Good day, and thank you for standing by. Welcome to the NovoCure Q3 2022 earnings conference call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a Q&A session. To ask a question during the session, you will need to press star one one on your telephone. Please be advised that today's conference is being recorded. I would now like to hand the conference over to Ingrid Goldberg.
Good morning, everyone, and thank you for joining us to review NovoCure's third quarter 2022 performance. I'm joined on the phone by our Executive Chairman, Bill Doyle, our CEO, Asaf Danziger, and our CFO, Ashley Cordova. Other members of our executive leadership team are also on the call and available for Q&A. For your reference, slides accompanying this earnings release can be found on our website, www.novocure.com, under Quarterly Reports on our Investor Relations page. Before we start, I would like to remind you that our discussions during this conference call will include forward-looking statements, and actual results could differ materially from those projected in these statements. These statements involve a number of risks and uncertainties, some of which are beyond our control and are described from time to time in our SEC filings. We do not intend to update publicly any forward-looking statements except as required by law.
Where appropriate, we refer to non-GAAP financial measures to evaluate our business, specifically adjusted EBITDA, a measure of earnings before interest, taxes, depreciation, amortization, and share-based compensation. We believe adjusted EBITDA is an important metric as it removes the impact of earnings attributable to our capital structure, tax rate, and material non-cash items and best reflects the financial value generated by our business. Reconciliations of non-GAAP to GAAP financial measures are included in our press release, earnings slides, and in our Form 8-K filed with the SEC today. These materials can also be accessed from our Investor Relations page on our website. Following our prepared remarks today, we will open the line for your questions. I will now turn the call over to our Executive Chairman, Bill Doyle.
Thank you, Ingrid, and good morning, everyone. At NovoCure, our mission is to extend survival in some of the most aggressive forms of cancer through the development and commercialization of our life-extending therapy, Tumor Treating Fields. In the third quarter, we consistently executed across our business in service of our mission. Our team is diligently working to reach additional patients in our current markets, expand into new markets, enhance our Tumor Treating Fields delivery systems, and treat patients in new indications throughout the body. We made significant advancements in our clinical and product development programs, and we are eagerly awaiting data readouts from multiple pivotal trials starting in the first quarter of 2023. Our GBM business remains the core driver of our financial stability and enables us to invest aggressively in a variety of clinical and product development initiatives, as well as commercial programs designed to increase adoption.
In the third quarter, we generated $131 million in net revenues and $22 million in cash flow from operations. The US market is our largest revenue contributor, in which currently approximately 40% of newly diagnosed GBM patients receive a prescription for Optune. We believe there is room to drive greater adoption of Optune in newly diagnosed GBM, given the best-in-class outcomes demonstrated by our EF-14 randomized clinical study, a growing body of basic and translational science from leading academic research centers, and ongoing confirmation from real-world evidence analyses throughout the globe. There are three key publications that we would like to highlight this quarter. First, a manuscript by Dr. Shadi Chamseddine and Chirag Patel of MD Anderson Cancer Center, which has been accepted for publication in the Journal of Molecular Cell Biology, reviews the multiple distinct mechanisms of action of TT Fields.
This paper is a comprehensive review of TT Fields in a high-impact journal and highlights the fast-growing body of scientific research converging to demonstrate the effects of TT Fields on cancer growth. The paper validates the multiple ways that TT Fields can disrupt critical cellular processes, supports TT Fields as a potential backbone therapy for other modalities, and adds to our arsenal of independent support to be used for broader education and awareness. Second, Dr. Xun Chen published real-world evidence from one of the most reputable hospitals in Shanghai, Huashan Hospital, in the Journal of Clinical Medicine. Dr. Chen's analysis reproduced the results of the pivotal EF-14 study and confirms Optune's efficacy in the largest group of patients treated with TT Fields in China to date. Dr.
