Objective: To document real-world treatment patterns in elderly patients with high-risk (stage IIB/C, IIIA/B, IIIC) or metastatic (stage IV) melanoma. Methods: Data was taken from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database combining clinical information on incident cancer cases in the US between 1991 and 2002 with longitudinal (1991-2005) Medicare claims. Subjects =65 years with =1 stage IIB or higher melanoma diagnosis and =6 months of subsequent benefits coverage were selected. We documented utilization patterns of four major therapies (surgery, radiation, chemotherapy, immunotherapy) following the diagnosis. Results: A total of 6470 subjects met all criteria. Stage distribution was: IIB/C (38%); IIIA/B (46%); IIIC (1%); IV (15%). Median follow-up was 56, 39, 16, and 6 months, respectively. Surgery (primarily tumor excision) was the predominant 1st line treatment, received by >85% of subjects with stage IIB/C, IIIA/B, or IIIC melanoma and 60% of stage IV cases, but was a rare 2nd line approach. Radiation was 1st line treatment in only 2%, 5%, and 13% of stage IIB/C, IIIA/B, and IIIC cases, respectively, but was more common as a 2nd line approach in these subjects (15%, 24%, and 41%, respectively). Radiation was equally prevalent (~30% of cases) as 1st or 2nd line treatment in stage IV. Chemotherapy was uncommon as 1st line treatment (<4% of all cases), but prevalent as 2nd line therapy (by respective stage, 14%, 20%, 41%, and 22% of cases). Immunotherapy was rare, except as 2nd line treatment in stage IIIC (26% of cases). Conclusion: Beyond surgery as a 1st line approach, relatively few patients received other types of treatment as either 1st or 2nd line therapy. These findings demonstrate an unmet need in high risk and metastatic melanoma. Additional analyses of administrative data characterizing real-world treatment patterns in melanoma are needed to help inform the direction of future clinical trials.