1 Thursday, 26 February, 2015
2 [Open session]
3 [Accused not present]
4 --- Upon commencing at 2.30 p.m.
5 JUDGE DELVOIE: Good afternoon to everyone in and around the
7 Madam Registrar, could we have the appearances, please.
8 THE REGISTRAR: Good afternoon, Your Honour. This is case number
9 IT-04-75-T, the Prosecutor versus Goran Hadzic.
10 JUDGE DELVOIE: Thank you.
11 May we have the appearances, please, starting with the
13 MR. STRINGER: Good afternoon, Mr. President, Your Honours.
14 Douglas Stringer, Sarah Clanton, Elizabeth Spelman, Thomas Laugel for the
16 JUDGE DELVOIE: Thank you.
17 Mr. Zivanovic, for the Defence.
18 MR. ZIVANOVIC: Good afternoon, Your Honours. For the Defence of
19 Goran Hadzic, Zoran Zivanovic and Christopher Gosnell, with legal interns
20 with Sara Butkovic and Raila Abas.
21 JUDGE DELVOIE: Thank you very much. And we note for the record
22 that Mr. Hadzic is not present and we received the waiver that has been
24 Before we call the expert, Dr. Seute, the Chamber would like to
25 put on the table again whether we should go into private session. The
1 Chamber is of the view that yesterday nothing has been revealed that is
2 not already in the public due to the Defence's decision to make public
3 the elements of Mr. Hadzic's health condition. There is no indication
4 that today's hearing would be any different.
5 Therefore, there seems to be little or no reason for private
6 session today, as well as yesterday.
7 Mr. Zivanovic, would you agree?
8 MR. ZIVANOVIC: Yes. Your Honours, yesterday I just conveyed the
9 information I've got after consultation with Mr. Hadzic and he didn't
10 change his mind, but it is on you to decide.
11 JUDGE DELVOIE: Prosecution, anything?
12 MR. STRINGER: We have no position on that, Mr. President.
13 JUDGE DELVOIE: Thank you.
14 [Trial Chamber confers]
15 JUDGE DELVOIE: Can we go into closed session for a moment,
16 please -- or private session, rather. Just private session.
17 [Private session]
10 [Open session]
11 THE REGISTRAR: We are in open session, Your Honour.
12 JUDGE DELVOIE: Thank you.
13 The witness, Dr. Seute, may be brought in.
14 [The witness entered court].
15 JUDGE DELVOIE: Good afternoon, Doctor.
16 THE WITNESS: Good afternoon.
17 JUDGE DELVOIE: Could I please ask you, for the record, to state
18 your name and date of birth.
19 THE WITNESS: Tatjana Seute, November 15th, 1971.
20 JUDGE DELVOIE: Thank you. And your profession?
21 THE WITNESS: I'm a neuro-oncologist.
22 JUDGE DELVOIE: Thank you very much.
23 Dr. Seute, you are about to make the solemn declaration by which
24 all witnesses before this Tribunal commit themselves to tell the truth.
25 I must point out to you that by doing so you commit yourself to the --
1 you expose yourself, sorry, to the penalties of perjury should you give
2 false or untruthful information to the Tribunal.
3 So this being said, could I ask you to give the solemn
4 declaration. The text of it will be given to you by the usher.
5 THE WITNESS: Very well. I solemnly declare that I will speak
6 the truth, the whole truth, and nothing but the truth.
7 JUDGE DELVOIE: Thank you very much. Please be seated.
8 THE WITNESS: Thank you.
9 WITNESS: TATJANA SEUTE
10 JUDGE DELVOIE: Mr. Stringer.
11 MR. STRINGER: Thank you, Mr. President.
12 Examination by Mr. Stringer:
13 Q. Good afternoon, Dr. Seute.
14 A. Good afternoon.
15 Q. My name is Douglas Stringer and I'm an attorney for the
16 Prosecution here at the Tribunal, and I've got some questions about the
17 report that you've prepared on the basis of the Chamber's request. Do
18 you have the report with you?
19 A. Um-hm, I have.
20 Q. In the course of my questions, if there is anything that you
21 don't understand or that you wish me to be clearer on, please don't
22 hesitate to let me know.
23 A. Okay.
24 Q. Dr. Seute, your background, as I understand it you're a
25 practicing neuro-oncologist.
1 A. Um-hm.
2 Q. Which means that, I guess, in layman's terms your job largely
3 involves treating people, patients who have conditions such as the one
4 that has been the recent diagnosis for Mr. Goran Hadzic; is that correct?
5 A. That's correct. I diagnose, treat, and guide patients with
6 glioblastomas. That's my main job, yeah.
7 Q. And you examined Mr. Hadzic on the 11th of February?
8 A. Correct.
9 Q. And examination occurred closer to where you work at the
10 UMC Utrecht, the hospital out in Utrecht?
11 A. Correct.
12 Q. The exam, according to your report, lasted about one and one
13 quarter hours.
