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Operator
Good morning. My name is Vaishnavi, and I'll be your conference operator for today. At this time, I would like to welcome everyone to the Carrier Farm Therapeutics Fourth Quarter and Full Year 2020 Financial Results Conference Call. There will be a question and answer session to follow. Please be advised that this call is being recorded at the company's request. I would now like to turn the call over to Mr. Ian Karp, Carrier Farm Senior Vice President, Investor and Public Relations. Please go ahead.
Vaishnavi
Thanks so much, and thank you all for joining us on today's conference call to discuss Carrier Farm's fourth quarter and full year 2020 financial results and business update. This is Ian Karp, and I'm joined today by Dr. Michael Kaufman, our Chief Executive Officer, Mr. Mike Mason, Chief Financial Officer, Mr. John Demery, Chief Commercial Officer, Dr. Jayden Shah, Chief Medical Officer, and Mr. Stephen Michener, Chief Business Officer. On the call today, Mike will provide an overview of key recent corporate developments and an update on our commercial progress. and then Mike Mason will provide an overview of the fourth quarter and full year 2020 financial results. We will conclude with a Q&A portion of the call. Earlier this morning, we issued a press release detailing Carrier Farms' results for the fourth quarter and full year of 2020. This release, along with a slide presentation that we will reference, are available on our website at carrierfarm.com. Before we begin our formal comments, I'll remind you that various remarks we will make today constitute forward-looking statements for purposes of the safe harbor provisions under the Private Securities Litigation Reform Act of 1995, as outlined on slide three. These include statements about our future expectations, clinical developments, and regulatory matters and timelines, the potential success of our products and product candidates, including our expectations related to the commercialization of Expovio, financial projections, and our plans and prospects. Actual results may materially differ from those indicated by these forward-looking statements as a result of various important factors, including those discussed in the risk factor section of our most recent quarterly report on Form 10-Q, which is on file with the SEC, and in other filings that we may make with the SEC in the future. Any forward-looking statements represent our views as of today only, but we may elect to update these forward-looking statements at some point. We specifically disclaim any obligation to do so, even if our views change. Therefore, you should not rely on these forward-looking statements as representing our views as of any date subsequent to today. With that, I'll now turn the call over to Michael Kaufman, Chief Executive Officer.
Ian Karp
Thank you, Ian, and good morning, everyone. 2020 was a pivotal year for Cary Farm, and I'm extremely proud of the significant progress our team has made towards our commercial, clinical development, and operational objectives with the ultimate goal of having positive impact on the lives of patients battling cancer. Most notably, our year was marked by two U.S. FDA approvals for Expovio, first in June for the treatment of patients with relapsed or refractory diffused large B-cell lymphoma, or DLBCL, And then in late December, once weekly, Expovio received additional approval in combination with bortezomib and dexamethasone for the treatment of adult patients with multiple myeloma who have received at least one prior therapy. We expect to carry the momentum of these important achievements into 2021 and have already started the year with several recent accomplishments, as outlined on slide four. Expovio net product revenue for the fourth quarter and full year of 2020 were $20.2 million and $76.2 million, respectively. More than 170 and 700 new physicians and accounts prescribed Expovio for the first time in Q4 and in 2020 overall, respectively. These achievements are particularly encouraging, keeping in mind that Expovio was only first approved for use by the FDA in July of 2019. And of course, for most of 2020, we've all been impacted in some shape or form by the ongoing COVID-19 pandemic. The expansion and launch of Expovio into the second and third line treatment settings significantly increases the addressable patient population for Expovio and represents a meaningful growth opportunity for carry of harm in both the near and long term. Separately, in December, the addition of three Expovio treatment regimens for multiple myeloma to the National Comprehensive Cancer Network's clinical practice guidelines in oncology represented another key achievement that we believe will help further expand Expovio's utilization. For our pipeline progress, we recently announced that the European Medicines Agency's Committee for Medicinal Products for Human Use, or CHMP, adopted a positive opinion recommending