“Doc, if we got it all, why am I here?”

This week, I met with a man in his late 60s for a consultation. He had recently noticed a dark spot on his chest that grew and eventually started bleeding, leading him to see a dermatologist. A shave biopsy confirmed it was melanoma. He was appropriately referred to a cancer surgeon for a wide excision, and because of its size, a nearby lymph node excision was also advised.

The surgery went well, and he came back to review the final pathology. The surgeon told him:

“Everything went well. We removed it all, and the margins were clear. However, we did find melanoma in one of the lymph nodes, so we’d like you to meet with a medical oncologist to discuss ways to reduce the risk of it returning.”

This is often where things get trickier and, for many patients, confusing. After surgery, everything seems reassuring, with the hope of simply healing, recovering, and moving on. But for some, this is when some of the toughest decisions in oncology arise—what to do next after the visible part of the cancer has been removed.

The patient came to me after doing some research before his appointment, trying to understand why we might consider additional treatment. It’s a question that comes up often in my practice.

He seemed a little frustrated at the start of our meeting.

“Doc, if we got it all, why am I here?”

I took some time to listen and understand his frustration. The communication had been a bit unclear, and he’d only received a few highlights of what I might cover. He’d heard something about immunotherapy but didn’t have much context beyond that. Surgeons can’t always predict exactly what we’ll recommend, so they tend to keep things a bit general when referring patients to us.

These are the kinds of discussions oncologists often have with patients after surgery, focusing on what’s known as adjuvant treatment. This refers to therapy given after the tumor has been removed, with the aim of reducing the risk of it coming back. It can be difficult to grasp because the decision is based on possibility rather than something visible or measurable, which can be pretty overwhelming when someone is just starting to understand their condition.

In these cases, the focus is on the potential presence of microscopic disease that might still exist even when everything appears clear.

I usually try to break this down in simple terms. Think about a dandelion in your yard. You pull the weed or dig it out, making sure the roots are intact, and it looks like you got it. But if it already released seeds, those seeds are now scattered even though you can’t see them. Over time, new dandelions show up.

Cancer can behave in a similar way. It’s opportunistic, like a weed, but far more complex. The main tumor is removed, but tiny clusters of cells may have already traveled elsewhere. They’re too small to show up on scans, but they have the potential to grow over time.

At the same time, the body plays an active role in all of this. The immune system is constantly surveying and, in many cases, eliminating abnormal cells before they ever become a problem. Part of what we’re trying to do with treatment in this setting is to strengthen that immune surveillance, and in some cases directly target any remaining cancer cells in a way that makes it harder for them to survive and grow.

Treatment after surgery is an attempt to deal with those seeds before they grow into something we can see.

And not all cancers are at the same point in that process.

Some are more like a small yellow dandelion that hasn’t released its seeds yet. That’s closer to what we see in many early-stage cancers, where surgery alone can be enough and additional treatment is not needed.

Others are more like the dandelion after it’s turned white, when the seeds are already dispersing. That’s more in line with higher-risk cancers, including many stage III cases, where we know there has already been some spread beyond the original site, often to nearby lymph nodes.

That distinction is important, because it changes how likely it is that those “seeds” are already out there and how we think about further treatment.

To make sense of this, it helps to step back and look at how we think about cancer across different stages.

In early-stage disease, surgery is often enough. The risk of recurrence is low, and additional treatment usually doesn’t make sense.

In advanced or metastatic disease, we are treating something we can directly measure on a scan, and decisions tend to feel more direct because we can track what is happening in real time.

In between is where things become more nuanced.

Stage II and stage III cancers sit in that middle space where many patients are still curable, but the risk of recurrence is meaningful. The challenge is that we cannot tell who still has microscopic disease and who doesn’t, so every decision becomes a conversation about probability.

I’m thinking about this patient with stage IIIA melanoma. The surgery went smoothly, the primary tumor is gone, and a sentinel lymph node revealed a small focus of melanoma. The rest of the workup looks reassuring. By all our tests, there’s no visible disease, yet the risk of recurrence remains in the range of 20–30%. About one in four patients with this diagnosis will face recurrence at some point.

That’s when we start talking about treatment after surgery, which in melanoma today often means immunotherapy, but in other cancers can include chemotherapy, targeted therapy, or a combination depending on the biology of the disease.

Drugs like nivolumab and pembrolizumab have changed melanoma care. They help the immune system recognize and attack cancer cells more effectively, and when we use them after surgery, fewer patients have their cancer come back over time.

Where this becomes more nuanced is translating what that benefit actually means for an individual patient.

I often frame it in practical terms. If we lined up a hundred patients with stage IIIA melanoma, some are going to do well regardless of what we do next. Some will have recurrence even if we treat them. And then there is a group in the middle where treatment likely makes the difference.

The reality is that we don’t know which group any one person belongs to at the time we are making the decision.

We often talk about concepts like absolute risk reduction and number needed to treat, which are helpful because they turn broad statements into something more concrete. In practical terms, this could mean treating 8 to 12 patients to prevent a single recurrence.

At the same time, we have to be honest about the risks.

Immunotherapy is often described as easier than chemotherapy, and in many cases it is, but it can still cause serious immune-related side effects. I treat enough patients with these therapies to know that these complications are real. Most patients do well, but some develop significant inflammation affecting organs like the lungs, liver, colon, or endocrine system. Some of these effects require prolonged treatment, and some can be permanent.

So now we are weighing a reduction in recurrence risk against the possibility of meaningful, sometimes long-lasting toxicity. For a patient with stage IIIA disease, those two sides can feel fairly close to each other.

Deciding on treatment is a pivotal moment. The oncologist’s role is to listen and understand what feels right for each person. Some patients choose to pursue every option to reduce risk, even for a small benefit. Others focus on the possibility that they may never need treatment at all.

This is what being “on the fence” looks like in cancer care.

It should also be recognized that these decisions often happen during times of uncertainty, stress, and emotional strain. They should never be rushed or influenced by pressure.

In the last few years, we’ve had another piece of information that has started to shape these discussions. Circulating tumor DNA, or ctDNA, gives us a way to look for fragments of cancer DNA in the bloodstream after surgery. If it is present, it suggests that microscopic disease may still be there. If it is not detected, the risk of recurrence is likely lower.

For a patient with stage IIIA melanoma, that kind of information can be helpful. It adds a biologic signal to what has traditionally been a statistical discussion. At the same time, we are still early. The data is evolving, and while ctDNA is clearly prognostic, we are still learning how best to use it to guide decisions in a way that improves outcomes.

So it becomes part of the discussion rather than the answer.

Over time, I’ve learned there’s no one “right” decision in this space—only the decision that best suits the person in front of you. My job is to make sure they understand all their options* as clearly as possible, including the benefits, the limitations, and the uncertainty that comes with each.

After a thoughtful conversation with my patient, he chose not to pursue additional treatment. I fully supported his decision, even though it’s not what I would have chosen for myself. Spending that time together helped me understand his priorities, and avoiding toxicity was high on his list—important enough that he was willing to accept some risk.

*For patients who opt out of treatment, I place even more focus on metabolic health. I make sure to discuss ways to improve it through diet and exercise, and I connect them with our cancer dietitian and integrative oncology team.

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Feb 28

A few years ago I sat across from one of my patients, 43-year-old mechanical engineer who had just had a stage II melanoma removed from his back. The surgery went well, he had widely clear margins and no evidence of spread to his lymph nodes.