Next steps after a melanoma diagnosis

Learning that you have melanoma, the most-serious type of skin cancer, can make it difficult to hear anything else your doctor says. After leaving the office, you may wonder what happens next.

While what happens next varies with each patient, there is a process after diagnosis. The following picture shows the steps often included in this process.

Steps after a melanoma diagnosis.

Step 1: Skin exam and physical

If you’ve been diagnosed with melanoma, you’ve already had a skin biopsy. This biopsy was taken when you had part (or all) of the suspicious spot removed. After it was removed, a doctor looked at the spot under a microscope to find out if it contained cancer cells. This is currently the only way to tell if someone has skin cancer.

After getting the diagnosis, the next step is to get a complete skin exam and physical.

During the physical, your dermatologist (or other doctor) will feel your lymph nodes. This is where melanoma usually goes when it begins to spread. It usually travels to the lymph nodes closest to the melanoma.

If there is a risk the cancer could have spread, your dermatologist may recommend that you have a lymph node biopsy. If a sentinel lymph node biopsy is recommended, it can be performed at the time of your surgery for melanoma.

After the skin exam and physical, your dermatologist may recommend testing, such as a CAT scan, MRI, or a blood test. These can also help detect spread.

Step 2: Staging

Your dermatologist will use the information from the skin exam, physical, and skin biopsy to determine the stage of your melanoma. Your dermatologist may call this the “clinical stage.” This stage can change if cancer is found in your lymph nodes or elsewhere after more testing.

The following table gives you a very simple explanation of the stages. This explanation can be far more complex. Within stages I, II, and III, the stages are further divided. For example, a patient could be diagnosed with melanoma that is in stage Ia or lb. This detailed information helps doctors plan treatment.

Your dermatologist can tell you more about your individual stage.

Stage	What the stage means
Stage 0 (melanoma in situ)	Melanoma is in the outer layers of the skin. Treatment in this stage often cures the patient of melanoma.
Stage I	Melanoma is in the outer layers of skin (epidermis) and sometimes the upper part of the inner layers (the dermis). A cure is often possible.
Stage II	Melanoma is found in the outer layers of skin and in the lower layers of the dermis. The likelihood of a cure is still good.
Stage IIII	The cancer cells have spread beyond the skin and are found in a lymph node(s) or lymph vessel(s) closest to where the melanoma began.
Stage IV	The cancer has spread beyond the closest lymph nodes to one or more parts of the body.

Step 3: Testing

Some — but not all — patients need testing. Testing can help your dermatologist discover whether the melanoma has spread beyond the skin.

Medical tests that you may need include blood work and imaging tests like an MRI scan, CAT scan, or x-ray. Some patients get a fine needle aspiration biopsy, which involves inserting a needle into an area that may contain cancer cells in order to remove some of the cells.

Your dermatologist will use these test results along with the results from the skin biopsy, skin exam, and physical to create a treatment plan for your melanoma.

If you have advanced melanoma, you’re likely to see a team of medical specialists. An oncologist (doctor who specializes in cancer) may create your treatment plan.

While melanoma can spread quickly, there is usually time to get a second opinion. In fact, some insurance companies require a 2nd opinion. Be sure to act quickly if you want (or need) a 2nd opinion.

Step 4: Treatment (and possible restaging)

The goal of treatment is to remove all of the cancer. For this reason, surgery is often part of the treatment plan.

Surgery may be the only treatment needed when melanoma is found early. A dermatologist can often perform this type of surgery during an office visit while you remain awake.

During this surgery, the dermatologist removes any remaining tumor (after the skin biopsy) and some normal-looking skin. In the earliest stages, this surgery often cures melanoma.

Because melanoma can spread quickly, many treatment plans include more than one treatment.

Treatment may begin with medication used to shrink the melanoma tumor before surgery. After surgery, another treatment may be given to kill any remaining cancer cells.

