Tribunal Criminal Tribunal for the Former Yugoslavia

Page 12657

 1                           Friday, 21 August 2015

 2                           [Open session]

 3                           [The accused not present]

 4                           --- Upon commencing at 3.29 p.m.

 5             JUDGE DELVOIE:  Good afternoon to everyone in around the

 6     courtroom.

 7             Madam Registrar, could you call the case, please.

 8             THE REGISTRAR:  Good afternoon, Your Honours.  This is the case

 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

12     Prosecution.

13             MR. OLMSTED:  Good afternoon, Your Honours.  It's Matthew Olmsted

14     and Elizabeth Spelman for the Prosecution, with Case Manager

15     Thomas Laugel.

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 Corey Stevens,

20     legal assistant, and Carlos Correa, legal intern.

21             JUDGE DELVOIE:  Thank you.

22             May the record show that Mr. Hadzic has waived his right to be

23     present and has provided documentation to that effect.  And may the

24     record also reflect that the Trial Chamber is sitting 15 bis,

25     Judge Mindua being absent.

Page 12658

 1             Today's hearing arises from the proprio motu order of the Trial

 2     Chamber issued on the 1st of April, 2015, ordering the appointment of

 3     independent experts to assist the Tribunal in the determination of

 4     Mr. Hadzic's -- whether Mr. Hadzic is fit to stand trial.  The aim of

 5     this hearing is to have the appointed independent expert, Dr. Specenier,

 6     answer questions from the Prosecution, the Defence, and possibly the

 7     Chamber to provide further explanation and clarification regarding his

 8     expert report filed on 15 July 2015.

 9             The hearing will begin with 45 minutes of questioning from the

10     Prosecution, followed by 45 minutes of questioning for the Defence and

11     conclude with the Chamber's questions, if any.

12             When hearing the expert, Dr. Martell, the parties opted for an

13     open session with one particular restriction, however, at the request of

14     the Defence.  Unless the parties' position has changed, I would suggest

15     the same course of action.

16             MR. ZIVANOVIC:  Our position has not been changed, Your Honour.

17             MR. OLMSTED:  No objection from the Prosecution.

18             JUDGE DELVOIE:  So we will be in -- stay in open session.

19             Could the Court Usher bring in the witness, please.

20                           [The witness entered court]

21             JUDGE DELVOIE:  Good afternoon, Dr. Specenier.  For the record,

22     would you please state your name, your date of birth, and your

23     profession.

24             THE WITNESS:  My name is Pol Specenier.  I am born on 21st --

25     31st of January, 1955, and I'm a Belgian medical oncologist.

Page 12659

 1             JUDGE DELVOIE:  Thank you.  Next I will ask you to read the

 2     solemn declaration by which witnesses commit themselves to tell the truth

 3     and expose themselves to the penalty of perjury should they give false or

 4     untruthful information to the Tribunal.

 5             Please read out the solemn declaration.

 6             THE WITNESS:  I solemnly declare that I will speak the truth, the

 7     whole truth, and nothing but the truth.

 8                           WITNESS:  POL SPECENIER

 9             JUDGE DELVOIE:  Thank you very much.  You may be seated.

10             THE WITNESS:  Thank you.

11             JUDGE DELVOIE:  Mr. Olmsted, you may begin.

12             MR. OLMSTED:  Thank you, Mr. President.

13                           Examination by Mr. Olmsted:

14        Q.   Good afternoon.

15        A.   Good afternoon.

16        Q.   Perhaps I should begin by asking you whether you prefer to be

17     referred to as doctor or professor.

18        A.   Doctor is fine.

19        Q.   Thank you.  My name is Matthew Olmsted and I'm a Trial Attorney

20     with the Prosecution, and I'm going to ask you a series of questions with

21     regard to the report you prepared for this case.  You brought a copy of

22     that with you?

23        A.   I brought a copy.

24        Q.   Great.  You conducted your examination of Mr. Hadzic on the 27th

25     of June of this year; is that correct?

Page 12660

 1        A.   That's correct.

 2        Q.   And that examination consisted of both an interview as well as a

 3     physical examination?

 4        A.   That's correct.

 5        Q.   And I should just tell you now for -- I think we do have

 6     interpreters.  We need to make sure there's a delay between my question

 7     and your response so they have time to --

 8        A.   Okay --

 9        Q.   -- to do their business.

10             With regard to the physical examination, other than an unsure

11     gait and a slight tremor, the results were normal.  Is my understanding

12     correct on that?

