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Hepzato Kit: A New Era in Liver-Directed Therapy | The Eye Believe Podcast · The Eye Believe Podcast

• 0:03
  hey guys welcome back to the Eye Believe Podcast
• 0:05
  I'm Danet
• 0:06
  and I am back here with Doctor Zachary Berman
• 0:09
  from the university of California
• 0:11
  San Diego
• 0:12
  and we're going to chat a little about Hepzato Kit
• 0:14
  which has been FDA approved now for
• 0:16
  I think about two years
• 0:18
  it was like two summers ago is when it was FDA approved
• 0:20
  but before we get into that Zach
• 0:22
  do you want to tell me about these incredible photos
• 0:23
  behind you because I'm like totally awestruck
• 0:26
  yeah yeah
• 0:26
  so my day job is interventional oncology
• 0:29
  but I guess my my night and weekend job is is imaging
• 0:33
  and so these are photos of the Andromeda Galaxy and the
• 0:36
  the Horsehead Nebula that I took on
• 0:38
  through my telescope it's absolutely incredible
• 0:41
  I love photography and this kind of like you said
• 0:43
  it's called astro photography
• 0:45
  exactly yep
• 0:47
  it's so cool to see my kids would go nuts
• 0:49
  they're always wanting to look at the stars
• 0:50
  and look for comets and like that kind of stuff
• 0:53
  yeah it's a real test in patience
• 0:55
  I wish him luck
• 0:56
  haha I believe it haha
• 0:58
  um okay
• 0:58
  so like I said guys
• 0:59
  we're here to talk about Hepzato Kit
• 1:01
  it's role in treating liver metastases
• 1:04
  and the latest and what patients need to know
• 1:06
  just as a reminder
• 1:07
  we're here to give you information to help you develop
• 1:10
  like a an informed opinion
• 1:12
  and to basically better advocate for yourself
• 1:15
  please make sure to
• 1:16
  seek personal medical advice from your doctor
• 1:18
  and use this episode again
• 1:19
  like just as a simple way to learn more about Hepzato Kit
• 1:22
  and to be your best advocate
• 1:24
  for the purpose of this episode
• 1:25
  I'm gonna kind of play the part of a metastatic patient
• 1:28
  who's been told you know
• 1:29
  Hepzato is on the table and Doctor
• 1:31
  Berman is going to just kind of play that role of like
• 1:33
  okay he's explaining to you or me
• 1:36
  or both of us as though we've never heard about this
• 1:39
  so bear with us um
• 1:41
  but can you just explain you know
• 1:42
  when in a metastatic journey
• 1:44
  like I'm you know why would I be coming to you
• 1:46
  I guess as a uveal melanoma metastatic patient
• 1:49
  yeah so um
• 1:50
  ocular melanoma is a very interesting and you know
• 1:53
  obviously a very rare disease and for whatever reason
• 1:57
  I don't know think we fully understand why
• 1:59
  it really likes to go to the liver
• 2:01
  it's usually the first place that metastasizes
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  and most patients over the course of
• 2:05
  you know their
• 2:06
  their cancer journey
• 2:07
  will eventually end up with liver metastases
• 2:11
  some series up to 80% over 10 years
• 2:13
  and so most patients
• 2:15
  would have usually had their
• 2:17
  initial primary cancer treated
• 2:18
  maybe a couple years in the past or so
• 2:21
  and they were getting their routine scans
• 2:22
  or maybe there was an elevated
• 2:24
  test on one of their routine blood works
• 2:26
  and all of a sudden there's now liver metastases
• 2:28
  and that's usually when they'll come and at least
• 2:30
  have a discussion with with me
• 2:32
  I work in
• 2:33
  in a shared clinic with our melanoma oncologists
• 2:37
  and so usually
• 2:37
  they'll see both of us together
• 2:38
  and kind of create
• 2:40
  or formulate a plan for
• 2:41
  what we think might be the best way to
• 2:43
  to tackle these these tumors
• 2:45
  for the sake of this discussion
• 2:47
  I've got maybe 1 2 kind of larger ish
• 2:51
  you know 1 or 2 centimeter lesions
• 2:53
  and I have a couple of those
• 2:55
  what they call like satellite lesions around them right
• 2:57
  I I joke that it's like we've got the mothership
• 3:01
  and then we've got all the little stars
• 3:02
  or the little babies around it
• 3:03
  why would that make me a good candidate for like
• 3:06
  Hepzato as opposed to
• 3:07
  maybe
• 3:07
  something else that interventional radiology might do
• 3:10
  like cause I mean
• 3:10
  I've had like a microwave ablation before
• 3:12
  like why couldn't I just do that
• 3:14
  yeah of course
• 3:15
  unfortunately because it is such a rare disease
• 3:18
  um it is really hard to do large clinical trials
• 3:21
  where we kind of examine every single patient scenario
• 3:24
  and say what would be the best option
• 3:26
  so for the most part a lot of what we're doing
• 3:29
  when we see new patients is kind of saying
• 3:31
  this is our best medical judgment
• 3:33
  we can look at other sorts of
• 3:35
  you know cancers that metastasize to the liver
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  like colorectal cancer or pancreatic cancer or
• 3:39
  something like that and say
• 3:40
  these are the sorts of options that we usually
• 3:42
  we tackle and these are the options that we have
• 3:46
  now if you had a single tumor
• 3:47
  you know like you mentioned before
• 3:49
  it might make sense that only
• 3:50
  we should only need to treat that one
• 3:52
  single tumor with something like a microwave ablation
• 3:54
  or or any of the other ablative technologies that
• 3:57
  that are out there unfortunately
• 3:58
  what usually is the case is
• 4:00
  maybe you only see one on a CT scan
• 4:03
  but then you get an MRI which has better resolution
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  you might see 5 6
• 4:07
  7 and you know
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  sometimes many many
• 4:09
  many more tumors throughout the entire liver
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  and when that becomes the case
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  if you imagine doing a microwave ablation
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  and having to treat every single one individually
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  you would have no liver left
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  and so you can't really get rid of the entire liver
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  it's called the liver for a reason
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  you need it to live uh
