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Yang Y, Zhang H, Gichoya JW, Katabi D, Ghassemi M. The limits of fair medical imaging AI in real-world generalization. Nat Med 2024:10.1038/s41591-024-03113-4. [PMID: 38942996 DOI: 10.1038/s41591-024-03113-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 06/05/2024] [Indexed: 06/30/2024]
Abstract
As artificial intelligence (AI) rapidly approaches human-level performance in medical imaging, it is crucial that it does not exacerbate or propagate healthcare disparities. Previous research established AI's capacity to infer demographic data from chest X-rays, leading to a key concern: do models using demographic shortcuts have unfair predictions across subpopulations? In this study, we conducted a thorough investigation into the extent to which medical AI uses demographic encodings, focusing on potential fairness discrepancies within both in-distribution training sets and external test sets. Our analysis covers three key medical imaging disciplines-radiology, dermatology and ophthalmology-and incorporates data from six global chest X-ray datasets. We confirm that medical imaging AI leverages demographic shortcuts in disease classification. Although correcting shortcuts algorithmically effectively addresses fairness gaps to create 'locally optimal' models within the original data distribution, this optimality is not true in new test settings. Surprisingly, we found that models with less encoding of demographic attributes are often most 'globally optimal', exhibiting better fairness during model evaluation in new test environments. Our work establishes best practices for medical imaging models that maintain their performance and fairness in deployments beyond their initial training contexts, underscoring critical considerations for AI clinical deployments across populations and sites.
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Affiliation(s)
- Yuzhe Yang
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Haoran Zhang
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Judy W Gichoya
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Dina Katabi
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Marzyeh Ghassemi
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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Wei Y, Deng Y, Sun C, Lin M, Jiang H, Peng Y. Deep learning with noisy labels in medical prediction problems: a scoping review. J Am Med Inform Assoc 2024; 31:1596-1607. [PMID: 38814164 PMCID: PMC11187424 DOI: 10.1093/jamia/ocae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/27/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVES Medical research faces substantial challenges from noisy labels attributed to factors like inter-expert variability and machine-extracted labels. Despite this, the adoption of label noise management remains limited, and label noise is largely ignored. To this end, there is a critical need to conduct a scoping review focusing on the problem space. This scoping review aims to comprehensively review label noise management in deep learning-based medical prediction problems, which includes label noise detection, label noise handling, and evaluation. Research involving label uncertainty is also included. METHODS Our scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched 4 databases, including PubMed, IEEE Xplore, Google Scholar, and Semantic Scholar. Our search terms include "noisy label AND medical/healthcare/clinical," "uncertainty AND medical/healthcare/clinical," and "noise AND medical/healthcare/clinical." RESULTS A total of 60 papers met inclusion criteria between 2016 and 2023. A series of practical questions in medical research are investigated. These include the sources of label noise, the impact of label noise, the detection of label noise, label noise handling techniques, and their evaluation. Categorization of both label noise detection methods and handling techniques are provided. DISCUSSION From a methodological perspective, we observe that the medical community has been up to date with the broader deep-learning community, given that most techniques have been evaluated on medical data. We recommend considering label noise as a standard element in medical research, even if it is not dedicated to handling noisy labels. Initial experiments can start with easy-to-implement methods, such as noise-robust loss functions, weighting, and curriculum learning.
