Justin M Ko, MD MBA

All Publications

• Dermatologist-level classification of skin cancer with deep neural networks. Nature Esteva, A., Kuprel, B., Novoa, R. A., Ko, J., Swetter, S. M., Blau, H. M., Thrun, S. 2017; 542 (7639): 115-118

  Abstract

  Skin cancer, the most common human malignancy, is primarily diagnosed visually, beginning with an initial clinical screening and followed potentially by dermoscopic analysis, a biopsy and histopathological examination. Automated classification of skin lesions using images is a challenging task owing to the fine-grained variability in the appearance of skin lesions. Deep convolutional neural networks (CNNs) show potential for general and highly variable tasks across many fine-grained object categories. Here we demonstrate classification of skin lesions using a single CNN, trained end-to-end from images directly, using only pixels and disease labels as inputs. We train a CNN using a dataset of 129,450 clinical images-two orders of magnitude larger than previous datasets-consisting of 2,032 different diseases. We test its performance against 21 board-certified dermatologists on biopsy-proven clinical images with two critical binary classification use cases: keratinocyte carcinomas versus benign seborrheic keratoses; and malignant melanomas versus benign nevi. The first case represents the identification of the most common cancers, the second represents the identification of the deadliest skin cancer. The CNN achieves performance on par with all tested experts across both tasks, demonstrating an artificial intelligence capable of classifying skin cancer with a level of competence comparable to dermatologists. Outfitted with deep neural networks, mobile devices can potentially extend the reach of dermatologists outside of the clinic. It is projected that 6.3 billion smartphone subscriptions will exist by the year 2021 (ref. 13) and can therefore potentially provide low-cost universal access to vital diagnostic care.

  View details for DOI 10.1038/nature21056

  View details for PubMedID 28117445

• Crowdsourcing dermatology: DataDerm, big data analytics, and machine learning technology. Journal of the American Academy of Dermatology Park, A. J., Ko, J. M., Swerlick, R. A. 2017

  View details for DOI 10.1016/j.jaad.2017.08.053

  View details for PubMedID 29042152

• Safety and efficacy of the JAK inhibitor tofacitinib citrate in patients with alopecia areata. JCI insight Kennedy Crispin, M., Ko, J. M., Craiglow, B. G., Li, S., Shankar, G., Urban, J. R., Chen, J. C., Cerise, J. E., Jabbari, A., Winge, M. C., Marinkovich, M. P., Christiano, A. M., Oro, A. E., King, B. A. 2016; 1 (15)

  Abstract

  Alopecia areata (AA) is an autoimmune disease characterized by hair loss mediated by CD8(+) T cells. There are no reliably effective therapies for AA. Based on recent developments in the understanding of the pathomechanism of AA, JAK inhibitors appear to be a therapeutic option; however, their efficacy for the treatment of AA has not been systematically examined.This was a 2-center, open-label, single-arm trial using the pan-JAK inhibitor, tofacitinib citrate, for AA with >50% scalp hair loss, alopecia totalis (AT), and alopecia universalis (AU). Tofacitinib (5 mg) was given twice daily for 3 months. Endpoints included regrowth of scalp hair, as assessed by the severity of alopecia tool (SALT), duration of hair growth after completion of therapy, and disease transcriptome.Of 66 subjects treated, 32% experienced 50% or greater improvement in SALT score. AA and ophiasis subtypes were more responsive than AT and AU subtypes. Shorter duration of disease and histological peribulbar inflammation on pretreatment scalp biopsies were associated with improvement in SALT score. Drug cessation resulted in disease relapse in 8.5 weeks. Adverse events were limited to grade I and II infections. An AA responsiveness to JAK/STAT inhibitors score was developed to segregate responders and nonresponders, and the previously developed AA disease activity index score tracked response to treatment.At the dose and duration studied, tofacitinib is a safe and effective treatment for severe AA, though it does not result in a durable response. Transcriptome changes reveal unexpected molecular complexity within the disease.ClinicalTrials.gov NCT02197455 and NCT02312882.This work was supported by the US Department of Veterans Affairs Office of Research and Development, National Institute of Arthritis and Musculoskeletal and Skin Diseases National Institutes of Health grant R01 AR47223 and U01 AR67173, the National Psoriasis Foundation, the Swedish Society of Medicine, the Fernström Foundation, the Locks of Love Foundation, the National Alopecia Areata Foundation, and the Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research.

  View details for PubMedID 27699252

  View details for PubMedCentralID PMC5033755

• Implementation and evaluation of Stanford Health Care direct-care teledermatology program. SAGE open medicine Pathipati, A. S., Ko, J. M. 2016; 4: 2050312116659089-?

