Objective: This study aims to uncover the opaque decision-making process of an artificial intelligence (AI) agent for automatic treatment planning. Approach: We examined a previously developed AI agent based on the Actor-Critic with Experience Replay (ACER) network, which automatically tunes treatment planning parameters (TPPs) for inverse planning in prostate cancer intensity modulated radiotherapy. We selected multiple checkpoint ACER agents from different stages of training and applied an explainable AI (EXAI) method to analyze the attribution from dose-volume histogram (DVH) inputs to TPP-tuning decisions. We then assessed each agent's planning efficacy and efficiency and evaluated their policy and final TPP tuning spaces. Combining these analyses, we systematically examined how ACER agents generated high-quality treatment plans in response to different DVH inputs. Results: Attribution analysis revealed that ACER agents progressively learned to identify dose-violation regions from DVH inputs and promote appropriate TPP-tuning actions to mitigate them. Organ-wise similarities between DVH attributions and dose-violation reductions ranged from 0.25 to 0.5 across tested agents. Agents with stronger attribution-violation similarity required fewer tuning steps (~12-13 vs. 22), exhibited a more concentrated TPP-tuning space with lower entropy (~0.3 vs. 0.6), converged on adjusting only a few TPPs, and showed smaller discrepancies between practical and theoretical tuning steps. Putting together, these findings indicate that high-performing ACER agents can effectively identify dose violations from DVH inputs and employ a global tuning strategy to achieve high-quality treatment planning, much like skilled human planners. Significance: Better interpretability of the agent's decision-making process may enhance clinician trust and inspire new strategies for automatic treatment planning.

Radiation therapy, treating over half of all cancer patients, involves using specialized machines to direct high-energy beams at tumors, aiming to damage cancer cells while minimizing harm to nearby healthy tissues. Customizing the shape and intensity of radiation beams for each patient leads to solving large-scale constrained optimization problems that need to be solved within tight clinical time-frame. At the core of these challenges is a large matrix that is commonly sparsified for computational efficiency by neglecting small elements. Such a crude approximation can degrade the quality of treatment, potentially causing unnecessary radiation exposure to healthy tissues--this may lead to significant radiation-induced side effects--or delivering inadequate radiation to the tumor, which is crucial for effective tumor treatment. In this work, we demonstrate, for the first time, that randomized sketch tools can effectively sparsify this matrix without sacrificing treatment quality.