Health Committee on June 18th, 2009

[The Chair, Conservative, Joy Smith]

Good afternoon, ladies and gentlemen. I want to welcome our guests. It is delightful that you could be here today at such short notice for our discussion on such an important topic.

Before we begin our committee, I would like to speak to the committee members for a moment. We have a motion to consider before we start, and that is the budget in the amount of $5,500 for the study of health implications of the supply of radioisotopes.

Could I have this motion adopted?

(Motion agreed to)

Now we will proceed.

As you know, guests, we have each organization give a seven-minute presentation. Following the seven-minute presentation, there are two rounds of questioning. The first one is seven minutes as well, for both questions and answers, and the second one allows five minutes for both questions and answers.

We will begin with the University of Ottawa Heart Institute. Who would like to start with that? Who would be the first speaker?

[Dr. Rob Beanlands, Director, National Cardiac PET Centre, Chief of Cardiac Imaging, University of Ottawa Heart Institute]

I can start.

[The Chair, Conservative, Joy Smith]

Please go ahead, Dr. Beanlands.

[Dr. Rob Beanlands]

I'm very pleased to be here on behalf of the University of Ottawa Heart Institute. I'm the chief of the cardiac imaging program. We also have in our facility a cyclotron that makes PET isotopes.

First and foremost, I think the main goal for all of us is for the care of our patients to be given in a timely manner and for this timely care to be provided to the best of our abilities.

Part of why we're here is to look for solutions. There are short-term, medium-term, and long-term solutions.

There are already some initiatives in place to evaluate some long-term solutions. There's a plan for a workshop and a program to look at some of these very seriously in the fall, and we're very pleased to be part of that initiative.

We heard about medium-term solutions from the Minister of Health earlier this week, when she spoke about the CIHR grant program to try to look at alternatives to technetium.

Short-term solutions are things that we are doing on-site in the heart institute. For example, in cardiac imaging in our facility we have switched to a tracer called thallium, which can be used quite reliably to image the blood flow in the heart. We also have acquired--I think Dr. Ruddy can speak more to this--a scanner that uses less technetium. That's a new technology. We also have access to PET imaging for blood flow agents, and we do PET imaging of the heart as well, so we have been able to adapt with those situations.

In addition, our staff are working extremely hard. Many of them are coming in on the weekends to help deal with the situation.

All in all, because of our planning and our local teamwork, we've been able to weather the storm, if you will, and none of our patients are waiting significantly longer that they were before the Chalk River reactor shut down.

I should add that in the heart institute we are also helping with the production of sodium fluoride. This is thanks to the foresight of Dr. McEwan, whom you'll hear later, the University of Alberta team, and the McMaster group as well. We worked with them to submit a proposal to Health Canada, which was rapidly reviewed and approved. We will now be ready to provide sodium fluoride as an alternative in bone-scan imaging in Ottawa. We'll supply it to the Ottawa Hospital. The Heart Institute will also provide access to our cameras so that if there is patient overload at the Ottawa Hospital, we'll be able to do some on our system as well.

I think one of the key things here is that we are working together within the city and with the Ottawa Hospital. The University of Ottawa Heart Institute is also working with the other cyclotron facilities across the country and with the nuclear medicine community to try to find solutions for the problem we now face.

I should add that we were recently at the Society of Nuclear Medicine meeting, and many of my colleagues in the cardiac imaging field commended us on the initiatives that we've taken already to solve this. We're proud of that. I think we've been working together very well to try to achieve that.

That's where I'll stop, Madam Chair.

[The Chair, Conservative, Joy Smith]

We have a few more minutes, if you have anything else to say, but if that's the end of your presentation, that's great too.

We'll now go to Jean-Luc Urbain from the Canadian Association of Nuclear Medicine.

[Dr. Jean-Luc Urbain, President, Canadian Association of Nuclear Medicine]

Madam Chair, members of the committee—

[The Chair, Conservative, Joy Smith]

Excuse me. Dr. Ruddy wants to use the rest of the seven minutes.

