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Maria Gritsai had run out of options.
Having been diagnosed with late-stage cervical cancer, treated with chemotherapy, and told by her Russian doctors that there was nothing more they could do, the 35-year-old Moscow region resident decided to look abroad for treatment.
In doing so, she joined many other gravely ill Russians who seek medical care in foreign countries, where they believe they will benefit from better technology, more considerate doctors and less red tape.
Gritsai's family found a clinic in Israel that offered treatment for $200,000, an "astronomical sum" for them, Maria wrote in a on her husband's blog in August. They collected donations and later found a cheaper treatment option in Germany, at the Grosshadern Clinic in Munich.
Doctors there said that Gritsai could have been misdiagnosed because not enough examinations had been done and that she could have been treated and cured if Russian doctors hadn't missed the early stages of her cancer.
Gritsai died at the clinic on Oct. 22, but apparently not from cancer. Her German doctors told her husband, Yevgeny, that she had been poisoned by the chemotherapy drugs Cisplatin and Xeloda.
These drugs are also used in Germany but are accompanied by supportive drug therapy to reduce the risk of harmful side effects.
In her online appeal, Gritsai said doctors at Moscow's Blokhin Cancer Center, where she was treated, told her that her cancer was incurable and that chemotherapy would do her no good.
But her husband found a doctor at the clinic who prescribed chemotherapy treatments for Gritsai "at his own risk," which were performed at their home by a local doctor.
Alexander Nikolayev, head physician at the Blokhin Center, one of Russia's top oncology hospitals, said he couldn't comment on Gritsai's medical records due to privacy laws. But he said that in general, if a patient has advanced cancer, it becomes impossible to perform surgery on a tumor as it spreads, while chemotherapy and radiation therapy cannot guarantee a cure. In many cases, he said, the prognosis becomes unfavorable.
"In such cases, the patient and his or her relatives don't want to accept the doctor's response," Nikolayev said. "Often, people hope that somewhere abroad they will be definitely cured."
Seeking Foreign Help
Gritsai said she sought treatment abroad partly because she considered the quality of care in Russia to be poor. But she was also frustrated by the difficulty of getting it, facing long waits, red tape and doctors she considered abrasive or judgmental.
There are even greater difficulties for cancer treatment, she said during an interview with her and her husband at their apartment in the town of Chekhov, 60 kilometers south of Moscow, in late September.
She pointed specifically to a deficit of drugs and equipment, the harsh side effects of certain drugs used in state-run clinics, and the absence of an individual approach to treatment. She referred specifically to the fact that the same drugs and dosages are prescribed for all patients with a particular diagnosis and using a patient's weight as the reference point, without taking into account other medical conditions or the peculiarities of each patient.
The rules for treating malignant tumors and other diseases are known as protocols and spell out other methods of treatment apart from chemotherapy, as well as , including exams and lab tests.
Chemotherapy protocols are used in other countries, although the types of drugs used in Russia and elsewhere may differ.
One of the chemotherapy drugs used in Maria's treatment was Cisplatin, which was created in the 1980s and is often used to treat cancer patients in Russia. The drug, which is also used in Western countries including Germany, can cause potentially life-threatening side effects, including damage to the heart, kidneys and liver.
Yevgeny Gritsai bought his wife a modern foreign-made drug whose name he could not recall, but he said Russian doctors refused to use it because it wasn't on a list of chemotherapy drugs doctors are allowed to dispense as part of the free health care system.
Doctors said that by law they are not allowed to use drugs that are not licensed in Russia, or even drugs that are licensed in Russia but aren't included on a list of drugs that can be prescribed to a patient free of charge.
Nikolayev said Russians have less trust in Russian doctors than in foreign ones, who can treat them with a new drug that is not yet licensed in Russia and "get some effect from treatment, or maybe not."
"But whatever happens, everyone looks upon it as if everything possible was done," Nikolayev said.
He also noted that it was "quite profitable" for foreign medical institutions to take on Russian patients, implying that foreign clinics sometimes admit them to earn money even while knowing they have little chance at recovery.
Gritsai and her husband also complained about some Russian doctors' critical attitude toward their patients.
For example, Vladimir Kazachenko, an oncologist and gynecologist at the Blokhin Center, blamed the existence of cervical cancer on premarital sex.
"If women were virgins when they were married, then it [cervical cancer] would not exist at all," said Kazachenko, who has dozens of years of work experience.
Cervical cancer is almost always caused by an infection of the human papillomavirus, or HPV, which is often transmitted sexually.
Yevgeny Gritsai said those kinds of attitudes toward patients made care worse.
"Maybe they will conduct the same medical procedures with us abroad, but there at least we will not be blamed for falling ill," he said.
Better Treatment Abroad?
Three senior Russian oncologists said in interviews that Russia's medical institutions in general are roughly on par with those in Western Europe and the U.S. in terms of treatment options.
Indeed, there does not seem to be conclusive evidence that cancer death rates are significantly higher in Russia than in many Western countries.
