Robust Mitigation of Age-Dependent Confounding Effects via Sample-Difficulty Decorrelation
Authors: Nikhil Cherian Kurian, Victor Caquilpan Parra, Abin Shoby, Luke Whitbread, Lyle J. Palmer
Organizations: Australian Institute for Machine Learning, Adelaide University, Adelaide, Australia
Abstract
Age dependent performance disparities in medical image classification often arise because age acts as a confounder, linking imaging morphology with disease prevalence. In practice, disparities can manifest as overdiagnosis at ages where disease prevalence is higher and underdiagnosis at ages where prevalence is lower, and can worsen under train test shifts in the age distribution. Conventional mitigation approaches that enforce strict age invariance may suppress diagnostically meaningful information encoded in age. We therefore propose a robust framework that mitigates the effects of age-dependent confounding by targeting spurious age linked trends rather than enforcing invariance. Following a warm-up phase, we characterize sample difficulty and model its age-dependent trends in a label-conditioned manner. We decorrelate age from dominant age difficulty trends using robust, Huber weighted affinity weights, attenuating confounding-driven shortcuts while preserving clinically meaningful, nonlinear age information. We further introduce an Age Coverage Score that scales the decorrelation penalty by minibatch age variance to ensure stable optimization under limited age diversity. Across two radiology datasets, our approach reduces age dependent true and false positive disparities with minimal AUC impact and remains robust to increasing train test age distribution shifts.
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.
Nikhil Cherian Kurian, Victor Caquilpan Parra, Abin Shoby +6
Deep learning models for medical image classification are susceptible to subgroup performance disparities across demographic attributes such as age, gender, and race. We identify a latent representational mechanism underlying these disparities: in transfer-learned models, the dominant penultimate-layer activation channel under positive predictions is co-activated by both disease-positive samples and privileged demographic groups (male, older patients), producing over-diagnosis; conversely, the dominant channel under negative predictions is co-activated by disadvantaged groups (female, younger patients), producing systematic under-diagnosis. To address this, we propose Neuron Incidence Redistribution (NIR), a lightweight regularization method that penalizes the variance of predicted-probability-weighted mean activations across penultimate-layer neurons, requiring no demographic labels at training time. On HAM10000, TPR disparity drops from 10.81% to 0.93% across age groups and from 12.04% to 0.74% across gender, with a marginal AUC improvement of 0.51 points. On Harvard OCT-RNFL, NIR reduces FPR disparity for race (from 15.68% to 10.66%) and age (from 12.69% to 1.80%), demonstrating that distributing latent disease evidence across the full penultimate layer is a principled and effective strategy for improving demographic fairness in medical AI.
Abin Shoby, Lyle John Palmer, Nikhil Cherian Kurian
Medical image classifiers are often trained within one source population, yet clinical deployment requires robustness to patients whose appearance, acquisition style, and disease prevalence differ from the source cohort. Existing fairness and robustness methods often require group supervision or treat appearance variation as an undifferentiated nuisance, which is insufficient when population-correlated low-level cues and lesion evidence share edge and texture structure. We study a strict source-only cross-population setting, where external populations are unseen during optimization, validation, scheduling, hyperparameter and model selection. We propose RED-Sphere, a plug-and-play robustness framework for image classification under unseen population shifts. It estimates shortcut-sensitive nuisance responses with an edge and feature energy prior, attenuates dominant responses through residual soft gating, regularizes masked nuisance views with counterfactual-inspired consistency and separation losses, and predicts labels with normalized spherical prototypes. It favours angular semantic evidence over source-correlated activation magnitude while preserving lesion structure. Although demonstrated on 2D Scanning Laser Ophthalmoscopy (SLO) fundus classification for Age-Related Macular Degeneration (AMD) and Diabetic Retinopathy (DR), RED-Sphere is not tied to retinal anatomy: the same principle can be adapted with modality-specific nuisance priors wherever appearance shortcuts and semantic evidence are entangled. Under a strict White-only Harvard-FairVision protocol, RED-Sphere improves held-out macro-F1 across all 20 task and backbone comparisons, with average gains of 1.28 and 2.98 F1 points on AMD and DR. Gains in AUC and PR-AUC, visual diagnostics, ablations, and sensitivity analyses further support stronger external semantic alignment and more stable angular disease geometry.