Accuray Incorporated (ARAY) Earnings Call Transcript & Summary

Good afternoon, everyone, and welcome to Accuray's Analyst briefing. We're coming to you from the ASTRO conference in San Francisco for 2025. We'll be leading a discussion about leading in the adaptive era of radiation medicine. I want to welcome everyone. It's absolutely a privilege to be here with a distinguished group of our global key opinion leaders in radiation oncology as well as our research analysts and shareholders who are joining us virtually. Our analysts that cover medtech and radiation oncology market, and they write notes for investors and advise on investment decisions. You're all experts and who -- how we shape, how we understand innovation in medical technology and how we bridge clinical insight, patient outcomes and investment perspectives. As you know, at Accuray, we believe our role is not just to build devices, but to advance medicine by partnering with clinicians and researchers who set the standard of care. Today, we're going to have an open dialogue about the trends in adaptive radiation medicine treatment. We'll be sharing science behind the technology and hearing perspectives from our esteemed panel, and we'll be exploring how we can make the greatest impact for patients and health care systems to deliver clinical and economic value. So thank you for taking the time to be here. We'll dive into the conversation. I'll make a few opening remarks, and then we'll go right into the discussion. Let's start with our safe harbor statement. And again, this is a presentation that is intended exclusively for investors. Again, from an agenda standpoint, we're going to talk a little bit about technology. We have Mu Young Lee here who will be talking about our technology. And then I'm going to hand it over to Seth Blacksburg, who is going to talk about Clinical Trends in Radiation Medicine and introduce our esteemed panel that will cover a number of topics in radiation medicine. And then we'll close and before we close, we'll do some questions and answers, and we'll have the opportunity for those listening and to submit questions. Just very quickly, when we talk about Accuray and where we are today, we are a global leader. We are dedicated in everything that we do to precision radiation therapy, technology and clinical outcomes. Our vision is really to expand the technology and our solutions really to further the curative power of radiation therapy so that we can impact lives truly through transforming care. Right now, we have achieved in FY '25. We just finished our fiscal year in FY '25 with the highest revenue that we've had in history. As well, we have increased our overall EBITDA by 30% year-over-year. And we've also completed a debt refinancing as of June 2025, which really gives us the flexibility for operational investment back into the business. And we also have a new Board member that's bringing new insights, a new lender and Board member that is really making a difference, I think, in how we take a look at the business. From an overall revenue standpoint, one of the areas that's a highlight for us is the growth of our recurring revenue as we see this as the future for our overall profitability as well as top line growth. As you know, we have over 1,100 systems installed globally. This year, we have really made a significant expansion into new markets and new countries, and you'll see that, that's a major cog in our overall strategy. We have two major unique technology platforms which Mu will talk a little bit more about the power and potential of these delivery systems. But we've also had a number of new introductions with the Tomo C system for China. The Accuray Helix, which is a new system for rest of world manufactured in Madison, Wisconsin. We have introduced the compatibility of surface-guided radiation therapy and also introduced additional operational and commissioning improvements for the CyberKnife through our CyberComm introduction. So we'll get right into some of the things, but we do want to reinforce our strategy, which is really all around closing the gaps to cancer care. We will continue to advance care through innovation through our new product innovation. We certainly are introducing some very significant things here at ASTRO, and I'm going to talk about that. But another major part of our overall strategy is going to emerging markets that are higher growth markets that don't necessarily need the higher-end advanced applications and are really focused on throughput because the capacity is limiting for those that can get radiation therapy. Additionally, we have placed a significant importance on our service and support for our customers. We know that if our customers are down and they cannot perform treatments that, that has a massive impact on overall patient outcome. And so we are committed to really providing service that reduces patients being rescheduled. And then finally, we think it's our obligation as a radiation therapy leader to connect the global radiation medicine community. And we're going to talk a little bit about that as it relates to adaptive radiation medicine. One area that we also want to focus on, and I think this is true not only for Accuray, but really across the developed markets is there's a lot of aged systems that are out there that do not have all of the latest capabilities. This is certainly a focus for us in our innovation, especially in the developed markets to make sure that those customers and those sites have the latest technology capable to do SBRT to do SGRT, et cetera. So that's a major focus for us for both of our platforms. And here at ASTRO, we have introduced a new platform. It's Accuray Stellar. It's a helical based platform. It really is fully loaded with all of the latest capabilities, including ClearRT imaging, including Synchrony, real-time imaging as well as the full adaptive suite, which you're going to hear a little bit more from Seth and from Mu on it as well. But inclusive of that is also a training program and a confidence building effort to make sure that the integration of new technology is done in the right way, in a practical way to ensure adoption. Because overall, we do believe that there are 3 key requirements to advancing care and really making a difference and it starts with making sure that we are addressing a clinical need with our technology development. And that ensures, of course, that we are closing a gap to care but at the same time, we need to ensure that it's adopted. And it's adopted on a full-scale basis and understanding what it takes to integrate new technology into the department is critical to our success. And then finally, being supported by reimbursement that truly is commensurate with the value that we provide to patients only then can we really have a true impact on care. And we believe when these requirements are met, that the result is not just incremental progress, but can be transformational in terms of patient outcomes that are sustainable providers and health care systems. So with that, I'm going to hand it to Mu, who will talk more about technology.