13        A.   I have -- I will check.

14             MR. GOSNELL:  Objection.  Objection, Mr. President.  I don't know

15     what is meant by the word "normal" and I'm not sure that the witness

16     could understand what is meant by the word "normal".

17             MR. OLMSTED:  Your Honours, I'm referring to -- perhaps I should

18     give the page number.  Page 10, at the very bottom.

19        Q.   Doctor, it's written, "Neurological examination was normal except

20     for an unsure gait."

21             Is that correct?

22        A.   That's correct.  What I have to mention also is his performance

23     status which was 2.

24        Q.   And I'll get to that in a moment, doctor.

25             But just focussing right now on the results of your physician

Page 12661

 1     examination, you report that Mr. Hadzic's pulse rate at the start of the

 2     examination was 68 beats per minute and at the end was 80 beats per

 3     minute.  That is within the range of the normal resting heart rate of an

 4     adult, isn't it?

 5        A.   That's correct.

 6        Q.   As you just mentioned, you rated Mr. Hadzic's ECoG performance

 7     status as a two out of five, and if I'm correct, the ECoG performance

 8     status measures the level of a patient's autonomy in engaging in daily

 9     activities; is that correct?

10        A.   That's correct.

11        Q.   And according to the chart that you provide under footnote 6 of

12     your report, an ECoG 2 means that Mr. Hadzic is capable of self-care and

13     up and about for most of the day but unable to carry out any work; is

14     that correct?

15        A.   That's correct.

16        Q.   Could you tell us what information did you base this ECoG

17     assessment on.

18        A.   Well, it was based on his interview, on the questions about his

19     activities and what was he -- what he was doing during the day.

20        Q.   So it was based upon his self-reporting to you?

21        A.   Yes.

22        Q.   Can you explain to us what is meant by "unable to carry out any

23     work" under ECoG 2?  What is meant by that term, "any work"?

24        A.   It's doing, well, any work, any activity.

25        Q.   Well, what kind of work did you have in mind when you made that

Page 12662

 1     assessment and --

 2        A.   Working on the computer.  Reading for a prolonged time, yeah.

 3        Q.   And when you say "a prolonged time," how long would you mean?

 4        A.   More than one hour, for instance.

 5        Q.   Based on your own observations, is Mr. Hadzic capable of

 6     participating in a prolonged conversation and rationally and accurately

 7     answering your questions?  I'm referring to page 11 of your report.

 8        A.   That's a difficult question.  I think at this -- at that time, at

 9     that particular day, he was able to carry on a conversation with me for

10     80 minutes, at that particular time in that private situation, one on

11     one, without interfering other persons.  So this he was able to do.  I

12     think it's another matter to put him in a situation where many people are

13     talking or when he is under stress because, of course, he was very

14     relaxed.  At that time in this situation, he was -- at that time he was

15     able to have a conversation.

16        Q.   I'll come back to the issue of him dealing with multiple people

17     at the same time --

18        A.   Mm-hm.

19        Q.   -- as you mention that later on in your report.

20             Were you aware that as part of his neuropsychological examination

21     which was conducted a couple of weeks after your examination, Mr. Hadzic

22     responded to 567 questions, written questions, over approximately a

23     three-hour period.

24        A.   I have seen the report.  I have the report with me, yes.

25        Q.   And would that qualify, responding to those 567 questions, would

Page 12663

 1     that qualify as work under ECoG?

 2        A.   Yes.  This would qualify as work.

 3        Q.   Now, going back to what you have said in your previous answer, I

 4     see that in your report at page 11 you caution that your interview with

 5     Mr. Hadzic is not entirely comparable to cross-examination or a situation

 6     where multiple people intervene, and you further caution that your

 7     interview had lasted for 80 minutes.

 8        A.   Mm-hm.

 9        Q.   I take it you made these cautionary remarks because they reflect

10     your understanding of the activities that Mr. Hadzic might have to engage

11     in during the course of his trial.

12        A.   I had that in mind, yes, indeed.

13        Q.   Before you were contacted by this Tribunal, had you followed at

14     all this case?

15        A.   No.

16        Q.   During your interview with Mr. Hadzic, did he discuss with you

17     any aspects of his case?

18        A.   No.  He only very -- in a very vague way he said he had a

19     responsibility or an activity at that time, but no particulars about the

20     case.

