Natural Resources Committee on Aug. 21st, 2009

[Nathan Cullen, NDP, Skeena—Bulkley Valley, BC]

When we get to offering Canadians confidence that these tests will be there for them in the future, we hear terms like “may”, “perhaps”, and “there might be supplies available”. To families and individuals dealing with the tragedy of having to go through cancer and heart diagnosis, that doesn't help very much.

To this point, our hospitals have been able to triage the situation and make do over a short period of time. We now hear from the government that this shutdown will last many months longer than first predicted.

You talked earlier about becoming more reliable and consistent in your estimations, but it seems to the public that you've just pushed back the opening of a possible reactor further and further. While that's being reliable and consistent, it's hardly being helpful or hopeful.

There's the suggestion that Australia can pick up the tab and fill in, and hospitals can continue to scrape together some sorts of solutions. We heard from Dr. Atcher that the accuracy of tests are much less, the radiation doses are much higher, and the procedures are much riskier. How long can Canadians expect to have no plan available from this government, other than a report that you might issue towards the end of the year, many months from now? I'm still trying to find where the competence is for this, as someone practising the medicine yourself.

[The Chair, Conservative, Leon Benoit]

Go ahead, Dr. McEwan.

[Dr. Sandy McEwan]

Mr. Chairman, I will remind the member of the committee that I am not a member of the government, I'm an adviser to the minister. My requirement is to provide advice on dealing with the crisis, and I believe I am doing that to the best of my ability.

When I look across the country, certainly in Alberta we are coping very well indeed. When I talk to my colleagues in small urban Ontario, I know they're having more difficulties.

If the NRU is going to be down, we have to find alternatives. In terms of alternatives we have found, iodine-131 from South Africa is approved and is now in routine use, and we have not seen any significant disruption in the treatment of patients with thyroid cancer.

The government—

[Nathan Cullen, NDP, Skeena—Bulkley Valley, BC]

Then, Doctor, I wonder if—

[The Chair, Conservative, Leon Benoit]

Mr. Cullen, please give the doctor a chance to answer the question. He hadn't finished.

[Nathan Cullen, NDP, Skeena—Bulkley Valley, BC]

I thought he had paused and stopped.

[The Chair, Conservative, Leon Benoit]

Okay. By video conference, it's a little bit difficult.

[Nathan Cullen, NDP, Skeena—Bulkley Valley, BC]

I understand there's a delay. I heard a pause and thought that response was over, so I'm continuing with the rest of my questions.

[The Chair, Conservative, Leon Benoit]

But I do want the doctor to have a chance to finish. Thank you.

Go ahead, Dr. McEwan.

[Dr. Sandy McEwan]

We have to look at the best options we can for our patients. We are looking, through CIHR, at alternative radio-pharmaceuticals. We have approved fluoride for bone scanning. In my own hospital, we have now moved 50% of our bone scans to fluoride so we can free up technetium for other tests. Thallium is a very effective test for cardiac imaging. It was the standard of care for many years. People are rediscovering that it is actually a pretty good test. But we clearly have to look at other alternatives.

[Nathan Cullen, NDP, Skeena—Bulkley Valley, BC]

I just worry because some of the alternatives that are being suggested we know don't fit the entire population. Some of the tests that you said are reliable alternatives don't actually assist in diagnosing the same ailments in children and other places.

Lastly, Doctor, as we asked previous folks dealing with this issue, is there anybody who understands where the shortage levels are in the country right now? Is there anybody who is collecting the data to understand where patients are waiting longer, where certain tests are not available, and what the total supply level of isotopes in Canada is? Do you or anyone you're working with have that information for Canadians?

[Dr. Sandy McEwan]

There is a weekly bulletin put out on supply levels for the following week. That is now proving to be remarkably accurate and to help hospitals plan.

The use of alternative tests frees up technetium for those patients in whom the alternative tests are not appropriate. For example, regarding fluoride bone scanning, I would not do fluoride bone scanning routinely in children. It's a very effective test in patients with cancer, so for every patient for whom I use fluoride, I free technetium for somebody else who can't have fluoride.

We are currently getting from the provincial and territorial ministries fairly accurate listings of what the test delays are in each province, so I think the answer to the question is that we are providing that information. I am provided that information, and I believe the provinces and territories also have it.

[The Chair, Conservative, Leon Benoit]

Thank you, Mr. Cullen. Your time is up.

