Ablation Study of a Fairness Auditing Agentic System for Bias Mitigation in Early-Onset Colorectal Cancer Detection

Treatment planning in precision oncology requires synthesizing heterogeneous patient information with rapidly evolving clinical guidelines to ensure guideline-concordant care. While large language models (LLMs) show promise in many diagnostic tasks, their adoption for high-stakes treatment planning is hindered by complex reasoning, adherence to timely clinical guidelines, and safety concerns. In this study, we present GatorOnco, an agentic LLM for colorectal cancer (CRC) treatment planning. GatorOnco is developed using a total of 282 billion tokens of biomedical text, including healthcare system-scale clinical text comprising 166 billion tokens from UF Health. We implemented a domain-adaptation method that integrates pre-training, model merging, a two-stage post-training approach, and agent-based reinforcement learning. An agentic retrieval-augmented generation (RAG) approach dynamically integrates time-sensitive clinical guidelines into the reasoning process. In a blind, randomized clinical evaluation conducted by five UF Health oncologists, GatorOnco significantly outperformed open-source LLMs (P < 0.01) and achieved expert-level performance comparable to UF Health oncologists. Compared with expert oncologists, GatorOnco received significantly higher ratings for readability (4.46 vs. 4.19, P < 0.01) and completeness (3.91 vs. 3.52, P < 0.01), while showing statistically comparable performance in correctness (4.09 vs. 4.11, P = 0.921), currency (4.04 vs. 3.98, P = 0.478), and safety (4.22 vs. 4.22, P = 0.999). These findings demonstrate that integrating agentic reasoning with large-scale domain adaptation can help bridge the gap for generative AI in high-stakes cancer treatment planning.

Prior benchmarking work has shown that a single large language model (LLM), forced to make life-or-death resource-allocation decisions, exhibits measurable demographic bias. Real deployments, however, rarely use a single agent: they use pipelines, with review steps meant to catch exactly this kind of failure. We study what happens to bias when the same decision is distributed across a role-differentiated multi-agent pipeline (assessment, allocation, independent audit) instead of made and checked by one model alone. Using a synthetic disaster-triage simulator with paired cases that are clinically identical except for one demographic attribute, we run 192 episodes (2,304 resolved case pairs) on GPT-4o-mini comparing a single-agent control condition to a nine-agent pipeline under three independently varied pressure dimensions. We find no measurable difference in how often biased outcomes occur between the two conditions (6.9% vs. 6.1%, p = 0.498). We do find a large and significant effect of audit capacity on whether bias is caught: 30.0% of biased outcomes go entirely undetected, rising to 43.8% when the auditor is overloaded and falling to 18.4% when it is not. Decomposing this effect shows it is driven almost entirely by coverage (whether a case is reviewed at all, which collapses from 100.0% to 65.6% under load, p < 0.001) rather than by degraded judgment on the cases that are reviewed (81.6% vs. 85.7%, p = 1.000, direction reversed). A follow-up experiment shows that reordering the audit queue by estimated risk, rather than first-come-first-served, recovers most of the lost coverage under the same capacity constraint (65.6% to 91.7%, p = 0.028). We discuss the implications for any system that adds independent oversight to an LLM agent pipeline under resource constraints, and report the study's limitations honestly: one model, modest sample sizes, and no adversarial replication.

Fairness in medical agents is becoming critical as tool-using clinical AI systems orchestrate specialized vision and language modules for tasks such as chest X-ray question answering. While these medical AI agents can improve flexibility, their added pipeline complexity also creates new pathways for demographic bias beyond standalone models. We present DUCK, Decomposing Unfairness in Chest X-ray agents, a systematic audit of fairness in tool-using chest X-ray agents instantiated with MedRAX. To localize where disparities arise, we introduce a stage-wise fairness decomposition that separates end-to-end bias from three agent-specific sources: tool exposure bias, or utility gaps conditioned on tool presence; tool transition bias, or subgroup differences in tool-routing patterns; and model reasoning bias, or subgroup differences in synthesis behaviors. Extensive experiments on tool-using agentic frameworks across five driver backbones reveal that demographic gaps persist in end-to-end performance, with equalized odds up to 20.79% and the lowest fairness-utility tradeoff down to 28.65%. Intermediate behaviors, including tool usage, transition patterns, and reasoning traces, exhibit distinct subgroup disparities that are not predictable from end-to-end evaluation alone. For example, conditioned on segmentation-tool availability, the subgroup utility gap reaches as high as 50%. Our findings underscore the need for process-level fairness auditing and debiasing to ensure the equitable deployment of clinical agentic systems. Code: https://github.com/Nanboy-Ronan/DUCK.