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Puma Biotechnology Inc (PBYI 0.40%)
Q1Â 2020 Earnings Call
May 9, 2020, 8:30 p.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good afternoon. My name is Paula, 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. Please go ahead. You may begin.
Mariann Ohanesian -- Senior Director of Investor Relation
Thank you, Paula. Good afternoon, and welcome to Puma's conference call to discuss our financial results for the first quarter of 2020. Joining me on the call today are Alan Auerbach, Chief Executive Officer, President and Chairman of the Board of Puma Biotechnology; and Maximo Nougues, Chief Financial Officer. After market close today, Puma issued a news release detailing first quarter 2020 financial results. That news release, the slides that Alan will refer to and a webcast of this call are accessible via the home page and Investors 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 due to a number of factors, which include the risk factors disclosed in the periodic and current reports. Filed by Puma with the Securities and Exchange Commission from time to time. 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, May 7, 2020. The company undertakes no obligation to revise or update any forward-looking statements to reflect events or circumstances after the date of this call, except as required by law. During today's call, we may also 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 first quarter 2020 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 revenue for the first quarter of 2020 of $51.2 million. Total revenue consisted of license revenue of $2 million, royalty revenue of $0.6 million and net sales of NERLYNX of $48.6 million. Net sales of $48.6 million in the first quarter of 2020 represented a decline from the $58.7 million in net sales reported in the fourth quarter of 2019 and an increase of 6.7% from the $45.6 million reported in Q1 of 2019. I will begin with a review of some of the highlights of the quarter and then provide more details on NERLYNX' commercial activities in the U.S. Maximo Nougues will follow with highlights of the key components of our financial statements. For the first quarter of 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. Based on the results of the NALA trial, Puma filed a supplemental new drug application or sNDA for neratinib for the treatment of third-line HER2-positive metastatic breast cancer in June of 2019. The sNDA was accepted by the FDA in September 2019 and NERLYNX was approved in this indication in February 2020, two months before our anticipated PDUFA date.
As investors are also aware, Puma has an ongoing basket trial of neratinib in HER2 mutated cancers referred to as the SUMMIT trial. The SUMMIT trial was modified in early 2020, and 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 of the amended study will initially enroll seven patients during stage 1, and if no patient in a given arm responds, that arm will be closed for 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. The amendment to the SUMMIT protocol has been approved by many of the clinical sites that are participating in the study. Enrollment into the ER-positive HER2-negative cohort in Q1 of 2020 was slightly higher than enrollment to this cohort in the fourth quarter of 2019 and did not appear to be impacted during the month of March due to the COVID-19 pandemic. Enrollment in the month of April, however, did decline to a level that is toward the lower range of the range of monthly enrollment that was seen in this cohort during 2019. We believe that this decline may be due to the impact of the COVID-19 pandemic. Based on this, we anticipate that we will receive the initial results from the Simon two-stage trial in Q1 of 2021. Once we receive these initial results, we plan to schedule a pre-NDA meeting with the FDA to discuss the potential for accelerated approval.
Over the past six to 12 months, Puma has been making a number of key additional hires in order to strengthen our commercial presence with NERLYNX. Most recently, in late March, we announced that Jeff Ludwig joined Puma as the Chief Commercial Officer. Jeff brings with him extensive experience in commercial sales and marketing in oncology, including previous positions at Astellas and Amgen. Jeff has led multiple sales teams across several successful launches of oncology therapeutics, and we are pleased to welcome Jeff to Puma and look forward to working with him to grow the NERLYNX commercial franchise. I will now review our U.S. commercialization progress for NERLYNX. Just a reminder, I will be making forward-looking statements. 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 distributor channel, or also referred to it as our in-office dispensing channel. In the first quarter, bottles sold in the specialty distributor channel represented approximately 23% of the total bottles sold in the quarter. This represents a slight increase from the 22% we reported in the fourth quarter. During the fourth quarter, we also noted an increase in the number of new physicians in the specialty pharmacy network writing prescriptions for NERLYNX. The total number of NERLYNX prescribers increased approximately 6.8% in the first quarter of 2020 compared to the total number of NERLYNX prescribers in the fourth quarter of 2019. Later in the call, Maximo will review the full financial results, but I will now provide you with the current sales results.
