Well, it is March 9, the third anniversary of the day I was first diagnosed with breast cancer.  It has become my tradition to do a video blog on my cancerversary, so here it is.  Thank you for sticking with me for three years.  Whether you are following this blog because you are a friend or a relative or yourself a cancer patient, thank you so much. Writing to you all has helped keep me sane. So far.

Stupid thyroid

                Well, when I last wrote here, we were hoping we had found a breakthrough in the mystery of why my hair isn’t growing back.  I mean, it is about 2 ½ years since chemo ended, and I am still bald.  Bald enough that strangers stop me in the supermarket to compare notes on how we got bald.

We had hoped that we had found the culprit in my case:  a lazy thyroid, possibly because it had accidentally got nuked while we were deliberately nuking the lymph nodes nearby.  This would have been a relatively easy problem to fix.

                I am very sad to report that my blood test results are back, and my thyroid numbers are perfect. So were all my other numbers.  Even my cholesterol, which I am the first person to admit, is unfair as hell, given what I eat.  I am healthy as a horse.  I mean, if your horse has breast cancer and mysterious baldness. I should be happy about this, I know.

                The next step, apparently, is to talk to a dermatologist.  My doctor suspects I was just going to be an old lady with thinning hair, anyway, eventually, because of genes, and the chemotherapy just speeded up the timing of that.  I have my doubts, since all the elderly women ancestors I can remember had plenty of hair.  But I will go talk to the dermatologist anyway.  I suspect he will simply recommend Rogaine for Girls, which I rejected a year ago because of the potential side effects.  Am I desperate enough to try it now?  I don’t think so, but ask me tomorrow…

                I do think all the oncologists out there should stop telling women that their hair will definitely grow back after chemotherapy.  Yes, it usually does.  But not always, and I have now heard enough comments around the Internet and at the supermarket from women whose hair didn’t grow back, to know I am not alone in my shiny baldness.  Researchers, are you listening?  Saving our lives is Priority One, for sure.  But if you want to take a crack at the baldness thing, there are a lot of us out here who would appreciate it.

Apparently healthy but still bald. Where is House when you need him?

                It’s been six months since I updated this blog. Frankly, nothing has been going on, cancer-wise, I am happy to say. But it’s the time of year when I tend to have a bunch of medical tests come due, so I wanted to let you all know that it seems to be going as well as it possibly can. And another thing is making me very happy—we may be on the verge of solving a little medical mystery that has had my crack team of cancer doctors puzzled for some months now!

                So, I’ve had a bunch of tests.  This is never fun. For each one, my blood pressure jumps and I get the inevitable “scanxiety,” as others have called it. You imagine all kinds of things while you are sitting half-naked on some doctor’s exam table.

I had my nasty breast MRI in December.  Nothing wacky was found.  This is one of my least-favorite moments of the year, for a couple reasons.  For one thing, the MRI is inside one of those large, extremely loud and clanky tube-shaped scanners, and I am claustrophobic.  You also have to remain perfectly still for more than 20 minutes, while not thinking about claustrophobia or the fact that your nose itches and you can neither sneeze nor scratch it or they’ll have to start over.  I generally end up frazzled to the point where, when it is over, I barely make it to the car before I burst into tears.

For another thing, they have to inject you with “contrast,” and this means they have to give you an I.V. When I had my I.V. for my colonoscopy a few months back, it took them six tries to find a vein, and I was black and blue and crying by the time they were done. But when I mentioned my lack of viable veins to the person getting me ready for the MRI, she decided to bring in reinforcements. She called in a nurse they referred to as “the vein whisperer,” and damn if that woman didn’t find a gusher with one try, and painlessly, too.  I want her to be my nurse from now on, please.

                Then, after Christmas, while on vacation, I got sick with a basic head cold, and a few days later I had serious problems breathing. It turned out I was having a severe asthma attack.  I had had asthma as a kid, always allergy-related, with one notable flare-up once a few years ago. I didn’t realize a cold could set it off, and at my age.  Live and learn! In the process of figuring out why I couldn’t breathe, they had to rule out other more scary stuff—particularly pneumonia and metastasized breast cancer. It was a scary hour or so while waiting for the X-rays to be looked at, but in the end they were all negative.  No tumors in these lungs!

