Dr. Carmen Balding is a board certified dermatologist with special training in Mohs micrographic surgery, currently practicing at Soderstrom Dermatology Center in Peoria. She’s a diplomat of the American Academy of Dermatology and the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Balding practiced Mohs micrographic and dermatologic surgery from 1999 to 2001 in Lima, Peru.
She completed a one-year fellowship training in Mohs micrographic surgery in 1999 in Los Angeles, Calif. Balding’s dermatology residency took place from 1995 to 1998 at Rush Presbyterian St. Luke’s Medical Center in Chicago, and she interned from 1993 to 1995 at the University of Kentucky in Lexington. Balding received bachelor’s and medical degrees from the Universidad Peruana Cayetano Heredia in Lima, Peru.
Balding and her husband live in Peoria and have two children.
Tell us about your background, schools attended, family, etc.
I was born in the highlands of Peru in a town called Huancayo. I lived in the area until I graduated from high school. I moved to Lima, the capitol of Peru, to attend medical school at the Universidad Peruana Cayetano Heredia. In Peru, medical school is eight years and combines the four-year university degree and four-year medical degree you have here. I received my medical degree in 1990. I was a physician for PetroPeru, the Peruvian oil company, working at the pipeline pump stations in the jungle and providing rural medical service for the surrounding communities for 15 months. All medical graduates in Peru are required to work for a period of time in underserved areas.
In 1992, I passed the required tests for medical practice in the United States. In July 1993, I began my internship in internal medicine at the University of Kentucky in Lexington. I completed two years of internal medicine there. I then completed my residency in dermatology at Rush Presbyterian St. Luke’s Medical Center in Chicago. I was married in 1998, and my husband and I moved together to Los Angeles, Calif., so I could pursue my fellowship in Mohs Micrographic Surgery. I completed the one-year fellowship with Richard G. Bennett, M.D., from 1998 to 1999. During my fellowship, I received extensive training in Mohs Micrographic Surgery and reconstructive surgery. I also received training in dermatologic surgery. Dr. Bennett and I saw patients principally at his private offices in Santa Monica and Pasadena, but we also saw patients routinely at the Department of Dermatology at UCLA, at the county hospital affiliated with USC, and at Martin Luther King Hospital.
To receive medical training in the United States, I obtained a visa from the United States government, which stipulated that upon the completion of my training, I had to return to Peru for at least two years. So, in July of 1999, I returned to Peru with my husband, and I began to practice Mohs Micrographic Surgery there. While in Peru, my first child, Emily, was born. I enjoyed being back in my country, teaching and working in my field—not to mention spending time with my extended family. My husband and I decided to move back to the United States once my two-year requirement had been fulfilled. In October of 2001, we moved to Peoria, where I began my work as a Mohs micrographic surgeon at the Soderstrom Dermatology Center. On tax day of 2002, I was blessed with a son, Abraham.
Who/what influenced you to become a physician, particularly a dermatologist?
I wanted to be a physician since I was a child, when I observed the respect, admiration, and pride my family had for my cousin, who’s a physician. He lived in Lima, and every time he came to visit us in Huancayo, all of my relatives would get so excited, and each family would invite him to come and spend some time with them at their home. Later, in high school, I became very interested in anatomy and biology. During medical school, I got interested in dermatology when I was rotating in the Department of Tropical Medicine. I was amazed by the different cutaneous manifestations of systemic infections.
My dermatology rotation was actually a disappointment because my group was assigned to a small service with only a few cases since most of the cases were seen in the Department of Tropical Medicine. My outpatient surgical rotation excited me because I saw many different surgical procedures performed on the skin, including incision and drainage of abscesses, removal of cysts, nail surgery for ingrown toenails, etc. I began to envision a specialty that combined clinical and surgical aspects of medicine—dermatology.
To pursue dermatology, I decided to come to the United States because dermatology in Peru was not a well-developed specialty at that time. I applied for my internship and then found out you had to apply two years in advance for dermatology. Because of this, I completed two years of internal medicine (instead of only one) while I waited to begin a residency program in dermatology. Prior to my internship, I spent four months as a volunteer researcher in the Dermatology Department laboratory at the Medical College of Wisconsin in Milwaukee. There, I performed experiments testing patient immunoglobulin G subtypes for reactivity with BP180 (Collagen XVII). BP180 is a known antigen of three autoimmune blistering disorders that affect the skin and/or mucosal tissues—bullous pemphigoid, cicatricial pemphigoid, and herpes gestationis.
