POST TIME: 21 October, 2019 00:00 00 AM / LAST MODIFIED: 20 October, 2019 11:50:51 PM
Melanoma stages: Prognosis, survival rates and treatment
Patients who notice visible skin changes, or maybe a significant other observes a suspicious growth on areas like the back, can prompt a timely visit to a primary care physician or dermatologist.
U.S.News & World Report

Melanoma stages: Prognosis, survival rates and treatment


Melanoma is one of the most serious forms of skin cancer. In early stages, it may be treated through relatively simple surgery, but advanced stages can be lethal. The National Cancer Institute's Surveillance, Epidemiology and End Results program estimates that nearly 97,000 new U.S. cases of melanoma are expected to occur in 2019. And about 7,230 people will die of melanoma in the same year, according to SEER estimates.

Fortunately, sophisticated treatments such as immunotherapy and targeted drugs are progressing and improving the prognosis for people with advanced melanoma. What's encouraging is that more than 92% of people diagnosed with melanoma from 2009 to 2015 reached the five-year survival milestone, according to SEER.
Melanoma affects the skin cells that make melanin, the pigment that gives skin its color. Most cases start in the skin and are called cutaneous melanoma. Risk is strongly related to sun exposure, specifically to ultraviolet rays (which tanning beds and sun lamps also emit). However, about 5% of melanoma cases arise in other types of tissue.

In these other types of melanoma, called acral lentiginous and mucosal melanoma, tumors develop in parts of the body usually protected from the sun, such as the linings of your sinuses, anus or vagina, in your eye or on the palms of your hands or soles of your feet.

Other risk factors include having many moles, having an inherited skin condition called dysplastic nevus syndrome and having moles at birth. Whites, particularly those with red or blonde hair, green or blue eyes or with pale skin that burns or freckles easily, are at higher risk. However, people of any racial or ethnic group can develop melanoma and should have skin changes evaluated.

Age can also play a factor. Older people are more likely to have melanoma. However, it can also affect younger patients. In fact, between 1995 and 2014, head and neck melanoma cases increased by more than 50% among people from infants to adults under 40, according to a study published online October 3, 2019, in the journal JAMA Otolaryngology--Head & Neck Surgery.

Melanoma can appear on the skin in several ways. It could be flat like a freckle or protrude like a mole. You could see changes in the size, color or shape of a birthmark or mole that you may have had for a long time.
Pay attention to a spot that looks different than others on your skin. Multiple moles, such as satellite moles, which are new moles that grow near existing moles, are also a concern.

The ABCDE rule, created by dermatologists, provides a simple guide on melanoma signs to watch for:
-- A for Asymmetry. One half of a skin growth doesn't match the other half.
-- B for Border. Edges are irregular, ragged, blurred or notched.
-- C for Color. The skin area color is not uniform. Different shades of brown or black, or possibly patches of white, pink, red or blue can appear.
-- D for Diameter. A spot is larger than one-quarter of an inch across. However, some melanomas can be smaller.
-- E for Evolving. A mole's size, shape or color is changing.

As melanoma progresses, skin changes may be more obvious, with symptoms including hardness, lumpiness, sensitivity to touch, oozing or bleeding.

Melanoma is diagnosed under a microscope based on a variety of features, in particular tumor depth or thickness, says Dr. Charlotte Ariyan, a surgeon and melanoma expert at Memorial Sloan Kettering Cancer Center in New York City.

"You could have a very narrow lesion that goes very deep," Ariyan says. "It's measured by the thickness -- how much it penetrates into the skin."

Understanding melanoma stages
When an abnormal skin area causes concern, you should pay your primary care provider or dermatologist a visit. Your doctor will do a thorough examination of the abnormal area. In addition to inspecting any moles, birthmarks or discolored areas, he or she may recommend a skin biopsy for a pathologist to examine the sample for possible cancerous cells.

If melanoma is diagnosed, surgery is the standard first treatment. During surgery to remove the original tumor, your doctor may also biopsy nearby lymph nodes to do additional testing for cancerous cells. If the lymph node biopsy is positive, you will likely undergo a variety of imaging and blood tests to determine whether the cancer has spread to various parts of your body.

Physicians take all these findings into account to pinpoint the severity of the disease and diagnose the melanoma stage. The staging system is detailed in the AJCC Cancer Staging Manual released by the American Joint Committee on Cancer.

Melanoma is classified into five basic stages, from stage zero and earlier stages 1 or stage 2 to more advanced stage 3 or stage 4 disease. Basic stages are further subdivided into various levels (like stage 3a or stage 3b).

What does all this mean for you as a patient? The specific stage at which you are diagnosed has a significant impact on treatment decisions, the risk of melanoma returning and average survival rates. Here's a condensed breakdown of melanoma stage divisions as described on the NCI's online patient pages:

Stage zero
Cancerous cells only exist in the outer layer of the skin, or epidermis, in this preliminary stage. It's also called melanoma in situ, referring to abnormal cells that remain in the place where they first formed. Eventually, abnormal cells may spread into healthy tissue nearby.

Stage 1 and stage 2 Melanoma
This is localized melanoma. Although cancer has grown to the next layer of skin, or the dermis, it has not reached the lymph nodes. Tumor thickness, or depth, and the presence of ulceration -- skin breakage visible only under a microscope -- further indicate how serious melanoma is.

