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Puma Biotechnology Inc (PBYI -5.85%)
Q2Â 2020 Earnings Call
Aug 6, 2020, 4:30 p.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good afternoon. My name is Jessie, 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 -- Investor Relations
Thank you, Jessie. Good afternoon, and welcome to Puma's conference call to discuss our financial results for the second quarter of 2020.
Joining me on the call today are Alan Auerbach, Chief Executive Officer, President and Chairman of the Board of Puma, Maximo Nougues, Chief Financial Officer, and Jeff Ludwig, Chief Commercial Officer.
After market closed today, Puma issued a news release detailing second quarter 2020 financial results. That news release, the slides that Jeff will refer to, and a webcast of this call are accessible via the homepage in 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 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, August 6, 2020. 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 if 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 second quarter 2020 news release for a reconciliation of our GAAP to 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 second quarter of 2020 of $70.6 million. Total revenue includes net US NERLYNX sales as well as license and royalty fees from our sublicensees. Net NERLYNX sales were $48.8 million in the second quarter of 2020, representing a slight increase from the $48.6 million in net sales reported in the first quarter of 2020 and a decrease from the $53.8 million reported in Q2 of 2019.
As we reported on our fourth quarter earnings call, during the fourth quarter of 2019, there was an increase in inventory purchased by the specialty pharmacies, which we estimate was approximately one week of excess inventory. And we also reported on our fourth quarter earnings call, there was an approximately four weeks of inventory in our distribution network. On our first quarter call, we reported that the specialty pharmacies had drawn down some of their excess inventory to meet demand. However, our distribution network still maintained approximately four weeks of inventory at the end of the first quarter.
During the second quarter, we saw specialty pharmacies continue to draw down from their existing inventory to meet demand, which we believe may have negatively impacted second quarter revenue by approximately $4 million to $5 million. Our distribution network had approximately three weeks of inventory at the end of the second quarter of 2020, which is more in line with the level seen in 2019 prior to the inventory buy-in during the fourth quarter of 2019. Also during the second quarter, license fees increased to $20.7 million, which included a one-time payment due to the regulatory approval of NERLYNX in Mainland China, and royalty revenue during the quarter was $1.1 million.
I will begin with a review of some of the highlights of the quarter, and then Jeff Ludwig will provide more details on NERLYNX commercial activities. Maximo Nougues will follow with highlights of the key components of our financial statements for the first quarter of 2020. As investors are aware, Puma has an ongoing trial of neratinib in extended adjuvant, HER2-positive early breast cancer referred to as the CONTROL trial, while we are investigating the use of several prophylactic techniques, including the use of antidiarrheal drugs or dose escalation to reduce the incidence of neratinib-related diarrhea and improve the tolerability of the drug.
Interim results from the CONTROL trial were published online in the medical journal, Annals of Oncology, in May of 2020. These results demonstrated that the incidence of grade 3 diarrhea with neratinib can be reduced and the tolerability of the drug can be improved significantly using a variety of anti-diarrheal strategies. We believe this publication will help to increase the awareness of using these techniques to improve the tolerability of the drug. We further anticipate that additional results from the trial will be presented in the fourth quarter of 2020, which may further help to increase awareness of these prophylactic techniques.
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, 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 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 arms 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.
As we reported on our first quarter earnings call, enrollment into the SUMMIT trial in Q1 of 2020 was slightly higher than enrollment in Q4 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 end of the range of monthly enrollment that we saw in this cohort during 2019, and we believe that this decline was due to the impact of the COVID-19 pandemic. Enrollment in the trial further declined during the month of May, but then began to slightly improve in June and slightly improve again in July. We continue to believe that enrollment in the trial is being impacted by the COVID-19 pandemic. We continue to anticipate that we will receive the initial results from the initial Simon 2-stage for the HR-positive breast cancer cohorts in Q1 of 2020 -- sorry, in Q1 of 2021. However, we recognize that this could continue to be impacted by COVID-19 and also recognize the potential uncertainty associated with any additional wave of COVID-19 should one occur later this year.
Once we receive the initial results from the Simon 2-stage in the HR-positive breast cohorts, we plan to schedule a pre-NDA meeting with the FDA to discuss the potential for an accelerated approval. In addition, we recently announced that the Phase II data from the cohort of the SUMMIT trial with HER2-mutant metastatic cervical cancer were published online in the Journal of Gynecologic Oncology in July of this year. And finally, the results of our Phase III trial of neratinib for the treatment of third-line HER2-positive metastatic breast cancer also referred to as the NALA trial, were published in the Journal of Clinical Oncology in July of this year as well.
