Somewhere in Sheelagh Nolan's body was a cancer that had spread from her thyroid and taken hold elsewhere. Where it had travelled was a mystery — one that could only be solved through a PET scan. With no such machine of its own, the Nova Scotia government paid for Ms. Nolan to undergo a scan at an Ontario hospital in May, 2004.
Ms. Nolan, then only 41 and the wife of former Nova Scotia Liberal leader Danny Graham, was grateful for the scan but troubled by an injustice: Her provincial government paid twice for her to have scans at St. Joseph's Health Care in London — but Ontario patients in her situation did not have the same access to the high-tech machines. That's because hospitals were limited in the types of cancer patients they could scan.
“This particular issue, the fact that Ontario, a relatively well-off province, was not providing this service to Ontario patients for her was unconscionable,” said Mr. Graham, speaking about his wife's care.
In Canada, in fact, no other technology promises cancer patients such inequitable access as PET scanners, and, among provinces that have them, Ontario is the most restrictive of all.
Its use of the scanners is so tightly controlled that when London doctors have been unable to fill their half of the PET/CT slots with cancer patients, researchers used the empty spaces to do experiments on laboratory-bred animals.
“This is absolutely the world upside down,” said Jean-Luc Urbain, citywide chief of nuclear medicine in London. “... Instead of being used for their own health, clinical pieces of equipment are being used on pigs, dogs and other animals.”
Despite the name, of course, this technology has nothing to do with pets. PET stands for Positron Emission Tomography. It works by injecting patients with a short-lived radioactive tracer isotope that has been mixed with a sugar called fluorodeoxyglucose. Cancer absorbs the glucose more readily than healthy tissue, causing it to light up on a scan.
Essentially, a PET scan can pick up the metabolic signal of cancer cells. It can find a lung cancer that has spread, preventing a futile operation. A lymphoma patient may learn a worrisome lump is merely scar tissue. Colorectal cancer patients may discover the tumours on their liver can be safely removed. A scan can help determine when chemotherapy is not working, prompting doctors to change a drug cocktail.
The results need to be carefully interpreted, as non-cancerous conditions can resemble cancer; only a biopsy can confirm the presence of cancer. But for certain kinds of cancer, the PET can be more revealing than the CT scan. In 20 to 40 per cent of cases, cancer patients will have their treatment plan changed based on PET-scan results.
“Everywhere else in the country, it has become a routine test,” said Sandy McEwan, an Edmonton-based nuclear medicine physician and president-elect of the U.S.-based Society of Nuclear Medicine. “Ontario remains the only part of the OECD [the Organisation for Economic Co-operation and Development] that does not have routine access to PET services.”
Dr. Urbain offers an even more telling indictment: “I've never seen in 25 years of care so many advanced cancers because of the lack of access to this type of technology.”
Consider the facts: Quebec cancer patients have the broadest access to PET scans; in 2007, the government plans to do 21,000 scans annually. Patients can access PET scans in British Columbia, Alberta, Manitoba and, as of this month, New Brunswick. Nova Scotia also plans to purchase a scanner and expects to have it operational by the fall of 2007.
So what's the problem in wealthy Ontario?
It's part financial, part scientific. Given the high cost — as much as $2,500 a scan — government agencies want to limit their use to the patients who benefit most. In all, Ontario has nine public PET machines, and cancer patients can get access to them under five clinical trials or through a patient registry introduced a year ago. But the registry is restricted to suspected recurrent colorectal, thyroid or germ cell cancers and patients with certain solitary pulmonary nodules.
Lymphoma patients are not included, which is particularly disturbing to doctors. In those cases, PET scans can help determine what kind of chemotherapy should be used, and for how long; after treatment, they can distinguish whether bulky masses are scar tissue or cancer that has not been eradicated.
As of Oct. 31, 408 Ontario patients had obtained PET scans through the registry, and 926 patients had scans as part of the clinical trials, said Bill Evans, chairman of the PET steering committee in Ontario, the body that makes recommendations about its use to the provincial government.
“There's been criticism in Ontario in its seeming tardiness to adopt. But it's a decision taken by cancer specialists of the province, various surgeons and medical and radiation oncologists,” said Dr. Evans, who is also president of Hamilton's Juravinski Cancer Centre. “... In cancer, we have to figure out how best to use it.”
When the clinical trials are completed, “there will be a lot of people who will thank us,” said Dr. Evans, who is also an oncologist. He said Ontarians' access to PET scans is “as good as anywhere else.”
But Christopher O'Brien, past president of the Canadian Association of Nuclear Medicine, called it “health care by postal code.” The government, he said, “is attempting to justify the spending of public tax dollars but they are going about it the wrong way.”
