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Objectives To determine if predictions of the Lung Cancer Prediction convolutional neural network (LCP-CNN) artificial intelligence (AI) model are analogous to the Brock model. Methods In total, 10,485 lung nodules in 4660 participants from the National Lung Screening Trial (NLST) were analysed. Both manual and automated nodule measurements were inputted into the Brock model, and this was compared to LCP-CNN. The performance of an experimental AI model was tested after ablating imaging features in a manner analogous to removing predictors from the Brock model. First, the nodule was ablated leaving lung parenchyma only. Second, a sphere of the same size as the nodule was implanted in the parenchyma. Third, internal texture of both nodule and parenchyma was ablated. Results Automated axial diameter (AUC 0.883) and automated equivalent spherical diameter (AUC 0.896) significantly improved the accuracy of Brock when compared to manual measurement (AUC 0.873), although not to the level of the LCP-CNN (AUC 0.936). Ablating nodule and parenchyma texture (AUC 0.915) led to a small drop in AI predictive accuracy, as did implanting a sphere of the same size as the nodule (AUC 0.889). Ablating the nodule leaving parenchyma only led to a large drop in AI performance (AUC 0.717). Conclusions Feature ablation is a feasible technique for understanding AI model predictions. Nodule size and morphology play the largest role in AI prediction, with nodule internal texture and background parenchyma playing a limited role. This is broadly analogous to the relative importance of morphological factors over clinical factors within the Brock model. Key Points •  Brock lung cancer risk prediction accuracy was significantly improved using automated axial or equivalent spherical measurements of lung nodule diameter, when compared to manual measurements . •  Predictive accuracy was further improved by using the Lung Cancer Prediction convolutional neural network, an artificial intelligence-based model which obviates the requirement for nodule measurement . •  Nodule size and morphology are important factors in artificial intelligence lung cancer risk prediction, with nodule texture and background parenchyma contributing a small, but measurable, role .

Developing an understanding of artificial intelligence lung nodule risk prediction using insights from the Brock model