Health Committee on June 18th, 2009

[Dr. François Lamoureux]

We live in uncertain times. We never know whether a product will be available from one week to the next. Two weeks ago, we were supposed to receive an entire stock of generators, but they were not authorized because they were not regulation.

Remarkable efforts are being made in the Health Canada access program. That is not the problem. The problem is we are in a constant state of uncertainty. From July 14 to August 14, the Petten nuclear reactor will be shut down, and it is supposed to be closed for another six months as of January 1, 2010. There will be a crisis.

The people I work with ask me questions that I cannot answer. They ask me, for example, why the federal government has already invested $28 million, whether it consulted the international experts who were in Toronto this week, and whether the rest of the world agrees with the solutions that have been suggested.

If the Canadian government has decided to stop producing isotopes, then why is it investing in replacement options? Why does it not let countries like Germany, France, Argentina, Australia or Holland supply us with technetium? We do not understand. It is a mystery to us.

The patients are our priority at the moment. It is all very well to say that iodine is available, but we do not know whether we are going to get it. Canada is not the only country that wants it: the whole world needs it.

[Nicolas Dufour, Bloc, Repentigny, QC]

On June 16, you said that, to date, no one had died in Quebec since the beginning of the crisis, but that if it continued, such a thing could happen. What is your position today?

[Dr. François Lamoureux]

When we testified before the Standing Committee on Natural Resources, it was Dr. Karen Gulenchyn, from Hamilton, who said that if the amount of technetium available dropped lower than 50%, there could be deaths. So you would have to put that question to Dr. Gulenchyn.

[Nicolas Dufour, Bloc, Repentigny, QC]

You still have not obtained any information from the government at all. You are completely in the dark.

[Dr. François Lamoureux]

I will give you an example. Our group was never consulted about the decision to spend the $28 million. I do not believe that the Canadian, Quebec and Ontario associations—although I cannot speak for my colleagues—were consulted either.

We are specialists in nuclear medicine and we work in the area every day. For us, for patients and for the media, it is incomprehensible. If it had been me, I would have asked for an opinion, especially since experts from 70 countries were in Toronto this week. The former president of the American Association of Nuclear Medicine even said that we were in the midst of one of the largest crises that has ever threatened modern medicine. This is clearly not just a minor problem; it is a crisis. The government denied it at first, then recognized it. Now, once again, they are claiming that there is no crisis.

[Nicolas Dufour, Bloc, Repentigny, QC]

Too little, too late. But the Minister of Health has set up a consultation group of which Mr. McEwan is a member.

What is your opinion not only on the creation of this committee, but, especially, the fact that... We felt repeatedly that you wanted to see consultation with most partners and organizations, not just with individuals, but also with organizations representing large numbers of physicians.

What is your opinion not only on the appointment of Mr. McEwan, but the general attitude we are seeing here? Because I feel that the comments and suggestions you have been making for the past few weeks are not being taken into consideration.

[Dr. François Lamoureux]

May I answer that, Madam Chair...

In the province of Quebec, things do not work that way. After all, there are 7.8 million of us, we are Canadians and we work directly with our government. Since you ask, in my opinion, it is just to separate the Department of Health from I know not whom.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair.

I also would like to thank the witnesses for taking time out from what I'm sure are very busy schedules and joining us here today.

I think as a health committee we need to be particularly interested in the short-term solutions. I recognize long-term solutions are also critical, but again, this is the health committee.

My first questions focus on that, and perhaps I would direct them at Dr. McEwan. This is an international crisis. From conversations, do you have any sense of what other countries--because obviously they're also dealing with shortfalls--are doing in terms of solving those short-term issues?

[Dr. Sandy McEwan]

Madam Chair, to respond to that, during the Society of Nuclear Medicine meeting in Toronto, I convened a broadly representative meeting. There were members of the two Canadian societies, the European Association of Nuclear Medicine, and the British Nuclear Medicine Society. There was a member of the Australian community there, and obviously my colleagues at the Society of Nuclear Medicine. We really discussed impact across the world. We looked at what was happening throughout Europe, what was happening in the U.K., and what was happening in the United States.

I think what is encouraging is that a number of the initiatives that we have adopted through the ad hoc working group are those that are currently being adopted in the other countries or that they will now take back and start working on. Certainly, we had conversations around information for patients, conversations around how best to utilize the generator to ensure there was the maximum number of patients coming out of each individual generator, and conversations on how best to use alternative tests.

I do believe the CIHR initiative is an important one. My belief, from talking to my colleagues in the radiopharmaceutical community, is that we can probably, with this grant, find two alternative radiopharmaceuticals that can be brought into the clinic, probably within a year, to replace technetium products. I will remind you that technetium is still needed; not all tests can be done with PET. So any increase in PET services that we can provide to our patients, if you like, frees up technetium for other tests.

I believe there are a number of initiatives in place that are remarkably concordant around the world. I have to say that I think the ad hoc working group has done a remarkably effective job in doing that, and it's been a pleasure working with Dr. Urbain on that group to ensure that we really are leading the way. This meeting was interesting. I think there's no doubt that the initiatives we have put in place in Canada have enabled us to avoid some of the problems that are being faced in other countries that haven't been quite so proactive.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

If I have another minute, I wanted to know whether, in this day of computerized maps where we can show every site that does particular tests, and the volumes, we have that kind of provincial base information, or is it something you're looking towards doing?