Please go right ahead.

[Dr. Terrence Ruddy, Professor, Medicine and Radiology, Chief of Radiology, Director of Nuclear Cardiology, University of Ottawa Heart Institute]

I'm Dr. Terry Ruddy, head of cardiology at the University of Ottawa Heart Institute and director of nuclear cardiology at that site. I'm also head of nuclear medicine at the Ottawa Hospital, so I look at business from both ends.

In the cardiac world we're doing well. It's more or less business as usual, but not exactly. When we switch to thallium from the technetium compound, we're actually using a compound that has a less favourable symmetry and less favourable imaging characteristics. It's adequate, but sort of borderline adequate. It's a band-aid solution that works okay, but something you wouldn't really want as a long-term solution.

So we need either our technetium compounds restored in a way that we can count on them, or we need to go into PET imaging to a greater degree. Technetium-labelled compounds for cardiac imaging are adequate or borderline adequate compared to PET. PET diagnostic accuracy is much greater in cardiac disease than SPECT technetium compounds. You can look at this as an opportunity to move more toward PET. That means more PET cameras across Canada and more development of cyclotrons so we can use a superior alternative to technetium, get away from the concern about technetium, and actually have better diagnostic imaging.

In nuclear medicine, bone scans are an essential test in about 50% or so of patients. The other 50% can be moved to other tests that may be similar or may not be exactly similar--sort of like apples and oranges. There is a significant population for whom there's really no alternative to a bone scan. Bone scans can be done with either technetium or a PET tracer, the way Dr. McEwan has developed the sodium fluoride.

To offset future shortages, having more PET cameras across the country would be very desirable. It would also be very desirable for the bone scans that are at risk with our technetium shortage.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Ruddy.

Now we'll go to Dr. Jean-Luc Urbain from the Canadian Association of Nuclear Medicine.

[Dr. Jean-Luc Urbain]

Thank you very much.

Madam Chair, honourable members of the committee, on behalf of the Canadian Association of Nuclear Medicine (CANM), I would like to thank all of you for giving us the opportunity to appear in front of your committee.

The Canadian Association of Nuclear Medicine was founded in 1971. The CANM is the national voice of nuclear medicine physicians across Canada and the two million patients that they serve every year.

Since the first dramatic shutdown of the NRU reactor in December of 2007, the Canadian Association of Nuclear Medicine has worked relentlessly on the ad hoc health experts working group constituted by the Ministry of Health to mitigate the effect of the isotope shortage on the well-being of Canadians.

In May of 2008, the ad hoc health experts working group on medical isotopes published and submitted to the Ministry of Health a report detailing the lessons learned from the December 2007 shutdown of the NRU reactor. In that report, the working group emphasized the need to: ensure efficient and effective communications with the medical community and the public; in decision-making, ensure a balance between the health and safety of the public and the health outcomes of individual patients; assure appropriate physician participation and input into the decision-making process; and establish a clear and appropriate alignment of authority and accountability for the management of medical radioisotope supplies.

Among other recommendations, our working group proposed that the Government of Canada: secure a "made in Canada" solution for the supply of isotopes, particularly molybdenum and technetium 99m by expeditiously commissioning the MAPLE 1 and 2 reactors; work with its international partners to review global capacity to produce medical isotopes, encourage the development of international protocols and remove current barriers or obstacles to international movement of radio isotopes during periods of shortages; actively engage in developing and approving other medical isotope technologies, such as positron emission tomography.

On May 16, 2008, and while we were finalizing our report in open consultation with Health Canada, the federal government made the unilateral decision and announcement to abandon the MAPLE 1 and 2 reactors project. Since May 2008, the medical community has gone through five or six isotope shortages.