the conditional approval for Nexpovio, the brand name for Selenexer in Europe, in combination with dexamethasone for the treatment of myeloma in adult patients with heavily pretreated disease, an indication nearly identical to the approved indication that Expovio received in the 2019 accelerated approval issued by the FDA in the United States. I will talk a bit more about our expecting steps for Europe in just a few minutes. Additionally, we were excited to secure our first regulatory approval outside the United States in Israel for both myeloma and DLBCL, which we announced last week. Turning now to other program updates from our ongoing hematological and solid tumor clinical studies. Our Phase III Siendo study evaluating expovial endometrial cancer passed its planned interim futility and upsizing analysis, and we look forward to the top-line results expected in the second half of this year. In addition, the first patient in the Phase 2-3 Export DLBCL-030 study evaluating Expovio in patients with DLBCL has now been treated, and this study will serve as a confirmatory study for Expovio's accelerated approval in DLBCL granted last year. Finally, on the financial front, we ended the quarter with a strong cash position of approximately $276.7 million that, along with expected future revenues, we anticipate will be sufficient to fund our planned operations into late 2022. Let me now turn to slide five to provide additional details on Expovio sales performance through 2020. In the first three quarters of 2020, we generated steady increased sales for Expovio due to both the unique attributes of Expovio as well as the hard work of our dedicated commercial team. Net sales for both the full year of 2020, as well as for the fourth quarter specifically, were largely driven by prescription demand from both academic and community-based oncologists for patients with penta-refractory multiple myeloma. The 5% decrease in product sales in the fourth quarter as compared to the third quarter was a result of the impact from both the recent surge in US COVID-19 cases as well as some increased competition for patients. More specifically, as we turn to slide six, we believe the surge in COVID-19 cases impacted both patient visits to their healthcare providers as well as in-person access for KarioPharm's commercial team to its physician customers. Additionally, increased competition from recently launched drugs in pentarefractory myeloma and in refractory DLBCL settings also contributed to some additional sales pressure in the quarter. However, we are seeing a meaningful rebound in demand and new patients start since the expanded approval, further reinforcing our confidence in the future growth potential for Expovio. As mentioned previously, The addition of multiple Expovio combination regimens to the NCCN guidelines and the expanded FDA approval of Expovio provided strong tailwinds for sales growth in December, following declines in October and November. We're still in the very early stages of the launch of Expovio into the second and third line settings, but we expect to see significant increase in annual sales largely driven by both earlier use and longer duration of treatment in patients with myeloma. Moving now to slide seven, the graph here shows the prescription refill rate for Expovio over 2020 for both the first and second refills for those patients eligible for these refills. These numbers have remained encouraging throughout 2020 and are significantly higher as compared to our initial launch period in 2019. These refill rates, coupled with an average of nearly three treatment cycles per patient as of the end of 2020, further reinforce the positive feedback we have received from physicians and patients regarding their experience and uses of Expovio. Importantly, the patient discontinuation rate due to side effects remain relatively low at 13%, which we believe is a testament to more and more physicians gaining comfort in helping their patients prevent and manage the side effects of Expovio with proper prophylactic and supportive therapies, as well as dose modification. In addition to the expanded label for Expovio in the U.S., we believe the future International expansion of Expovio in Europe will be another key strategic area of growth for CarioPharm, which I'll now highlight on slide eight. The CHMP positive opinion for Nexpovio, which was issued at the end of January, could lead to our first regulatory approval in Europe and recognizes the positive clinical benefit risk profile of oral Nexpovio. We look forward to the European Commission's final decision on an Expovio submission, which is expected in April 2021. We intend to submit a second regulatory filing based on the data from the Phase 3 Boston study with the goal of further expanding the global reach of Nexpovia to additional patients in need of new treatment options. And encouragingly, even before a possible European regulatory approval, the European Hematology Association and