Altru dermatologist among five in North Dakota with specialized Mohs training
Dr. Katie Shahwan joined Altru in August 2021.
GRAND FORKS – Ed Goetz has much to feel good about concerning his appearance these days – and he has a dermatologist at Altru Health System to thank for it.
In the last couple of years, he’s had skin cancer on both ears, his face and each side of his neck – probably the result of “fishing, working in the yard and blowing snow – and not wearing a hat,” he said.
Goetz, 79, of Grand Forks, sought treatment for the cancer from Dr. Katie Shahwan, who specializes in the Mohs micrographic surgical technique at Truyu Aesthetic Center.
“She’s my favorite doctor,” Goetz said with a big smile. “She’s fantastic.”
The lesion on the left side of his nose was most serious. It required a more extensive procedure, taking cartilage from his ear to restore that area of his nose – where now there’s virtually no scar.
After each procedure, he said, there was “a little soreness, but no pain.”
Mohs fellowship training
Shahwan joined Altru in August 2021, soon after completing a one-year fellowship in Mohs micrographic surgery and dermatologic oncology at The Ohio State University Medical Center.
Originally from Hudson, Wisconsin, Shahwan earned the Doctor of Medicine degree at Rosalind Franklin University of Medicine and Science in Chicago and completed dermatology residency at the University of Minnesota in 2020, before pursuing Mohs fellowship training.
In her medical practice, Shahwan treats the most common types of skin cancer, including basal cell carcinoma, squamous cell carcinoma and melanoma, but also a variety of rare types that come up less frequently, she said.
“Basically any type of skin cancer, we can treat it,” she said.
Mohs surgery differs from other skin cancer treatments in that it permits the immediate and complete microscopic examination of the removed cancerous tissue, so that all “roots” and extensions of the cancer can be eliminated, according to the American Society for Mohs Surgery.
The major difference between Mohs and other treatment methods is how the tissue is processed, Shahwan said.
Similar to other skin cancer treatments, the Mohs technique involves a simple excision to remove cancerous tissue with a scalpel and then, usually, putting in stitches, she said.
However, Mohs is a much more precise technique, which offers a much higher cure rate.
“(The rate) varies based on the type of skin cancer and if it’s recurrent and things like that,” she said. “But, for a brand new basal cell carcinoma, the cure rate is actually 99% – the highest of any treatment.
The high cure rate is “because, with Mohs, we actually check 100% of the margin under the microscope, whereas with (other methods), the way it’s processed in the pathology lab, they’re only checking a small sampling of the margin. So, the areas they’re checking, it may look like the margin is clear and that the skin cancer is treated. But (the cancer) can basically ‘sneak’ to the margin in between the areas that they’re looking (at) – so, leading to a lower cure rate, essentially.”
“(Mohs) is basically a way to map out the skin cancer under the microscope as we’re looking at 100% of that margin. So, for most cases, if it’s a little round skin cancer, we’ll cut that out as a disk of skin. I put little hash marks in it so that the hashes line up on their body as well as the specimen that I’m taking to the lab. I put different colored inks in the different hashes. So, when I look under the microscope, if, for example, I see if there’s still cancer between my yellow and red hashes, I can go back to the person and, just in that quadrant of the area, take another sliver of skin instead of having to go around the entire thing again.”
“Because we’re checking 100% of the margin, we also can get away with taking a lot less normal healthy skin with it, so it’s also a tissue-sparing procedure,” Shahwan said. “We start with much more narrow margins and then we also target any subsequent layers to what we’re seeing under the microscope. So if it comes back positive, we only have to go back to the area that still has cancer cells. We don’t have to cut around the entire thing again.”
Shahwan’s patients are happy that the Mohs “tissue-sparing approach leads to a smaller defect, which leads to more options for reconstruction and typically a smaller and less noticeable scar,” she said. “They are also happy about the high cure rate because it’s less likely the skin cancer will grow back.”
Another advantage to Mohs is that the procedure is done “in the clinic, under local numbing medicine, so they avoid the risk of going to the operating room, being put to sleep and being intubated,” Shahwan said. “Patients don’t need to stop normal medicines; they don’t need to fast the night before and the morning of; they can eat and drink throughout the day.
“The biggest downside is just having to wait around for the results, but as long as they bring something to do – like a book or something like that – it’s usually a very tolerable procedure to go through.”
Access to care
Shahwan is one of five board-certified and fellowship-trained Mohs surgeons in North Dakota, she said, “whereas most cities will have five within a few-mile radius of each other. So we’re very much underserved in terms of access to Mohs care, and you see the same patterns in terms of dermatologists as well.”
In this region, access to dermatologic care “is much lower than other parts of the country,” she said. “Patients who have a cancer that they’re worried about, are waiting a long time to (see a dermatologist). It’s sometimes a delay of months and even years to get in to have it biopsied. So, often we’re dealing with skin cancers that are larger, more advanced than they would be if they’d been able to be seen quicker.”
Incidence of skin cancer in this region could be associated with the “lake culture that is very common here” or the practice of vacationing or snowbirding to areas with intense sun, she said.
Oftentimes, skin cancers can be traced to “intermittent bursts of intense sun that make even more of a difference than low-grade sun over time,” she said.
“Most of the time when I see a patient who’s had a delay, it’s usually because they’ve been worried about it but haven’t had that access (to a dermatologist).”
To address that problem, she’s implemented an urgent-access biopsy clinic. Every Friday morning, unless she is out of town, she sees patients who are worried about a lesion or who are referred by their primary care provider, she said.
“I can usually get those patients in within about two weeks for a biopsy,” she said.
These “very quick visits” do not include in-depth exams, but are meant for those who have a lesion that they’re worried about or that is growing, she said.
She gives credit to her colleagues.
“My team here at Altru is, by far, the best team in the entire world. My nurses and my histotech are so good at their jobs,” she said.
She asks her staff to stress to patients that “no question is too small” to bring to her attention, so the clinic can provide “really good, thorough after care,” she said.
Shahwan is continuing her dedication to patients with skin cancer. She has been selected to participate in the American College of Mohs Surgery “Mohs Surgeons Leading the Future” program. The one-year program is aimed at increasing racial and ethnic diversity in the discipline and “almost serves as a pipeline to get young (surgeons)” involved in leadership for the college and to advocate for policy changes, among other objectives.
How to minimize your risk for skin cancer
As summer approaches, Shahwan suggested ways to reduce skin cancer risk.
“Even making some small lifestyle adjustments to minimize how much sun damage or sunburns you’re getting” is helpful, she said.
“Sun protection is obviously very important,” she said, noting the value of wearing sunscreen and reapplying it every couple of hours when you’re outside.
Wear broad-brimmed hats and photoprotective clothing, which “has SPF protection built into it,” she said, “and then you don’t have to reapply (sunscreen).”
Avoid outside activities during peak sunlight hours, noon to 2 p.m., she said. “If you can go for that walk at 2:30 or 3, that’s going to be better than going at 1 p.m.”
Most important, though, is catching skin cancer as early as possible, she said.
“When we catch them when they’re very small and early, no matter what the type is, there are so many more options for treatment and the treatments are so much easier to go through,” she said.
Visit a dermatology provider regularly for skin checks, she said. “As soon as you notice anything popping up on your skin that’s behaving unusually, try to get in for an appointment.”
If you’re unable to see a dermatology provider quickly, see “your primary care doctor first, if you can get in with them faster, because they can directly message us,” she said. “Or, a lot of them even do their own biopsies to sort of expedite things for patients.”