Early-stage cervical cancer is commonly treated with surgery while locally advanced disease is treated with definitive concurrent chemotherapy and external beam radiation therapy (EBRT) followed by brachytherapy (BT) boost [1]. BT is a critical component of the definitive treatment in patients with cervical cancer; it allows dose escalation to the central disease while limiting the dose to the normal surrounding organs such as bladder, rectum, small bowel and sigmoid, yielding excellent clinical outcomes [2]. The omission of brachytherapy has been shown to negatively impact survival [3,4]. Volumetric target delineation in BT using MRI and CT-based planning as established by the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) [5], is strongly recommended by the American Society for Therapeutic Radiology and Oncology (ASTRO) [1]. Compared to 2D-planning, Image-Guided Brachytherapy (IGBT) has resulted in improved local control rates and decreased grade 3 and 4 toxicities [[6], [7], [8]]. Alternative EBRT techniques such as intensity modulated radiation therapy (IMRT) and stereotactic body radiotherapy (SBRT) are not recommended as a boost due to the increased toxicity and inferior clinical outcomes [1,3,4,9]. Indeed, in a phase II trial evaluating SBRT boost as an alternative to BT in locally advanced cervical cancer, lower than expected local control, progression-free and overall survival with increased toxicity resulted in early closure of the trial [9].

Despite the recent advances in BT and improved outcomes, disparities in the treatment of cervical cancer and utilization of BT in the United States (US) persist. Various factors including socio-economic determinants, age, geographical location, access to health-care facility, type of health care facility and insurance has been shown to be associated with lower BT boost rates in these patients [10]. Thus, disparities lead to exponential detriment in local control and survival.

The goal of this comprehensive literature review is to discuss the disparities in BT utilization in the US and its impact on outcomes in cervical cancer patients.