I was told for the very first time I had Stage 4 Breast Cancer that has Metastasized to my Lymph Nodes, Liver, Right Lung, and T-9 area of my Spine. I have never heard those words before. I was put on Ibrance 125 mg and Letrozole 2.5 mg. I take the Ibrance 21 days out of 28 and my 7 days off I take Zometa for the bone cancer. I have been told they can't cure me they only hope to put it to sleep to give me a few more years. I'm a 58 year old woman with very little support from my family. I lost my husband of 31 years Jan 2016 and found the lump in Nov 2016. I had no insurance so it was late June 2017 before I could get insurance to get it looked at. I have gone to someone enjoying life to the fullest to someone that can barely get out of bed. I don't even know myself anymore. The side effects have been the worse. If anyone going through what I am please let me know. Mine is ER+ so it is harmone driven and I have never taken a harmone pill in my life. Thanks for taking the time to read my story and passing along any help you can. It has been more than I can deal with at times.
Living with Stage 4 Breast Cancer tha... - SHARE Metastatic ...
Living with Stage 4 Breast Cancer that has Metastasized
Hi Pj,
I was DX Feb9,2016 and I was also told that the Cancer had been in my right breast for appx 13 months pior🐞Im am currently on the same treatment as you with the exception of the ibrance.My oncologists felt that since I have been stable on the Letrozole that I didn’t need to add the ibrance yet!
Although the head nurse was concerned that I wasn’t in ibrance so sounds like your on the right treatment ♥️
I do believe that some of what your feeling is due to the side efffects of the meds.
I have a lot of joint pain and weight gain of 30 pounds other than Some fatigue after my infusions for maybe a day I am doing well!
I can say that for me the symptoms? Have got worse in the beginning I felt no fatigue at all or pain just weight gain😢
walk small walkmdaily that will help and also drink lots of 💧 Also when your moving and it’s painful keep moving the more I move the better I feel!
I am always here to share and help we will be 🙏 God Bless you
Have an awesome day🐞
I have a lot of joint pain and pain in my breast. I have lost about 40 pounds since July. The Zometa makes me sick sometimes. Now my port is messing up the last two months they have not been able to get the blood out for my blood work. I'm just tried of being tired cause that never was me. I was always the type that hit the floor running and never let up till everything was done. Now I can't even clean my kitchen without it taking me two or three times to get it done.
Pj, something to try, when your port won’t work, is to switch positions. Raising your left arm often moves the end enough to allow flow. Twisting slightly also seems to work, and even getting drawn while laying down is a trick the oncology nurses passed onto me. Make sure they are flushing it really well when it does work, request an extra vial of saline before the heparin they put in. Ports can be tricky, but really it is quite odd it hasn’t worked two months in a row.
I’ve been stage 4 for 8 years. My treatment plan is different, though I am Er+ as well. All I can say is, getting it “to sleep” is a hard journey, but once it is, years can follow. Don’t give up. I wanted to give up when my cancer was active. I had 5 years of “sleep” and am now active again. One thing I’ve learned is “live for something else”. Don’t live for your doctors appointment tomorrow, or your next infusion, or your side effects. Live for the movie you want to see, spring flowers popping up, and so much more, I know it’s hard, and I slip often, but try to remind myself to live for something besides cancer. Because it is not who I am. God Bless.
Thanks for the kind words. We have done the moving around, lying down, holding my arm behind my head, coughing, leaning forward, I really think we have done everything but have me stand on my head. Last month it was almost 3 hours before it would work. They finally ran this blood thinner thru it that they really don't like to do. I have never been one to drink a lot of water, I live on Sundrops which don't help at all. I have really been trying to drink an extra glass of water each day so when I go back maybe it will work. We know it is still in place cause I have that taste in my mouth. Maybe the water will be the answer.
The taste does not indicate correct placement. It only indicates that your port is open. The end of mine inverted toward the vessel wall so when they would draw (suction) it would literally attach via suction to the wall. When something is pressed thru however it can go. If you are having issues, request an X-ray to look at placement. They can move, invert, etc. they are placed right at the opening into the heart but still within the vessel. Just wanted to give you some options. (My nurse also used raising my heart rate, I would fast walk the clinic after she got the needle in, then she would draw. For some reason the extra blood flow helped it stay in a better place). What we don’t do for science right? Lol. If it works, so be it.!
