An important new scientific review of lymphatic microsurgery from Quebec.

OnJuly 12th, 2022, the Quebec “Institut national d’excellence en santé et en services sociaux (INESSS)”, published a report entitled “Use of microsurgery for the prevention and treatment of cancer-related lymphedema.”

This study, mandated by the Quebec Ministry of Health, involved a systematic review of the literature and on the last four years of experience of lymphatic surgeries in the province.

The programs for lymphatic surgeries are in their infancy in Quebec, as they started to be offered only in 2018. At the moment, two health care facilities are offering microsurgeries for the treatment of lymphedema of any etiology, and a third one will be offering soon. Those three centers are all located in Montreal.

The INESSS report is a thorough evaluation of the literature. Their mandate was to evaluate the clinical relevance of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), both in prevention (the procedure is called LYMPHA) and in treatment of cancer-related lymphedema. With this report, the INESSS is providing recommendations regarding the organization of lymphatic surgery services in the province of Quebec. The full report and summary are available at: Avis - Utilisation des microchirurgies pour la prévention et le traitement du lymphœdème lié au cancer

An important new scientific review of lymphatic microsurgery from Quebec

By Marie-Eve Letellier

(inesss.qc.ca). (The full report is available only in French, however a six-page English summary is included).

The document is divided into two main sections: 1) Methodology, and 2) Results. Everything is covered in 267 pages, under five dimensions and 12 specific questions aiming to answer the overarching question of whether preventative lymphatic surgery (LYMPHA) and/or LVA and/or VNLT should be offered in Quebec’s health care facilities, and if so, which modalities and for which target patients. Their original work was searching for evidence for all cancer-related lymphedema. However, the level of evidence available enabled them to conclude only for breast cancer-related lymphedema (BCRL).

They recognize that actual lymphedema management involves complex decongestive therapy (CDT), which has the capacity of reducing the limb volume without restoring the damaged lymphatic network. They acknowledge that CDT represents a significant burden on the patient: limited access, psychosocial issues, financial and time investment, and compliance to daily care (e.g. compression, exercises).

On the other hand, the rationale behind offering lymphatic surgery is that it could restore the damaged lymphatic vessels,

Marie-Eve Letellier, PhD, is a kinesiologist, a lymphedema therapist (Vodder) and an aqualymphatic therapy instructor (Tidhar). She is a clinician-researcher working in a hospital setting and she also has a private practice. She is a theory lymphedema instructor for the Vodder School International.

which could ultimately reduce the burden of lymphedema. Their cost analysis estimated that LYMPHA surgery would involve a total cost of $5,149 per patient to the Quebec hospital system, whereas LVA would cost $9,956 and VLNT $15,745. From expert opinion, they assume that approximately 25% of people with lymphedema could be candidates for microsurgery. Lymphatic surgeries could ultimately require a budget commitment between $1.4 million and $3.8 million annually. However, for example, this budget does not take into account the possible reduced costs related to less cellulitis hospitalization and/or wound care related to lymphedema.

The INESSS summarizes their position and recommendations as follows: Considering:

4 The important health needs of people with lymphedema related to all types of cancer in Quebec;

4 The promise of microsurgeries for the prevention and treatment of lymphedema related specifically to breast cancer, although the evidence currently available does not allow concluding with certainty as to the clinical benefit of these microsurgeries compared to complex decongestive therapy;

4 The limited service offer already in place in some centres in Quebec and the quality of clinical studies currently underway that will complete the level of scientific evidence. INESSS supports the development of therapeutic microsurgeries, i.e. lymphaticovenous anastomosis and vascularized lymph node transfer, for the treatment of lymphedema specifically related to breast cancer.

Considering:

4 the presence of significant organizational issues, the difficulty in targeting patients who might benefit from preventive microsurgery, and the anticipated decrease in need over time.

INESSS does not support the development of a systematized and expanded practice of LYMPHA for the prevention of breast cancerrelated lymphedema.”

This report proposes priorities and future directions for development that could be an important game changer and/or impact strategic planning for lymphedema programs, such as:

– To evaluate the long-term effectiveness of CDT;

– To develop and disseminate information and teaching tools related to lymphedema and its management;

– To educate health care professionals regarding risk reduction strategies regarding lymphedema;

– To advocate for early detection of lymphedema following oncology surgery.

The INESSS report seems to be well received by the lymphedema community in Quebec. Programs will get organized to offer LVA and/ or VLNT to BCRL in specific health care facilities under specific candidate selection and pre/post-op care. Patients can be reassured that, regardless of the actual INESSS recommendations, Quebec surgeons will continue to advocate for preventative lymphatic surgeries and to offer LVA and/or VLNT to those with other lymphedema etiologies.

In the Pathways Fall 2021 edition, I had the opportunity to write the article “Overview of Lymphatic Surgeries” where I ended saying: “To conclude on a more serious note, lymphatic surgeries are not a cure and should not be seen as a “quick fix.” They are a “no go” if the person is not a good candidate. Finally, they may potentially help patients who are already compliant with conventional therapies, have plateaued, have recurrent episodes of cellulitis, and/or want to obtain further improvement through lymphatic surgery. A full multidisciplinary team should be involved to work hand-in-

hand, in a patient-centered approach.”

Now a year later, having read the INESSS report, I would conclude that progress is made toward a better management of cancer-related lymphedema. As the INESSS report states, a collaborative effort needs to be put in place in order to be successful. As of now, it is BCRL that is considered. Knowledge will be gained through further research, and ultimately this information will hopefully be able to benefit patients with all lymphedema etiologies.

Let’s all collaborate and work hand-in-hand with each other! The future for lymphedema management seems promising. LP

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