An interpretable machine learning system for colorectal cancer diagnosis from pathology slides.

Considering the profound transformation affecting pathology practice, we aimed to develop a scalable artificial intelligence (AI) system to diagnose colorectal cancer from whole-slide images (WSI). For this, we propose a deep learning (DL) system that learns from weak labels, a sampling strategy that reduces the number of training samples by a factor of six without compromising performance, an approach to leverage a small subset of fully annotated samples, and a prototype with explainable predictions, active learning features and parallelisation. Noting some problems in the literature, this study is conducted with one of the largest WSI colorectal samples dataset with approximately 10,500 WSIs. Of these samples, 900 are testing samples. Furthermore, the robustness of the proposed method is assessed with two additional external datasets (TCGA and PAIP) and a dataset of samples collected directly from the proposed prototype. Our proposed method predicts, for the patch-based tiles, a class based on the severity of the dysplasia and uses that information to classify the whole slide. It is trained with an interpretable mixed-supervision scheme to leverage the domain knowledge introduced by pathologists through spatial annotations. The mixed-supervision scheme allowed for an intelligent sampling strategy effectively evaluated in several different scenarios without compromising the performance. On the internal dataset, the method shows an accuracy of 93.44% and a sensitivity between positive (low-grade and high-grade dysplasia) and non-neoplastic samples of 0.996. On the external test samples varied with TCGA being the most challenging dataset with an overall accuracy of 84.91% and a sensitivity of 0.996.

BOLD: Blood-gas and Oximetry Linked Dataset - Open Source Research.

Pulse oximeters measure peripheral arterial oxygen saturation (SpO 2 ) noninvasively, while the gold standard (SaO 2 ) involves arterial blood gas measurement. There are known racial and ethnic disparities in their performance. BOLD is a new comprehensive dataset that aims to underscore the importance of addressing biases in pulse oximetry accuracy, which disproportionately affect darker-skinned patients. The dataset was created by harmonizing three Electronic Health Record databases (MIMIC-III, MIMIC-IV, eICU-CRD) comprising Intensive Care Unit stays of US patients. Paired SpO 2 and SaO 2 measurements were time-aligned and combined with various other sociodemographic and parameters to provide a detailed representation of each patient. BOLD includes 49,099 paired measurements, within a 5-minute window and with oxygen saturation levels between 70-100%. Minority racial and ethnic groups account for ∼25% of the data - a proportion seldom achieved in previous studies. The codebase is publicly available. Given the prevalent use of pulse oximeters in the hospital and at home, we hope that BOLD will be leveraged to develop debiasing algorithms that can result in more equitable healthcare solutions.

Evaluating the ability of an artificial-intelligence cloud-based platform designed to provide information prior to locoregional therapy for breast cancer in improving patient's satisfaction with therapy: The CINDERELLA trial.

BACKGROUND: Breast cancer therapy improved significantly, allowing for different surgical approaches for the same disease stage, therefore offering patients different aesthetic outcomes with similar locoregional control. The purpose of the CINDERELLA trial is to evaluate an artificial-intelligence (AI) cloud-based platform (CINDERELLA platform) vs the standard approach for patient education prior to therapy. METHODS: A prospective randomized international multicentre trial comparing two methods for patient education prior to therapy. After institutional ethics approval and a written informed consent, patients planned for locoregional treatment will be randomized to the intervention (CINDERELLA platform) or controls. The patients in the intervention arm will use the newly designed web-application (CINDERELLA platform, CINDERELLA APProach) to access the information related to surgery and/or radiotherapy. Using an AI system, the platform will provide the patient with a picture of her own aesthetic outcome resulting from the surgical procedure she chooses, and an objective evaluation of this aesthetic outcome (e.g., good/fair). The control group will have access to the standard approach. The primary objectives of the trial will be i) to examine the differences between the treatment arms with regards to patients' pre-treatment expectations and the final aesthetic outcomes and ii) in the experimental arm only, the agreement of the pre-treatment AI-evaluation (output) and patient's post-therapy self-evaluation. DISCUSSION: The project aims to develop an easy-to-use cost-effective AI-powered tool that improves shared decision-making processes. We assume that the CINDERELLA APProach will lead to higher satisfaction, better psychosocial status, and wellbeing of breast cancer patients, and reduce the need for additional surgeries to improve aesthetic outcome.

