This conference call transcript was computer generated and almost certianly contains errors. This transcript is provided for information purposes only.EarningsCall, LLC makes no representation about the accuracy of the aforementioned transcript, and you are cautioned not to place undue reliance on the information provided by the transcript.
Operator
Good morning. My name is Drew, and I will be your conference operator today. At this time, I would like to welcome everyone to the CarioPharm Therapeutics Third Quarter 2023 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. If you require operator assistance, press star then zero. I would now like to turn the call over to Ilhan Webb, Senior Vice President, Investor Relations.
Ilhan Webb
Thank you, and thank you all for joining us on today's conference call to discuss Kara Farms' third quarter 2023 financial results and recent company progress. We issued a press release this morning detailing our financial results for the third quarter 2023. This release, along with a slide presentation that we will reference during our call today, are available on our website. For today's call, as seen on slide 2, I'm joined by Richard, Rejma, Sohani, and Mike, who will provide an update on our results for the third quarter and recent clinical developments. Before we begin our formal comments, I'll remind you that various remarks we'll make today constitute forward-looking statements, FLS, for purposes of the safe harbor provisions under the Private Securities Litigation Reform Act of 1995, as outlined on slide 3. Actual results may differ materially from those indicated by these epaules as a result of various important factors, including those discussed in the Risk Factors section of our most recent 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 FLS represent our views as of today only. While we may elect to update these FLS at some point in the future, we specifically disclaim any obligation to do so, even if our views change. Therefore, you should not rely on these FLS as representing our views as of any later date. I will now turn this slide over to Richard. Please turn to slide four.
Kara Farms '
Thank you, Elhan. Good morning, everyone, and thank you for joining CarioFarm's Q3 2023 earnings call. Turning to slide five, we are strongly positioned for our next stage of growth, driven by our focused and rapidly advancing mid and late stage pipeline of innovative, first in class, oral, selective inhibitors of nuclear export that target XPO1, as well as a strong commercial organization that continues to positively impact the lives of multiple myeloma patients every day. Our U.S. and global commercial presence is on track to deliver 145 to 160 million of annual total revenues in 2023 and provides us with the capabilities needed to launch in new indications, if approved, following the outcome of our three pivotal Phase III clinical trials. We have the opportunity to significantly improve standard of care for patients across these indications, and we continue to generate compelling data, including impressive durability data observed with Selenexor 60 mg in combination with Ruxolitinib in patients with myelofibrosis, as well as substantial progression-free survival observed in patients with TP53 wild-type endometrial cancer, which Reshma will expand upon shortly. We are committed to deliver on the opportunities ahead of us and believe Selinexor could generate approximately $2 billion of peak annual revenues in the U.S. alone. With a cash runway through late 2025, we have the financial strength to deliver on key data readouts from our three phase three studies. We will continue to be disciplined about our expense management, focusing our resources on our prioritized late stage pipeline. As we move to slide six, presented here is an overview of the timing of the upcoming key data readouts, which we expect in 2024 and 2025. Each of our ongoing Phase III clinical trials, if successful, represents an incredibly meaningful growth opportunity for our organization with the potential to deliver roughly $2 billion in annual peak revenues. Our proven and established commercialization and late-stage development capabilities are focused on executing with our current label and rapidly progressing these pivotal Phase III programs. An approval in just one of these three indications is a transformational opportunity for CarioPharm, and the clinical data that Raishma will review today continues to strengthen our confidence in each of these programs. With the potential for pivotal catalysts over the next two years, and with the cash runway to deliver on each of these top line readouts, we are well positioned for our next stage of growth. Moving to slide seven, I would now like to turn the call over to Reshma to expand further on our clinical pipeline progress. Reshma?
