The Practice of Cytopathology in India: Insights From a 2025 Nationwide Survey

ABSTRACT

Cytopathology is a widely practiced, low‐cost diagnostic modality in India. However, nationwide data on infrastructure, contemporary practices, and use of ancillary techniques remain limited. We conducted a nationwide survey to describe current practice patterns and identify existing gaps. A cross‐sectional online questionnaire (Google Form) was shared amongst practicing pathologists in India from June 12, 2025 to July 15, 2025. The data collected included laboratory type, specimen workload, staining, cell‐block preparation, ancillary testing, adoption of standardized reporting systems, turnaround time (TAT), and use of digital pathology. Descriptive statistics were generated. Of 235 respondents, 84.7% (199/235) reported having a dedicated cytopathology laboratory; 130 (55.3%) were from teaching hospitals. FNAC remains widely practiced throughout the country: 72.8% of FNACs are performed by pathologists and 37% of centers receive > 2000 FNAC cases annually. Cell blocks were prepared in 72.3% (170/235) of centers; ancillary techniques were available in 37.9% (89/235). Standardized reporting systems were used by 80.9% (190/235) respondents, and 50.2% routinely performed ROSE. Only 10.2% had access to whole‐slide imaging and 2.6% reported use of AI tools. A TAT of ≤ 24 h was followed in 46.8% (110/235) centers. Significant differences across center types were observed for reporting patterns, accreditation, ancillary testing, and quality assurance practices (p < 0.05). Cytopathology services in India are widespread but heterogeneous: infrastructure, ancillary testing, and digital adoption vary significantly with center type. Nation‐wide efforts to standardize reporting, strengthen training in specimen triage, and expand accreditation and EQAS participation are essential to improve uniformity and quality of services.

Abbreviations

A&E

accreditation and examination

AI

artificial intelligence

AIIMS

All India Institute of Medical Sciences

CAP

College of American Pathologists

CME

continuing medical education

CNB

core needle biopsy

COVID‐19 (SARS‐CoV‐2)

Severe Acute Respiratory Syndrome Coronavirus 2DNB: Diplomat of National Board

EBUS‐TBNA

endobronchial ultrasound‐guided transbronchial needle aspiration

EQAS

external quality assurance

EUS‐FNAC

endoscopic ultrasound‐guided FNAC

FISH

fluorescence in situ hybridization

FNAC

fine‐needle aspiration cytology

GMS stain

Grocott–Gömöri's methenamine silver stain

H&E

hematoxylin and eosin

HPV

Human Papilloma Virus

IAC

Indian Academy of Cytologists

ICMR

Indian Council of Medical Research

ICP

Indian College of Pathologists

IHC

immunohistochemistry

LBC

liquid‐based cytology

LMICs

low‐ and middle‐income countries

MD

doctor of Medicine

MGG

May‐Grünwald Giemsa stain

MLT

medical laboratory technicians

MOSE

macroscopic on‐site evaluation

NABL

National Accreditation Board for Testing and Calibration Laboratories

NGS

next‐generation sequencing

NICPR

National Institute of Cancer Prevention and Research

NMC

National Medical Council

Pap stain

papanicolaou stain

PAS stain

periodic acid‐schiff stain

PCR

polymerase chain reaction

PDCC

postdoctoral certificate course

PGIMER

Postgraduate Institute of Medical Education and Research

ROSE

rapid on‐site evaluation

TAT

turnaround time

TBS

the Bethesda system

TMH

Tata Memorial Hospital

WHO‐IACR

The World Health Organization‐International Agency for Research on Cancer

WSI

whole slide imaging

ZN stain

Ziehl‐Neelsen stain

1. Introduction

Cytopathology including fine‐needle aspiration cytology (FNAC), exfoliative cytology and effusion cytology has served as a low‐cost, minimally‐invasive, reliable diagnostic tool. Cytopathology has not only proven as a valuable tool for low‐ and middle‐income countries (LMICs), but also emerged as a treasure trove for molecular testing and next‐generation sequencing (NGS) across the world in the form of smears and cell block specimens. The postgraduate pathology curriculum envisages the basic practices and skill required for cytopathology diagnosis. In addition, short term courses and cytopathology fellowships are available for in‐depth training. Cytology has faced its challenges and dilemmas and yet continues to be the investigation of choice for various non‐neoplastic and neoplastic lesions in day‐to‐day clinical practice.

