Melanoma Skin Cancer

MELANOMA SKIN CANCER
What Is Cancer?
Cancer develops when cells in a part of the body begin to grow out of control. Although there are many kinds of cancer, they all start because of out-of-control growth of abnormal cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide more rapidly until the person becomes an adult. After that, cells in most parts of the body divide only to replace worn-out or dying cells and to repair injuries. Because cancer cells continue to grow and divide, they are different from normal cells. Instead of dying, they outlive normal cells and continue to form new abnormal cells. Cancer cells often travel to other parts of the body where they begin to grow and replace normal tissue. This process, called metastasis, occurs as the cancer cells get into the bloodstream or lymph vessels of our body. When cells from a cancer like breast cancer spread to another organ like the liver, the cancer is still called breast cancer, not liver cancer. Cancer cells develop because of damage to DNA. This substance is in every cell and directs all its activities. Most of the time when DNA becomes damaged the body is able to repair it. In cancer cells, the damaged DNA is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times though, a persons DNA becomes damaged by exposure to something in the environment, like smoking. Cancer usually forms as a tumor. Some cancers, like leukemia, do not form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow. Remember that not all tumors are cancerous. Benign (noncancerous) tumors do not spread to other parts of the body (metastasize) and, with very rare exceptions, are not life-threatening. Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind cancer. Cancer is the second leading cause of death in the United States. Half of all men and one-third of all women in the U.S. will develop cancer during their lifetimes. Today, millions of people are living with cancer or have had cancer. The risk of developing most types of cancer can be reduced by changes in a person's lifestyle, for example, by
2002 American Cancer Society
Melanoma Skin Cancer 1/4/02
quitting smoking and eating a better diet. The sooner a cancer is found and treatment begins, the better are the chances for living for many years.
What Is Melanoma Skin Cancer?

About Normal Skin The skin is the largest organ in your body. It covers the internal organs and protects them from injury, serves as a barrier between microbes such as bacteria and internal organs, and prevents the loss of too much water and other fluids. The skin regulates body temperature and helps rid your body of excess water and salts. Certain cells in your skin communicate with your brain and allow you to feel sensations of temperature, touch, and pain. The skin has 3 layers called the epidermis, dermis, and subcutis. The top layer is the epidermis. The epidermis is very thin, averaging only 0.2 mm (about 1/100 of an inch). It protects the deeper layers of skin and the organs of the body from the environment.
The outermost part of the epidermis is called the stratum corneum, or horny layer. It is composed of dead keratinocytes (the main type of cell of the epidermis) that are continually shed. Below the stratum corneum are layers of living keratinocytes, also called squamous cells. These cells form an important protein called keratin. Keratin contributes to the skin's ability to protect the rest of the body. The lowest part of the epidermis, the basal layer, is formed by basal cells. These cells continually divide to
form new keratinocytes, which replace older keratinocytes that wear off the skin's surface. Melanocytes are also present in the epidermis. These skin cells produce the protective pigment called melanin. Melanin gives a tan or brown color to the skin and helps protect the deeper layers of the skin from the harmful effects of the sun. The basement membrane separates the epidermis from the deeper layers of skin. The middle layer of the skin is called the dermis. The dermis is much thicker than the epidermis. It contains hair follicles, sweat glands, blood vessels, and nerves that are held in place by a protein called collagen. Collagen, which is made by skin cells called fibroblasts, gives the skin its resilience and strength. The deepest layer of the skin is called the subcutis. The subcutis and the lowest part of the dermis form a network of collagen and fat cells. The subcutis conserves heat and has a shock-absorbing effect that helps protect the body's organs from injury. Skin Tumors Skin cancers are divided into 2 general types: melanoma and non-melanoma skin cancers. Non-melanoma skin cancers (usually basal cell and squamous cell cancers) are the most common cancers of the skin. They are called non-melanoma because they develop from skin cells other than melanocytes. Because they rarely metastasize (spread elsewhere in the body) they are treated differently. Nonmelanoma skin cancers are discussed in another American Cancer Society document. Melanoma is a cancer that begins in the melanocytes, the cells that produce the skin coloring or pigment known as melanin. Other names for this cancer include malignant melanoma, melanoma skin cancer, and cutaneous melanoma. Because most melanoma cells still produce melanin, melanoma tumors are often brown or black. Melanoma is much less common than basal cell and squamous cell skin cancers, but it is far more serious. Melanoma most often appears on the trunk of fair-skinned men and on the lower legs of fair-skinned women, but people with other skin types and other areas of the skin are commonly affected. Having darkly pigmented skin lowers your risk but it is not a guarantee that you will not develop melanoma. People with darker skin can deve lop this cancer on the palms of the hands, soles of the feet, and under the nails. Rarely, melanomas can form in parts of your body not covered by skin such as the eyes, mouth, vagina, large intestine, and other internal organs. Melanoma, like basal cell and squamous cell cancers, is almost always curable in its early stages. However, melanoma is much more likely than basal or squamous cell cancer to metastasize (spread) to other parts of the body.
Most tumors of the skin are not cancerous and rarely if ever turn into cancers. Moles are benign skin tumors that develop from melanocytes. See the section "What are the Risk Factors for Melanoma Skin Cancer?" for more information about moles. Benign tumors that develop from other types of skin cells include seborrheic keratoses (tan, brown, or black raised spots with a "waxy" texture or rough surface), hemangiomas (benign blood vessel growths often called strawberry spots or port wine stains), lipomas (soft growths of benign fat cells), and warts (rough-surfaced growths caused by a virus).
What Are the Key Statistics About Melanoma Skin Cancer?

Cancer of the skin is the most common of all cancers. Melanoma accounts for about 4% of skin cancer cases, but causes about 79% of skin cancer deaths. The American Cancer Society estimates that about 53,600 new melanomas will be diagnosed in the United States during 2002. The number of new melanomas diagnosed in the United States is increasing. Since 1973, the incidence rate for melanoma (the number of new melanomas diagnosed per 100,000 people each year) has more than doubled from 5.7 to 14.3. About 7,400 people in the US are expected to die of melanomas during 2002. Since 1973, the mortality rate for melanoma (the number deaths from melanoma per 100,000 people each year) has increased by about 44%, from 1.6 to 2.3. The good news is that melanoma mortality rates have remained stable during the past 10 years.
What Are the Risk Factors for Melanoma Skin Cancer?

