Information on Melanoma Treatment, Causes and Symptoms - Information Book

• What Is Melanoma?
• The Skin
• Melanocytes and Moles
• Cancer
• General Information on Melanoma
• Signs and Symptoms of Melanoma
• Pictures of Melanoma
• Diagnosis and Staging
• Information on Melanoma Treatment
• Getting a Second Opinion
• Preparing for Melanoma Treatment
• Methods of Treatment
• Surgery
• Chemotherapy
• Biological therapy
• Radiation therapy
• Clinical Trials
• Side Effects of Melanoma Treatment
• Surgery
• Chemotherapy
• Biological therapy
• Radiation therapy
• Nutrition for People with Cancer
• Followup Care
• Recovery and Outlook
• Support for People with Cancer
• Causes, Risk Factors, and Prevention
• Keeping on Top of Your Condition

Common Misspellings:  melonoma, melenoma, melinoma

What Is Melanoma?

Melanoma is a type of skin cancer. It begins in certain cells in the skin called melanocytes. To understand melanoma, it is helpful to know about the skin and about melanocytes -- what they do, how they grow, and what happens when they become cancerous.

The Skin

The skin is the body's largest organ. It protects against heat, sunlight, injury, and infection. It helps regulate body temperature, stores water and fat, and produces vitamin D. The skin has two main layers: the outer epidermis and the inner dermis.

The epidermis is mostly made up of flat, scalelike cells called squamous cells. Round cells called basal cells lie under the squamous cells in the epidermis. The lower part of the epidermis also contains melanocytes.

The dermis contains blood vessels, lymphatic vessels, hair follicles, and glands. Some of these glands produce sweat, which helps regulate body temperature, and some produce sebum, an oily substance that helps keep the skin from drying out. Sweat and sebum reach the skin's surface through tiny openings called pores.

Melanocytes and Moles

Melanocytes are found throughout the lower part of the epidermis. They produce melanin, the pigment that gives skin its natural color. When skin is exposed to the sun, melanocytes produce more pigment, causing the skin to tan, or darken.

Sometimes, clusters of melanocytes and surrounding tissue form benign (noncancerous) growths called moles. (Doctors also call a mole a nevus; the plural is nevi.) Moles are very common. Most people have between 10 and 40 of these flesh-colored, pink, tan, or brown areas on the skin. Moles can be flat or raised. They are usually round or oval and smaller than a pencil eraser. They may be present at birth or may appear later on -- usually before age 40. Moles generally grow or change only slightly over a long period of time. They tend to fade away in older people. When moles are surgically removed, they normally do not return.

Cancer

Cancer is a group of many different diseases that have some important things in common. They all begin in cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy. Sometimes cells keep dividing when new cells are not needed, creating a mass of extra tissue. This mass is called a growth or tumor. Tumors can be benign or malignant.

• Benign tumors are not cancer. They often can be removed and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Most importantly, benign tumors are rarely a threat to life.

• Malignant tumors are cancer. Cells in malignant tumors are abnormal and divide without control or order. These cancer cells can invade and destroy the tissue around them. Cancer cells can also break away from a malignant tumor and enter the bloodstream or lymphatic system (the tissues and organs that produce and store cells that fight infection and disease). This process, called metastasis, is how cancer spreads from the original tumor to form new tumors in other parts of the body. When cancer spreads (metastasizes) to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the original tumor.

General Information on Melanoma

Melanoma occurs when melanocytes (pigment cells) become malignant. Most pigment cells are in the skin; when melanoma starts in the skin, the disease is called cutaneous melanoma. Melanoma may also occur in the eye and is called ocular melanoma or intraocular melanoma. Rarely, melanoma may arise in the meninges, the digestive tract, lymph nodes, or other areas where melanocytes are found. Melanomas arising in areas other than the skin are not discussed in this booklet.

Melanoma can occur on any skin surface. In men, it is often found on the trunk (the area from the shoulders to the hips) or the head and neck. In women, melanoma often develops on the lower legs. Melanoma is rare in black people and others with dark skin. When it does develop in dark-skinned people, it tends to occur under the fingernails or toenails, or on the palms or soles. The chance of developing melanoma increases with age, but this disease affects people of all age groups. Melanoma is one of the most common cancers in young adults.

