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Apr 17

Cost-effectiveness analysis for therapy sequence in advanced cancer: A microsimulation approach with application to metastatic prostate cancer

Purpose. Patients with advanced cancer may undergo multiple lines of treatment, switching therapies as their disease progresses. Motivated by a study of metastatic prostate cancer, we develop a microsimulation framework to study therapy sequence. Methods. We propose a discrete-time state transition model to study two lines of anti-cancer therapy. Based on digitized published progression-free survival (PFS) and overall survival (OS) curves, we infer event types (progression or death), and estimate transition probabilities using cumulative incidence functions with competing risks. Our model incorporates within-patient dependence over time, such that response to first-line therapy informs subsequent event probabilities. Parameters governing the degree of within-patient dependence can be used to calibrate the model-based results to those of a target trial. We demonstrate these methods in a study of two therapy sequences for metastatic prostate cancer, where Docetaxel (DCT) and Abiraterone Acetate (AA) are both appropriate for use in either first or second line treatment. We assess costs, Quality-Adjusted Life Years (QALYs) and Incremental Cost Effectiveness Ratio (ICER) for two treatment strategies: DCT then AA vs AA then DCT. Results. Using digitized survival curves from relevant clinical trials, we identified 8.6-13.9% of PFS times that should be categorized as deaths, allowing for estimation of cumulative incidence functions. Models assuming within-patient independence overestimated OS time, corrected with our calibration approach. Correction resulted in meaningful changes in the difference in QALYs between treatment strategies (0.07 vs 0.15) and the ICER (-\76,836/QALY vs -21,030/QALY). Conclusions. Microsimulation models can be successfully used to study cost-effectiveness of therapy sequences, taking care to account correctly for within-patient dependence.

  • 5 authors
·
Oct 10, 2022

InT: Self-Proposed Interventions Enable Credit Assignment in LLM Reasoning

Outcome-reward reinforcement learning (RL) has proven effective at improving the reasoning capabilities of large language models (LLMs). However, standard RL assigns credit only at the level of the final answer, penalizing entire reasoning traces when the outcome is incorrect and uniformly reinforcing all steps when it is correct. As a result, correct intermediate steps may be discouraged in failed traces, while spurious steps may be reinforced in successful ones. We refer to this failure mode as the problem of credit assignment. While a natural remedy is to train a process reward model, accurately optimizing such models to identify corrective reasoning steps remains challenging. We introduce Intervention Training (InT), a training paradigm in which the model performs fine-grained credit assignment on its own reasoning traces by proposing short, targeted corrections that steer trajectories toward higher reward. Using reference solutions commonly available in mathematical reasoning datasets and exploiting the fact that verifying a model-generated solution is easier than generating a correct one from scratch, the model identifies the first error in its reasoning and proposes a single-step intervention to redirect the trajectory toward the correct solution. We then apply supervised fine-tuning (SFT) to the on-policy rollout up to the point of error concatenated with the intervention, localizing error to the specific step that caused failure. We show that the resulting model serves as a far better initialization for RL training. After running InT and subsequent fine-tuning with RL, we improve accuracy by nearly 14% over a 4B-parameter base model on IMO-AnswerBench, outperforming larger open-source models such as gpt-oss-20b.