Slide four shows our quarterly net sales of NERLYNX since FDA approval. As I previously stated, our net product sales revenue was $48.6 million in the first quarter compared to $58.7 million in net sales reported in the fourth quarter of 2019. During 2019, at the American Society of Clinical Oncology Annual Meeting and the San Antonio Breast Cancer Symposium, we presented data from our control trial showing that using dose escalation during the first month of NERLYNX treatment reduces the grade-3 diarrhea associated with NERLYNX and improves tolerability. As you can see on slide five, the percent of new prescriptions that appear to be using this dose escalation technique continues to increase. And in fact, increased from 28.7% in Q4 of 2019 and to 30.4% in Q1 of 2020. Slide six shows the total bottles of NERLYNX sold by quarter. You will notice that the number of bottles sold in Q1 declined sequentially from 4,935 in the fourth quarter of 2019 to 4,035 in the first quarter of 2020. As we noted in our Q4 call in February, during the fourth quarter, there was an increase in inventory purchased by the specialty pharmacies, which accounted for about $5 million in increased inventory. During Q1 of 2020, the specialty pharmacies drew down some of this excess inventory to meet demand, which may have negatively impacted our bottles sold during the quarter. In addition, as we also mentioned on our call in February, we saw a decline in NRx in the fourth quarter of 2019 that occurred mostly during the Thanksgiving, Christmas and New Year's holidays which we believe may have been due to patients delaying starting NERLYNX until after the holidays. This may be due to patients wanting to avoid potential GI side effects, which tend to occur with the greatest frequency in the first month or so after initiation.
As we also discussed on our call in February, we did indeed see a large increase in the number of new patients signing up to the specialty pharmacy in January. As we have discussed with investors in prior earnings calls, when these new patients sign up through specialty pharmacy, it takes approximately two weeks for the patient to actually receive their prescription and for Puma to see the NRx. Although therefore, although there was a sharp increase in the number of patients signing up through the specialty pharmacy in January. Due to this delay, actual NRxs started out lighter than expected and may have negatively impacted our total bottles sold in the quarter. We did see this trend move in a more positive direction in late January and early February. NRx in the first quarter of 2020 increased 7.9% from the fourth quarter of 2019 while TRx in the first quarter declined 6.3% from the fourth quarter of 2019. We believe that the previously mentioned trends involving delays in NRxs in January may have negatively impacted refills in the first two months of the quarter, resulting in a TRx decline quarter-over-quarter. Refills did pick up in March, leading to a 12% TRx increase in March versus February. In April, the number of new patients signing up for the specialty pharmacy was essentially flat with the numbers signing up in March. However, we are remaining conservative in our outlook for whether or not COVID-19 will have a negative impact on sales. Due to the COVID-19 pandemic, our commercial teams have experienced a decline in our access to physicians and healthcare providers. Our teams have worked hard to adapt to this new environment with an increase in nonpersonal promotion and virtual interactions. With that said, there still remains a significant amount of uncertainty as to when states will open up and what access restrictions when will be lifted. Given this level of uncertainty, we are taking a conservative outlook with regard to future sales trends. We will continue to monitor these trends closely and look forward to updating our investors in future earnings calls.
