The challenges of implementing less invasive surgical management for cervical cancer in a limited-resource setting in Botswana: A case series

• Imaging and post-surgical cervical cancer stages were concordant in 50% of cases. • Nineteen percent of patients were understaged by imaging. • Median 68-day delay between MRI and surgery. • Risk of understaging complicates less invasive surgery. Cervical cancer is the number one cause of cancer-related mortality for women in Botswana, where care is complicated by the country’s severe shortage of gynecologic oncologists. Recent data suggests that “low-risk” stage I cervical cancers can be treated with simple hysterectomy (SH) rather than radical hysterectomy (RH), potentially reducing specialist burden and surgical morbidity. This case series evaluates the accuracy of clinical and image-based staging for risk stratification and examines the challenges to implementing less invasive surgery among patients with early-stage cervical cancer in Botswana. Data were retrospectively collected for patients who underwent preoperative MRI and curative surgery for cervical cancer at Princess Marina Hospital (PMH) in Gaborone from September 2022 to December 2024. All patients were FIGO stage IA1-IB2 and had not received chemotherapy or radiation prior to surgery. Descriptive analysis comparing staging across clinical diagnosis, MRI imaging, and final pathology was completed. Thirty-two patients with early-stage cervical cancer were included in this study, 15 (47%) of whom underwent RH and 17 (53%) underwent SH. Staging between MRI and final surgical pathology was concordant in 16 (50%) patients. Four patients had the same stage across clinical, MRI, and surgical staging. There were substantial delays between imaging-based staging and surgery, ranging from 27 to 151 days (median 68 days). Though patients in LMICs would stand to benefit most from less invasive cervical cancer surgery, limited reliability of staging, inadequate preoperative imaging, and delays to care complicate risk stratification and limit application of evidence favoring SH.