Thank you, Suzanne. I'm really happy to be here, especially with our esteemed guests and all the people -- so a little bit about our technology. Well, Accuray has always been about focusing on the patient first. And so the notion of precision medicine is well understood by a lot of people, including late persons. And it really means making sure that in how you choose the therapy you look at the unique aspects of the patient. Oftentimes, that means doing genetic screening of the patient, maybe understanding the mutations in the tumor. But we've always thought about the need to adapt technology to the patient. Today, you're going to hear about from our clinician colleagues about adaptive therapy, which has a very specific meaning in radiation oncology today. But let's zoom out a little bit, and I'll talk about why adapt at all? And what are we adapting to? And it really means that if you put the patient at the center, the patient is not static. The patient is dynamic. Whether those changes are happening on the order of seconds or minutes or days or years, we've focused our technology strategy in adapting to the patient and how they change over time. So let me take you back a little bit in time to -- at the time that Accuray was founded. Coincidentally -- or this picture on the left is an image from a patent that was granted at the same time that our company was founded. And the patent was for a fixation device for doing stereotactic radio surgery at a very demanding technically challenging form of radiation therapy that requires submillimeter accuracy. And at the time, knowing that the patient is difficult for them to stay still, this patent disclosed that, well, we're going to bolt the spine to the piece of equipment. And so the paradigm of that error was because the machines that deliver radiation are rigid, large and flexible, let's contort or conform the patient to fit into the limitation of the machine. Certainly, about 30 years ago, around the time that our company was founded, CT imaging became more and more prevalent in the treatment of radiotherapy. And the use of CT to create a digital twin of the patient was an important part of planning the therapy. And most people today because of big data and the hype around AI, you've heard of the terminology digital twin. But this is something that's been prevalent in our field for decades. But if we go back to that era, what we did with CT images in the beginning was looked at the shape of the tumor and there was a type of therapy that was delivered at the time called conformal radiation therapy. And to put it simply, it really treated the patient as if there was this tumor floating in space and the beams were shaped for the tumor, not taking into account all the other information about the tissue that was present in the CT image because at the time, the computers of that era and the radiotherapy systems of that era we're not powerful enough to take that into account. And yet the folks here at Accuray had a different mindset and an idea. We said, let's take -- let's make use of all that information because we could deliver a better treatment and take into account the radiation that's incident upon all the healthy tissue as well as the tumor. So if you've got a patient that it's difficult to stay still, well, how is our technology going to adapt to the patient rather than force the patient to adapt to the technology. On the CyberKnife side, the key idea was make it frameless, don't immobilize the patient by literally fixating their cranium or their spine to the machine. And so the form factor of our devices look very different from the other machines of that era. In fact, they still look different. If you look at most of our competitors, their main products, the form factors have been the same for the last 70 years. So at the essence of our CyberKnife system is a robot and the type of robot is called the manipulator robot. And that shares the same Latin root word for hand because when you're doing surgery, the surgeon's hands are what adapt to the patient. When you're doing radiosurgery with the machine, you need a machine that's capable of having that level of flexibility and adaptability. And so that's why the essence of the CyberKnife was built around a robot. If you look at the Radixact System and its predecessor, the TomoTherapy System, it looks like a CT machine. And why does it look like a CT machine. If we're using CT to look inside the patient and understand the anatomy, why would we not develop a therapy system that does the inverse of that. So if you're using CT, computed tomography, let's do tomographic therapy. And we leverage and make use of the entire information about the patient anatomy, not only targeting the tumor but preserving as much healthy tissue as possible. So that's again why our products look so different than anything else out there from their origins and even until today. Let's make the technology adapt and conform to the patient and not vice versa. So a lot of improvements have been made, both at Accuray and our competitors over the years. We took a step further. We know that a lot of the tumors inside a patient move over time. And some of those movements are quite quick and they happen over a period of seconds. So we've got a unique technology in our portfolio called Synchrony, and it's available on both of our robotic and our Helical platforms. And what this does, it uses a machine learning model. So knowing that every patient is unique and that the motion of their tumors is unique, our systems autonomously generate an AI model for each patient and predict what that tumor motion will be. And redirect the treatment beam to follow the tumor wherever the tumor is. And the benefit of that, you don't have to be a physician to understand what these pictures are telling you. Just if you look at the left, look at the right, around the bright spot, that's the tumor. And they're sort of a gray cloud around either of those pictures. On the right, a treatment delivered with Synchrony, you see that sort of gray cloud is very compact. And on the left, if you do not have access to technology at Synchrony, the approach is to radiate a large volume of tissue, expecting that wherever the tumor may move, you're still going to hit it. The trade-off, of course, is you treat a lot of healthy tissue. And so again, because the machines were incapable of tracking the tumor, what you typically do without access to something like Synchrony is irradiate a large volume of healthy tissue. Another example of forcing the patient to conform to limitations of the technology and not vice versa. So that's an emotion. But we also have -- I'm going to -- this is the same image, but the title is different in the sense that when you use Synchrony, you're able to track motion that's happening on the order of seconds and minutes. But another benefit over the years, some people have said, "Hey, Accuray, what's the big deal? Why do you care so much about precision and accuracy.'' We can deliver to a large region and control the tumor. Just this year, the American Association of Cancer Research, ACR published their 2025 report that said over the last 3 decades, cancer death rates in America have dropped by 34%, and that's because of the amazing advancements in medicine, both in radiation oncology, immunotherapy and in oncology in general. So people are living longer with cancer, which means just probabilistically, stochastically, as they survive cancer, they're at a higher likelihood of getting additional lesions or tumors again. And the benefit of being able to have something like Synchrony or a system like the CyberKnife or the Radixact that could compactly deliver dose to the tumor and spare healthy tissue is that it opens up greater possibilities for retreatment because people are living longer and longer with cancer. So there was a technological advantage that we had for a long time that for many years, people said, is it absolutely necessary? Well, I think people will come back to retreatments today would definitely say it's necessary, and they appreciate what Accuray has done. So in summary, our technology is always inherently designed to adapt to the patients rather than forcing patients to adapt the technology. We have adaptations that will allow machines to respond to patient changes on the order of milliseconds to seconds. Our precision and accuracy and targeting and healthy tissues bearing allows us to have additional treatments and options for patients for curative intent when they get retreated, perhaps sometimes months and years later. And just at this ASTRO, we released our adaptive solution, which incorporates large population-based AI models to speed up the workflow so that for changes that occur in the anatomy over a period of days or weeks can be managed. And that's really that last adaptive -- that paradigm of treating changes that happen over days or weeks is what our clinician partners today are going to speak about. And so with that, I'm going to hand it over to Seth.

Thank you, Mu, and thank you so much for joining us. We're not going to go over the clinical trends in radiation medicine. And when one looks from a longitudinal perspective, the key trends in radiation, what we see over time is 2 key areas. One is the ever improvement in advancing technology and Mu, who has deep experience in the field has highlighted some of that, and we'll focus on that a little bit here as well. And then also the improvement in precision and personalization in cancer care and especially in radiation delivery. And as we all know, the goal in treatment is to enhance patient convenience and quality of life. And there are several different parameters of that statement. One is to improve just overall control of disease and the other is to reduce the cost of care. And so radiation has been around for well over a century, but we're living in interesting times. And we are now at the convergence of advanced technology, biology, physics, that are allowing radiation to truly enter into a new era of transformative care. And we're seeing ongoing engineering advances that are continuing to drive precision, but obviously, that takes time. And fortunately, Accuray has quite a head start. And in general, if we take a look at overall personalized cancer care has three primary treatment modalities. One is, as folks know, is surgery. Surgery removes all or some tumor. It is invasive and very much subject to complications as well as a dependency on the operator skills. Chemotherapy or systemic agents kill a proportion of tumor cells, and these are effective adjunct treatments, but they usually aren't stand-alone treatments in the vast majority of cancer cases. Accuray is a radiation company. We are a radiation solution company and radiation therapy and radiation medicine is minimally invasive, highly precise and machine-guided treatments. It's personalized inherently to patient anatomy and well over 50% of all patients with cancer will require radiation at some point in their cancer journey. All of the esteemed panelists here that we'll introduce have lived during the era of a rapid advancement in radiation. All of us have seen this. We lived in the era where radiation was prescribed through plain radiographs, and it was administered through a very limited number of angles where we did our best to address the tumor and our very best to minimize the adjacent normal structures. But as you can see, we were incredibly limited. A very exciting innovation came about within 10, 20 years ago, where radiation was starting to get developed and designed based on 3-dimensional imaging. And that was the 3D conformal era, where physicians were able to outline on a computer, the type of structures they wanted to treat. It was no longer based on 2 dimensions. It was 3 dimensions, and we were able to put blocks in certain areas, and we got better at increasing the dose to the tumor and decreasing the dose to the normal tissues. And we now are living in incredibly exciting times where with our amazing machines, we could paint the dose of radiation preferentially to areas with such a high degree of specificity and at the same time, minimize the dose to normal tissues where we're able to expand the range of treatments that we can offer and minimize long-term effects of treatment and have patients receive curative treatments that allow them to get back to their daily lives much quicker. And what we know is that there are significant tailwinds from an increasing global cancer incidence. This is data that comes from the WHO and the United Nations, which shows a rapid expected increase in the diagnosis of cancer. And as we've mentioned, radiation is critical to addressing cancer. And the primary concerns in cancer care are not only cure or survivorship, but quality of care and cost and access to care. And this is where we believe Accuray has very much a right to win. Accuray is a revolution in radiation technology. And so we were always at the forefront of developing shorter treatment cycles and allowing clinicians to have the confidence that they could deliver better patient outcomes, and that all is predicated on having precision that we believe our technology can best deliver. And as Mu mentioned, the hallmarks of our treatment fleet include 2 systems. One is the CyberKnife system, which is a robotic-guided radiosurgery device that could treat with a high degree of precision and sub-millimeter accuracy. And the other is the Radixact system, which is able to move around the body and treat with an incredible level of precision to shape the doses to broader areas of the body. And what both of these have in common is a revolutionary innovation, which we call real-time adaptive radiotherapy. And at Accuray, we've always labeled as Synchrony where we are able to dynamically in real time, follow a target as it's moving. So just like all of us are breathing and the lungs move, every part in the body, the normal anatomy moves. And when we're treating a patient, the tumor is moving as well. And at Accuray, we have technology that's able to follow that. The challenge that we have is that overall, things are changing in our body. And this gets into the concept of adaptation, adaptive radiotherapy. And adaptive radiotherapy represents some of the challenges that we experience, which is on a day-to-day, minute-by-minute basis, all of patient anatomy is changing. Not only does the anatomy change, but the tumor shrink. Tumor shift, they shrink and they respond to treatment. Patients also can move during treatment. What adaptive radiotherapy offers and what you'll hear from the panelists is an ability to increase the personalization of cancer care that we can improve our targeting and minimizing normal tissue toxicity and increasing the dose to the areas that we want to treat. And we know that we're at the very beginning of an exciting evolution in radiation. What we know is that when we look at the total fleet of linear accelerators in the United States and in fact, globally, those -- the number of dedicated machines in adaptive is relatively small. And so there's a need for luminaries like on this panel and others that we'll discuss to help guide the field to feel confident in how to use adaptive therapy. And it's also incredibly important for companies like Accuray to lead the charge and to provide the right technology. We believe we have a right to win. And so we've helped develop an interstellar peer-to-peer education program that we are growing. And this includes a panel of international luminaries who have experience in providing adaptive radiotherapy to different anatomical sites of the body and the different constellation of adaptive treatments and is designed to pair these clinician leaders to others learning adaptive therapy to improve their trust and to facilitate their adoption of adaptive radiotherapy. We know that this is going to help enhance new users to utilize the technology and to feel comfortable in leveraging the best possible treatments for their patients. And so now I am absolutely delighted to introduce our panelists. And the panelists here are international luminaries in the field of radiation medicine, and these are thought leaders. In addition, many of us have been mentored by individuals here on the panel. And so what we'll begin with is Dr. Shalom Kalnicki, who's the Chairman of Montefiore Medical Center, Albert Einstein College of Medicine. And Dr. Kalnicki will give us a talk on the future of radiation oncology, precision real-time adaptive, followed by Dr. Jonathan Haas. Dr. Jonathan Haas is the Chairman of Radiation Oncology at NYU Grossman, Long Island School of Medicine, and Dr. Haas will provide a lecture on how early adoption of adaptive and AI-based radiation can be used to build a thriving radiation oncology department. Following Dr. Haas's lecture, Professor Peppe Sasso from Auckland Radiation Oncology will provide us a view of motion management and imaging from the global perspective. And afterwards, Dr. John Kresl, who leads the Phoenix CyberKnife and Radiation Oncology Center in Arizona, will provide us a view of radiation oncology, where we are now and where we are going. And following this, we'll have a brief Q&A. So with that said, it's my absolute pleasure to introduce Dr. Kalnicki to provide his lecture.