We have formed partnerships with companies that have commercial and regulatory expertise outside the United States in order to make NERLYNX available to patients across the world. During 2019, NERLYNX was approved in several countries outside the U.S. and Europe, as is seen on the slide. This morning, we were pleased to announce the approval of NERLYNX in China. During the remainder of 2020, we look forward to the potential approval of NERLYNX in additional countries including parts of Latin America and South America, as shown on the slide. In Europe, in the fourth quarter, our partner Pierre Fabre, launched NERLYNX in Germany, the United Kingdom and Australia. Although it is still early, we are very pleased with their initial success. NERLYNX was launched in the first quarter in Sweden, and we anticipate that Pierre Fabre will launch NERLYNX in approximately eight to 10 additional countries in Europe throughout 2020. We look forward to updating investors on the European launch in the future. We have formed partnerships with companies that have commercial and regulatory expertise outside the United States in order to make NERLYNX available to patients across the world. During 2019, NERLYNX was approved in several countries outside the U.S. and Europe, as is seen on the slide. This morning, we were pleased to announce the approval of NERLYNX in China. During the remainder of 2020, we look forward to the potential approval of NERLYNX in additional countries including parts of Latin America and South America, as shown on the slide. In Europe, in the fourth quarter, our partner Pierre Fabre, launched NERLYNX in Germany, the United Kingdom and Australia. Although it is still early, we are very pleased with their initial success. NERLYNX was launched in the first quarter in Sweden, and we anticipate that Pierre Fabre will launch NERLYNX in approximately eight to 10 additional countries in Europe throughout 2020. We look forward to updating investors on the European 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 first quarter of 2020. Please note that I will make comparisons to Q4 and Q3 2019, which we believe are better indications of our progress as a commercial company in year-over-year comparisons. For more information, I recommend that you refer to our 10-Q, which will be filed today and includes our consolidated financial term. For the first quarter of 2020, we reported a net loss based on GAAP of $16.9 million or $0.43 per share. Our GAAP net losses for Q4 and Q3 2019 were $11.2 million and $16.9 million, respectively. On a non-GAAP basis, which is adjusted to remove the impact of stock-based compensation, we reported a net loss of $8 million or $0.20 per share for the first quarter of 2020. Gross revenue from NERLYNX sales was $58 million in Q1 2020 versus $68.5 million in Q4 2019. As Alan mentioned, net revenue from NERLYNX sales was $48.6 million, a decrease from net sales of $58.7 million for the fourth quarter of 2019.
In Q1, in 2020, we recognized $2 million of license revenue related to our metastatic approval and $0.6 million in royalty revenue from our global partners. Our gross to net adjustment in Q1 was about 16%, an increase from the 14% gross to net adjustment in Q4. The increase was driven mostly by higher co-pay and coverage GAAP expenses driven by seasonality. Cost of sales for the first quarter was $9.1 million, which included amortization of milestone payments to the licensor of neratinib of approximately $1 million. Going forward, we will continue to recognize amortization of the milestone payments to the licensor for about $1 million per quarter as cost of sales.
For the fiscal year 2020, Puma continues to anticipate that NERLYNX net sales will be in the range of $215 million to $225 million. We also anticipate that our gross to net in 2020 will be between 16% and 17%. Furthermore, we anticipate receiving royalties from our partners around the globe in the range of $3 million to $5 million, which represents a decline from the prior guidance of $5 million to $10 million and potential licensing fees in the range of $2.5 million to $22 million. We recognize there is a great deal of uncertainty with regards to the impact of COVID-19, and this may have a negative impact on our sales. Additionally, our NERLYNX net revenue expectation for Q2 are in the range of $48 million to $50 million. We anticipate that the gross to net in Q2 will be approximately 15.5% to 16.5%.
