Objective To investigate the correlation of atrophy and intestinal metaplasia (IM) stage with gastric cancer and to optimize biopsy strategy. Methods Data of patients who underwent endoscopy and five-point biopsy at Shandong Provincial Hospital between November 2020 and October 2022 were collected. The baseline characteristics of gastric cancer and non-gastric cancer patients, as well as the occurrence and severity of atrophy and IM in different areas were compared. Logistic regression analysis was used to evaluate the correlation of operative link for gastritis assessment (OLGA) and operative link for gastric intestinal metaplasia assessment (OLGIM) staging with gastric cancer. The Kendall tau correlation coefficient was used to compare the consistency of different biopsy strategies (two-point, three-point, and four-point) with the standard five-point biopsy in OLGA and OLGIM staging. Receiver operating characteristic (ROC) curve analysis was further performed to compare the diagnostic performance of different biopsy strategies in identifying the OLGA and OLGIM Ⅲ-Ⅳ stage. Results A total of 122 patients were included in the analysis, with age of 61.0±10.0 years. Multivariate analysis showed that OLGA staging was not associated with gastric cancer (P=0.788), while OLGIM Ⅲ-Ⅳ staging was significantly correlated with gastric cancer (P=0.006, OR=3.39, 95%CI: 1.41-8.17). The occurrence of atrophy and IM were higher in lesser curvature of the antrum [56.6% (69/122) and 66.4% (81/122)] and incisura angularis [57.4% (70/122) and 52.5% (64/122)], with higher severity, while lower in greater curvature of the corpus [2.5% (3/122) and 5.7% (7/122)], with lower severity. The consistency of four-point and three-point biopsies with standard five-point biopsy in OLGA and OLGIM staging was high. The consistency of three-point biopsy in incisura angularis, lesser curvature of the antrum and corpus was exceptionally high among them, with correlation coefficients of 0.969 and 0.987, respectively. Conclusion OLGIM Ⅲ-Ⅳ stages increase the risk of gastric cancer. Three-point biopsy in incisura angularis, lesser curvature of the antrum and corpus are recommended for the screening and monitoring of atrophy or IM.