European Society for Medical Oncology recently updated their treatment guidelines for myeloma in November of 2020 and added Selenexer, Velcade, dexamethasone regimen to their second-line recommendations and Selinexa with dexamethasone to the third-line plus treatment guidelines. In parallel to the regulatory experts, we're also continuing to evaluate potential collaborations with partners in Europe and Japan. We're committed to making Expovio available in Europe if approved in April with the greatest opportunity to come potentially before the end of 2021 when we would hope to receive an expanded approval in Europe based on the data from our phase three Boston study. I'd be remiss if I did not mention updates on a number of additional exciting pipeline opportunities that we are pursuing for Expovio, which can be seen on slides nine and 10. We have a robust clinical development plan for Expovio in both hematological malignancies and solid tumors. This includes our phase three Ciendo study in patients with endometrial cancer, where we expect to have a top line data readout before the end of this year. I'll note that there are two additional new important clinical trials we plan to initiate in 2021, which we believe will help further define the broad clinical utility of Expovio as a potential partner of choice with other active anti-cancer agents. First, we expect to initiate a new randomized Phase III study evaluating Expovio in combination with pomalyst and dexamethasone in patients with previously treated myeloma. If the results of this trial are positive, this regimen would represent a potent oral drug option to patients with refractory disease. Next, we plan to initiate a new phase two study evaluating Expobio in combination with Keytruda in patients with newly diagnosed or recurrent metastatic melanoma. We're particularly excited about this study based on some encouraging data from the MD Anderson investigator sponsored trial evaluating this combination regimen, which was presented at the annual ESMO conference in 2020. With that, I'll now turn the call over to Mike Mason to review the quarterly financials. Mike.
Ian
Thank you, Michael. Since we issued a press release earlier today with the full financial results, I will just focus on the highlights, which begin on slide 12. Net product revenue for the fourth quarter of 2020 was $20.2 million compared to $17.7 million for the fourth quarter of 2019. Net product revenue for the year ended December 30, 2020 was $76.2 million compared to $30.5 million for the year ended 2019. The estimated gross net discount for Expobio in 2020 fell within our estimated range of 15 to 20%. License and other revenue for the fourth quarter of 2020 was 14.9 million compared to 0.4 million for the fourth quarter of 2019. This increase was driven by a $9.8 million payment from Antigene for milestone payments associated with regulatory filings in Asia, as well as a $5 million upfront payment from Forest Therapeutics upon the execution of a commercial distribution agreement for Canada. License and other revenue in 2020 were 31.9 million compared to 10.4 million in 2019. R&D expenses for the fourth quarter of 2020 were 37.2 million compared to 31.6 million for the fourth quarter of 2019. R&D expenses for the year ended 2020 were 150.8 million compared to 122.3 million for the year ended 2019. The increase in R&D expenses in 2020 compared to 2019 was primarily attributed with costs associated and incurred related to our COVID-19 trial activity, which will not reoccur in 2021, and continued activity in our other ongoing clinical trials and regulatory activities. Selling general and administrative expense for the fourth quarter of 2020 was $33.9 million, compared to $28.4 million for the fourth quarter of 2019. The increase in SG&A expenses compared to the prior year was $2.5 commercialization of Xtovio. On slide 13, you can see that cash, cash equivalents, restricted cash investments as of December 30, 2020, totaled $276.7 million compared to $265.8 million as of December 31, 2019. Finally, based on our current operating plans, Cary Farm expects non-GAAP R&D and SG&A expenses for the full year of 2021 to be in the range of $280 to $300 million. The company expects that its existing cash, cash equivalents, and investments and the revenue it expects to generate from Expovio product sales and other licensed revenues will be sufficient to fund its planned operations into late 2022. We are not providing revenue guidance for 2021 today as we have just begun the initial launch of Expovio and its expanded indication, but we do expect to see meaningful growth 2021 relative to 2020, with the ramp of sales increasing in the second half of the year, as we expect to see the benefit of a longer duration of treatment for multiple myeloma patients being prescribed Expovio earlier in their treatment course and or in combination with Velcade. I'll now turn the call back over to Michael for some concluding remarks. Michael?
