Nottingham Score for Breast Cancer

What is a Nottingham score?

The Nottingham Scoring System is used to give each breast cancer a Nottingham score. Your Nottingham score is also called a grade or a histologic score and rates how aggressive a tumor may be.

To figure out your score, you need a biopsy done. A pathologist looks at samples of your breast tissue and lymph nodes in a lab using a microscope. The pathologist writes up a summary of their findings, which is called a pathology report.

The characteristics that the pathologist looks at are:

• Tubule formation: How much the tumor looks like normal cell structure.
• Nuclear pleomorphism: How different the tumor cells look from normal cells.
• Mitotic activity: How fast cells are dividing or reproducing.

How is a Nottingham score created?

Your Nottingham score is the total of 3 numbers. Each characteristic listed above is given a score from 1 to 3. 1 is the closest to normal and 3 is the most abnormal. These 3 scores are added together, making the Nottingham Score. The lowest score possible is 3 (1+1+1) and the highest is 9 (3+3+3).

The total score is assigned to a grade:

• Grade I (one) if your total score is 3 to 5. This is also called well differentiated.
• Grade II (two) if your total score is 6 or 7. This is also called moderately differentiated.
• Grade III (three) if your total score is 8 or 9. This is also called poorly differentiated.

Grade I cancers tend to be less aggressive. They are often estrogen receptor-positive (ER+). Grade III cancers tend to be more aggressive and more likely to be triple-negative breast cancer. This means the cancer is negative for ER (estrogen receptor) and PR (progesterone receptor) hormones and HER2 receptors.

How is the Nottingham score and grade used to help plan treatment?

A high-grade (grade III) tumor is seen as a higher risk for recurrence and having radiation therapy may lower this risk. The grade can help you and your care team make decisions about your treatment like:

• If radiation should be used after surgery (lumpectomy or mastectomy).
• If you could benefit from a boost dose of radiation (an added dose given to a specific area at the end of the radiation course).
• If accelerated partial breast radiation (APBI) is right for you. This is when radiation is not given to the whole breast, but only to the area where the primary tumor was located.
• Using radiation to treat your lymph nodes.

The grade is not used as often when deciding if medications like chemotherapy or hormone therapy are needed. The exception to this is in young patients with triple-negative cancer with no lymph node involvement. For these patients, having a high-grade tumor suggests that chemotherapy may be part of their treatment.

If a Nottingham score is on your pathology report, talk to your provider about what it means and the treatment you will be having. Ask your provider any questions you have about your breast cancer treatment.