A risk factor is anything that increases a person's chance of getting a disease such as cancer. Different cancers have different risk factors. Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, and several other organs. But having a risk factor, or even several, does not mean that a person will get the disease. The main risk factors for developing melanoma are: Moles A nevus (the medical name for a mole) is a benign (noncancerous) melanocytic tumor. Moles are not usually present at birth, but begin to appear in children and teenagers. Having certain types of moles makes a person more likely to develop melanoma. One type of mole that increases the risk of melanoma is the dysplastic nevus or atypical mole. Dysplastic nevi (nevi is the plural of nevus) look a little like normal moles, but also typically look a little like melanoma. Refer to the section "Can Melanoma Skin Cancer be Found Early?" for descriptions of the appearance of
moles and melanomas. The moles can appear in areas that are exposed to the sun as well as those areas that are usually covered, such as the buttocks and scalp. They are often larger than other moles. Some people have many dysplastic nevi. Dysplastic nevi often run in families. If you have family members with dysplastic nevi you have about a 50% chance of developing these nevi. Someone with one or more dysplastic nevi and with at least 2 close relatives with melanoma has a 50% or greater risk of developing melanoma. Lifetime melanoma risk is estimated to be between 6% and 10% for those with dysplastic nevi, depending on age, family, history, the number of dysplastic nevi, and other factors. Moles present at birth are called congenital melanocytic nevi. The average lifetime risk of developing melanoma may be about 6% for people with congenital melanocytic nevi. However, this risk is affected by the size of a congenital nevus. People with large congenital nevi have a greater risk, while the risk is smaller for those with small nevi.
The lifetime melanoma risk for the overall United States population is about 1.4%. Moles that are not dysplastic or congenital are not likely to turn into a melanoma. However, people with lots of moles and those who have some large moles have an increased risk for melanoma. Fair Skin, Freckling and Light Hair The risk of melanoma is about 20 times higher for whites than for African Americans. This is due to the protective effect of skin pigment. Whites with red or blond hair and fair skin that freckles or burns easily are at especially high risk. Darkly pigmented people can also develop melanoma, particularly on the palms of the hands, on the soles of the feet, under the nails, inside the mouth, and, rarely, in internal organs. Family History Risk of melanoma is greater if one or more of a person's first degree relatives (mother, father, brother, sister, child) have been diagnosed with melanoma. Depending on the number of affected relatives, the risk can be up to eight times greater than that of persons without a family history of melanoma. Around 10% of all people with melanoma have a family history of melanoma. Immune Suppression People who have been treated with medicines that suppress the immune system, such as organ transplant patients, have an increased risk of developing melanoma. Excessive Exposure to Ultraviolet (UV) Radiation and Sunburn
The main source of UV radiation is sunlight. Tanning lamps and booths are another source. People with excessive exposure to light from these sources are at greater risk for skin cancer, including melanoma. The amount of UV exposure depends on the intensity of the light, length of time the skin was exposed, and whether the skin was protected with clothing and sunscreen. If you have had severe, blistering sunburns, particularly in you childhood or teenage years, you also have an increased risk of developing melanoma. Intermittent, intense exposures are more associated with melanoma risk than lower level, chronic exposures, even if the total dose of UV is the same. Age About half of all melanomas occur in people over the age of 50. However, young people (ages 20 to 30) can also be diagnosed with melanoma. In fact, melanoma is one of the most common cancers in people less than 30 years of age. Familial melanoma occurs at a younger age. Xeroderma Pigmentosum Xeroderma pigmentosum ( XP) is a rare, inherited condition resulting from a defect in an enzyme that repairs damage to DNA. People with XP have a high risk for both melanoma and nonmelanoma skin cancers. Because people with XP are less able to repair DNA damage caused by sunlight, they can develop many cancers on sunexposed areas of their skin. These facts help explain the connection between sunlight and skin cancer.
Do We Know What Causes Melanoma Skin Cancer?

DNA is the genetic material in our cells. It passes along genetic information to the next generation, making children resemble their parents, for example. In addition to information about hair color, facial features, and other aspects of our outward appearance, DNA also contains information that tells the cells of o ur body how to grow and how to perform the metabolic activities needed for life. Ultraviolet (UV) radiation can damage DNA. Most melanomas have abnormalities in their chromosomes, which is where the DNA is found. This damage makes the DNA less able to control how and when cells grow and divide. In some situations, this results in the formation of a cancer. Most ultraviolet radiation comes from sunlight, but some may come from artificial sources, such as tanning booths. Some of this exposure may have occurred within the few years before the beginning of the cancer. However, much of it may be due to exposures that happened many years earlier. Children and young adults often receive a lot of intense ultraviolet sun exposure that may not result in an actual cancer for many years or even decades.
Scientists continue to study connections between DNA and melanoma. They have found the DNA of certain genes is often damaged in melanoma cells. Most of these DNA changes are not inherited. Instead they may be the result of damage caused by sunlight. In the future, better understanding of the way these DNA changes lead to melanoma might be used in gene therapy to overcome or repair that damage. DNA changes found in some melanomas may be inherited. Inheriting certain mutant (abnormal) genes from one parent can increase a person's risk of developing melanoma. Scientists are working on a blood test for one of these genes. For information about current research, see the section "What's New In Research and Treatment of Melanoma Skin Cancer?" Although most nevi (moles) never turn into a melanoma, some do. Researchers have found some changes that occur in benign nevus cells can cause transformation into melanoma cells. However, we still don't know exactly why some nevi become malignant or why having many moles or atypical moles increases your risk of developing melanoma.
Can Melanoma Skin Cancer Be Prevented?

The most important ways to lower the risk of melanoma are to avoid being outdoors in intense sunlight too long, and to practice sun safety when you are outdoors. You can maintain your level of physical activity and practice sun safety at the same time. Practicing sun safety includes: Seeking shade - The simplest and most effective way to limit exposure to ultraviolet light is to avoid being outdoors in sunlight too long. This is particularly important in the middle of the day when ultraviolet light is most intense. Protecting your skin with clothing -You can protect most of your skin with clothing, including a shirt with long sleeves and a hat with a broad brim. Fabric with a tight weave generally provides the best sun protection. Using sunscreen - Sunscreens with a SPF factor of 15 or more should be used on areas of skin exposed to the sun, particularly when the sunlight is strong. Always follow directions when applying sunscreen. To work best, you should apply sunscreen before you go outside, use it thickly on all sun-exposed skin, and reapply it every two hours. A one -ounce application (a palmful of sunscreen) is recommended. Many sunscreens wear off with sweating and swimming and must be reapplied for maximum effectiveness. Use sunscreen even on hazy days or days with light or broken cloud cover because the UV light still comes through. Sunscreen should not be used to gain extra sun exposure time. Sunscreen will not prevent melanoma, it just reduces the amount of UV light exposure. Researchers have found that many people will use sunscreens to let them stay out in the sun longer. This results in the same amount of UV light exposure as if
they hadn't used sunscreen at all and doesn't reduce their risk. All excessive sun exposure is unhealthy. Sunscreen should only be used to protect against normal sun exposure. Wearing sunglasses - Wrap-around sunglasses with 99%-100% UV absorption provide the best protection for the eyes and the skin area around the eyes. Avoiding other sources of UV light - The use of tanning beds and sun lamps is hazardous because the ultraviolet radiation they deliver can damage your skin. Therefore, you shouldnt use them. There is growing evidence that they may increase your risk of developing melanoma. This is an area of active research. Being especially careful about sun protection for children - Children require special attention. Parents should protect them from excess sun exposure by using the measures described above. Older children need to be cautioned about sun exposure as they become more independent. It is important, particularly in high sun exposure parts of the world, to develop the habit of using sunscreen whenever you go outdoors and may be exposed to large amounts of sunlight. Identifying abnormal moles and having them removed - As noted in the section "What Are The Risk Factors For Melanoma Skin Cancer?" certain types of moles ha ve an increased risk of developing into a melanoma. Depending on the appearance of these moles, your doctor may monitor them closely by periodic examinations or may remove them if they have certain features that suggest they may be changing into a melanoma. Routine removal of many moles is not generally recommended as a way to prevent melanoma. If you have many moles, careful periodic examination by a dermatologist, in combination with monthly skin self-examination, is recommended. Any changing mole should be checked by a doctor who is experienced in recognizing skin cancers. See the section on "Can Melanoma Be Found Early?" for information on how to recognize suspicious moles and melanoma. Learning more about skin cancer prevention - Many organizations conduct skin cancer prevention activities in schools and recreational areas. Others distribute informational brochures and public service announcements. For more information, refer to the section "Additional Resources."
