July 16, 2025 • 32 mins
What's the difference between standard skin cancer removal and Mohs surgery? Ashley McGuinness, MD, FAAD breaks down this specialized technique that achieves remarkable 98-99% cure rates while preserving healthy tissue. While standard excisions examine only 1-2% of margins, Mohs surgery meticulously evaluates 100% through a precise mapping approach.
During this eye-opening conversation with host Dr. Jason Edwards, Dr. McGuinness addresses the alarming 1.8% annual rise in skin cancer rates since 2000. She attributes this to better detection methods, our aging population, and the consequences of tanning bed popularity in past decades. When discussing internet myths claiming sunscreen causes cancer, she provides clear evidence of UV radiation's harmful effects while offering practical alternatives like physical blockers or UPF clothing for those with chemical concerns.
The discussion takes a fascinating turn toward technology as Dr. McGuinness reveals how AI is transforming dermatology. From full-body mole mapping to algorithms that detect subtle changes invisible to the human eye, these advances complement clinical expertise without replacing it. For self-examination, she emphasizes the critical "ABCDE" approach to identify potential melanomas: check for Asymmetry, Border irregularity, Color variations, Diameter larger than a pencil eraser, and most importantly, Evolution over time.
Beyond cancer detection, the conversation explores factors in skin aging, from UV exposure and dehydration to facial movements and lifestyle choices. Dr. McGuinness shares simple strategies anyone can implement: staying well-hydrated, using daily sunscreen, and avoiding tobacco and excessive alcohol. Whether you're concerned about skin cancer prevention or preserving your skin's youthful appearance, this episode delivers practical wisdom from a leading specialist in the field.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, this is Jason Edwards and this is Doc
Discussions.
I'm here with one of myco-workers, ashley McGinnis.
Ashley, how are you doing today?
Speaker 2 (00:09):
I'm good.
Thanks so much for having me.
Speaker 1 (00:11):
Ashley, you're a dermatologist who specializes in
Mohs surgery.
Is that correct?
Speaker 2 (00:15):
That's correct.
Speaker 1 (00:16):
Yeah, and where are you from?
Speaker 2 (00:18):
I'm originally from St Charles, so I'm a St Louis
local.
Speaker 1 (00:21):
Very good.
And then, where did you do yourschooling at?
Speaker 2 (00:25):
So I did my undergraduate studies at
Rockhurst University in KansasCity, Missouri.
Speaker 1 (00:29):
How about that?
It's a Jesuit college, right.
Speaker 2 (00:31):
Jesuit college.
So I went through the Catholicschool system here and stuck
around with it for college andthen transitioned to SLU here in
town for medical school.
Speaker 1 (00:41):
Okay.
Speaker 2 (00:42):
And then after that I did my intern year and my three
years of dermatology trainingat the University of Iowa City
or University of Iowa and IowaCity.
Speaker 1 (00:50):
Sure.
Speaker 2 (00:51):
And then after dermatology I did the Mohs
Surgery Fellowship up at MayoClinic in.
Speaker 1 (00:55):
Rochester Just up the road a little bit right.
Speaker 2 (00:57):
Yeah, just up the road, Kept graduating further
and further north before I movedhome.
Speaker 1 (01:01):
Yeah, I remember my interview at Iowa.
To me it seemed like a greattown, iowa City and Corvallis, I
think, which is right next toit.
I'm probably mispronouncingthat.
Speaker 2 (01:15):
No, that's okay.
Iowa City is a great city andit's not too far from St Louis,
great college town feel.
Lots of fun things to do.
You get the Division I sportskind of experience.
Coralville is the neighboringsuburb and it's exploded.
I mean, even since we startedresidency there it grew a lot.
They now have a minor leaguehockey team there.
Speaker 1 (01:36):
That's pretty fun to attend to and you know Iowa's
kind of famous for theirchildren's hospital, overlooks
the football stadium and ofcourse football's huge in any
Big Ten university, butespecially Iowa, and the
football players always wave atthe kids in the Pediatric Cancer
Center, which is a beautifulthing.
Speaker 2 (01:52):
It's amazing and it's really fun.
I mean being on both ends One,if you're on a pediatrics
rotation, being up there withthe kiddos and seeing it.
I mean it makes everybody's day.
And then if you're in thecrowds getting to wave up there,
I mean it's very cool to seeboth the home team and the
opposing team all getting intoit too.
Speaker 1 (02:09):
Yeah, what a special thing.
And so and you're married to aphysician, is that right?
Speaker 2 (02:12):
I am yeah.
Speaker 1 (02:13):
So what's your husband do?
Speaker 2 (02:15):
So he is a board certified anesthesiologist but
he actually did a fellowship ininterventional pain.
Speaker 1 (02:21):
How about?
Speaker 2 (02:21):
that, so he practices interventional pain over in
Alton.
Speaker 1 (02:24):
Very good, very good, and so you've got a practice
here in St Louis and we'veshared a few mutual patients.
Yes, can you explain to peopleyou know, like the lay person,
what Mohs surgery is?
Speaker 2 (02:36):
Yeah, that's a great question.
So Mohs surgery is aspecialized form of skin cancer
removal, a surgical form of skincancer removal, and the way we
do Mohs surgery is it's allunder local anesthesia, meaning
the patient's not asleep for theprocedure.
We just numb it with injectionsand we remove the skin cancer
with a small rim of healthy skin.
(02:57):
And while the patient waits wecheck all of the edges, both on
the outside and the deep edge,to see if everything's off the
patient, if there's a little bitmore.
I have a map that I've createdon both the patient and on the
tissue that I've removed.
That tells me where we need toremove a little additional skin
and we repeat that process untileverything's gone and then we
(03:18):
reconstruct the patient based onwhat the final defect is.
Speaker 1 (03:23):
And so when you make the map, I remember in textbooks
they kind of quartered it wherethey make it into quarters.
Is it more complicated thanthat, or is each section
quartered?
Speaker 2 (03:32):
It's a good question.
So it depends on the size andthe shape of the lesion itself.
So sometimes you'll process itjust in one single piece.
I personally make more of ourstandard size pieces.
I mark a 12 o'clock kind ofsome hashes at 12 o'clock, 3
o'clock, 6 o'clock and 9 o'clock, so it almost looks like a
little clock face and we putinks in there.
(03:52):
So it tells us you know, theblue ink may be at your 12
o'clock and your green ink is atyour 6 o'clock, and if you see
something between 12 and 3, youjust take tissue between 12 and
three and you can spare the restof the healthy skin.
Speaker 1 (04:05):
Yeah, so so, um, you know you, you excise kind of the
same amount of tumor as youwould with um.
You know which is all of itwith the normal excision.
But the beauty of Moses, itleaves more natural tissue, more
normal tissue, and so yoursurgical defect is less right.
You got it and so you have abetter cosmetic outcome.
Speaker 2 (04:24):
You got it Better.
Cosmetic outcome it's tissuesparing and then the way we
actually process the tissue.
You're actually evaluating 100%of the margin as opposed to a
standard excision.
You look at 1% to 2% actuallyof the standard margin.
Speaker 1 (04:37):
Yeah.
Speaker 2 (04:38):
So it does give you a superior cure rate.
You're talking more for youraverage run-of-the-mill skin
cancer 98, 99%, as opposed toabout a 95 to 97% cure rate.
But huge benefit forcosmetically sensitive areas
like the face, where you don'thave much real estate to spare
and you want all the healthytissue you can keep.
Speaker 1 (04:55):
For sure.
And when we're talking aboutskin cancers specifically here
we're talking about basal cellcarcinomas and squamous cell
carcinomas, correct?
Speaker 2 (05:04):
Those are our most common kind of bread and butter
cases that we do.
A lot of People are starting touse Mohs for melanoma in situ
and thin melanomas, your earlystage melanomas, especially on
the head and neck.
Yeah, we do Mohs for moreuncommon skin cancers as well,
but they're just few and farbetween, as opposed to the basal
(05:24):
cells and squamous cells.
Speaker 1 (05:25):
And the rationale for not doing it for kind of a
standard melanoma or moreadvanced is you really want a
very large rind of normal tissuebetween the blade and the tumor
, because you don't want themargin to be as close with the
melanoma, because the recurrencerate's higher.
Speaker 2 (05:42):
That's correct and the other thing is is that it
just has been standard of careto have wide local excision for
so long.
