Abstract
BACKGROUND: Early and precise diagnosis is vital to improving patient outcomes and reducing morbidity. In resource-limited settings, cancer diagnosis is often challenging due to shortages of expert pathologists. We assess the effectiveness of general-purpose pathology foundation models (FM) for the diagnosis and annotation of nonmelanoma skin cancer (NMSC) in resource-limited settings. METHODS: We evaluated three pathology FMs (UNI, PRISM, and Prov-GigaPath) using deidentified NMSC histology images from the Bangladesh Vitamin E and Selenium Trial to predict cancer subtype based on zero-shot whole-slide embeddings. In addition, we evaluated tile aggregation methods and machine learning models for prediction. Lastly, we employed few-shot learning of PRISM tile embeddings to perform whole-slide annotation. RESULTS: We found that the best model used PRISM's aggregated tile embeddings to train a multilayer perceptron model to predict NMSC subtype [mean area under the receiver operating characteristic curve (AUROC) = 0.925, P < 0.001]. Within the other FMs, we found that using attention-based multi-instance learning to aggregate tile embeddings to train a multilayer perceptron model was optimal (UNI: mean AUROC = 0.913, P < 0.001; Prov-GigaPath: mean AUROC = 0.908, P < 0.001). We finally exemplify the utility of few-shot annotation in computation- and expertise-limited settings. CONCLUSIONS: Our study highlights the important role FMs may play in confronting public health challenges and exhibits a real-world potential for machine learning-aided cancer diagnosis. IMPACT: Pathology FMs offer a promising pathway to improve early and precise NMSC diagnosis, especially in resource-limited environments. These tools could also facilitate patient stratification and recruitment for prospective clinical trials aimed at improving NMSC management.