AI, AI, Oh! Oncologists face the rise of the machines

Artificial intelligence (AI) is making rapid advancements in medicine, including oncology—with ChatGPT, perhaps, grabbing the most headlines of the day. But for all its promise and potential, AI has also unleashed a wave of less savory sentiments in the medical community, from apprehension and skepticism, to outright mistrust, and even fear.

The current state of AI in oncology

Back in 2012, when IBM launched its landmark Watson for Oncology program, the notion of AI digital assistants—dare we call them robots?—seemed like the stuff of science fiction.

Although Watson was largely unsuccessful, AI-driven tools are now notably impacting various areas of oncology—from enhancing early detection and diagnosis through sophisticated imaging and screening algorithms, to rapidly analyzing and managing vast amounts of healthcare data for better HCP efficiency. 

One thing we know from our survey data: Today's oncologists are clearly intrigued by this burgeoning technology—nearly all of our survey respondents (95%) indicated they were somewhat or very interested in AI’s potential use in the diagnosis and treatment of cancer.

On the other hand, while new AI devices and software are already proving successful in the field, less than one-third of oncology specialists surveyed by MDLinx are currently using AI technologies in their practice.

Where is AI's impact most visible in oncology?

Cancer diagnosis—radiology and pathology specifically—are the areas where AI is having the most impact, according to experts.

"The most developed component of AI in oncology is diagnosis optimization. We're now using computer vision to help us find more things in pathology slides," says Arturo Loaiza-Bonilla, MD, MSEd, FACP. Dr. Loaiza-Bonilla is the medical director of oncology research at Capital Health in Pennington, New Jersey, and is on the faculty at Drexel University College of Medicine.

"In radiology, on average, a radiologist must interpret an image every three to four seconds to maintain the daily workflow. Clinicians also experience sustained inattentional blindness," he said. 

Dr. Loaiza-Bonilla's observation about the areas seeing the most impact from AI aligns with research. A 2022 analysis of AI-based, FDA-approved devices found cancer radiology to be the field with the largest number of AI devices—accounting for 54.9% of approved devices, followed by pathology with 19.7%.[1]

This popularity is mirrored in practice. Studies have revealed that some hospitals and point-of-care centers are already using radiologic AI products successfully. Moreover, radiologists who utilize AI in their practices are generally satisfied with their experience and gain value from its use. In fact, the majority of radiologists and residents anticipate substantial changes in the radiology profession over the next decade.[2]

Cancer screening, detection, and diagnosis

According to the American Cancer Society, screening mammograms fail to identify around 1 in 8 breast cancers, and about half of the women who get screenings over a 10-year period will have a false-positive finding.[3]

In an August 2023 study published in The Lancet, researchers conducted a clinical safety analysis of an AI-supported screen-reading protocol, compared with standard screen reading by radiologists following mammography.[4]  

In an earlier study, Google's AI system's performance was tested on mammograms of more than 25,000 women in the UK and 3,000 in the US. The 2020 study results indicated that Google's AI could identify breast cancers about as accurately as radiologists while reducing false-positives by 5.7% in the US group and 1.2% in the UK group. And when compared with the original radiologists' diagnoses, Google’s AI reduced the number of missed cases by 9.4% in the US group and 2.7% in the UK group.[5]

In 2021, the FDA approved Paige Prostate, an AI pathology tool designed to screen prostate biopsies and identify areas with a high likelihood of cancer. According to the FDA's news release at the time, prostate cancer detection improved by 7.3% on average when pathologists were assisted by the AI tool compared with when pathologists were unassisted.[6]

AI's areas of promise and potential

Data management and analysis

Data organization is the component of oncology where AI has the most promise now, according to Dr. Loaiza-Bonilla.

NLP tools provide a rich opportunity to uncover valuable insights into care quality and patient outcomes. Around 80% of medical data stays unstructured and untapped after its creation.[7] NLP tools can parse and transform unstructured text (clinical notes) from EHR data into actionable information, a process that would otherwise require significant and time-consuming manual effort.

Finally, researchers should use all available data to further advance precision oncology and enhance understanding of our complex biological systems, according to Dr. Loaiza-Bonilla. Datasets—omics, sequencing, EHRs—are continually increasing in volume, dimensionality, and complexity. AI has proven itself to be the only feasible means of continuing to collect, manage, and accurately analyze the ever-growing volume of health data.

Treatment planning, outcomes prediction, and monitoring

Researchers have been looking into using AI in image-based cancer treatment planning by developing algorithms that automatically segment tumors and healthy tissues in medical images.