14 A. Um-hm.
15 Q. And you've indicated in your report, actually, that in relation
16 to one of the questions, you've never been to the Detention Unit --
17 A. Um-hm.
18 Q. -- here at the Tribunal.
19 A. Um-hm.
20 Q. So you don't know what the conditions are out there in which
21 Mr. Hadzic is currently being detained?
22 A. Um-hm. Correct.
23 Q. I can see some of the papers you've got, and I know from its
24 Scheduling Order, that the Chamber directed that you be provided with
25 papers that have been submitted by the parties; the Prosecution and the
1 Defence, in regard to sort of the legal question that's currently with
2 the Chamber, which is to release Mr. Hadzic from the detention unit so he
3 can go back to Serbia for the next few months until he comes back in May
4 for his MRI evaluation.
5 A. Um-hm.
6 Q. Do you understand that that's the main issue that's before the
7 Chamber today?
8 A. Um-hm, I understand.
9 Q. When you spoke to Mr. Hadzic, did you discuss with him anything
10 about the conditions, the place where he's proposing to go live in Serbia
11 if he's released?
12 A. No, no.
13 Q. Okay.
14 A. We don't speak about that.
15 Q. So you don't know anything about where he would go --
16 A. No.
17 Q. -- if he was released?
18 A. No.
19 Q. Before you examined Mr. Hadzic, you've indicated in your report
20 that you reviewed all of the medical reports, the data, the images that
21 were available to you; correct?
22 A. Correct.
23 Q. I think you had at least once conversation with Dr. Falke, whose
24 the chief medical officer here at the --
25 A. Right.
1 Q. -- what we call the DU, the detention unit. And are you aware
2 that the Chamber appointed another person to serve in your capacity -
3 that is, as an independent expert?
4 A. I was and I was aware and I also spoke.
5 Q. And that's Dr. Cras.
6 A. Yeah.
7 Q. And as I understand it you spoke to Dr. Cras, maybe just briefly,
8 but just around the time that each of you submitted your reports?
9 A. Right, right.
10 Q. Have you seen Dr. Cras's report?
11 A. Yes, I have.
12 Q. Okay. And then you're aware, I take it also, that Mr. Hadzic,
13 his treating physician is Dr. Martin Taphoorn.
14 A. Um-hm.
15 Q. And he's based with the MCH, the hospital group here in The
16 Hague. Is that --
17 A. Yes.
18 Q. And he is like yourself a neuro-oncologist?
19 A. Right.
20 Q. Do you know Dr. Taphoorn?
21 A. Yes, I know him.
22 Q. Based on your knowledge of Dr. Taphoorn and your review of the
23 medical file for Mr. Hadzic, can you comment on the quality of the
24 medical care that Mr. Hadzic has received so far in this case?
25 A. Yes, yes, I can. The quality of the care Mr. Hadzic received
1 until now is of very high quality. It's based on standard treatment
2 decisions as we know until now in Europe and America and all over the
3 world. Imaging is of excellent quality. Pathological reports are of
4 excellent quality, and Professor Taphoorn is a highly respected
5 oncologist in the neurological field.
6 Q. And as I understand it Dr. Taphoorn is one of the people who
7 developed or at least published what we've been referring to as the Stupp
8 scheme which is sort of the regime of treatment that Mr. Hadzic is now
10 A. Yeah. It was a very large trial performed in the early end 1990s
11 to 2000, 2005, a lot of neuro-oncologists put in their patients so that
12 is why we are all there on the list of authors. Yeah.
13 Q. Yeah, I saw your name on a number of publications as well,
14 related to treatment of glioblastoma.
15 A. Um-hm.
16 Q. Before we actually move to the substance of your findings or your
17 opinion, I did want to direct you to one part of the report and ask for a
19 A. Um-hm.
20 Q. If you could go to page 4, which is the last page of your report,
21 and the last paragraph there, and this is the answer to the question that
22 is in the small Roman numeral (v).
23 You said:
24 "The median survival of patients diagnosed with glioblastoma
25 multiforme varies from 12 to 14 months, however median indicates 50
1 per cent."
2 And then the next sentence says:
3 "The two year survival ranges from 25 to 30 per cent."
4 So I wanted to ask you if you could clarify the 12 to 14 months
5 there and whether that is accurate?
6 A. Yeah, yeah. It is accurate. You know, these numbers come,
7 actually, from the Stupp trial, you know, this treatment, regimen
8 Mr. Hadzic is receiving right now, is undergoing, is based on the Stupp
9 trial. There were lots of patients in this trial, and if you look at the
10 survival rates of these patients, you will get to a median survival close
11 to 14 months. But if you -- because that's why I also took into account,
12 I said from these numbers are based on trials and based on personal
13 experience from our own hospital, because I run the biggest clinic in
14 Holland. We have the largest amount of patients. Then you have to be --
15 no, you can have the number of 13.7 months. I took the number of 12 to
16 14 months because if you look at the at the whole of Holland, that will
17 be the median survival. But to be very clear, for the patient in front
18 of you, especially in this early phase of his disease, nothing is to be
19 said about these 12 to 14 months.
20 Q. Okay. And I bring this to your attention because I think, again,
21 for those of us who are not physicians or experts in your field,
22 Dr. Cras --
23 A. Um-hm.
24 Q. -- in his second report actually says that at present
25 Mr. Hadzic's survival can be estimated in the range of 12 to 24 months.
1 A. Yeah.
2 Q. -- depending on the success of radio and chemo. So perhaps you
3 can explain what is the -- what's behind the different ranges --
4 A. Yeah.
5 Q. -- that we're seeing here.
6 A. Yeah, I think that what's behind if you look at the 12 to 14
7 months, that's -- that's the number that came out of the trial. All
8 sorts of patients are in there, like, all the patients in bad physical
9 condition even before starting, before diagnosed with the glioblastoma.
10 There are patients who underwent surgery, like resection of the tumour.
11 There are patients who didn't undergo surgery. There are patients with
12 very large tumours in very eloquent sections of the brain. There are
13 patients with very small tumours. All with the same diagnosis. So a
14 very large scale of different sorts of patients. So if you look at the
15 case, the patient as Mr. Hadzic, there is also in Dr. Cras's report,
16 there are some elements that could be judged as beneficial prognostic
17 factors like his relatively young age, although this disease is a disease
18 of young people; his good physical condition; and then on the other hand,
19 there are some factors that -- that are negatively -- negative prognostic
20 factors like the multi- -- the fact that the tumour is in different parts
21 of the brain so that a resection was not possible. If you add up all of
22 these factors, then you can make little bit -- you can try -- let me
23 clarify that. You can try to make little bit of a broad view. And then
24 also Professor Taphoorn and Professor Cras think that it might be
25 somewhere between 12 to 24 months.
1 Personally, I think that in this part of his -- this stage of his
2 disease, it's extremely difficult to say anything about his future.
3 Q. Okay. When you examined Mr. Hadzic on the 11th of February, you
4 indicated that although you did not perform any neuropsychological tests,
5 you stated that he did appear to have no cognitive dysfunction?
6 A. Correct.
7 Q. Dr. Cras indicated in his report that he found Mr. Hadzic to be
8 well-oriented, to express himself clearly --
9 A. Yeah.
10 Q. -- and that he tested normally on the Montreal Cognitive Exam.
11 A. Um-hm.
12 Q. My question is whether Dr. Cras's findings and observations are
13 generally consistent with your own on that?
14 A. Yes, yes, they are generally consistent. I thought Mr. Hadzic
15 was very clear minded. He answered my questions through the interpreter
16 very quickly. Didn't need allot of time to think. Was orientated in
17 time, space, and person. But -- well, as stated, I didn't do a real
18 large battery of neuropsychological tests because that would take me
19 like --
20 Q. Yes?
21 A. -- hours to do that and I would have to involve my
22 neuropsychologist and didn't go to that effort because I didn't think
23 that it was necessary at that time.
24 Q. And then getting to really the main point that you've been asked
25 to address, if I could direct you to page 2 of your report. Actually,
1 we're going to look at a couple of questions. And this is question
2 number 2. And your -- here you're asked whether Mr. Hadzic will have the
3 capacity to physically attend and participate in trial proceedings for a
4 period of four months either during or after treatment. And then in your
5 answer that follows, you state that in your opinion he would not be able
6 to participate for four months during treatment or during episodes with
7 serious side effects.
8 A. Um-hm.
9 Q. And before I come back to the question, if we could just turn the
10 page and go to question 4, which also relates to the same issue. This
11 was if Mr. Hadzic is incapable of physically attending proceedings at the
12 Tribunal, would he have the capacity to participate via video conference
13 link set up in the UN Detention Unit. Now, as one of the people who was
14 involved in suggesting questions, I think we might have done a better job
15 for you in distinguishing between "attending" or what maybe I'll use
16 today as "being present at" versus "participation," and so I would like
17 to distinguish between those if I may in the questions that follow.
18 Because in your answer to this question that we've just read,
19 you -- first of all, you indicate or you refer to your previous answer,
20 and then you express concern about the burden of intensive questioning
21 and also the length of the proceedings, that being several months.
22 A. Um-hm.
23 Q. So, Dr. Seute, if I could ask you, first of all, perhaps you
24 could describe or indicate for us when you were responding here, what was
25 in your mind when you were thinking of "participation"?
