Cancer  
Cancer is a disease of the body’s cells. Our bodies are always making new cells: so we can grow, to replace worn-out cells, or to heal damaged cells after an injury. This process is controlled by certain genes. All cancers are caused by changes to these genes. Changes usually happen during our lifetime, although a small number of people inherit a changed gene from a parent. Normally, cells grow and multiply in an orderly way. However, changed genes can cause them to behave abnormally. They may grow into a lump. These lumps can be benign (not cancerous) or malignant (cancerous). Benign lumps do not spread to other parts of the body. A malignant lump (more commonly called a malignant tumour) is made up of cancer cells. When it first develops, this malignant tumour may be confined to its original site. If these cells are not treated, they may spread into surrounding tissue and to other parts of the body. When these cells reach a new site, they may continue to grow and form another tumour at that site. This is called a secondary cancer or metastasis.  
For a cancer to grow bigger than
the head of a pin, it must grow
its own blood vessels. This is
called angiogenesis.
 
The skin  
The skin has many important functions. It protects us from injury, cools us when we get too hot and prevents us from becoming dehydrated. The skin has two main layers. The top layer is called the epidermis.
This layer contains, among other things, melanocytes—cells that produce melanin, the substance that gives skin its colour. The layer underneath the epidermis is called the dermis. The dermis contains the roots of hairs, glands which make sweat and oil, blood and lymph vessels and nerves. top of page
 
     
Anatomy of the skin    
 
     
Skin cancer  
Like all body tissues, the skin is made of tiny ‘building blocks’ called cells. These cells can sometimes become cancerous, for example under the influence of ultraviolet (UV) radiation. The epidermis contains three different types of cells: squamous cells, basal cells and melanocytes. Skin cancers are named after the type of cell they start from. The three main types of skin cancer are basal cell cancer, squamous cell cancer and—the most serious skin cancer—melanoma. top of page  
       
  Melanoma  
  Melanoma develops from melanocytes (pigment cells). Melanoma usually occurs on parts of the body that have been sunburned. However, melanomas can sometimes start in parts of the skin or other parts of the body that have never been exposed to the sun. If detected early, most melanomas are curable. If they are not detected until later, they can become more serious. A melanoma may appear as a new spot on normal skin, or develop from an existing mole. Melanomas usually begin as a flat spot that changes in size or shape or colour over months. While they remain flat they are generally curable. They usually remain flat for six to 12 months. Later, melanomas become bigger, irregular in shape and often darker in colour. A less common type of melanoma (called nodular melanoma) is not flat, but is raised from the start. These melanomas are often pink or red, and grow quickly. Not all melanomas are dark or black in colour. top of page  
       
  Causes of Melanoma  
 

People can be at greater risk of melanoma if they have one or more of the following:
• large numbers of moles
• large, irregularly shaped and unevenly coloured moles called dysplastic naevi
• previous melanomas
• many severe sunburns
• other people in the family who have had melanoma (a ‘family history’).
Each time your unprotected skin is exposed to the sun’s UV radiation or other sources of UV radiation such as solariums, the UV radiation causes changes to take place in the structure of the cells and in what they do. 
Too much UV radiation causes the skin to become permanently damaged. The damage worsens with more UV radiation. The most important years for sun protection are during childhood. Sunburn and overexposure to UV radiation during these years greatly increase the chance of melanoma.
Melanoma is common in people with naturally fair complexions who are exposed to higher levels of UV radiation than their skin can protect them against. People with naturally darker skins (for example, Australian Aborigines and Torres Strait Islanders) are much better protected against UV radiation but can still get melanomas.

