Melanoma: Chemotherapy

What is chemotherapy?

Chemotherapy (chemo) uses anticancer medicines to kill cancer cells. The medicines are made to attack and kill cancer cells that grow quickly. Some normal cells also grow quickly. Because of this, chemotherapy can also harm those cells. This can cause side effects.

When might chemotherapy be used for melanoma?

Chemotherapy is sometimes used to treat advanced melanomas. But it isn't used as often as it was in the past because newer types of medicines are more helpful. Examples are immunotherapy and targeted therapy. Chemo is most often used to treat advanced melanomas if other treatments are no longer working. Chemo may also be used if you are not able to tolerate the side effects of immunotherapy or targeted therapy

How is chemotherapy given for melanoma?

Chemo medicine is most often given through an IV (intravenous) line. It may also be taken by mouth as a pill or as an injection. The treatment may be done as an outpatient visit to a hospital, and you go home the same day. Or it may be done at your healthcare provider's office, a chemotherapy clinic, or at home. In some cases, you may stay in the hospital during treatment.

You'll receive chemo treatment in cycles over a period of time. That means you may take the medicine for a set amount of time and then you have a rest period. Each period of treatment and rest is one cycle. You may have several cycles. Having treatment in cycles helps by:

• Killing more cancer cells. The medicine can kill more cancer cells over time because cells aren't all dividing at the same time. Cycles allow the medicine to fight more cells.

• Giving your body a rest. Treatment is hard on other cells of the body that divide quickly. This includes cells in the lining of the mouth and intestines. This causes side effects, such as sores and nausea. Between cycles, your body can get a rest from the chemotherapy.

• Giving your mind a rest. Having chemo can be stressful. Taking breaks between cycles can let you get an emotional break between treatments.

What types of medicines are used to treat melanoma?

Chemo medicines used to treat melanoma include:

• Dacarbazine

• Nab-paclitaxel

• Carboplatin

• Cisplatin

• Paclitaxel

• Docetaxel

• Temozolomide

• Vinblastine

• Lomustine

For melanoma, you may get just 1 medicine. Or you may get more than one medicine. This is called combination therapy. The schedule of treatment varies for each person. Which medicines you take and how often you take them depend on many factors, such as your general health.

What are common side effects of chemotherapy?

Side effects of chemo depend on the type and amount of medicines you’re taking. They vary from person to person. Some common short-term (temporary) side effects from chemo include:

• Loss of appetite, nausea, and vomiting

• Infections from low white blood cell counts

• Easy bruising or bleeding from low blood platelet counts

• Severe tiredness (fatigue) from low red blood cell counts

• Numbness or tingling in the hands or feet (peripheral neuropathy)

• Constipation or diarrhea

• Hair loss

• Mouth sores 

• Skin changes

Most side effects will go away or get better between treatments and a few weeks after treatment ends. You may also be able to help control some of these side effects. Tell your healthcare providers about any side effects you have. They can help you treat and cope with the side effects.

A more serious possible side effect of some chemo medicines is organ damage. This can include damage to the kidneys, liver, testicles, ovaries, brain, heart, or lungs. You may have blood tests while you’re getting chemo. This is to make sure you aren’t having harmful reactions to the medicine.

Chemotherapy through isolated limb perfusion (ILP) or isolated limb infusion (ILI)

If the melanoma is recurrent, confined to a leg or arm, and unable to be surgically removed (unresectable), you may get the chemo medicine by isolated limb perfusion (ILP) or isolated limb infusion (ILI). The goal is to give high doses of chemo to the affected limb (regional chemo) to prevent the side effects experienced from systemic chemo. These approaches may shrink the tumor and help prevent amputation. It may also relieve symptoms, such as pain and swelling. Typically, this therapy is given with general anesthesia in the operating room.

How ILP is done

ILP combines surgery and medicine. First the surgeon temporarily stops the blood circulation to the affected arm or leg. Keeping the blood in the limb stops high doses of chemo medicine from traveling around the body and affecting other organs.

Then two small tubes called catheters are put into the limb. One is put in an artery and one is put in a vein. Blood from the vein goes into a machine called a pump-oxygenator. This machine is like the one used in heart bypass surgery. There the blood is mixed with oxygen and chemo medicine. Melphalan is the most common medicine used for this. The blood is then sent to the limb through the artery. 

Chemo medicine moves through the limb for up to 90 minutes. During this time, blankets keep the limb warm. The medicines are also warmed as they move through the pump-oxygenator. This may help the chemo work better. At the end of the procedure, the medicines are flushed out of the limb. Normal circulation is resumed. The whole procedure takes about 2 to 3 hours.

ILP and ILI are similar because both involve isolating the limb's circulation and forcing fluid through the limb with chemo medicines. There are several differences between ILP and ILI. With ILI there is no surgical procedure to place the catheters. Instead, the procedure uses a tourniquet to isolate the circulation. This procedure is less complex, shorter in duration, can be repeated, and used in people who are frail and elderly.

How ILP and ILI may help

The main advantage of ILP and ILI is that they let high doses of chemo medicine be given to the affected limb. But they spare the rest of the body from the medicine’s side effects. Side effects are mostly limited to the limb, such as limb swelling.

But ILP also has a few drawbacks. For one, it is a major procedure. Also it doesn't affect any cancer that has spread beyond the limb. And while this procedure can often shrink tumors, it may not improve long-term survival better than other treatments.

Working with your healthcare provider

It's important to know which medicines you're taking. Write your medicines down, and ask your healthcare team how they work and what side effects they might have.

Talk with your healthcare providers about what signs to look for and when to call them. For example, chemo can make you more likely to get infections. Make sure you know what number to call with questions. Is there a different number for evenings, weekends, and holidays?

It may be helpful to keep a diary of your side effects. Write down physical and emotional changes, as well as those in your thought patterns. A written list will make it easier for you to remember your questions when you go to your appointments. It will also make it easier for you to work with your healthcare team to make a plan to manage your side effects.