Myths & Facts: Melanoma

ACCORDING TO THE Centers for Disease Control and Prevention (CDC), cancer is the second leading cause of death in the United States, exceeded only by heart disease, and one of every four deaths in the U.S. is due to cancer. Also in the U.S., skin cancer is the most common form of cancer.¹ Melanoma, one of three major types of skin cancer, accounts for only about 1 percent of skin cancers, but it causes a large majority of skin cancer deaths.² In 2018, the latest year for which incidence data are available, 83,996 new cases of melanoma were reported, and 8,199 people died. For every 100,000 people, 22 new melanoma cases are reported, and two people die (Figure 1).¹ The rates of melanoma have been rising rapidly over the past few decades, but have stabilized in the last five years and vary by age. In 2022, the American Cancer Society estimates about 99,780 new melanoma cases will be diagnosed (about 57,180 in men and 42,600 in women) and about 7,650 people are expected to die of melanoma (about 5,080 men and 2,570 women).²

Melanoma is more than 20 times more common in whites than in African Americans. Overall, the lifetime risk of melanoma is about 2.6 percent (one in 38) for whites, 0.1 percent (one in 1,000) for Blacks and 0.6 percent (one in 167) for Hispanics. However, the risk for each person can be affected by a number of different factors. Melanoma is more common in men overall, but before age 50, the rates are higher in women.² It is the fifth most common cancer among men and women.3 And, the risk of melanoma increases as people age. The average age at diagnosis is 65, but melanoma is not uncommon even among those younger than 30. In fact, it’s one of the most common cancers in young adults (especially young women).²

The underlying cause of these grim statistics could lie in the fact that so many people disbelieve melanoma is a serious disease. Yet, the reality is this misunderstood deadly and costly disease (treatment is estimated to cost approximately $3.3 billion each year in the U.S.⁴) can often be prevented. So dispelling the many myths surrounding it could potentially help to save millions of lives.

Separating Myth from Fact

Myth: Only adults get melanoma; it doesn’t affect children.

Fact: Melanoma can develop from the day an individual is born until the day he or she dies.⁵ While it is the most common form of cancer in young adults ages 25 years to 29 years, it is also increasing faster in younger women ages 15 years to 29 years.⁶ Yes, melanoma is rare in children, but between 300 and 400 cases are diagnosed in the United States each year.⁷ In fact, pediatric melanoma has increased on average 2 percent per year since 1973, although its incidence seems to have decreased over the last few years.⁸ And, because it is so rare, many childhood melanomas are found in the later stages when treatment becomes more involved.⁷ What’s important to know is that among children and teenagers, melanoma often looks different and may grow faster than it does in adults.⁸

Myth: Individuals who tan easily and rarely burn won’t get melanoma.

Fact: Cases of melanoma are more prevalent in individuals with fair skin, freckles, blue or green eyes, and blond, red or light brown hair, but everyone is at risk. What’s more, melanoma is less frequently diagnosed among Blacks, Hispanics or Asians, and when it is found in these ethnicities, it is often in its late stages.9 As such, the death rates are higher in darker-skinned people. “It is often diagnosed later, at a more advanced stage, because both doctors and patients may not even be considering the possibility of skin cancer developing on darker skin until it’s too late,” says Saira George, MD, a dermatologist at MD Anderson Cancer Center.¹⁰

Myth: A mole has to be raised and turn color to be a possible melanoma.

Fact: It doesn’t matter whether a mole is flat or raised. In fact, a lesion’s texture is less important than its color or changes in either color or shape. “In my experience, it’s just the opposite — 90 percent of melanomas I’ve treated in moles were flat,” explains Jenny Nelson, MD, a dermatological surgeon at Avera Medical Group in Sioux Falls, S.D. In addition, oddly shaped moles, especially ones that may not be circular should be sampled. For example, a mole that has a “tail” shooting off in one direction is indicative of melanoma.¹¹

There are four main types of melanoma: superficial spreading, nodular, lentigo maligna and acral lentiginous.¹²

1) Superficial spreading melanoma is the most common type of melanoma skin cancer, occurring in approximately 70 percent of cases. This melanoma tends to grow outward (called radial growth) and spread across the surface of the skin, but it can also start to grow down into the skin (called vertical growth). It is often flat and thin (less than 1 mm thick) with an uneven border. It varies in color and may have different shades of red, blue, brown, black, grey and white. It usually develops on the central part of the body (trunk), arms and legs, and it tends to happen on the back in men and the legs in women.