Can Melanoma Skin Cancer Be Found Early?

Melanoma can be found early. Everyone can play an important role in finding skin cancer early, when it is curable. Part of a routine cancer-related checkup should include a skin examination by a health care professional qualified to diagnose skin cancer. Doctors should be willing to discuss any reservations patients might have about this examination. The American Cancer Society recommends a cancer-related checkup,
including a skin examination, every 3 years for people between 20 and 40 years of age, and every year for anyone age 40 and older. It's also important to check your own skin, preferably once a month. You should know the pattern of moles, blemishes, freckles, and other marks on your skin so that you'll notice any changes. Self-examination is best done in front of a full-length mirror. A hand-held mirror can be used for areas that are hard to see. A spouse or other partner may be able to help you with these examinations, especially for those hard-to-see areas, like the lower back or the back of your thighs. All areas should be examined, including the palms and soles, the lower back, and the back of the legs. Be sure to show your doctor any area that concerns you. Friends and family members can also help by telling one another about abnormal-appearing areas of skin. Be sure to ask your doctor to look at areas that may be hard for you to see. About 1 of every 3 melanomas in men are on the back. Spots on the skin that are changing in size, shape, or color should be evaluated promptly. Any unusual sore, lump, blemish, marking, or change in the way an area of the skin looks or feels may be a sign of skin cancer or a warning that it might occur. The skin might become scaly or crusty or begin oozing or bleeding. It may feel itchy, tender, or painful. Redness and swelling may develop. Since moles may develop into melanoma or indicate an increased risk for melanoma, it is important to know the difference between melanoma and an ordinary mole. Sometimes this may be difficult to tell -- show your doctor any mole that you are unsure of. A normal mole is generally an evenly colored brown, tan, or black spot on the skin. It can be either flat or raised. It can be round or oval. Moles are generally less than 6 millimeters ( inch) in diameter (about the width of a pencil eraser). A mole can be present at birth or it can appear during childhood or young adulthood. Several moles can appear at the same time, especially on areas of the skin exposed to the sun. Once a mole has developed, it will usually stay the same size, shape, and color for many years. Moles may eventually fade away in older people. Most people have moles, and almost all moles are harmless. But it is important to recognize changes in a mole that can suggest a melanoma may be developing. Signs and Symptoms of Melanoma The ABCD rule can help distinguish a normal mole from a melanoma. Asymmetry: One half of the mole does not match the other half. Border irregularity: The edges of the mole are ragged or notched.
Color: The color over the mole is not the same. There may be differing shades of tan, brown, or black, and sometimes patches of red, blue, or white. Diameter: The mole is wider than 6 millimeters (about inch) although in recent years doctors are finding more melanomas between 3 and 6 millimeters. Other important signs of melanoma include changes in size, shape, or color of a mole. Some melanomas do not fit the ABCD rule described above, so it is particularly important for you to be aware of changes in skin lesions.
How Is Melanoma Skin Cancer Diagnosed?

If the abnormal appearance of an area of your skin raises the possibility of skin cancer, additional medical examinations and tests will be used to be sure whether this is melanoma or nonmelanoma skin cancer or some other skin condition. History and Physical Examination Usually the first step is for your doctor to take your medical history (questions about symptoms and risk factors). The doctor probably will ask about your age, when the mark on the skin first appeared, and whether it has changed in size or appearance. You may also be asked about past exposures to known causes of skin cancer, and whether anyone in your family has had skin cancer. During the physical examination, your doctor will note the size, shape, color, and te xture of the area in question, and whether there is bleeding or scaling. The rest of your body will be checked for spots and moles that may be related to skin cancer. The doctor may also examine lymph nodes in the groin, underarm, or neck areas near the abnormal area of skin. Enlarged lymph nodes might suggest the spread of a melanoma. Types of Skin Biopsy If the doctor thinks a melanoma might be present, he or she will take a sample of skin from the suspicious area for examination under a microscope. This is called a skin biopsy. Different methods can be used for a skin biopsy. The choice depends on the size of the affected area and its location on your body. Any biopsy is likely to leave a scar. Since different methods produce different types of scars, you should ask the doctor about biopsies and scarring before the procedure is done. All skin biopsy samples are examined under a microscope. The skin sample is sent to a pathologist, a doctor who has been specially trained in the microscopic examination a nd diagnosis of tissue samples. Often, the skin sample is sent to a dermatopathologist, a dermatologist or pathologist who has additional training in making diagnoses from skin
samples and may be more experienced with certain skin cancers than a general pathologist. All skin biopsies are performed using a local anesthetic. You will feel a small needle stick and a little burning with some pressure for less than a minute, but no pain. Shave biopsy: After numbing the area with a local anesthetic, the doctor "shaves" off the top layers of the skin (the epidermis and the most superficial part of the dermis) with a surgical blade. A shave biopsy is useful in diagnosing many types of skin diseases and in treating benign moles. But, it is not recommended if a melanoma is suspected, because a shave biopsy sample may not be thick enough for accurate measurement of the melanoma depth of invasion. Punch biopsy: A punch biopsy removes a deeper sample of skin. The doctor uses a punch biopsy tool that looks like a tiny round cookie cutter. Once the skin is numbed with a local anesthetic, the doctor rotates the punch biopsy tool on the surface of the skin until it cuts through all the layers of the skin, including the dermis, epidermis, and the upper parts of the subcutis. This is usually not recommended for suspected melanomas. Incisional and excisional biopsies: If the doctor has to examine a tumor that has grown into the deeper layers of the skin, he or she will perform an incisional or excisional biopsy. A surgical knife is used to cut through the full thickness of skin. A wedge or ellipse of skin is removed for further examination, and the edges of the wound are sewn together. An incisional biopsy removes only a portion of the tumor. Removal of the entire tumor is called an excisional biopsy. Both types of biopsies can be done using local anesthesia. Excisional biopsy is the method usually preferred when melanoma is suspected. Diagnosis of Metastatic Melanoma Although many melanomas are completely cured, some melanomas spread so quickly that a patient can have large masses of melanoma in the lymph nodes, lungs, brain, gastrointestinal tract, or liver while the original skin melanoma is still small. Melanoma that has spread to other parts of the body may not be detectable until long after the original melanoma was removed from the skin. When such spread has occurred, the metastatic melanoma in certain organs might be confused with a cancer starting in that organ. For example, melanoma that has spread to the lung might be confused with a primary lung cancer (cancer that starts in the lung). There are special tests that can be done on biopsy samples that can tell whether it is a melanoma or some other kind of cancer. This is important because different cancers are often given different treatments.
