Can stereotactic body radiotherapy replace brachytherapy in gynecologic cancers? A systematic review of current evidence.

Brachytherapy (BT) is a cornerstone of curative radiotherapy for gynecologic cancers due to its ability to deliver high intratumoral doses with steep dose gradients. Limited availability and declining utilization have increased interest in stereotactic body radiotherapy (SBRT) as a non-invasive alternative. This systematic review evaluates the current evidence comparing SBRT and BT in gynecologic cancers. A systematic search of PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science was conducted for studies published between 2014 and 2025. Eligible studies included dosimetric analyses, observational cohorts, and consensus statements comparing SBRT and BT. Outcomes of interest were target coverage, intratumoral dose escalation, organ-at-risk exposure, conformity and homogeneity indices, and overall survival when available. Eleven studies met the inclusion criteria, including nine dosimetric studies, one population-based cohort, and one consensus guideline, mainly focused on locally advanced cervical cancer. BT consistently achieved superior intratumoral dose escalation and higher central dose heterogeneity, while SBRT showed competitive peripheral target coverage and improved conformity in margin-free scenarios. These advantages were reduced when clinically realistic planning margins were applied. The only available survival analysis reported no significant difference in overall survival between techniques after adjustment for prognostic factors. BT remains the reference standard for dose escalation in gynecologic cancers. SBRT may be considered a selective alternative when BT is not feasible, but prospective studies with standardized planning and long-term follow-up are needed to define its clinical role.