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Puma Biotechnology Inc (PBYI)
Q3Â 2019 Earnings Call
Nov 6, 2019, 4:30 p.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good afternoon. My name is Doug and I will be your conference call operator today. [Operator Instructions].
I would now like to turn the conference call over to Mariann Ohanesian Senior Director of IR for Puma Biotechnology. You may begin your conference.
Mariann Ohanesian -- Senior Director of Investor Relations
Thank you, Doug. Good afternoon and welcome to Puma's conference call to discuss our financial results for the third quarter of 2019. Joining me on the call today are Alan Auerbach Chief Executive Officer President and Chairman of the Board of Puma; and Maximo Nougues Chief Financial Officer. After market close today Puma issued a news release detailing third quarter 2019 financial results. That news release the slides that Alan will refer to and a webcast of this call are accessible via the homepage and investor sections of our website at pumabiotechnology.com. The webcast and presentation slides will be archived on our website and available for replay for the next 90 days. Today's conference call will include statements about the company's future expectations plans and prospects that constitute forward-looking statements for purposes of federal securities laws. Such statements are subject to risks and uncertainties and actual events and results may differ from those expressed in these forward-looking statements.
For a full discussion of these risks and uncertainties please review our annual report on Form 10-K for the year ended December 31 2018 and any subsequent documents we file with the U.S. Securities and Exchange Commission. You are cautioned not to place undue reliance on these forward-looking statements which speak only as of the date of this live conference call November 6 2019. The company undertakes no obligation to revise or update any forward-looking statements to reflect events or circumstances after the date of this conference call except as required by law. During today's call we may refer to certain non-GAAP financial measures that involve adjustments to our GAAP figures. We believe these non-GAAP metrics may be useful to investors as a supplement to but not a substitute for our GAAP financial measures. Please refer to our third quarter 2019 news release for a reconciliation of our GAAP and non-GAAP results.
I will now turn the call over to Alan.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Thank you, Mariann and thank you all for joining our call today. Today Puma reported total product revenue for the third quarter of 2019 of $53.5 million. Total product revenue consisted of product revenue for sales of NERLYNX. Net sales of NERLYNX were $53.5 million in the third quarter of 2019 a 0.6% decline from the $53.8 million in net sales reported in the second quarter of 2019. I will begin with a review of some of the highlights of the quarter and then provide some more detail on the NERLYNX commercial activities in the U.S. Maximo Nougues will follow with highlights of the key components of our financial statements for the third quarter of 2019. In July we announced that our licensing partner in Canada Knight Therapeutics received marketing authorization from Health Canada for NERLYNX for extended adjuvant treatment of adult patients with hormone rerceptor positive HER2-positive early stage breast cancer following completion of adjuvant trastuzumab-based therapy.
In September we announced that our licensing partner in Latin America Pint Pharma received their regulatory approval in Argentina for the same indication. Earlier this week we announced that our licensing partner in Greater China CANbridge received marketing approval in Hong Kong. According to the terms of the licensing agreements with all three of those entities Puma will be receiving royalties from the sales of NERLYNX in those territories once they are commercialized. In collaboration with our licensing partners we also anticipate announcing additional regulatory decisions neratinib in additional countries outside of the United States in Europe in the remainder of 2019 and in 2020. As investors are aware in the second quarter of 2019 we presented results from our Phase III trial of neratinib in third-line HER2-positive metastatic breast cancer also known as the NALA trial at the American Society of Clinical Oncology Annual Meeting in June.
A copy of the ASCO presentation is accessible on the Events and Webcast page of Puma's website. Based on the results of the NALA trial Puma filed a supplemental new drug application for neratinib for the treatment of third-line HER2-positive metastatic breast cancer in June 2019. The supplemental new drug application was accepted by the FDA in September and our anticipated PDUFA date is April of 2020. We will continue to keep investors updated on our regulatory progress with this as it progresses. In addition in September 2019 the FDA granted orphan drug designation to neratinib for the treatment of breast cancer patients with brain metastasis. As investors are aware Puma has an ongoing basket trial of neratinib in HER-2 mutated cancers referred to as the SUMMIT trial. We recently met with the FDA to discuss the regulatory path forward for this indication and I will refer you to the slide deck on the webcast to discuss this further. As a reminder I will be making forward-looking statements. On this slide the current SUMMIT basket trial is shown.
The meeting with the FDA focused on the two baskets that are circled in blue more specifically the HER-2 mutated cervical cancer basket and the hormone receptor positive HER2-mutated breast cancer basket. First I will discuss the hormone receptor positive HER2-mutated breast cancer baskets. HER2 mutations in ER-positive breast cancer have been shown to occur in between 7% to 9% of ER-positive breast cancer patients. They tend to occur in patients who have previously been treated with multiple lines of endocrine therapy and has been suggested that HER2 mutations may be a mechanism of resistance to endocrine therapy. They tend to be mutually exclusive with HER2 amplifications so patients with ER-positive breast cancer who have a HER2 mutation tend to be HER2-negative. Preclinical data has shown that in ER-positive tumors that have a HER2 mutation there is cross talk that occurs between the estrogen receptor and the HER2 mutation such that if one of these is inhibited the other one becomes more active. Due to this we previously modified the SUMMIT trial to treat the ER-positive breast cancer patients with both fulvestrant which is also known as Faslodex and is an estrogen receptor degrader and neratinib to inhibit both the ER and the HER2 mutation.