1.1. Historical Perspective

The origins of cytopathology in India can be traced to the 1950s, when Dr. P N Wahi pioneered exfoliative cytology for oral and cervical cancers. Over the following decade, dedicated cytopathology laboratories were established at the two premier institutions: All India Institute of Medical Sciences (AIIMS), New Delhi and Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. The formation of the Indian Academy of Cytologists (IAC) under Prof. Wahi marked a significant step in institutionalizing cytopathology practice, with continued academic contributions through annual conferences (CYTOCON) and the Journal of Cytology. Key names among the many major contributors to Cytopathology during that period include Dr. Usha Luthra, Dr. Bhaskar Reddy, Dr. Meera Aikat, Dr. Usha Saraiya, Dr. Kamla Chandra, Dr. Geeta Jayaram, Dr. Shobha Grover, Dr. Maya Lulla, Dr. Mohini Nayyar, Dr. Satya Monga, Dr. Padam K Agarwal, Dr. Maitreyee Munshi, Dr. Kusum Verma, and Dr. Subhash Kumari Gupta. Dr. Hana Peters initiated cytology at Tata Memorial Hospital (TMH), Mumbai. In 1951, the Department of Cytopathology was established at TMH by Dr. D. J. Jussawala. By 1960, two cytology centers existed in Bombay‐ at TMH and the ICMR Contraceptive Testing Unit. Further expansion included a cytology clinic at Cama and Albless Hospital in 1967, with a dysplasia clinic added in 1976 under the Indian Cancer Society.

FNAC as a routine practice was introduced during this era by Dr., Subash Kumari Gupta in Chandigarh and Dr., MS Sukumaran in “Madras”, now known as Chennai, Tamil Nadu. Dr. Gupta acquired the skill from Karolinska Institute, Sweden and strongly advocated the use of the Franzen handle. She further propagated the skill and science to the different parts of the country. She eventually handed over the baton to Dr., Arvind Rajwanshi, who advanced this discipline to greater heights. The needle started to precede the scalpel for diagnosing accessible lesions across various body sites throughout the country. The minimal invasiveness, ease, cost‐effectiveness, low capital investment and yet high diagnostic accuracy soon transfigured both government and private institutes to embrace cytology. Later in 1975, Accreditation and Examination (A&E) Committee was formed under the auspices of IAC to regulate and teach cytopathology practices across the country [1, 2, 3].

The menace of cervical cancer and the knowledge of its preventive aspect led to the introduction of Pap smears and cervical cancer screening program in urban and rural community in India in the 1970s [3]. Studies have proven that a cytological screening for cervical cancer is easy to perform in the lowest resource settings [4, 5]. The year 1982 marks the emergence of the journal of cytology create a national platform for research and ideas and encouraging academic excellence. EQAS program was started by PGIMER, Chandigarh under the aegis of IAC in the year 2000. Between 1987 and 2002, India contributed ~48% of FNAC publications from the developing world, ranking second globally in cytopathology research‐ signifying broad clinical and scientific engagement [2]. Gradually ancillary techniques such as special staining for lepra and tuberculosis bacilli were introduced in the early 1970s. Thereupon, additional special stains, cell blocks, immunohistochemistry (IHC), flow cytometry and molecular techniques such as polymerase chain reaction (PCR), fluorescence in situ hybridization (FISH), NGS have been increasingly developed across premier institutes in the country. Dr. Nalini Gupta was among the first in India to receive formal training in Liquid‐based Cytology (LBC) in England, contributing to its introduction at PGIMER, Chandigarh around 2012 and its wider application in both gynecological and non‐gynecological cytology. This was followed by emergence of molecular cytopathology and utilizing the “less is more” in real sense. In 2019, the IAC formulated guidelines for the collection, preparation, interpretation and the reporting of serous effusion fluid samples, including cell block preparation techniques [6]. The havoc of COVID‐19 mandated the need for safe practices for the laboratory personnel while maintaining diagnostic services. IAC formulated guidelines for cytopathology laboratories for handling suspected and positive COVID‐19 (SARS‐CoV‐2) patient samples [7]. Guidelines for processing and reporting EBUS‐TBNA samples were published as a collaborative project involving some of the leading institutes in India [8]. By 2022, India was included among the top five countries in the world who publish in international cytopathology journals [9]. Figure 1 illustrates the timeline of cytopathology practice from early years. Core needle biopsy (CNB), owing to its higher tissue yield and better suitability for ancillary techniques in certain settings, emerged as a preferred alternative to FNAC for breast and prostatic lesions, leading to a gradual decline in the role of FNAC for these sites over time [10]. However, with the availability of IHC being performed on cell blocks, FNAC is still used in many centers across the country for breast lesions.

