Foundation models pretrained on large natural-image collections are increasingly adapted for medical image segmentation, in the expectation that they will replace models trained for each task. Most comparisons, however, use data from the training distribution and a single task-specific baseline whose configuration is rarely justified, and therefore provide limited evidence of performance at new clinical sites. It also remains unclear how much of a foundation model must be adapted, and what determines this. We adapted a foundation model, DINOv2, with strategies ranging from tuning only its bias terms to full fine-tuning, and compared it with U-Nets and ResU-Nets trained from scratch. Experiments covered colonoscopy, breast ultrasound and dermoscopy, with testing on held-out data from the training source and on independent datasets from other institutions. The adapted foundation model generalised better on every external dataset. Within the training distribution, the task-specific models remained competitive when training data were abundant, and delineated boundaries more precisely, while the foundation model more often missed small lesions. Only a small fraction of the foundation model required adaptation, and the capacity needed was determined by the imaging domain rather than by the adaptation method. A widely used polyp test set was also found to duplicate images from another benchmark. Foundation-model adaptation is therefore warranted where models must work across sites, with capacity selected on the target domain.

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