When melanoma spreads, cancer cells are also found in the lymph nodes (also called lymph glands). If the cancer has reached the lymph nodes, it may mean that cancer cells have spread to other parts of the body such as the liver, lungs, or brain. In such cases, the cancer cells in the new tumor are still melanoma cells, and the disease is called metastatic melanoma rather than liver, lung, or brain cancer.

Signs and Symptoms of Melanoma

Often, the first sign of melanoma is a change in the size, shape, color, or feel of an existing mole. Most melanomas have a black or blue-black area. Melanoma also may appear as a new, black, abnormal, or "ugly-looking" mole.

Pictures of Melanoma

If you have a question or concern about something on your skin, do not use these pictures of melanoma to try to diagnose it yourself. The following melanoma pictures are useful examples, but they cannot take the place of a doctor's examination.

Thinking of "ABCD" can help you remember what to watch for:

• Asymmetry -- The shape of one half does not match the other.

  

• Border -- The edges are often ragged, notched, blurred, or irregular in outline; the pigment may spread into the surrounding skin.

  

• Color -- The color is uneven. Shades of black, brown, and tan may be present. Areas of white, grey, red, pink, or blue also may be seen.

  

• Diameter -- There is a change in size, usually an increase. Melanomas are usually larger than the eraser of a pencil (5 mm or 1/4 inch).

  

Melanomas can vary greatly in the ways they look. Many show all of the ABCD features. However, some may show changes or abnormalities in only one or two of the ABCD features.

Early melanomas may be found when a pre-existing mole changes slightly -- such as forming a new black area. Other frequent findings are newly formed fine scales or itching in a mole. In more advanced melanoma, the texture of the mole may change. For example, it may become hard or lumpy. Although melanomas may feel different and more advanced tumors may itch, ooze, or bleed, melanomas usually do not cause pain.

Melanoma can be cured if it is diagnosed and treated when the tumor is thin and has not deeply invaded the skin. However, if a melanoma is not removed at its early stages, cancer cells may grow downward from the skin surface, invading healthy tissue. When a melanoma becomes thick and deep, the disease often spreads to other parts of the body and is difficult to control.

A skin examination is often part of a routine checkup by a doctor, nurse specialist, or nurse practitioner. People also can check their own skin for new growths or other changes. (The "How To Do a Skin Self-Exam" section has a simple guide on how to do a skin self-exam.) Changes in the skin or a mole should be reported to the doctor or nurse without delay. The person may be referred to a dermatologist, a doctor who specializes in diseases of the skin.

People who have had melanoma have a high risk of developing a new melanoma. Also, those with relatives who have had this disease have an increased risk. Doctors may advise people at risk to check their skin regularly and to have regular skin exams by a doctor or nurse specialist.

Some people have certain abnormal-looking moles, called dysplastic nevi or atypical moles, that may be more likely than normal moles to develop into melanoma. Most people with dysplastic nevi have just a few of these abnormal moles; others have many. They and their doctor should examine these moles regularly to watch for changes.

Dysplastic nevi often look very much like melanoma. Doctors with special training in skin diseases are in the best position to decide whether an abnormal-looking mole should be closely watched or should be removed and checked for cancer.

In some families, many members have a large number of dysplastic nevi, and some have had melanoma. Members of these families have a very high risk for melanoma. Doctors often recommend that they have frequent checkups (every 3 to 6 months) so that any problems can be detected early. The doctor may take pictures of a person's skin to help in detecting any changes that occur.

Diagnosis and Staging

If the doctor suspects that a spot on the skin is melanoma, the patient will need to have a biopsy. A biopsy is the only way to make a definite diagnosis. In this procedure, the doctor tries to remove all of the suspicious-looking growth. If the growth is too large to be removed entirely, the doctor removes a sample of the tissue. A biopsy can usually be done in the doctor's office using a local anesthetic. A pathologist then examines the tissue under a microscope to check for cancer cells. Sometimes it is helpful for more than one pathologist to look at the tissue to determine whether melanoma is present.