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  and so you just can't get rid of it all
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  so now you have to start thinking
• 4:27
  about different types of therapies
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  that you can do to the entire liver
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  to treat all of the tumors that you're seeing
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  and many of the ones that you're probably not seeing
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  because they're too small to be seen on a CT or an MRI
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  or a pet scan at the same time
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  and for a while
• 4:40
  there was a lot of different therapies that were given
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  and and usually when you're at this scenario
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  it's it's what we call transarterial therapy
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  the liver uh is a very unique organ
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  where it has a dual blood supply
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  what does that mean well
• 4:52
  if you think about your brain
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  or your heart or your kidneys
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  there's usually an artery that goes into it
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  and a vein that drains it uh
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  in the brain
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  it's the carotid artery in the jugular vein
• 5:01
  in the kidney it's the renal artery
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  in the renal vein and in the heart
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  it's the the coronary artery
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  I'm sure you've heard of all of those
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  you know bad things that can happen inside of them
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  but the liver is unique
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  it has not only an artery that goes into it
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  um but a vein and the portal vein
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  portal vein drains all of your intestines
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  and drains all of the nutrients and everything
• 5:18
  back to the liver but interestingly
• 5:20
  while it goes to the normal liver cells
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  it doesn't go necessarily to a lot of the
• 5:25
  the cancer cells actually
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  very little of it actually will go to the cancer cell
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  the cancer cells in turn
• 5:32
  get most of their blood supply from the artery
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  and the background liver
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  only gets about
• 5:36
  20% or so of its blood supply from the artery
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  so we can use that to our advantage
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  where we can put something into the artery
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  that goes to the tumors preferentially
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  and less to the background liver
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  not 100% but less to the background liver
• 5:51
  and there's a whole bunch of different things
• 5:52
  that have been kind of experimented in the past with
• 5:54
  like chemo embolization or immuno embolization
• 5:57
  I'm sure you've heard in the past for uveal melanoma
• 5:59
  and again
• 6:00
  those are different sorts of agents that we can give
• 6:02
  either chemotherapy
• 6:03
  or an agent to stimulate your immune system
• 6:05
  like
• 6:05
  GM-CSF (Granulocyte-macrophage colony) to really go and fight the cancer uh
• 6:09
  more recently uh
• 6:10
  as we were mentioning before
• 6:11
  this concept of Intrahepatic
• 6:14
  or percutaneous hepatic delivery
• 6:16
  of a really strong chemo agents called melphalan
• 6:19
  it has gained a lot of usage over time and you know
• 6:22
  it's marketed on the market now as the Hepzato Kit
• 6:25
  and the reason why it's called a kit is
• 6:27
  the melphalan itself is quite toxic
• 6:31
  it's an incredibly powerful chemotherapy
• 6:34
  it's what they actually give to get rid of your bone
• 6:36
  marrow before you get a bone marrow transplant
• 6:37
  for instance and so
• 6:39
  we obviously
• 6:39
  don't want to give you a bone marrow transplant
• 6:41
  if we're trying to you know
• 6:42
  cure your your
• 6:43
  your treat your uveal melanoma
• 6:45
  so at the same time too we have to filter
• 6:48
  the chemo out before it goes to the rest of your body
• 6:50
  and that's what that kit does
• 6:51
  and I'm sure you know the whole ins and outs
• 6:54
  and nitty gritties has been explained on a different
• 6:56
  podcast I won't go into it
• 6:57
  but essentially the idea is put the chemo
• 7:00
  the really strong chemo
• 7:01
  that kind of fills your entire liver
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  but
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  filter it out before it goes to the rest of your body
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  oh so I love this and I love your explanation
• 7:09
  but I also want to like you said
• 7:11
  like just refer people back to some of the podcast
• 7:13
  that we've done before
• 7:14
  we've had Doctor Dr. Padia who's also in California
• 7:16
  talk about Hepzato in multiple different ways
• 7:18
  he's talked about it on the podcast
• 7:20
  and he also was part of our liver directed
• 7:22
  like puzzling out liver directed therapies on our
• 7:25
  quarter one webinar I believe
• 7:27
  and that was earlier this year in 2025
• 7:29
  so you can find those on our YouTube channel
• 7:31
  feel free to um
• 7:32
  check the show notes or the description below
• 7:34
  we'll make sure to include those
• 7:35
  so that aside okay
• 7:37
  back to I'm a patient so you're my doctor now
• 7:40
  like because we've decided