FIGURE 1.

Timeline of cytopathology development in India. [Color figure can be viewed at wileyonlinelibrary.com]

Endoscopic ultrasound‐guided FNAC (EUS‐FNAC) and endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) have emerged as safe modalities for sampling deep‐seated lesions. EUS‐FNAC is used for diagnosing lesions in the pancreas, hepatobiliary system, adrenal gland and kidney, while EBUS‐TBNA is used for aspiration of mediastinal lymph nodes, offering high diagnostic accuracy [8, 11, 12].

Since the inception till date, industrious Indian cytopathologists have toiled hard and the Indian cytopathology scenarios has witnessed momentous advancements. Figure 2 pays a tribute to the stalwarts of cytopathology in India.

FIGURE 2.

Pioneers of cytopathology in India. [Color figure can be viewed at wileyonlinelibrary.com]

Despite these advancements and widespread adoption, cytopathology practices in India remain heterogeneous, particularly with respect to infrastructure, training, ancillary testing, and adoption of standardized reporting systems. There is limited contemporary nationwide data capturing these variations. The present survey was undertaken to characterize current cytopathology practices across India, identify gaps in infrastructure and training, and highlight areas for standardization and quality improvement.

2. Materials and Methods

The study was approved by the Institute Ethics Committee (INT/IEC/2025/SPL‐716; dated 25.05.25). A cross‐sectional, online questionnaire circulated via Google Forms was designed to analyze the knowledge, attitude, and perceptions about practices of cytopathology in India. A link to a questionnaire in the form of Google form was shared among the cytopathologists and general pathologists via email or WhatsApp from June 12, 2025 to July 15, 2025. The questionnaire comprised approximately 35 questions. Participation was voluntary, and informed consent was obtained electronically. Responses were anonymized. Descriptive statistics were used to summarize data.

3. Results

A total of 235 pathologists across the country from different institutes and setups participated in the survey. Of the 235 respondents, 130 (55.3%) were teaching hospitals, 49 (20.8%) were laboratories associated with corporate hospitals; 44 (18.7%) were private practitioners, 6 (2.5%) were non‐teaching government hospitals and the other 6 (2.5%) included charity hospitals and trust‐funded hospitals. Table 1 summarizes the key findings.

TABLE 1.

Summary of key findings from the questionnaire survey.