If melanoma is found, the doctor needs to learn the extent, or stage, of the disease before planning treatment. The treatment plan takes into account the location and thickness of the tumor, how deeply the melanoma has invaded the skin, and whether melanoma cells have spread to nearby lymph nodes or other parts of the body. Removal of nearby lymph nodes for examination under a microscope is sometimes necessary. (Such surgery may be considered part of the treatment because removing cancerous lymph nodes may help control the disease.) The doctor also does a careful physical exam and, depending on the thickness of the tumor, may order chest x-rays; blood tests; and scans of the liver, bones, and brain.

Information on Melanoma Treatment

After diagnosis and staging, the doctor develops a treatment plan to fit each patient's needs. Treatment for melanoma depends on the extent of the disease, the patient's age and general health, as well as other factors.

People with melanoma are often treated by a team of specialists, which may include a dermatologist, surgeon, medical oncologist, and plastic surgeon. The standard treatment for melanoma is surgery; in some cases, doctors may also use chemotherapy, biological therapy, or radiation therapy. The doctors may decide to use one treatment method or a combination of methods.

Some patients take part in a clinical trial, which is a research study using new treatment methods. Such trials are designed to improve cancer treatment. (The "Clinical Trials" section has more information about clinical trials).

Getting a Second Opinion

Before starting treatment, the patient may want a second doctor to review the diagnosis and treatment plan. It may take a week or two to arrange for a second opinion. A short delay will not reduce the chance that treatment will be successful. Some insurance companies require a second opinion; many others will cover a second opinion if the patient requests it.

There are a number of ways to find a doctor who can give a second opinion:

• One doctor may refer the patient to another who has special interest and training in treating melanoma.

• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.

• Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.

• The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their background. This resource is in most public libraries.

Preparing for Melanoma Treatment

Many people with cancer want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Patients do not need to ask all their questions or remember all the answers at one time. They will have other chances to ask the doctor to explain things and to get more information.

Methods of Treatment

Surgery

Surgery to remove (excise) a melanoma is the standard treatment for this disease. It is necessary to remove not only the tumor but also some normal tissue around it in order to minimize the chance that any cancer will be left in the area.

The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin. In cases in which the melanoma is very thin, enough tissue is often removed during the biopsy, and no further surgery is necessary. If the melanoma was not completely removed during the biopsy, the doctor takes out the remaining tumor. In most cases, additional surgery is performed to remove normal-looking tissue around the tumor (called the margin) to make sure all melanoma cells are removed. This is necessary, even for thin melanomas. For thick melanomas, it may be necessary to do a wider excision to take out a larger margin of tissue.

If a large area of tissue is removed, a skin graft may be done at the same time. For this procedure, the doctor uses skin from another part of the body to replace the skin that was removed.

Lymph nodes near the tumor may be removed during surgery because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has spread to other parts of the body.

Surgery is generally not effective in controlling melanoma that is known to have spread to other parts of the body. In such cases, doctors may use other methods of treatment, such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods. When therapy is given after surgery (primary therapy) to remove all cancerous tissue, the treatment is called adjuvant therapy. The goal of adjuvant therapy is to kill any undetected cancer cells that may remain in the body.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. It is generally a systemic therapy, meaning that it can affect cancer cells throughout the body. In chemotherapy, one or more anticancer drugs are given by mouth or by injection into a blood vessel (intravenous). Either way, the drugs enter the bloodstream and travel through the body.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

One method of giving chemotherapy drugs currently under investigation is called limb perfusion. It is being tested for use when melanoma occurs only on an arm or leg. In limb perfusion the flow of blood to and from the limb is stopped for a while with a tourniquet. Anticancer drugs are then put into the blood of the limb. The patient receives high doses of drugs directly into the area where the melanoma occurred. Since most of the anticancer drugs remain in one limb, limb perfusion is not truly systemic therapy.

