The Guide to Health Informatics 3rd Edition

How should we interpret research reporting the performance of #AI in clinical practice?

[This blog collects together in one place a twitter review published 9 March 2018 at https://twitter.com/EnricoCoiera/status/971886744101515265 ]

Today we are reading “Watson for Oncology and breast cancer treatment recommendations: agreement with an expert multidisciplinary tumor board” that has just appeared in the Annals of Oncology.

https://academic.oup.com/annonc/article/29/2/418/4781689

This paper studies the degree of agreement or “concordance” between Watson for Oncology (WFO) and an expert panel of clinicians on a ’tumor board’. It reports an impressive 93% concordance between human experts and WFO when recommending treatment for breast cancer.

Unfortunately the paper is not open access but you can read the abstract. I’d suggest reading the paper before you read further into this thread. My question to you: Do the paper’s methods allow us to have confidence in the impressive headline result?

We should begin by congratulating the authors on completing a substantial piece of work in an important area. What follows is the ‘review’ I would have written if the journal had asked me. It is not a critique of individuals or technology and it is presented for educational purposes.

Should be believe the results are valid, and secondly do we believe that they generalizable to other places or systems? To answer this we need to examine the quality of the study, the quality of the data analysis, and the accuracy of the conclusions drawn from the analysis.

I like to tease apart the research methods section using PICO headings – Population, Intervention, Comparator, Outcome.

(P)opulation. 638 breast cancer patients presented between 2014-16 at a single institution. However the study excluded patients with colloid, adenocystic, tubular, or secretory breast cancer “since WFO was not trained to offer treatment recommendations for these tumor types”.

So we have our first issue. We are not told how representative this population is of the expected distribution of breast cancer cases at the hospital or in the general population. We need to know if these 3 study years were somehow skewed by abnormal presentations.

We also need to know if this hospital’s case-mix is normal or somehow different to that in others. Its critical because any claim for the results here to generalize elsewhere depends on how representative the population is.

Also, what do we think of the phrase “since WFO was not trained to offer treatment recommendations for these tumor types”? It means that irrespective of how good the research methods are, the result will not necessarily hold for *all breast cancer cases”

All they can claim is that any result holds for this subset of breast cancers . We have no evidence presented to suggest that performance would be the same on the excluded cancers. Unfortunately the abstract and paper results section do not include this very important caveat.

(I)ntervention. I’m looking for a clear description of the intervention to understand 1/ Could someone replicate this intervention independently to validate the results? 2/ What exactly was done so that we can connect cause (intervention) with effect (the outcomes)?

WFO is the intervention. But it is never explicitly described. For any digital intervention, even if you don’t tell me what is inside the black box, I need 2 things: 1/ Describe exactly the INPUT into the system and 2/ describe exactly the OUTPUT from the system.

This paper unfortunately does neither. There is no example of how a cancer case is encoded for WFO to interpret, nor is there is an example of a WFO recommendation that humans need to read.

So the intervention is not reported in enough detail for independent replication, we do not have enough detail to understand the causal mechanism tested, and we don’t know if biases are hidden in the intervention. This makes it hard to judge study validity or generalizability

Digging into an online appendix, we do discover some details about input, and WFO mechanism. It appears WFO is input a feature vector:

 

It also appears that vector is then input to an unspecified machine learning engine that presumably associates disease vectors with treatments.

So, for all the discussion of WFO as a text-processing machine, at its heart might be a statistical classification engine. It’s a pity we don’t know any more, and it’s a pity we don’t know how much human labour is hidden in preparing feature vectors and training cases.

But there is enough detail in the online appendix to get a feeling about what was in general done. They really should have been much more explicit and included the input feature vector, and output treatment recommendation description in the main paper.

But was WFO really the only intervention? No. there was also a human intervention that needs to be accounted for and it might very well have been responsible for some % of the results.

The Methods reports that two humans (trained senior oncology fellows) entered the data manually into WFO. They read the cases, identified the data that matched the input features, and then decided the scores for each feature. What does this mean?

Firstly, there was no testing of inter-rater reliability. We don’t know if the two humans coded the same cases in the same way. Normally a kappa statistic is provided to measure the degree of agreement between humans and allow us to get a sense for how replicable what they did was.

For example, a low kappa means that agreement is low and that therefore any results are less likely to replicate in a future study. We really need that kappa to trust the methods were robust.

If humans are pre-digesting data for WFO how much of WFO’s performance is due to the way humans seek, identify and synthesize data? We don’t know. One might argue that the hard information detection and analysis task is done by humans and the easier classification task by WFO.

So far we have got to the point where the papers’ results are not that WFO had a 93% concordance with human experts, but rather that, when humans from a single institution read cancer cases from that institution, and extract data specifically in the way that WFO needs it, and also when a certain group of breast cancers are excluded, then concordance is 93%. That is quite a list of caveats already.

(C)ompartor: The treatments recommended by WFO are compared to the consensus recommendations of a human group of experts. The authors rightly noted that treatments might have changed between the time the humans recommended a treatment and WFO gave its recommendation. So they calculate concordance *twice*.

The first comparison is between treatment recommendations of the tumor board and WFO. The second is not so straightforward. All the cases in the first comparison for which there was no human/WFO agreement were taken back to the humans, who were asked if their opinion had changed since they last considered the case. A new comparison was then made between this subset of cases and WFO, and the 93% figure comes from this 2nd comparison.