About 285,000 Russians died of cancer in 2008, the fifth-largest total of any country in the world behind China, India, the United States and Japan, according to the gathered by the WHO's International Agency for Research on Cancer.
But Russia is not among the top 25 countries in the world in terms of age-adjusted and "crude" death rates from cancer per 100,000 people, or in terms of incidence rates.
According to the , the age-adjusted cancer death rate in Russia in 2008 was 283 people per 100,000. That compares with 245 in the United States, 269 in Britain, 277 in France, 255 in Germany and 249 in Italy.
However, a separate set of data by the International Agency for Research on Cancer also from 2008 provides differing figures for each country. The discrepancies could not immediately be reconciled.
According to , the cancer incidence rate increased from 272 people per 100,000 in 1992 to 366 per 100,000 in 2011, and the absolute number rose from 403,000 to 522,000 in those years. The ministry data did not indicate whether the rates were crude or age-adjusted.
Thirty percent of Russian cancer patients die within a year of being diagnosed, Vladimir Starinsky, deputy head of the Moscow Oncological Research Institute, .
Nikolayev, the top doctor at the Blokhin Center, said hospital equipment and doctors' level of training is "approximately the same" in Russia, Europe and the U.S.
He also said that cancer treatment is "standard" around the world, including at large specialized medical centers in Russia, and that treatment results at such centers are the same as in Europe.
In some cases, Russia even has an advantage over the West in certain areas of treatment, the doctors said, noting that there are surgeons in Russia who can perform unique procedures.
"There are kinds of single-stage surgery that can't be done abroad because they are linked to a certain surgeon," Nikolayev said. As an example, he named Mikhail Davydov, the director of the Blokhin Center, who has developed new surgical methods for treating lung, stomach and alimentary canal cancer.
Nikolayev also said that Russian and foreign doctors share know-how at international conferences and that many Russian doctors study at leading clinics abroad.
But the doctors conceded that Russian institutions can treat fewer patients at any given time, are sometimes slow in providing treatment and use cheaper medicine with harsh side effects — circumstances they blame on insufficient equipment and financing and on red tape.
Nikolayev said his center's expenses for treatment of a cancer patient can be several times higher than what is financed by the state. In such cases, he said, the hospital asks charities for help to pay the difference.
He also said cancer detection rates in the early stages are "considerably lower" in Russia than in Europe and the United States.
Kazachenko, the Blokhin Center oncologist and gynecologist, said that "all the modern methods" used abroad are used in Russia, too, but that the number of patients who can be provided high-tech care differs "considerably" in Russia and in Europe.
He said the main reason for the more limited access to high-tech help in Russia is insufficient equipment at hospitals, as opposed to a lack of good doctors.
Nikolayev lamented the fact that almost no medical equipment or materials are produced domestically.
"We produce next to nothing and buy everything abroad … and [it's] not cheap," he said.
Kazachenko said he hopes the government's 2011 and 2012 program for modernizing health care would gradually solve hospitals' financial problems.
The government has spent 318.6 billion rubles ($10.1 billion) on equipment for hospitals as part of the program, which could be extended through next year, Health Minister Veronika Skvortsova said in late October.
But Nikolayev said he has the "impression that the state is trying to make hospitals provide for themselves," in particular with the latest introduction of paid medical services.
Since January, a law titled "" has limited the amount of free medical services to which people are entitled.
Nikolayev also lamented the fact that fundamental research in all scientific spheres is poorly financed, not only in health care. He blamed the lack of funding for Russia's lagging behind Europe and the U.S. in medical research, saying that as a result, Russian researchers do not often discover new treatment methods but instead must rely on those developed abroad.
Anatoly Makhson, Moscow's top oncologist and head doctor at the city-financed Oncology Hospital No. 62, said the simple fact that German doctors agreed to treat Maria Gritsai did not mean she would be helped.
"All stages of cancer are treated in Russia, but like everywhere in the world, in most cases patients with early stages are cured," Makhson said. "Sometimes, patients come to us who were treated abroad not in a very proper way, to put it mildly."
Nevertheless, Nikloayev, Kazachenko and Makhson all said there was little chance they would be able to eliminate advanced cervical cancer in a patient. A senior European cancer researcher and practicing oncologist said patients with this type of cancer had recovery rates of up to 50 percent at European clinics.
"Treatment of advanced-stage cervical cancer may save you from cancer, for sure," said Murat Gultekin, council member at the European Society of Gynecological Oncology and the International Agency for Research on Cancer.
In Europe, "even conventional treatments yield a 10 to 20 percent cure rate in advanced-stage patients," Gultekin said.
He said European clinics have "outstanding" results with certain kinds of surgery and chemotherapy, noting that advanced-stage patients treated with such methods have a recovery rate of up to 50 percent at most clinics.
Gultekin also noted that many large European cancer centers offer clinical trials of new drugs for advanced-stage patients, unlike state-run Russian clinics.
Coping With Cancer:
