Majority of flat epithelial atypia diagnosed on biopsy do not require surgical excision.

•Flat epithelial atypia (FEA) is increasingly being diagnosed on biopsies done for screen-detected lesions.•Surgical excision has often been recommended due to the possibility of malignant upgrade.•Rate of upgrade was 3.1% in this study and occurred when atypical ductal hyperplasia (ADH) was also present in the biopsy.•Apart from ADH, no other clinical or pathological parameter predicted for a malignant upgrade.•We therefore propose that women with biopsy-proven FEA can be managed non-operatively in the absence of co-existent ADH.