Three different problems seen in recent weeks— a steroid reflex, a test without a plan, a patient chasing a rumor — but the same underlying discipline: ask whether what you’re doing actually changes the outcome, and be honest when it doesn’t. As always, I welcome pushback and other perspectives — feel free to reach out.
Every so often, a handful of unrelated cases land in the same week and you realize they’re all pointing at the same lesson. These are three of mine. I’ve changed identifying details so no patient — or colleague — is recognizable, but the patterns themselves are worth talking about, because if I’m seeing them, they’re probably happening everywhere.
Pet Peeve #1: Steroids Before They’re Needed
A patient with biopsy-proven metastatic malignancy, a couple of small, asymptomatic brain, lung, liver metastases, two larger lesions that 1-2cm in size and no neurologic symptoms was doing well on systemic therapy. Given the size of the two lesions, we added stereotactic radiotherapy to the plan alongside doublet immunotherapy — a combination associated with roughly a 50% response rate in asymptomatic, steroid-naïve patients with CNS disease.
At my weekly clinic pod meeting — where our team reviews every new patient and anyone recently started on therapy — my nurse mentioned that this patient was recently started on high dose steroids and asked how we wanted to wean them off. I was caught completely off guard. I’d just seen this patient; there were no new symptoms, no edema, nothing in the chart that explained it. No recent hospitalization, no reported reported new scans. Nobody on my own team could tell me why steroids had been started at all. It took some digging to learn that another physician had started steroids prophylactically, before a planned procedure, as a routine step rather than a response to anything clinical.
I understand steroids when they’re earned: edema, seizures, symptomatic mass effect. You don’t have a choice. Also, historically pre immunotherapy era, we as treating providers had no problem “marinating” the brain with steroids as we effectively didn’t much to offer in the past. But immunotherapy responses in the brain are some of the best tools we have, and steroids blunt exactly the mechanism we’re counting on. NCCN guidance is clear that steroid dosing should be minimized whenever possible and escalated only if symptoms demand it — not front-loaded as a reflex.
I reached out to the physician, kept it collegial, and we talked through the reasoning. To their credit, they weaned the dose quickly for that week, and the patient subsequently started the next round of immunotherapy steroid-free. It’s a reminder that a well-intentioned habit, applied without asking why, can work against the very treatment you’re trying to protect.
Pet Peeve #2: ctDNA as a Glorified Tumor Marker
I’m a believer in circulating tumor DNA testing — when it answers a real question. The clearest use case is minimal residual disease: after surgery, does a positive or negative result change whether we escalate or de-escalate adjuvant therapy, imaging frequency, etc? The other clear use case, especially in my world of melanoma, is after immunotherapy — when a patient reaches a durable remission that starts to look like cure. Whether it’s checkpoint inhibition, TIL, intratumoral therapy, or another form of IO, a sustained negative ctDNA can help confirm that a deep, lasting response is holding and again inform de-escalation/escalation of treatment.
What I find harder to justify is ctDNA ordered on a schedule, without a plan. At a recent meeting in Chicago, I heard two cases by medical oncologists that stuck with me. In the first, a resected stage III colon cancer patient went from ctDNA-negative to strongly, unambiguously positive — and the response was to start checking it every four weeks. When I asked what that would change, there was a long pause and no clear answer. A strongly positive result already tells you what you need to know: the risk profile has flipped from a favorable, largely cured picture to one requiring close surveillance. Checking every 4 weeks doesn’t add information that changes management.
The second case was a stage IV lung cancer with pleural carcinomatosis patient on maintenance therapy, well past the point of expected immunotherapy responsiveness, whose ctDNA was being tracked essentially out of curiosity about the kinetics — rising, falling, rising again — while scans remained the actual clinical anchor.
The question I keep coming back to: will this result change what I say or do next? If the answer is no, I’m not testing — I’m just watching a number move. We’re stewards of a limited pool of resources, and that discipline matters as much as the science.
Pet Peeve #3: The Ivermectin Conversation (Almost Every Day Now)
This isn’t new — twenty years ago it was vitamin C, or blue scorpion venom, or high-dose cannabis oil. What’s changed is the frequency and the source. Thanks to a wave of viral podcast appearances and celebrity anecdotes, I now field questions about ivermectin and fenbendazole nearly daily.
My approach hasn’t changed: this is shared decision-making, not a lecture. I lay out what curative-intent treatment looks like — systemic therapy, radiation, surgery, clinical trials, cellular therapy — versus what palliative-intent care looks like, and I’m honest about which category someone is in. If a patient wants to try something outside that framework, I don’t fight them on it. I ask if they want scans to track it, and I stay in the conversation.
One case has stayed with me: a patient who tried an unproven approach on his own, and over two months, a tumor grew from one centimeter to ten. No judgment, just an honest look at the scan and an open door. He agreed to switch to chemotherapy plus immunotherapy. The next scan showed the tumor essentially gone — which allowed him to be evaluated again for definitive curative surgery. He went from mistrustful of the system to fully bought in, not because I talked him out of anything, but because I stayed honest and stayed available.
Misinformation online isn’t going away. But respect, patience, and keeping the door open tend to outperform an argument.
If there’s a thread running through all three of these, it’s this: none of it was ever really about the steroid dose, the lab value, or the drug someone found online. It was about staying honest enough to ask why we’re doing what we’re doing, and humble enough to change course the moment the answer doesn’t hold up. Every patient in these stories trusted me, and my colleagues, with something they couldn’t take back once the decision was made — and that trust is the actual job. Getting the science right matters enormously, but so does getting the conversation right: listening without judgment, correcting course with respect instead of ego, and never forgetting that behind every chart is a person hoping we’ll get this one right for them. That’s the standard we should try to hold for ourselves, and it’s the one I hope we keep holding each other to. As always, I welcome pushback and other perspectives — feel free to reach out.
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. He brings a wealth of expertise to the complex and challenging world of oncology.
Disclosures:
Dr. Thomas serves as a speaker for BMS, Merck, Ipsen, Natera, Immunocore, Pfizer, Sun Pharma, SpringWorks. He also receives industry grants in support of numerous clinical trials.
Patient cases described in this post are composites and have been altered — including but not limited to diagnosis specifics, demographics, timeline, and clinical details — to protect patient privacy and confidentiality. No case represents an actual, identifiable patient, and any resemblance to a specific individual is coincidental. Clinical scenarios involving other providers have similarly been altered and are presented for educational purposes only, not as a representation of any specific person’s practice. This post is for general educational purposes and does not constitute medical advice; it should not be used to guide individual treatment decisions.
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