No need to have taken hormones to have this. I haven’t either. My SE are not as severe as those that you are describing. But we all respond differently. A couple of thoughts/ideas:
Some people do better on a lower ibrance dose. It’s very common. I’m ok with the max but I have a lot of achy parts and stiffness when I start moving. But water and movement really does help.
You have been dealt some really tough blows in the last few years. I am on antidepressant and will be doing some therapy just to keep my head in a decent place.
The overwhelming feeling is quite normal but still sucks big time. Best wishes for your day - keep in touch venting always helps me.
Dear Pjriggs
I think in some states mbc is automatic disability and that can include benefits that you don’t have now. The social worker at yout doctors hospital should be able to help, or call social security or the American Cancer Society. Maybe someone on this board has better info in that regard. My psychiatrist offered to help me go out in disability because I was an absolute mess for a long time. Do you have some friends who can help you? This is so overwhelming you really need help and support. Is there a support group nearby? Although there are many breast cancer support groups I’d seek out one for people with metastatic disease. Call Share or living beyond breast cancer and talk to someone. I had to go and have continued to go to therapy and am in antidepressants and once in a while xanax first anxiety’. Do you still work? I am so sorry life hit you so hard following the death of your dear husband. Please continue to reach out on this board. Talking to a peer buddy thru SHARE was so helpful to me. And although I sat in my couch wrapped in a blanket for weeks shaking the worst thing you can do is isolate yourself. I hope you have a friend or friends that you can get out of your house with and go for lunch or a movie. It might sound trite considering what you are dealing with but you need a break however small from being a Cancer patient. Please Stay in touch on this board and let me know how it is going. I’ll keep you in my thoughts.
I was approved for my disability 2 weeks after I applied. They put me on TennCare Medicaid and I can't get any of the meds I was on before changing to TennCare Medicaid. I live in a small town and there is no support group around here. Thanks for your reply and with my faith maybe things will get better for me. I'm not able to work anymore so I said this year will be the year I work on me getting back to myself. It's just been so long I don't remember what me feels like anymore.
I am going back to work slowly. You can do this, with support from this board if that's all you can get!!! Avoid sugar and all white carbs, they will make you feel crappy. Work on your nutrition, experiment to see what works. I juice, eat mostly protien, fruits and vegetables, and pure dairy. Exercise, keep cleaning your kitchen! I go to the gym four times weekly. Get a social worker, they know of program to help you. Get a therapist, talking helps. And you can learn new coping skills. Also take this on like this is your job...if this was a person who you had to care for...like make a schedule to follow for health, spend time every day exercise , prep food as you are able, do paperwork, self-education.
Hi. I am also on Ibrance 125mg and Letrozole 2.5mg. It's been difficult to adjust to the side effects, especially the fatigue, but as was mentioned above, some people can't tolerate the highest Ibrance dose and need to have it lowered... something you may want to discuss with your oncologist. I to was in a very dark place shortly after being diagnosed and know it's frightening and feels overwhelming. What helped me was my faith, joining online support boards such as this one, where I learned so much from others in the same situation and found support, and speaking with an oncology social worker, which some support groups offer free of charge. I also went on antidepressants for a few months and use anti-anxiety meds as needed. I'm glad that you found this group and reached out...there are great people here who can help answer your questions and offer support. I hope you stay and keep us posted.
My Dr said after they do my three month scans this next time if everything is still looking good she will about dropping me down to the 100 mg. She said I was doing great with it and my blood work is staying good. I was approved for my disability in July last year and they put me on TennCare Medicaid. I can't get them to cover any of my meds I was on with my other insurance. They have a formula and untill I get everything on their formula they are not going to approve me for anything else. Being told I can't be cured and having to fight the insurance company is more than I can handle at times. Thanks for your kind words I do feel like I'm alone fighting this and not knowing how much time I have left. I do take something for my anxiety. I just have a hard time sleeping and I want sleep in fear I won't wake back up.
Hi PJ,
I feel your pain and can tell you are still in a very dark place right now. This online group is so nice and helpful. Nobody judging anybody and we all have this same exact crappy disease. I too went to a very dark place for a while after being diagnosed.
There are drugs for this very thing-who knew lol. Get some-take them.
Take the Tylenol to get you thru the day until you can’t take it any longer then take the more intense pain relief.
