노보큐어(NVCR) 2026년 3분기 실적 발표회: 매출 1억 9,300만 달러 달성, 가이던스 상향

핵심 요약

• 노보큐어의 분기 순매출은 사상 최고치인 1억 9,300만 달러를 기록하며 전년 동기 대비 16% 증가했습니다. 이는 활성 환자 수의 19% 성장과 미국 및 독일 내 승인율 상승에 따른 400만 달러의 일회성 이익에 힘입은 것입니다.
• 매출총이익률은 77%로, 전년 동기의 73%에서 개선되었습니다. 조정 EBITDA는 플러스 1,600만 달러를 기록해 2025년 3분기의 마이너스 300만 달러 대비 흑자 전환했습니다.
• 회사는 2026년 순매출 가이던스를 7억 3,600만~7억 4,300만 달러로 상향 조정했으며, 이는 12%~13% 성장에 달하는 수준입니다. 또한 조정 EBITDA 가이던스도 2,400만~3,400만 달러로 올려 잡았습니다.
• 옵튠 지오는 이번 분기를 사상 최고치인 4,729명의 활성 교모세포종 환자 수로 마감했으며, 이는 전년 동기 대비 11% 증가한 수치입니다.
• 옵튠 루아는 전 세계에서 800만 달러의 매출을 올렸고 활성 환자 255명에 도달했습니다. 일본 시장은 110명의 활성 환자와 400만 달러의 매출을 기여했습니다.
• 옵튠 팍스는 다락손라십 출시 이후 미국 내 성장세가 둔화되며 3분기 말 기준 활성 환자 276명 및 370만 달러의 순매출을 기록했습니다.

주요 재무 데이터

매출에는 200만 달러의 환율 관련 역풍도 포함되었습니다. 경영진은 마진 개선의 일부 원인을 환자 수 증가에 따른 공급망 효율성 향상 때문으로 보았습니다.

사업 및 영업 실적

옵튠 지오 및 교모세포종

옵튠 지오는 노보큐어의 주요 성장 동력 자리를 유지했습니다. 활성 교모세포종 환자 수는 기존 시장과 신규 시장 모두의 기여에 힘입어 전년 동기 대비 11% 증가한 4,729명으로 늘어났습니다.

임상 3상 KEYNOTE-D58 연구는 교모세포종 환자를 대상으로 옵튠 지오와 펨브롤리주맙 및 저용량 화학요법의 병용 효과를 평가하고 있습니다. 경영진은 환자 등록이 2026년 말까지 완료될 수 있도록 예정대로 진행되고 있다고 밝혔습니다.

옵튠 마이아

FDA는 비소세포폐암의 뇌전증 치료에 대한 노보큐어의 옵튠 마이아 시판 전 승인(PMA) 신청건을 심사하고 있습니다. 이번 신청은 대조군 대비 TTFields 투여군의 뇌 내 진행 시간을 2배 연장한 임상 3상 METIS 임상시험을 바탕으로 합니다.

경영진은 2026년 말까지 FDA의 결정이 내려질 것으로 계속 예상하고 있으며, 2027년 초에 출시가 이어질 수 있다고 말했습니다. 회사는 출시 후 2년 이내에 보험 급여가 적용될 것으로 예상하고 있습니다.

옵튠 루아

옵튠 루아는 전 세계 활성 환자 255명에 도달했으며 분기 매출 800만 달러를 기록했습니다. 일본 시장은 110명의 환자와 400만 달러의 매출을 차지했습니다.

경영진은 제품의 적응증 라벨이 일본의 2차 면역관문억제제 사용 가이드라인과 일치함을 강조했습니다. 협상된 일본 내 월 사용료는 글로벌 옵튠 지오 가격과 거의 비슷한 수준입니다.

옵튠 팍스

옵튠 팍스는 3분기를 활성 환자 276명 및 370만 달러의 순매출로 마감했습니다. 경영진은 다락손라십 출시 이후 췌장암 치료 현장에서 보험 이의신청 및 피부 자극 관리 관련 업무 부담이 커지면서 미국 내 성장 모멘텀이 둔화되었다고 밝혔습니다.

