Trauma‐informed care within oncology? Understanding the impact of childhood trauma on experiences of cancer and cancer services in adulthood

Abstract

Objectives

This research aimed to explore whether Adverse Childhood Experiences (ACEs) shape adults' engagement with cancer services, including satisfaction with care and whether services reflect trauma‐informed principles.

Design

Mixed‐method sequential explanatory design. Stage one used a cross‐sectional online survey; stage two comprised semi‐structured interviews informed by the survey findings.

Methods

Survey responses (N = 266) were analysed using descriptive statistics, correlations and mediation analysis. Qualitative data used inductive‐deductive reflexive thematic analysis, guided by the Substance Abuse and Mental Health Services Administration trauma‐informed care (TIC) framework.

Results

Childhood trauma was moderately negatively correlated with patient satisfaction (r = −.40), with illness perceptions mediating this relationship. Thematic analysis yielded four themes relating to experiences of cancer care: (1) ‘Connecting the dots’: Resonance of childhood memories and current experiences. (2) ‘Nobody ever told me’: Powerlessness & cancer‐related losses. (3) ‘I just wanted everyone else around me to be okay’: Distributed effects of cancer through the social network. (4) ‘It's down to bedside manner’: Patient satisfaction is shaped by relational care. Patients only made connections back to their childhood trauma in Theme 1.

Conclusions

Findings suggest ACEs may influence cancer care satisfaction through illness perceptions, supporting the clinical relevance of trauma‐informed approaches to the cancer population. While the interview findings do not conclusively support this, it remains a significant clinical consideration that cancer services in the UK may benefit from adjustments to incorporate TIC for the UK cancer population.

Statement of Contribution.

What is already known on this subject?

• TIC is minimally applied in UK cancer services.

• Trauma is a predisposing factor that may affect engagement with cancer care.

• Attending cancer services can trigger re‐traumatisation and psychological distress

What does this study add?

• Identifies an association between ACEs and satisfaction with cancer services, mediated by illness perceptions

• Demonstrates how trauma patterns may resurface during adult cancer care, potentially influencing access and utilization.

• Highlights the potential of TIC to foster empathetic, patient‐centred oncology services

INTRODUCTION

Cancer is a complex and increasingly prevalent disease, with 18.1 million new cancer cases and 9.6 million deaths worldwide in 2018 (World Health Organisation, 2024). By 2040, new cancer cases are projected to reach 29.9 million annually (National Cancer Institute, 2024). A cancer diagnosis can profoundly affect mental health, especially for individuals with a history of trauma (Marshall et al., 2023). Despite significant advancements in research and treatment, the cancer journey remains highly personal and challenging, with significant implications for psychological well‐being and overall quality of life (Ramasubbu et al., 2020).

Adverse childhood experiences (ACEs) and cancer care

Adverse Childhood Experiences (ACEs) refer to a range of events occurring before age 18, including abuse, neglect or unsafe environments (Felitti et al., 1998). Extensive research demonstrates that ACEs are cumulative and interrelated (Dong et al., 2004). Individuals with higher ACEs are more likely to experience chronic illness and poorer health outcomes (Mersky et al., 2013) and reduced engagement with healthcare services (Menschner & Maul, 2016).

Within the context of cancer care, these early adversities may shape how patients perceive, access and engage within healthcare systems. In adulthood, ACEs may increase vulnerability to re‐traumatisation within healthcare contexts characterised by power imbalances and loss of control, which is common within cancer diagnosis and treatment pathways (Kimberg & Wheeler, 2019; Marshall et al., 2023). Within cancer care specifically, these patterns may influence how patients interpret diagnostic processes, respond to uncertainty, engage with treatment and evaluate interactions with healthcare professionals. Consequently, understanding ACEs may provide a critical framework for understanding patients' psychological responses to cancer and their interactions with cancer services.

From early adversity to emotional burden: Psychological distress, shame and illness perceptions

Building on this, cancer patients face significant psychological challenges, including adjusting to diagnosis, relationship strains and treatment side effects (Hussain et al., 2016). Common reactions include shock, denial, anxiety or anger. Approximately 13% are clinically diagnosed with depression, and up to 20% self‐report depressive symptoms (Pitman et al., 2018). Shame, fuelled by stigma or self‐blame, further undermines help‐seeking and adjustment (Akin‐Odanye & Husman, 2021; Cancer Research UK, 2022). Shame in the cancer context can arise through multiple pathways. In some cases, it is linked to socially constructed stigma associated with particular diagnoses, where illness becomes moralised or attributed to personal behaviour. For example, women diagnosed with cervical cancer may experience moral judgement related to perceived sexual promiscuity (Kinsella & Kavanagh, 2025). Similarly, individuals with cancers linked to lifestyle factors (e.g., lung cancer) may experience blame or perceived responsibility for their illness (Chappel et al., 2004). However, shame is not limited to specific cancer types. More broadly, a cancer diagnosis can evoke shame through perceived loss of bodily integrity, changes in identity or dependency on others (Thamm et al., 2024). These experiences may be particularly pronounced for individuals with a history of adversity, who may be more vulnerable to internalising negative self‐beliefs and self‐blame (Webb et al., 2007). More broadly, patients may internalise blame for lifestyle‐ or hereditary‐associated cancers (Bae & Temkin, 2025). ACEs may further reinforce these processes, increasing susceptibility to shame‐based responses and reducing coping capacity (Rollins & Crandall, 2021), contributing to poorer adjustment to cancer (Davis et al., 2023).

In addition to emotional distress, the way individuals interpret and make sense of their illness plays a central role in their cancer experience. Illness perceptions, shaped by personal history, prognosis and cancer type, affect both psychological distress and life satisfaction (Bahçecioğlu Turan & Türkben Polat, 2024; Cockle & Ogden, 2021; Marshall et al., 2023; McCorry et al., 2013). Patient‐centred communication and trust in clinicians can mitigate negative illness perceptions and improve satisfaction (Elkefi et al., 2024; Husson et al., 2013). Thus, healthcare providers should be aware of the impact of illness perceptions on cancer care (Petrie et al., 2007), making this a critical emerging area in health psychology. Among the psychological sequelae of ACEs, shame warrants particular attention as a potential mediating mechanism. Unlike discrete emotions such as fear or anger, shame is a self‐evaluative state that shapes how individuals relate to themselves and others over time (Tangney & Dearing, 2002). Childhood maltreatment is consistently linked to elevated shame proneness in adulthood (Webb et al., 2007), and shame has been identified as a mediator between ACEs and mental health difficulties (Dearing et al., 2005). Shame has also been identified as a barrier to healthcare engagement across multiple contexts, including cancer screening (Brennan & Reay, 2024) and treatment (Brennan & Reay, 2024). In the cancer context, shame may operate through avoidance (Orth et al., 2006): individuals who feel fundamentally flawed or unworthy may delay seeking help, minimise symptoms or disengage from care providers perceived as judgemental (Dolezal & Lyons, 2017). Thus, shame represents a theoretically coherent pathway through which early adversity may influence adult healthcare experiences – one that is amenable to trauma‐informed intervention.