21        Q.   I take it, then, you were not aware that Mr. Hadzic testified a

22     year ago and therefore would not be subject to further cross-examination

23     or examination --

24        A.   No --

25        Q.   -- in this case.

Page 12664

 1        A.   No.

 2        Q.   Were you aware that Mr. Hadzic is represented in court by a legal

 3     team, including two Defence counsel, and therefore he is not directly

 4     involved in examining witnesses or making oral arguments or making

 5     written submissions in this case?

 6        A.   No, I'm not aware of that.

 7        Q.   Were you aware that the Trial Chamber is considering proposals to

 8     complete this trial on an expedited basis, to shorten the trial day, to

 9     increase the number and length of breaks to allow Mr. Hadzic adequate

10     time to recuperate and rest?

11        A.   No, I'm not aware of any particular manner of conducting a trial.

12        Q.   You also weren't aware that one of the proposals is that

13     Mr. Hadzic stays in Serbia and he can follow the case, if he wants to, on

14     videolink.

15        A.   No.

16        Q.   No.  Would you agree that these considerations are relevant to

17     assessing Mr. Hadzic's ability to function for purposes of this trial?

18        A.   These would be pertinent, but you have to know -- you -- I come

19     back to the statement, on that particular day, I assume that his

20     situation is fluctuating, it's not a stable condition.  His condition is

21     evolving from day to day.  And it is -- it can be expected that it will

22     worsen rapidly.  So one day, one hour, is not representative of a whole

23     period of life.

24        Q.   I understand that.  But my question was -- and I think you -- I

25     believe you did answer that these considerations, whether he has to face

Page 12665

 1     cross-examination or whether he has to withstand long court sessions,

 2     these considerations are relevant to determine whether he can function?

 3        A.   These make it a little easier, yes.

 4        Q.   On page 8 of your report, you mention that the 12 May 2015 MRI

 5     scan showed that the lesion in the right temporal lobe of Mr. Hadzic's

 6     brain had grown and that a new lesion was seen in his corpus callosum;

 7     correct?

 8        A.   That's correct, yes.

 9        Q.   Any did the MRI show lesions affecting any other parts of

10     Mr. Hadzic's brain at the time?

11        A.   It was increased edema with shifting of the midline which is

12     making an impact on the whole functioning of the brain.

13        Q.   Was there any indication that the cancer had spread to the

14     eloquent portions of Mr. Hadzic's brain?

15        A.   No.

16        Q.   Generally, what does that mean in terms of cognitive function?

17        A.   That the cognitive function will decline.

18        Q.   But my question is the fact that the cancer was not in the

19     eloquent portion, what does that mean, when it's absent from that portion

20     of the brain?

21        A.   Well, it is interfering with speech but not with cognitive

22     function.

23        Q.   Not with cognitive function.

24        A.   Not with -- well, yes, it's not interfering with verbal

25     communication but it can interfere with cognitive function.

Page 12666

 1        Q.   And just to clarify because I think we're going back and forth on

 2     this.  The eloquent portion of the brain deals with cognitive function;

 3     correct?

 4        A.   No.

 5        Q.   Perhaps you can explain to us what the eloquent portion deals

 6     with.

 7        A.   I understand that this is with verbal communication.

 8        Q.   And what portion deals with executive function?

 9        A.   The whole brain deals with executive function.

10        Q.   And which portions deal with memory?

11        A.   Well, there are several parts in the brain which interfere with

12     memory.  There is no particular point.

13        Q.   Now, is it based on these MRI results that you arrived at the

14     conclusion that Mr. Hadzic was a recurrent glioblastoma patient?

15        A.   Yes.

16        Q.   And in your report, at pages 11 and 12, you provide statistical

17     data on the probability of survival of patients with recurrent

18     glioblastoma based on two phase three clinical trials involving three

19     cancer treating drugs.  And I believe you also go into more detail in

20     footnote 7 and 8 of your report.

21        A.   Yes, that's correct.

22        Q.   And these clinical trials used two clinical end-points - overall

23     survival and progression-free survival; correct?

24        A.   That's correct.

25        Q.   And both used as their beginning points the date of

Page 12667

 1     randomisation.  Could you explain to us what the date of randomisation

 2     was for purposes of these trials?

 3        A.   Well, that is the time when the treatment was chosen.  The

 4     patients entered in a trial and they were allocated to one -- to one of

 5     the two arms, and the time of choosing the treatment arm is the time

 6     point at which starts that curve.

 7        Q.   Would the date of randomisation be before or after the patient

 8     was diagnosed with recurrent glioblastoma?

 9        A.   This will be at the time of diagnosis of recurrence.  Mr. Hadzic

10     would correspond to, let's say, April, May.

11        Q.   He was -- the MRI showed progression and therefore that could be

12     the point of recurrence?

13        A.   It would be the point of recurrence -- at that time he could be

14     randomized in one of these trials and let's say within one month he would

15     start with a new treatment.

16             MR. OLMSTED:  If we could go into private session, Your Honours.

17             JUDGE DELVOIE:  Private session, please.

18                           [Private session]

19   (redacted)

20   (redacted)

21   (redacted)

22   (redacted)

23   (redacted)

24   (redacted)

25   (redacted)

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10   (redacted)

11   (redacted)

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16   (redacted)

17                           [Open session]

18             THE REGISTRAR:  We're in open session, Your Honours.

19             JUDGE DELVOIE:  Thank you.

20             MR. OLMSTED:

21        Q.   Turning to progression-free survival, which is the second

22     end-point these studies used, it appears the end-points were either the

23     patient's glioblastoma worsened or the patient died.

24        A.   Correct.

25        Q.   In other words, the end-point for these patients wasn't

Page 12669

 1     necessarily death for this study?

 2        A.   No, it could be progression.

 3        Q.   And if we could look --

 4             THE INTERPRETER:  Interpreter's note:  Kindly pause between

 5     questions and answers.  Thank you.

 6             JUDGE DELVOIE:  Mr. Olmsted, we are going too fast for the

 7     interpreters.  Please pause between questions and answers.

 8             MR. OLMSTED:  Thank you for the reminder, Mr. President.  I see

 9     it on the screen.

10             If we could call up on the screen 65 ter 6818.

11        Q.   And, doctor, I went on to the Internet and pulled off this first

12     study by Wick et al on the clinical trial we were discussing, and if we

13     could turn to page 3 and zoom in on the table on the bottom left part of

14     the page, we can see that while a significant number of patients

15     experienced disease progression during the study, only 15 died.  Is that

16     a correct reading of this?

17        A.   I think that's not entirely -- that's not completely correct.

18     The patient reaches an end-point at progression or he dies, but he --

19     it -- as soon as the end-point is reached, the patient is not in this

20     end-point category anymore.  So he will -- they probably have died also.

21     But the end-point was progression.

22        Q.   So in this study let me make sure that I understood you

23     correctly, the end-point for the vast majority of these patients was

24     progression and a handful, the end-point for them was their death.

25        A.   The first end-point was progression in most of them and the first

Page 12670

 1     end-point was death in the other.  But the end-point progression, of

 2     course, does not preclude a second end-point, death, which comes a little

 3     later.

 4        Q.   And the death need not be as a result of the cancer.  It could be

 5     from any cause.

 6        A.   It could be from any cause, but in this type of tumour, overall

 7     the vast majority will be due to the cancer.

 8             THE INTERPRETER:  May the interpreters kindly ask the doctor to

 9     speak into the microphone, please.

10             JUDGE DELVOIE:  Did you hear that --

11             MR. OLMSTED:  [Overlapping speakers] ... I see I've been

12     reminded, Your Honour.  I will do my best.

13             JUDGE DELVOIE:  No, it's for Dr. Specenier.  Did you hear,

14     Dr. Specenier, the interpreters ask that you speak into the microphone.

15     The Court Usher could perhaps re-direct the microphone a little bit.

16             THE WITNESS:  Okay.

17             JUDGE DELVOIE:  Okay.  We'll see.

18             Please proceed, Mr. Olmsted.

19             MR. OLMSTED:  Thank you, Mr. President.

20        Q.   If we can look or zoom in towards the abstract, the -- I think

21     it's the third paragraph, the abstract.  We see that, in fact, five

22     patients died for reasons unrelated to the cancer itself, four because of

23     adverse events, and one was drug-related.

24        A.   That's correct, yeah.

25        Q.   All right.  Doctor, could you tell us, can brain tumour

Page 12671

 1     progression be asymptomatic, in other words only detectable through MRI

 2     results or other medical tests?

 3        A.   It can.

 4        Q.   So progression may not necessarily impact a patient's ability to

 5     function.

 6        A.   Not immediately, not necessarily immediately.

 7        Q.   Other than overall survival and progression-free survival, there

 8     are other types of end-points; correct?

 9        A.   Yeah.

10        Q.   There is a timed progression and others such as that.

11        A.   That's correct.

12        Q.   And the reason clinical trials use different types of end-points

13     is that each has their limitations.

14        A.   That's correct.

15        Q.   For example, one of the limitations of overall survival is that

16     the end-point, it includes deaths unrelated to cancer.

17        A.   That's correct.

18        Q.   One of the limitations of progression-free survival is that it

19     may be subject to investigator bias.

20        A.   That's correct.  But most of the time this is dealt with to -- by

21     sending the images to a third party who evaluates the images, and in the

22     case -- well, you are correct in saying that survival, overall survival,

23     other causes of death are also important.  But in the case of

24     glioblastoma, this is not a large portion.  Let's say in breast cancer or

25     other tumour types this can be a bigger fraction of the patients.  But in

Page 12672

 1     glioblastoma, the overall or the vast majority will be due to the

 2     glioblastoma.

 3        Q.   Given these limitations --

 4             THE INTERPRETER:  Microphone, please.

 5             JUDGE DELVOIE:  Microphone, please.

 6             MR. OLMSTED:  Let me repeat myself.

 7        Q.   Given these limitations but also given the fact that individual

 8     patients have individual characteristics/attributes, the results of these

 9     types of clinical trials can only provide an approximation as to when a

10     particular patient suffering from glioblastoma will progress or may die;

11     isn't that correct?

12        A.   Well, the trials are statistics.  This is not -- you cannot say a

13     lot about an individual patient.  Indeed, when you start with a hundred

14     patients, these are the outcomes.  But, of course, as you already

15     mentioned earlier, there are about 10 or 15 per cent who live longer than

16     14 months.  You never know before who will be in this 15 per cent.  This

17     is a game of chances.

18        Q.   Clinical trials are not crystal balls.

19        A.   No, these are meant to be statistics.  But I have to say that you

20     can have some ideas, of course, because relapse after one year after the

21     end of treatment is not -- has a better prognosis than progressing during

22     treatment.  So we have to also take into account the characteristics of

23     the disease.

24             Mr. Hadzic had a progression just at the end of adjuvant

25     treatment which is worse than when he would progress, let's say, after an

Page 12673

 1     interval of a year or longer.  So these are also characteristics which

 2     you have to take into account.  You have also to take into account that

 3     the tumour was not resected.  It was only a biopsied.  So these are all

 4     unfavorable characteristics of his disease.  Another is that there was no

 5     MGMT methylation so it make the tumour less responsive to chemotherapy.

 6     So you have to balance all these characteristics.

 7        Q.   Other characteristics --

 8        A.   Can I say it other ways?  Sorry for interrupting.  It would

 9     surprise me very, very much if he would -- if he would be in the tail of

10     the curve.  I could be wrong, but it would surprise me.

11        Q.   Other characteristics that play into this would include the age

12     of the patient --

13        A.   Sure.

14        Q.   -- as well as the location of the tumour --

15        A.   Sure.

16        Q.   -- and many other factors.  In fact, I think I saw in one study

17     that it could be as many as 50 to 60 factors, variables?

18        A.   Sure.

19        Q.   All right.

20             MR. OLMSTED:  No further questions, Your Honour.

21             JUDGE DELVOIE:  Thank you.

22             Mr. Gosnell, when you're ready.

23             MR. GOSNELL:  Thank you.  Good afternoon, Mr. President,

24     Your Honour.

25                           Examination by Mr. Gosnell:

Page 12674

 1        Q.   Good afternoon, Dr. Specenier.  Am I pronouncing your name

 2     correctly?

 3        A.   Specenier.

 4        Q.   Specenier.  My name is Christopher Gosnell.  I represent

 5     Mr. Hadzic, and I'll have a few questions for you today.  If any of my

 6     questions, as they come from a layperson are not understandable or clear,

 7     please feel free to ask for clarification.

 8        A.   I'm a layperson in this setting also.

 9        Q.   Now, at page 11 of your report, which I understand you have there

10     in front of you, under the answer to question 2, you say, "The

11     glioblastoma did not respond" - and you've underlined and bolded those

12     words, "not respond" - "well to the treatment.  In fact, the disease

13     progressed," which means worsened, "despite the treatment.  This

14     assessment is based on the review of the MRI images performed at the MCH

15     on May 12, 2015, which shows that the diameter of the largest lesion has

16     increased, that there is a new lesion, and that there is edema with shift

17     of the midline."

