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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

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Abstract

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

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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 information

Authors and Affiliations

  1. Health Systems and Services Research, Duke NUS Medical School, 8 College Road, 169857, Singapore, Republic of Singapore

    Ka Keat Lim

  2. Healthcare Statistics Unit, National Clinical Research Centre, 3rd Floor, MMA House, 124 Jalan Pahang, 53000, Kuala Lumpur, Malaysia

    Ka Keat Lim

  3. Cancer Research Malaysia, 2nd floor, Outpatient Centre, Subang Jaya Medical Centre, 47500, Subang Jaya, Selangor, Malaysia

    Sook Yee Yoon & Soo Hwang Teo

  4. Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Nur Aishah Mohd Taib & Soo Hwang Teo

  5. Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Fatiha Hana Shabaruddin

  6. Julius Centre, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Maznah Dahlui

  7. Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Yin Ling Woo

  8. Department of Paediatrics, Faculty Of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia

    Meow Keong Thong

  9. Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Muang, Phitsanulok, Thailand

    Nathorn Chaiyakunapruk

  10. School of Pharmacy, Monash University Malaysia, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia

    Nathorn Chaiyakunapruk

  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 Malaysia, Bandar Sunway, 47500, Subang Jaya, Selangor, Malaysia

    Nathorn Chaiyakunapruk

  12. School of Pharmacy, University of Wisconsin, Madison, USA

    Nathorn Chaiyakunapruk

Authors
  1. Ka Keat Lim
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  2. Sook Yee Yoon
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  3. Nur Aishah Mohd Taib
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  4. Fatiha Hana Shabaruddin
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  9. Nathorn Chaiyakunapruk
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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.

Corresponding author

Correspondence to Nathorn Chaiyakunapruk.

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Funding

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.

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Lim, K.K., Yoon, S.Y., Mohd Taib, N.A. et al. 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. Appl Health Econ Health Policy 16, 395–406 (2018). https://doi.org/10.1007/s40258-018-0384-8

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  • DOI: https://doi.org/10.1007/s40258-018-0384-8

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