SG&A expenses were $30.9 million in the first quarter of 2020 compared to $31.3 million and $31.4 million for Q4 and Q3 2019, respectively. SG&A expenses included noncash charges for stock-based compensation of $4.7 million for the first quarter of 2020 compared to $5 million and $5.6 million for Q4 and Q3 2019, respectively. Research and development expenses were $25.5 million in the first quarter compared to $30.2 million and $30 million for Q4 and Q3 2019, respectively. R&D expenses, including noncash charges, for stock-based compensation of $4.2 million in Q1 compared to $6.5 million and $6.6 million for Q4 and Q3 2019, respectively. In the first quarter of 2020, Puma reported cash burn of approximately $11.6 million compared to cash burn of approximately $1.2 million in Q4 2019, cash burn of $7.3 million in Q3. We ended the first quarter of 2020 with $100.6 million in cash, cash equivalents and marketable securities. Our accounts receivables balance at March 31 was $31.5 million. Our accounts receivable terms range between 10 and 68 days while our day sales outstandings are about 46 days. Our distribution network maintains approximately four weeks of inventory. Overall, we continue to deploy our financial resources to focus on the advancements of neratinib through ongoing clinical trials and the commercialization of NERLYNX.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Thanks, Maximo. We continue to recognize that we need to improve NERLYNX sales growth. Puma senior management in cooperation with the commercial committee of the Board of Directors continues to remain focused on NERLYNX' revenues and sales growth in 2020 and beyond. We have made a number of new hires in our commercial team, and we are hopeful that these new team members will make a positive contribution to NERLYNX' sales growth, and we look forward to updating investors on this in the future.
There remains a significant unmet need for women battling breast cancer. We at Puma are committed and passionate about finding more effective ways and helping these patients during their journey and we will continue to strive to achieve that goal.
This concludes today's presentation. We will now turn the floor back to the operator for questions. Operator?
Questions and Answers:
Operator
[Operator Instructions] And our first question will come from Yigal Nochomovitz with Citigroup.
Yigal Nochomovitz -- Citigroup -- Analyst
Okay, great. Thanks for taking the question. I just had a few. Alan, can you comment at all about how much metastatic revenue you generated in the first quarter? I know you just got the approval, but I'm just curious if you could provide any comments on that.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. Yigal, thanks for the questions. So to give kind of a comparison. In Q4 of 2019, 8.9% of our bottles sold were in the metastatic setting. While some of that is in the HER2 amplified, and some of that is in the HER2 mutated. In Q1 of 2020, it was 9.3%.
Yigal Nochomovitz -- Citigroup -- Analyst
Okay. Got it. That's very helpful. And then just I wanted to get a better understanding with respect to the guidance. I know you mentioned that you're going to take a conservative approach with respect to the sales trends this year. And I think you also mentioned that Q2, you expect $48 million to $50 million. So that maintaining the guidance of $215 million to $225 million suggests you are still expecting some growth in the back half of the year. I just wondered if you could comment on that in view of the situation with COVID and where you're comfortable maintaining that $215 million to $225 million range.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So again, we are taking a conservative outlook with regard to COVID-19 because I think that there's a lot of uncertainty in terms of when the country opens up, what that looks like, do we see a second surge, etc. We do feel, obviously, a lot more comfortable that toward the second half of 2019, access will be higher. So I think that's where that guidance is coming from. That's kind of being conservative now and recognizing that as access improves later in the year, that should obviously help sales growth as well. All right. I appreciate it. Thank you.
Operator
Moving on we'll go to Cory Kasimov with JP Morgan.
Matthew Holt -- JP Morgan -- Analyst
Hi guys, This is Matthew on for Cory. Thanks for answering my questions. So I just wanted to follow up on the question on 2020 guidance. Does that factor in another price increase beyond what was taken in March?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
I don't remember if there was one that was planned for later this year. I don't have that information in front of me. I don't remember the answer to that.
Matthew Holt -- JP Morgan -- Analyst
Okay. And then I guess just for the metastatic opportunity, curious to understand what you're hearing in the field. And I guess my question is, do you expect to see patients undergoing multiple treatment regimens with capecitabine recycling through TKIs given that there are multiple TKIs approved in combination with capecitabine?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
That is a good question. I would say that in terms of the use of NERLYNX in the metastatic setting, we do again, anecdotally, we hear from physicians that they use NERLYNX sometimes just as a single agent, right? Because it's very well published. The drug works as a monotherapy. And sometimes they use it in combination with chemo, sometimes it's capecitabine, sometimes it's not. We also hear quite frequently that they're using it for HER2-mutated patients as well because there's a tremendous amount of data published on HER2-mutated breast cancer.
