Ask-the-Expert Online Conference
The Ask-the-Expert Online Conference called Breast Cancer Pain featured Ann Berger, R.N., M.S.N., M.D. and Marisa Weiss, M.D. answering your questions about managing pain caused by breast cancer and breast cancer treatments.
Editor's Note: This conference took place in April 2002.
Questions from this conference
- Pain how long after surgery? Percocet addictive?
- Suggestions for extensive bone/joint pain?
- Options for arthritis when history of cancer?
- Tamoxifen causes leg aches and stiffness?
- Post-lumpectomy pain, numbness after two years?
- Does Neurontin always work?
- Why is there so much pain after lumpectomy?
- Severe pains in legs, hips normal with TAC?
- Question from Barb: I had my lymph nodes removed two weeks ago. The drain is still in, and it is painful. Is this normal? Is Percocet addictive?
- Answers - Ann Berger Actually that's a two-part question. The first part has to do with the pain under the armpits, which is normal after an operation, and, in fact, could last for a long period of time. Initially, the pain under the armpit is going to be acute pain, because it's immediate postoperative pain, and part of the discomfort is actually from the drains themselves. Later on, you might develop more numbness and burning sensations. Right now, it's probably very numb, feels very heavy, and also like an achy pain, which is very normal. There is nothing to be concerned about. I would be concerned if you had a fever, and that's actually something to watch for.
- Marisa Weiss, M.D. Before surgery, you probably thought very little about your armpit, but after surgery, all of a sudden your armpit demands a lot of attention. In addition to the pain, you can also have swelling. You may have numbness on the surface but soreness underneath. And with all the movement of your arm back and forth in that area, the whole situation can be aggravated.
To answer the question about Percocet—it is very appropriate to use opiates for this type of underarm pain and no, it is not addictive. These are terms that we really need to go over. When you take opiates or Percocet-type medications, which include morphine, Percocet, and Dilaudid, long-term, they can cause what's called physical dependence. This is not a bad thing. This is what I call a 'Dunkin' Donuts' phenomenon. What that means is that if you drink 24 cups of coffee, and you take away the coffee, you're going to withdraw. If you have 25 Percocet-type medicines a day for many months and many years, and then you quickly take it away, you're going to withdraw. That's not going to happen with a few Percocets a day over a short period of time. That is very different from addiction.
Addiction is a psychological need for the medicine without real pain. It's using the medicine even though you're causing harm to yourself and others. It's a person on the street stealing a TV set to get drugs. That's not anyone on this conference call, and it's, in fact, pretty difficult to become addicted to opiates like morphine and Percocet.
Another thing you can try to do to ease the pain are the exercises you can learn about through Reach for Recovery. They'll bring you a ball, special pillows, and they will show you climbing exercises.
- Marisa Weiss, M.D. When can someone start doing those exercises? And how do you get started?
- Ann Berger Almost immediately after the operation. This I can only answer from my personal experience, which was almost immediately after the operation.
- Question from Jennifer: Since chemo two years ago, I have had extensive pain in bones/joints. X-rays have revealed some arthritis, but not enough to be causing this much pain. I've used Vioxx, Celebrex, Disalcid, Tylenol, Aleve, Ibuprofen, etc. Nothing seems to help. Doctors can't find a cause, so I don't know what to do. Any suggestions?
- Answers - Ann Berger Treatment for arthritis-type pains are the nonsteroidals, which are drugs like Motrin—all those you've listed. When those don't work, or if they cause side effects (sometimes they will cause stomachaches and things like that, such as nausea), it's perfectly reasonable for a physician to consider using opioid drugs like morphine and Percocet-type medicines. What you should know is that sometimes the etiology (the cause of the pain) may not be known. Sometimes that happens with pain syndromes. This is not something that is ringing bells, not something we see frequently, but it sounds like you've developed some kind of arthritis-type syndrome.
Marisa Weiss, M.D.
Arthritis is a syndrome where you have pain in and around the joints. Some people also experience prolonged, persistent discomfort in the long part of the bone, as well as in the muscles surrounding the bone. Chemotherapy, such as Taxol, tends to produce discomfort in the joints, as well as in the lower legs and forearms. It occurs during the period of time that you are receiving it, over months. But it can also persist for a long time after you are finished getting it. I have several patients who have had persistent lower leg and arm discomfort that's lasted from six months up to a year.
