Reading your pathology report

Can Cancer Grade — Change Between Biopsies?

Two biopsy reports giving different grades for the same cancer is more common than most patients expect. It does not automatically mean the cancer has changed. It usually means the two samples came from different parts of a tumour that is not uniform throughout.

Medically reviewed by Dr. Bharati Devi Gorantla, Medical Oncologist, MBBS · MD · DM (Adyar, Chennai) · ECMO · MRCP SCE (UK) · Last reviewed September 2026

Different grade does not always mean change — Tumours are not uniform throughout. Two samples from different areas can give different results even when nothing has progressed.
Sample size matters — A needle biopsy takes a narrow core. A surgical specimen gives a more complete view of the whole tumour and usually a more representative grade.
One number is not the full story — Your oncologist weighs both reports alongside the full clinical picture before deciding which grade guides your treatment.
Both reports belong in the room — Bring both pathology reports to your next appointment so your team can review them together, not separately.

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Yes, grade can differ between biopsy samples from the same tumour. This most often reflects tumour heterogeneity — the fact that different areas of a tumour can look different under a microscope. Your oncologist uses both results alongside the full clinical picture to decide which grade guides your treatment plan.

Why does the grade on my second biopsy report look different?

Reason for the difference	What it means	What your team does with it
Tumour heterogeneity	Different areas of the tumour naturally have different grades — this is common in many cancers	Both results are considered alongside where each sample was taken from
Small initial sample	A needle biopsy takes a narrow core; a higher-grade area nearby may not have been sampled	A larger specimen, such as from surgery, often gives a more representative grade
Tumour evolution over time	Some cancers do change grade between an early biopsy and a later procedure	The time gap between samples is noted and factored into the clinical assessment
Variation between laboratories	Borderline cases can be scored slightly differently by different pathologists	Both slides can be reviewed by a single specialist to reach a reconciled result

Which grade does your oncologist use for your treatment plan?

There is no fixed rule that the higher grade always takes precedence, or that the most recent result automatically overrides the earlier one. Your oncologist weighs both reports against the wider clinical picture — where each sample came from, how much tissue was taken, how much time passed between the two procedures, and how the cancer has been behaving.

When one result comes from a surgical specimen and the other from a needle biopsy, the surgical result is generally given more weight. Surgical specimens contain more tissue, which means the pathologist has a more complete view of the tumour.

If both samples were needle biopsies, your team may ask for both slides to be reviewed by the same pathologist before a treatment grade is finalised.

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What do the terms in these biopsy reports actually mean?

Grade: A score that describes how different cancer cells look from normal cells under a microscope. Lower grades mean the cells still resemble normal tissue. Higher grades mean the cells look more abnormal.
Differentiation: The same concept expressed as words rather than numbers. Well-differentiated means the cells retain some resemblance to normal tissue. Poorly differentiated means they look very different from normal tissue.
Tumour heterogeneity: The variation that exists within a single tumour. Cells in different parts of the same tumour are not identical, which is why sampling different areas can produce different grade results from the same cancer.
Mitotic index: A count of how many cells in the sample were actively dividing at the time the tissue was taken. It contributes to the overall grade in some cancer types.
Representative sample: A sample that reflects the tumour as a whole. A small needle biopsy may not be fully representative if the tumour contains zones of different grades.

Should you bring both reports to your next appointment?

Yes. If you have two pathology reports with different grades, bring both — or ask your team to pull both from your file before the appointment. Reviewing them side by side gives your oncologist more information than either report alone.

It is reasonable to ask what the difference means for your treatment plan. If the grade difference is significant, your oncologist should be able to explain how each result is being weighted and why.

You do not need to decide which report is correct. That is a clinical judgement that takes into account information you may not have in front of you. Your part is to make sure both reports are available in the consultation.

Did you know?

When pathology slides from the same tumour are reviewed by a second specialist pathologist, a proportion of grade scores are revised — not because either pathologist made an error, but because grading involves interpretation, and the boundary between grades is not always a sharp line.

This is one reason ASCO and ESMO guidance encourages independent pathology review before treatment begins for many cancer types.

Source: ASCO and ESMO guidance on pathology quality in cancer diagnosis

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Common questions

Frequently asked questions

If the grade went up on the second biopsy, does that mean the cancer is getting worse?

Not necessarily. A higher grade on the second sample more often reflects where the needle landed than a change in the cancer itself. Tumours are not uniform — one area may look higher-grade than another under the microscope, even when nothing has changed between procedures. Your oncologist will consider how much time passed between samples and what other clinical information shows before drawing any conclusion about whether the cancer has actually progressed.

Can the grade go down as well as up between biopsies?

Yes. Because the difference is usually about which part of the tumour was sampled, grade can appear to go down on a repeat sample just as it can appear to go up. A lower grade on the second biopsy does not automatically mean the cancer has improved — it means the second needle landed in an area with lower-grade cells. Your oncologist interprets both results in context rather than assuming either direction of change has a straightforward meaning.

Should I ask for a third biopsy to settle the difference between two results?

That is a decision for your oncologist rather than something to request independently, and a third needle biopsy would face the same sampling limitation as the first two. The more useful step is usually to have both existing slides reviewed by a single specialist pathologist. If a surgical specimen is planned as part of your treatment, that will provide more tissue and a more complete grade assessment than any additional needle biopsy.

Does a different grade on the second biopsy mean my treatment plan has to change?

It depends on how different the grades are and what the rest of the clinical picture shows. A one-step difference in a borderline case may not change the plan at all. A larger shift may prompt your team to review the planned approach. This is a question to put directly to your oncologist at your next appointment, with both reports in front of you so the discussion is grounded in the actual numbers.

My oncologist described the grade differently from what is written in the report. Why?

Grade can be expressed as a number or as words — well-differentiated, moderately differentiated, poorly differentiated — and different cancer types use different grading systems. What your oncologist says aloud may be a plain-language translation of the number in the report, or they may be referring to a grading system specific to your cancer type. If the description does not match what you have read, ask them to point to the part of the report they are referring to. That is a reasonable thing to ask.

Are some cancers more likely to show different grades between biopsies?

Yes. Cancers that are naturally more heterogeneous — where the tumour varies significantly from one area to another — are more likely to show grade differences between samples. This tends to be more common in larger tumours and in cancers that have been growing for longer. Your oncologist will know whether the type of cancer you have is one where this variability is well-recognised, and that context will shape how they interpret the two results.

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