POSTED BY
Liz Moyles
JOHN ADLER,
SURGEON, EX-PAPERBOY, CEO ZAP SURGICAL, EMERITIUS PROFESSOR OF NEUROSURGERY, STANFORD UNIVERSITY, EDITOR IN CHIEF OF CUREUS AND SERIAL ENTREPRENEUR!!!
Where Can I Get My Next Linear Accelerator?!!!!!!
I am often shy and quite stage struck by the people I am lucky enough to speak with for the “Leader In The Spotlight Interviews”. Dare I say it, I was super awed by speaking with John. I knew I had to dress to impress - therefore, I wore one of my best Christmas jumpers, (mid-November), sure I would make an instant impression! He laughed at me.
I began by telling this esteemed Surgeon and Emeritus Professor of Neurosurgery at Stanford university, that I had also dreamt of becoming a surgeon but had to swap out of med school to Biochemistry because of my lifetime phobia of blood. Biochemistry was John’s first university degree. The similarities continued. John as you may know is in the world of radiosurgery. He was incredulous when I revealed that during my brief career in research I too had dabbled with radiation and radioactive materials and unfortunately spilled them on myself a few times too many, hence my sharp exit from this career.
Professor John is a wonderful guy. At one point in this interview, I was in stiches when he said “So, I looked around and thought, where can I get my next linear accelerator” ………. I couldn’t stop laughing. He said it as I might ask “where can I get a new dress / phone / laptop …. !”.
In this interview we learn how John saw his first brain operation and fell in love with neurosurgery, how he aimed to make the holy grail of non-invasively and painlessly altering the human body in a therapeutic way, into a reality; how he accidentally became a CEO, how he really didn’t want to set up his second or third start-up, but still did, about the many rejections from VCs and strategics, about selling his own equipment and goods, and convincing friends and fellow neurosurgeons to lend him enough funding to start Accuray and how he sees the treatment of Brain and other tumors in the future decades.
Thanks for your time, John. I can’t wait to come and see you in the USA!
So briefly who is John Adler
John Adler is a serial entrepreneur and the inventor of the CyberKnife® Radiosurgery System as well as the ZAP-X platform used to for precision radiosurgery and treatment of tumours in the head, neck, and brain. He went to Stanford, eventually becoming an Emeritus Professor but whilst there he developed a prototype Stereotactic Radiosurgery System, (SRS), which became the CyberKnife, and the product which Accuray launched and sold. He also founded and for more than a decade was the CEO of Cureus, a web-based peer-reviewed medical journal. He was once the Chief of New Clinical Applications at Varian Medical Systems and he has also been awarded the Cushing Award for Technical Excellence and Innovation in Neurosurgery. Wowsers!!!!!
- So, tell me John, when you were kicking a football around the playground, did you ever dream of becoming a surgeon or an entrepreneur?
No-not ever. I enjoyed science at school, and I was always a ‘completer finisher’ – I couldn’t leave things half done. I became a paperboy aged 11 and realised I was quite good at managing money. That means that I have now been gainfully employed for 60 years!!
I applied to and was accepted at Harvard to study Biochemistry and that University opened doors for me in ways I never envisaged at that stage. While majoring in Biochemistry I realised the life of a basic scientist just wasn’t for me. In pondering what do to, I remembered the physician in my small hometown who was hugely respected. Moreover, I looked at the earnings of a Biochemist as opposed to a physician, and despite the lengthy training it required to transfer, it seemed a logical step for me to make. And that’s how I ended up attending medical school.
- So how did you get into Neurosurgery – why not orthopedics or something else?
Funnily enough, Neurosurgery was an accident of fate. In medical school I had to elect 4 options for a month-long clinical elective “rotation”, and the last choice I listed was Neurosurgery. Usually, medical schools try to facilitate your first or second choice, but instead I got my 4th. Yet the minute I saw a brain operation, I fell in love, and I never looked back.
I completed a neurosurgical residency at Massachusetts General Hospital and Brigham and Women's Hospital. Towards the end of my last year, I had to do a year’s research. I was married. We had a son and were expecting our second so I looked for somewhere that was a family friendly location and applied successfully for a radiosurgery fellowship at the Karolinska Institute in Sweden.
By good fortune I happened to find myself sidelined in an office far away from others and next to the amazing Professor Lars Leksell. He invented the Gamma Knife and the field of stereotactic radiosurgery (SRS), a procedure that would over time emerge as a non-invasive alternative to surgery for treating brain tumors and other intracranial functional and vascular diseases.
As I learned about SRS, it was like a light switch going on. I was a good surgeon but I wanted even better for my patients. In speaking with Professor Leksell I saw the future of surgery – what he was doing was Star Trek-like and I wanted to be part of this revolution.