Deep Edge Detection Methods for the Automatic Calculation of the Breast Contour.

Breast cancer conservative treatment (BCCT) is a form of treatment commonly used for patients with early breast cancer. This procedure consists of removing the cancer and a small margin of surrounding tissue, while leaving the healthy tissue intact. In recent years, this procedure has become increasingly common due to identical survival rates and better cosmetic outcomes than other alternatives. Although significant research has been conducted on BCCT, there is no gold-standard for evaluating the aesthetic results of the treatment. Recent works have proposed the automatic classification of cosmetic results based on breast features extracted from digital photographs. The computation of most of these features requires the representation of the breast contour, which becomes key to the aesthetic evaluation of BCCT. State-of-the-art methods use conventional image processing tools that automatically detect breast contours based on the shortest path applied to the Sobel filter result in a 2D digital photograph of the patient. However, because the Sobel filter is a general edge detector, it treats edges indistinguishably, i.e., it detects too many edges that are not relevant to breast contour detection and too few weak breast contours. In this paper, we propose an improvement to this method that replaces the Sobel filter with a novel neural network solution to improve breast contour detection based on the shortest path. The proposed solution learns effective representations for the edges between the breasts and the torso wall. We obtain state of the art results on a dataset that was used for developing previous models. Furthermore, we tested these models on a new dataset that contains more variable photographs and show that this new approach shows better generalization capabilities as the previously developed deep models do not perform so well when faced with a different dataset for testing. The main contribution of this paper is to further improve the capabilities of models that perform the objective classification of BCCT aesthetic results automatically by improving upon the current standard technique for detecting breast contours in digital photographs. To that end, the models introduced are simple to train and test on new datasets which makes this approach easily reproducible.

A CAD system for automatic dysplasia grading on H&E cervical whole-slide images.

Cervical cancer is the fourth most common female cancer worldwide and the fourth leading cause of cancer-related death in women. Nonetheless, it is also among the most successfully preventable and treatable types of cancer, provided it is early identified and properly managed. As such, the detection of pre-cancerous lesions is crucial. These lesions are detected in the squamous epithelium of the uterine cervix and are graded as low- or high-grade intraepithelial squamous lesions, known as LSIL and HSIL, respectively. Due to their complex nature, this classification can become very subjective. Therefore, the development of machine learning models, particularly directly on whole-slide images (WSI), can assist pathologists in this task. In this work, we propose a weakly-supervised methodology for grading cervical dysplasia, using different levels of training supervision, in an effort to gather a bigger dataset without the need of having all samples fully annotated. The framework comprises an epithelium segmentation step followed by a dysplasia classifier (non-neoplastic, LSIL, HSIL), making the slide assessment completely automatic, without the need for manual identification of epithelial areas. The proposed classification approach achieved a balanced accuracy of 71.07% and sensitivity of 72.18%, at the slide-level testing on 600 independent samples, which are publicly available upon reasonable request.

Symmetry-based regularization in deep breast cancer screening.

Breast cancer is the most common and lethal form of cancer in women. Recent efforts have focused on developing accurate neural network-based computer-aided diagnosis systems for screening to help anticipate this disease. The ultimate goal is to reduce mortality and improve quality of life after treatment. Due to the difficulty in collecting and annotating data in this domain, data scarcity is - and will continue to be - a limiting factor. In this work, we present a unified view of different regularization methods that incorporate domain-known symmetries in the model. Three general strategies were followed: (i) data augmentation, (ii) invariance promotion in the loss function, and (iii) the use of equivariant architectures. Each of these strategies encodes different priors on the functions learned by the model and can be readily introduced in most settings. Empirically we show that the proposed symmetry-based regularization procedures improve generalization to unseen examples. This advantage is verified in different scenarios, datasets and model architectures. We hope that both the principle of symmetry-based regularization and the concrete methods presented can guide development towards more data-efficient methods for breast cancer screening as well as other medical imaging domains.

Quality Control in Digital Pathology: Automatic Fragment Detection and Counting.