18             And then back at page 8 of your report, you give a description as

19     to how the visible lesion has increased in size, and you say that the

20     lesion has increased from 2.9 by 2.6 centimetres, and I would understand

21     that that was from the MRI in November --

22        A.   Base-line, yes.

23        Q.   And then that increased to 4.1 by 4.8 centimetres.  So that

24     means, if my math is more or less correct, it increased from 7.5 square

25     centimetres to 20 square centimetres in size; is that correct?

Page 12675

 1        A.   That's correct.  But -- well, that's correct.  So we don't

 2     calculate in squares normally because, of course, a tumour is a sphere or

 3     an irregular volume.

 4        Q.   It's an irregular shape.

 5        A.   Yeah.

 6        Q.   But would it be fair to say that it is approximately trebled in

 7     size?

 8        A.   That's correct.  At least.

 9        Q.   And so that means now it's approximately - given it's an

10     irregular shape - approximately, the circumference of a tennis ball.

11        A.   That's correct.

12        Q.   And regardless of the statistics about median progression, this

13     itself constitutes progression, doesn't it?

14        A.   This is progression.

15        Q.   And, in fact, that's -- I'm now using the word of one of the

16     medical officers from the United Nations Detention Unit in her report of

17     the 17th of June, in fact, that's dramatic progression, isn't it?

18        A.   You can qualify it as dramatic.

19        Q.   And you say in your report, again back on page 11, that there is

20     a new lesion.  Can you tell us anything about the size of this new

21     lesion?

22        A.   Unfortunately, I did not measure it and I don't have the size

23     with me.

24        Q.   Can you give us an approximate relative to the size of the other

25     lesion or --

Page 12676

 1        A.   Small.  I think less than a centimetre.

 2        Q.   And you say that there is a edema with shift of the midline.  How

 3     large, how much in millimetres was the shift in the midline?

 4        A.   Again, I have to remind me on -- it would about 5 millimetres.

 5        Q.   And 5 millimetres, is that a significant shift?

 6        A.   That's significant.

 7        Q.   And is it right that when you have a shift of the midline of that

 8     degree we are talking about an indicator of significant intracranial

 9     pressure?

10        A.   Yes.

11        Q.   And intercranial pressure as reflected in that level of shift can

12     be fatal, can it not?

13        A.   It can be fatal in a short -- relatively short-term.

14        Q.   When you say "relatively short-term," do you mean to say that

15     that can cause sudden death?

16        A.   No, I wouldn't expect sudden death.  No.

17        Q.   And what do you mean by short-term --

18        A.   I would -- I would expect a gradual decline in his neurological

19     functioning and in his consciousness.  I would not expect a really sudden

20     death.

21        Q.   Are we talking about symptoms that would manifest themselves week

22     to week and lead to death?

23        A.   It can occur week to week, yeah.

24             MR. GOSNELL:  Mr. President, we'll have to go into private

25     session for a few questions.

Page 12677

 1             JUDGE DELVOIE:  Private session, please.

 2                           [Private session]

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Page 12678











11  Pages 12678-12680 redacted.  Private session.















Page 12681

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21                           [Open session]

22             THE REGISTRAR:  We're in open session, Your Honours.

23             JUDGE DELVOIE:  Thank you.

24             MR. GOSNELL:

25        Q.   And, Dr. Specenier, now I'd like to get away from mortality and

Page 12682

 1     we're not going to talk more about mortality.  We're going to talk now

 2     about the deficits.  And at page 12 of your report, you say:

 3   (redacted)

 4   (redacted)

 5   (redacted)

 6             Now, can I just first ask:  When you refer here to deficits, are

 7     you also referring to cognitive deficits?

 8        A.   I am.

 9        Q.   And you said earlier that after progression, you said the

10     condition of a client can be expected to worsen rapidly.  How rapidly?

11     Are we talking one week to the next there can be a decline in --

12        A.   There can be a deterioration one week to another.

13             JUDGE DELVOIE:  You may proceed, Mr. Gosnell.

14             MR. GOSNELL:  Thank you, Mr. President.  I am aware of the

15     problem.

16        Q.   And given the progress in the size of Mr. Hadzic's lesions --

17     lesion, the main lesion, that was observed between December and May,

18     would you agree that it's quite possible - and we're talking now about

19     his case - that he has worsened from week to week?

20        A.   It's very plausible, yes.

21        Q.   And that could have happened even during the two and a half weeks

22     between your examination of Mr. Hadzic and the neuropsychologist's

23     examination of Mr. Hadzic; isn't that right?

