Active learning (AL) has emerged as a crucial strategy for reducing the prohibitive costs associated with medical image segmentation. However, standard uncertainty-based AL methods typically focus on maximizing performance metrics, ignoring performance disparities or fairness across groups with sensitive attributes. While fair active learning has been explored in classification tasks, its intersection with medical image segmentation remains unaddressed. In this work, we introduced a fairness-aware active learning framework with a Weighted Entropy selection strategy that modulates uncertainty based on current group-specific performance estimates on the labeled set. To decouple true epistemic uncertainty from anatomical volume variances, we further utilized a masked, scaled entropy restricted to the region of interest. The framework was evaluated on synthetic T1-weighted brain MRIs with controlled left caudate bias in both strong and weak bias settings. A 3D U-Net was trained to segment the left caudate under several AL strategies, starting from both demographically balanced and strongly imbalanced initial labeled sets. Experiments demonstrated that our method markedly reduces performance disparities between groups compared to random sampling and standard uncertainty sampling. By prioritizing poorly segmented subgroups during the AL cycles, our method consistently achieved the highest equity-scaled performance and reduced the disparity metric by 75% (strong bias) and 86% (weak bias) relative to standard entropy at the final budget. Overall, this work is among the first studies on fair AL for medical image segmentation, offering an efficient strategy to train more equitable models in resource-constrained environments.
Labeled datasets reflect the biases of their annotation pipelines, which sometimes introduce label bias: group-conditional label errors that cause systematic performance disparities across demographic subgroups. Label bias in image segmentation remains underexplored, as even detecting it typically requires clean, unbiased annotations, which are not readily available. We present a data-centric adaptation of Confident Learning to segmentation, allowing detection of label bias directly in the training data without a clean, unbiased ground truth. By comparing the provided training labels to the model's confident predictions, we isolate directional errors that quantify the presence and nature of bias, where standard overlap metrics like Dice fail. We further show that label bias influences subgroup separability in the encoder's feature space, an artifact we leverage for bias mitigation rather than suppressing it. We evaluate three datasets, spanning from synthetic to real-life bias, showing how our framework reliably detects and mitigates bias without access to clean labels, achieving equitable performance across experimental conditions.
Medical image segmentation models can perform unevenly across subgroups. Most existing fairness methods focus on improving average subgroup performance, implicitly treating each subgroup as internally homogeneous. However, this can hide difficult cases within a subgroup, where high-loss samples are obscured by the subgroup mean. We call this problem \textbf{intra-group hidden failure}. To solve this, we propose \textbf{DuetFair} mechanism, a dual-axis fairness framework that jointly considers inter-subgroup adaptation and intra-subgroup robustness. Based on DuetFair, we introduce \textbf{FairDRO}, which combines distribution-aware mixture-of-experts (dMoE) with subgroup-conditioned distributionally robust optimization (DRO) loss aggregation. This design allows the model to adapt across subgroups while also reducing hidden failures within each subgroup. We evaluate FairDRO on three medical image segmentation benchmarks with varying degrees of within-group heterogeneity. FairDRO achieves the best equity-scaled performance on Harvard-FairSeg and improves worst-case subgroup performance on HAM10000 under both age- and race-based grouping schemes. On the 3D radiotherapy target cohort, FairDRO further improves worst-group Dice by 3.5 points (↑6.0%) under the tumor-stage grouping and by 4.1 points (↑7.4%) under the institution grouping over the strongest baseline.
In practical settings, medical image segmentation models are often developed with limited annotated data rather than fully labeled datasets. Training frequently begins in ultra-low labeled regimes where only a small number of volumes are annotated. In such scenarios, practitioners must simultaneously decide which cases to annotate and how to best use the remaining unlabeled data. Although active learning (AL) and semi-supervised learning (SSL) both target annotation scarcity, they are typically designed and optimized independently, resulting in objective mismatch and unstable training during early-stage "cold start" conditions. We propose RegAL, a unified active semi-supervised framework governed by a shared topology-aware Pareto optimization that couples sample acquisition with unlabeled data utilization. RegAL evaluates images along three complementary axes, voxel-wise uncertainty, feature diversity, and a novel topological consistency metric, to select anatomically informative edge cases for annotation. On the other hand, the same criteria are used to identify geometrically stable atlas candidates for diffeomorphic registration-guided augmentation to train a self-supervised Mean Teacher segmentation network. Across BraTS 2021, dHCP, and ProstateX, RegAL remains stable with few labeled volumes and consistently outperforms state-of-the-art AL, SSL, and active semi-supervised baselines across Dice and boundary-distance (ASD, HD95) metrics under extreme annotation scarcity.