An agentic AI system enhances clinical detection of immunotherapy toxicities: a multi-phase validation study

Immune-related adverse events (irAEs) affect up to 40% of patients receiving immune checkpoint inhibitors, yet their identification depends on laborious and inconsistent manual chart review. Here we developed and evaluated an agentic large language model system to extract the presence, temporality, severity grade, attribution, and certainty of six irAE types from clinical notes. Retrospectively (263 notes), the system achieved macro-averaged F1 of 0.92 for detection and 0.66 for multi-class severity grading; self-consistency improved F1 by 0.14. The best-performing configuration cost approximately $0.02 per note. In prospective silent deployment over three months (884 notes), detection F1 was 0.72-0.79. In a randomized crossover study of clinical trial staff (17 participants, 316 observations), agentic assistance reduced annotation time by 40% (P < 0.001), increased complete-match accuracy (OR 1.45; 95% CI 1.01-2.09; P = 0.045), and improved inter-annotator agreement (Krippendorffs from 0.22-0.51 to 0.82-0.85). These results demonstrate that agentic AI coupled with human verification could enhance efficiency, performance, and consistency for irAE assessment.