Elhan
Thank you, Richard. Turning to slide eight, we have a very promising late stage pipeline with pivotal data readouts over the next two years. I will focus on our three phase three trials where our confidence only grows given the positively evolving preclinical and clinical data that support each indication. Each of these trials could position salinexor to substantially change the treatment paradigms in each of these populations if approved. Turning our attention first to myelofibrosis on slide 10, treatment of JAK-naive myelofibrosis patients remains an area of high admit need with more than 20,000 myelofibrosis patients in the U.S. alone. Ruxolitinib remains the standard of care for the majority of JAK-naive patients. However, there is an opportunity to improve benefit given that the efficacy with Ruxolitinib is limited with less than 50% of patients achieving an SCR35 and TSS50. We are evaluating the potential for Selinexor in combination with Ruxolitinib to provide benefit across all of the hallmarks of the disease, including spleen reduction, symptom improvement, disease modification, and stabilization, if not improvement of cytopenias. On slide 11, you see that XPO1 inhibition is a fundamental mechanism in myelofibrosis, given that it targets both JAK and non-JAK pathways. Underscoring Selinexor's additive or potentially synergistic activity when dosed in combination. Non-JAK mechanisms include inhibition of NF-kappa-beta, induction of cell cycle arrest, and p53-driven cell death. Together, XPO1 inhibition increases malignant cell death, decreases malignant cell proliferation, and reduces inflammation. We presented updated phase one data at the ASCO and EHA conferences in June 2023, which can be seen on slide 12. These data show meaningful SVR35 and TSS50 improvement with 60 milligrams Selinexor, including a 79% SVR35 and a 58% TSS50 at week 24 in the intent to treat populations. Importantly, amongst the evaluable patients, 100% achieved an SVR 35 at any time. Today at the NPN Congress, data are being presented including SVR response and TSS 50 durability amongst the 11 out of 14 patients who achieved a 35% or greater spleen volume reduction at week 24 and the 7 out of 12 patients who achieved a TSS 50 at the same time point. We are very encouraged by these data given the impressive durability seen on slide 13 for both of these endpoints. As of August 1st, 2023, none of the week 24 SVR35 responders dosed at Selenoxor 60 milligrams had observed radiographic progressions. Note that the longest patient has been followed for 78 weeks and the median duration of follow-up as of the data cutoff is 32 weeks. Similarly, none of the week 24 TSS50 responders had observed symptom progressions, with the longest follow-up of 64 weeks and a median duration of 51 weeks. While I acknowledge the apparent limitations in cross-trial comparisons, contrast these data to ruxolitinib alone, in which only approximately 70% of responses were ongoing at 78 weeks. Data for ruxolitinib TSS50 durability data beyond week 24 have not been provided. These data add to the substantial benefit observed with week 24 SVR and TSS50 and highlight the substantial benefit that may be observed with this novel combination compared to ruxolitinib alone. Together, these data illustrate the rapid, deep, and now durable spleen and symptom improvement achieved with Selinexor in combination with ruxolitinib and further demonstrate the potential for this combination to change treatment paradigms for JAK-naive myelofibrosis patients. This profile in conjunction with the subgroup analysis shown on slide 14, which depict SVR35 and TSS50 responses despite treatment with suboptimal doses of ruxolitinib, which is suggestive of potential monotherapy activity, underscores our confidence in the ongoing phase three study. As seen on slide 15, our phase three study is evaluating the combination of Selinexor 60 milligrams with Ruxolitinib versus Ruxolitinib alone in 306 JAK-naive myelofibrosis patients. This important trial in addition to the phase two Selinexor monotherapy trial that we are planning in treatment naive myelofibrosis patients with moderate thrombocytopenia has the potential to entrench Selinexor as a foundational therapy in approximately 90% of all treatment naive myelofibrosis patients. As we turn to slide 17, endometrial cancer is a key focus in our pipeline given the high end met need and the substantial benefit observed in patients whose tumors are P53 wild type. Advanced and recurrent endometrial cancer is the most common form of gynecologic cancer in the United States with the current treatment landscape being driven by molecular classifications. As a result, in MMR deficient patients who represent approximately 20% of all advanced recurrent endometrial cancer patients, the new FDA-approved standard is distarlimab in combination with chemotherapy, followed by distarlimab maintenance. For MMR proficient patients, which represent the remaining 80% of advanced recurrent endometrial cancer, checkpoint inhibitors are not approved. As such, the primary treatment option is chemotherapy followed by watch and wait. Importantly, wild type P53 is found in a majority of all advanced recurrent endometrial cancer. As seen on slide 18, taken together, patients whose tumors are both MMR proficient and P53 wild type represent 40 to 55% of all advanced or recurrent endometrial cancer patients. In the substantial population, the benefit observed with Selinexor is considerable, as seen on slide 19, given that a 68% decrease in the risk of disease progression or death corresponding to a hazard ratio of 0.32, and the median progression-free survival that has not been reached was observed in this exploratory subgroup of patients from the SIANDER trial as of a March 30, 2023 data cutoff. The progression-free survival results observed in those patients who are P53 wild-type and MMR deficient are also noteworthy with a median PSS for Selinexor of 13.1 months and a hazard ratio of 0.45. Further strengthening our rationale in P53 wild-type endometrial cancer, are the preclinical data that were recently presented at the AACR NCI EORTC International Conference on Molecular Targets and Cancer Therapeutics in October. These data from endometrial cancer models further confirmed the biology by demonstrating significantly better potency in p53 wild-type models as compared to p53 mutant models, further validating the design of the ongoing phase 3 study as shown on slide 20. The ECO42 Pivotal Phase III study is evaluating Selenexor as a maintenance therapy in patients with TP53 wild-type advanced or recurrent endometrial cancer. The study will enroll approximately 220 women whose tumors are TP53 wild-type. Ultimately, this trial will enable the development of a companion diagnostic, and we anticipate the approval of a companion diagnostic would occur at the same time as Selenexor if approved. The study is a collaboration between CarioPharm and NGOT, the European Network for Gynecological Oncological Trial Group and GOG, the Gynecology Oncology Group. NGOT and GOG include the top opinion leaders in gynecology oncology. Their participation in the ongoing phase three study further underscore the strength of the data observed in the p53 wild-type subgroups, and the potential Selinexor may have in providing a new standard of care to p53 wild-type endometrial cancer patients. Together, we are making strong progress and have been intensely focused on activating sites and enrolling patients. We are now expecting top line results in the first half of 2025 with the slight timing shift related to country specific regulatory delays in a few European countries. As seen on slide 22, we are expanding our multiple myeloma franchise with the ongoing phase three trial that is evaluating Selinexor at the low dose of 40 milligrams in combination with the well established backbone therapy of pomalidomide and dexamethasone. SPD, an all-oral combination, and evaluated after an anti-CD38 antibody, has the potential to benefit a significant number of patients across the multiple myeloma treatment journey. As seen on slide 23, the phase 3 trial is enrolling patients with relapsed refractory multiple myeloma who have received an anti-CD38 antibody as their most recent therapy. Patients are randomized one-to-one to the oral regimen of selenexor, pomalidomide, and dexamethasone, or elotuzumab, pomalidomide, and dexamethasone. The primary endpoint is progression-free survival. The potential approval of this combination could lead to the only all-oral potentially T-cell sparing regimen for patients with relapsed refractory multiple myeloma, which is gaining increased importance given the incorporation of T-cell therapies in the multiple myeloma treatment landscape. As seen on slide 24, we are evaluating the effect of Selinexor on the immune environment through preclinical, translational, and real-world data, as well as clinical trials. We recently announced a collaboration with BMS that will evaluate Selinexor in combination with mezidimide, a novel cell mod or cereblon E3 ubiquitin ligase modulator in triple-class exposed multiple myeloma patients. This combination has the potential to reverse T-cell resistance and builds upon the multiple selenoxor combinations that have already demonstrated clinical benefit in multiple myeloma. In summary, we have near-term late-stage opportunities supported by compelling data in our rapidly advancing pipeline that will potentially benefit multiple cancer patient populations of high-end met need building on our approved indications. With that, please turn to slide 25, and I will now hand it over to Sohanya for a review of our commercial performance for this quarter.
Richard
Thank you, Reshma, and good morning, everyone. On slide 26, I am pleased to present the progress we have made in our third quarter performance as we delivered sequential growth in net product revenues over three consecutive quarters in 2023 in an increasingly competitive landscape and amidst high utilization of free drug through our patient assistance program. Expobio delivered 30.2 million in net sales in Q3, and when compared to Q3 of last year, net sales was adversely impacted by higher utilization of our patient assistance program due to the impact from myeloma foundation closures as we have previously discussed. In the third quarter, two of the four main multiple myeloma foundations were open and continue to remain open. As a result, new patients entering PAP have largely normalized, although we saw the refill impact of patients already in PAP earlier in the year. Total PAP utilization contributed to 9% of total demand in Q3 2023 versus 4% in Q3 2022. As we mentioned before, In 2024, due to the IRA related changes in the design of Medicare Part D, which will eliminate the patient burden of the 5% beneficiary coinsurance requirement, we expect significantly less need for Medicare Part D patients to utilize PAP for copay assistance. Additionally, net revenue was impacted by two points, higher year over year gross to net in the third quarter, driven by increased Medicaid rebates and 340B discounts. Total demand year over year declined 3% when compared to Q3 of last year, which was our strongest quarter thus far. Total demand growth year over year for Q3 was negatively impacted by increased competition in the late lines in the academic setting. In the earlier lines, we continue to make strong progress. In Q3 2023, Expovio new patient share mix was greater than 60% in the second to fourth line, which represents approximately 20% growth year over year. This shift in mix of patients continues to drive higher refill use as early aligned patients tend to stay on therapy longer. Furthermore, our opportunity in the earlier lines is enhanced by the elevation of Expobio in the NCCN guidelines to a category one and now preferred regimen in the lenalidomide refractory patient population in relapsed or refractory multiple myeloma. This is meaningful in guiding treatment choices for physicians, particularly in the community, and for patients progressing from regimens like the Darzalex, Revlimid, dexamethasone combination. In addition, new subgroup data was presented at the European Hematological Association from our Phase III Boston study, which showed that patients that are PI-naive or not previously exposed to a proteasome inhibitor and that are treated with XVD showed an approximately tripling of PFS of 29.5 months versus the control arm VD of 9.7 months with a hazard ratio of 0.29. Patients are increasingly treated with PI-free regimens like the Darzalex Revlimid dexamethasone combination in the front line. which constitutes up to about 10% of frontline patients with this segment growing over time. As multiple myeloma patients are living longer with the emergence of new classes of therapy, Expobio represents an opportunity for these patients to be treated with an effective and novel class of therapy earlier in their treatment journey and allow for potential sequencing in the future with other classes of therapies. Our commercialization team is laser focused on sharing our new data, sideline updates, and leveraging the experience of our broad base of physicians that have used Expovio to drive further youth and in earlier lines, all amidst an intensifying competitive landscape in the late lines. We reaffirm our U.S. Expovio net revenue guidance of 110 to 125 million in 2023. Let's now turn to slide 27 to review how we are distinctly positioning Expovio in the community and academic settings in an evolving landscape. In the community setting, while we do see competitive pressures in the late line with some larger accounts, the majority of physicians in the community tend to treat early aligned patients and are looking for agents that are effective, manageable, and convenient. We believe Expovio as a novel class that is an effective, manageable, easily combinable, and a convenient oral therapy fits the needs of the community well. Furthermore, the NCCN has recently updated their guidelines to recommend switching classes of therapy that patients have not been exposed to previously versus recycling the anti-CD38 class, which occurs frequently in the community. This update, combined with the elevation of Expovio and the NCCN guidelines, highlights the importance of changing the mechanism of action with a novel class like Expovio. A highly compelling new PI-naive subgroup data further strengthens our positioning in the community in the second to fourth line. In the academic setting where we're seeing the impact of competition from new approvals, including T-cell therapies, We continue to build the body of evidence to demonstrate how Expobio may be used as an optimal therapy with a novel mechanism of action pre- or post-T cell therapies. Also, the opportunity to launch SPD when approved at the lower dose of 40 milligrams could lead to the only all oral and potentially T cell sparing regimens. In Q4, we remain focused on entrenching Expovio in the community, which represents about 60% of our business, and driving earlier line growth, while we expect further intensification of the competitive landscape in the later lines. In the mid to long term, we believe that the potential approval of SPD and further data generation around the T-cell fitness space with novel combinations could unlock further benefit for myeloma patients with Expobio. Furthermore, KaryoPharm has a tremendous opportunity for growth across multiple indications in the future, and we look forward to leveraging our strong commercialization team and capabilities and our deep relationships in the community and centers of excellence for these launches. Please advance now to slide 28, and I'll turn the call over to Mike.
