Background: Artificial intelligence can be trained to outperform dermatologists in image-based skin cancer diagnostics. However, the networks' sensitivity to biases and overfitting may hamper their clinical applicability. Objectives:The aim of this study was to explain the potential consequences of implementing convolutional neural networks for stand-alone melanoma diagnostics and skin lesion triage. Methods:In this algorithm validation study on retrospective data, we reproduced and evaluated the performance of state-of-the-art artificial intelligence (convolutional neural networks) for skin cancer diagnostics. The networks were trained on 25,331 annotated dermoscopic skin lesion images from an open-source data set (ISIC-2019) and tested using a novel data set (AISC-2021) consisting of 26,591 annotated dermoscopic skin lesion images. We tested the trained algorithms' ability to generalize to new data and their diagnostic performance in two simulations (melanoma diagnostics and skin lesion triage). Results: The trained algorithms performed significantly less accurate diagnostics on images of nevi, melanomas and actinic keratoses from the AISC-2021 data set than the ISIC-2019 data set (p < 0.003). Almost one-third (31.1%) of the melanomas were misclassified during the melanoma diagnostics simulation, irrespective of their Breslow thickness. Furthermore, the algorithms marked 92.7% of the lesions 'suspicious' during the triage simulation, which yielded a triage sensitivity and specificity of 99.7% and 8.2%, respectively. Conclusions: Although state-of-the-art artificial intelligence outperforms dermatologists on image-based skin lesion classification within an artificial

Most artificial intelligence (AI) research and innovations have concentrated in high-income countries, where imaging data, IT infrastructures and clinical expertise are plentiful. However, slower progress has been made in limited-resource environments where medical imaging is needed. For example, in Sub-Saharan Africa, the rate of perinatal mortality is very high due to limited access to antenatal screening. In these countries, AI models could be implemented to help clinicians acquire fetal ultrasound planes for the diagnosis of fetal abnormalities. So far, deep learning models have been proposed to identify standard fetal planes, but there is no evidence of their ability to generalise in centres with low resources, i.e. with limited access to high-end ultrasound equipment and ultrasound data. This work investigates for the first time different strategies to reduce the domain-shift effect arising from a fetal plane classification model trained on one clinical centre with high-resource settings and transferred to a new centre with low-resource settings. To that end, a classifier trained with 1792 patients from Spain is first evaluated on a new centre in Denmark in optimal conditions with 1008 patients and is later optimised to reach the same performance in five African centres (Egypt, Algeria, Uganda, Ghana and Malawi) with 25 patients each. The results show that a transfer learning approach for domain adaptation can be a solution to integrate small-size African samples with existing large-scale databases in developed countries. In particular, the model can be re-aligned and optimised to boost the performance on African populations by increasing the recall to $$0.92 \pm 0.04$$ 0.92 ± 0.04 and at the same time maintaining a high precision across centres. This framework shows promise for building new AI models generalisable across clinical centres with limited data acquired in challenging and heterogeneous conditions and calls for further research to develop new solutions for the usability of AI in countries with fewer resources and, consequently, in higher need of clinical support.