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Register a new userCheXternal: Generalization of Deep Learning Models for Chest X-ray Interpretation to Photos of Chest X-rays and External Clinical Settings
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Recent advances in training deep learning models have demonstrated the potential to provide accurate chest X-ray interpretation and increase access to radiology expertise. However, poor generalization due to data distribution shifts in clinical settings is a key barrier to implementation. In this study, we measured the diagnostic performance for 8 different chest X-ray models when applied to (1) smartphone photos of chest X-rays and (2) external datasets without any finetuning. All models were developed by different groups and submitted to the CheXpert challenge, and re-applied to test datasets without further tuning. We found that (1) on photos of chest X-rays, all 8 models experienced a statistically significant drop in task performance, but only 3 performed significantly worse than radiologists on average, and (2) on the external set, none of the models performed statistically significantly worse than radiologists, and five models performed statistically significantly better than radiologists. Our results demonstrate that some chest X-ray models, under clinically relevant distribution shifts, were comparable to radiologists while other models were not. Future work should investigate aspects of model training procedures and dataset collection that influence generalization in the presence of data distribution shifts.
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The use of smartphones to take photographs of chest x-rays represents an appealing solution for scaled deployment of deep learning models for chest x-ray interpretation. However, the performance of chest x-ray algorithms on photos of chest x-rays has not been thoroughly investigated. In this study, we measured the diagnostic performance for 8 different chest x-ray models when applied to photos of chest x-rays. All models were developed by different groups and submitted to the CheXpert challenge, and re-applied to smartphone photos of x-rays in the CheXphoto dataset without further tuning. We found that several models had a drop in performance when applied to photos of chest x-rays, but even with this drop, some models still performed comparably to radiologists. Further investigation could be directed towards understanding how different model training procedures may affect model generalization to photos of chest x-rays.
Clinical deployment of deep learning algorithms for chest x-ray interpretation requires a solution that can integrate into the vast spectrum of clinical workflows across the world. An appealing approach to scaled deployment is to leverage the ubiquity of smartphones by capturing photos of x-rays to share with clinicians using messaging services like WhatsApp. However, the application of chest x-ray algorithms to photos of chest x-rays requires reliable classification in the presence of artifacts not typically encountered in digital x-rays used to train machine learning models. We introduce CheXphoto, a dataset of smartphone photos and synthetic photographic transformations of chest x-rays sampled from the CheXpert dataset. To generate CheXphoto we (1) automatically and manually captured photos of digital x-rays under different settings, and (2) generated synthetic transformations of digital x-rays targeted to make them look like photos of digital x-rays and x-ray films. We release this dataset as a resource for testing and improving the robustness of deep learning algorithms for automated chest x-ray interpretation on smartphone photos of chest x-rays.
Although deep learning models for chest X-ray interpretation are commonly trained on labels generated by automatic radiology report labelers, the impact of improvements in report labeling on the performance of chest X-ray classification models has not been systematically investigated. We first compare the CheXpert, CheXbert, and VisualCheXbert labelers on the task of extracting accurate chest X-ray image labels from radiology reports, reporting that the VisualCheXbert labeler outperforms the CheXpert and CheXbert labelers. Next, after training image classification models using labels generated from the different radiology report labelers on one of the largest datasets of chest X-rays, we show that an image classification model trained on labels from the VisualCheXbert labeler outperforms image classification models trained on labels from the CheXpert and CheXbert labelers. Our work suggests that recent improvements in radiology report labeling can translate to the development of higher performing chest X-ray classification models.
Although there have been several recent advances in the application of deep learning algorithms to chest x-ray interpretation, we identify three major challenges for the translation of chest x-ray algorithms to the clinical setting. We examine the performance of the top 10 performing models on the CheXpert challenge leaderboard on three tasks: (1) TB detection, (2) pathology detection on photos of chest x-rays, and (3) pathology detection on data from an external institution. First, we find that the top 10 chest x-ray models on the CheXpert competition achieve an average AUC of 0.851 on the task of detecting TB on two public TB datasets without fine-tuning or including the TB labels in training data. Second, we find that the average performance of the models on photos of x-rays (AUC = 0.916) is similar to their performance on the original chest x-ray images (AUC = 0.924). Third, we find that the models tested on an external dataset either perform comparably to or exceed the average performance of radiologists. We believe that our investigation will inform rapid translation of deep learning algorithms to safe and effective clinical decision support tools that can be validated prospectively with large impact studies and clinical trials.
We systematically evaluate the performance of deep learning models in the presence of diseases not labeled for or present during training. First, we evaluate whether deep learning models trained on a subset of diseases (seen diseases) can detect the presence of any one of a larger set of diseases. We find that models tend to falsely classify diseases outside of the subset (unseen diseases) as no disease. Second, we evaluate whether models trained on seen diseases can detect seen diseases when co-occurring with diseases outside the subset (unseen diseases). We find that models are still able to detect seen diseases even when co-occurring with unseen diseases. Third, we evaluate whether feature representations learned by models may be used to detect the presence of unseen diseases given a small labeled set of unseen diseases. We find that the penultimate layer of the deep neural network provides useful features for unseen disease detection. Our results can inform the safe clinical deployment of deep learning models trained on a non-exhaustive set of disease classes.
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