Explain your specialty as a Mohs micrographic surgeon. What is Mohs Micrographic Surgery? Why did you decide to undergo the extra training to become a Mohs surgeon?
A dermatologist is a medical doctor who has completed at least one year of internship and three years of training in an approved dermatology residency program. During the three years of residency, residents are exposed to clinical dermatology, dermatopathology, and dermatologic surgery including Mohs Micrographic Surgery if the program has a Mohs micrographic surgeon. After becoming a dermatologist, one may pursue further training. Fellowship programs are offered for immunology, pediatric dermatology, dermatopathology, and Mohs Micrographic Surgery.
A Mohs micrographic surgeon who’s a diplomat of the American College of Mohs Micrographic Surgery and Cutaneous Oncology is a dermatologist who’s been trained for at least one year in an approved fellowship program of the college. The fellowship provides extensive training and experience in the treatment of skin cancers. The fellowship also provides training in the different aspects of dermatologic surgery and cutaneous oncology such as pathology and reconstructive technique. Some fellowships also offer training in cosmetic procedures.
Mohs Micrographic Surgery is a unique surgical technique developed by Dr. Frederic Mohs (1910-2002) of the University of Wisconsin—initially as a fixed tissue technique in the 1930s and modified over the years to the fresh tissue technique currently used. It involves the step-by-step surgical removal of cancer-containing tissue and utilizes complete microscopic examination of all cut surfaces. Tissue specimens are correlated with a drawn map of the wound to direct subsequent steps of excision only to areas that still contain cancer cells. It’s a highly specialized procedure designed to completely remove skin cancers.
I decided to pursue Mohs Micrographic Surgery and dermatologic surgery because I found I had a special interest in the surgical aspects of patient care. My interest in dermatologic and Mohs Micrographic Surgery was developed through my training with Dr. Heidi J. Donnelly, the director of Mohs micrographic, laser, and dermatologic surgery at Rush Presbyterian St. Luke’s Medical Center during my residency. In addition, I sought out an elective in the plastic surgery practice of Dr. Gary Burget in Chicago. Following many interesting and diverse patients in the clinic and during surgery made these experiences by far the most rewarding and enjoyable of all my rotations. Facing diagnostic challenges, identifying skin disorders, and formulating treatment plans are sources of great satisfaction for me. I think one of the most attractive aspects of cutaneous surgery is it requires a vast amount of knowledge in the different areas of dermatology—clinical dermatology, dermatopathology, and anatomy and physiology of the skin—to approach and effectively treat the patient. I also enjoy the interaction needed to calm a patient’s anxiety about surgery and the immediate gratification of treatment results. These experiences confirmed my decision to become a Mohs micrographic surgeon.
Why is Mohs Micrographic Surgery more effective in treating skin cancer? How does it help minimize disfigurement?
Because of the unique way tissue specimens are cut and processed with Mohs Micrographic Surgery, we’re able to observe 100 percent of the tissue margins. Standard frozen sections sample the specimen, examining less than 1 percent of the tissue edges. Also, because of the specialized mapping technique used for Mohs Micrographic Surgery, we’re able to pinpoint areas of remaining tumor. As a result, roots of tumors are found and traced to their ends using Mohs Micrographic Surgery, while roots can be missed during excision followed by either standard pathology or standard frozen sections.
All methods of skin cancer treatment except for Mohs Micrographic Surgery require a guess as to how wide and deep to treat the tumor. Thanks to the mapping system and microscopic analysis of tissue specimens, in Mohs Micrographic Surgery, the guessing is eliminated. Since standard surgical excision of non-melanoma skin cancers involves guessing surgeons typically remove a minimum of three to five millimeters of normal-appearing skin around the lesion. With Mohs Micrographic Surgery, we only remove one to two millimeters of normal-appearing skin at a time and only in the area where the tumor cells are found, thus sparing more normal skin. In general, if more normal skin is spared, there will be less scarring and disfigurement.
Tell us about a typical patient who would benefit from Mohs Micrographic Surgery.