So I know a lot of people arestarting to do studies and kind
of compare MOSE for melanoma toyour standard of care, which is
wide local excision.
Speaker 1 (05:55):
Yeah.
Speaker 2 (05:56):
The other thing that makes it difficult is if you
need to do a sentinel lymph nodebiopsy for an aggressive
melanoma.
You can't necessarily time thatvery well with Mohs.
It's hard to do when there'stwo surgical subspecialties that
are both in the mix.
Speaker 1 (06:13):
And another thing I remember from my textbooks there
was kind of a region of theface and I think the rationale
was that it was kind of likethis embryological H or center
point where cancers were thoughtto be more aggressive.
Am I anywhere close on this?
Speaker 2 (06:30):
That's correct.
So there is.
We call them the high risk,medium risk and low risk
locations but it is more centralface, so kind of eyelids,
temples, ears, nose, lips thatare traditionally thought of as
your high risk areas.
Speaker 1 (06:43):
Yeah.
Speaker 2 (06:44):
Skin is thinner there .
From a cosmetic standpoint, afunctional standpoint, you don't
have much real estate andbecause of the nature of the
tissue there skin cancers canbehave more aggressively in
those areas.
So typically if you have abasal cell or a squamous cell in
those areas it automaticallyqualifies for most.
Speaker 1 (07:05):
And then I also remember, like with the lips
specifically, that cancers aremore prevalent on the lower lip
compared to the upper lip.
Do you know why that is?
Speaker 2 (07:13):
It may be, I don't know if it's because you get
some shading from nose and thatsort of thing.
Speaker 1 (07:20):
Good mustache.
Speaker 2 (07:20):
A good mustache on a man, or a woman, I guess.
But you know, I think some ofit is just anatomic location,
with it being a little moreexposed to the sun.
Speaker 1 (07:30):
Yeah.
Speaker 2 (07:30):
I don't know with tobacco exposure.
You know, a lot of times withlike chewing tobacco and things
like that, a lot of times peoplehave it stored in their lower
lip and we know tobacco use alsoincreases your risk of squamous
cells on the lip as well.
Speaker 1 (07:43):
Yeah, now I'm going to get into the old online
misinformation here.
I love it so recently I've seensome posts where people talk
about it's actually thesunscreen that's causing the
cancers and not the sun itself.
What are your thoughts on that?
Speaker 2 (08:02):
So I think it's been well proven that UV exposure
both chronic, you knowcumulative sun exposure, as well
as intermittent intense sunexposure.
So a sunburn here or there doesincrease your risk of
developing skin cancer.
Yeah, I know there's been a lotof concerns over especially
chemical sunscreens in recentyears.
You know what types of effectsare these having?
(08:24):
I don't necessarily thinkthey're causing skin cancers.
I don't think we necessarilyknow.
You know, could they be harmfulin high, high doses.
If they were in your bloodstream, Maybe I don't think you're
absorbing enough of it toprobably reach those levels of
harm in general, which is whythey've been approved for use.
But I always tell people ifyou're very concerned about it,
(08:46):
some good alternatives would belike a zinc oxide, titanium
dioxide, more of those physicalsunscreens, because the way they
work is they actually sit ontop of the skin, they're not
actually absorbed into the skinand they still provide a
protective barrier from UV, orjust using sun protective
clothing.
They make a lot of UPF clothingthat actually has that sun
protection built in now.
(09:06):
So if you're concerned about it, you know there are
alternatives to still protectyou from the sun and protect you
from that UV induced damage.
Speaker 1 (09:14):
Yeah, I mean, and you know, when it comes to just
like misinformation and stufflike this in general, I mean
it's okay to be skeptical Ithink you don't want to be naive
and so it's okay to have someskepticism.
But you know, from all theevidence out there, it looks
like sunscreen in general isvery safe.
And then there's some kind of,like you said, higher end ones
(09:35):
that you know maybe technicallysafer, right, but yeah, and then
the sun shirts, I mean thosework you can get in the water
and they don't.
It's not like the old cottonhang shirt.
I mean they're breathable andthe technology with the clothing
is good.
Speaker 2 (09:52):
Yeah, and so that's always a strong move.
Yeah, and I think it's nice too, for people who say they don't
like the feel of sunscreen orjust forget to reapply.
Yeah, you know, if it's on, ifyou've got a sun shirt on,
you've got that UPF, that SPF of50, essentially built in for as
long as you've got it on, whichis very nice.
Yeah, if you're going to planon spending the whole day
outside.
Speaker 1 (10:07):
I totally agree, and you know you're in the water
that comes off, or I don't knowhow well it's done.
Even if it's the waterproof,you don't know if it's going to
stay or not.
Speaker 2 (10:14):
Right, exactly.
Speaker 1 (10:15):
Um, there there does appear to be a trend, um, with
increasing not only rates ofsquamous cell carcinoma and
basal cell carcinoma, but alsomelanoma since 2000, at least
through 2020.
And what I'm looking at here itsays about 1.8% annually, which
seems like a lot.
(10:35):
Have you guys noticed that, andwhat do you think's behind it?
Speaker 2 (10:41):
That's a good question, and I think there's a
lot of factors that probablyplay into us seeing more and
more of it.
One is, I think, patienteducation.
You know people are more andmore aware and are taking a look
at their own skin, which isawesome because you know you're
your own best advocate.
So if you're the one that seesyour body every day, so if
you're noticing it and bringingit to somebody's attention, I
(11:02):
think that is something that hasdriven numbers up.
So just better detection Betterdetection and better detection
by patients, better detection bydermatologists.
As we know, more and more andmore patients are seeing
dermatologists.
I think our aging population ingeneral increases those numbers
just because it's cumulativesun exposure risk increases
(11:24):
those numbers, just because youknow it's cumulative sun
exposure risk.
I think tanning bed use,especially in you know, we think
about rates of tanning bed use80s, 90s, early 2000s.
I think we're seeing a lot ofrepercussions of tanning bed use
as well.
Speaker 1 (11:36):
I grew up in a small town.
In small towns, you know,everything's tanning.
It's like there's a pizza shopand tanning it's like a combo.
There's the gas station andtanning.
It just goes hand in hand.
Speaker 2 (11:46):
Yeah, and it's shocking that you're like you
still see them.
Speaker 1 (11:48):
We know how bad they are and there's still a few
lingering, which is concerningyeah, so when you talk about
ultraviolet light, which is whatwe consider, the kind that
damages the skin, that causesDNA changes which precipitates
cancer, there's UVA and UVBlight.
(12:10):
Is one of them worse than theother?
Speaker 2 (12:13):
It's typically thought that you know.
Uvb typically causes burningrays.
It doesn't penetrate as deepinto your skin as the UVA.
Uva penetrates a little bitdeeper, so traditionally people
think UVA is what causes agingand more of the skin cancer that
those cellular changes but,it's really a combination of
both.
So that's why they always saywhen you look for a sunscreen,
(12:34):
look for something that saysbroad spectrum, because you want
to cover yourself for both, andthey both penetrate even car
windows.
So I always tell people youshould at least be putting
something on in the morning.
At least do your face.
You know a daily moisturizerwith a sunscreen.
Even if you're not going to beout and about, you are still
getting some of that exposure.
Speaker 1 (12:51):
Yeah, I started using this brand called proven, and
you probably I mean there's allthese products, right Um, but it
was, of course, developed bydermatologists.
That should be your nextventure, right?
Speaker 2 (13:02):
I mean you can do it, but um but it, you know
developed by dermatologists andeverything's.
Speaker 1 (13:10):
You know, um, supposed to be like heavily
scientifically studied, and theytake, you know it's
personalized, right.
I mean, people don't know youcan get personalized vitamins.
You can.
You know you can send off astool sample and get
personalized vitamins, all kindsof personalized stuff.
But it's, it's.
You know this is not, as youknow, intricate.
They just get your demographicswhere you live and then send
(13:30):
you, you know, face cream orwhat, but, but it has, I can
tell there's sunscreen in it.
I don't get out that much, butum, but you know we all want to
stay looking young and um, and,and part of it's certainly sun
damage.
What are the things that youknow cause the wrinkles?
Um, or you know, or age theskin?
Speaker 2 (13:50):
Yeah, so I think UV exposure is a big thing.
A lot of times people alsonotice that just dryness of the
skin.
