• Melanoma treatments vary by stage and can include surgery, medications, and radiation therapy.
• Most melanomas are treated with surgery, but you may need additional treatment to destroy any remaining cancer cells.
• Your doctor will recommend the treatment options most likely to reduce the risk of your melanoma returning.

If your melanoma grows and spreads, your oncologist (cancer specialist) will adapt your treatment plan. Most early-stage melanomas can be treated and cured with surgery, but the more advanced stages require additional treatment. So, what can you expect if your melanoma progresses?

This article will cover your melanoma treatment options at different stages, which range from stage 0 to stage 4. (Cancer stages are sometimes noted with Roman numerals, e.g., “stage III” instead of “stage 3.”) If you have questions about your specific treatment plan, talk to your oncologist.

Stage 0 Melanoma Treatment

Stage 0 melanoma — also known as melanoma in situ — refers to a tumor found only on the epidermis (top layer of skin). At this stage, melanoma can be cured with surgery. Your doctor will likely perform a wide excision to entirely remove the melanoma tumor and a thin margin of healthy skin around it.

The removed tumor is then sent to a lab, where a pathologist (tissue specialist) looks at it under a microscope. If there are cancer cells in the margin of the sample, your doctor may perform a second surgery to remove more tissue. This helps lower your chances of the melanoma returning.

Stage 1 Melanoma Treatment

In stage 1 melanoma, the tumor has spread from the epidermis down into the next layer of skin, known as the dermis. Most stage 1 melanomas are treated with surgery to remove the tumor and a margin of healthy skin cells. Your doctor will likely perform a wide excision. If there are no cancer cells around the edges off the removed sample, you won’t need any additional treatment.

Stage 1 tumors haven’t spread into any nearby lymph nodes. As part of your immune system, lymph nodes filter out cancer cells and other harmful substances from your body.

Depending on how thick your tumor is and how deep it goes into the skin, your doctor may want to check the lymph nodes. Melanoma usually spreads into lymph nodes first before traveling to other parts of the body. A sentinel lymph node biopsy (SLNB) is a procedure used to find and remove lymph nodes near melanoma tumors to check for cancer cells.

Stage 2 Melanoma Treatment

The standard treatment for stage 2 melanoma is wide excision to remove the tumor. Your doctor may recommend an SLNB at this stage as well to make sure your cancer hasn’t spread to the lymph nodes. If there are no melanoma cells in the lymph nodes, you’ll still be monitored over time.

Adjuvant Treatment for Stage 2 Melanoma

If your melanoma has a high risk of returning, your doctor may choose to add an adjuvant therapy. Adjuvant treatment helps destroy any cancer cells left behind after surgery. High-risk melanoma is defined as a primary (main) tumor that’s at least 4 millimeters thick or has spread into nearby lymph nodes. This means there’s a greater chance that melanoma cells will be left behind after surgery. Adjuvant treatment helps prevent melanoma from returning by destroying any remaining cancer cells.

Immunotherapy uses lab-made protein drugs to activate your immune system against cancer. Immune checkpoint inhibitors (ICIs) are a common choice for treating melanoma. These drugs help specialized immune cells — known as T cells — recognize and attack cancer cells.

In some cases, doctors give the ICIs pembrolizumab (Keytruda) or nivolumab (Opdivo) as an adjuvant therapy after melanoma surgery. Large studies known as clinical trials have shown that ICIs reduce the risk of a person’s cancer returning.

Stage 3 Melanoma Treatment

In stage 3 melanoma, the cancer has spread into the lymph nodes next to the tumor. Surgery at this point includes removing the entire tumor and all nearby lymph nodes. This is known as a lymph node dissection.

Your doctor will also check the skin and tissue around your primary melanoma tumor for signs of spread. Some people develop local metastatic melanoma tumors near the primary tumor. If possible, your doctor will remove these tumors with surgery.

Adjuvant Treatment for Stage 3 Melanoma

If your melanoma is at a high risk of returning, your doctor will likely give adjuvant treatment with ICIs, targeted therapy, or radiation therapy. The U.S. Food and Drug Administration (FDA) has approved nivolumab and pembrolizumab as adjuvant treatments for stage 3 melanoma.

The FDA has also approved talimogene laherparepvec (T-VEC, sold as Imlygic) for treating stages 3B and 3C melanoma that can’t be removed with surgery. T-VEC uses a virus that’s injected directly into the tumor to kill melanoma cells.

Around half of all melanomas have changes or mutations in the BRAF gene in their cells. The BRAF gene controls cell growth and division. If you have a BRAF mutation, your doctor can use a BRAF inhibitor for adjuvant therapy.

Examples of BRAF inhibitors include:

• Dabrafenib (Tafinlar)
• Encorafenib (Braftovi)
• Vemurafenib (Zelboraf)

BRAF inhibitors can also be combined with another targeted therapy known as MEK inhibitors. BRAF and MEK proteins work together to send growth signals in cancer cells. Studies show that blocking both of these proteins works better for treating melanoma.

Examples of MEK inhibitors include:

• Binimetinib (Mektovi)
• Cobimetinib (Cotellic)
• Trametinib (Mekinist)

Stage 4 Melanoma Treatment

Also known as metastatic melanoma, stage 4 melanoma has spread from the primary tumor to distant parts of the body. At this point, surgery alone isn’t effective for treating melanoma. Instead, your doctor will likely recommend a combination of surgery and systemic therapy to help shrink your tumors.

The overall goal of stage 4 melanoma treatment is to control tumor growth and help you live longer. New advances in immunotherapy are improving survival for people with this skin cancer.

Surgery

Surgery may be an option if you have only a few metastases. Your doctor can also remove tumors or large lymph nodes causing uncomfortable symptoms to improve your quality of life.

Immunotherapy

Doctors typically prefer to give immunotherapy first to treat stage 4 melanoma. This is because immunotherapies work longer than targeted therapies.

Pembrolizumab and nivolumab are given on their own for one to two years, or until your melanoma starts progressing (growing). Your doctor may prescribe a combination of nivolumab and ipilimumab for stage 4 melanoma. Ipilimumab can also be given by itself if your melanoma keeps progressing after treatment with pembrolizumab or nivolumab.

In 2022, the FDA approved a combination product of nivolumab and relatimab-rmbw (Opdualag). This drug treats metastatic melanoma and tumors that can’t be removed with surgery.

T-VEC is also FDA-approved for treating metastatic melanoma that has spread to other areas of the skin or the lymph nodes.

Targeted Therapy

If your melanoma has a BRAF mutation, your doctor may prescribe a BRAF and MEK inhibitor together. Targeted therapy helps increase your life expectancy with stage 4 melanoma. However, most people eventually experience tumor progression.

Doctors can also prescribe vemurafenib and cobimetinib with the immunotherapy atezolizumab (Tecentriq) for treating metastatic melanoma.

Chemotherapy

Chemotherapy typically isn’t used to treat stage 4 melanoma anymore. This is because immunotherapy and targeted therapy are much more effective. Your doctor may choose to use certain chemotherapy drugs if your other treatments stop working. Examples include dacarbazine and temozolomide.

Radiation Therapy

Radiation therapy helps treat metastatic melanoma that has spread to the brain and bones. This is especially useful for tumors that can’t be removed with surgery or tumors that have returned after previous treatment.

Talk With Others Who Understand

MyMelanomaTeam is the social network for people with melanoma and their loved ones. On MyMelanomaTeam, members come together to ask questions, give advice, and share their stories with others who understand life with melanoma.

Have you received treatment for melanoma? Share your experience in the comments below, or start a conversation by posting on your Activities page.