We will go now to the government side.

Mr. Allen, you have up to seven minutes.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Thank you, Mr. Chair.

I would appreciate it if Dr. McEwan could stay a couple more minutes.

I appreciate the fact when he said that now that Petten is back up we've fared a little bit better than we expected and that the accuracy of the supply data is getting better, but I want to pick up on one of Mr. Malo's points here on the regional disparities. We've referred to that before.

Doctor, you were talking about looking at an assessment of those regional disparities. Can you elaborate a little bit on what your game plan is for that assessment and when you might have that done? Presumably, with the NRU going out into the first quarter, we're going to continue to have these regional issues. How do we get a handle on those?

[Dr. Sandy McEwan]

My game plan is, I guess, a three-step plan. The first step is to increase my conversation with AMSMNQ and with the OANM, because those are the two areas where these regional imbalances are occurring. The second step is to work with the provinces and territories to try to get a handle on what their understanding of the disparities is. The third step is to continue to expand my conversations with individual sites to understand how individual sites are faring. I've had a small number of conversations and intend to continue doing that.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Do you have a timeline as to when you're looking to finish that assessment?

[Dr. Sandy McEwan]

I'm hoping to get as much of it done as I can. The minister will be meeting with the provincial and territorial ministers of health in September, and I think it would be very helpful if I could have at least a somewhat clearer understanding in advance of that meeting.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Okay, thank you.

In terms of the national picture on the PET scanning, you've talked a little bit about alternatives. Of course, we've heard in some of our previous testimony that PET scanning is an option as well. Have provinces that have used it coped better during this shortage, and how have they coped better?

[Dr. Sandy McEwan]

Mr. Chairman, those data aren't in yet.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Okay.

The next question is, based on the alternatives that you're using, at this point in time, what percentage of these treatments would you say are using other technologies? Do you believe that some of these can continue into the future or that as soon as the NRU is back and we have the supply of the isotopes, we will be going right back into the molybdenum and technetium?

[Dr. Sandy McEwan]

That actually is a very complex question. I think there's no doubt that we have learned from this supply shortage that the business model we have used in nuclear medicine is perhaps imperfect. I think that if we try to look at the tests that can be utilized as alternatives, there are some PET tests. Thallium is an effective test for cardiac imaging in perhaps 50% or 60% of patients. There is a PET cardiac test that we need to look at going into the future. Clearly, there has been some shift to non-nuclear-medicine-based testing as well. So I think that as this goes forward there will be a complete re-evaluation of the way in which we offer nuclear medicine services.

[Mike Allen, Conservative, Tobique—Mactaquac, NB]

Thank you, Doctor.

Dr. Atcher, I'll pick up on some of your comments earlier on the entry of the U.S. into the medical isotope industry. How do you figure it's going to change the situation we have now? Can you elaborate a little bit on that discussion?

[The Chair, Conservative, Leon Benoit]

Dr. Atcher, go ahead.

[Dr. Robert Atcher]

Thank you.

One of the things we have been discussing since the outages at NRU and now Petten, briefly over the last month and potentially four to six months in 2010, has been how we can address the rather substantial problems associated with these outages. We recently did a survey of our membership and determined that 80% of them say that they currently have had an impact based on the outage at NRU and at Petten, and many of them have no alternative sources. Some 53% said that they had no alternative source of the molybdenum-99-based generators.

So one of the things we have been trying to work with--and I just came from a meeting of an intergovernmental group here in the U.S. that is proposing to look at some alternatives to help in the short term with the shortages--is to use reactors based in the United States to irradiate targets, which would then be shipped to Chalk River for processing. That's one option.

One thing to keep in mind is the fact that we have plenty of reactors in the U.S. and around the world that are capable of irradiating these targets, but we have a limited number of sites that are capable of processing those targets, removing the molybdenum, and producing a quality of molybdenum that's qualified for use in humans. In particular, those sites have to be approved by the FDA in the U.S. and the TGA in order to have that material used in human imaging. So it's the processing facilities that turn out to be the bottleneck.

Of course, when a reactor the size of NRU is off-line, it creates a serious problem for us, as I mentioned, not only for the supplies that we routinely get from it, but also for the excess capacity that we can take advantage of when one of the other reactors is off-line.

[The Chair, Conservative, Leon Benoit]

Mr. Allen, you have another minute.