Yuvraj Singh and cancer treated abroad: who takes over follow-up on returning to Brazil

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

In February 2012, the Indian cricketer Yuvraj Singh was diagnosed with a germ cell cancer between the lungs. According to the BCCI, the body that governs cricket in India, he underwent three cycles of chemotherapy in the United States, finished treatment in mid-March, spent a few days in London recovering from the side effects and returned home on 9 April. At his first press conference after his return, which the BCCI recorded on 11 April as following treatment for a mediastinal seminoma, he spoke of his mother as his greatest support and said something simple: he would have to look after his health, and the body would take time. The account is his own, about his own journey; it gives no information on costs, on the criteria for choosing the service or on the follow-up plan, and nothing is said here about the doctors, the hospitals or the clinical decisions of that treatment.

What carries over to other patients is the question the story leaves for anyone who treats a cancer outside Brazil, whether by choice, on medical advice or because they were living abroad when the disease appeared: when chemotherapy ends there and follow-up needs to continue here, who takes over, with what documents and under what obligation? The article goes through the science of follow-up, Brazilian law, three foreign models and liability when the bridge between systems fails.

The end of treatment is not the end of care

The US National Cancer Institute (NCI) explains, in its patient summary on extragonadal germ cell tumors, that these tumors can arise outside the testicles and the ovaries, including in the mediastinum, the region between the lungs, and that the malignant ones are divided into seminomas and nonseminomas. The version for health professionals, updated on 9 December 2024, adds that they are rare tumors, that a diagnosis of seminoma requires a normal serum alpha-fetoprotein and that many patients finish treatment with a residual mass: below 3 centimetres, “most experts agree that observation is appropriate”; above that, some prefer to resect and others to observe. A mediastinal seminoma is not lung cancer, and the follow-up schedule of one does not serve the other.

The prognosis is, as a rule, good, and that is precisely why follow-up matters. In the international prognostic classification of germ cell tumors, reproduced by the NCI, no seminoma is classified as poor prognosis. Two recent series confirm the picture in the mediastinum. In 24 patients with pure primary mediastinal seminoma treated between 1994 and 2025, Sebai and colleagues (Clinical Genitourinary Cancer, 2026) measured five-year progression-free survival of 86.2% and overall survival of 95.2%; three patients progressed, “all within the mediastinum and within 7.8 months” of the end of chemotherapy, and all three progressions were detected by CT scan, which allowed second-line therapy, with durable remission in two of them. In Germany, Kidess and colleagues (BJUI Compass, 2026), with 34 extragonadal patients, measured 100% three-year relapse-free survival in mediastinal seminoma, worse results in nonseminomas and relapses, across the whole group, at a median of 0.79 years after chemotherapy. Read together, the message is clear: the first year after treatment concentrates the risk of relapse, and a relapse found in time can still be treated.

The second horizon is a long one. In the largest study on the subject, Travis and colleagues (Journal of the National Cancer Institute, 2005) gathered 40,576 survivors of testicular cancer from 14 population-based registries in Europe and North America and found a risk of a second solid tumor almost twice as high among those who had been diagnosed at age 35 and were already ten years past treatment (relative risk of 1.9), an increase that remained significant 35 years later; the patterns were similar for seminoma and nonseminoma. The NCI summary on testicular cancer for health professionals (16 May 2025) further records more cardiovascular events after chemotherapy or radiotherapy, an association of chemotherapy with metabolic syndrome and hypogonadism and, in a Dutch study of 2,339 survivors, a 2.5 times higher risk of coronary heart disease after mediastinal radiotherapy. The data come mainly from testicular tumors and from older regimens: they indicate that the survivor needs someone who knows the history; they do not predict the individual case.