The results which showed an increase in the response rate and duration of response in patients receiving this combination were previously presented at the San Antonio Breast Cancer meeting in 2018. We performed paired biopsies on ER-positive patients with a HER2 mutation who were treated with fulvestrant plus neratinib. The results of this showed that although the patients were HER2 non-amplified or HER2-negative when they started treatment the tumor appeared to amplify the HER2 receptor as a way to get around the fulvestrant and neratinib dual blockade. Therefore the tumor was switching from being HER2-negative to being HER2-positive and using the HER2 amplification as a mechanism of resistance to the neratinib plus fulvestrant dual blockade. Due to this we modified at the SUMMIT trial to treat the ER-positive patients with the combination of fulvestrant plus neratinib plus trastuzumab which is also known as Herceptin so that will be inhibited the estrogen receptor with fulvestrant the HER2 mutation with neratinib and potentially inhibited the mechanism of resistance with trastuzumab.
On slide six you can see the waterfall plot for the updated interim results of the SUMMIT trials for the patients treated with neratinib monotherapy neratinib plus fulvestrant and the combination of neratinib plus investment plus trastuzumab. Please note that there is one patient in the neratinib monotherapy cohorts and two patients in the neratinib plus fulvestrant arm that are not shown because they did not have a post-baseline target lesion available. This was the data that was discussed with the FDA during our meeting to discuss the regulatory path forward for neratinib in this indication. An update on this data including more patients in the neratinib plus for fulvestrant plus trastuzumab arm will be presented at the San Antonio Breast Cancer meeting in December. On this slide you can see the updated progression-free survival curves for the SUMMIT trial for the patients treated with neratinib monotherapy neratinib plus fulvestrant and the combination of neratinib plus fulvestrant plus trastuzumab. The results show that the median PFS for the patients treated with neratinib monotherapy was Three, Six months the median PFS for the patients in the neratinib plus for fulvestran arm was 5.7 months and the median PFS for the patients in the neratinib plus fulvestrant plus trastuzumab arm has not been reached. This data was also discussed with the FDA during our meeting to discuss the regulatory path forward for neratinib in this indication. An update on this data will also be presented at the San Antonio Breast Cancer meeting in December. During the meeting with the FDA the FDA suggested that Puma modify the existing SUMMIT trial to randomize patients to one of three arms: fulvestrant alone; fulvestrant plus trastuzumab; I'm sorry -- fulvestrant alone; neratinib plus fulvestrant; or neratinib plus fulvestrant plus trastuzumab.
The FDA stated that the reason for requesting this was that there was very little published clinical data on the activity of fulvestrant alone or fulvestrant plus trastuzumab in ER positive HER2-mutated breast cancer and that this data would help to isolate neratinib's contribution to the efficacy of the triplet. During the meeting it was discussed that since these patients have received multiple prior endocrine treatments it would not be expected that fulvestrant alone would have much activity on its own. In addition since these tumors are HER2-negative one would not anticipate the combination of trastuzumab plus fulvestrant to have much activity. The FDA understood this concern and therefore recommended the modification be structured such that uses a Simon two-stage design with an early stopping rule such that if indeed the fulvestrant alone arm or the fulvestrant plus trastuzumab arm did not show efficacy enrollment to those arms could be stopped early. Based on this meeting Puma is modifying the SUMMIT trial such that ER-positive HER2-negative breast cancer patients who have a HER2 mutation will be randomized to receive either fulvestrant alone fulvestrant plus trastuzumab or the combination of neratinib plus fulvestrant plus trastuzumab. Each arm will initially enroll seven patients during Stage 1 and if no patient in a given arm responds that arm will be closed to further enrollment. If in the first stage one or more patients respond the cohort will then be expanded up to 18 patients. If less than four patients in the expanded arm respond that arm will be closed to further enrollment. If more than four patients respond the arm will be expanded and further patients will be enrolled. Based on the feedback from its meeting with FDA Puma plans to schedule a pre-NDA meeting with the FDA after it receives the initial results from the Simon two-stage trial to discuss the potential for accelerated approval of neratinib in ER-positive HER2-negative breast cancer that has a HER2 mutation. Puma anticipates that this meeting will take place sometime between the fourth quarter of 2020 and the second quarter of 2021 which is in approximately 12 to 18 months.