Manual assessment of fragments during the pro-cessing of pathology specimens is critical to ensure that the material available for slide analysis matches that captured during grossing without losing valuable material during this process. However, this step is still performed manually, resulting in lost time and delays in making the complete case available for evaluation by the pathologist. To overcome this limitation, we developed an autonomous system that can detect and count the number of fragments contained on each slide. We applied and compared two different methods: conventional machine learning methods and deep convolutional network methods. For conventional machine learning methods, we tested a two-stage approach with a supervised classifier followed by unsupervised hierarchical clustering. In addition, Fast R-CNN and YOLOv5, two state-of-the-art deep learning models for detection, were used and compared. All experiments were performed on a dataset comprising 1276 images of colorec-tal biopsy and polypectomy specimens manually labeled for fragment/set detection. The best results were obtained with the YOLOv5 architecture with a map@0.5 of 0.977 for fragment/set detection.

iMIL4PATH: A Semi-Supervised Interpretable Approach for Colorectal Whole-Slide Images.

Colorectal cancer (CRC) diagnosis is based on samples obtained from biopsies, assessed in pathology laboratories. Due to population growth and ageing, as well as better screening programs, the CRC incidence rate has been increasing, leading to a higher workload for pathologists. In this sense, the application of AI for automatic CRC diagnosis, particularly on whole-slide images (WSI), is of utmost relevance, in order to assist professionals in case triage and case review. In this work, we propose an interpretable semi-supervised approach to detect lesions in colorectal biopsies with high sensitivity, based on multiple-instance learning and feature aggregation methods. The model was developed on an extended version of the recent, publicly available CRC dataset (the CRC+ dataset with 4433 WSI), using 3424 slides for training and 1009 slides for evaluation. The proposed method attained 90.19% classification ACC, 98.8% sensitivity, 85.7% specificity, and a quadratic weighted kappa of 0.888 at slide-based evaluation. Its generalisation capabilities are also studied on two publicly available external datasets.

3D Breast Volume Estimation.

INTRODUCTION: Breast volume estimation is considered crucial for breast cancer surgery planning. A single, easy, and reproducible method to estimate breast volume is not available. This study aims to evaluate, in patients proposed for mastectomy, the accuracy of the calculation of breast volume from a low-cost 3D surface scan (Microsoft Kinect) compared to the breast MRI and water displacement technique. MATERIAL AND METHODS: Patients with a Tis/T1-T3 breast cancer proposed for mastectomy between July 2015 and March 2017 were assessed for inclusion in the study. Breast volume calculations were performed using a 3D surface scan and the breast MRI and water displacement technique. Agreement between volumes obtained with both methods was assessed with the Spearman and Pearson correlation coefficients. RESULTS: Eighteen patients with invasive breast cancer were included in the study and submitted to mastectomy. The level of agreement of the 3D breast volume compared to surgical specimens and breast MRI volumes was evaluated. For mastectomy specimen volume, an average (standard deviation) of 0.823 (0.027) and 0.875 (0.026) was obtained for the Pearson and Spearman correlations, respectively. With respect to MRI annotation, we obtained 0.828 (0.038) and 0.715 (0.018). DISCUSSION: Although values obtained by both methodologies still differ, the strong linear correlation coefficient suggests that 3D breast volume measurement using a low-cost surface scan device is feasible and can approximate both the MRI breast volume and mastectomy specimen with sufficient accuracy. CONCLUSION: 3D breast volume measurement using a depth-sensor low-cost surface scan device is feasible and can parallel MRI breast and mastectomy specimen volumes with enough accuracy. Differences between methods need further development to reach clinical applicability. A possible approach could be the fusion of breast MRI and the 3D surface scan to harmonize anatomic limits and improve volume delimitation.

CAD systems for colorectal cancer from WSI are still not ready for clinical acceptance.

Most oncological cases can be detected by imaging techniques, but diagnosis is based on pathological assessment of tissue samples. In recent years, the pathology field has evolved to a digital era where tissue samples are digitised and evaluated on screen. As a result, digital pathology opened up many research opportunities, allowing the development of more advanced image processing techniques, as well as artificial intelligence (AI) methodologies. Nevertheless, despite colorectal cancer (CRC) being the second deadliest cancer type worldwide, with increasing incidence rates, the application of AI for CRC diagnosis, particularly on whole-slide images (WSI), is still a young field. In this review, we analyse some relevant works published on this particular task and highlight the limitations that hinder the application of these works in clinical practice. We also empirically investigate the feasibility of using weakly annotated datasets to support the development of computer-aided diagnosis systems for CRC from WSI. Our study underscores the need for large datasets in this field and the use of an appropriate learning methodology to gain the most benefit from partially annotated datasets. The CRC WSI dataset used in this study, containing 1,133 colorectal biopsy and polypectomy samples, is available upon reasonable request.

