Standardizing serial prostate MRI in active surveillance: a practical review of PRECISE scoring

Active surveillance (AS) is an established management strategy for men with low-risk and some favorable intermediate-risk prostate cancer. Multiparametric MRI (MRI) plays an increasingly important role in AS, contributing to initial risk stratification, confirmatory evaluation, and longitudinal monitoring. However, comparing baseline and follow-up MR images is challenging because acquisition varies, readers differ, and imaging alone has limited ability to define clinically meaningful progression. The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system was developed to standardize the assessment of interval change on serial prostate MRI. PRECISE provides a structured framework for categorizing radiologic regression, stability, and progression, thereby addressing a key limitation of Prostate Imaging - Reporting and Data System (PI-RADS), which was designed for lesion detection rather than longitudinal assessment. PRECISE version 2 further refines definitions and introduces clearer categories, including separation of stable visible and stable non-visible disease and recognition of non-diagnostic examinations. Available evidence suggests that PRECISE performs best as a rule-out tool, with consistently high negative predictive value for clinically significant progression, while radiologic progression demonstrates more limited positive predictive value for histopathologic upgrading. Although PRECISE reduces subjective interpretation through structured scoring, its application remains affected by variability in MRI quality and heterogeneity in AS protocols. To mitigate these limitations, radiologists should incorporate prostate-specific antigen kinetics, biopsy results, and clinical context into their interpretation of serial MRI. In this review, we provide a practical, radiologist-focused overview of PRECISE, summarize its evolution and evidence base, and illustrate its application in clinical practice. We also discuss key limitations, common pitfalls, and the importance of MRI quality and standardization in improving reproducibility. PRECISE represents an important step toward standardized longitudinal assessment in prostate cancer AS and supports more consistent, evidence-based multidisciplinary decision-making.