You know, when you're dry youtend to notice some of those
fine lines and wrinkles morethan you would if your skin is
moisturized.
Speaker 1 (14:02):
Yeah.
Speaker 2 (14:02):
So keeping nice, moisturized skin also makes you
look a little more youthful.
And then also just dynamicmovement.
You know we move all of ourmuscles.
Every time we move our musclesof our face they make wrinkles.
The more you move those musclesyou get wrinkles, which is why
people do Botox to paralyze someof those muscles.
Speaker 1 (14:21):
Okay, yeah.
And then, of course, you know,there's, you know, one thing I
notice with patients if I seesomebody who looks, you know,
significantly younger than theirage, you know, with regard to
their skin, I think usually I,you know, I'll ask them do you
drink a lot of water?
Because people will just drinka lot of water, you know, or you
know that that's a part oftheir, you know their regimen is
(14:44):
to, you know, drink plenty ofwater, and I think that alone,
you know, helps reduce thewrinkles.
Speaker 2 (14:49):
Oh yeah, hydration status is huge, definitely.
And then things like you know,smoking and alcohol use, we know
contribute to accelerated agingas well, so kind of just having
that healthy lifestyle overall,you know, water consumption,
healthy diet, avoiding heavyamounts of alcohol or tobacco
use in general.
Speaker 1 (15:07):
Yeah.
Speaker 2 (15:08):
All go a long way, both on the inside and on the
outside.
Speaker 1 (15:10):
For sure.
Yeah, you know, I think ofLydie Kravitz, the singer, who's
a raw vegan, and I mean thatguy looks great he does look
great and I mean sometimes itcould be just genetics too,
right, but I mean certainlyeating kind of a low nitrate
diet, you know, like you said,helps inside and outside, and if
you have great blood flow, um,you know, to your heart and your
kidneys, you probably havegreat blood flow to your skin
(15:33):
exactly.
Exactly the.
You know.
Ai, artificial intelligence, iskind of all the new rave.
Have they integrated any ofthat technology into Mohs or
dermatology?
Speaker 2 (15:47):
They are starting to and starting to do some studies.
Actually, when I was at MayoClinic for fellowship, they were
starting to utilize a full bodycamera for high risk patients
and kind of studying that formole mapping, essentially to
look for changes, and they weregoing to use AI technology.
Then at each visit they have thepatient photographed and then
(16:08):
have an AI algorithm look forsubtle changes in moles.
That then would be followed upwith a dermatologist.
You know dermatoscopic, youknow better evaluation.
So that's one thing I've seen.
I've seen a lot of apps nowkind of advertise that are take
a photo of your spot and uploadit and kind of get a diagnosis.
So I think they're trying torefine some of those and some of
(16:29):
that may be very helpful,especially when triaging
patients.
You know, and you're doingalmost a telederm.
Especially when triagingpatients.
You know, and you're doingalmost a telederm, does this
need to be seen next week or canwe maybe see this next month?
So I think that's nice andpeople are starting to actually
implement it in Mohs in terms ofseeing how AI compares to a
physician in terms of can itidentify a basal cell or not,
(16:52):
and what's that agreement likewith the Mohs surgeon.
Speaker 1 (16:55):
Okay, so they do like a Kappa analysis between the
two.
Yeah, the, I think the, thetaking the pictures I mean even
with people with their phones,is one of the things that you
just never had before, becauseyou know when you see a patient
and make a note in a you know,write about something or or it,
you know it's hard to reallytell how it changes over time.
(17:17):
Usually as a doctor you justsee them in one point in time
and kind of make a judgment overthat, and so that's really cool
to have you know something thatkind of tracks it, and so you
kind of have this dynamicpicture of what's going on with
the lesion over time.
Speaker 2 (17:29):
Yeah, it's very, very interesting and they were even
talking about adding dermoscopy,so like magnifying the lesion
and looking at pigment patternsand even from that even
magnified view, looking at thesevery subtle changes in moles,
which is very cool because it'ssomething like you said.
I mean, we're seeing them assnapshot in time.
So if you have thesephotographs and then have
(17:50):
something that can pick up verysubtle changes in color that
maybe our eyes can't even pickup, yeah.
I mean just adding another toolto your armamentarium.
Obviously, you always need theclinical aspect behind some of
that AI stuff, but I think it'sjust going to be another tool
for us to use.
Speaker 1 (18:04):
Yeah, yeah, I think that's.
It's kind of like a copilot,right.
Speaker 2 (18:07):
Yeah.
Speaker 1 (18:08):
Just something to help you be better.
And then, ok, so you've gotsquamous cell carcinoma, we've
got basal cell carcinoma, andthese are the common cancers and
most of the time, you know,they don't spread to the lymph
nodes and they don't metastasize.
When they do, it's wild.
I mean, you know it's very rare.
But when they do spread toother parts of the body, I mean
they can be really aggressive.
(18:28):
Yes, but melanoma is like thereally scary cancer, because
that doesn't have to be very bigbefore it gets into the
bloodstream and can spreadanywhere and everywhere.
And it does, and the metastasiscan bleed and you know that's a
big deal.
What are the you know, whensomebody's looking at a lesion,
(18:48):
what are the main criteria thatwould be suggestive of a
melanoma?
Speaker 2 (18:54):
That's a good question.
So for the most common subtypeof melanoma it's called a
superficial spreading melanomaand because it's the most common
, people have come up with allsorts of things to help people
identify, you know, worrisomesigns on themselves.
So I think the most common andmost helpful one is the ABCDEs
of melanoma.
So when you look at a mole,something that's asymmetric,
(19:15):
something that's borders areirregular, if a lesion's got
multiple colors.
So if you're looking at a spotand it's uniformly brown, that's
a reassuring sign.
But if you see brown with blackand blue, that might raise your
suspicion.
For D they usually say biggerthan the diameter of a pencil
eraser.
And then the big thing for meis the E is the evolution.
(19:37):
So if you had a mole that youknow it looked one way for 10
years and three months ago itlooks a little, started to look
a little bit different, thatshould really raise your
suspicion.
Speaker 1 (19:48):
Yeah.
Speaker 2 (19:52):
And all of those are, but it's helpful for somebody
who's seeing their skin at homeor having a loved one take a
peek at their skin to say whatof these might be worth calling
a doc about.
Speaker 1 (20:03):
You know I have a rule with things that may be
melanoma and it goes with your E.
You know, you're saying the Eis really important for you.
If a patient's concerned, youknow, then then usually I'm
concerned, you know, or I'msaying don't sleep on that,
trust your instinct, because Imean we all have spots all over
us.
There's a reason you'reconcerned and it's probably that
(20:24):
it's evolving and it's changinga little bit quicker.
And so I always tell patientsyou know, if you're concerned,
just go ahead and get in and seesomebody.
Speaker 2 (20:31):
It's better safe than sorry you bet Now Merkel cell
carcinoma.
Speaker 1 (20:40):
they always say it's similar to melanoma.
I mean it's caused bypolyomavirus and stuff like that
.
Speaker 2 (20:43):
It's a little bit different.
But is that mostly on the skintoo?
It is, and I think Merkel cellin general tends to overall
behave more aggressively whenyou catch it.
Typically people are needing asentinel lymph node, biopsy
sampling their lymph nodes, nomatter what in addition to local
control of the tumor, whereasmelanoma, if you catch it early
enough, it's surgical removaland you're kind of done with it.
Speaker 1 (21:05):
Yeah.
Speaker 2 (21:05):
But it tends to be on the skin as well.
Speaker 1 (21:09):
And the very first episode we ever did.
I talked about Jimmy Buffett,who I'm a big fan of we ever did
.
I talked about Jimmy Buffett,who I'm a big fan of, and he had
Merkel cell carcinoma andultimately died from it.
And of course Jimmy's near anddear to my heart, but the one.
There's several cancers thatare highly immunogenic cancers,
meaning the immune system playsa big role in modulating the
(21:31):
cancer and kind of keeping it incheck or not.
And so if you're immunecompromised, you know you'd have
worse results and if you had agood immune system it may keep
it from spreading.
But specifically melanoma andMerkel cell carcinoma are highly
immunogenic cancers and sothey've got these new immune
therapies that they usesometimes in lieu of
chemotherapies.
But it's a systemic therapy andI've seen some just dramatic
(21:54):
responses, especially withMerkel cell carcinomas.
