Geron Corporation (GERN) Earnings Call Transcript & Summary

Hello, and welcome to the Geron Corporation Second Quarter 2024 Earnings Call. [Operator Instructions]. I would now like to turn the conference over to Aron Feingold, Vice President of Investor Relations and Corporate Communications. You may begin.

Good morning, everyone. Welcome to the Geron Corporation Second Quarter 2024 Earnings Conference Call. I am Aron Feingold, Geron's Vice President of Investor Relations and Corporate Communications. I'm joined today by several members of Geron's management team. Dr. John Scarlett, Chairman and Chief Executive Officer; Dr. Andrew Grethlein, Executive Vice President and Chief Operating Officer; Dr. Faye Feller, Executive Vice President and Chief Medical Officer; and Michelle Robertson, Executive Vice President and Chief Financial Officer. On today's call, Chip will start off with introductory remarks on commercial execution and value creation. Andy will provide a commercial and operations update. Faye will speak to medical and clinical update. Michelle will provide a financial review. And Chip will close with some final remarks. Before we begin, please note that during the course of this presentation and question-and-answer session, we will be making forward-looking statements regarding future events, performance, plans, expectations and other projections including those relating to the launch, commercial opportunity and therapeutic potential of RYTELO, anticipated clinical and commercial events and related time lines, the sufficiency of Geron's financial resources and other statements that are not historical facts. Actual events or results could differ materially. Therefore, I refer you to the discussion under the heading Risk Factors in Geron's most recent periodic report filed with the SEC which identifies important factors that could cause actual results to differ materially from those contained in the forward-looking statements. Geron undertakes no duty or obligation to update our forward-looking statements. With that, I'll turn the call over to Chip. Chip?