• 7:41
  or it's been decided by this group of people
• 7:43
  um that I should have Hepzato Kit on the table
• 7:46
  so I guess I wouldn't I mean
• 7:49
  would I just come to you like
• 7:51
  would I have just found you
• 7:52
  or would my medical oncologist
• 7:53
  have to refer to an interventional radiology
• 7:56
  so so it's a little bit of a mix of both right
• 7:58
  so not every single center
• 8:00
  cause it is a little bit um
• 8:01
  intensive as far as resources
• 8:03
  you need to have a certain type of anesthesiologist
• 8:05
  you have a a perfusionist
• 8:06
  you have to have the right space
• 8:07
  you have to have people who are trained in it
• 8:09
  it is a little bit of a different procedure from
• 8:11
  from an interventional radiology perspective
• 8:14
  and so there's a lot of
• 8:15
  specialized training that goes into it
• 8:16
  so only a few centers throughout the US do it
• 8:19
  obviously we're one of them
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  I would say some of our patients kind of find us
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  and then some of our patients we find internally
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  just through our natural um
• 8:27
  care network I found it particularly rewarding
• 8:30
  if someone comes in from the outside
• 8:32
  to also have a consultation with
• 8:34
  one of our medical oncologists
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  cause again
• 8:36
  we do a lot of clinical trials here in the space
• 8:38
  as well and so I think it's
• 8:39
  it's really beneficial to
• 8:41
  not only get the second opinion
• 8:43
  but I think it's nice to have both
• 8:44
  a medical oncologist
• 8:45
  and an interventionalist in the same space
• 8:47
  to have a multidisciplinary and kind of more holistic
• 8:50
  approach to to how it is
• 8:51
  so if someone comes in from the community
• 8:53
  I always offer them
• 8:54
  a consultation with our medical oncologist as well
• 8:57
  just to make sure that you know
• 8:58
  they get a second opinion
• 9:00
  to make sure everything makes sense or uh even
• 9:03
  you know as we go down the Hepzato journey
• 9:05
  if down the line there's a clinical trial
• 9:07
  or something else that has come onto the market
• 9:08
  since then they're they're always giving you know
• 9:10
  the most up to date information yeah
• 9:13
  that makes total sense okay
• 9:14
  so let's just say for the sake of chatting
• 9:17
  that I'm a patient who I've also got like
• 9:20
  I don't know one bone met right
• 9:21
  I've got like one metastatic spot in my hip bone
• 9:24
  is Hepzato gonna help me with that
• 9:27
  uh no
• 9:27
  so the whole
• 9:28
  idea of Hepzato is that it doesn't get systemically
• 9:30
  right so
• 9:31
  we talked about how powerful the chemotherapeutic agent
• 9:34
  um the melphalan is
• 9:35
  so the whole goal is to prevent as little as you can
• 9:38
  getting to this you know
• 9:39
  the whole body the numbers vary depending on
• 9:42
  on who you ask but it's usually less than 10%
• 9:44
  of the chemo that you're giving
• 9:45
  actually ends up getting systemic well
• 9:47
  that's insane like
• 9:49
  that's a very small amount of chemo compared to
• 9:51
  obviously like
• 9:52
  I mean I think the stereotypical cancer journey says oh
• 9:55
  I got chemo I'm gonna have stomach problems
• 9:58
  I'm gonna lose my hair I'm going to
• 10:00
  you know have susceptibility to the sun
• 10:02
  like there's so many different side effects
• 10:04
  that can happen from chemotherapy correct
• 10:06
  and and the inverse is also true
• 10:08
  since so little of it gets into your system
• 10:10
  that allows us to really intensify
• 10:12
  the amount that we put in the liver right
• 10:13
  so there's always limits you know
• 10:15
  there's different curves
• 10:16
  the LD fifty curve is something you may have heard
• 10:18
  if you I don't know
• 10:20
  Google this kind of stuff
• 10:21
  where there's a certain dosage of the chemo
• 10:23
  that will kill the tumor
• 10:25
  but there's also a certain amount of
• 10:26
  dosage of the chemo that will kill the background
• 10:28
  you know normal tissues
• 10:30
  and you're always balancing that right
• 10:32
  with any chemo agent that you get
• 10:34
  the beauty of being able to filter most of it out
• 10:36
  before it gets to your entire body
• 10:38
  the liver is actually pretty resilient to this chemo
• 10:40
  drug so
• 10:41
  you can give a much higher dose
• 10:42
  without affecting the liver
• 10:43
  which means that you can give a much higher
• 10:45
  dose to the tumors as well
• 10:46
  so not only is it not gonna go to your entire body
• 10:48
  but you can give it a higher concentration
• 10:51
  inside of the liver than you would normally
• 10:53
  if you were to get it like an IV infusion of this yeah
• 10:56
  that totally makes sense hypothetically
• 10:57
  I'm on Kimmtrak or Ipi Nivo
• 10:59
  like am I gonna have to stop that
• 11:01
  to have the Hepzato treatment
• 11:02
  because those are what my doctors are telling me is
• 11:05
  that's the stuff that's gonna make sure that
• 11:06
  you know
• 11:07
  the hip bone metastatic spot doesn't become like
• 11:09
  20 billion little hip bone metastatic spots
• 11:12
  do I get to keep doing
• 11:13
  I'm just gonna say Kimmtrak for the
• 11:15
  the simplicity of it of course
• 11:16
  so let's take a step back and say
• 11:19
  just because you have the hip bone metastasis
• 11:22
  doesn't necessarily
• 11:22
  mean that you wouldn't have a benefit
• 11:24
  from treating the liver disease right
• 11:26
  so let's say you have a 1 cm hip bone metastasis
• 11:30
  you're probably not gonna end up you know
• 11:32
  having issues down the line because of that
• 11:35
  maybe you might have pain eventually or or
• 11:37
  you know a little discomfort but the liver
• 11:41
  if you run into having too many tumors
• 11:43
  inside of your liver
• 11:43
  where it eventually replaces too much of your liver
• 11:46
  or blocks a bile duct or something like that
• 11:48
  you could really run into a lot of problems
• 11:50
  so whenever we have these sorts of scenarios
• 11:53
  it really helps
• 11:54
  to have that multidisciplinary conversation
• 11:55
  and say I really think
• 11:57
  the liver is what's gonna get us into trouble
• 11:59
  in that you know short to intermediate term future
• 12:01
  it really does make sense that we should treat
