Natural Resources Committee on Oct. 19th, 2009

[Steve West]

I think the committee knows I'm a little biased on this issue. We do believe that the MAPLE completion is the best option for Canada and, frankly, for the world.

There have been a number of submissions to the blue-ribbon panel. I don't know exactly how many--in fact, that would be an interesting statistic to know--but of the 22, I imagine probably at least five or six different proposals have gone before that blue-ribbon panel. We have provided letters of support for some of those; in fact, in partnership with South Africa, we have put our own submission in there for the completion of MAPLE.

From our standpoint there are a couple of observations.

It's been over a year now since the MAPLE project was abandoned, and it's been a year of no progress. I just wonder; if you think about getting MAPLEs back online, the longer we wait, the longer this shortage issue continues to play out. As other members of the panel have pointed out, we are potentially approaching a situation in which the dependency on a very small number of reactors is creating a much more critical situation than the one the physicians have been coping with today.

I'd also be interested in knowing how much money is being spent on keeping NRU going and how many hundreds of millions of dollars are being poured into NRU that could perhaps have gone into completing the MAPLE project with the right expertise working on that project. Our view has always been that we did need an international consortium of expertise to resolve the MAPLE issue.

[The Vice-Chair, Liberal, Alan Tonks]

Mr. West, I'm going to have to leave it with that thought.

Thank you, Madame Brunelle.

We'll go to Mr. Cullen.

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

Thank you, Mr. Chair.

Thank you to our witnesses.

When one of the incarnations of this crisis arose, the then minister called it a life-and-death situation. There is also in this a question to you, Mr. Urbain, that the alternative tests available for certain types of cancer and certain types of heart conditions were of a poorer quality in that they exposed patients to higher levels of radiation and were often more expensive. All these things have been going on since. It feels like the medical community has been in a bit of a triage situation in trying to get to the most critical cases first, and you should be commended for that.

What I'm trying to establish today with the government's response is how much longer the system can go on before it hits that breaking point, before it starts to show up in all the communities that we represent and to Canadians broadly. I get the sense that we've been able to manage for six months and have reallocated resources as well as we can. It's cost us more and it's cost people more time in terms of getting their tests, but will it be six months out, or 12 months, or 18 months, when we hit a point at which the system can't actually absorb this any more, when we're just cancelling, and more and more patients are not getting those tests, and we're exposing people to the wrong types of tests?

[Dr. Jean-Luc Urbain]

There are a few aspects to your question. The most direct answer to you is that it's not going to depend on isotopes and it's not going to depend on technology; it's going to depend on people and on when people will quit on us, on when the technologists will say that they've had enough of this nonsense and cannot cope any longer.

As I said, we have seen a decrease in enrolment of students and a decrease of physicians in nuclear science, so the effect in the short term is going to be essentially in the middle term and long term. I don't have a crystal ball; I do not know, but what I know for a fact is that's the way I feel and that's the way it is.

Over the past six months we went back in time. We now practise nuclear medicine the way I was practising it in the 1980s. We went from a 21st century type of service to a 20th century type of service.

Thallium is a good isotope. Actually, physiologically it's still the best, although not the ideal isotope. Radiation is definitely increased. We can use it, but not necessarily for the next few years.

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

I have a question for you, Mr. West, about the notion of domestic supply.

In the conversations--and Mr. Tracey raised this, as well--it seemed that where these isotopes are produced is actually of significance to Canadians. How important is that? Is it not simply like any other type of market commodity that you can go out and buy, and Canada simply buys them just as other countries have been buying them from you and from us for many years? Why is Canada's presence in the market so critical in Canadian patients getting the types of tests they need?

[Steve West]

I think it's really been a function of the role that Canada has played globally, because we've not been a small player, we've been a big player. As a result of simply the amount of isotopes that Canada has provided, which has ranged over the years from somewhere between 50% and 30%, when we're out of the game, then that shortage plays back into Canada, and in fact it plays back into Canada more significantly than it plays back anywhere else.

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

That's the point I want to understand.

So if the supply goes down, if Canada gets out of the isotope business, as the Prime Minister said back in June, the effects, as the system is built right now, will be harder upon Canadians than patients in other countries?

[Steve West]

It seems to be that way. I can't give you a specific cause and effect, but clearly Europe looks after Europe, I think. It makes its own isotopes, and Europe looks after Europe. We see that at the European meetings.

In North America what happens is you have different supply chain dynamics. In the United States there are probably contractual obligations. There are integrated supply chain streams that give preferential supply into the United States medical communities. There are centralized radiopharmacies in the United States and there are not in Canada. So there are a bunch of supply chain issues.

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

Mr. McEwan, I'm trying to understand your mandate. You're appointed by the health minister, correct?

We've often struggled at this committee, and we hope to make some recommendations to the government as to what should happen. I know there's this expert panel. We haven't seen anything from them, and won't see anything till November, but we wanted to have a national view. And you pointed out that while this points out the national numbers, there are going to be regional discrepancies, and that's regional shortages.

Does the Government of Canada have any guaranteed supplies? Does it have any contracts? Does it have any known estimate of what kinds of isotopes we can expect over the next six to twelve months, let's say? Does that exist? Does it work that way?

[Dr. Alexander McEwan]

I'm going to answer that in two ways, if I may. The first is that individual hospitals or pharmacies will negotiate and have a contract with the supplier of a generator. Those contracts will be up on a rolling basis, so this comes back to some of the cost issues. It also comes back to widening supply. There are two suppliers of generators to the Canadian market. Those big central radiopharmacies that have generators from both suppliers have tended to survive a little better than those that have had a single generator supplier, particularly Lantheus.

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

Do we know the percentages for Canadian facilities?