  Abstract

  Teledermatology has proven to be an effective means of providing dermatologic care. The existing research has primarily evaluated its usefulness in a consultative model. Few academic centers have evaluated a patient-initiated model, and direct-to-consumer services remain the subject of controversy. Stanford Health Care recently launched a direct-care, patient-initiated teledermatology pilot program. This article evaluates the viability and patient satisfaction with this service.During the pilot period, patients were able to seek remote dermatologic care using an eVisit tool in their MyHealth account. Patients initiated the consultation, answered questions regarding their complaint, and uploaded a picture if relevant. A Stanford dermatologist reviewed each eVisit and responded with an assessment and plan. The dermatologist noted whether they were able to make a diagnosis and their level of confidence in it. After the study, 10 patients participated in a focus group to provide feedback on the service.In all, 38 patients sought care during the pilot period. A dermatologist was able to make a diagnosis in 36 of 38 (95%) cases, with an average confidence level of 7.9 of 10. The average time to consultation was 0.8 days. Patients indicated high levels of satisfaction with the service although they had suggestions for improvement.Patients provided clinically useful images and information in a direct-care teledermatology model. Such services allow dermatology providers to increase access while maintaining high-quality care in an academic medical center. Further research is needed on standalone services that cannot integrate encounters with the patient's existing medical record.

  View details for DOI 10.1177/2050312116659089

  View details for PubMedID 27493756

  View details for PubMedCentralID PMC4959300

• A new era: melanoma genetics and therapeutics JOURNAL OF PATHOLOGY Ko, J. M., Fisher, D. E. 2011; 223 (2): 241-250

  Abstract

  We have recently witnessed an explosion in our understanding of melanoma. Knowledge of the molecular basis of melanoma and the successes of targeted therapies have pushed melanoma care to the precipice of a new era. Identification of significant pathways and oncogenes has translated to the development of targeted therapies, some of which have produced major clinical responses. In this review, we provide an overview of selected key pathways and melanoma oncogenes as well as the targeted agents and therapeutic approaches whose successes suggest the promise of a new era in melanoma and cancer therapy. Despite these advances, the conversion of transient remissions to stable cures remains a vital challenge. Continued progress towards a better understanding about the complexity and redundancy responsible for melanoma progression may provide direction for anti-cancer drug development.

  View details for DOI 10.1002/path.2804

  View details for Web of Science ID 000285554600013

  View details for PubMedID 21125678

• Pathways to Melanoma SEMINARS IN CUTANEOUS MEDICINE AND SURGERY Ko, J. M., Velez, N. F., Tsao, H. 2010; 29 (4): 210-217

  Abstract

  Melanoma is one of the most aggressive and yet poorly understood of human malignancies. Advances in genomics has allowed a more nuanced understanding of the disease, moving beyond the traditional dysplastic nevus-to-melanoma model and identifying multiple divergent oncogenic pathways leading to melanoma. An understanding of the molecular mechanisms driving melanoma has opened the doors for the development of targeted therapeutic approaches. As we enter the era of personalized medicine, it will be critical for clinicians to both appreciate and be able to determine the molecular profile of their patients' melanoma because this profile will guide risk stratification, genetic counseling, and treatment customization. A review of the divergent pathways of melanoma development is presented here, with a particular emphasis on recently identified mutations, and their implications for patient care.

  View details for DOI 10.1016/j.sder.2010.10.004

  View details for Web of Science ID 000287382200003

  View details for PubMedID 21277534

• Skin and bone: the pathogenetic relationship between psoriasis and psoriatic arthritis GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA Ko, J. M., QURESHI, A. W. 2010; 145 (3): 393-406

  Abstract

  Our current understanding of the relationship between psoriasis and psoriatic arthritis remains incomplete, though the evidence from the clinical setting, response to therapeutics, epidemiology, genetics, imaging, and immunopathologic models suggest that they make likely share a common pathogenesis. Psoriatic disease can no longer be thought of as a condition limited to skin and joints. Rather, it must be considered a multi-faceted disorder in which systemic inflammation plays a central role. There is now convincing evidence that individuals with psoriasis have a higher prevalence of co-morbid disease, particularly cardiovascular risk factors, metabolic disorders, and other immune-mediated inflammatory diseases. The cutaneous manifestations of psoriasis place dermatologists in a crucial and privileged role--one that affords us the potential for early detection of associated co-morbid conditions through screening and perhaps impact disease course and clinical outcomes.