Ordinal losses for classification of cervical cancer risk.

Cervical cancer is the fourth leading cause of cancer-related deaths in women, especially in low to middle-income countries. Despite the outburst of recent scientific advances, there is no totally effective treatment, especially when diagnosed in an advanced stage. Screening tests, such as cytology or colposcopy, have been responsible for a substantial decrease in cervical cancer deaths. Cervical cancer automatic screening via Pap smear is a highly valuable cell imaging-based detection tool, where cells must be classified as being within one of a multitude of ordinal classes, ranging from abnormal to normal. Current approaches to ordinal inference for neural networks are found to not sufficiently take advantage of the ordinal problem or to be too uncompromising. A non-parametric ordinal loss for neuronal networks is proposed that promotes the output probabilities to follow a unimodal distribution. This is done by imposing a set of different constraints over all pairs of consecutive labels which allows for a more flexible decision boundary relative to approaches from the literature. Our proposed loss is contrasted against other methods from the literature by using a plethora of deep architectures. A first conclusion is the benefit of using non-parametric ordinal losses against parametric losses in cervical cancer risk prediction. Additionally, the proposed loss is found to be the top-performer in several cases. The best performing model scores an accuracy of 75.6% for seven classes and 81.3% for four classes.

Evaluation of Combined Artificial Intelligence and Radiologist Assessment to Interpret Screening Mammograms.

Importance: Mammography screening currently relies on subjective human interpretation. Artificial intelligence (AI) advances could be used to increase mammography screening accuracy by reducing missed cancers and false positives. Objective: To evaluate whether AI can overcome human mammography interpretation limitations with a rigorous, unbiased evaluation of machine learning algorithms. Design, Setting, and Participants: In this diagnostic accuracy study conducted between September 2016 and November 2017, an international, crowdsourced challenge was hosted to foster AI algorithm development focused on interpreting screening mammography. More than 1100 participants comprising 126 teams from 44 countries participated. Analysis began November 18, 2016. Main Outcomes and Measurements: Algorithms used images alone (challenge 1) or combined images, previous examinations (if available), and clinical and demographic risk factor data (challenge 2) and output a score that translated to cancer yes/no within 12 months. Algorithm accuracy for breast cancer detection was evaluated using area under the curve and algorithm specificity compared with radiologists' specificity with radiologists' sensitivity set at 85.9% (United States) and 83.9% (Sweden). An ensemble method aggregating top-performing AI algorithms and radiologists' recall assessment was developed and evaluated. Results: Overall, 144 231 screening mammograms from 85 580 US women (952 cancer positive ≤12 months from screening) were used for algorithm training and validation. A second independent validation cohort included 166 578 examinations from 68 008 Swedish women (780 cancer positive). The top-performing algorithm achieved an area under the curve of 0.858 (United States) and 0.903 (Sweden) and 66.2% (United States) and 81.2% (Sweden) specificity at the radiologists' sensitivity, lower than community-practice radiologists' specificity of 90.5% (United States) and 98.5% (Sweden). Combining top-performing algorithms and US radiologist assessments resulted in a higher area under the curve of 0.942 and achieved a significantly improved specificity (92.0%) at the same sensitivity. Conclusions and Relevance: While no single AI algorithm outperformed radiologists, an ensemble of AI algorithms combined with radiologist assessment in a single-reader screening environment improved overall accuracy. This study underscores the potential of using machine learning methods for enhancing mammography screening interpretation.

Automatic detection of perforators for microsurgical reconstruction.