Chen reports a statistically significant 45% improvement in median overall survival with a P value of less than 0.001 when comparing TTFields plus temozolomide to temozolomide alone. Third, real-world evidence from Dr. Matthew Ballo at the West Cancer Center was published in Neuro-Oncology Advances, underlining the benefits of TTFields and demonstrating that greater TTFields exposure correlates to improved overall survival regardless of subgroup or treatment factors. Publications like these serve to strengthen the underpinnings of research supporting the use of our therapy. Provide additional educational resources for practitioners as they learn more about TTFields. Next, I would like to highlight the leadership changes we announced last month, and the creation of a new U.S. CNS Cancers franchise. Frank Leonard, who most recently served as our chief development officer, will lead this new organization as franchise president.
Frank has succeeded in a number of leadership roles during his 12-year tenure at NovoCure, and we believe Frank will drive impactful results in this new role. The new U.S. CNS Cancers franchise combines sales, marketing, and medical leadership under one umbrella, and strengthens our focus on driving adoption of TTFields for newly diagnosed GBM in our largest and most important market. It is important to remember that Optune is still a new therapy to many physicians. The onus is on NovoCure to provide the educational resources needed for prescribing physicians to fully understand the many benefits of TTFields therapy for their patients. With the creation of the U.S. CNS franchise, we have streamlined decision-making and improved coordination across our U.S. teams with the ultimate goal of increased Optune adoption in GBM.
Continuing the theme of greater TTFields awareness and education, in August, we introduced a new marketing campaign designed to drive awareness and interest in TTFields in the broader oncology community beyond neuro-oncology. The campaign emphasizes the versatility of the TTFields modality, its multi-mechanistic capabilities, and ability to expand the treatment possibilities for patients. The campaign explained that TTFields are electric fields that exert physical forces to kill cancer cells via a variety of mechanisms, including the disruption of mitosis, interference with cell motility and migration, activation of antitumor immunity, and downregulation of genes important for DNA damage repair. One facet of this campaign is the creation of a new Tumor Treating Fields website, which serves as a central educational resource to learn more about our therapy. The website is now live at www.tumortreatingfieldstherapy.com. I would encourage all of you to explore this resource.
Before I turn the call over to Asaf, I'd like to reiterate my excitement for the upcoming pivotal trial readouts. For the last 10 years, NovoCure's primary focus has been treating patients with glioblastoma. The top-line readouts from both the pivotal LUNAR and INNOVATE-3 studies next year should be transformational for our company, and potentially enable tens of thousands of patients to utilize our therapy for treatment of non-small cell lung cancer and ovarian cancer. We look forward to sharing data from these studies with you as soon as possible. With that, I'll turn the call over to Asaf to discuss our clinical and product development updates.
Thank you. I would like to echo Bill Doyle's anticipation for the upcoming pivotal readouts. 2023 will be a very exciting year. As a reminder, we currently have four phase III pivotal studies approaching completion. The first to read out will be the LUNAR study evaluating the use of TTFields together with docetaxel or physician's choice checkpoint inhibitor for the treatment of stage four non-small cell lung cancer following platinum failure. We completed enrollment in this study in the fourth quarter of 2021, which started a 12-month follow-up period. We plan to announce top-line results from both the primary and powered secondary endpoints early next quarter. The next phase III data readout will be from the INNOVATE-3 pivotal trial. INNOVATE-3 is studying the efficacy of TTFields together with paclitaxel for the treatment of platinum-resistant ovarian cancer. Ovarian cancer is deadly, especially once a patient has become resistant to platinum-based therapy.
Enrollment in INNOVATE-3 was completed in October 2021, which started the 18-month follow-up period. Top-line results are expected in the second half of 2023. Our next top-line data release will be from our METIS study evaluating TTFields as a monotherapy for the treatment of brain metastases from non-small cell lung cancer. Treatment of brain metastases is a significant unmet need. Brain metastases often go untreated due to the diminished blood-brain barrier permeability of many cancer drugs. METIS continues to enroll well, and we have visibility to final patient enrollment, but we will need an additional quarter to reach this milestone. Given the 12-month follow-up period for METIS, we now expect top-line results in Q1 of 2024. The final readout from our current slate of phase III pivotal trials is the PANOVA-3 study evaluating the use of TTFields together with nab-paclitaxel and gemcitabine in locally advanced pancreatic cancer.
