La tomographie par émission de positons au Canada

Context

Positron emission tomography (PET) is a nuclear medical imaging tool. PET scanners require a cyclotron or a positron-emitting generator to manufacture the isotopes used in PET scans.¹ PET represents a nuclear imaging alternative to single-photon emission computed tomography, or SPECT.¹ Both technologies provide images of the structure and function of tissues and organs.

The majority of the latest generation PET scanners are combined with a computed tomography (CT) or magnetic resonance imaging (MRI) component, which allows for minimization of patient-motion between functional (PET) and anatomic (CT) imaging.² Hybrid PET/MRI scanners provide additional detail on soft-tissues and may be more clinically relevant for head and neck cancers, and neoplasms in the pelvis and abdomen.³ Because of its lower ionizing radiation dose, in comparison to PET/CT, PET/MRI may also be useful for pediatric patients and for pregnant women.³ Both PET/CT and PET/MRI availability in Canada is mostly limited to facilities in large urban centres.¹ This Environmental Scan uses the term PET to refer to all PET modalities, including PET/CT and PET/MRI, unless otherwise specified.

The 2007 and 2009 shortages of technetium-99m (99mTc) — the medical isotope used in single- photon emission CT scans — mobilized the medical community to look for alternative imaging techniques.⁴ More recently, it was announced that the National Research Universal reactor in Chalk River, which produces medical isotopes, will stop production in 2018.⁵ In 2009, the Government of Canada appointed an independent Expert Review Panel on Medical Isotope Production to assess more reliable ways of supplying isotopes. Among its recommendations, the Panel suggested that the government invest in PET to reduce the demand for 99mTc over the short- and long-term.⁴ The government responded by confirming its support to the continued diversification of advanced medical imaging technologies, including PET.⁶ This report provides an update on the availability of PET scanning services in Canada.

Objectives

This Environmental Scan is an update to two previous CADTH reports from 2010⁷ and 2011.⁸ The objective of this report is to identify and summarize information regarding the use of PET across Canada. The following questions are addressed:

1. How many publicly and privately funded PET scanners and cyclotrons are there in each Canadian jurisdiction?
2. How many PET scans are funded annually in each jurisdiction?
3. What are the approved publicly funded indications for PET in each jurisdiction?

Methods

The findings of this report are based on responses to the CADTH Positron Emission Tomography in Canada 2015 survey. Survey respondents were asked to update and complete data tables from the 2011⁸ (Table 1) and 2010⁷ (Table 2) reports according to their jurisdiction. The survey was sent to key informants from organizations and health authorities specializing in medical imaging in jurisdictions across Canada. Survey data were gathered until September 16, 2015. In addition, a limited search of the grey literature was performed as of July 28, 2015.

Findings

Surveys were distributed to contacts in all 10 provinces. There are no PET scanners in the territories, thus surveys were not sent to these jurisdictions. Survey responses were received from informants in Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario, Prince Edward Island, and Saskatchewan (one response per province) (Appendix 1).

Number of Funded Annual Scans

As at September 2015, there are 45 publicly funded PET scanners in Canada, operational in 34 centres (see Table 1). This includes 39 PET/CT, four PET, and two PET/MRI scanners. Two of these scanners are located in British Columbia, four in Alberta, one in Saskatchewan, one in Manitoba, 16 in Ontario, two in New Brunswick, and one in Nova Scotia. Newfoundland and Labrador anticipates a PET/CT scanner to be operational in 2016. Based on data from the 2011 report,⁸ there are 18 PET scanners in Quebec. Since the 2011 report,⁸ PET scanning and cyclotron capacity in Canada has generally increased (Table 1). In Canada, 62,668 PET scans were performed in 2011-2012, and more than 98% of these were conducted in hospital settings.⁹

According to the respondent from British Columbia, the province has two PET scanners located at the BC Cancer Agency’s Vancouver Centre. There are two cyclotrons in operation: one used principally for research at the University of British Columbia, the other at the BC Cancer Agency used for both research and clinical purposes. The province of British Columbia is funded to perform 7,775 PET/CT scans per year.

Alberta has four PET/CT scanners located in three facilities: two facilities in Edmonton and one facility in Calgary. The Cross Cancer Institute in Edmonton has a cyclotron in addition to a PET/CT scanner. In 2014-2015, the province funded 9,919 PET scans. According to the respondent, more than 10,000 scans are projected for 2015-2016.

Saskatchewan has one PET/CT scanner located in Saskatoon, and one cyclotron will be tentatively operational in 2016. The number of publicly funded annual scans is unknown.