노보큐어는 KRAS 억제제 관련 소규모 안전성 및 타당성 연구 2건을 계획하고 있습니다. PANOVA-5 연구는 국소 진행성 췌장암 환자를 대상으로 옵튠 팍스, 젬시타빈, 냅-파클리탁셀 및 베라스템의 VS-7375 병용 요법을 평가합니다. PANOVA-6 연구는 전이성 질환에서 옵튠 팍스와 다락손라십의 병용을 평가할 예정입니다. 두 연구 모두 2027년 상반기에 시작되어 각각 약 25명의 환자를 모집할 것으로 예상됩니다.

경영진 가이던스

경영진은 당분간 연구개발비(R&D) 지출이 대체로 현재 수준 이하를 유지할 것으로 예상합니다. 2027년 R&D 비용은 KEYNOTE-D58 및 LUNAR-2가 여전히 주요 지출 항목으로 남아 있는 가운데, 전년과 비슷하거나 약간 낮아질 것으로 전망됩니다.

회사는 옵튠 팍스 및 옵튠 마이아에 대해 제한적인 추가 마케팅 투자를 진행하면서 주로 기존 영업팀에 의존할 계획입니다. 일반관리비(G&A)는 최소한의 인플레이션 관련 증가 외에는 현재 수준 부근을 유지할 것으로 예상됩니다.

경영진은 두 자릿수 매출 성장을 달성하겠다는 장기 목표를 재확인했습니다. 또한 조정 EBITDA 손익분기점 달성, 이어서 현금흐름 손익분기점, 최종적으로 순이익 손익분기점 달성으로 이어지는 3단계 수익성 확보 경로를 제시했습니다. 특히 노보큐어가 신제품 출시를 준비함에 따라 분기별 실적 경과는 변동될 수 있습니다.

리스크 및 주요 관전 포인트

• 다락손라십 출시 이후 의료진의 관심 유도 경쟁이 펼쳐지면서 옵튠 팍스의 미국 시장 출시 속도가 둔화되었습니다.
• 옵튠 팍스에 대한 민간 보험사의 보장 범위 확대는 향후 개정될 NCCN 췌장암 가이드라인 포함 여부에 일부 달려 있습니다. 엘레반스는 이미 보장 정책을 마련했습니다.
• 3분기 매출에는 일회성 승인율 수혜가 포함되어 있어 4분기 실적과의 직전 분기 대비 직접 비교에는 한계가 있습니다.
• 환율 변동 영향으로 3분기 매출이 200만 달러 감소했습니다.
• 조정 EBITDA는 매출 변동성과 신제품 출시 관련 지출로 인해 분기별로 변동할 수 있습니다.

애널리스트 Q&A 하이라이트

경영진은 옵튠 팍스에서 다락손라십으로 전향하는 환자가 대규모로 발생하거나, 표준 화학요법을 내약할 수 없는 환자 이외에 1차 치료제로서 다락손라십이 광범위하게 쓰인다는 명확한 증거는 확인되지 않는다고 밝혔습니다. 회사는 현재 바쁜 의료 현장에 대한 접근성 제한을 옵튠 팍스 처방의 가장 큰 제약 요인으로 보고 있습니다.

일본 시장의 경우, 경영진은 2027년 1분기에 옵튠 팍스의 보험 급여 적용이 결정되어 상업적 출시가 가능해질 것으로 예상합니다. 회사는 일본에서 폐암과 췌장암 모두 상당한 시장 기회로 평가하며, 향후 일본이 미국에 이어 두 번째로 큰 시장으로 자리잡을 것으로 기대하고 있습니다.

4분기 매출과 관련하여 경영진은 약 440만 달러의 일회성 이익을 제외한 3분기 실적이 반복될 경우 연간 매출이 7억 4,000만 달러 부근에 도달하여 업데이트된 가이던스의 중간 수준이 될 것이라고 설명했습니다.

