Todd McNutt: how an AI software solution enables creation of the best possible radiation treatment plans
Todd McNutt is a radiation oncology physicist at Johns Hopkins University in the US and the co-founder of Oncospace, where he led the development of an artificial intelligence (AI)-powered tool that simultaneously accelerates radiation planning and elevates plan quality and consistency. The software, now rebranded as Plan AI and available from US manufacturer Sun Nuclear, draws upon data from thousands of previous radiotherapy treatments to predict the lowest possible dose to healthy tissues for each new patient. Treatment planners then use this information to define goals that streamline and automate the creation of a best achievable plan.
Physics World’s Tami Freeman spoke with McNutt about the evolution of Oncospace and the benefits that Plan AI brings to radiotherapy patients and cancer treatment centres.
Can you describe how the Oncospace project began?
Back in 2007, several groups were discussing how we could better use clinical data for discovery and knowledge generation. I had several meetings with folks at Johns Hopkins, including Alex Szalay who helped develop the Sloan Digital Sky Survey. He built a large database of galaxies and stars and it became a huge research platform for both amateur and professional astronomers.
From that discussion, and other initiatives, we looked at moving towards structured data collection for patients in the clinical environment. By marrying these data with radiation treatment plans we could study how dose distributions across the anatomy affect patient outcomes. And we took that opportunity to build a database for radiotherapy.
What inspired the transition from academic research to founding the company Oncospace Inc in 2019?
After populating the database with data from many patients, we could examine which anatomic features impact our ability to generate a plan that minimizes radiation dose to normal tissues while treating target volumes as best as possible. We came up with a feature set that characterized the relationships between normal anatomy and targets, as well as target complexity.
This early work allowed us to predict expected doses from these shape-relationship features, and it worked well. At that point, we knew we could tap into this database and generate a prediction that could help create treatment plans for new patients. We thought of this as personalized medicine: for the first time, we could see the level of treatment plan quality that we could achieve for a specific patient.
I thought that this was useful commercially and that we should get it out to other clinics. Praveen Sinha, who I’d known from my previous work at Philips and now leads Sun Nuclear’s software business line, asked if I wanted to create a startup. The timing was right for both of us and I had a team here ready to go, so we went ahead and did it. With his knowledge of startups and my knowledge of what we wanted to achieve, we had perfect timing and a perfect group to work with.
Plan AI enables both predictive planning and peer review, how do these functions work?
The idea behind predictive planning is that, for a given patient, I can predict the expected dose that I should be able to achieve for them.


Treatment planning involves specifying dosimetric objectives to the planning system and asking it to optimize radiation delivery to meet these. But nobody really knows what the right objectives even are – it is just a trial-and-error process. Plan AI’s prediction provides a rational set of objectives for plan optimization, allowing the planning system’s algorithm to move towards a good solution and making treatment planning an easier problem to solve.
Peer review involves a peer physician looking at every treatment plan to evaluate it for quality and safety. But again, people don’t really know the level of quality you can generate, it depends on the patient’s anatomy. Providing a predicted dose with clinical dose goals enables a rapid review to see whether it is a high-quality plan or not.
In the past we looked at simple things like whether a contour is missing slices or contains discontinuities and Plan AI checks for this, but you can do far more with AI. For example, you could look at all the contoured rectums in the system and predict if your contour goes too far into the sigmoid colon, then it may be mis-contoured. We have research software that can flag such potential anomalies so they don’t get overlooked.
The Plan AI models are developed using Oncospace’s database of previous treatments; can you describe this data lake?
When we first started, we developed a large SQL database containing all the shape-relationship features and dosimetry features. The SQL language is ideal for being able to query and sift through the data, but when the company was formed, we recognized that there was some age to that technology.
So for the Plan AI data lake, we extracted all the different shape-relationship and shape-complexity features and put them into a Parquet database in the cloud. This made the data lake much more amenable to applying machine learning algorithms to it. The SQL data lake at Johns Hopkins is maintained separately and primarily used to investigate toxicity predictions and spatial dose patterns. But for Plan AI, the models are fixed and streamlined for the specific task of dose prediction.
What does the model training process entail?
One of the first tasks was to curate the data, using the AAPM’s standardized structure-naming model. Our data scientist Julie Shade wrote some tools for automatic name mapping and target identification; that helped us process much larger amounts of data for the model.
Once we had all the shape-relationship and shape-complexity features and all the doses, we trained the models by anatomical region. We have FDA-approved models for the male and female pelvis, thorax, abdomen and head-and-neck. For each of these, we predict the doses for every organ-at-risk. Then we used a five-fold validation model to make sure that the predictions were good on an internal data set.