Thanks, Aaron. Good morning, everyone. Thanks for joining us. It was just 8 weeks ago that FDA approved RYTELO, our branded name for imetelstat as the first and only telomerase. And it was just 6 weeks ago that RYTELO became commercially available in the U.S. With our strong commercial infrastructure in place at launch and the efficient mobilization of our field teams, we've seen encouraging early launch results. As of July 31, 60% of the top decile 1 to 4 accounts have been reached by our team across both community and academic settings. This has led to gratifying uptake. We estimate again as of July 31 that approximately 160 patients have received RYTELO, which is quite encouraging given the very early stage of this launch. The enthusiastic reception for RYTELO that we've seen within the hematology community reinforces the unmet needs for lower-risk MDS patients with symptomatic transfusion-dependent anemia. Many of our customers are passionate about getting access to RYTELO for their patients, and we've seen a strong push across the U.S. to add RYTELO to formularies, treatment pathways and EMRs, including in the community setting. In addition, the MDS NCCN guidelines were updated this July 25 to include RYTELO as a category 1 and 2A treatment for lower-risk MDS patients. That is, RYTELO is now designated for use in both RS positive and RS negative first-line ESA ineligible patients as well as in both RS positive and RS negative second-line patients regardless of prior first-line treatment. We believe that these favorable NCCN guidelines have put RYTELO in a strong competitive position. During their portions of this call today, Andy and Faye will walk through how clinical, formulary and treatment pathway decision-making is guided by the NCCN guidelines. With the introduction of RYTELO as a new therapeutic option, we're seeing increasing dialogue among hematologists, rethinking treatment approaches for eligible low-risk MDS patients with transfusion dependent anemia. Consequently, we believe that RYTELO can become part of the standard of care for both eligible first and second-line patients. As shown on this slide, from the approximately 13,200 U.S. patients with lower-risk MDS who need treatment for symptomatic anemia, approximately 1 in 10 are ESA ineligible due to serum EPO levels higher than 500 mU/mL. These first-line patients have limited treatment options. RS-positive patients make up approximately 25% of the lower-risk MDS patient population, many of whom continue to experience high transfusion burden despite available therapies. RS-negative patients make up approximately 75% of lower-risk MDS patient populations, many of whom are particularly vulnerable to poor clinical outcomes and have few other treatment options. In support of our commercial opportunity, we believe we have strong regulatory exclusivity and patent protection in the U.S. for RYTELO for this disease. Following approval, we completed the listing of our patents in the FDA's Orange Book. We also received confirmation from the FDA of imetelstat's orphan-drug exclusivity for lower-risk MDS into June of 2031. We've also filed our applications for patent term extension or PTE, including for our method of use patent covering MDS and MS. If the PTE application is granted and applied to this patent, we estimate that the patent term would extend through August of 2037. We believe this IP protection as well as several key factors I'll discuss on the next slide, position us well to create long-term commercial value with RYTELO. Based on the clinical profile of RYTELO, the approved U.S. prescribing information and now a great set of NCCN guidelines we believe we are well positioned to build long-term commercial value with RYTELO. More specifically, first, there's a high unmet treatment need for patients with lower-risk MDS as many patients progress and do not respond to current treatments, achieve a durable response or experience extended and continuous red blood cell transfusion independence. Treatment options for red blood cell transfusion-dependent patients who are relapsed or refractory to or ineligible for ESAs, can have significant limitations underscoring the needs for novel treatment options such as RYTELO. Second, as demonstrated by the totality of clinical benefit in the IMerge Phase 3 clinical trial, RYTELO can offer eligible low-risk MDS patients with meaningful clinical benefit including durable and sustained red blood cell transfusion independence and reduction in transfusion burden. In IMerge, this treatment effect was consistent across key lower-risk MDS subgroups, including both RS-positive and RS-negative patients who are not eligible for ESAs as well as both RS-positive and RS-negative patients who are relapsed or refractory to ESAs. RYTELO was also shown in IMerge Phase 3 to have a well-characterized safety profile with generally manageable and short-lived thrombocytopenia and neutropenia, which are familiar adverse events for hematologists who are experienced with managing cytopenias. Third, from an EU perspective, we also have a marketing authorization application, or MAA, under review in transfusion-dependent lower risk MDS which we expect could be completed in early 2025. We're working to finalize our strategy for EU commercialization as we continue to explore our options in the interest of maximizing our ability to serve all of our stakeholders, patients, health care providers and shareholders. We're continuing to engage in discussions with EU regulators, authorities and payers as we assess those options, which include self-commercialization or partnering. Then fourth, from a clinical development perspective, our pivotal Phase 3 IMpactMF OS clinical trial in JAK-inhibitor relapsed/refractory myelofibrosis patients has now achieved approximately 70% enrollment. An interim analysis is still expected in early '26. This JAK relapsed/refractory MF population represents a high unmet need population and significant commercial opportunity. Lastly, our highly experienced team is driving performance across our business, passionately serving patients and customers and staying focused on quality and operational excellence. I'm also happy to report today that we have had an exceptionally strong response to our Chief Commercial Officer search and that we've made great progress in identifying several candidates with strong leadership skills and a history of outstanding commercial execution. We expect to be able to make an announcement in the next month or so. With that, I'll turn the call over to Andy for commercial and operations update. Andy?