Heating pads can be you very best friend. The fatigue is completely normal too unfortunately, but I found that with time this gets better and I spent fewer and fewer hours sleeping. I’ve been at this for 22 months now and am happy to tell you that most of my days are pretty normal now. Up at 8 or 9, some days a hour and half nap about 4 and then to bed for the night around 11.
Yes, I am in constant pain from numerous parts of my body but I have found a way (over time) to say “I’m not listening to you right now and I have things to do”. I no longer work outside the home but I spend my days doing exactly what I want to do. I walk the dog, I sew, I garden, I cook, I read, however much or little I choose to do.
PJ, I can’t even imagine adding the death of my husband into this cancer party and you must be an incredibly strong woman! We are all right here for you to share your journey. Please reach out to us as often as you want.
Please Don’t give up! Baby steps. Make tomorrow morning the first day of your adventure. Find just 2 things to smile about and report back to us what they were 👍🏻
God blesses us every day with miracles 🙏
So sorry to read about your story, but the good news is you have the courage to post it, to keep fighting it and know that like many wonen on this site, knowing and being reassured that God loves us deeply, cares for each one of us, no matter the case or who ee are, and wants to do something really special with our lives. If you haven’t had this experience, I challenge you to find a support group of beautiful women who are there to help you and be of confort at this time. That is key to be able to cope with it all.
God bless you richly and return your joy and purpose in life!
Hi, and welcome to a group nobody wants to qualify for. Lots of wisdom, information and support here. I sure understand feeling unlike yourself! I've had to deal with that, too! Later this week, I will hit the 14 year mark of living with metastatic breast cancer, MBC. I was diagnosed at stage IV, with bone mets and an estrogen + bc. Early in my treatment with Femara and Zometa, I would get hit with waves of fatigue and feel as though I needed to lie down on the floor where I stood for a four year long nap! I also got hot flashes that turned me bright red and had sweat pouring down my face, neck, chest......... I was 57 years old, newly remarried and totally devastated about this diagnosis. If only I had known then that I would live at least another 14 years, probably quite a few years more than that.....but we don't live life that way! One way that I have coped is to learn everything I can about bc, mbc and treatment. One thing I learned is that there are oncologists who specialize in treating bc and both see patients and do research. The best places to see them are Comprehensive Cancer Centers and there is one of those in Nashville...I just looked it up on the National Cancer Institute website, it's Vanderbilt-Ingram Cancer Center 691 Preston Research Building
, Nashville, Tennessee 37232 (615) 936-8422
cancer.gov/research/nci-rol...
I saw a bc specialist onc about a month after I was first diagnosed, at the suggestion of my own local general onc who got an appt set up for me within ten days. When that onc examined my breasts, it felt totally different than when any other doctor or nurse had done it--it was as though she had done it not just thousands of times but tens of thousands or hundreds of thousands and she had radar in her finger tips. She looked me in the eye and said "you are not dying, you have years not months" and I left there feeling ten pounds lighter!
Both Femara and Zometa can cause achy bones. There are some things to ask your onc about. Sometimes switching meds can help and there are meds very similar to those two. Arimidex is like Femara in that both are non-steroidal aromatase inhibitors and they are often used interchangeably. Often individual oncs just prefer one or the other. And the bone drug Xgeva is newer than Zometa and is easier to get as it is an injection rather than an IV. I was already on the arthritis drug Celebrex when I was diagnosed and it has helped my bone pain alot and I have not had bone pain the whole time I have been in treatment. Ibrance was not around when I was diagnosed but my onc added it to the Faslodex I am on now about two years ago and I did not tolerate it at all well and have ended up with damaged lungs, which are not definitely from the Ibrance but developed while I was on it.
I've met alot of women with mbc, have attended several big bc conferences and was trained as a bc patient advocate. One of the big things I have learned is that each of us has our own individual set of cancer cells and experience with cancer. What works for one does not work for all, even all with estrogen positive mbc. It is unpredictable but oncs use their knowledge of bc research and their experience to make the best recommendations they can for us Another thing I have learned is that many and probably most of us use meds for sleep, depression and/or anxiety at some time during this whole cancer experience. I used Rx sleeping meds for about 18 months early on in treatment. I may need to do that again sometime soon as I am not sleeping more than about 4 to 6 hours most nights. My gynecologist had a long talk with me several years ago about how both having cancer and taking cancer meds change brain chemistry and cause us to really need those meds! I always take a Xanax or Ativan before I have MRIs as the noise makes me want to scream and get outta there! lol
It's been a huge challenge to me to learn to ask for help! One of the first places that cropped up has been at the grocery store! I often need help getting my groceries out to and into my car. Asking for that simple help that they have people to do was huge for me! And I still have to push myself to ask for help around the house, even something as simple as tying my shoe!