An FDA-approved software that does this is the VBrain, which detects brain metastases and conducts segmentation for stereotactic radiosurgery.[8] 

Imaging-based ML models may also enable the prediction of future cancer outcomes, such as locoregional recurrence, distant recurrence, and mortality. For instance, different emerging image-based ML models can predict clinical outcomes such as overall survival and disease-free survival for pancreatic cancer patients.[9]

In the future, this information may power post-treatment surveillance and recurrence prevention strategies. Finally, using similar techniques as in cancer detection and diagnosis, AI can potentially monitor tumors—determining their stability or progression.

Precision medicine

Precision medicine applications for cancer typically rely on the detection of specific genetic variations and alterations. Now, AI tools are being developed to identify specific gene mutations from tumor pathology images as an alternative to traditional genomic sequencing that typically requires invasive biopsies. They are also accelerating drug discovery.[10]

Challenges and limitations of AI in oncology

Data access and quality 

Despite these benefits, concerns remain. AI relies on vast amounts of data, and the first hurdle in developing AI-based oncology tools is data accessibility. There's a lack of structured, cancer-related health data and standardization in the collection, storage, and sharing of existing structured health data in and between EHRs and digital health tools.

Getting quality data to develop and train AI-based models also poses a challenge. Data from retrospectively acquired datasets are usually the easiest to amass. Still, questions around their purity for use are raised because predetermined inclusion and exclusion criteria might lead to unconscious biases in newly developed AI algorithms.[11]

Practitioner concerns

"As clinicians, we're rightfully worried about the AI ‘black box’ phenomenon, which is basically that we don't know what's behind the algorithm," Dr. Loaiza-Bonilla says about HCP concerns that may hinder adoption. "How can we be sure that the decision process taking place is fully vetted by a professional with the requisite healthcare/patient care expertise?"

MDLinx survey data mirrors these concerns, with 64.3% of respondents citing accuracy and reliability as a concern of integrating AI into clinical practice, and 64.3% citing liability issues. Finally, half of respondents are concerned about the implications of major tech companies shaping current and future healthcare practices.

Clinicians may not be the only ones concerned with the potential for an algorithm to skew the facts—their patients could harbor these fears as well. Or worse, they may not even know AI is being used in their care. Approximately 60% of the physicians surveyed by MDLinx believe their patients are aware of AI tools being used in their oncological care; 36% were not sure.

Regulatory challenges

Integrating AI tools and devices in medical care delivery presents many regulatory challenges. Key challenges include:

• Establishing appropriate validation processes.

• Determining evidentiary standards.

• Addressing the dynamic nature of AI to evolve with continuous data input.

• Maintaining transparency in decision-making.

Additionally, regulatory agencies must tackle data privacy and security issues, and minimize the risks of bias and discrimination that could stem from inadequate or unrepresentative training data.

Currently in the US, the FDA classifies software intended to treat, diagnose, cure, mitigate, or prevent disease or other conditions as a medical device. Most AI-enabled products that fall under this medical device classification are specifically categorized as either Software as a Medical Device (SaMD) or Software in a Medical Device. However, a gap exists because there are AI-enabled software utilized in healthcare and life sciences excluded from the definition of a medical device and consequently not subject to the FDA's authority.[12]

Ethics and bias

Several challenges must be addressed to minimize bias and facilitate fairness in AI-powered oncology tools.

“The potential for bias in using AI in oncology really comes into play with clinical decision support tools. Does the AI tool take into account demographics that could affect outcomes?" Dr. Loaiza-Bonilla questions.

"It's always going to be important to include the right population of patients when building AI models. For instance, are we taking datasets from only fully insured patients or persons working or living around academic centers and using them as the ground benchmark? That may not reflect the population of patients living in more rural areas without access to clinical trials or even genomic testing, who may also be underinsured."

Integrating AI into oncology practice

AI use in oncology is still in its infancy. The majority of studies and research centers around developing valid methods and not on integrating these methods into clinical practice. There's still a long way to go in validating these methods, finding effective pathways for the clinical integration of the tools, educating clinicians on their benefits and disadvantages, and thoroughly assessing associated outcomes and costs.

Future outlook

Three-quarters of the physicians surveyed by MDLinx reported they expect AI technologies to become an “essential” part of their everyday practice, and the vast majority cited optimism for AI's role in cancer care in the future.

But others report concerns over the lack of human input. 

While this may be a version of the truth, AI is still in its nascent stages in many areas of oncology, and its potential to revolutionize cancer care remains immense. And while there are significant challenges facing the widespread adoption of AI in oncology, the potential benefits of this technology cannot be ignored. 

Healthcare professionals, patients, researchers, and policymakers must work together to ensure that AI is used responsibly and effectively in oncology and beyond.

"We should try to stay within the conversation around the development of AI tools," Dr. Loaiza-Bonilla advises healthcare professionals. "This way, we'll be on top of issues around ethics, bias, and decision quality."