Heterogeneous impacts: adverse childhood experiences and cancer screening

Association between adverse childhood experiences and health related quality of life in adult cancer survivors in the United States

PURPOSE

The impact of adverse childhood experiences (ACEs) on health-related quality of life (HRQOL) is increasingly recognized, however, this has not been studied in cancer survivors in the United States. This study investigates if ACEs are associated with HRQOL in cancer survivors.

METHODS

We conducted a cross-sectional analysis of the 2020 Behavioral Risk Factor Surveillance System from states that administered ACEs and Cancer Survivorship modules. Eligibility criteria included being a cancer survivor and not currently receiving cancer treatment. Primary exposure was number of ACEs (categorized as 0, 1-2, 3, or ≥ 4). Primary outcomes were self-reported measures of HRQOL including worse overall health and ≥ 14 unhealthy days (mentally or physically) per month. Mantel-Haenszel stratified analyses were performed and prevalence ratios were adjusted for age.

RESULTS

Of 5,780 participants, 62.0% were female and 67.8% were ≥ 65 years. Prevalence of worse overall health was 22.5% for individuals with no ACEs compared to 30.2% for 2-3 ACEs (aPR = 1.4, 95% CI 1.2, 1.5) and 38.5% for ≥ 4 ACEs (aPR = 1.7, 95% CI 1.5, 2.0). Prevalence of ≥ 14 unhealthy days was 18.1% with no ACEs compared to 21.0% for 1 ACE (aPR = 1.3, 95% CI 1, 1.3), 29.0% for 2-3 ACEs (aPR = 1.6, 95% CI 1.4, 1.8), and 44.8% for ≥ 4 ACEs (aPR = 2.2, 95% CI 2.0, 2.5).

CONCLUSIONS

Our study provides novel evidence of the association of multiple ACEs with higher prevalence of poor HRQOL in cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Screening for ACEs is warranted in all patients to guide targeted interventions to improve HRQOL and mitigate the impact of ACEs on HRQoL in cancer survivors.

Examining relationships between adverse childhood experiences and coping during the cost-of-living crisis using a national cross-sectional survey in Wales, UK

OBJECTIVES

Adverse childhood experiences (ACEs) can affect individuals' resilience to stressors and their vulnerability to mental, physical and social harms. This study explored associations between ACEs, financial coping during the cost-of-living crisis and perceived impacts on health and well-being.

DESIGN

National cross-sectional face-to-face survey. Recruitment used a random quota sample of households stratified by health region and deprivation quintile.

SETTING

Households in Wales, UK.

PARTICIPANTS

1880 Welsh residents aged ≥18 years.

MEASURES

Outcome variables were perceived inability to cope financially during the cost-of-living crisis; rising costs of living causing substantial distress and anxiety; and self-reported negative impact of rising costs of living on mental health, physical health, family relationships, local levels of antisocial behaviour and violence, and community support. Nine ACEs were measured retrospectively. Socioeconomic and demographic variables included low household income, economic inactivity, residential deprivation and activity limitation.

RESULTS

The prevalence of all outcomes increased strongly with ACE count. Perceived inability to cope financially during the cost-of-living crisis increased from 14.0% with 0 ACEs to 51.5% with 4+ ACEs. Relationships with ACEs remained after controlling for socioeconomic and demographic factors. Those with 4+ ACEs (vs 0 ACEs) were over three times more likely to perceive they would be unable to cope financially and, correspondingly, almost three times more likely to report substantial distress and anxiety and over three times more likely to report negative impacts on mental health, physical health and family relationships.

CONCLUSIONS

Socioeconomically deprived populations are recognised to be disproportionately impacted by rising costs of living. Our study identifies a history of ACEs as an additional vulnerability that can affect all socioeconomic groups. Definitions of vulnerability during crises and communications with services on who is most likely to be impacted should consider childhood adversity and history of trauma.

A practical guide to the trauma-informed physical examination

ABSTRACT

About two-thirds of patients have a trauma history, such as experiencing abuse or community violence. Clinicians must be knowledgeable about trauma because of its high prevalence and long-lasting effect on patients. The medical encounter can be triggering for patients with a history of trauma, especially when power differentials are intensified, such as during the physical examination. Clinicians can improve the interaction by incorporating simple trauma-informed techniques, such as adjusting communication, positioning, and contact during the physical examination. These modifications foster a sense of patient safety and collaborative decision-making. This article describes the background of trauma-informed care and outlines trauma-informed techniques for physical examinations.

Effects of trauma history on cancer-related screening, diagnosis, and treatment

Trauma has substantial effects on human health and is recognised as a potential barrier to seeking or receiving cancer care. The evidence that exists regarding the effect of trauma on seeking cancer screening, diagnosis, and treatment and the gaps therein can define this emerging research area and guide the development of interventions intended to improve the cancer care continuum for trauma survivors. This Review summarises current literature on the effects of trauma history on screening, diagnosis, and treatment among adult patients at risk for or diagnosed with cancer. We discuss a complex relationship between trauma history and seeking cancer-related services, the nature of which is influenced by the necessity of care, perceived or measured health status, and potential triggers associated with the similarity of cancer care to the original trauma. Collaborative scientific investigations by multidisciplinary teams are needed to generate further clinical evidence and develop mitigation strategies to provide trauma-informed cancer care for this patient population.

