The Missing Element

Every day, U.S. doctors perform more than 50,000 state-of-the-art procedures using a radioactive isotope called technetium-99. Injecting technetium into a patient allows doctors to monitor the blood supply to the heart, look at cardiac function in chemotherapy patients, see whether certain cancers have spread to a patient’s bones, or monitor a tumor during breast cancer surgery.

Most patients take for granted their ability to undergo these procedures. But they might be surprised to learn that nuclear medicine in the United States is dependent on one 52-year-old, leak-prone nuclear reactor that is currently offline, should have been shut down for safety reasons a decade ago, and moreover, undermines international nuclear nonproliferation goals.

How did we get into this predicament? In short: Blame Canada.

The National Research Universal (NRU) reactor in Chalk River, Ontario, supplies about one-third of the world’s supply and about half of the U.S. supply of the molybdenum isotope that decays to form technetium. The reactor, built in 1957, is operated by the government-owned company Atomic Energy of Canada Limited. The reactor was first shut down for safety only a year after it opened, when a nuclear fuel rod caught fire, and it has suffered sporadic accidents and outages ever since. In 2007, after the reactor was shut down for a safety upgrade, the Canadian government, due to fears of an isotope shortage, ordered it open again over the objections of the Canadian Nuclear Safety Commission.

Canada’s Natural Resources Ministry, which oversees the nuclear power industry, never intended for the NRU reactor to still be operating. Construction of two new reactors, known as MAPLE 1 and 2, began in 1996 after it became clear the NRU reactor was nearing the end of its useful life. The MAPLES were supposed to have become operational in 2000, but after numerous construction delays and unresolved safety issues and hundreds of millions of dollars spent, they were finally scuttled by Prime Minister Stephen Harper’s government in 2006.

So the NRU reactor was left to sputter on alone, without backup. This May, the inevitable happened: A leak of radioactive water was detected at the facility, and it was again shut down.

The government’s handling of the isotope debacle has been a front-page political story in Canada, particularly after Natural Resources Minister Lisa Raitt was caught on tape describing it as a "sexy" issue that she wanted to resolve to further her political career. Raitt later issued a tearful public apology to cancer patients.

Because disruptions to medical care have been minor in the United States so far, the issue hasn’t garnered much attention below the border. But that could change in March. Since the NRU reactor went down, a Dutch reactor in Petten has been picking up the technetium slack, along with smaller reactors in Belgium, France, and South Africa. But starting in late March, Petten, itself a 48-year-old dinosaur plagued by technical glitches, will be off-line for scheduled maintenance.

The Canadian Natural Resources Ministry expects the NRU reactor "will return to service in the first quarter of 2010," according to spokesperson Micheline Joanisse. But that date has already been pushed back several times. And even if the reactor does go back online in 2010, it’s unclear how much longer it can stay operational. The University of Texas at Austin’s Alan Kuperman, a former senior policy analyst for the Nuclear Control Institute, notes the fragility of the situation. "Even if the Canadian reactor comes back online, we’re only going to be one blip from a major supply crisis," he says.

This would be a serious blow to hospitals and cancer patients in the United States and abroad. "If the Canadian reactor isn’t up and running, we’re going to really be struggling come April," says Robert Atcher, director of the National Isotope Data Center and former president of the Society of Nuclear Medicine, who thinks that current technetium supplies are enough for only about two-thirds of global demand. Depending on how long the United States goes without a reliable supply of technetium, the effect could be anything from a minor irritation to a major catastrophe. In Canadian hospitals, which were almost entirely dependent on domestic technetium supplies and are already feeling the pinch, some nuclear-medicine practitioners report canceling the majority of their diagnostics, and tests for heart damage and the spread of cancers have been delayed for weeks, with untold financial and health costs.

Giuseppe Esposito, director of nuclear medicine at Georgetown University Hospital, says that his department hasn’t felt the effects of the shortage yet, but that a more permanent disruption would make many of his regular procedures impossible to carry out. "For lung and bone imaging, there really are no substitutes [to technetium]," he says.

You might think that, given the relatively small number of suppliers, the United States, which accounts for about 50 percent of global demand for technetium, would have wanted to develop its own supply. And indeed, there were plans to build a reactor for medical use in New Mexico in the mid-1990s. But the project was abandoned after Canadian authorities made what Atcher describes as a "compelling case" that the ill-fated MAPLE facility would meet international demand.

Joanisse denies that the Canadian government misrepresented the state’s production capabilities to its customers. "All along, our message to the international community has been simple," she said via e-mail. "We rely on ageing reactors and a fragile supply chain. There is a collective responsibility to bring forward additional sources of supply and to manage available supplies responsibly, particularly in periods of shortage."

But given the costs of building a nuclear reactor, governments, including the U.S. government, were all too happy to let Canada shoulder the burden. "No one wants to spend the money and political capital to build a new reactor these days," says Edwin Lyman, senior scientist at the Union of Concerned Scientists’ global security program. "Everyone put their eggs in the Canadian basket."

Faced with the possibility of a technetium shortage within coming years or even months, the U.S. government is finally taking action. A bill passed in the House of Representatives and under consideration in the Senate would allocate $163 million to investigate new methods for producing medical isotopes. Although this money probably isn’t enough to build even a single reactor, it’s the first step the United States has taken in years to developing isotope independence. A research reactor in Missouri is also being converted to produce isotopes, though Lyman notes that even under the best conditions, "there won’t be a stable substitute … for at least three years."

Most importantly, the proposed legislation would also specify how medical isotopes are made. Both the Canadian and Dutch reactors produce technetium from bomb-grade highly enriched uranium, a situation that keeps nonproliferation experts up at night.

"The Canadian government always gets up and says, ‘We’re a leader on nonproliferation,’" U.T. Austin’s Kuperman says. "But they’re also the country in the world using the largest amount of bomb-grade uranium for civilian purposes. You can’t have it both ways."

Under the proposed legislation, all suppliers to the U.S. market would be required to use safer, though slightly more expensive, low-enriched uranium. An expert panel convened by Canada’s Natural Resource Ministry recommended last week that the country switch entirely to low-enriched uranium, though in the short term highly-enriched will continue to be used at the NRU reactor.

In any event, Canada’s days as a leader in medical isotopes seem to be over. The Natural Resource Ministry’s panel recommended the construction of a brand-new multipurpose research reactor, though given the emergency measures that other countries are taking — the Netherlands and Australia are also looking to boost their production capacity — it’s not clear that there will still be a market by the time it is completed.

In June, Harper said, "Eventually, we anticipate Canada will be out of the business" of producing medical isotopes — a realization that patients around the world might have wished for a decade ago.