                Then, when we got home to Maryland, just because it was the beginning of the year, I had my regular appointment with my OB-GYN.  Again, all good.

And today, I had my annual appointment with my radiation oncologist, who seemed absolutely delighted with how things are going, now that we are two years out from the end of treatment. It was she who had told me, in 2011 that she would never be telling me I am “cured,” but that the best we could hope for was a long, long remission. But remission we have! She was really happy.  “This is good,” she said.  “This is really good,” and she hugged me.  And she was very, very impressed with the way the new boob turned out. “It’s really good,” she said.  “Really good.” When you see your oncologist that happy, it is more reassuring than I can say.

                And maybe we made some progress figuring out why I still haven’t got my hair to grow back!

                All my many doctors (I have six now, if I didn’t forget anybody) have agreed, it is strange how poorly my hair has done. Only about half of it came back after I finished chemo, and that was two and a half years ago.  This is not how it is supposed to go. I still have a big bald patch on the back of my head, and it’s pretty thin on the sides, too. In the morning, when I wake up, I look interesting, and not in a good way. My youngest, Matt, enjoys sculpting my hair into various amusing shapes with his hands. One day last week, I woke up looking like the Sydney Opera House.  My doctors have been sympathetic, but they are much more worried about me being healthy, than about me being attractive. Given the problems I could be having, I shouldn’t be whining about having hair like my Great Aunt Em when she was in her eighties. No, I should probably be thankful to be healthy and if my hair was gone entirely, well, things could be worse.

                Of course, the hair thing bugged me even though I was supposed to be all about life and health, and not about appearance. Once in a while, you catch a view of yourself from a mirror that shows the back of your head, and yes, appearance DOES matter.

                So today, one of the nurses in radiation oncology was taking notes on me, and she asked me how the Tamoxifen was going.  I told her I was seriously considering stopping taking it, even though it is supposed to be keeping the cancer at bay, because I was blaming the drug for my achy hands and achy knees and ongoing baldness. “It makes me feel old,” I said, and I had been spending considerable time thinking about quality of life versus quantity of life. I expected her to take me to task, and remind me—as others have done—about how the benefits of Tamoxifen outweigh the risks for the vast majority of people like me, etc. etc.

                She stopped me in my tracks.

                “Achy joints.  Alopecia. How is your libido?”

                “I’m sure there is some libido around here somewhere,” I said, and she laughed.

                “Has anyone ever tested your thyroid levels?” she asked.

                “No, not as far as I know.”

                Well, it turns out that an underactive thyroid can cause swelling and pain in joints in the knees and the hands.  And it can cause hair loss.  And it can cause dry skin, and weight gain. I have all of those. I was gobsmacked. Why hadn’t anyone asked me this a year ago?

But why would my thyroid be slacking off all of a sudden?

                My radiation oncologist, who thinks the nurse is on to something, explained that I had had a lot of radiation to my upper body in 2011. Some of it was deliberately pointed at lymph nodes near my thyroid gland, because cancer cells had spread to a bunch of lymph nodes, and we were trying desperately to wipe out any that were still out there. The thyroid may have taken a little friendly fire, which can reduce its hormone output, over time.

So the next step is another blood test—can I have the vein whisperer again, please--and if it turns out my thyroid is underperforming, I have to take…more pills and probably for the rest of my life! But if it means my hair grows back and I lose weight and my knees don’t hurt, I for one will not be complaining.

July update

                It has been a while since I have posted, because there hasn’t been much going on on the cancer side of things. I can now give you a quick update.

                I have been having some nasty pain in my hands and knees, and we had thought that it might be a side effect of one of my medications, Tamoxifen. When I saw my oncologist recently, I told him it was still very bothersome. I asked him when we might start investigating to make sure something worse wasn’t going on, specifically rheumatoid arthritis or some such thing.  “Now,” he said, and he sent me off to a big-shot rheumatologist.

                I am happy to report that I don’t have rheumatoid arthritis. Nor is it a side effect of the tamoxifen. What I have in my hands is good old-fashioned osteoarthritis, like my grandma had. Only, I am 50 and she was a lot older than that. But if I live to be 101 like she did, my hands are going to be a mess. I have bought mass quantities of Aleve. Life goes on.

