The cancer sufferer was told they needed a PET-CT scan of their stage 3 melanoma. File photo. Photo: 123rf.com
An Auckland cancer patient was forced to go to Australia for an urgent scan, because New Zealand's only producer of radioactive medical material had shut down for two weeks.
The man's whānau is asking why New Zealand has such a fragile cancer care system, and why the trip was necessary when the cyclotron in Wellington could make 10 times more of the radio isotopes than it currently does.
The cancer sufferer - who RNZ will not identify - was told just before Christmas they needed a PET-CT scan of their stage 3 melanoma.
But maintenance at the cyclotron, run by Cyclotek NZ in Rongotai, meant no fresh isotopes - made daily - were on hand and the earliest scan would be 12 January.
"Even urgent PET-CT couldn't be done," his wife told RNZ.
"Until you're personally affected by this, you can't understand how hard it is.
"And it was really hard for us - and also knowing that we were then going to have to go through Christmas and New Year, on tenterhooks wondering if he had metastatic cancer," she said.
They quickly booked a scan in Sydney, flew over, and then back with the results already in hand - and at a cost for the scan of just $750, compared to $2500-$3500 here.
"That raises another question for me is, you know, exactly why is it that the cost of a private PET-CT in New Zealand and other case CT scans, why are they so high compared to Australia?"
PET-CT is used heavily in Australia, but its use here has been growing only slowly for a decade, constrained partly by lack of public funding. PET scans here are a bit more comprehensive than across the Tasman.
One consequence of this is that demand has allowed for just one manufacturing cyclotron, and it has to shut down for maintenance for two weeks a year.
Scanning providers also struggle when air flights with isotopes on board are delayed or cancelled out of Wellington airport - with the isotopes rapidly decaying, losing half their radioactivity every two hours.
"Everything has to work like a well-oiled military machine for us to get the stuff in time and scan our patients," said Dr Remy Lim, medical director of Mercy Radiology.
When Covid disrupted flights, Mercy was only able to scan half its usual number of patients.
Many hospitals in major cities around the world operate cyclotrons in the basement. "They just have to transport it up the lift," said Lim, but "we rely on multiple logistical factors to work in our favour".
"So, the flight from Air New Zealand, for example, landing on time, the courier company from the airport ... [if not] we have patients come from overseas or out of the region, they have to have their scans deferred or cancelled".
The tenuous supply chain persists because manufacturer Cyclotek NZ found it was easier to build a cyclotron in Wellington than Auckland a decade ago, and because of the regular lack of demand.
But the company bent over backwards to keep isotope supplies going, said Dr Trevor FitzJohn, chair of Cyclotek NZ, even to rival scanning services - Cyclotek is a joint venture involving Pacific Radiology.
"They start working at about 2am to get the product out the door at about 7.30 to catch flights," he told RNZ.
Australia has many more cyclotrons, many more PET scanners and far more publicly funded scans per capita. There are no scanning machines in public hospitals here - all seven in the country are privately owned.
Astra Radiology lead radiologist Dr David Rogers said successive governments had shied away from big investment or encouragement of PET scanning.
"It had a slow start because the Department [ministry] of Health had a plan to sort of reduce uptake a little," Rogers said..
"As a consequence, there is only one cyclotron in New Zealand, because there was no room for a second one."
The upshot is high costs. FitzJohn said on average isotopes cost twice what they did in Australia - even though margins were the same.
"At the moment it's quite expensive, because the volume is low. But if you increase the volume, the cost per scan goes down," said FitzJohn.
On the flip-side, local doctors must order 2-3 times more isotopes just to make sure they have enough if some decays.
The cancer patient's wife said she did find it surprising that there was only one supplier.
"Surely this poses questions around risk of supply disruption, and potentially has an implication for the cost of imaging procedures as it is a monopoly situation."
FitzJohn said it was not that simple - the Wellington cyclotron could make 10 times more material to "supply all of NZ's need for years to come. But with a small volume of scans, that has price implications", plus not all providers keyed into the long-term discounts on offer.
However, there are strong signs of change.
Cyclotek plans to open a new cyclotron in Auckland in a year - even though that will dilute demand.
"We expect to be making a loss for the first three years," FitzJohn said.
A second cyclotron for Auckland, in a joint venture between Mercy and Australian firm Cyclowest, is about two years away.
All the private players are betting on demand for PET scanning growing strongly from here on.
They are doubling down by almost doubling scanner numbers to more than a dozen, including outside the main centres, in Northland, Manawatu, Hawkes Bay, Tauranga and Dunedin.
Rogers is among those playing catch-up.
"The future is another cyclotron in Auckland, and the future is lower prices for FDG [isotopes]," he said.
Cyclowest said it has settled on a site and was working with Auckland Council on consents.
Longer-term Te Whatu Ora contracts would be a big boost to PET.
Health NZ Te Whatu Ora said it was intent on securing access to the advanced scans across all parts of the country.
New national criteria for getting a scan had been developed with expert input and was expected to be in place by the end of next month.
"Whether Te Whatu Ora purchases from the private sector for emerging technologies like this, or develops its own capacity, is something that is continually reviewed in the context of price and the funding available," it said on Wednesday.
"Being a single national health agency does also provide Te Whatu Ora with opportunities to explore the most cost-effective way of providing equitable and timely access to PET-CT scans."