You've obviously had three new drugs approved in kind of this third-line and beyond HER2-positive metastatic breast cancer setting. As you know, in HER2, which is the ADC from AstraZeneca and Daiichi Sankyo, was approved in December of 2019. Then NERLYNX was approved in February, and then most recently, tucatinib from Seattle Genetics was approved. Obviously, when HER2 came out, launched it in the space prior to us being able to and prior to the COVID-19 pandemic, our bottles in the metastatic went from 8.9% in Q4 of 2019 to 9.3% in Q1 of 2020. So short term, it did appear that HER2 had the impact on our metastatic sales. That's short term, obviously.
How it ends up playing out in terms of sequencing of other TKIs with capecitabine, etc? I don't know the answer to that. I think we're just going to need to wait and see.
Michael Schmidt -- Guggenheim -- Analyst
Thanks for taking my questions.
Operator
Moving now, we'll go to Michael Schmidt with Guggenheim.
Michael Schmidt -- Guggenheim -- Analyst
. Hey, Alan, thanks for taking my questions. Maybe a question, just a financial question. I appreciate that you're maintaining NERLYNX sales guidance. Just wondering, any updated thoughts on kind of the roadway to cash flow breakeven. Is it something that you think might be achievable this year, for example?
Maximo F. Nougues -- Chief Financial Officer
Yes. This is Maximo. Our goal for 2020 is to be cash flow neutral.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
So we're maintaining that goal, Michael.
Michael Schmidt -- Guggenheim -- Analyst
Great. And then maybe just another question on market dynamics. Just curious now that the drug's been on the market for some time, the majority of sales obviously coming still from the adjuvant setting. I'm just wondering if you've seen any changes here in market dynamics since Kadcyla had been approved last year in early breast cancer as well.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. Thanks for that question, Michael. So the data on Kadcyla in the adjuvant setting, the cathrine data, was presented at the San Antonio Breast Cancer meeting in December of 2018, if I remember this correctly, and I believe it was approved in April 2019. When the data came out at San Antonio, our understanding is that docs immediately began switching their patients to Kadcyla. So if they had a patient that was through six months of Herceptin Perjeta, they switched them to Kadcyla, and they were starting all new patients on it as well. So throughout 2019 and into 2020, I would estimate that the large percentage of our patients have already previously seen Kadcyla. So I don't we haven't yet, to my knowledge, seen any impact of that. And I don't know that I would anticipate that changing in the future.
Michael Schmidt -- Guggenheim -- Analyst
Okay. And then maybe Maximo, just to confirm. I want I'm not sure if I heard that earlier, whether you guided to $48 million to $50 million in sales for the second quarter. Could you just confirm that?
Maximo F. Nougues -- Chief Financial Officer
Our guidance was $215 million to $225 million.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
For the year. Yes.
Maximo F. Nougues -- Chief Financial Officer
For the year. And the second quarter was on the second quarter, we said $48 million to $50 million.
Operator
And next we'll go to Kennen Mackay with RBC Capital Markets.
Kennen Mackay -- RBC Capital Markets -- Analyst
Yeah. Hi, thank you for taking the question. Maybe first, initially, Alan, that 0.4% increase in bottles sold in the metastatic setting after the approval translates to about 16 bottles or maybe 16 prescriptions, given this was sort of on the market for about 1.5 months in Q1. Has this picked up at all in April given the NCCN COVID-19 guidelines to preferentially consider oral therapies whenever possible? Or has this sort of been maintained and maybe conversely to that, has there been any impact to metastatic prescriptions that you've seen after the approval of tucatinib?