Navigating barriers: Delays in help‐seeking behaviours

These psychological processes also have implications for health behaviour. Delays in seeking cancer care can result from symptom misinterpretation and severity, stigma, fear and shame (Cotterill, 2023). Despite widespread awareness of cancer symptoms, many UK adults postpone consulting their General Practitioner after noticing symptoms due to fear (NHS England, 2022; Smith, 2022). Available research suggests that ACEs predict lower trust in healthcare and reduced willingness to seek timely care (Munoz et al., 2019), potentially compounding delays. Building on these behavioural implications, it is important to consider how these psychological processes may be addressed within healthcare systems.

Towards healing: The role of trauma‐informed care (TIC) in cancer services

Given the cumulative impact of ACEs on emotional wellbeing, illness perceptions and help‐seeking behaviour, there is growing interest in care approaches that explicitly address trauma. Trauma‐Informed Care (TIC) aims to reduce re‐traumatisation by promoting safety, trust, empowerment and cultural sensitivity (Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative et al., 2014; Sweeney et al., 2016). TIC has been shown to foster trust and engagement, especially in individuals with ACEs (Gieseler et al., 2018).

Shame may influence how ACEs affect current healthcare behaviours (Orth et al., 2006). If unaddressed, shame can lead to avoidance and poorer outcomes (O'Mahony & Hegarty, 2009). Shame was selected as a potential mediator in this study due to its established role in linking trauma histories to emotional distress, interpersonal difficulties and reduced engagement with healthcare services (Dolezal & Lyons, 2017; Schnur et al., 2018). There is a dearth of empirical evidence regarding the psychological impact of ACEs on the cancer experience in adulthood. Understanding how ACEs influence health behaviours, particularly through shame and illness perceptions, may help clarify mechanisms underlying these challenges and could inform care strategies within cancer care.

To bridge this research gap, two exploratory research questions are proposed:

1. (a) Does childhood trauma correlate with delays in seeking help for cancer symptoms, experiences of shame, illness perceptions and patient satisfaction in oncology services? Additionally, (b) does shame mediate the relationship between childhood trauma and satisfaction with oncology services?

2. What are patients' experiences of their cancer diagnosis and cancer services (in adulthood), and does childhood trauma impact these?

By addressing these questions, this study extends psychological perspectives on cancer care and highlights the potential role of healthcare providers in developing more effective and holistic approaches to support the psychological well‐being of cancer patients.

MATERIALS AND METHODS

This study received ethical approval from the University of Nottingham Research Ethics Committee (ref: 3002). An Expert by Experience (EBE), defined as an individual with lived experience relevant to the study, contributed to developing the study by advising on the research focus and refining research materials to ensure they were sensitive, relevant and trauma‐informed.

Epistemological stance

Critical realism was adopted as the epistemological position. This position assumes that reality is constructed through individual observable meanings and contexts in which it is experienced (Pilgrim, 2019). In this research, this approach guided the interpretation of participants' accounts reflecting both their subjective experiences and underlying social and structural influences, which informed how the data were interpreted.

Study design

A mixed‐methods sequential explanatory design (Ivankova et al., 2006) was implemented. Stage one involved quantitative data collection via an online survey. Stage two consisted of semi‐structured interviews. This design was chosen given the limited research on TIC in UK oncology services. While studies from other countries have begun to explore how TIC can affect oncology practice (Simkhaev, 2024), organisational context and health system differences mean findings cannot be assumed to apply to the UK without empirical investigation. A mixed‐methods approach therefore enables the capture of both broad statistical patterns and in‐depth experiences pertinent to UK oncology services.

Recruitment: Online survey

Participants for the online survey were recruited using convenience sampling. Recruitment materials were disseminated via UK cancer charities, online cancer support groups, social media platforms (e.g., Facebook, X/Twitter), university networks and Prolific. Interested individuals accessed the Qualtrics survey through a secure link. Eligibility was confirmed through self‐report screening items requiring participants to be aged 18 or over, reside in the UK and have a current or previous cancer diagnosis. After providing informed consent, participants completed the anonymous survey, with a ‘prefer not to say’ option available for all sensitive items. The voluntary, self‐selected nature of this recruitment approach subsequently limited the extent to which purposive sampling could be applied when inviting participants to the qualitative phase.

Measures

The online survey included validated psychometric measures of ACEs, shame, illness perceptions and patient satisfaction with cancer services (Table 1). Demographic data contextualised the sample, including time taken to seek medical help after first noticing cancer symptoms. Due to the sensitive nature of the questions, a ‘prefer not to say’ response option was provided for all survey items.

TABLE 1.

Validated measures used in the online survey.

Measure	Target construct	Number of items	Example items	Scoring	Reliability
Maltreatment and Abuse Exposure Scale (MAES; Teicher & Parigger, 2015)	Measures exposure to different types of maltreatment/abuse in childhood (defined as the first 18 years of life).	52	‘Hit you so hard that it left marks for more than a few minutes,’ ‘Forced or threatened you to do things you did not want to do.’	Items rated ‘yes/no.’ Total score is the sum of all items (0–52). Provides a scaled cumulative ACE score. Higher scores indicate greater exposure to childhood maltreatment/abuse.	Cronbach's α †  = .98
The External and Internal Shame Scale (EISS; Ferreira et al., 2020).	Global sense of shame.	8	‘I am unworthy as a person.’ ‘Other people are judgemental and critical of me.’	Items scored on a 5‐point Likert scale ranging from 0 = ‘never’ to 4 = ‘always’. Scores are summed to produce a single total. Higher scores indicate greater shame.	Cronbach's α = .89
Brief Illness Perception Questionnaire (Brief IPQ; Broadbent et al., 2006).	Cognitive and emotional representations of an illness.	8	‘How much control do you feel you have over your illness?’ (0 = ‘absolutely no control and 10 = extreme amount of control’)	Eight items, each scored on a 0–10 Likert scale. Scores are totalled to yield a single measure. Higher scores indicate a more threatening illness perception.	Cronbach's α = .73
The FAMCARE‐Patient Scale (FAMCARE‐P13; Lo et al. 2009).	Patient satisfaction with cancer services.	13	‘The way tests and treatments are performed.’ ‘Information given about side effects.’	Items rated on a 5‐point Likert scale (1 = ‘very dissatisfied’ to 5 = ‘very satisfied’). Totalled to produce a satisfaction score. Higher scores reflect greater satisfaction with cancer care.	Cronbach's α = .93.

Note: Validated psychometric measures administered in the online survey, including their target constructs, number of items, example items, scoring procedures and reported reliability.