Thank you Dr. Blacksburg [Audio Gap] cost-efficient curative cancer treatment in the market today. The future is bright. We have expanding indications, but those depend all in perfect technique, comprehensive execution, and this is where integration with clinical trials, health delivery science with the 2 other specialties, surgery and chemotherapy, integration with the new theranostics treatments that are coming on market and the new field of radiation immunology open tremendous perspectives. The new era, as Dr. Blacksburg explained, started with precision radiation therapy. You can see on the left what radiation beams did in the past in terms of treating so much more normal tissue and how we can today shape it precisely, completely skipping organs like the bladder and the bowel at the center, like the hips in the periphery and concentrating the radiation in the target lymph nodes where the tumor is on the right figure. But with this precision, the problem is one cannot miss. Tumor moves, during treatment, it shrinks and changes shapes, Normal tissues start occupying spaces that were previously contained by cancer, and this is extremely important to prevent side effects. Breathing, items like bowel gas, bladder feeling and other changes of internal anatomy happen. And this is where the platform that was previously shown, the Radixact and now the Stellar innovation has to be consistent with us addressing all these issues. Instead of taking a snapshot from a CT or an MRI in the beginning of a series of treatments that can last up to 2 weeks, we now consider adaptive therapy the standard of care and the future of radiation oncology. It is the process enabling the modification of a radiotherapy treatment in response to changes that happen, like we said before, in the anatomy, in the biology and in the whole patient. It's a huge paradigm shift. We are moving from static one-size fits all treatment plans to dynamic, precise and patient-specific care. There are different technical considerations how this is done. It can be done offline. It can be done offline, but the ideal holy grail that we are getting to it now is real-time adaptive therapy, the plan of the day, looking at how the original plan is adjusted as necessary while the treatment proceeds treatment after treatment, day after day. The future of radiation therapy is that adaptation will move from niche to mainstream and radiotherapy vendors are being challenged to provide the tools that will make this daily part of our lives. Daily setup images need to be utilized. The formable contouring algorithms with AR need to adjust sometimes up to 32 different structures for a head and neck in cancer. Those has to be recalculated in seconds and those variations have to be tracked. And this is what we do in adaptive radiotherapy, and we are moving from offline to online to real time. This for everyone to have an idea, this is how we track the daily dose of targets and look on the right, how many normal tissues, OAR is an acronym for organs at risk. These are the normal tissues, and we track every single one of them. And when we move over time, we look at our graphs on how we are adapting for every single fraction, and this is a visual realization on how we follow a head and neck cancer shrinking. This can all be done because leaves in the multi-leaf collimator precisely dense according to the movement of the tumor and according to the plan of the day that we created. We need to go and we are getting there to efficient continuous delivery by following the actual holy grail of radiation therapy, reducing artificial margins that we put around the tumor targets to actually compensate for our lack of precision. And Accuray is proud that the Radixact team in our hospital won the prize of the American Association of Physicians of Medicine for being the closest real-time motion management and adaptation with less than 1 millimeter variation for precision in every direction. In short, we are dealing with highly improved image quality, which makes auto contouring and AI algorithms actually a possibility. AI algorithms for automated contouring are directly linked to the quality of the image of the CT that you are using to base your AI into. Continued computational advances will lead to quick adaptive replanning that can now be done in minutes. Online adaptive planning require, again, incredibly precise imaging tools. And advances in medical technology of including all the imaging and computer software are making an adaptive radiation therapy a practical reality for more and more clinics around the world. This will not only improve quality or -- improve cure rates, but also improve quality of life, decrease side effects and have a tremendous impact in many, many countless patients all over the world. Thank you for your attention.

Thank you, Dr. Kalnicki, and we'll now have Dr. Haas present his talk.

So thank you for allowing me to speak today. I was asked to speak about how early adoption of adaptive AI-based radiation can be used to build a thriving radiation oncology department. So I'm the Chair of Radiation Oncology at NYU Long Island. And this is our story. So we weren't always NYU Long Island. We used to be a hospital called Winthrop University Hospital, a small community hospital, really close to downtown New York City, but we are in downtown Mineola. So right out of the gate, I have to overcome misconceptions that the best level of medicine is done at major cities. So you can see all these little bubbles here. So we're right in the center surrounded by multiple academic and private really high-level radiation oncology departments. So in 2005, I thought I was smart. I was a young Chief of service, and I thought I was going to get a machine that -- a Varian TrueBeam that could do some SBRT, some IMRT, and I thought I had it figured out. And there's a reason why I am not a CEO. So this is what I got, a first-generation CyberKnife. And this is what I thought I got. But we decided to try to build a world-class center. So Jack Welch, who is a role model of mine, I've met him, said the former CEO of GE. He was never the smartest guy in the room. From the first person I hired, I was never the smartest guy in the room. That's a big deal. If you're going to be a leader and you're the smartest guy in the room, you've got real problems. So everyone who knows me knows I'm far from the smartest guy in the room. But I have plenty of people that are. So we worked with this. We went from 2 sites to 6 sites. For a while, I was the only radiation oncologist for 3 months in my department. We're now at 7. We went from 5 to 14 physicists, 10 to 25 therapists, doubled our linacs, and we have strategic growth aligned with vision for precision and innovation. So what does adaptive mean, right? It's the sexy word now. There's real-time adaptive, which adjusts during treatment, such as Synchrony, there's off-line adaptive, which modifies the plan between fractions and there's online adaptive, which replans in real time before each fraction based on the daily anatomy for highest precision. So CyberKnife was the first adaptive AI platform decades before it became sexy. This is John Adler with a first-generation CyberKnife probably from the 1990s at Stanford. But the company continues to innovate. This is an S7 CyberKnife, which we have 2 of them and we're going to get more. So radiation oncology sounds pretty simple, right? Just hit the target. Target moves lots of ways, 6 degrees like an airplane, XYZ, petrol and yaw. And when people come to try to sell me linacs, they say, well, it's accurate. What does that really mean? There's a lot that goes into treatment, beam delivery, treatment planning, imaging. Patients are going to move. Patients are going to set up and the tumor is going to move. And all that has to go into our planning. So the CyberKnife system has a mechanical accuracy of 0.2 millimeters, less than the diameter of a piece of hair. What makes the CyberKnife system unique? It's a robotic system. It's noncoplanar, which means that the beams come in at hundreds or many different angles. It's nonisocentric, so we don't have to focus on one point in time or one point in the tumor. It has submillimeter accuracy. It knows the target position throughout the entire treatment. It tracks and corrects in real time. And again, it was AI long before AI became sexy. So I want to see data, right? I'm a clinician, the company can tell me something, that sounds great. But there is fantastic high-level data proving this for fixed targets, you can see in the middle bar, super sub-millimeter accuracy and for moving targets in lung, liver, also submillimeter accuracy. And it's AI for reactive tracking, things that don't move such as the skull, the spine, fiducials, and it's proactive. It can anticipate where a tumor is going to be for things like liver or lung, which move in real time. So we're tracking, we're detecting and we're correcting while the patient is being treated. So Synchrony is how we treat our moving targets such as lung and liver. This is -- you can see a lung tumor moving up and down, left right. And in real time, it perceives the change in target position. It uses AI decision-making to adjust the treatment delivery in real time to make those changes and it synchronizes the treatment beam to the target location so we can reduce the margins. That's the volume of normal tissue that we treat around the tumor. So as part of the outcome, it reacts to real-time changing circumstances while the patient is being treated. And Accuray is comfortable in their own skin. So this is one of the sentinel studies that has recently come out, the PACE trial. It's a Phase III trial. PACE-A was a trial randomizing healthier patients to surgery versus SBRT. And PACE-B was a randomized trial, randomized patients that were in candidas for surgery to either SBRT, 5 fraction radiation versus conventional radiation. And imagine you're Adidas and you sponsor an event and you say, well, you can wear Converse, you can wear Nike. Accuray was comfortable enough to support that study. And they just wanted to show that the SBRT was better. And despite that, and they didn't try to do this. That wasn't -- this was a secondary analysis, but in the SBRT arm of PACE-B, patients that treated at a center that used CyberKnife had the lowest toxicity compared to other platforms. They weren't trying to do that. They were just trying to show that the treatment was [ equipos ] that it was equivalent, and this was the outcome anyway. So our CyberKnife System success led us to explore forward technology on the Radixact System. Both systems leverage Synchrony technology, enabling real-time motion tracking and correction and adaptation. It's enabled us to publish. So I'm a clinician. I like to get my hands dirty. That said, since we were early with this, we were able to have papers at the highest generals for prostate, for breast, even the red journal, which is our luminary journal, a little 6-person department in Mineola is competing at the highest level. We're able to punch above our weight. And we've become a global department due in no small part to Accuray. This is -- I was a keynote speaker last year in Brazil. Every year, Seth and I host an international training course for prostate SBRT, and we're comfortable in our own skin. This is a platform-neutral course that we have. So with Accuray's help, we have a platform-neutral course because we're comfortable with our system, but we want to teach the world to use whatever they feel comfortable with. It's enabled me and my department in the most competitive market in the country to be one of the busiest radiation oncologists. This is from ProPublica. If you remember, I told you that we used to compete with Manhattan. We now are in Manhattan. We were the first CyberKnife in New York City 10 years ago. So why online adaptive and why now? It aligns with commitment to precision, personalization and progress, a high-volume clinic demands efficiency, elevates knowledge of the entire team and build similar expertise. And we're now going to be starting emulator-based training to get better before we take all of this and go live. So thank you for allowing me to speak. This is where I grew up, Long Beach Long Island. Thank you.