The five-year survival rate for patients with pancreatic cancer is only 10%. We are hopeful that TTFields can play a part in extending survival for this patient population. PANOVA-3 remains on track for top-line results in 2024. In addition to our clinical pipeline, we are also exploring avenues to increase the TTFields dose delivered to patients, as well as improve patient experience through product development. TTFields dose is defined as the amount of energy delivered to the tissue, and one of the key levers for increased dose is TTFields intensity. Today, we are excited to share the data from our EF-33 pilot study. As a reminder, EF-33 is our first study to evaluate the safety and preliminary efficacy of a higher intensity array design in 25- patients with recurrent GBM as compared to a historical control.
Among those who used Optune as directed with high-intensity arrays for at least one month, median progression-free survival was four and a half months versus 2.2 months in our EF-11 trial. Further, notwithstanding the increased TTFields intensity, EF-33 patients reported no TTFields-related toxicity. EF-33 is an important step in our ongoing product enhancement efforts and supports a much faster development cycle by accelerating the clinical testing of the innovations delivered by our product development teams. Building upon our goal to enhance patient experience in TTFields intensity, we are introducing the flex array. As a reminder, the flex array utilizes new materials which are lighter and more flexible than those used in our current arrays. Flex arrays also have the potential to deliver higher and more consistent TTFields intensities to the target regions without increasing heat.
Pre-clinical research in the Red Journal has shown that increased field intensity and greater time on therapy lead to a higher cancer cell kill rate. We believe the Flex Arrays have the potential to meaningfully improve patient comfort and improve the efficacy of our therapy. We are on track to treat our first patients with Flex Arrays in Europe later this year, pending regulatory approval. We look forward to updating you on this release, as well as our plans for broader distribution. Before I hand the call over to Ashley, I would like to thank all of my NovoCure colleagues for their continued dedication to our mission. 2023 could be transformational for NovoCure as soon we may have the opportunity to treat thousands of additional patients. I know you will rise to the challenge as you have many times before.
With that, I will turn the call over to Ashley to review our financial performance.
Thank you, Asaf. The third quarter of 2022 was another period of consistent commercial execution as the profits from our GBM business continued to finance ongoing investment in clinical development and commercial expansion. Net revenues in the third quarter were $131 million, with $22 million in cash flow from operations. We ended the period with 3,420 patients on therapy. There were several notable headwinds this quarter that impacted net revenues, including the volume of cash collections from aged claims in the U.S., the ongoing impact of German coverage updates, and FX pressure from both the weakening Japanese yen and Europe. With respect to aged claims in the U.S., we continue to pursue previously denied claims. However, the accessible collections will largely be exhausted this year, and the remaining outstanding aged claims will take more time and effort to collect.
As we look ahead to 2023, we expect our net revenues to more closely reflect the core drivers. Active patients on therapy times the net revenue earned per active patient times 12 months. Gross margin for the third quarter was 77%. Impact to our gross margin from inflationary pressures has been minimal to date, and we are working with suppliers to optimize our cost of revenues. SG&A expenses for the third quarter totaled $74 million, an increase of 16% year-over-year . We are investing aggressively in our commercial capabilities with multiple future growth levers in mind. These include investments in pre-commercial groundwork for potential launches across multiple cancer indications and the expansion of our international footprint. We invested $52 million in research and development in the third quarter, an increase of 8% from the third quarter of 2021.
One of the hallmarks of our therapy is the broad applicability and combinability with numerous treatment modalities and pharmacological agents. We will continue to invest to explore using our therapy in new cancer indications and in novel combinations, as well as in product development initiatives designed to improve the efficacy and experience for our patients. Our net loss for the third quarter was $0.25 per share or $27 million. Adjusted EBITDA was $4 million, and we finished the period with $970 million in cash and short-term investments on the balance sheet. This cash reserve enables us to pursue a number of avenues for growth with maximal flexibility. I'd like to close today by highlighting one of our Optune users. In July 2021, Jovan Knutson was preparing for a backpacking trip when she found herself unable to read or comprehend text messages.
