Clinically Aware Learning: Ordinal Loss Improves Medical Image Classifiers

<b>Background:</b> BI-RADS (Breast Imaging Reporting and Data System) mammogram classification is central to early breast cancer detection. Despite being an ordinal scale that reflects increasing levels of malignancy suspicion, most models treat BI-RADS as a nominal task using cross-entropy loss, thereby disregarding the inherent class order. This mismatch between the clinical severity of misclassification and the model's optimization objective remains underexplored. <b>Methods:</b> We systematically evaluate whether incorporating ordinal-aware loss functions improves BI-RADS classification performance under controlled, architecture-fixed conditions and dataset imbalance. Using a unified training pipeline across multiple datasets, we compare ordinal losses to standard cross-entropy, analyzing the effect of dataset- and label-level balancing. Area under the receiver operating characteristic curve (AUROC) and macro-F1 scores are reported as averages over five seeds. <b>Results:</b> Balanced sampling across datasets during training led to statistically significant improvements. Ordinal loss functions, such as Earth Mover Distance (EMD), consistently achieved higher performance across multiple metrics compared to conventional cross-entropy approaches commonly reported in the literature. Improvements were particularly evident in reducing severe misclassifications, demonstrating that aligning the learning objective with the ordinal structure of BI-RADS enhances robustness and clinical relevance. <b>Conclusions:</b> Aligning the learning objective with the ordinal BI-RADS structure substantially improves classification accuracy without changing the underlying architecture. These findings emphasize the importance of loss design, regularization, and data-balancing strategies in medical AI, supporting more reliable breast cancer screening.