Thank you so much, Dr. Haas and will now be joined by Professor Sasso, who will give his talk.

Thank you so much, and good afternoon, everyone. I'm going to try and convince you why motion management is helpful and give you a global perspective on how we can transform cancer treatment with increased precision and this technique of treatment that you heard from the other luminaries. I actually have a dreadful Imposter syndrome at the moment being sitting here, how actually this is going to change cancer management and cancer care. A little bit about me. You can see New Zealand, it's quite a big country in the Southern Hemisphere, quite. And I work across a number of institutions, in particular, Health in New Zealand, Te Aka Whai Ora is the Maori name, the native language name for our public health system and also private center, CyberKnife and University of Auckland. I have some disclosures. I love tennis almost as much as I like my CyberKnife, and I am extremely interested in radiogenomics, which I'm going to try and explain you how also works in perfect combination as an extra element of precision within highly precise radiation medicine. So going back to the main talk is, is adaptive radiotherapy the future of cancer care and in particular, precise cancer care, why should we consider using adaptive therapy and also trying to introduce you this concept that radiotherapy doesn't have just 3 dimensions, it has the fourth dimension we've heard before. There's a fifth dimension that we can talk about biological and then potentially even a sixth dimension that is how the biology changes and we want to track that. So this is me. This is what made my CyberKnife program. We heard about what happened in New York. This is what made my CyberKnife program so successful, one of the most relevant newspapers in a small country like New Zealand, like 5 million people and 20 million ships. We had an article about it, and this is how AI likes to think I could be. Now why I'm here? I'm here because I was lucky enough for short period of time to be the President and the Board Chair for -- I was in the Board for about 7 years and Board Chair for about 2 years of the third largest radiation oncology cooperative group for clinical trials in the world, which is called Trans Tasman Radiation Oncology Group. So we have now more than 15,000 patients enrolled into clinical trials. So this gives a bit of perspective of where radiation research is going and how precision medicine and precision radiotherapy can play a role over the near future. So we heard about the clinical trial of PACE. We -- I was actually one of the investigators, the PI for New Zealand. And also, I was lucky enough with Shankar Siva to be part of a clinical trial of pulmonary metastasis, which made quite a bit of news comparing a single fraction versus multifraction stereotactic. So -- but now I have a secret to tell you something that you probably don't know about it. They're actually not all machines are the same, okay? So you do have machines that are reliable, efficient, machines that are very accessible and foundational. But you will see there is a fundamental differences between the old-fashioned CRM linac that have been dominated radiation medicine for the last 50 years, which are machines that are bolted to the wall. They are quite flexible in treating a number of indications, but they have a number of limitations, as John was saying earlier on. And so you can actually not compare the ability to acquire imaging with a CT scanner integrated inside your radiotherapy device to what you can do with the cone beam panels, which can only have a slower rotation and therefore, they are much more subject to image errors due to patient motion. And also the CyberKnife, as we heard from John, is completely different technology. And I like to compare that not all the cars are the same. And perhaps if you want to really have a car that has ultra-high precision on the road for ultimate performance, you need a different design. You can't go with a more traditional design. So radiation medicine is changing. When I was the Chairman of the Radiation Oncology working group at the Ministry of Health, we set up a national repository called [ ROC ], which look at how the number of fractions or the number of sessions of radiotherapy is changing over time. And this is a trend that is global, it's international. It's not just in Australasia. And we are also seeing that the interest for more precise, more intense doses of radiation delivered over a much shorter period of time with sharper dose gradients called stereotactic radiotherapy is increasing, especially in Australia and New Zealand. This has a very important effect on patients because long treatments with potential large volumes and side effects are actually affecting quality of life of patients. And we need to remember, as we heard before, that patients are living longer and therefore, avoiding even mild side effects can actually have a major impact on patients when they will be 20-, 30-year survivors of radiotherapy. Grade 2 toxicity is not a small point. It's a very important point because a minor dysphagia that is present at 3 years after an oropharyngeal cancer can be a major issue 20 years later when patients are still having a really good quality of life with their family and whanau, it's a Maori word for family and extended members of friends around that. So we have heard about the Radixact technology and CyberKnife precision. I'm not going to mention that on that more, but our center in Auckland has been lucky enough to be implementing offline adaptive radiotherapy for 10 years now. And you probably have seen some of these white papers that we presented very early. And the great thing about the adaptive radiotherapy that you can perform with the Radixact or the real-time adaptive that you can perform with the CyberKnife is that you actually have much less uncertainty about where your dose cloud is going to be in the surrounding [ organ rest ]. And this does play an effect. You will see here if you are constantly on target, you can make sure that your 40-gray isodose is actually not going around and spilling outside your target in ways that in the long run can always cause an increased risk of side effects. So why do I like Accuray is because it's got a comprehensive portfolio with solutions that complement with each other. You have obviously, the unsurpassed quality of 3-dimensional imaging with Radixact and more recently with the stellar of this presentation was made before the announcement of yesterday. And then the CyberKnife, you heard about it. Now other companies are trying to compete with the same principle by improving the software around it. But the reality is that the quality of the hardware, it's very hard to be compensated with the software. And when the hardware is superior, is the same hardware that you actually have in a high standard CT scanner. It's very likely that your software implementation will actually overperform an inferior hardware even if they invest a lot into AI and software with this. This is an example, for instance, when I first saw this slide, I couldn't really see the difference between a scan that was taken at the time of treatment with ClearRT and a scan that was taken when we were planning the radiotherapy, as you've heard before, in the process of radiotherapy planning. And the accuracy of less than 1 millimeter is actually something we see in the clinic every day. It's not just across one center. It's seen across multiple centers. These are the experience we've had. So we heard from John, why would you want a CyberKnife because you actually get over 96% cancer control rate, for instance, in clinical trials being published so far. And a relative risk of reduction, as we've seen from PACE clinical trial of 60% to 90% of side effects. This is -- these are not small numbers for our patients. We are seeing here, for instance, the difference between CyberKnife and CRM linac that was in the PACE trial. And these are competitive technologies, very good with MRI, but you will see how tighter are the color lines of the isodoses when you compare a CyberKnife with a competitive technology. And this is an example of how, for instance, reducing margins that we heard from our previous speakers can reduce the number of side effects. And this was a clinical trial one before showing how you compare a cone beam CT guided, so treatment of prostate cancer with CT guidance versus MRI. But you will see this is the yellow bar from the CyberKnife treatment when you compare it with MRI. There is a significant difference between the results that we've been published, and that's where the value stands. So why do I like CyberKnife and Radixact. There is a unique design and performance. There is an attention to details. And also, as we heard, the way of tracking is, in a way, simple yet elegant, simple ingredients, very well put it together. So the other important aspect is the importance of taking away the uncertainty of human driving the precision. We know that, for instance, AI can do a great job. It doesn't go parting the night before. It's no -- doesn't have any headache. It doesn't have -- and so you take away some uncertainty, which is related to individual. What we can deliver now, we can deliver high-quality imaging with stellar. We can have the formation, accurate registration and monitoring management. This is the Helical platform to give you an idea of the large acquisition and the image quality that you can have for both online adaptive radiotherapy in real time with continuous motion tracking that you can mix together in just one platform. And this is pretty unique in the global portfolio today. So why should I want to buy Ferrari, I'm originally from Italy because you have engineering excellence, investment potentially add values, it grows over time, emotional connection and this exclusive ownership experience. I've had all this in my CyberKnife experience in my center. It was like having a fantastic Ferrari. And with this, I'm closing my talk, and thank you so much for your time.

