Targeted cancer drugs and immunotherapy for melanoma skin cancer

Targeted cancer drugs work by targeting the differences in cancer cells that help them to grow and survive. Other drugs help the immune system to attack the cancer. They are called immunotherapies.

This page is about targeted cancer drugs and immunotherapy for melanoma skin cancer that:

• can be removed with surgery
• hasn’t spread to other parts of the body such as your lungs or liver

Cancer that has spread to other parts of the body is called advanced cancer. Some stage 3 melanomas cannot be removed with surgery. Doctors treat these with the same targeted cancer drugs and immunotherapy they use for advanced melanoma.

When do you have targeted cancer drugs and immunotherapy?

Doctors use targeted cancer drugs or immunotherapy to treat melanoma skin cancers that have been removed and either:

• have a high chance of coming back
• have spread to an area near the melanoma or to the nearby lymph nodes

Doctors also recommend an immunotherapy cream to treat melanoma in situ that cannot be removed.

If you need targeted cancer drugs or immunotherapy, which ones you have depends on:

• how thick the melanoma is and if it has spread – this is called the stage

• any cancer drugs you may have had in the past for the melanoma

• your general health

• if there are changes in the cancer genes

Melanoma skin cancer in situ (stage 0)

Surgery is the main treatment for melanoma in situ. Sometimes the melanoma cannot be removed. If this happens, your doctor may recommend you have a cream called imiquimod. This is a type of immunotherapy.

Stage 1 melanoma skin cancer

Surgery to remove the melanoma is the main treatment. Your surgeon also removes an area of skin around the melanoma. This reduces the risk of it coming back. You don’t need targeted or immunotherapy drugs for stage 1 melanoma skin cancer.

Stage 2 melanoma skin cancer

You may have an immunotherapy drug for stage 2 melanoma if you have had surgery to completely remove it and it was either:

• stage 2B - this means it is between 2 and 4 mm thick and the top layer of skin was broken (ulcerated) when looked at under a microscope. Or the melanoma was thicker than 4mm and not ulcerated
• stage 2C - this means it is thicker than 4 mm and is ulcerated

You have an immunotherapy drug called pembrolizumab (Keytruda). A nurse gives it to you as a drip into your bloodstream (intravenously). It helps reduce the risk of the cancer coming back. This is called adjuvant treatment.

Stage 3 melanoma skin cancer

If your doctor has been able to remove the original melanoma, you have adjuvant treatment. This is either with targeted cancer drugs or immunotherapy. Which treatment you have, depends on any gene changes in the melanoma cells.

Tests on the melanoma cells

If you have stage 3 melanoma, your doctor sends a sample of the cancer for genetic testing. They might also do this if you have stage 2 melanoma. The test looks for changes in the melanoma genes such as changes to the BRAF gene. Changes in this gene can make the melanoma cells grow.

About 40 to 50 out of every 100 people with skin melanoma (40 to 50%) have a change in the BRAF gene.

If you don’t have changes in the BRAF gene, then the melanoma is BRAF negative. This is also called BRAF wild type.

If you have changes in the BRAF gene, doctors describe the melanoma as BRAF positive. This is also called BRAF mutated.

BRAF negative melanoma skin cancer

Your doctor normally recommends a type of immunotherapy called a checkpoint inhibitor. These block a protein on the cancer cells that stop the immune system from attacking them.

You usually have either:

• pembrolizumab
• nivolumab (Opdivo)

These are called PD-1 (programmed cell death protein 1) checkpoint inhibitors. You have them intravenously.

BRAF positive melanoma skin cancer

Doctors can use immunotherapy to treat BRAF positive melanoma skin cancer. You may have either:

• pembrolizumab
• nivolumab

Or you might have targeted cancer drugs instead of immunotherapy.

BRAF positive melanoma produces too much of the BRAF protein. This also affects other proteins such as MEK.  Both of these can make the cancer grow. Targeted cancer drugs work by blocking the proteins. This slows or stops the growth of the cancer cells.  They are called cancer growth blockers or inhibitors.

You usually have a BRAF protein inhibitor with a MEK protein inhibitor as they work better together. This is normally dabrafenib (Tafinlar) and trametinib (Mekinist). Dabrafenib is a BRAF inhibitor and trametinib is a MEK inhibitor.

You take these as tablets or capsules.

Side effects

Everyone is different and side effects can vary from person to person. The side effects you may have depend on:

• which cancer drugs you have
• whether you have it alone or with other drugs
• the amount of the drug you have (the dose)
• your general health

A side effect may get better or worse during the course of your treatment. Or more side effects may develop as the treatment goes on.

Immunotherapy drugs may cause inflammation in different parts of the body.  This can cause serious side effects. They could happen during treatment, or some months after treatment has finished. In some people, these side effects could be life threatening.

For more information about the side effects of your treatment, go to the individual drug pages.

Clinical trials

Sometimes your doctor might talk to you about having your treatment as part of a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.

Researchers continue to look at new immunotherapy drugs to treat melanoma skin cancer. They are also looking at using targeted therapy after surgery if there is a higher risk of the melanoma coming back.