1 A. In my mind, as a medical doctor, I was thinking of
2 "participating" being here in the trial room, being aware of what was
3 said in the trial room, and being able to answer questions as I am now.
4 That was my perception of participating in the trial.
5 Q. Okay. Now setting aside participation, those three things that
6 you've just described - as being present, his listening, and his
7 answering questions - setting that aside and focusing strictly on his
8 capacity or ability to be present which is the first one -- maybe the
9 first two, to be present and to follow the proceedings, let's say that
10 that's what means -- that's sort of how we will define being present.
11 He's physically present in the courtroom, he'd be sitting over there on
12 that back bench, or even being in his room at the detention unit watching
13 the proceedings live on a video screen, even perhaps with the ability to
14 direct or to contact his lawyers here in the courtroom in realtime.
15 So if that's how we define being present, taking that aside, and
16 I guess I'm going to digress for a quick second to talk about the
17 treatment regime now that he's going to be undergoing for the coming
18 months. And as I understand it, he's going to be looking at least two
19 more 28-day cycles, each of which involves five days where he's actually
20 taking the chemotherapy --
21 A. Correct.
22 Q. -- drug, and that's followed by a 23-day period of recovery.
23 A. Yeah.
24 Q. That is how one cycle runs.
25 A. Yes, correct.
1 Q. In your report you said that if Mr. Hadzic's blood counts will
2 improve it may be possible for him to attend and participate in a hearing
3 for a limited time per day. Setting aside again participation in
4 answering of questions, are you saying that during, say, the 23-day
5 periods of recovery, it may be possible for Mr. Hadzic to attend as we've
6 defined it either by being present in the courtroom or following from the
7 UN Detention Unit?
8 A. Um-hm.
9 Q. Obviously depending upon how he's affected by the side effects?
10 A. Yeah. Well, that's a crucial thing you are mentioning there. I
11 think depending on whether or not he will experience side effects, I can
12 only then -- let me rephrase: If you know how he will react to this
13 chemo regimen, then you can make a medical fair judgement about whether
14 he will be able to be present. We know now that from his first treatment
15 phase with the combination of chemotherapy and radiotherapy that he has a
16 serious blood count drop. That's a serious side effect. The counts he
17 had are not life threatening be if they go down more, they are. They are
18 a serious threat to his life.
19 Now this new phase or this second phase of treatment is the same
20 chemotherapy and it's indeed five days, but it's a much higher dose. So
21 he will pulse -- he will get a lot of chemotherapy at once and especially
22 the first cycle, you will not know what's going to happen afterwards. At
23 this point, I'm not informed also about his blood counts right now. So
24 I'm not even sure as far as I know right now, whether he will be able to
25 start these cycles.
1 But let's assume he will. Then I think you can make a fair
2 judgement during the first 23 days of rest how this will affect him, how
3 this will affect his blood counts, and then you can judge whether he can
4 be present. If his blood counts stay at normal level, if he doesn't
5 experience nausea and vomiting, if he doesn't experience extreme fatigue,
6 then he can be present here. Yes.
7 Q. Okay.
8 A. And if I may make --
9 Q. Please.
10 A. -- just one more adjustment to that. I can imagine that you
11 think, well, the five days of chemotherapy are the worst, but the phase
12 afterwards, the recovery phase, that's when the patients experience the
13 side effects. Mostly not during the five days of taking the medication.
14 The blood counts are lowest at day 21, that's when I assume
15 Professor Taphoorn will also do a blood count. And then at day 28,
16 that's when I assume he will decide whether the second cycle will take
17 place, assuming the first one will take place.
18 Q. So, really, the possibilities in terms of Mr. Hadzic's ability to
19 be present, aren't necessarily linked to whether he's taking his chemo on
20 a given day or not?
21 A. Yeah.
22 Q. It's linked to more how he's feeling and what his blood count is?
23 A. Yeah, yeah.
24 Q. Okay. Now in terms of -- I don't know how much or how little you
25 know about what a trial day is here or how the schedule runs. One
1 question on that: If -- would the possibility of Mr. Hadzic's ability to
2 be present, would it be increased if the Chamber -- the Trial Chamber and
3 the judges showed flexibility in scheduling shorter trial days, for
4 example, of a few hours, or having the trial take place at times of the
5 day that are better suited to Mr. Hadzic's schedule? I saw in one of the
6 reports that he's got some insomnia but he's sleeping more during the
7 day. So would flexibility on those lines also contribute to his ability
8 to be present?
