Evidence shows brachytherapy to be an essential component of definitive treatment for locally advanced cervical cancer (LACC) in combination with external beam radiation and cisplatin-based chemotherapy. The omission of brachytherapy for LACC is associated with inferior survival, even when replaced with an intensity-modulated or stereotactic body radiation therapy boost, according to research findings. Despite the success of brachytherapy, several studies have reported overall declines in brachytherapy use for LACC during the 1990s through the 2010s, while other studies examining privately insured populations during the same period found no declines. Because of this discrepancy, we analyzed brachytherapy utilization by insurance category in the National Cancer Database from 2004 to 2014, with the hypothesis that the burden of declined brachytherapy use was primarily felt by uninsured patients or those with Medicaid or Medicare. Our analysis, published in Gynecologic Oncology, showed that use of brachytherapy declined in the late 2000s and disproportionately affected government-insured patients; however, in the early 2010s, these trends reversed, such that patients of all insurance types experienced overall improved rates of brachytherapy utilization. We believe that contemporaneous publications, press, and awareness raised at national meetings may have been important in reversing this trend. Additionally, the implementation of the Affordable Care Act, which had wide-reaching effects on healthcare—including provisions aimed at strengthening care in underserved areas—may have also positively influenced this trend.
Given the importance of brachytherapy in LACC treatment, it is critical that these gains are solidified and encouraged. With the previous declines in brachytherapy appearing to affect patients with government insurance more severely—despite the encouraging recent trends—it may be prudent to implement additional measures for government-insured patients to buffer against any subsequent declines. Alternative payment models (APMs), which align compensation with high-quality and cost-efficient care, have been proposed in this area. APMs for cervical cancer, however, must be constructed carefully to avoid disincentivizing brachytherapy delivery in a fixed payment system, as brachytherapy is more expensive to providers than external beam boost. Overall, recent trends in brachytherapy use in LACC patients are positive, and hopefully the implementation of well-designed APMs can promote these gains.