We now have a new problem. You know you are at risk of introducing bias in a study if you do something to one group that is different to what you do to the other groups, but still pool the results. In this case, the tumor board was asked to re-consider some cases but not others.

The reason for not looking at cases for which there had been original agreement could only be that we can safely assume that the tumor board’s views would not have changed over time. The problem is that we cannot safely assume that. There is every reason to believe that for some of these cases, the board would have changed its view.

As a result, the only outcomes possible at the second comparisons are either no change in concordance or improvement in concordance. The system is inadvertently ’rigged’ to prevent us discovering there was a decrease in concordance over time because the cases that might show a decrease are excluded from measurement.

From my perspective as a reviewer that means I can’t trust the data in the second comparison because of a high risk of bias. The experiment would need to be re-run allowing all cases to be reconsidered. So, if we look at the WFO concordance rate at first comparison, which is now all I think we reasonably can look at, it drops from 93% to 73% (Table 2).

(O)utcome: The outcome of concordance is a process not a clinical outcome. That means that it measures a step in a pathway, but tells us nothing about what might have happened to a patient at the end of the pathway. To do that we would need some sort of conversion rate.

For example if we knew for x% of cases in which WFO suggested something humans had not considered, that humans would change their mind, this would allow us to gauge how important concordance was in shaping human decision making. Ideally we would like to know a ‘number needed to treat’ i.e. how many patients need to have their case considered by WFO for 1 patient to materially benefit e.g. live rather than die.

So whilst process outcomes are great early stepping-stones in assessing clinical interventions, they really cannot tell us much about eventual real world impact. At best they are a technical checkpoint as we gather evidence that a major clinical trial is worth doing.

In this paper, concordance is defined as a tricky composite variable. Concordance = all those cases for which WFO’s *recommendation* agreed with the human recommendation + all those cases in which the human recommendation appeared in a secondary WFO list of *for consideration* treatments.

The very first question I now want to know is ‘how often did human and WFO actually AGREE on a single treatment?” Data from the first human-WFO comparison point indicates that there was agreement on the *recommended* treatment in 46% of cases. That is a very different number to 93% or even 73%.

What is the problem with including the secondary ‘for consideration’ recommendations from WFO? In principle nothing, as we are at this point only measuring process not outcomes, but it might need to be measured in a very different way than it is at present for the true performance to be clear.

Our problem is that if we match a human recommended treatment to a WFO recommendation it is a 1:1 comparison. If we match human recommended to WFO ‘for consideration’ it is 1:x. Indeed from the paper I don’t know what x is. How long is this additional list of ‘for consideration’ treatments. 2,5,10? You can see the problem. If WFO just listed out the next 10 most likely treatments, there is a good chance the human recommended treatment might appear somewhere in the list. If it had listed just 2 that would be more impressive.

In information retrieval, there are metrics that deal with this type of data, and they might have been used here. You could for example report the median rank at which WFO ‘for considerations’ matched human recommendations. IN other words, rather than treating it as a binary yes/no we would better assess performance by measuring where in the list the correct recommendation is made.

Now lets us turn to the results proper. I have already explained my concerns about the headline results around concordance.

Interestingly concordance is reportedly higher for stage II and III disease and lower for stage 1 and 1V. That is interesting, but odd to me. Why would this be the case? Well, this study was not designed to test for whether concordance changes with stage – this is a post-hoc analysis. To do such a study, we would likely have had to have seek equal samples of each stage of disease. Looking at the data, stage I cases are significantly underrepresented compared to other stages. So interesting, but treat with caution.

There are other post-hoc analyses of receptor status and age and the relationship with concordance. Again this is interesting but post-hoc so treat it with caution.

Interestingly concordance decreased with age – and that might have something to do with external factors like co-morbidity starting to affect treatment recommendations. Humans might for example, reason that aggressive treatment may not make sense to a cancer patient with other illnesses and at a certain age. The best practice encoded in WFO might not take such preferences and nuances into account.

Limitations: The authors do a very good job overall in identifying many, but not all, of the issues I raise above. Despite these identified limitations, which I think are significant, they still see WFO’s producing a “high degree of agreement’ with humans. I don’t think the data yet supports that conclusion.

Conclusions: The authors conclude by suggest that as a result of this study WFO might be useful for centers with limited breast cancer resources. The evidence in this study doesn’t yet support such a conclusion. We have some data on concordance, but no data on how concordance affects human decisions, and no data on how changed decisions affects patient outcomes. Those two giant evidence gaps mean it might be a while before we safely trial WFO in real life.

So, in summary, my takeaway is that WFO generated the same treatment recommendation as humans for a subset of breast cancers at a single institution in 46% of cases. I am unclear how much influence human input had in presenting data to WFO, and there is a chance the performance might have been worse without human help (e.g. if WFO did its own text processing).

I look forward to hearing more about WFO and similar systems in other studies, and hope this review can help in framing future study designs. I welcome comments on this review.

[Note: There is rich commentary associated with the original Twitter thread, so it is worth reading if you wish to see additional issues and suggestions from the research community.]

Tagged: Artificial Intelligence