This retrospective study aimed to compare the diagnostic accuracy of conventional forceps biopsy (CFB) and endoscopic submucosal dissection (ESD) in screening for gastric epithelial neoplasia (GEN) and adenocarcinoma. The study included 444 patients who underwent ESD at the First Affiliated Hospital, College of Medicine, Zhejiang University, from January 1, 2009, to September 1, 2015. The concordance rate between CFB and ESD specimens was 68.92% (306/444). Men had a lower concordance rate (63.61% vs 79.33%; P = 0.001) and were younger (P = 0.048). Multivariate analysis showed that men had a significantly lower concordance rate (coefficient – 0.730, P = 0.002) and a higher rate of pathological upgrade (coefficient – 0.648, P = 0.015). The location of CFB did not significantly affect the concordance rate. The study concluded that old men with CFB in the gastric fundus or antrum should strongly consider ESD if precancerous lesions are found, while young women with low-grade intraepithelial neoplasia (LGIN) can opt for regular follow-up. Further large-scale prospective studies are needed to validate these findings.This retrospective study aimed to compare the diagnostic accuracy of conventional forceps biopsy (CFB) and endoscopic submucosal dissection (ESD) in screening for gastric epithelial neoplasia (GEN) and adenocarcinoma. The study included 444 patients who underwent ESD at the First Affiliated Hospital, College of Medicine, Zhejiang University, from January 1, 2009, to September 1, 2015. The concordance rate between CFB and ESD specimens was 68.92% (306/444). Men had a lower concordance rate (63.61% vs 79.33%; P = 0.001) and were younger (P = 0.048). Multivariate analysis showed that men had a significantly lower concordance rate (coefficient – 0.730, P = 0.002) and a higher rate of pathological upgrade (coefficient – 0.648, P = 0.015). The location of CFB did not significantly affect the concordance rate. The study concluded that old men with CFB in the gastric fundus or antrum should strongly consider ESD if precancerous lesions are found, while young women with low-grade intraepithelial neoplasia (LGIN) can opt for regular follow-up. Further large-scale prospective studies are needed to validate these findings.