Childhood trauma can increase a breast cancer survivor’s chance of experiencing more severe and longer-lasting treatment-related anxiety, depression and fatigue, as well as reduced cognitive function, years after cancer treatment has ended, according to a preliminary study led by Jamie Myers, Ph.D., FAAN, research associate professor at the University of Kansas School of Nursing.
Adverse childhood experiences (ACES) have been linked to the onset of disease, including heart disease and cancer, for decades. These experiences include abuse, neglect, violence, parental divorce or separation and living among people with mental or emotional problems.
Studies have also shown that cancer patients with a history of adverse childhood experiences are at greater risk for anxiety, depression and fatigue for weeks or months after they have finished treatment. But little research had been done looking at the longer-term effects of adverse childhood experiences in patients who have completed cancer treatment. The KU Medical Center researchers set out to fill that research gap.
Myers reached out to Lori Ranallo, MSN, APRN, a nurse practitioner at The University of Kansas Cancer Center’s Breast Cancer Survivorship Clinic, and the Masonic Cancer Alliance, the outreach arm of KU Cancer Center. “We wanted to find out if it was feasible to evaluate and assess ACES within the population Lori supports,” said Myers, “and we wanted explore whether there was a relationship between having had these adverse childhood experiences and more significant anxiety, depression, fatigue, cognitive impairment and sleep disturbance.”
With help from KU Cancer Center’s Patient and Investigator Voices Working Together Rapid Reactor Team, also known as PIVOT, the researchers devised a questionnaire about adverse childhood experiences to administer to women at their breast cancer survivorship clinic visit. The questionnaire was given to consenting women who had completed breast cancer treatment, were at least three years post-diagnosis and were receiving follow-up care and surveillance at the survivorship clinic.
The questionnaire asked the participants to indicate what kind of adverse events they had experienced by the age of 18. “Did they live with someone who had substance issues or struggled with mental illness, or someone who'd been incarcerated? Did they live with people who had gone through a divorce or a separation? Were they exposed to any kind of physical or emotional abuse? Did they live in a community where they were exposed to violence? Those were the types of things on that questionnaire,” said Myers.
Patients also were asked to rate their depression anxiety, depression, fatigue, cognitive function and sleep on a form designed according to the National Institutes of Health’s PROMIS (Patient-Reported Outcomes Measurement Information System) format. Because the researchers hypothesized that women who were more resilient — better able to bounce back from adversity — would report fewer long-term health problems, the participants also rated their resilience according to the Brief Resilience Scale.
Additionally, study participants agreed to have their blood screened for biomarkers associated with adverse childhood experiences, which may lead to a prolonged stress response in the body that research has shown can cause changes such as chronic inflammation. Such inflammation is linked to cognitive decline as well as to depression, anxiety, fatigue and sleep disturbances, Myers said.
The average age of the 120 women who participated in the study was 63, and the average time since diagnosis was nearly 15 years. The study found that for these women, higher ACE scores were correlated with greater fatigue, anxiety and depression, as well as with reduced cognitive function.
Overall, the study also found that breast cancer survivors with higher resilience scores reported higher cognitive function and less anxiety, depression and fatigue. However, the study did not show that resilience mitigated the severity of those health problems in people with ACES. Myers thinks this may have been because the study had no participants who’d had stage 4 breast cancer. “We may have missed the group that would have been able to tell us if resilience was having an impact,” she said. “Also, we were seeing women who were coming in for a survivorship visit, so they might not have been the group facing the most challenges in terms of social determinants of health.”
Now that the researchers have demonstrated the feasibility of such a study, they want to do another study evaluating more patients over time and including more variety in both the stages of disease represented and in the social and economic backgrounds of participants. As they expand the study, they also expect to be able to get more meaningful results about the blood biomarkers.
In the meantime, the study has implications for the care of patients. Providers may want to conduct assessments for adverse childhood visits for patients receiving survivorship care for breast cancer. “And then that would lead us down the path of intervention research, where we could develop something to enhance people’s resilience or design interventions to help make sure that survivorship is better, with better quality of life,” said Myers.
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