The guidelines and the gap between one system and another

The European reference guideline, published in 2022 by the European Society for Medical Oncology with the EURACAN network (Oldenburg and colleagues, Annals of Oncology), carries in its very title the design that matters to the patient: diagnosis, treatment and follow-up. Diagnosis, treatment and follow-up form a single pathway, and the schedule of imaging and markers depends on what was done before. Without the staging, the regimen, the number of cycles and the size of the residual mass, that schedule cannot be built safely.

The literature on those who cross borders for treatment shows that this passage is the weak point of the system, and that it is still poorly measured. In a survey of 52 physicians from 17 African countries, Rubagumya and colleagues (JCO Global Oncology, 2024) recorded that 92% knew of patients who had referred themselves abroad, that India was the most common destination (94%) and that the most cited reason (93%) was the perception of better quality abroad. A rapid review published in BMJ Open in 2026 (England and colleagues) measured the cost, to the British public system, of treating complications of elective surgery performed abroad, between 1,058 and 19,549 pounds per patient, and concluded that, without systematic data, “we cannot fully understand the risk”; cancer was outside the scope of the review. In the Caribbean, the first multinational study on travel for cancer treatment and survival is still under way (CaSIDEC protocol, Auguste, JMIR Research Protocols, 2026), with the declared aim of filling “performance gaps in transnational cancer care systems”.

What to ask the foreign service for before returning

In Brazil, the Code of Medical Ethics (CFM Resolution 2.217/2018) prohibits, in art. 88, “Denying the patient or, where that is impossible, their legal representative, access to their medical record, failing to provide a copy when requested, and failing to give the explanations needed for their understanding, except where these would create risks for the patient or for third parties”, and the Patients’ Rights Statute (Lei 15.378/2026) guarantees, in art. 19, access to the medical record “without having to give reasons” and a copy “free of charge”. These rules bind Brazilian services; the foreign hospital follows the law of its own country, and requesting documents from a distance, months later, is slower and more expensive. That is why the dossier is assembled before boarding. It gathers the pathology report (and where the slides and blocks are kept), the discharge summary with staging, regimen, cycles, dates and complications, the digital images with their reports, the markers with the units used, the follow-up plan of the treating team and a contact for pending results.

A one-page timeline helps the Brazilian oncologist more than a folder of receipts. Lei 15.378 does not deal with translation; a version of the essential terms makes the consultation easier, and the formal requirement of a sworn translation and an apostille is a different conversation, which matters when the document has to serve as evidence, as shown in the article on why the apostilled medical report still proves nothing (in Portuguese). If the team here wishes to review the diagnosis, the route for the material is described in the article on slides and blocks for a second opinion (in Portuguese), and the statute itself guarantees a second opinion “at any stage of treatment” (art. 18).

In the SUS: those treated abroad come in through the same door

Lei 8.080/1990 (the Organic Health Law) defines, in art. 7, II, comprehensiveness of care as the “articulated and continuous set of preventive and curative, individual and collective, actions and services required for each case at all levels of complexity of the system”. The adjective “continuous” has a direct consequence here: the law does not make follow-up conditional on the previous treatment having been carried out within the SUS (Brazil’s public health system) itself. Anyone who brings a diagnosis from abroad has the same door of entry as any other user, the health unit of their territory or the service indicated by local regulation, and the medical report turns “I have come from abroad” into a referral with a defined purpose: an oncology consultation, a pathology review, a surveillance test or care for a late effect.

The National Policy for Cancer Prevention and Control (Lei 14.758/2023) gives this continuity concrete instruments. Art. 7 sets as guidelines “timely and safe” treatment as close as possible to the patient’s home (III), the treatment of rare cases “in health establishments of national reference” (IV), a category into which a germ cell tumor of the mediastinum may fall, and the provision of rehabilitation (V). Art. 4 requires public authorities to maintain a data system that records the entire care process, “from suspicion onwards”, and that allows “consultation of one’s position on the waiting list”. And art. 13 established the National Navigation Programme for Persons Diagnosed with Cancer, defining navigation as “the active search for and individual monitoring of the processes involved in the diagnosis and treatment of cancer” and the barriers to be overcome as obstacles “of a social, clinical, economic, educational, cultural, structural or access-related nature”. Lei 12.732/2012, which guarantees the first treatment within 60 days of the pathology report (art. 2), does not expressly deal with those who had that first treatment abroad; if a relapse is confirmed here, the therapeutic need recorded in the medical record is what guides the urgency.

