Battle in Silicon Valley: Device makers trade barbs in the fight to gain share in robot assisted procedures

boxing gloves

Radiosurgery innovator and medtech veteran John Adler is ready for a fight.

The outspoken inventor of Accuray’s (NSDQ:ARAY) CyberKnife system, as well as the company’s founder and former CEO, Adler is an evangelist for radiosurgery and its potential in a variety of applications.

As chief medical officer for rival device maker Varian Medical (NYSE:VAR), Adler hopes to see radiosurgery companies push the envelope in fighting for mindshare among surgeons, especially in challenging Intuitive Surgical’s (NSDQ:ISRG) da Vinci surgical robot, he told

Adler is unabashedly enthusiastic about radiosurgery’s future, which he views as limitless, albeit a bit sluggish to arrive. He’s been actively watching the industry from Silicon Valley where Varian, Accuray and Intuitive Surgical’s headquarters lie within a 10-mile radius.

"I would have thought where we are today we would have been 10 years ago, but nothing happens too fast in medicine," Adler said in an exclusive interview. "But it’s unstoppable – radiosurgery is coming and it’s going to change the world."

In order to do so, Adler added, radiosurgery players need to adopt a more aggressive strategy to engage surgeons, especially in urology and prostate cancer treatment where Intuitive Surgical has a strong presence.

"Radical prostatectomy’s not a very good procedure, I don’t care how you do it," Adler said. "It’s certainly no better with the da Vinci."

Radiosurgery devices use precisely targeted, massive doses of X-ray radiation to destroy tumors without any incisions and while minimizing the amount of radiation exposed to healthy organs or tissues. The da Vinci system is a manually operated surgical tool that allows physicians to perform tiny procedures using a set of small instruments that are manipulated remotely from an operating booth that magnifies the field of view.

Intuitive Surgical has proven to be something of a powerhouse, quickly gaining traction among surgeons and cornering the prostatectomy market, a move that Adler lamented as a missed opportunity for his former company.

“You can’t win this war without engaging urologists,” said Varian chief medical officer John Adler.

"One of the main reasons I left Accuray was the decision by the company to focus on a core radiotherapy market and give up trying to drive radiation adoption through the surgical community," he told us. "You can’t win this war without engaging urologists."

Adler invented the CyberKnife radiosurgery system in 1987, using it as the platform to found Accuray in 1990. CyberKnife gained FDA clearance in 1999, the same year that Adler assumed the role of CEO. He maintained the position for 3 years, after which he was chief medical officer until 2007. Adler remained with the company on its board of directors until he stepped down in February 2010, telling reporters that his role was "constructively terminated" by opposing voices within the company and that he gradually "ceased to have any meaningful leadership role within the company or on the board of directors."

Shortly after, Adler joined Accuray rival Varian as its CMO, where he remains today.

In his absence, Accuray has turned up the heat on its competition with Intuitive Surgical, launching a 1st-of-its-kind head-to-head clinical trial comparing CyberKnife radiosurgery against da Vinci surgery in treatment of early-stage prostate cancer.

Accuray CEO Euan Thompson told earlier this year that his company’s CyberKnife is the "true robotic system," dubbing the media’s treatment of the da Vinci as a surgical robot a bit of a misnomer.

"I think [da Vinci] is a great tool and I don’t want to criticize it, but there are certain things about it that I think people need to be realistic about," Thomson said in an exclusive interview. "There really is a difference between a robot and something which is under a sort of manual control."

"A car is a machine, but it’s not a robot," he added. "If you wanted to make a robotic car you’d make one without a driver."

By comparison, the CyberKnife system receives instructions and carries them out on its own, even automatically compensating for patient movement.

“If I was running the show I’d be much more direct, much more adversarial,” said former Accuray CEO John Adler. “But I’m not running the show.”

Accuray hopes to drive demand for radiosurgery in part by reaching out to patients with data from the ongoing clinical trial directly comparing CyberKnife therapy with other treatment options, including da Vinci prostatectomy, Thomson added.

"The reality is that the da Vinci is a mechanical system and it’s driven by a surgeon," he told us. "Just like with a a car, a really good driver will get really good results and a really good operator of the da Vinci robot will get really good outcomes – but it doesn’t mean everybody behind the wheel of a car is a great driver."

"There is nothing about the system that will automatically make the surgery a better surgery," he added.

It certainly seems like Accuray is taking a stronger stand against the market leader, but Adler told that it isn’t enough.

"If I was running the show I’d be much more direct, much more adversarial," he chuckled. "But I’m not running the show."

Intuitive Surgical CEO Gary Guthart isn’t as eager to play up the rivalries brewing among his Sunnyvale, Calif., neighbors, he told during an exclusive interview at the company’s headquarters. In his view, radiosurgery device makers aren’t his main concern.

"From the point of view of what trials they want to run, I totally understand. They’re not the only ones who are interested in trials looking at radiation and surgery," Guthart told us. "I worry a lot more about what Intuitive is doing to better patient care through improving our products, providing products to our customers, than I worry about what trials Accuray is running or what their long-term interest is."

Intuitive Surgical and its photogenic da Vinci system has attracted a lot of media attention, and with it a good bit of criticism. Clinical studies demonstrating the value of robot assisted surgery over laparoscopic procedures or other treatment options are limited, and some researchers have criticized hospitals for over-stating the benefits of da Vinci surgery without the science to back it up.

“Making broad statements about where surgery will outperform radiation or vice versa is more speculation than it is science,” said Intuitive Surgical CEO Gary Guthart.

"The data just isn’t there," Adler said of da Vinci surgery. "In terms of giving people disease-free lifespan and also preserving all the function, radiation is incredibly sexy."

For its part, Intuitive Surgical tends to stay out of the fray, choosing neither to denigrate radiosurgery or promote da Vinci procedures as a direct rival to radiosurgery.

"Making broad statements about where surgery will outperform radiation or vice versa is more speculation than it is science," Guthart told us. "Both of them are effective tools for an oncologist in the fight against cancer, and that’s great. It’s important for the world to have access to both."

"We focus on delivering value to our customer," he added. "Our customer is a surgeon who wants to provide minimally invasive surgery to a patient, and so far that’s created a lot of value for patients, it’s created value for surgeons."

However, it doesn’t look like Varian or Accuray are ready to let Intuitive Surgical continue running away with the market.

Accuray’s ongoing Prostate Advances in Comparative Evidence study, launched in April, plans to follow more than 1,000 patients across 30 to 40 centers globally for up to 5 years after treatment.

And with Adler at its side, Varian isn’t likely to back down either.

"The best thing for radiation companies to do is get in the face of Intuitive Surgical," Adler said. "You say it’s gotten tense, but I disagree. I don’t think radiation companies have even started the real battle."

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