실적발표 컨퍼런스 콜 전문

전체 실적 발표 컨퍼런스 콜 녹취록

경영진 발표

Operator

Good day, and welcome to the NovoCure Q3 2026 Earnings Call. [Operator Instructions]

Please note, this call may be recorded. I would now like to turn the call over to Adam Daney. Please go ahead.

Adam Daney

Good morning, and thank you for joining us to review NovoCure's third quarter 2026 performance. I'm joined on the phone today by our Executive Chairman, Bill Doyle; CEO, Frank Leonard, Chief Innovation and Medical Officer, Uri Weinberg; and CFO, Christoph Brackmann.

For your reference, slides accompanying this earnings release can be found on our website, www.novocure.com on the Investor Relations page under Quarterly Results. 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 statement, except as required by law. Where appropriate, we will refer to non-GAAP financial measures to evaluate our business and 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 noncash items and best reflects the financial value generated by our business.

We do not provide forward-looking guidance for adjusted EBITDA on a GAAP basis due to the inability to predict share-based compensation expenses contained in the reconciled GAAP measure, net income without reasonable efforts.

Reconciliations of non-GAAP to GAAP financial measures are included in our press release, earnings slides and in our Form 10-Q filed with the SEC today. These materials can be accessed from the Investor Relations page of our website. Following our prepared remarks, we will open the line for questions. I will now turn the call over to our Executive Chairman, Bill Doyle.

William Doyle

Thank you, Adam. This morning, NovoCure reported results for the third quarter of 2026. This quarter was marked by solid execution with continued momentum in our Optune Gio business and our promising launch of Optune Lua in Japan. We reached a record number of active patients on therapy, generated record high quarterly net revenue, and made strong progress on our path to profitability.

We experienced headwinds in our Optune Pax launch this quarter, but remain committed to establishing TTFields therapy in the evolving PDAC standard of care. As we enter the final months of the year, we are on track to achieve our 2026 goals, and we believe we are well positioned to drive this positive momentum into 2027.

I will begin this morning with a review of our Optune Gio and Optune Mya programs. Frank will provide an update on Optune Pax and Optune Lua, and Christoph will conclude our prepared remarks with a review of our third quarter financial results and updated guidance. We will then open the line for questions.

Q3 was another strong quarter for our Optune Gio business. We finished the period with 4,729 GBM patients on therapy, an 11% increase year-over-year and our highest GBM active patient count to date. A notable feature of this growth cycle is the mix of contributions from both new and established markets. We continue to believe many more patients can benefit from Optune Gio, and we are determined to find the avenues to reach them.

Each of our active markets has opportunities to increase adoption in GBM, and our country-level teams are focused on improving outreach and targeting to connect with physicians and patients at the optimal points in their treatment journeys. Optune Gio is a standard of care for newly diagnosed GBM, established on the foundation of the best-in-class clinical data for overall survival. And we are working to extend survival further.

Our Phase III KEYNOTE-D58 clinical trial is evaluating adding the immunotherapy pembrolizumab to Optune Gio and low-dose chemotherapy in diagnosed glioblastoma. We've been pleased with the strong interest in D58 since launch as physicians are eager to see whether concomitant use of TTFields and immunotherapy can improve survival in GBM further. D58 remains on track to complete enrollment by year-end, and we look forward to sharing more information from this trial in the periods ahead.

Turning to Optune Mya, our PMA application for the treatment of brain metastases from non-small cell lung cancer is under review with the FDA. As a reminder, this application is based on the data from the Phase III METIS trial, which showed a doubling in time to intracranial progression in patients on the TTF arm compared to control.

We continue to expect a final decision on our PMA application by year-end with a potential launch in early 2027. As with our other launches, we expect to establish reimbursement within two years of launch.

NovoCure continues to grow and evolve. We have reignited growth in our core GBM business and launched Optune Lua and Pax in multiple countries, with Mya expected to follow. We've established the infrastructure to service larger patient populations and have initiated structural changes to accelerate our transition to profitability. I'll now pass the call to Frank to discuss the ongoing launches of Optune Pax and Lua.