Manitoba has one PET/CT scanner and one cyclotron located in Winnipeg. According to the Manitoba respondent, the province funds 2,000 scans per year.

Ontario has 16 PET scanners at 10 centres:

• one stand-alone PET scanner and one PET/CT scanner in Hamilton
• three PET/CT scanners in Ottawa
• one stand-alone PET scanner, six PET/CT scanners, and one PET/MRI scanner in Toronto
• one PET/CT scanner and one PET/MRI scanner in London
• one PET/CT scanner in Thunder Bay.

The Royal Ottawa Mental Health Centre is also anticipating the addition of one PET/MRI scanner to be used for research purposes, only. Ontario is home to eight cyclotrons: one in Hamilton, one in Ottawa, four in Toronto, one in London, and one in Thunder Bay. According to the survey respondent, Ontario funded 11,081 PET scans in 2014.

Quebec has 14 PET scanners at 11 major hospitals, with the remaining 4 PET/CT scanners at smaller centres. Two stand- alone PET scanners and eight PET/CT scanners are located in Montreal. There is one PET/CT scanner in each of the following cities: Quebec City, Gatineau, Laval, Trois-Rivières, Rimouski, and Chicoutimi. Two PET/CT scanners are located in Sherbrooke. There are two cyclotrons in Quebec, one in Montreal, and one in Sherbrooke. One PET/CT is anticipated to be operational in 2017 in Lévis. In 2009, Quebec funded approximately 22,400 scans.²

There are two PET/CT scanners in New Brunswick: one is located in Saint John and one is located in Moncton. Approximately 1,340 scans were funded in New Brunswick in 2014-2015 according to the respondent from this province.
According to the survey response, Newfoundland and Labrador are planning to have an operational cyclotron and PET/CT scanner in 2016. In 2009, there were approximately 100 scans funded; patients were sent out-of-province for PET scans.²
Nova Scotia has one cyclotron and one PET/CT scanner located in Halifax. In 2009, there were approximately 1,600 scans funded at the facility in Halifax, and approximately 1,500 were funded by Nova Scotia, as a small number of these patients were from out of the province.²

Prince Edward Island currently does not have PET scanners or a cyclotron. In 2014-2015, 104 patients were sent out of the province to have scans, according to the respondent from Prince Edward Island. The Northwest Territories, Nunavut, and the Yukon do not have PET scanners; patients must be sent out of territory to have scans.⁷

Table 1: Location of Publicly Funded PET Scanners and Cyclotrons in Canada (2015)

CT = computed tomography; 18F = fluoride-18 isotope; MRI = magnetic resonance imaging; PET = positron emission tomography;
QE = Queen Elizabeth; TRIUMF = Canada’s National Laboratory for Particle and Nuclear Physics; UBC = University of British Columbia.

Privately Funded PET Scanning Services

According to the surveys and published information,² there are seven privately funded PET scanning facilities in addition to the 45 publicly funded PET scanners in Canada. British Columbia has one privately funded PET/CT scanner located in Burnaby.² In Ontario, three scanners are located in private facilities: Mississauga has two PET/CT scanners and Windsor has one PET/CT scanner. Patients requiring a PET scan in Ontario through the publicly funded system may be referred to one of these private facilities. There are three facilities with privately funded PET scanners in Quebec: Montreal has one stand-alone PET scanner and one PET/CT scanner, and Quebec City has one PET/CT scanner.²

Publicly Funded Indications for PET Scanners

A primary indication for publicly funded PET scanning services is oncology, where PET scanning can be used for diagnosis, staging, and detection of disease.2 Oncology indications include lung, breast, solitary pulmonary nodule, head and neck, and esophageal cancers. PET scanners are also used for cardiac imaging (such as myocardial viability assessment) and neurological imaging (such as in patients with dementia). In Alberta, PET scanners can also be used in cases of infection or inflammation. Additionally, each jurisdiction may have specific requirements for each approved indication for PET scans, such as in Ontario10 and Quebec.7 Table 2 provides detailed information on the publicly funded indications for PET scanning in each jurisdiction.

Conclusion

There are approximately 34 centres performing publicly funded PET scans in eight Canadian provinces. There are 45 publicly funded PET scanners currently in operation in Canada. Additionally, seven facilities perform privately funded PET scans in Canada, three of which are in the province of Quebec, three in Ontario, and one in British Columbia. In Canada, 62,668 PET scans were performed in 2011-2012, and more than 98% of these were conducted in hospital settings.⁹ The most popular application of PET across Canada is for oncology, and it is also used for cardiac and neurological imaging.