Until then, I had only ever seen manual, open procedures in which a surgeon would physically open a patient’s skull to remove a tumor or blood clot from the brain. Professor Leksell was helping patients, not just with a scalpel, but with precision energetic X-rays, which were in effect serving the function of a “metaphorical” knife.
- Can you tell me what SRS is , in a way I can try to understand it John ?
Yes sure. To me the ability to be able to non-invasively and painlessly alter the human body in a therapeutic way appeared like “the holy grail of medicine”. So what is SRS? SRS uses a myriad of tiny beams of radiation to destroy tumors, abnormal blood vessels, and treat other diseases in the brain. It’s likened to what a magnifying glass does to sunlight. The sun is not so powerful by itself, but if you put a magnifying glass in front of it, it has a transformative effect.
The delicate and critical structure of the brain leaves little margin for error when an aggressive treatment like radiosurgery is used. Prior to SRS, the pre-existing radiation machines broadly bathed, over time, a field of ionizing radiation over a cancerous region of the patient’s anatomy to biologically treat the tumour, and to kill, it while aiming to not damage the normal surrounding tissue too badly.
In contrast an accurately focused radiosurgery beam permits surgeons to efficiently, painlessly and non-invasively, ablate tumours and in effect perform “brain surgery”.
- Thanks for explaining that so clearly John, because it isn’t a straightforward concept for many mere mortals like me, to grasp. So, what happened after the end of your year in Sweden?
After my year in Stockholm, my young family and I returned to the US and I eventually joined the faculty of Stanford University School of Medicine as an Assistant Professor in the Department of Neurosurgery. My thinking was simple. Stanford seemed like a good place to raise children. The salary sucked but, when life gives you lemons, you ideally “make lemonade.”
Stanford is close to Silicon Valley, investors, start-ups, genius minds, innovation and that played a large part in the eventual decision to start my own company.
- When life gives you lemons you make Lemonade! Love it. So how did you move from academia to industry?
I realised then, and the same is true today, that you can’t make fully fledged medical devices at an American University. There’s too much red tape, not enough freedom and not enough capital. I tried to get capital from Stanford. I also tried reaching out to Siemens, GE, and others but couldn’t get any interest.
So, I started unknowingly building what would someday become Accuray by working with a supplier of linear accelerators. I wrote patents, got a handful of small grants and then ultimately realised we had the potential for a start-up.
Finally, I concluded that the only way forward was to start my own company and develop what would become the CyberKnife. That’s when I set up Accuray.
- Wow. That was a brave move – from Academia to leading a start-up. How did you go about making it happen?
To get things started at Accuray I needed to proverbially “beg, borrow and steal” to raise enough funds and with a smidgeon of credibility, eventually, this led to a handful of sales……..by me! I wasn’t the CEO at that point, as I was still at Stanford, but I joined the Board of Accuray and served as the Chairman Chief Medical Officer. Meanwhile a CEO was appointed and over time several more followed suit.
However, it got to a point where I needed to step in if a nearly bankrupt Accuray was going to survive, so that’s what I did. Having never managed more than a half dozen people in an operating room I was suddenly leading 100 employees.
As a newbie leader I tried to make many changes to the culture, organization, way of selling and a myriad of other things. Eventually it got to a point where Sales were booming, the technology was very well received by our customers, and in fact it was almost selling itself!
After a couple years as CEO, I had many ideas for alternative novel clinical applications involving treatments for pancreas, prostate, spine, and lung tumours, but I couldn’t find a strong enough Clinical Innovator to make such treatments a reality. I decided the best course of action for Accuray was for me to step back from the CEO position and return to Stanford full time, where I could then function as the company’s primary physician KOL while also continuing to serve as Chairman of the Board.
Leaving the CEO job meant I had to recruit a new executive leader which is always fraught with risk when the founder steps back from leading. Needless to say my decision proved to be fateful producing some good but also undermined some of what could have been long term company success.
Over the ensuing few years Accuray went public on the NASDAQ market and when it did, I decided to entirely extract myself from the company I founded.
- That must have been a difficult decision John, and probably quite sad too. So tell me, if you knew then, what you now know about start-ups and running them would you have set one up?
No way. Absolutely not. I was an accidental entrepreneur….not that I even thought of that word at the time. I blundered into startup life, not knowing better. I only stayed on so long because I am a very stubborn person.
When you are innovating, you are, by definition , going into the unknown. You learn a million ways of not doing things before you hopefully get it right. It’s a constant learning experience. Try, fail, try, fail, try, fail, fall, fall again but each time get up once more and somehow find a way to try something new once more – and then finally it all works!! Hurray. No genius, only stubbornness!