Before cancer, I always looked forward to retirement as a time I would be able to read some of the books I've not had time for and travel to some of the places I've never been but want to see. HA! My concentration is not good and my short term memory is full of holes so reading is a struggle. I don't have energy for much travel. I do have to drive 50-60 miles each way to see specialist doctors but that is not the travel I had in mind, but it is my new reality.
Alot to adjust to, that is for sure.. I hope that you will find peace amidst all this and treatment that keeps the cancer controlled and leaves you feeling more like your old self. Do keep in touch with us!
I have been reading a lot about Hemp Oil and the benefits of it. I really didn't want to go there and when someone mentioned it to me was very stern that it wasn't for me! I broke down and contacted the guy about it and more information. I told him to send me a months supply and I would try it, I have to do something I can't stand the fact that it has been so long since I have felt normal I don't even know what that feels like. My TennCare Medicaid is not going to approve anything for long lasting pain unless I take what they want me to take. I can't take Morphine I run a high fever, and makes me really sick. I was told that wasn't a life threatening situation. The other is Fentanyl and I refuse to have that in my home. July 16, 2013 we had to make one of the hardest decisions of my life and I pray no other family will have to deal with what my family did when we had to make the decision to unplug my baby brother from a Fentanyl overdose. I live alone and will not have it in my home to be broken into by someone that knows I have it. They have already told me and my Dr that before they approve anything else I have to fill those two drugs. I get so tried of fighting the insurance and this disease too. I shouldn't have too. Thanks for the kind words and the support. It means a lot. I lost my Mother in 1987 at the of 46 to Cervical Cancer and my Father in 2011 to lung cancer.
You may never feel exactly the way you did before cancer but that doesn't mean you won't feel better than you do now! You may need to adjust your expectations some. Non medical people are going to tell you all sorts of things! Change your diet, use this "natural" thing, that herb, don't do radiation, do radiation, etc etc etc. Expect it and insulate yourself from it. Medical marijuana is said to help with pain, appetite, who knows what, but is only legal in some places. You should let your onc know everything you are taking. About Fentanyl -- I am so sorry that your brother died from an overdose! But don't allow that to keep you from using it. Alot of women with mbc have found it really helpful for managing pain. And how would anybody know that you have it unless you tell them? If you are worried about picking it up at the pharmacy, call them and find out when they are least busy and share your concern with them. They don't have to announce it to the world when you pick it up. Does the place you go for treatment have a social worker you can talk with about getting back more of your sense of self? That might be really helpful. They would also know local resources for cancer patients.
It was his RN friend that got the patch for him and told him to put in his mouth to dissolve faster. I hear on the TV everyday that when responders went to a Fentanyl Overdose they would double glove because just a small amount could kill them. I will not have it around me even if it means I can't get approved for another long lasting pain med. I would never do anything without talking to my Oncologist and pain Dr first.
PJ, Hi there I was diagnosed last November with already stage 4 breast cancer(wide spread metastasis to the bone) and I enjoy reading long time survivors because gives me a lot of hope. Although have never read about any 14 years surviver. Browsing support groups helps a lot, there's always incentive and good advice but reading about long term survivors helps to keep my hopes up. God bless you for sharing
Several months after I was diagnosed, I heard of a couple of women who had been living with mbc for twenty years! That was so encouraging. And when I attended a conference of the Metastatic BC Network around ten years ago. there was a 30 year survivor there! More and more of us are living longer and longer. was pretty scared the first year--I got a knot in my stomach just walking into the cancer center every month. Now, I worry so much less about the cancer! I was 57 when diagnosed, now I'll be 72 later this month. And sometimes I wonder what my life would be like at this age without the cancer! lol I hope you will do well for a long long time! Peace.