How Is Melanoma Skin Cancer Staged?
Staging is a process of finding out how widespread a cancer is. This includes describing its size as well as if it has spread to any other organs. A staging system is a standard way of summarizing how far a cancer has spread. The system used most often to stage melanoma is the TNM system. In this system, each cancer is given a T category, an N category, and an M category. The T category is based on the tumor's thickness and whether it is ulcerated (the layer of skin covering the melanoma is absent). The N category reflects whether the melanoma has spread to lymph nodes (small bean-shaped collections of immune system cells that help the body fight infections and cancers) near the melanoma. The N category also reflects whether the melanoma cells have begun to spread to lymph nodes and are found in the lymphatic channels connecting to the lymph nodes. The M category indicates whether there are metastases to distant organs.
In TNM staging, information about the tumor, lymph nodes, and metastasis is combined according to a process called stage grouping to assign a stage. The stage is described using 0 and Roman numerals from I to IV. Several tests and procedures are used to gather information about a melanoma and whether it has spread to lymph nodes and distant organs. This information is used to assign T, N, and M categories and a grouped stage. Examination of the Skin Biopsy It is important to measure the size of a melanoma under a microscope because measuring its thickness is believed to be the best way to determine the patient's prognosis (the outlook for chances of survival). The pathologist examining the skin biopsy specimen measures the thickness of the melanoma under the microscope with a device called a micrometer, which is like a small ruler. This technique is called the Breslow measurement. The thinner the melanoma, the better the prognosis. In general, melanomas less than 1 millimeter (mm) in depth (about 1/25 of an inch or the diameter of a period or a comma), have a very small chance of spreading. As the melanoma becomes thicker, it has a greater chance of spreading. The thickness of the melanoma also guides the choice of treatment. Another system describes the thickness of a melanoma in relation to its penetration into the skin instead of actually measuring it. The Clark level of a melanoma uses a scale of I to V (with higher numbers indicating a deeper melanoma) to describe: If the cancer stays in the epidermis (Clark leve l I) If the cancer has begun to penetrate to the upper dermis (Clark level II) If the cancer involves most of the upper dermis (Clark level III) If the cancer has penetrated to the lower dermis (Clark level IV)
If the cancer has penetrated very deeply, to the subcutis (Clark level V).
In the newest classification, the Breslow measurement of thickness has displaced the Clark level of penetration as the first prognostic factor. This is because the thickness measurement is easier and depends less on the pathologist's judgment. Sometimes, however, the Clark level tells us a melanoma is more advanced than we may think it is from the Breslow measurement. Because of this, both systems may be used to describe a melanoma. In either system, the melanoma is said to have a worse prognosis if the pathologist says it is ulcerated (covering layer of skin is absent). Procedures and Tests to Detect Metastases Fine needle aspiration biopsy: A fine needle aspiration (FNA) biopsy uses a syringe with a thin needle to remove very small tissue fragments from a tumor. The needle is smaller than the needle used for a blood test. A local anesthetic is sometimes used to numb the area. This test rarely causes much discomfort and does not leave a scar. It is not used for diagnosis of a suspicious mole, but may be used to biopsy large lymph nodes near a melanoma to find out if the melanoma has metastasized (spread). Sometimes a computed tomography (CT) scan (a special type of x-ray) is used to guide a needle into a tumor in an internal organ, such as the lung or liver. This test can be used if the doctor suspects the melanoma has spread to these organs. Surgical (excisional) lymph node biopsy: This procedure involves removing an abnormally large lymph node surgically, through a small skin incision. Local anesthetic is generally used. This is often done if a lymph node's size suggests spread of melanoma, but the FNA did not find any melanoma cells. Sentinel lymph node biopsy: This is a new and very promising procedure. It is not yet standardized, so different doctors may disagree about when to use the sentinel node biopsy. This procedure can find the lymph nodes that drain lymph fluid from the area of the skin where the melanoma developed. These lymph nodes will then be checked for any spread of melanoma, because if the melanoma does spread, these lymph nodes will be the first place it will go. A surgeon injects a small amount of either a harmless blue dye or radioactive chemical into the site of the melanoma. After about an hour, the lymph nodes are checked to find which one is draining lymph fluid from the skin near the melanoma. If blue dye has been used, it will be visible. A small Geiger counter will be used if radioactive tracer chemical has been injected. When the appropriate lymph node (it will be blue or radioactive), called the sentinel node, has been found, it will be removed for microscopic examination. If melanoma cells are found in this lymph node, the remaining lymph nodes in this area are surgically removed. If the sentinel node does not contain melanoma cells, further lymph node surgery can be avoided.
