Role of sureness in evaluating AI/CADx: Lesion-based repeatability of machine learning classification performance on breast MRI.

BACKGROUND: Artificial intelligence/computer-aided diagnosis (AI/CADx) and its use of radiomics have shown potential in diagnosis and prognosis of breast cancer. Performance metrics such as the area under the receiver operating characteristic (ROC) curve (AUC) are frequently used as figures of merit for the evaluation of CADx. Methods for evaluating lesion-based measures of performance may enhance the assessment of AI/CADx pipelines, particularly in the situation of comparing performances by classifier. PURPOSE: The purpose of this study was to investigate the use case of two standard classifiers to (1) compare overall classification performance of the classifiers in the task of distinguishing between benign and malignant breast lesions using radiomic features extracted from dynamic contrast-enhanced magnetic resonance (DCE-MR) images, (2) define a new repeatability metric (termed sureness), and (3) use sureness to examine if one classifier provides an advantage in AI diagnostic performance by lesion when using radiomic features. METHODS: Images of 1052 breast lesions (201 benign, 851 cancers) had been retrospectively collected under HIPAA/IRB compliance. The lesions had been segmented automatically using a fuzzy c-means method and thirty-two radiomic features had been extracted. Classification was investigated for the task of malignant lesions (81% of the dataset) versus benign lesions (19%). Two classifiers (linear discriminant analysis, LDA and support vector machines, SVM) were trained and tested within 0.632 bootstrap analyses (2000 iterations). Whole-set classification performance was evaluated at two levels: (1) the 0.632+ bias-corrected area under the ROC curve (AUC) and (2) performance metric curves which give variability in operating sensitivity and specificity at a target operating point (95% target sensitivity). Sureness was defined as 1-95% confidence interval of the classifier output for each lesion for each classifier. Lesion-based repeatability was evaluated at two levels: (1) repeatability profiles, which represent the distribution of sureness across the decision threshold and (2) sureness of each lesion. The latter was used to identify lesions with better sureness with one classifier over another while maintaining lesion-based performance across the bootstrap iterations. RESULTS: In classification performance assessment, the median and 95% CI of difference in AUC between the two classifiers did not show evidence of difference (ΔAUC = -0.003 [-0.031, 0.018]). Both classifiers achieved the target sensitivity. Sureness was more consistent across the classifier output range for the SVM classifier than the LDA classifier. The SVM resulted in a net gain of 33 benign lesions and 307 cancers with higher sureness and maintained lesion-based performance. However, with the LDA there was a notable percentage of benign lesions (42%) with better sureness but lower lesion-based performance. CONCLUSIONS: When there is no evidence for difference in performance between classifiers using AUC or other performance summary measures, a lesion-based sureness metric may provide additional insight into AI pipeline design. These findings present and emphasize the utility of lesion-based repeatability via sureness in AI/CADx as a complementary enhancement to other evaluation measures.