Upon the May 18 announcement that the NRU reactor had to be shutdown again, this time for one month due to a leak—and we now know that it will be for at least three months—the CANM expressed major concerns regarding the ability of its members to deliver 21^st century medicine to Canadians.

Over the past four weeks, our community has maximized and overstretched the use of personnel and equipment resources to service patients with totally unpredictable and unreliable supplies of technetium. We have cancelled on-call service to spare the technetium that we had and have turned toward the less desirable thallium isotope to perform cardiac stress tests. Pediatric patients have been given priority for technetium imaging tests when available.

Positron emission tomography, also called PET, as mentioned before, uses medical isotopes that characterize extremely well the physiology and pathophysiology of the human body, such as cardiac diseases, most cancers, and neurological conditions like Alzheimer's disease. Most of the nuclear medicine tests performed on cancer patients with technetium-99m can be replaced with PET procedures. The absence of availability of the PET technology and isotopes throughout Canada severely impact our ability to diagnose and offer expedited treatment to our cancer patients.

Our community is very confused and frustrated by the recent announcement from the Ministry of Health to allocate a total of $28 million for research projects aiming, at least in part, at developing methods to produce technetium with alternative technologies that, to our best understanding, have failed in other parts of the world. In the best-case scenario, these methods would not yield any results for at least three to five years. Based on the cancer registry throughout Canada, we estimate that Canada needs about 125,000 PET studies per year for cancer patients. With $28 million, one could perform about 28,000 of those PET studies and provide adequate diagnosis and treatment today and over the next three to four months to cancer patients across Canada, while securing a reliable source of technetium.

So we are very confused. Patients across Canada need solutions today, not five years down the road. The Canadian Association of Nuclear Medicine would like to recommend that this committee and the government urgently consider the following aspects.

One, the decision to abandon MAPLE 1 and MAPLE 2 should be immediately and thoroughly revisited by an international experts panel.

Two, the federal government, through Health Canada, should expeditiously approve the use of positron-emitting isotopes and their radiopharmaceuticals. This is based on preclinical and clinical trials performed in Europe and the United States over the past 20 years and the criteria established by the United States and the European Union regulatory agencies.

Third, we'd like to recommend that for a period of five years the federal government work with the provinces and territories to support and subsidize the recent increased cost of technetium-99m and the cost of deployment of the PET technology.

Fourth, the Ministry of Natural Resources and Health Canada should work formally and expeditiously with their international counterparts to secure a reliable and affordable supply of technetium-99m until the NRU is restarted or the MAPLEs are commissioned.

Fifth, the Ministry of Natural Resources and Health Canada should clearly define the processes by which they're engaging the relevant medical organizations, and the Ministry of Health should define the mandate of the special advisor that was just appointed.

The CANM strongly believes that the current challenges still represent a unique opportunity for Canada to salvage its nuclear industry and to reaffirm its leadership and prominence in the world. It's also an opportunity to update the Canadian health care system with the 21st century nuclear medicine diagnostic and therapeutic tools that Canadians deserve.

The Canadian Association of Nuclear Medicine would like to reiterate once again its offer to provide its ongoing support, experience, expertise, and testimony to achieve these goals.

Thank you very much.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Urbain.

We'll now go to the Quebec Association of Nuclear Medicine Specialists, with Dr. Francois Lamoureux, president.

[Dr. François Lamoureux, President, Quebec Association of Nuclear Medicine Specialists]

Thank you, Madam Chair.

I thank the distinguished members of this committee for giving me the opportunity, as the President of the Quebec Association of Nuclear Medicine Specialists, to appear before you on behalf of my fellow nuclear medicine specialists.

As soon as we learned that the shutdown of Chalk River would continue, we knew that there would be a crisis, because 18 months ago, we had a problem and we knew that it would happen again.

Last week, I heard a heart-breaking story from a young 21-year-old patient suffering from thyroid cancer. She was plainly terrified by the possibility of not getting her iodine-131 treatment for her cancer. She was also worried about the other patients.

In Canada, there are 5,000 new cases of thyroid cancer, 75% of which are women. The chances of surviving for 10 years, if the cancer is properly treated, are more than 95%. If these patients can no longer access this treatment, what will their future be like? This week, we were supposed to receive some iodine-131 from South Africa for treatment purposes. However, there was a problem and we were not able to use it this week. So our cases must wait until next week. Every day, we have to explain to the patients why tests are delayed and why their treatment is delayed.

It is also a fact that one woman out of nine in Canada will develop breast cancer. Today, to treat these patients, we use a nuclear medicine technique called a sentinel lymph node procedure. This consists of giving injections around the tumour, and when the patient arrives in the operating room one hour later, the surgeon tries to detect whether tumour cells have moved to any lymph node. If so, he removes the node, a pathologist studies it, and if there are no malignant cells, the surgery is minimal. If there is a spread, the treatment will be more extensive, sometimes involving a mastectomy, which is a much more radical procedure. If we can no longer get technetium, we can no longer provide this service to our patients, and the surgeon has to find all the lymph nodes in the area, as many as 10 or 20. This has a terrible impact.

The same happens with melanoma or skin cancer, the incidence of which is rapidly increasing. We treat it with the same technique.

As for diabetes patients, the situation is almost turning into a pandemic. These patients are often prone to heart attacks or heart disease, and 15% of them will spontaneously die of their first attack. The cardiac perfusion tests, as Dr. Ruddy and Dr. Beanlands explained, are preventive tests that we carry out for these patients. We even use them at the pre-operative stage for elderly patients before a serious procedure.

This shows you how these tests are used; they cannot be replaced by any other tests.

Patients are really concerned. On a daily basis, with our technicians and our secretaries, we are in the tragic situation of having to explain to the patients that their treatment will be delayed again and again. Patients need to know the truth about the current situation. The government first has to take appropriate steps to help these patients. A patient does not much care what could happen in 3 years, 5 years, 10 years or even in 18 months. The research projects that are being advertised with full page ads in the papers are not what the patients care about. Nor do we, for that matter. Our concern is more immediate, we have to answer the patients' questions and provide them with the treatments and the care that they need.

In Quebec, as soon as we learned about this problem, we worked together with the Quebec government to develop our response to a potential crisis. We are working very closely with Quebec's Department of Health and Social Services and with the Association of Nuclear Medicine Specialists. We have implemented all the measures mentioned by my colleagues from the Heart Institute. Moreover, Quebec has an advantage over the rest of Canada: we have 15 clinical positron emission tomography scanners in our hospitals. They are accessible to all patients in the province, because they are situated in most regions of Quebec. Let me add that this service involves no costs either for hospitals or for patients. We also extended the hours. It does not matter which hospital has the equipment; patients can access it according to their clinical condition. The hospital where I practise in Montreal does not have a positron emission tomography scanner, but every week, I send about 20 patients to another hospital, either to the Montreal General Hospital or to the Maisonneuve-Rosemont Hospital where they can have access to the technology. I think that it is a pity that other Canadians have no access to these essential and very important services.

In France, cancer is the number one priority. They have 80 PET clinics and they are going to open 40 more, for a total of 120. So the situation in Canada is inexplicable. We have not explained the importance of this technology clearly enough to our decision-makers, a technology that also allows us to conserve technetium and use it for other purposes.

For us, this situation was kind of predictable. We are still asking ourselves, with no answers when our patients ask us, what the government did 18 months ago. We keep asking ourselves the question. We read all kinds of things in the newspapers: that the MAPLE reactors are operational, that they are fine. As recently as today, our patients could read that in the Globe and Mail and then they ask us the questions. My answer is that I do not have the expertise to answer. But the government has to be able to answer. They want to know how come they do not have access to technetium when there are people falling all over themselves to publish full pages in newspapers saying that everything is working. I do not have this expertise, and the people do not trust what the government says. The government says that it wants an independent international committee of experts to answer this question.

As to the number of PET tests done in Quebec, it currently stands at about 30,000 per year. So, as Dr. Urbain said about the forecast of 120,000, this might be more or less equivalent to what is likely done everywhere.

We also use sodium fluoride, which we get from the University of Sherbrooke, for the same purposes.

In Quebec, therefore, we fully support the Canadian association's assessment, and we are ready to cooperate along the same lines.

Thank you, Madam Chair.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Lamoureux. There will be time for questions very shortly. Thank you so much.

From the University of Western Ontario, I'd like to hear from Dr. Albert Driedger.

[Dr. Albert Driedger, Emeritus Professor, University of Western Ontario]

Thank you, Madam Chair.

I would like to approach my comments here from two levels. The first level comes from something someone said to me earlier: “It seems we're trying to do surgery with boxing gloves on.”

The development of the technology to produce isotopes is one that takes a long time and requires a lot of exacting technology, so we need a long-term plan to come to a renewed stabilization of our supplies. We also need short-term solutions. We've been hearing a little bit about both of them, and I think they need to be clearly separated in an operational sense.

The second issue I want to raise is one that's been bothering me a long time, because I'm not getting clear answers about the MAPLEs. I have worked much of my life in the milieu of reactors and I at least know some of the words, if not all the physics. Every power reactor in Canada operates with a positive void coefficient, which is shorthand for the reason why the MAPLEs were said not to be licensable. I don't have a clear answer as to whether there was a change in the regulations that made positive void coefficients untenable in new reactors or whether there really is an operational problem.

The second part around this, which I see is in today's Globe and Mail, is where the president of MDS Nordion says the MAPLEs are safe to operate and that if they could be operated at half of full power, they would produce as much molybdenum as the NRU is capable of producing. So perhaps, in the short term, we have a solution, if we could get all the documentation on the table and examined by experts, as Dr. Urbain was suggesting.

I was speaking yesterday to a senior oncologist in our centre who told me how all of the clinical trials are now in deep disarray, because the protocols for what would be done to and for patients had been written a long time ago. Now there were deviations from protocols that made it difficult to evaluate, for a time, the direction that patients' treatments are taking, especially when these are in any sense experimental treatments. He was quite dismayed about what was happening, sort of one step away from us in that regard. This is one of the knock-on effects that we are beginning to see. I'm sure this is a factor in clinical trials in many parts of Canada.

The final thing I want to say is that I am, for the most part, a thyroid cancer doctor. I've been keeping an eye on the supply of I-131, and I was assured, until the beginning of this week, that there would always be an adequate supply of I-131. But in the last two days I've been receiving a lot of e-mails telling me that the supply is in difficulty. It takes a long time to prepare patients for treatment, and it's costly to get them prepared. It's a major disruption if one is not, at the end of the day, able to deliver the radioiodine treatments, so there is some impact beginning to be felt at that level.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Driedger.

We'll now go to Dr. Sandy McEwan, who is here as the medical adviser to the minister.

[Dr. Sandy McEwan, Medical Advisor to the Minister of Health, As an Individual]

Madam Chair, thank you, and thank you for the invitation to speak to this committee.

By way of background, I am a nuclear medicine physician who works at the Cross Cancer Institute in Edmonton. My clinical interests, as are Dr. Driedger's, are patients with thyroid cancer and also patients with neuroendocrine tumours; both conditions use radioactive iodine as part of their treatment.

My current role is as chair of oncology at the University of Alberta, and I am also a past chair of radiology at the same university. I am a past president of the Canadian Association of Nuclear Medicine, the Canadian Society of Nuclear Medicine, and also the American Society of Nuclear Medicine. I am now two days into being the society's past president.

I have been a member of the ad hoc regulatory working group, and since the beginning, along with Dr. Urbain, I have also been a member of the advisory group working on medical isotopes.

A few days ago the minister asked me if I would agree to be her special adviser on medical isotopes, and I was honoured and pleased to accept, because I do think I have some skills that may be of use to the medical community and to the minister in moving this forward.

I was particularly encouraged by the words of endorsement and encouragement from the president of the CMA, speaking on behalf of both nuclear medicine organizations in the country. As I said, I have worked with Dr. Urbain on the working group for 18 months now, and I am really looking forward to working with him in the future to help us move forward solutions on this issue.

My role in this position I think is going to be increasingly complex. I will obviously be working closely with my colleagues on the ad hoc working group, and in particular working to understand what is happening in other provinces. In Alberta we have different challenges from the ones Ontario has and the ones Quebec has.

I will obviously be providing updates on the clinical situation and on the effect on patients as the process moves forward, and in this I'll obviously be working very closely with my clinical colleagues and Dr. Urbain to make sure that the best advice and the best information is going forward.

I hope I will also be able to advise the minister on how to deal with provincial and territorial issues and ensure that there is information flow backwards and forwards from the different levels of government. It's important that I am able to provide some background information in terms of communicating the impact to the minister and allowing her to be able to do that to her colleagues in cabinet and in Parliament.

It's important to recognize that the community, that is, Health Canada and the medical community, has been working for 18 months on this. When the problems arose in 2007, it was clear that this was not going to be something we could pass by, and that we should look forward to some proactive planning. The working group has come forward with a guidance document. It's a draft guidance document because we regard it as a living document that will need modification. I think we have provided effective communications to our clinical colleagues.

We've also come forward with a toolkit that I know is in use in many centres, helping triage, helping look at alternatives, and also ensuring that we maximize the use of the technetium that comes out of the generators.

One particularly encouraging thing to me has been the speed with which we have been able to get special access program approvals through for radiopharmaceuticals. And in the light of Dr. Driedger's comment about iodine, I think it's particularly encouraging that special access program approval has been given for radioactive iodine for South Africa, whilst the regulatory approval process is going forward to enable DRAXIMAGE to offer that as an approved product.

The clinical trials application process has been streamlined significantly. It took me under a week to get approval for the use of fluoride to replace bone scanning. At the Cross Cancer Institute on July 2 we will be substituting fluoride for all technetium bone scans at our institution and making it available to the hospitals in Edmonton, Calgary, and Winnipeg. This has been a collaboration with McMaster University, with the University of Ottawa Heart Institute, and with colleagues in Winnipeg.

The minister announced on Tuesday of this week that CIHR will make available $6 million to look at research to replace technetium-ready pharmaceuticals. The terms of these grants call for a rapid introduction of these new products into clinical practice. The expectation is that this will occur within one to two years. I believe we have strategies to ameliorate the short term as well as the long term. We are now depending on the working group that Minister Raitt has established to look at the alternative methods of producing technetium. So I believe there are short-term, medium-term, and long-term strategies.

That doesn't mean we're not affecting our patients and our clinical colleagues in a significant way. This is a serious situation. I know that my clinical colleagues are frustrated by our inability to provide the best care. Patients clearly are worried. I think we need to recognize that staff in nuclear medicine departments across the country have been working above and beyond the call of duty to ensure that care is provided to patients in the best way.

With this appointment, I think the minister has recognized that there are a number of important issues that we have to address. I believe I bring the necessary skills and the necessary links to my colleagues in the community to ensure that the minister, cabinet, and Parliament are getting the best advice.

I'm looking forward to working with Dr. Urbain, Dr. Driedger, Dr. Lamoureux, Dr. Ruddy, and Dr. Beanlands to ensure that we can ameliorate the situation across the country. There are clearly wide regional variations, which I believe are often related to the geography of the country. I think the situation in Alberta is more easily manageable than it would be in, say, Quebec or Ontario.

