GRAIL, Inc.

Good day, ladies and gentlemen, and welcome to the Grail fourth quarter 2024 earnings call. At this time, all participants are in listen-only mode. After the speaker's presentation, there'll be a question and answer session. Please be advised that this conference call is being recorded. Grail Investor Relations, please begin.

Thank you, and thank you all for joining us today. On the call are Bob Ragusa, our Chief Executive Officer, Ayrton Frieden, our Chief Financial Officer, Dr. Joshua Offman, our President, and Sirharpur Kumar, our President, International Business and Biopharma. Before we get underway, I'd like to remind everyone that we'll be making forward-looking statements on this call based on current expectations. It's our intent that all statements, other than the statements of historical fact made during today's call, including statements regarding our anticipated financial results and commercial activity, will be covered by the safe harbor provisions for forward-looking statements contained in Section 27A of the Securities Act of 1933 as amended and Section 21 of the Securities Exchange Act of 1934 as amended. Forward-looking statements are subject to risks and uncertainties. Actual events or results may differ materially from those projected or discussed. All forward-looking statements are based upon currently available information and GRAIL assumes no obligation to update these statements. To better understand the risks and uncertainties that could cause actual results to differ, we refer you to the documents that GRAIL files with the SEC, including the Risk Factor section in GRAIL's most recent quarterly report on Form 10-Q and the company's upcoming annual report on Form 10-K. This call will also include a discussion of gap results and certain non-gap financial measures, including adjusted gross profit and adjusted EBITDA, which are adjusted to exclude certain specified items, including accounting impacts related to Illumina's acquisition of Grail. Our non-gap financial measures are intended to supplement your understanding of Grail's financials. Reconciliations of the non-gap measures to most directly comparable gap financial measures are available in the press release issued today, which is posted to our website. And with that, I'll turn the call to Bob.

Good afternoon, everyone, and thank you for joining us to review results for the fourth quarter and full year 2024. 2024 was a transformative year for Grail as we separated from Illumina and began publicly trading in June. In July, we completed final study visits for our two registrational studies, the NHS Gallery Study and Pathfinder 2. In the third and fourth quarters, we implemented a significant restructure intended to extend our capital runway past some major anticipated milestones, including the completion of our modular PMA submission for FDA approval of Gallery. In addition, we grew U.S. Gallery revenue 45% year-over-year, selling more than 137,000 Gallery tests. We are pleased with Gallery's commercial momentum and are excited to progress initiatives to make it easier for physicians to order the test, including our recent integration into Quest Diagnostics' test ordering system. This integration enables easy ordering for more than 500,000 physicians and allows patients to access the Gallery test at 7,400 Quest locations nationwide without needing to bring along a test kit. To discuss some additional recent highlights, I'll hand it over to Grail's president, Dr. Josh Hoffman.

Thanks, Bob. As you may know, Gallery was designed to be utilized at population scale, and we've continued to enhance our technology and our laboratory infrastructure to enable all this future growth. Over the past several years, we've been working on an updated version of Gallery, which will enable efficient growth and support testing at scale. At the end of 2024, we rolled this enhanced version out, which includes a reduced panel size, allowing us to lower sequencing costs and to run approximately four times the number of samples on every flow cell. Additionally, the testing workflow is now both fully automated and integrated, meaning we've been able to eliminate numerous manual steps in the lab, allowing for much greater efficiency. The implementation of these updates has substantially expanded our lab capacity, and we do not anticipate any additional CapEx investment will be needed to support our expected volume for the foreseeable future of the next several years. We began offering this version of the test in December and expect to see COGS improvements as we continue to scale. We're also really pleased that the U.S. military's TRICARE health insurance program has added the Gallery test to the approved list of lab-developed tests as a covered benefit for patients who are 50 years or older with an elevated risk of cancer. This addition came after the Defense Health Agency reviewed Gallery to determine if it met TRICARE requirements for both safety and effectiveness. We're currently working with TRICARE's carriers to implement this new offering. We're really pleased with the progress we've made since GROW was founded in 2016. The gallery test is identifying deadly cancers in asymptomatic adults in clinical care today. We continue to demonstrate our scientific leadership in this emerging field to completely transform how we screen for cancer and to dramatically improve the cancer detection rate in the population. We continue to make progress on our modular FDA submission And we're looking forward to continuing to help individuals and their families detect cancer early when it can be cured. To discuss our fourth quarter financial results, I'll hand it over to Grail's Chief Financial Officer, Aaron Frieden.

Thanks, Josh. And good afternoon, everyone. And please present results for our fourth quarter and the full year of 2024. Fourth quarter results were strong with revenue of $38.3 million up $7.9 million, or 26%, as compared to Q4 2023. Total revenue for the quarter is comprised of $31.6 million of screening revenue and $6.7 million of development services revenue. Development services revenue includes services we provide to biopharmaceutical and clinical customers, including support of clinical studies, pilot testing, research, and therapy development. Full year revenue was $125.6 million, up 35% from full year revenue in 2023. 2024 full year revenue was comprised of $108.6 million screening revenue, up 45% over full year 2023, and in line with our narrowed guidance in the fall of 40 to 50% growth. Revenue also included $17 million of development service revenue, a decrease of 6% from 2023. We see continued demand for our gallery test and sold more than 40,000 tests in the fourth quarter and a total of approximately 137,000 tests throughout the year. Screening revenue of $31.6 million in the fourth quarter was up 39% as compared with the fourth quarter of 2023, primarily based on increased sales volumes. Development service revenue in Q4 24 was $6.7 million, a decrease of 13% as compared with the fourth quarter of 2023. Net loss for the quarter was $97.1 million, an improvement of 48% as compared to Q4 2023. Net loss for the full year was $2 billion, an increase of $561 million, or 38% as compared to full year 2023. Net loss was primarily different by goodwill and intangible asset impairments. Non-GAAP adjusted gross profit for the fourth quarter of 2024 was $17.9 million, an increase of $2.6 million or 17% as compared with Q4 2023. Primary drivers of the increased margin were revenue mix and efficiencies of scale related to increased gallery volume. Full-year non-GAAP adjusted gross profit was $57.8 million, an increase of $17.6 million or 44% as compared with full-year 2023. Adjusted EBITDA for the fourth quarter of 2024 was negative $84 million, representing an improvement of $39.4 million, or 32% as compared to Q4 2023. Adjusted EBITDA for the full year 2024 was negative $483.5 million, an improvement of $40.3 million, or 8% as compared to full year 2023. We ended the year with a cash position of $766.8 million. We are focused on driving growth efficiently and reducing our spending profile. In 2024, we made significant strides here, and we plan to continue to reduce burn in 2025. In January, we guided that we expect cash burn for the full year of 2025 to be no more than $320 million, a projected decrease of more than 40% over our cash burn in 2024. As we've shared before, our cash runway extends into 2028, enabling us to achieve major milestones such as readouts of our registrational studies and completion of our modular PMA submission. I'll turn it back to Bob for concluding remarks.

Thank you, Aaron. Since the separation from Illumina in June of last year, we have made great progress as a public company. We have seen strong growth per gallery, improved our cost efficiency, and recently completed a major initiative to launch the new version of the test, preparing us for scalability. We believe we are in a strong financial position and are pleased with the momentum we are seeing as we continue to drive multi-cancer early detection from an idea towards becoming a new standard of care. We are in the final stages of data collection for our registrational studies and are looking forward to readouts from the Pathfinder 2 and NHS Gallery studies, as well as completion of our modular PMA submission with the FDA in the first half of 2026. We are grateful to our employees for their incredible commitment and dedication to our mission to detect cancer early when it can be cured. We'll now turn the call over to Q&A. Operator, please go ahead.

Thank you. At this time, if you would like to ask a question, please click on the raise hand button, which can be found on the black bar at the bottom of your screen. You may remove yourself from the queue at any time by lowering your hand. When it is your turn, you will hear your name called and receive a prompt to unmute. As a reminder, we are allowing analysts one question and one related follow up today. We will wait one moment to allow the queue to form.

