Applied Health Economics and Health Policy

, Volume 16, Issue 3, pp 395–406 | Cite as

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

  • Ka Keat Lim
  • Sook Yee Yoon
  • Nur Aishah Mohd Taib
  • Fatiha Hana Shabaruddin
  • Maznah Dahlui
  • Yin Ling Woo
  • Meow Keong Thong
  • Soo Hwang Teo
  • Nathorn Chaiyakunapruk
Original Research Article



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.

Author Contributions

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.

Supplementary material

40258_2018_384_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 18 kb)
40258_2018_384_MOESM2_ESM.docx (28 kb)
Supplementary material 2 (DOCX 27 kb)
40258_2018_384_MOESM3_ESM.pdf (94 kb)
Supplementary material 3 (PDF 95 kb)


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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Health Systems and Services ResearchDuke NUS Medical SchoolSingaporeRepublic of Singapore
  2. 2.Healthcare Statistics UnitNational Clinical Research CentreKuala LumpurMalaysia
  3. 3.Cancer Research MalaysiaSubang JayaMalaysia
  4. 4.Department of Surgery, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
  5. 5.Department of Pharmacy, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
  6. 6.Julius Centre, Department of Social and Preventive Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
  7. 7.Department of Obstetrics and Gynaecology, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
  8. 8.Department of Paediatrics, Faculty Of MedicineUniversity of MalayaKuala LumpurMalaysia
  9. 9.Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical SciencesNaresuan UniversityMuangThailand
  10. 10.School of PharmacyMonash University MalaysiaSubang JayaMalaysia
  11. 11.Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform Monash University MalaysiaSubang JayaMalaysia
  12. 12.School of PharmacyUniversity of WisconsinMadisonUSA

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