Strategies to prevent and treat chronic pain complaints in breast cancer survivors: A realist impact evaluation of an intervention aimed at integrated follow-up care.
Authors: Slaghmuylder Yaël , Pype Peter , Lauwerier Emelien 
Published: January 2024

Background: Although many breast cancer survivors experience persisting pain complaints with a negative impact on their quality of life, there are no guidelines in place for breast cancer follow-up care with regard to long-lasting complaints such as pain.

Objective: Both prevention and adequate pain treatment are important in reducing the burden for the individual as well as for society (e.g. on a social, health, and financial level). When addressing the prevention and treatment of chronic pain, change at various levels such as the level of patients, healthcare providers, and at the context level is essential. In co-design with relevant stakeholders, an intervention aimed at integrated care for breast cancer survivors with pain complaints is developed and implemented in practice. With this study, we want to gain insight into the implementation process and underlying mechanisms of the intervention through a realist impact evaluation. As such, we do not only intend to answer the question ‘What works?’, but also ‘How does the intervention work, why, in which contexts, and for whom?’.

Methods: The intervention consists of two components. First, an interdisciplinary e-learning training is rolled out, aimed at changing healthcare providers’ knowledge, beliefs, and interprofessional behaviour regarding pain prevention and treatment. Second, two guides are implemented: one to empower patients and normalize talking about pain, and a second guide to raise awareness regarding existing pain interventions and stimulate referral to other disciplines. A mixed-methods pre- and post-test design is used to evaluate the intervention. Healthcare providers as well as breast cancer survivors are questioned by means of online questionnaires at three different time points and individual semi-structured interviews.

Results: The evaluation of the intervention components is currently ongoing and will be finished in March 2023. An important element of a realist impact evaluation is the development and investigation of a program theory. This theory is based on configurations between context, mechanisms, and outcomes. A context-mechanisms-outcomes hypothesis will be presented with context representing circumstances under which the intervention works, mechanisms explaining how the intervention contributes to benefits, and outcomes describing the intended consequences of the intervention. Furthermore, the possible barriers to adoption and sustainable implementation will be discussed. 

Conclusions: Based on the context-mechanisms-outcomes hypothesis, the intervention design and evaluation can be further optimized, and eventually a scale-up can be prepared. Additionally, in a realist impact evaluation the context in which the intervention is implemented is not considered an independent variable, but an interactive element. As such, the developed intervention can be adapted according to the target population and context, and used for other cancer patients.