I will now turn the call over to Jeff Ludwig, Puma's Chief Commercial Officer, for a review of our commercial performance during the quarter.
Jeff J. Ludwig -- Chief Commercial Officer
Thanks, Alan. Really appreciate it.
It is great to be here, and I'm honored to be leading Puma's commercial organization. We are proud of what we have accomplished so far, but clearly know there is much more to do to support patients and their families battling breast cancer. Before I move into the commercial review, just a reminder that I will be making forward-looking statements.
During the second quarter of 2020, Puma's commercial access was negatively impacted by the COVID-19 pandemic. As we reported on our first quarter earnings call, we did not see an impact from COVID-19 on new patient starts in Q1. However, we did see an impact in mid-Q2. As we previously reported, the number of new patients signing up in April through our specialty pharmacy channel was essentially flat compared to those signing up in March. We did, however, see a decline in May, more specifically in the latter part of the month, which we believe was due to the COVID-19 pandemic and the stay-at-home orders and quarantines that were in place in various parts of the US. This trend did start to recover in June, which we believe may have been related to states beginning to open back up. We are aware of other companies who have drugs that treat early stage, HER2-positive breast cancer reporting similar dynamics in May and June. So we believe that this COVID-19 impact may have had a broader impact on the early stage breast cancer market.
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 in-office dispensing channel. In the second quarter, bottles sold in the specialty distribution channel represented approximately 22% of the total bottles sold in the quarter. This is very similar to the 23% we reported in the first quarter.
Later in the call, Maximo will review the full financial results, but I will now provide you with the current US sales results. Slide 4 shows US quarterly net sales of NERLYNX since FDA approval. As Alan noted, our net US product sales were $48.8 million in the second quarter of 2020. This is a slight increase over the $48.6 million we reported in Q1 of 2020. Slide 5 shows the bottles of NERLYNX sold by quarter since launch. We sold 3,728 bottles of NERLYNX in Q2 of 2020, which is a decrease of about 7.6% from our reported Q1 2020 bottle sales of 4,035. Now clearly, we do not like to see bottle sales decline. But as Alan mentioned, we believe this is directly correlated with an approximate one-week reduction in distributor inventory. Our commercial teams have worked very hard to adapt to this new COVID environment, and we are pleased to see that gross demand has stayed flat compared to Q1 despite decreased customer access and reported patient flow impact.
As highlighted during our Q1 earnings call, NERLYNX received third-line approval for the treatment of HER2-positive metastatic breast cancer. This was clearly an important milestone as it brought forth an additional treatment option for patients battling metastatic disease. In Q2, roughly 8% to 10% of our new patient starts were in the metastatic setting. The vast majority of our overall business and of our new patient starts continue to be in the larger extended adjuvant setting.
Alan mentioned that the interim results of the CONTROL trial were published online in Annals of Oncology in May. We believe the CONTROL data is very important as it shows that proactive management of diarrhea can significantly improve NERLYNX tolerability by reducing grade 3 diarrhea and overall discontinuations. Utilizing a dose-escalation strategy in the extended adjuvant setting, coupled with prn loperamide showed a greater than 60% reduction in grade 3 diarrhea and an approximate 80% reduction in discontinuation. As you can see on Slide 6, approximately 31% of new patient starts were initiated at a reduced dose in Q2, which is a slight increase over Q1. With the recent publication, coupled with an additional planned communication in Q4, we would expect this trend to continue. We believe that improving the tolerability of NERLYNX and reducing discontinuations should increase the average length of therapy and ultimately help patients in their battle with breast cancer.
Moving on to rest of the world partnerships. We have formed strategic partnerships with regional pharmaceutical companies that have commercial and regulatory expertise within their respective geographies, with the goal of making NERLYNX available to patients across the world. During 2019, NERLYNX was approved in several countries outside the United States, and this trend has continued in 2020, as seen on this slide. Most recently, Specialised Therapeutics received approval in Brunei in April, New Zealand in June and Malaysia in July. Medison received both regulatory approval and national reimbursement in Israel in Q1 of this year. And just yesterday, CANbridge received regulatory approval in Taiwan. And finally, Pint Pharma launched NERLYNX in Argentina earlier this year and received approval in Chile in late April.