We also performed external validation at institutions including Johns Hopkins and Montefiore hospitals. We created predicted plans from recent treatment plans that had been evaluated by physicians. For almost all cases, both plan quality and plan efficiency were improved with Plan AI.
One aspect of this training is that whenever we drive optimization via predictive planning we want to push towards the best achievable dose. Regular machine learning predicts an expected, or average, dose across all patients. But you never want to drive a treatment plan towards the average dose, because then every plan you generate will be happy being average. Our model predicts both the average and the best achievable dose, and drives plan optimization towards the best achievable.
When implementing new technology in the clinic, it’s important to fit into the existing treatment workflow. How clinic-ready are these AI tools?
Radiation therapy is protocol-driven: we know what technique we’re going to use to treat and what our clinical dose goals are for different structures. What we don’t know is the patient-specific part of that. So for each anatomical region, we built models out of a wide range of treatment protocols, with many different types of patients, to ensure that the same prediction model works for any protocol. This means a user can use any protocol for treatment and the predictions will work, they don’t have to retrain anything. It’s ready to go out of the box, there’s a library of protocols to start with, and you can change protocols as you need for your own clinic.
The other part of being clinic-ready is aligning with the way that planning is currently performed, which is using dose–volume histograms. Treatment plans are optimized by manipulating these dose objectives, and that’s exactly what we predict. So users aren’t changing the whole paradigm of how planners operate. They still use their treatment planning system (TPS) – we just put the objectives in there. Basically, a TPS script sends the patient’s CT and contours to the cloud, where Plan AI makes the predictions. The TPS then pulls back in the objectives built from the models, based on this specific patient’s anatomy. The TPS runs the optimization and, as a last step, can send the plan back to Plan AI to check that it fits within the best achievable predictions.
Did you encounter any challenges bringing AI into a clinical setting?
Interestingly, the challenges aren’t technical, they are more human related. One of the more systemic challenges is data security when using medical data for training. A nice thing about our system is that the features we generate from treatment plans are just mathematical shape-relationship features and don’t involve a lot of identifiable information.
AI has been used in radiation therapy for image contouring and auto-segmentation, and early efforts were not so good. So, there’s always a good, healthy scepticism. But once you show people that it works and works well, this can be overcome. I have seen some people worried about job security and AI taking over. We are medical professionals designing a treatment plan to care for a patient and there’s a lot of pride and art in that – if you automate that, it takes away some of this pride and art.
I tell people that if we automate the easier things, then they can spend their quality time on the more difficult and challenging cases, because that’s where their talent might be needed more.
Do you have any advice for clinics looking to adopt AI-driven planning?
Introduce it as an assistant, not as a solution. You want people that already know what they’re doing to be able to use their knowledge more efficiently. We want to make their jobs easier and show them that it also improves quality.
With dosimetrists, for example, they create a plan and work hard getting the dose down – and then the physician looks at it and suggests that they can do better. Predictive planning gives them confidence that they are right and takes the uncertainty out of the physician review process. And once you’ve gained that level of confidence, you can start using it for adaptive planning or other technologies.
Where do you see predictive modelling and AI in oncology in five years from now?
Right now, there’s been a lot of data collected, but we want that data to advance and learn. Having multiple centres adding to this pool of knowledge and being able to continually update those models from new, broader data sets could be of huge value.
In terms of patient outcomes, we’ve done a lot of the work looking at how the spatial pattern of dose impacts toxicity and outcomes. This is part of the research being performed at Johns Hopkins and still in discovery mode. But down the road, some of these predictions of normal tissue outcomes could be fed into the planning process to help reduce toxicity at the patient level.
Finally, what’s been the most rewarding part of this journey for you?
During my prior experience building treatment planning systems, the biggest problem was always that nobody knew what the objective was. Nobody knew how to tell the system: “this is the dose I expect to receive, now optimize to get it for me”, because you didn’t know what you could do. For any given patient, you could ask for too much or too little. Now, for the first time, I argue that we actually know what our objective is in our treatment planning.
This levels the playing field between different environments, different countries, or even different dosimetrists with different levels of experience. The Plan AI tool brings all this to a consistent state and enables high quality, efficient planning everywhere. We can provide this predictive planning tool to clinics around the world. Now we just have to get everybody using it.
- You can listen to the full interview with Todd McNutt in the Physics World Weekly podcast.
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