Expobio
Thank you, Suhanya. During 2023, we have further reduced our cost structure to focus resources on our pivotal phase three trials. And in August, we reduced our workforce by approximately 20%, including contractors. These steps further strengthen our financial position to invest in our three ongoing phase three studies with top line data readouts expected within our cash runway. Now on slide 29, I will focus on the quarter's financial highlights. Total revenue for the third quarter of 2023 was $36 million compared to $36.1 million for the third quarter of 2022. Net product revenue from U.S. commercial sales of Expovio for the third quarter of 2023 was $30.2 million compared to $32 million for the third quarter of 2022. As Sohanya discussed, net product revenue continued to be adversely affected by more patients using our patient assistant program as well as higher growth-to-net discounts. Growth-to-net discounts were 20% in the third quarter of 2023 as compared to 18% in the third quarter of 2022. Turning to costs, with our continued focus on cost management, we are pleased to be delivering a combined 12% year-over-year reduction in our R&D and SG&A expenses for the nine months ended September 30th, 2023. R&D expenses for the third quarter of 2023 were $35.6 million compared to $31.4 million for the third quarter of 2022. We expect fourth quarter 2023 R&D expenses to be relatively consistent to the third quarter as we continue to invest in our three ongoing phase three studies with each representing a large addressable market with unmet patient needs. We have reduced SG&A expenses in the third quarter of 2023 by 12%. at $30.8 million compared to $34.6 million for the third quarter of 2022. Cash, cash equivalents, restricted cash and investments as of September 30th, 2023 total $209.2 million compared to $279.7 million as of December 31st, 2022. Based on our current operating plans, we are reaffirming revenue guidance for the full year of 2023 as follows. Total revenue is expected to be in the range of $145 to $160 million. Expovio net U.S. product revenue is expected to be in the range of $110 to $125 million. We are also reaffirming our expense guidance for the full year of 2023 as follows. Non-GAAP R&D and SG&A expenses, which exclude stock-based compensation expense, is expected to be in the range of $240 to $255 million. And importantly, coming to our cash guidance, our existing cash, cash equivalents and investments, as well as the revenue we expect to generate from Expovio product sales and other license revenues, will be sufficient to fund our planned operations through late 2025, excluding maturity of our convertible bonds in October 2025. I'll now turn to slide 30 and some final thoughts from Richard.
Kara Farms '
Thank you, Mike. Turning to slide 31. As we have discussed today, we are rapidly advancing our pipeline, concentrating our investments in three phase three programs that are expected to read out through 24 and 25 as we work to create near and long-term value for all our stakeholders. We are well prepared for the next stage of growth as we continue to expand on our foundation in multiple myeloma with our proven commercialization and late-stage development capabilities. I would like to thank our teams who continue to execute in a disciplined manner and who strive each day for patients with high unmet needs. Thank you again for joining us today, and I would now like to ask the operator to open the call up to the Q&A portion of today's call. Operator?
Operator
We will now begin the question and answer session. To ask a question, you may press star then 1 on your telephone keypad. If you're using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star then 2. At this time, we will pause momentarily to assemble our roster. The first question comes from Peter Lawson with Barclays. Please go ahead.
Peter Lawson
Hi, good morning. This is Shayon for Peter. Thanks for taking our question. Congratulations on the new MF data announced today. Maybe help contextualize for us as we think about getting that top line data from phase three in 2025. Maybe what the more appropriate bar is to be looking at rather than just JAK inhibitor monotherapy. And then secondly, just a quick add-on question. For Elton Exxon and MDS, I believe we're potentially going to get an update on development plans here. Is that still on track for something we could learn about more in this quarter? Is it something we should be thinking to see prioritized for CaryoPharm at this point? Thank you.
Kara Farms '
Thanks, Shay. For your question, I'll turn to Reshma for that. Reshma?
Elhan
Yeah. Thank you, Shay. A lot of excitement around the new MF data that we are presenting today at the NPN Congress in New York. You know, it only builds upon the impressive efficacy that we see with the combination of solanexor and ruxolitinib in this JAK-naive patient population. You know, as you mentioned, you know, we've already presented data at week 24 for both SVR as well as TSS50, a 79% SVR rate as well as a 58% TSS50 rate. You know, what patients and physicians really want to know is that how long are those SVR and TSS data or, you know, responses going to last. And that's the durability data that we're presenting today. And what you see is a very impressive durability for both of these endpoints. In fact, as of the data cutoff of August 1st, None of the patients experienced a radiographic progression for either SVR or TSS50. So it, again, just builds upon the body of evidence that really suggests that this combination could be a game changer for patients who are JAK-naive myelofibrosis. And we'll continue to evaluate this as part of our Phase III study. Right now, the focus is very much on SVR, TSS50 at week 24. But as you mentioned, we'll continue to look at durability as well as multiple other efficacy endpoints that are relevant to this patient population. In regards to your question about the appropriate comparator, it still remains ruxolitinib. So ruxolitinib is the standard of care for patients who are JAK-naive myelofibrosis who have platelet counts above 100. So the study design is appropriate and evaluates, again, the efficacy with this combination relative to the current standard of care. In terms of your question about L-tenexor, great question. Very enthusiastic about those data as well, specifically observed from the Phase I, Phase II study. We have been evaluating L-tenexor in a very hard-to-treat patient population, specifically relapsed, refractory, higher-risk MDS patients. Overall survival is very poor in this patient population around four to six months. And as we've disclosed previously, the survival that we've seen as part of both the phase one and phase two are very encouraging, right? Nine to 10 month median overall survival. We are in the process of optimizing our next steps in this program and look forward to updating everybody probably around the Q4 call.