During the remainder of 2020 and beyond, we look forward to the potential for NERLYNX to be approved in additional countries, including in Latin America, Asia, Southeast Asia and the Middle East. In Europe, in the fourth quarter, our partner Pierre Fabre launched NERLYNX in Germany, the United Kingdom and Austria. Recently, they launched NERLYNX in Sweden and received regulatory approval in Switzerland. Although it is still early, we have been very pleased with their initial success, and we anticipate that Pierre Fabre will launch NERLYNX in several additional countries in Europe throughout the remainder of 2020. We look forward to updating investors on our European progress in the future.
I will now turn the call over to Maximo for a review of our financial results.
Maximo F. Nougues -- Chief Financial Officer
Thanks, Jeff.
I will begin with a brief summary of our financial results for the second quarter of 2020. Please note that I will make comparisons to Q1 2020 and Q4 2019, which we believe are better indications of our progress as a commercial company and 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 statements.
For the second quarter of 2020, we reported net income based on GAAP of $3.4 million or $0.08 per diluted share. Our GAAP net losses for Q1 2020 and Q4 2019 were $16.9 million and $11.2 million, respectively. On a non-GAAP basis, which is adjusted to remove the impact of stock-based compensation, we reported net income of $14 million or $0.35 per diluted share for the second quarter of 2020. Gross revenue from NERLYNX sales was $57 million in Q2 2020 versus $58 million in Q1. As Alan mentioned, net revenue from NERLYNX sales was $48.8 million, a slight increase from net sales of $48.6 million in the first quarter of 2019.
In Q2 2020, we recognized $20.7 million in license revenue and $1.1 million in royalty revenue from our global partners. Our gross to net adjustment in Q2 was 14.4%, a decrease from the 16.3% gross to net adjustment in Q1. The decrease was driven mostly by lower co-pay and coverage GAAP expenses driven by seasonality. Cost of sales for the second quarter was $9.4 million, which included the amortization of milestone payments to the licensor of neratinib of approximately $1.3 million. Going forward, we will continue to recognize amortization of the milestone payments to the licensor or about $2 million per quarter as cost of sales.
For full year 2020, Puma anticipates that NERLYNX net sales will be in the range of $200 million to $210 million. This is a reduction from our prior estimate of $215 million to $225 million. We also anticipate that our gross-to-net adjustment in 2020 will be between 16% and 17%. Furthermore, for the full year 2020, we continue to anticipate receiving royalties from our partners around the world in the range of $3 million to $5 million, and potential licensing fees in the amount of $22.7 million. We recognize there is a great deal of uncertainty with regards to the impact of COVID-19, and this may continue to negatively impact our sales, royalties and license fees.
Additionally, our NERLYNX net revenue expectations for Q3 2020 are in the range of $48 million to $50 million. We anticipate that the gross to net in Q3 will be approximately 16.5% to 17.5%. SG&A expenses were $29.4 million in the second quarter of 2020 compared to $30.9 million and $31.3 million for Q1 2020 and Q4 2019, respectively. SG&A expenses included non-cash charges for stock-based compensation of $4.7 million for the second quarter of 2020 compared to $4.7 million and $5 million for Q1 2020 and Q4 2019, respectively.
Research and development expenses were $24.7 million in the second quarter compared to $25.5 million and $30.2 million for Q1 2020 and Q4 2019, respectively. R&D expenses included non-cash charges for stock-based compensation of $5.9 million in Q2 compared to $4.2 million and $6.5 million for Q1 2020 and Q4 2019, respectively. In the second quarter of 2020, Puma reported cash earned of $6.2 million compared to cash burn of $11.6 million in Q1 2020 and cash earned of approximately $1.2 million in Q4 2019.
We ended the second quarter of 2020 with $107.3 million in cash, cash equivalents and marketable securities. Our accounts receivables balance at June 30 was $24 million. Our accounts receivable terms ranged between 10 and 68 days while our days sales outstandings are about 44 days. We estimate that as of June 30, 2020, our distribution network maintained approximately three weeks of inventory.
Overall, we continue to deploy our financial resources to focus on the advancement 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's senior management in cooperation with the Commercial Committee of the Board of Directors continue to remain focused on NERLYNX revenue and sales growth in 2020 and beyond. We've made a number of new hires in our commercial team, and we are also adapting to the virtual commercial environment that we need to pivot toward due to the COVID-19 pandemic. We are hopeful that these new team members and changes to our commercial infrastructure will make a positive contribution to NERLYNX sales growth, and we look forward to updating investors on this in the future.