Adverse childhood experiences, diabetes and associated conditions, preventive care practices and health care access: A population-based study

Our objective was to examine how Adverse Childhood Experiences (ACEs) are associated with diabetes mellitus, diabetes-related conditions, and preventive care practices. We used data from the Behavioral Risk Factor Surveillance System (BRFSS) 2009-2012, a cross-sectional, population-based survey, to assess ACEs, diabetes, and health care access in 179,375 adults. In those with diabetes (n = 21,007), we assessed the association of ACEs with myocardial infarction, stroke, and five Healthy People 2020 (HP2020) diabetes-related preventive-care objectives (n = 13,152). Healthcare access indicators included lack of a regular health care provider, insurance, and difficulty affording health care. Regression analyses adjusted for age, sex, and race. The adjusted odds ratio (AOR) of diabetes increased in a stepwise fashion by ACE exposure, ranging from 1.2 (95% CI 1.1-1.3) for 1 ACE to 1.7 (95% CI 1.6-1.9) for ≥4 ACEs, versus having no ACEs. In persons with diabetes, those with ≥4 ACEs had an elevated adjusted odds of myocardial infarction (AOR = 1.6, 95% CI 1.2-2.0) and stroke (AOR = 1.8, 95% CI 1.3-2.4), versus having no ACEs. ACEs were also associated with a reduction in the adjusted percent of HP2020 diabetes objectives met: 72.9% (95% CI 71.3-74.5) for those with no ACEs versus only 66.5% (95% CI 63.8-69.3%) for those with ≥4 ACEs (p = 0.0002). Finally, ACEs predicted worse health care access in a stepwise fashion for all indicators. In conclusion, ACEs are associated with greater prevalence of diabetes and associated disease conditions, and with meeting fewer HP2020 prevention goals. Implementing ACE screening and trauma-informed health care practices are thus recommended.

Treatment Adherence in Adolescents With Histories of Adverse Childhood Experiences: A Systematic Review

Adverse childhood experiences (ACEs) are associated with poor treatment adherence and worse health outcomes among adults, but evidence among adolescents is less clear. The current systematic review identified and synthesized results from studies examining associations between ACEs and treatment adherence among adolescents. An expert medical librarian conducted searches in seven databases. Results were analyzed using a narrative synthesis framework. A total of six studies were eligible for review. Assessment strategies for ACEs and treatment adherence varied across studies. Most studies assessed for histories of maltreatment and neglect. Treatment adherence was most often defined as some form of attendance in a treatment program. Results support a relationship between ACEs and treatment nonadherence in adolescents. ACEs related to maltreatment, particularly emotional abuse, may be more predictive of treatment nonadherence than other types of ACEs. Specific qualities of ACEs (e.g., timing, intensity, frequency) may influence the relationship between ACEs and treatment nonadherence. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Sexual Assault and Cancer Screening Among Men and Women

Emerging research has shown that experiences of sexual violence are associated with cancer screening behaviors. However, to date, little attention has been given to the impact of sexual assault on cancer screening behaviors, particularly among men. To address this, we used data from the 2014 Kansas Behavioral Risk Factor Surveillance System. This survey is conducted annually via telephone. Logistic regressions were used to calculate odds of ever engaging (i.e., lifetime) in specific screening behaviors (clinical breast exam [CBE], mammogram, Pap test, colonoscopy/sigmoidoscopy, fecal occult blood test and prostate-specific antigen [PSA] test) and current compliance with cancer screening recommendations (CBE, mammogram, Pap test, colorectal cancer screening, and PSA test), with lifetime sexual assault as the independent variables. Colorectal cancer screening models were stratified by gender. All models adjusted for confounders. Sexual assault was associated with lower odds of ever receiving a PSA test and, for women, higher odds of ever receiving a colonoscopy or sigmoidoscopy. Sexual assault was associated with lower odds of current compliance with CBE, mammogram, Pap test, and PSA test screening recommendations. A history of sexual assault was associated with lower odds of current compliance with cancer screening procedures, with the notable exception of colorectal cancer screening. Less consistent patterns were seen for lifetime screenings. Results suggest that alternatives to currently recommended procedures (like self-collection of HPV [human papilloma virus] DNA) or modified screening procedures may be a promising route to increase current compliance with cancer screening among a population that may avoid these procedures due to pain or fear of retraumatization.

Trauma and cervical cancer screening among women experiencing homelessness: A call for trauma-informed care

OBJECTIVE

Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness.

METHODS

We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis.

RESULTS

Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening.

CONCLUSION

Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.

Practitioner Review: Twenty years of research with adverse childhood experience scores - Advantages, disadvantages and applications to practice

BACKGROUND

Adverse childhood experience (ACE) scores have become a common approach for considering childhood adversities and are highly influential in public policy and clinical practice. Their use is also controversial. Other ways of measuring adversity - examining single adversities, or using theoretically or empirically driven methods - might have advantages over ACE scores.