Abbreviation: ACE = Adverse Childhood Experiences.

^† α = Cronbach's alpha (internal consistency coefficient).

Recruitment: Semi‐structured interviews

Participants for the qualitative phase were drawn from the online survey cohort. At the end of the survey, respondents were invited to indicate whether they were willing to be contacted for a follow‐up interview. Purposive sampling was planned to maximise variation in demographic characteristics, cancer type and levels of childhood trauma exposure. However, the pool of potential interviewees was limited to those who had self‐selected for further contact; the scope for purposive sampling was reduced.

The interview schedule was developed following preliminary analysis of survey data to explore quantitative patterns in greater depth. Findings from the quantitative phase, including patterns of association between ACEs, illness perceptions and patient satisfaction, informed the development of interview questions exploring how participants made sense of their cancer experiences and interactions with healthcare providers. The interview schedule was piloted with the Expert by Experience researcher and trainee clinical psychologist colleagues to ensure questions were sensitively worded and trauma‐informed (see supporting information for full interview schedule).

Of the 20 participants who initially consented to further contact, 11 completed an interview. Interviews lasted on average 40 min, were conducted via Microsoft Teams, and were recorded and transcribed verbatim by the first author (BK). BK had no prior relationship with participants and did not disclose personal or professional positioning, other than being a trainee clinical psychologist. BK drew on clinical experience and skills in trauma and oncology to support rapport building, active listening and the sensitive use of open questions. Pseudonyms were randomly assigned, identifying details removed and participants were entered into a prize draw for a £50 ‘Love2Shop’ gift voucher.

Analysis

Quantitative Analysis: Preliminary analysis of the online survey involved data exploration, assumption checking and descriptive statistics using IBM's Statistical Package for the Social Sciences Programme Version 29. Participants who failed to complete at least one of the main measures were excluded.

For Aim 1a, correlational analyses (Pearson's r) assessed associations between ACEs, time to help‐seeking, shame, illness perceptions and satisfaction with cancer services. Correlation coefficients interpreted as: .10 = ‘small’, .30 = ‘moderate’ and .50 = ‘large’; with coefficients <.10 = ‘negligible’. (Cohen, 1992).

To explore Aim 1b, mediation analysis was conducted using Hayes' PROCESS macro (Model 4 parallel mediation; Hayes, 2022). ACEs (MAES) were entered as the independent variable with shame (EISS) and illness perceptions (IPQ) as mediators, and patient satisfaction (FAMCARE‐P13) as the outcome. Analyses used robust standard errors and 99% confidence intervals based on 5000 bootstrap samples (Hayes, 2022).

Qualitative Analysis: Addressing Aim 2, data analysis followed Clarke and Braun's (2022) six‐phase reflexive thematic analysis to code the whole dataset. Initial inductive coding was undertaken at a semantic level (i.e. focusing on what the participants explicitly said). Then re‐analysis using the SAMHSA's six TIC principles (Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative et al., 2014) as a deductive framework (Table 2) by looking at evidence for or against each of the principles across the dataset; although the latter was more interpretive at times, there had to be clear evidence within participants' words to avoid latent‐level over‐interpretation in the deductive analysis. Coding was conducted by the first author, with collaborative discussions in supervision to guide coding. All codes – both inductive and deductive ‐ were then integrated and grouped into initial themes by the first author before being further reviewed, defined and named through discussion among the team.

TABLE 2.

Deductive framework: Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative et al. (2014) Trauma‐Informed Care (TIC) Principles.

TIC principle	TIC principle definitions
Does the data show evidence for or against…
Safety	Individuals feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety.
2Trustworthiness and transparency	Decisions are conducted with transparency to build and maintain trust with clients, staff and others involved in the service.
3Peer support	Peer support and mutual self‐help are key to establishing safety and hope, building trust, enhancing collaboration and utilising stories and lived experiences to promote recovery.
4Collaboration and mutuality	Levelling of power differences between staff and clients. Demonstrating that healing happens in relationships and the meaningful sharing of power and decision‐making.
5Empowerment, voice and choice	The ability of individuals, organisations and communities to heal and promote recovery from trauma. Foster empowerment for clients and staff alike. Clients are supported in shared decision‐making choices and goal‐setting to determine the plan of action needed to heal and move forward.
6Cultural, historical and gender issues	The organisation actively moves past cultural stereotypes and biases and incorporates policies, protocols and processes that are responsive to the racial, ethnic and cultural needs of individuals, addressing historical trauma.

Note: Deductive framework applied in the current study, based on Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative et al. (2014) six trauma‐informed care (TIC) principles.

Abbreviations: SAMHSA = Substance Abuse and Mental Health Services Administration, TIC = Trauma‐Informed Care.

Reflexivity and rigour

The research team brought diverse perspectives that shaped data collection and interpretation. The first author (BK), with a background in ACEs research and personal experience of family cancer, approached participants' emotional experiences with sensitivity while remaining vigilant against over‐identification with their accounts. Two members of the research team lacked direct experience in oncology settings, which allowed for data‐driven interpretations without bias from clinical assumptions. In contrast, two supervisors with direct oncology experience provided valuable insights for understanding the data with a broader clinical context. Additionally, one team member brought lived experience of both childhood trauma and cancer, offering interpretations grounded in both data and personal experience. To maintain rigour, BK kept a reflective diary documenting analytical decisions, emotional responses to data and evolving interpretations. Regular supervision sessions provided space for collaborative reflection and ensured interpretations were critically interrogated. Methodological quality was self‐assessed against the Good Reporting of A Mixed Methods Study (GRAMMS) framework (O'Cathain et al., 2008) and the 15‐point quality checklist for reflexive thematic analysis (Clarke & Braun, 2022).

RESULTS

Participant characteristics: Online survey

A total of 266 UK adults completed the survey (174 female, 88 male, 1 undisclosed). Ages ranged from 21 to 83 years (M = 51). All had received at least one cancer diagnosis, with 92.9% (n = 247) reporting a single diagnosis and 6.8% (n = 18) multiple diagnoses.

Most participants identified as White British (n = 247, 92.9%), which is slightly higher than national census estimates in England and Wales (81.7%; Office for National Statistics, 2021).

Questionnaire results (Aim 1a)

Descriptive statistics, correlations and reliability coefficients are presented in Table 3.

TABLE 3.

Pearson correlations, descriptive statistics and reliability coefficients from the online survey (stage one).

