PolypSteer: Counterfactual Endoscopic Synthesis via Training-Free Activation Steering

Medical image analysis is often hindered by biased datasets, which can lead to biased models and limited clinical applicability. A promising strategy for mitigating such biases is to augment training data with synthetic images. Counterfactual (CF) generation is one such strategy, though the term is used in two different senses: in some works, CFs are produced through causality-based interventions derived from structural causal models, whereas in others, they are produced by non-causal image edits or conventional conditional generative models, such as altering anatomy or adding pathologies. In this work, we study this distinction and evaluate its practical consequences for medical image augmentation. We compare three conditioning strategies: $\textit{Deterministic}$, which changes selected variables while holding the remaining variables fixed; $\textit{Undirected}$, which updates variables according to learned statistical associations without assigning causal directions; and $\textit{Causal}$, which propagates interventions along a directed causal graph. We analyse how these choices affect the resulting images, and explore when causally grounded methods improve dataset augmentation or bring limited benefit. In particular, we assess downstream performance and fairness, where fairness refers to reduced sensitivity to dataset biases across sensitive subgroups. Our experiments demonstrate that using a causal approach to synthetic training data generation can lead to tangible benefits, with these insights offering valuable guidance to machine learning practitioners for the effective design of data generation protocols.

Medical counterfactual generation modifies images to change model predictions for interpretability. However, existing diffusion-based approaches are often prohibitively slow and memory-intensive, making them difficult to apply in high-resolution settings. Moreover, existing masking strategies are tightly coupled with pixel-space representations, making them incompatible with latent-space diffusion editing. To address these challenges, we propose MedDiME, a latent-space classifier-guided diffusion framework that reduces computational and memory overhead while introducing a latent-compatible, gradient-driven adaptive masking mechanism for spatially precise medical counterfactual generation. Extensive experiments demonstrate that MedDiME achieves high-quality counterfactual generation with significant efficiency gains compared to prior classifier-guided diffusion baselines, achieving up to 40 times faster inference and 13 times lower peak GPU memory usage.

Counterfactual image generation enables controlled data augmentation, bias mitigation, and disease modeling. However, existing methods guided by external classifiers or regressors are limited to subject-level factors (e.g., age) and fail to produce localized structural changes, often resulting in global artifacts. Pixel-level guidance using segmentation masks has been explored, but requires user-defined counterfactual masks, which are tedious and impractical. Segmentor-guided Counterfactual Fine-Tuning (Seg-CFT) addressed this by using segmentation-derived measurements to supervise structure-specific variables, yet it remains restricted to global interventions. We propose Positional Seg-CFT, which subdivides each structure into regional segments and derives independent measurements per region, enabling spatially localized and anatomically coherent counterfactuals. Experiments on coronary CT angiography show that Pos-Seg-CFT generates realistic, region-specific modifications, providing finer spatial control for modeling disease progression.