Nathaniel S. O'Connell

Ziyu Su, Yongxin Guo, Robert Wesolowski et al.

Accurate recurrence risk stratification is crucial for optimizing treatment plans for breast cancer patients. Current prognostic tools like Oncotype DX (ODX) offer valuable genomic insights for HR+/HER2- patients but are limited by cost and accessibility, particularly in underserved populations. In this study, we present Deep-BCR-Auto, a deep learning-based computational pathology approach that predicts breast cancer recurrence risk from routine H&E-stained whole slide images (WSIs). Our methodology was validated on two independent cohorts: the TCGA-BRCA dataset and an in-house dataset from The Ohio State University (OSU). Deep-BCR-Auto demonstrated robust performance in stratifying patients into low- and high-recurrence risk categories. On the TCGA-BRCA dataset, the model achieved an area under the receiver operating characteristic curve (AUROC) of 0.827, significantly outperforming existing weakly supervised models (p=0.041). In the independent OSU dataset, Deep-BCR-Auto maintained strong generalizability, achieving an AUROC of 0.832, along with 82.0% accuracy, 85.0% specificity, and 67.7% sensitivity. These findings highlight the potential of computational pathology as a cost-effective alternative for recurrence risk assessment, broadening access to personalized treatment strategies. This study underscores the clinical utility of integrating deep learning-based computational pathology into routine pathological assessment for breast cancer prognosis across diverse clinical settings.

Nathaniel S. O'Connell

We develop a finite-sample, design-based theory for random forests in which each tree is a randomized conditional predictor acting on fixed covariates and the forest is their Monte Carlo average. An exact variance identity separates Monte Carlo error from a covariance floor that persists under infinite aggregation. The floor arises through two mechanisms: observation reuse, where the same training outcomes receive weight across multiple trees, and partition alignment, where independently generated trees discover similar conditional prediction rules. We prove the floor is strictly positive under minimal conditions and show that alignment persists even when sample splitting eliminates observation overlap entirely. We introduce procedure-aligned synthetic resampling (PASR) to estimate the covariance floor, decomposing the total prediction uncertainty of a deployed forest into interpretable components. For continuous outcomes, resulting prediction intervals achieve nominal coverage with a theoretically guaranteed conservative bias direction. For classification forests, the PASR estimator is asymptotically unbiased, providing the first pointwise confidence intervals for predicted conditional probabilities from a deployed forest. Nominal coverage is maintained across a range of design configurations for both outcome types, including high-dimensional settings. The underlying theory extends to any tree-based ensemble with an exchangeable tree-generating mechanism.