Ian Karp
Thank you, Mike. Before moving to the Q&A, let me highlight some of the key commercial, clinical, and regulatory milestones that that we expect for 2021 on slide 14. First, we are actively in the process of launching Expobio into the second and third line settings in myeloma in the US, and we expect a significant increase in annual sale in 2021 as compared with 2020. Next, we anticipate a decision on the conditional approval of an Expobio in Europe based on the storm data in April and plan to submit the Boston data via type two variation shortly thereafter, which could result in expanded approval in Europe later this year. Finally, in the second half of this year, we expect top-line data from the Phase III Ciendo study in endometrial cancer, as well as multiple clinical trial initiations and the presentation of additional combination data with Expovio and other cancer therapies at various medical meetings. Before we open the call to questions, I do recognize our full KaryoPharm team for a truly remarkable 2020. We've already started the new year off strongly, and I am confident that we are well positioned to execute on the commercial, clinical development, and operational goals and growth opportunities outlined today. We appreciate your ongoing support and look forward to keeping you updated on our future progress. I'll now turn the call over to the operator for questions. Operator?
Operator
We will now begin the question and answer session. To ask a question, you may press star, then one on your touchtone phone. If you're using a speakerphone, please pick up your handset before pressing the keys. To withdraw your question, please press star, then two. Please limit yourself to one question and one follow-up. If you have further questions, you may re-enter the question queue. At this time, we will pause momentarily to assemble our roster. The first question comes from Maury Raycroft with Jefferies. Please go ahead.
Maury Raycroft
Hi, good morning, everyone, and congrats on the progress. Thanks for taking my question. So for sales, we likely won't see a major rise in the number of refills in at least the next quarter. And so if the numbers are presented in aggregate, so would you consider breaking out that number or other sales numbers by line of treatment in 2021? I guess you plan on providing more granularity going forward. Let me turn it to Ian to start.
Vaishnavi
Yeah, thanks, Maureen. I think for now, the reality is, in terms of the clarity of data we get, we don't see from our distributors, and especially pharmacies, we don't get a level of data that tells us what line of therapy the Excobio prescription was given in. So right now, we don't have that clarity. We do get some of that information from market research, which we'll do later in the year. But that won't be available until later in the year. So I think we'll see kind of, you know, let's let the launch play out. And as we get more information, I think we'll be more specific in terms of where the growth is coming from.
Maury Raycroft
Got it. Okay. And then one follow-up just on potential BD opportunities in Europe. Just wondering if you could say anything additional on that and if that could take place prior to the Boston acceptance and approval there.
Ian Karp
Let me turn that over to Stephen Michener, our Chief Business Officer. Stephen? Yes. Hi. Good morning, Maury. It's a great question, and certainly since we've gotten a positive opinion in Europe, there's been a lot of great momentum. So we're currently under a number of discussions for both Europe and Japan, and we're looking to make some decisions that hopefully in the next few months where we can bring that effectively to our European patients. I think the other thing I would add, too, is that On a positive note, we've had a lot of interest beyond just the multiple enoma indications and something that we're looking to expose and help out beyond just the first part of our hematology portfolio.
Maury Raycroft
Great. Okay, thank you for taking my questions.
Operator
The next question comes from Brian Abrahams with RBC Capital Markets. Please go ahead.
Brian Abrahams
Hey, good morning. Thanks for taking my questions. Congrats on all the progress. So I'm curious what some of the key metrics that you guys are going to be looking for in order to assess earlier line uptake, I guess beyond new patient starts. Is this primarily duration? Is there anything that you might be able to tell from dose levels just given the spread on that already? And I understand you're not looking for or not expecting a major inflection until closer to the back half of the year, but how quickly might you expect some of these potential leading indicating signals to manifest themselves? Are you starting to see any initial trends here since December, now that we're close to mid-February?
Ian Karp
Yeah, let me start with Ian and then move it over to John, our Chief Commercial Officer. Ian?
