Quebec continues leadership in PET/CT
October 29, 2020
Earlier this year, the small mining town of Val d’Or, 525 kilometres north of Montreal, welcomed the arrival of a state-of-the-art PET/CT, bringing advanced imaging to the 135,000 people in northwestern Quebec’s Abitibi-Temiscamingue region.
The GE Healthcare Discovery MI PET/CT at the 90-bed Hôpital de Val d’Or will serve patients throughout the sparsely populated region, including the towns of Rouyn-Noranda and Amos, as well as patients flying in from Indigenous communities in the province’s Far North.
The $7 million project – $3.2 million for the PET/CT and $3.8 million for an expanded suite to accommodate it – was funded entirely by Quebec’s Ministère de la Santé et des Service Sociaux, underlining the province’s commitment to ensuring equal access to advanced medical imaging outside the province’s major urban centres.
PET/CTs have also recently been deployed in two other mid-sized communities across Canada – Kelowna and Sudbury – but Quebec leads all provinces in the number of PET/CTs and accounts for more than half of the PET/CT exams performed in Canada.
Preliminary data from the Canadian Agency for Drugs and Technologies in Health’s (CADTH) 2020 Canadian Medical Imaging Inventory, scheduled for release in January 2021, reports 67,849 PET/CT exams for the 2018-2019 fiscal year in Quebec and only 23,564 exams in Ontario for the fiscal year 2019-2020.
That equates to 1.6 exams per 1,000 population for Ontario’s 20 PET/CTs and 8.0 exams per 1,000 population for Quebec’s 23 devices.
Dr. Francois Lamoureux, a nuclear medicine specialist at Hôpital de Val d’Or and president of the Canadian Association of Nuclear Medicine, attributes Quebec’s leadership in PET/CT accessibility to a long-running education campaign to educate specialists, general practitioners, healthcare administrators and the general public about the value of PET technology.
Whole body PET scans show abnormal metabolic activity at the molecular level using an injected radioactive sugar solution that “lights up” fast-growing lesions, while CT scans show physical structures using X-rays, allowing for precise localization.
PET technology has come a long way in recent years, said Dr. Lamoureux.
“Ten years ago, when we started talking about using more PET technology clinically, there were many drawbacks. It was difficult to have the tracers and the ones we were using were very limited. You needed a cyclotron that cost $15 million and specialized staff. Now we have much less expensive radionuclide generators to produce tracers.”
Using PET/CT imaging, “you can change the therapeutic approach for patients in 30 to 40 percent of cases,” claims Dr. Lamoureux,
Using a CT or X-ray imaging alone, there’s no way of knowing if a pulmonary lesion or nodule, for example, is benign, requiring in some cases a very invasive biopsy, he explained.
However, if a PET scan is performed and there is no uptake of the tracer, the patient will be deemed to have a benign lesion, and no further investigation is required. “If there is an uptake – because it’s a whole body investigation – you are able to see not only the primary lesion, but also the metastases that could exist elsewhere.”
With the Discovery MI PET/CT at Val d’Or, said Dr. Lamoureux, “we are able to detect lesions as small as four millimetres. To see a lesion using a CT, it has to be about one centimetre.”
PET/CTs can also be used to assess how a lesion is responding to chemotherapy.
“Suppose you are prescribed six rounds of chemo. It’s very expensive and very hard on the patient, but if you do another PET study after the first treatment and find there is no more lesion, you can stop the treatment,” he said.
That’s what happened with Montreal Canadiens captain Saku Koivu, who was diagnosed with non-Hodgkin’s lymphoma in September 2001. A PET scan performed in Sherbrooke prior to the conclusion of the prescribed course of chemotherapy pronounced him cured, allowing him to return to the ice the following April.
Having to endure more chemo than necessary, said Dr. Lamoureux, “is almost unethical.”
“The technology has evolved so rapidly that we can now use it to diagnose cardiac and neurodegenerative diseases like Alzheimer’s, Parkinson’s and vascular dementia (in addition to cancer),” he noted.
“In Canada, neurodegenerative diseases cost us $33 billion per year, so you can see the importance of making the right diagnosis. With PET imaging, you can distinguish between different neurodegenerative diseases and offer the appropriate treatment.”
According to Dr. Lamoureux, the Montreal Heart Institute performs 60 PET/CT cardiac studies per week, but because of the shortage of PET imaging availability in the other nine provinces, studies are mostly limited to oncology.
The CADTH’s 2020 Canadian Medical Imaging Inventory reveals up to 11.8 percent of the 128,121 PET studies performed in Canada during the most recent fiscal year (or for 2018-2019 in Quebec) were for cardiology cases and only up to 5.7 percent were for neurological investigations.
“The other nine provinces are 10 years behind the rest of the world in PET use,” said Dr. Lamoureux. “I think the general public should be aware of that because in many situations, patients aren’t being offered the appropriate investigation.
“The situation in the rest of Canada is completely unacceptable. The technology is there. The specialists are there, and it’s no longer an expensive tool. Every nuclear medicine centre should have a SPECT/CT and a PET/CT. It should be the same for all of Canada.”
Dr. Lamoureux also disagrees with the policy in Ontario and other provinces of relying on local fundraising to cover the cost of PET/CTs.
“I’m completely against that,” he complained. “Doctors are like soldiers. We’re fighting disease. We don’t rely on local fundraising to buy tanks for the military.”
Reliance on local fundraising also discriminates against smaller, remote centres of population like Val d’Or that don’t have the ability to raise large sums of money.
“Radiotherapy for six weeks costs $30,000,” he said. “It’s expensive and time-consuming, and it’s a very local treatment. If you give chemo to a patient who doesn’t need it or you do extensive surgery on a patient and it’s not the right treatment, it’s very expensive.”
PET imaging, he claims, can save money and result in better patient outcomes.
Until now, Abitibi-Temiscamingue patients prescribed a PET/CT scan had to travel to Montreal or Gatineau, but 60 percent of them declined the opportunity because of the cost, the time required, the distance and the danger of traveling by car – especially in winter, said Dr. Lamoureux.
The recent acquisition of PET/CTs in Val d’Or, Sudbury and Kelowna will allow patients to remain close to home and to take advantage of the same advanced imaging modalities available to patients in larger communities.