Frank Leonard

Thank you, Bill. We believe that we have multiple drivers of long-term growth, including increasing adoption of Optune Gio, successfully launching new indications like Optune Pax and Mya and pursuing opportunistic launches such as the Optune Lua launch in Japan. We are 2.5 quarters into our launch of Optune Pax, and we finished the third quarter with 276 active patients on therapy and generated $3.7 million in net revenue.

We have seen momentum slow in the U.S. due to the introduction of daraxonrasib. Our ability to access practices to detail Optune Pax is significantly limited at this time. We acknowledge the challenges in the Optune Pax launch, and we will continue to evolve our tactics to ensure we maintain our share of voice in our approved indication, which is different than the approved indication for daraxonrasib.

We will also continue to monitor the details of the daraxonrasib launch and invest appropriately in relation to the market realities. We look forward to the upcoming annual update of the NCCN guidelines for the treatment of pancreatic cancer, and we'll update our marketing materials accordingly.

Most importantly, we will work closely with our physician collaborators to establish the best next set of clinical trials to establish TTFields more firmly as the standard of care for PDAC.

We are specifically eager to generate data focused on concomitant use of TTFields and KRAS inhibitors. The initial step in this effort will be through two small safety and feasibility trials. The PANOVA-5 trial will explore the concomitant use of Optune Pax, gemcitabine, nab-paclitaxel and Verastem's KRAS G12D inhibitor, VS-7375 in our approved locally advanced setting. We are excited to collaborate with Verastem in this effort and expect to initiate this study in the first half of 2027.

The PANOVA -6 trial will explore concomitant use of Optune Pax and daraxonrasib in the metastatic setting, which we also expect to initiate in the first half of 2027.

Moving to Optune Lua. We continue to see momentum in our launch in Japan. We finished the quarter with 255 Optune Lua active patients and $8 million net revenue globally, with 110 active patients and $4 million in net revenue contributed by Japan. Second-line use of immune checkpoint inhibitors is standard of care in Japan, which overlaps well with our label and the strongest outcomes from the LUNAR trial data.

In addition to the promising commercial landscape, the negotiated monthly price for Optune Lua in Japan is approximately in line with our global price for Optune Gio. Optune Pax was also approved by Japanese regulators earlier this year with reimbursement likely in the first half of 2027. Together with our growing Optune Gio business, we expect Japan will eventually be our second largest market behind the U.S.

As Bill said earlier, we focused in recent years on diversifying and expanding our growth drivers. We are beginning to see those drivers contribute, specifically in our continued Optune Gio growth and Optune Lua launch in Japan. We expect Optune Pax to return to growth in the coming quarters. And with these drivers in place as well as enhanced controls on operating expenses, we believe we are well positioned to make material strides forward in our path to profitability next year. I'll now pass the call over to Christoph to review our third quarter financials.

Christoph Brackmann

Thank you, Frank. This was a very strong commercial quarter. We generated $193 million in net revenue, an increase of 16% year-over-year. This includes contributions of $8 million and $4 million from Optune Lua and Optune Pax, respectively. The increase in net revenue was primarily driven by a 19% year-over-year increase in active patients as well as a onetime benefit of $4 million from increased approval rates in the U.S. and Germany. We also experienced a $2 million headwind from foreign exchange rates in the quarter.

Based on our strong commercial performance this quarter, we are raising our revenue guidance. We now expect 2026 net revenue between $736 million and $743 million, representing 12% to 13% growth. This includes net revenues from Optune Lua and Optune Pax collectively between $30 million and $34 million.

Gross margin for the quarter was 77% compared to 73% in Q3 of last year. An important aspect in our pursuit of profitability is optimizing our supply chain efficiency as we treat larger patient populations, and we continue to see progress on these initiatives. We expect to maintain our gross margin in the mid- to high 70s through the final quarter of 2026.

Turning to our operating expenses. Research and development costs this quarter were $58 million, an increase of 8% year-over-year. The increase was primarily driven by expenses related to our KEYNOTE-D58 trial as we finalize enrollment.

R&D expenses can fluctuate quarter-to-quarter, largely around clinical activity for services delivered in the period. We are confident that we can keep R&D costs roughly at or below current levels for the foreseeable future.