Biological therapy

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen side effects caused by some cancer treatments. Biological therapy is also a systemic therapy and involves the use of substances called biological response modifiers (BRMs). The body normally produces these substances in small amounts in response to infection and disease. Using modern laboratory techniques, scientists can produce BRMs in large amounts for use in cancer treatment. In some cases, biological therapy given after surgery can help prevent melanoma from recurring. For patients with metastatic melanoma or a high risk of recurrence, interferon-alfa and interleukin-2 (also called aldesleukin) may be recommended after surgery. Colony-stimulating factors and tumor vaccines are examples of other BRMs under study.

Radiation therapy

In some cases, radiation therapy (also called radiotherapy) is used to relieve some of the symptoms caused by melanoma. Radiation therapy is the use of high-energy rays to kill cancer cells. Radiation therapy is a local therapy; it affects cells only in the treated area. Radiation therapy is most commonly used to help control melanoma that has spread to the brain, bones, and other parts of the body.

Clinical Trials

Many people with melanoma take part in clinical trials (research studies). Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. In some trials, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group; or they may compare one standard treatment with another. Research like this has led to significant advances in the treatment of melanoma. Each achievement brings researchers closer to the eventual control of melanoma.

A new procedure under study, called sentinel lymph node biopsy, may eventually reduce the number of lymph nodes that need to be removed for biopsy and possibly prevent or lessen the severity of lymphedema (build up of excess lymph in tissue that causes swelling). In this procedure, either a blue dye or a small amount of radioactive material is injected near the area where the tumor was. This material flows into the sentinel lymph node(s) (the first lymph node(s) that the cancer is likely to spread to from the primary tumor). A surgeon then looks for the dye or uses a scanner to find the sentinel lymph node(s) and removes it for examination by a pathologist. If the sentinel lymph node(s) is positive for cancer cells, then the rest of the surrounding lymph nodes are usually removed; if it is negative, the remaining lymph nodes may not need to be removed.

Doctors are also studying new ways of giving chemotherapy, biological therapies, and radiation therapy; new drugs and drug combinations; and new ways of combining various types of treatment. Some trials are designed to explore ways to reduce the side effects of treatment and to improve the quality of life.

People who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science. While clinical trials may pose some risks for the people who take part, each study takes steps to protect patients. Patients who are interested in taking part in a clinical trial should talk with their doctor.

Another way to learn about clinical trials is through PDQ , a cancer information database developed by the National Cancer Institute. PDQ contains information about cancer treatment and about clinical trials in progress throughout the country. The Cancer Information Service can provide PDQ information to patients and the public.

Side Effects of Melanoma Treatment

Doctors plan treatment to keep side effects to a minimum, but it is hard to limit the effects of therapy so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes side effects.

The side effects of cancer treatment depend mainly on the type and extent of the treatment. Side effects may not be the same for everyone, and they may change from one treatment to the next. Doctors and nurses can explain the possible side effects of treatment, and they can help relieve symptoms that may occur during and after treatment.

Surgery

The side effects of surgery depend mainly on the size and location of the tumor and the extent of the operation. Although patients may be uncomfortable during the first few days after surgery, this pain can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for awhile. The length of time it takes to recover from an operation varies for each patient.

Scarring may also be a concern for some patients. To avoid causing large scars, doctors remove as little tissue as they can without increasing the chance of recurrence. In general, the scar from surgery to remove an early stage melanoma is a small line (often 1 to 2 inches long), and it fades with time. How noticeable the scar is depends on where the melanoma was located, how well the person heals, and whether the person develops raised scars called keloids. When a tumor is large and thick, more surrounding skin and other tissue (including muscle) are removed. Although skin grafts reduce scarring from the removal of large growths, these scars will still be quite noticeable.

Surgery to remove the lymph nodes from the underarm or groin may damage the lymphatic system and slow the flow of lymph in the arm or leg. Lymph may build up in a limb and cause swelling (lymphedema). The doctor or nurse can suggest exercises or other ways to reduce swelling if it becomes a problem. Also, it is harder for the body to fight infection in a limb after nearby lymph nodes have been removed, so the patient will need to protect the arm or leg from cuts, scratches, bruises, or burns that may lead to infection. If an infection does develop, the patient should see the doctor right away.