You know, previously youthought, like you know, we can
give them something, but it's,you know, some chemotherapy but
they're not going to do well,and then I've seen patients
where it just melts away.
I mean it's very remarkable.
Speaker 2 (22:08):
Yeah, the immunotherapy has been a total
game changer.
I mean for really.
I mean for metastatic squamouscell, for melanoma, for Merkel
cell, because traditionalchemotherapy one from a side
effect profile, you know hashistorically been really tough
on patients and two outcomes fora lot of these skin cancers
were not as good as for othertypes of cancer with traditional
chemotherapy.
(22:28):
And with time they've justexpanded the armamentarium,
which is awesome because itgives us more backup options and
just more options for patientsif they don't tolerate things.
Speaker 1 (22:39):
Yeah, now, so you're a Mohs surgeon, do you do?
Are you doing strictly Mohssurgery or do you do some like
regular derm with Mohs?
Speaker 2 (22:48):
Right now I'm only doing Mohs surgery.
Speaker 1 (22:50):
Good, that's a good sign.
Speaker 2 (22:51):
I miss general dermatology a little bit, but
yeah, unfortunately slash.
Fortunately the skin cancertreatment does keep me busy.
Speaker 1 (22:59):
Good.
Speaker 2 (23:00):
But like you said before, I mean so many of ours
are curable with very, very highcure rates, so it's a very
rewarding type of procedure.
Speaker 1 (23:10):
Yeah, for sure, and you know, kind of going back to
your training, I meandermatology is a tough, tough
specialty to get into.
I mean it be able to do that atthe University of Iowa and then
Mayo Clinic is reallyremarkable and, to be honest,
(23:41):
we're really lucky to havesomebody like you in our
community and I'm glad thatyou're doing mostly Mohs
surgeries because that's yourspecialty and I'm glad you're
popular enough that you'regetting enough patients to stay
busy with just that.
If you're a patient out therelooking for a doctor, a busy
doctor is typically a gooddoctor because other doctors are
(24:04):
referring to them.
I've been told to never to dothis, but I noticed you might be
a little bit pregnant.
What's going on there?
Speaker 2 (24:13):
My husband and I are expecting identical twin girls
come here June of this year, sonot too far from now.
Speaker 1 (24:21):
Well, God bless you.
What are your thoughts on that?
I mean, that seems like it'sgoing to be a lot.
Speaker 2 (24:27):
Yeah, so we're going from zero to two, which is
awesome, amazing.
We're very excited, but alsoterrifying at the same time.
But you know, we're going totake it one day at a time and
they're already very loved byeverybody in their lives, so
we're very excited.
Speaker 1 (24:41):
Yeah, I mean, you and your husband seem like you're
very functional human beings,and it certainly helps to have
some family nearby, and soyou're going to have a little
bit of support from mom and dad.
Speaker 2 (24:52):
Absolutely, and we knew we always wanted to move
home, we wanted to care forpeople in our community.
But it's just an extra bonusnow, with two on the way that
our parents are at most 10 to 15minutes away from us.
Speaker 1 (25:03):
Oh, so your husband's parents are here as well.
Yeah, oh, thank goodness it'sgoing to be so awesome.
Speaker 2 (25:07):
So he grew up in O'Fallon, I grew up in St
Charles and we've got family allaround.
Speaker 1 (25:12):
Yeah, you know it's.
It's, in many ways, the mostdifficult thing you'll ever do,
but also the most rewarding andchallenging, but I think, I
think it'll be a true blessingand you're probably bringing two
smart kids into this world.
Speaker 2 (25:31):
I hope so.
We've had challenges in a lotof other areas of life, but this
will be a totally new challengeand, yeah, I think we're up for
it.
Speaker 1 (25:39):
Yeah, and I mean, challenges are good for us, it's
you know Sisyphus pushing theboulder up the mountain, you
know it's he need.
You need that boulder.
You know you don't want to justskip through life and not
continue to grow as a person andI think one of the things that
makes people universally happyis to see progress in their own
life.
And then the beauty of having achild is you know, you can, you
(26:01):
know, once you've kind of ranyour course, you know you get to
see the progress through yourown child's life and so in a
sense it's kind of redoing thehero's journey.
If you're a Joseph Campbell fan, Absolutely.
Speaker 2 (26:15):
Yeah.
I think it'll be very rewardingand very exciting to see them
grow and kind of do their ownthing and develop their own
personalities, and so it'll bevery, very fun.
Speaker 1 (26:24):
Yeah, I'm happy for you.
Speaker 2 (26:27):
Thank you so.
Speaker 1 (26:28):
I mentioned Joseph Campbell.
Are there any good books thatyou like?
Speaker 2 (26:32):
So I am a historical fiction lover that's like what I
tend to gravitate towards.
So I actually just finished theWomen it's about the nurses in
the Vietnam War.
And it's a historical fictionbook but it's kind of about the
unsung people who weren'tacknowledged but did a lot of
care and hard work during theVietnam War.
(26:53):
But I love historical fictionbooks, especially ones that have
strong heroine stories.
So the Alice Network is anothergreat one about like an
underground female driven spynetwork during the Great War and
I just love those books becauseyou learn a little bit but
they're still enjoyable from afictional standpoint.
Speaker 1 (27:12):
I agree.
I mean stories.
Just hearing facts don't reallystick Right.
You need to be able to tell astory.
Speaker 2 (27:18):
Yes.
Speaker 1 (27:19):
So in that book the Women does it take place
stateside or in Vietnam, or inboth?
Speaker 2 (27:26):
Mostly in Vietnam.
Okay, yeah, so it starts thefirst chapter or two they're
back state side, but then she isdeployed and working in army
(27:48):
hospitals in Vietnam and itmakes you appreciate people who
put their lives on the line andtake care of people who put
their lives on the line for uson a daily basis.
Speaker 1 (27:57):
Yeah, yeah.
Actually it makes me think ofmy father.
He was a corpsman, which iskind of like a nurse at Balboa
Hospital during Vietnam.
So he wasn't in Vietnam, butwhen patients came back, or were
flown over, you know, saw a lotof patients and in the military
medical system it's a littlebit different than the general
(28:19):
medical system.
I mean you have nurses do a lotmore, you know, in the field of
battle for sure, the theaterwar.
Then you know, they do stateside.
Not that they don't do a lotstateside, but I mean they're
allowed to do a lot more.
Speaker 2 (28:34):
It's all hands on deck, especially, you know, in
the book they talked about themass casualties and it really is
.
You know you need everybodyjust to pick up whatever you can
do.
So I think it was a great storyabout like teamwork and, you
know, emotional strength,physical strength and just being
there for each other and that'swhat's important.
Speaker 1 (28:52):
Yeah, for sure, I'll end on this.
Actually, I did a short stintat Mayo Clinic and they had a
mass casualty event when I wasthere.
Oh my gosh, which isRochester's a small city?
It is very small, I meanbeautiful hospital, huge
hospitals, a hundred andsomething OR beds.
Yeah, it's huge but um, it wasthis huge car wreck that
(29:13):
happened.
I don't think it was like foggyor something like that.
And they like we're asking, likeother doctors, to come to the
ER because, I mean, it's justthe last place.
You'd expect a mash casualtyevent.
Um, but um, uh.
That would have been like maybe2010 or something like that.
Speaker 2 (29:29):
I can gosh, I can't imagine.
Speaker 1 (29:30):
Yeah, it was pretty crazy.
I obviously didn't go, butanyway.
Speaker 2 (29:38):
What a wild experience.
Speaker 1 (29:40):
Yeah, you always got to be ready, oh my gosh, yes,
and sometimes things like thathappen and you just got to jump
in and help.
Speaker 2 (29:46):
You do.
It's like when you're on anairplane.
Speaker 1 (29:48):
Yeah, I'm always with my wife, who's an OB-GYN, so
I'm always safe on that one.
Same with myself and my husband.
I'm like if they call over.
Speaker 2 (29:55):
I'm like, you're the anesthesiologist.
If you need me, then call forme yeah.
Speaker 1 (29:59):
I'll be your backup.
I'll be right there.
Yeah, I'm the backup, yourprimary.
Speaker 2 (30:12):
Ashley, how do people ?
As a patient, you will need areferral from your general
dermatologist.
If you have a biopsy provenskin cancer that needs treatment
, you can either call our officeor make an appointment on that.