And then second, just on the Q1 guidance versus results. The outperformance versus the earlier guide, wondering sort of where that came from and if there were any dynamics in the tail end of the quarter that has contributed to that?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Okay. Kennen, I have three questions from you. The first one is, do we see any change in metastatic prescriptions with NERLYNX in April after the NCCN COVID-19 preferentially said to prefer oral prescriptions. I don't know the answer to that. I don't have the data in front of me, so I can't answer that without the data. In terms of any impact from the approval of tucatinib, I know it was very, very recently. So I don't know if we have seen any. I don't remember if we've seen any. Obviously, that's something we'll be looking at, but I don't know that we've seen any to date yet. And I think we'll have to take a wait-and-see approach. Your last question in terms of the outperformance in Q1. Yes, you're correct. We guided to, I believe it was $40 million to $42 million was our guidance for Q1, and we came in at $48 million. That was definitely driven by sales in extended adjuvants, and we are definitely continuing to see new prescribers being a very big driver of sales. And I think our NRxs in Q1, if I had to ballpark it, I would say 40% to 50% of them are coming from new prescribers. So I know in the past, we had shown a metric that was how many prescribers we had the reach, if you will. And again, that was just defined as had we contacted the doctor once, and I'm sure you can appreciate just contacting a doctor once, often doesn't make them prescribe the drug. They often have questions, and it could take 4, five or six calls to do that. So I think with time and with the increased efforts of the team to increase their outreach and increase their calls, especially to people who've not written the prescription, I think that's likely what we're seeing of that execution from that perspective.
If I had to estimate of the entire population of, which is probably ballpark somewhere in the range of 8,000 to 9,000 physicians, I would ballpark estimate probably half of them, if not more, have yet to write a prescription for the drug. So there is clearly a continued opportunity to grow NRx through new prescribers. And that's something that the commercial team is going to be focusing on.
Kennen Mackay -- RBC Capital Markets -- Analyst
And maybe just a follow up on that. Any plans, given some of these new prescriptions, especially in extended adjuvant, are starting at lower doses. Either maintaining that or you've been looking at titrating? Any plans to release like a different tablet that could be priced the same on a monthly basis to maintaining some of that revenue recognition?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. You asked that question, I believe, on the last call as well. So thank you for asking it again. We are indeed looking into that. We are indeed looking into that, Kennen. I understand the idea. I'm not at all disagreeing with you. It's a good idea. We are looking into that. I just think there's a little bit of lead time to get that done.
Operator
And next, we'll go to Chris Shibutani with Cowen & Company.
CJ Zopf -- Cowen & Company -- Analyst
This is CJ Zopf on for Chris, tonight. Thanks for the thorough quarterly update. I was wondering if the following up on that last question, getting into the NRxs, with the kind of ongoing situation in hospitals and patients not seeing their physicians as much perhaps. Is there any expectation for or what efforts are ongoing that may enable you to kind of keep that momentum going in terms of growing new prescribers to keep the NRxs up? And then perhaps, I may have missed this earlier, but with respect to the patients starting on lower doses, do you have a sense yet of what the average duration of treatment might be by the end of the year as more and more prescribers adopt that?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. Thanks, CJ. So to your first question, in terms of what's happening with COVID-19 and how we are addressing that. Yes, you are correct that you do have a lot of patients who are not going to see their doctor because of the COVID-19. And I will, again, state, as we get in our prepared comments, that the commercial team is definitely working hard to try to adapt to this new environment. And doing a lot of non-personal interactions, we're more virtual ones and things like that. And as states start to open up, obviously, that helps them as well because it opens up access as well. So now they can kind of do more face-to-face meetings or rather than doing a big Webex call or something like that, actually meet in physical location or restaurants or something like that. So as the states open up, that will obviously help that tremendously.
Your second question, we do not have I don't have it in front of me what the estimate is in terms of people who are dose escalating and is it leading to a longer duration or not. I don't have that information in front of me. I think we have to wait a little longer to see that.
CJ Zopf -- Cowen & Company -- Analyst
Great, thanks so much.
