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Patient-specific rubric-based evaluation of large language models across longitudinal cancer care

Wei-Wei Zhang, Pengkai Wang, Yan Li, Zhijie Sang, Guan-Qun Zhou, Jun-Yan Li, Shu-Han Zhou, Pei-Wen Liu, Ting-Xi Tang, Min Tang, Zhitian Hou, Jianmin Wu, + 4 more

Abstract

Large language models (LLMs) show promise in specialty medicine, yet existing evaluations largely focus on isolated clinical encounters rather than tracking how clinical responsibilities evolve across a longitudinal care pathway. Here we introduce NPC-RubricBench, a phase-aware benchmark for evaluating multistage clinical reasoning across the cancer care continuum, using nasopharyngeal carcinoma as a defined disease context. Curated from longitudinal records of 405 patients across two cancer centers, the benchmark comprises 941 patient-phase units across six sequential care phases and 17,688 patient-specific atomic criteria spanning five evaluation dimensions, with each assessment strictly restricted to decision-time clinical evidence. Evaluating 30 general-purpose and medical LLMs revealed that strong diagnostic performance does not carry over to downstream care. We evaluated 30 general-purpose and medical LLMs, showing that high diagnostic performance did not translate into improved downstream care. Instead, the dominant failure modes reversed across phases. Explicit decision errors dominated anatomical staging at 48.2%, whereas decision omissions dominated initial work-up and post-treatment follow-up at 33.4% and 30.4%, respectively. In the evaluated model set, medically adapted models showed higher omission rates than general-purpose models. Moreover, varying query granularity exposes a critical specification trade-off: broad open-ended requests degrade Decision Quality across all 30 models, while more detailed, checklist-like prompts raise Decision Quality but reduce Evidence Faithfulness and Safety Adherence. Furthermore, NPC-RubricBench demonstrates that static diagnostic benchmarks are insufficient to ensure consistent clinical reliability over time, highlighting the importance of phase-adaptive safeguards in multistage medical AI.

Filed underevaluationllm

We introduce Heads of Security (HoS), a prompt injection defense that enforces instruction-data separation via a small set of learned per-head attention gates. HoS learns how each head should redistribute attention between trusted and untrusted tokens, enabling models to reason over untrusted content without following injected instructions. We evaluate HoS on Llama-3.3-70B-Instruct and GPT-OSS-20B. We compare it against SecAlign++, a state-of-the-art finetuning-based defense, and ASIDE, a defense that, like ours, builds instruction-data separation into the model architecture. We show that HoS offers greater robustness to adaptive attacks, better performance on standard utility benchmarks, and matches top performance on standard agentic prompt injection benchmarks. More specifically, the black-box RL-Hammer attack reaches 97% ASR against GPT-OSS-20B and 85% against SecAlign, but only 10% against HoS. Claudini, a state-of-the-art white-box attack, strengthened against HoS through autoresearch, requires 3 times more FLOPs to reach the same ASR on HoS as it does on GPT-OSS-20B or SecAlign. HoS preserves base-model utility across standard multiple-choice benchmarks and prompting setups, whereas SecAlign and ASIDE degrade in few-shot settings. On agentic benchmarks with static attacks, HoS and SecAlign perform similarly and substantially improve the security-utility trade-off over the base model. ASIDE struggles with tool use, achieving only 10% utility. These results show that prompt injection robustness can be achieved and improved through targeted attention interventions.

Igor Shilov, Xiaoxue Yang +7

Large Language Models (LLMs) are increasingly used in multi-turn agentic workloads that require sustained interaction with complex environments. Existing reflective prompt optimizers such as GEPA learn from failed rollouts, but agentic failures can also come from prompt weaknesses, harness limitations, stochastic execution, or noisy judges. We argue that such failures may not provide useful learning signal, and may even be harmful; and thus it is essential to curate which tasks are provided to the prompt optimizer for better performance. We introduce GEPA-Curator, a framework that augments the prompt optimizer to select which agent experiences should shape prompt optimization. In particular, GEPA-Curator consists of two components: task curation, which filters out tasks that are likely to provide noisy or unreliable learning signals, and prior success retrieval, which selectively retrieves past successful trajectories for a task and provides them as additional context to the prompt optimizer. We evaluate GEPA-Curator on GoBrowse, ALFWorld, AppWorld, and $τ$-bench, using both Gemini 3.1 Pro and Claude Opus 5 as optimizer models. GEPA-Curator matches or exceeds the mean performance of both baselines, with gains of up to 20.7% over GEPA and 21.2% over ACE.

Zack Yu, Nicholas Lee +9

We explore how to build performant large language model (LLM) tool-use agents that complete complex, multi-step tasks. Specifically, we study how data composition in synthetically generated tool-use environments affects the training of such agents. To do so, we propose the SynthAPI pipeline, which explicitly controls the diversity of generated environments along the axes of tools, tasks, and the databases on which the tools operate. By systematically varying SynthAPI's generation controls in 458,752 tasks across 849 trained models of four different sizes, we derive a scaling law that predicts downstream tool-use agent generalization based on the scale and composition of the synthesized environments. These predictable relationships reveal several lessons for scaling tool-use agent data. As data budgets grow, scaling tool and database diversity becomes more effective than increasing the number of tasks, and increasing data complexity yields larger gains. Scaling according to these findings yields agents that outperform models trained on data from prior work in large-scale tool-use agent and synthetic environment generation across four evaluation benchmarks.

Andrew Szot, Samira Abnar +6