Thanks, Chip, and good morning to everyone on the call. We have built a strong commercial infrastructure that has enabled us to activate the launch effectively. First, we are pleased with the early awareness of RYTELO among prescribers and payers. Based on our market research before FDA approval in May of 2024 of over 100 U.S. hematologists and oncologists, over 80% of those surveyed were aware of imetelstat. One in 3 surveyed physicians indicated familiarity with the clinical data and a majority of these physicians look favorably on the efficacy profile and mechanism of action, which is especially important for a first-in-class treatment. Payers are expressing high levels of interest and already have a strong understanding of the RYTELO U.S. prescribing information and IMerge Phase 3 clinical data. From an operational perspective, both dosage strengths of RYTELO, the 188 mg vials and 47 mg vials were available in our distribution channel for customers to order from specialty distributors as of June 27, 2024. Our distribution network is fully activated with our specialty distributor network actively supporting customer demand across hospitals and community oncology clinics. Across the contiguous 48 states, RYTELO is available to HCPs within 24 to 48 hours from our specialty distribution networks. We also believe that RYTELO's inclusion in the updated NCCN guidelines has been important in spreading awareness among the prescriber community. The NCCN guidelines are a highly regarded resource in clinical decision-making for prescribers as well as provide critical considerations from a formulary and treatment pathway development perspective. Generally, the top national payers and Medicare cover oncology medicines categorized as 1 or 2A treatment by NCCN guidelines. Our patient access and affordability solutions are fully activated. Our patient hub is fully operational and supporting inquiries from HCPs and patients. Our J-code application was submitted in July 2024, and we expect issuance of a permanent J-code in the first quarter of 2025. We have seen a strong push by prescribers to add RYTELO to their formularies and EMRs that can help accelerate access in the meantime. Lastly, we engaged with the major national payers within 30 days of launch and look forward to continued dialogue as they adopt their national coverage policies, which we expect to occur in the first quarter of 2025. On this next slide is a snapshot of our medical and commercial field teams that have been fully deployed to cover the entire U.S. market, supporting HCP and account education and uptake. This includes 50 key account managers, our oncology clinical educator liaisons, field reimbursement access directors and national account teams, along with our field medical affairs teams. We are pleased that since these commercial and medical field teams were deployed in June, there has been a strong level of in-person access to community and academic accounts and HCPs. We believe that the experience and relationships that our talented field teams bring to Geron have enabled them to quickly access these accounts. We believe that the strong RYTELO value proposition, commercial foundation and the execution of our entire organization is driving encouraging early results over these first 6 weeks of launch. As we commented earlier, we estimate that as of July 31, 2024, approximately 160 patients have received RYTELO. This demand was generated in part by reaching approximately 60% of top decile 1 through 4 accounts and includes orders from roughly 115 unique accounts. We are seeing an encouraging range of customers ordering RYTELO in these early days from small community to large aggregator accounts with hospitals ranging from community, academic centers, teaching hospitals and large health systems. In July, we kicked off our national speakers program with the launch of our national broadcast event featuring medical experts, which garnered over 300 medical professional participants. These events are a critical component of our marketing strategy to make sure HCPs are aware of the new treatment option for their eligible patients. Overall, our teams have focused on delivering our launch strategic objectives, supporting a positive first experience for HCPs and patients, encouraging adoption among prescribers and facilitating patient access. We believe our early performance reinforces that executing against these objectives can meaningfully drive awareness and uptake for appropriate patients. With that, I'll turn the call over to Faye for a medical and clinical update. Faye?

