Dr. John R. Adler Jr.

With Zap-X, the creator of CyberKnife aims to give radiation a better image

October 19, 2018
by Gus Iversen, Editor in Chief
Best known as the creator of the CyberKnife and a pioneer in image-guided radiation targeting, Dr. John R. Adler Jr. is a familiar name to most people involved in radiation oncology. What many people may not know, however, is that he is currently in the process of bringing a new radiosurgical tool to head and neck cancer treatment that promises lower cost to providers.

In early July, HealthCare Business News sat down with Dr. Adler to learn about his new company, Zap Surgical Systems, and why the Zap-X radiosurgical solution could fill an important gap in the existing radiosurgical landscape.

HCB News: Is it fair to say the Zap-X surgical solution is like a Gamma Knife combined with a CyberKnife?
Dr. John R. Adler Jr.: Technologically, and kind of in its primary design specifications, but it’s like neither one exactly. It does things slightly different from both of them but the primary objectives and some of the major design specifications are quite similar.

It uses a linear accelerator, which makes it like a CyberKnife, CyberKnife uses image guidance to target and it also uses a linac. The defining feature of the Gamma Knife, I might argue, is that it specializes on the brain and goes after a specific subset of the anatomy, which makes it like the Zap-X machine – but in the end Zap-X is its own unique animal.

HCB News: What sets it apart from other linear accelerators? Are there specific cancers it would be ideal for?
JA: It focuses on radio surgery not radiotherapy… I would argue that there is value to focusing on specific anatomy because you can optimize performance for the specific anatomy and also simplify the process of treating specific anatomy, and also focus on cost. You can strip out a lot of useless function that people don’t want.

Think about a linear accelerator that is designed to treat all parts of the anatomy. Intrinsically, that’s good, but along with that comes a lot of complexity and a lot of cost, and so our design here was to break down what we think are the cost and procedural complexity barriers that prevent the wider availability of brain radiosurgery, specifically.

A Siemens MR scanner can do head and kidney and ankles, for example, but now more and more we see more people who just want an extremity MR scanner. We are like that extremity MR scanner. We are the first ever to segment the overall radiotherapy marketplace with a linac. Zap-X is used for brain and head and neck; it goes down to the base of the neck.

HCB News: Are there any currently installed? Does it have regulatory clearance?
JA: We have FDA clearance as of last year, but not yet in clinical use. First machine is installed in Barrow Brain and Spine in Phoenix, Arizona, a partner of Barrow Neurological Institute. That is a 40-person neurosurgery practice and they installed it in the last couple months. They’re planning to treat the first patient next month.

HCB News: In June we heard about Foxconn opening up a manufacturing plant in Wisconsin. What role is Foxconn playing in the efforts to ramp up awareness and access to Zap X?
JA: My investor, my primary investor is Foxconn, they are led by Terry Gou, the chairman, who is a major industrial figure well-known in Silicon Valley, sort of like an Elon Musk or Jeff Bezos figure in Taiwan. Foxconn makes iPhones, and they have 1.5 million employees. Four percent of all Chinese exports are exported by them and [they represent] 20 percent of the GNP of Taiwan. It is the 30th biggest company in the world by revenue, but they are always behind the scenes so they don’t have such a big profile.

That may be changing, which relates to what was going on in Wisconsin, where they are investing $10 billion into building a manufacturing city that is close to four square miles. They plan to hire 20,000 to 30,000 new employees and they want to focus on manufacturing American technologies.

One of the primary focuses that has gotten a lot of publicity is making displays for TVs, they bought Sharp Electronics – so Sharp’s next generation TV will be made in Wisconsin using what’s called a micro LCD. There will be a few other products manufactured there as well, including ours.

HCB News: How was the Zap-X technology developed?
JA: It was developed by me. After inventing the CyberKnife and creating Accuray, I went back to Stanford 10 years ago, wanting to make a next generation product because I was kind of disappointed that radiosurgery didn’t have a bigger footprint. I thought the technology warranted even greater usage, even in developed countries like the U.S. but especially around the developing world.

A survey we did suggested more than 2 million patients every year in the wealthiest part of the world should undergo SRS (stereotactic radiosurgery) for brain tumors but only 150,000 patients do. So we were driven by the opportunity to address an unmet need, and wanting to make something that overcame the limitations, the limitations boil down to cost and complexity.

If one backs up for a second and looks at the landscape of medical procedures and devices, it’s pretty clear that radiosurgical technology specifically, not just radiotherapy, is the most expensive technology in the healthcare landscape, and the most complex. So with Zap-X we’re trying to address that problem.

Ideally this would be a handheld consumer device, so give me a thousand years on that one, but right now we’re trying to strip away to the best of our abilities, the complexity and cost. One of the striking features of the Zap-X is that it does not require a radiotherapy vault. It the first therapeutic radiation device ever made that does not require a vault, because we find that the vault itself is a major impediment to the wider dissemination and availability of radiosurgery.

It is entirely self-shielding, which is a bit of a breakthrough, and is only possible by virtue of the fact that we are focusing on a specific set of anatomy.

HCB News: How is Zap-X different from Gamma Knife?
JA: Gamma Knife uses radioactive cobalt to generate its radiation, and that in itself is a big problem. Cobalt is magical stuff in some respects and makes optimally-tuned energetic particles, but it’s such a dangerous thing and poses lots of complexity in the way access to cobalt is regulated. For instance, a terrorist incident with a Gamma Knife could be very destructive.

The Zap-X radiosurgical system
Gamma Knife also requires a vault and stereotactic frame to immobilize the patient’s head, whereas we use image guidance, which is nicer for the patients and also allows us to spread treatment out over a few days more easily. We have a potential to be much faster and perform higher-quality treatments, but a lot of that isn’t fully baked into the product yet, so that’s coming.

HCB News: In terms of cost, what kind of savings are we looking at?
JA: One of the objectives is to sell a Zap-X with the facility in which it goes, for approximately half to one-third of the cost a competing device might have. It really depends on what kind of facility you’re trying to build, but since we don’t require a vault, which can be a $1-2 million proposition, that’s a big part of our savings – and the machine itself costs much less as well.

HCB News: Is the footprint comparable to CyberKnife and Gamma Knife?
JA: Yes, the square feet required to install the system is the same, although an alternative system would have five to six feet of concrete taking up a lot of that space.

HCB News: What’s next for Zap X?
JA: We need to start patient treatments and we will learn a lot as we treat our first few patients. We expect to install two or three in the next year in the U.S., and a system is going to a prestigious hospital in China called Beijing 301, but we won’t grow substantially until the following year, and after that we have significant plans for growth. This year we’re still doing our initial clinical shakedown.

I would argue that therapeutic radiation is among the worst brands in healthcare, patients would rather undergo just about anything else other than radiation, and this harkens back to a time when radiation was incredibly primitive, 30 or 40 years ago and beyond… Image guidance and accurate targeting and stereotactic techniques have transformed what’s possible with modern radiation, but the world doesn’t know about it.

Part of the reason is because most equipment has been hidden away in basements, entombed in concrete, so now that we don’t need vaults anymore we intend to be much more in your face with what new modern equipment looks like, so it is rather dramatic looking.