The first question is from Doug Schenkel at Wolf Week Research. Please unmute yourself and begin with your question.

Okay, good afternoon, and thank you for taking my questions. And I'll just – I think I have two, and I'll just throw them out there and get out of the way. First, I think it's a Josh question. Regarding, you know, essentially the new gallery, if you will, would you be able to share – a little more detail on how the lower COGS per test allows you to be more flexible from a pricing standpoint. And maybe more importantly, I'm just wondering if, in the early going, you're seeing anything to suggest that lower pricing will actually result in actual true elasticity for the test in terms of demand. So really a question about how low COGS can go, how much it allows you to change pricing, and whether you're seeing any evidence of elasticity in the market. And then the second topic is more of a current events question on MCED. And our understanding is that essentially the bill was reintroduced in the House a couple of weeks ago. I'm wondering if you could share anything in terms of what you're hearing and what might come next there. Thank you very much.

Great. Thank you, Doug.

Josh, let me take it first and I'll go over to you. Go ahead, Bob. Yeah, so I appreciate the questions. So on the new version of the test, as Josh mentioned in his prepared remarks, we're able to put significantly more know more samples on so 4x the number of samples due to a more focused panel you know so clearly we have a near-term uh reduction in you know variable reduction in cogs in terms of the longer term and any price elasticity you know we really look at this platform to be able to build out the scalability and the long-term cost structure that we'll need um in order to meet what you know we think kind of population scale um pricing and margins will will get to And so we won't see the fixed cost leverage on the automation that Josh referred to for a period of time until volumes really build. So we haven't done the elasticity testing with it. And so it's really a future proofing to get us to the scalability and cost structure that we know we'll need over the long term. Josh, any pieces to add on that?

No, just that it's early days, and as volumes increase, we'll be able to take advantage of that scalability, but not today.

The legislation, you know, so we remain encouraged, you know, by the reintroduction, by the momentum, you know, the stakeholder groups that have been advocating for this, you know, remain very strong and vocal. We continue to have bipartisan, bicameral support for the bill. So, you know, a lot of good momentum, really looking for, you know, the right vehicle and to be able to move it forward. But again, you know, I would say no real change in the level of support for it. And Josh, maybe I don't know if you have any other color to add.

No, I think that's right. It's got great support, bicameral, bipartisan. It's been reintroduced. And we're hopeful that in one of the moving vehicles, either the first spending bill or in reconciliation, that it'll get seriously considered.

Thank you again, guys.

The next question is from from Morgan Stanley. Please unmute yourself and begin with your question. Please unmute yourself and begin with your question.

Sorry. Hi, this is Jason for Tejas. Congratulations on the quarter and thank you for taking our questions. So maybe just starting off on the recent collaboration with Quest Diagnostics, can you share what's embedded in your 2025 guide regarding this collaboration and confirm if it was incorporated in your pre-announcement from mid-January? And similarly, on a similar note, the TRICARE news, was this incorporated in your mid-January 2025 guide or do they represent sources of upside? Thank you.

Aaron, you want to take that? Yeah, definitely. Yeah, so we're excited about both these opportunities, as Josh really elaborated on, for both Quest and Tricare. Quest is going to make the test directly available to be ordered through their system. Patients won't need to get a kit to go with their blood drawn and so on. And Tricare, as Josh said, very, very excited and working with the payers to implement coverage. As far as guidance goes, we contemplated several things and opportunities for the U.S. Gallery next year. And right now, there's no change to our 25 guidance guidelines.

Got it, thank you. And then I guess just following up on Doug's question on the MSAT legislation. So I believe there was a December bill that mentioned reimbursement beginning in 2029, and then a more recent bill from February in the Senate, which had reimbursement beginning in 2028. Could you share thoughts on how these timelines align for expectations? And then on a related note, I believe the bill in February also mentioned reimbursement in line with multi-target stool screening tests. So does that potential reimbursement rate for MSTAT tests also align with your expectations? Thank you.