Variables	1	2	3	4	5	Measure	Min.	Max.	M	SD	Range	ɑ
Time (1)	—	.03	.03	.10	−.18**	Time†	0.0	54.0	3.5	7.3	54.0
Childhood Trauma (2)		—	.21**	−.56**	−.40**	MAES‡	0.0	51.0	13.2	11.1	51.0	.95
Illness Perceptions (3)			—	.33**	−.22**	Brief IPQ§	13.0	65.0	51.3	10.4	52.0	.58
Shame (4)				—	−.24**	EISS¶	0.0	31.0	12.4	7.8	31.0	.92
Patient Satisfaction (5)					—	FAMCARE††	0.0	64.0	31.3	13.2	64.0	.94

Note: Pearson correlations, descriptive statistics (minimum, maximum, mean, standard deviation and range), and Cronbach's α coefficients for the measures used in the online survey (stage one). α = Cronbach's alpha (internal consistency in the present sample). *p < .05; **p < .005.

^† Time = Number of months participants waited before seeking medical help after first suspecting cancer symptoms (0 = sought help immediately).

^‡ MAES = Maltreatment and Abuse Exposure Scale; higher scores indicate greater childhood trauma exposure.

^§ IPQ = Brief Illness Perception Questionnaire; higher scores indicate more negative/threatening illness perceptions.

^¶ EISS = External and Internal Shame Scale; higher scores indicate greater shame levels.

^†† FAMCARE = Patient Satisfaction Scale; higher scores indicate greater satisfaction with cancer care.

Participants reported relatively lower ACE scores, high levels of patient satisfaction and high illness threat perceptions, so those with higher trauma or lower satisfaction may be underrepresented.

Correlation analysis (Aim 1a) indicates that higher ACEs were significantly associated with greater shame (r = .21, p < .005), more negative illness perceptions (r = .56, p < .005) and lower satisfaction with care (r = −.40, p < .005). The relationship between ACEs and time to help‐seeking was negligible and non‐significant (r = .03, p = .688).

Mediation analysis (Aim 1b)

The mediation model (Figure 1) tested whether shame and illness perceptions mediated the relationship between ACEs and patient satisfaction with cancer services. Mediation modelling demonstrated that illness perceptions, but not shame, mediated the association between ACEs and patient satisfaction. The direct effect of ACEs on satisfaction remained significant, suggesting that patients who perceive their cancer as more threatening, particularly those with higher ACEs, report lower satisfaction with care.

FIGURE 1.

Mediation Model of Childhood Trauma (ACEs), Shame, Illness Perceptions and Patient Satisfaction in Cancer Care. * indicates a statistically significant relationship at p < .05.

Participant characteristics: Interviews

Eleven participants (8 female, 3 males; mean age = 61 years, range 34–91 years) were interviewed. All identified as White British and received NHS cancer care. Cancer types across the 11 included melanoma (N = 4), breast (N = 3), Non‐Hodgkin's Lymphoma (N = 2), testicular (N = 1) and Lung & Chronic lymphocytic leukaemia (N = 1). Most (7) had self‐identified cancer, two had incidental detection, another had cancer detected through screening, and one did not report the specific detection. Table 4 summarises the survey scores for the participants selected for interview.

TABLE 4.

Online survey scores of the interviewed participants (N = 11).

Measure	Min.	Max.	M	SD
Time†	0.0	13.0	2.90	3.93
MAES‡	2.0	27.0	10.36	7.28
FAMCARE§	37.0	65.0	55.55	7.95
EISS¶	0.0	26.0	13.91	9.53
IPQ††	5.0	57.0	30.27	14.73

Note: Descriptive statistics (minimum, maximum, mean and standard deviation) for online survey scores from interviewed participants (stage two).

Abbreviations: Min. = Minimum, Max. = Maximum, M = Mean, SD = Standard deviation.

^† Time = Number of months participants waited before seeking medical help after first suspecting cancer symptoms (0 = sought help immediately).

^‡ MAES = Maltreatment and Abuse Exposure Scale; higher scores represent greater childhood trauma exposure.

^§ FAMCARE = Patient Satisfaction Scale; higher scores indicate greater satisfaction with cancer care.

^¶ EISS = External and Internal Shame Scale; higher scores indicate greater shame levels.

^†† IPQ = Brief Illness Perception Questionnaire; higher scores indicate more negative/threatening illness perceptions.

Interview participants showed wide variation in childhood trauma, shame, illness perceptions and satisfaction with cancer care. Based on score distributions within the qualitative subsample, several participants (Jack, Eden, Kathryn) scored at the lower end of the MAES and EISS, indicating lower childhood adversity and low shame, while others (Bailey, Ari, Kendall) scored at the higher end, reflecting greater adversity and elevated shame. Illness perceptions also varied: some (Eden, Kathryn) reported very low threat appraisals, whereas others (Ari, Bailey, Kendall) viewed cancer as highly threatening. Satisfaction with cancer care (FAMCARE) was generally moderate to high, though a few participants (Danni, Ari) reported comparatively lower satisfaction. As the MAES, EISS, IPQ and FAMCARE lack validated clinical cut‐offs, these interpretations reflect relative score ranges rather than diagnostic thresholds. A summary table of participant ages can be referred to in the Supplementary Materials to support contextual interpretation of interview accounts.

Interview findings (Aim 2)

Four main themes were interpreted, three had subthemes as described below: (1) ‘Connecting the dots’: Resonance of childhood memories and current experiences; (2) ‘What have they done to me’: Powerlessness & cancer‐related losses; (3) ‘I just wanted everyone else around me to be okay’: Distributed impact of cancer within the social network; and (4) ‘It's all down to bedside manner’: Satisfaction of cancer services shaped by relational care.

Theme 1 captures explicit connections participants drew between childhood adversity and their cancer experiences. Themes 2–4, while not articulated by participants as directly linked to childhood, address the research questions through a trauma‐informed interpretive lens. Trauma theory posits that early adversity shapes characteristic patterns of responding to threat, loss and relational dynamics, patterns that may be reactivated in adulthood without conscious awareness of their origins (Van der Kolk, 2014). Thus, participants' accounts of powerlessness (Theme 2), relational burden (Theme 3) and sensitivity to provider manner (Theme 4) may reflect underlying vulnerabilities shaped by early experience, even when participants did not make this connection explicitly. This interpretation is consistent with the quantitative finding that ACEs predicted more threatening illness perceptions, a cognitive‐affective pattern that may manifest in the experiences described across all four themes. Importantly, the absence of explicit ACE‐cancer connections in Themes 2–4 is itself meaningful, suggesting that trauma's influence on healthcare experience may operate implicitly, with implications for the value of trauma‐informed approaches that do not require patients to disclose or recognise their trauma histories.

