# Nottingham grade (breast cancer grade 1, 2 and 3)

Source: https://onco.cc/terms/nottingham-grade/  
OnCo record `nottingham-grade` (Term). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

The grade on a breast report is a sum of three scores: how much of the tumour still forms tubes, how ugly its nuclei are, and how many cells are caught dividing. Each is scored 1 to 3, and the total of 3 to 9 becomes grade 1, 2 or 3. Grade says how the cancer behaves, not how far it has spread.

## Summary

The method is the one Elston and Ellis described in 1991, a deliberately more objective revision of Bloom and Richardson's grade, and UK practice allows no other: the dataset in force says that grading systems other than this one should not be used. Three features are scored from 1 to 3. Tubule and acinar formation: score 1 if more than 75 percent of the tumour forms tubular structures with a clear central lumen, 2 if 10 to 75 percent, 3 if under 10 percent. Nuclear atypia and pleomorphism: score 1 for small regular nuclei up to about twice the diameter of a red blood cell, rising to 3 for obvious atypia. Mitotic count: counted in a defined field area and standardised to the microscope's field diameter, because the number of cells in a high-power field varies between microscopes. The three scores are added: 3, 4 or 5 is grade 1, 6 or 7 is grade 2, 8 or 9 is grade 3. Tubule formation is judged across the whole tumour; nuclei and mitoses are judged in the worst area, usually at the edge.

The grade earns its place on the report. In the Nottingham/Tenovus study, grade was assessed in 1,831 of more than 2,200 patients with primary operable breast cancer entered since 1973, and grade 1 tumours had significantly better survival than grade 2 and 3 (p less than 0.0001) (Elston 1991). Grading is required for every invasive carcinoma, including the rare special types and including adenoid cystic carcinoma, because prognosis varies by grade within a type. For audit it is mandatory to record the three component scores and not only the total.

Two cautions a reader should have. First, the grades are not meant to come out in equal thirds: the dataset gives the expected ratio of grades 1, 2 and 3 as about 2:3:5 in symptomatic breast cancer and about 3:5:2 in screen-detected breast cancer, and a unit whose distribution departs far from that is told to review its fixation and grading protocols. A grade 3 is therefore commoner in a cancer found because of a lump than in one found by screening. Second, the grade on the needle biopsy and the grade on the surgical specimen agree only about 70 percent of the time, and where they differ the surgical specimen is normally used for management; if a mixed tumour turns out to have a higher-grade component that the biopsy missed, the dataset asks for the receptor assays to be repeated as well.

## Fields

- Kind: Term
- Last checked: 2026-09-25
- Also known as: Nottingham grade; Nottingham grading system; Nottingham histological grade; Elston-Ellis grade; Elston and Ellis; Bloom-Richardson; Bloom and Richardson; Scarff-Bloom-Richardson; SBR grade; breast cancer grade; grade 1 breast cancer; grade 2 breast cancer; grade 3 breast cancer; tubule formation; nuclear pleomorphism; mitotic count; histological grade breast

## Notes

- Grade is not the grade of a side effect. A treatment side effect is also given a grade, from 1 to 5, on a completely separate scale (see `toxicity-grade`). A grade 3 cancer and a grade 3 side effect have nothing to do with each other.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Breast_cancer_classification
- Royal College of Pathologists G148: dataset for histopathological reporting of breast disease in surgical excision specimens of breast cancer, version 3, November 2024 (full review due November 2026): https://www.rcpath.org/resourceLibrary/g148-dataset-for-histopathological-reporting-of-breast-disease-in-surgical-excision-specimens-of-breast-cancer.html
- Elston and Ellis, Histopathology 1991;19:403 to 410: pathological prognostic factors in breast cancer, the value of histological grade, with long-term follow-up of 1,831 graded patients: https://doi.org/10.1111/j.1365-2559.1991.tb00229.x
- Tan et al., Histopathology 2020: the 2019 WHO classification of tumours of the breast (5th edition): https://doi.org/10.1111/his.14091

## Connected records

- terms: [Grade](https://onco.cc/terms/tumour-grade/), [Grade versus stage](https://onco.cc/terms/grade-vs-stage/), [Grade, stage and receptor status: three different things on one breast report](https://onco.cc/terms/grade-stage-receptor-breast/), [Nottingham Prognostic Index (NPI), and PREDICT](https://onco.cc/terms/nottingham-prognostic-index/), [The WHO classification of breast tumours, and what the 6th edition changed](https://onco.cc/terms/who-breast-classification/), [Tumour differentiation (well / moderately / poorly differentiated)](https://onco.cc/terms/tumour-differentiation/), [Tumour size on a breast report, and why it differs from the scan](https://onco.cc/terms/breast-tumour-size-on-the-report/)
- technologies: [Digital pathology & AI](https://onco.cc/technologies/digital-pathology-ai/)
- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [Carcinoma with medullary pattern (medullary breast cancer)](https://onco.cc/cancers/medullary-pattern-breast-carcinoma/), [Ductal carcinoma in situ (DCIS)](https://onco.cc/cancers/ductal-carcinoma-in-situ/), [HER2-positive breast cancer](https://onco.cc/cancers/breast-her2-positive/), [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Invasive breast carcinoma of no special type (invasive ductal carcinoma)](https://onco.cc/cancers/invasive-breast-carcinoma-no-special-type/), [Invasive lobular carcinoma of the breast](https://onco.cc/cancers/invasive-lobular-carcinoma/), [Triple-negative breast cancer (TNBC)](https://onco.cc/cancers/tnbc/)
- fronts: [Diagnostics & Biomarkers](https://onco.cc/fronts/diagnostics/)

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