Sales and marketing expenses in the quarter were $53 million, a decrease of 9% from the same period last year. The change was primarily driven by lower share-based compensation and lower general marketing expenses in the quarter. As we look ahead to Q4 and 2027, we intend to largely leverage our existing sales forces.

We do expect to make limited incremental marketing investment intended to support the launches of Optune Pax and Optune Mya.

General & Administrative Expenses for the quarter were $44 million, a decrease of 5% year-over-year. The primary driver of the decrease was lower share-based compensation expenses. We have made the G&A investments required to support larger patient populations, and our aim is to maintain the current level of G&A with minimal increases due to inflation.

Net loss in the quarter was $10 million compared to a $37 million loss for Q3 of last year and loss per share was $0.09. Our EBITDA loss in the quarter was $2 million compared to a loss of $32 million in Q3 of 2025.

Adjusted EBITDA, which removes the impact from share-based compensation was positive $16 million this quarter compared to a negative $3 million of last year. We are updating our full year adjusted EBITDA guidance today to a range of $24 million to $34 million.

Our cash and investment balance as of September 30 was $463 million. Our focus on profitability has been a key performance metric for the entire organization in 2026, and we are pleased with the progress made this quarter. The third quarter marked a new record high net revenue generated and our strongest EBITDA and adjusted EBITDA quarter in over four years.

The investments necessary to launch new indications and support larger patient populations have largely been made. As we continue to gain traction across our commercial portfolio, we believe there is significant P&L leverage to be realized. Achieving adjusted EBITDA positivity this year is an important first step in the profitability journey, and we look forward to updating you on our progress and future objectives in the coming months.

With that, we will now open the line for your questions.

Operator

[Operator Instructions]

Our first question comes from Vijay Kumar with Evercore ISI.

질의응답

Vijay Kumar

Frank, maybe my first one on Pax trends. And I know in the past, you've said this is not like a drug launch. Don't expect script volume similar to drugs. And I understand that, but sequential step down here on patients and script volumes, right? If you could just elaborate on what happened in the quarter? How are we thinking about Pax launch, I think that will be helpful.

Frank Leonard

Yes. Thank you, Vijay, for the question. It's clear, we had a record quarter overall in terms of our commercial execution, as Christoph just detailed, really strong progress across Gio around the world as well as our Japan launch. But it is clear to us that we faced significant challenges in the U.S. Pax launch this quarter. To give a little bit of color, I think we all need to think about just the sheer volume of patients now coming into practices and asking for daraxonrasib.

And that has an immediate effect on the practice in a few different ways. I mean, one is that immediately, the insurance appeals start. And I think as some on the line are tracking, the journey for daraxonrasib through the insurance process is just starting. And on the other side, as the patients progress on therapy, they do see a lot of skin irritation.

So what we face in terms of getting into practices right now is really just a share of voice issue as we see it right now that the practices are just a bit overwhelmed. They're overwhelmed with appeals, they're overwhelmed with skin irritation. But we do see that continued interest when we engage with clinicians in explaining Optune Pax.

So to look ahead, we are committed to this market. We still see strong recognition of the clinical value of Optune Pax as a first-line treatment in locally advanced pancreatic cancer. And we are eager to see this early disruption kind of the practice disruption settle down in the coming quarters and give us a chance to really get back in there and earn the patients that could really benefit from Tumor Treating Fields.

Vijay Kumar

Understood. Maybe Christoph, one for you. Adjusted EBITDA performance here in the quarter was really a standout. Sustainability of this level of sequential improvements in adjusted EBITDA. I mean what's the path forward when you think about adjusted EBITDA trends?

Christoph Brackmann

Yes. Thank you, Vijay. Yes, you said it. I mean, we had a very strong quarter of financial performance, both across all lines really on the P&L, right? I mean, starting with revenue growth, very strong revenue growth based on active patient growth, but also with some onetime benefit. We had strong gross margin, relatively lower cost to previous quarters. And all of that culminated in a record high EBITDA and adjusted EBITDA. So the first comment is, as we said in the past, we are really committed to this path of profitability, and we always said for us, it's three steps.