• 12:03
  the liver you know
• 12:04
  even though there may be a metastasis
• 12:06
  outside of the liver and again
• 12:08
  that's something unique to uveal melanoma
• 12:10
  where it really does
• 12:12
  it does metastasize to other places
• 12:13
  but it really loves to go to the liver
• 12:15
  now to the question you
• 12:17
  you directly asked me which is the systemic therapies
• 12:19
  we don't actually know the answer to that question
• 12:22
  so when they did the trial
• 12:23
  the focus trial
• 12:25
  which is the phase 3 trial that got it FDA approved
• 12:28
  they were just getting that the um
• 12:29
  the Hepzato the Melphalan
• 12:31
  in in and of itself
• 12:33
  there is an ongoing trial in Europe
• 12:35
  um called the Chopin trial
• 12:37
  which the first safety analysis came out
• 12:38
  where they were doing the combination of Ipi Nivo plus
• 12:42
  Hepzato
• 12:43
  and it seemed that it was safe
• 12:44
  and in the early efficacy
• 12:46
  or how well it was doing seems to be um encouraging
• 12:50
  uh we're still awaiting the final results
• 12:51
  and those should be coming out
• 12:52
  hopefully in the very short to near term future
• 12:56
  and that'll give us a lot more insight
• 12:57
  as it relates to that uh
• 12:59
  now uh
• 13:00
  now you ask about Kimmtrak uh
• 13:02
  or Tebentafusp
• 13:03
  that's a little bit harder um to know uh
• 13:05
  we definitely have treated patients
• 13:07
  in a combination with that
• 13:08
  but again
• 13:09
  we don't have any clinical trial evidence to say
• 13:11
  it's a good idea it's a bad idea mechanistically
• 13:14
  the immunotherapy works
• 13:16
  functionally different than the chemotherapy
• 13:19
  melphalan does
• 13:19
  so mechanistically it makes sense but again
• 13:23
  going back to what we were talking
• 13:24
  in the very beginning of our conversation
• 13:26
  a lot of the stuff
• 13:27
  we're not gonna have clinical trials for
• 13:29
  and it really is gonna be kind of
• 13:30
  a multidisciplinary discussion
• 13:32
  kind of with everybody right
• 13:33
  so you have a medical oncologist
• 13:34
  you can have the interventional oncologist
• 13:36
  but more importantly
• 13:37
  the patient's gonna be involved in this as well
• 13:39
  so we would meet with you in clinic and say
• 13:42
  we don't really know what's gonna happen
• 13:43
  we don't have you know
• 13:44
  phase 3 evidence to say this is definitely a good idea
• 13:46
  but in our clinical experience
• 13:48
  our rational these are the side effects
• 13:50
  we think you may derive a benefit
• 13:52
  what do you think
• 13:52
  and then you're obviously part of the decision
• 13:55
  you know process as well
• 13:56
  and your input could be at the same time too
• 13:58
  where you could say it seems like too much um
• 14:01
  or I have other patients who are like
• 14:03
  can't we just do Ipi Nivo Tebentafusp
• 14:05
  melphalan immuno embolize
• 14:06
  let's just do it all at once right
• 14:08
  uh do everything but
• 14:09
  you know so it
• 14:10
  it it's a patient by patient kind of
• 14:13
  discussion that needs to be had
• 14:15
  I think that makes total sense
• 14:16
  and I'm just gonna interject my own
• 14:18
  like real life experience here
• 14:19
  to just say that I did choose
• 14:21
  you know after having this discussion with my doctor
• 14:23
  and with the intervention radiologist here in Arizona
• 14:26
  I did end up choosing to have an immunotherapy
• 14:28
  just kind of going off of the
• 14:30
  the hope of the Chopin trial from the UK
• 14:33
  which like you said that's coming out sometime
• 14:35
  I think in the fall is what I've heard noised about
• 14:37
  so hopefully we hear we'll hear soon
• 14:39
  but I did choose to do that
• 14:40
  the downside for me at least
• 14:41
  was that the immunotherapy that we chose
• 14:43
  ended up stimulating liver hepatitis
• 14:46
  um autoimmune hepatitis
• 14:48
  so that obviously wasn't great
• 14:49
  my immune system decided to attack my liver
• 14:52
  which in theory could be you know
• 14:54
  we're my doctors over here like well
• 14:55
  that could be good right
• 14:56
  you know we stopped it
• 14:57
  we got it we got
• 14:58
  got it under control but also
• 15:00
  like we turned your immune system on really well
• 15:03
  so that could be a good thing
• 15:04
  so and
• 15:05
  and I appreciate you know
• 15:06
  having that kind of hopeful thing to think about
• 15:08
  but I digress
• 15:09
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  back to I pretend I know nothing
• 15:30
  okay so I think I'm on board
• 15:31
  like I think I want to have the Hepzato treatment
• 15:33
  what do I need to expect like from the treatment days
• 15:36
  and kind of like you know
• 15:38
  how often do we do this yeah
• 15:40
  so if we look at the uh
• 15:42
  the focus trial
• 15:44
  which is really how this all got started
• 15:46
  it was up to six cycles
• 15:47
  and each cycle is each treatment
• 15:49
  that's what we kind of call it
• 15:50
  um I think in the trial
• 15:52
  most patients got about four
• 15:53
  um and in our experience
• 15:54
  sometimes patients need four
• 15:56
  sometimes they need less
• 15:57
  but you would come in for a procedure
• 15:59
  so just like any other you know surgery
• 16:01
  you wouldn't eat the night before
• 16:02
  you'd come into a pre operative area
• 16:04
  you'd meet the anesthesiologist
• 16:05
  some patients have to get a cardiac work up
• 16:08
  before you might get a uh
• 16:09
  echo cardiogram of your heart or an EKG
• 16:12
  just depending on your other medical factors
• 16:14
  you come in for your procedure um
• 16:16
  it's always done under general anesthesia
• 16:18
  so you'll be completely asleep
• 16:20
  then
• 16:21
  you know without going too much in the nitty gritty
• 16:23
  see you have the previous episodes
• 16:24
  you would have the Hepzato procedure done and
• 16:27
  and then I think most people now are recovering in a
• 16:30
  what we call a short recovery unit
• 16:31
  where you would spend the night in
• 16:33
  in the hospital
• 16:34
  but it's usually not necessarily like uh
• 16:36
  the impatient side of the hospital at least for us
• 16:38
  we have a called the rapid recovery area where uh
• 16:41
  it's not like you're in the hospital for
• 16:43
  it's a separated area
• 16:44
  where you're expected to spend less than 24 hours
• 16:46
  so
• 16:47
  most of our patients have the procedure done by noon
