Understanding the PULSAR Effect in Combined Radiotherapy and Immunotherapy through Attention Mechanisms with a Transformer Model

PULSAR (personalized, ultra-fractionated stereotactic adaptive radiotherapy) is the adaptation of stereotactic ablative radiotherapy towards personalized cancer management. For the first time, we applied a transformer-based attention mechanism to investigate the underlying interactions between combined PULSAR and PD-L1 blockade immunotherapy based on a murine cancer model (Lewis Lung Carcinoma, LLC). The proposed approach is able to predict the trend of tumor volume change semi-quantitatively, and excels in identifying the potential causal relationships through both self-attention and cross-attention scores.

Performance Deterioration of Deep Learning Models after Clinical Deployment: A Case Study with Auto-segmentation for Definitive Prostate Cancer Radiotherapy

In the past decade, deep learning (DL)-based artificial intelligence (AI) has witnessed unprecedented success and has led to much excitement in medicine. However, many successful models have not been implemented in the clinic predominantly due to concerns regarding the lack of interpretability and generalizability in both spatial and temporal domains. In this work, we used a DL-based auto segmentation model for intact prostate patients to observe any temporal performance changes and then correlate them to possible explanatory variables. We retrospectively simulated the clinical implementation of our DL model to investigate temporal performance trends. Our cohort included 912 patients with prostate cancer treated with definitive radiotherapy from January 2006 to August 2021 at the University of Texas Southwestern Medical Center (UTSW). We trained a U-Net-based DL auto segmentation model on the data collected before 2012 and tested it on data collected from 2012 to 2021 to simulate the clinical deployment of the trained model starting in 2012. We visualize the trends using a simple moving average curve and used ANOVA and t-test to investigate the impact of various clinical factors. The prostate and rectum contour quality decreased rapidly after 2016-2017. Stereotactic body radiotherapy (SBRT) and hydrogel spacer use were significantly associated with prostate contour quality (p=5.6e-12 and 0.002, respectively). SBRT and physicians' styles are significantly associated with the rectum contour quality (p=0.0005 and 0.02, respectively). Only the presence of contrast within the bladder significantly affected the bladder contour quality (p=1.6e-7). We showed that DL model performance decreased over time in concordance with changes in clinical practice patterns and changes in clinical personnel.