It's unclear exactly what's causing the pain, but it has many components to it. It has a nerve (neuropathic) component, and also muscle, joint, and ligament components. It can respond to a drug called Neurontin, or other anti-seizure medicines, as well as some other of the tricyclic antidepressants. The good news is it eventually goes away, but it can linger for a while. Occasionally, the pain may persist. If this happens to you, ask to speak to a pain specialist.
Another thing that may help, since you're complaining of bone and joint-type pain, may be heat, massage and swimming. If the testing is continuously being done, and if when you're under treatment, you are continuously tested, and it is normal, and your bone scans are normal, you should not be concerned this is cancer.
I know from my personal experience that three days after being diagnosed, I had severe back pain and thought it was cancer, and it turned out to be a herniated disk. Six to seven months later, when running around lecturing, the back pain returned, and I thought it was cancer even though I'd had normal scans, and the cancer likelihood was extremely low.
That's probably, many times, one of the biggest questions people have in the back of their mind—whether it's the cancer that's returned. I've experienced that myself, and understand that feeling, because once you've had cancer, pain, or any other prolonged symptom, it's never just a symptom anymore. Be reassured that as long as you're having the scans and seeing your doctors, these symptoms are probably not the cancer. But it's important to remember that if the pain gets worse or changes character, then you should go for more testing.
- Question from Mandy: What options, in terms of pain management treatment, would you recommend when you suffer from arthritis and have a history of breast cancer?
- Answers - Ann Berger The same type of treatments I'd recommend for arthritis without breast cancer, which would be nonsteroidals. If those don't work, opioid medications, exercise, massage, and heat—the same types of things whether you have breast cancer or not.
- Question from Stephanie: Could tamoxifen be connected to leg aches and stiffness? After sitting for a long time, and when sleeping, I feel a stiffness and achyness that I don't think was there before tamoxifen. I've been taking it for two and a half years. Thank you.
- Answers - Ann Berger I have heard of women who are on tamoxifen and do complain of these types of pains, so this is probably normal. It's not something we see commonly, but it's certainly something that I've seen, and it's also an arthritis-type of condition. It's probably exacerbated by the hormonal properties of tamoxifen.
Marisa Weiss, M.D.
For women who first went through chemotherapy, and who then go on tamoxifen, sometimes it's hard to tell which symptoms that you're having are due to the chemotherapy or due to the tamoxifen. Also, most women take tamoxifen for five years.
So as you grow older through those five years, you may notice some new aches and discomforts, because you're growing older and you're experiencing the wear and tear of living. Some women also become relatively inactive for a period of time between diagnosis, end of treatment, and recovery, and may gain weight through that period of time, as well. These things together can lead to lack of conditioning and some increased stiffness.
- Question from Phoenix: It's been more than two years since I had two lumpectomies to remove a 1.7 cm tumor, followed by chemo and radiation, and I still have pain in the breast, and numbness in my armpit and under my arm. Is this normal? The breast pain is worrisome, and the numbness is annoying and upsetting. How long will it take to get full sensation back under the arm? Should I be worried about the breast pain?
This is not an uncommon problem. It's a common phenomenon in at least 25 percent of women—post-lumpectomy pain. Generally, when they have this syndrome, women will feel a lot of pain, numbness, and burning under the armpit and across the chest. Sometimes there are shooting sensations from areas on the scar itself. Sometimes there's a sensation of a constricting band around the arm, almost as if there were a blood pressure cuff on the arm all the time. Most of the time this occurs because of injury to a nerve. Commonly, there's a nerve called the Intercostal Brachial nerve, which is injured during surgery.
These sensations can last for a long period of time, and can actually occur anywhere from weeks after the surgery itself, to years later. Women who experience this pain should be seen in a pain center, because there are definitely treatments for it. If it were nerve pain, or neuropathic pain, the treatments that would help would be drugs like tricyclic antidepressants, which are old-time antidepressants, or anti-seizure medications like Neurontin.
There are also topical medications that we can use, medicines like EMLA, Lidoderm patches, and Capsaicin, which is available over the counter and made from hot peppers. For some people, it could burn. For others, it can help the pain itself, but with an initial sensation of warmth. It's important to be seen in a pain center, because there are some nerve blocks that can be done. In particular, one that is sometimes helpful would be the Stellate Ganglion Block, which would be done by an anesthesiologist trained in pain medicine.