If it’s likely the cancer has spread, surgery becomes more complex. A surgeon may remove the melanoma along with the first lymph node to which the cancer is likely to spread. Removing this lymph node is actually a type of biopsy called a sentinel lymph node biopsy.

This type of surgery and biopsy must be performed in a hospital, and you receive anesthesia to make you unconscious.

When cancer cells are found in the removed lymph node, the stage of the cancer changes. This is called restaging. More surgery may be needed, and another treatment that can kill the cancer cells may be added to the treatment plan.

When the cancer has spread to other parts of the body, treatment becomes quite complex.

Step 5: Observation (or more treatment)

Observation (or more treatment) may be recommended for a patient in any stage. If your treatment plan calls for observation, you’ll be watched closely. You’ll have regularly scheduled check-ups and tests to find out if the cancer has returned or spread.

The following table shows the usual options (after the first treatment) for each stage.

Stage	What happens after treatment
0 or IA Melanoma found in the outer layers of the skin	After treatment, you begin observation. The risk of melanoma returning or spreading in these stages is low. Still, there is a risk, so it is important to keep all appointments for exams and tests.
IB or IIA Melanoma found in upper part of the lower layers of the skin	Most patients begin observation. Another option is to join a clinical trial, a study that looks at the safety and effectiveness of a new treatment. You would be closely watched during a clinical trial.
IIB or IIC Melanoma has reached the lower layers of the skin	Your options after treatment are likely to include: Interferon alfa, treatment that helps kill stray cancer cells Observation Join a clinical trial
III Melanoma spreads to lymph nodes or lymph vessels	After treatment, your treatment plan may recommend one of the following: Join a clinical trial Observation Interferon alfa Radiation treatments (select group of patients)
IV Melanoma spreads beyond the closest lymph nodes	Your options depend on whether all of the cancer could be removed. If it could, your treatment plan may call for one of the following: Additional treatment to kill stray cancer cells, possibly receiving this treatment in a clinical trial Observation If all the cancer could not be removed, you begin treatment for widespread melanoma.

Step 6: Lifelong follow up

After you finish treatment, your dermatologist (or other doctor) will still want to see you regularly. Melanoma can return or spread after treatment. If this happens, it’s most likely to occur within the first 5 years.

During the first 5 years, you’ll need thorough check-ups. You may have a check-up every 3 months in the beginning. You may also need to get chest x-rays, CT/PET scans, or MRIs. These can help find cancer that has returned or spread.

Skin self-exams for life: You’ll also learn how to examine your own skin (and sometimes lymph nodes) for signs of cancer. It’s extremely important that you examine your skin and lymph nodes as often as your dermatologist recommends. Anyone who has had melanoma has a higher risk of getting another melanoma.

You’ll want to perform skin self-exams for life.

Skin exams for life: Once your dermatologist says you no longer need to return for regular check-ups, you’ll need to get a complete skin exam every year. You should have this exam every year for life. The American Academy of Dermatology recommends that you see a board-certified dermatologist for this exam.

If you find anything during your self-exam, call your dermatologist’s office immediately. Explain that you have had melanoma.

Ask questions

Now that you have an idea of what happens after the diagnosis, it’s important to understand that one patient’s progress through these steps can differ greatly from another patient’s. Step 3 is often unnecessary for patients with an early melanoma, who may complete steps 1, 2, and 4 in one office visit. Patients with advanced melanoma may spend months getting treatment, step 4, in a clinical trial.

To get an idea of what lies ahead for you, it’s best to ask questions.

References
Bichakjian CK, Halpern AC, et al. “Guidelines of care for the management of primary cutaneous melanoma.” J Am Acad Dermatol 2011;65:1032-47.
National Comprehensive Cancer Network (NCCN). “NCCN Guidelines for Patients®: Melanoma.” Version 1.2014. Last accessed March 20, 2016.

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Next steps after a melanoma diagnosis