Thanks, Andy, and thanks to everyone for joining our call today. As Chip mentioned, on July 25, the NCCN published updated MDS treatment guidelines including RYTELO for the treatment of symptomatic anemia in patients with lower risk MDS. We believe that RYTELO placement in the updated NCCN guidelines reflects the strength of our Phase 3 data, which shows the clinical benefit of imetelstat regardless of ring sideroblasts status or serum EPO level as well as the favorable U.S. prescribing information, where RYTELO is indicated broadly across RS-positive and RS-negative patients who are both ESA-ineligible and ESA relapse/refractory. The MDS NCCN guidelines characterize lower-risk MDS patients without the del(5q) abnormality and with symptomatic anemia on the basis of ring sideroblasts status and serum EPO levels without specifying red blood cell transfusion burden. Overall, and as shown in the purple common boxes on the far right of this slide, these updated MDS NCCN treatment guidelines include RYTELO as a Category 2A treatment for both RS-positive and RS-negative first-line ESA-ineligible patients and as a Category 1 treatment for both RS-positive and RS-negative second-line patients, regardless of first-line therapy. Diving into these guidelines in more detail. On the left side of the slide is a schematic representing the NCCN guidelines for the treatment of RS-positive patients. For ESA-ineligible patients who have serum EPO levels greater than 500 mU/mL, imetelstat is included as a Category 2A first-line treatment for RS-positive ESA-eligible patients, with serum EPO levels, 500 mU/mL and below. Imetelstat is included as a Category 1 treatment second line after luspatercept. Additionally, as shown in the 2-plus line at the bottom of schematic, imetelstat is included as a Category 1 treatment for the later lines of therapy after ESA or luspatercept treatment in these RS-positive ESA eligible patients. On the right side of the slide is a schematic representing the NCCN guidelines for RS-negative patients. For ESA-ineligible patients who have serum EPO levels greater than 500 mU/mL, imetelstat is included as the Category 2A first-line treatment. For RS-negative, ESA-eligible patients with serum EPO levels 500 mU/mL and below, imetelstat is included as the Category 1 treatment regardless prior first-line therapy with either ESAs or luspatercept. Turning now to clinical development update from our myelofibrosis program. Our pivotal Phase 3 IMpactMF of imetelstat in JAK inhibitor relapsed/refractory MS, the first and only Phase 3 trial in MS overall survival as the primary endpoint has reached approximately 70% enrollment as of August 2024. Per protocol interim analysis has been planned when approximately 35% of the planned enrolled patients have died, which we anticipate in early 2026. A final analysis is planned when approximately 50% of the planned enrolled patients have died, which is currently anticipated in early 2027. If the interim analysis is statistically significant, we would plan to file a supplemental new drug application with the FDA based on the interim analysis. As an overall survival study, the time line for the interim and final analysis is dependent not only on the rate of enrollment but also on the event rate or patients death rate in the trial. Today, treatment of myelofibrosis is dominated by JAK inhibitors or therapies with other mechanisms of action in combination with JAK inhibitors. Once patients become unresponsive to JAK inhibitors, which leads to treatment discontinuation for approximately 75% of patients after 5 years, they face a dismal overall survival of approximately 11 to 16 months. We believe that if our trial is successful and imetelstat is approved in this indication, it could transform treatment for these myelofibrosis patients. Lastly, we are also evaluating imetelstat in the IMproveMF Phase I study as combination therapy with ruxolitinib in patients with frontline myelofibrosis. Our main goal for this combination study is to determine the safety profile of the regimen of ruxolitinib and imetelstat as well as to explore potential activity of imetelstat in a frontline MS disease setting. Part 1 of the study is designed to be dose finding. In July 2024, after no dose-limiting toxicities were experienced by the first 3 patients in the dose level 4 cohort or imetelstat sodium 9.4 mg per kg, the study evaluation team or SET unanimously recommended expanding the cohort per the trial protocol. This is the final step before dose selection and progression to part 2 of the study that is designed for expansion and dose confirmation. We hope to provide an update from Part 1 of the study at an upcoming medical meeting. With that, I'll turn the call over to Michelle for a financial update. Michelle?

Thanks, Faye, and good morning, everyone. For detailed Q2 2024 financials, please refer to the press release we issued this morning, which is available on our website. Now let me bring your attention to a few highlights from the quarter. As of June 30, 2024, the company had approximately $430 million in cash, cash equivalents and marketable securities. Total product revenue net for the 3 and 6 months ended June 30, 2024, was approximately $780,000. RYTELO became available for prescribers to order from specialty distributors as of June 27, 2024. Total revenues for the 3 and 6 months ended June 30 were $882,000 and $1.2 million, compared to $29,000 and $50,000 for the same period in 2023. The increase in revenue is due to product revenue from U.S. sales of RYTELO that commenced in June 2024. Total operating expenses for the 3 and 6 months ended June 30 were $70.2 million and $126.7 million compared to $52 million and $92.1 million for the same periods in 2023. Cost of goods sold was approximately $17,000 for the 3 and 6 months ended June 30, which consisted of cost to manufacture and distribute RYTELO. R&D expenses for the 3 months and 6 months ended June 30, 2024, were $30.8 million and $60.2 million, respectively, and $35.5 million and $62.7 million for the same period in 2023. Our clinical development costs for IMerge Phase 3 have decreased as we move into the long-term follow-up stage. Selling, general and administrative expenses for the 3 and 6 months ended June 30, 2024, were $39.4 million and $66.5 million, respectively, and $16.5 million and $29.4 million for the same period in 2023. The increase in selling, general and administrative expenses primarily reflects higher commercial launch expenses, increases in headcount and stock-based compensation recognized due to the vesting of performance-based stock options upon FDA approval of RYTELO. As of June 30, 2024, we had 220 full-time employees. We plan to grow to a total of approximately 230 to 260 employees by year-end 2024. Our projected full year 2024 operating expenses are expected to be between $270 million and $280 million, which is unchanged from our prior guidance. Based on our current operating plans and assumptions, we believe that our existing cash, cash equivalents and marketable securities, together with our projected revenues from U.S. sales of RYTELO, will be sufficient to fund our projected operating requirements into the second quarter of 2026. I will now turn the call back over to Chip.

