Cervical cancer is the largest cause of female cancer mortality in Nepal with an annual death rate of approximately 2000 cases (WHO data 2008). No formal government-led cervical cancer screening programme currently exists in Nepal though a commitment to such a programme was published by the Department of Health Services and Ministry of Health and Population in 2010. Meanwhile, the non-governmental organisation Practical Help Achieving Self-Empowerment (PHASE) has been working in partnership with the Nepal Network for Cancer Treatment and Research (NNCTR) to improve existing colposcopy provision in Nepal and to introduce new colposcopy services using the technique of visual inspection with acetic acid (VIA) and treatment by LLETZ. To date PHASE has introduced two new weekly colposcopy clinics at the Maternity Hospital, Kathmandu and has supported lectures and hands-on training for Nepalese colposcopists. Histology services for cervical specimens are provided by a variety of government and private laboratories, for which the reference centre is based at the National Public Health Laboratory, Kathmandu (NPHL) where Dr Geeta Shakya is Director. UKAID awarded us monies for colpscopy and cervical pathology capacity development, This is our report up to March 2013.

Fields of work Reproductive Health/Obstetrics/Gynaecology
UK Partner Nottingham University Hospital NHS Trust
Developing Country Partner Maternity Hospital, Kathmandu
Contact Dr David Nunns - david.nunns@nuh.nhs.uk



The NNCTR is an NGO based in Banepa outside KTM. They arrange ad-hoc screening camps both in and outside the KTM valley. Around 6000 women are screened in camps for both cervical and breast cancer each year. There are plans to increase the numbers of cases over the next few years.  The camps are successful as the NNCTR work closely with community groups and local NGOs and do much background networking to ensure that the women attend.

Patients are screened (100 day) by the Visual Inspection with Acetic acid (VIA) and Visual Inspection with Lugols iodine (VILI)  techniques by a team of skilled nurses (pool of 8) overseen by Nurse Mamata from the NNCTR who does much validation of the other nurses work. There is excellent data collection. Some patients get antibiotic for PID and treatment for prolapse.  A gynaecologist (Dr Meeta Singh and Dr Malla) sometimes attend. Dr Singh has been to the UK for colposcopy training. Screen negative patients are discharged.

If a camp is far from KTM then a colposcope is taken to the camp and screen positive patients  have a colposcopy by Mamata or the gynaecologist and a biopsy taken. If the biopsy shows low grade CIN then the patient is followed up. If high grade then the patient has to come to KTM for treatment. Treatment ideally would be a loop diathermy.  Patients are contacted by phone. The DNA rate can be high for a variety of reasons  (work commitments, money for travel, low priority of screening) . Smoking is very common especially in poor populations.

If the camp is close to KTM, then no colposcope is taken and screen positive patients come to KTM for a colposcopy and possible biopsy and then return for treatment if necessary. Some patients travel for a day. Patients are counselled on camp by the nurses and they give consent with a fingerprint for the colposcopy and possible treatment.

Pathology sample go to NHPL, Maternity hospital or Teaching hospital for processing and assessment Treatments are carried out in Maternity Hospital (Dr Madhu and team) or Teaching Hospital (Dr Meeta Singh and team).



Facilitators -  Dr Surendra Bade ( Director, Nepal Network for Cancer Treatment and Research), Dr Sheela Verma (Director Maternity Hospital)


Facilitator– Dr Geeta Shakya (Director, National Public Health Laboratory, Teko)

UK delegates - Jane Pannikar, (Shrewsbury), Val Brown, (Colposcopist, Sheffield) Tervinder Sokhi, (Biomedical Scientist, Birmingham) David Nunns, (Colposcopist, Nottingham)



Day 1 was the dry run without patients. The format was introductions, lecture on cervical cancer and screening (JP) then  group work . Group one – colposcope use, group two -  slideshow of disease, group three - discussion group covering QA, proctocols and guidelines. There was a variable level of understanding on colposcopy amongst the candidates who varied from senior and junior  medical staff, nurses and NAs.

Day 2 and 3 were the clinical sessions with women attending from the screening camps organised by NNCTR. Some patients were seen in Feb and September 2012 and had either had just a VIA/VILI  test and referral if positive or had had a VIA test and then a colposcopy and biopsy by Mamata in the camp and then referral on if the biopsy was abnormal.  Around 40 new patients attended. The DNA rate was high for reasons mentioned above. Some of the pathology reports were difficult to interpret.

One room was in the OT and prepared for treatments (DN) Delegates were Dr Vijay Consultant Gynaeoncologist  from Bharatpur Hospital, his out patient sister and Mamata.

There were two rooms for diagnostics. VB  and Dr Malla (former director of the hospital) in one room. JP and Dr Madu Consultant Gynaecologists Maternity Hospital in another. The rooms were clean ,well set up, with running water with sterile packs from NNCTR. There were three colposcopes, two from the NNCTR which were good and one from the Maternity Hospital which was poor. The patients  came with paper work. Specimens were transported to NNCTR and then to lab in Teko the following week.

Tev Sokhi facilitated 1)review the current processes in the department, 2) review of existing equipment, 3) Advice on Improvements/Quality Assurance Measure were taken to improve these processes and the outcome of his visit was a clear improvement in these processes by the end of the visit ready for the pathology visit


    In 2011 PHASE approached the British Association of Gynaecological Pathologists (BAGP) to explore the possibility of support for Nepalese cervical histology services in the form of training from specialist UK gynaecological pathologists. Drs Raji Ganesan and Michael Coutts from the BAGP Council agreed to design and provide a package of support.