Based on the meeting with FDA the FDA confirmed that Puma could pool the results from the ongoing SUMMIT trial of neratinib plus trastuzumab plus fulvestrant with the results from the neratinib plus trastuzumab plus fulvestrant arm of the newly amended randomized study for the accelerated approval NDA filing. During the meeting with the FDA Puma also discussed the data from SUMMIT for the HER2-mutated cervical cancer cohorts. Approximately 5% of metastatic cervical cancer has a HER2 mutation. It tends to occur in adenocarcinomas and in HPV-positive tumors. Investors will remember that data from the SUMMIT trial for patients with HER2-mutated cervical cancer treated with neratinib monotherapy were presented at the SGO Annual Meeting earlier this year. This was the waterfall plot and swimmer plots that was presented during FCO. This data was also discussed with the FDA during our meeting to discuss the regulatory path forward for neratinib in this indication. slide 12 shows the PFS data that was presented at the SGO Annual Meeting. The median PFS for the patients taking the neratinib monotherapy was shown to be seven months. This data was also discussed with the FDA during our meeting to discuss the regulatory path forward for neratinib in this indication. Based on the meeting with the FDA Puma plans to enroll additional patients with HER2-mutated cervical cancer on the neratinib monotherapy arm of SUMMIT.
We plan to use this monotherapy data to file for accelerated approval for this indication. Puma plans to schedule a pre-NDA meeting with the FDA to discuss filing for accelerated approval for neratinib monotherapy in HER2-mutated cervical cancer. We plan to have this meeting sometime between the fourth quarter of 2020 and the second quarter of 2021 which is in approximately 12 to 18 months. In order to expedite enrollment in the SUMMIT study for both ER-positive HER2-negative HER2-mutated breast cancer and HER2-mutated cervical cancer Puma plans to expand its current HER2 mutation screening trial known as HER-SEQ. The HER-SEQ trial was initiated with the goal of using our proprietary liquid biopsy test developed by Puma to screen patients with breast cancer and cervical cancer for HER2 mutations. This test is a low-cost validated NGS-based clinical trial assay run in a central lab and represents an efficient high throughput way to screen patients for HER2 mutations who can subsequently be enrolled in the SUMMIT trial. The trial was initiated in December of 2018 and the protocol is shown on the slide. Blood samples are taken from patients with metastatic breast cancer or cervical cancer and are screened with a proprietary HER2 mutation liquid biopsy test developed by Puma.
If the patient is found to have a HER2 mutation the patient is referred to the SUMMIT trial to see if they are eligible to enroll. If the patient does not have a HER2 mutation the patient is retested three to six months later and the same exercises performed again. The HER-SEQ trial is currently opened at 15 sites and is in the process of being expanded to the approximately 50 sites that are currently participating in SUMMIT. The goal in HER-SEQ is to screen 2500 breast cancer patients and 1200 cervical cancer patients which should identify more than enough patients for the SUMMIT trial to support the accelerated approval NDA filing. To conclude based on our recent meeting with the FDA Puma will be modifying this SUMMIT trial to expand the HER2 mutation breast cancer cohorts will continue to enroll the HER2-mutated cervical cancer monotherapy cohorts and expand HER-SEQ to expedite the enrollment into SUMMIT with the goal of conducting a pre-NDA meeting with FDA for both the HER2-mutated breast cancer and HER2-mutated cervical cancer indications in approximately 12 to 18 months.
We anticipate that investors may ask whether this expansion of HER-SEQ and SUMMIT trial will have a negative impact on Puma's expenses going forward. Puma anticipates that its research and development budget will be decreasing significantly going forward due to the expenses associated with the ExteNET trial NALA trial and CONTROL trials declining significantly going forward. These three trials make up approximately 23% to 25% of Puma's current clinical research and development budget. Puma expects that the decrease in these expenses should open up room in the research and development budget for the HER-SEQ and SUMMIT expansions such that there should continue to be no increase in Puma's R&D expenses and that Puma will continue to see an overall decline in R&D expenses going forward. I will now review our U.S. commercialization progress for NERLYNX. Just a reminder that I will be making forward-looking statements. On slide three as you may recall we have two channels that provide NERLYNX to patients. We refer to these as our specialty pharmacy channel and our specialty distribution channel or we also refer to this as our in-office dispensing channel. In the third quarter bottles sold into the specialty distribution channel represented approximately 21.5% of the total bottles sold in the quarter.
This is similar to the approximately 21.8% in the second quarter. Later in the call Maximo will review the full financial results but I will now provide you with the current sales numbers. slide four shows the quarterly net sales of NERLYNX since FDA approval. As I previously stated our net product sales revenue was $53.5 million in the third quarter a 0.6% decline from the $53.8 million in net sales reported in the second quarter of 2019. Although new prescriptions grew 4% sequentially in Q3 over Q2 we still saw a decline in product sales. We experienced the decline in Q3 due to two key factors. First we have mentioned in previous calls that in the commercial setting patient discontinuations have had an adverse impact in NERLYNX revenues as patients tend to discontinue neratinib early in the treatment course usually the first month which greatly reduces the potential revenue per patient that we are able to achieve. This continued to play a role in the third quarter. As investors are also aware the current label for NERLYNX only includes data from the loperamide alone arm of control and therefore loperamide tends to be the most frequently used anti-diarrheal to prevent neratinib-related diarrhea. In this arm of the controlled trial which is shown on the slide discontinuations due to diarrhea or other reasons were 44.5% in the poster presented at ASCO in 2009 as is highlighted in red on slide five. In 2018 Puma filed with the FDA to have the label expanded to initially include the data from the leperamide plus budesonide arm of the trial and this label expansion was approved last month.
