Cumulative burden of adverse childhood experiences (ACEs) and non-adherence to breast cancer screening: A dose-response and network intervention analysis

Abstract Adverse childhood experiences (ACEs) are established determinants of adult health behaviors, yet their specific impact on cancer screening adherence remains under-explored. Understanding how distinct ACE patterns interact to hinder screening is essential for designing targeted interventions. This study aim to investigate the dose-response association between cumulative ACEs and mammography screening non-adherence, examine the independent effects of ACE types, and identify optimal targets for improving screening adherence. Data were drawn from the 2020, 2022, and 2024 Behavioral Risk Factor Surveillance System (BRFSS) surveys, including 47,939 women aged 50 to 74 years. Poor adherence was defined as self-reported lack of mammography screening within the past two years. Logistic regression was used to assess the association between ACEs scores, individual ACE, and adherence. Ising model estimated the network structure of eight ACE indicators, the NodeIdentifyR algorithm (NIRA) was deployed to simulate node-specific intervention effects and identify high-impact targets. Among the 47,939 respondents, 21.5% reported non-adherence to guideline-recommended screening (hereafter poor adherence, PA). Adjusted odds of PA were 42% higher for those with an ACEs ≥4 (OR 1.42, 95% CI 1.22–1.64) and increased 7% per additional ACE (OR 1.07, 95% CI 1.04–1.10). Sexual abuse had the strongest independent association. “Household Substance Abuse” exhibited the highest betweenness centrality and expected influence, decreasing the impact of “Emotional Abuse” resulted in the greatest projected reduction in cumulative adversity load. ACEs were associated with mammography non-adherence in a dose-response manner. Trauma-informed strategies addressing the sequelae of emotional abuse might most effectively improve screening uptake among women with high ACE burden.