9 A. Yes, I think that would -- that would be helpful, although it's
10 very hard to -- to predict now how he will react and what adjustments
11 have to be made. If I may speak from my experience, with, like -- I've
12 seen like over 900 patients now who received this treatment and I all
13 guided them myself. I've now got staff doing that with me. Then, I have
14 patients who are in good condition, good physical health, even do some
15 working chores during this chemotherapy; on the other hand, there are
16 other patients, also young and physically well-fit patients, who really
17 need hours of extra sleep during the day. It's really not possible up
18 front to predict how it's going to be for him. But both scenarios and
19 everything between that are possible.
20 Q. Okay. One last question. And given what you've said earlier
21 about the prognosis --
22 A. Um-hm.
23 Q. -- and also given that his condition and his treatment programme,
24 as I understand it, will be re-evaluated in the early part of May --
25 A. Yeah.
1 Q. -- would it be correct to say that Mr. Hadzic's ability to be
2 present in trial proceedings will diminish over time just in a -- as a
3 general rule?
4 A. That's very hard to say now. As in a general rule, yes, because
5 he has a progressive disease and the treatment is aimed to slow it down,
6 to stop it at best. And as you can read in my report, sometimes we're
7 very successful. That means that we also have long survivals, also
8 patients who didn't have a resection. But it's a small group, very
9 small. Most people benefit from this treatment, of course, otherwise we
10 wouldn't give it, but in time -- and it's really not possible to say at
11 this point in time in what time, but in time he will diminish. He will
12 develop neurological dysfunction, he will develop cognitive dysfunction,
13 that is a matter of time, but just the amount of time we have can't be
14 predicted right now, yeah.
15 Q. Thank you, Dr. Seute.
16 A. You're welcome.
17 JUDGE DELVOIE: Mr. Gosnell.
18 MR. GOSNELL: Yeah. Thank you, Mr. President. Good afternoon.
19 Examination by Mr. Gosnell:
20 Q. And good afternoon, Dr. Seute. My name is Christopher Gosnell.
21 I'm here for Mr. Hadzic. You say in your report in answer to question
22 4(b)(ii) -- well, actually, it's just 4 -- 4(b) -- well, in any event,
23 it's on page 3, you say:
24 "The expected consequences of the radiotherapy and the
25 chemotherapy are low blood count, fatigue, nausea, vomiting, rare. On
1 the mid-long cognitive dysfunction, ranging from mild problems with
2 concentration to serious amnesia."
3 Are you -- and I'm interested in the expression mid- --
4 A. Yeah.
5 Q. -- long cognitive dysfunction. Is there a distinction in your
6 mind between mid-long dysfunction and some shorter dysfunction?
7 A. Yes, definitely. As I -- it's hard to explain like without
8 starting lecturing, but radiotherapy -- I'm referring here to the side
9 effects that radiotherapy can give to a person. The radiotherapy
10 Mr. Hadzic underwent is aimed, of course, at the areas in the brain where
11 the tumour is -- where the tumour locations are, because there are
12 multiple locations. When you -- when the radiotherapist makes his plan,
13 he will aim the radiotherapy, as I said, at the tumour locations, but
14 also healthy neurons, healthy brain cells will be involved in this
15 radiotherapy scheme. This will not affect you directly. You will not
16 notice that. When you're receiving the radiotherapy, you will be --
17 patients can complain of fatigue, but they will not suffer from
18 concentration loss directly.
19 Within a time, and that's where the mid-long is kind of fake, and
20 I can't be more specific about it, but the mid-long is then months to
21 years, the healthy neurons, the healthy brain cells that receive
22 radiotherapy will diminish in function, and then you can start
23 experiencing concentration loss. And if it's a serious case, you can
24 have serious amnesia.
25 Q. But is it common that you have glioblastoma patients --
1 glioblastoma multiform, while they are undergoing their chemotherapy, who
2 present no apparent cognitive dysfunctions but who nevertheless complain
3 and in reality have significant deficits in terms of more complicated
4 sustained intellectual tasks?
5 A. Do you mean during treatment or afterwards?
6 Q. During treatment.
7 A. In my experience, most patients do complain in some -- to some
8 extent of cognitive dysfunction. Although, I must say again there is a
9 very wide range of how that affects them in life. I also have a quite
10 some patients, quite some percentage of patients who continue doing their
11 job, also highly educated patients, and continue being fully active in
12 social and working life. Very different -- very difficult to say
13 something in general about it because it's also because, like I said
14 before, patients with brain tumours have cancer but they also have a
15 neurological disease very much dependent on where the tumour is located
16 in the brain.
17 Q. Okay. Let me put it a different way: Would it be unusual for
18 you or would you consider it unlikely if a patient were to tell you that
19 they have significant difficulties maintaining a train of thought or
20 maintaining concentration over a one- or a two hour time-period, but when
21 you see them you see no apparent cognitive dysfunction?
22 A. And the question is whether that would be unusual? I'm not --
23 Q. Whether that would be something that you would suspect that what
24 they were telling you wasn't true or that they didn't, in fact, have such
25 difficulties maintaining a train of thought or concentrating for one hour
1 or two hours?
