# OpenMTB-Audit: Exposing Over-Refusal and Clinical Expert Perspectives in LLM-Based Molecular Tumor Board Safety Evaluation

arXiv: https://arxiv.org/abs/2610.01497 · HTML: https://mlsanity.com/paper/2610.01497/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 7 of its 21 references that are in the map.
- First posted on arXiv 1 Oct 2026.

## Placed in

- LLM safety and security

## Builds on (most cited first, 7 of 7)

- [Large Language Models Encode Clinical Knowledge](https://mlsanity.com/paper/2212.13138/) (2022)
- [Capabilities of GPT-4 on Medical Challenge Problems](https://mlsanity.com/paper/2303.13375/) (2023)
- [XSTest: A Test Suite for Identifying Exaggerated Safety Behaviours in Large Language Models](https://mlsanity.com/paper/2308.01263/) (2023)
- [OR-Bench: An Over-Refusal Benchmark for Large Language Models](https://mlsanity.com/paper/2405.20947/) (2024)
- [Understanding and Mitigating Overrefusal in LLMs from an Unveiling Perspective of Safety Decision Boundary](https://mlsanity.com/paper/2505.18325/) (2025)
- [MTBBench: A Multimodal Sequential Clinical Decision-Making Benchmark in Oncology](https://mlsanity.com/paper/2511.20490/) (2025)
- [Health-ORSC-Bench: A Benchmark for Measuring Over-Refusal and Safety Completion in Health Context](https://mlsanity.com/paper/2601.17642/) (2026)

## Abstract (arXiv)

Molecular tumor boards integrate genomic findings, clinical context, and therapeutic evidence to support precision oncology. As AI enters this workflow, a key safety challenge is distinguishing truly unsupported recommendations from evidence-supported options that still require oncologist review because of incomplete information, poor ECOG performance status, or other clinical caveats. We introduce OpenMTB-Audit, an open-source benchmark of 500 synthetic non-small cell lung cancer cases spanning five adversarial error categories and four safety labels: Supported, Partially Supported, Unsupported, and Insufficient Information. Across eight large language model configurations, we identify pervasive over-refusal: all LLM configurations failed to retain the Partially Supported label in 83.3-100% of true Partially Supported cases, achieving high aggregate safety scores through label collapse rather than clinically calibrated reasoning. To address this limitation, we developed MTB-AuditAgent, a deterministic seven-module framework separating evidence verification, missing-information detection, safety classification, and abstention. It reduces over-refusal to 6.7% and achieves 91.2% accuracy (95% CI: 88.6-93.6%). A two-oncologist annotation study found disagreement concentrated at the boundary between information sufficiency and treatment optimization, underscoring the need to preserve clinically meaningful distinctions.