Shay
Was there a follow-up, ma'am?
Peter Lawson
That's it. Thanks so much.
Operator
Thank you. The next question comes from Maury Raycroft with Jefferies. Please go ahead.
Maury Raycroft
Hi. Good morning. Congrats on the progress, and thanks for taking my questions. I was going to ask one on endometrials. So, for Selenaxor as maintenance in endometrial, When do you think you could show the initial overall survival data from the Siendo Phase 3 study? And then also separately, how is the export Phase 3 in the TP53 wild-type patients enrolling? And do you have a sense of how many patients are getting anti-PD-1 therapy with chemo up front, if you can provide any perspective on that?
Elhan
Yeah, great question, Maury. So, you know, as you know, so we continue to follow overall survival. We are very excited. We are going to be presenting overall survival data for the first time from the Siendo trial, specifically from the P53 wild-type subgroup later this year, so more to come in the next couple of months. Obviously, a key endpoint in addition to the progression-free survival, so more to come over there. In terms of the question around the PD-1 inhibitors in combination with chemotherapy, so there is a new standard, as I mentioned on the call. It is Dostarlimab in combination with chemotherapy, followed by Dostarlimab maintenance. Keep in mind that the approval is only for patients who are MMR deficient, so they represent the minority of patients at only 20%. The remaining patients who are PMMR or proficient in their MMR, as well as TP53, do not have a new standard of care, continues to remain chemotherapy followed by watch and wait.
Shay
Got it.
Maury Raycroft
That's helpful. And any other perspective into enrollment and how that's going? And then also wanted to ask a separate question on multiple myeloma commercial. You said there was approximately 20% year-over-year growth in second-line to fourth-line new starts. Can you give us some color on how refill rates have evolved specifically in these early-line patients versus when you were just in the later-line setting?
spk11
Yeah, maybe I'll turn to Reshma just to follow up on the trial question and then Sohania on the progress in multiple myeloma. Reshma? Yeah.
Elhan
Yeah, thank you. So enrollment is going well. There's a lot, and largely that's due just from the enthusiasm around these data. And I think that was highlighted most recently at ESMO, you know, a couple of weeks ago in Spain. A lot of enthusiasm largely because the benefit that we are demonstrating is, again, in this high admit need patient population that doesn't have a new standard of care. That is translating to activation in sites, and enrollment onto our clinical trials. We, in fact, have 70-plus sites that are already active and enrolling patients onto the study. So the study is proceeding quite nicely.
Richard
Melania? And I can address the question around the 20% year-over-year growth. So when you look at our mix of Expobio new starts, Over 60% of that is in the second to fourth line, which represents in Q3, year over year, a 20% growth. Now, this shift into earlier lines, as you pointed out, is a huge growth driver for us, primarily because of the benefit of duration that we see. Now, as we think about duration of therapy data, as we've discussed previously, The data can be choppy, takes time to mature, but as we triangulate multiple data sources, we are seeing a nice upward trend in our duration of therapy and refills. And this is largely driven by this increase in patients on the earlier lines and also better management of patients on the lower dose and supportive care.
Maury Raycroft
Got it. That's helpful. Thanks for taking my questions. Thanks, Corey.
Operator
Again, if you have a question, please press star, then 1. The next question comes from Colleen Cousy with Baird. Please go ahead.
Colleen Cousy
Great. Thanks. Good morning, and thanks for taking our questions. First one on multiple myeloma. With the elevation of the NCCN guideline recommendation for XVD to Category 1, can you help us understand how much of a tailwind that could be through the end of the year? And then I will follow up.