• 16:49
  or 1 or 2 PM they're
• 16:51
  you're eating you're walking around
• 16:53
  and then you spend the night in the hospital
• 16:55
  make sure everything's okay
• 16:57
  and the next day you go home
• 16:58
  we usually check in with you a
• 16:59
  couple of days afterwards
• 17:01
  just to make sure everything's okay
• 17:02
  seeing what your side effects are uh
• 17:04
  and then um about a week or 2 weeks later
• 17:06
  our current practice is to get a uh
• 17:08
  a blood draw to see what your
• 17:10
  your white blood cell counts are doing
• 17:11
  cause I know some patients can have some decrease in
• 17:13
  their white blood cell counts afterwards
• 17:16
  based on that then I see uh
• 17:18
  you know
• 17:18
  I let you live your life for about a month or so
• 17:20
  see you in clinic you know
• 17:21
  there after see how everything is going
• 17:23
  and if you're up for it
• 17:24
  we'll kind of get another one scheduled
• 17:26
  our cadence is every six weeks to two months
• 17:29
  and then every two months we'll do that
• 17:31
  uh after the second cycle
• 17:32
  we usually get our first what I call the report card uh
• 17:34
  where we'll go back in and rescan
• 17:36
  and see how things are going
• 17:37
  and make future treatment decisions again
• 17:40
  uh in a combination with you
• 17:42
  as well as the medical oncology team
• 17:44
  okay I think that makes sense
• 17:46
  I've kind of heard some noise from other friends
• 17:48
  who've had this procedure
• 17:49
  and they've just said that
• 17:51
  you know especially
• 17:52
  the first time that you have the Hepzato treatment
• 17:54
  it can kind of feel like you've been hit by a bus
• 17:56
  I mean is that something that I should expect as well
• 17:58
  like just physically to be pretty knocked out for a bit
• 18:01
  yeah so it is a big procedure
• 18:03
  um you're under general anesthesia
• 18:04
  so you don't actually feel any of the procedure
• 18:06
  as it's being done but
• 18:07
  you know you're
• 18:08
  you're getting decently sized tubes put into
• 18:10
  you know three veins and one artery
• 18:13
  and there's a lot of uh
• 18:14
  fluid shifts happening as the
• 18:16
  you know the blood is being taken
• 18:17
  out of your
• 18:18
  your body filtered and then put it back into your body
• 18:20
  so there's just a lot happening and in
• 18:22
  during the procedure
• 18:23
  there are some physiologic changes at different parts
• 18:26
  as you're going on the pump and coming off of the pump
• 18:29
  and so it's just a lot of
• 18:30
  just fluid shifts and stuff like that
• 18:33
  and so it really can kind of knock you out
• 18:36
  and like you said
• 18:36
  a lot of my patients say they got hit by a bus right
• 18:38
  for the first couple of days afterwards
• 18:40
  the good news is the first cycle is usually the worst
• 18:43
  cause you're not you're not knowing what to expect
• 18:45
  but after that
• 18:46
  it doesn't like become cumulative where each cycle gets
• 18:51
  gets worse um
• 18:52
  it's all the same and usually
• 18:54
  once you know what to expect and how to plan for it
• 18:56
  you're usually in a pretty good place for it
• 18:58
  yeah I think that makes sense
• 18:59
  um and I mean
• 19:00
  I've had like liver surgery before
• 19:02
  so I mean that knocked me out for a solid six weeks
• 19:04
  so hopefully this will be a little less than that
• 19:07
  it's definitely way less than liver surgery
• 19:09
  I'll tell you that yeah
• 19:10
  for sure what about the whole laying flat thing
• 19:13
  like I've heard of chemo embolization and like
• 19:15
  immuno embolization
• 19:16
  and they always talk about how hard it is to have
• 19:18
  to lay flat
• 19:19
  is that something that happens across the board
• 19:22
  or does it kind of depend patient to patient with you
• 19:24
  with like how you guys do this procedure
• 19:26
  it's gonna be center to center
• 19:28
  cause every center has a different kind of um
• 19:30
  techniques for how they do it
• 19:31
  we reverse the anticoagulation that you have
• 19:34
  during the procedure during the procedure
• 19:35
  so you're back to a normal
• 19:37
  coagulation limit by the end of it um
• 19:39
  and we also have techniques for how we kind of
• 19:41
  close the little holes
• 19:42
  that we made in the arteries and the veins
• 19:44
  so all of our patients are ambulatory within two hours
• 19:47
  and so
• 19:47
  our goal is to get you walking as soon as possible
• 19:51
  now you know there's a lot of stuff happening
• 19:53
  you're still waking up from the anesthesia
• 19:55
  you might want to eat a little bit you know
• 19:57
  kind of get acclimated
• 20:01
  yeah exactly
• 20:01
  so you may not be walking
• 20:03
  but our goal is to get you walking
• 20:04
  definitely the same day and as soon as possible
• 20:06
  I think that makes sense so you mentioned
• 20:09
  you know as far as the other side effects
• 20:11
  not just like in the hospital things to expect
• 20:13
  I'm just recapping like the white blood cell count drop
• 20:16
  uh
• 20:16
  platelets down just because of anticipated blood loss
• 20:19
  would I like always need a blood transfusion
• 20:22
  uh for like I guess what is it like just bags of blood
• 20:24
  I know like
• 20:25
  some people say
• 20:25
  they have to go to the ICU for this procedure
• 20:28
  and they have to have blood
• 20:29
  like it's always gonna happen
• 20:30
  since we take all of the different
• 20:31
  we call them sheaths or the little tubes
• 20:33
  that we put into the arteries and veins out
• 20:35
  during the procedure um
• 20:36
  none of our patients go to the intensive care unit
• 20:38
  afterwards
• 20:39
  they all just go to this rapid recovery area
• 20:42
  and spend a night over there
• 20:44
  we don't give very many blood transfusions
• 20:46
  most patients
• 20:48
  come in with a normal level of hemoglobin
• 20:50
  or the red blood cell count
• 20:52
  and even though
• 20:53
  you do lose a little bit of blood during the procedure
• 20:55
  it it's not a lot and and not enough to require um
• 20:58
  a transfusion occasionally
• 21:00
  and it's usually not the day off or the next day
• 21:02
  but it's like a week or two later
• 21:04
  if your white blood cell count is quite low
• 21:06
  um we call it neutropenia uh
• 21:08
  you may need to have a different type of medication
• 21:10
  given so
• 21:11
  it kind of boosts how much your bone marrow produces
