Dr. John Adler: The Story behind CyberKnife & ZAP-X

0:00 The problem with invention is you are largely failing. You are a failure almost on a daily basis, almost on an hourly basis. Occasionally you have a big win, but you have to learn to accept failure as an essential part of your life. And I would urge anybody who's thinking about invention to first and foremost come to grips with that idea that you're mostly going to be failing.

0:20 As a full Stanford faculty professor to develop a system like the CyberKnife and to establish a company like Echoray and then do the same thing again with Zepp and Zepp Sajika is really an outstanding achievement. Please welcome Dr. John Eglach. I quote from a famous Hong Kong neurosurgeon who said a good neurosurgeon knows how to operate.

0:43 The better neurosurgeon knows when to operate and the greatest neurosurgeon knows when not to operate. So I mean the point is surgeons need to expand their view of who and what we are. I think radiation oncology has a very important role in that transition because this is not anti-radiation oncology.

0:57 I think in the end this is a T-sport. What advice do you give physicians or medical students who have other bold technological ideas but are unsure to translate this into reality? Don't do it. The fact is that most of the time you're going to fail. That's why it's so easy when you're failing day after day after day just say, I want to give up.

1:17 And the fact is you can't give up if you're going to be successful. You just cannot give up and if you're going to do that, don't do it. I'd like to call out myself and everybody, all of us, to see if we can't do better to help what I believe is millions of millions of patients each year. Okay, John, let's start right away.

1:51 So I think you started with the cyber knife idea at the end of the 80s, right? By this time, robotic device coupled with a radiation machine was far from every idea. How did you get to this idea that this could be a worthwhile technological piece in medicine? Well, I had no idea what whether it would be truly successful or not, but I fell under the sway of Lars Lexel when I did my fellowship at the Carolinska.

2:30 And the importance of Lexel was not just that he was a big neurosurgical thinker, but he also put his ideas into action. He was really was willing and committed to commercializing them. He was fortunate to have a son that really wanted to do this for Harvard Business School grad, but from the start, Lexel knew that ideas by themselves were nothing that to make them real required this commercialization process.

3:00 So I could say with my own eyes, flesh and blood do this. And so as great a figure, his Lars Lexel was in my life, it became tangible. And so I quickly realized that Lexel had done in the brain with my way of thinking genius. So just to explain to the audience, not everybody knows Lexel. So Lexel is the founder and the pioneer in radio surgery.

3:27 He developed the idea of radio surgery. Radio surgery is a high ultra high precision radiation with maximum accuracy for brain structures. And so this was his idea, actually at the end of the 50s, I think. And then he developed a so called gamma knife system, which was the first radio surgery device, which was coupled with the frame head frames or frame screw to the head.

3:54 And that's the place in Sweden where John, doing your residency, or when was that? I was in folded fellowship during my residency. And if you go down to the zaps, sweet downstairs, you'll see Lars Lexel's face, visage, right? So that's the background of Lexel. And that's where you did your fellowship and you saw and learned what radio surgery is.

4:19 And then came your idea, how can I develop that further, right? Yeah, I said, if it works in the brain, why wouldn't it work elsewhere in the body? And just a little bit too much time on my hands, I figured out a basic construct for how that might happen. And that became the core imaging system of the cyber knife.

4:37 And I mean, in the very earliest days, what were your biggest hurdles in pursuing that? Well, virtually everything, I didn't know what I was doing, which is both a good thing and a bad thing. It's good to be naive, if you're naive, you don't know what you can't do. It's bad to be naive because you do a lot of stupid things.

5:02 But when you're young and energetic, you just keep pounding away. And I was fortunate enough, it's all just good fortune to land as Stanford. And Stanford just happened to be the center of the world linear accelerator business. And I should, the modern linear accelerator came out of Stanford, came out of the Clistron, came out of developing radar and sonar, which was what the Clistron was developed for.

