurrent disease, desmoplastic melanoma specifically with neurotropism and where adequate margins cannot be attained; at regional sites depending on the location, size and number of nodes specifically when extra-nodal extension is present
  • palliative treatment for life prolongation (stereotactic radiotherapy for oligometastatic disease) and symptom relief/prevention, particularly for brain and spinal disease.

Timeframe for starting treatment

If not urgent, radiation therapy should begin within four weeks of the MDM. Some patients will require urgent treatment.

Training and experience required of the appropriate specialists

The radiation oncologist should be a Fellow of the Royal Australian and New Zealand College of Radiologists, or equivalent, with adequate training and experience that enables institutional credentialing and agreed scope of practice in melanoma.

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics

To provide safe and quality care for patients having radiation therapy, health services should have these features:

  • linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
  • dedicated CT planning
  • access to MRI and PET imaging
  • automatic record-verify of all radiation treatments delivered
  • a treatment planning system
  • trained medical physicists, radiation therapists and nurses with radiation therapy experience
  • coordination for combined therapy with systemic therapy, especially where facilities are not co-located
  • participation in Australian Clinical Dosimetry Service audits
  • an incident management system linked with a quality management system

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

Systemic therapy should be prescribed and conducted under the supervision of a medical oncologist.

Timeframes for starting treatment

If systemic therapy is to be given as adjuvant therapy, this should occur within 12 weeks of the definitive surgery.

If systemic therapy is to be given to treat stage IV disease, therapy should begin as soon as clinically relevant (as soon as possible), ideally within four weeks.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access

Stage III melanoma

Patients with resected stage IIIB/C/D melanoma should be considered for adjuvant systemic therapy. The prognosis for patients with stage IIIA melanoma is good and adjuvant systemic therapy is not recommended for this sub-group. For patients with a BRAF V600 mutant melanoma, targeted therapy (combination BRAF and MEK inhibitors) or adjuvant immunotherapy (single agent anti PD-1) can be recommended. For patients without a BRAF mutation, adjuvant immunotherapy should be used. Therapy is given for up to a year.

Currently, there is strong evidence for clinically significant improvements in relapse-free survival with the adjuvant use of targeted therapy or anti-PD1 immunotherapy; however, improvements in overall survival from these treatments have not yet been demonstrated. These may emerge with further follow-up. The decision to recommend adjuvant treatment should be taken by a suitably experienced oncologist and consider the health status and preferences of the individual patient.

Unresectable stage III and stage IV melanoma

All patients with unresectable stage III or stage IV melanoma should be considered for systemic therapy. Enrolment into clinical trials is encouraged where possible.

Immunotherapy, with either anti-PD-1 agents (pembrolizumab or nivolumab) alone or with nivolumab in combination with the anti-CTLA-4 agent ipilimumab can be given as the first line of therapy for metastatic melanoma. Combination immunotherapy results in higher response rates and longer progression-free survival but has significantly greater toxicity, necessitating careful patient selection. Immunotherapy should be continued until disease progression, unacceptable toxicity or completion of two years of treatment. Immunotherapy can cause a unique set of side effects, referred to as immune-related adverse events (irAEs). These toxicities result in inflammation occurring in normal tissues and can affect any part of the body. The most common irAEs are rash, itch, thyroid dysfunction, hypophysitis, hepatitis, colitis, arthritis and pneumonitis. Patients with pre-existing autoimmune conditions are at risk of exacerbation of their autoimmune disease. Clinically significant irAEs require interruption of the immunotherapy and, usually, immunosuppressive doses of corticosteroids. As these are a unique set of toxicities very distinct from traditional chemotherapy side effects, practitioners involved in managing these patients should seek expert advice from the patient’s treating unit if toxicity is suspected.

Patients with BRAF V600 mutant melanoma are also candidates for targeted therapy. Combination therapy with both a BRAF and a MEK inhibitor should be used in preference to treatment with single-agent BRAF inhibition. Treatment with targeted therapy should continue until the development of disease progression or intolerable toxicity. There is no randomised data to suggest a superior sequence of treatment (targeted therapy followed by immunotherapy or vice versa) for metastatic BRAT-mutant melanoma.

For patients who are not responding to treatment or with very advanced disease, early referral to palliative care can improve the quality of life for people with melanoma, and in some cases may be associated with survival benefits (Haines 2011; Temel at al. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

More information

These online resources are useful:

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/depression, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of physical symptoms such as pain, fatigue, loss of appetite or weight loss
  • decline in mobility or functional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council’s 13 11 20 information and support line can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation.

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with melanoma, all team members should recommend that people with melanoma work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing melanoma-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to melanoma and its sequels. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible side effects of treatment, managing symptoms between active treatments, how to access care, self-management strategies and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
    • the treatment plan, including intent and potential side effects
    • supportive and palliative care requirements
    • the patient’s prognosis and their understanding of this
    • enrolment in research or clinical trials
    • changes in treatment or medications
    • the presence of an advance care directive or appointment of a substitute decision-maker
    • recommendations from the multidisciplinary team.
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.