Combination Therapies: Taking... Health Article

The incidence of cutaneous melanoma--the most serious form of skin cancer--is rising faster than any other cancer in the United States .

Melanoma is classified into stages to show how far it has spread into the body.

• Stage I melanoma is no more than 2 millimeters thick. 

• Stage II melanoma is more than 2 millimeters thick if it does not have a break in the skin, called ulceration. If it has ulceration, it can be more than 1 millimeter thick.

• Stage III melanoma has spread to lymph nodes.

• Stage IV melanoma has spread to other parts of the body.

Doctors use both standard and experimental treatments for Stages III and IV melanoma. Deciding on a treatment plan can be confusing. Different doctors may recommend different treatments. It is important to really understand your options.

Here are stories about 2 people who needed to make these difficult decisions and the treatment options they had.

Jason’s Story

Ilan Shanon, a Utah resident, says that he knew nothing about melanoma until his 24-year-old son, Jason, was diagnosed with it.

“Pimple” is stage III melanoma. During the summer of 1997, Jason noticed a small red “pimple” on his arm. The pimple became annoying. Jason picked at it often until it bled. His dermatologist removed it and thought nothing more. But Jason suggested he biopsy it because he had had 2 cases of basal cell cancers removed in the past. The seemingly harmless “pimple” turned out to be Stage III melanoma. The news was shocking because Jason had no other symptoms and felt perfectly fine.

First 2 treatments are surgeries. Jason had a wide excision. For it, the doctor removed the tumor and some tissue around it to ensure that no cancer cells stayed in his skin. He also had a sentinel node biopsy. Lymph nodes are small structures throughout the body that make and store infection-fighting cells. The sentinel node is the lymph node that cancer is likely to spread to first. For the biopsy, doctors remove this node and check it for cancer cells.

Immunotherapy gets added. Jason’s biopsy was positive, meaning that the melanoma had spread. His surgeon removed the lymph nodes under his arm. Then Jason started on the drug interferon. His doctor gave him this immunotherapy drug to help Jason’s immune system fight off cancer cells.

The cancer returns. “Jason appeared well and we thought maybe we had licked this thing,” says his father. But 2 years later, Jason developed stomach pains. X-rays showed 2 new tumors in his liver and 24 smaller tumors in his lungs. Doctors said the melanoma was now stage IV. His father was stunned. “The oncologists gave us almost no hope. We felt they had given Jason a death sentence.”

Refusing to give up, Shanon and his wife did 4 weeks of intensive research. They contacted major cancer centers across the country. In November 1999, Jason entered the John Wayne Cancer Center in California . This center has a melanoma research program.

Jason has combination therapy. The difference in care was like night and day. “Immediately we had hope. Jason started an 18-week regimen of biochemo, a combination of chemotherapy to destroy the tumors and interleukin and interferon to boost his immunity,” says Shanon. Interleukin is another type of immunotherapy. Jason’s tumors shrank and some even disappeared. The family was thrilled. Jason began a maintenance program on interleukin.

Ultimately, though, the melanoma came back by late March 2000. Several new tumors again formed throughout Jason’s body, along with an infection. Three weeks later, Jason died peacefully at home surrounded by his family and friends.

A Doctor’s Battle with Melanoma

Casey Culbertson, MD, is a California-based doctor who treats children with heart problems. When he first discovered a lump in his armpit, he wasn’t sure what to think. “It wasn’t a funny color and it didn’t hurt or appear unusual,” he says.

But his doctor’s instinct prompted him to have a biopsy. It turned out to be stage III melanoma.

“After reading up on melanoma, I was planning my funeral that night more than anything else,” says Culbertson. But he soon shook off those thoughts. He researched his condition and sought a second opinion. Doctors removed the lymph nodes under his arm. Culbertson then studied new treatments that would kill any remaining cancer cells. He drew graphs about each type of treatment and weighed the pros and cons.

He decided to forego the popular interferon treatments and try an experimental vaccine. Doctors gave him 4 shots under his skin twice a month. Although Culberton’s doctors had first planned a longer course of treatment, they stopped it after 3 months because it was working so well.

Culbertson’s cancer is now in remission. He goes to his doctor every year for magnetic resonance imaging (MRI) and computed tomography (CT) scans to screen for new tumors. He also sees a dermatologist every 4 months for skin exams.

Culbertson wouldn’t recommend vaccines for everyone, nor would everyone be eligible for them. He believes people need to research what might work best for their own situation. It’s a message he preaches regularly through the Melanoma Research Foundation, a nonprofit group that educates and funds research on melanoma.

Treatments at Each Stage

If you get a diagnosis of melanoma, your doctor will stage the disease to determine treatment options. Stage I may mean removing the melanoma and then following up every few months for skin exams. Stages II, III, or IV may mean researching new therapies or clinical trials.

The chart below lists possible melanoma treatments for each stage as outlined by the National Cancer Institute. It lists the more commonly used standard treatments and the newer treatments available. Adjuvant therapies are therapies added to the main treatment to boost its effectiveness. 

*Sentinel Node Biopsy. The sentinel node is the lymph node where cancer is likely to spread first. Doctors will biopsy it to check for melanoma. If this node is normal, the other lymph nodes are likely to be normal too and they can be left in place.

**Immunotherapy (Interferon/Interleukin/Vaccines). These lab-made substances mimic the ones naturally made by the body. They stimulate the body’s natural immune system to find and kill cancer cells.

***Isolated limb perfusion. This treatment injects a high dose of chemotherapy directly into the affected arm or leg.

The Best Weapon Against Melanoma Is You

“There is no perfect treatment for stages III and IV melanoma,” says Culbertson. You need to do your homework.

• Learn about melanoma and write down questions for your doctor.

• Learn your stage of melanoma and research the treatments available for that stage.

• Learn about new therapies through respected web sites, such as the National Cancer Institute and CancerSource. Find places that offer new therapies for melanoma. Acurian, the Melanoma Research Foundation, and the Melanoma Patient’s Information Page, linked below, give information on current clinical trials and doctors and institutions that specialize in melanoma.

• List the pros and cons of each treatment plan. Check the side effects, success rates, effects on your work or family, etc.

• Talk about a follow-up or post-treatment plan with your oncologist. For instance, see whether you need to have immunotherapy, CT scans, or skin screenings.

Related Sites:

National Cancer Institute: www.cancer.gov