If a lymph node near a melanoma is abnormally large, a sentinel lymph node biopsy is usually not done. Instead, a FNA or surgical biopsy of that lymph node is done. Imaging Tests X-rays: Sometimes the doctor will order x-rays of the chest to look for any spread of the melanoma. Computed tomography (CT): If your doctor suspects there is metastatic melanoma elsewhere, he or she may order CT scans of the brain or other parts of the body. CT uses multiple x-rays images from various angles, which are combined by a computer to produce a detailed cross-sectional view of the body. Magnetic resonance imaging (MRI): MRI is like a CT scan in that it produces cross sectional images of the body. Unlike CT, MRI also produces longitudinal sections of the body, and does not use x-rays. Instead, a large magnetic coil is used that energizes molecules to produce an image. Nuclear scans: In this procedure a radioactive chemical (in very low doses) is injected into a vein. The radioactivity over the body or part of the body is detected with a special type of camera. If the melanoma has spread to bones or liver, the scan will often detect this spread. Descriptions of Grouped Stages These descriptions are based on current TNM staging definitions. A new staging system was proposed for the year 2000 but not yet officially adopted, and is described in parentheses and Italics. Stage 0: The melanoma is in situ, meaning that it involves the epidermis but has not spread to the dermis. This is also called Clark level I. (New system -- unchanged.) Stage I: Based on the Breslow measurement, the melanoma is a low-risk tumor (less than 1 mm or about 1/16 inch in thickness). Using the Clark system, this can be level II or III. It appears to be localized in the skin, and has not been found in lymph nodes or distant organs. (New system --Breslow thickness is less than 2 mm without ulceration and less than 1 mm with ulceration. The melanoma doesn't involve lymph nodes or distant organs.) Stage II: The melanoma has a Breslow thickness of greater than 1 mm (about 1/16 inch), or it can have a Clark level of IV or V. It still appears to be localized to the skin and has not been found in lymph nodes or distant organs.
(New system -- Breslow thickness can be any thickness greater than 1 mm with ulceration or any thickness greater than 2 mm without ulceration and the melanoma doesn't involve lymph nodes or distant organs.) Stage III: The melanoma has spread to lymph nodes near the affected skin area. There is no distant spread. The thickness of the melanoma is not considered, although it is usually thick in people with stage III melanoma. Stage IV: The melanoma has spread beyond the original area of skin and the nearby lymph nodes to other organs, such as the lung, liver, or brain, or to distant areas of the skin or lymph nodes. Neither the lymph node status nor thickness is considered, but in general, the melanoma will be thick and will have spread to lymph nodes. Survival Rates by Stage The 5-year survival rate refers to the percent of patients who live at least 5 years after their cancer is diagnosed. Many of these patients live much longer than 5 years after diagnosis, and 5-year rates are used to produce a standard way of discussing prognosis. Five-year relative survival rates for melanoma indicate that the patient died of the melanoma and not some other disease. This is considered to be a more accurate way to describe the prognosis for people with a particular type and stage of cancer. Of course, 5-year survival rates are based on patients diagnosed and initially treated more than 5 years ago. Improvements in treatment often result in a more favorable outlook for recently diagnosed patients. The 5-year relative survival rate for stage 0 melanoma is 97%. The 5-year survival rate for stage I melanoma is more than 90%. The 5-year relative survival rates of stages II and III are about 80% and 50%, respectively. The 5-year survival rate for stage IV melanoma is about 20%.
How Is Melanoma Skin Cancer Treated?

Types of Surgery for Melanoma Skin Cancer Simple excision: Thin melanomas can be completely cured by a relatively minor surgery called simple excision. The tumor is cut out, along with a small amount of normal, noncancerous skin at the edges. This differs from an excisional biopsy in which the margins are wider because the diagnosis is already known. The normal, healthy skin around the edges of the cancer is referred to as the margin. The wound is carefully stitched back together. This will leave a scar. Re-excision (wide excision): When the diagnosis of melanoma is established by biopsy, the site will need to be excised again. More skin will be cut away from the
melanoma site and the tissue from the final excision will be examined to make sure that no cancer cells remain in the skin. Amputation: If the melanoma is on a finger or toe, the treatment is to amputate as much of that digit as is necessary. At one time, some melanomas of the arms a nd legs were also treated by amputation, but this is no longer done. Studies have demonstrated that wide excision of arm and leg melanomas is as effective as amputation. Therapeutic lymph node dissection: After the diagnosis of melanoma is made, the physician will examine the lymph nodes nearest the melanoma. If these lymph nodes feel abnormally hard or large, a therapeutic lymph node dissection may be performed. This procedure removes most of the lymph nodes in the area of the melanoma, and they will be e xamined microscopically to see whether melanoma cells have spread there. A fine needle aspiration biopsy (FNA) or excisional lymph node biopsy is often done first, and if it shows evidence of melanoma, then a therapeutic lymph node dissection is performed. Some doctors recommend a lymph node dissection for all patients who might have melanoma in their lymph nodes. If the lymph nodes are not enlarged, then a sentinel node biopsy procedure may be done. If the sentinel lymph node does not show cancer, then it is unlikely the melanoma has spread to the lymph nodes; there is no need for a lymph node dissection. Therapeutic lymph node dissection can cause some important side effects that may be permanent. The most troublesome is called lymphedema. Lymph nodes in the groin or under the arm help drain fluid from the limbs. Without them fluid may accumulate. Elastic stockings or sleeves can help some people with this condition. Sometimes special devices that squeeze the limbs are used and may be helpful. These side effects, along with the discomfort from the procedure itself, are why this procedure is not done unless the doctor thinks it is absolutely necessary. Surgery for Metastatic Melanoma Once there is evidence that melanoma has spread from the skin to dista nt organs (such as the lungs or brain), doctors generally assume that the cancer is no longer curable by surgery. Even when only 1 or 2 metastases are found by imaging studies, such as CT or MRI scans, many other areas of metastasis are likely to be present that are too small to be found by these scans. Nevertheless, surgery is sometimes performed in these circumstances. If one or even a few metastases are present that can be completely removed, this surgery may help some patients to live longer. Also, removing metastases in the brain that might eventually cause symptoms can help improve the patient's quality of life. Chemotherapy for Melanoma Skin Cancer
Systemic chemotherapy uses anticancer drugs that are usually injected into a vein or given by mouth. These medications travel through the bloodstream to all parts of the body and attack cancer cells that have already spread beyond the skin to involve lymph nodes and other organs. Chemotherapy drugs kill cancer cells but also kill some normal cells. Therefore, your doctor will pay careful attention to avoiding or minimizing side effects, which depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects of systemic chemotherapy might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores. Because chemotherapy can kill normal blood cells (like the blood-producing cells of the bone marrow, the cells lining the gastrointestinal tract, and hair), patients may have low blood cell counts, nausea, vomiting, mouth sores, or hair loss. Low blood cell counts result in: An increased chance of infection (due to a shortage of white blood cells), Bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets) Fatigue (due to low red blood cell counts). Most side effects disappear once treatment is stopped. There are remedies for many of the temporary side effects of chemotherapy, so be sure to discuss side effects with your cancer care team. For example, antiemetic drugs to prevent or reduce nausea and vomiting can be given to relieve and sometimes prevent these side effects. Several types of systemic chemotherapy can be used for stage IV melanoma. Although chemotherapy is usually not as effective in melanoma as in some other types of cancer, it may relieve symptoms or extend survival of some patients with stage IV melanoma. Recent studies have found that combining several chemotherapy drugs with one or more immunotherapy drugs is much more effective than a single chemotherapy drug alone. Chemotherapy drugs often used to treat melanoma include: dacarbazine (also called DTIC), carmustine (also known as BCNU), and cisplatin. The combination of these three chemotherapy drugs, together with tamoxifen (a hormonal therapy drug most often used to treat breast cancer) is called the "Dartmouth regimen." Cisplatin, vinblastine, and DTIC is another chemotherapy combination for treating melanoma. Both of these chemotherapy combinations may also be combined with immunotherapy drugs such as interferon-alpha and/or interleukin-2 (see the section on immunotherapy). Isolated limb perfusion is an experimental type of chemotherapy sometimes used for treating melanomas on arms or legs. This method temporarily separates the circulation of the involved limb from the rest of the body and injects high doses of chemotherapy
