Melanoma used to be rare; North Amer­i­cans’ life­time risk of de­vel­op­ing the dis­ease was one in 1,500. But the in­ci­dence is on the rise—and it of­ten tar­gets healthy peo­ple in the prime of their lives.

Canadian Living - - Contents - BY WING SZE TANG

Learn how ow to spot melanoma ma and pro­tect your­self f from skin can­cer

NATALIE LOVE WAS 24 and in the midst of wed­ding plan­ning when she first no­ticed what she thought was a pim­ple on her tem­ple. When it started chang­ing size and colour over the next few months, she men­tioned it to her doc­tor, who wasn’t wor­ried, so she didn’t think it was ur­gent. She got mar­ried, she got preg­nant—but she kept an eye on the blem­ish. “It was chang­ing and grow­ing even more,” re­calls Natalie, now a 41-year-old mom in Stonewall, Man. In fact, she re­al­ized that it was look­ing more like a mole.

Though her doc­tor still wasn’t con­cerned, she did agree to re­fer her to a sur­geon. Just af­ter her first son was born in June 2001, Natalie went in to have the mole re­moved and biop­sied. The di­ag­no­sis: melanoma. “I was shocked,” she says.

Sim­ply call­ing melanoma “can­cer of the skin” is a bit mis­lead­ing. A more ac­cu­rate de­scrip­tion would be “starts in the skin, then can spread any­where” can­cer. It’s a ma­lig­nant tu­mour that orig­i­nates in melanocytes, the cells re­spon­si­ble for mak­ing melanin, and can de­velop in weeks or take years to ma­te­ri­al­ize. But if not caught, it “will start to in­vade,” says Dr. Har­vey Lui, head of the depart­ment of der­ma­tol­ogy and skin sci­ence at The Univer­sity of Bri­tish Columbia and a der­ma­tol­o­gist at BC Can­cer Agency. “It will go deeper into the skin and reach a blood ves­sel, a nerve or the lym­phatic sys­tem. That’s when it can ac­cess the rest of your body.”

Melanoma is the third most com­mon type of skin can­cer, and the most dan­ger­ous—and its in­ci­dence has been ris­ing for decades.

In the 1930s, the life­time risk of melanoma for North Amer­i­cans was one in 1,500; now, it’s one in 63. (Cana­dian women fare a lit­tle bet­ter than av­er­age, with a risk of one in 90.) The Cana­dian Can­cer So­ci­ety es­ti­mates that 6,800 peo­ple were di­ag­nosed last year.

The steady up­swing in melanoma comes down to sun safety. Al­though we all know to use sun­screen, many peo­ple are “half-hearted” about it, says Dr. Elaine Mcwhirter, a med­i­cal on­col­o­gist spe­cial­iz­ing in melanoma at the Ju­ravin­ski Can­cer Cen­tre in Hamil­ton, an as­so­ciate pro­fes­sor at Mcmaster Univer­sity and a mem­ber of the Melanoma Net­work of Canada’s board of di­rec­tors. It’s thought that about 90 per­cent of cases are re­lated to UV ex­po­sure and a his­tory of blis­ter­ing sun­burns. UV ex­po­sure da­m­ages DNA in skin cells, caus­ing ge­netic mu­ta­tions that can lead to cells be­com­ing can­cer­ous. What’s more, tan­ning beds—which the World Health Or­ga­ni­za­tion calls “car­cino­genic”—re­main read­ily ac­ces­si­ble. Plus, even if Cana­di­ans are prac­tis­ing sun safety now, those who grew up be­fore it was a public health con­cern can still de­velop can­cer due to sun ex­po­sure in their youth.

Natalie says she was never a sun­seeker, but sun­screen wasn’t com­mon when she was young, and on oc­ca­sion she did get scorched. Be­cause her melanoma was caught in Stage I, mean­ing it was less than one mil­lime­tre thick and hadn’t bro­ken open or spread, the treat­ment sim­ply called for cut­ting it out, also known as a wide ex­ci­sion. “The sur­geon was very pos­i­tive. He said the like­li­hood of it com­ing back was slim,” re­calls Natalie, who went for post­surgery check­ups for the next eight years. “I felt like I had dodged a bul­let.”

But one cruel char­ac­ter­is­tic of melanoma is how un­pre­dictably it can be­have. In 2008, she started get­ting what she thought were si­nus headaches. They got pro­gres­sively worse, un­til they were bad enough to cause blurred vi­sion and make her vomit. A CT scan in De­cem­ber 2009 re­vealed a fist-size brain tu­mour. The can­cer had spread, af­ter all, and she needed surgery. “Ini­tially, I thought, OK, they’ll re­move this, then I’ll be fine. But I re­al­ized quickly that this can­cer was go­ing to keep com­ing back. I’m liv­ing with can­cer, and it’s not just go­ing to be cured,” says Natalie, whose can­cer is now con­sid­ered Stage IV, or metastatic melanoma.

“It is rare to see very late re­cur­rences,” says Dr. Mcwhirter. “The ma­jor­ity of re­cur­rences are within the first two to three years af­ter surgery in those with higher risk melanoma.” Yet, mys­te­ri­ously, the dis­ease can come back sev­eral decades af­ter some­one is seem­ingly cured, with no symp­toms in be­tween. It’s called tu­mour dor­mancy. “A few mi­cro­scopic cells may have es­caped be­fore the melanoma was cut out,” Dr. Mcwhirter ex­plains. “It’s likely our im­mune sys­tem then keeps them in check for a long pe­riod of time.”