After consulting with physicians and undergoing a battery of scans, she was diagnosed with GBM. Jovan first underwent debulking surgery at the Mayo Clinic and then began using Optune. In the year since her diagnosis, Jovan's disease has not progressed. She continues to maintain an active lifestyle while using TTFields. This past summer, Jovan biked more than 100 miles to the Mayo Clinic for her most recent MRI. We take our mission very seriously at NovoCure to extend survival in some of the most aggressive forms of cancer. Extending survival means allowing patients like Jovan the time and ability to continue pursuing their passions, whether that's a long bike ride, watching a football game with her husband, or getting lunch with her dad. We're proud to play our part in Jovan's story. With that, we'll open the call to questions.
As a reminder, to ask a question, please press star one one on your telephone. Please stand by while we compile the Q&A roster. Our first question comes from Gregory Fraser with Truist. Your line is now open.
Good morning, folks, and thanks for taking the questions. Wanted to ask about Germany. When do you expect reimbursement to return to a more normalized level? And how do we think about normalized in terms of net revenue per patient per month?
Greg, this is Ashley. Thanks for the question and for joining the call today. As a reminder, in the second quarter, we disclosed that we had received formal DME listing in Germany and contracted pricing with all of the large payers. You asked specifically what we should expect in the long term. I'll say our price in Germany is in line with our global ASP, so that's what you should expect us to ramp back up to. We continue to face headwinds to our German net revenue for patients who started prior to defined coverage and for whom we are no longer being paid. That's consistent with that last quarter, but we expect to continue to see an impact for the next five quarters or so through the end of 2023.
Separately, we reviewed our AR balance this quarter to reflect the updated coverage criteria, and that was an additional headwind one time in the quarter. If we summarize it all, you know, as we mentioned last quarter, so it's short-term pain for long-term gain as we now have formal DME listing and established reimbursement pathway in Germany and pricing in Europe in line with our global pricing ASP.
Got it. Can you talk a bit more about what you're seeing in Japan in terms of demand? Prescription volume there has been trending down over the last few quarters. Is there something driving that trend?
Yes. This is Pritesh. I'll take that question. Thank you for asking the question. Our business in Japan is strong and growing, and we're very pleased to see the active patient trends over quarter over quarter grow there. Through better physician education, we have transitioned to a model where we are receiving prescriptions for patients that are actually able to start. So we wanna improve our ability to impact patients that can actually receive the therapy. Any variability that you see in the prescription is just noise, and I would continue to look at active patients as a measure of our growth in Japan.
Got it. The fill rate has gone up essentially versus what it used to be?
Yes.
Got it. Okay, can you also talk about expectations for the ramp in France once you finalize reimbursement? Is it fair to look at the experience in Germany? Do you expect faster adoption given adoption is more established now?
Yeah. Thank you again for that question. In France, just as a reminder, we're in the process of securing reimbursement, and it's too early for us to determine what the ramp-up will be. We're doing everything we can, applying all of our learnings from Germany and other markets to educate the marketplace, prepare our teams to make sure that as soon as we get the green light, we can start helping patients in France.
One more quick one, and I'll get back in the queue. Do you already have patients on treatment now in France that will become paying patients after you secure reimbursement? Thanks so much.
Yeah. We have patients today that we're treating in France. Those are through clinical trials. Those are the TRIDENT trial that we have ongoing in France. We don't have any commercial patients outside of that in France today.
Thank you.
Please stand by for our next question. Our next question comes from Jason Wittes with Loop Capital. Your line is now open.
Hi. Thanks for taking the questions. First off, you're beefing up your infrastructure for GBM sales in the U.S. You're at 40%. Should we anticipate that you're gonna see some meaningful move on that 40% penetration number next year with these changes, or is this gonna be a more gradual slope?
Good morning, Jason. This is Bill. I'll start off here. You know, as you point out, I'll just level set for everyone, the U.S. is our largest and most important market. We receive approximately 40% prescriptions, meaning we have approximately 40% penetration in newly diagnosed GBM. We've got tier one recommendation per the NCCN and guidelines. We've established essentially a universal pricing and reimbursement for patients in the U.S., and it really is the core driver of our profitable business that's funding all of the other activities that we discussed. You know, that's sort of the big picture. We believe there are significant opportunities to increase that 40%.