Theme 1: ‘Connecting the dots’: Resonance of childhood memories and current experiences

For some participants, ACEs significantly shaped their cancer experiences in adulthood. Notably, explicit use of the term ‘trauma’ was rare; more commonly, participants connected childhood feelings of inferiority, rejection and invisibility to similar patterns during cancer without labelling these as traumatic. This distinction between experiencing adversity and identifying it as trauma has implications for how services might sensitively enquire about early experiences. For example, Danni linked invalidating childhood relationships to self‐doubt, feelings of worthlessness and delayed healthcare seeking, ‘…I just always think that people are just gonna think I'm being mardy or stupid or whatever because that's the message I had when I was growing up and certainly around this cancer….’ Similarly, Izzy, who felt like a ‘nuisance’ and feared rejection or dismissal, spoke about suppressing her emotional needs as a child. These emotions resurfaced during her cancer experience, reactivating her fear of being rejected or dismissed by healthcare professionals: ‘The feeling seems to come back a similar feeling to the one you had as a kid. Please don't leave or I'm going to be alone. With this, it comes back in an adult version…’

Most participants made meaning of their own cancer diagnosis through their experiences of a family history of cancer, including cancer‐related grief. This shaped their perspectives on health and how they experienced their own illness and other family members' responses. Kendall reflected on her father's absence during her treatment, recognising that his traumatic memories from his mother's cancer may have affected his behaviour: ‘…my grandma, she got diagnosed with myeloma…we had to turn her machine off… So, him [dad] being in the ICU room was probably, Christ, so traumatic. Actually, I can see why he wasn't a regular visitor…’.

The influence of a family cancer history was interpreted as a factor to consider in understanding people's emotional responses during their cancer experiences. Some, like Jack, suggested cancer services should incorporate questions about family cancer history to assess the potential emotional or traumatic impact. He argued that understanding such history could guide more trauma‐informed empathic care, ‘…‘Have you ever experienced cancer within your own immediate family?’…if they say ‘yes’, it might help to see what kind of experience they had and try and remove any trauma to the individual …that could be quite significant…’.

It was evident that both early adversity and people's family history of cancer influenced their own reactions to a cancer diagnosis. It appears people would welcome recognition of, and routine enquiry, into both ACEs and family history of cancer, which could help clinicians to better understand reactions and concerns, and adapt care approaches accordingly.

Theme 2: ‘What have they done to me?’: Powerlessness and cancer‐related losses

Participants did not link their cancer experiences with past childhood trauma in relation to powerlessness and cancer‐related losses. We interpreted that powerlessness was often experienced as a loss of control over diagnosis, treatment or outcomes, leading to emotional and physical distress.

The imposition of a cancer identity itself feels akin to being trapped with no means of control or escape, ‘…you get on a rollercoaster, and you can't get off…everyone's like ‘you're so brave’… you don't really have a choice….’ (Kendall). Despite external praise for bravery, Kendall acknowledges that bravery during cancer treatment is not a conscious choice but a forced response, emphasising powerlessness in the face of psychologically distressing and uncontrollable circumstances.

A lack of control was common, especially regarding medical decision‐making. Izzy, for instance, recounted when her consultant dictated her treatment without consultation or discussion: ‘I remember one consultant shouting for about an hour and a half…he said, ‘right I'm sending you straight away for a mastectomy. I don't wanna hear any more talk’.

Based on our psychological knowledge and experience, we interpret the absence of patient involvement in medical decision‐making and the lack of transparency in the communication between clinicians and patients as likely to undermine emotional safety. This is likely to contribute to heightened psychological distress if unaddressed.

Aim 1a established that individuals with higher ACE scores viewed their cancer as more threatening. Ari, who experienced physical abuse as a child, voiced her overwhelming fear of cancer and the psychological toll it takes daily,‘… you always fear scans…I get scanxiety…it is really awful waiting for results to know whether things are progressing or staying the same…’ The phrase ‘scanxiety’ demonstrates experiences of powerlessness regarding health outcomes. The fear of scans and the wait for results highlight the vulnerability of not knowing what lies ahead, reinforcing a sense of helplessness, underscoring the importance of emotional support and recognising emotional distress as an integral part of patient care.

Subtheme 2a. The body as site of violation

While bodily integrity might be expected to be related to ACEs, participants discussed it mainly in the context of cancer and adjusting to life with cancer more broadly.

Cancer treatments often cause dramatic bodily changes, such as, from surgery, hair loss, infertility or immunosuppression, which can trigger profound emotional responses, especially when emotional support and communication are lacking. For example, Kathryn vividly described the distress of seeing her body after surgery, ‘…I've never seen anything as horrible… it was like the size of a tennis ball had been carved out of my leg…I looked at it and I thought what have they done to me?…’ This experience challenges her sense of bodily autonomy and was compounded by inadequate support, leaving her questioning what had been ‘done to’ her.

The impact of cancer and treatment on bodily autonomy was long‐lasting for some. Eden reported reliving the experience of losing her hair ‘in handfuls’ ‘as if it was yesterday,’ suggesting a need to support individuals with the psychological impact of powerlessness over physical changes. Distress in some cases took the form of anger (Kendall), which is a common emotional response to intense threats following trauma; activating survival instincts, providing protection from helplessness and masking depression that often accompanies trauma survival. However, Danni identified that learning to ‘consistently withhold emotions’ in the context of childhood adversity led to ‘not being able to express emotions, in particular anger.’ Such emotional suppression could contribute to a sense of powerlessness.

This subtheme highlights that the loss of autonomy in decision‐making processes and the inability to influence treatment outcomes can contribute to a profound sense of powerlessness.

Subtheme 2b. Losing the person I used to be

Cancer forces identity shifts and self‐reflection, with loss of former roles and increased vulnerability. This was especially true for those whose self‐concept was tied to occupation or hobbies, requiring individuals to reconsider how they present themselves and define their self‐worth.

Bailey shared the difficulty in accepting changes to her body, which affected her self‐image and ability to work, ‘Embarrassment certainly. I hide from the world because of it…it's difficult to tell people, isn't it? And it's difficult to find jobs because of it.’ While Bailey acknowledged a history of ACEs, she did not link this to her desire to hide or her identity. Cancer caused a destabilising shift in identity, especially when it affected core aspects like career or hobbies. This forced self‐reflection and loss of control over how others perceive her, increasing psychological distress.

The threat of mortality intensifies identified shifts, as fear of death undermines a stable sense of self, ‘…I got actually quite scared…all I could think to say which was, ‘Will I see my next birthday?’ (Jack), reflecting helplessness and loss of control. Facing mortality forces individuals to re‐examine their values and goals, which is especially challenging for those used to independence.

Ari, a healthcare professional, described her role reversal: ‘… I was always on the one side treating people in the same situation. There I was suddenly teetering on the top of the fence and seeing the other side…’ (Ari). This highlights the profound psychological impact of moving from a position of power (caregiver) to one of vulnerability (patient), resulting in emotional turmoil and a disrupted sense of identity.

This subtheme demonstrates how a cancer diagnosis strips individuals of control, both over their future and their bodies, creating a profound sense of vulnerability and uncertainty and a struggle to redefine their identity.

Overall, Theme 2 examines the intersection of powerlessness and identity transition in cancer patients. The lack of empowerment, especially when medical decisions feel imposed, undermines patient agency and satisfaction. It highlights the importance of TIC principles, particularly ‘trustworthiness and transparency’ and ‘empowerment, voice and choice,’ suggesting that the application of TIC principles would be welcome to reduce distress and foster a more supportive, empowering environment.