- So, what came after Accuray -?
Things became bumpy and directionless for a bit. I had some vague notions about a next generation radiosurgery device, which in turn led to some very informal discussions with Varian Corp as I sought out a new linear accelerator. Before too long, discussions became more formal and then they offered me a chance to make my new ideas a reality within Varian.
The offer seemed a no brainer. The location was a mile from my home, and it allowed me to do what I loved to do whilst paying me a tonne of money. I eventually abandoned my chaired professorship at Stanford and began working at Varian. Unfortunately, 2 years later the company made a change of strategic direction and decided to jettison my radiosurgery project and me.
At this point I thought to myself, ‘I love what I’m doing, I believe in it, BUT I really don’t want to set up another start-up’. I just didn’t think I had it in me. Initially Varian encouraged me to go continue the work and promised to do a JV with me. I was ok with that plan and then at the last-minute, Varian decided to dump me completely and offered me instead a licensing agreement….to my own inventions! I was bummed as I really didn’t want to do another raw startup.
- I’m sorry to hear that happened John, genuinely. So what happened to change your mind about setting up again?
In parallel, I was having funding discussions with Terry Guo, a Taiwanese billionaire and politician to whom I originally met whilst helping to care for his brother, Tony who was suffering from cancer. As a result, Terry decided to invest some of his wealth in supporting the development of cancer related technologies. Terry seemed to like and trust me, and he believed in the field of radiosurgery, having seen it work for his brother’s cancer. We spoke and Terry Guo agreed to fund my ideas for a next generation radiosurgery machine.
And so it happened, I did another start up – Zap Surgical.
- Wow. That is like serendipity! And how is Zap Surgical doing now?
We are doing very well. Great in fact! I believe we now have a solid technology which is on par with all our entrenched competitors. However, more importantly, it provides an essential platform for further improvements, thereby re-energizing the field of medicine, which in my opinion has become too static.
In fact, the latest generation of the ZAP-X is clearly the best radiosurgery device ever made, while also being much less expensive and easier to use. We have 27 ZAP-X systems installed and well over that number to be installed shortly in the next 1-2 years.
- Where do you see the future of SRS?
I believe it’s still in the very early days. In 100 years, I think this space will look very different. The future will allow surgeons access to ever more precise directed radiation energy sources that can destroy or alter the function of diseased patient anatomy.
In doing so, surgeons will accomplish what they have always done through the millennia but without the pain and injury that accompanied conventional surgery. I think we will be able to use SRS to better treat intractable depression and addiction, diseases which are also now starting to be treated with alterative types of directed energy, such as focused ultrasound or transcranial magnetic stimulation.
Given the nature of ionizing radiation, I think it can become the mainstay for treating psychiatric diseases, especially if we collaborate with a new generation of pharmaceuticals. I see so much potential for SRS while also acknowledging that humankind will always need some limited traditional open brain operations.
I also see a chance to drastically reduce the footprint of the SRS machines we use, by using lasers to generate the ionizing radiation (as opposed to linear accelerators). When that happens, we will be on a different playing field.
Quite realistically we can someday soon get highly energetic laser light delivered via optical fibres threaded i.e. through the nose or down the oesophagus, or up the urethra or rectum, or through blood vessels into almost any area of the human body and use that to deliver ionizing radiation where it is needed more accurately, effectively and safely.
By delivering radiation from inside the body as opposed to from outside the body, radiation will be less scattered and more focused, so you need orders of magnitude less of it. Theoretically all doctors might then have access to what is a great miracle of modern medicine, such as cardiologists, neurologists, urologists, ENTs etc. Precisely threading catheters throughout the body will likely be done with next generation surgical robots. Maybe one day, 99% of everything done in surgery will be done by robots.
Of course there will be a lot of resistance to these changes; change doesn’t happen overnight, and many parts of the medical world will initially fear and resist whereas some intrepid physicians will embrace.
- So John, as the intrepid physician you are, tell me , what would you like to leave as your legacy?
That I was a Neurosurgeon who pushed the boundaries of Neurosurgery. I’d love all surgery in the future to use plasma laser generated photon machines. It won’t happen in my lifetime, but I hope to have given a ‘leg- up’ to the ‘giant minds’ of tomorrow.
Wow John. I feel I have learned so much and to be honest, I can’ t wait for your vision of the future to become a reality – not only with tumours within and beyond the brain, but also especially when it comes to the treatment of diseases such as addiction, depression and other such very challenging conditions. I think we can safely say, what you have already achieved, has elevated the level from which the giants of tomorrow will need to work with.
Thank you John!!!!!