24        A.   That is completely right.  And I think there are two differences

25     between our examination.  My examination was only an interview; his

Page 12683

 1     examination was very in-depth.  These are -- is one explanation.  Another

 2     potential explanation is I'm, like, which would also could -- it is very

 3     possible that in this interval, there was a decline in condition.

 4        Q.   You performed no formal cognitive tests on Mr. Hadzic, did you?

 5        A.   No, no.

 6        Q.   You didn't perform any tests without the intercession of the

 7     interpreter; correct?

 8        A.   No, no.

 9        Q.   You didn't perform any tests in his own language?

10        A.   No.

11        Q.   You didn't perform any non-verbal cognitive testing --

12        A.   No --

13        Q.   -- such as using diagrams or images?

14        A.   No, no.

15        Q.   And that's why, at page 11 of your report, you specifically say

16     that a more thorough neuropsychological examination by a

17     neuropsychologist is warranted; is that correct?

18        A.   That's correct.

19        Q.   And you'd agree with me, I guess, based on all those factors,

20     that Dr. Martell is in a better position to give an opinion about his

21     cognitive performance than you?

22        A.   I completely agree.  And I also was aware of the fact that a more

23     thorough examination was planned at the time I saw the patient, so I was

24     aware that I did not have to do that because it was already scheduled.

25        Q.   If we can just refer again to this report from the medical

Page 12684

 1     officer dated the 8th of June, the end of paragraph 4, said:  "With a new

 2     tumour treatment, this prognosis could possibly be extended with months."

 3             Now, Dr. Specenier, I won't mention the exact number of months

 4     because that's something that we're keeping out of the public eye, so I'm

 5     not going to mention the specific reference there.

 6             But then it says:  "Of course, it cannot be predicted to what

 7     extent the treatment would be successful and to what side effects this

 8     would lead with the individual patient."

 9             And then paragraph 5 says:  "And the DMO," that's the Deputy

10     Medical Officer, "concluded in his report of the 22nd Mr. Hadzic decided

11     not to go ahead with new chemotherapy in my professional opinion for

12     obvious and understandable reasons."

13             Now, can you think of any obvious and understandable reasons why

14     he would not wish to continue with the particular course of chemotherapy

15     that was proposed?

16        A.   The most obvious reason is, I think, the low chances of improving

17     his prognosis.  Because I think here the statement by Dr. Taphoorn are a

18     little optimistic, because I think there are no real data that show that

19     a second-line treatment really improves the survival.  Therefore, I added

20     this two publications showing that, in fact, it is very difficult to find

21     any treatment which even improves the prognosis with a few weeks.

22     That's -- and even -- not even -- and there's not many months.  I think

23     treatment does not make any difference, or very minimal difference.

24        Q.   And given Mr. Hadzic's reaction to the adjuvant chemotherapy,

25     would there also be a danger of, in his case, a particular susceptibility

Page 12685

 1     of the side effects of the second-line chemotherapy --

 2        A.   Sure --

 3        Q.   -- treatment?

 4        A.   Well, if I would be in his case, diagnosed with a recurrent

 5     disease, I would not accept second-line treatment for myself.

 6        Q.   Doctor, I just want to show you one last report with the

 7     assistance of the Registry.

 8             Doctor, I just would like you to direct your attention to

 9     paragraph 3 of this medical report, which is dated the 18th of June, 2015

10     from the Deputy Medical Officer.  And he also is recording a

11     communication with Professor Taphoorn, and he says:  "I asked

12     Professor Taphoorn whether a weekly telephone conversation with the

13     Reporting Medical Officer would be too strenuous for Mr. Hadzic.  He felt

14     this was not the case.  However, he did feel that cognitive testing would

15     be too strenuous for Mr. Hadzic at this stage of his disease.  Also, from

16     a medical point of view, he felt this was not indicated."

17             Now all I want to focus on for the -- as a preliminary is to

18     understand the expression "at this stage of the disease," because you

19     used that expression as well at page 12 of your report.  In fact, it's

20     the very last line of your report where you say:  "However, it is not so

21     that this choice will definitely have a negative impact on his survival

22     as the benefit of treatment is minimal in that stage of this disease."

23             What stage of disease are you referring to?

24        A.   I am --

25        Q.   -- for starters?

Page 12686

 1        A.   -- referring to recurrent glioblastoma.  Recurrent.  That's the

 2     stage of his situation.

