DuetFair: Coupling Inter- and Intra-Subgroup Robustness for Fair Medical Image Segmentation

Medical image analysis models can exhibit performance disparities across patient subgroups, threatening clinical safety and fairness. Existing methods typically address this issue by optimizing accuracy and fairness metrics for visible demographic attributes (e.g., sex or age) considered in isolation. This strategy not only overlooks potentially more informative latent stratifications, which may reveal deeper sources of model error and inequity, but also fails to scale when multiple demographic attributes are considered simultaneously due to the resulting sparsity of training data within each subgroup. We deal with these issues by introducing the label-free hidden-cohort fairness (LHCF) training paradigm that instead of maximizing fairness over visible demographic attributes, it optimizes fairness across latent subpopulations discovered from image appearance. By clustering images into K appearance-based cohorts and applying fairness optimization over them, LHCF uncovers underlying sources of model error and avoids the combinatorial sparsity of multi-demographic attributes, reducing disparities across both single and multiple demographic attributes. We demonstrate on our proposed fairness benchmark, HIDFairBench, that LHCF provides state-of-the-art fairness results on single and multiple demographic attributes, despite never using demographic labels for training. Our results position hidden-cohort fairness as a practical, scalable, and robust alternative to demographic-based fairness optimization for trustworthy medical image analysis.

Diagnostic performance in medical AI varies systematically across demographic groups, yet subgroup AUC can mask clinically important disparities. At a fixed inference-time operating point, some groups may exhibit over-diagnostic behaviour, characterized by elevated true and false positive rates, while others show under-diagnostic patterns with reduced true and false positive rates. These opposing tendencies can cancel in aggregate AUCs while producing meaningful inequities in clinical decision-making. Motivated by the need to assess and mitigate such disparities at the operating point and across multiple demographic attributes simultaneously, we propose a worst-group equalized-odds margin regularizer. The proposed regularizer explicitly targets subgroup-level deviations on both the true positive and false positive sides at inference. At each update, the method identifies subgroups defined by explicit demographic attributes (e.g., age, sex, and race) that exhibit the most extreme margin deviations and applies a unified penalty, enabling fairness optimization across multiple demographic axes without requiring explicit intersectional constraints. Across two medical imaging datasets in realistic multi-label settings, our method consistently reduces disparities in Equalized Odds and Equalized Opportunity with minimal impact on AUC, preserving diagnostic performance while improving fairness.

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.