5:28 And lo and behold, I landed right next door to where the only place in the world, probably a next generation radiation product could be developed. And it was the moment when you were told, this is not going to work. There was like an hourly basis I was told it was not going to work. In fact, I just only happened about, heard about 10, 15 years ago.

5:52 But my closest partner in radiation oncology quietly told me one time over drinks that for the first 10 years of our relationship, he and the entire Department of radiation oncology used to call the Cyberknife Adler's Folly. It was little more than a joke. And little that I know, they were the people I was working with each and every day.

6:17 And but I believed in eventually pounding my head against enough bureaucratic barriers. It did become real. So how did you stay focused then? And how did you overcome all the skepticism around you? I'm just pig-headed. If you were to ask me what my saving grace is, I think I have a few IQ points, but not that special.

6:42 But I am pretty damn persistent. And I've won very few athletic competitions through skill. If I win, it's just through sheer hardheadedness and determination. And I took the same approach to my invention. And with enough persistence, it did become real. And what motivated you then finally to come from a full stuff, academic neurosurgeon, basically in the foundation of equity, to become a physician entrepreneur?

7:19 A lot of necessity. And it would be my dream, like my mentor, Lars Lexell, to have somebody dear and close and trusted in my life, like my son, for example, who would take care of all the commercial side of things. But it just didn't happen. In the best of the world, I would have had a close commercial partner.

7:39 I do think, in the end, my perhaps best skill set is translating a tool into the clinic. But I just never found that partner. And I like it myself a little bit to like Stradivaris, I wish I was Stradivaris. But we heard the musicians play recently. And it's one thing to make a beautiful instrument. It's another thing to use it.

8:05 And those are two discrete skill sets. And I had to pick one, and I couldn't find someone to make my damn machine. So I had to leave my academic appointment and make these machines. So looking back, what is your biggest lesson, either good or bad, to have a disruptive medical technology transferred into a commercial product?

8:32 I mean, I have myriad lessons. I'd have to say, in the end, it's you, like Steve Jobs famously once said, it's impossible to look forward and predict the path that life is going to bring you. You just have to be persistent in some ethereal, high-minded objective. And your life will only make sense looking backwards.

8:59 And I realized that, yes, my persistence was very important in life. But some wasn't just good luck. Now, maybe luck favors the prepared mind, as Fleming so famously said. But I just believe in persistence. You will be failing. The problem with invention is you are largely failing. You are a failure almost on a daily basis, almost on an hourly basis.

9:27 Occasionally you have a big win. But you have to learn to accept failure is critical as an essential part of your life. And I would urge anybody who thinking about invention to first and foremost come to grips with that idea that you're mostly going to be failing. Okay, then this Ivernife had undoubtedly a pretty good success story.

9:51 But ultimately you were not satisfied. And you said that you're still frustrated that the radio surgery is not really accessible to many parts in the world. And this made you to transition or to motivate you for even another newer technology, which is the ZAPX, how did that happen? Well, I don't think any of us should be satisfied.

10:21 I mean, you look around the world and you realize that these miracles of modern medicine and I would argue radio surgery is one of them are grossly underutilized. And they're not just underutilized in Bangladesh. They're underutilized even in highly developed rich places like California. And for whatever reason, and I had my thoughts as to why radio surgery has not had the penetration that it deserves.

10:54 And patients are not getting the best in class treatment. Patients get mutilated with surgery or they get a second rate or and much more expensive radiotherapy procedures. I just felt that was unacceptable and I figured that it needed to change. And if I didn't do it, I didn't know who would do it. So presumptuous, but it's how I felt.

11:20 I always wish someone else would do it for God's sake. So you thought you would not be able to do the same thing with a cyber knife because the cyber knife is more complex or maybe more expensive? Well, I thought that the cyber knife achieved many very important things, especially as a whole body radiotherapy device.

11:43 And that was wonderful. And I really was excited and believed strongly that there are a number of important extracranial applications that the cyber knife is really poised to transform like prostate cancer. And I think I'm particularly excited about cardiac ablation and lung cancers and things. So a lot of good things happening with the cyber knife.