First and foremost is penetration at the academic centers. This is where the ISTs that we've discussed previously, as well as the TTFields, the new Tumor Treating Fields campaign that we discussed in the script. Also the power of the academic papers that are now coming from independent researchers that are validating the EF-14 clinical trial. All those are important for our growth. Then again, we have now streamlined our organization to really focus on driving this. With that, I'd like to ask Frank Leonard, who's on the call and is our new franchise president. Frank, maybe you could just give a little bit of a background and your thoughts in terms of how we're gonna drive growth in the U.S.
Thank you, Bill. Yes, we're excited to launch the new CNS franchise. It's a new organization that combines sales, marketing, medical leadership, as well as our patient support functions in a single operating unit in the U.S. I think first and foremost, the creation of the unit ensures that we do maintain the focus on increasing the number of GBM patients receiving Optune, while allowing the rest of the organization to prepare for the future. We're really within this new organization, focused on two key operational changes. First, we want to streamline the decision-making related to the U.S. GBM business to ensure we can get faster implementation of changes that support our prescribers and our patients.
Second, we also wanna build an organization that can prioritize the strategic objective for growth while decentralizing the tactics and the execution to the teams that are closest to our customers. I'd also mention just lastly that I wanna highlight that we just returned from the ASTRO conference in San Antonio. As a reminder, ASTRO is the largest conference focused on radiation oncology, and our radiation oncology prescribers are some of our most engaged and confident customers. With over 7,500 attendees at the conference, we had four days of significant customer engagements face-to-face, which we still believe is the best way to engage our customer. My main takeaway from ASTRO is that the radiation oncology community understands the long-term potential for Tumor Treating Fields, both in GBM and in the other solid tumors we're studying.
We had an excited customer base that was eager to talk to us both about applications in GBM, as well as aware of the fact that there's upcoming data releases that will be meaningful.
Thank you. Again, maybe to summarize, we have a very strong foundation in GBM. It is among our highest priorities to grow in GBM and hence the reorganization to provide that focus. We have significant evidence that continues to build. You know, while I wish there were a magic bullet that I could fire and would drive immediate growth, I think this growth will build over time, but we're committed to getting the therapy to these patients.
Okay. I appreciate all that color. If I could just ask one other question then, on high-intensity arrays. You know, the 25-patient pilot study was pretty impressive. It looks like you doubled progression-free survival. It sounds like it will be out officially in Europe this year, from your comments. Can you give us any guidance in terms of how things play out in the U.S. in terms of what the regulatory pathway might be, for that?
You know, again, our focus has been on building, you know, first of all, developing the array, then building the manufacturing infrastructure to supply the array. We made the decision to launch in Europe first, which we expect to occur this year. We'll announce that when we do have the first patients on these arrays. We'll start the regulatory process in the U.S. next year.
Jason, just for the avoidance of doubt, the EF-33 data is on our 14 disc array. Flex is another kind of leapfrog generation of high-intensity array that is lighter and more flexible.
Yeah. Ashley, that's a great point. You know, we started the first trial with an early design that delivered the high intensities, and it. We tested those on some of the sickest patients. Again, these were recurrent GBM patients. As you point out, we were delighted to see the improvement in overall survival in these patients. We were also delighted to see that there was no toxicity. For this initial trial, that was, those were both important endpoints. Again, I'm just repeating what Ashley said, the Flex is another step forward that not only delivers the high intensity but is a much more comfortable, lighter, easier to use array. We're as excited as can be about this launch.
Great. Thanks for the info. I'll drop back in queue.
Please stand by for our next question. Our next question comes from Emily Bodnar with H.C. Wainwright. Your line is now open.
Hi. Good morning. Thanks for taking the questions. I'm curious how much of a larger sales force would you need to bring TTFields to market for lung cancer? Are you looking to build like a completely new sales force for that, or do you think there's some synergy with your ongoing sales force in GBM and mesothelioma? Could you maybe provide some background on the METIS trial and what's kind of driving the slower enrollment there? Thank you.