This is what Natalie and her doc­tor sus­pect may have hap­pened in her case: A few can­cer cells were left be­hind; they lay dor­mant for years and then, for rea­sons un­known, woke up. (What ul­ti­mately re­ac­ti­vates the can­cer cells is not fully un­der­stood.) Al­though the sur­geon suc­cess­fully re­moved Natalie’s first brain tu­mour, she has de­vel­oped new tu­mours since then, in­clud­ing spots on her lung, which were also sur­gi­cally re­moved. There have been so many re­cur­rences over the years, she hasn’t kept count, and she’s cur­rently un­der­go­ing treat­ment for small tu­mours in her brain.

Deal­ing emo­tion­ally with melanoma has been “up and down, up and down,” says Natalie, who keeps a blog on liv­ing with can­cer (ithinki­will­go­ “But once I re­al­ized that this is sort of my job now, it was a bit eas­ier. Some peace came with that.”

If melanoma is caught early, it’s con­sid­ered very treat­able. For those with Stage I dis­ease, the five-year sur­vival rate is 88 to 95 per­cent, says Dr. Mcwhirter. But if the can­cer has spread, the out­look has his­tor­i­cally been bleak. “In the old days, for in­cur­able [Stage IV] melanoma, the five-year sur­vival was about five per­cent,” says Dr. Mar­cus Butler, a med­i­cal on­col­o­gist at the Princess Mar­garet Can­cer Cen­tre in Toronto. This was the case even a decade ago, says Dr. Mar­iusz Sapi­jaszko, an Ed­mon­ton-based der­ma­tol­o­gist and pres­i­dent of the Cana­dian Der­ma­tol­ogy As­so­ci­a­tion.

But now, there’s rea­son to feel more op­ti­mistic: In just the past few years, sev­eral ground­break­ing treat­ments for Stage III or IV melanoma have been ap­proved. “With th­ese ad­vances, the prospects for pre­vi­ously hope­less sit­u­a­tions are bet­ter than ever be­fore,” says Dr. Sapi­jaszko.

Th­ese game-chang­ers in­clude im­munother­apy drugs known as “check­point in­hibitors,” which un­leash the power of our im­mune sys­tem. Nor­mally, this sys­tem keeps us healthy by de­ploy­ing T-cells, which go look­ing for things that don’t be­long; when an in­vader is found, our sys­tem ramps up to snuff it out, but then it winds down, so it’s not in con­stant fight mode. What check­point in­hibitors do is “take away the brakes, so the im­mune sys­tem doesn’t turn off,” says Dr. Mcwhirter. “We want it to rec­og­nize the melanoma cells so it can at­tack.” There may be side-ef­fects to th­ese drugs, in­clud­ing joint pain, itch­ing, thy­roid dys­func­tion and less com­monly se­ri­ous prob­lems in the lungs, liver or kid­neys, but since the drugs are in­tended for ad­vanced cases, the po­ten­tial ben­e­fit out­weighs the risk. The more ef­fec­tive of th­ese drugs are pem­brolizumab and nivolumab.

Another new ap­proach to melanoma is called tar­geted ther­apy, which in­cludes pair­ing med­i­ca­tions like dabrafenib with tram­e­tinib. Ac­cord­ing to Dr. Mcwhirter, “com­bi­na­tions of tar­geted ther­apy are more ef­fec­tive and of­ten have fewer side-ef­fects.” Whereas chemo­ther­apy can kill even healthy cells, tar­geted ther­apy fo­cuses on can­cer­ous cells by zeroing in on what makes them dif­fer­ent, such as an al­tered pro­tein.

But what doc­tors find es­pe­cially promis­ing is com­bi­na­tion ther­apy—such as us­ing im­munother­apy along­side tar­geted drugs, and com­bi­na­tions of check­point in­hibitors—which has the po­ten­tial to be more ef­fec­tive and to help patients live longer. Al­ready, this two-in-one ap­proach has seen great suc­cess; the sur­vival rate for peo­ple with Stage IV melanoma in Canada is now 10 to 19 per­cent. “We have seen a dra­matic in­crease in the per­cent­age of peo­ple alive five years later,” says Dr. Butler. “‘Cure’ is a word we’re anx­ious about us­ing, but we ac­tu­ally do have patients with Stage IV dis­ease who look as if they’re ‘cured.’ ”

Natalie’s most re­cent scan showed that a cou­ple of her brain tu­mours have shrunk. She’s tak­ing an im­munother­apy drug and re­spond­ing well. The can­cer re­mains some­thing she’ll need to treat in­def­i­nitely, but at this point, it’s a chronic ill­ness, not a ter­mi­nal one. She’s grate­ful for the care she has re­ceived, and the break­throughs that have saved lives like hers. “They didn’t have th­ese drugs a few years ago,” she says. “It’s pretty amaz­ing.”

“I re­al­ized quickly that this can­cer was go­ing to keep com­ing back. I’m liv­ing with can­cer, and it’s not just go­ing to be cured.”

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