Vaishnavi
Yeah, great question. I mean, clearly, one of the most obvious indicators will be new patient starts. And for some of the data that we received, And we did mention on the call that we have seen an uptick in or certainly growth in new patient starts. So that's certainly encouraging. And we'll continue to follow that. We've also seen a reduction in the percent of Expobio prescriptions at the 80 milligram twice a week dose and an increase in the doses that would indicate that Expobio is being used in combination. So doses lower than the 80 milligrams twice a week. So we think that's also another positive indicator that more physicians are likely choosing to use Expobio as a combination regimen. Now, we don't have visibility as to what percent of that is with Velcade, what percent of that is with another anti-myeloma agent. But certainly, we're encouraged that the percentage of prescriptions written for the 80 milligram dose is coming down quite significantly. So those are the kinds of things that we're looking at. And I think you mentioned, as we get into probably the second half of the year, we'll really be looking at duration of treatment. And that is a metric that we can follow with at least half of our business that goes through the specialty pharmacies. We can see what the numbers of prescriptions that each individual patient is getting. But again, that's a number that we wouldn't expect to materially increase until we get to the back half of the year as the duration, we get a benefit from the duration of treatment. I don't know, John, if there's anything you
Expobio
Did you add to that? Yeah, thank you. And in addition to duration of therapy and the SKU mix to look at what combinations we're getting, we also are doing monthly ATU readouts to look at intent to prescribe by line of therapy and by combination. So that'll be a leading indicator of uptake. We also have pulse research going on on a regular basis to measure physician opinions and prescribing intent, as well as the number of ad boards to track and our uptake in the Boston space.
Brian Abrahams
Great. And what are you seeing on some of those, I guess, just initially with the label expansion and NCCN guideline inclusion? John?
Expobio
Yeah. Well, of course, we're still less than two months into launch. We're very encouraged by what we're seeing there. The feedback we're receiving from physicians in the one-on-one meetings, in the market research, in the ad boards has been quite positive. And we're already seeing an increase in prescription demand relative to what we saw, as mentioned, for October and November. We were able to launch immediately at approval across all functions in the company, which was imperative. And we're seeing the impact of that in the context of the rapid promotional efforts. We're already seeing the shift that Ian mentioned in terms of dosage in more patients now starting on XVD than starting on XD. Early signs from the market research and from the ad boards are positive. Again, it's early, but the early leading indicators are headed the right direction.
Brian Abrahams
That's really helpful. Then maybe just a quick follow-up if I could. With respect to the competitive landscape, I'm curious what your market research and on-the-ground physician discussions are telling you are some of the key considerations for docs in their choice of a new myeloma treatment to add on in later stage refractory patients. I'll hop back in the queue. Thanks.
Ian Karp
Yeah, let me start here, and then we'll turn it over to some of the others on the call. I think the main point here is that while there are a number of different therapies people can take in the second and third line settings, the XVD regimen is really unique in many ways. First of all, it is the therapy that appears to have the fewest number of overall doses and the least amount of clinic time that a patient's required to spend. And that's a super important point at any time, especially when you consider that three quarters of the patients are over 70 years old, uh, and really don't, don't have a ease of transportation and so on. And, and most, in fact, no patient wants to spend a lot of time at the hospital and that's even more important during COVID. The second point is that the data we get from this study are, are potentially very relevant to the real world. These are the fact that we used once weekly Velcade in the experimental arm. This is the only study, that's resulted in a Velcade-based approval that's used actually what people, what doctors are treating with. So it's a very unique regimen. And the last point to make is, and I think John's research has really honed this carefully for us, is that we represent the fourth independent mechanism for use in the early levels of disease. Obviously, the proteasome inhibitors, IMiDS, and CD38 monoclonal antibodies are very important in these areas, but when a patient goes through them and sometimes now in front line patients are getting all three of these regimens plus steroids. It begs the question of what to do in the second and third lines and we represent the fourth independent mechanism that's now approved in combination for the use there and not only approved for Velcade but has NCCN guidance beyond that for POM and DARA with data of course with Kyprolis. Jay, do you want to add anything and then John?