Richard
Yeah, thanks Colleen. So, yeah, so as we think about the evolving competitive landscape and multiple myeloma, Expobio has become established as a foundational mechanism. Now this elevation from, of Expobio from category one, which used to be other recommended regimens to now category one and preferred regimens is meaningful, particularly in the community setting where it's a large driver of treatment decisions. So notably, the NCCN guidelines made two updates that were favorable for Expovio, as I mentioned. One was recommending class switching. Again, supports a novel class of therapy like Expovio, as well as the elevation of Expovio Velcade Dex into the category one and preferred status. In terms of impact, we are not going to see an impact overnight. However, with multiple myeloma, it is an area that is highly promotionally sensitive, and we see steady growth over time. So we are excited that our field team is now able to actively promote this update today and moving forward, and we believe this strengthens our position in the community and in the early alliance.
Colleen Cousy
That's helpful. Thank you. And then for endometrial, given the evolution of the treatment landscape with dostarlumab and DMMR, and you're really encouraging results in PMMR, have you pre-specified any sort of analysis in this PMMR, P53 wild-type patient population for the ongoing Phase III study?
Elhan
Yeah, great question, Colleen. So similar to C&O in which, you know, we had endpoints Looking specifically at the DMMR versus PMMR, we'll continue to do that in our ongoing phase three as well. It's not a stratification factor. We assume that the vast majority of patients are going to be MMR proficient, given the fact that they represent 80%. That'll ensure balance, likely. But again, we will be looking specifically at the efficacy across these two MMR subgroups.
Colleen Cousy
Great. Thanks for taking our questions.
Operator
The next question comes from Eric Joseph of J.P. Morgan. Please go ahead.
Eric Joseph
Hi there, thanks for taking your question. This is Billy, I'm for Eric. Quick one from ours just on the combination with the BMS drug, the megadigidamide. Just a little bit of thoughts on what the rationale there is in terms of the combination with Sonexo.
Elhan
Absolutely great question. We're really, really excited about this novel combination. Just to give you a little bit of insight, this combination was pushed by some of our key KOLs coming out of Dana-Farber Cancer Institute, specifically Paul Richardson. He just thought that this builds upon the number of combinations that Selinexor has already shown remarkable efficacy in patients with multiple myeloma. The other aspect that is intriguing to him, but also BMS and of course us, is the fact that both of these drugs, XPO1 inhibition with Selinexor, as well as this novel cell mod in Mivigdamide, have individually and potentially in combination shown that it can reverse T cell resistance. And this concept of T cell resistance is, of course, becoming more and more important for multiple myeloma treaters, given the fact that they are now introducing T-cell therapies into the multiple myeloma arsenal. So this novel combination potentially gives them a really important tool to help with sequencing of these therapies for their multiple myeloma patients.
Eric Joseph
That's helpful. Thank you. And I just want to put your mind quickly on the patient assistant program and how kind of You see the impact of these foundation closures going forward and then kind of a Medicare fund redesign might be affecting this in 2024.
Richard
Yes, thank you for the question. I can take that. In terms of PAP, as we know, we saw an increased utilization of PAP, a free drug, this year due to foundation closures. Now, year to date, through Q3, the impact of PAP has been roughly $5 to $6 million, which includes about a $1 to $2 million PAP impact in Q3. Now, in Q3, there were two of the foundations that were open, and we, as a result, saw new patient starts in Pap normalized, but the refill impact remained. Now, in Q4, these two of the four foundations remain open to date, and we anticipate the Pap impact being very similar in Q4 as it was in Q3, assuming the foundation dynamic does not change. Now, as we move forward into 2024, we are encouraged by the IRA-related change to the design of the Medicare Part D, which eliminates the patient burden of the 5% beneficiary coinsurance requirement, and we expect, therefore, significantly less need for these patients to utilize our patient assistance program for copay assistance.
Shay
Great. Thanks for taking our questions. Again, if you have a question, please press star, then 1.
Operator
This concludes our question and answer session. I would like to turn the conference back over to Richard Paulson for any closing remarks.
Kara Farms '
Thank you, Operator, and thank you, everyone, for joining us today. As we mentioned, we are well prepared for the next stage of growth, as we continue to expand on our foundation of multiple myeloma with our proven commercialization and late stage development capabilities, and as we continue to rapidly advance our pipeline, concentrating investments in our three phase three programs that are expected to read out through 24 and 25 as we work to create near and long-term value for all stakeholders. Thank you for joining and have a wonderful day.
Operator
The conference has now concluded. Thank you for attending today's presentation You may now disconnect.
Disclaimer