In the data presented at ASCO the data from this arm of the trial showed an improved tolerability profile as only 20.3% of the patients discontinued neratinib due to diarrhea or other reasons. Puma believes that the inclusion of this data in the label will increase awareness of the loperamide plus budesonide combination which could help to reduce discontinuations. In addition Puma expects that the interim results of the CONTROL trial including data on the cohorts of patients receiving loperamide alone or in combination with budesonide or colestipol and also from the dose escalation cohort will be published in a medical journal in the fourth quarter of 2019 as well which Puma believes will further improve the awareness of these techniques for reducing the neratinib-related diarrhea and improving the tolerability of the drug. Investors will note that the dose escalation arm of the CONTROL trial which involve starting neratinib at a lower dose and then increasing the dose of neratinib during the first month of treatment showed a low rate of patient discontinuations with 13.3% of the patients discontinuing neratinib as shown in the poster presented at ASCO. Since this data was presented at ASCO this year we have noticed that an increasing percentage of new prescriptions are starting with a lower dose of NERLYNX which we believe is indicative of patients using this dose escalation technique. As you can see from the slide the percent of new prescriptions that appear to be using this dose escalation technique increased from 9% in Q2 to 18% in Q3 and has increased further 25% in the month of October. Slide seven shows the bottles of NERLYNX sold by quarter.
You will notice that the number of bottles sold in Q3 declined sequentially by 2% from 4791 in Q2 to 4696 in Q3. We believe that this may have been impacted by discontinuations but may also have been impacted by new patients who started NERLYNX at a lower dose and therefore I had less refills in the quarter. The commercial bottle of NERLYNX contains 180 tablets which are 40 milligrams each. When a patient is given a full dose of NERLYNX at 240 milligrams a day or six tablets a day the prescription is refilled once a month. If the dose escalation technique used in CONTROL is used then patient initially starts NERLYNX at 120 milligrams per day then is escalated 200 milligrams per day and then is escalated to 240 milligrams per day during the first month. If the patient uses this dose escalation approach then the first prescription will last longer than a month as the 180 tablets will last longer than four weeks. Once the patient dose escalates to 240 milligrams the refill frequency will then be once per month. With the increase in the number of patients in the third quarter that used the dose escalation technique shown on the slide we may have seen an initial decline in bottles sold due to less refills in these patients.
However although initially the dose escalation leads to a decline in bottles sold if indeed it decrease the discontinuation rates similar to what we've seen in CONTROL it is anticipated that this will lead to an overall increase in the potential revenue per patient that we are able to achieve. You will note on slide seven that the number of bottles sold in October was approximately 1650 which represents a 5.4% increase over the average bottles sold per month in the third quarter. We speculate that this increase may result from patients' dose escalating in Q3 to Q4 so that there are refilling their prescriptions more frequently and also due to a higher percentage of patients not discontinuing NERLYNX which may also result in a higher number of bottles sold per patient. We will continue to monitor these trends and look forward to reporting this to investors in future earnings calls. On slide eight we are committed to making NERLYNX available to patients across the world and have also formed great partnerships throughout the world with companies who have commercial and regulatory expertise in that region. We are pleased with the recent approvals in Argentina and Hong Kong and look forward to more this year as you can see in slide eight.
In Europe our partner Pierre Fabre is currently planning on launching NERLYNX in Germany the United Kingdom and Austria this quarter and we look forward to updating investors on that launch in the future.
I will now turn the call over to Maximo Nougues for a review of our financial results.
Maximo F. Nougues -- Chief Financial Officer
Thanks Alan. Let me start with a quick summary of our financial results for the third quarter of 2019. Please note that I will make comparisons to Q2 and Q1 2019 which we believe are better indications of our progress as a commercial company than year-over-year comparisons. For more information I recommend that you refer to our 10-Q which will be filed tomorrow and includes our consolidated financial statements. For the third quarter of 2019 we reported a net loss based on GAAP of $16.9 million or $0.44 per share. Our GAAP net losses for Q2 and Q1 2019 were $37.4 million and $10.1 million respectively. As you may recall in Q1 2019 we booked $53.5 million of license revenue received from our sub-licenses. That revenue was partially offset by $16.4 million of net expense as a result for March 2019 jury verdict against Puma. On a non-GAAP basis which is adjusted to remove the impact of stock-based compensation we reported a net loss of $4.7 million or $0.12 per share for the third quarter of 2019. Gross revenue from NERLYNX sales was $60.8 million in Q3 2019 versus $60.3 million in Q2 2019. As Alan mentioned net revenue from NERLYNX sales was $53.5 million a slight decline from net sales of $53.8 million for the second quarter of 2019.