S-c-h-w-e-i-g-e-r-d-e-r-mcomand I am currently at the office
(30:37):
in Chesterfield.
So Schweiger Dermatology inChesterfield.
Speaker 1 (30:41):
And so they can reach you at 314-878-3839.
Speaker 2 (30:45):
That's correct.
Speaker 1 (30:46):
Well, I want to thank you for the good care that
you've given our mutual patientsand I want to thank you for
coming on today, and I reallyappreciate you.
Speaker 2 (30:54):
Thank you so much for having me and, of course, for
sharing patients and taking goodcare of our mutual patients.
It's always a pleasure to sharepatients and discuss cases with
you.
Speaker 1 (31:04):
You bet Thanks so much.
Speaker 2 (31:05):
Ashley, thank you.
Hello, this is Jason Edwards and this is Doc
Discussions.
I'm here with one of myco-workers, ashley McGinnis.
Ashley, how are you doing today?
Speaker 2 (00:09):
I'm good.
Thanks so much for having me.
Speaker 1 (00:11):
Ashley, you're a dermatologist who specializes in
Mohs surgery.
Is that correct?
Speaker 2 (00:15):
That's correct.
Speaker 1 (00:16):
Yeah, and where are you from?
Speaker 2 (00:18):
I'm originally from St Charles, so I'm a St Louis
local.
Speaker 1 (00:21):
Very good.
And then, where did you do yourschooling at?
Speaker 2 (00:25):
So I did my undergraduate studies at
Rockhurst University in KansasCity, Missouri.
Speaker 1 (00:29):
How about that?
It's a Jesuit college, right.
Speaker 2 (00:31):
Jesuit college.
So I went through the Catholicschool system here and stuck
around with it for college andthen transitioned to SLU here in
town for medical school.
Speaker 1 (00:41):
Okay.
Speaker 2 (00:42):
And then after that I did my intern year and my three
years of dermatology trainingat the University of Iowa City
or University of Iowa and IowaCity.
Speaker 1 (00:50):
Sure.
Speaker 2 (00:51):
And then after dermatology I did the Mohs
Surgery Fellowship up at MayoClinic in.
Speaker 1 (00:55):
Rochester Just up the road a little bit right.
Speaker 2 (00:57):
Yeah, just up the road, Kept graduating further
and further north before I movedhome.
Speaker 1 (01:01):
Yeah, I remember my interview at Iowa.
To me it seemed like a greattown, iowa City and Corvallis, I
think, which is right next toit.
I'm probably mispronouncingthat.
Speaker 2 (01:15):
No, that's okay.
Iowa City is a great city andit's not too far from St Louis,
great college town feel.
Lots of fun things to do.
You get the Division I sportskind of experience.
Coralville is the neighboringsuburb and it's exploded.
I mean, even since we startedresidency there it grew a lot.
They now have a minor leaguehockey team there.
Speaker 1 (01:36):
That's pretty fun to attend to and you know Iowa's
kind of famous for theirchildren's hospital, overlooks
the football stadium and ofcourse football's huge in any
Big Ten university, butespecially Iowa, and the
football players always wave atthe kids in the Pediatric Cancer
Center, which is a beautifulthing.
Speaker 2 (01:52):
It's amazing and it's really fun.
I mean being on both ends One,if you're on a pediatrics
rotation, being up there withthe kiddos and seeing it.
I mean it makes everybody's day.
And then if you're in thecrowds getting to wave up there,
I mean it's very cool to seeboth the home team and the
opposing team all getting intoit too.
Speaker 1 (02:09):
Yeah, what a special thing.
And so and you're married to aphysician, is that right?
Speaker 2 (02:12):
I am yeah.
Speaker 1 (02:13):
So what's your husband do?
Speaker 2 (02:15):
So he is a board certified anesthesiologist but
he actually did a fellowship ininterventional pain.
Speaker 1 (02:21):
How about?
Speaker 2 (02:21):
that, so he practices interventional pain over in
Alton.
Speaker 1 (02:24):
Very good, very good, and so you've got a practice
here in St Louis and we'veshared a few mutual patients.
Yes, can you explain to peopleyou know, like the lay person,
what Mohs surgery is?
Speaker 2 (02:36):
Yeah, that's a great question.
So Mohs surgery is aspecialized form of skin cancer
removal, a surgical form of skincancer removal, and the way we
do Mohs surgery is it's allunder local anesthesia, meaning
the patient's not asleep for theprocedure.
We just numb it with injectionsand we remove the skin cancer
with a small rim of healthy skin.
(02:57):
And while the patient waits wecheck all of the edges, both on
the outside and the deep edge,to see if everything's off the
patient, if there's a little bitmore.
I have a map that I've createdon both the patient and on the
tissue that I've removed.
That tells me where we need toremove a little additional skin
and we repeat that process untileverything's gone and then we
(03:18):
reconstruct the patient based onwhat the final defect is.
Speaker 1 (03:23):
And so when you make the map, I remember in textbooks
they kind of quartered it wherethey make it into quarters.
Is it more complicated thanthat, or is each section
quartered?
Speaker 2 (03:32):
It's a good question.
So it depends on the size andthe shape of the lesion itself.
So sometimes you'll process itjust in one single piece.
I personally make more of ourstandard size pieces.
I mark a 12 o'clock kind ofsome hashes at 12 o'clock, 3
o'clock, 6 o'clock and 9 o'clock, so it almost looks like a
little clock face and we putinks in there.
(03:52):
So it tells us you know, theblue ink may be at your 12
o'clock and your green ink is atyour 6 o'clock, and if you see
something between 12 and 3, youjust take tissue between 12 and
three and you can spare the restof the healthy skin.
Speaker 1 (04:05):
Yeah, so so, um, you know you, you excise kind of the
same amount of tumor as youwould with um.
You know which is all of itwith the normal excision.
But the beauty of Moses, itleaves more natural tissue, more
normal tissue, and so yoursurgical defect is less right.
You got it and so you have abetter cosmetic outcome.
Speaker 2 (04:24):
You got it Better.
Cosmetic outcome it's tissuesparing and then the way we
actually process the tissue.
You're actually evaluating 100%of the margin as opposed to a
standard excision.
You look at 1% to 2% actuallyof the standard margin.
Speaker 1 (04:37):
Yeah.
Speaker 2 (04:38):
So it does give you a superior cure rate.
You're talking more for youraverage run-of-the-mill skin
cancer 98, 99%, as opposed toabout a 95 to 97% cure rate.
But huge benefit forcosmetically sensitive areas
like the face, where you don'thave much real estate to spare
and you want all the healthytissue you can keep.
Speaker 1 (04:55):
For sure.
And when we're talking aboutskin cancers specifically here
we're talking about basal cellcarcinomas and squamous cell
carcinomas, correct?
Speaker 2 (05:04):
Those are our most common kind of bread and butter
cases that we do.
A lot of People are starting touse Mohs for melanoma in situ
and thin melanomas, your earlystage melanomas, especially on
the head and neck.
Yeah, we do Mohs for moreuncommon skin cancers as well,
but they're just few and farbetween, as opposed to the basal
(05:24):
cells and squamous cells.
Speaker 1 (05:25):
And the rationale for not doing it for kind of a
standard melanoma or moreadvanced is you really want a
very large rind of normal tissuebetween the blade and the tumor
, because you don't want themargin to be as close with the
melanoma, because the recurrencerate's higher.
Speaker 2 (05:42):
That's correct and the other thing is is that it
just has been standard of careto have wide local excision for
so long.
So I know a lot of people arestarting to do studies and kind
of compare MOSE for melanoma toyour standard of care, which is
wide local excision.
Speaker 1 (05:55):
Yeah.
Speaker 2 (05:56):
The other thing that makes it difficult is if you
need to do a sentinel lymph nodebiopsy for an aggressive
melanoma.
You can't necessarily time thatvery well with Mohs.
It's hard to do when there'stwo surgical subspecialties that
are both in the mix.
Speaker 1 (06:13):
And another thing I remember from my textbooks there
was kind of a region of theface and I think the rationale
was that it was kind of likethis embryological H or center
point where cancers were thoughtto be more aggressive.
Am I anywhere close on this?
Speaker 2 (06:30):
That's correct.
So there is.