Yeah, so on the first piece in terms of the timeline, you know, the piece in December was what was, you know, kind of negotiated back and forth. And then You know, what's currently in there is just kind of resetting back to the beginning position. So as it gets reintroduced, it's, you know, kind of back into the beginning starting position for the bill. The pricing, you know, the pricing is referenced in that as well, you know, similar to, you know, similar to the current market for stool-based testing. So that seems to be accurate.

Great. Just to tie it back. Sorry, just to tie it back to the conversation on COGS and margins. we're saying we've implemented this new version in contemplation of population scale. So we've contemplated that pricing and that endeavor.

Thank you. I appreciate the call.

The next question is from Subbu Nambi from Guggenheim Partners. Please unmute yourself and begin with your question.

Hey guys, it's Thomas on for Subaru. Thanks for taking our questions. Just to start, maybe one on Pathfinder too. I'm curious to know what success looks like for you guys for that study. Any color on what sort of readout you're looking for? Maybe any endpoints as well? And then obviously acknowledging its early days. When would you call it, say, if it wasn't playing out to expectations?

Josh, you want to jump in on that one?

Sure. So as you remember, Pathfinder 2 is a U.S. study, single-arm interventional trial, where we're really evaluating the safety and the performance of gallery in an adult U.S. population over the age of 50 with elevated risk for cancer. So really the main endpoints of that study are going to be traditional measures of test performance, the diagnostic evaluation, the workups, the specificity, sensitivity, predictive values. And then on the safety issue, obviously the traditional safety measures of complications associated with workups and whether individuals continue to get their standard of care screening. And that's all very similar to what was in Pathfinder 1 as well. And so, you know, we will read that study out and it will be part of our final modular submission to the FDA in the first half of 26. And so I guess that probably answers your question.

Great. That's helpful. And then just one follow-up on a separate note on cash. As you closed out 2024, can you speak to what cash preservation initiatives may have done to efforts to get more payer coverage. I know there was the recent announcement that you said on the call, but any new color on longer-term impacts there? Thanks.

Yeah, no change from what we communicated to J.P. Morgan and Pryor. You know, the restructuring we completed last year, performed last year, you know, gives us cash runway to 28 with cash burn decreasing, you know, over the coming years as we get there. Awesome. Thanks, guys.

And the final question is from Carl Mixon from Canaccord. Please unmute yourself and begin with your question.

Hi, everyone. This is Alex for Carl Mixon. So obviously a major topic of discussion has been the company's spending and burn profile. You know, obviously there continues to be a lot of uncertainty related to AMSA legislation, which was noted earlier in the call. So if your internal FDA submission and approval timelines are ultimately either meaningfully elongated or shortened, how could this impact your cash burn? Thanks.

Yeah, so currently our plans for FDA PMA submission are the first half of 26. You know, we see cash runway into 2028. So we believe we've built in some cushions and flexibility there to cover any sort of delay if that were to happen. You know, today, sitting here confidently, though, with our first half of 26 timeline. Bob, Josh, anything else you guys want to add?

Yeah, no, I just think the, you know, as Aaron mentioned, we have built in some buffer, you know, we wanted part of choosing to do the restructure and drive our cash runway into 2028 was to give us some level of flexibility. So we believe that's built in.

Got it. Thank you. And one quick follow-up. So in January 2025, President Trump announced Oracle OpenAI and SoftBank joined forces to launch Stargate. Essentially a lot of funding going towards AI. And Larry Elson actually noted early cancer detection and AI could kind of team up, join forces over time. I was curious if any of this... Any of this news impacted results in one queue at all thus far? Thank you.

Yeah, so we think that's more about, you know, longer term opportunity. It was great to see, you know, it was great to see, you know, cancer in the forefront as the killer, kind of the killer application for, you know, AI that was called out in that press conference. But in terms of Q1 impact, I don't think we'll see anything there.

Got it. Thank you.

Thank you. There are no further questions at this time. I will now turn the call back to Grail for closing remarks.

So thank you, everyone, for joining the call today.

Ladies and gentlemen, this concludes the call. You may now disconnect.