John
No, I think you're exactly right, Michael. The key consideration is really novel mechanism of action. They have their PIs and image that they're giving, including C38s in the first line. And so new mechanisms are a key consideration and then convenience at the end of the day because a lot of these patients will live for many years. And so having something that's well-tolerated without residual long-term side effects is key, at least from what they're thinking about. sequencing and what they're looking at in earlier lines of therapy. So those are the two key considerations, and I think it uniquely positions this combination well.
Brian Abrahams
Thanks so much. That's really helpful, Colin. I appreciate it.
Operator
The next question comes from Peter Larson with Barclays. Please go ahead.
Peter Larson
Hi. Thanks for taking my questions. I guess the first one is just around what the current duration of treatment is, if you can get a Give us any kind of sense around that and where that could potentially increase to over time. Sure. Ian?
Vaishnavi
Yeah, I mean, well, what we've said, and certainly we said it on the call, it's about three months right now that we're through 2020. And that's been consistent for probably the last couple of quarters and also consistent with the data that we saw coming out of the original storm study that showed about a three-month average duration of treatment. And remember, you know, there will be patients that are on for a month, and there'll be patients that are on for, you know, over a year, but the average is about three. What we did see in the Boston study was that the average was about 10 months on therapy. So I think that gives you sort of the range from the clinical studies, and our hope is that, you know, obviously we're able to grow the average duration of therapy from a point of three today to something closer to 10. but obviously time will tell how effective we are at moving as many patients as we can to early allows of treatment. So that's where the numbers stand today, and I think that gives you some sense of how high they could possibly go.
Peter Larson
Is there any kind of sense that they are ticking up, or do you think that's more of a kind of back half of the year event?
Vaishnavi
Yeah, it's way too early to know that. Yeah, the 10 months I was talking about was from the Boston study, just to be clear. Yeah. Yeah, again, it's way too soon to know if there's been any changes to the average duration of treatment.
Peter Larson
Okay, thank you. And then is there any way of kind of quantifying the COVID impact on whether it's the number of scripts or the number of new docs and kind of what gives you the confidence that this is kind of a temporary event versus a kind of hidden penetration?
Ian Karp
John, do you want to talk about that?
Expobio
Yeah, we do think the COVID impact is having multiple impacts. We know in-person visits by our sales force, nurse liaisons, payer teams to key stakeholders continues to be impacted in most parts of the country. Research estimates that we've seen are that 15% to 20% of HCPs can be seen in person. We continue to believe that it's challenging to educate physicians in this environment and are putting in place multiple tactics both digitally and with additional training on virtual engagements to try and enhance that. We also know the impact of COVID includes reduced patient visits that we saw from different data sources, particularly with the spike as mentioned in the fourth quarter. So a dual impact we saw from COVID in the context of the fourth quarter.
Peter Larson
But it sounds like this is definitely kind of a temporary issue as opposed to you kind of capping out on multiple myeloma or
Ian Karp
Yeah, absolutely. We're seeing a lot more doctors get interested in this. And remember, this is a fundamentally different asset now in the second and third line setting, with patients now getting a new option, a very convenient option, a very real-life set of data in which to base a clinical decision to administer XVD, and then, as we said, additional support with the other. So we absolutely believe this is the beginning of a fundamentally new asset and RAMP for expofio and myeloma.
Peter Larson
Great. Thanks for taking my questions.
Operator
The next question comes from Jonathan Chang with SVB Learing. Please go ahead.
Jonathan Chang
Good morning and thanks for taking my questions. First question, why wouldn't we see an inflection in sales until the second half of Boston? So I understand the first half numbers might not fully reflect a longer duration of treatment, but shouldn't it reflect the significantly increased number of patients available in the earlier line settings? Yeah, I'll turn that to Ian to start.