                The knees are another story. My left knee is giving me all kinds of problems. As it turns out, the problem there is not arthritis at all, but something involving my kneecap being in the wrong place. Ouch! This problem is apparently very common and is not fixed with drugs but with lots of physical therapy. This will commence in August. The only bright side is:  in the meantime, I am strictly forbidden from doing squats, lunges and other things like that where my knee makes me want to scream in pain. My doctor circled this in red ink and drew arrows around it. My trainer, Mija, is grumpy about this.She enjoys making me do squats very much. Oh well.

                Now, when I saw my oncologist, the other thing he had said was, it really was time for me to get a colonoscopy. He said that is one test that is known to save many many lives. Period.

                 I had had one several years back, when one of my brothers was diagnosed with colon cancer, and my test then came back clean. But I turned 50 this year. And it seems that my immune system is slacking at the cellular level,  which can lead to not only breast cancer but skin cancer, colon cancer, etc. So the oncologist wanted it done. Last week, I bit the bullet and did it. The results came back clean. But they want me back in five years, not the usual ten.

                 Here is a picture of all the stuff they make you chug before a colonoscopy. It made my Weight Watchers number very happy the next day, I can report:

                The one part that was a bummer was trying to get an IV in my poor arm. Since all the chemotherapy two years ago, my veins don’t cooperate any more. It took two nurses and an anesthesiologist a total of six tries to get an IV going. Twice, they started one only to have it fail, and they had to do it again. By the end of that performance, I was crying and shaking. Here is what my arm looks like, a week later:

I am here to tell you the colonoscopy itself was nothing. Even the prep wasn't too bad. If you are supposed to get one, GO GET ONE! I can't tell you how much easier a colonoscopy is than chemotherapy. Just do it.

Graduation Day update

                Well, tomorrow our oldest child, Sean, graduates from high school. It’s an emotional time as he’s been at the same school, Sandy Spring Friends, since he was four years old, and now he and the friends of his whole life are going out separately into the big world. Sean is off for the University of Toronto.  I am acutely feeling the absence of my mom, who died in January, and John’s mom, whose doctor told her not to fly out here. They would have loved to be here. And everyone is on pins and needles wondering if Tropical Storm Andrea is going to wash out the traditional Sandy Spring Friends outdoor barefoot graduation ceremony and all the lawn parties thereafter…

                I had my quarterly check-up with my oncologist on Tuesday and I have been in that three-day period where your heart stops every time the phone rings, because it could be them calling back with bad news. But the phone hasn’t rung.

                Yesterday, our youngest, Matt, finished fourth grade and there was a festive picnic for that. The Lower School assembly in the morning was lovely, and I got through the whole thing without crying once, almost made it, until they brought out one of Matt’s teachers, Linda, who is retiring after 20 years at our school, and she was crying. That was it for me. I may stop crying sometime next week. Happy trails, Linda! As the great Warren Zevon has said, may you enjoy every sandwich.

                I did some graduating yesterday, too. I had my last appointment with my plastic surgeon.  It has taken nearly two years to go from the original mastectomy to the finished product. I will now see my plastic surgeon, Dr. Kathy Huang, once a year for a quick check.  At some point down the road, maybe ten years from now, I will need to get that implant changed, because they don’t last forever. In the meantime, I’ve got my little exercises to do from now on to make sure that this boob stays nice and boobular, and doesn’t go hard as rock.  Who knew that could happen? But for now, I’ve got my plastic-surgery diploma.

                Let’s mix some metaphors! I am going to toot my own hooter. Everyone who has seen my new boob, which isn’t many people, I’ll admit, is absolutely delighted with how it turned out. In fact, yesterday, the doctor took photos of me to use when she speaks to breast cancer survivors’ groups and potential future patients. It turns out that in my surgery, they used a new-and-improved pattern for where to make the incisions, which results in less-obvious scars. I have to say, it worked beautifully.  If I was of a later generation that didn’t mind plastering nude photos of itself on the Internet, I would be doing that myself, just to show how good a job Dr. Huang did. But I am of an older generation, so I shall restrain myself. Someday, I may go to the hot springs and have a few beers and get naked like everyone else, just because I can, and from the day I had my mastectomy I never really thought I would get to this happy point. I wish I could tell other women going through this how well it can turn out. (And I do believe I have actually caught men looking at my chest! Ha! They may have no idea what it took to get to the point where a guy would want to do that…Take that, stupid cancer!)