Sure. We'll take this in two parts, but we alluded to this in the remarks, but we are making very large investments in the organization for the future. I'd like Pritesh to describe some of those activities.
Yes. Thank you, Bill. I appreciate the question, and I'll start off with answering your question first. How large of an investment are we going to be making in the sales organization? And will it be a dedicated sales team? I think one of the key takeaways from what we shared, and Frank just talked about with the CNS infrastructure, is that we're excited about the focus on GBM while we work on how to structure and how to resource the opportunity in the future. It's too early for us to say that we will have a sales force just of lung cancer or just of ovarian cancer. What we're excited about is taking this journey of helping more patients.
What we're doing on this front, number one, is to ensure the broader medical oncology community is aware of Tumor Treating Fields. This is the work that Bill described in the prepared remarks related to the launch of the Tumor Treating Fields therapy website and the work we're doing on education related to the mechanism of action. The second step we're taking here is to understand the marketplace as we await the data, working on the patient journey, ensuring we understand how decisions are made, how TTFields will insert into the decision making framework. The last step on this front is to make sure that we're preparing the organization for these milestones that will come forward. A lot happening on the planning front as we await the data.
Once we see the data and have a chance to digest the data, we'll have more opportunities to think about what are the right plans and where do we make sure that we can make some decisions off of that.
Emily, with respect to your question on METIS has been enrolling consistently. We're right near the end. We have line of sight. It's just gonna cross over into the next quarter. It's nothing more than that.
Got it. Thank you.
Please stand by for our next question. Our next question comes from Jason Bednar with Piper Sandler. Your line is now open.
Hey there. Thanks for taking the questions. Maybe, you know, I'll text a few here first on LUNAR, with a couple clarifying questions. You know, at first it looks like the early language was removed from the press release, early Q1, but I thought I heard you reference that early point for the top line data during the prepared remarks. Just clarifying that the timing there is unchanged. We're still thinking about early 2023, as in, like, you know, sometime in, like, maybe mid-January. And then I think you noted we'll see primary and secondary endpoints on LUNAR. Just wondering if you can discuss whether we'll see any hazard ratios when you report those items.
You know, finally, can you discuss what kind of preparations you're making today, just with respect to, like, submission materials, the FDA and international agencies, as well as fees you're planning with payers to have those conversations start as soon as possible once you do have that data, you know, fully in hand and cleaned? Thanks.
Sure. First and foremost, let me just underline there's no change with respect to the report timing. No need to read any tea leaves there. Secondly, as we've said before, our first announcement in January you should expect to be consistent with other announcements from other companies in oncology. We plan to make sure everyone understands whether or not we've hit the primary and the secondary endpoints. We do not expect to provide detail that will compromise our ability to either publish or present the data in the first opportunity that we have in a major medical conference.
With respect to preparation, I would say that, you know, our regulatory capacity is one of our tremendous strengths at NovoCure. It's among our strongest core capabilities. We are doing everything that is possible to do to prepare. This will be a PMA supplement. It will go in three subcategories. There's a manufacturing supplement, there is a pre-clinical supplement, and then there's the data package. All of that is being prepared and worked on so that it can be filed at the first opportunity.
Okay. I have another question. I wanna come back to it. Bill, you said PMA supplement. I've been operating under the assumption this was gonna be a full PMA. Is that?
Uh, it's a full-
Has something shifted or?
My mistake. Okay.
It'll be a full PMA.
Good catch. I'm thinking PMA supplements because we're so busy doing other PMA supplements, but this is a full new PMA.
Okay. Okay, thanks. Ashley, are you willing at all to provide some view on pricing or revenue per patient in some of your markets? I guess I know the original discussion was to reference for us on the street to reference year-end 2021 revenue per patient levels. But I mean, I think we all can see like what FX is doing across your P&L and, you know, changes in Germany that just make year-end 2021 that, you know, just really tough to use. Is there anything you're willing to reference today as we think about modeling revenue per patient in future quarters and years across your respective markets?