Theme 3: ‘I just wanted everyone else around me to be okay’: Distributed effects of cancer through the social network

This theme highlights the distributed effects of cancer within social networks, illustrating how a cancer diagnosis affects not only the individual but also their family, friends and support systems. Participants made no connection between their childhood trauma and cancer experiences.

Subtheme 3a. Managing others' distress alongside my own

Diagnosis disrupted family dynamics and imposed emotional burdens on loved ones. Family roles and routines often shifted, with many participants relying on family and friends for support but also feeling their illness negatively affected those around them. Kendall, for example, said ‘…it had ruined everybody's lives around me…I just felt like I was a bit of a problem…’ Viewing oneself as a ‘burden’ illustrates how cancer can reshape family roles and lead to guilt or self‐blame.

Acceptance of the diagnosis within the family was especially significant when there was a family history of cancer. Cameron found it difficult to disclose his diagnosis, saying, ‘…the most difficult thing for me was to communicate the diagnosis…to my parents specifically…we had many cases of cancer in our family, and you know that they would not take that well.’ His concern highlights the emotional strain of having a family history of cancer, fearing that sharing his diagnosis would distress his parents. This reveals the psychological burden cancer has not only on the individual but also on their family, as it forces them to confront their fears and vulnerabilities.

However, not all participants felt supported. Danni, who felt dismissed by her family, particularly her sister, struggled with feelings of invalidation:

…my sister who I'm very close to…‘well it's only skin cancer; they've cut it out, so what are ya worried about?’… that really does trigger in me that feeling of…‘you just need to get just stop being stupid and get on with it’, and that's the bit I struggle with…

This demonstrates how a lack of understanding from family could create frustration and isolation. Different family responses to a cancer diagnosis can create emotional disconnection, especially when some family members fail to fully understand the emotional toll cancer takes.

This subtheme demonstrates how a cancer diagnosis affects both the individual and family dynamics. Feelings of being a burden or difficulty communicating the diagnosis illustrate the emotional toll that cancer has on the entire family unit. Conflicting reactions, from concern to minimisation or dismissiveness, can complicate support, leading to additional psychological distress as individuals confront cancer.

Subtheme 3b. Accessing cancer support networks and connections with shared experiences

Becoming a member of the cancer community and seeking peer support networks is often a new and proactive process for those diagnosed. Half of the participants, including Nicole, welcomed this aspect of their identity, finding peer support and cancer communities helpful for validation and shared experience through social media and organisations such as Maggie's and Macmillan. Nicole emphasised the value of shared experiences, ‘…that's the biggest support you can give anybody because you're meeting like‐minded people…’ This shows the importance of finding a community that understands and validates the emotional impact of cancer.

Others, like Eden, preferred independent coping, shaped by past experiences, ‘…I'm one of these people who just get on with things and try to do it myself without any outside assistance…’ This mindset was shaped by her childhood experiences, where she lacked emotional support and was taught to be self‐reliant, making it difficult for her to ask for help when needed.

Izzy showed ambivalence toward support networks, torn between wanting a sense of belonging and connection with others and wanting to maintain her privacy,’…I don't want to have to explain everything to everybody… all I really wanted was somebody to just put your arm around you and say, ‘hey, come on, whatever happens, we'll be fine’. This highlights a desire to be offered comfort without the need for explanation. The need for a compassionate approach may be fulfilled through more intimate support networks, such as family, friends or those who have shared experiences.

The diverse experiences in this subtheme highlight the importance of healthcare professionals signposting patients to peer support networks, as some individuals may require guidance and support in accessing these resources. For those who value shared experiences, such networks can provide crucial emotional support.

In summary, cancer's social impact is complex and can influence support‐seeking behaviours and autonomy in choosing support systems is important. These findings align with the ‘peer support’ principle of TIC, though patients often seek support independently if healthcare providers fail to signpost to relevant services.

Theme 4: ‘It's down to bedside manner’: Patient satisfaction is shaped by relational care

The participants did not connect their ACEs with their current cancer care experiences. Relational care met psychological needs and built trust, enhancing patient satisfaction.

Danni's account exemplifies the importance of the components contributing to relational care in patient satisfaction:

…it's about that human touch…not being told about staging in a waiting room full of people, not having consultants with their back to you when they're telling you these things…and have that nurse in the room with you, with the appropriate information…

(Danni)

Compassionate, personalised care helped patients feel valued, rather than care being overly clinical and detached or impersonal. Simple gestures, such as the clinician's body language, can alleviate anxiety and help patients feel seen and valued, and not merely seen just as a diagnosis.

This subtheme recognises the necessity of privacy and dignity during medically sensitive discussions, such as cancer staging, to increase satisfaction, supporting a trauma‐sensitive approach to cancer care.

Subtheme 4a. How a diagnosis is delivered shapes what it does

The way a diagnosis is communicated greatly influences relational care and patient satisfaction. For Izzy, receiving a cancer diagnosis over the phone, without consideration for her emotional state, undermined her trust in the healthcare system:

…he phoned me up and said, ‘By the way you've got secondary bone cancer.’ Hang on a minute. I live by myself…you haven't said, ‘Are you by yourself? Would you like to sit down? I would like you to come in and have a chat’… as he put the phone down, he said, ‘Mind you the x‐ray wasn't that brilliant.

(Izzy)

Izzy's experience illustrates how a lack of empathy when delivering a cancer diagnosis can worsen emotional distress and erode trust in healthcare providers, shaping perceptions of care.

Similarly, non‐verbal cues and communication style affected how valued patients felt:

…somebody's telling them in a really lovely, calm way, very close to them and looking at them in the eye. This guy had his back to me…that's where I get these images in my head that I'm not worth their time…I see it as being a reflection of my value…

(Danni)

Additionally, Danni's unmet expectations about how a cancer diagnosis should be communicated also stemmed from social media representations. Effective diagnosis communication involves tone, non‐verbal cues and consideration of the patient's emotional state. Poor communication can lead to feelings of powerlessness and erode trust, particularly for patients already feeling emotionally overwhelmed by their diagnosis and treatment.

We believe this theme demonstrates how poor relational care can affect how cancer patients perceive themselves and their illness, with negative perceptions (as identified in Aim 1) lowering satisfaction with cancer services. Compassionate interactions appeared to improve satisfaction. However, this would need to be empirically tested.

