Your Patient Has Been Dealt a Hand With Four ACEs. What Now?

In most card games, four aces are desirable. Conversely, an “ACE” — adverse childhood experiences — score of 4 can be hazardous to health. We cannot change the hand that our patients are dealt, but as healthcare providers we need to ask the correct questions, facilitate healing, and work to prevent further physical and mental maladies in our patients.

ACEs are events during childhood that impact mental, emotional, and physical well-being. To assess childhood trauma, a set of 10 “yes” or “no” questions was developed in the 1990s, with 10/10 being the “worst” score with the highest risk and 0/10 being the “best” score.

There is compelling data to show ACE-associated risks of developing chronic disease, obesity, cancer, depression, anxiety, and suicidality in the individual’s lifetime. In fact, an ACE score of 4 or more is associated with an increased incidence of cancer. While a higher score means higher risk, it does not mean that someone caused their disease. On the contrary, a higher score means having had significant trauma prior to the age of 18. We, as healthcare professionals, must look for and address these traumas as we treat physical diseases in our patients.

One patient in particular taught me this valuable lesson. In fall 2019, my patient Terese* (who actually is a teacher) found a mass on her back that just didn’t feel right. She was 43 years old at the time, and had successfully completed treatment for stage II breast cancer at the age of 34. After a 3-month diagnostic debacle, I met her in January 2020 when she was referred to me to remove a stage IV metastatic lesion on her back.

The surgery I performed was minor, but she later told me that I was the first physician that actually “saw” her — as a full human — and she trusted me. I asked Terese to speak to a group of young breast cancer surgeons as a woman living with stage IV cancer. What I didn’t know before her talk was that she had an ACE score of seven: the combination of childhood trauma, neglect, and abuse coupled with a horrific orthopedic surgery likely contributed to her physical and mental health issues. It wasn’t just isolated trauma from her cancer.

She educated us about what I had been missing for years with my patients. Finding resources for her to address these traumas became essential.

Through her therapist who focused on The Richards Trauma Process (TRTP), a 3-step therapy process for resolving trauma-related issues — as opposed to standard psychotherapy, which had previously not addressed her childhood trauma — Terese started the healing process. Because of TRTP she began taking better care of her mental health.

“I finally felt able to talk openly with my doctors about what it’s like inside my head. I have major depressive disorder (since childhood), anxiety disorder, and PTSD (relationship abuse). Because I can name these issues, I can treat them. I am more mentally well-adjusted today than I have ever been in my life.”

Terese is now 48 and currently has no progression of her disease.

My 38-year clinical practice has been focused on treating diseases of the breast and educating colleagues in state-of-the-art surgical techniques. I was trained that to cut is to cure. Prior to 2021, I thought of “aces” only in relation to card games.

As a cancer surgeon, I should have been educated in medical school or residency about the effect that adverse experiences at a young age have on a person’s mental and physical well-being. Instead, I didn’t learn about ACEs until my training in the therapeutic use of entheogens to treat depression and PTSD, and to address the existential crisis of cancer.

I have since shifted from focusing only on the operating room to simultaneously embracing and cultivating survivorship. Improving the quality of life of those living after cancer is my priority. Survivorship must begin at the time of diagnosis. If we eradicate cancer in the body and fail to address patients’ fear, we have failed.

Mitigating side effects of treatment and addressing underlying early childhood traumas is essential. The Body Keeps Score by Bessel van der Kolk, MD, is a “must read” for all physicians. If we simply treat the symptoms of a disease we may miss the opportunity to heal the underlying cause.

The higher the ACE score, the higher the risk of cancer. But cancer doesn’t simply shuffle the deck of cards, it tosses them up in the air and patients are left to pick up the hand they have been dealt.

I certainly do not have all of the answers to how we help our patients heal from these traumas, but ignoring their existence could potentially lead to more disease. I believe it is time to start this conversation and work to help heal these deep wounds in our patients. In cancer survivorship, nutrition and exercise are key components to prevention, but asking our patients to change their behaviors needs to begin with addressing their psychological and emotional wellness first.

Beth Baughman DuPree, MD, is a breast cancer surgeon at Redeemer Health in Huntingdon Valley, Pennsylvania.

*Patient’s name has been changed for confidentiality.

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