Comprehensiveness does not guarantee an automatic place at the centre chosen by the patient, nor the same medication used abroad; the Brazilian team assesses the course of treatment with what is recorded and available in the network, and it is on the basis of that written response that any failure is discussed. Public funding of treatment abroad is a different matter: in June 2026, the Second Panel of the STJ (Superior Court of Justice) (REsp 1.860.543, Justice Marco Aurélio Bellizze as rapporteur) held that it is admissible only on an exceptional basis, with cumulative proof of the absence of an effective therapeutic alternative in the country, robust scientific evidence of efficacy and safety, clinical indispensability and financial inability, as detailed in the article on treatment abroad through the SUS (in Portuguese). Follow-up on return does not depend on those requirements, and the guide to what citizens can demand of the SUS (in Portuguese) sets out the administrative routes.

In the health plan: what happened there and what is owed here

Lei 9.656/1998 (the Health Plans Act), in art. 10, establishes the reference plan with coverage of “childbirth and treatments carried out exclusively in Brazil”. The rule cuts both ways. On the one hand, the minimum statutory coverage does not extend to chemotherapy given abroad; if the contract offers anything beyond that, it is the contract that must say so, in writing, as detailed in the article on health-plan coverage outside the country (in Portuguese). On the other hand, follow-up carried out in Brazil follows the ordinary coverage rules, within the contracted segmentation and the ANS list of mandatory coverage (the “rol”): among the exceptions that art. 10 itself lists, there is no mention of the diagnosis or the previous treatment having taken place outside the country. Denying follow-up because “the treatment was abroad” confuses who paid for the past with what is owed now; the medical request should describe the current situation, not “continuation of treatment abroad”. The deadlines are the ordinary ones: ANS Normative Resolution (RN) 566/2022 sets up to 14 working days for a consultation in a specialty such as oncology (art. 3, II), requires the health-plan operator to provide a protocol number (art. 12) and, where the deadline is not met, to reimburse care obtained outside the network (art. 10).

The situation changes when the plan is taken out after the return. The cancer is then a pre-existing disease, and the law has its own rule. Art. 11 prohibits the exclusion of coverage for pre-existing diseases and injuries after twenty-four months of the contract being in force, “the burden of proof and of demonstrating the consumer’s or beneficiary’s prior knowledge resting with the respective operator”. During that interval, the operator may offer temporary partial coverage, which ANS Normative Resolution 558/2022, in art. 2, II, defines as “the suspension of coverage for High-Complexity Procedures (PAC), high-technology beds and surgical procedures, provided they relate exclusively to the pre-existing diseases or injuries declared by the beneficiary”. Consultations and tests that do not fall into those categories are outside the suspension. And the health declaration must be truthful: the diagnosis treated abroad is exactly what it asks about, and the Patients’ Rights Statute places on the patient the responsibility of sharing “information on past illnesses, hospital admissions and medications” with the professionals (art. 22).

Comparative law: three ways of making care portable

Three different choices show what is at stake. The European Union created a legal duty of follow-up. Directive 2011/24/EU, on cross-border healthcare, requires the Member State of affiliation to ensure that, where a patient has received healthcare in another country and medical follow-up proves necessary, “the same medical follow-up is available as would have been if that healthcare had been provided on its territory” (art. 5(c)), and guarantees those treated abroad at least a copy of the medical record (art. 4(2)(f) and art. 5(d)). Brazil is not part of that system, and the directive does not apply here; it serves as a mirror. What the European legislator had to lay down in positive law for twenty-seven countries, Lei 8.080 already contains in the word “continuous”.