into the artery feeding the limb. This allows high doses to be given to the area of the tumor without exposing internal organs to these doses that would otherwise cause severe side effects. So far, this treatment has not helped people with melanoma to live longer and is not recommended outside of a clinical trial (see section on "Clinical Trials"). Radiation Therapy Radiation therapy uses high-energy rays or particles to kill cancer cells. External beam radiation therapy focuses radiation from outside the body on the skin tumor. This type of radiation therapy is used for treating some patients with melanoma. Radiation therapy is not commonly used to treat the primary tumors of melanoma (the original melanoma that developed on the skin). The main role of radiation therapy for melanoma is palliation (to relieve symptoms) of metastases to the brain or perhaps bone. Palliative radiation therapy is not expected to cure the cancer. For example, a brain metastasis from melanoma might cause partial paralysis, severe dizziness, or other symptoms that can be temporarily relieved by radiation therapy. Immunotherapy Immunotherapy enhances and encourages a patient's immune system to recognize and destroy cancer cells more effectively. There are several types of immunotherapy used in treating patients with advanced melanoma. Cytokine therapy: Cytokines are proteins that activate the immune system in a general way. Two cytokines, interferon-alpha and interleukin-2, can help boost immunity in patients with melanoma. Both drugs can help shrink metastatic (stage III and IV) melanomas in about 10% to 20% of patients. Patients with deeply invasive stage II melanomas often have cancer cells that break away from their primary melanoma and travel to other parts of the body. But these cells have not yet grown into metastatic tumors that are large enough to be detected by routine tests. Some researchers feel that giving cytokines to these patients will help prevent growth of melanoma cells in other organs. This is called adjuvant immunotherapy. Side effects of cytokine therapy may include fever, chills, aches, and severe tiredness. Interleukin-2, particularly in high doses, can cause fluid to accumulate in the body so that the person swells up and can feel quite sick. Some patients may need to be hospitalized because of this problem. Vaccine therapy: Antimelanoma vaccines are, in some ways, similar to the vaccines used to prevent diseases caused by viruses suc h as polio, measles, and mumps. Antivirus vaccines usually contain weakened viruses or parts of a virus that cannot
cause the disease. The vaccine stimulates the body's immune system to destroy the more harmful type of virus. In the same way, weakened melanoma cells or certain chemical substances found in melanoma cells can be injected into a patient in an attempt to stimulate the body's immune system to selectively destroy melanoma cells. Usually, the melanoma cells are mixed with substances that help stimulate the body's immune system. However, developing a vaccine against a tumor like melanoma is more difficult than developing a vaccine to fight a virus. Clinical trials are in progress to test the value of treating stage III or stage IV melanoma patients with vaccines, sometimes combined with cytokine therapy as well. Clinical Trials The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions: Is the treatment helpful? How does this new type of treatment work? Does it work better than other treatments already available? What side effects does the treatment cause? Are the side effects greater or less than the standard treatment? Do the benefits outweigh the side effects? In which patients is the treatment most likely to be helpful? Types of clinical trials: There are three phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration). Phase I clinical trials: The purpose of a Phase I study is to find the best way to give a new treatment and how much of it can be given safely. Physicians watch patients carefully for any harmful side effects. The treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial will start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug. Phase II clinical trials: These are designed to see if the drug works. Patients are given the highest dose that doesnt cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The doctors will also look for side effects. Phase III clinical trials: These Phase III studies involve large numbers of patients. Some clinical trials may enroll thousands of patients. One group (the control group) will
receive the standard (most accepted) treatment. The other groups will receive the new treatment. Usually doctors study only 1 new treatment to see if it works better than the standard treatment, but sometimes they will test 2 or 3. All patients in Phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better result than the others. If you are in a clinical trial, you will receive excellent care. You will have a team of experts looking at you and monitoring your progress very carefully. The study is especially designed to pay close attention to you. However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. While most side effects will disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial. Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study will not prevent you from getting other medical care you may need. To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are: What is the purpose of the study? What kinds of tests and treatments does the study involve? What does this treatment do? What is likely to happen in my case with, or without, this new research treatment? What are my other choices and their advantages and disadva ntages? How could the study affect my daily life? What side effects can I expect from the study? Can the side effects be controlled? Will I have to be hospitalized? If so, how often and for how long? Will the study cost me anything? Will any of the treatment be free? If I am harmed as a result of the research, what treatment would I be entitled to? What type of long-term follow-up care is part of the study? Has the treatment been used to treat other types of cancers? You can get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll free at 1-800-4-CANCER or visiting the NCI clinical trials Web sites for patients (cancertrials.nci.nih.gov) or health care professionals (cancernet.nci.nih.gov/prot/protsrch.shtml).
Treatment of Melanoma Skin Cancer by Stage Stage I: Treatment of stage I melanoma consists of surgical removal of the melanoma and removal of a margin of normal skin. The amount of normal skin removed depends on the thickness of the melanoma. When the thickness is less than 1 mm, wide excision with 1 cm margins is recommended. For stage I melanomas between 1 mm and 1.5 mm thick, the tumor and 1 cm to 2 cm of surrounding normal-appearing tissue are removed. One cm and 2 cm are about 3/8 inch and 3/4 inch, respectively. No more than 2 cm of normal skin needs to be removed from all sides of the melanoma in stage 1. In the past, wider margins were used but healing was more difficult and the wider margins did not help people live longer. Removal of lymph nodes near the cancer does not improve survival of patients with stage I melanoma. Stage II: Treatment of stage II melanoma also depends on the thickness of the melanoma. When the thickness is greater than 1.5 mm but less than 4 mm, excision with 2 cm margins is recommended. When thickness is equal to or greater than 4 mm, wide excision with margins of at least 2 cm is recommended. Doctors will often recommend adjuvant therapy (additional medical treatment after surgery) with interferon-alpha. Other d rugs, in addition, may also be recommended as part of a clinical trial to try to reduce the chance the melanoma will come back. Some doctors recommend removing lymph nodes near stage II melanomas. These doctors feel this will reduce the chance the melanoma will come back. Other doctors feel the value of this surgery has not been proven. A second opinion may be useful. In some patients, a sentinel lymph node biopsy may be helpful in deciding whether lymph nodes should be removed. This procedure is explained earlier in this section under "Types of surgery for melanoma skin cancer." Stage III: In addition to excision of the primary tumor as in stage II, surgical treatment for stage III melanoma requires therapeutic lymph node dissection. Immunotherapy with interferon may help some patients with stage III melanomas to live longer. However, this treatment may cause severe side effects. Newer treatments being evaluated in clinical trials may benefit some patients. Because current treatments do not cure most patients with stage III melanoma, participation in clinical trials should be considered. Stage IV: No current treatment is able to cure stage IV melanoma. Skin tumors or lymph node metastases causing symptoms can be removed by surgery. Metastases to internal organs are sometimes removed, depending on how many are present, their location and likelihood of causing symptoms. Metastases that cause symptoms but cannot be removed surgically may be treated with radiation or chemotherapy. Chemotherapy drugs available at this time are of limited value in most people with stage IV melanoma. Even when chemotherapy can shrink these cancers, the effect is only temporary, usually 3 to 6 months.