Thank you so much, Professor Sasso. And we'll now hear from Dr. Kresl.

Thank you. I love the opportunity to talk, and I'm glad I'm going last. You guys have teed up everything that I'm going to talk about. I was asked to kind of give a perspective with regards to where are we now and where are we going from a radiation oncology perspective. So I'm going to kind of overlay one of the most important parts of radiation oncology, which is kind of the reimbursement and what's driving a lot of the development. But you've already seen how the evolution has gone from 2-dimensional, 3-dimensional setup utilizing surface anatomy to plain films to cone beam CT. So over that time, I'm going to kind of give you a little bit of the snapshot of where we are in the last 10, 15 years and how it's driven some of the decisions going forward. Some of the other things I've been involved with where there on the disclosure slide. But here is kind of one of the main drivers. Over the last 10, 15 years, there's been a reduction in the number of fractions delivered in a single treatment course for either breast or prostate patients. And this is U.S. data that shows the 2 main disease sites in the U.S., breast and prostate, have had a significant decline in the blue line, which is just a conventional fractionation that most people are familiar with and an increase in both hypofractionation or reduced number or the extreme hypofractionation, which is radiosurgery and SBRT. And that's important not only for just breast and prostate, which makes up about 1/3 of all radiation oncology patients in the U.S., but you can also see that there's been an impact in the decline of the number of fractions kind of delivered in a single treatment course for other disease sites as well as the metastatic population. This is important because it's one of the drivers of payments for you in the U.S. The treatment duration. You kind of get paid to some extent on how many fractions you deliver to treat an individual patient in an individual treatment course. The treatment modality also goes into determining kind of the reimbursement for that patient, 2D, SRS, SBRT on the lower end, 3D conformal IMRT and protons on the upper end. And then finally, treatment location. And that means treating a patient in a freestanding center or treating a patient in a hospital center is different in the United States with regards to reimbursement. And what all that does when you kind of combine them all together and calculate everything is that over the last 10, 15 years, there's been cuts in the reimbursement rates. There's been a reduction in the number of fractions to treat a patient. And this has led to kind of creating an uncertainty or a little bit of instability around the Medicare physician fee schedule and the hospital outpatient department setting payments. On the left is the decline in overall reimbursement for the freestanding centers. On the right is kind of the [ HOPs ] or the hospital outpatient department decline. So in reality, we've experienced about a 20% reduction while we've been developing and advancing the technology. Well, typically, every year, we go through a Medicare rule-making cycle where there's a proposed rule that kind of is reevaluating or resetting the reimbursement for the different codes. And coding is just another language that allows -- basically translates what you do or what you deliver for a patient into different numbers that allow you to get reimbursed. And that's important to run a department and keep your doors open. Well, we're through the July proposed rule. We're in the public comments, which have kind of closed, and we're now kind of waiting for the final rule. But for the first time this year, there's been a little bit of a difference in the Medicare rule-making change approach. Instead of just kind of reevaluating or reaffirming or slightly modifying the 17 treatment delivery codes and the 6 treatment imaging codes, which are primarily for the Medicare physician fee schedule, they are now proposing combining all of those into 3 treatment delivery codes, which is more along the line of how the hospitals have been paid with a reduction in -- or with a reduced number of overall delivery codes. And why that's important is that these kind of now represent the 3 proposed levels for reimbursement in radiation oncology in the U.S. with a simple Level 1 code, the 402 code, which is going to be electrons and 2D. So very simple. The 407 or the intermediate and Level 2 code, which is going to be most of the IMRT and 3D conformal that represents the majority of radiation oncology patients being treated today. And then the more complex Level 3, 412 code, which for the first time, really acknowledges and reimburses patients being treated with active motion management, which is the, again, highest level of complex SRS, SBRT or IMRT. And why that's important is everything you've heard so far clinically on how everything is involved, evolved along the lines of having to identify your target, image your target, track your target and deliver treatment. The better you can do that, the better you can physically deliver dose to target and physically exclude those to surrounding tissues and organs at risk results in 2 things. Obviously, if you reduce dose, you're going to reduce -- to surrounding tissues, you're going to reduce side effects. But what's also important is you can now increase your dose on a daily or fraction basis to the target, which doesn't necessarily mean you're just increasing dose on a linear scale. There's the biological involvement of how radiation interacts with tissues results in a higher radiobiologically equivalent dose. It's actually a more potent dose, even though the actual number might be the same. But if you deliver it in a shorter period of time, you get more cell kill, cancer kill and better outcomes. Well, to do that, I was lucky enough to be introduced to CyberKnife in radiosurgery early in my career, had a chance to utilize it. Over a long period of time, I had serial #9 for my first CyberKnife and developed a number of different CyberKnife centers up and down the west of the U.S. and help start centers around the world. And it was always driven by physicians and organizations that wanted to deliver the highest level of SRS, SBRT and IMRT. So now finally, CMS is acknowledging this by integrating active motion management into the reimbursement, not only because of better patient outcomes, but because of the extra time that is required for physicians to have practice expense and equipment. With this, the Accuray has provided a small health economic simulator where you can kind of plug these new numbers in should they go into effect to see how it affects the future of your clinical practice and future going forward, is really going to be what's called ROCR. And this is the Radiation Oncology Case Race Act that's been proposed and is in kind of in the process of working its way through Congress. But it's going to accomplish the 5 things that ASTRO and our professional committee kind of set out to do about 10 years ago, which is kind of become free of how best to choose your patient by blending the impact of financial hypofractionation or the incentive to kind of deliver a large number of fractions for your treatment, eliminate away or eliminate or reduce prior authorization delays, help give some access to patients that are underserved or hard to reach and to unify payment across the different settings. So it no longer is dependent on whether it's hospital or freestanding. Kind of the basic details is the 15 most common cancer patients -- disease sites, I'm sorry, will be under ROCR. It simplifies the payment. So now it's just going to be a single payment regardless of the technique or technology you choose. There is an accreditation component, which is -- incentivizes and increases your payment should you be accredited. And it also still allows for low-volume disease sites as well as increasing or allowing development of new technologies. The way it works kind of in the simplest form is, again, we're going to have a base payment for the 15 most common types of cancer. The important part here is it's now going to apply an adjusted inflation update and savings. So we will not kind of have that steady decline over time. There'll be stability as well as expansion of use and capabilities. There's an incentivized for accreditation, which will help quality of care. And then there's also some support for helping patients access those that are in underserved areas. Again, this was introduced in March. It's working its way through, but hopefully, it will be enacted in the next year or 2. We've got all kinds of supporting groups at the very top of that list on the left-hand side is Accuray, both by alphabet and I think also early identification of how important this is. And then for the future directions, yes, the reimbursement models are always going to reward investments in advanced technologies in the U.S., and that's because of the incentive to reduce the fractionation, reduce the dose to surrounding tissues and organs at risk and increase the dose to target. And that's that continued focus and evolution that we're all after. And that requires integration of this advanced technology, both hardware and software and increasing its ability to be incorporated and utilized throughout the U.S. as well as throughout the world. So that's where we're going, and it's being driven by better outcomes. Thanks for listening.