12:05 But maybe there was, I overreached then. You know, it turns out that medicine is not a, and not always a rational practice. We surgeons, we want our own tools. We're very, we're like craft, we are craftsmen. And a woodworker wants different tools than a cabinet maker wants different tools and a general carpenter.

12:43 And I think that we neurosurgeons, didn't embrace radio surgery as much as we should because the tools were too generic. The tools quickly became radiotherapy tools. And they failed to be, I've continued to be more and more evolved for the brain, for example. And my own view of the whole radio surgery business is we're thinking one machine can do all.

13:06 Maybe the future is subspecialized machines optimized for specific radio surgical applications. Now I can't do it all at once, but I figured I would start in the brain where they're pretty well defined indications. And very importantly, I think we're just getting started in brain radio surgery. That's what I said in the beginning.

13:30 The, for the audience, I mean, I like what you say that this is a neurosurgery tool. That's how we see it, not everybody sees it like that. But we strongly believe that either the cyber knife or the zap is so called a surgical tool. I mean, you know, in the past, with big surgeons, big cuts and it went smaller and smaller and minimally invasive and keyhole surgery.

13:57 And we claim we do surgery without even cutting, right? And I think that is important to mention not everybody gets that this is not just another radiation machine. This is as precise as effective as good as surgery, but without cutting. And that is something I think you cannot state often enough. I was just in Hong Kong a couple weeks ago and was introduced to a quote from a famous Hong Kong neurosurgeon who said a good neurosurgeon knows how to operate.

14:34 He said a better neurosurgeon knows when to operate. And the greatest neurosurgeon knows when not to operate. So, so I mean, the point is surgeons need to expand their view of what, who and what we are. I think radiation oncology has a very important role in that transition because this is not anti-radiation oncology.

14:56 I think in the end, this is a team sport. But I still see and as recently as just a few weeks ago, how at some of the best institutions of world, the greatest, the people at the top five institutions of the world, the famous biggest names in neurosurgery, still fail to embrace modern radiocergery techniques and are hurting patients very badly.

15:20 Mutilating patients. And I'm talking about the marquee names at the big meetings that we go to. And they either don't believe in radiocergery, which is a little true. I think more, I think radiocergery is unavailable in their life. And the goal of this app is to make radiocergery front and center available to all neurosurgeons.

15:42 It should be one of the many tools you use in managing complex brain surgery cases. I know exactly what you mean. Several years ago, there was a big European neurosurgery meeting, young neurosurgery meeting in Prague. And there was the key talk by our friend, Arnefty, who is a very famous neurosurgeon.

16:09 And he talked 45 minutes about failures in radiocergery and why it is so bad and why everything has to be operated on. This was just four or five years ago. There were 1,000 young neurosurgeons and they all applauded. He got standing ovation for that. And I was the only one who got up and I was so mad at him.

16:34 I said, this is the worst and most biased talk in neurosurgery I ever heard. And then they removed me from the audience. No one applauded you with that meeting. But I applaud you now. But that's what that's exactly that is the mindset. That's a mindset. And the frustrating these are young people. You know, they're 28, 29, 30, 32 years old.

17:01 You know, not somebody who never has seen a radiocergery device. And that's a frustrating thing. And that's why we have to fight so much. And here, that institution right now, our second rate radiocergery. And so at this stage of my career, I am committed to being the voice in the distance, you know, telling people what you're doing is not right.

17:21 Patients are being hurt. So I have a group of patients, but they're really almost like family to me, who I advised, all who got operated on by the most famous brain surgeons in the world. And all of them were badly injured. One of them, we know we're ended up getting, she decided to commit suicide. She was so damaged by the neurosurgeon who claims to be the greatest neurosurgeon in the world.