Immunotherapy using interferon or interleukin-2 can help some patients with stage IV melanoma to live longer. No particular program has been very successful. Each seems to benefit some patients. The patient should carefully evaluate the benefits and side effects of any program that is recommended. Because of the poor prognosis of stage IV melanoma, patients should consider participation in a clinical trial. Clinical trials of new chemotherapy drugs, new methods of immunotherapy or vaccine therapy, and combinations of different types of treatments may benefit some of these patients. Recurrent melanoma: Treatment of recurrent melanoma depends on the stage of the original melanoma, the initial treatment, and the type of recurrence. In general, local (skin) recurrence is treated by surgery similar to that recommended for a primary melanoma. Lymph node recurrence is treated by therapeutic lymph node dissection. Patients with distant recurrences have the same treatment options as those with stage IV melanoma.
What Should You Ask Your Doctor About Melanoma Skin Cancer?
It is important for you to have honest, open discussions with your cancer care team. They want to answer all of your questions, no matter how trivial you might think they are. Some questions to consider: What type of skin cancer do I have? How far has my melanoma spread within or beneath the skin? How thick is my melanoma? What are my treatment options? What do you recommend? Why? What are the risks or side effects that I should expect? What is my expected prognosis, based on my cancer as you view it? Will a scar remain after treatment? What should I do to be ready for treatment? What are the chances of my cancer recurring (coming back) with the treatment programs we have discussed? Should I take special precautions to avoid sun exposure? Do I need follow-up appointments to check for recurrence or formation of a new cancer? How can I arrange to have my family members screened? In addition to these sample questions, be sure to write down your own questions. For instance, you might want more information about recovery times so you can plan your work schedule. Or, you may want to ask about second opinions or about clinical trials for which you may qualify.
What Will Happen After Treatment For Melanoma Skin Cancer?

Even when a melanoma skin cancer has been completely removed and is considered cured, follow-up examinations are needed to see if the cancer recurs (comes back). This includes examination of skin by the patient and by the cancer care team. Your doctor will also check for lymph node swelling and do a general physical examination. How often a patient needs follow-up visits depends on the stage of the patient's melanoma when they were diagnosed. In addition to the examinations, blood and imaging tests are recommended for some patients. For example, a typical follow-up schedule for melanomas thinner than 1 mm generally calls for physical exams every 6 months for 2 years. If these exams are normal, the patient then returns for a checkup once a year. Your doctor may recommend more frequent exams if you have many moles or a few atypical moles. For thicker melanomas that have not spread to lymph nodes, physical exams are done every 3 to 6 months for 3 years, then every 6 to 12 months for the next 2 years. After that, exams are done once a year. Some doctors also recommend chest x-rays (to detect lung metastases) and certain blood tests (to detect liver or bone metastases) every 6 to 12 months. If the melanoma has spread to regional lymph nodes (stage III), the usual exam schedule is every 3 to 6 months for 3 years, every 4 to 12 months for the following 2 years, and once a year thereafter. Chest x-rays and blood tests may be done every 3 to 12 months for some patients in this group. It is also important for a melanoma skin cancer survivor to regularly examine him or herself. You should see your doctor if you find any new lump or change in your skin. You should also report any new symptoms (for example, pain, cough, fatigue, loss of appetite) that persist to your doctor. Patients with stage IV melanoma whose cancer has been completely removed or disappeared after treatment usually have the same follow-up schedule as for stage III. Patients with persistent stage IV melanoma have a follow-up schedule that is individualized based on their specific medical situation. In addition, someone who has had one melanoma may still be at risk for developing another melanoma or a non-melanoma type of skin cancer. People cured of one melanoma should continue to examine their skin every month for new skin cancers and should avoid overexposure to the sun, and use protection when in the sun.
Whats New in Research and Treatment of Melanoma Skin Cancer?

