Natural Resources Committee on June 9th, 2009

[The Chair, Conservative, Leon Benoit]

Good afternoon, everyone. We're ready to start the meeting.

I would just like to say before we start that we'll need a budget to cover any claims for travel expenses from this study. If we could just hang around a little bit at the end to deal with that, I would appreciate it.

Secondly, you will get your copy of the report on integrated energy systems towards the end of the meeting, so you'll have that today. We'll deal with it Thursday.

Today we are continuing our study, pursuant to Standing Order 108(2), of the Atomic Energy Canada Limited facility at Chalk River and the status of the production of medical isotopes.

We have with us today four groups of witnesses, three here in person and one by video conference. From the Canadian Association of Nuclear Medicine we have Jean-Luc Urbain, president, and Peter Hollett, past president. From the Canadian Association of Radiologists we have Edward Lyons, president, and Jacques Lévesque, vice-president. From the Quebec Association of Nuclear Medicine Specialists we have the president, François Lamoureux. By video conference from Hamilton, from the Hamilton Health Sciences and St. Joseph's Healthcare Hamilton, we have Karen Gulenchyn, the medical chief of the department of nuclear medicine.

We will go in the order listed on the agenda for today, starting with witnesses from the Canadian Association of Nuclear Medicine, for up to ten minutes. Whether one of you will give the presentation or you want to share, it's entirely up to you, but please limit it to ten minutes.

Thank you very much, and go ahead.

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

Mr. Chairman, members of the committee, on behalf of the Canadian Association of Nuclear Medicine, I would first like to thank you all for giving our organization the opportunity to appear before you to discuss the scarcity of medical isotopes.

It is with mixed feelings and emotions that Dr. Peter Hollet, seated to my right, and I are here before you today as the spokespersons for Canada's doctors specialized in nuclear medicine. I have been working in the field of nuclear medicine for a little more than 30 years. I consider myself to be very privileged for having had this opportunity to practise my specialty for just over 20 years in Belgium, in the United States and, for nearly 6 years, in Canada. During all these years, my colleagues and I practised our profession knowing that we would have the best possible isotopes available to us in order to carry out our diagnoses and treat the patients referred to us every day. This feeling was based primarily on the fact that we knew that Canada had developed a nuclear energy and medical isotope production program unparalleled in the world and that it was in fact the envy of the world.

Since the first dramatic shutdown of the NRU reactor in December of 2007, our association, in cooperation with numerous colleagues, has worked relentlessly to mitigate the effects of the isotope shortage on the well-being of Canadians, and, it must be said, to try to save Canada's credibility on the international scene.

In May of 2008, the working group established by the Ministry of Health, of which we were a part, submitted to the Minister of Health a report detailing the sequence of events of December of 2007, outlining the impact of the reactor shutdown on health care and the weaknesses of the current systems, and, in addition, made recommendations that were both general and specific to prevent any reoccurrence of this type of situation.

We emphasized two basic issues in this report. First of all, we discussed the need to secure a made-in-Canada solution for the supply of isotopes, particularly molybdenum-99 and technetium-99m, by expeditiously commissioning the Maple I and II reactors.

Secondly, we discussed the need to develop and market alternative medical isotopes, particularly positron-emitting isotopes, which can be detected through positron emission tomography, which could partially alleviate the shortage of reactor-produced isotopes.

Over the past 18 months, our community has witnessed five to six significant fluctuations in technetium-99m delivery, forcing us to change drastically our patients' scheduling and our practice, and to reschedule patient examinations. We knew that any further prolonged shortage of isotope procurement would have a dramatic effect on our ability to provide services to our patients.

The announcement last month of the prolonged shutdown of the NRU reactors is a real catastrophe for the two million nuclear medicine patients in Canada, and also for the credibility of Canadian nuclear technology and industry. The chronic and acute shortage of medical isotopes is neither a funny nor sexy story. It is a real drama that we and our patients have to live with on a daily basis.

As physicians, we must practise medical, and not political, correctness. We must provide the very best diagnostic tests and treatments for our patients in Canada and across the world, and we are obligated to be truthful to our patients and ourselves. Our association has never shied away from its mission, responsibilities, or duties. And while we have worked relentlessly with Health Canada to try to mitigate as much as possible this new and prolonged crisis, we have expressed to the government, to our patients, and to the media our grave concern regarding our ability to delivery optimal diagnostic tests and therapeutic procedures. Unfortunately, our concerns have not really been taken seriously, and have even been qualified as ridiculous.

In reality, the current crisis is forcing us to use 20th century medical isotopes, diagnostics, and therapeutics, which are far from ideal. For example, we have used thallium chloride to replace technetium-99m-labeled cardiac tracer in order to make the diagnosis of cardiac disease. Thallium was one of the first isotopes that we used routinely in nuclear medicine in the seventies and eighties. While it represents a short-term alternative, thallium does not have ideal imaging characteristics. It requires drastic changes in patient scheduling and increases by a factor of 1.5 to 2 the radiation exposure of patients. We also have had to replace some of our nuclear medicine tests with radiology procedures that do not provide information on the function of the organs.

I mentioned earlier that I've been privileged to practise nuclear medicine in Europe and the United States. Positron emission tomography, what we also call PET, uses medical isotopes that characterize extremely well the physiology and pathophysiology of the human body, cardiac diseases, and most the cancers and neurological conditions, like Alzheimer's disease. PET education and training was an integral part of my education in Belgium in the eighties. And in 1990, based on the overwhelming evidence of its usefulness for the conditions I mentioned above, the Belgian government decided to provide access to this technology to its ten million citizens at no cost.

Some of the nuclear medicine tests that use technetium-99m can be replaced with the PET procedure. Should Canada have authorized the physicians and scientists to develop and implement this technology in the nineties and at the beginning of this century, we would now be able to provide a 21st century diagnostic tool to all Canadians. To our community, it is inconceivable that Canadians must go to China, Singapore, India, Australia, Kuwait, Europe, South America, and the United States to have unrestricted access to this proven technology and receive adequate treatment with state-of-the-art isotopes. In the eyes of our international colleagues, nuclear medicine in Canada is falling into a third, if not a fourth, world practice.

The absence of PET technology has already taken its toll on Canadians. I must say that I've never seen as many advanced cancers in my career as over the past six years of practice in Canada. Also, it is the first time in my career that I have been.... [Technical Difficulty]

[The Chair, Conservative, Leon Benoit]

We will have to suspend the meeting until the microphones can be repaired.

[The Chair, Conservative, Leon Benoit]

We will now resume the meeting. My mike is working.

Could you try yours again, Mr. Urbain? Great. Please continue and we'll hope that it works from now on.

[Dr. Jean-Luc Urbain]

Thank you very much. I'll try to be brief for the rest of my presentation.

What I was saying is that the absence of PET technology has already taken its toll on Canadians, and I must say that I have never seen as many advanced cancers in my career as over the past six years of practice in Canada. Also, it is the first time in my career that I have been forced to perform PET clinical trials that are qualified by the international community as unethical.

Without access to these 21st century technologies and isotopes, it is extremely difficult to attract medical students into this critical field and to retain our young graduates and senior physicians in Canada. Middle term and long term, losing its very best is always detrimental to any society.

The CANM would like to strongly recommend to this committee that, first, the government rescind the decision to abandon MAPLE 1 and MAPLE 2 reactors to produce medical isotopes, and immediately convene an international expert panel to analyze in depth the real issues related to the commissioning of these reactors and release all the conclusions of the panel to the public and medical organizations.

Second, we recommend that the federal government, through Health Canada, expeditiously approve the use of positron emitting isotopes and their radiopharmaceuticals based on the pre-clinical and clinical trials performed in Europe and the United States and the criteria well established by the United States and the European Union regulatory agencies for the safe clinical use of these radioisotopes.

Third, we recommend that for a period of five years the federal government work with the provinces and territories to support and subsidize the recent increase of, in particular, technetium-99m costs imposed by the manufacturer and distributor, and the cost of the deployment and implementation of positron emission technology throughout Canada.

Fourth, we recommend that the Minister of Natural Resources and Health Canada work formally and expeditiously with the relevant medical organizations, rather than relying on expert individuals who might have personal conflicts of interest, and establish rapidly the processes to implement these recommendations.

The CANM strongly believes that Canada must update its health care system and provide its citizens with 21st century nuclear medicine diagnostic and therapeutic tools. The CANM is also pleased to reiterate its offer to work very closely with the government and provide its support, experience, expertise, and testimony to achieve this goal.

Dr. Peter Hollet, immediate past president of the CANM, and I would be pleased to answer any questions you may have. We thank you for your attention.

[The Chair, Conservative, Leon Benoit]

Thank you.

And now we go to the Canadian Association of Radiologists, Edward Lyons, president, and Jacques Lévesque, vice-president.

Go ahead, gentlemen. Hopefully, you'll keep it under ten minutes.

[Dr. Edward Lyons, President, Canadian Association of Radiologists]

Mr. Chairman and members of the committee, thank you for the opportunity to address this committee on this issue.

We've had the opportunity to serve on the ad hoc committee on medical isotopes. As Dr. Urbain mentioned, as a group of physicians representing the CAR, we were recently put on this committee.

The Canadian Association of Radiologists is the national voice of radiology committed to promoting highest standards in patient-centred imaging, lifelong learning, and research. We are also radiologists as an integral part of the health care team.

The CAR has been monitoring the effects of the Chalk River shutdown, as a prolonged shortage of medical isotopes has implications for radiology services across the country. Patients needing nuclear medicine scans may be required to move to other imaging modalities for their diagnoses and treatment monitoring, notably CT and MRI.

The effect on an already stressed imaging system with long waiting lists for CT and MRI can be significant. The availability of PET and CT PET scanners varies widely, but relatively few are available in Canada to meet the increased demand.

Provinces and territories individually manage their own isotope supplies. Therefore the effect of a shortage differs across the country. The CAR is trying to monitor any increased demand for radiology through its provincial organizations, and no change has been detected in just the last few weeks.

There is a need to maximize collaboration in Canada among provincial, territorial, and federal governments, health care authorities, and medical organizations as this shortage continues.

The CAR believes a coordinated national standard and strategy would ensure that the needs of all Canadian patients from coast to coast are at the forefront as we manoeuvre through a limited supply of medical isotopes. Perhaps a pan-Canadian committee might collectively manage the issue and develop strategies that address the best interests of all Canadians in the short and long term.

Such a committee would need to be comprised of representatives from and have mechanisms in place to seek input from provincial, territorial, and federal governments; provincial and territorial health care authorities; national and provincial imaging associations; colleges and educational institutions that provide health and human resources; and finally, but not least, the industries that are producing or distributing the isotopes.

Only through a concerted effort of government, medicine, and industry will Canada successfully navigate this critical health care situation. The CAR is willing to play a key role in this committee.

Coordinated consultation with imaging groups, accommodating more imaging studies in an already stretched medical imaging system, will require a detailed assessment and consultation with other imaging groups. This would include groups such as the Canadian Association of Medical Radiation Technologists, their representatives being here, and the Canadian Society of Diagnostic Medical Sonographers, in consideration of the impact of increased demand on technologists' manpower and training. CAR is willing to play a role in this kind of needed consultation.

In developing short-, mid-, and long-term strategies, it is critical that Canadians have access to required nuclear medicine services. This will require immediate action. The CAR identifies numerous areas it sees as requiring attention and in which the CAR might assist in managing the current isotope shortage.

First, we could assist in a comprehensive study on the realistic impact of how decreased supply worldwide will impact Canada. How many patients with no access to nuclear medicine tests would be affected? How many of these could and would be transferred to radiology imaging? What would be needed to accommodate these patients? Could increased workload be accommodated with the current system? If so, for how long and at what degree? Could we and how would we expand the operating time of facilities to impact patient needs? What would be the impact on staff, both physicians and technologists? Finally, who would absorb all these new costs for both capital and operating?

Secondly, we need to assess and monitor the effect of a prolonged isotope shortage on radiology demand and workload. Adjusting workload and manpower supply to optimize the use of isotopes and shifting imaging examinations to other nuclear or non-nuclear modalities, such as CT and MRI , are affected by and dependent on current imaging resources now and in the long term. Specifically, there's a need to monitor and report on the system impacts, including those. These will be useful in planning for the investment in isotope supply for the future, including staff--radiologists and technologists, their work hours, overtime, and sick leave; management; the number of units being produced in nuclear medicine radiology at facilities at the national, provincial, and regional levels; resource use; the total cost to treatment point as patients move through the system; machine use and operating time; wait times for nuclear medicine for diagnostic imaging; and ultimately cost overruns within the radiology system.

One solution we might offer is expanded use of the CAR evidence-based diagnostic imaging referral guidelines as a way to prioritize patients. Guidelines assist patients in ordering the best test first. They have a positive impact on the management of imaging, health, human, and equipment resources; patient safety through reduced exposure to unnecessary radiation; and wait times. Improved management of current imaging resources creates more capacity. The CAR now has five years of experience in implementing evidence-based and transparent diagnostic imaging guidelines with specialists, family physicians, and general practitioners, and can help expand the use of these guidelines across the country.

Next is developing clinical protocols, strategies, and algorithms for prioritizing patients based on local and regional resource availability, and developing special request forms or formats to identify these patients and assist them to monitor requests that might take into consideration already existing wait lists.

Another point is to assist in the development of a coordinated approach to assess radiology needs to ensure that all regions have fair and equitable access to available isotopes and alternative radiology services.

Next is to assist in the careful planning and coordination for the long term that will be required to avoid a similar situation in the future. The need to expand replacement technologies should be studied, such as adding more CT-PET and CT-NMR. The CAR might assist with issues to be resolved, such as how the actual demand would be met over the next five years; how many new units would be needed to meet the demand; how to deal with existing wait lists; how soon there could be a realistic increase in supply; and how we could meet the manpower needs.

Finally, managing the shortage of medical isotopes now and creating future supplies is a global, national, provincial, and territorial issue that will require collaborative efforts within and between all levels of government, health care authorities, medical associations, and industry, now and in the years ahead. Management of an isotope shortage in the short term must coincide with mid- and long-term strategies for supplies. The CAR is open to continuing involvement at each of these levels in order to assist in the evolution of isotope supply and management.

Finally, the CAR believes that beginning with a commitment to a national approach that considers the health care of each Canadian equally is an important first step on this journey.

Thank you very much.

Dr. Lévesque, our vice-president, and I will entertain questions at the appropriate time.

[The Chair, Conservative, Leon Benoit]

Thank you, Dr. Lyons, for your presentation and for your specific recommendations.

We go now to the third group to present, Dr. François Lamoureux, from the Quebec Association of Nuclear Medicine Specialists. Go ahead, please, for up to ten minutes.

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

Mr. Chairman, distinguished members of the committee, I would like to thank you, as the President of the Quebec Association of Nuclear Medicine Specialists, for giving me this opportunity to appear before you on behalf of my nuclear medicine specialist colleagues from Quebec.

We are currently experiencing a crisis which is truly medical and not political. This morning I listened to the CBC and heard the heart-wrenching testimony of a young 21-year-old patient suffering from thyroid cancer who was literally terrorized by the thought that she may not be able to receive an iodine 131 treatment for her cancer, and she was also concerned about other patients.

In Canada, 5,000 new cases of thyroid cancer are detected every year. Seventy-five per cent are women. If the cancer is treated adequately, the survival rate at 10 years is over 95%. If these patients no longer have access to this treatment, what will their future be? In Canada, the crisis has got so bad that now sick people are worried about other sick people, because this government does not appear to understand how tragic, how catastrophic this is for sick Canadians who need these tests and treatments. We have abandoned our sick. First of all, we denied that the crisis existed and now, we find it "sexy". Such grief, such sorrow? It is difficult to be a Canadian today. Who is going to protect the patients in this country? This medical disaster was foreseeable. Everybody knew this. It was not about if it would happen, but when it would happen.

As the national medical organization, the Canadian Association of Nuclear Medicine, as explained clearly by its president Jean-Luc Urbain, offered its cooperation from the outset. However, the government preferred to use obscure expert consultants. Why this obscurity? Were there any unacknowledged commitments or interests that the people should know about?

In Quebec, our association, in cooperation with Quebec's Ministry of Health, immediately reactivated its crisis cell the day after it was announced, on May 25, 2009, that the Chalk River reactor would be shut down for a prolonged period of time. We in Quebec, unlike the rest of Canada, have 15 positron emission tomography machines, commonly referred to as "PET scans", we were able to immediately mitigate this impact for cancer patients requiring positron emitting tomography by redirecting them to centres set up throughout the province. I would like to thank this government who had the vision to set up this technology throughout the province. In France, there are already 80 clinical centres, and since the main priority is cancer, this number will be brought up to 120.

We then decided to extend hours. As we speak, technologists, doctors and secretaries are contacting patients. We must constantly establish new appointment lists, cancel and postpone appointments and make decisions with respect to priorities. We are also using other radioactive tracers. We therefore totally support the assessment of the problem and the proposals made by the Canadian Association of Nuclear Medicine. We can no longer live with this uncertainty. The sick people in this country have completely lost confidence in our leaders. We need an independent committee to assess the situation. Using the media for diversion or concealing the collateral damage inflicted on patients offers no comfort. We have been thrown head first into a medical emergency.

On Thursday and Friday, several regional centres in Ontario will have to shut down their nuclear medicine service completely because they are out of technetium. The reactors in South Africa and Holland were not operating this week. Sick people need your help. Without exception, the 101 nuclear medicine physicians of Quebec add their voices to those of their nuclear colleagues in the rest of Canada through the Canadian Association of Nuclear Medicine in order to immediately offer their full cooperation to the elected officials of this land.

I am prepared to answer any question you may wish to ask. Thank you.

[The Chair, Conservative, Leon Benoit]

Thank you, Monsieur Lamoureux, for your comments. They are much appreciated.

We go now to the witness by teleconference. The witness is Dr. Karen Gulenchyn, medical chief, department of nuclear medicine, at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton.

Go ahead, please, Ms. Gulenchyn.

[Dr. Karen Gulenchyn, Medical Chief, Department of Nuclear Medicine, Hamilton Health Sciences and St. Joseph's Healthcare Hamilton]

Thank you, Mr. Chair and committee members, for the opportunity to appear once again before you. I last spoke to this committee in February 2008 in the aftermath of the regulatory shutdown at the NRU at Chalk River. I'm also a member of the group of experts that was called together in December 2007 by the federal Minister of Health to provide advice on the medical isotope supply, and I continue to serve in that capacity.

When I appeared here some 16 months ago, I spent some time describing my practice and its dependence upon the secure supply of medical isotopes. That dependence on a secure supply hasn't changed, but I'm not going to return to that description, as I know that members of the government have been involved in a detailed exploration of those issues since that time. However, I would like to present to you today what we have done in the interim to prepare for this crisis, which I think Dr. Lamoureux had referred to. We knew it was going to happen; we just didn't know when it was going to happen. We in fact believed this was going to be inevitable.

As an advisor to the federal Minister of Health, the group as a whole has provided advice on alternative radiopharmaceuticals, advice regarding alternative diagnostics and treatments, and information to assist in the preparation of a document that outlines strategies to maximize the use of any existing radiopharmaceutical supplies. That document has been very useful to all the centres across this country in dealing with the current issue.

I've also provided advice to the Ontario Ministry of Health and Long-Term Care, where we drafted a plan to use in the case of this particular event. In fact as the ink was drying on the last version of that plan, the shutdown at Chalk River occurred this past May.