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Affiliation(s)
- Yishu Wei
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
- Reddit Inc., San Francisco, CA 16093, United States
| | - Yu Deng
- Center for Health Information Partnerships, Northwestern University, Chicago, IL 10611, United States
| | - Cong Sun
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
| | - Mingquan Lin
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, United States
| | - Hongmei Jiang
- Department of Statistics and Data Science, Northwestern University, Evanston, IL 60208, United States
| | - Yifan Peng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
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Schaekermann M, Spitz T, Pyles M, Cole-Lewis H, Wulczyn E, Pfohl SR, Martin D, Jaroensri R, Keeling G, Liu Y, Farquhar S, Xue Q, Lester J, Hughes C, Strachan P, Tan F, Bui P, Mermel CH, Peng LH, Matias Y, Corrado GS, Webster DR, Virmani S, Semturs C, Liu Y, Horn I, Cameron Chen PH. Health equity assessment of machine learning performance (HEAL): a framework and dermatology AI model case study. EClinicalMedicine 2024; 70:102479. [PMID: 38685924 PMCID: PMC11056401 DOI: 10.1016/j.eclinm.2024.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 05/02/2024] Open
Abstract
Background Artificial intelligence (AI) has repeatedly been shown to encode historical inequities in healthcare. We aimed to develop a framework to quantitatively assess the performance equity of health AI technologies and to illustrate its utility via a case study. Methods Here, we propose a methodology to assess whether health AI technologies prioritise performance for patient populations experiencing worse outcomes, that is complementary to existing fairness metrics. We developed the Health Equity Assessment of machine Learning performance (HEAL) framework designed to quantitatively assess the performance equity of health AI technologies via a four-step interdisciplinary process to understand and quantify domain-specific criteria, and the resulting HEAL metric. As an illustrative case study (analysis conducted between October 2022 and January 2023), we applied the HEAL framework to a dermatology AI model. A set of 5420 teledermatology cases (store-and-forward cases from patients of 20 years or older, submitted from primary care providers in the USA and skin cancer clinics in Australia), enriched for diversity in age, sex and race/ethnicity, was used to retrospectively evaluate the AI model's HEAL metric, defined as the likelihood that the AI model performs better for subpopulations with worse average health outcomes as compared to others. The likelihood that AI performance was anticorrelated to pre-existing health outcomes was estimated using bootstrap methods as the probability that the negated Spearman's rank correlation coefficient (i.e., "R") was greater than zero. Positive values of R suggest that subpopulations with poorer health outcomes have better AI model performance. Thus, the HEAL metric, defined as p (R >0), measures how likely the AI technology is to prioritise performance for subpopulations with worse average health outcomes as compared to others (presented as a percentage below). Health outcomes were quantified as disability-adjusted life years (DALYs) when grouping by sex and age, and years of life lost (YLLs) when grouping by race/ethnicity. AI performance was measured as top-3 agreement with the reference diagnosis from a panel of 3 dermatologists per case. Findings Across all dermatologic conditions, the HEAL metric was 80.5% for prioritizing AI performance of racial/ethnic subpopulations based on YLLs, and 92.1% and 0.0% respectively for prioritizing AI performance of sex and age subpopulations based on DALYs. Certain dermatologic conditions were significantly associated with greater AI model performance compared to a reference category of less common conditions. For skin cancer conditions, the HEAL metric was 73.8% for prioritizing AI performance of age subpopulations based on DALYs. Interpretation Analysis using the proposed HEAL framework showed that the dermatology AI model prioritised performance for race/ethnicity, sex (all conditions) and age (cancer conditions) subpopulations with respect to pre-existing health disparities. More work is needed to investigate ways of promoting equitable AI performance across age for non-cancer conditions and to better understand how AI models can contribute towards improving equity in health outcomes. Funding Google LLC.