The deep inferior epigastric perforator (DIEP) is the most commonly used free flap in mastectomy reconstruction. Preoperative imaging techniques are routinely used to detect location, diameter and course of perforators, with direct intervention from the imaging team, who subsequently draw a chart that will help surgeons choosing the best vascular support for the reconstruction. In this work, the feasibility of using a computer software to support the preoperative planning of 40 patients proposed for breast reconstruction with a DIEP flap is evaluated for the first time. Blood vessel centreline extraction and local characterization algorithms are applied to identify perforators and compared with the manual mapping, aiming to reduce the time spent by the imaging team, as well as the inherent subjectivity to the task. Comparing with the measures taken during surgery, the software calibre estimates were worse for vessels smaller than 1.5 mm (P = 6e-4) but better for the remaining ones (P = 2e-3). Regarding vessel location, the vertical component of the software output was significantly different from the manual measure (P = 0.02), nonetheless that was irrelevant during surgery as errors in the order of 2-3 mm do not have impact in the dissection step. Our trials support that a reduction of the time spent is achievable using the automatic tool (about 2 h/case). The introduction of artificial intelligence in clinical practice intends to simplify the work of health professionals and to provide better outcomes to patients. This pilot study paves the way for a success story.

3D digital breast cancer models with multimodal fusion algorithms.

Breast cancer image fusion consists of registering and visualizing different sets of a patient synchronized torso and radiological images into a 3D model. Breast spatial interpretation and visualization by the treating physician can be augmented with a patient-specific digital breast model that integrates radiological images. But the absence of a ground truth for a good correlation between surface and radiological information has impaired the development of potential clinical applications. A new image acquisition protocol was designed to acquire breast Magnetic Resonance Imaging (MRI) and 3D surface scan data with surface markers on the patient's breasts and torso. A patient-specific digital breast model integrating the real breast torso and the tumor location was created and validated with a MRI/3D surface scan fusion algorithm in 16 breast cancer patients. This protocol was used to quantify breast shape differences between different modalities, and to measure the target registration error of several variants of the MRI/3D scan fusion algorithm. The fusion of single breasts without the biomechanical model of pose transformation had acceptable registration errors and accurate tumor locations. The performance of the fusion algorithm was not affected by breast volume. Further research and virtual clinical interfaces could lead to fast integration of this fusion technology into clinical practice.

Evolution, current challenges, and future possibilities in the objective assessment of aesthetic outcome of breast cancer locoregional treatment.

The Breast Cancer overall survival rate has raised impressively in the last 20 years mainly due to improved screening and effectiveness of treatments. This increase in survival paralleled the awareness over the long-lasting impact of the side effects of treatments on patient quality of life, emphasizing the motto "a longer but better life for breast cancer patients". In breast cancer more strikingly than in other cancers, besides the side effects of systemic treatments, there is the visible impact of surgery and radiotherapy on patients' body image. This has sparked interest on the development of tools for the aesthetic evaluation of Breast Cancer locoregional treatments, which evolved from manual, subjective approaches to computerized, automated solutions. However, although studied for almost four decades, past solutions were not mature enough to become a standard. Recent advancements in machine learning have inspired trends toward deep-learning-based medical image analysis, also bringing new promises to the field of aesthetic assessment of locoregional treatments. In this paper, a review and discussion of the previous state-of-the-art methods in the field is conducted and the extracted knowledge is used to understand the evolution and current challenges. The aim of this paper is to delve into the current opportunities as well as motivate and guide future research in the aesthetic assessment of Breast Cancer locoregional treatments.

The value of 3D images in the aesthetic evaluation of breast cancer conservative treatment. Results from a prospective multicentric clinical trial.

PURPOSE: BCCT.core (Breast Cancer Conservative Treatment. cosmetic results) is a software created for the objective evaluation of aesthetic result of breast cancer conservative treatment using a single patient frontal photography. The lack of volume information has been one criticism, as the use of 3D information might improve accuracy in aesthetic evaluation. In this study, we have evaluated the added value of 3D information to two methods of aesthetic evaluation: a panel of experts; and an augmented version of the computational model - BCCT.core3d. MATERIAL AND METHODS: Within the scope of EU Seventh Framework Programme Project PICTURE, 2D and 3D images from 106 patients from three clinical centres were evaluated by a panel of 17 experts and the BCCT.core. Agreement between all methods was calculated using the kappa (K) and weighted kappa (wK) statistics. RESULTS: Subjective agreement between 2D and 3D individual evaluation was fair to moderate. The agreement between the expert classification and the BCCT.core software with both 2D and 3D features was also fair to moderate. CONCLUSIONS: The inclusion of 3D images did not add significant information to the aesthetic evaluation either by the panel or the software. Evaluation of aesthetic outcome can be performed using of the BCCT.core software, with a single frontal image.

A Regression Model for Predicting Shape Deformation after Breast Conserving Surgery.