                There was a woman in the doctor’s waiting room yesterday, a bit older than me, bald, no eyebrows, wearing the pink scarf-thing on her head. It was like looking back through time at my two-years-ago self. You could tell how crappy she was feeling. It was all I could do not to go up to her and give her a big hug and tell her to hang in there. That is not something you do in a doctor’s waiting room, where there are understood rules about respecting each other’s privacy. But I am sending her all kinds of good energy and prayers.

                 

In Which I Get Cut Down to Size

                It has been a busy couple days on the breast cancer front. Heck, it’s been a busy couple days on every front. The high-schoolers are taking their AP exams, and the fourth-grader just did his CTP tests. It is the end of the lacrosse, track, and baseball seasons, which means playoffs. My oldest son, Sean, is graduating in two weeks, and that means meetings, dinners, breakfasts and parties. Oh, and John is in China.

                Yesterday was also the finale—we all hope—of my long, drawn-out breast reconstruction. In the end, the nipple they made out of skin from under my arm was just too big and droopy. So they had to literally whittle it down to size. This they did yesterday afternoon. It took about twenty minutes, after I went to the gym, and before carpool.

                I think I earned my badass credentials yesterday. They do this procedure without any form of anesthesia whatsoever. I had been so convinced that there would be Novocain involved that I did not even bring a flask of huckleberry vodka with me.

                Ha.

                The doctor said, sure, they could numb it, but I wouldn’t feel anything anyway, so why do that?

                I thought about walking out. I pointed out that they had said I wouldn’t feel anything for the tattoo, either, and that turned out to hurt like hell.

                “Oh, lots of people feel the tattoo,” she said. “Nobody feels this.”

                And she went on to demonstrate that, in fact, my inch-wide tattoo circle zone certainly has gotten its feeling back, as nerves have regenerated.  But the actual nipple itself has no feeling at all.

                She was right. It didn’t hurt. But I was wincing and grimacing and holding my breath just the same, because technically, someone was cutting off part of my nipple while I was wide awake and hadn’t had so much as an Advil. My skin might not know enough to hurt, but my brain understood what was going on.

                “I know you aren’t feeling this,” the doctor said, “because you are wincing at all the wrong times.  I already did the cutting. It’s done.”

                And so it was.  I felt the stitches, though. Ouch. Although it was more the weird sort of sensation that, for example, you have when you have a C-section. You feel someone pulling at you, and while it doesn’t actually hurt, you know what they are pulling on is your guts, and your brain tells you it probably hurts anyway. “Creepy” doesn’t cover it.

                So I did earn my badass wings yesterday. I got my stitches, utterly unmedicated, and went out and drove carpool and watched a track meet got the boy a haircut and took him to his piano recital. I got the cookies there on time, and I didn’t forget to feed him. And I had already seen my trainer in the morning. At about 9pm, when I finally got my glass of wine, I sat down and fell asleep. Being a badass is exhausting.

                The upshot of all this is the boobs look pretty good now. Truly. If you look you can see some surgical scars, but they are the kind that anybody who has had any “work” done on their breasts would have. And a lot of it is on the underside anyway, so you wouldn’t see it unless you were, well, looking from a fairly interesting angle. Otherwise they are pretty normal -looking breasts. This is amazing to me. I believe if I waited until the stitches were out, I could show up at the clothing-optional hot springs and get naked and nobody would probably notice anything amiss at all.

                Well, if I am being completely honest, I should admit that the “real” breast is a little bigger than the “fake” one right now. That’s because I’ve put on ten pounds, mostly from comfort eating in the wake of my mom’s death. And if I gain weight the “real” breast gets bigger.  The other one is like the boob of Dorian Gray. It stays the same, while everything else grows or shrinks or sags around it. But as far as I’m concerned, that’s just added incentive to not let my weight get out of control. Otherwise, it’s all good. In fact, the girls are downright perky. Take that, stupid cancer!

                Flying the metaphorical bird at stupid cancer has been the other theme of the week. Saturday morning was the Race for the Cure here in DC, and our family participated as Team Honey Badger.

                John and our son, Sean, ran the 5k race. John actually ran in serious fashion. He came in 26^th overall, second in his age group, which made him very happy. He was beaten by one of Sean’s friends from school, Manny, which made him happy.  And he was beaten by one very perky breast cancer survivor woman, which no doubt made her very happy.

