# AI second reads to stop borderline lesions being upgraded to cancer

Source: https://onco.cc/ideas/idea-prev-pathology-ai-borderline-anchor/  
OnCo record `idea-prev-pathology-ai-borderline-anchor` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Whether a lesion is called precancer or cancer varies between pathologists, and over time the bar has drifted lower. AI reference reads could hold the line.

## Summary

Inter-observer disagreement is high for DCIS versus atypia, Gleason pattern 3 versus 4, and melanocytic lesions; diagnostic drift inflates incidence. Propose AI reference classifiers calibrated to historical outcome-linked cohorts, used as mandatory second reads for borderline categories, with discordance triggering expert review.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: AI second reads reduce upgrade rates of borderline lesions by at least 20% and reduce inter-laboratory variation without increasing subsequent invasive cancer.
- Rationale: Digital pathology AI already matches expert Gleason grading; anchoring to outcome-linked training sets counters drift.
- Proposed test: Multi-laboratory study comparing diagnosis rates with and without AI second read, with five-year outcome linkage.
- Maturity: early-clinical
- Actor: clinic

## Sources

- Bottleneck evidence (Overdiagnosis and false alarms): Welch & Black, Overdiagnosis in cancer (JNCI 2010): https://doi.org/10.1093/jnci/djq099

## Connected records

- fronts: [Diagnostics & Biomarkers](https://onco.cc/fronts/diagnostics/)
- technologies: [Digital pathology & AI](https://onco.cc/technologies/digital-pathology-ai/), [Pathology & radiology foundation models](https://onco.cc/technologies/pathology-foundation-model/)
- companies: [Paige AI](https://onco.cc/companies/paige/), [PathAI](https://onco.cc/companies/pathai/)
- bottlenecks: [AI that is built but not validated or deployed](https://onco.cc/bottlenecks/b-ai-validation/), [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/)
- key papers: [Overdiagnosis in cancer](https://onco.cc/key-papers/paper-welch-j-natl-cancer-inst/)

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