We've prepared plans, as well, to roll out sodium fluoride bone imaging, but that is only going to replace a small proportion of the bone scans that are performed across the province. That plan was worked on in concert with people at the Cross Cancer Institute in Alberta, and I believe another plan was worked on as well in Sherbrooke, Quebec. Finally, we have developed a plan to monitor the situation in each local health integration network across the province.

Internally at Hamilton Health Sciences and St. Joseph's, my staff has been working to be sure we're in a position to be able to take that plan out of the drawer and in fact implement it. In particular, we've developed communication strategies so that the medical staff and the public in our city of Hamilton—all of whom are very concerned about the current situation—are kept informed.

Where do we stand today? We're four weeks into the current situation, which was triggered by a safety shutdown at the NRU. In large part, the planning undertaken by the nuclear medicine community in conjunction with the federal and provincial health ministries has worked. The radiopharmaceutical suppliers have developed backup supplies, but these are in smaller quantities and at an increased price. Of course, my organization and other organizations across the country are struggling within their constrained budgets to deal with that price increase.

We've maintained our usual workloads for the first three weeks using these strategies, but last week we experienced a 20% reduction in the number of examinations we were able to perform, and this week we expect a reduction of about 30% of our usual volumes.

To a lot of observers from the outside, it might not appear there is a crisis. That's because of the very talented and dedicated staff who work in each of Canada's 245 nuclear medicine facilities and radiopharmacies. Patients are booked and rebooked to make the best use of radiopharmaceuticals. Doses and patients are transferred from one facility to another to ensure that the patient in the greatest need of the examination receives the dose of the radiopharmaceutical.

But the efforts to manage this situation come at a considerable cost. I think the increased costs of radiopharmaceuticals are perhaps the simplest example. More important are the opportunity costs—the time spent by a technologist to reorganize workflow, rather than providing that extra bit of care that's really so important to our patients with cancer and heart disease, and the time spent by physicians and scientists managing this effort rather than teaching tomorrow's physicians or exploring new frontiers. So this is a costly event that we are attempting to manage.

When I appeared here last February, I was asked a very difficult question on whether patients would have died had the reactor not resumed operations. The answer that I gave at that time was understood by the media to be no. I'd like to set that record straight today.

In large part, what we are dealing with here is a limitation in diagnostic testing, as opposed to therapy, which has been caused by a shortage of medical isotopes. A diagnostic test is one element of a process that begins with a patient complaint and leads to a history and physical examination by a physician and eventually to a diagnosis and a prescription of therapy.

Appropriate diagnostic tests, as prescribed by the physician, are used to increase the certainty about the diagnosis. If the test is not available then the level of certainty remains at a lower level, and in fact the diagnosis may be incorrect. There are many steps between the initial assessment and eventual patient outcome, and the drawing of a direct line between the lack of a specific test and the death of an individual patient is a difficult connection to make. However, the withdrawal of nuclear medicine testing from the Canadian health care system, which operates at the best of times within significant constraints, is resulting in difficulties in delivering care to patients.

I would like to think that we can manage this event, but if the level of medical isotope supply falls to the point that we are able to deliver fewer than 50% of our usual examinations, then I believe that deaths could occur due to the additional strain placed on the health care delivery system.

I want to stress again that although we are coping reasonably well in mitigating the impact on patients at this time, this is taking a toll on our health care system and each individual involved in the system, in particular the patients. It results in increased costs and the refocusing of already stretched resources.

I'd like to thank the committee today for the opportunity to appear before you, and along with the others, I would be pleased to answer any questions you might have.

Thank you.

[The Chair, Conservative, Leon Benoit]

Thank you very much, Dr. Gulenchyn, for your explanation of the preparation done over the past year and a half, and for your description of how you've implemented the plan for dealing with this inevitability.

I will go now directly to questioning, for up to seven minutes, starting with the official opposition. Ms. Bennett.

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

Thanks very much.