Parameters	Teaching hospitals (n = 130)	Corporate hospitals/labs (n = 49)	Private practitioners (n = 44)	Government hospitals (n = 6)	Others (n = 6)	Total (n = 235)
Dedicated cytopathology lab	125 (96.1%)	36 (73.5%)	27 (61.4%)	5 (83.3%)	6 (100%)	199 (84.7%)
Accreditation	85 (65.4%)	36 (73.5%)	17 (38.6%)	0 (0%)	3 (50%)	141 (60.0%)
Participation in EQAS	77 (59.2%)	42 (85.7%)	11 (25.0%)	0 (0%)	4 (66.7%)	134 (57.0%)
Use of FNAC handle	81 (62.3%)	23 (46.9%)	18 (40.9%)	3 (50.0%)	2 (33.3%)	127 (54.0%)
MOSE	82 (63.1%)	22 (44.9%)	27 (61.4%)	3 (50.0%)	5 (83.3%)	139 (59.1%)
ROSE	71 (54.6%)	22 (44.9%)	24 (54.5%)	0 (0%)	1 (16.7%)	118 (50.2%)
FNA material triage for ancillary tests	59 (45.4%)	17 (34.7%)	19 (43.2%)	2 (33.3%)	3 (50.0%)	100 (42.5%)
Special stains	117 (90.0%)	44 (89.8%)	27 (61.4%)	2 (33.3%)	5 (83.3%)	195 (83.0%)
Cell block preparation	108 (83.1%)	38 (77.6%)	17 (38.6%)	3 (50.0%)	4 (66.7%)	170 (72.3%)
Reporting by trained cytopathologist (> 1 year experience)	70 (53.8%)	22 (44.9%)	29 (65.9%)	0 (0%)	2 (33.3%)	123 (52.3%)
Use of standardized reporting systems	125 (96.2%)	39 (79.6%)	17 (38.6%)	5 (83.3%)	4 (66.7%)	190 (80.9%)
Ancillary techniques (IHC/molecular/flow cytometry)	62 (47.7%)	20 (40.8%)	6 (13.6%)	0 (0%)	1 (16.7%)	89 (37.9%)
Liquid‐based cytology (LBC)	67 (51.5%)	34 (69.4%)	11 (25.0%)	0 (0%)	1 (16.7%)	113 (48.1%)
Awareness of IAC guidelines	115 (88.5%)	33 (67.3%)	13 (29.5%)	5 (83.3%)	5 (83.3%)	171 (72.8%)
Use of IAC effusion guidelines	89 (68.5%)	23 (46.9%)	9 (20.5%)	3 (50.0%)	5 (83.3%)	129 (54.9%)
Cyto‐histological audits	41 (31.5%)	40 (81.6%)	9 (20.5%)	3 (50.0%)	5 (83.3%)	98 (41.7%)
Turnaround time ≤ 24 h	53 (40.8%)	23 (46.9%)	29 (65.9%)	1 (16.7%)	4 (66.7%)	110 (46.8%)
Whole slide imaging (WSI)	10 (7.7%)	5 (10.2%)	7 (15.9%)	1 (16.7%)	1 (16.7%)	24 (10.2%)
Artificial intelligence use	4 (3.1%)	0 (0%)	2 (4.5%)	0 (0%)	0 (0%)	6 (2.6%)
Structured training programs	82 (63.1%)	17 (34.7%)	12 (27.3%)	6 (100%)	3 (50.0%)	120 (51.1%)

3.1. Infrastructure and Laboratory Practices

Overall, 84.7% (199/235) of centers had a dedicated cytopathology laboratory, with higher representation in teaching hospitals (96.1%) compared to private practitioners (61.4%).

3.2. Accreditation/EQAS

Accreditation was reported in 60% (141/235) of laboratories, predominantly in corporate hospitals [73.5%; 36/49] and teaching institutions [65.4%; 85/130]. Most laboratories were accredited by the National Accreditation Board for Testing and Calibration Laboratories (NABL), followed by IAC, College of American Pathologists (CAP) and Indian College of Pathologists (ICP).

3.3. FNAC Practices

FNAC is a well‐practiced diagnostic technique in the country and 37% (87/235) of the centers receive more than 2000 FNAC cases annually. Most FNACs are performed by the pathologists [72.8%; 171/235], while 20% (47/235) of FNACs are performed in collaboration with radiologists. Palpation‐guided FNAC is common, especially at peripheral laboratories and radiologically guided FNACs are practiced mostly at institutional levels and in advanced centers. Image‐guided FNACs for deep‐seated lesions are available in 92% (216/235) centers. Among these, in 63% centers, guided FNACs are performed by the pathologists in collaboration with the radiologists, while in 37% centers these are done only by the radiologists.

3.4. Procedural Practices

FNAC handle also referred to as the Franzen handle or the Cameco syringe holder constitutes the ideal instrument to create ample vacuum and ensures a precise procedure. It is noteworthy that only 33.2% (78/235) of pathologists used the handle routinely, 20.8% (49/235) used it selectively, and 45.9% (108/235) did not use it. Use of the FNAC handle is more common in teaching hospitals (62.3%; 81/130) and government centers (50.0%; 3/6), compared with hospitals (46.9%; 23/49) and private practitioners (40.9%; 18/44).