  View details for Web of Science ID 000279937700007

  View details for PubMedID 20461047

• Paying for Enhanced Service Comparing Patients' Experiences in a Concierge and General Medicine Practice PATIENT-PATIENT CENTERED OUTCOMES RESEARCH Ko, J. M., Rodriguez, H. P., Fairchild, D. G., Rodday, A. M., Safran, D. G. 2009; 2 (2): 95-103

  Abstract

  Concierge medical practice is a relatively new and somewhat controversial development in primary-care practice. These practices promise patients more personalized care and dedicated service, in exchange for an annual membership fee paid by patients. The experiences of patients using these practices remain largely undocumented.To assess the experiences of patients in a concierge medicine practice compared with those in a general medicine practice.Stratified random samples of patients empanelled to each of the four doctors who practice at both a general medicine and a concierge medicine practice separately situated at an academic medical center were drawn. Patients were eligible for the study if they had a visit with the physician between January and May 2006. The study questionnaire (Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey, supplemented with items from the Ambulatory Care Experiences Survey) was administered by mail to 100 general medicine patients per physician (n = 400) and all eligible concierge medicine patients (n = 201). Patients who completed the survey and affirmed the study physician as their primary-care physician formed the analytic sample (n = 344) that was used to compare the experiences of concierge medicine and general medicine patients. Models controlled for respondent characteristics and accounted for patient clustering within physicians using physician fixed effects.Patients' experiences with organizational features of care, comprising care co-ordination (p < 0.01), access to care (p < 0.001) and interactions with office staff (p < 0.001), favored concierge medicine over general medicine practice. The quality of physician-patient interactions did not differ significantly between the two groups. However, the patients of the concierge medicine practice were more likely to report that their physician spends sufficient time in clinical encounters than patients of the general medicine practice (p < 0.003).The results suggest patients of the concierge medicine practice experienced and reported enhanced service, greater access to care, and better care co-ordination than those of the general medicine practice. This suggests that further study to understand the etiology of these differences may be beneficial in enhancing patients' experience in traditional primary-care practices.

  View details for DOI 10.2165/01312067-200902020-00005

  View details for Web of Science ID 000208001400005

  View details for PubMedID 22273085

• Induction and exacerbation of psoriasis with TNF-blockade therapy: A review and analysis of 127 cases JOURNAL OF DERMATOLOGICAL TREATMENT Ko, J. M., Gottlieb, A. B., Kerbleski, J. F. 2009; 20 (2): 100-108

  Abstract

  There are reports of rare adverse effects of tumor necrosis factor (TNF) inhibitors, including infections, malignancies, and induction of autoimmune conditions. Intriguing, are cases of induction or exacerbation of psoriasis in conjunction with TNF inhibitor therapy, given that they are approved for treatment of the same condition. Objective: Published cases of psoriasis occurring during anti-TNF therapy were analyzed, including overviews of proposed etiologies and treatment recommendations.A literature search using Ovid MEDLINE and PubMed was performed for articles published between January 1990 and September 2007 to collect reported cases of psoriasis in patients receiving therapy with TNF blocking agents.A total of 127 cases were identified: 70 in patients on infliximab (55.1%), 35 with etanercept (27.6%), and 22 with adalimumab (17.3%). Females comprised 58% of cases; mean age of reported patients was 45.8 years, and the time from initiation of treatment to onset of lesions averaged 10.5 months. These patients suffered from a number of primary conditions, with rheumatoid arthritis, ankylosing spondylitis, and Crohn's disease accounting for the vast majority. Palmoplantar pustular psoriasis was observed in 40.5% of the cases, with plaque-type psoriasis in 33.1%, and other types comprising the remainder. Topical corticosteroids were the most commonly employed treatment modality but led to resolution in only 26.8% of cases in which they were employed solely. Switching to a different anti-TNF agent led to resolution in 15.4% of cases. Cessation of anti-TNF therapy with systemic therapy led to resolution in 64.3% of cases.More information and cases are needed. Biopsies of TNF-blockade-induced lesions may reveal what cytokines and cell types drive the development of these lesions. Additionally, there is a need to develop an algorithm to treat this paradoxical side effect of therapy with TNF-blockers.