• 21:14
  your white blood cells um
• 21:16
  so that might be an additional medication that might
• 21:18
  you might need to augment how much you know
• 21:20
  your your bone marrow is producing
• 21:52
  okay I think that makes sense
• 21:54
  as far as like the procedure goes
• 21:55
  that seems I mean
• 21:56
  as straight forward as I mean
• 21:58
  I feel like I would explain this to somebody
• 22:00
  and they would say that sounds like so much
• 22:01
  but also like you said you know
• 22:04
  it's not as much as liver surgery
• 22:06
  it's not as much of a recovery time
• 22:07
  like to so to me
• 22:08
  this sounds great you mentioned a little bit of
• 22:11
  kind of a check Mark with like
• 22:13
  a report card on the imaging
• 22:14
  of checking in after two treatments
• 22:16
  so like this is an image based procedure right
• 22:19
  you use a
• 22:19
  an angiogram to like visualize where you're going
• 22:22
  that's why interventional radiology is needed
• 22:24
  um so why do we still need scans
• 22:27
  like I hate scans
• 22:29
  of course yeah
• 22:30
  so you know
• 22:31
  if we were look at the focus trial
• 22:33
  not every single patient responded to this
• 22:35
  this treatment now
• 22:36
  I think in our collective experience
• 22:37
  since it's been FDA approved
• 22:39
  and we've been doing more of it
• 22:40
  I think we're seeing better results
• 22:43
  and I don't know if that was just how the patients
• 22:44
  were selected for the
• 22:46
  for the focus trial or you know
• 22:47
  weird things can happen when things are
• 22:49
  in a clinical trial
• 22:49
  because of how regimented it has to be
• 22:51
  but in the real world
• 22:52
  when we're a little bit more free to
• 22:53
  kind of choose the patients who need it
• 22:55
  and image at different time points etcetera
• 22:57
  we're seeing that patients are actually
• 22:59
  responding at a higher rate
• 23:01
  and the only way you're gonna really know that
• 23:03
  is to take a look at the liver
• 23:04
  now theoretically
• 23:05
  you could get one of those angiograms
• 23:07
  to see what's going on in your liver
• 23:08
  but that's an invasive procedure uh
• 23:11
  and uh it requires uh you know
• 23:13
  you being in the hospital and having
• 23:15
  stuck in the artery and taking pictures versus an IV
• 23:18
  and looking at your liver that way
• 23:20
  so uh it's also cheaper uh to do it that way and uh
• 23:24
  so anything that's less invasive and cheaper um
• 23:26
  I think most people would agree
• 23:28
  is probably the best way of
• 23:29
  of doing it okay
• 23:30
  I think that makes sense
• 23:31
  I guess I will go in the MRI tube
• 23:33
  it'll be fine so listen to music and get through it
• 23:36
  thank goodness it's not too long these days
• 23:38
  what about like blood tests
• 23:39
  I've heard a couple of patients talking about how
• 23:41
  like their doctors are all doing like
• 23:43
  I think in Wisconsin
• 23:44
  and like some people on the East Coast
• 23:46
  like their doctors are doing a CT DNA with like
• 23:48
  signatera or something similar
• 23:50
  how do you see that as something that we could use
• 23:53
  is that something you use with patients like these days
• 23:55
  yeah so CT DNA is like one of the hottest topics in
• 23:59
  in uh
• 23:59
  kind of tumor marker space these days
• 24:01
  not only with melanoma but other malignancies as well
• 24:04
  the uh
• 24:05
  Tebentafusp trial that got Kimtrack approved by the FDA
• 24:08
  had that as one of their endpoints
• 24:09
  where they were looking at
• 24:10
  the percentage reduction in your CT DNA
• 24:12
  or circulating tumor cells
• 24:14
  um DNA in
• 24:15
  in in your body
• 24:16
  I don't really know what to do with those numbers
• 24:18
  I think going down is good
• 24:20
  I know zero is you know
• 24:22
  undetectable is the best
• 24:23
  but let's say it's going down but not zero
• 24:26
  but we don't see anything on your MRI
• 24:29
  I don't have the knowledge to know that
• 24:31
  we need to
• 24:31
  continue treating you with this invasive procedure
• 24:34
  or if we can just take a
• 24:35
  look at things and see how things are going
• 24:36
  so unfortunately in 2025
• 24:38
  our best biomarker or something that tells us like
• 24:41
  what we should be doing is imaging however
• 24:44
  as we are starting to get more experience with stuff
• 24:46
  like circulating tumor DNA
• 24:48
  I think in the future
• 24:49
  that's gonna play a much bigger role
• 24:50
  and who knows
• 24:51
  maybe in 2030 when we're doing the same podcast
• 24:53
  I may have egg on my face cause they're gonna be like
• 24:56
  yeah everyone needs to see yes
• 24:58
  be here be back in five years guys
• 25:00
  be back seriously
• 25:02
  I will I like the idea obviously
• 25:05
  of a blood test instead of an MRI
• 25:07
  but like it like
• 25:07
  you said
• 25:07
  it makes sense that we can't necessarily use it
• 25:10
  alone quite yet because it's still developing
• 25:14
  still getting better so moving on
• 25:16
  I have you know just some concerns a lot of people um
• 25:21
  kind of noise about or maybe they just wonder like okay
• 25:23
  you're giving chemo to the liver
• 25:25
  like
• 25:25
  is that gonna cause liver failure or like cirrhosis
• 25:29
  and maybe like define what cirrhosis is
• 25:30
  because I think not everybody knows what that is
• 25:33
  of course so um
• 25:34
  cirrhosis um all it really means is that it's causing
• 25:38
  scarring of the liver
• 25:39
  and there's different forms of that
• 25:41
  and fibrosis or the fibrous bands that
• 25:44
  that kind of form within the liver have
• 25:46
  have a the staging score
• 25:48
  there's a lot of different ways
• 25:50
  that you can end up with getting cirrhosis
• 25:52
  I think
• 25:52
  most people think it's like hepatitis or alcohol um
• 25:55
  actually in the US right now the
• 25:56
  the leading cause of cirrhosis is actually obesity
• 26:00
  or fatty liver disease is becoming a huge problem um
• 26:03
  but the other way you can also get it is
• 26:05
  you might hear some people on chemotherapy getting it
• 26:08
  and that some people call it pseudocirrhosis
• 26:10
  for me it doesn't really matter there
• 26:11
  there's the scarring inside of the liver
• 26:13
  it's the same physiology
• 26:15
  for those patients who are usually getting it
• 26:16
  it's years and years and years of chemo
• 26:19
  it's usually not the
• 26:20
