Whatever happened to the medical isotope crisis? The story dominated headlines back in the spring, as the shutdown of a key nuclear reactor turned into a political hot potato, while leaving thousands of patients in the lurch.
And then along came swine flu.
Somewhere in the confusion over H1N1 and the politics of a pandemic, the isotopes story fell off the radar. But the crisis has continued for patients and likely will continue still, even after the reactor gets back online next spring, doctors say.
Atomic Energy of Canada Ltd.'s NRU reactor at Chalk River supplied a third of the world's medical isotopes and 80 per cent of the isotopes for the Canadian market before workers discovered a pin-sized hole in the reactor, back in May.
NRU was supposed to be shut down for a month for a quick fix, then that that turned into three months. Then, when the reactor was drained and more holes found, the reactor was shut down for a long-term repair. At the moment, AECL's best estimate is the reactor will be back up in March.
For months now, nuclear medicine practitioners in Canada have been without their key supply of molybdenum-99 (mo-99), whose derivative, technetium-99m (Tc-99m), is the most widely used isotope in nuclear medicine scans. Only a handful of nuclear reactors in the world make mo-99 and most of North America's supply came from Chalk River.
Within weeks of the shutdown, medical tests were postponed and some cancelled, while Canada procured isotopes from a handful of other reactors around the world and doctors scrambled to make do with an erratic supply.
None of that has changed over the last seven months, Dr. Jean-Luc Urbain, president of the Canadian Nuclear Medicine Association, told a Commons committee back in October.
Urbain said the supply of Tc-99m that Canadian hospitals have been able to get their hands on has varied from week to week, with most weeks seeing about half the supply they used to have access to.
Doctors, technologists, and support personnel have had to work double shifts and juggle patient and physician appointments when supplies of technetium were good, then switch to different protocols and isotopes when they weren't.
They've have also had to rely on alternative and older isotopes as well -- thallium-201 to image patients with cardiac diseases, as an example.
"Over the past six months, we went back in time and we now practise nuclear medicine the way I was practising in the 1980s," Urbain told the MPs. "So we went from a 21st-century type of service to a 20th-century type of service."
Layoffs, rising costs and delayed testing
Dr. Christopher O'Brien, the president of the Ontario Association of Nuclear Medicine, noted that some patients who would have had nuclear medicine tests have been referred instead for CT and MRI procedures, which are not as detailed and much more expensive to conduct.
Dr. Alexander McEwan, head of oncology at the University of Alberta and the special advisor on isotopes to the Minister of Health, testified to the committee that patients who rely on nuclear medicine to treat their illness -- not just diagnose it -- have been affected as well.
He said many have been sent to the U.K., Holland, or Germany for treatment "at two, three times the price we would be able to provide in Canada."
And while most diagnostic tests haven't had to be cancelled, Urbain knows that physicians are simply not referring as many patients for nuclear medicine tests as they once did.
"The CANM is extremely concerned by the significant decrease -- from 10 to 25 per cent, depending on the region -- of patient referrals for nuclear cardiac and oncology tests," he told the committee.
"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."
For that reason, he said, the true effect of the isotope shortage may not be seen for a few years yet, when patients are finally diagnosed with advanced heart problems or cancer.
The isotope shortage has had other effects as well. Urbain says he's seen reduced enrolment of medical students into nuclear medicine. And Dr. Kevin Tracey, the vice-president of the Ontario Association of Nuclear Medicine told the MPs that some technicians and technologists have lost their jobs or been laid off.
"These technologists are difficult to train, and once they leave the community, in our area, they go to the U.S. To get them back is an extreme challenge," he told the committee.
Bill Pilkington, AECL's senior vice-president and chief nuclear officer, told the committee that the estimated repair bill of the Chalk River reactor will be about $70 million, including lost isotope revenue.
While more than half of that has already been spent and seven months have passed, the strange thing is the repairs are only just getting started now.
Work has focused, up to this point, on how to repair the leak. Because of the locations of the holes on the highly radioactive vessel, a full-scale NRU mock-up had to be built to rehearse repairs. Then dozens of engineers and technicians have had to develop specialized remote-control tools to carry out the work. Operators then needed to be trained to use the equipment.
Pilkington told members of the Canadian Nuclear Safety Commission last week that workers are finally ready to begin the first real repair weld.
Still no long-term solution
Meanwhile, there are still no clear answers on how long the reactor can be expected to last even once it's back up and running again. Nor is it clear what Canada should do to replace it.
Dr. Anne Doig, president of the Canadian Medical Association, told a House of Commons health committee last month that while the health-care system has been "coping" with the isotope shortage, the ongoing problems with Canada's supply cannot continue to be ignored.
"Lest you interpret my comments to mean 'all is well,' let me be clear. Much is being done, but the current situation is neither optimal nor sustainable, and there appears to be no long-term plan," she said.
An Expert Review Panel on Medical Isotope Production, created in the spring after the NRU reactor went down, released a report last month recommending that the best long-term solution would be to build a new reactor, even though that could cost as much as $1.2 billion.
Urbain immediately dismissed the report noting it ignored the prospect of revisiting the Maple I and II reactors, which were supposed to replace the NRU reactor but ran $700 million over budget and were eventually mothballed.
At the same time, the panel recommended looking into cyclotron technology, a type of particle accelerator. Urbain rejected that option, noting the technology has not been proven viable.
Doig said the government needs to develop a five-year action plan that includes increased use of PET (positron emission technology), as well as the production of low-enriched uranium radio isotopes.
Dr. O'Brien has said he would like to see a new multi-purpose reactor that could be used for research as well as isotope production.
"A multi-purpose reactor makes a lot of sense," says. "It will ensure Canada has significant research capabilities."
Whichever long-term solution Canada decides to go with, it should be chosen soon, say most observers. The current crisis has already been a black eye to Canada, compromised the health of too many patients and hurt, perhaps permanently, the country's reputation as a leader in nuclear medicine.