Our gross to net adjustment in Q3 was about 12% a slight increase from the 11% net adjustment in Q2. The increase was driven by higher Medicare reimbursements and GPO expenses. We expect gross to net to increase to approximately 13% for Q4 2019. Cost of sales for the third quarter was $9.4 million which included the amortization of milestone payments to the licensure of neratinib of approximately $1 million. Going forward it will continue to recognize amortization of the milestone payments to the licensor or about $1 million per quarter as cost of sales. For fiscal year 2019 Puma anticipates the NERLYNX net sales will be in the range of $205 to $210 million. This represents a reduction versus our prior guidance. This reduction is due to an increase in the gross to net which we now anticipate will be between 13% and 14% for the full year 2019 as well as flat revenue in Q3. We are also taking a conservative view to Q4 to account for a possible reduction in new patient starts due to the holidays as well as a short-term impact of more patients starting NERLYNX at a lower dose based on using the dose escalation technique.
We continue to anticipate that Puma will receive licensing and royalty revenues from its licensing partners in the range of $56 to $60 million in 2019. SG&A expenses were $31.4 million in the third quarter of 2019 compared to $33.5 million and $45.5 million for Q2 and Q1 2019 respectively. SG&A expenses included non-cash charges for stock-based compensation of $5.6 million for the third quarter of 2019 compared to $7.4 million and $9.9 million for Q2 and Q1 2019 respectively. Research and development expenses were $30 million in the third quarter compared to $36.9 million and $35.7 million for Q2 and Q1 2019 respectively. R&D expenses included non-cash charges for stock-based compensation of $6.6 million in Q3 compared to $8 million and $8.3 million for Q2 and Q1 2019 respectively. In the third quarter of 2019 Puma reported cash burn of approximately $7.3 million compared to cash burn of approximately $14.3 million without one-time events in Q2 and $15 million in Q1 2019.
We ended the third quarter of 2019 with $110.4 million in cash cash equivalents and marketable securities. Our accounts receivables balance of September 30 was $27.2 million. Our cash receivable terms range between 10 and 68 days while our day sales outstanding are about 42 days. Our distribution network maintains approximately three weeks of inventory. Overall we continue to deploy our financial resources to focus on the advancement of neratinib to ongoing clinical trials and the commercialization of NERLYNX.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Thank you Maximo. We are not pleased with our third quarter revenues and recognize that we need to improve NERLYNX sales growth. Puma senior management in cooperation with the commercialization committee of the Board of Directors continues to remain focused on NERLYNX revenues and sales growth in 2019 and beyond. As was mentioned in the commercial presentation October's bottle sold showed an increase of the average monthly bottle sold in Q3 which we are hopeful is indicative of an improvement in NERLYNX sales and we will continue to monitor these trends and look forward to discussing them further with investors in future calls.
Operator
This concludes today's presentation. We will now turn the floor back to the operator for Q&A. Operator?
Questions and Answers:
Operator
Thank you. [Operator Instructions] Our first question comes from the line of Alethia Young with Cantor Fitzgerald. Please proceed with your question.
Alethia Young -- Cantor Fitzgerald -- Analyst
Thanks for taking my question here. I have a couple. The first one: could you potentially clarify the percentage of people that you kind of estimate might have gone to a titration regimen so we can maybe perhaps put in context how to think about October? And then the second question is: looking at what the math says on your fourth quarter number we need to be $53 million to up $58 million if I think my math is right. So maybe talk about under scenario why you have confidence that you think you can maintain kind of flat revenues from where we are today. I know one might be the titration but I just wanted to talk about other puts and takes related to that as well. Thanks.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Okay Alethia. Thank you for the question. Your first question was on what percent of the patients are using the dose titration. Correct?
Alethia Young -- Cantor Fitzgerald -- Analyst
Yes a ballpark if possible.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. If you look on slide six of our commercial presentation we said that 18% of the patients in Q3 we believe used a dose titration and in Q4 for October the month of October it was up to 25%.
Alethia Young -- Cantor Fitzgerald -- Analyst
Okay. And then can you just -- so that's -- so when you -- can you kind of walk us through the math? So think about how you could get kind of an acceleration as you were talking about? It seems like the scenario is that people were -- the titration disrupted the amount bottles sold and then there was some possibility you get the math back on that in the fourth quarter and beyond. So maybe can you just flesh that out a little bit more?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes sure. Okay. So let's look at it this way right? So just using the loperamide alone regimen from CONTROL the discontinuation rate was 45% right? And we know that the discontinuations with neratinib tend to all be pretty much in month one or in month 12. So it's kind of a barbell right? If they make it past that first month they go all the way to month 12. So using that assumption in the model right for every 100 patients if you have 45% of them just get one bottle and stopped and the other 55 get the full year right the average bottle sold to those 100 patients is somewhere around six or seven. If you use the budesonide arm which is a lower discontinuation rate which is 20% and do the same math right assume 20% of them just get one bottle the rest go the full year that takes the average up somewhere between nine to 10 bottles per patient.
And on the dose escalation using the 13% discontinuation rate from the data presented at ASCO again assume that you get 13 patients who just get one bottle and stop and then assume for the others they're just getting 11 bottles right because they're one short because of the dose escalation. That again takes you up to an average bottles of between nine and 10. So using that math I can see where we can get to an increase in the average bottles per patient.