Subtheme 4b. Needing to be heard as well as helped

The distinction of emotional and practical support in the context of cancer care highlights how both types of support play crucial roles in patients' experiences. While some participants had access to psycho‐oncology services, specialist psychological support integrated within cancer care, addressing emotional distress, adjustment difficulties and mental health needs arising from diagnosis and treatment,this was inconsistent and dependent on the care team and hospital location. Ari noted, ‘… it's just how good your team or consultant is who may present you with it [Psycho‐Oncology referral] as a choice…’

Emotional support from staff reassured patients and alleviated isolation, ‘…‘I'm gonna help you with that.’ That was her statement…straight away it felt like, okay, I'm not having to fight through this on my own…’ Danni's experience highlights the importance of validation, communicating a strong sense of partnership and empathy, and relieving individuals of the emotional burden of feeling alone during cancer.

Practical support with transport and finances reduced stress and improved wellbeing. Bailey received practical advice about benefits and transport, easing the burden of logistical concerns, ‘Maggie's were giving me lots of amazing advice about benefits and hospital transport and school transport because I couldn't even get my son to school.’

Regrettably, gaps in support led to isolation, unmet needs and feelings of abandonment, ‘…Nobody contacted me at all. It was just, you know, get on, on your own…the stupid thing was they've got a new Hospice unit that'd just been opened, and nobody even mentioned it!’ Nicole explained that her hospital's unit for individuals with non‐terminal cancer diagnoses was still called the ‘hospice,’ which was misleading and affected people accessing the unit.

Continuity of care, including support with travel and managing multiple hospital locations for appointments, was described as ‘far worse than the actual treatment’ (Jack). If unaddressed, practical barriers such as long travel distances or inconvenient appointment scheduling can create significant additional stress. Therefore, practical support, such as help with transportation, scheduling of appointments and accessibility, could be crucial for reducing stress and improving the overall experience of care.

The importance of both emotional and practical support in cancer care is clear. Emotional support, like empathy from nurses, helps patients cope with the psychological challenges of cancer, while practical support, such as advice on financial benefits and transportation, can address logistical burdens. When both emotional and practical supports are coordinated and compassionate, patients feel empowered, valued and less isolated during their treatment journey.

Overall, compassionate care, clear communication and coordinated practical support enhanced satisfaction. Gaps remain in accessing psychological support; however, relational care that incorporates empathy, communication and practical support can improve patient satisfaction and overall well‐being, highlighting the need for trauma‐informed approaches.

DISCUSSION

At the time of writing, this research represents the first known UK study to explore the relevance of TIC in oncology, integrating mixed‐methods to examine how ACEs relate to adult cancer experiences. While TIC in oncology has begun to receive empirical attention internationally, particularly in the US and Canada (Davidson et al., 2022), the UK context differs in ways that may shape both the relevance and implementation of such approaches. The NHS operates as a publicly funded, universally accessible system in which cancer services are delivered through structured pathways, multidisciplinary teams and regionally commissioned psycho‐oncology provision. This differs substantially from the insurance‐based, provider‐fragmented systems where much extant TIC research has been conducted; consequently, findings from international contexts cannot be assumed to apply without empirical investigation within UK service structures. Before discussing findings, an important interpretive caveat is warranted: the sample may underrepresent individuals with more severe childhood trauma or complex health needs. Survey participants reported relatively lower ACE scores and high satisfaction with care, and those interviewed, while diverse in age and cancer experience, were predominantly White British and sufficiently resourced to engage in research participation. The patterns described below may therefore reflect experiences of those with moderate rather than severe adversity histories, and those with sufficient psychological resources to reflect on difficult experiences. With this caveat in mind, the implementation of a hybrid mixed‐methods approach captures both statistical associations and in‐depth personal narratives, thereby illuminating aspects of patient experience that might otherwise remain unexplored (Leahey, 2007).

Findings in context

The findings support calls for integrating TIC in oncology, as individuals with ACEs reported more negative illness perceptions and lower satisfaction with care, consistent with evidence that trauma histories can shape health engagement (Sinko et al., 2023; Stillerman et al., 2023). Interestingly, while prior research identifies shame as a significant mediator in health avoidance behaviours (Schnur et al., 2018) and health outcomes of those with ACEs (Dolezal & Lyons, 2017), the results from this study highlight illness perceptions as a stronger mediator between ACEs and patient satisfaction. This complements existing studies that recognise illness perceptions mediate cancer‐related distress (Lee et al., 2023) and aligns with trauma theory suggesting that survivors may be more attuned to perceived threats, such as cancer (Watkins et al., 2018).

The qualitative findings highlight how past trauma can shape cancer care experiences, emphasising the need for clear communication, supportive environments and TIC. Strong provider relationships and TIC approaches can build trust and improve satisfaction outcomes (Lawson & Lawson, 2018). Although TIC appears broadly beneficial in oncology, further research is needed to evaluate its effectiveness. Even patients without explicit trauma histories may benefit from TIC principles, and the emotional responses described by participants echo wider evidence that medical settings can reactivate embodied memories of earlier adversity, particularly in contexts involving uncertainty or reduced control (Kimberg & Wheeler, 2019; Marshall et al., 2023).

The study highlights key themes of disempowerment, trust and autonomy, underscoring the importance of enhancing patient agency and transparency in cancer care. This aligns with Aim 2, which explored psychological mechanisms linking ACEs to cancer‐related experiences and patient satisfaction. Participants often did not consciously link ACEs to their cancer care, but their experiences reflected trauma theory, which posits that unresolved childhood trauma influences present‐day stress responses (Herman, 1992). These accounts also resonate with wider oncology literature showing that cancer diagnosis and treatment frequently involve diminished control and heightened vulnerability, particularly during periods of diagnostic uncertainty or treatment decision‐making (Husson et al., 2013).

Patients' lack of control and emotional burden highlight the critical need for empathic interactions and supportive environments, which are core TIC principles. Effective healthcare‐provider relationships foster trust and satisfaction, supporting findings from Murray and McCrone (2015), key TIC components. TIC addresses both psychological and physical needs, suggesting its universal relevance in cancer care while calling for further empirical testing in oncology settings, directly contributing to the understanding of how trauma impacts cancer care experiences in adulthood, as outlined in Aim 2. Participants' concerns about burdening others and the emotional labour involved in navigating cancer also reflect wider evidence that cancer affects not only the individual but their broader social network (Thamm et al., 2024).

Although most interviewees did not explicitly connect ACEs to cancer, their accounts frequently described experiences that resonate with trauma‐informed principles, suggesting that sensitivity to power dynamics, needs for transparency and desire for collaborative decision‐making may reflect early relational patterns. For instance, Izzy described a consultation where ‘the feeling seems to come back, a similar feeling to the one you had as a kid. Please don't leave or I'm going to be alone’, a moment of implicit connection she did not label as trauma‐related, but which she recognised as emotionally familiar. This aligns with literature showing that unrecognised trauma histories can undermine patients' engagement in care (Lawson & Lawson, 2018) and that trust and compassionate communication are central to overall satisfaction with cancer services (Lown et al., 2011). These relational dynamics mirror wider evidence that empathy, attunement and communication quality are among the strongest predictors of patient satisfaction in oncology (Elkefi et al., 2024). Overall, even those unaware of trauma's role could benefit from TIC's focus on control, communication and emotional support, enhancing care satisfaction and reducing anxiety.