Francois Lamoureux, president of the Association des médecins spécialistes en médecine nucléaire du Québec, said for many cancer patients, a PET scan helps ensure an accurate diagnosis.
“It is difficult to understand how they can still do oncology treatment without doing a complete scan of their whole body to make sure that the treatment is the right one,” Dr. Lamoureux said.
No one would agree more than Ed Marchant, a 79-year-old Oakville man who had non-Hodgkins lymphoma.
After completing eight cycles of chemotherapy in March, 2006, Mr. Marchant had a CT scan, which suggested the chemotherapy had not eradicated his disease.
He consulted with doctors and, ineligible for a public PET scan, ended up at CareImaging in Mississauga, a private clinic. The scans, done in May and July of 2006, found the mass a doctor had interpreted on the CT was likely scar tissue. In other words, he required no further cancer treatment.
“What worries me is that there are millions of people who can't do anything about it,” said Mr. Marchant. “I was able to go and scrape up enough money to get a PET scan.”
In another case, Thanh Nhan was suffering excruciating back pain while undergoing chemotherapy for colorectal cancer in Windsor, Ont., in 2004, when his doctors ordered CT and MRI scans. Those tests failed to find cancer, according to the Health Services Appeal and Review Board, an Ontario board that hears from patients who want their treatment reimbursed by the government.
Mr. Nhan requested a PET scan, but he was refused. The pain worsened as the months passed, however, so Mr. Nhan decided to pay out of pocket.
That scan, done at CareImaging on Dec. 23, 2004, revealed that a cancer was located outside the rectum, attached to the sacrum. He was referred to Toronto's Mount Sinai Hospital, where, at 53, he is undergoing chemotherapy.
In an April, 2006, decision, the board refused to reimburse Mr. Nhan $2,358 for the scan, saying that, since it is not listed in the Ontario's Schedule of Benefits, it was not an insured service.
Nowhere are Ontario's problems better illustrated than at St. Joseph's Health Care London.
When the health centre acquired its $4-million PET scanner in 2002, the plan was to split its use between patient care and animal research, with the cost of the machine being shared by the centre and its research arm, Lawson Research Health Institute, said Frank Prato, Lawson's imaging program leader.
“It's important to understand that this was a partnership, we thought it would work out,” said Dr. Prato. “... We thought it would be working 24/7, it hasn't been possible from the start because we have not been able to do the patients.”
Dr. Prato stressed he did not want the public to think a clinical instrument that could be used on patients was instead being diverted to animal research. In fact, he said, empty patient slots are occasionally filled to do animal research so the machine does not go to waste.
Doctors, in turn, say they often cannot fill their half of the slots with people because of the limitations in the types of cancer patients they can scan.
Until recently, the London scanner was screening one patient a week; with the registry, that number has increased to four or five patients a week, said Al Driedger, professor of nuclear medicine at the University of Western Ontario. However, if doctors could fill their half of the slots, 20 cancer patients a week could be scanned, he said.
“I'm sure that even researchers thought by now we'd have people lined out the doors and onto the street and that's just not been possible,” Dr. Driedger said.
Doctors also say the province reimburses poorly. In London, a scan comes at a financial loss: FDG, the intravenous drug required to obtain the images, costs $1,100 a scan, but the hospital is only reimbursed $725 by the province, said Dr. Urbain, chairman of nuclear medicine at the University of Western Ontario and president of the Canadian Association of Nuclear Medicine. (Ontario Health Ministry spokesman John Letherby said the province pays hospitals an average of $1,084 a PET scan.) Dr. Urbain likened the running of a PET machine to “running a business without money.”
At the same time, Robert Lisbona, chief of the department of radiology and nuclear medicine at the McGill University Health Centre, said that since the summer of 2004, one person a week from Ontario has been sent to his hospital for a PET scan.
“What we used to see before PET was the tip of the iceberg. With PET, you see the whole iceberg,” said Dr. Lisbona. “It's unfortunate the patients in Ontario actually do not have access to PET. ... You can't manage cancer patients without it.”
That's what bothered Ms. Nolan of Nova Scotia.
At the time, she prevailed upon her husband the politician to discuss this inequity with senior Ontario government officials. Mr. Graham said he did not know what came of his actions — although today Ontario patients with suspected, recurrent thyroid cancer like Ms. Nolan can obtain PET scans under the registry.
In Ms. Nolan's case, her first PET scan in London, in May, 2004, revealed that her thyroid cancer had spread to her lungs. In May, 2005, another scan found it had spread to her spine.
“Each time the PET scan showed dramatically new information,” recalled Mr. Graham. “The decisions with respect to radiation and chemotherapy were substantially affected by the learning in London.”
Despite treatment that included radioactive iodine, chemotherapy and surgery, Ms. Nolan's cancer was unstoppable. She died on May 1. She was 43.