2 A. I don't understand the question. Whether I expect them to -- to
3 have that or to not to have that or?
4 Q. Well, I'm asking you whether you would find that unusual or
5 outside of the bounds of what would be expected for someone with a
6 glioblastoma while undergoing the chemotherapy?
7 A. Well, again, it would depend on the location of the tumour. If
8 you got a tumour in the frontal lobes, I would really be surprised if
9 there would be no -- if a patient would tell me, "I've got no problems
10 with maintaining thought" or "maintaining concentration over hours." If
11 the tumour is in the occipital lobe, which is in the back of the head,
12 that could probably be the case, yeah.
13 Q. But in either way it would be quite possible or even probable in
14 either of those cases that the person would complain exclusively about
15 their ability to concentrate over a long period, digest information over
16 that long period, engage in executive function over a long period,
17 maintain short-term memory over a long period. Those wouldn't be
19 A. No, that wouldn't be unusual. In our hospital, if patients
20 complained of that and there is a -- we have different neurological
21 psychological tasks we perform on this patient, I would order a full
22 neuropsychological exam to also examine the range of how long somebody
23 can maintain concentration. You can just examine that. Yeah.
24 Q. Now in answer to question (a)(ii), you say:
25 "In my opinion, Mr. Hadzic will not be able to participate in
1 trial proceedings for four months during treatment and/or during episodes
2 with serious side effects like low blood counts," and then you go on.
3 And it was read by my learned friend opposite, so I won't repeat
4 it except for the sentence after that where you say:
5 "The near and median term future is very uncertain for him. His
6 physical and neurological condition can change rapidly over time."
7 Now, when you say "rapidly," do you mean to say that his
8 condition could change from day-to-day to a significant degree?
9 A. Yes, that is possible. But if I may explain a little bit how
10 that can happen. At this time -- at this point of time, we -- or I are
11 sort of clueless about in how the treatment is affecting Mr. Hadzic,
12 how -- if the tumour is responding to it.
13 THE INTERPRETER: The speakers are kindly asked to make pauses
14 between question and answer for the purpose of interpretation. Thank
16 MR. GOSNELL:
17 Q. I think you can proceed, Dr. Seute.
18 A. Oh, okay. So -- where were we. Oh, the rapidly -- rapidly
19 change in his functioning. So at this time we don't know whether the
20 treatment is effective. If we go to a worse-case scenario, then the
21 treatment is not effective and tumour is growing inside his brain. You
22 might say, well, we will notice that from the outside. He will have
23 cognitive dysfunction or he will have neurological deficient or he will
24 have another seizure. That doesn't have to happen. Mostly it doesn't
25 even happen. Mostly what we notice is when the -- a tumour cell grows
1 notice brain, then the healthy neurons will start swelling in the brain
2 and brain edema will develop. That develops really rapidly and that's
3 why patients can deteriorate in days. It's not the tumour growth itself
4 that will be notable.
5 Q. And in answer to my learned friend, you described that the
6 consequences or side effects of the Temozolomide treatment can be felt --
7 in fact, is characteristically felt during the rest period, and that
8 includes low blood platelets.
9 A. Um-hm.
10 Q. Now, I don't know whether you've seen the medical report of the
11 18th of February, 2015, but the indication in that report is that:
12 "The chemotherapy has had to be postponed due to a negative
13 effect on the bone marrow leaving him with a serious platelet deficiency.
14 He has shown a small recovery. The platelet numbers are increasing."
15 Now as I understand it, the platelets were low enough that the
16 chemotherapy was terminated on the 21st of January. So that means, as I
17 understand it, that the platelets levels have been below the minimum
18 between the 21st of January and the date of this report, the 18th of
19 February. Now, is that a negative prognostic indicator about his ability
20 to successfully undergo the rest of the chemotherapy and --
21 A. Well --
22 Q. -- and can his anticipated life expectancy?
23 A. That's hard to answer right now because if his -- if his
24 platelets go up within a week, then I assume that Professor Taphoorn will
25 continue giving him chemotherapy. And then, of course, you have to be
1 really careful with, like, the dosage of the chemotherapy because you
2 know Mr. Hadzic is prone to develop low platelets, have bone marrow
3 suppression. But it's not necessarily that the -- that the next cycles
4 will fail, you know. This can be a temporarily problem, and we've seen
5 that patients are sometimes able to succeed six cycles of chemotherapy
6 also with having these platelet drops in the first period. That is
7 because this is a different regimen. You know, his first treatment was
8 totally different -- different regimen with daily chemotherapy combined
9 with radiotherapy.
