Every surgical oncologist bristles when considering whether to offer an operation of questionable benefit. Patient, oncologic, and clinician factors all influence whether a surgery is indicated and how to effectively navigate the necessary preoperative counseling and preparation.1 The inherent risks and rewards of cancer surgery are magnified when the underlying physical fitness of the patient is in question. Even when dealing with technically feasible operations for potentially curable malignant tumors, a patient’s ability to recover and survive long enough to realize the benefit of surgery is critical.