There continues to remain a significant unmet need for women battling breast cancer. We at Puma are committed and passionate about finding more effective ways at 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 Q&A. Operator?
Questions and Answers:
Operator
[Operator Instructions]
Our first question comes from the line of Yigal Nochomovitz with Citi. Please proceed with your question.
Samantha -- Citi Research -- Analyst
Hi, this is Samantha [Phonetic] on for Yigal. Thank you very much for taking our question. First, I want to start with just how do you see the contribution of metastatic revenues to overall NERLYNX picture evolving as you work to develop this indication? And so far, have you seen any off-label use of other HER2-driven cancers, given the solid benefit you've seen on brain mets?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Hi Samantha, thank you for the question. So I believe Jeff said in his presentation that somewhere between 8% to 10% of our usage is in the metastatic setting. So I think that's remained what we've continued to see. Now when they come in as a script for metastatic, we don't know whether or not it's a HER2-positive metastatic or HER2-mutated or they have brain mets or they don't have brain mets. I can definitely say, anecdotally, we certainly hear from physicians that they're using NERLYNX commercially in HER2-mutated breast cancer, and they're using it in HER2-positive metastatic breast cancer that has brain mets. I don't, unfortunately, have any breakdown of exactly the numbers that are behind that.
Samantha -- Citi Research -- Analyst
Got it. That's helpful. And then just on the guidance -- on the updated guidance, I wanted to confirm that, that is for both the adjuvant setting and the metastatic. Is that correct?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. That is correct.
Samantha -- Citi Research -- Analyst
Okay, great. Thanks so much for taking our questions.
Operator
Thank you. Our next question comes from the line of Kennen MacKay with RBC. Please proceed with your question.
Kane -- RBC Capital Markets -- Analyst
Hi, this is Kane [Phonetic] on for Kennen. Thanks for taking our question. So first question is about an interesting research paper recently, like identifying neratinib as a potent COVID-19 environment produce inhibitor using computational approaches. The research kind of followed an earlier nature publication looking at four different [Indecipherable] that can delve [Phonetic] into the main produce functional side in which neratinib's chemical structure just look like kind of resemble the M3 class. So does this kind of research came into your awareness, too, and that will trigger your interest to do some like biochemical acids, there may be animal studies, there may be clinical trials. Thank you.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. Thank you for the question. Yes, we are aware of that publication from that Russian group. And we have had investigators who have been doing work on neratinib in COVID-19. I don't want to say too much about that research. But it is suffice it to say, we have had many external researchers who have done some work with neratinib in COVID-19 coming up with similar types of conclusions. Once we get some more data on this under our belt, I think we will plan to, in some way, communicate that to investors, either by publishing it or in some way, getting it to be public information. But yes, it is something we have interest in, and it is something we have active research looking into.
Kane -- RBC Capital Markets -- Analyst
All right. Thank you. Then we have one follow-up on the HER2-mutant cervical cancer cohort update. So compared to the SGO data, there were five more patients data included for the safety analysis and one more patient data included for the efficacy analysis. Can we know like approximately how many patients have been enrolled into the cervical cancer cohort so far? And may you provide guidance on the timing and the size for the next data update? And more -- like how many like cervical cancer patients data are required by FDA for regulatory discussions? That's all our questions. Thank you.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yeah. Thank you for the question on the HER2-mutated cervical cancer. I apologize I do not have the update on that in front of me. I know we do plan on presenting more data on that. I don't know the exact timing of that. So I'll need to get back to you on that. So I apologize for not having that in front of me. To your question, which is how many patients do we need to go to the FDA and discuss it with them, this would be an sNDA. And again, HER2-mutated cervical cancer, as I recall, is about 5% of the cervical cancer population. So it's not like 10,000 patients or something, it's obviously much smaller. And I'm aware of -- for instance, I know KEYTRUDA got approved in the PD-L1 high, and I don't think their end was a huge number.
So I'm not imagining we're going to need like hundreds of patients here. But let me get back to you with a little more of an update on where that is and what our timing would be for expanding the label.
Kane -- RBC Capital Markets -- Analyst
Thank you. That's very helpful.
Operator
Thank you. Our next question comes from Cory Kasimov with JP Morgan. Please proceed with your question.
Matthew -- JP Morgan -- Analyst
Hey guys, thanks for taking my question. This is Matthew [Phonetic] on for Cory. Just wanted to get your thoughts on NERLYNX pricing. Are you comfortable where NERLYNX is currently priced? Or should we expect the pace of increases to be similar to the four increases at 10% each that has occurred over the last 18 months?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Jeff, would you like to handle that?