Alethia Young -- Cantor Fitzgerald -- Analyst
Okay. And then can you talk a little bit more about trends related to discontinuations perhaps in the fourth quarter. It seems like probably from kind of the middle of November to December might be a challenge but just maybe you can you talk about how you think those might play out for you as well just based on -- not discontinuations but just people not going on therapy shall we say?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So we don't notice -- I'm not aware of any patients taking a drug holiday stopping during the holidays and then restarting in January. So for continuing patients I don't see any disruption. In terms of new patient starts for Thanksgiving and Christmas different regions and different sales reps give us different indications. Some say they don't feel it will be a slow down; some say there might be. So I think we're kind of -- we don't have any reason to absolutely believe that we're going to see that in this Thanksgiving and Christmas. We're just taking the conservative route which is to assume that's correct. And we're just taking the conservative view on that.
Alethia Young -- Cantor Fitzgerald -- Analyst
Okay great. Thank you.
Operator
Our next question comes from the line of Yigal Nochomovitz with Citigroup. Please proceed with your question.
Yigal Nochomovitz -- Citigroup -- Analyst
Hi Alan and team. Thanks for taking the questions. Alan are you seeing any early trends in the fourth quarter with respect to the prophylactic budesonide and the uptake of that relative to the paramine?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
That is a good question Yigal. Because that label update was just done recently I have not been able to -- it was just in October. I have not gotten a chance to look at that data. I know last time I looked at the voucher analysis if I remember and I'm grabbing to see if I have it here. Hang on. I thought I brought it with me. I did yes. If you look at the vouchers because we have the anti-diarrheal vouchers in Q3 other than the use of loperamide budesonide was the most frequently used drug through the vouchers.
Yigal Nochomovitz -- Citigroup -- Analyst
Okay got it. And then with respect to -- I had a question on this new trial for -- the updated design for the SUMMIT trial. So I think you were saying that the FDA was saying you wouldn't expect to see a response on fulvestrant since they had previously been exposed to that mechanism. And then you wouldn't expect to see a response on trastuzumab either because they weren't HER2 amplified. So I guess the question is why does the FDA even insist on for fulvestrant monotherapy? Why not just do fulvestrant plus tras compared to the triple? Is there a reason you wanted fulvestrant by itself?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
That's a good question. That was discussed. And in our meeting with them I think it was just to be able to separate the activity of all of the components because clearly if you look at -- the activity of the triple it looks very good and I think they just wanted to get a better feel for what role each of the components was playing. And so by -- I completely understand your concern which is you wouldn't really expect for fulvestrant alone to have much activity and so that was one of the reasons we perceived that they recommended this type of a Simon two-stage so you're just exposing a small number of patients to it and if indeed there is no signal it drops off quick and you limit the exposure of the patients to what is perceived to be an inferior regimen.
Yigal Nochomovitz -- Citigroup -- Analyst
All right. Okay got it. And then with respect to the finance side of the company and the R&D budgeting you said your R&D budget was decreasing significantly with the roll-up of ExteNET now on CONTROL. So I'm just wondering if the revenues sort of stay where they are at the current rate do you think you can get to cash flow break even just by tightening up on the opex line or is that not a fair consideration?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Well look obviously our goal is to grow NERLYNX revenue. You've certainly seen a pretty sharp drop in our R&D expenses from Q2 to Q3 and we're going to obviously continue to drop that again. I don't know the answer to that. We haven't really modeled the scenario of what happens if we just get to flat revenues. I don't think that's something we really want as a goal. We're obviously looking to grow them. So I don't know the answer that question.
Yigal Nochomovitz -- Citigroup -- Analyst
Okay. And then just one more. Given the recent results with Ponatinib in the metastatic breast cancer setting I was just very curious to get your thoughts on how you see what the NALA trial as providing a differentiated option for patients in metastatic breast cancer and where you would see neratinib of fitting in with respect relative to Ponatinib in this.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
I think we aren't going to know the answer to that until we see the data and get a better understanding for both the safety as well as the efficacy from that trial. So I don't know that we can't answer that until we see the data.
Yigal Nochomovitz -- Citigroup -- Analyst
Okay fair enough. All right thank you.
Operator
Our next question comes from the line of Michael Schmidt with Guggenheim. Please proceed with your question.
Michael Schmidt -- Guggenheim -- Analyst
Alan thanks for taking my question. I had two. So one question on regarding the cervical cancer cohort or study. I guess what did the FDA communicate to you with respect to potential size a number of patients required at a minimum for an IND filing -- or SNDA filing rather? And then what sort of is the efficacy hurdle in that setting?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
So in terms of the cervical cancer cohorts I don't remember any specific number being discussed with the FDA. I think that it was somewhat in our judgment. I'm comfortable especially with the screening from using HER-Seq which obviously is going to find a lot of these patients to put into SUMMIT that we'll have a comfortable number to be able to put in the SNDA in the timeline we're looking for. In terms of the bar if you will I don't know the answer to that. I seem to remember that KEYTRUDA got approved on a single-arm study and I'm talking off the top of my head here but I seem to recall that response rate was somewhere around 15% to 20% or something like that. So I think that was -- that seems to be my recollection of it.