-- Stage 1A. Tumor thickness measures at 1 millimeter or less. (1 millimeter equals about 0.04 inches.)
-- Stage 1B. Tumor thickness ranges from more than 1 millimeter up to 2 millimeters. Ulceration is not seen in stage 1.
To give a sense of relative tumor sizes in stage 1 melanoma, the NCI website notes that a sharp pencil point is about 1 millimeter thick. A new crayon point is about 2 millimeter thick. In comparison, a new pencil eraser is about 5 millimeter thick.

-- Stage 2A. Tumor thickness ranges from more than 1 millimeter up to 2 millimeters and ulceration is present, or tumor thickness ranges from more than 2 millimeters up to 4 millimeters without ulceration.

-- Stage 2B. Tumor thickness ranges from more than 2 millimeters up to 4 millimeters and ulceration is present, or tumor thickness is more than 4 millimeters without ulceration.

-- Stage 2C. Tumor thickness is more than 4 millimeters thick and ulceration is present.
Treatment for melanoma starts with a surgical procedure called wide excision to remove the tumor, along with a margin of healthy surrounding tissue.

"Early-stage disease -- stage 1 and stage 2 -- really involves surgery, which cures a majority of early patients," Ariyan says. "Depending on the risk factors, which are the tumor's primary characteristics, in general, it's an excision of the primary melanoma, and in some cases, a lymph node biopsy."

Although the differences within stages might seem subtle, they matter. For instance, while treatment may be similar for stage 2A and stage 2C melanoma, recurrence rates are higher for the latter, Ariyan says.

Stage 3 and stage 4 melanoma
If the pathology exam reveals that the sentinel lymph nodes near the primary tumor contain cancerous cells, melanoma is classified as at least stage 3.

"Stage 3 means it's usually spread to the lymph nodes, or what we call 'in transit' -- between the primary tumor and the lymph nodes," Ariyan says. When lymph nodes are positive and your diagnosis becomes Stage 3 melanoma, she says, that's significant in terms of prognosis.

At this point, imaging tests such as CT, PET or MRI scans and ultrasound exams are typically used to check for malignant tumors in other parts of the body. Certain blood tests and genomic evaluation of the tumor help predict whether someone is likely to respond to specific treatments.

-- Stage 3A. The tumor is 1 millimeter thick or less with ulceration, or 2 millimeters thick or less without ulceration. Sentinel lymph node biopsy reveals one to three lymph nodes with cancer.

-- Stage 3B. Lymph node involvement, tumor thickness and ulceration are similar to Stage 3A, although the tumor may be up to 4 millimeters thick. Other findings include satellite or microsatellite tumors, or in-transit spread of cancer on or beneath the skin.

-- Stage 3C. Similar to stage 3B, it may be unclear where the cancer began. Cancer may appear in four or more lymph nodes, or multiple lymph nodes that are matted together.

-- Stage 3D. The tumor is thicker than 4 millimeters and ulceration is present. Cancer is present in multiple lymph nodes or lymph nodes that are matted together. Satellite, microsatellite or in-transit spread is found on or beneath the skin.

-- Stage 4. Stage 4 melanoma is extremely advanced. Cancer has spread to distant parts of the body such as remote lymph nodes or the lungs, liver, bone, soft tissue, spinal cord or brain.

Survival rate differences
For a comparison of survival rates for melanoma, the American Cancer Society summarizes data from the SEER database, which tracks five-year survival rates in the U.S. The SEER database uses a simplified grouping scheme, with localized, regional and distant stages.

The following figures are based on patients who were diagnosed with melanoma between 2008 and 2014:
-- Localized melanoma. For cancer with no sign of spread beyond where it started in the skin, the five-year relative survival rate is 98%.

-- Regional melanoma. For cancer that has spread to nearby lymph nodes or nearby areas of the body, the five-year survival rate is 64%

-- Distant melanoma. For cancer that has spread to remote parts of the body, such as distant skin areas, or the lungs or liver, the five-year survival rate is 23%.

The ACS notes that these general estimates cannot predict what will happen in any individual case. In addition, access to melanoma treatment advances like immunotherapy may lead to increased survival rates.

Early detection and prevention
At the Inova Melanoma and Skin Cancer Center, part of the Inova Schar Cancer Institute in Northern Virginia, patients are seen with melanoma of all stages, says Dr. Suraj Venna, a dermatologist and the center's medical director.

The center offers care from melanoma screening and prevention services to multidisciplinary treatment approaches including immunotherapy for those with more advanced disease.

When it comes to the detection, skin cancers actually give patients an advantage. "Unlike other types of cancer, we have a chance to catch it early because of visual diagnosis," Venna says. "You don't need a CT or PET scan to find melanoma on the skin."

Patients who notice visible skin changes, or maybe a significant other observes a suspicious growth on areas like the back, can prompt a timely visit to a primary care physician or dermatologist.

If you have melanoma, your doctor will discuss surgery to remove the primary growth. In addition, you'll learn about next-phase treatments such as immunotherapy or targeted chemotherapy drugs for later-stage disease.

To prevent melanoma, you can reduce "modifiable" risk factors like sun exposure. Using sunscreen and wearing sun-protective clothing, sunglasses and hats are all commonsense precautions.
Venna emphasizes that anyone can develop melanoma. If you notice skin changes that could potentially be related to skin cancer, be proactive and seek an evaluation.