[Dr. Alexander McEwan]

Across the country, it's sort of 75-25, but with huge regional variability. For example, in the east, Lantheus is a much bigger supplier than in the west, where Covidien is a bigger supplier.

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

That adds a certain amount of fragility to the system, I would imagine.

[Dr. Alexander McEwan]

Covidien and Lantheus have been sharing when they can, but it does add to the fragility. So I think we're dealing with that.

The second way is supply of molybdenum to the individual generator manufacturer and the approval of the molybdenum supply from a regulatory point of view.

There has already been approval by Health Canada for molybdenum supplied by Australia. They're not yet in a position to supply as much as is needed. The hope is that they will be able to expand supply going forward.

Secondly, there are other manufacturers of generators around the world, and one of those manufacturers is currently having their generators tested in Canada at the moment. We're looking for quality, we're looking for quality assurance, we're looking for reliability. If it looks as if they meet those criteria, then we can look at a regulatory approval for another generator supply.

So the answer to your question is the supply is obviously dependent on the beginning of the supply chain, which is the reactor's supply of molybdenum. If that is disrupted at the beginning, then no matter how carefully anybody plans, the rest of the world is going to be down.

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

Right.

[The Vice-Chair, Liberal, Alan Tonks]

Mr. Cullen, I'm going to have to interrupt. We're out of time on that.

Thank you, Dr. McEwan.

We go to Mr. Trost.

[Bradley Trost, Conservative, Saskatoon—Humboldt, SK]

Thank you, Mr. Chair.

In preparation for this committee, one of the things that came across our desks was a survey by the Canadian Association of Medical Radiation Technologists. I'm going to read some quotes from some of the responses.

The following represent a sample of additional comments on challenges and solutions.... We are experiencing slightly fewer bookings than normal.... ...the impact has been negligible. Things have been better than expected. Suppliers are keeping us informed and to their credit are cooperating to help the industry and subsequently patients. To date our site has been impacted minimally. We report on numbers of patients affected on a weekly basis and to date - no significant impact. Our facility has fared very well during this time of shortages. I think that people are concerned, but not overly so.

And here's one I thought was very good:

We are thinking further into the future than the current shortage.

Those were a few of the remarks of the participants, the medical radiation technologists who participated in the survey they released on October 7. And reading all the comments--and there's other technical stuff--I thought it fit very well with what Dr. McEwan had said about where the situation is now. “Stressed but stable” was the way he termed it.

Judging from these comments, by and large most people are getting what they need. Could you, however, explore the areas where there are more stresses and the areas where there is stability and refer us to anything we could do to help in the short term to support the areas where there are currently more stresses?

[Dr. Alexander McEwan]

Thank you.

The CAMRT survey was very useful because it did answer some of the questions. If you look at some of the degrees to which they are concerned, most of them, about two-thirds of the centres that responded, are having to add shifts and work.

As we look across the country, there are big regional variations. British Columbia and Alberta are coping very well indeed. Parts of Ontario are coping well. Parts of Ontario are not coping well at all.

My sense is that some of that reflects the smaller centres that are getting single generator supply. If you have a small amount of a small generator, you're going to be struggling more than if it's a small amount of a very large generator.

One of the struggles I've had in this role is to understand those centres that are really struggling. In Quebec, it's the same. Some centres are doing just fine. Some centres, again, particularly the smaller ones, are having some difficulty coping.

As we go forward, I look at three or four important issues. The first is the assumption that both Petten and NRU will be fine next year, in which case the community can continue pretty much as it has been doing, without the stresses, but it doesn't abrogate us from the requirement to plan the next generation of nuclear medicine, departments, and tests. If we have issues with either NRU or Petten next year, then we really do have to look at alternatives.

One of the important things that I hope will come out of the CIHR will be the development of mechanisms for evidence for introducing, for example, a new test in cardiac imaging or a new test in kidney imaging. It is important that we really do build the evidence very quickly so it can be introduced into clinical practice as quickly as possible.

We need to look very carefully at the results of the NRCan expert panel. All of us are aware of one or two, probably different ones or twos, of the proposals that have gone in. We're a small community, and many of us are either directly or peripherally involved in some of the submissions. Some of them are very innovative. Some of them are very expensive. We need to understand how quickly they can be brought into routine production of technetium for our patients.

Importantly, we need to look at transitioning too. Are we going to be using technetium for the next 200 years, or do we have to look at developing the next generation of tests? That is very important. As we move to the concept of personalized medicine, it becomes very important that we plan proactively how nuclear medicine fits into that.

I have said in meetings that in some ways this crisis is an opportunity for the community because it is creating the wherewithal and the terms for us to look at how we help the next generation of patients with our technologies.

[Bradley Trost, Conservative, Saskatoon—Humboldt, SK]

How much time...?

[The Vice-Chair, Liberal, Alan Tonks]

You have a minute and a half, Mr. Trost.

[Bradley Trost, Conservative, Saskatoon—Humboldt, SK]

Dr. Tracey, you mentioned that Ontario has specific concerns. We've heard about regional problems, and some of that has to do with generator supply, etc. Are some of these problems due to things the various provinces are doing in their health jurisdictions? Are the provincial ministers of health, the provincial authorities, interacting properly, or are there things we could encourage them to do better without interfering in their jurisdictions?

[Dr. Kevin Tracey]

Ontario has a uniquely funded way of reimbursing imaging in nuclear medicine. It worked very well up until recently.

[Bradley Trost, Conservative, Saskatoon—Humboldt, SK]

So the Ontario provincial government needs to change how it funds nuclear medicine.

[Dr. Kevin Tracey]

Until recently, the radiopharmaceutical costs within the framework of their billing practices have not been addressed. Those discussions are just starting.

[Bradley Trost, Conservative, Saskatoon—Humboldt, SK]

I have a short time. There are a couple of other things we can do quickly if people want to answer.