We call them the high risk,medium risk and low risk
locations but it is more centralface, so kind of eyelids,
temples, ears, nose, lips thatare traditionally thought of as
your high risk areas.
Speaker 1 (06:43):
Yeah.
Speaker 2 (06:44):
Skin is thinner there .
From a cosmetic standpoint, afunctional standpoint, you don't
have much real estate andbecause of the nature of the
tissue there skin cancers canbehave more aggressively in
those areas.
So typically if you have abasal cell or a squamous cell in
those areas it automaticallyqualifies for most.
Speaker 1 (07:05):
And then I also remember, like with the lips
specifically, that cancers aremore prevalent on the lower lip
compared to the upper lip.
Do you know why that is?
Speaker 2 (07:13):
It may be, I don't know if it's because you get
some shading from nose and thatsort of thing.
Speaker 1 (07:20):
Good mustache.
Speaker 2 (07:20):
A good mustache on a man, or a woman, I guess.
But you know, I think some ofit is just anatomic location,
with it being a little moreexposed to the sun.
Speaker 1 (07:30):
Yeah.
Speaker 2 (07:30):
I don't know with tobacco exposure.
You know, a lot of times withlike chewing tobacco and things
like that, a lot of times peoplehave it stored in their lower
lip and we know tobacco use alsoincreases your risk of squamous
cells on the lip as well.
Speaker 1 (07:43):
Yeah, now I'm going to get into the old online
misinformation here.
I love it so recently I've seensome posts where people talk
about it's actually thesunscreen that's causing the
cancers and not the sun itself.
What are your thoughts on that?
Speaker 2 (08:02):
So I think it's been well proven that UV exposure
both chronic, you knowcumulative sun exposure, as well
as intermittent intense sunexposure.
So a sunburn here or there doesincrease your risk of
developing skin cancer.
Yeah, I know there's been a lotof concerns over especially
chemical sunscreens in recentyears.
You know what types of effectsare these having?
(08:24):
I don't necessarily thinkthey're causing skin cancers.
I don't think we necessarilyknow.
You know, could they be harmfulin high, high doses.
If they were in your bloodstream, Maybe I don't think you're
absorbing enough of it toprobably reach those levels of
harm in general, which is whythey've been approved for use.
But I always tell people ifyou're very concerned about it,
(08:46):
some good alternatives would belike a zinc oxide, titanium
dioxide, more of those physicalsunscreens, because the way they
work is they actually sit ontop of the skin, they're not
actually absorbed into the skinand they still provide a
protective barrier from UV, orjust using sun protective
clothing.
They make a lot of UPF clothingthat actually has that sun
protection built in now.
(09:06):
So if you're concerned about it, you know there are
alternatives to still protectyou from the sun and protect you
from that UV induced damage.
Speaker 1 (09:14):
Yeah, I mean, and you know, when it comes to just
like misinformation and stufflike this in general, I mean
it's okay to be skeptical Ithink you don't want to be naive
and so it's okay to have someskepticism.
But you know, from all theevidence out there, it looks
like sunscreen in general isvery safe.
And then there's some kind of,like you said, higher end ones
(09:35):
that you know maybe technicallysafer, right, but yeah, and then
the sun shirts, I mean thosework you can get in the water
and they don't.
It's not like the old cottonhang shirt.
I mean they're breathable andthe technology with the clothing
is good.
Speaker 2 (09:52):
Yeah, and so that's always a strong move.
Yeah, and I think it's nice too, for people who say they don't
like the feel of sunscreen orjust forget to reapply.
Yeah, you know, if it's on, ifyou've got a sun shirt on,
you've got that UPF, that SPF of50, essentially built in for as
long as you've got it on, whichis very nice.
Yeah, if you're going to planon spending the whole day
outside.
Speaker 1 (10:07):
I totally agree, and you know you're in the water
that comes off, or I don't knowhow well it's done.
Even if it's the waterproof,you don't know if it's going to
stay or not.
Speaker 2 (10:14):
Right, exactly.
Speaker 1 (10:15):
Um, there there does appear to be a trend, um, with
increasing not only rates ofsquamous cell carcinoma and
basal cell carcinoma, but alsomelanoma since 2000, at least
through 2020.
And what I'm looking at here itsays about 1.8% annually, which
seems like a lot.
(10:35):
Have you guys noticed that, andwhat do you think's behind it?
Speaker 2 (10:41):
That's a good question, and I think there's a
lot of factors that probablyplay into us seeing more and
more of it.
One is, I think, patienteducation.
You know people are more andmore aware and are taking a look
at their own skin, which isawesome because you know you're
your own best advocate.
So if you're the one that seesyour body every day, so if
you're noticing it and bringingit to somebody's attention, I
(11:02):
think that is something that hasdriven numbers up.
So just better detection Betterdetection and better detection
by patients, better detection bydermatologists.
As we know, more and more andmore patients are seeing
dermatologists.
I think our aging population ingeneral increases those numbers
just because it's cumulativesun exposure risk increases
(11:24):
those numbers, just because youknow it's cumulative sun
exposure risk.
I think tanning bed use,especially in you know, we think
about rates of tanning bed use80s, 90s, early 2000s.
I think we're seeing a lot ofrepercussions of tanning bed use
as well.
Speaker 1 (11:36):
I grew up in a small town.
In small towns, you know,everything's tanning.
It's like there's a pizza shopand tanning it's like a combo.
There's the gas station andtanning.
It just goes hand in hand.
Speaker 2 (11:46):
Yeah, and it's shocking that you're like you
still see them.
Speaker 1 (11:48):
We know how bad they are and there's still a few
lingering, which is concerningyeah, so when you talk about
ultraviolet light, which is whatwe consider, the kind that
damages the skin, that causesDNA changes which precipitates
cancer, there's UVA and UVBlight.
(12:10):
Is one of them worse than theother?
Speaker 2 (12:13):
It's typically thought that you know.
Uvb typically causes burningrays.
It doesn't penetrate as deepinto your skin as the UVA.
Uva penetrates a little bitdeeper, so traditionally people
think UVA is what causes agingand more of the skin cancer that
those cellular changes but,it's really a combination of
both.
So that's why they always saywhen you look for a sunscreen,
(12:34):
look for something that saysbroad spectrum, because you want
to cover yourself for both, andthey both penetrate even car
windows.
So I always tell people youshould at least be putting
something on in the morning.
At least do your face.
You know a daily moisturizerwith a sunscreen.
Even if you're not going to beout and about, you are still
getting some of that exposure.
Speaker 1 (12:51):
Yeah, I started using this brand called proven, and
you probably I mean there's allthese products, right Um, but it
was, of course, developed bydermatologists.
That should be your nextventure, right?
Speaker 2 (13:02):
I mean you can do it, but um but it, you know
developed by dermatologists andeverything's.
Speaker 1 (13:10):
You know, um, supposed to be like heavily
scientifically studied, and theytake, you know it's
personalized, right.
I mean, people don't know youcan get personalized vitamins.
You can.
You know you can send off astool sample and get
personalized vitamins, all kindsof personalized stuff.
But it's, it's.
You know this is not, as youknow, intricate.
They just get your demographicswhere you live and then send
(13:30):
you, you know, face cream orwhat, but, but it has, I can
tell there's sunscreen in it.
I don't get out that much, butum, but you know we all want to
stay looking young and um, and,and part of it's certainly sun
damage.
What are the things that youknow cause the wrinkles?
Um, or you know, or age theskin?
Speaker 2 (13:50):
Yeah, so I think UV exposure is a big thing.
A lot of times people alsonotice that just dryness of the
skin.
You know, when you're dry youtend to notice some of those
fine lines and wrinkles morethan you would if your skin is
moisturized.
Speaker 1 (14:02):
Yeah.
Speaker 2 (14:02):
So keeping nice, moisturized skin also makes you
look a little more youthful.
And then also just dynamicmovement.
You know we move all of ourmuscles.
Every time we move our musclesof our face they make wrinkles.
The more you move those musclesyou get wrinkles, which is why
people do Botox to paralyze someof those muscles.
Speaker 1 (14:21):
Okay, yeah.
And then, of course, you know,there's, you know, one thing I
notice with patients if I seesomebody who looks, you know,
significantly younger than theirage, you know, with regard to
their skin, I think usually I,you know, I'll ask them do you
drink a lot of water?