Michael Schmidt -- Guggenheim -- Analyst
Got it. Understood. All right cool. Helpful. And then I guess the other question I had just on the bottled volume the chart that you show. I'm just curious. And I know you didn't mention the slight increase in gross to net this year toward the end of the year it sounds like more so. But I guess did you notice any impact on demand as opposed potentially driven by some of the price increases that have been taken?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
We have not noticed any change in demand due to the price increase.
Michael Schmidt -- Guggenheim -- Analyst
Understood. Okay great. Thank you for taking my questions.
Operator
Our next question comes from the line of Kennen MacKay from RBC Capital Markets. Please proceed with your question.
Kennen MacKay -- RBC Capital Markets -- Analyst
Hi thanks for taking the question. Alan just one housekeeping question as we think about the CONTROL trial. You've mentioned in the second expansion portion of that trial if more than four patients respond of the 18 in that setting this could be expanded further. What was the third expansion be and potentially how many patients from your conversations with the FDA might be required for a registrational package in HER2-mutated? And apologies that was SUMMIT not CONTROL. I think I misspoke. And then on commercial I just wanted to make sure I heard you correctly that prescriptions grew sequentially quarter-over-quarter? Was there a qualifier that was around and NRx and not TRx? And just thinking about the reduced dosing dynamic and potential of the monthly bottle to last beyond month can you help us understand trends in new to brand prescriptions which might be indicative of new starts and whether there is new growth there? Thanks so much.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Okay. So in terms of your first question on the SUMMIT study so we will be expanding it so that it's fulvestrant alone trastuzumab fulvestrant neratinib plus fulvestrant plus trastuzumab. The end is seven in the first. If the if one of seven doesn't respond you shut it down. If it does we expanded to 18. So it's another 11 patients there. In terms of what it expands to and what's needed for the approval for the SNDA it's really going to depend on what we see and how much the separation is. I mean without seeing the data on the trastuzumab fulvestrant or fulvestrant alone it's obviously challenging to see that. I mean we can get a pretty good idea of what we think the triplet will show based on the data we have so far it's just very challenging to say what the other two arms will show. So if they are indeed a low in activity I don't think we would need a lot of patients. If for some reason we see activity more than we expected you may need more. So I don't know the answer to that but I think we are comfortable based on our assumptions that the timeline we looked at which is kind of the Q4 2020 through Q2 of 2021 that timeframe would be enough data for us to have the pre-NDA meeting with FDA.
Kennen MacKay -- RBC Capital Markets -- Analyst
Got you. Thanks Alan. And just any commentary around the prescription or any clarification around the prescription commentary according to brand?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
So there was NRx increase of 4% from Q2 to Q3. I don't have the TRx in front of me so I can't answer that question. Yes I don't have that data in front of me and I don't remember it so I don't know the answer to that one.
Kennen MacKay -- RBC Capital Markets -- Analyst
Okay. Thanks for clarifying.
Operator
Our next question comes from the line of Paul Choi with Goldman Sachs. Please proceed with your question.
Paul Choi -- Goldman Sachs -- Analyst
Hi. Good afternoon everyone and thank you for taking our questions. My first question is: you presented a slide on CONTROL with regard to the results with the various anti-diarrheal strategies and I guess Alan as your sales force has been in the field has there been any updated thought on views on non-loperamide utilization and has any one of the other options there proven to be or resonate more with clinicians in the field? Any color there you could provide would be great.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So I would say that based on the slide you saw in our commercial deck with regards to the adoption of the dose escalation the feedback we've been getting is it resonates very positively. And residents say very positively because a lot of physicians already do this for a lot of oral cancer drugs where they'll start at half a dose and kind of work their way up for tolerability. The second is it's very easy to implement right? It doesn't require another prescription to be written; it's not an increase in the pill burden on the patients that they're taking lots of pills during multiple times a day. That has definitely resonated well so I would say I would not be surprised to see the people who we're just using IMODIUM alone right to prophylax the patient switching to using the dose escalation -- and remember when you do the dose escalation there is no prophylaxis used. There is no anti-diarrhea prophylaxis used. You just use IMODIUM if you need it.
Paul Choi -- Goldman Sachs -- Analyst
And any utilization of any of the other agents either in combination with dose escalation or in combination at higher doses of NERLYNX?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. I don't know if once they -- with NERLYNX the side effect profile is that you get a very high incidence of Grade 3 diarrhea in the first month it's lower in the second month and then by kind of month three four etcetera it diminishes greatly. So it's really that first month or two you have to get past. I'm not aware of people using the dose escalation when they do get Grade 3 diarrhea are they just using IMODIUM or a combination. The feedback we've tended to be getting from the field is that when they're using the dose escalation they're just not seeing Grade 3 diarrhea. They might be seeing Grade 1 or Grade 2 but they're not seeing the Grade 3.
