Is BRCA Mutation Testing Cost Effective for Early Stage Breast Cancer Patients Compared to Routine Clinical Surveillance? The Case of an Upper Middle-Income Country in Asia
Previous studies showed that offering BRCA mutation testing to population subgroups at high risk of harbouring the mutation may be cost effective, yet no evidence is available for low- or middle-income countries (LMIC) and in Asia. We estimated the cost effectiveness of BRCA mutation testing in early-stage breast cancer patients with high pre-test probability of harbouring the mutation in Malaysia, an LMIC in Asia.
We developed a decision analytic model to estimate the lifetime costs and quality-adjusted life-years (QALYs) accrued through BRCA mutation testing or routine clinical surveillance (RCS) for a hypothetical cohort of 1000 early-stage breast cancer patients aged 40 years. In the model, patients would decide whether to accept testing and to undertake risk-reducing mastectomy, oophorectomy, tamoxifen, combinations or neither. We calculated the incremental cost-effectiveness ratio (ICER) from the health system perspective. A series of sensitivity analyses were performed.
In the base case, testing generated 11.2 QALYs over the lifetime and cost US$4815 per patient whereas RCS generated 11.1 QALYs and cost US$4574 per patient. The ICER of US$2725/QALY was below the cost-effective thresholds. The ICER was sensitive to the discounting of cost, cost of BRCA mutation testing and utility of being risk-free, but the ICERs remained below the thresholds. Probabilistic sensitivity analysis showed that at a threshold of US$9500/QALY, 99.9% of simulations favoured BRCA mutation testing over RCS.
Offering BRCA mutation testing to early-stage breast cancer patients identified using a locally-validated risk-assessment tool may be cost effective compared to RCS in Malaysia.
Data Availability Statement
All data used in the analyses are referenced and described in the text and listed in Supplementary File 2. All other information is available from the corresponding authors on reasonable request.
SYY, SHT and NC conceptualized the research idea; KKL and NC formulated the research questions, and designed and performed the analysis; NAMT, YLW and MKT assisted in model building by providing their clinical inputs, FHS and MD provided secondary data on resource consumption, and assisted in data analysis and interpretation of findings. KKL prepared the first draft of the manuscript. All authors were responsible for critically revising the manuscript and agreed on the final content before submission.
Compliance with Ethical Standards
No funding was involved for this study.
Human or animal rights
This article does not contain any studies with human participants or animals performed by any of the authors.
Conflict of interest
All authors (KKL, SYY, NAMT, FHS, MD, YLW, MKT, SHT, NC) declare no conflicts of interest related to BRCA mutation testing.
- 8.Tengs TO, Berry DA. The cost effectiveness of testing for the BRCA1 and BRCA2 breast-ovarian cancer susceptibility genes. Dis Manag Clin Outcomes. 2000;1:15–24.Google Scholar
- 12.Ministry of Health Malaysia and Academy of Medicines Malaysia. Management of Breast Cancer, 2nd Ed. Ministry of Health Malaysia: Putrajaya; 2010. http://www.moh.gov.my/penerbitan/CPG2017/6915.pdf.
- 15.Cancer Research Malaysia. Breast Cancer Current Research and Programme: MyBrCa and MyMammo. 2016 05/06/2016]. http://www.cancerresearch.my/our-research/breast-cancer-research/more-than-a-mammo-programme/. Accessed 20 June 2017.
- 16.Husereau D et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BMJ Br Med J 2013;346:f1049.Google Scholar
- 29.Department of Statistics Malaysia. Malaysia economics statistics—time series 2015. 2015 30/12/2015 10/05/2016]. https://www.statistics.gov.my/index.php?r=column/ctimeseries&menu_id=NHJlaGc2Rlg4ZXlGTjh1SU1kaWY5UT09. Accessed 20 June 2017.
- 30.Central Bank of Malaysia. Kuala Lumpur US$/MYR Reference Rate. 2016 20/06/2017]. http://www.bnm.gov.my/index.php?ch=statistic&pg=kualalumpurusdmyrreferencerate. Accessed 20 June 2017.
- 31.Attorney General’s Chambers of Malaysia. Fees (Medical Cost of Services) Order 2014. Putrajaya: Attorney General’s Chambers of Malaysia; 2014.Google Scholar
- 32.Clinical Research Centre (CRC). National Healthcare Establishment and Workforce Statistics (Hospital) 2011. Kuala Lumpur: Clinical Research Centre, Ministry of Health Malaysia; 2013.Google Scholar
- 34.Ministry of Health Malaysia. Pharmacoeconomic guideline for Malaysia. Kuala Lumpur: Pharmaceutical Services Division; 2012.Google Scholar
- 36.Malaysian Health Technology Assessment Section. Establishing a cost-effectiveness threshold value for health technologies Newsletter, Vol 17. Putrajaya: Malaysian Health Technology Assessment Section (MaHTAS) Medical Development Division Ministry of Health Malaysia; 2015.Google Scholar
- 39.Briggs A, Claxton K, Sculpher M. Chapter 4: making decision model probabilistic. In: Grey A, Briggs A, editors. Decision modelling for health economic evaluation. Oxford: Oxford University Press; 2011.Google Scholar
- 43.International Agency for Research on Cancer (IARC). GLOBOCAN 2012: Estimated cancer incidence, mortality and prevalence worldwide in 2012: Malaysia. 2012 20/12/2016]. http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed 20 June 2017.