                I did not run; I walked with my younger kids. It was the third time I had done the Race for the Cure, but only the first time I had done it since developing breast cancer myself.  What was different?

                The race was certainly smaller than it used to be. There was a story in the Washington Post that said there were about 21,000 people formally registered to run. That’s a lot fewer than the last time I ran, and 6,000 fewer than last year, according to the Post. They quoted Komen as saying the shrinkage was due not only to the kerfuffle over Planned Parenthood getting money from Komen, but also the economy, the number of competing breast cancer events that are now available, and the fact that the U.S. Park Service asked Komen to move the race from June to Mother’s Day weekend.               

                Of course, this race was way different for me, personally. For me, it was much less about the race and race times, and much more about the ambiance.

                In the weeks before the race, the Komen organization had survivor volunteers call each survivor racer, including me, and it was actually good to talk with that woman. I have not participated in any formal support groups; the only networking I’ve done is talking with women at church or at school who have been through this. It probably would have been a good idea to have done more of that.

                The Komen people gave cancer survivors special shirts and hats, and laid on a nice breakfast for us. They handed out lots of pink bling. Pink Mardi-Gras beads and flags and water bottles and whatnot. Most of us were pinked-out already, so this was pretty much a waste of money and energy, as far as I was concerned.

                It was good to be there, though. It was great to see all the survivors, who were clearly color-coded a darker shade of pink. It was nice, when, at the end of the race, a volunteer, a young black guy, college age, handed me a pink medal for surviving and looked me in the eye and congratulated me as if he meant it.

                It seemed to me there were many, many more survivors in evidence since the last time I had done the race, ten years ago. Quite a few of them were older people, who clearly were surviving for the long haul. This was personally very encouraging to me. Often, breast cancer feels like a death sentence, though it may be a delayed one. These women were very much alive.

                It was fun taking photos. Photos of us, photos of total strangers, photos FOR total strangers, and they took photos of us. Here are bald women with pink deely-boppers. Here is an 18-year-old guy in a pink tutu. Here is a woman in a pink cowboy hat with all her kids! It was all very jovial and it was fun to declare a joint, “Fuck you!” to cancer.

                It was particularly lovely to be there with all my children. When my daughter posted photos of us on Face book and said, “Love you mommy,” it made me cry, but in a good way.

                It was hard when they had the sheets of paper where you write the names of who you are running in celebration of or in memory of.  I used to have one name to write down:  my mother-in-law, Diane.  Now I have more than I can list. Something is wrong with this picture, and we have to find out what it is. The club has gotten way too big.

                One thing I would suggest is that Komen re-design the walking route. There was a massive bottleneck near the beginning of the walk, which led to crowding, claustrophobia and great uneasiness among some, including my son. Had a Boston-Marathon style loony wanted to try something nasty, this would have been the ideal place to do it. There was no way to get out of there, and it took at least 15 minutes before things opened up.

                The other annoyance I could have done without was a group of loony anti-abortion protesters who planted themselves near the starting line, in the bottleneck area, with HUGE posters featuring graphic photos of, get this, aborted fetuses AND cancerous breasts. Abortion causes breast cancer, they lied. Shame on them.

                Part of me wanted to laugh, because, really, they came to the wrong parade with this one. For one thing, a good proportion of the racers were from churches, mosques and synagogues, not exactly your pro-abortion demographic. But even more funny to me, did they think really they could scare a parade full of cancer survivors with ugly pictures of cancerous breasts? Please. We have seen those pictures before. They were pictures of our own selves, and we have long since gotten over it. And anyway, we do not scare easy.

                But sadly, I did let these morons piss me off. I ended up doing some personal screaming and flipping-off, of which I am not proud, but there it is. I will never be a Gandhi, I guess. I react too much. I particularly resented their graphic tasteless hatefulness in front of so many hundreds of small kids, including mine. I guess the protesters got their martyrdom fix out of it, and I helped because I let them raise my blood pressure. In the end, I ended up comforting myself with the fact that there were 20,000 of us and maybe six of them. And Planned Parenthood is getting our money, so there. Which is a good thing if you are looking to prevent abortions, but these fools were too willfully ignorant to see that.