Vaishnavi
Yeah, yeah. We certainly, we do expect that. I'm not sure, so I'm sorry if that wasn't clear. We actually do expect growth beginning in this first quarter of this year. So absolutely expect to see growth because at to your point, we should have additional patients, or we do have additional patients that we're now eligible to treat, and that's a much larger patient pool. So we absolutely expect to see growth relative to the fourth quarter of last year. I think the point that we're making is that that growth should accelerate throughout the year, and certainly as we get into the second half of the year, because not only do you have the benefit of more patients, but you have the benefit of the longer duration of treatment. for patients that are getting treated today. So that's the dynamic that we expect to see.
Jonathan Chang
Understood. Just one follow-up to that. Could Boston and the earlier line sales cannibalize the storm opportunity? And are you seeing any evidence of that? Thank you.
Ian Karp
Yeah. I mean, nearly all drugs are used multiple times in a given patient during their journey on therapy. And so the real use of Expovio will not be really the storm administration, but it'll be in earlier lines. We expect it'll be mostly Expovio-Veldex with some Expovio-Palmdex if someone wants to use an NCCN-guided all-oral therapy. And then later on, it could be Expovio-Daridex or Expovio-Kyprolisdex in the later lines. So we do expect that we will see multiple uses of Expovio. We don't have any data on it yet, Anecdotally, we've heard of a couple patients who are getting their second course of Expobio in their treatment journey, but right now it's too small numbers.
Jonathan Chang
Got it. Thank you.
Operator
The next question comes from Eric Joseph with JP Morgan. Please go ahead.
Eric Joseph
Good morning. This is Hannah on for Eric. Thanks for taking our questions. Just a couple from us. So first, what is the status of commercial preparations for Nixpovio and the U? Are you scaling for the pentorefractory population or scaling more in anticipation of accessing the third and second line patient populations with exhaustion submission? And then I have another one after that.
Ian Karp
Yeah, Steven, you want to take that? Sure. So, you know, as we mentioned before, we are very excited that we got positive opinion on the storm indication. We are having a number of discussions right now, both internally and with external partners on the best way to leverage that opportunity with the pending Boston indication that should come hopefully by the end of this year. So it's something that we're just really working through in terms of how to best bring that asset to that market appropriately with all the different pricing implications and sequencing that we can work through. So hopefully that answered your question. Just to add, we absolutely have the drug. We'll make the drug available once it's got European Commission approval, assuming that that goes well. The real market opportunity here is clearly in the Boston-type population. And so the big push that we're going to have is going to be for the Boston approval by the end of the year. But we will have the drug available for patients on time.
Eric Joseph
Okay, great. Thank you. That's helpful. And then also in that vein, do you expect that physician prescribing patterns will differ between the EU and the U.S.? Just preliminary thoughts on that.
John
Jayton, do you want to take that? In terms of prescribing patterns?
Ian Karp
I can just jump in and do it real quick. One of the problems in Europe is that one of the challenges is that there's a lot less reimbursement for off-label use. And so physicians tend to be restricted to what's on-label, at least in certain places. In most of the countries, there are some countries that are more liberal and provided that the line of therapy is appropriate, physicians would be using the drug as they see fit. But I think the main difference will be just on the restricted access or reimbursement. John, do you want to pick up on that?
Expobio
And I would say while prescribing patterns may differ somewhat across the U.S. and Europe, early research that we've done does get a positive reaction for the XED or Boston profile. So we do expect to have good penetration in the European market as well once we launch in that education.
Eric Joseph
Okay, great. Very helpful. Thanks for taking the question.
Operator
The next question comes from Mike Olswood-Baird. Please go ahead.
Mike Olswood - Baird
Hi, guys. Thanks for taking the questions, and congratulations on all the progress as well. Maybe I could just ask to follow up on some of the prior questions related to foveo trends. So you guys sort of mentioned an increase in demand starting in December and also in January. So just curious, the month-over-month trend, were you seeing an acceleration there? I'm going to have a follow-up.
Vaishnavi
Yeah, I think we'll – Yeah, I think we'll leave it at, again, we don't want to get too into the weeds in terms of weekly or monthly prescription trends. So we'll leave that to our quarterly summation when we have these kinds of calls. I think suffice it to say, we are pleased with the early indicators and the growth that we're seeing since approval. And again, I think when we get to our full Q1 numbers, it'll be much clearer. in terms of how we've done overall for the full first quarter.