The other thing worth thinking about and considering would be acupuncture. I say that because there is little written about it, but acupuncture clearly helps what we call neuropathic pain. From my experience, that's what helped me. I had severe nerve pain post-mastectomy, down one side, and I immediately went for acupuncture. It seemed to relieve it rather quickly.
- Marisa Weiss, M.D. In someone who experiences neuropathic pain in a particular area, you might end up guarding that area, meaning that you try not to use it or move it at all.
- Ann Berger That will cause a myofascial, or muscular, problem. So along with pain treatments, it's always advisable, in particular for post-mastectomy pains, to add physical therapy, stretching, exercises, and massage.
- Question from DT: Does Neurontin always work? I am taking it now for pain in my shoulder, arm, and back. I keep increasing the dosage per my doctor's instructions. It seems to work for a few days, but then the severe pain returns. My doctors have not been able to determine the exact cause of my pain, but they believe it is nerve damage caused by radiation.
- Answers - Ann Berger No, Neurontin doesn't always work. It works about 40 to 50 percent of the time. But there are other medications if Neurontin doesn't work. Also, you need to get to a therapeutic dose, and chances are you're not at that dose. A therapeutic dose is 3600mg, and that's per day. Normally, it's a medication you divide between three doses a day. Sometimes with that particular medication, you can feel very sleepy, particularly when you take it during the day. A way we have been able to manage people with pain with that medication is to use higher doses at night, and lower doses during the day.
- Marisa Weiss, M.D. It takes trial and error. Also, when you try a new medication or a combination of new medications, you're trying to handle some of the side effects of the pain medication as well. You might find a medication that takes care of your pain completely, but it leaves you with other issues to manage, like constipation or sleepiness. Dr. Berger, how do you handle some of the constipation problems that go along with using opioids or narcotics?
- Ann Berger The way we handle it is to prevent it. Constipation is something that will happen almost 100 percent of the time on opioids, so the trick is to treat it before it happens. At the moment you start with the medication, you should also be taking something for your bowels. Unfortunately, this isn't always done. That something will be a stool softener, as well as something to help move your bowels like a Senna and Colace combination. Senokot is one you can take up to eight a day before you can say that it doesn't work. Other ones are Lactulose and MiraLax, which is a new one. We also advise doing all the things you would routinely do for constipation, like pushing fluids, lots of water, and eating high-fiber foods like bran products, whole wheat breads and fruit juices.
- Marisa Weiss, M.D. How do you handle some of the nausea?
- Ann Berger If you become nauseated from an opiate and the nausea doesn't go away, you can always switch to another opiate. But for all medications, you can also add an anti-nausea medicine. Now that's sometimes trial and error, because there are different reasons why women might be nauseated. The reason could be because of a central mechanism, meaning there's an area in the brain that responds to medications and causes nausea, or because there's what we call a peripheral mechanism, something in the stomach area, or a mechanism related to motion sickness. So the anti-nausea medicines will be chosen based on what mechanism is involved.
- Question from Jenn: I have recently had a lump removed, and it came back showing three different types of cancer. Now I face a mastectomy, but as I wait, I am in a lot of deep pain with my breast and a prickly pain around the nipple area. Why?
- Answers - Ann Berger It's probably a fluid or blood collection around the site of the lumpectomy, and some inflammation.
- Marisa Weiss, M.D. The collection can put pressure on the nerve and the surrounding tissues that can be uncomfortable.
Another thing is that, in general, most women don't feel their breasts except for perhaps during their cycle. That was true for me. Then during all of this, you start feeling sensations you've never felt before. This is normal. Some of it is probably psychological. Some is probably due to the lumpectomy and inflammation, and some sensations come up because you're noticing things with a problem you never thought of before.
There is sometimes breast discomfort and a normal sensation as if the breast were there after mastectomy, particularly during your cycle. I personally experienced that. I initially thought it was crazy with no breast tissue. I never felt my breasts during my cycles. Now I have discomfort as if there were breasts there. It's only during a cycle. When I asked my oncologist colleague, she said she hears this a fair amount. So it could be a hormonal thing.