Strengths & limitations and future research

The hybrid methodology provided a nuanced understanding, offering both breadth and depth in understanding the links between ACEs and cancer care, capturing statistical aspects and lived experiences. Thematic analysis combined inductively developed themes and the pre‐existing SAMHSA (2014) TIC framework, enhancing credibility. This hybrid approach allowed themes to be grounded in participants' accounts while remaining theoretically connected to trauma‐informed principles, strengthening the study's contribution to both empirical and applied literatures. Adhering to mixed‐methods quality standards, the study employed the Good Reporting of A Mixed Methods Study (GRAMMS) checklist (O'Cathain et al., 2008) and a 15‐point quality checklist (Clarke & Braun, 2022) to ensure rigour and credibility. Variability in participant quotes used contributed to the rigour of the findings by providing a comprehensive representation of experiences, supporting the study's validity, transferability, transparency and robustness (Clarke & Braun, 2022). Identifying illness perceptions as a mediator between ACEs and patient satisfaction is relatively niche, adding to an underexplored area of oncology and extended evidence on how early experiences can shape adult healthcare behaviours, which in turn can affect overall satisfaction with healthcare services (Schnur et al., 2018).

This study has several limitations that should inform future research. While the quantitative sample size was large, it may not adequately represent individuals with more severe childhood trauma or complex health needs. The use of retrospective self‐reporting introduces potential recall bias (Raja et al., 2021), and the absence of normative comparison data further limits generalisability. The cross‐sectional design also prevents causal conclusions. Additionally, the lack of information on cancer type and service location restricts the transferability of findings to other contexts.

The sample lacked ethnic diversity, with most participants identifying as White British, despite targeted recruitment through culturally specific cancer organisations. This limits insight into the experiences of ethnically diverse groups, who often face systemic barriers such as institutional racism and inadequate care (Hamed et al., 2022; Vaismoradi et al., 2022). Similar disparities exist for sexual and gender minority populations (Kent et al., 2019; Pratt‐Chapman et al., 2021). The interviewed participants also skewed older, limiting relevance to younger patients, whose experiences of ACEs and healthcare may differ.

ACEs were assessed cumulatively, without considering subtypes, which may have obscured more specific trauma patterns. The overall low trauma diversity in the sample also restricts broader applicability. One participant withdrew from the interview due to emotional distress, highlighting the importance of trauma‐sensitive research practices. Future studies should explore trauma subtypes (e.g., using the MAES measure), examine cultural and demographic influences on trauma and care experiences and consider the emotional impact of discussing trauma in cancer settings. Building on Simkhaev's (2024) emphasis on trauma‐informed oncology practices, longitudinal research is needed to examine the pathways through which adverse childhood experiences shape illness perceptions, engagement and satisfaction with cancer care.

Clinical implications

The findings have significant clinical implications. While most participants were satisfied with their care, qualitative themes emphasise relational and emotional needs that are not always met. Given the negative impact of ACEs on patient satisfaction, UK cancer services should adapt by implementing TIC, which prioritises safety, trustworthiness and collaboration between healthcare providers and patients (SAMHSA et al., 2014).

Adopting TIC means recognising early signs of patient distress and acknowledging that trauma can affect both physical and mental health, influencing coping mechanisms and overall response to cancer and recovery (Simkhaev, 2024). This study supports viewing cancer as a potentially traumatic event that can worsen psychological vulnerabilities. TIC offers a framework to address these needs by prioritising safety, trust, empowerment and collaborative communication (Substance Abuse and Mental Health Services Administration (SAMHSA) Trauma and Justice Strategic Initiative et al., 2014). Recognising that trauma responses (e.g., fight, flight, freeze, fawn, flop) can affect information processing (Hayes et al., 2012), clinicians should adapt communication strategies and integrate early distress screening into routine care.

This study's findings align with the NHS Long Term Plan for Cancer Care (NHS, 2019) and the ‘major conditions strategy’ in the UK (Department of Health & Social Care, 2023), which advocate for more personalised, patient‐centred approaches to cancer care. These policies could benefit from incorporating TIC frameworks to address emotional needs, especially for those with ACEs.

Clinical recommendations include incorporating trauma‐informed interventions to reshape illness perceptions, attentive and clear communication and early distress screening. Simple, open questions and awareness of trauma responses and inquiring about a family history of cancer could help tailor care to patients' emotional needs and support information processing. It is crucial to be mindful that some trauma responses (fight, flight, freeze, fawn, flop) can hinder an individual's ability to process information (Hayes et al., 2012). In the context of cancer, this could partially affect the ability to process information related to their diagnosis and treatment plans at that moment.

TIC training for clinicians is essential for recognising trauma‐responding and coping behaviours, reducing provider burnout and fostering a safe and supportive environment. Training should address non‐verbal communication and provider biases to enhance patient engagement, as patients are more likely to trust and engage with providers who demonstrate a trauma‐sensitive approach (De Hert, 2020).

Finally, implementing TIC is a complex, ongoing, multifaceted process, which requires both training and supportive systems and policies throughout healthcare.

CONCLUSION

This study found that individuals with greater ACEs often viewed their cancer as more threatening and reported lower satisfaction with cancer services, regardless of trauma history. Adopting TIC principles, healthcare providers can better meet the complex needs of oncology patients, creating a more compassionate and supportive environment. This study advocated integrating TIC into oncology settings to foster a compassionate, patient‐centred approach that addresses both physical and emotional needs. While this research supports incorporating TIC in cancer care, it does not provide a standardised framework. Implementing TIC may enhance the therapeutic relationship, reduce re‐traumatisation and promote compassionate cancer care for those living with and beyond care. Further research should evaluate TIC's effectiveness in diverse settings and address current limitations.

AUTHOR CONTRIBUTIONS

Brooke Kesic: Conceptualisation; methodology; software; data curation; investigation; validation; formal analysis; visualisation; project administration; resources; writing – original draft; writing – review and editing. Anna Tickle: Conceptualisation; data curation; validation; formal analysis; supervision; visualisation; project administration; resources; writing – original draft; writing – review and editing. Nima Moghaddam: Conceptualisation; methodology; software; data curation; validation; formal analysis; supervision; visualisation; project administration; resources; writing – original draft; writing – review and editing. Michael Rennoldson: Conceptualisation; methodology; formal analysis; resources. Joanna Levene: Conceptualisation; methodology; resources. Hannah Harris: Conceptualisation; resources.

FUNDING INFORMATION

Trent Doctorate in Clinical Psychology, funded by Health Education England.

CONFLICT OF INTEREST STATEMENT

None.

Supporting information

Table S1. Interview participant pseudonyms and ages.

Data S1: Supporting Information.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.