Augmenting Large Language Model With Prompt Engineering and Supervised Fine-Tuning in Non-Small Cell Lung Cancer Tumor-Node-Metastasis Staging: Framework Development and Validation.

BACKGROUND: Accurate tumor node metastasis (TNM) staging is fundamental for treatment planning and prognosis in non-small cell lung cancer (NSCLC). However, its complexity poses significant challenges. Traditional rule-based natural language processing methods are constrained by their reliance on manually crafted rules and are susceptible to inconsistencies in clinical reporting.

OBJECTIVE: This study aimed to develop and validate a robust, accurate, and operationally efficient artificial intelligence framework for the TNM staging of NSCLC by strategically enhancing a large language model, GLM-4-Air (general language model), through advanced prompt engineering and supervised fine-tuning (SFT).

METHODS: We constructed a curated dataset of 492 deidentified real-world medical imaging reports, with TNM staging annotations rigorously validated by senior physicians according to the AJCC (American Joint Committee on Cancer) 8th edition guidelines. The GLM-4-Air model was systematically optimized via a multi-phase process: iterative prompt engineering incorporating chain-of-thought reasoning and domain knowledge injection for all staging tasks, followed by parameter-efficient SFT using low-rank adaptation for the reasoning-intensive primary tumor characteristics (T) and regional lymph node involvement (N) staging tasks. The final hybrid model was evaluated on a completely held-out test set (black-box) and benchmarked against GPT-4o using standard metrics, statistical tests, and a clinical impact analysis of staging errors.

RESULTS: The optimized hybrid GLM-4-Air model demonstrated reliable performance. It achieved higher staging accuracies on the black-box test set: 92% (95% CI 0.850-0.959) for T, 86% (95% CI 0.779-0.915) for N, 92% (95% CI 0.850-0.959) for distant metastasis status (M), and 90% for overall clinical staging; by comparison, GPT-4o attained 87% (95% CI 0.790-0.922), 70% (95% CI 0.604-0.781), 78% (95% CI 0.689-0.850), and 80%, respectively. The model's robustness was further evidenced by its macro-average F1-scores of 0.914 (T), 0.815 (N), and 0.831 (M), consistently surpassing those of GPT-4o (0.836, 0.620, and 0.698). Analysis of confusion matrices confirmed the model's proficiency in identifying critical staging features while effectively minimizing false negatives. Crucially, the clinical impact assessment showed a substantial reduction in severe category I errors, which are defined as misclassifications that could significantly influence subsequent clinical decisions. Our model committed 0 category I errors in M staging and fewer category I errors in T and N staging. Furthermore, the framework demonstrated practical deployability, achieving efficient inference on consumer-grade hardware (eg, 4 RTX 4090 GPUs) with latencies suitable and acceptable for clinical workflows.

CONCLUSIONS: The proposed hybrid framework, integrating structured prompt engineering and applying SFT to reasoning-heavy tasks (T/N), enables the GLM-4-Air model to serve as a highly accurate, clinically reliable, and cost-efficient solution for automated NSCLC TNM staging. This work demonstrates the efficacy and potential of a domain-optimized smaller model compared with an off-the-shelf generalist model, holding promise for enhancing diagnostic standardization in resource-aware health care environments.