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Affiliation(s)
| | | | - Malcolm Pyles
- Advanced Clinical, Deerfield, IL, USA
- Department of Dermatology, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | | | | | - Yuan Liu
- Google Health, Mountain View, CA, USA
| | | | | | - Jenna Lester
- Advanced Clinical, Deerfield, IL, USA
- Department of Dermatology, University of California, San Francisco, CA, USA
| | | | | | | | - Peggy Bui
- Google Health, Mountain View, CA, USA
| | | | | | | | | | | | | | | | - Yun Liu
- Google Health, Mountain View, CA, USA
| | - Ivor Horn
- Google Health, Mountain View, CA, USA
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Meissen F, Breuer S, Knolle M, Buyx A, Müller R, Kaissis G, Wiestler B, Rückert D. (Predictable) performance bias in unsupervised anomaly detection. EBioMedicine 2024; 101:105002. [PMID: 38335791 PMCID: PMC10873649 DOI: 10.1016/j.ebiom.2024.105002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND With the ever-increasing amount of medical imaging data, the demand for algorithms to assist clinicians has amplified. Unsupervised anomaly detection (UAD) models promise to aid in the crucial first step of disease detection. While previous studies have thoroughly explored fairness in supervised models in healthcare, for UAD, this has so far been unexplored. METHODS In this study, we evaluated how dataset composition regarding subgroups manifests in disparate performance of UAD models along multiple protected variables on three large-scale publicly available chest X-ray datasets. Our experiments were validated using two state-of-the-art UAD models for medical images. Finally, we introduced subgroup-AUROC (sAUROC), which aids in quantifying fairness in machine learning. FINDINGS Our experiments revealed empirical "fairness laws" (similar to "scaling laws" for Transformers) for training-dataset composition: Linear relationships between anomaly detection performance within a subpopulation and its representation in the training data. Our study further revealed performance disparities, even in the case of balanced training data, and compound effects that exacerbate the drop in performance for subjects associated with multiple adversely affected groups. INTERPRETATION Our study quantified the disparate performance of UAD models against certain demographic subgroups. Importantly, we showed that this unfairness cannot be mitigated by balanced representation alone. Instead, the representation of some subgroups seems harder to learn by UAD models than that of others. The empirical "fairness laws" discovered in our study make disparate performance in UAD models easier to estimate and aid in determining the most desirable dataset composition. FUNDING European Research Council Deep4MI.
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Affiliation(s)
- Felix Meissen
- Chair for AI in Healthcare and Medicine, Klinikum rechts der Isar der Technischen Universität München, Einsteinstr. 25, Munich, 81675, Germany.
| | - Svenja Breuer
- Department of Science, Technology and Society, School of Social Sciences and Technology, and Technical University of Munich, Arcisstr. 21, Munich, 80333, Germany; Department of Economics and Policy, School of Management, Technical University of Munich, Arcisstraße 21, 80333, Munich, Germany
| | - Moritz Knolle
- Chair for AI in Healthcare and Medicine, Klinikum rechts der Isar der Technischen Universität München, Einsteinstr. 25, Munich, 81675, Germany; Konrad Zuse School of Excellence in Reliable AI, Munich Data Science Institute (MDSI), Walther-von-Dyck-Str. 10, Garching, 85748, Germany
| | - Alena Buyx
- Department of Science, Technology and Society, School of Social Sciences and Technology, and Technical University of Munich, Arcisstr. 21, Munich, 80333, Germany; Institute for History and Ethics of Medicine, School of Medicine, Technical University of Munich, Prinzregentenstraße 68, Munich, 81675, Germany
| | - Ruth Müller
- Department of Science, Technology and Society, School of Social Sciences and Technology, and Technical University of Munich, Arcisstr. 21, Munich, 80333, Germany; Department of Economics and Policy, School of Management, Technical University of Munich, Arcisstraße 21, 80333, Munich, Germany
| | - Georgios Kaissis
- Chair for AI in Healthcare and Medicine, Klinikum rechts der Isar der Technischen Universität München, Einsteinstr. 25, Munich, 81675, Germany; Institute for Machine Learning in Biomedical Imaging, Helmholtz Munich, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany; Department of Computing, Imperial College London, London, SW7 2AZ, UK
| | - Benedikt Wiestler
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Ismaninger Str. 22, Munich, 81675, Germany; TranslaTUM, Center for Translational Cancer Research, Technical University of Munich, Ismaninger Str. 22, Munich, 81675, Germany
| | - Daniel Rückert
- Chair for AI in Healthcare and Medicine, Klinikum rechts der Isar der Technischen Universität München, Einsteinstr. 25, Munich, 81675, Germany; Department of Computing, Imperial College London, London, SW7 2AZ, UK
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