  the patients who are getting short little bits
• 26:22
  bursts of chemo like you
• 26:24
  would with something like Hepzato
• 26:25
  where you're only going to get it four to six times
• 26:27
  um and so
• 26:28
  even though you are kind of saturating the liver
• 26:29
  in chemo it's not that continuous exposure
• 26:32
  um and
• 26:33
  and the liver has time to kind of like
• 26:34
  regenerate in between now
• 26:36
  if you were to get Hepzato 20 or 30 times
• 26:39
  you may see some of those changes down the line
• 26:41
  but at least where we are right now
• 26:43
  in kind of current clinical use
• 26:44
  we're just not seeing it
• 26:46
  okay well
• 26:47
  that makes me feel better because I just know
• 26:49
  obviously you talked about this
• 26:51
  the liver is something you need to live like
• 26:53
  so we really need my liver to be working and not have
• 26:56
  you know potential damage to it
• 26:57
  so that's reassuring why do I need to do it now
• 27:00
  or why would it be better to do it now while I have
• 27:02
  like kind of what looks like
• 27:03
  like my oncologist said
• 27:04
  it's kind of a smaller disease burden right
• 27:06
  I've only got a little bit like maybe
• 27:08
  I don't know 5
• 27:09
  10% of the liver is involved
• 27:11
  why do Hepzato now as opposed to waiting until like
• 27:13
  there's just more going on in the liver
• 27:16
  yeah that's the million dollar question
• 27:18
  obviously the timing of when to do all of this
• 27:20
  so so what do we know
• 27:21
  we know that the more you have in your liver
• 27:23
  the worse you do 25
• 27:25
  to 50% versus 50% or greater
• 27:27
  have very different outcomes
• 27:29
  and so
• 27:30
  our goal is to prevent you from ever becoming the
• 27:33
  greater than 50% of patients
• 27:34
  and so if you had a solitary lesion
• 27:37
  I think
• 27:38
  we would start talking about ablative techniques right
• 27:40
  but if you have 4 5
• 27:41
  6 7
• 27:41
  8 tumors even though it might only be 25
• 27:44
  or 30% of your total liver
• 27:46
  I think we still are in the
• 27:47
  the realm of let's prevent those from getting to
• 27:50
  being more of your liver
• 27:51
  but we still can't do ablation per se
• 27:54
  or surgery or whatever yeah
• 27:56
  so that would be the rational for why to do it
• 27:58
  and again this is where the art of medicine comes in
• 28:00
  rather than the science sometimes it's really difficult
• 28:03
  and some of our patients
• 28:04
  they don't want invasive procedures
• 28:06
  they would rather just get the MRI's and
• 28:08
  and and you know
• 28:08
  pull the trigger on a procedure
• 28:09
  when it absolutely is needed
• 28:11
  and again that's where this the discussion with
• 28:13
  you know
• 28:14
  your physician about what's the optimal thing for you
• 28:17
  in the absence of randomized clinical data
• 28:21
  my last question as far as
• 28:22
  you know maybe myths and things that we could bust here
• 28:24
  I work with an integrative oncologist
• 28:26
  or like a naturopath oncologist
• 28:28
  he's got me taking you know
• 28:29
  various different supplements
• 28:30
  we do the occasional I don't know
• 28:32
  like an IV vitamin C um
• 28:34
  and you know
• 28:35
  occasionally we do like ozone therapy
• 28:37
  are those kinds of things
• 28:39
  something that I have to stop in order to have Hepzato
• 28:43
  or is there you know
• 28:44
  room for me to continue doing those in between
• 28:46
  you know cause like you said
• 28:47
  this is every six to eight weeks
• 28:49
  yeah in general
• 28:50
  I ask my patients to stop it
• 28:52
  just because I don't know what's gonna happen right
• 28:54
  so when they do these clinical trials
• 28:57
  a lot of the conventional medications
• 28:58
  that you talk about are recorded and
• 29:00
  and documented
• 29:01
  and it's all reported as part of the clinical trial
• 29:03
  of these patients had these medications
• 29:05
  and it's safe so
• 29:06
  when it comes to like herbal supplements
• 29:09
  and kind of over the counter supplements
• 29:10
  and stuff like that
• 29:11
  it's really hard to know exactly what to do
• 29:13
  um in that regard
• 29:14
  the other issue
• 29:15
  becomes a problem is that it's not regulated
• 29:18
  as closely so
• 29:20
  even though the bottle might say 200 mg of milk thistle
• 29:23
  or whatever it may be 20,000 right
• 29:26
  and so maybe 200 was actually fine
• 29:28
  but 20,000 wasn't and so uh
• 29:31
  rather than taking the risk
• 29:32
  I just asked could we just stop it while we're doing
• 29:34
  doing the therapy just
• 29:35
  just to be safe and abundance of caution
• 29:38
  and I mean like you said
• 29:39
  like it's this is 6 ish 6 to 8 cycles
• 29:42
  depending on who you talk to like
• 29:44
  so it's not like you're stopping this forever
• 29:46
  it's just temporarily like taking a break
• 29:48
  kind of scaling it back and I think that makes sense
• 29:50
  let's just chat a little more about the future of
• 29:52
  Hepzato and like we've mentioned clinical trials
• 29:55
  you mentioned the Chopin trial and or Chopin Chopin
• 29:58
  I don't know how we say it
• 30:00
  I call it Chopin or whatever that's worth
• 30:03
  probably correct it's probably correct
• 30:05
  where do you see the future of Hepzato heading
• 30:07
  you know I don't know in the next five years
• 30:10
  obviously
• 30:10
  in combination with other different therapies
• 30:13
  it's gonna be incredibly important to see
• 30:15
  can it stack with you know
• 30:17
  Tebentafusp or Ipi Nivo
• 30:19
  or any of the other medications that we're
• 30:21
  that we're giving it
• 30:22
  it's also under clinical evaluation for other tumors
• 30:25
  that have metastasized to the liver
• 30:27
  like colorectal for instance
• 30:29
  I think they just enrolled their first patient
• 30:31
  on the colorectal trial recently
• 30:32
  and so uh
• 30:33
  we may have more different therapies
• 30:35
  for other types of cancer
• 30:36
  in the future as well um
• 30:38
  and then also importantly
• 30:39
  um as we gain more clinical evidence
• 30:41
  or real world evidence
• 30:42
  we're going to start to see things oh
• 30:43
  this worked oh this didn't work etcetera
• 30:45
  and you're gonna start to see publications
• 30:48
  about people's experience in the real world
• 30:50
  so to speak and
• 30:51
  and that's gonna kind of inform us like oh
• 30:53
  maybe we only need to do two cycles
• 30:55
