Stage 4

Patient Guide

What is Stage 4 melanoma?

Stage 4 melanoma which have spread (metastasised) beyond the original skin site (the primary site) to a distant part of the body (where it becomes a metastasis). This could be lymph nodes and skin in a distant location from the original melanoma, or organs such as the lungs, liver, brain, bones and the bowel. Stage 4 melanoma is also called advanced melanoma.

How is stage 4 melanoma diagnosed?

If you have persistent, unexplained, symptoms your doctor may already suspect that your melanoma has spread. These symptoms can vary depending on where the melanoma has spread to.

Examples of symptoms include one or more of the following: persistently swollen lymph nodes (lymph node spread); shortness of breath and persistent cough (potential spread to the lungs); unexplained, worsening headaches or seizures (potential spread to the brain); unexplained loss of weight; spread to lymph nodes, and/or other organs and a decrease in appetite (potential spread to the liver) or pain in your bones (potential spread to the bones).

However not everyone who is diagnosed with Stage 4 melanoma will experience these symptoms – there may be no symptoms or you may experience different symptoms.

CT and MRI scans

CT and MRI scans may also be undertaken to help diagnose stage 4 melanoma. They are used to find where the melanoma has spread to within the body. They may be offered as part of your routine surveillance following surgery for high risk melanoma or they may be arranged because you are experiencing persistent new symptoms which you and your doctor are unable to explain.

Who may be involved in my care?

You should be cared for by a Specialist Skin Multidisciplinary Team (SSMDT) This team includes the following members:

  • An oncologist (cancer doctor)
  • A specialist nurse
  • A radiologist (x-ray/scan doctor)
  • A surgeon
  • Possibly some other types of medical support staff

>See more information on medical teams involved in care for melanoma

What can I expect after a diagnosis of Stage 4 melanoma?

Some people are diagnosed with Stage 4 melanoma, having already had treatment for an earlier stage of melanoma in previous months or years. For other patients, their melanoma may be Stage 4 at the point at which they learn they have melanoma. Stage 4 melanoma cannot be cured and treatment is aimed at controlling it for as long as possible rather than getting rid of it completely. Having said that, it is now possible to live alongside Stage 4 melanoma for a long time and there are patients alive and well many years after their diagnosis, who may have very little evidence of melanoma left on their scans.

You may have lymph nodes in the body removed with surgery if they are causing symptoms and are few in number.

If your melanoma is considered inoperable, you may be considered for immunotherapy or BRAF-targeted therapy.

Immunotherapies are drug treatments that aim to enhance your own body’s immune system so that it an recognise and destroy cancer cells more effectively. By enhancing the immune system, it is common for healthy parts of the body to be affected too. There are now a number of immunotherapy treatments available that may be offered to you. They are given via an intravenous drip, usually in hospital. A single immunotherapy treatment or a combination of two different immunotherapy treatments may be administered

>See our video explaining immunotherapy treatment

BRAF-targeted therapy

Your melanoma should be tested to see if it carries a faulty BRAF gene. This is a mistake (mutation) that develops in the BRAF gene in around half of melanomas. It is NOT a genetic mutation that you can pass down to your children. If your melanoma is ‘BRAF mutant’ it produces an over-active BRAF protein which drives the growth of the melanoma. It is important to know whether your melanoma has the BRAF mutation as this may give you the option of treatment with BRAF-targeted therapy.

>View our video for further information on BRAF mutation and targeted therapies

Your medical team may also test your melanoma for other genetic mutations, for instance some melanomas have mistakes in the NRAS or c-KIT gene. Therapies to reverse the effects of these gene mutations can help. Although there is much less evidence that targeting these mutations can be helpful, this information may increase the treatment options your medical team can discuss with you – for instance in opening up opportunities to take part in clinical trials.

Other options for treatment your medical team may discuss with you

Although immunotherapy and BRAF-targeted therapy are the most common treatments used for Stage 4 melanoma, your medical team may consider other treatments, depending on your situation. These may happen alongside or instead of immunotherapy or BRAF-targeted therapy.

Surgery: although your medical team might not feel that surgery will cure your melanoma, they are still likely to consider whether surgery might help control your disease. Sometimes surgery can be helpful alongside systemic (medical) treatments – for instance if most of your melanoma is responding to treatment but one area is getting bigger. It is always important that you understand what surgery can or cannot achieve in your own particular situation, and what the risks of any surgery might be – your medical team will be able to discuss this with you.

>Specialised radiotherapy techniques

>TILs

As a Stage 4 melanoma patient whose melanoma cannot be removed with surgery you could be considered for other treatments that include electrochemotherapy, isolated limb perfusion/infusion, tumor-infiltrating lymphocytes (TILS) therapy and T-VEC.

>See our video on T-VEC

>Learn more about other treatments when your melanoma cannot be removed with surgery

Clinical trials

Clinical trials are an essential step in improving the care we are able to offer to patients with melanoma. They help us learn about whether new treatments work, and how to use them most effectively. Taking part in clinical trials might offer you the offers the opportunity to access a new treatment before it is more widely available and will help the melanoma community move forward in its knowledge and understanding of this disease. It is important to bear in mind that not everyone in clinical trials will receive new treatments. Many trials compare new treatments with standard treatments and you will not be able to choose which group you are allocated to. Clinical trials all have strict criteria about who can take part and so even if you are keen to take part in a clinical trial, it may not be possible for you to be included. For more detailed information:

>See our page explaining clinical trials

and

>Search for clinical trials on our Melanoma Trialfinder

Stage 4 melanoma: Questions you may have for your medical team

  • How was it determined I have stage 4 melanoma?
  • Where has my melanoma spread to?
  • Will my melanoma be tested for BRAF mutation?
  • If I am BRAF positive, what does that mean for my treatment?
  • If I am BRAF negative, what does that mean for my treatment?
  • Will I be tested for NRAS or c-Kit mutation?
  • What treatment options are available for me?
  • What are the advantages and disadvantages of these options?
  • How important is it to have oral treatment or treatment in hospital?
  • How much time will I spend having treatment?
  • How could the treatment affect my lifestyle and work?
  • What are the possible side effects of the treatments?