I'm looking for advice and guidance from my colleagues, the committee, and my clinical colleagues in cardiology and oncology. But at the end of the day, we have to remember that this is a situation of great concern to our patients, and that everything we do in the working group as individual physicians and in our communications with the minister and this committee must reflect that priority.

Thank you.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. McEwan.

Dr. Bennett.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thanks very much.

Dr. McEwan, in January I believe you said it would be “criminal” for Canada, which had been such a leader in nuclear medicine, to get out of the business or not be where it is. According to today's Globe and Mail and testimony we've heard here, MAPLE could be a solution. Will you be asking the two ministers to revisit this decision and have a look at a made-in-Canada solution?

[Dr. Sandy McEwan]

I made those comments before the establishment of the international expert working group by Minister Raitt and before the decision was made. I believe we have an opportunity in working with the Minister of Health, and that is my mandate. It would be unwelcome if I moved beyond that mandate. I believe my job is to ensure that the Minister of Health has the best advice on how to deal with short-term issues and with replacement-ready pharmaceuticals. We need to ensure that technetium is employed to the best effect, that we can facilitate clinical trial applications and SAP processes, and that our colleagues have access to the pharmaceuticals they need.

[Carolyn Bennett, Liberal, St. Paul's, ON]

I think there's been some concern that it would be problematic if you were to speak for yourself and not on behalf of the associations of nuclear medicine. Are you saying that you disagree with the Canadian Association of Nuclear Medicine's first recommendation, which is to set up the international committee and explore the commissioning of MAPLE 1 and MAPLE 2? What happens when you disagree with your professional organization?

[Dr. Sandy McEwan]

I rarely disagree with my clinical colleagues. We are usually unanimous in our views. At the Society of Nuclear Medicine meeting in Toronto yesterday and today, there was a meeting with the NEA, which is the OECD nuclear energy authority. The meeting, which also included producers, members, and some government agencies, looked at integrating supply across the world. I will remind you that I have been president of all three associations. I am aware of the responsibilities of an association, and I am also aware of my responsibilities to my clinical colleagues.

[Carolyn Bennett, Liberal, St. Paul's, ON]

One of the problems we've had is that nuclear medicine is available in 245 places across Canada. Their alternatives are not. Certainly, with thallium it's a little bit different, even though it's not as good. But because of the patchy coverage with PET scanning across the country, it seems that it's going to require some triage that may actually cross borders. There's a PET scanner in Gatineau, but as yet there's not one here that is being used clinically.

Do you see your role as helping to form a triage system that even the Prime Minister has now agreed is necessary? Would you be prepared to stand up at the Health Canada operations centre and figure out the patients who need it and how long they're waiting?

I have yet to see a map that shows, of the 245 sites across the country, where the sources are, because even in Newfoundland, two of the clinics get it from Chalk River and two of the clinics get it from Holland. Obviously, in Alberta you're way better off because you get yours from Holland and you have secure contracts, like B.C. does. How are you going to share across the country if this 70% drop, the global shortage, happens in July, and how are you going to make sure--for example, for the kids--there is access to PET scanning across the country? Turning the Ontario research ones into clinical ones, and perhaps even exploring the portable PETs that seem to be available in the United States on 18-wheeler tractor trailers, ready to come north if we need them...are these the kinds of things you will be doing?

[Dr. Sandy McEwan]

I think those are important elements of the advice that I would be expected to give and to pass on as feedback from my clinical colleagues in the societies. If I can use the Alberta example, the fluoride that is made in Edmonton supports three cities. We are using our PET scanners to maximum--

[Carolyn Bennett, Liberal, St. Paul's, ON]

But you're skipping across Saskatchewan, which has no capacity at all. So what are you going to do for them?

[Dr. Sandy McEwan]

We are routinely in Edmonton, Madam Chair, performing PET scans for patients from Saskatchewan until they get capacity there. There is already interprovincial collaboration in developing protocols to enable...because obviously every PET scan that is done for a bone scan frees up technetium.