Australia has the highest rate of skin cancer in the world. Each year about 1700 people in Victoria are 
diagnosed with melanoma. Melanoma is diagnosed most often in older adults, but it also sometimes occurs in younger adults and occasionally in teenagers. It is rarely seen in children.
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  Diagnosis  
 

The first sign of a melanoma is usually the appearance of a new spot or a change in an existing freckle or mole. The change may be in size, shape and/or colour and the change is normally noticed over months rather than days. A normal freckle or mole is usually small and has an even colour and a smooth edge. 
A melanoma often has an irregular edge or surface. It becomes more uneven in colour than other moles and eventually multiple colours develop (brown, black, blue, red, white or grey). A freckle or mole that itches or bleeds is sometimes (but not always) a melanoma. A freckle or mole that becomes larger or irregular in shape may be a melanoma. It is quite normal for new moles to appear and change during childhood. However, as we progress into adulthood new moles become is less common and changes in moles are more suspicious for melanoma. Melanoma can occur anywhere on the body but the great majority occur in sites that have received sun exposure.
Melanoma is diagnosed by physical examination and biopsy. Your doctor will first examine the suspicious spot or mole and other spots and moles and ask about your risk factors for melanoma.
If your doctor suspects that you have melanoma, they will suggest that you have a biopsy.
This is a quick and simple procedure. It may be done by your family doctor, or you may be referred to a dermatologist or surgeon. The doctor will give you a local anaesthetic and then use a surgical instrument to remove the spot and some surrounding tissue. You may have a stitch or stitches to help the wound to heal. Sometimes only a part of the lesion may be sampled. The tissue that is cut out will be sent to a laboratory to be examined under a microscope. It will probably take around a week for the results of your tests to be ready, and a follow-up appointment may be arranged for you. This waiting period can be an anxious time and it may help to talk things over with a close friend or relative. If the cells are found to be cancerous, a wider safety margin is removed around the site of the melanoma.

 The diagnosis of melanoma prior to biopsy may be assisted by:

1. Dermoscopy is a method of examining skin lesions in greater detail to assess structures and pigment distribution beneath the surface of the skin. The dermoscope is a hand held device that has a magnifying lens and a light source. It is also possible to attach a dermoscope to a camera to obtain photographs of skin lesions which can be useful in detecting changes in lesions over time.

2. Confocal Microscopy  This instrument can examine the cellular structure of a mole or melanoma while it is still on the skin and assess changes in the shape and arrangement of cells that may indicate melanoma. It is used at the Victorian Melanoma Service to diagnose difficult lesions and to assess the extent of some melanomas.

 3. Total Body Photography A set of photographs of the skin surface of the whole body are taken and then used as a reference to detect changes in lesions and new lesions both for checking at home and at later review appointments.

4. Sequential Dermoscopy  Successive dermoscopic images of a lesion can be used to look for short term (3 month)
or long term (12 month) change to help with the diagnosis of melanoma. top of page
 
       
 

Measures to Assess Melanoma

 
 

Thickness
Tumour thickness is the most important measure of the risk associated with a primary melanoma. It is measures by the pathologist  when examining a melanoma biopsy. It is measured in millimeters from the skin surface to the deepest melanoma cell.

Level
Tumour level (or Clark level) is another measure of depth and assesses the tissue plane that the deepest part of the melanoma has reached. The levels go from I to V.

In Situ and Invasive
If your melanoma has been called in situ by the pathologist, abnormal cells are found only in the outer layer of skin cells (the epidermis) and have not penetrated deeper tissues (the dermis). In situ melanomas have no potential to spread or to be life threatening unless left in place and allowed to grow deeper.
Invasive melanomas have penetrated to the dermis. With greater depth of penetration of the dermis there is increasing risk of spread to other sites in the body via lymph or blood vessels.
Stage
Stage I (1): cancer is found in the epidermis and/or the upper part of the dermis but has not spread to nearby lymph nodes. The tumour is usually less than 1 mm thick. This stage also includes tumours up to 2 mm thick if they are not ulcerated.
Stage II (2): cancer has spread to the deeper part of the dermis but not into the tissue below the skin or into nearby lymph nodes. The tumour can be up to 4 mm thick.
Stage III (3): the tumour may be larger or smaller than 4 mm and/or may have spread to deeper layers of the skin. There may be additional tumour growths between the original tumour and the nearby lymph nodes; tumour cells may have spread to surrounding lymph nodes.