Mohs Micrographic Surgery is primarily used to treat basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) but can be used to treat less common tumors, including melanoma. The criteria used to determine whether Mohs Micrographic Surgery should be employed are the pathology of the tumor, the location and size of the lesion, and whether the tumor was treated previously or not. Mohs Micrographic Surgery offers the highest cure rates for treatment of primary tumors that are located in an area at high risk for developing invasive skin cancers and normal tissue sparing is vital (nose, lips, ears, eyelids, genitalia, and digits); have aggressive pathology (infiltrative and anaplastic BCCs, acantholytic SCCs, perineural tumors, dermatofibrosarcoma protuberans, extraordinary paget’s disease, and rare tumors); and are large (greater than two centimeters).
In addition, Mohs Micrographic Surgery offers the highest cures rates for tumors that are recurrent or persistent and is usually used when conservation of normal tissue is important. Most patients meet two or more of the criteria. Mohs Micrographic Surgery is also useful when the edges of the cancer can’t be clearly defined, when scar tissue exists in the area of the cancer, and when the cancer grows rapidly or uncontrollably.
What are the current statistics of people suffering from skin cancer? What are the most common places for skin cancer to occur?
About one in five Americans will be diagnosed with skin cancer in their lifetime, with an estimated one in 74 developing malignant melanoma. There are approximately 1.3 million new cases of skin cancer every year in the United States. Skin cancer accounts for roughly half of all new cancers diagnosed each year. Approximately 75 percent of skin cancers are BCCs, about 20 percent are SCCs, and around 5 percent are melanoma. About 10,000 people will die from skin cancer this year in the United States. Nearly 20 percent of skin cancer-related deaths are from SCCs, while almost 80 percent are from melanoma. Skin cancer affects nearly twice as many men as women. The risk of non-melanoma skin cancer also varies according to race and ethnic group. There’s an increased incidence in whites, especially those who have blue eyes, have a fair complexion, sunburn easily, suntan poorly, freckle with sun exposure, have red or blonde hair, or are of Celtic ancestry.
The most common places to get skin cancer are sun-exposed areas. More than 80 percent of non-melanoma skin cancers occur on the head, neck, and back of the hands.
Are there more cases in the Midwestern states and/or in other parts of the country or world?
The number of cases of non-melanoma skin cancer increases proportionately with proximity to the equator. There are more cases in Florida and southern California and other places with lots of year-round sun where people live that have fair complexions. When I came to Peoria, though, I was surprised at how many squamous cell carcinomas there are here.
How can one best avoid the occurrence of skin cancer?
Cover up. Wear a long-sleeved shirt and pants, a wide-brimmed hat, and UV-protective sunglasses. Use sunscreens and sun blocks. Choose one with UVA and UVB coverage and a minimum SPF of 15 for daily use and higher if you’ll be staying outdoors. Most people don’t apply enough sunscreen to achieve adequate protection. Apply roughly an ounce to your whole body each time. Ideally, you should apply it 15 to 30 minutes before going outside, and reapply it every two hours while you remain outdoors. Minimize sun-exposure, especially between 10 a.m. and 4 p.m. Avoid getting sunburns. The biggest misconception with sunscreens is people think if they use sunscreen once, they can sunbathe or have extensive sun exposure for hours. This isn’t true. Sunscreens only delay the inevitable result of prolonged exposure to the sun, and that’s sunburn. Also don’t go to tanning booths.
Tell us how your specialty compliments the services offered by Soderstrom Dermatology.
I’m the only fellowship-trained Mohs micrographic surgeon in central Illinois. Prior to my arrival, patients with skin cancers that could benefit from Mohs Micrographic Surgery either had to travel to Chicago, Springfield, St. Louis, the Quad Cities, or further to have Mohs Micrographic Surgery—or opt for a treatment with a lower overall success rate than Mohs Micrographic Surgery. Since my arrival, Soderstrom Dermatology has been able to offer comprehensive care for patients with cutaneous malignancies.
What are the misperceptions the public may have regarding dermatology?