 3        Q.   Does that encompass the notion of being post-progression?

 4        A.   Yes.

 5        Q.   And then Dr. Taphoorn says from a medical point of view, he felt

 6     this was not indicated.

 7             What does it mean in medical terminology when a doctor uses the

 8     expression that a particular course of action is "not indicated"?

 9        A.   I suppose, but I'm not Dr. Taphoorn, of course, but I suppose he

10     thinks that it -- that he would not do it.  And I would not do it either.

11        Q.   Why would you not do it either?

12        A.   Well, as I mentioned, his ECoG stage was 2, and I think I saw

13     that he was -- he had to perform for more than two hours, which is long,

14     of course.

15        Q.   Would you say that would pose a significant strain on him?

16        A.   It is a strain, yeah.

17        Q.   Would it be medically unhelpful?

18        A.   It will not improve his condition.

19        Q.   If he was required to do that day in, day out, would it damage

20     his health?

21        A.   I think it could damage, yes.

22             MR. GOSNELL:  Thank you, Mr.  President.  Those are my questions.

23        Q.   Thank you, Dr. Specenier.

24                           [Trial Chamber confers]

25             JUDGE DELVOIE:  Dr. Specenier, this hearing comes to an end --

Page 12687

 1             Yes, Mr. Olmsted.

 2             MR. OLMSTED:  Sorry, Mr. President.  I didn't realise that there

 3     would be no questions from the Trial Chamber.  May I just raise a few

 4     questions arising out of Defence counsel's examination?

 5             JUDGE DELVOIE:  Please go ahead.

 6             MR. OLMSTED:  Thank you, Mr. President.

 7                           Further Examination by Mr. Olmsted:

 8        Q.   First of all, just with regard to the last line of questioning, I

 9     know you cannot interpret Dr. Taphoorn's words, but "could not indicated"

10     also mean not necessary?

11        A.   It could.

12        Q.   Now, in your report, you found no signs of impaired memory,

13     either long or short; correct?

14        A.   That's correct.

15        Q.   Over your 25 years of experience as an oncologist, you've had --

16     had the opportunity to observe quite a number of cancer patients; is that

17     correct?

18        A.   Sure.

19             MR. GOSNELL:  Mr. President, I'm going to object.  I don't hear

20     anything related to anything I asked Dr. Specenier about.

21             MR. OLMSTED:  It's coming, Your Honours, if I may.  I was laying

22     some foundation here.  Thank you.

23        Q.   Now, based on your 25 years of experience as an oncologist, what

24     signs would you expect to find in a patient with a significantly impaired

25     short-term memory?

Page 12688

 1        A.   I wouldn't --

 2             MR. GOSNELL:  I'm sorry, Mr. President, I do object.  This

 3     doesn't at all come out of any questions that I asked.

 4             JUDGE DELVOIE:  Objection sustained.

 5             MR. OLMSTED:

 6        Q.   Well, let me ask this, and this is with regard to the line of

 7     questioning regarding the interval between the doctor's examination of

 8     Mr. Hadzic and the examination conducted by Dr. Martell and that this is

 9     a variable situation and he may or may not have diminished in his

10     cognitive abilities between those two points in time.

11             My question is:  Based upon your professional experience, would

12     you expect signs of short-term memory loss to be noticeable in a patient

13     whose short-term memory functions at the bottom 1 per cent of the

14     population, based on your experience?

15             MR. GOSNELL:  No, Mr. President, objection.  Again, I'm sorry,

16     but this is going -- this has nothing to do with the questions that were

17     asked and the manner in which it was posed, I would suggest, is

18     inappropriate.

19             JUDGE DELVOIE:  I agree, Mr. Olmsted.

20             MR. OLMSTED:  All right.  No further questions, Your Honours.

21             JUDGE DELVOIE:  So, Dr. Specenier, this is the end of the

22     hearing.  We thank you for coming to the Tribunal to assist us.  You are

23     released as a witness.  The Court Usher will escort you out of the

24     courtroom, and we wish you a safe journey home on this Friday evening

25     with lots of traffic between The Hague and Antwerp.

Page 12689

 1             THE WITNESS:  Thank you.

 2                           [The witness withdrew]

 3             JUDGE DELVOIE:  The parties are aware of the fact that their

 4     submissions are expected to come in by Tuesday, if I'm not wrong?

 5             Then, if there is nothing else, court adjourned.

 6                            --- Whereupon the hearing adjourned at 4.35 p.m.,

 7                           sine die.