METHODS

In this narrative review we critique the conceptualisation and measurement of ACEs in research, clinical practice, public health and public discourse.

RESULTS

The ACE score approach has the advantages - and limitations - of simplicity: its simplicity facilitates wide-ranging applications in public policy, public health and clinical settings but risks over-simplistic communication of risk/causality, determinism and stigma. The other common approach - focussing on single adversities - is also limited because adversities tend to co-occur. Researchers are using rapidly accruing datasets on ACEs to facilitate new theoretical and empirical approaches but this work is at an early stage, e.g. weighting ACEs and including severity, frequency, duration and timing. More research is needed to establish what should be included as an ACE, how individual ACEs should be weighted, how ACEs cluster, and the implications of these findings for clinical work and policy. New ways of conceptualising and measuring ACEs that incorporate this new knowledge, while maintaining some of the simplicity of the current ACE questionnaire, could be helpful for clinicians, practitioners, patients and the public.

CONCLUSIONS

Although we welcome the current focus on ACEs, a more critical view of their conceptualisation, measurement, and application to practice settings is urgently needed.

Childhood maltreatment as a risk factor for cancer: findings from a population-based survey of Canadian adults

BACKGROUND

Childhood maltreatment (CM) is an established risk factor for various mental and substance use disorders. This study adds to existing evidence that CM may also be a risk factor for cancer.

METHODS

Based on data from a sample of 9783 men and 12,132 women from the 2012 Canadian Community Health Survey - Mental Health (CCHS-MH), this analysis explores mediated associations between cancer in adulthood and different levels of exposure to three types of CM-childhood physical abuse (CPA), childhood sexual abuse (CSA), and childhood exposure to intimate partner violence (CEIPV). "Cancer" was defined as an affirmative response to either of these questions: "Do you have cancer?" or "Have you ever been diagnosed with cancer?" The potential mediators were: smoking, depression, alcohol abuse/dependence, life stress, obesity, and physical activity.

RESULTS

For women, but not men, having experienced CM was significantly associated with a cancer diagnosis in adulthood, even when effects due to age and socio-demographic characteristics were controlled. Smoking, life stress, depression, and alcohol abuse/dependence reduced the strength of the association between CM and cancer in women. However, most associations remained statistically significant when controlling for effects due to these behavioural and other mediators. Evidence indicated a "dose-response" relationship, in that the likelihood of reporting cancer increased with the number of abuse types (CPA, CSA, CEIPV) reported, and with the severity of CPA.

CONCLUSIONS

The analyses suggest an association between CM and cancer in women, even when the effects of known risk factors were taken into account. The association was graded, becoming stronger as CM exposure increased. Implications for the provision of cancer screening and other health care services to women with histories of CM to reduce health disparities are discussed.

Colonoscopy and Sigmoidoscopy Use among the Average-Risk Population for Colorectal Cancer: A Systematic Review and Trend Analysis

Monitoring population-level colonoscopy and sigmoidoscopy use is crucial to estimate the future burden of colorectal cancer and guide screening efforts. We conducted a systematic literature search on colonoscopy and sigmoidoscopy use, published between November 2016 and December 2018 in the databases PubMed and Web of Science to update previous reviews and analyze time trends for various countries. In addition, we used data from the German and European Health Interview Surveys and the National Health Interview Survey to explore recent time trends for Germany and the US, respectively. The literature search yielded 23 new articles: fourteen from the US and nine from Australia, Canada, England, Germany, Saudi Arabia, and South Korea. Colonoscopy use within 10 years was highest and, apart from the youngest age groups eligible for colorectal cancer screening, kept increasing to levels close to 60% in the US and Germany. A recent steep increase was also observed for South Korea. Limited data were available on sigmoidoscopy use; regional studies from the US suggest that sigmoidoscopy has become rarely used. Despite high uptake and ongoing increase in the US, Germany, and South Korea, use of colonoscopy and sigmoidoscopy has either remained low or essentially unknown for the majority of countries.

Examining the Impact of Child Adversity on Use of Preventive Health Care among Children

Child adversity has a negative impact on child and adult health. The present study aimed to determine whether adverse family experiences (AFEs) were associated with use of preventive health care (PHC) among children and whether insurance status affected this association. This study examined data from the 2011-2012 National Survey of Children's Health (N = 88,849) and included responses for children ages zero to 17 years. Logistic regression models were used to estimate odds of using PHC from AFEs. Results were stratified by insurance status and confounders were accounted for. Among the entire sample and the insured, most AFEs were not associated with use of PHC. Among the uninsured, several AFEs-lived with parents or guardians who were separated, lived with parent or guardian who was incarcerated, witnessing or experiencing violence in the household, and living with anyone who had substance abuse problems-and the sum of AFEs were associated with increased use of PHC. Findings are consistent with newer research showing that some disadvantage or adversity is associated with more optimal use of PHC. In addition, uninsured children with a history of AFEs would benefit from insurance, given their increased use of PHC.