Development and evaluation of CADe systems in low-prevalence setting: The RARE25 challenge for early detection of Barrett's neoplasia

Computer-aided detection (CADe) systems for colonoscopy promise to reduce clinical miss rates, yet reliable real-world deployment remains elusive. This translational gap stems in part from a structural flaw in model development: the reliance on curated datasets that under-represent the long negative stretches and procedure-related artifacts characteristic of routine examinations. Training and evaluating architectures strictly on these lesion-centric benchmarks creates an illusion of success, since such benchmarks cannot capture clinically crucial metrics. To expose this gap, we establish TRUE-Colon, a standardized benchmarking protocol that measures key deployment characteristics alongside localization accuracy, and evaluate four real-time architectures (Faster R-CNN, YOLOv8, YOLOv11, RT-DETR) across curated benchmarks (SUN, PICCOLO) and 60 unedited, full-length procedures (REAL-Colon). We observe a consistent transfer asymmetry: models trained strictly on curated clips suffer a severe performance collapse when evaluated on full procedures, whereas procedure-trained models substantially improve rejection of non-polyp content on REAL-Colon, and largely retain their accuracy on curated benchmarks. Beyond transferability, we find that the Transformer detector attains the strongest sensitivity and the earliest, most persistent detections, while the convolutional detectors stay competitive at a higher throughput. Together, these results indicate that both training and benchmarking for deployable CADe should shift from curated, lesion-centric clips toward full-procedure data and deployment-relevant operating points. Source code is available at https://github.com/sdoerrich97/true-colon.

Clinical decision-support systems are expert systems whose recommendations clinicians act on directly, yet they are usually cleared on one aggregate accuracy number from a held-out test set. That number says nothing about input reliability under encoding shifts, subgroup gaps, threshold sensitivity, or operational feasibility. We present RISED, a pre-deployment evaluation framework operationalising five dimensions (Reliability, Inclusivity, Sensitivity, Equity, Deployability) through BCa bootstrap 95% confidence intervals, literature-grounded thresholds, and Holm-Bonferroni-corrected PASS / FAIL / INCONCLUSIVE verdicts; Equity is a proxy-dependence diagnostic rather than a gating test. Applied to seven cohorts spanning 35 years (n from 303 to 99,492), RISED surfaces failures invisible to AUROC: on Diabetes 130, Reliability passes by three orders of magnitude (PSS = 0.0004) while Inclusivity (AUC parity gap = 0.262) and Sensitivity (max threshold-flip rate 49.1%) fail decisively; both NHIS cohorts reproduce this. NHANES 2021-2023, with a complete feature profile, achieves INCONCLUSIVE verdicts; BRFSS 2024 produces the suite's most severe Sensitivity failure (max threshold-flip rate 64.2%) after instrument rotation removed hypertension and cholesterol. The pattern recurs on credit- and income-prediction cohorts, confirming domain-agnosticity; a multi-model check shows the failures are data-driven, not model-specific. RISED ships as an open-source Python package complementing TRIPOD+AI, FUTURE-AI, and Fairlearn with the structured numerical evidence those standards require but do not prescribe.

False-positive computer-aided detection (CADe) prompts may divert endoscopists' attention during colonoscopy, yet the attentional impact of individual prompts remains unclear. We used event-locked eye tracking to quantify gaze attraction and attention occupation in complementary retrospective and prospective studies. In a retrospective paired-video experiment, 3 senior and 2 novice endoscopists viewed 60 colonoscopy videos with and without CADe. The prospective study recorded gaze during 42 real-time CADe-assisted colonoscopies performed by 9 senior endoscopists. Screened CADe prompts outside expert-annotated lesion windows were classified as false-positive artifact events. False-positive prompts attracted gaze in 48.6% (68/140) of retrospective observations and 65.2% (533/817) of prospective events. Among attraction events with complete recovery, median attention occupation lasted 1000 ms in the retrospective study and 1100 ms in the prospective study. Corresponding median prompt durations were 33 ms and 267 ms, with median time amplifications of 17.55-fold and 5.15-fold, respectively. In paired retrospective comparisons, visible artifact prompts drew gaze closer to the prompted region than did the same-coordinate unassisted reference. Secondary retrospective analyses showed high lesion gaze recognition without and with CADe (98.0% versus 99.0%). First gaze entry into lesion regions occurred 147.8 ms earlier with CADe. Across controlled and real-time clinical settings, false-positive CADe prompts frequently captured gaze, with attention persisting beyond prompt visibility. These findings support considering prompt-related attentional burden in CADe evaluation and design.