Because people will just drinka lot of water, you know, or you
know that that's a part oftheir, you know their regimen is
(14:44):
to, you know, drink plenty ofwater, and I think that alone,
you know, helps reduce thewrinkles.
Speaker 2 (14:49):
Oh yeah, hydration status is huge, definitely.
And then things like you know,smoking and alcohol use, we know
contribute to accelerated agingas well, so kind of just having
that healthy lifestyle overall,you know, water consumption,
healthy diet, avoiding heavyamounts of alcohol or tobacco
use in general.
Speaker 1 (15:07):
Yeah.
Speaker 2 (15:08):
All go a long way, both on the inside and on the
outside.
Speaker 1 (15:10):
For sure.
Yeah, you know, I think ofLydie Kravitz, the singer, who's
a raw vegan, and I mean thatguy looks great he does look
great and I mean sometimes itcould be just genetics too,
right, but I mean certainlyeating kind of a low nitrate
diet, you know, like you said,helps inside and outside, and if
you have great blood flow, um,you know, to your heart and your
kidneys, you probably havegreat blood flow to your skin
(15:33):
exactly.
Exactly the.
You know.
Ai, artificial intelligence, iskind of all the new rave.
Have they integrated any ofthat technology into Mohs or
dermatology?
Speaker 2 (15:47):
They are starting to and starting to do some studies.
Actually, when I was at MayoClinic for fellowship, they were
starting to utilize a full bodycamera for high risk patients
and kind of studying that formole mapping, essentially to
look for changes, and they weregoing to use AI technology.
Then at each visit they have thepatient photographed and then
(16:08):
have an AI algorithm look forsubtle changes in moles.
That then would be followed upwith a dermatologist.
You know dermatoscopic, youknow better evaluation.
So that's one thing I've seen.
I've seen a lot of apps nowkind of advertise that are take
a photo of your spot and uploadit and kind of get a diagnosis.
So I think they're trying torefine some of those and some of
(16:29):
that may be very helpful,especially when triaging
patients.
You know, and you're doingalmost a telederm.
Especially when triagingpatients.
You know, and you're doingalmost a telederm, does this
need to be seen next week or canwe maybe see this next month?
So I think that's nice andpeople are starting to actually
implement it in Mohs in terms ofseeing how AI compares to a
physician in terms of can itidentify a basal cell or not,
(16:52):
and what's that agreement likewith the Mohs surgeon.
Speaker 1 (16:55):
Okay, so they do like a Kappa analysis between the
two.
Yeah, the, I think the, thetaking the pictures I mean even
with people with their phones,is one of the things that you
just never had before, becauseyou know when you see a patient
and make a note in a you know,write about something or or it,
you know it's hard to reallytell how it changes over time.
(17:17):
Usually as a doctor you justsee them in one point in time
and kind of make a judgment overthat, and so that's really cool
to have you know something thatkind of tracks it, and so you
kind of have this dynamicpicture of what's going on with
the lesion over time.
Speaker 2 (17:29):
Yeah, it's very, very interesting and they were even
talking about adding dermoscopy,so like magnifying the lesion
and looking at pigment patternsand even from that even
magnified view, looking at thesevery subtle changes in moles,
which is very cool because it'ssomething like you said.
I mean, we're seeing them assnapshot in time.
So if you have thesephotographs and then have
(17:50):
something that can pick up verysubtle changes in color that
maybe our eyes can't even pickup, yeah.
I mean just adding another toolto your armamentarium.
Obviously, you always need theclinical aspect behind some of
that AI stuff, but I think it'sjust going to be another tool
for us to use.
Speaker 1 (18:04):
Yeah, yeah, I think that's.
It's kind of like a copilot,right.
Speaker 2 (18:07):
Yeah.
Speaker 1 (18:08):
Just something to help you be better.
And then, ok, so you've gotsquamous cell carcinoma, we've
got basal cell carcinoma, andthese are the common cancers and
most of the time, you know,they don't spread to the lymph
nodes and they don't metastasize.
When they do, it's wild.
I mean, you know it's very rare.
But when they do spread toother parts of the body, I mean
they can be really aggressive.
(18:28):
Yes, but melanoma is like thereally scary cancer, because
that doesn't have to be very bigbefore it gets into the
bloodstream and can spreadanywhere and everywhere.
And it does, and the metastasiscan bleed and you know that's a
big deal.
What are the you know, whensomebody's looking at a lesion,
(18:48):
what are the main criteria thatwould be suggestive of a
melanoma?
Speaker 2 (18:54):
That's a good question.
So for the most common subtypeof melanoma it's called a
superficial spreading melanomaand because it's the most common
, people have come up with allsorts of things to help people
identify, you know, worrisomesigns on themselves.
So I think the most common andmost helpful one is the ABCDEs
of melanoma.
So when you look at a mole,something that's asymmetric,
(19:15):
something that's borders areirregular, if a lesion's got
multiple colors.
So if you're looking at a spotand it's uniformly brown, that's
a reassuring sign.
But if you see brown with blackand blue, that might raise your
suspicion.
For D they usually say biggerthan the diameter of a pencil
eraser.
And then the big thing for meis the E is the evolution.
(19:37):
So if you had a mole that youknow it looked one way for 10
years and three months ago itlooks a little, started to look
a little bit different, thatshould really raise your
suspicion.
Speaker 1 (19:48):
Yeah.
Speaker 2 (19:52):
And all of those are, but it's helpful for somebody
who's seeing their skin at homeor having a loved one take a
peek at their skin to say whatof these might be worth calling
a doc about.
Speaker 1 (20:03):
You know I have a rule with things that may be
melanoma and it goes with your E.
You know, you're saying the Eis really important for you.
If a patient's concerned, youknow, then then usually I'm
concerned, you know, or I'msaying don't sleep on that,
trust your instinct, because Imean we all have spots all over
us.
There's a reason you'reconcerned and it's probably that
(20:24):
it's evolving and it's changinga little bit quicker.
And so I always tell patientsyou know, if you're concerned,
just go ahead and get in and seesomebody.
Speaker 2 (20:31):
It's better safe than sorry you bet Now Merkel cell
carcinoma.
Speaker 1 (20:40):
they always say it's similar to melanoma.
I mean it's caused bypolyomavirus and stuff like that
.
Speaker 2 (20:43):
It's a little bit different.
But is that mostly on the skintoo?
It is, and I think Merkel cellin general tends to overall
behave more aggressively whenyou catch it.
Typically people are needing asentinel lymph node, biopsy
sampling their lymph nodes, nomatter what in addition to local
control of the tumor, whereasmelanoma, if you catch it early
enough, it's surgical removaland you're kind of done with it.
Speaker 1 (21:05):
Yeah.
Speaker 2 (21:05):
But it tends to be on the skin as well.
Speaker 1 (21:09):
And the very first episode we ever did.
I talked about Jimmy Buffett,who I'm a big fan of we ever did
.
I talked about Jimmy Buffett,who I'm a big fan of, and he had
Merkel cell carcinoma andultimately died from it.
And of course Jimmy's near anddear to my heart, but the one.
There's several cancers thatare highly immunogenic cancers,
meaning the immune system playsa big role in modulating the
(21:31):
cancer and kind of keeping it incheck or not.
And so if you're immunecompromised, you know you'd have
worse results and if you had agood immune system it may keep
it from spreading.
But specifically melanoma andMerkel cell carcinoma are highly
immunogenic cancers and sothey've got these new immune
therapies that they usesometimes in lieu of
chemotherapies.
But it's a systemic therapy andI've seen some just dramatic
(21:54):
responses, especially withMerkel cell carcinomas.
You know, previously youthought, like you know, we can
give them something, but it's,you know, some chemotherapy but
they're not going to do well,and then I've seen patients
where it just melts away.
I mean it's very remarkable.
Speaker 2 (22:08):
Yeah, the immunotherapy has been a total
game changer.
I mean for really.
I mean for metastatic squamouscell, for melanoma, for Merkel
cell, because traditionalchemotherapy one from a side
effect profile, you know hashistorically been really tough
on patients and two outcomes fora lot of these skin cancers
were not as good as for othertypes of cancer with traditional
chemotherapy.
(22:28):
And with time they've justexpanded the armamentarium,
which is awesome because itgives us more backup options and
just more options for patientsif they don't tolerate things.
Speaker 1 (22:39):
Yeah, now, so you're a Mohs surgeon, do you do?