Gene Therapy One of the most promising new approaches to treating melanoma adds certain genes to the cancer cells. Gene therapy can be used in 3 general ways. In the first way, scientists attempt to replace some of the damaged genes in the melanoma cells that scientists believe are causing the cells to grow and spread abnormally. This approach has had limited success, perhaps because most melanoma cells have several abnormal genes that all contribute together to their malignant behavior. Another approach is to add a specific gene to melanoma cells. This gene can make the melanoma sensitive to a drug that would otherwise not affect the cancer. Augmerosen is an example of a drug that uses this approach. It is an antisense drug, made up of short strands of DNA that can neutralize the melanoma cells ability to make certain proteins. This particular drug prevents the cells from producing the BCL2 protein, which is found at high levels in most melanoma cells, and preventing the cancer cells from dying. In preliminary studies, the combination of this drug plus chemotherapy with dacarbazine caused some metastatic melanoma tumors to shrink, even in patients whose cancers had not responded to chemotherapy alone. The third strategy adds certain genes to melanoma cells, which are then used for vaccine therapy. Addition of these genes to melanoma cells can help the immune system start to attack the altered cells as well as the unaltered cells remaining in the patient. Many researchers feel that progress in the third strategy is the farthest along. Several clinical trials testing these gene therapy approaches are currently in progress. Melanoma DNA Research Scientists have made considerable progress during the past few years in understanding how ultraviolet light damages DNA, and how changes in DNA cause normal skin cells to become cancerous. They have also found that DNA damage affecting certain genes is important in causing melanocytes to change into a melanoma. Often, this damage is due to sun exposure. On the other hand, some people may inherit mutated (damaged) genes from their parents. Inherited genes not only cause us to look like our parents, the y can make us likely to get the same diseases as our parents. Scientists recently discovered a gene that causes some melanomas that run in certain families. This is called the p16 gene. People who have a strong family history of melanoma should speak with a cancer genetic counselor or a physician with experience in cancer genetics to discuss the benefits, limitations, and potential disadvantages of this test. Molecular Staging
Advances in melanoma DNA research are also being applied to molecular staging. In ordinary staging, a lymph node removed from a patient is examined under a microscope to see if melanoma cells have spread to the lymph node. In molecular staging, RNA (a chemical related to DNA) is extracted from the lymph node. Certain types of RNA are made by melanoma cells but not by normal lymph node cells. A very sensitive and sophisticated test called a reverse transcription polymerase chain reaction (RTPCR) is used to detect these types of RNA. Preliminary studies have found that RTPCR is more sensitive than routine microscopic testing in detecting the spread of melanoma to lymph nodes. In fact, RTPCR can detect 1 melanoma cell among a million normal cells. This test may help identify some patients who might benefit from additional treatment (such as immunotherapy) after surgery. Immune Therapy New ways of manipulating the immune system are being developed. This may be the most promising area of melanoma therapy research. As we learn more about how the immune system works, immune treatments will become more effective. Public Education Most skin cancer is preventable. The greatest reduction in the number of skin cancer cases and a reduction in the pain and loss of life from this disease will come from preventive strategies. This involves educating the public, especially parents, about skin cancer risk factors. It is important for health care professionals and skin cancer survivors to remind everyone else about the dangers of excessive sun exposure and about how easy it can be to protect your skin against ultraviolet radiation. Melanoma should be detected early, when it is most likely to be completely cured. Monthly skin self-examination and awareness of the warning signs of melanomas may be helpful in detecting melanoma at an early, curable stage. The American Academy of Dermatology (AAD) sponsors annual free skin cancer screenings throughout the country. The American Cancer Society works closely with AAD to provide volunteers for registration, coordination, and education efforts related to these free screenings. Look for information locally about these screenings or call the American Academy of Dermatology for more information. Their telephone number and internet address are listed in the section "Additional Resources." A slogan popularized in Australia, and now used in the United States, focuses the public's attention on skin cancer prevention. The American Cancer Society's skin cancer prevention message is "Slip Slop Slap! Wrap!TM Slip on a Shirt! Slop on Sunscreen! Slap on a hat! Look for shade in the middle of the day and Wrap around sunglasses when outdoors to protect eyes and sensitive skin around them.
It is important to remember that sunscreen is used to protect from the sun's rays during normal activity. It should not be used to spend more time exposed to the sun than necessary.
Additional Resources
National Organizations and Web Sites* American Academy of Dermatology Telephone: 1-847-330-0230; Automated Information Center 888-462-DERM (3376) Internet Address: www.aad.org Environmental Protection Agency Telephone: 1-800-296-1996 Internet Address: www.epa.gov/sunwise National Cancer Institute Telephone: 1-800-4-CANCER Internet Addresses: www.nci.nih.gov and cancernet.nci.nih.gov Skin Cancer Foundation Telephone: 1-800-754-6490 Internet Address: www.skincancer.org *Inclusion on this list does not imply endorsement by the American Cancer Society Additional American Cancer Society Information Books American Cancer Societys Guide to Pain Control (Book; Code #9438) Cancer in the Family: Helping Children Cope with a Parents Illness (Book; Code #9435) Caregiving: A Step-By-Step Resource for Caring for the Person with Cancer at Home (Book; Code #9422) Coming to Terms with Cancer: A Glossary of Cancer-Related Terms (Book: Code #9505) Consumers Guide to Cancer Drugs (Book; Code #9436) Informed Decisions, Second Edition: The Complete Book of Cancer Diagnosis, Treatment, and Recovery (Book; Code #9449.02)
Brochures After Diagnosis: A Guide for Patients and Families (Booklet; Code #9440) Caring for the Patient with Cancer at Home (Booklet; Code #4656) It's Your Skin. Wear It Well! (Information Card; Code# 2085.01) It's Your Skin. Wear It Well! (Spanish version; Code# 2087) Questions and Answers About Pain Control (Booklet; Code #4518) Why You Should Know About Melanoma (Booklet; Code# 2619) Other Publications* *Inclusion on this list does not imply endorsement by the American Cancer Society Capossela, Cappy, Warnock, Sheila. Share the Care: How to Organize a Group for Someone Who Is Seriously Ill. New York, Ny: Simon and Schuster; 1995. Dollinger, Malin, Ernest H. Rosenbaum, and Greg Cable. Everyone's Guide to Cancer Therapy. Kansas City, Mo: Somerville House Books; 1994. Holland Jimmie C, and Sheldon Lewis. The Human Side of Cancer. New York, HarperCollins Publishers. 2000. Morra, Marion and Eve Potts. Choices. New York, Ny: Avon Books; 1994.
References
American Cancer Society. Cancer Facts and Figures 2002. Atlanta, GA: American Cancer Society; 2002. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 5th ed. Philadelphia, PA: Lippincott-Raven; 1997: 157-160. Brash DE, Safai B. Cancer of the skin. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. Philadelphia, PA: Lippincott-Raven; 1997: 1879-1933. Gilchrest BA, Eller MS, Geller AC, Yaar M. Mechanisms of disease: The pathogenesis of melanoma induced by ultraviolet radiation. New Engl J Med. 1999; 340:1341-1348.
Houghton A, et al. NCCN melanoma practice guidelines. National Comprehensive Cancer Network. Oncology. 1998; 12(7A): 153-177. Morton DL, Essner R, Kirkwood JM, Selch MT. Malignant melanoma. In: Bast RC, Kufe DW, Pollock RE, Weischselbaum RR, Holland JF, Frei E, eds. Cancer Medicine. Hamilton, Ontario:.BC Decker Inc.: 2000: 1849-1869. National Cancer Data Base. Cancer Statistics by Disease Site: Relative Survival of Patients Diagnosed with Malignant Melanoma of the Skin by AJCC Stage of Disease at Diagnosis, 1985-1989 Cases. American Cancer Society & American College of Surgeons; 1999. Available at www.facs.org/dept/cancer/ncdb/melano4.html. PDQ database. Skin cancer, melanoma. Bethesda, Md: National Cancer Institute; 2001. Available at cancernet.nci.nih.gov/Cancer_Types/Melanoma.shtml. Rigel DS, Carucci JA. Malignant melanoma: Prevention, early detection, and treatment in the 21st century. CA Cancer J Clin 2000; 50: 215-236. Urist MM, Heslin MJ, Miller DM. Malignant melanoma. In: Clinical Oncology. Lenhard RE Jr, Osteen RT, Gansler T eds. Atlanta, GA: The American Cancer Society; 2001: 553-561.

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2002 American Cancer Society