3.5. Macroscopic On‐Site Evaluation (MOSE) and ROSE (Rapid On‐Site Evaluation)

MOSE was also used to assess cellularity by identifying the microfragments in the smear. 59.1% (139/235) of the cytopathologists also used MOSE, of which 63% (82/130) were from the teaching hospitals; 61.4% (27/44) were private practitioners and 44.9% (22/49) were from the corporate hospitals. ROSE is routinely performed in 50.2% (118/235) laboratories and is common in teaching hospitals (54.6%; 71/130) and private practitioners (54.5%; 24/44), but relatively less practiced in the corporate settings (44.9%; 22/49). The triage of FNAC material for various ancillary techniques and its judicious use is being performed by less than half of the centers evaluated (42.5%; 100/235).

3.6. Routine and Special Stains

Hematoxylin and eosin (H&E), Giemsa, May‐Grünwald Giemsa (MGG) stain and Papanicolaou (Pap) stains were the most commonly used stains in the cytopathology laboratories with seven centers using Leishman stain along with Pap and Giemsa, while one center used Field stain. 75.3% (177/235) cytopathologists were reporting cytology samples using all the three stains routinely. Cytochemistry and special stains such as Ziehl‐Neelsen (ZN), Periodic Acid‐Schiff (PAS), Grocott–Gömöri's methenamine silver (GMS) stain, Congo red, mucicarmine and Gram stain were routinely performed across different laboratories [83%; 195/235]. Ninety percent of the teaching hospitals (117/130) and corporate hospitals (89.8%; 44/49) performed special stains as and when needed, while 61.4% (27/44) private practitioners had special staining facilities.

3.7. Cell Block Preparation

Cell block is a widely accepted useful adjunct to the routine FNAC practice [8]. As per the data obtained from the survey, 72.3% (170/235) centers across the country prepared cell blocks in their laboratories using different techniques including the plasma thrombin/thromboplastin method, formalin alcohol method, agar method, sodium alginate method, egg albumin method, direct centrifugation etc. The most commonly used method was the Plasma thrombin/thromboplastin method, practiced by 31.5% (74/235) pathologists. The IAC formulated guidelines for the collection, preparation, interpretation and the reporting of serous effusion fluid samples, including cell block preparation techniques [6].

3.8. Primary Screening and Reporting

The primary screening of the cytopathology specimens is performed by the pathologists in 57% (134/235) of the laboratories, followed by training residents in 40.4% (95/235) laboratories. Only a few laboratories have trained technical staff for the preliminary screening. The final reporting of specimens is done by the certified pathologists, including doctor of Medicine (MD) and/or Diplomat of National Board (DNB). A total of 123/235 (52.3%) centers finalized cytology reports by pathologists with more than 1 year experience in cytopathology.

3.9. Use of Standardized Reporting Systems

The adoption of global standardized reporting systems is increasing across various laboratories given the availability of resources. Various standardized reporting systems have been developed including the Bethesda System (TBS) for cervical and thyroid cytology specimens; Milan System (2nd edition) for salivary gland aspirates; Yokohama System of breast FNAC, with increasing validation from Indian institutes; Paris System of the urinary cytology, with published validation in tertiary centers; Sydney and the World Health Organization (WHO)‐International Agency for Research on Cancer (IARC) system for lung, lymph node, pancreaticobiliary systems, along with various others in the pipeline [13, 14]. The standard reporting formats are being used by approximately 80.9% (190/235) of the pathologists, of which 96.2% (125/130) practiced at the teaching hospitals, 83.3% (5/6) at the government hospitals and 79.6% (39/49) practiced at the corporate hospital laboratories, while 38.6% (17/44) were private practitioners. The TBS for reporting cervical and thyroid cytology is practiced across most centers.

3.10. Ancillary Techniques

IHC, molecular tests, flowcytometry and Human papilloma virus (HPV) testing is practiced in 37.9% (89/235) centers, of which 47.7% (62/130) were teaching hospitals, 40.8% (20/49) were corporate hospital laboratories, while 13.6% (6/44) were private practitioners. Among these centers, the most commonly used ancillary technique was IHC (83.8%) followed by various forms of molecular testing such as real time PCR, FISH, NGS etc. The increasing number of centers utilizing the ancillary techniques indicates the advancement of cytology in the country.