Jeff J. Ludwig -- Chief Commercial Officer
Sure. Matthew, good question. I appreciate it. First of all, I would say we're not going to proactively comment on any future potential pricing strategies. We wouldn't do that. But what I will tell you the way you want to think about it is we are very, very committed to ensuring a very strong value proposition in this marketplace. We also want to ensure that there is very strong physician and patient access. And obviously, as part of our discussions, we continue to look at the competitive marketplace. So we've made some decisions in the past, but we won't -- we wouldn't comment at this point in any future potential pricing decisions.
Matthew -- JP Morgan -- Analyst
Great, thanks for taking my question.
Operator
Thank you. Our next question comes from the line of Geoff Meacham with Bank of America. Please proceed with your question.
Scott -- BofA Global Research -- Analyst
Hey guys, this is Scott [Phonetic] on for Geoff. Thanks for taking our question. I believe there was new language added to the package in sort of NERLYNX recently as it relates to ExteNET trial, specifically in regard to no statistical difference in the OS after eight years of follow-up. So just wondering how you guys think this will impact sales moving forward? And then for the patients that are starting on the lower dose, do you know what dose these patients are typically starting on and the duration the average patient is on this lower dose until they reach the 240 milligrams? And given the small difference in benefit, whether it's the DFS or the OS, how confident are you that these lower doses aren't impacting results and potentially making them more equivalent to placebo patients? Thanks.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yes. So to answer your first question, Scott, as you know, the ExteNET trial rolled a wide range of patients. And in the ITT population, it was both hormone-receptor-positive and hormone-receptor-negative patients. As you know, the actual use of the drug clinically does not tend to be in the ITT population, it's not in all-comers. And the typical what you hear from physicians is they use it in the HR-positive patients and/or the HR-positive patients who are at a high risk. We plan on presenting the data from those cohorts, specifically the HR-positive group and the HR-positive, high-risk group at the San Antonio breast cancer meeting this year.
Obviously, we can't comment on that. But clearly, if we were to see a positive impact in those subgroups where the drug is used commercially, we think that, yes, it could have a positive impact on our sales. Obviously, we have to wait for that data to be presented. And we can't comment on it until it is, but I think you can understand that logic. Can you repeat your second question, please?
Scott -- BofA Global Research -- Analyst
Yeah, sure. Just wondering about the patients on the lower dose. Do you know what dose these patients are typically starting on and the duration that they're on that lower dose until they reach the 240 milligrams? And given the kind of tighter range in the benefit, if this lower dose is potentially having any impact on the overall survival or the DFS as you kind of look at it?
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Okay. So I think Jeff will take the first part, I'll take the second part of that question.
Jeff J. Ludwig -- Chief Commercial Officer
Scott, I think it's a good question. Obviously, as we highlighted in this -- in our opening statements about the CONTROL data, we feel very good about the CONTROL data in that it does significantly change the tolerability of NERLYNX. And if you follow that paper and the data that was presented, what we're suggesting in that paper, at least on the dose-escalation arm, is to start patients on three pills for first week, four pills for the second week and then you're up to the full dose at the third week. So again, that's the data that we have out there. That's the protocol that many customers are beginning to adopt. So you do have some variability, but that is really the flow. And ultimately, the idea is to get patients up to the full dose.
In the ExteNET study, the average dose was somewhere around 211-or-so milligrams. And ultimately, that's where we expect patients to get in the relatively near future. Given that when they dose-escalated, it happens relatively quickly, we do not expect to see a negative impact on efficacy. Now you asked a broader question about...
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Yeah. So just a follow-up. In terms of the dosage, the three pills a day would be 120, the four pills would be 160 and the six pills would be 240 milligrams a day. In terms of your question do we expect it to impact efficacy, I can answer that in two ways. First of all, as Jeff just outlined, look, it's a 12-month course of therapy. And if they do the dose escalation the way it's in the CONTROL trial, you're talking about two weeks where they're getting a lower dose. I wouldn't imagine that two weeks of a lower dose compared to 50 weeks at full dose is going to have a negative impact on the efficacy. I will also note that we had looked at this in -- when we were first preparing for the ODAC back in 2017, I guess that was. And we had looked at it, I don't remember the number off the top of my head, but it was somewhere in the range of 30-plus percent of the patients in ExteNET had actually gone to a lower dose and stayed on that lower dose going forward.