Thanks, Michelle. To close, we're encouraged by our early commercial launch performance and the feedback we're receiving from customers and payers. We're pleased with our strong execution to date, but also recognize that we're still in the very early stages of our U.S. launch with many more patients to serve and many more customers to engage. . We have conviction that RYTELO can become part of the standard of care for eligible patients in this high unmet need lower-risk MDS treatment paragon and bring differentiated benefits to patients. And in addition to our launch in lower-risk MDS, we're also advancing our imetelstat development program in myelofibrosis, which pending positive outcomes from the trials, we believe will contribute significantly to the commercial value proposition for RYTELO in the future. Thank you, and we'll now open the line to questions. Operator?

[Operator Instructions]. Your first question comes from the line of Tara Bancroft with TD Cowen.

So I guess to start, I would love to get a better sense of expectations for the year and what you're targeting. And for that, I know you're probably not providing revenue guidance, but I think it would be helpful to know whether a couple of things you think a J-code could be finalized potentially before January and other metrics like how soon you think the field team will hit 100% of the target prescriber base.

Thanks a lot, Tara. I appreciate the questions, which you're quite correct. We have limited ability to answer 6 weeks into the launch. I think we're really, really happy with where we've ended up in such a short period of time and think that, that is -- we hope that, that's a harbinger of performance as we continue on. I think the J-code, I think we're guiding to the first quarter because we are honestly not 100% sure when it will come. History suggests that there is some variability at the end. But we gave that guidance. And I think we'll stick by it for the moment as we get a little bit closer, we may or may not have more information. But as of the moment, I think we would still stick to the early -- earlier part of the year. I think with regard to metrics on the sales force, well, the sales force is completely engaged, as you can imagine. I don't actually have any predictions available to any of us on that. But I do know that they are as, what's the best word for it, they are as enthusiastic and as hard-working group of both cans, not only the key account managers, but also the folks responsible for trading channel and for all of the various activities involved in a sophisticated commercial launch. I think it's probably all we can say today, but thanks for the question. Look forward to seeing this all evolve over the remainder of the year.

Your next question comes from the line of Carter Gould with Barclays.

Congrats to Chip and team on the early days here. Appreciating that it's early, how would you -- I guess, that initial 160 patients, would you characterize that sort of as a bolus or potentially something more sustainable? Again, I appreciate it's early, but were your were sort of -- you have a sense that these patients were sort of identified by clinicians ahead of the launch or sort of more spontaneous use. And then on the patent term extension side of things, my understanding as I recall, I think sort of USPTO has, I think, statutorily has like 14 months to respond to your extension. Is that correct? And is that a fair characterization of the time line we should expect to hear back on this front?