3.11. Conventional Pap Smears and LBC

Pap smear testing for cervical cancer screening is fairly common and 41.3% (97/235) of the centers/laboratories received more than 2000 Pap smears in a year. Conventional Pap smears remain predominant, while LBC was available in 48% (113/235) of centers, primarily in corporate hospitals [69.4%; 34/49] and teaching hospitals [51.5%; 67/130]. Most private practitioners (75%; 33/44) and peripheral laboratories lacked the infrastructure for LBC. Few centers process both conventional and LBC smears.

3.12. Effusion Cytology

In the year 2020, IAC published the guidelines for collection, preparation, interpretation, and reporting of serous effusion fluid samples [6]. Since then various authors have shared the experience of the application of these guidelines [15]. Awareness of IAC effusion guidelines was reported by 72.8%, while 54.9% (129/235) actively implemented them. Cyto‐histological audits were performed in 41.7% (98/235) of centers, more commonly in corporate settings (81.6%).

3.13. Quality Assurance/Audits

Regular audits and cytology‐histology correlation is essential for the internal quality control and external quality assurance (EQAS). Seventy percent of the laboratories had regular audits. Cyto‐histopathology correlations and regular audits were practiced more commonly in the corporate hospital laboratories (81.6%; 40/49) than in the laboratories of the teaching hospitals (31.5%; 41/130).

3.14. Turnaround Time (TAT)

TAT is a predictor of quality and efficiency of the laboratories. Most laboratories (46.8%; 110/235) had a TAT of 24 h, followed by 34.9% (82/235) of the laboratories, which had a TAT of 48 h. Majority of private practitioners (65.9%; 29/44), teaching hospitals (40.8%; 53/130) and corporate laboratories 47% (23/49) claimed a TAT of less than 24 h.

3.15. Whole Slide Imaging (WSI) and Artificial Intelligence (AI)

WSI constitutes a revolution in the world of pathology, including digitization of the glass slides. WSI has enabled telepathology, interminable archival and led ways for computer‐aided diagnosis. However, the technical learning curve and high cost of the instrument has limited its use to tertiary care institutes and corporate hospitals with a high turn‐over. At present, 90% of the pathologists at various centers/laboratories did not have access to the WSI. A total of 10 teaching hospitals, 7 private practitioners, 5 corporate hospitals claim to be using WSI. AI has gradually percolated in all pursuits of pathology. As per the survey, only 2.6% (6/235) of pathologists used AI based application for cytology diagnosis. These applications were mainly employed for screening Pap samples, particularly in research settings. The usage and penetration of artificial intelligence is limited among pathologists in India.

3.16. Education and Training

51% (120/235) of the centers have structured training programs for residents and cytotechnicians. However, formal subspecialty certification is lacking with only a few institutions offering postdoctoral certificate 1 year course (PDCC) in cytopathology. Exposure to LBC, molecular diagnostics, digital pathology, and AI is uneven across various centers in the country owing to a variable infrastructure and regional practices. The survey revealed that only 54% (127/235) of the pathologists conducted/attended cytopathology related CMEs regularly.

4. Discussion

The questionnaire survey reflects on the various aspects of cytopathology practice. There is stark difference in terms of the work load, existing facilities, infrastructure and reporting patterns in different settings. A dedicated cytopathology laboratory is a prerequisite for efficient cytology training during the post graduate degree/diploma in pathology. Around 96% of teaching hospitals have a cytopathology lab which reflects the significance of cytopathology training in pathology residency in the country. More than 60% private practitioners have developed a dedicated lab attesting that cytopathology is an essential diagnostic service for routine practice. The usage of cytology as an essential diagnostic tool has seen exponential increase in the last three decades. Das et al. showed that more than 10,000 FNACs/year were performed in only 2 centers across the country in the late 1990s, as opposed to 2025, where more than 11 centers perform > 10,000 FNACs/year [2].

The FNAC handle is specifically designed for controlled and easy FNACs as it helps in creating effortless negative pressure with one handed control. The non suction capillary aspiration is usually suggested only for too small or too vascular lesions. Despite the proven utility, around 45% cytologists do not use the handle. The triage of FNAC material for cell block, bacterial culture, flowcytometry or molecular tests is done by less than half of pathologists. This may be due to lack of infrastructure or facilities for performing further tests. There is a need of workshops and seminars for training the residents and budding pathologists in the art of performing an optimal FNAC procedure, the usage of a handle and specimen triage for cell blocks, LBC, flow cytometry and molecular tests. The knowledge and awareness of standard algorithmic approach and use of ancillary techniques for grey‐zone lesions in cytology can expand the diagnostic capacity of cytopathologists multifold [16].