10 Q. But this would be an example of what you were describing earlier;
11 namely, the platelet levels decreasing at some period after the
12 administration --
13 A. Yeah.
14 Q. -- or ingestion of the drug and having that effect continue for a
15 considerable period. And in fact, here it seems it has spanned almost
16 the entire recovery period of the first cycle.
17 A. Yeah.
18 Q. Is that correct?
19 A. That's correct.
20 Q. Now, I'd like to just ask you a couple of questions, and I'm not
21 going to enlighten you about the specific details about what goes on in a
22 trial here. But I would like to ask you about a more generic example
23 that may be more familiar to you and to consider someone who is, for
24 example, taking a seminar at the Utrecht University, and this seminar
25 requires them to participate for a two-hour period and do, let's say, 200
1 pages of reading per class. And you have a person who comes to you with
2 glioblastoma and they are taking the chemotherapy, and they say, "Doctor,
3 I feel generally all right, but I cannot maintain my concentration
4 sufficiently to do all of these readings and to be able to follow the
5 class and occasionally to intervene."
6 Now, can I first of all ask you would that be an unusual set
7 of -- or description or self-reporting by the person of how they are able
8 to function under these circumstances, and assume that the person has the
9 profile of Mr. Hadzic?
10 A. No, that would not be unusual.
11 Q. Now, let's say the professor in the class decided that they
12 didn't want to take the person's word for that, and they came to you and
13 they said, "Dr. Seute, I don't believe that what this person is saying is
14 true" or "maybe I believe what they are saying is true, but I'd
15 nonetheless like to double-check and see precisely what is their
16 performance level in relation to this seminar."
17 Now, first of all, is there a test that you could or would
18 administer to try to give some kind of a score or a measure in relation
19 to that task? Is that possible, medically?
20 A. Yes, that's possible medically. Actually, you could perform,
21 again as I stated, a neuropsychological examination. That's an
22 examination of a couple of hours, at least in our university hospital,
23 and then you can address these issues.
24 Q. The Montreal Cognitive Assessment would be totally inappropriate
25 for that; correct?
1 A. Yes.
2 Q. Now you also say in your report that -- and it's in respect of
3 the questions I was asking you earlier about variability. And if this
4 student came to you and said I am having this problem, how long would the
5 tests -- or let's not say the student. Let's say the professor. How
6 long would the test take to perform in order to achieve some kind of a
7 score about this person's capacities?
8 A. You mean how long would a neuropsychological examination take?
9 Q. Yes.
10 A. Three to four hours.
11 Q. And then is it possible that the person's capacities are varying
12 from day-to-day?
13 A. Yes, but well trained neuropsychologists take all that kind of
14 information into account. Before making a report about the cognitive
15 function, you also have to take into account the pre-illness level of a
16 patient, and they are really trained to do that. Yeah.
17 Q. So it would certainly be possible for someone one day to have a
18 certain level of mid- to long cognitive capacity which changes over the
19 course of several days?
20 A. Yes, of course. That's also the case with healthy persons. If
21 you're tired, your capacity to concentrate diminish. If for patients
22 with neurological illness, irrespective of whether it's a tumour or a
23 haemorrhage, this fluctuates through the day. Yeah. That's why I said
24 it's very hard to predict for the long-term how it's going to be. Yeah.
25 Q. And it's very difficult to measure over an extended period
1 because it could change; isn't that right?
2 A. Yes, that's right. And it's very hard at this time to predict or
3 to even say something about Mr. Hadzic because we don't even know, you
4 know, what his status is at this moment.
5 Q. Now, I'd just like to ask you a few questions about prognosis.
6 A. Um-hm.
7 Q. And you've confirmed today what you said in your report, that the
8 median survival is 12 to 14 months. Is the starting point for that
9 median the beginning of radiotherapy?
10 A. No, the starting point is the -- they had two different trials,
11 because these are again trial numbers, trial figures. The starting point
12 is the day the diagnosis was made by the pathologist, so the day of
13 surgery, the day of biopsy. That's the starting date.
14 Q. And you talked a little bit about progression in response to some
15 questions by my learned friend. Do you know the median time to
16 progression for students -- patients with glioblastoma, multiform?
17 A. Depends if you go to general, for the general population, so all
18 sorts of patients are involved in this -- in this illness, so the older
19 patients, the younger patients, then the median time to progression is
20 around six months.
21 Q. And I think that the Stupp report that you referred to as a
22 landmark, the median time to progression in that study where the median
23 age was 56, the median time to progression was seven months; is that
25 A. That's correct.
1 Q. And would you agree that progression is usually, not always, but
2 usually associated with a steep decline in physical and cognitive
4 A. I think it's too harsh to say "usually," and that is because in
5 my experience, and I know that's also the way Professor Taphoorn works,
6 we perform quite a lot of MRI scans once we started. Every three months
7 we look at these patients. A lot of times we see progression on the scan
8 before patients will experience complaints from that progression. And of
9 course from -- taken from the point of the landmark study of Stupp,
10 that's 2005, you know, a lot of -- fortunately, a lot of progress has
11 been made, and we start second-line treatments, experimental treatments.
