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These models are beginning to move beyond encoding image patches toward whole-slide understanding, but their clinical utility remains limited. Here we present PRISM2, a multimodal slide-level foundation model trained on 2.3 million whole-slide images and 14 million question\u2212answer pairs derived from 700,000 pathology reports. Through clinical dialogue supervision, PRISM2 aligns histomorphology with diagnostic reasoning, yielding representations that support both prompt-based inference and transferable embeddings for downstream tasks. With prompt-based inference, PRISM2 achieves or exceeds (\n                    <jats:italic>P<\/jats:italic>\n                    \u2009&lt;\u20090.05) the balanced accuracy of clinical-grade products calibrated for cancer detection in the prostate, breast and breast lymph node. Additionally, across comprehensive diagnostic, biomarker and survival benchmarks, PRISM2 embeddings never statistically underperform previous foundation models via linear probing (\n                    <jats:italic>P<\/jats:italic>\n                    \u2009&lt;\u20090.05). Furthermore, task-specific fine-tuning on survival prediction outperforms training from scratch on the same large survival dataset. PRISM2 demonstrates how language-supervised pretraining provides a scalable, clinically grounded signal for generalizable pathology representations, bridging human diagnostic reasoning and foundation model performance.\n                  <\/jats:p>","DOI":"10.1038\/s41591-026-04521-4","type":"journal-article","created":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T09:04:02Z","timestamp":1785488642000},"page":"3203-3213","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["End-to-end multimodal pathology foundation model with clinical dialogue"],"prefix":"10.1038","volume":"32","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4530-533X","authenticated-orcid":false,"given":"Eugene","family":"Vorontsov","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-8475-9594","authenticated-orcid":false,"given":"George","family":"Shaikovski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Casson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Viret","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-6805-1561","authenticated-orcid":false,"given":"Eric","family":"Zimmermann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1250-3716","authenticated-orcid":false,"given":"Neil","family":"Tenenholtz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi Kan","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0381-355X","authenticated-orcid":false,"given":"Jan H.","family":"Bernhard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ran A.","family":"Godrich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan A.","family":"Retamero","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4351-2511","authenticated-orcid":false,"given":"Jinru","family":"Shia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8683-8477","authenticated-orcid":false,"given":"Mithat","family":"Gonen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9577-7984","authenticated-orcid":false,"given":"Martin R.","family":"Weiser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David S.","family":"Klimstra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Razik","family":"Yousfi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4102-0169","authenticated-orcid":false,"given":"Nicol\u00f2","family":"Fusi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas J.","family":"Fuchs","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0412-4217","authenticated-orcid":false,"given":"Kristen","family":"Severson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4169-7567","authenticated-orcid":false,"given":"Siqi","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,31]]},"reference":[{"key":"4521_CR1","doi-asserted-by":"publisher","unstructured":"Zimmermann, E. et al. 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E.Z., N.T., N.F. and K.S. are employees of Microsoft. S.L., E.V., G.S., A.C., J.H.B., R.A.G. and T.J.F. are inventors on a provisional US patent application (no. 18\/521903) related to methodological aspects of this work. The other authors declare no competing interests.","order":1,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Ethics"}}]}}