The adequacy of aspirated material is the key goal of the operator performing the FNAC procedure. Rapid on‐site evaluation (ROSE) done at the time of FNAC and requires a basic microscope and rapid stain such as Toluidine blue or Rapid Hematoxylin and eosin. The smears are prepared and stained with a rapid stain and visualized under the microscope to confirm the adequacy and limit the number of passes. The cytopathologist can decide the number of wet fixed and air‐dried smears to be made and further triage the specimen.

The advancement and reach of radiological equipment in peripheral centers, increasing radiologist collaboration and expertise in interventional radiology has led to increased number of image‐guided FNACs in teaching institutes and other centers alike. A few centers have radiologists who perform FNAC in absence of pathologists. However, it is advocated that image guided FNACs should be ideally performed by radiologists in collaboration with pathologists. The pathologists are trained in ROSE and can immediately comment on the adequacy of the specimen and triage of the precious FNAC material. The collaboration can effectively streamline the procedure, reduce the number of repeat procedures and can be more productive. Thus, the presence of a pathologist is preferred for performing any FNAC [17]. Regular radio‐cytological correlation audits can be beneficial in training the radiologists and pathologists.

The standardized tiered reporting systems ensures uniformity in terminology and improves reliability among physicians by commenting on risk of malignancy. However, the adoption of the latest standard reporting systems needs awareness regarding recent updates in cytopathology [13]. These reporting systems often advocate the use of ancillary techniques in further categorization of the grey‐zone lesions. The challenge in inculcating the standard reporting systems include uneven training, reluctance to adopt risk‐based categorization, and a limited infrastructure for ancillary techniques.

The index study revealed that all the cytopathologists in the survey follow the TBS system for cervical cancer reporting. The use of conventional smear is higher than the LBC counterparts which is largely due to high equipment and running costs. Although LBC has its own advantages, the conventional smear is cheaper and requires no equipment or trained personnel [18].

In the past, the LBC technology was primarily available with SurePath and ThinPrep, but there is a recent surge of relatively cost‐effective LBC equipment many of which are in process of validation. The LBC samples also hold a greater advantage as the same specimen can be used for HPV testing. However, the strategies and implementation of HPV based cervical cancer screening and reflex HPV testing is yet to be incorporated in the national policies. The LBC equipment can also be used for non‐gynecological purposes. The IAC effusion cytology guidelines have illustrated the prerequisites for collection, preparation, interpretation and reporting of serous effusion fluid samples. The IAC has listed the LBC as optional preparation, while cell block preparation is highly desirable. The IAC guidelines are followed by less than 60% centers and these categories need to be inculcated in routine practice by more cytopathologists. More than 75% cytopathologists prepare cell blocks from FNAC material as well as effusion specimens. The sodium alginate is a low‐cost alternative to plasma thrombin/thromboplastin method with shorter processing time and easily available reagents for preparation, however, only three centers use the sodium alginate method [19].

Cyto‐histological audits were found to be more common in corporate hospital laboratories. The possible reasons might be mandatory accreditation requirements, quality metrics, and different workflow structures in corporate hospital laboratories. In government hospitals, on the other hand, the patient load is higher and standard operating procedures might not be defined. The manpower is government hospitals is usually multitasking, yet limited which affects the frequency of audits. The accreditation for cytopathology labs in India can be availed from the National Accreditation Board for Testing and Calibration Laboratories (NABL), which accredits medical testing laboratories based on the ISO 15189 standard and IAC, which has a dedicated EQAS program [20, 21]. The IAC accreditation program grants a third‐party recognition for maintaining the desired level of proficiency. About 60% cytopathology labs are accredited by one or more agencies. There is an evident need of accreditation drive for maintaining higher standards of cytopathology reporting. More labs and centers should be encouraged to participate in EQAS programs and apply for accreditation. The e‐EQAS format introduced recently by IAC can be instrumental in ensuring increased participation in EQAS program. The laboratories which have registered for EQAS must be motivated to apply for accreditation. The national conferences and workshops can initiate separate sessions regarding the importance of accreditation. EQAS predictors such as internal audits are also useful tools for maintaining high standards of reporting. The fraction of pathologists who attend cytology seminars and updates is bothersome.