Paul Choi -- Goldman Sachs -- Analyst
Okay thank you for that. And then just on the international side you've had some approvals and other additional countries come online recently. I was just wondering could you maybe lay out for us in the next year or so any other geographies that we should be mindful of where you could see incremental contributions from your partners in 2020? Thank you.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes so in terms of the -- from a launch perspective Pierre Fabre our partner in Europe is going to first launch in the U.K. Germany and Austria and then we'll roll out the other 25 to 30 countries during 2020. So that obviously will have a revenue add for us. In terms of new approvals China is probably the next big one for us and I believe in the slide we gave a timing for that. If I remember correctly that was for sometime in the first half of 2020. Let me check that slide real quick. Yes China in the first half of 2020. So that would probably be the next big one.
Paul Choi -- Goldman Sachs -- Analyst
Thank you for that.
Operator
Our next question comes from the line of Thomas Smith from SVB Leerink. Please proceed with your question.
Thomas Smith -- SVB Leerink -- Analyst
Thanks for taking the questions. First just in terms of the prescriber base Alan can you give us a sense for how many unique physicians prescribed NERLYNX in the quarter and then I guess how this has changed versus last quarter? Do you still feel like you're still growing the prescriber base here?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So I don't have the number of new prescribers in the quarter in front of me but yes we do monitor kind of new physicians if you will and every week we continue to see new physicians prescribing the drug. So I don't think we've maxed out in terms of our total number of new physicians. And like I said I don't have the numbers in front of me so I can't really give any transparency into kind of how quick it's growing or anything like that. But from a numerical standpoint yes it is increasing.
Thomas Smith -- SVB Leerink -- Analyst
Okay. And then can you comment on sales force stability? I know this was an issue back in Q1 but I just wanted to get your sense for any changes in the makeup of the sales force and whether this could have had any impact on sales in the quarter.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So we have 80 sales reps and usually the average is you'll have 10% to 15% of your territories open at any time point. Currently we've got seven open positions so we're kind of below that 10% threshold. So that continues to remain on the low side for us and we're very pleased with that.
Thomas Smith -- SVB Leerink -- Analyst
Right OK. And then one last question around off-label use: I was wondering if you could just give us a sense for how much of NERLYNX sales are coming from either the metastatic setting or use in patients with brain mets? Just any kind of quantification around that would be really helpful.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
So we see less than 5% of our sales coming from the metastatic indication and that tends to be spread across metastatic use not necessarily in the NALA regimen in combination with capecitabine but they can give it as a single agent and things like that. We can get used in brain mets and then we also get off label use in the HER2 mutations. So because we don't market that we only market the extended adjuvant we don't get a lot of transparency on exactly what percent of that less than 5% is coming from each one. But I can say anecdotally speaking to physicians we do hear a lot of people using it for the HER2 mutations.
Thomas Smith -- SVB Leerink -- Analyst
Okay thanks. That's helpful.
Operator
Our next question comes from the line of Cory Kasimov from JPMorgan. Please proceed with your question.
Neena Bitritto -- JPMorgan -- Analyst
Hi. This is Neena on for Cory. So just a follow-up on the prior question about the prescriber base can you share what percentage of target prescribers you've been able to reach this quarter? I think it was 75% last quarter. And kind of just follow on that can you also share what percentage you're seeing actually convert over to prescribers?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So in terms of our prescriber reach I don't think it increased much from the last quarter. And again reach is defined as just we met with them once. That's not obviously means their prescribers. I don't have the numbers in front of me of what percent of the prescribers we've reached have actually converted to prescribers. But as I said it's continuing to increase.
Neena Bitritto -- JPMorgan -- Analyst
Okay great. And then what are you kind of seeing from talking about the sales force kind of turnover? Are you seeing kind of the new sales reps that you put in place earlier this year starting to get a little bit more productive? What are you just generally seeing there?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes that's a good question. I think that what we tend to see with the sales force is that obviously when they first come online just having someone there can help the productivity. But over time the more meetings they're doing with doctors and obviously the more active they're getting we do tend to see them getting more productive. So yes I do think with the newer reps from earlier this year we are seeing good growth in them going forward.
Neena Bitritto -- JPMorgan -- Analyst
Great thank you.
Operator
This concludes our Q&A session. I'd like to turn the call back to Mariann for closing remarks.
Mariann Ohanesian -- Senior Director of Investor Relations
Thank you, Doug. Thank you for your time and attention today. As a reminder this call may be accessed via replay of the webcast at pumabiotechnology.com beginning later today. Have a good evening.
Operator
[Operator Closing Remarks].
Duration: 57 minutes
Call participants:
Mariann Ohanesian -- Senior Director of Investor Relations
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Maximo F. Nougues -- Chief Financial Officer
Alethia Young -- Cantor Fitzgerald -- Analyst
Yigal Nochomovitz -- Citigroup -- Analyst
Michael Schmidt -- Guggenheim -- Analyst
Kennen MacKay -- RBC Capital Markets -- Analyst
Paul Choi -- Goldman Sachs -- Analyst
Thomas Smith -- SVB Leerink -- Analyst
Neena Bitritto -- JPMorgan -- Analyst
