Team shot of people in masks
The IMBRASE Program is helping cancer patients avoid the need for urgent care or hospital visits by proactively monitoring their symptoms. (L to R) Dr. Luisa Bonilla, Dr. Marcus Butler, Simonne Simon, Nancy Gregorio, Dr. David Hogg, Michelle Mackay, Dr. Keith Stewart, Dr. Sam Saibil, Alyssa Macedo, Dr. Lesley Moody. (Photo: UHN)

A specialized interprofessional clinical program at Princess Margaret Cancer Centre is helping cancer patients on immunotherapy avoid side effects that could impact their treatment plan or lead to urgent hospital visits.

The Immune and Molecular Therapy Bolstering and Supporting Patient Adverse Events (IMBRASE) Program facilitates proactive symptom assessment and management for melanoma patients receiving immunotherapy treatment.

Immunotherapy is a rapidly advancing field in cancer treatment and teams have to adjust rapidly alongside it.

Compared to chemotherapy, immunotherapy is more idiosyncratic – with side effects occurring differently for different people and sometimes starting out very subtly.

This makes it challenging for patients to know when they should tell their care team about their symptoms, and for staff in knowing what they should look out for and when.

"Patients are hesitant to tell us about initial symptoms that may seem minor, like little rashes or loose bowel movements," says Dr. Marcus Butler, medical oncologist and Clinical Head of the Immune Profiling Team at the Princess Margaret. "These side effects seem insignificant at first, but minor things left unmonitored could lead to bigger problems."

Addressing the gap in care

If left unchecked, these minor symptoms could mean urgent clinic or Emergency Department (ED) visits, and could even interfere with treatment plans.

A need emerged to address the gap in care to support patients and nurses in helping identifying symptoms or side effects early, before they cause trouble.

Nancy Gregorio, Registered Nurse in Princess Margaret's Melanoma Clinic, stepped up through UHN's CAP (collaborative academic practice) Fellowship Program to develop IMBRASE: a remote, cost-effective and proactive approach to ensure patient safety and support during treatment, while bolstering confidence and education for nurses.

Buy-in from the team was widespread.

"Everyone was incredibly motivated to prevent any challenging situations for our patients," says Nancy. "There was a consensus that a gap existed in this part of the patient journey and everyone wanted to bridge the gap."

The project started with a process mapping exercise and after more than six months of teamwork evolved into a robust remote assessment tool that allows the team to:

  • Identify if a patient is at high risk of developing side effects, informed by their unique treatment plan
  • Schedule regular phone-calls between patients and specialized oncology nurses to check in and talk about any new or worsening symptoms
  • Monitor symptoms to ensure safe, proactive and responsive intervention if needed
  • Schedule patients to come in and see their physician if symptoms start to become worrisome or direct patients to the most appropriate care setting for symptom management
Nancy at the board with sticky notes
In a photo shot before the COVID-19 pandemic was declared, RN Nancy Gregorio, the Program Lead, takes the team through a process mapping exercise to identify the gap in care. (Photo: Courtesy of Nancy Gregorio)

After IMBRASE was implemented, more than 80 per cent of patients received proactive phone calls to check in about their symptoms, and the rate of ED visits for high-risk patients reduced significantly.

"Our patients feel more supported and we have the opportunity to identify problems before they occur," says Dr. Butler. "We're also able to have a better understanding of how quickly a side effect develops, which expands our knowledge and helps us respond appropriately."

The program was so successful it was awarded the 2020 Quality Award from the Cancer Quality Council of Ontario (Ontario Health), making this the third consecutive year the Princess Margaret has been one of two awarded across the province for either quality or innovation.

"It's an honour to be recognized amongst our colleagues across the province," says Michelle Mackay, Nurse Manager, Solid Tumor Oncology Ambulatory and Urgent Care at the cancer centre.

"What's particularly exciting is that this is a cost-effective program that could be applied to different cancer centres and disease sites. It could benefit many, not just a few." 

Throughout implementation, the incredible teamwork from the melanoma team stands out for Nancy.

"We worked well as a team even before this," she says. "But now, with COVID and increasing virtual care, we work even better. We support each other, step in when needed, and we've rallied around our goal to close this gap.

"We should be proud of how far we've come."

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