Okay. Thanks, Carter. So with regard to the initial uptake in demand and the question of a bolus. You only know a bolus for sure, and you see it in the rearview mirror, right? I mean if the trend line continues, it's not a bolus. If it lacks a bit at some point, I guess, you would say it is a bolus. All I can say, Carter is, we didn't -- we did not, in our own thinking models in a bolus. I think we've been pretty consistent about that and how we've set it. So it's a little hard to know exactly where this will go from here. We do think this is all very indicative of a strong degree of organic demand that really reflects all of the great things that really happened starting with the ODAC, which seems like a million years ago, but it wasn't. And then we got, of course, an excellent, very clean label. And then with the NCCN guidelines that really placed this as a forefront of potential standard of care in this space. I think all we can say is we're just seeing a tremendous amount of interest on the part of HCPs, on the part of accounts. And when that -- whether that's going to -- whether this is going to reflect a bolus or not, we don't really know, but I don't think that's something that we've anticipated given the bill-and-buy -- the buy-and-bill nature of the mechanics around all of it. With regard to the PTE, I wish it was 14 months, that would be great. I don't know if it's statutorily there or not, I guess it is. But when we've spoken to our IP council and others, we're seeing anywhere from 3 to 5 years for the PTO to really get back with definitive, yes, you can apply it to this patent, we can apply it to that patent, et cetera. So I would not be holding my breath on that. It's out of our hands. We've done everything we can to make these applications. But the historical performance has been really slow.

Your next question comes from the line of Stephen Willey of Stifel.

I appreciate some of the early metrics here. But just curious of the 160 patients that have started therapy, can you comment as to how many of those patients are actually paying for drug? Is there a yet to be worked out reimbursement process for some of these patients?

I think I'm going to let probably either Andy or Michelle take that. I have a few comments, but they may be in a better position to answer that question. Andy, do you have any thoughts about that?

I think it's way early, Chip, to know, although what we do know is that we haven't had any issues with any of the submissions that have been made to date. These patients have just gone through their first cycle.

Yes. I mean I guess I would add that, again, as Andy said, we haven't received any pushback. I mean we have a hub set up for reimbursement process even with the temporary J-code, customers are pushing us through formularies. And so it has -- reimbursement has not been an issue so far.

And Steve, I guess the only other comment I would have, which may or may not be helpful in this regard. Remember everyone, this is predominantly a Medicare population. And while we don't have as fine to insight into the exact breakdowns of where reimbursement is coming from. We know that the majority of it is PHS. And that's historically not had a lot of pushback as long as you have the NCCN guidelines where they are today for us in Category 1 and Category 2A. So again, early days, we may be able to give a little bit more insight into this. But I think it bodes the current situation as we see it bodes well for the future.

Understood. And again, I guess, understanding that it's early, but do you have any early information on just whether or not you're seeing patients who are newly starting RYTELO being switched off of other salvage therapy. And I guess in your conversation with physicians, is that a dynamic that you expect to play out as the launch proceeds?

Yes. I'll take that, and then I'll invite my colleagues to make any additional comments, if any. Look, I think we just naturally expect that some of these patients will be, as you said, patients from the third line, if you will, or second or third line for sure that would be natural in the availability of a new agent and so forth. But we don't really have a way to characterize that. Our information that comes to us on an individual patient data is very limited -- extremely limited, if any, at all. We're really seeing the demand from accounts flowing into the specialty distributors and occasionally to a specialty pharmacy and that's what we're really able to infer and figure out the dynamics on. We don't -- I'm not sure when and exactly how much fine-tooth detail we're going to get on individual patients. I think that's going to take some more anecdotal information and eventually perhaps even some studies or whatever, I don't want to promise anything here. Of course, we're deeply interested in knowing the answer to all of that. But 6 weeks in, I can tell you right now, Steve, we're just not really 100% sure exactly the circumstances of these patients and exactly the buckets as it were that they're coming out of. We're just grateful that they're there.

Understood. And then maybe just one quick question for Faye. Can you just remind us what the DLT window and the IMproveMF trial is? And for a patient who progresses on frontline rocks, are the next-gen JAK inhibitors allowed in best available therapy?