The present study has shown that the penetration of WSI and AI is low across the country as also illustrated by Sharma M, et al. [22] Gupta R, et al. have reviewed the role of WSI and AI‐based algorithms for cervical cancer screening and found that the usage of AI can be very promising [23]. Thakur N, et al. also found that AI holds bright future for non‐gynecological specimens also [24]. The training and validation of algorithms is an arduous task. Despite existing gaps and challenges such as high cost, steep learning curve and lack of infrastructure, WSI and AI continue to excite and percolate cytopathology as well.

The education and training programs in cytopathology are a part of the 3 year post graduate residency programs in medical colleges and institutes wherein the basic skills for practicing cytopathology are taught and inculcated. Postgraduate programs (MD/DNB Pathology) have structured rotations existing in the premier centers; but smaller institutions often lack dedicated cytopathology faculty or a sufficient caseload. The IAC and academic bodies conduct workshops, fellowships (e.g., ICMR‐NICPR certified courses), and CME programs. In addition, the cytotechnologists and cytotechnicians learn the cytology processing as a part of medical laboratory technicians (MLT) courses conducted by government and private institutes. The IAC also has various platforms for on‐going training of cytotechnicians and cytopathologists and accreditation and EQA programs. The residents are taught using routine reporting done with the help of five‐header teaching, cytology‐ biopsy rounds, cyto‐histo audits and cyto‐radio audits. However, the multi‐head microscope teaching is available in premier institutes only. The national medical commission (NMC) under the post graduate MD Pathology course has outlined seven competencies, which mandate the learning of basic cytopathology for a resident including performing FNACs, making smears, preparing cell blocks, assisting guided FNACs, perform ROSE, decide on the sample triage, processing fluids and various exfoliative cytology specimens along with an accurate diagnosis of common lesions. The National Medical Council (NMC) targets to elevate the research quotient of the pathologist and promotes conduct of research. As per the NMC guidelines, the postgraduate student must accomplish at least two presentations at the state or at the national level conference and one paper (thesis or non‐thesis related work) should be published/accepted/publication draft in an indexed journal before appearing for the examination [25].

The variability in terminology, inconsistent report template necessitates the need of efficient training programs, fellowships, workshops and national guidelines for uniform reporting, finally influencing patient care.

4.1. Limitations

The study offers perception regarding cytopathology practice in India; however, the data is limited by the fact that results are calculated from a self‐reported survey data and does not analyze regional differences. The data may be skewed due to increased number of responses from teaching hospitals and may not be enough to comprehensively capture the diversity of practices found across India.

5. Conclusions

Cytopathology in India demonstrates notable progress but retains heterogeneity in reporting, training, and quality assurance. Cytology techniques such as cell block, LBC, IHC and molecular are being increasingly used in routine practice depending on the resources. Conventional smears stained with Pap, H and E and Giemsa stains dominate. The consistent implementation of the structured reporting frameworks, widespread use of ancillary techniques, and standardized education are needed. The nationwide survey has offered data‐driven insights regarding the variation in training, infrastructure and reporting systems. The availability of robust infrastructure and trained man‐power for advanced diagnostics, and structured training programs, is essential. Coordinated efforts at national level and the adherence to established standardized cytopathology guidelines are key to building consistent and high‐quality cytopathology services.

Author Contributions

S.G.: conceptualization, data curation, data analysis, and manuscript drafting. I.G.: data collection, data curation, statistical analysis, and manuscript drafting. N.G.: Study design, supervision, data interpretation, and critical revision of the manuscript. B.R.: Data interpretation and critical revision of the manuscript. All authors have read and approved the final manuscript.

Funding

The authors have nothing to report.

Ethics Statement

The study was approved by the Institute Ethics Committee (INT/IEC/2025/SPL‐716; dated 25.05.25).

Consent

Participation was voluntary, and informed consent was obtained electronically.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.