12 So I would say regularly we see that patients decline after --
13 physically after progression of disease, yeah.
14 Q. And cognitively?
15 A. Depending on the -- on the location of the tumour.
16 Q. It's not unusual that there is a decline in cognitive and
17 physical condition around the --
18 A. No.
19 Q. -- time of progression; is that right?
20 A. That's right.
21 MR. GOSNELL: Thank you, Mr. President. Those are my questions.
22 JUDGE DELVOIE: Thank you, Mr. Gosnell.
23 Questioned by the Court:
24 JUDGE DELVOIE: Dr. Seute, I have a few questions as well, and
25 they might appear to you as repetitive but that is probably because we
1 need a little bit more time to understand all these things that we are
2 not used to handle.
3 In your report, you have indicated that Mr. Hadzic will not be
4 able to participate in trial proceedings during treatment and/or during
5 episodes with serious side effects like low blood counts.
6 A. Um-hm.
7 JUDGE DELVOIE: There are two elements here. During treatment,
8 on the one hand; and on the other hand, during episodes with serious side
9 effects like low blood counts. Am I correct in reading this as serious
10 side effects, like low blood counts, can occur during the treatment days
11 but they could also occur or continue during nontreatment days; is that
13 A. Yes, that's correct. And then I specifically refer to the blood
14 count. They drop after the therapy is given.
15 JUDGE DELVOIE: Yes. Yesterday Dr. Cras told us that in general
16 the side effects other than the blood count are related to the time of
17 administration of the drug, so they occur shortly after administration
18 but would probably last throughout the day. Would you agree with that
20 A. I would agree with that assessment if you refer to the nausea and
21 vomiting. Vomiting is very rare with this kind of chemotherapy.
22 However, the fatigue, which is explained by bone marrow suppression, you
23 know, your body has to work hard to keep up your blood count, that
24 patients experience that, well, yes, during treatment, but mostly after
25 the treatment, and that's an experience that's not in the books.
1 JUDGE DELVOIE: Yes. I would come back now to that, to the blood
2 count. And with regard to that problem, Dr. Cras explained to us
3 yesterday that this side effect does not have an influence on the
4 patient's physical status. The reduction of blood platelets, he told us,
5 and reduction of white blood cells leads to an increased tendency to
6 bleed and increased tendency to have an infection.
7 A. Yes, that's correct.
8 JUDGE DELVOIE: You would agree?
9 A. Yes, that's correct. However -- you know, let me explain
10 differently: The fact that if I have a low blood count, you wouldn't see
11 anything from the outside. If I were to fall, I wouldn't bleed to death.
12 Nothing would happen. However, there's another mechanism there. Your
13 bone marrow production, your blood cell production we all have, is making
14 all of hours. And that's -- that's not what I'm thinking, that's not a
15 hypothesis, that's what's going on in your body. Chemotherapy is
16 directed to dividing cells. Tumour growth is dividing cells. It's
17 nothing more, nothing else. Chemotherapy will go and try to address all
18 cells in your body that are dividing. Well, as mature persons, of
19 course, most organs don't have dividing cells any more, but the bone
20 marrow, so that's where the blood cells are generated, has constantly
21 dividing cells and your chemotherapy is trying to diminish that. So the
22 production is going up anyway, and that's what the fatigue causes. Not
23 the fact that the blood platelets are low, no, but the bone marrow
24 production has to go up.
25 However, the fatigue, if I may elaborate a little bit on that.
1 It's, as I stated before, it's very much based on individuals. I mean,
2 some person doesn't experience fatigue at all or only to a very, very
3 small amount. Other persons have to rest for several hours during the
5 JUDGE DELVOIE: Thank you very much.
6 If there are no further questions from the parties, Dr. Seute,
7 thank you very much for coming to The Hague to assist the Tribunal. You
8 are now released as a witness and the court usher will escort you out of
9 the court. Thank you very much.
10 THE WITNESS: Thank you.
11 [The witness withdrew]
12 JUDGE DELVOIE: Before we adjourn, the Chamber would like to put
13 a few questions to the Defence with regard of their request for
14 provisional release.
15 First question is this: Who will serve as Mr. Hadzic's doctor in
16 Novi Sad eventually? You should indicate -- one moment, please.
17 [Trial Chamber and legal officer confer]
18 JUDGE DELVOIE: Perhaps it's a good idea, indeed, to go into
19 closed session now -- private. Private session will be sufficient.
20 Thank you.
21 [Private session]
11 Pages 12623-12625 redacted. Private session.
6 --- Whereupon the hearing sine die at 3.40 p.m.