PJ, sorry to hear of your trouble. I too had terrible depression to start with and it came back every time my treatment started to fail and a new drug was prescribed. Just for fun, the anti-depressants started to cause me to grind my teeth and get very sore jaws (to add to the ankle and knee pains!) and also to sweat very heavily from my head and face! I am currently on Faslodex and hope it will work - the worst part of all this is the roller-coaster we all have to ride. Keep as positive as you can, talk to the lovely people on this site - they are amazingly supportive - and do try to walk a little every day and drink lots of water - it seems to help.
Good luck and keep improving on your meds
I’m so sorry to hear this news. Life isn’t fair. Sending you hugs and prayers xxoo. Marianne
I am so sorry to hear this. I have Stage 4 to lymphnodes and liver as well. I was on 100 mg Ibrance and Faslodex shots for 6 months. I had very few side effects and everything was going well. Just this last month everything changed...the drugs stopped working. Now I am looking at IV chemo (again). I go 2 Thursdays, take a week off, go 2 Thursdays..and so on....until these drugs stop working. Carboplatin and Gemzar are my new best friends. I’ll be 54 this year and I so hate to give up, but the treatments are so harsh on my body. I have no weight left, no muscles and soon no more hair. This disease is awful! I am still working as much as I can and am very thankful that I have understanding employers. My job helps me keep some sanity, but there are days that I can hardly get out of bed. I pray for all of us that someday we may not have to go through this horrible ordeal. Keep your faith and don’t be afraid to reach out for help.
I hate your story but it makes me feel not alone. I was diagnosed in 2011 and had a radical mastectomy and hysterectomy. was told I would never have cancer again...a pretty good prognosis right? After almost 5 years of followup and meds, found out I have stage 4..bones and liver is full of cancer. I did AC IV chemo. knocked the tumor marker down from over 3400 to 67. started Ibrance and Fluvestrant in April. numbers keep going up and bigger jumps. Friday did all the CTs and PET (again) and the news is my liver is showing enlarging and new cancer. I probably cried for 18 hours straight yesterday. I have a 20 yr old daughter who is my life. I am so sad, you work so hard to fight and it just slaps you in the face. I'm starting IV chemo again soon. while I know I will never see my daughter get married and have kids, I pray I can see her turn 21 and graduate with her BSN in December
Aelgersma,
There are so many of us warriors out there! I pray that you can enjoy many more years with your daughter! I have two sons and three grand kids. They, and my husband are my world. I will continue to fight and pray that there are new drugs and new procedures for me to try. Never, ever give up! Keep fighting and praying!
My Best to you!
I can't add much. In 2013 I was srrarrred on Arimidex. Within 2 months I couldn't walk. My joints hurt so bad ibthoght my bones were breaking. They switched me to Tamara and what a difference. Thrry ought to try that as both pills do the same thing. Just possibly with your depression, you might ask them to lower your Ibrance. I started at 125. After I took one I felt dark and the most horrible thoughts went through my mind. They lowered me to 100. What a difference. Would have sta had there but Ibrance and Faslodex did not work for me. You are all in my prayers.
Thanks they don't want to adjust it cause they say I'm handling it very well. I was in dentistry for 10 years and never lost a tooth or had the first mouth sore. These mouth sores are so bad and even go into my nose. I have never been sick I always took care of a loved one that was sick.
I’m so sorry you’re going through this. Support is key. If you haven’t any family support than look for local groups and services. You can’t do this alone! I wish I could help you! Where do you live?
Hi!
I thought i was reading my own post!
In 2013 i was diagnosed metastatic to right lung, liver, T9 of spine and a speck on my Iliac. I took Xeloda and it didnt work. Then i took Arimidex hormone blocker and started getting the Xgeva shot for bones and within months i had a clean CT scan. The lung met was gone, the T9 lesion was calcified and dormant, the speck on my iliac went away and they decided last year my liver spot was just a cyst.
I hope you get these results! Never give up.
In jan of 2017 my lung spot came back and i took Ibrance and then switched to kisqali and after all year of taking that, the lung spot is not active at all.
Feel free to contact me. My email is mrsbobleck@aol.com
Melissa
Hey dear, please hang in there. I promise you, you can do this. I was diagnosed with stage 2b Er+ at 27 years. I am 36 now with stage 4, met to the lungs, liver, lymph nodes and whole of my spine. I have a 5 year old, live with him alone. His dad is not in the countrt.I do not have insurance as well. Had to undergo surgery to take out my ovaries. It's tough, but I got to keep fighting. I'm on same meds you take. I had radiation January, couldn't eat solid food for 1 month plus. In and out of hospital. Just got discharged 4 days ago.