2) Nodular melanoma is the second most common type, making up about 15 percent to 20 percent of cases. It grows down into the skin and spreads more quickly than other types. It is a raised growth that sticks out from the skin (polypoid), and the growth may be shaped like a mushroom with a stem or stalk (pedunculated). It is usually black, but sometimes can be red, pink or the same color as skin. It usually develops on the face, chest or back, and it can be found on areas of skin not exposed to the sun.

3) Lentigo maligna melanoma most often develops in older people, and it makes up about 10 percent to 15 percent of all melanoma skin cancers. It usually appears as a large, flat tan or brown patch with an uneven border, and it tends to get darker as it grows and has many shades of brown or black. It often starts from an in situ tumor called lentigo maligna, which is an early form of the growth only in the top or outer layer of the skin (epidermis). Lentigo maligna melanoma usually grows outward across the surface of the skin for many years before it starts to grow down into the skin. It usually develops on areas of skin that are regularly exposed to the sun without protection such as the face, ears and arms.

4) Acral lentiginous melanoma is most common in people with dark skin such Africans, Asians and Hispanics. It is not related to being exposed to the sun, and it makes up less than 5 percent of all melanoma skin cancers. Acral lentiginous melanoma appears as a small, flat spot of discolored skin that is often dark brown or black. It usually grows outward across the surface of the skin for a long time before it starts to grow down into the skin. And, it usually develops on the soles of the feet, palms of the hands or under the nails.

It’s important to note that many melanomas occur in pre-existing spots or moles, so a doctor should evaluate all moles, lesions or spots that have changed.

And, individuals with multiple moles should undergo routine full-body exams by a dermatologist.¹³

Myth: Melanoma is only possible if the body is regularly exposed to the sun.

Fact: Sun exposure can be a primary cause of melanoma, but there are many other risk factors. Exposure to ultraviolet (UV) radiation from the sun plays a major role. People who live at high altitudes or in areas with bright sunlight year-round have a higher risk of developing skin cancer, and those who spend a lot of time outside during the midday hours also have a higher risk.

Exposure to UVB radiation from the sun appears more closely associated with melanoma, but newer information suggests UVA may also play a role. While UVB radiation causes sunburn and does not penetrate through car windows or other types of glass, UVA can pass through glass and may cause aging and wrinkling of the skin in addition to skin cancer.

People who use tanning beds, tanning parlors or sun lamps have an increased risk of developing all types of skin cancer.

Other risk factors for melanoma include many moles or unusual moles, fair skin, family history (about 10 percent of people with melanoma have a family history of the disease), familial melanoma caused by mutations in specific genes, other inherited conditions, including xeroderma pigmentosum, retinoblastoma, Li-Fraumeni syndrome, Werner syndrome and certain hereditary breast and ovarian cancer syndromes, previous skin cancer, race or ethnicity, age and a weakened or suppressed immune system.¹⁴

Also, melanoma can develop over time. So, regular or extreme exposure to sunlight may not lead to immediate skin cancer. “It could take months or years to see a lesion develop. Extreme exposure does add to the overall toll,” explains Dr. Nelson, but “the damage and risk add up over time.”¹¹

Importantly, some types of melanoma are not related to sun exposure and can occur in unexpected places such as the vagina, rectum, inside the mouth, the soles of the feet and the palms of the hands.¹³ “I’ve removed melanomas from armpits and feet; they can develop anywhere and are more related to skin type than sun exposure,” says Dr. Nelson. “Your genetics play a big role, too, and while cancers develop on the hands and face, they can happen anywhere.”¹¹

Myth: Getting a base tan will protect against melanoma.

Fact: There’s no such thing as a safe tan or a tan that prevents sunburns. When exposed to UV rays from the sun or tanning booth, they damage the DNA of skin cells. To protect the cells, the body sends melanin, or pigment, to the surface of the skin, and the skin turns color at the expense of health. The minor protective effect of a tan can easily be wiped out by additional UV exposure, leading to more damage.¹⁰

Myth: Sunscreen with a high SPF will protect against melanoma.