[Dr. Sandy McEwan]

The Canadian Society of Nuclear Medicine did a broad study, I think it was about four years ago, looking at distribution of tests across the country. I know the two associations are looking at addressing that. I agree it's something that is important to know.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

If I have any seconds left, I'll ask you--perhaps for some of us--is the PET scan an expensive piece of equipment? Is it a big piece of equipment? Could you just talk a little bit more about PET in terms of the actual mechanical issues?

[Dr. Sandy McEwan]

There are two scanners used in nuclear medicine: the gamma camera, which uses technetium, and the PET scanner, which uses PET-ready pharmaceuticals. The gamma camera, depending on what you get, will cost something between $350,000 to $700,000 or $800,000. A PET scanner will cost something between $2 million and $3 million. The images you get from a PET scanner are a little different from those you get from a gamma camera. They do function in the same diagnostic manner; they give you the same broad information. PET scanners do require an infrastructure around them. They need cyclotrons within a geographic area. As I said, the Edmonton cyclotron is actually supplying two provinces directly and one province indirectly.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. McEwan.

Now Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Madam Chair.

I want to thank everyone for coming and having to answer the same questions over and over, but I know that you are finally flushing out some of the answers. I think most of us are concerned about the immediate availability of isotopes for all of the various needs. I think we have been told by the minister that there was going to be a sufficient supply, and for those that weren't sufficient in terms of the isotopes, there would be ones that could be substituted.

I first want to ask you, are there substitutes?

The second thing I heard is on the medium and long term, because I believe we know the reactors are always subject to breakdown faults, etc., so we could be looking at this happening over and over if we depend for isotopes solely on reactors. We know PET, obviously. I must say that I heard in fact in the United States for the first time this year that they sold more PET cameras than they sold SPECT cameras, so they are seeing a movement towards PET.

I wanted to talk a bit about that sustainable supply of isotopes. We know that here in Canada we have TRIUMF, which is working on small cyclotrons that can fit into regional hospitals where you can continue to produce your supplies as you need them. We also know that, as Dr. McEwan said, while PET gives you as good a picture, or some say better, it also can have markers that can find out if a tumour, for instance, is estrogen-dependent, etc., so you can actually focus on your treatment exactly rather than guessing the treatment.

So my question is, given that we know that TRIUMF could, with $50 million, be online and ready to produce in 2012 these small cameras using photofission, why is it that we're not talking about that as a reliable, clean source of production that would allow everyone to be able to turn on and off their cyclotrons as they need them, and then turn them off when they don't? It's an easy turn on and off cyclotron. It could cost us more, but in the long run it also puts Canada in the driver's seat for new, alternative technology for producing isotopes. What do you think of that?

I look at everybody shaking their heads. I don't know if that's a yes or a no.

[The Chair, Conservative, Joy Smith]

Who would like to answer that? I'll start with Dr. McEwan and then Dr. Urbain.

[Dr. Sandy McEwan]

I think we need to be very clear that we understand that many of the PET--and I actually gave many talks last week around this--radiotracers that you're talking about are not in routine use at the moment. So, for example, estrogen-receptor imaging is not a routine test that will be done currently with technetium. So I think we need to concentrate on those techniques that we can use to replace the current technetium radiopharmaceuticals, or substitute for the current technetium radiopharmaceuticals. That's the intent of the CIHR award; that's the intent in our hospital of shifting to fluoride.

[The Chair, Conservative, Joy Smith]

Dr. Urbain.

[Dr. Jean-Luc Urbain]

Yes, I agree with your assessment. It's very clear that we need a sustainable, reliable, and affordable--I think “affordable“ is a key word--source of technetium for the future. Reactors, as you said, break down, and that's the reason why Canada built two MAPLEs and not one MAPLE. In the mid and long term, we have to look at that.

In terms of PETs, I said, and I'm assuming that Mr. Trost will remember, I've been practising in Canada for six years--I practised before in Europe and in the United States--and I've never seen so many advanced cancers as in Canada, and the reason is because PET has not been available in Canada, so it's a drama. As I said before, let's take advantage of this crisis to bring the health care system in Canada into the 21st century, and PET is a good way to go.

[The Chair, Conservative, Joy Smith]

We'll hear from Dr. Ruddy and Dr. Beanlands. Dr. Ruddy, do you want to start?

[Dr. Terrence Ruddy]

I was going to say that PET is superior to SPECT for many things, like the diagnosis of cancer, so you're actually looking for a better test. So if we go the PET way, we actually are going towards a better test.

Going back to TRIUMF and the photofission, that's research. That's something that may or may not work out. It's sort of a speculative, almost penny-stock kind of thing, so we don't know if that will work.

We do know that PET works. PET oncology scans work right now. If you go to Quebec and you have cancer, you get a PET scan, and you are glad you have that opportunity. In Ontario, it's very limited, so right now that's an issue. We'd love to have a PET scan for cancer in Ontario.

[Hedy Fry, Liberal, Vancouver Centre, BC]

If I may quickly intervene here, we know that actually TRIUMF is making the small cyclotrons that you can put into regional hospitals now. So that's a made-in-Canada solution. It's a made-in-Canada answer, to get those to get to PET. I'm not talking about the photofission right now; I'm talking fission. I'm talking about what we have now in terms of cyclotrons.

[The Chair, Conservative, Joy Smith]

Go ahead, quickly, Dr. Ruddy.

[Dr. Terrence Ruddy]

I'm just going to come back on that.

You're right. TRIUMF could help us establish cyclotrons to make PET tracers across Canada.