Mike Olswood - Baird
Got it. That's fair. And then maybe just a follow-up on NCCN guidelines. Obviously, you've got recommendation in combination with Velcade, which is on-label, but you've also got recommendations off-label with Pomalyst and Darzalex. And I know it's early, but just since those guideline updates, have you noticed an uptick sort of in off-label use in those combinations? Thanks. John, do you want to take that?
Expobio
Sure, glad to address that. So our sales team and marketing team will, of course, only promote Expovio on its approved FDA label, which is the DXVD combination. We do know that many physicians and payers rely on the NCCN guidelines to help make treatment decisions. And as you mentioned, NCCN recently added three different Expovio regimens. The Bortezomib regimen, or XVD, in combination with daratumumab, or XDD, and with pomalidomide, or XPD. Importantly, the once-weekly XVD regimen was approved with Category 1 recommendation, which represents the highest level assigned by the NCCN. As we track in secondary market research, as Ian mentioned, and we're doing going forward, we will look at a breakout and see how much use it is in XVD versus XPD versus XKD, etc., It's too early to have those data to date, but those are data we'll gather from market research as we go throughout the year.
Mike Olswood - Baird
Got it. Thank you very much.
Operator
The next question comes from Ed White with HC Wainwright. Please go ahead.
Ed White
Morning, everyone. Maybe if I can ask a question on the pipeline. if you can list your priorities in solid tumors, uh, you had mentioned the endometrial and metastatic melanoma studies, but I just wanted to get an update for, um, lung, um, colorectal cancer and, uh, GBM.
Ian Karp
Yeah, well, those are all, you know, these, these are all sort of equal priorities where we're enrolling patients into our own studies and all the ones that you mentioned, lung colorectal and GBM, um, You have single agent activity in GBM, which we've talked about 10%, and we've seen activity as well in colorectal, and we've seen an investigator-sponsored trial, as I've mentioned, that's been ongoing now with some activity in the lung. So, you know, this drug seems to be a very important add-on therapy or addition to some of the active drugs that are used across multiple different indications, and that's That's because this is a fundamental mechanism of, we attack a fundamental mechanism of cancer, which is inactivation of tumor suppressor proteins, and we reactivate those tumor suppressor proteins. And then, of course, don't forget, we have our Ciendo Phase 3 study reading up by the end of this year, where we're using Expovio versus placebo in the maintenance setting after frontline therapy. So, broadly active drug, and, you know, we're being very careful about how we use our precious resources, but we see it across a number of different therapies, and we'll pick the best winners and move them forward as expeditious as possible.
Ed White
Great, thanks, Michael. And maybe just talking about resources, a question for Mike or Ian. Did you use the ATM in the fourth quarter or thus far in 2021 And are you including any proceeds from the ATM in the cash runway guidance? Thanks. Mike?
Ian
Yeah, so we certainly don't comment on ongoing fundraising. The ATM, we definitely did not use it during the fourth quarter. And we don't include that in our in our guidance. It's more on current, you know, improvement indications plus current collaborations that we already have in place offset by spend, which we guide to would be somewhere between 280 and 300 million in 2021.
Ed White
Okay, thanks, Mike. And also just as far as that guidance goes on the runway, does that include any milestone payment or potential milestone payment from a European partnership?
Ian
We don't include any new collaborations. Obviously, it's something that's a big part of Stephen's focus for 2021 as well as the entire company to make sure we're ready to commercialize in Europe. But no, it does not include any significant payments or new alliances.
Ed White
Okay, great. Thanks for taking my questions.
Operator
This concludes our Q&A session. I would like to turn the conference back over to Michael Kaufman, CEO, for any closing remarks.
Ian Karp
Thank you, everybody, for joining today's call, and we do look forward to updating you on our progress as soon as we can. Talk to you soon. Bye-bye.
Operator
The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.
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