Stage IV (4): the tumour cells have spread to other organs or lymph nodes far away from the original tumour.

Your doctor will provide more information on the stage of your melanoma when discussing treatment. top of page
 
       
  Sentinel lymph node biopsy  
  In patients with tumours thicker than 1.0 mm, a sentinel lymph node biopsy may be used  to assess whether or not there has been spread to regional lymph nodes (the most common site of spread). This procedure involves the injection of radioactive dye in the region of the melanoma in order to identify the lymph node that is receiving the first lymphatic drainage from the site of the melanoma (the “sentinel” node). Once identified, it is excised and examined for melanoma cells. Sentinel lymph node biopsy can be associated with certain, usually minor, complications and requires a general anaesthetic. The procedure provides more information about whether spread has occurred but does not improve the chance of cure. The risks and benefits are explained to patients and they are encouraged to make their own decision as to whether it is something they would like to procede with. top of page  
       
  Other tests  
  If you have melanoma, your doctor may recommend other tests. This is generally if surgery is being planned or if there is evidence that the melanoma may have spread to other parts of the body. The tests include:
• blood tests: to check your general health
• scans: to see if the cancer has spread to other parts of your body. These may include ultrasound, a computerised tomography (CT) scan, a PET scan and/or a magnetic resonance imaging (MRI) scan. Not   everybody needs these additional tests. top of page
 
       
  Treatment  
 

Many years of treating cancer patients and testing different treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread, your general health, and what you want. Treatments for melanoma include surgery, radiotherapy and chemotherapy. Some new treatments are tested in clinical trials. You may have one of these treatments or a combination. 
For most people who develop melanoma, surgery is all that is required. top of page

Surgery
Melanomas are always removed surgically. The tumour is cut out and when the diagnosis of melanoma has been confirmed, another procedure is undertaken to remove an appropriate safety margin of normal-looking skin from around the melanoma. All melanomas need to be removed with a safety margin of normal skin. People with a melanoma which has grown deeper into the skin need a larger amount of skin to be cut out. This may be done under a local or a general anesthetic. It is generally done as a second procedure after the initial removal. This margin will vary from 5 millimeters to 2 centimeters according to the depth of the melanoma. The purpose is to remove any persisting melanoma in the surrounding skin and to prevent the melanoma growing back at the same site. top of page

Skin grafts
Sometimes a skin graft is required to cover the wound. For the graft, the surgeon will take a layer of skin from another part of your body and place it over the wound. The other possibility is to do a ‘flap’, where the surgeon will close the wound using a nearby flap of skin. Most people however will be able to have the skin sewn up without a graft or flap. top of page

After the operation
The wound will be covered with a dressing and left undisturbed for several days. It will then be checked to see if it is healing properly. If you had a skin graft, you will also have dressings on any area from which the skin was taken.
You may be uncomfortable for some days after your operation. If you have pain, tell your doctor or nurse. If you have a skin graft, the area where the skin is grafted on may be discoloured for months after the operation, but eventually the redness will fade. There is a risk of infection, haematoma and scarring following surgery for melanoma. Occasionally, the skin graft fails to take. If this happens to you, your doctor will explain what further treatment you will need. top of page

Lymph node biopsy and dissection
If there is suspicion that the melanoma might have spread to your lymph nodes, your doctor may recommend that you have a fine needle aspiration biopsy or sentinel lymph node biopsy (see above). In a fine needle aspiration biopsy, the doctor inserts a needle into the node suspected of being affected by cancer and draws tissue into the syringe. Sometimes this is done in conjunction with an ultrasound assessment of the lymph node. This tissue is then examined under a microscope to see if it contains cancer cells. Occasionally, a node is removed surgically (‘open biopsy’) so that the tissue can be examined. If cancer cells are found in the node/s, other nodes in the region may be surgically removed (‘dissected’) to eradicate melanoma in adjacent lymph nodes. top of page