Chemotherapy

The side effects of chemotherapy depend mainly on the drugs and the doses received. In addition, as with other types of treatment, side effects vary from person to person. Generally, anticancer drugs affect cells that divide rapidly. In addition to cancer cells, these include blood cells, which fight infection, help the blood to clot, or carry oxygen to all parts of the body. When blood cells are affected, people are more likely to get infections, may bruise or bleed easily, and may feel unusually weak or tired. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, people may lose their hair and may have other side effects, such as poor appetite, nausea and vomiting, or mouth and lip sores. These side effects generally go away gradually during the recovery periods between treatments or after treatment is over.

Biological therapy

The side effects caused by biological therapy vary with the type of treatment. These treatments may cause flu-like symptoms, such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, and diarrhea. Patients may also bleed or bruise easily, get a skin rash, or have swelling. These problems can be severe, but they go away after treatment stops.

Radiation therapy

The side effects of radiation therapy depend on the amount of radiation given and the area being treated. Side effects that may occur during treatment include fatigue and hair loss in the treated area. Although the side effects of radiation therapy can be unpleasant, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.

Nutrition for People with Cancer

Eating well during cancer treatment means getting enough calories and protein to help prevent weight loss and regain strength. This often helps people feel better and have more energy.

Some people with cancer find it hard to eat well because they may lose their appetite. In addition, common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods taste different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.

Doctors, nurses, and dietitians can offer advice on how to get enough calories and protein during cancer treatment.

Followup Care

Melanoma patients have a high risk of developing separate new melanomas. Some also are at risk for a recurrence of the original melanoma in nearby skin or in other parts of the body.

To increase the chance that a new melanoma will be detected as early as possible, patients should follow their doctor's schedule for regular checkups. It is especially important for patients who have dysplastic nevi and a family history of melanoma to have frequent checkups. Patients also should examine their skin monthly (keeping in mind the "ABCD" guidelines in the "Pictures of Melanoma" section and the skin self-exam guide described in "How To Do a Skin Self-Exam") and follow their doctor's advice about how to reduce their chance of developing another melanoma. General information about preventing melanoma is described in the "Causes, Risk Factors, and Prevention" section. You may also wish to examine the section below: "Keeping on top of Your Condition"

The chance of recurrence is greater for patients whose melanoma was thick or had spread to nearby tissue than for patients with very thin melanomas. Followup care for those who have a high risk of recurrence may include x-rays; blood tests; and scans of the chest, liver, bones, and brain.

Recovery and Outlook

It is natural for anyone facing cancer to be concerned about what the future holds. Understanding the nature of cancer and what to expect can help patients and their loved ones plan treatment, anticipate lifestyle changes, and make quality of life and financial decisions.

Cancer patients frequently ask their doctors, "What is my prognosis?" Prognosis is a prediction of the future course and outcome of a disease and an indication of the likelihood of recovery. When doctors discuss a patient's prognosis, they are attempting to project what is likely to occur for that individual patient.

Sometimes people use statistics they have heard to try to figure out their own chances of being cured. However, statistics reflect the experience of large groups of patients; they cannot be used to predict what will happen to a particular patient because no two patients are alike. The prognosis for a person with melanoma can be affected by many factors, particularly the stage of the cancer and the patient's general health and response to treatment. The doctor who is most familiar with the patient's situation is in the best position to help interpret statistics and discuss the patient's prognosis.

When doctors talk about surviving cancer, they may use the term remission rather than cure. Although many people with melanoma are successfully treated, doctors use this term because cancer can return. Many patients find it helpful to discuss the possibility of recurrence with the doctor.

Support for People with Cancer

Living with a serious disease is not easy. People with cancer and those who care about them face many problems and challenges. Coping with these problems is often easier when people have helpful information and support services.

Friends and relatives can be very supportive. It also helps many patients to discuss their concerns with others who have cancer. Cancer patients often get together in support groups, where they can share what they have learned about coping with cancer and the effects of treatment. It is important to keep in mind, however, that each person is different. Treatments and ways of dealing with cancer that work for one person may not be right for another -- even if they both have the same kind of cancer. It is always a good idea to discuss the advice of friends and family members with the doctor.