I break down, I cry, I pray.. but got to keep fighting.
Please dear, we can do this together. We can fight it.please hold your head up, there will be joy in the morning. This phase shall pass and you shall be stronger.
Will keep you in my prayers
Greetings: Waaaaaariorrrrr/Swtberry/Overcomer . Your testimony of being diagnosed at the
age of 27, and at age 36 being the mother of a 5 year old, who you are raising as a single
mother. I admire your strength, and your tenacity. Your don't give up attitude ,even as you
face continuing challenges is so uplifting. I am sure your testimony is giving so many hope. I
pray our Lord/God will restore your body to full health, and that you will have many many
more years of living, laughing and loving milestones with your child and loved ones Amen.
There are people who stub there toe, and they say the world is ending, but Y-O-U are one of
those people God has created that let's those struggling with challenges see the silver lining,
the rainbow, and, the sunshine. Yesssssssssssss in the worst situations you/we can see the
blessings. After being diagnosed, every day, week,,month, and year is a gift. Thank-you for
your story XoXoXoXo. To my siters/Warriors , who are struggling , remember this, and these
inspiring amazing testimonies. Be encouraged Waaaaaaaarriors have an attitude of, giving
up is not an option.
I am so sorry for what you are going through. I am 58 as well, but do have a good support system. Part of that system is my meditation group (popularly called a sangha). We rarely talk about our individual difficulties, but can if we are moved to. We mainly come together to meditate. Meditation helps me to understand that I am not the only one that suffers, that my suffering is a matter of how I think of my situation, and it increases my capacity for compassion for others. You can also look on line for videos that are useful toward that end, but I encourage a group as it does offer support. My best, my very best to you and your struggle. Michelle
Sorry to hear of the Mets, I think it takes time to sink in and then decide how best to live your life! Try some exercise, a little at a time, try something new to learn. It's so easy to let, treatments take over your life. Some days will just be hard! You can count on that! But if you look forward to something you enjoy, or try when you don't feel like trying, life gets better. You can do more than you think that you can. I have to work at this everyday! 😉
Hello PJ,
I noticed that your post was from 6 months ago. I hope that you are feeling better physically and emotionally since then. My disease is ER+ too, so I can relate to that. My emotions were a bit up and down in the first two weeks or so and I had terrible pain in my back. I am still in my 30s. My last period was within two weeks after I had started treatment, and now I feel that my body has adjusted to the treatment.
I don't tend to talk to friends much about the disease (apart from a few who have had cancer) and I don't like to worry my dad with what's going on, so I talk to my husband and that helps.
I find it really helpful to talk to others who know what you are going through.
Al the best,
Sophie x
Talk to your doc about quality of life and suggest lowering the Ibrance dose to increase sol. My dose was decreased to 100 because of neutropenia, continued the same problem, got switched to 75 and now my sol is much better (not perfect of course but feel better and have more energy). It's ok to switch for sol reasons and the lower doses are working the same as higher. They always research at higher doses thinking they'll have more success and push the drug thru the FDA faster.
CHECK OUT a great closed Facebook group l am in for people with stage IV metastatic disease it is NBC end of life/quality of life ( eol/qol) issues.
Hello Pjriggs...I am so sorry that you are going through this and you are not alone. I am stage iv as well , its spread from my left breast, to my bones, abdomen, liver, and the lining of my lungs. Ive been in the hospital a couple of time for shortness of breath and had to gey fluid drained from my lungs. Its horrible whay we are going through and i'm just praying for a miracle.
I am so sorry for your difficult life experience...I am so upset that your sorrows have been compounded by the trouble with health insurance. Your story and the story of every woman , every person affected by lack or the high cost of health insurance , should be highlighted in our government’s agenda. My story is one of many here...but I’m grateful for health coverage and I am older so I’m on a different clock.
I hope you feel better and your meds continue to work. Prayers.🙏
I am so sorry that Ibrance is hitting you so hard....I hope they can moderate the dose! And don’t worry about taking hormones....I have taken them for more than a year without serious side effects....