Are you doing strictly Mohssurgery or do you do some like
regular derm with Mohs?
Speaker 2 (22:48):
Right now I'm only doing Mohs surgery.
Speaker 1 (22:50):
Good, that's a good sign.
Speaker 2 (22:51):
I miss general dermatology a little bit, but
yeah, unfortunately slash.
Fortunately the skin cancertreatment does keep me busy.
Speaker 1 (22:59):
Good.
Speaker 2 (23:00):
But like you said before, I mean so many of ours
are curable with very, very highcure rates, so it's a very
rewarding type of procedure.
Speaker 1 (23:10):
Yeah, for sure, and you know, kind of going back to
your training, I meandermatology is a tough, tough
specialty to get into.
I mean it be able to do that atthe University of Iowa and then
Mayo Clinic is reallyremarkable and, to be honest,
(23:41):
we're really lucky to havesomebody like you in our
community and I'm glad thatyou're doing mostly Mohs
surgeries because that's yourspecialty and I'm glad you're
popular enough that you'regetting enough patients to stay
busy with just that.
If you're a patient out therelooking for a doctor, a busy
doctor is typically a gooddoctor because other doctors are
(24:04):
referring to them.
I've been told to never to dothis, but I noticed you might be
a little bit pregnant.
What's going on there?
Speaker 2 (24:13):
My husband and I are expecting identical twin girls
come here June of this year, sonot too far from now.
Speaker 1 (24:21):
Well, God bless you.
What are your thoughts on that?
I mean, that seems like it'sgoing to be a lot.
Speaker 2 (24:27):
Yeah, so we're going from zero to two, which is
awesome, amazing.
We're very excited, but alsoterrifying at the same time.
But you know, we're going totake it one day at a time and
they're already very loved byeverybody in their lives, so
we're very excited.
Speaker 1 (24:41):
Yeah, I mean, you and your husband seem like you're
very functional human beings,and it certainly helps to have
some family nearby, and soyou're going to have a little
bit of support from mom and dad.
Speaker 2 (24:52):
Absolutely, and we knew we always wanted to move
home, we wanted to care forpeople in our community.
But it's just an extra bonusnow, with two on the way that
our parents are at most 10 to 15minutes away from us.
Speaker 1 (25:03):
Oh, so your husband's parents are here as well.
Yeah, oh, thank goodness it'sgoing to be so awesome.
Speaker 2 (25:07):
So he grew up in O'Fallon, I grew up in St
Charles and we've got family allaround.
Speaker 1 (25:12):
Yeah, you know it's.
It's, in many ways, the mostdifficult thing you'll ever do,
but also the most rewarding andchallenging, but I think, I
think it'll be a true blessingand you're probably bringing two
smart kids into this world.
Speaker 2 (25:31):
I hope so.
We've had challenges in a lotof other areas of life, but this
will be a totally new challengeand, yeah, I think we're up for
it.
Speaker 1 (25:39):
Yeah, and I mean, challenges are good for us, it's
you know Sisyphus pushing theboulder up the mountain, you
know it's he need.
You need that boulder.
You know you don't want to justskip through life and not
continue to grow as a person andI think one of the things that
makes people universally happyis to see progress in their own
life.
And then the beauty of having achild is you know, you can, you
(26:01):
know, once you've kind of ranyour course, you know you get to
see the progress through yourown child's life and so in a
sense it's kind of redoing thehero's journey.
If you're a Joseph Campbell fan, Absolutely.
Speaker 2 (26:15):
Yeah.
I think it'll be very rewardingand very exciting to see them
grow and kind of do their ownthing and develop their own
personalities, and so it'll bevery, very fun.
Speaker 1 (26:24):
Yeah, I'm happy for you.
Speaker 2 (26:27):
Thank you so.
Speaker 1 (26:28):
I mentioned Joseph Campbell.
Are there any good books thatyou like?
Speaker 2 (26:32):
So I am a historical fiction lover that's like what I
tend to gravitate towards.
So I actually just finished theWomen it's about the nurses in
the Vietnam War.
And it's a historical fictionbook but it's kind of about the
unsung people who weren'tacknowledged but did a lot of
care and hard work during theVietnam War.
(26:53):
But I love historical fictionbooks, especially ones that have
strong heroine stories.
So the Alice Network is anothergreat one about like an
underground female driven spynetwork during the Great War and
I just love those books becauseyou learn a little bit but
they're still enjoyable from afictional standpoint.
Speaker 1 (27:12):
I agree.
I mean stories.
Just hearing facts don't reallystick Right.
You need to be able to tell astory.
Speaker 2 (27:18):
Yes.
Speaker 1 (27:19):
So in that book the Women does it take place
stateside or in Vietnam, or inboth?
Speaker 2 (27:26):
Mostly in Vietnam.
Okay, yeah, so it starts thefirst chapter or two they're
back state side, but then she isdeployed and working in army
(27:48):
hospitals in Vietnam and itmakes you appreciate people who
put their lives on the line andtake care of people who put
their lives on the line for uson a daily basis.
Speaker 1 (27:57):
Yeah, yeah.
Actually it makes me think ofmy father.
He was a corpsman, which iskind of like a nurse at Balboa
Hospital during Vietnam.
So he wasn't in Vietnam, butwhen patients came back, or were
flown over, you know, saw a lotof patients and in the military
medical system it's a littlebit different than the general
(28:19):
medical system.
I mean you have nurses do a lotmore, you know, in the field of
battle for sure, the theaterwar.
Then you know, they do stateside.
Not that they don't do a lotstateside, but I mean they're
allowed to do a lot more.
Speaker 2 (28:34):
It's all hands on deck, especially, you know, in
the book they talked about themass casualties and it really is
.
You know you need everybodyjust to pick up whatever you can
do.
So I think it was a great storyabout like teamwork and, you
know, emotional strength,physical strength and just being
there for each other and that'swhat's important.
Speaker 1 (28:52):
Yeah, for sure, I'll end on this.
Actually, I did a short stintat Mayo Clinic and they had a
mass casualty event when I wasthere.
Oh my gosh, which isRochester's a small city?
It is very small, I meanbeautiful hospital, huge
hospitals, a hundred andsomething OR beds.
Yeah, it's huge but um, it wasthis huge car wreck that
(29:13):
happened.
I don't think it was like foggyor something like that.
And they like we're asking, likeother doctors, to come to the
ER because, I mean, it's justthe last place.
You'd expect a mash casualtyevent.
Um, but um, uh.
That would have been like maybe2010 or something like that.
Speaker 2 (29:29):
I can gosh, I can't imagine.
Speaker 1 (29:30):
Yeah, it was pretty crazy.
I obviously didn't go, butanyway.
Speaker 2 (29:38):
What a wild experience.
Speaker 1 (29:40):
Yeah, you always got to be ready, oh my gosh, yes,
and sometimes things like thathappen and you just got to jump
in and help.
Speaker 2 (29:46):
You do.
It's like when you're on anairplane.
Speaker 1 (29:48):
Yeah, I'm always with my wife, who's an OB-GYN, so
I'm always safe on that one.
Same with myself and my husband.
I'm like if they call over.
Speaker 2 (29:55):
I'm like, you're the anesthesiologist.
If you need me, then call forme yeah.
Speaker 1 (29:59):
I'll be your backup.
I'll be right there.
Yeah, I'm the backup, yourprimary.
Speaker 2 (30:12):
Ashley, how do people ?
As a patient, you will need areferral from your general
dermatologist.
If you have a biopsy provenskin cancer that needs treatment
, you can either call our officeor make an appointment on that.
S-c-h-w-e-i-g-e-r-d-e-r-mcomand I am currently at the office
(30:37):
in Chesterfield.
So Schweiger Dermatology inChesterfield.
Speaker 1 (30:41):
And so they can reach you at 314-878-3839.
Speaker 2 (30:45):
That's correct.
Speaker 1 (30:46):
Well, I want to thank you for the good care that
you've given our mutual patientsand I want to thank you for
coming on today, and I reallyappreciate you.
Speaker 2 (30:54):
Thank you so much for having me and, of course, for
sharing patients and taking goodcare of our mutual patients.
It's always a pleasure to sharepatients and discuss cases with
you.
Speaker 1 (31:04):
You bet Thanks so much.
Speaker 2 (31:05):
Ashley, thank you.
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