  and if you're having a response
• 30:56
  you only get two cycles um
• 30:58
  or maybe it's the opposite
• 30:59
  maybe it's even if you don't see anything you need
• 31:01
  to keep going right
• 31:02
  so optimizing the number of cycles you're gonna have
• 31:05
  and even the frequency right
• 31:06
  maybe you just get it once every six months
• 31:08
  I we have no idea right
• 31:10
  and so as we gain more experience
• 31:11
  what will have a better sense of those
• 31:13
  those sorts of questions
• 31:15
  I think my like
• 31:16
  favorite thing that I'm looking forward to learning
• 31:19
  and I don't know if this is officially
• 31:20
  gonna become an actual trial
• 31:22
  that they're gonna be checking and testing
• 31:23
  but I hope it is
• 31:24
  is just for them to look at treating adjuvantly
• 31:29
  right or you know
• 31:29
  semi adjuvantly like
• 31:30
  where we have somebody
• 31:31
  who had a massive tumor in their eye
• 31:34
  we know they're class 2 like high risk melanoma
• 31:36
  like uveal melanoma patient
• 31:38
  they've got the highest risk of Mets
• 31:40
  and instead of saying yeah
• 31:41
  let's just
• 31:42
  let you sit and wait for the next two to five years
• 31:44
  and hope you don't get Mets
• 31:45
  let's actually do something first
• 31:47
  I think that what I heard was
• 31:48
  either considering an adjuvant treatment trial
• 31:51
  where they would say OK
• 31:53
  you're high risk
• 31:54
  we're gonna give you one dose of Hepzato
• 31:56
  and then just see what happens
• 31:57
  see if we can kind of log any data from that
• 32:01
  I think that's incredibly interesting
• 32:02
  you know unfortunately
• 32:03
  as you mentioned
• 32:05
  or as we talked about earlier
• 32:06
  most patients will develop liver metastases
• 32:09
  the problem is
• 32:09
  it might take five to 10 years before that develops
• 32:12
  and so if you're starting a clinical trial today
• 32:13
  looking into that it may be quite a few years before
• 32:16
  maybe a while your data it is like you said
• 32:19
  one of the most important
• 32:21
  open questions we have right now
• 32:22
  the level of personal frustration that I have with it
• 32:25
  it's like it like you said OK
• 32:26
  we've got an image right
• 32:28
  we've got to look at the MRI
• 32:29
  we're treating the tumors that we do see
• 32:31
  but also the ones that we don't right OK
• 32:33
  we've got like I said
• 32:34
  I said we've got seven tumors in my liver
• 32:36
  but you're saying we have the potential
• 32:38
  that there's a bunch of other little ones
• 32:40
  that we just don't see on the MRI yet
• 32:41
  because they're too small
• 32:43
  and you're saying let's treat what we don't see
• 32:45
  by treating the entire liver
• 32:46
  so then I'm over here like
• 32:47
  but but then that may make sense to do adjuvant
• 32:50
  because we're just gonna treat what we don't see anyway
• 32:53
  so it will just have to see where it goes right
• 32:55
  like you said we're you know
• 32:57
  we're all in the the ride together
• 33:00
  yeah exactly
• 33:00
  well you guys
• 33:01
  if you have any questions
• 33:02
  please drop those in the comments below
• 33:04
  we'll do our best to get an answer from Doctor Berman
• 33:06
  or I'm just kind of forward that to him
• 33:08
  like we said we can't give personal medical advice
• 33:10
  but we would just love to answer any general questions
• 33:13
  that you have around this treatment
• 33:15
  or just around kind of maybe the places
• 33:17
  that you could have this treatment done
• 33:19
  Doctor Berman is that something that you know
• 33:20
  like where people can learn and like
• 33:22
  reach out for care directly
• 33:24
  like if they're not local to the the UCSD area
• 33:28
  yeah I think there's a website from the company
• 33:31
  I think if you Google it
• 33:32
  you can probably find it oh yeah
• 33:34
  I do have that sorry it's in my notes
• 33:35
  and so put that in the the description below
• 33:38
  the company will very much help you
• 33:40
  not only find a position that can do this procedure
• 33:43
  cause again
• 33:43
  it's quite specialized but more importantly
• 33:45
  they've also worked with other companies
• 33:47
  to help get insurance approval
• 33:49
  which is
• 33:49
  you know a major limitation a lot of people run into um
• 33:52
  and so
• 33:52
  they can help you with the insurance aspect of it
• 33:54
  as well
• 33:56
  okay and just for my notes
• 33:57
  that's the Hepzato Access website
• 34:00
  so if you search Hepzatoaccess.com and again
• 34:03
  I'll put it in the show notes
• 34:04
  it'll go into the description
• 34:06
  then that's gonna make sure that you can find
• 34:08
  centers that actually are doing this
• 34:09
  and the nice thing is that you guys
• 34:11
  Delcath
• 34:11
  has been so hard at work at opening these centers
• 34:14
  and finding places um
• 34:15
  I know like we have an area in in the um
• 34:18
  the Phoenix area
• 34:19
  but we've had representatives out here
• 34:22
  like kind of scoping and panning the hospitals
• 34:24
  and looking for like okay
• 34:25
  who else can do this because this is gonna be such a
• 34:28
  a promising procedure for of course
• 34:31
  uveal melanoma
• 34:31
  and we're so glad that it's helping us right
• 34:33
  I'm
• 34:34
  I'm glad that we get to be the first ones to benefit
• 34:36
  but also I think it's really unique
• 34:37
  that it's gonna be the kind of therapy
• 34:39
  that will also benefit other cancers
• 34:41
  it's just nice for once to have it go us first
• 34:43
  and then them with that um
• 34:46
  Doctor Berman thank you so much for your time today
• 34:48
  and for your expertise
• 34:49
  and just sharing your knowledge and your opinions
• 34:52
  and I I really think this is such a unique procedure
• 34:55
  I've talked about this a lot the last few years guys
• 34:57
  so definitely check it out
• 34:58
  reach out if you have questions
• 35:00
  and we will see you guys next time
• 35:01
  thank you again thank you again to our sponsors of the
• 35:04
  Eye Believe Podcast we've got Delcath
• 35:06
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• 35:10
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• 35:11
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• 35:13
  and our podcast we could not do this
• 35:15
  so thank you again subscribe
• 35:17
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• 35:18
  and we'll see you guys next time