- Question from D. Brooks: I am in my fifth out of sixth treatment with the TAC Aredia, Cytoxan, and Taxotere (all together) protocol. I have severe aches and pains throughout my legs, hips, etc. Is this normal? Every treatment is worse and lasts longer.
- Answers - Ann Berger Absolutely. It's from the treatment. You're probably also on GCSF or Neupogen (it stimulates new immune cell production). Those are feelings that are perfectly normal.
- Marisa Weiss, M.D. Taxotere and Taxol can both cause some of these discomforts, as well.
- Ann Berger The treatment, if nonsteroidals don't work, usually ends up being opioid medication. It's not uncommon that this gets worse with each cycle. That's typical.
- Marisa Weiss, M.D. After these treatments have been completed, these symptoms usually go away, but it takes a while and sometimes the pain lingers for a long time.
- Question from Rita: Are anti-depression drugs good for pain?
- Answers - Ann Berger The antidepressant drugs that are helpful for pain are the old types called tricylics. The newer types like Prozac and Zoloft are not usually helpful for pain.
- Marisa Weiss, M.D. Does one take this type of medication alone, or would you combine it with another?
- Ann Berger For some neuropathic pain, you can get away with it alone, but sometimes with an opioid. For things like diabetic neuropathy, it's the treatment of choice just alone, and sometimes it works just alone. Not usually, but sometimes.
- Marisa Weiss, M.D. With these types of pain medications, how quickly do they relieve the discomfort? How long should we wait to give them a fair shot?
- Ann Berger Much like drugs like Neurontin that we talked about, it takes time, and you have to get what's called a therapeutic dose. A therapeutic dose is different for each individual. In general, with the tricyclic antidepressants, you need to get to antidepressant levels, so that might be 100-150mg of a medication a day. Don't become discouraged if you're at 25mg and nothing's happening, because it's not uncommon for physicians to give low doses. After that, if this isn't working, then we drop the medicine.
- Question from Cookie: From the chemo, I have a lot of pain during intercourse. Is this normal?
- Answers - Ann Berger Yes, because there is more vaginal dryness. You can use lubrications. Chances are the chemotherapy put you into a menopausal state.
- Marisa Weiss, M.D. You can find a lot of information about how to handle painful sex and a dry vagina at Breastcancer.org in the section on menopause. We also had online conferences on this subject.
- Question from Blue Hat: I'm worried that if I complain about pain, my family will just worry about me even more, and that'll just make it harder for me. What can I do?
This is actually not an uncommon problem. Usually, one of the barriers to treatment is that patients don't tell their doctors they have pain. I think one of the reasons they don't tell is exactly what you are saying, which is that it will alarm the family. You have the sense that if you complain about it, the fear is it's probably the cancer, and you don't want to deal with that. There's also a sense that you don't want to interfere with your doctor taking care of your cancer, and if you tell about these ancillary problems, he won't be concentrating on treating the cancer.
It is important to communicate to your physician or nurse about pain. It is important that it is known. First of all, it's important to find out if it's the cancer or not. Everybody needs to have his or her pain treated. You do not need to live with pain. As a pain and palliative care physician, I see it as a failure to cure breast cancer but have somebody in chronic pain. The important thing is to have somebody that is having quality of life and is totally cured, and not just have the cancer cured or put into remission.
- Marisa Weiss, M.D. I agree completely. I have some patients who just throw up their hands and say, "I guess I should just be grateful that I'm alive." And what Dr. Berger is saying is that we need to shoot for a higher goal than just that.
- Ann Berger This is also normal, because many women think their doctors won't listen, and they don't. In my experience, when I had my episode of neuropathic pain, I was about a week to two after the operation, and I couldn't sleep at night, which is a normal problem. It wasn't pain; I just couldn't sleep. And then a few nights, I'd wake up with nerve pain down my arm, and it was like my arm felt blown out, my hand was blown up, and I knew I was dealing with a potentially long-term problem. The first thing my husband said at three o'clock a.m. after a few nights was, "What's going on?" I answered that this was nerve pain. His comment was that maybe I need to tell the surgeon or plastic surgeon involved, and my comment was, "I'm not calling those dummies. They're going to blow me off." The person I did call was a physician who did acupuncture. At my next visit, I did say something to my plastic surgeon, who was an excellent plastic surgeon, but the first thing she said was, "I don't know why you'd be having pain. It doesn't make sense."
- Marisa Weiss, M.D. Whom do you think the best physician or nurse is to bring your pain concerns to as a first step?
- Ann Berger I think you need to take it to your surgeon or oncologist, depending on your physician at that time in your treatment. If that person does not listen, then look further. Go back to your primary care physician, if you have one, or demand that somebody who may be able to help your pain, like a pain management person, see you. In terms of not telling family, families are more concerned when they don't know what's going on. Particularly if you're in pain, family members who care about you are going to know you're in pain even if you don't say something. They'll be more concerned if you don't say something. Sometimes the not knowing can be more concerning than knowing something.
- Marisa Weiss, M.D. Take care of your pain! Don't let these concerns stand in your way!
- Question from Rita: I still have pain from Taxol, neuropathy in my fingers, and it really hurts bad sometimes. What can I do?
- Answers - Ann Berger The same medications we've talked about before—the tricyclics and antidepressants, like Desipramine, Nortriptyline, and Elavil—are some examples. Also, drugs like Neurontin, Tegretol, or Dilantin. The other thing would be going for rehabilitation medicine. They actually do things like what they call sensitization. They work with exercises with balls, and they are sometimes able to help neuropathic pain.
- Marisa Weiss, M.D. There are some pain management protocols that include both Neurontin and Glutamine with significant success. These are still in the research phase. Again, this type of pain can be very difficult to manage. I have a patient, for example, who had trouble walking because of this type of pain in her feet and ankles. But miraculously, about six months after her treatment was over, the pain did go away, and she was able to stop all these medications.
- Ann Berger In conjunction with these medications, one may be giving morphine-type medicines, opioids, which usually will take the edge off. They will take the pain from a ten to a seven, but not take away the pain totally.
- Marisa Weiss, M.D. Dr. Berger, would you agree that insomnia and chronic sleep deprivation can make any pain worse than it has to be?
- Ann Berger It's cyclical, because pain causes insomnia, and it works both ways, but absolutely.
- Marisa Weiss, M.D. Are there sleeping medicines that work well or don't work well with the pain medications we're discussing here?
I never add sleep medicines, because the tricyclic antidepressants and the gabapentin (Neurontin), the anti-seizure medicines, as well as the opiates, are extremely sedating. That's usually the limiting side effect in terms of not being able to increase doses, and so what I would normally do is give those medicines at night, or more of it at night to help with sleep, but then I know I'm taking away the pain. The sleep medications that are generally used are more benzodiazepines like Ativan.
Those medicines are not going to help the pain, so you can make people sleep better, but they will wake up in pain. My goal is to help the pain, and all of them make people so sleepy that, if you give enough of them, you don't need to give an extra sleep medicine.
- Marisa Weiss, M.D. If some of you are experiencing pain as well as hot flashes, the hot flashes coming from early onset of menopause or related to medications you're taking, the good news is that some of these pain medications can also improve hot flashes.
- Question from Mary: Can Taxol cause continuing pain after treatment? It's been almost three years, but I had some problems before diagnosis of breast cancer, and I wonder if I had the fibro all along. The Taxol just seemed to send it into overdrive. I was diagnosed with fibromyalgia after treatment.
- Answers - Ann Berger Yes, it's not uncommon to have pain after Taxol for long periods. What you're probably experiencing is widespread muscle, or myofascial-type, pain. Whether it's fibromyalgia or not, it's muscle-type pain. Fibromyalgia is a very difficult diagnosis. It's widespread muscle pain, and it is not uncommon for women, after Taxol, to have it, and not uncommon for women without breast cancer. Fibromyalgia-type pains are common. The treatments would be tricyclic antidepressants. Sometimes muscle relaxant-type medications like Baclofen, and definitely massage and acupuncture play a role here. Acupuncture is widely accepted in fibromyalgia.
- Marisa Weiss, M.D. What role do visualization, meditation, and biofeedback play?
- Ann Berger All of those things help pain tremendously. We use probably 50-80 percent of nonpharmacologic methods in our NIH pain clinic, meaning non-medication. The things we use include massage, relaxation, hypnosis, and Reiki therapy, which is also very helpful in fibromyalgia and chronic fatigue syndromes. We have an acupuncture therapist, a music therapist, pet therapy, and art therapy. All of these things are very helpful in all of pain management in whatever pain people are experiencing, whether Taxol or fibromyalgia. It doesn't have to be cancer-related pain.
- Marisa Weiss, M.D. How about chocolate?
- Ann Berger That helps me! It increases your endorphins.
- Question from Binney: Eight months ago, the lining of my rib became inflamed from radiation; it still aches, and it makes wearing my prosthesis difficult, especially as the day wears on. The oncologist says women learn to live with that, but is there something I can do to relieve it?
- Answers - Ann Berger That's not easy. That's probably partly neuropathic, and it may be partly inflammatory, so try medications for nerve pain. Try some nonsteroidal-type medicines. I have the implants, and I have found that I cannot wear a bra at all because of the same problem. I did not have radiation. I had bilateral mastectomies and saline implants, and I have constant chronic pain at the end of the day if I wear any kind of real bra. Basically, what I wear are sports bras.
Marisa Weiss, M.D.
The surface around the bone, called the periosteum, is very sensitive. The implants can put a lot of pressure on the rib cage and can actually depress it, and this is one source of discomfort. Radiation-related chest wall discomfort is not uncommon. It does tend to ease up over time. It may take weeks or months. It can be made worse by extra bursts of activity. The muscle that connects the shoulder to your chest, called the pectoralis muscle, is in most radiation treatment fields and can become stiffer and tender. This type of discomfort responds to regular symmetrical conditioning.
Some of my patients find yoga to be helpful, as well, because it gently stretches the muscles and tissues of the body, and it increases muscle tone and helps strengthen your mind's ability to focus away from the pain. It also strengthens the muscle and improves the tone of the general area.
- Ann Berger But you should know that what you're feeling is normal. When I said something to my plastic surgeon, he didn't understand. I've gone to another here, and the response was the same. They don't understand. They say, "Most people don't have this problem." I think most people just don't say they have the problem. The reality is, I suspect, that this is rather normal, and you do learn to live with it. But if the prosthesis hurts halfway through the day, then take it off. My solution is not to wear a bra at all. And at this point, even for important formal events, I just won't do it. I don't want to pay the price later.
- Marisa Weiss, M.D. After breast cancer surgery, many of the cushions are removed that normally protect the tissues of the chest wall and the armpit. The breast, besides being a source of nutrition for a baby and a sexual organ, also function as a cushion for your chest wall. Lymph nodes are removed from under your arm along with a pad of fat that cushions the movement of your arm against your body. When these cushions are removed, the structures underneath lose some of their protection and can become sensitized.
- Question from PJ: My breast has been painful during a week of every month since my treatment ended one year ago. (Lumpectomy, radiation). Recently, the pain is daily and is in the ribs below my breast. I take 2mg Dilaudid, which helps for about four hours. I'm not as concerned about the pain as I am about what it means. Does new pain always mean a new problem?
I'm not sure whether you are taking dilaudid once a day or every four hours. If you need it every four hours, your pain is severe enough that you should get tests to rule out metastatic cancer. If you're taking it once a day, and the pain is relieved for the day, it sounds like what the person just before described. But particularly where you're describing it at the ribs and chest wall area, if x-rays are normal and exam is normal, then be reassured that this is probably not cancer. Yes, it's fine if you take the Dilaudid every day.
Pain and palliative care, symptomatic management, and dealing with quality of life issues are probably the fastest growing medical fields right now. Lots of research is being done in these areas, and a lot more emphasis is being put on the importance of treatment of symptoms and of the whole person. It's now becoming a requirement from the Joint Commissions that all institutions look at pain. Soon, it will be pain and other symptoms because, basically, it's part of a patient's bill of right not to have these symptoms. So as more and more research is being done on it, there's more and more acceptance in the medical field that these are important issues that need to be dealt with.
- Marisa Weiss, M.D. It can be very helpful to prepare a report about your pain before you go to the doctor. Think about what the nature of the pain is, where it's located, what makes it better, what makes it worse, and if there are other symptoms that go along with the pain. Another thing that can make communication difficult is that many people have different words for pain. For example, I have many times asked a patient if she's having any pain and she might say, "No," but she might then add, "But I am having some discomfort," or "I do have an ache or some soreness," or "I have a nagging problem over here." So it is important to make your doctor understand what's bothering you and what's getting in your way of feeling comfortable each day and night so that you can return to a life that is enjoyable, fun, and fulfilling.