TRUST: Threshold-Recalibrated Uncertainty-Safe Training for Certified Dismissal in Breast Cancer Screening

Reducing the review of clearly cancer-negative screening mammograms could lower radiologist workload without compromising cancer detection. We propose a closed-loop threshold-aware training strategy in which the dismissal threshold is recalculated during training and used to penalize cancer-positive images that approach the dismissal region. We evaluated the method on NLBS and RSNA using five controlled training configurations, with case-level assessment based on a one-sided 99\% Clopper--Pearson upper bound for cancer prevalence among dismissed cases. The proposed model achieved the highest case-level dismissal rates at both 98\% and 95\% recall targets. On NLBS, dismissal reached 19.74\% and 21.70\%, while the cross-entropy baseline did not meet either recall target. On RSNA, dismissal improved from 7.04\% to 14.31\% and from 13.49\% to 19.69\%. In external RSNA$\to$NLBS evaluation, the proposed model achieved dismissal rates of 12.95\% and 19.87\% at the 98\% and 95\% recall targets, respectively. These results support closed-loop threshold-aware training for high-recall selective dismissal.

Re-thinking Mammography Transfer Learning: The Dataset-Informed Transfer Learning (DITL) Framework for Breast Cancer Screening and Lesion Diagnosis

Enhancing classification performance in mammography remains a persistent challenge across both small curated datasets and large-scale clinical cohorts. Conventional transfer learning approaches often neglect dataset-specific characteristics, while recent neighborhood-informed methods have been restricted to narrow tasks with rigid formulations, limiting their scalability to population-level datasets. To address these challenges, we propose the Dataset-Informed Transfer Learning (DITL) framework, which integrates dataset-derived difficulty signals with neighborhood-based triplet supervision in a unified objective. DITL introduces two adaptive components: (i) Adaptive Difficulty-Weighted Cross-Entropy (A-DWCE), which assigns per-sample weights based on k-nearest neighbor label purity in a self-supervised feature space, and (ii) Adaptive Neighborhood Representation Triplet (A-NR-Triplet), which enforces intra-class compactness and inter-class separation using a learnable margin. Unlike focal loss, DITL requires no hyperparameter tuning, removes heuristic weighting and fixed margins, and incurs negligible computational overhead, yielding a robust and scalable optimization strategy. On the large-scale VinDR-Mammo dataset, DITL achieves state-of-the-art performance for whole-image breast density classification, with significant improvements across accuracy, F1-score, and AUC (p < 0.0001). Beyond large cohorts, DITL also delivers consistent, statistically significant gains on small ROI datasets (p < 0.0001). By bridging small-scale lesion analysis with large-scale density estimation, DITL establishes a clinically relevant, scalable, and generalizable framework for mammography classification, spanning the full breast cancer screening-to-diagnosis spectrum.