Cancer patients may worry about holding their jobs, caring for their families, keeping up with daily activities, or starting new relationships. Concerns about tests, treatments, hospital stays, and medical bills are also common. The doctor can answer questions about treatment, working, outlook (prognosis), and the activity level people may be able to manage. Meeting with a nurse, social worker, counselor, or member of the clergy can be helpful to people who want to talk about their feelings or discuss their concerns.

Causes, Risk Factors, and Prevention

Researchers at hospitals and medical centers all across the country are studying melanoma. They are trying to learn what causes the disease and how to prevent it.

At this time, the causes of melanoma are not fully understood. It is clear, however, that this disease is not contagious; no one can "catch" cancer from another person.

By studying patterns of cancer in the population, researchers have found certain risk factors that are more common in people who develop melanoma than in people who do not get this disease. It is important to know, however, that most people with these risk factors do not get melanoma, and many who do get this disease have none of these risk factors.

The following are some of the factors associated with this disease:

• Family history of melanoma -- Having two or more close relatives who have had this disease is a risk factor because melanoma sometimes runs in families. About 10 percent of all patients with melanoma have family members who also have had this disease. When melanoma runs in a family, the family members should be checked regularly by a doctor.

• Dysplastic nevi -- Dysplastic nevi are more likely than ordinary moles to become cancerous. Many people have only a few of these abnormal moles; the risk of melanoma is greater for people with a large number of dysplastic nevi. The risk is especially high for people who have a family history of both dysplastic nevi and melanoma.

• History of melanoma -- People who have been treated for melanoma are at a high risk for developing a second melanoma.

• Weakened immune system -- People whose immune system is weakened by certain cancers, by drugs given following organ transplants, or by AIDS are at increased risk of developing melanoma.

• Many ordinary moles (more than 50) -- Because melanoma usually begins in the melanocytes of an existing mole, having many moles increases the risk of developing this disease.

• Ultraviolet (UV) radiation -- Experts believe that much of the worldwide increase in melanoma is related to an increase in the amount of time people spend in the sun. This disease is also more common in people who live in areas that get large amounts of UV radiation from the sun. In the United States, for example, melanoma is more common in Texas than it is in Minnesota, where the sun is not as strong. UV radiation from the sun causes premature aging of the skin and skin damage that can lead to melanoma. (Two types of ultraviolet radiation -- UVA and UVB -- are explained in the Dictionary.) Artificial sources of UV radiation, such as sunlamps and tanning booths, also can cause skin damage and probably an increased risk of melanoma.

  To help prevent and reduce the risk of melanoma caused by UV radiation, people should avoid exposure to the midday sun (from 10 a.m. to 3 p.m.) whenever possible. Another simple rule is to protect yourself from the sun when your shadow is shorter than you are. Wearing a hat and long sleeves offers protection. Also, lotion, cream, or gel that contains sunscreen can help protect the skin. Many doctors believe sunscreens may help prevent melanoma, especially those that reflect, absorb, and/or scatter both types of ultraviolet radiation. Sunscreens are rated in strength according to a sun protection factor (SPF). The higher the SPF, the more sunburn protection is provided. Sunscreens with an SPF value of 2 to 11 provide minimal protection against sunburns. Sunscreens with an SPF of 12 to 29 provide moderate protection. Those with an SPF of 30 or higher provide high protection against sunburn. Sunglasses that have UV-absorbing lenses should also be worn. The label should specify that the lenses block at least 99 percent of UVA and UVB radiation.

• Severe, blistering sunburns -- People who have had one or more severe, blistering sunburns as a child or teenager are at increased risk for melanoma. Because of this, doctors advise protecting children's skin from the sun, which they hope will help prevent, or at least reduce the risk of, melanoma later in life. Sunburns in adulthood are also a risk factor for melanoma.

• Fair skin -- Melanoma occurs more frequently in people who have fair skin that burns or freckles easily (these people also usually have red or blond hair and blue eyes) than in people with dark skin. White people get melanoma far more often than do black people, probably because light skin is more easily damaged by the sun.

People who are concerned about melanoma should talk with their doctor about the disease, the symptoms to watch for, and an appropriate schedule for checkups. The doctor's advice will be based on the person's personal and family history, medical history, and the other risk factors described above.

Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.

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