Fact: SPF protection doesn’t increase proportionately with the designated SPF number. For example, SPF 30 absorbs 97 percent of UV rays, while SPF 50 absorbs just slightly more — 98 percent — and SPF 100 absorbs 99 percent. Therefore, an SPF of at least 30 should be applied.10 Also, sunscreen must be applied correctly. Most people use only 25 percent of what is needed to obtain protection. For instance, an SPF 100 sunscreen applied at 25 percent has an effective SPF of only 3.1. And, sunscreen must be reapplied every two hours or according to the product label. Water-resistant sunscreens should be reapplied every 40 minutes to 80 minutes. Sunscreen should also be reapplied after swimming or participating in any activity that causes perspiration. Just to note, the U.S. Food and Drug Administration prohibits the labeling of sunscreen as “waterproof,” “sweatproof” or “sunblock.”⁹

Myth: Sunscreen isn’t necessary in the winter.

Fact: Harmful UV rays are present year-round and can reach and damage skin even on hazy days or days with light or broken cloud cover or shade.⁹

Myth: Primary care doctors can diagnose melanoma.

Fact: General practitioners can suspect melanoma, but they usually lack sufficient training to accurately diagnose melanoma. Even dermatologists can’t always tell if a suspicious skin growth is cancerous just by looking, but they do have the experience, diagnostic technology and resources general practitioners don’t have.⁵

Melanoma is typically diagnosed by pathologists, doctors who specialize in interpreting laboratory tests and evaluating cells, tissues and organs to diagnose disease, or dermatopathologists, pathologists with specialty training in diagnosing skin cancer and other disorders of the skin using a microscope and other laboratory tests. To diagnose melanoma, a biopsy of the suspicious skin area, called a lesion, is tested in a laboratory. The pathologist or dermatopathologist will then write a pathology report that notes the thickness of the melanoma, the presence or absence of ulceration, whether the cells are dividing (called the mitotic rate), the type/subtype of melanoma, the presence of immune cells called tumor-infiltrating lymphocytes, margin status (which describes whether melanoma cells can be seen at the deep and/or peripheral [side] edges of the biopsy sample), and presence or absence of certain markers associated with prognosis and/or response to different therapies.¹⁵

Doctors will also test whether the melanoma has spread beyond the original site. If there’s a risk that the cancer has spread to the lymph nodes, a procedure known as a sentinel node biopsy is performed. During a sentinel node biopsy, a dye is injected in the area where the melanoma was removed, and the dye flows to the nearby lymph nodes. The first lymph nodes to take up the dye are removed and tested for cancer cells. If these first lymph nodes (sentinel lymph nodes) are cancer-free, there’s a good chance the melanoma has not spread beyond the area where it was first discovered.

For people with more advanced melanomas, imaging tests can look for signs that the cancer has spread to other areas of the body. These tests include X-rays, CT scans, MRIs and PET scans. However, these imaging tests generally aren’t recommended for smaller melanomas with a lower risk of spreading beyond the skin.¹⁶

Myth: There are very few treatments for melanoma.

Fact: Actually, while the incidence of melanoma has increased, treatment and survival for patients with localized or metastatic melanoma have improved dramatically in the past 10 years with improved management.

Treatment recommendations depend on many factors, including the thickness of the primary melanoma, whether the cancer has spread, the stage of the melanoma, the presence of specific genetic changes in melanoma cells, rate of melanoma growth and the patient’s other medical conditions.

Other factors used in making treatment decisions include possible side effects, as well as the patient’s preferences and overall health.

Surgery is first performed to remove the original melanoma. If it is determined the cancer has spread to the lymph nodes and beyond, a number of other therapies can be tried. These include:¹⁷

• Radiation therapy uses high-energy X-rays or other particles to destroy cancer cells. In some instances, adjuvant radiation therapy is recommended after surgery to prevent the cancer from recurring.
• Systemic therapy is given through the bloodstream to destroy cancer cells. Systemic therapies used for melanoma include: immunotherapy, targeted therapy and chemotherapy.

