Natural Resources Committee on Oct. 19th, 2009

[The Vice-Chair, Liberal, Alan Tonks]

Good afternoon, members of the committee and invited guests. Pursuant to the Standing Orders, I wish to inform the committee that the chair is not able to be here. He will be unavoidably absent, and I have been designated to take the chair. It was not a totally popular decision, but it is one that I have taken.

I would like to remind the members that the proceedings are televised today and that we will, pursuant to Standing Order 108(2), continue the study of the Atomic Energy Canada Limited facility at Chalk River and the status of the production of medical isotopes.

Members of the committee, you will recall that at our last meeting we agreed we would have two panels today. The first panel will be between 3:30 and 5:00; then from 5:00 to 5:45 we will go into the hearings with respect to panel two.

The witnesses on the first panel are, from the Canadian Association of Nuclear Medicine, Dr. Jean-Luc Urbain; from the Ontario Association of Nuclear Medicine, Dr. Kevin Tracey, vice-president; from MDS Nordion, Mr. Steve West, president; and from the Department of Health, Dr. Alexander McEwan, special advisor on medical isotopes to the Minister of Health. Welcome to you all.

I understand, Dr. McEwan, that you would like to be last on the order of proceedings, and that is fine. Let me remind the witnesses that we try to keep the presentation to a maximum of ten minutes, to be followed by a regular order of questions from the members of the committee.

Without any further ado, we will proceed with Dr. Urbain. Please begin.

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

Thank you very much.

Mr. Chair and honourable members of the committee, on behalf of the Canadian Association of Nuclear Medicine, I would like to thank all of you for giving us the opportunity to appear in front of the Standing Committee on Natural Resources and to report back to the committee on the effect of the isotope shortage.

As you know, the CANM is the national voice of the nuclear medicine physicians across Canada and the two million patients they serve every year. Since the first shutdown of the NRU reactor in December of 2007, the Canadian Association of Nuclear Medicine has worked relentlessly with the Ontario Association of Nuclear Medicine, the Association des médecins spécialistes en médecine nucléaire du Québec, the Canadian Association of Medical Radiation Technologists, the Canadian Association of Radiologists, the Canadian Association of Radiopharmaceutical Scientists, the Canadian Organization of Medical Physicists, Health Canada, and the NRCan expert panel and its international sister organizations in order to mitigate the effect of the isotope shortage on the well-being of Canadians.

The NRU reactor has been out of service for five months. The impact on Canadians and the Canadian nuclear medicine community has been very significant. It will also have a lasting effect on patient health, the practice of medicine in Canada and across the world, the Canadian and international nuclear medicine community, and Canadian nuclear technology.

Over the past five months, the weekly supply of technetium across Canada has varied between 0% and 100%, with an average of 50% to 70%, depending on the geographic location and the suppliers. Nuclear medicine professionals, technologists, physicists, radiopharmacists, support personnel, and physicians across Canada have worked tirelessly to accommodate the needs of their patients. By working double shifts, by reorganizing examinations around the timing of the delivery of the spare technetium available, by using different protocols and isotopes, by spending an enormous amount of time on the phone contacting patients and referring physicians to reschedule studies, and by not providing core services, our community was able to minimize the effect of the shortage of isotopes on Canadian patients.

Due to that very delicate balancing act, and at the expense of a significant increase in operational costs, the cancellation of patient tests has been limited. This extraordinary and unsustainable effort of our community, the unreliability of technetium supply, and the uncertainty of medical isotope production in Canada have already generated serious and very damaging consequences. The enrollment of students, mainly technologists and physicians, in nuclear medicine sciences is down. The first layoff of technologists has been witnessed, and nuclear scientists are contemplating or are already moving out of the country.

By its unique ability to investigate the function of cells, tissues, and organs, nuclear medicine enables the detection and treatment of diseases at the molecular level before those diseases become evident anatomically and before patients become symptomatic. The earlier the diagnosis of a disease is made, the better the chance of cure for the disease. The CANM is extremely concerned by the significant decrease—from 10% to 25%, depending on the region—of patient referrals for nuclear cardiac and oncologic tests. Without early detection and assessment, cardiac diseases and cancer progress to a point where a patient's well-being is severely compromised and morbidity is higher regardless of the treatment, not to mention the increased financial burden on the health care system and society.

A fair number of us attended the meeting of the European Association of Nuclear Medicine that was held last week in Barcelona. The annual EANM meeting is one of the largest annual gatherings of nuclear medicine professionals in the world. This year more than 5,000 people attended the conference.

It is not an understatement that the credibility of Canada in its ability to build up nuclear reactors to produce medical isotopes has been thoroughly shattered. Also, our colleagues from Europe simply do not understand why Canada is currently entertaining the production of technetium, whose experimental technologies using cyclotron and linear accelerator have all failed in Europe and Japan. In fact many western European countries have decided to continue relying on their nuclear reactor technology for another 25 years.

France is currently building a reactor to produce medical isotopes in the south of France, and the European countries have reached an agreement to build a new reactor to replace the Petten reactor in Holland. The CANM strongly encourages the members of this committee to consult the European expert reports that have been generated over the summer on the subject.

Based on more than 600,000 years of experience and expertise of worldwide physicians in the field of nuclear medicine, the numerous national and international expert reports that have been generated over the past few months, and the technologies available today, the CANM recommends that this committee and the government urgently consider the following.

Number one is that the decision to abandon the MAPLE 1 and MAPLE 2 reactors to produce medical isotopes be immediately and thoroughly revisited by an international expert panel, and the conclusion of the panel be released to the public and medical organizations.

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

Number three is that for a period of five years, the federal government work with the provinces and territories to support and subsidize the increased cost of technetium-99m imposed by the manufacturer and the distributor and the cost of the deployment of the positron emission tomography across Canada.

Four is that the ministries of natural resources and Health Canada work firmly and expeditiously with the relevant medical national and international organizations rather than relying on expert individuals and that they rapidly establish processes to implement these recommendations.

In addition to the deployment of PET in Canada and in order to mitigate the chronic and drastic shortage of technetium, the CANM also believes that the short-, middle-, long-term, and immediately implementable solution is the use of the newer gamma camera that uses a solid-state crystal detector and resolution recovery software. These new and clinically available technologies reduce by a factor of two to three the amount of technetium-99m needed to perform the nuclear medical procedure and radiation exposure to the patient and personnel.

To accomplish this, a nuclear medicine equipment fund should be established for all clinics and hospitals to replace older equipment with more modern and efficient scanners. As stated in our letter to Minister Raitt in December 2008, the CANM strongly believes that current challenges still represent a unique opportunity for Canada to salvage its nuclear technology and industry, to reaffirm its leadership and prominence in the world, and to update the Canadian health care system with 21st century nuclear medical, diagnostic, and therapeutic tools that Canadians deserve.

The Canadian Association of Nuclear Medicine would like to reiterate its offer to provide its ongoing support, experience, expertise, and testimony to achieve this goal.

Thank you very much.

[The Vice-Chair, Liberal, Alan Tonks]

Thank you, Dr. Urbain. That was almost right on time. Thank you so much for that too.

I neglected to also say that Ms. Jill Chitra, the vice-president of Strategic Technologies, is also here. Welcome. Thank you.

We'll move along. We have all the deputations and then we have our question period, if I hadn't made that clear.

From the Ontario Association of Nuclear Medicine, we have Dr. Kevin Tracey. Dr. Tracey.

[Dr. Kevin Tracey, Vice-President, Ontario Association of Nuclear Medicine]

Thank you, Mr. Chairman and honourable members of the committee.

The Ontario Association of Nuclear Medicine is glad to present the views of the physicians who oversee the approximately 100 departments and clinics that offer the services of nuclear medicine across the province of Ontario. Half of these, approximately, are hospital-based facilities and half are in clinics or independent health facilities dispersed widely throughout the province.

There are significant challenges related to that geographic dispersal of resources in nuclear medicine in Ontario. That has been challenged over the past decade by little change in the technical fees reimbursed for procedures done in both clinics and hospitals. As a result, nuclear medicine, which has been in a situation of financial restraint over the past year, has found itself in a fragile financial situation. This crisis has tipped us over into a period in which it is extremely challenging for our physicians to deliver health care to the patients of Ontario.

Most clinics and hospitals have worked in situations of barely breaking even, or, currently, of operating at significant losses due to the unique situation of reimbursement in Ontario relative to the rest of the country. As a result, equipment and software that could assist us in addressing some of the concerns brought to our practices on a daily basis cannot be responded to.

We see a silver lining in this crisis, in that by working with our physicist colleagues and with developments in the science of nuclear medicine, the ability to do more with less has been presented to us. As Dr. Urbain has said, there are new technologies available, both in the detectors used in nuclear medicine and in software, that use the activity from a patient more efficiently to reconstruct the information derived from a patient, at a significantly lower dose to the patient and in a shorter time, which would allow a greater number of patients to be done on newer technology units. Unfortunately, the ability of hospitals and clinics in Ontario to acquire these technologies has been limited by financial constraints that are directly due to the increase in costs leading from the isotope shortage.

We concur with the Canadian Association of Nuclear Medicine on several of the points that have been brought forward.

We feel that there is a need for the development of a nuclear medicine fund to address the one-time and long-term funding issues we face in the wake of this shortage. This fund could assist hospitals and clinics across this country, and particularly in Ontario, which has been more significantly affected, in addressing the hardware and software shortfalls we're experiencing. Investment in these technologies could assist us in taking care of patients within the reduced activity situations we are weekly and monthly dealing with.

Additionally, we see PET, and particularly with the geography of Canada and Ontario, mobile PET, as a solution, both in the short term and in the long term, that will assist us in dealing with periodic and long-term shortages related to the isotope crisis.

The development and funding of regional radiopharmacies to assist us in more efficient distribution is something we would seek urgently to address.

Until the situation this spring, we had relative ease of distribution of the technetium supply given to us. Now the necessity of concentrating activity within geographic areas to allow us to distribute more efficiently is critical to further the delivery of health care services in Ontario.

We ask that we address the instability in supply, both in the delivery of services of isotope and in its distribution, so that we can count on a stable supply within institutions for planning of patient scheduling.

We also caution, as the Canadian Association of Nuclear Medicine has stated, with respect to having a stable alternative as we move forward. We are concerned about the implementation of experimental technologies prematurely, before we are sure that we are not going to result in a situation similar to what has occurred where technologies are not able to be deployed.

We also ask for an independent review, an international review, of the status of the MAPLEs, and to revisit whether this decision is sound and could be addressed to assist us in the short term and medium term.

The past six months have been extremely difficult for physicians across Ontario in delivering health care to their patients. I think communication has been an issue within this crisis as well. We ask that we all work together to assist physicians on the ground in communicating and planning so that when disruptions in delivery occur, we're able to address them in a timely manner and minimize the amount of disruption to patient services.

Thank you.

[The Vice-Chair, Liberal, Alan Tonks]

Thank you, Dr. Tracey.

We'll move on to MDS Nordion. Go ahead, Mr. West.

[Steve West, President, MDS Nordion]

Thank you.

Good afternoon. My name is Steve West, Chief Operating Officer of MDS Inc. and President of MDS Nordion. Accompanying me is Jill Chitra, Vice-President of Strategic Technologies for MDS Nordion.

Today, I would like to focus my remarks on the current status of the medical isotope supply shortage, the future of long-term medical isotope availability and Canada's critical role in the nuclear industry.

In order to better appreciate the industry in which we are a global leader, MDS Nordion often works with its market and its customers to understand the perspectives of the medical community. Recent market intelligence has led to a better comprehension regarding the impact of the medical isotope shortage on the North American and European technetium end-users. Although our work is qualitative and directional, it does provide relevant observations of the impact of the shortage, and we believe that further quantitative research would validate these findings.

From our research, we learned the following.

Not surprisingly, the NRU shutdown has resulted in a significant decrease in technetium supply to hospitals and clinics. Hospitals have been able to alter their behaviour to mitigate the effects of the shortage, but not in ways perceived by the clinical community to be sustainable in the long term. Based on our review, we estimate there has been a 15% decline in technetium administered in doses across North America and Europe due to the shortage.

The actual impact of the medical isotope shortage, however, is greater than this estimation. But due to changes in patient scheduling, longer work hours, greater efficiencies of preparation and administration to patients, the medical community has been able to reduce the impact. However, many end-users we have spoken to really don't believe this is a sustainable activity in the long term. In addition, and of critical importance, is our discussions and research indicate that Canada has been the hardest hit across North America and Europe, where we estimate the shortage in technetium to be greater than 35%. This is significantly greater than the impact we're hearing about in the U.S., which is estimated to be approximately 20%, and in Europe, where the impact has been negligible. Based on expected supply scheduling in the global supply network, the outlook for 2010 is not any better and in fact has the potential of being much worse.

The HFR reactor in Petten, in the Netherlands, will require an estimated shutdown of 26 weeks starting in mid-February. That means that potentially there will be a six-week time period when both the HFR reactor and the NRU are scheduled to be out of service, which represents about 70% of the global medical isotope supply. This assumes that there will be no issues with the NRU and HFR restarts. Any delays in NRU will only magnify the impact of the severity and increase the period of the shortage.

The impact becomes critical, both here in Canada and globally, of course. In addition, specifically in the timeframe from April to September of 2010, there's also the potential of only one or two reactors operating. And this is due to schedule-direct and maintenance shutdowns. As well, the new supply entrants, which were expected to be online earlier this year, continue to be delayed. So the completion of the NRU repairs are imperative. The CNSC has granted the NRU a licence until 2011; the government has asked AECL to apply for an extension of that licence. This will assist in furthering the life of the NRU reactor.

We strongly support these efforts. However, the extension of the NRU licence is not, in our view, a long-term solution for medical isotope supply. It does not preclude future issues with NRU, or provide a solution for the supply beyond the extension period.

This brings me to my second point regarding future outlook and the plan for long-term medical isotope supply beyond 2011.

At the end of July, expressions of interests were submitted to the Government of Canada's expert review panel on medical isotope and technetium generator production. MDS Nordion submitted a proposal and collaborated on several others. To date we have not been approached by the panel or by the expert consultant for any details or clarification of these highly technical and industry-specific proposals. At this time we are not aware of what decisions and/or actions will be forthcoming from the panel's report designed to address the medical isotope supply issue here in Canada.

We are also unaware of any definitive plan or timeline as to what occurs in November, once the proposals are reviewed. It's not clear what the recommendations to the government will entail or how long it will be before we have an implemented solution.

In the meantime, the Netherlands has publicly stated that it has no intention of giving up its European leadership role in the nuclear industry, with the announcement of its PALLAS reactor project, intended to replace the Petten reactor. The United States is moving forward with funding for domestic supply, and Australia is making an entrance into this market.

Canada, the longtime global leader and one of those hardest hit by the shortage, appears to be sacrificing its leadership position to rely on foreign countries to supply its medical isotope needs. This does not equate to a reliable long-term supply solution. If the Netherlands or the U.S. had MAPLE assets available to them today, I am sure they would be willing to evaluate and invest in a solution to bring those reactors online.

For us, as a global health science company headquartered here in Ottawa, assurance of secure long-term isotope supply has been and continues to be a fundamental focus at MDS Nordion. It is essential for the global nuclear medicine community, the patients they serve, and the future of innovation in health care.

We believe the role of government is critical. Governments provide biomedical infrastructure for research through hospitals and universities. Health is an investment that produces economic wealth and creates a better economy and a better world.

Canada has been a leader in isotope production and has fostered an innovative industry that creates high-value Canadian jobs, research and development opportunities, and economic value creation. Other nations will benefit from investing in this innovative and growing industry, an industry that started here in Canada.

To foster health care technology for Canadians, we need medical isotope production capacity to advance innovation and maintain our global leadership.

Thank you.

[The Vice-Chair, Liberal, Alan Tonks]

Thank you, Mr. West.

There are a couple of minutes. Ms. Chitra, did you wish to add anything to Mr. West's presentation?

[Jill Chitra, Vice-President, Strategic Technologies, MDS Nordion]

No, I will not at this time.

[The Vice-Chair, Liberal, Alan Tonks]

Thank you.

That leaves you, Dr. McEwan. Would you like to take over now?

[Dr. Alexander McEwan, Special Advisor on Medical Isotopes to the Minister of Health, Department of Health]

Mr. Chair, honourable members of the committee, thank you for the opportunity of again appearing before you to discuss this issue.

As I was coming to Ottawa, it occurred to me that this is an issue that, after many weeks of intense discussion in the press, has rather fallen off the precipice. We have seen very little in the press regarding this matter. It remains for me and for my colleagues in clinical medicine, however, a daily issue that we have to deal with. I'm grateful for the committee's bringing this to our attention again and for giving us an opportunity to meet before you. I know that I share with Jean-Luc and with Kevin the clinical concerns over the impact this has had on our patients and on the patients whom our departments serve.

You've heard from both Dr. Urbain and Dr. Tracey that this is a system that is coping, but the coping is stressed stability, and we feel almost as if we're on a knife-edge of supply. We've seen at every level of the delivery system, from the supplier to the technologist on the floor, a huge amount of flexibility in the way in which people have dealt with the uncertainties of medical isotope supply. I thought it would be helpful to the committee to review some of the activities that have been undertaken and then review some issues around supply.

First, we need to recognize the impact that this has had on our patients. Although I'm not aware that we have really not been able to provide care to our patients when they need it, this care has been done at inconvenience to them. Jean-Luc mentioned the calls changing appointment times to ensure that we could deal with isotope supply.

Within the provinces and health community there has been an extraordinary effort to re-engineer the processes by which we provide our patients with scans. Departments have remained open for long periods of time; we have, where we can, taken advantage of new technologies; we have worked weekends. We have also used alternative radiopharmaceuticals—thallium, as an example—wherever you can use a product that is not technitium-based to image patients with cardiac diseases.

We've seen significant efforts by industry to help us manage this. There's been a diversification of sources of molybdenum. This has given us something of a cushion in maintaining supply. It doesn't, however, provide a perfect cushion, as I think all three speakers before me have said. One more reactor going down means that the cushion is lost. There has been sharing of radioisotope between suppliers, and this has undoubtedly helped those centres that are only supplied by one of the generator suppliers. I also think we have become much better as a community at generating and communicating supply forecasts.

We have had regulatory approvals facilitated by Health Canada: a new source of iodine-131, for example, for treating patients with thyroid cancer; the clinical trial application for fluorine-18 to enable us to reduce the use of technetium MDP; and also the approval, in anticipation of their being able to produce, of the Australian reactor-produced molybdenum-99.

The guidance document that the expert panel has released and continues to update has been helpful. I think the CAMRT review gives some indication of the ways in which this has helped individual departments on the ground.

Finally, we have to recognize the superhuman efforts of our technologists in ensuring that we were able to make the changes in our work practices. If we look at the impacts of these work practices, we see that we have been able to maintain a service to our patients. We have achieved a period of stability, but as I said earlier, it is stressed stability.

We have, I think, been able to offer scans to all of the patients who have needed them. We really do need to recognize the hard work that our departments have put into managing this crisis. I was very pleased today to see the CMA letter identifying and recognizing the contributions that the medical community and the medical technology community have made.

There are a number of factors that I think have helped us to cope. Generally we've had a slightly better supply of technetium-99m than we had expected in the worst days after the NRU shutdown. I have provided to you for circulation two charts, one of which is a national forecast of technetium supply. This is the long-term chart showing that if we look at the national supply across the whole country, we have not, apart from the initial period, fallen below 50%. So nationally we have done well. What this does not reflect is some of the difficulties that individual sites have had in maintaining their supply.

The second chart is a snapshot of two weeks—last week and this week—of supply to individual sites in Ontario and in Quebec. We have given you the figures for Ontario and Quebec because those are the two provinces where the impact on supply has been most keenly felt.

I'll just take one minute to explain this chart to you. On the left-hand side where the 7,500 mCi figure is, that is the level of radioactivity that was supplied to individual sites before the crisis started. For the size of the order delivered, that is the amount of activity that the sites got in each of those two weeks. Obviously we've given the percentage of the pre-NRU shutdown supply in the second column. The shaded areas are basically where the individual hospitals asked for lower levels of activity. You can see that, in the two weeks that I've discussed, in one week we were broadly doing okay across the country; and this week, the supply is down. Because of a Petten shutdown, we predict that there will be some limitation in supply next week as well.

So we have data going back by each of these individual hospital sites through the period of the shutdown. It's notable that we have been able to do a large number of patients with less activity than we have been using in the past.

Also, the last time I met with you I discussed with you the importance of understanding the differences, particularly in Ontario, between large hospitals and small hospitals. As Dr. Tracey discussed, there are real issues with some of the smaller sites in Ontario not being able to react to uncertainties of supply or if there is a problem. For example, two or three weeks ago there was a shipment that was not carried by Air France because the pilot didn't want to carry radioactivity on his plane, so there was an acute crisis because we didn't get the activity that we had expected. It's the smaller centres that are unable to react as well as the larger centres to those unexpected issues.

Secondly, I am concerned that we are seeing across the country a reduction in the number of referrals for nuclear medicine procedures. I think this is based out of fear that the test will not be able to be performed. This is obviously a concern for two reasons: one, the patient will not be getting the best test first; and two, it places stresses on other parts of the imaging system that have to pick up the slack.

The other issue of concern that we're hearing is cost. As we're now six months into the crisis, I think we're beginning to understand the impact of these cost increases that have been caused both by planned increases prior to the NRU shutdown and increases that have occurred because of the shutdown. We're beginning to see the impact of those, particularly again on smaller departments that don't have the flexibility. As we move into the next planning cycle, we think it important that we understand the real impact of these costs.

Finally, the Canadian Association of Medical Radiation Technologists published a survey a couple of weeks ago in which they identified issues. These are burnout among technologists, because we are asking these people to do an extraordinary amount of work over a prolonged period of time; and secondly, at 8% to 9% of sites surveyed, layoffs were being considered because of reduced activity.

Furthermore, we really need to consider, as Steve West said, the fragility that is potentially coming in 2010. One of my roles over the course of the next couple of months is to really understand what the impact of the last six months has been, as we attempt to plan for 2010. In the best of all possible worlds, the NRU comes up and Petten is only down for the planned period and we're able to survive. But the system is stressed, stable, and only just coping.

Therefore, there are three or four initiatives I would like to highlight, Mr. Chair, for the committee. First, with the Canadian Institute for Health Information, we are planning to undertake a survey across the country of the impact of the last six months on referral patterns, utilization of other modalities, the use of radiopharmaceutical referral patterns, and use this to plan going forward.

I believe there will be some innovative suggestions coming out of the CIHR from the competition that is currently under way. I believe we may get some medium-term—albeit not short-term—help out of that research.

Thirdly, we're obviously all waiting for the expert panel review. I think all four of us have mentioned the expert panel review. I believe that of the 22 proposals, some are obviously innovative, and we really need to look at the ones that are going to help our community the most.

We need to understand the impact of technological advances. Whether it's using different radiopharmaceuticals, different technologies, or improved gamma cameras, we have to use this planning process and planning time to really understand the impact those advances can make and the evidence that has to be brought to bear to validate the introduction of those impacts to ensure that our patients get the best care they are going to get.

Finally, we consider it really important to work with the community to understand the financial and planning impacts as we go in, because we need to be aware of both the best and the worst of the options that may happen in 2010; and I'm committed to working with my clinical colleagues, industry, and the minister to ensure that we have the best options available to ensure that our patient care is not impaired.

Based on my last meeting, Mr. Chair, I will remind the committee, if I may, that I'm a practising physician. I see patients for diagnosis and therapy on a daily basis in my clinic. I discuss this impact with them on a daily basis, as my clinical colleagues do. We have to remember that the people at the end of this are actually the patients.

Thank you.

[The Vice-Chair, Liberal, Alan Tonks]

Thank you, Dr. McEwan, and thank you to all of our presenters.

We'll now go to the committee. The first round will be seven minutes of questioning each, and we'll start with Mr. Regan.

[Geoff Regan, Liberal, Halifax West, NS]

Thank you very much, Mr. Chairman.

Allow me to thank all of the witnesses today for their very interesting and troubling testimony about the situation that now exists, what we're looking forward to in the next number of months, and perhaps in the longer term. I have some more questions about some of this.

Dr. Urbain, first of all, you've talked about the impact of this on clinics across the country. In terms of a typical patient, whether they are receiving cardiac care or cancer treatment, what does the next six months look like, first of all in relation to supply, and secondly in relation to what it means for patients?

[Dr. Jean-Luc Urbain]

That's a very good question, a few-million-dollar one.

The bottom line is that we have learned to work on a day-to-day basis. There are days when we don't get any technetium and cannot perform any tests. There are days when there is plenty of technetium, but it's not necessarily easy to call the patient and ask them to come for their test.

It's very painful not to be able to provide services to patients. All of us who are practising nuclear medicine got involved in the field because we felt it was a step forward in being able to diagnose diseases way before they were obvious on a CT or MR scanner. If you look at the sequence of diseases, they start at the genomic or genome level, and then at the end of the road a patient will have symptoms and you will see the cancer, for example, on a CT and MR. Nuclear medicine has the unique ability to be able to diagnose those diseases before they explode in a patient's body.

So our concern is that we cannot perform enough tests, and second that what we now see is referring physicians not sending their patients. So the diagnoses will be at a later stage and the cancers and cardiac disease will have progressed by then. So at the end of day, the patient is losing in all of this and society is losing because it's going to cost much more money.

[Geoff Regan, Liberal, Halifax West, NS]

There's been speculation, Doctor, about whether or not the NRU will start up again as scheduled, perhaps by March. In the first part we were told next year, of course; in the spring we were hearing maybe three months, and then in July we heard it would be a much longer shutdown.

How long is this sustainable? You've just indicated that there are patients who because they're not getting the diagnosis early enough won't be treated the way they should be early enough, and, as you put it, will have their cancer explode. That's a frightening prospect.

[Dr. Jean-Luc Urbain]

Canada is very peculiar. Not only do we have a shortage of technicians, but except for Quebec, positron emission tomography has not been deployed.

As mentioned, many of us went to the European meeting last week in Barcelona. The two major topics of the conference were positron emission tomography and therapy with radioisotopes.

I am originally from Belgium, and starting in 1983 positron emission tomography was part of my training in nuclear medicine. As a matter of fact, Belgium approved the use of PET scans for the diagnosis for every stage of cancer in 1990. So Canada is 20 years behind. Quebec deployed PETs a few years ago. We are paying the price for a lack of basic technology.

We're not necessarily going to see the effect of the shortage of isotopes today, but we'll see it six months, a year, two years down the road. We're certainly going to see a lot of patients with advanced cardiac disease, advanced coronary arterial disease, and advanced cancer.

I've said many times that I've never seen as many patients with advanced cancer as I've seen in Ontario over the past five years, and the reason is that we don't have the tools to make those diagnoses. The shortage of isotopes will just increase this dramatic situation across Canada.

[Geoff Regan, Liberal, Halifax West, NS]

In terms of the approval of isotopes--I think both you and Mr. Tracey referred to the need for that--what is the situation?

[Dr. Jean-Luc Urbain]

I'm trying to help a patient with a very specific type of disease called neural endocrine disease. In neural endocrine disease there are so-called benign cancers with a very small tumour. The tumour produces very powerful hormones that basically debilitate the patient. Patients cannot function. They have diarrhea, day in and day out. That type of disease is a very good template for the future of nuclear medicine and molecular medicine. The reason is that it uses isotopes for the diagnosis, the treatment, and also for the follow-up.

Ontario and the rest of Canada have to send their patients to the U.K., Holland, or Germany to get treatment--this is absurd--at two, three times the price we would be able to provide in Canada. I think the entire system has to be revisited in terms of the isotopes available.

I'm very pleased that Health Canada and the Minister of Health have appointed Sandy McEwan to guide Health Canada through the process of approval. We all have to roll up our sleeves and get to work to make sure we can provide Canadians what they need and deserve in the 21st century.

[Geoff Regan, Liberal, Halifax West, NS]

Thank you.

Dr. Tracey, why is it important that this happened in Canada, in your view? We heard the Prime Minister say this spring that we were going to get out of the business of isotopes. Is it your view that it is important? I think it is, from what you said.

Second, when you talk about significant losses, how does a clinic cope? What happens as a result of that?

[Dr. Kevin Tracey]

To your first point, Canada has a long history of expertise in this area. The immediate reaction of most of us in the medical community in nuclear medicine is that we were a little shocked that there was discussion of moving away from this when we've spent generations building up that expertise within this country. That is a common reaction, even today, which we can't really accept. It's an Ontario industry that has been fostered by both the federal and provincial governments for many generations, and it would be a great loss to see this move to and be taken up by other countries.

[The Vice-Chair, Liberal, Alan Tonks]

I'll have to stop you there. We're out of time on this one, but you may want to come back to that theme in other answers to questions.

We'll now go to Madame Brunelle.

[Paule Brunelle, Bloc, Trois-Rivières, QC]

Good afternoon, ladies and gentlemen. Thank you for being here.

Mr. Urbain and Mr. Tracey, I would like to use this opportunity to ask you to congratulate your doctors for all their hard work and overtime hours. Listening to your presentation, I wonder just how far we can pull the rubber band before it snaps. I find it disturbing to see that some of the costs will fall to patients, not to mention the social costs.

Sir, you say that we need to understand the impact on technology. I imagine this nuclear medicine uses a whole system of technology. There is no long-term plan, and the government does not appear to want to restart the MAPLE project. If, as we believe, the government is discontinuing isotope production, what hope do we have? What do we do about all this, Dr. Urbain and Dr. Tracey?

[Dr. Jean-Luc Urbain]

You raise some very good points.

The association continues to ask that the MAPLE situation be revisited. Clearly, it is expensive to produce isotopes. Based on the information that we have received in recent months, reactor operators prefer to use their reactors for research instead of producing isotopes because it is much more profitable.

I do not have the inside track. We do not know whether, from a financial standpoint, the decision to stop producing medical isotopes for the rest of the world is a good one. But there is absolutely no question that Canada needs a domestic supply, so that what happened last week does not happen again, when the president of the Ontario Association of Nuclear Medicine commented that technetium could be sold on the market to the highest bidder. That would mean we are in a time of shortage.

Canada must, at the very least, produce its own domestic supply. According to reports published last year by the National Academy of Sciences in the United States, the world uses approximately 12,000 6-day curies. Canada needs at least 1,000 6-day curies a week for itself. That is the bare minimum. It is a shame to see technology disappearing and heading to other countries.

[Paule Brunelle, Bloc, Trois-Rivières, QC]

Dr. Tracey.

[Dr. Kevin Tracey]

The MAPLEs were well designed from the standpoint of having a backup situation and dealing with contingencies. We're really in that situation now. We'll be dependent on Petten over the next year. It's going down at the right time for us when we're able to produce. If they are down and we're not up, over that period of time the situation will be extremely challenging. It will be much worse than what we've been dealing with.

The lack of addressing that potential situation, which is very real to all of us, concerns us the most. I think it's the institution of some contingencies that really addresses that core issue. Dr. McEwan has stated that we've been coping with the situation, and that would really put us over the edge. We haven't been hearing about a good game plan to address that very real potential in February and March. That's what we'd like to hear.

[Paule Brunelle, Bloc, Trois-Rivières, QC]

I understand that Canada needs a domestic supply.

Mr. West, several of the experts who have appeared before us have asked why we do not invite experts from all over the world, Europe or elsewhere, in order to analyze the MAPLE project. Do you agree? Do you think that would be a good idea, despite the seemingly exorbitant costs associated with the project? We need to get a sense of what we are getting into, if we restart the project. Of course it will take time. You said that it could take a year or a year and a half before the project could be relaunched. And what do we do in the meantime?