Thank you for your excellent testimony and your obvious frustration, if not outrage, on behalf of your patients. We thank you for your frankness and your advocacy for the patients of Canada.

If we look first to nuclear medicine and to the working group that reported in May 2008, you had four points there--ensuring efficient and effective communication with the medical community and the public, and three others. But at the same time, you said that it was exactly the same time that MAPLE 1 and MAPLE 2 shut down. Obviously, an ad hoc committee is an ad hoc committee.

What has happened in terms of coordination of both the alternatives in patient care and securing a supply since the time of the tabling of the expert committee report of May 2008 at the same time as MAPLE 1 and MAPLE 2 were decommissioned?

[Dr. Jean-Luc Urbain]

Thank you for the question, Mrs. Bennett.

We have an outstanding group of medical imagers in this room, and we all work in concert. With your approval, I will ask Dr. Gulenchyn to answer your question.

Karen.

[Dr. Karen Gulenchyn]

Yes, I'm here. I'm getting used to the video conferencing thing here.

Really, the working group's efforts along with those of the federal Ministry of Health have largely been focused on strategies to maximize the use of existing supplies. We have spoken, I think, in the group many times about the need to secure the supply of isotopes. I don't think as a group we have the expertise to say how that supply should be secured. But clearly, having five reactors, all of which are more than 40 years old and therefore likely to suffer difficulties and breakdowns, does not leave us in a situation of having a secure supply. So I would say that we are disappointed that there has not been more movement forward on this particular issue.

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

The ad hoc committee has not had a process over this past year since the shutdown of MAPLE 1 and MAPLE 2. I have before me the draft guidance for maximizing the supply of technetium, and it seems to be based on the Ontario plan. I'm interested in whether there is a sort of single-bank-teller approach to how you would prioritize the patients and mobilize the alternatives. My concern has been that across this country the availability of the alternatives is very different. Could we say that, for example, bone scanning and myocardial perfusion testing are pretty well available across the country right now?

[The Chair, Conservative, Leon Benoit]

Who would like to answer that question?

[Dr. Jean-Luc Urbain]

I think I'll ask--

[The Chair, Conservative, Leon Benoit]

Mr. Urbain, I would just remind you that in the future, if you'd like to pass a question off to someone else, go through the chair, and I will do that if I think it's appropriate.

Thank you.

[Dr. Jean-Luc Urbain]

Okay.

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

Before the shortage....

[Dr. Jean-Luc Urbain]

Well, the difficulty in Canada, as you know, is that the regulatory body is at the federal level, and the dispensation of the health care is at the provincial level, and it's very difficult to coordinate and strategize for each province.

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

In terms of the cardiac testing, to begin with, 20 years ago you stopped using thallium, for a good reason. It seems from what I've heard that it's just not as good a picture, and you miss things. I was very concerned, Dr. Urbain, that you said you'd never seen such advanced disease until you came to Canada. Is that because things aren't detected earlier, because of the absence of PET scanning?

[Dr. Jean-Luc Urbain]

There are two aspects to your question. One is the thallium issue. I have to say that images with thallium are pretty good in today's world because the equipment has made a lot of progress. It's not the ideal trace, for the reason that I've mentioned, but it's a good temporary alternative.

As to your second question, about the fact that I've witnessed a lot of advanced cancer due to the lack of availability of PET scans, the answer is formally yes.

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

Of the available alternatives, if this had begun a year ago.... I believe that all these guidelines were prepared for a shutdown of a month. I don't think the prospect of going three or six months was in any of these guidelines.

If we had to move forward on PET scanning for Canadians, how would you do that across this country? Obviously, Quebec has lots of them, because it's a European model. You obviously feel the rest of Canada has slid behind. I understand that for some of the PET-scanning pharmaceuticals...and certainly in your second recommendation, in terms of Health Canada, the minister said that she was expeditiously approving things. I understand that you would need FDG and F-18 to be approved immediately. At the moment, it's just being used for research. Have you had any word from the minister as to whether these will be approved?