Many people—and even some physicians—view dermatology as a specialty that only treats acne, warts, and psoriasis or as a cosmetic specialty only. Actually, it’s a fascinating specialty that treats patients with a wide range of clinical conditions and cosmetic concerns. We care for patients with autoimmune disorders (dermatomyositis, lupus, and blistering disorders, among others); with inflammatory cutaneous disorders (eczema, seborrheic dermatitis, and psoriasis); and with rashes related to viral, bacterial, and fungal infections or systemic diseases. We also manage genodermatosis, which are inborn disorders, and treat non-melanoma and melanoma skin cancers. We utilize various dermatologic surgical procedures for benign and malignant tumors of the skin and lasers for certain medical and cosmetic conditions. We treat leg vein abnormalities and perform a variety of other cosmetic surgery procedures including Botox, collagen and other filling agent injections, liposuction, hair removal, and hair restoration, among others.
As a young mother, how do you balance work and family?
I’ve learned to prioritize my life. My relationship with God is my first priority, followed by my family and then my friends, which puts work in fourth place. I have two and a half scheduled days for patients. I also read dermatopathology slides and perform other work-related activities that aren’t on a fixed schedule. For these tasks, I choose what hours I will use to complete them so I can spend quality time with my children. My husband, who has a Ph.D. in biochemistry, supports me immensely. He has chosen to not work in his field in order to take care of our children while I’m at work.
Why did you decide to relocate from your native Peru to the U.S.?
The first time I relocated to the U.S.—in 1993—was because of the superior training in dermatology found here. The second time I came back here from Peru—in 2001, with my husband and daughter—was because my husband had been raised on a farm in Wisconsin, and he wanted to come back. I always wanted to have a family of my own and to raise them in a safe, loving, and caring environment. As much as I admire the extensive, diverse, and beautiful natural areas my country has, life isn’t easy there. Small cities in Peru don’t have the technological advances to make life comfortable and convenient that big cities have (there are only three or four large cities in Peru). The large cities in Peru (especially Lima, where my job would be) are extremely crowded, have a lot of air and terrestrial pollution and traffic problems, and are unsafe because of the poor economy of the country. Therefore, we decided to return to the United States to a small to medium-sized community in the Midwest, where I would have a sufficient patient base to practice Mohs Micrographic Surgery and where we could raise our family peacefully. While I was in Peru, I also felt I wasn’t maximizing my services. I felt I wasn’t helping as many people as I would like, since the incidence of skin cancer is much lower in Peru compared to the United States, due to the natural protection from the sun provided by our skin color.
Did you encounter any significant differences in practicing medicine in the U.S. after practicing in Peru?
The physician-patient relationship is the same anywhere you go. I felt the difference was enormous regarding compensation and paperwork. In Peru, despite having private insurance, patients have to pay cash for medical services rendered and then submit a form to their insurance for reimbursement on their own. Doctors aren’t required to provide patients with operative reports other than filling out the form the insurance company provides the patients with. I used to provide the patients with an operative report, but that was my choice. The other difference was the frequency of non-melanoma skin cancers is lower, as I mentioned previously, though I was surprised to see many patients with malignant melanoma during my time in Peru.
What does the future of dermatology look like? Are there any new procedures or products on the horizon?
Dermatology is a continually evolving specialty. Research in dermatology is an ongoing task and is sponsored by the NIH, the American Academy of Dermatology, the Dermatology Foundation, the Society for Investigative Dermatology, and many other organizations. Basic scientific research in dermatology provides dermatologists with new insights into the basic mechanisms of disease pathogenesis, and clinical studies and clinical trials attempt to develop new and more effective treatments for dermatology disorders. In recent years, the use of immunomodulators for various conditions has revolutionized dermatologic care that used to rely heavily on corticosteroid therapy. In cutaneous oncology, efforts are ongoing to understand the steps in tumor formation. Progress has been made to identify the cellular and biochemical mechanisms in the process of malignant transformation, so in the future, we hope to be able to prevent tumor formation or arrest its invasion rather than treating skin cancers the way we do now. This may be a long time coming and in fact, it may never arrive.
For now, Mohs Micrographic Surgery allows us to cure skin cancer by completely removing it through specialized excision. Also, Mohs Micrographic Surgery is being used with a wider variety of tumor types, since it’s been shown to be effective not only for BCCs and SCCs, but also for many other rare non-melanoma skin cancer types like merkel cell carcinoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and malignant fibrohistiocytoma, among others. It’s also used for malignant melanoma, especially the lentigo maligna and lentigo maligna melanoma forms located in high-risk areas. In addition to the use of standard stains, new immuno-histochemical studies are being evaluated to determine their usefulness in the determination of questionable areas of tumors to increase cure rates. TPW