So the first question -- so the first question is about IMproveMF, correct? DLT window. I'm not -- the cycle length is the 28 days and the DLT window is 1 cycle length. And the next question was about MYF3001 or -- and is whether next-gen....

Whether the next-gen JAK inhibitors are allowable therapy, the best available therapy controller.

No. There are no JAK inhibitors allowed on the [ BAT ].

Your next question comes from the line of Corinne Johnson with Goldman Sachs.

Maybe if you could just help us think directionally about the trajectory of new patient growth from here, probably through like the early launch period, do you anticipate that kind of the new patients going on therapy will come at a relatively steady clip that it could be more lumpy or that it would accelerate over time and maybe precedent would be helpful as you think about the answer there. And then in terms of just target engagement, you mentioned obviously top 60% of your -- or 60% of the top decile accounts. I guess how many patients on average are like from a range are these accounts treating, and of that, like what portion would be eligible for RYTELO?

I'll take the first one, which is the directionality and, as you said, the smoothness versus the lumpiness. I'm going to say the obvious trend. So forgive me. This is only the second new product launch in the last -- what 12 years, more risk MDS or maybe there's been a few others that they've been very modest launches. And so all we really -- we don't have a lot to go on this and 6 weeks isn't very much. I will say that maybe something that might be helpful is that we haven't seen a particularly so far in all of 6 weeks, we haven't seen a particularly lumpy accretion of patients. It's been pretty steady, but it's hard to do a trend line based on that. Maybe the next time we talk, we'll have a better feel for that. But I don't see any particular reason other than just natural variation as things go on, that we would expect anything different than what we've seen to date, but I don't really know. In terms of target engagement, just a couple of comments about this. These accounts are a very wide variety of accounts. So some accounts are large hospital systems, some accounts are individual practitioners. Everything in between that you can imagine. The top deciles tend to be larger aggregator accounts, many, many physicians. So I don't have an exact number of physicians, but I'm not sure how helpful it would be because it is such a wide variety. What we do know is that we've had really good traction in getting in. We've had excellent traction speaking to these accounts in person and the number of accounts touched and reached and including the vast majority in person, is growing every day. So Andy, again, I don't know if you have any insight into this, but I [indiscernible] invite any help you can get [indiscernible].

No. I think that's it, Chip. Yes, I mean it's account activation is accelerating. We believe that. So we're pretty pleased so far. And the top deciles we obviously modeled based on flow of prior treatments when they went for that launch, but I don't know that it's more proportionality. I don't think we can get patient numbers per account right now.

Your next question comes from the line of Gil Blum with Needham & Company.

So I know this is very early, but is there any information you can provide about the split of these patients that were dosed RS-positive, RS-negative, front line, second line, but whichever information you have?

Yes. Thanks, Gil, thanks for the question. We don't have it. It's not the kind of information that would come in at this moment in time. We get -- this is pretty much demand information that we're able to give you. This is the number of vials going out the door. And what we -- eventually, I think we will try very hard to get that. We're as interested as anybody in the nuances of again, which buckets these patients are coming in. But as of today, no, we don't have that. And it will take some tweaking of our information sources and how we get that over the next several, I would think, many quarters, perhaps, to actually get a really accurate view on that. But as of today, we just don't know.

That's very helpful. Sure. And another question and then kind of related one. How long do you think it would take so you start getting feedback from treating physicians or else challenges they're having at giving the drug or any other kind of bottlenecks?

Yes, thanks. Well, I think that boils down to the people that we have deployed in the field. Again, I didn't invite Andy to comment about that because if you remember that slide that he showed. We've got a really varied group of people out in the field, and I feel quite good about that. But Andy, you might want to just run through sort of how we get feedback.