    Twenty-six cases of routine cervical histology were forwarded from NPHL to the UK in order that Drs Ganesan and Coutts could assess the technical quality of the laboratory preparations and the quality of the histopathological reports. In essence, there were problems with tissue processing, fixation ,section cutting and staining which were felt to significantly hamper the pathologists’ ability to assess the material. To this end, Mr Tervinder Sokhi, Head Biomedical Scientist, Birmingham Women’s Hospital was asked to accompany Dr Nunns to Nepal in October 2012 to troubleshoot laboratory practices in NPHL. Mr Sokhi has produced a detailed report of his work and how he introduced changes to laboratory practice which have improved histological section quality. Drs Ganesan, Coutts and Nunns then followed up this visit with the NPHL cervical pathology workshop of 8-9th November.


    The workshop took place at the NPHL and local organisation was by Dr Shakya (Director), Dr Mukunda (Pathologist at NPHL) and Dr Surendra Bade Shrestha (Chairman, NNCTR). Twenty-seven pathologists attended from a variety of public and private hospitals drawn widely from Nepal and this number was from a total of approximately 100 histopathologists thought to be currently working in Nepal. Dr Rajesh Panth, President of the Association of Clinical Pathologists of Nepal (ACPN) was also in attendance. Ten light microscopes and videomicroscopy and laptop projector facilities were provided by NPHL.

    Drs Ganesan, Coutts and Nunns presented lectures which included: normal cervical histology and LLETZ dissection; principles of screening programmes and cytology; CIN and mimics; CGIN and mimics; invasive squamous carcinoma; invasive adenocarcinoma; clinical aspects, HPV testing and vaccination; minimum data reporting in cervical histology; correlation in cervical screening.

    Drs Ganesan and Coutts presented interactive histology seminars with videomicroscopy of squamous lesions and glandular lesions. Drs Ganesan and Coutts also provided six sets of twenty test slides which were viewed in an ‘assessment-style’ format by the delegates. These test slides were then discussed with the attendees in a third videomicroscopy seminar.

    Drs Ganesan and Coutts also reviewed histological slides and reports from thirteen cases seen in a colposcopy clinic which had followed Mr Sokhi’s visit.


    1. The facilitators were delighted with the high level of attendance at the workshop. More than a quarter of the Nepalese histopathology community were present and Dr Shakya indicated that more pathologists had wanted to attend but that there were insufficient space and facilities to accommodate them. The enthusiasm and interest for the subject from the delegates was very striking and encouraging. Several of the attendees commented that more additional continuing medical education in the Nepalese pathology system was very welcome.

    2. Judging from the delegates’ responses to the test set and comments made in the other interactive sessions, the facilitators are of the view that the attendees’ diagnostic ability is broadly sound and often very good. A detailed assessment of the ability of each candidate was however not within the remit of the workshop. To reinforce the teaching from the workshop, five sets of the test slides were left indefinitely at NPHL for rotation to pathologists in Nepal; copies of the new edition of NHS cervical screening programme publication no 10 on histology reporting are being sent to NPHL; and histology reporting proformas were produced and distributed to the pathologists to ensure consistency in terminology and the reporting of histological data necessary for effective patient management.

    3. An audit of the thirteen colposcopy cases revealed an improvement in laboratory processing relative to the material first submitted to the BAGP in 2011 and led to some recommendations in histological reporting (subject of a separate audit report see Appendix A).

    4. Overall, we were pleased with the correlation between the nurse colposcopists findings and our findings in the hands on workshop. There is great benefit for the nurse colposcopist working in the camp with a colposcopy as it streamlines the pathway for women and should increase sensitivity and specificity of the VIA/VILI test. The overall detection of HG CIN in our cohort was 17% which was encouraging in this setting.



    1. Lecture material to be freely available on the NPHL/NNCTR/International Network for Cancer Treatment and Research (INCTR) website. Copies of NHC CSP publication no 10 shortly to be made available.

    2. Test set slides (kept at NPHL lab) freely available in Nepal for review.

    3. Proforma reporting of cervical punch biopsies and LLETZs introduced. This enables rapid, standardised histological reporting on a sheet of A4 paper bringing consistency in terminology between laboratories and ensuring inclusion of minimum data necessary for clinical management.

    4. Introduction of SNOMED disease coding as a component of the proforma reports. This process essentially labels different pathologies with numerical codes for the purposes of audit and epidemiological studies. A commitment in principle was obtained from Dr Bade Shrestha to support the collation of this data in a central electronic format.

    5. Audit and other observational evidence of an improved quality of laboratory processing and of a broadly good quality of histological reporting.

    6. Agreement in principle to explore the possibility of posting difficult cervical histology cases from Nepal requiring a second opinion on the INCTR website area which is available for this purpose. INCTR to agree web support to the group for this service.

    7. Agreement in principle to repeat the workshop in one year’s time for the benefit of other attendees.

    8. An agreement to develop cold coagulation as a treatment option for patients as well as loop diathermy. This 'low-risk' technique could be used in the screening camps.