OBJECTIVES: In HR positive ABC, HT may be considered standard treatment before institution of chemotherapy. However, HT is sometimes substituted by CT early in the disease course, for example after failure of first-line HT. A common treatment sequence in Brazil is anastrozole followed by successive lines of docetaxel, capecitabine and gemcitabine. We evaluated the CE of this treatment sequence (CT sequence) compared to several other sequences (HT/CT sequences) in which anastrozole and fulvestrant are used in first and second lines, respectively, and then followed by exemestane and megestrol or megestrol and capecitabine or exemestane and capecitabine or megestrol and exemestane or exemestane and docetaxel, each pair introduced as third and fourth lines, respectively. METHODS: A Markov model describing the clinical history of HR positive, ABC, projected improvements in terms of quality-adjusted life months (QALM), costs, and CE of CT compared to HT/CT. The time horizon is four treatment lines or the time to patient's death, whichever occurred first. The simulations were with 10,000 patients for each treatment sequence studied. The reference patient is a post-menopausal woman with HR positive ABC, with previous definitive surgery and adjuvant HT with tamoxifen. The disease-progression probabilities for the different treatment drugs/lines and, the quality of life for each health state were based on the medical literature. Local management and costs of each health state was based on a Delphi panel, according to the private healthcare perspective. Outcomes were discounted at 3% annually. RESULTS: The CE of CT sequence in relation to HT/CT sequences ranged from R$ 15,000 to R$ 552,000 per QALM gained. CONCLUSION: As WHO-recommended cost-utility threshold for Brazil is R$ 2,435.75 per QALM gained, CT is not cost effective in relation to treatment sequences containing successive lines of HT with fulvestrant in the second line and introducing chemotherapy in later lines.