Yes. I mean we have several channels, obviously, but I think our MedAffairs team that's in the field and our medical affairs hub, which is fully active is right now, probably the main source of flow of certainly information requests. It's -- I think it's way early to start getting specific feedback. Again, given that we're only 6 weeks in, most of these patients are just through one -- a single cycle of treatment. But we have seen a strong and I think a strong volume of med info requests across a range of different areas from efficacy and safety to dosing and reactions to the prescribing information. So I think that bodes well that physicians are interested and becoming more and more educated about treating with RYTELO.

Your next question comes from the line of Kalpit Patel with B. Riley Securities.

For the launch, I guess, do you have an early estimate or early sense of what the gross to net adjustments would be for third quarter? And how you anticipate that to shift over time, maybe into fourth quarter or at least in '25.

I appreciate the question. I think Michelle is probably the best person to answer that question. Michelle?

Yes. Thanks, Kalpit. I mean we obviously only had 1 week for the June close in our gross to net calculation. So I mean, it's a pretty straightforward gross-to-net breakdown of components, I mean, because it is a primary Medicare population. So we know the PHS is going to be one of our largest deductions in the gross to net. But I would say it's too early for us to really be comfortable and we need more data as the July sales close out and as well as the rest of the quarter. But we'll have a pretty good sense after a full quarter worth of sales.

Okay. And as a follow-up, how are you viewing the current sell-side consensus estimates for RYTELO in the second half of this year under your current launch projectors?

Michelle, I think it's your [indiscernible]

Sure. So I would say from a consensus perspective, as I mentioned before, I think that we need to sort of sit down with you guys and go through some of the assumptions because they're definitely mixed among the different models and sort of mixed versus our internal models. And I think it's a lot on the annual cost per patient. There's a lot of variance between the models of the year. So -- which I think is probably contributing to that would be duration of therapy and penetration is pretty varied. So I think that we'll look to give guidance on that post this earnings call.

Okay. And then one last one on the NCCN guidelines. I guess were there any surprises based on where imetelstat is positioned in all the different subgroups of the treatment algorithm, and do your internal estimates of the percentage of low-risk MDS patients that could be treated with RYTELO, change based on this positioning.

Yes, I'll take that one, and then if Faye listens in and have anything else to contribute, I'd encourage you to do it. A great question, Kalpit. So first of all, I think if you go back to all the way back to top line results, what, close to 1.5 years ago, 2 years ago, we identified at that point in time, a couple of really big pockets of value here. The first one was, of course, that we thought that we were effective regardless of our status. And so -- in both the RS-positive and RS-negative. Second of all, we did have enough patients, although not a ton of luspatercept patients previously treated. And as we used to say, that was a highlight of the previous year's ASH that we saw some really good results there. So we thought that previously treated luspatercept patients who were not doing as well as physicians would likely be important. We thought that the high transfusion burden patients would be very attractive. And then we also identified that it looks like the patients who had serum EPO levels greater than 500. That is the officially the ESA ineligible patients had done pretty well. And so we actually saw from our Phase 3 results, pretty much the makings of where we ended up today. What I can say is the label which, of course, did have some transfusion burden requirements on, as you would expect based on the clinical trial. That didn't actually translate over to the NCCN guidelines, which is interesting, frequently is now the case in NCCN looks at treatment algorithms, if you will. And then all the other pockets really are completely there. So I have to say I don't think we -- what -- the pleasant surprise was that there were no unpleasant surprises. I think we just got a wonderful NCCN guideline affirmation of what we've always seen is the value in these various different areas. So I don't think that -- I think it's pretty much what we were hoping for and what we had always imagined. So Faye, I don't know if you have any other comments about it. It's a great question now.

Yes. Chip, I think you put it well. I think the only surprise was a pleasant one. We received everything that we were asking for and their strong Category 1 and 2A guidelines and a strong reflection of the data of the clinical trial. So all in all, a good result.

This concludes the question-and-answer session. I'll turn the call to Aron for closing remarks.

Thank you so much for joining us today. We appreciate your interest in Geron and look forward to keeping you updated during this very exciting time for our company. Goodbye.

This concludes today's conference call. We thank you for joining. You may now disconnect your lines.