Thank you so much, Dr. Kresl. We'll now begin our Q&A panel, and we'll open it up to asking -- to looking at some of the questions that have come forward as well as discussing some of the key elements of adaptive radiotherapy that have been covered already. And so we'll begin with Dr. Kalnicki. So Dr. Kalnicki, you've described adaptive radiotherapy as a paradigm shift in radiation medicine. Can you elaborate on what makes this shift, in your opinion, so significant especially compared to past innovations like IMRT or IGRT.

I would say thank you, Dr. Blacksburg. I would say it's not compared. It's a direct consequence actually. And one of the items that I would like to stress at this point is that hypofractionation was mentioned so many times by all of us. And I think that the new technologies with sparing of normal tissues by IMRT and IGRT have moved from us delivering what normal tissues could tolerate smaller daily doses of radiation on a protracted treatment time of almost 2 months usually to very high precisely localized doses that are radiobiologically much more effective. So this hypofractionation trend has proven to yield extremely high cure rates with the radiation regimens that we give today and with more precision and the realization like we discussed that everything moves and changes, adaptive has to be if we want to pursue the holy grail of high cure rates and excellent quality of life for our surviving patients. It has to be a consequence of increased precision.

Thank you, Dr. Kalnicki. The next question is for Dr. Haas. Dr. Haas, you've built one of the most competitive and high-volume practices in the country, if not the world, what role has precision and more specifically, real-time adaptive radiation played and helping your team differentiate and grow.

It essentially defined us. So 20 years ago or 21 years ago before we got our CyberKnife system, I was used to big margins, 20 millimeters around the prostate, 4 fields. And pretty quickly, I saw that if I can tighten the margins down to 3 to 5 millimeters and be the first in an aggressive market, that defined us. And we continue to kind of try and innovate with the technology. We've done 5 fractions for years. We have an open protocol for 2 fractions that's being presented at this meeting. So to answer your question, because of the technology and the precision, we became with a little bit of ego known for being among the first to be a super precise HD or SBRT practice because of this technology.

Thank you, Dr. Haas. And a follow-on question to that is, what practical challenges do you see when implementing online or real-time adaptive in a busy clinical workflow? And how do you manage them?

Yes. I mean so a lot of it is having a staff. I've got a world-class physic staff to help train my staff we were able to kind of forward see that with the success of the precision with the CyberKnife to pivot that to the Radixact. So instead of doing precision just for SBRT, we cannot do it for VMAT for a conventional fractionation also. So that really would help us for both.

Thank you, Dr. Haas. Next question comes to Professor Sasso. Professor Sasso, you've practiced and you've trained across multiple continents and care systems. How do you see the global perspective shaping the future of adaptive radiation therapy?

The most fascinating aspect is that we are seeing a globalization in upward trend of care. So we are actually thanks to the way we have now to meet and communicate. Centers and countries around the world and institutions are more and more taking experience internationally. I mean we heard from fantastic clinical trials coming from the subcontinent and we have some amazing technologies coming from all other continents. And I think there is a real positive effect of globalization. In my view, I mean, obviously, been lucky enough to have worked in different countries, including France and England, Australia and so forth and Italy and now New Zealand and also visiting other countries for periods of time. It does add you a global perspective and opens up your mind. And I think this is actually happening, thanks to technology across the whole world. And trends are not just coming from major -- a few handful of major institutions, but from a global network. And this is what I see, for instance, with Accuray, bringing people together a true democratic environment of multidisciplinary approach and it's fantastic. It's a breadth of fresh air.