  View details for DOI 10.1080/09546630802441234

  View details for Web of Science ID 000264554200008

  View details for PubMedID 18923992

• Prospective assessment of computer-aided detection in interpretation of screening mammography AMERICAN JOURNAL OF ROENTGENOLOGY Ko, J. M., Nicholas, M. J., Mendel, J. B., Slanetz, P. J. 2006; 187 (6): 1483-1491

  Abstract

  The purpose of this study was to prospectively assess the usefulness of computer-aided detection (CAD) in the interpretation of screening mammography and to provide the true sensitivity and specificity of this technique in a clinical setting.Over a 26-month period, 5,016 screening mammograms were interpreted without, and subsequently with, the assistance of the iCAD MammoReader detection system. Data collected for actionable findings included dominant feature (calcification, mass, asymmetry, architectural distortion), detection method (radiologist only, CAD only, or both radiologist and CAD), BI-RADS assessment code, associated histopathology for those undergoing biopsy, and tumor stage for malignant lesions. The study population was cross-checked against an independent reference standard to identify false-negative cases.Of the 5,016 cases, the recall rate increased from 12% to 14% with the addition of CAD. Of the 107 (2%) patients who underwent biopsy, 101 (94%) were prompted by the radiologist and six (6%) were prompted by CAD. Of the 124 biopsies performed on actionable findings in the 107 patients, findings in 79 (64%) were benign and in 45 (36%) were in situ or invasive carcinoma. Three study participants who were not recalled by the radiologist with the assistance of CAD developed cancer within 1 year of the screening mammogram and were considered to be false-negative cases. The radiologist detected 43 (90%) of the 48 total malignancies and 45 (94%) of the 48 malignancies with the assistance of CAD. CAD missed eight cancers that were detected by the radiologist, which presented as architectural distortions (n = 3), irregular masses (n = 4), and a circumscribed mass (n = 1). CAD detected two in situ cancers as a faint cluster of calcifications that had not been perceived by the radiologist and one mass that was dismissed by the radiologist, accounting for at least a 4.7% increase in cancer detection rate. Sensitivity of screening mammography with the use of CAD (94%) represented an absolute and relative 4% increase over the sensitivity of the radiologist alone (90%). Specificity of screening mammography with and without the use of CAD was 99%.Routine use of CAD while interpreting screening mammograms significantly increases recall rates, has no significant effect on positive predictive value for biopsy, and can increase cancer detection rate by at least 4.7% and sensitivity by at least 4%. This study provides "true" values for sensitivity and specificity for use of CAD in interpretation of screening mammography as measured prospectively in the context of a working clinical setting.

  View details for DOI 10.2214/AJR.05.1582

  View details for Web of Science ID 000242289200017

  View details for PubMedID 17114541

• A case and review of congenital leukonychia. Dermatology online journal Pathipati, A. S., Ko, J. M., Yost, J. M. 2016; 22 (10)

  Abstract

  Leukonychia refers to a white discoloration of the nails. Although several conditions may cause white nails, a rare, isolated, congenital form of the disease is hypothesized to stem from disordered keratinization of the nail plate. Herein, we report a case of a 41-year-old woman with congenital leukonychia and review prior cases.

  View details for PubMedID 28329587

• Validation of a Skin-Lesion Image-Matching Algorithm Based on Computer Vision Technology TELEMEDICINE AND E-HEALTH Chen, R. H., Snorrason, M., Enger, S. M., Mostafa, E., Ko, J. M., Aoki, V., Bowling, J. 2016; 22 (1): 45-50

  View details for DOI 10.1089/tmj.2014.0249

  View details for Web of Science ID 000368448900007

• Randomized Controlled Trial of Cryotherapy With Liquid Nitrogen vs Topical Salicylic Acid vs Wait-and-See for Cutaneous Warts ARCHIVES OF DERMATOLOGY Ko, J., Bigby, M. 2012; 148 (7): 840-842

  View details for Web of Science ID 000306417100014

  View details for PubMedID 22801618

• A Randomized, Prospective Trial Evaluating Surgeon Preference in Selection of Absorbable Suture Material JOURNAL OF DRUGS IN DERMATOLOGY Lu, L. K., Ko, J. M., Lee, J., Krum, D. M., Price, L. L., Finn, D., Lee, D., Rogers, G. S. 2012; 11 (2): 196-201

  Abstract

  This study is the first double-blinded, randomized comparison of two absorbable sutures. To better understand product characteristics and surgeon preference, we conducted a study of two similar-appearing FDA-approved sutures, glyconate and poliglecaprone 25. Four dermatologic surgeons were enlisted. A total of 48 patients with 53 surgical sites were examined. One half of each surgical wound was closed with one type of suture and the other half with the other type. Each half was evaluated for product characteristics. There was no statistically significant difference in surgeon preference for glyconate versus poliglecaprone 25 (P=0.64). Of the cohort preferring poliglecaprone 25, there was a correlation with speed of closure (P=0.06). Of the surgeons that preferred glyconate, we found significantly better visibility (P=0.03), reduced suture breakage during knot tying (P=0.05), and correlation with better handling properties (P=0.06) associated with that preference. The data from this study will enable products to be designed towards these needs and allow surgeons to select sutures that more precisely fit their particular requirements.

  View details for Web of Science ID 000299965700009

  View details for PubMedID 22270202