And if I remember correctly, the efficacy was not very much compromised to the patients that were on those lower doses. And again, a lot of those were -- they started at 240 milligrams, then went down to 200, 160, 120 or whatever milligrams, based on tolerability, and I don't remember that there was much, if any, compromise in the efficacy in that patient subgroup.
Scott -- BofA Global Research -- Analyst
Got it. Very helpful. Thanks, guys.
Operator
Thank you. Our next question comes from Paul Choi with Goldman Sachs. Please proceed with your question.
Paul Choi -- Goldman Sachs -- Analyst
Thank you and good afternoon everyone. My first question is for Jeff, and just if you can maybe just comment on how you're seeing the sales force, particularly with regard to virtual interaction capabilities. Is the sales force rightsized? And just what sort of feedback, given the commercial dynamics in the market right now, you're seeing with regard to other competing metastatic agents out there? And then my second question is just as you go into your pre-NDA meeting for HER2-mutated breast cancer in the front half of next year, can you maybe just remind us any additional studies or analysis that you'll have to conduct ahead of your pre-NDA meeting? Thank you very much.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Okay. Jeff, do you want to take the first one on the sales force?
Jeff J. Ludwig -- Chief Commercial Officer
Yeah, happy to. Thanks for the question, Paul. Yeah, obviously, a unique environment right now with the COVID pandemic that -- well, I guess, fortunately, none of us have been through before. Clearly, as you've seen, as we've highlighted, and I know many others have highlighted, the amount of direct access to customers have changed significantly. And ultimately, we're trying to pivot and adjust the field force to adapt to that new environment, which I wish I had a crystal ball, but is likely to go on at least for several additional months here.
So what we've really tried to do, Paul, in this situation, is to pivot quickly to remote or virtual interactions with customers. There are still some live interactions going on. And we think about this as a very local or regional decision. And where localities or regions open up, we will pivot back to as much as we can live interactions. Given that that has not happened a lot, we've significantly increased non-face-to-face interactions, increased peer-to-peer programs, and ultimately, tried to maintain a strong share of voice through phone, video, Zoom, etc. And so we're all adapting to that, and we feel good about our ability to compete in that environment. But we will continue to evolve as best we can.
We are also being very diligent and smart with our headcount, and we're making sure that our teams are rightsized. And as a role or position opens up, we evaluate that very closely and decide whether or not we're going to fill currently or whether we want to fill in the future. So we're being very smart with the utilization of resources given this time as well.
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
And then, Paul, on the second question regarding the HER2 mutant population. So in -- if I remember correctly, it was like September, October of last year, we had a meeting with the FDA to discuss what will be necessary for us to be able to file an NDA in the HER2-mutated breast indication. And we had shown them the data at that time on the neratinib plus Herceptin plus fulvestrant arm of the trial. And what they asked us to do was to help to better understand what neratinib's contribution was to that triplet. And therefore, to do the study -- the modification we've done, which is the Simon 2-stage, where one arm is the triplet, neratinib, Herceptin and fulvestrant, the other arm is Herceptin and fulvestrant, and the other one is fulvestrant alone.
And the way the Simon 2-stage works is you [Technical Issues] in each one, and if you don't see a responder in the first seven patients, you shut down the arm. If you do see a responder, you expand it to 18 patients. So I think we need to wait for that data to know what further analyses we need to do. I would imagine that if we continue to see the same response rate in the triplet arm and we don't see any responses in the other two arms, then that's a pretty easy one to answer. If you end up seeing, for some reason, responses in the others, then that's going to be a different situation. But I think we have to wait for that data before we can know exactly what we're going to need to file the NDA.
Paul Choi -- Goldman Sachs -- Analyst
Great. Thank you for clarifying that.
Operator
Thank you. This concludes our question-and-answer session. I would like to turn the conference back over to Mariann for closing comments.
Mariann Ohanesian -- Investor Relations
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: 41 minutes
Call participants:
Mariann Ohanesian -- Investor Relations
Alan H. Auerbach -- Chief Executive Officer, President and Chairman of the Board
Jeff J. Ludwig -- Chief Commercial Officer
Maximo F. Nougues -- Chief Financial Officer
Samantha -- Citi Research -- Analyst
Kane -- RBC Capital Markets -- Analyst
Matthew -- JP Morgan -- Analyst
Scott -- BofA Global Research -- Analyst
Paul Choi -- Goldman Sachs -- Analyst