Thank you, Professor Sasso. We actually have a follow-on question. You are known as a bit of a connoisseur of finer technologies, and you've worked with a number of them and published and presented on that. In your view, what differentiates Accuray's approach to motion management and imaging from others in the field?

In my view, is the -- as I mentioned in my presentation, is the simplicity taken to the extreme level. It's almost like -- I use an example. It is an example, but in Italian cuisine to have the most delicious field, you only want to have 3 ingredients, but perfectly made of the highest quality. If you look at the motion tracking of, for instance, fiducial tracking is actually a relatively simple concept, but implemented with the highest level of technology and in a very clever and elegant way. Similarly, if you want to have -- as we heard before from Shalom in his wonderful presentation, if you want to have great images, you have to have a great hardware. And you can only play as much with AI. But if you don't start from a good hardware, then any iterative reconstruction on CT scanner imaging is never going to give you the right quality. So I think the quality of the ingredients, the attention to detail is really what I value most.

Next question is for Dr. Kresl. Dr. Kresl, you've noted how reimbursement pressures are reshaping practice economics in radiation oncology in the United States. How are technologies, in your opinion, like motion management and adaptive helping practices remain financially viable?

Well, there's a couple of things involved there. I think throughout the evolution of radiation oncology, there's always been the need to improve. And then once that technology has been developed, the ability to then move it out into mainstream and have it penetrate the market and be used commonly is then based on the reimbursement or the realization of what the value is of that new technology for the patient population. And I think now we're seeing that with the proposed rules having the active motion management at the highest level. For me, it's been relatively simple. I love the technology of CyberKnife was the only and still is the only treatment platform that has the radiation beam move with the patient based on the tracking and treatment delivery and keeps the dose centered on the target. And now that's starting to move into IMRT, as you saw in my presentation, the fraction numbers are coming down because we're just getting better at delivering dose more easily, and that's -- a lot of that is involved with the different ways of tracking the motion management, whether it's Synchrony or whether it's surface or imaging. So I think now having the ability to support the technology is important, and that's the reimbursement component. And the other part that's also driving that is patients and other referring physicians are looking and seeking out the highest level of care.

Thank you. Dr. Kresl, you've been the principle of thriving private facilities. You've highlighted how your centers have used motion management is a core part of delivering efficient high-value care how did that influence purchasing decisions at your institutions?

I think I just went over it last time. I mean, right now, CyberKnife is the only 1 that delivers that kind of treatment tracking and delivery I think we saw a couple of examples of that with regards to treating the lung, which was a huge step. As in anything in medicine, you start off with the simple thing. So radio surgery was done in the brain because that doesn't move very much, especially if you've got it locked in a frame. But then when you take that principle and you want to deliver that elsewhere in the bodies, but specifically when you've got a moving target, you had to have new technology. And the new technologies, as you saw, you can't bolt a spine patient to a treatment couch very easily, and you can't do that with a lung cancer. So the ability to track and deliver radiosurgery with image guidance and motion management really is the only solution that makes any sense.

Next question comes to Dr. Kalnicki. Dr. Kalnicki, you were at the forefront of when we showed the trends in radiation medicine, you've been at the forefront of several of those major trends, helping to lead the evolution to IMRT and IGRT and now to adaptive radiotherapy. Given your experience leading large academic programs, Dr. Kalnicki, how do you see adaptive being integrated into real-world practice in terms of workflow, staffing and decision-making?

The most important is the ability to develop clinical protocols that are easily reproducible, that are simple, that are real quality driven and will allow the technology to spread with the quality and reproducibility it deserves. That's why it is so important to have the backing of computerization and a reliable hardware and software platform like it was discussed before. It allows to track proactively quality management. It allows to track results and publish them like was mentioned before, so we can get better and better at it. And it is very important, again, to develop the quality management systems that will spread the technology and be applied correctly by large amounts of clinics, so more and more patients can benefit.

Thank you, Dr. Kalnicki. And the next question is directed once again to Dr. Kalnicki, but also to the other panelists if they have thoughts that they'd like to share. Accuray is proud to have a constellation of different adaptive solutions to clinical problems. Question to Dr. Kalnicki and then to the rest of the panel, if somebody has a thought is, where do you see the greatest opportunity for adaptive radiotherapy to expand its clinical indications in the next 3 to 5 years? And specifically, are there disease sites or patient populations where you feel it's currently underutilized?

The greatest opportunity and need is what was explained before, which is the need of hypofractionation with less and less fractions, adaptation becomes almost a necessity and a corollary of the treatment philosophy. And as far as disease sites, it is hard to exclude any disease sites. Every disease site and every patient deserves the highest quality of care, and it comes with adaptive radiation in our view.

I agree entirely. I agree.

Yes. I just want to reinforce that. And we had a previous meeting a couple of days ago, and Shalom and I were at the meeting. And it's what I would call the Shalom's best principle is the opportunities to use adaptive radiotherapy to reduce side effects across the whole spectrum. Any potential indications from head and neck, [ kidney ], pelvic, other pelvic areas, ultracentral, where you actually have a risk of side effects that is related to tumor variations or uncertainty related to management of motion or changes of shape where you can use adaptive therapy to reduce the risk of side effects, that's your goal.

I'd love to thank our esteemed panel. Thank you so much for your guidance and for your thoughts and for sharing your wisdom with us. And we'll now turn it back to Suzanne Winter, our CEO, for some concluding thoughts.

Yes. I just want to thank all of you. This was just a wonderful discussion. And I think the questions that came in as well as your insights and sharing all of the challenges that you face on a day-to-day basis. Your perspective is essential to us, especially as we advance technology and clinical innovation and the reimbursement. And I think from a reimbursement standpoint, what's exciting, I think, is we're moving away from a period of time where there was great uncertainty and now there are signals that I think are very positive for greater precision, better technology. I started the talk talking about the number of aged equipment that's out there. And there really are a number of catalysts now, I think, that are available, not only the rise of SBRT, certainly technology development, getting more precise, more personalized and a signal toward Class III complex cases and reimbursement that just aligns very well with Accuray technology. So that's wonderful to see. But again, we look forward to continuing this dialogue and working together to shape the future of care. I thank you again for your time and your partnership, and we are grateful to everyone on the call for joining us today, and we look forward to connecting again soon.