Radiotherapy
Radiotherapy treats cancer by using radiation to kill or injure cancer cells. The radiation can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissue. You will probably have radiotherapy once a day from Monday to Friday, with a break at the weekend, over several weeks. The number of visits you need to make will depend on the size and type of the cancer and on your general health. The treatment itself only takes a few minutes, although you may need to wait before each treatment. Radiotherapy does not make you radioactive, so it is quite safe to be close to your partner, children and others during the course of treatment. Side effects of radiotherapy depend on the part of the body being treated. Radiotherapy for melanoma usually involves treatment to the skin and nearby lymph nodes. Side effects may include reddening of the skin. Others may occur, depending on where your treatment is. Talk with your doctor or the radiotherapy staff about any possible side effects and how to manage them. top of page

When cancer can’t be cured
If your cancer has spread and it is not possible to cure it by surgery, your doctor may still recommend treatment. 
In this case, treatment may help relieve any symptoms, can make you feel better and may allow you to live longer.
Whether or not you choose to have anti-cancer treatment, symptoms can still be controlled. For example, if you have pain, there are effective treatments for this. General practitioners, specialists and palliative care teams in hospitals all play important roles in helping people with cancer. For further information, contact the Cancer Helpline on 13 11 20 or Palliative Care Victoria on 9662 9644.top of page

Chemotherapy
Chemotherapy is the treatment of cancer with anti-cancer drugs. The aim is to kill cancer cells while doing the least
possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves. In melanoma, chemotherapy is used as palliative treatment to try to control the growth of the cancer. Chemotherapy usually does not cure melanoma. Chemotherapy is usually given by injecting the drugs into a vein (intravenous treatment). There are other types of chemotherapy, including tablets, which may be suitable for you. Some drugs used in chemotherapy can cause side effects. They may include feeling sick (nausea), vomiting, feeling unwell and tired, and some thinning or loss of hair from your body and head. Generally, these side effects are temporary and can be prevented or reduced. These days, new treatments are available that can help to make many side effects of chemotherapy much less severe than they were several years ago. top of page

 
       
  Prognosis  
  Melanoma is most likely to be cured when the cancer is treated in its early stages. More than 85% of people with melanoma diagnosed 15 years ago are alive and well today with no sign of the disease. This percentage has grown steadily over the years with early detection and treatment, so more people can expect to be cured. Other factors can influence your prognosis. For example, melanomas on the arms or legs have a better prognosis than those on the trunk, head or neck. Overall, women seem to fare better than men, although it is unclear just why this is so. You will need to talk with your doctor about your own prognosis. Your medical history is unique, so you will need to discuss with someone who knows your medical history what you can expect and the treatment options that are best for you. top of page  
       
  Follow up - the risk of further Melanoma  
  Most people treated for early melanoma do not have further trouble with the disease. However, when there is a chance that the melanoma may have spread to other parts of your body, you will need regular check-ups. Your doctor will decide how often you will need check-ups: everyone is different. They will become less frequent if you have no further problems. At least a yearly examination by a doctor is recommended, as people who have had one melanoma are at increased risk of another in the future. top of page  
       
  Protect your skin  
 

After treatment for melanoma, it is important to avoid strong sunlight. The following steps are sensible guidelines for everyone. Whenever UV radiation levels reach 3* (moderate) and above, sun protection is required. At that level UV radiation is intense enough to damage the skin and contribute to the risk of skin cancer.