Step 1 is to get adjusted EBITDA breakeven.

Step 2 is then cash flow breakeven, step 3 is net income breakeven.

And we are very happy that we passed the first step, and we are committed to adjusted EBITDA breakeven if you look at it on a full year basis.

Now I would caution, we will have some fluctuations quarter-to-quarter. You can also take from our guidance for adjusted EBITDA that we're not just straight line projecting a quarter-over-quarter increase, but we gave ourselves some room. One is on -- we have a range on revenue for our guidance, but then two is also now with Q4 coming up. It's typically a difficult quarter to estimate because we are getting ready for launches for next year.

So in short, we are committed to adjusted EBITDA breakeven. We are committed to really focus on the next call is cash flow breakeven, but I wouldn't want to commit to a straight line on a quarter-to-quarter basis.

Operator

Our next question comes from Larry Biegelsen with Wells Fargo.

Larry Biegelsen

So one on 2027, one on Pax. So Frank, I think at our healthcare conference, you talked about striving for double-digit growth in 2027. Is that still the case? And can you talk about the headwinds and tailwinds behind the outlook?

Frank Leonard

Thanks, Larry. Yes. So as we've talked about the future of NovoCure, what we have aspired to be is a company that produces double-digit top line growth and returns to profitability, as Christoph just outlined. We were really pleased in this quarter to have delivered double-digit growth, both when you look at all products together, but even in the Gio franchise, where existing markets like the U.S. were growing strong, and we found new markets to continue building like Spain.

I think that our commercial organization is really firing on all cylinders right now. And where there's opportunity, they're taking it. And I think I'm quite proud of those results. So yes, that's our vision is we remain committed to delivering that top line double-digit growth into the future.

Larry Biegelsen

That's helpful. And Japan was obviously very strong again this quarter. What are your expectations for Lua and Pax? Just remind us of the time line for reimbursement there. We saw, obviously, you got approval and remind us why this is an exciting opportunity.

Frank Leonard

Thank you, Larry. And I realize I missed the very end of your question. I didn't answer the very end of your first question here. In terms of possible tailwinds or real tailwinds for the company overall, our business in Japan is definitely one of those tailwinds. We have launched Optune Lua successfully, continued to build our active patient volume through the year this year.

We are already looking ahead to next year where we have our national symposium with all of the relevant physicians who treat non-small cell lung cancer in Japan coming into Tokyo to do a symposium just focused on Optune Lua in January. So we see that strong continued interest for Lua to continue growing in Japan.

Optune Pax was just approved for regulatory approval in the quarter, and we expect to have reimbursement early in 2027, first quarter of 2027, which would then allow us to begin the launch in Optune Pax. And as a reminder, for both of these products, we were able to reset our price levels with the MHLW in Japan. Both Lua is already priced at a higher level than our Gio product in Japan. And we're hopeful that we'll be able to achieve a similar outcome for the Pax product as it comes to market.

So the last thing I'll say is just to remind everyone in Japan, historically, our business in Japan has appeared relatively small, relative to the rest of the company because the incidence of GBM is very low in Japan. That's not the case for lung cancer. And in fact, in pancreatic cancer, it's actually a higher incidence than in the U.S. So these are real sizable markets with strong physician interest, and we are very excited for our Pax launch in Japan.

Operator

Our next question comes from Jason Bednar with Piper Sandler.

Jason Bednar

I'll ask the obligatory question here on Optune Pax as well. Just curious, Frank, I mean, I guess, what are you able to control with the process here? And when we think about the accounts you had that were initial users of Pax are they still using? Or did activity -- prescribing activity more or less dry up after the approval? And sorry, I'm going to add another one. Is this an issue you think of practices simply being overwhelmed and they don't have time? Or are you seeing just a lot of practices putting both locally advanced and metastatic PDAC patients on therapy?

Frank Leonard

Okay. Thank you, Jason. Yes, I'll jump in on the second part of this. That's obviously our focus right now is trying to understand what has caused the slowdown in prescribing patterns. We're looking at it both quantitatively in terms of buying data and qualitatively in terms of speaking with physicians. And first and foremost, what I want to highlight is that we're not seeing patients leaving Optune Pax in substantial numbers to start daraxonrasib.