The United Kingdom, outside the Union since 2020, has kept NHS-funded planned treatment in European countries (via the S2 route) when the NHS cannot provide it within a “clinically justifiable” time, without covering translation costs. For those who seek treatment abroad at their own expense, the NHS relies on preparation. The official checklist recommends talking to the GP beforehand, because they “may be involved in your aftercare”, and arranging the transfer of medical notes; another official page notes that the NHS “is not responsible for negligence or failure of treatment” carried out there. In this model, the bridge between the two systems is the patient’s responsibility.

The United States tackled the problem from the insurance side. With the 2010 reform, federal law came to prohibit group health plans and individual insurance from imposing “any preexisting condition exclusion” (42 U.S.C. § 300gg-3), defined as a limitation of coverage based on the fact that the condition existed before enrolment; the official portal sums it up by saying that no plan can reject the insured person, charge more or refuse to pay for essential benefits “for any condition you had before your coverage started”. And the 2020 law against surprise billing created a right of continuity (42 U.S.C. § 300gg-113): a patient undergoing treatment for a serious and complex condition, when the provider leaves the plan’s network, may keep the treatment on the same terms for up to 90 days. The rule deals with leaving the network, not with treatment abroad, but it shows the idea that the transition has a time limit and protects those who are midway through; in Brazil, the law still allows, for 24 months, temporary partial coverage of the declared disease.

When the bridge fails: who is liable

The legal question is what the Brazilian service did after taking on the patient. The Code of Medical Ethics prohibits physicians from failing to use the available means of diagnosis and treatment within their reach (art. 32) and from failing to inform the patient of the diagnosis, prognosis, risks and objectives of treatment (art. 34); Lei 15.378 guarantees the patient care “in a timely manner” (art. 8) and, where there is a transfer between units, that the record of care be forwarded by the service of origin to the receiving service (art. 8, sole paragraph, II), a domestic rule that shows the expected standard. The liability of the hospital, the clinic or the health-plan operator is strict as regards the services that are their own (Consumer Protection Code, art. 14); where the defect lies in the physician’s act, proof of fault is required (art. 14, § 4).

In oncology follow-up, the typical harm is delay. If an unfounded refusal or a stalled queue delays the surveillance test and the relapse is found later than it would have been, the Superior Court of Justice allows the loss of a chance to be argued. The reference precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi as rapporteur, judged on 4 December 2012), a case of inadequate treatment of breast cancer, not of follow-up, whose headnote accepts the theory in cases of medical error and sets the limit: “The chance, however, can never reach the value of the lost good”. The series cited show why the interval counts; proof that the delay changed the outcome, however, is always a matter of expert evidence and of the individual case.

When there is no right

Under the minimum rule of Lei 9.656, there is no right to reimbursement of treatment carried out outside the country, unless the contract provides for it; in the SUS, there is no right to choose the hospital by personal preference or to receive automatically the medication used abroad. Those treated abroad do not have fewer rights on their return, but neither do they bring with them the rules of the system they left.

Before deciding

Treatment carried out abroad and the follow-up owed in Brazil are different obligations. In the SUS, continuity is a statutory principle; in the health plan, the foreign origin of the treatment is not an exclusion, although a new contract coexists with the rules on pre-existing disease. In my view, a refusal based solely on the place where the chemotherapy took place finds no support in the law, either in the public network or in private health care. The frequency of tests and the need for new therapy remain a clinical decision for the Brazilian team, in the light of the documents brought, and the first year is the one that least tolerates waiting. Limits of another kind appear in the article on a transplant performed abroad outside the waiting list (in Portuguese). If follow-up was denied by the health plan or has stalled in the regulation system, get in touch with the firm with the discharge summary, the medical request and the response received; the analysis starts from those documents and does not replace medical assessment.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).