In Victoria from September to April, UV radiation levels are 3 and above for most of the day. Particular care should be taken between 10am and 2 pm (11 am and 3 pm daylight saving time) when UV radiation levels reach their peak. The SunSmart UV Alert is issued by the Bureau of Meteorology when the UV Index is forecast to reach 3 and above. It is reported in most daily newspapers and some television and radio weather forecasts across Australia.
To protect against skin damage and skin cancer when the UV level is 3 and above, use a combination of five sun protection measures:

1 Seek shade.
2 Wear clothing that covers as much skin as possible.
3 Wear hats that protect the face, ears and neck.
4 Wear wrap-around sunglasses that meet the Australian Standard 1067 (sunglasses category 2, 3 or 4).
5 Use SPF 30+ broad spectrum, water resistant sunscreen, and reapply it every two hours.

From May to August, UV radiation levels in Victoria are usually low (below 3). Therefore, sun protection measures are not necessary during these months unless you are in alpine regions, or near highly reflective surfaces like snow or water. top of page
 
       
  Making decisions about treatment  
 

Sometimes it is hard to decide which is the right treatment for you. You may feel that everything is happening so fast that you do not have time to think things through. Waiting for test results and for treatment to begin can be very difficult. While some people feel they have too much information, others may feel that they do not have enough. You need to make sure that you know enough about your illness, the possible treatment and side effects to make your own decisions. If you are offered a choice of treatments, you will need to weigh up the good and bad points about each treatment. If only one type of treatment is recommended, ask your doctor to explain why other treatment choices have not been advised. Some people with advanced cancer will always choose treatment, even if it only offers a small chance of cure. Others want to make sure that the benefits of treatment outweigh any side effects. Still others will choose the treatment they think offers them the best quality of life. Some may choose not to have treatment except to have any symptoms managed to maintain the best possible quality of life.

You may want to see your doctor a few times before making a final decision on treatment. It is often hard to take everything in, and you may need to ask the same questions more than once. You always have the right to find out what a suggested treatment means for you, and the right to accept or refuse it. top of page
 
       
  Talking with others  
  Once you have talked about treatment options with your doctor, you may want to talk them over with family or friends, with nursing staff, the hospital social worker or chaplain, or your own religious or spiritual adviser. Talking it over can help to sort out which course of action is right for you. You may be interested in looking for information about melanoma on the Internet. While there are some very good websites, you need to be aware that some websites provide wrong or biased information. top of page  
       
  The Role of Immunotherapy  
  Immunotherapy is the use of drugs which stimulate the body to fight infection. It is being researched as a possible future treatment in melanoma to stimulate the body’s normal cells to attack cancer cells. Clinical trials are testing the possible effectiveness of immunotherapy in treating melanoma. Your medical oncologist will be able to discuss these trials with you. top of page  
       
  Taking part in clinical trials  
  You may consider taking part in a clinical trial. Clinical trials are a vital part of the search to find better treatments for cancer. Doctors conduct clinical trials to test new or modified treatments and see if they are better than existing treatments. Many people all over the world have taken part in clinical trials that have resulted in improvements to cancer treatment. However, the decision to take part in a clinical trial is always yours. If you are considering taking part in a clinical trial, make sure that you fully understand the reasons for the trial and what it means for you. Before deciding whether or not to join the trial, you may wish to ask your doctor:

• Which treatments are being tested and why?
• Which tests are involved?
• What are the possible risks or side effects?
• How long will the trial last?
• Will I need to go into hospital for treatment?
• What will I do if any problems occur while I am in the trial?


If you decide to join a randomised clinical trial, you will be given either the best existing treatment or a promising new treatment. You will be allocated at random to receive one treatment or the other. In clinical trials, people’s health and progress are carefully monitored. If you do join a clinical trial, you have the right to withdraw at any time. Doing so will not affect your treatment for cancer. It is always your decision to take part in a clinical trial. If you do not want to take part, your doctor will discuss the best current treatment choices with you. top of page
 
       
  Acknowledgement    
  Much of this material was taken from a patient information publication of Cancer Council Victoria entitled “Melanoma”. We are grateful for their cooperation in allowing this material  to be reproduced here. top of page  
       
  Victorian Melanoma Service : the Alfred Hospital, Commercial Rd Prarhan
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