Operator
And next, we'll go to Paul Choi with Goldman Sachs.
Paul Choi -- Goldman Sachs -- Analyst
Hi, good afternoon and thanks for taking our questions. My first question is just, as you've gone partway through the second quarter here, could you maybe just comment on any behavioral changes that you're observing with patients, whether it's with regard to adherence and/or ability or follow through in terms of refilling prescriptions?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. Paul, thanks for the question. In terms of adherence, I don't know if we I get a question from investors quite a lot, which is because people are stuck at home and therefore, the side effects of the drug may not be as bothersome because they're not working and doing their daily activities. Are you seeing better compliance due to that? And I get that question quite frequently from investors. I don't know that we have enough data yet to be able I understand the thesis. I don't know we have enough data yet to be able to say yes or no on that. So I need a little more data to be able to say that.
In terms of patients refilling their prescriptions, etc, through the specialty pharmacy, this is a specialty pharmacy. This is not a CVS or a door in read that you just walk into. This is something where it's physically delivered to the patients. So I would envision that most of these are doing like hands-off deliveries where they can just ring the door bell and leave it on the front doorstep or I would imagine they're probably showing up in a mask in gloves and all these things as well to help make the patient more comfortable. So there isn't the need for the patient to physically go to a pharmacy. It's physically delivered to them. So I don't know that, that the question you're asking, which is our patients refilling less frequently because they're not able to go to pharmacy or something. They don't think physically go to a pharmacy, it's brought to them.
Paul Choi -- Goldman Sachs -- Analyst
I was referring maybe more to any macro-driven impact where patients are potentially dropping off to do either unemployment or insurance versus delivery mechanism? Sorry, if I was unclear.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. That's a good question. With the spike in unemployment, have we seen not to my knowledge. I'm not aware that we have seen any drop in insurance coverage or anything like that. I would I'm talking off the top of my head here, but if I remember correctly, usually, if you're unemployed, you can do...
Maximo F. Nougues -- Chief Financial Officer
COBRA.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. COBRA. Thank you. You can do COBRA to keep your benefits going for a certain period of time. So I would imagine a lot of these patients would have that opportunity. Again, I just haven't seen any data that says that we've seen due to the unemployment rise, any drop-off in insured patients.
Paul Choi -- Goldman Sachs -- Analyst
Got it. And then maybe just looking down the road a little bit here as you think about the cervical opportunity and post your discussions with the FDA for a potential accelerated approval here. Can you maybe just comment on where you think you are currently with regard to the commercial build, market development and market research? And just how you think about perhaps the expansion of the field force over the course of 2021 and beyond?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So thanks for that question, Paul. We do have an opportunity with the SUMMIT trial both in HER2-mutated breast cancer and in HER2-mutated cervical cancer. HER2-mutated breast is a much larger indication than is HER2-mutated cervical. Because we already have the commercial infrastructure and the sales outreach to breast cancer physicians, I don't anticipate we're going to need any additional build to do that. We do have a very strong marketing team, market access team, medical affairs team, etc, who has been very involved in our work in HER2-mutated breast cancer. So I anticipate that we're at this juncture, quite well positioned for 2021.
Operator
This concludes our question-and-answer session. I would now like to turn the conference back to Mariann for closing remarks.
Mariann Ohanesian -- Senior Director of Investor Relation
Thank you for your interest in Puma Biotechnology. 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: 42 minutes
Call participants:
Mariann Ohanesian -- Senior Director of Investor Relation
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Maximo F. Nougues -- Chief Financial Officer
Yigal Nochomovitz -- Citigroup -- Analyst
Matthew Holt -- JP Morgan -- Analyst
Michael Schmidt -- Guggenheim -- Analyst
Kennen Mackay -- RBC Capital Markets -- Analyst
CJ Zopf -- Cowen & Company -- Analyst
Paul Choi -- Goldman Sachs -- Analyst