17:46 What advice to give physicians or medical students who have other bold technological ideas but are unsure to translate this into reality? Not everybody is, you know, as proactive and self-confident and a little crazy to pursue his idea until the end. What advice do you give to young people? Don't do it.

18:16 I mean, I confront this a lot. And am I talking to myself, you know, 35 years ago? Maybe, but probably not myself. The fact is that most of the time you're going to fail. Most of the time you're going to use someone's, your parents or your families or not my case, but other people, your family money and you're going to burn it up and you're going to end up wasting time.

18:41 And it's not because you can't do it. I believe almost all these young individuals have something that they, if they were persistent enough, they could turn into a real product and change the world. But most of them are going to lose heart. It's like running a marathon. Do you tell someone to run a marathon because only prepared to run five miles or five kilometers, ten kilometers, forget where I am?

19:02 So no, you tell if you don't run the marathon unless you're committed to running. And the trouble with innovation is that you don't know what that distance is. The marathon, at least in Imperial units, is 26.3 miles or whatever. But you never know when you're doing a startup is it going to be 28, 29, 40?

19:23 And that's what makes it so disparity. And that's why it's so easy when you're failing day after day after day and just say, I want to give up. And the fact is you can't give up if you're going to be successful. You just cannot give up. And that's a hard mindset. And I've seen most of the young individuals come to me.

19:44 They try and they take a few steps and then they give up. And if you're going to do that, don't do it. That's why I, that's my read knee jerk reflex to start. When you reflect on your journey from the first prototype to potentially reshaping global cancer care, what do you hope your legacy will be? And what is probably not still not finished?

20:06 Well, I am a child of Silicon Valley. And I think the ethos there is never look backwards, only look forward. What you've done in the past is gone. Damn it, there's a lot of work yet to do. And I know I should pat myself in the back as many of you do and say, yeah, you did a good job, good, good. But I just see so much undone work, unfinished work.

20:33 And it's not my job to be honest, it's our job. I mean, those of us who believe in radio surgery should be doubled down and commit to making this better and better and better in the years to come. And one of my lament with the industry is it's too content. It's too content to say, you know, what we have is pretty good.

20:52 And the leader in this industry especially is just far too content to just say that we're making money and we're treating patients. No, we should be treating better and better and better. This is an unmet need. And the fact is if we don't do it, no one else will. These things don't get done by themselves.

21:12 And so it does take commitment from broad number of people, so many of investors, for example, but in patients, physicians, but certainly startups, people, entrepreneurs, we all have a stake in creating the future of medicine. So I don't spend too much time patting myself in the back although I acknowledge I've done some pretty good stuff.

21:34 But I do think I'd like to call out myself and everybody, all of us to see if we can't do better to help what I believe is millions and millions of patients each year. So you don't look so much back. So if you're starting your innovation journey today with today's capabilities like AI, cloud computing, and advanced robotics, what would you build next?

21:58 Oh, I think I'm building it. I like to be building it right now. I mean, the ZAP actually prepared to use all those capabilities and more as we go forward. I think we're still in the early, early days of radio surgery. I believe in 100 or 200 or 300 years for now the way we treat patients is going to look a lot like radio surgery.

22:21 I'd like to be smart enough to build that machine right now, but that's not going to happen. I only got a few years left in me, but I'm hoping that somebody in this audience or someone listening to this podcast will take my challenge to them that they shouldn't do it as a take it and push it in my face and show me what they can do.

22:44 I believe fervently that radio surgery is what medicine embodies the best of medicine. It is painless, it is highly effective, and it's very cost efficient. What is there to not like about radios? And it's not done. It's getting better and better and better. Now we've been refining open surgery for literally thousands of years and don't get me wrong.

23:10 I think open surgery is a beautiful, beautiful procedure in the right patients and I think I can conceive of open surgery having a role for a century more to come. But radio surgery is still in its infancy and I urge everyone here and everyone listening to this podcast to believe that and to push the frontiers further when I step off this stage.

23:32 That's a nice closing. Thank you very much, Dr. John Adler.