Breast cancer treatments can have a negative impact on breast aesthetics, in case when surgery is intended to intersect tumor. For many years mastectomy was the only surgical option, but more recently breast conserving surgery (BCS) has been promoted as a liable alternative to treat cancer while preserving most part of the breast. However, there is still a significant number of BCS intervened patients who are unpleasant with the result of the treatment, which leads to self-image issues and emotional overloads. Surgeons recognize the value of a tool to predict the breast shape after BCS to facilitate surgeon/patient communication and allow more educated decisions; however, no such tool is available that is suited for clinical usage. These tools could serve as a way of visually sensing the aesthetic consequences of the treatment. In this research, it is intended to propose a methodology for predict the deformation after BCS by using machine learning techniques. Nonetheless, there is no appropriate dataset containing breast data before and after surgery in order to train a learning model. Therefore, an in-house semi-synthetic dataset is proposed to fulfill the requirement of this research. Using the proposed dataset, several learning methodologies were investigated, and promising outcomes are obtained.

Supervised deep learning embeddings for the prediction of cervical cancer diagnosis.

Cervical cancer remains a significant cause of mortality all around the world, even if it can be prevented and cured by removing affected tissues in early stages. Providing universal and efficient access to cervical screening programs is a challenge that requires identifying vulnerable individuals in the population, among other steps. In this work, we present a computationally automated strategy for predicting the outcome of the patient biopsy, given risk patterns from individual medical records. We propose a machine learning technique that allows a joint and fully supervised optimization of dimensionality reduction and classification models. We also build a model able to highlight relevant properties in the low dimensional space, to ease the classification of patients. We instantiated the proposed approach with deep learning architectures, and achieved accurate prediction results (top area under the curve AUC = 0.6875) which outperform previously developed methods, such as denoising autoencoders. Additionally, we explored some clinical findings from the embedding spaces, and we validated them through the medical literature, making them reliable for physicians and biomedical researchers.

Proposal for a gold standard for cosmetic evaluation after breast conserving therapy: Results from the St George and Wollongong Breast Boost trial.

INTRODUCTION: Breast cosmesis is an important endpoint of breast conserving therapy (BCT), but a gold standard method of its evaluation is not yet established. The St. George and Wollongong Randomised Breast Boost trial used five different methods of cosmetic assessment, including both subjective and objective, to comprehensively evaluate the cosmetic outcome of the trial patients. This current study analyses the level of concordance between these methods in an attempt to determine a possible standard in the evaluation of breast cosmesis. METHODS: Patients attending follow-up clinic reviews at 5 years post breast radiotherapy were evaluated. Patients completed a cosmesis and functional assessment questionnaire, assessing clinicians completed an EORTC (European Organization for Research and Treatment of Cancer) cosmetic rating questionnaire and photographs were obtained. The photographs were later assessed by a panel of five experts, as well as analysed using the objective pBRA (relative Breast Retraction Assessment) and the BCCT.core (Breast Cancer Conservative Treatment.cosmetic results) computer software. Scores were dichotomised to excellent/good and fair/poor. Pairwise comparisons between all methods, except pBRA, were carried out using overall agreement calculations and kappa scores. pBRA scores were compared on a continuous scale with each of the other dichotomised scores obtained by the other four methods. RESULTS: Of 513 St George patients alive at 5 years, 385 (75%) attended St George for follow-up and consented to photography. Results showed that assessment by physicians in clinic and patient self-assessment were more favourable regarding overall cosmetic outcome than evaluation of photographs by the panel or the BCCT.core software. Excellent/good scores by clinician-live and patient self-assessments were 93% and 94% respectively (agreement 89%), as compared to 75% and 74% only by BCCT.core and panel assessments respectively (agreement 83%, kappa 0.57). For the pBRA measurements, there was a statistically significant difference (P <0.001) between scores for excellent/good versus fair/poor cosmesis by all four methods. The range of median pBRA measurements for fair/poor scores was 13.4-14.8 and for excellent/good scores was 8.0-9.4. CONCLUSION: Incorporating both BCCT.core assessment and patient self-assessment could potentially provide the basis of a gold standard method of breast cosmetic evaluation. BCCT.core represents an easy, time efficient, reproducible, cost effective and reliable method, however, it lacks the functional and psychosocial elements of cosmesis that only patient self-reported outcomes can provide.