                In the end, I am glad I went to the Race for the Cure. I was ambivalent at first, because I thought it was ridiculous that Komen would consider pulling funding from Planned Parenthood.  And there has been disturbing press about how much Komen officers are paid, and so on. And I did not really need a big event like this to help me dwell on the fact that I am now one of those pinked-out middle-aged bald women. But I met actual people who had been helped by Komen. The money does help. And my oncologist recently told me that, by the time my daughter is old enough to worry about her genetic predisposition to breast cancer, research will have made the game very different than it is today. That research is what we are paying for even with these silly pink events. Bottom line: my daughter’s life is worth getting pinked out for once in a while.

                                

The Tattooed Lady

                It has been a while since I checked in with you, but that is because not much was happening on the cancer front. I can now report that I got my tattoo yesterday! This was supposed to have happened some weeks ago, but it got postponed due to scheduling problems with my tattoo artist, Tina, and then I was in Montana for a while.

                To recap, my doctors have made me a new breast pretty much out of whole cloth. Since they took out the whole original one, they had to start from scratch. They stretched my own skin big enough to make one with the aid of a thing called a “tissue expander,” which they gradually pumped full of water and which set off the metal detector every single time I got on an airplane last year.  Then they took that thing out and replaced it with a garden-variety implant. Next, they did a skin graft and made me an origami nipple out of my own flesh and appliquéd it on there. Yesterday, it was time to color the little brown circle, or areola, on there. That’s where Tina came in.

                Tina owns the Tantric Tattoo and Boutique in Sandy Spring. But she also works with the Plastic Surgery Institute of Washington and my own surgeon, Dr. Kathy Huang, to reconstruct breasts for women like me. I asked her yesterday, while she was mixing her ink, how many of these she had done, and she said, “Thousands.”

                Tattooing one of these takes about an hour. Tina does the tattooing in the plastic surgeon’s office in North Bethesda.

                Now, back when I had discussed this tattoo procedure with Dr. Huang, I asked if there would be Novocain or something. She said since they had disconnected all the nerves when they did the mastectomy, I would not feel a thing. I told her I was pretty sure I was getting feeling back in that breast, and I told her there had better be Novocain or something, or I would arrange my own pain relief and that might get ugly. I have too many memories of doctors and technicians sticking needles into my breast the last two years, which hurts like hell, to sit there quietly while someone sticks a needle in my breast, over and over, for an hour, without medication.

                Dr. Huang and the nurse laughed and someone said I should get a margarita before I came in and everything would be fine. But then my appointment got moved to 10am and a margarita appeared unlikely. The Montana solution to this dilemma:  a hip flask full of huckleberry vodka, just in case.

                Well, don’t the Boy Scouts teach us it’s always good to be prepared? There was no Novocain or anything like it. So I went to the ladies’ room and tossed one back. As it turned out, that was a smart move, because getting a tattoo on your nipple hurts. A lot. When Tina began to “break up the skin,” as she put it, poking it with lots of holes so that the numbing spray she used would sink into the under layer of skin, I about jumped out of the chair. She was about half done when I called a time-out. This hurts, I said. It really hurts. What’s the deal with that?

                She said this was actually good news. It was unusual for this procedure to be painful, but what it meant was that my nerves are regenerating, and faster and better than expected. This bode well for me regaining some sensation in that breast, and what’s not to like about that? Meanwhile, Tina went and got some numbing cream that made it slightly less painful, and she was able to finish the job. I was pretty much cranky for the rest of the day. I laid off the vodka and switched to Advil, but it was sore.

                The good news: it really looks good, and that’s now, when the color is a little raw and overdone, and I still have that malformed nipple on there. When the color settles down a little and we fix that oversized nipple, it is going to be awesome. Much of the surgical scar is no longer visible, and the robo-boob now looks a lot like the other one. This is amazing to me. If I drink enough vodka one day, I might post before-and-after pictures, because the difference is astounding, but I hope that day never comes!

                That’s all until next time, when I will report on the Washington, DC, Race for the Cure! I bought an awesome pink cowboy hat in Montana for the occasion, but already the pink is literally chipping off in chunks. A fitting metaphor for the pinkwashing of America? Check out this article in the New York Times Magazine if you want to think long and hard about Komen, the way pink money is spent, and everything:

http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html?pagewanted=1&hpw