Multicentre validation of the PRECISE scoring system for prostate MRI during active surveillance

Objectives: The Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) recommendations assess radiological change in serial MRI during active surveillance (AS) for prostate cancer. PRECISE 1-2 indicates radiological regression, PRECISE 3 stability, and PRECISE 4-5 progression. Our aim was to test the PRECISE score as a predictive tool for disease progression in a multicentre international setting. Materials and methods: This is a retrospective study in which we collected data from 22 international centres from December 2005 to July 2022, applying two entry criteria: (1) at least two scans (baseline and follow-up); (2) at least two biopsies (baseline and follow-up, the latter after the second scan). Local radiologists reported scans according to PRECISE. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) according to different biopsy thresholds and definitions of progression were calculated. Results: A total of 1667 patients were included. Median follow-up was 4 years (IQR: 2.1-6.3). A total of 1248 (75%) patients underwent two MRIs and immediate subsequent biopsy, 300 (24%) of which had biopsy progression to Grade Group ≥ 2 and 77 (6%) to Grade Group ≥ 3. Patients with PRECISE 4-5 had 4.53-fold increased odds (95% CI: 3.37-6.12; p < 0.001) of biopsy progression compared to PRECISE 1-3. Using a PRECISE ≥ 4 cutoff to perform follow-up biopsies, overall sensitivity, specificity, PPV and NPV were 57%, 79%, 46%, and 85% for the first follow-up scan. Conclusion: The PRECISE recommendations could lead to timely identification of patients on AS who progress on MRI, prompting re-biopsy or treatment, and safe reduction of repeat biopsies for those with stable MRI and prostate-specific antigen kinetics. Key points: Question Can the PRECISE scoring system for monitoring prostate cancer lesions on active surveillance on MRI predict disease progression and avoid unnecessary biopsies? Findings The PRECISE score effectively predicts prostate cancer progression, with PRECISE 4-5 (progression) scores indicating 4.53-fold increased odds of biopsy progression compared to PRECISE 1-3 (regression/stability). Clinical relevance This study validates PRECISE as a tool for managing patients on active surveillance. It can help clinicians identify those needing timely re-biopsy or treatment, while reducing unnecessary biopsies in patients with stable disease on imaging and PSA kinetics.