It’s complicated

Before yesterday’s eventfulness, Carolyn Bennett’s office sent over a manifesto of sorts on the medical isotope shortage.

Now, as a general rule, most problems of any consequence can be solved with a five-point plan. In rare cases is the six-point plan necessary. Almost never does anyone bother going for seven points. And so it perhaps says something of our current situation that Dr. Bennett’s plan goes all the way to ten.

Full text, for the sake of discussion, after the jump. For fun, the Prime Minister might consider printing it off, signing his name at the bottom and handing it to Mr. Ignatieff when they meet today.

In the past few weeks, many Canadians have been learning 2 new words – ‘isotope’ and ‘PET scan’. Worried patients across Canada have been sharing their medical situation with their families and friends – they’ve been diagnosed with cancer but they won’t know if it has spread, won’t be able to start treatment until they get a bone scan or are able to get an alternative such as a PET scan.

The current medical crisis with the unplanned shutdown of the reactor at Chalk River puts the 2000 bone scans done every day in Canada in jeopardy. Chalk River produces the generators that turn Molybdenum into isotope Technetium 99m, the radioactive tracer used in bone scans and many other diagnostic tests.

Tc-99m is also the preferred isotope for cardiac stress testing. With the now scarce supply of Tc-99m, the 2000 patients each day with suspected heart disease have to undergo their cardiac test with Thallium, an isotope from the 20th century that is far from ideal.

Cancer patients require an urgent strategy. Up until now Tc-99 bone scans were available in every province in Canada. Their alternatives are not. Tc-99 bone scans are safe for children. Their alternatives are not. Nuclear Medicine Clinics are able to do 40 or 50 bone scans in a regular working day with Tc-99m. PET (Positron Emission Tomography) scans are a maximum of 12 per day. The wait-times can only increase.

PET scanners are unevenly distributed across Canada. Atlantic Canada has one in Halifax. Québec fully adopted the European preference for this excellent diagnostic test decades ago and has 20 sites in their province. Ontario elected to ‘study’ the ‘new test’ and has 15 scanners still only used for research – but these could be switched quickly to clinical use with the appropriate political will. Manitoba has a PET scanner. Alberta and BC have some scanners. Saskatchewan and Newfoundland do not.

For pediatric cancer patients PET scanning is NOT really an option because the tracer is too strong for children. We MUST protect our children from undue radiation exposure. Our children need a Tc99m and they need it urgently.

Canada needs a serious plan.

The Minister of Natural Resources has a 5-point plan that is just words. Words like
‘quickly and safely as possible’, ‘pursuing’, ‘mitigating’ ‘engaging’, ‘investigate’, ‘exploring,’ and ‘encouraging’ are cold comfort to a cancer patient waiting to have his or her cancer staging tests. These words in no way acknowledge the reality and gravity of this genuine health crisis. The Minister has NO assurances that the extra international isotopes will come to Canada. There is a bidding war going on. It is a seller’s market for the scarce but essential isotopes. Some companies have already begun to set ‘premiums’. If you pay the premium there will be some isotopes for your clinic, if not, none for your patients. The Minister of Natural Resources has let Canadians down.

The Health Minister up until now has stated that the supply of isotopes is the responsibility of the Natural Resources Minister. She has stated that getting the patients the tests that they need is provincial. The Minister of Health urgently needs a concrete plan to deal with the scarce isotopes that remain and the geographic challenges that exist for the ‘alternatives’.

After SARS, the Naylor Report had a number of important recommendations. The imperatives articulated were 4 C’s’- cooperation, collaboration, communication and a clarity of ‘who does what and when’. We have seen none of this so far.

This dramatic crisis deserves no less. The ‘lessons learned’ from SARS need to be applied immediately. During the SARS crisis, we had to deal with the fact that germs don’t respect borders. With the isotope shortage we MUST deal with the humanitarian imperative and put in place a plan that gets Canadians tests and treatments from the 21st century; they need this urgently regardless of where they live.

When Allan Rock as Minister of Health spoke at the Canadian Medical Association Annual General Meeting he said, ‘ Geography was no excuse for inequality’. Like SARS, or the ice storm or a tsunami, Canadians want fairness. We have to pull together and get the tests and treatment to those who need it most during this time of critical shortages.

This government needs to do the following things:

1. Appoint, through its medical organizations, a non-partisan, and unbiased medical ‘Isotope Czar’ like Dr. David Naylor was for SARS or Dr. Brian Postl was for wait-times. The people of Canada need to have confidence that the Isotope Czar really represents the entire Nuclear Medicine Community across Canada. That person should not carry his or her own personal agenda nor financial interests.

2. Clean up and stand up the Operations Centre at Health Canada in order to map out the situation across Canada. Each nuclear medicine clinic needs to report the source of their isotopes, the supply, the tests booked, delayed, alternatives utilized, the alternatives not available in their region, their capacity for them to help other regions.

3. The federal ‘Draft’ guidelines for prioritizing patients must be finalized and take into consideration the regional variations in capacity.

4. Launch a registry of patients requiring testing and use the existing guidelines to prioritize their need recognizing the urgency of children diagnosed with cancer for whom there is no alternative test.

5. The provinces and territories should appoint an expert to serve on an Isotope Network chaired by the federal ‘Isotope Czar’.

6. Health Canada must accelerate the approval of the radiopharmaceutical that can be used in PET scanning such as Sodium Fluoride F18. Nuclear medicine specialists and their medical organization have described the process as a federal/provincial ‘bureaucratic mess”. It must be fixed immediately.

7. The federal government must commit to paying for the 30% increase in imaging costs caused by the lack of isotopes. It is unacceptable that the global budget of hospitals or the tight health budgets of provinces and territories should have to pay for the absence of a back-up plan for isotopes after the cancellation of the Maples reactors project last year.
The federal government must pay the increased costs of the isotopes and the increased costs of the alternatives.

8. Accept the recommendation of the Canadian Association of Nuclear Medicine and the American Academy of Medicine to strike an international panel to relook at the feasibility of commissioning the Maple reactors.

9. Ensure that the Ministerial Advisory Committee on Isotopes represents all the appropriate stakeholders and that it will give regular ‘transparent’ advice to the Minister of Health so that public is always aware what the experts have told the Minister. There must be no suspicion of political interference in doing what is right for patients. If the Minister is unable to do as the experts have suggested, she must be able to explain the political or economic justification for her decisions to Canadians.

10. The Minister and the government must come clean with Canadians. Regular press conferences with officials and experts to explain to Canadians the extent of the shortages and the up- to-date situation with respect to alternatives and waiting times are essential. Canadians are very smart and deserve to be treated like grown-ups not kindergarten children. They are capable of learning a couple of new words like isotope and PET scan.


Like a cancer diagnosis, the government must get beyond denial, past anger, bargaining, depression and urgently move into reality and the acceptance phase. There must be the acceptance that there is indeed a crisis and the acknowledgement that the federal government has an essential leadership role to play. The federal government must work with the provinces and territories to ensure that Canadians get the best possible care regardless of where they live in Canada.

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