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. In recent years, major advances have been made in treating stage III and stage IV melanoma with immunotherapy. Both nivolumab (Opdivo) and pembrolizumab (Keytruda) have been shown to shrink melanoma for 25 percent to 45 percent of patients with unresectable or stage IV melanoma, depending on when treatment is given. Both drugs also have been shown to reduce the risk of the cancer coming back after surgery for stage III melanoma. More recently, pembrolizumab has been shown to reduce the risk of cancer coming back after surgery for higher risk stage II melanoma (stage IIB and stage IIC).

Other immunotherapy treatments include ipilimumab (Yervoy) that targets a molecule called cytotoxic T-lymphocyte associated molecule-4 (CTLA-4) and has been shown to shrink melanoma for 10 percent to 15 percent of patients; a combination of ipilimumab and nivolumab may be used for the treatment of unresectable stage III or stage IV melanoma; interleukin-2, which activates T cells; Talimogene laherparepvec (T-VEC; Imlygic), a herpes virus therapy designed in a laboratory to make an immune-stimulating hormone to treat unresectable stage III and stage IV melanoma; and interferon, including high-dose interferon alfa-2b (Intron A) and pegylated interferon alfa-2b (Sylatron).

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins or the tissue environment that contributes to cancer growth and survival. These include BRAF inhibitors to treat individuals with melanomas that have a mutated or activated BRAF gene; MEK inhibitors for unresectable or metastatic melanoma with a BRAF V600E or V600K mutation; combination BRAF-MEK inhibitors; KIT inhibitors that treat the KIT gene, which is mutated or present in increased numbers (extra copies of the gene) in some tumors in certain subtypes of melanoma; and tumor-agnostic treatment that is not specific to a certain type of cancer but focuses on a specific genetic change called an NTRK fusion.

• Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing and making more cells. However, because immunotherapy and targeted therapy have been more effective at treating melanoma, chemotherapy is used much less often.

Myth: Melanoma can be prevented.

Fact: There is no proven way to completely prevent melanoma, but individuals may be able to lower their risk by reducing exposure to UV radiation, limiting or avoiding direct exposure to the sun between 10:00 a.m. and 4:00 p.m., wearing sun-protective clothing, using a broad-spectrum sunscreen throughout the year that protects against both UVA and UVB radiation and has an SPF of at least 30, avoiding recreational outdoor sunbathing, not using sun lamps, tanning beds or tanning salons, and examining skin regularly.¹⁴

Myth: Melanoma can’t kill you.

Fact: Skin cancer can kill you, especially melanoma, which can be fatal if not treated promptly. Life expectancy for skin cancer depends on the type and stage of cancer and whether it has metastasized. Fortunately, with new treatments available today, survival rates are increasing.

Survival rates provide an idea of what percentage of people with the same type and stage of cancer are still alive a certain amount of time (usually five years) after diagnosis.19 For people with melanoma that is less than 1 mm in maximal thickness and has not spread to lymph nodes or other distant sites, the five-year survival is 99 percent. For people with thicker melanoma, the five-year survival may be 80 percent or higher. Survival rates at five years for people with melanoma that has spread to the nearby lymph nodes is 68 percent. But this number differs for every patient and depends on the number of lymph nodes involved, genetic changes, the amount of tumor in the involved lymph nodes and the features of the primary melanoma. If melanoma has spread to other parts of the body, the survival rate is lower, about 30 percent. The good news is treatment advances have doubled this survival rate since 2004, and only approximately 5 percent of cases are diagnosed at this stage.³

It should be noted that survival rates are estimates and are often based on previous outcomes of large numbers of people who had a specific cancer, but they can’t predict what will happen in any particular person’s case.¹⁹

Dispelling the Myths Now

Without a doubt, melanoma is a serious and often deadly disease. The good news for people diagnosed with melanoma today is they have a better outlook than ever before due to diagnostics and treatment. The bad news is that too many people are still being diagnosed with melanoma simply because they don’t understand the gravity of the disease and its risks, and they don’t take the necessary precautions to try to prevent it. Clearly, it’s imperative that we reverse the toll this disease is taking on the American public. In 2019, the U.S. Department of Health and Human Services published The Surgeon General’s Call to Action to Prevent Skin Cancer, which outlines action steps we can all take — as individuals, parents, educators, employers, policymakers, healthcare professionals and communities. This publication is a Call to Action to partners in prevention from various sectors across the nation to address skin cancer as a major public health problem.²⁰