Thank you.
Yeah. No, I appreciate it. It's actually a good question. Notwithstanding all of the puts and takes, year-end 2021 still is a pretty good reference. When we roll up to that kind of ASP that you see there, that's what I would recommend you use. As you noted, there will be puts and takes. What we've seen throughout 2023 is some tailwind from aged claims in the U.S. that's benefiting that price when you roll it in the model, but that's being offset by the transition that we're seeing in Germany. I would say those are netting to essentially the same place. Japan, of course, also has some FX impact, but that price is stable. If you look at actually those trends over time, you're seeing the impact of FX.
I would still recommend you look to that Q4, you know, exit ASP as a good number to model moving forward with some puts and takes in each region.
Year-end 2021 global revenue per patient is still how you suggest modeling forward for 2023 and beyond?
Yes.
Okay. All right. Thank you. Very helpful.
Please stand by for our next question. As a reminder, to ask a question, please press star one one on your telephone. Our next question comes from Vijay Kumar with Evercore. Your line is now open.
Hey, guys. Thanks for taking my question. Ashley, maybe my first one is for you. Did you quantify what the CMS contribution was for within the Q? Just based on what you're seeing right now, should we expect revenue growth in fiscal 2023?
Yeah, Vijay Kumar, thanks for the question. I mean, we've never broken down at a, you know, a detailed quantification, but what we have seen is a benefit throughout 2023 and in 2022 from H plans in the U.S. That's around $10 million a quarter, if you want a round number that I would look. We did have a headwind in the third quarter where that was down versus Q2. If you look at consistent active patient trends, you can see that drop in our net revenue in the US, and that is largely the impact of the aged claims decrease in the US. It is true that as we look to next year, we expect those aged claims to become more difficult to get. You know, we've kind of largely captured the low-hanging fruit there.
As you look forward, we would recommend you take our active patients on therapy, multiply it by that ASP that we just discussed with Jason, and times that by 12, and that will give you a good estimate.
I guess, isn't the back payments a headwind for 2023? Could total revenue be declining in 2022?
Yeah, no, aged claims in the U.S. will be a headwind in 2023. We want you to anchor to that ASP that we just referenced.
Understood. A couple of questions on LUNAR. Given this is a PMA, there were some trial design changes. Do you expect that there could be an FDA advisory committee on the, on a, you know, for this trial?
You know, we never know whether or not the FDA will decide that they want an advisory committee. I don't think it has anything to do with trial design. I think it will have to do with the data and the results and what the FDA chooses to do. I think the fact that Tumor Treating Fields is now established in GBM and is an established modality and of course, the safety is well established. I think this is a therapy that's much better understood at the FDA and in the community. Recall they did have an advisory committee for our very first approval in recurrent GBM, but they did not require an advisory committee for our second submission in newly diagnosed.
Yeah, that's helpful, Bill. Maybe my last one on the trial now. In LUNAR trials specifically, we're looking at 12 months of follow-up, right? Does that mean the median overall survival in this trial is less than 12 months? Or maybe just put the 12-month into context, because I know, you know, there was a data maturity. The trial started enrolling a while ago. What does the 12 months signify?
Again, Vijay, that's 12 months from the last patient in. It's not an average 12-month follow-up. I don't think there's any issue with respect to this follow-up time.
Understood. Thanks, guys.
Thank you.
At this time, there are no other questions in the queue. I would now like to turn the conference back to Bill Doyle for closing remarks.
I'd like to thank everyone for joining the call this morning and your continued interest in NovoCure. Q3 was another quarter of consistent execution across NovoCure. The fundamentals of our GBM business are strong, and the underlying evidence confirming the benefits of Tumor Treating Fields therapy continues to strengthen. January marks the beginning of a year that will feature readouts from multiple pivotal trials, potentially enabling us to treat tens of thousands of new patients in the coming years. 2023 will be transformational, and we look forward to updating you on our progress. Thanks again. Thanks again.
This concludes today's conference call. Thank you for participating. You may now disconnect.