And when we look at qualitative and quantitative data as well, we don't see strong signals that daraxonrasib is being used widespread in first line, except in the patients where they can't tolerate standard chemotherapy. So that leads us back to the hypothesis that we see the practices as just being simply overwhelmed right now and that is what's limiting our ability to get in.

As we spoke briefly about earlier in the call, again, this is a device-based launch. practices need training, they need support. They need help educating the patient. So we do see this as a bit of -- right now, we see it as an issue with the noise of getting into the practice. What can we control? I think first and foremost, we are as an organization, we remain committed to this indication, and our teams know we're committed to the indication, and we are continuing to get as much as we can to get to our physicians.

On that front, I would highlight one of the really promising signals that I picked up recently is I just came back from the ESMO conference in Madrid, we had incredible engagements with physicians across all of our indications. But when I look back at the numbers from the booth of unsolicited inquiries, the #1 product that led to inquiries in our booth was Optune Pax.

So that's where we feel that the recognition of the clinical value is still there. It is up to us to execute with our teams in the field, getting that message out and highlighting the different indications, different stage of treatment that our product is approved for. And then lastly, as we announced yesterday and spoke about today, we are going to continue building the evidence to support and consolidate our status as a valuable and standard of care treatment for PDAC.

Jason Bednar

Right. Very helpful and very clear. One follow-up quick and then a separate question. I'm not sure if I caught where you're at with respect to commercial payers on Optune Pax. Sorry if I missed that, but refresh me there. And then on R&D, obviously, a little bit of a step-up in the quarter, but you're coming to the close of KEYNOTE-D58. How should we think about R&D trending as we move beyond '26 once that KEYNOTE D58 trial ends? I know you got a couple of earlier-stage trials, but those should be far cheaper than KEYNOTE-D58.

Frank Leonard

Yes. Jason, I'll start and then I'll turn it over to Christoph. In terms of our payer engagement in the U.S., the next major milestone for us is to secure inclusion in the NCCN guidelines. The NCCN guidelines for pancreatic cancer are typically published once a year, either at the end of the year or early in the new year.

We have submitted. We understand that we've been reviewed, and we're eagerly waiting for those results to be published. That will trigger additional engagement with payers where we've already had and reported on our one success with Elevance, where we now have a coverage policy in place. Christoph, I'll turn it over to you to talk about any other emerging trends with payers as well as the R&D question.

Christoph Brackmann

Yes. I think on the payer side, I mean, as you noted, I think the real next milestone is NCCN guideline. And apart from that, we are having the discussions with the payer on the commercial side on the inclusion in policies. Obviously, this is a function of, one, the number of patients on therapy that helps us to mess and build pressure with payers and then two, the guideline inclusion is an important factor for that as well.

On the R&D question, Jason, so from a big picture perspective, 2026, we had larger Phase III trials roll off, as you know. And then we had particularly D58 now being close to full enrollment is really at the, let's say, highest level of activity and from that also from a spend intensity perspective at the highest level.

That essentially replaced the studies that we had that were rolling off. For 2027, we expect D58, but also LUNAR-2 still be a significant portion of our spend. So as we said, we expect our R&D expenses flat to slightly declining. And then going beyond that time frame, as large Phase III trials roll off, namely D58 and LUNAR-2, we would expect our R&D expense to go down if we don't replace it with other larger trials.

Operator

Our next question comes from Jessica Fye with JPMorgan.

Tanmay Patwardhan

This is Tanmay on for Jess. I have a question around the updated total revenue guidance. And when I was calculating, I saw that your revised annual revenue guidance now implies $185 million to $192 million in 4Q revenue, which is below the $193 million revenue recorded in 3Q. So can you talk about what assumptions are driving this sequential step down?

Christoph Brackmann

Yes, I can take this. So maybe I share a bit more thoughts on our revenue guidance in general. First, Q3 was really a very successful quarter in terms of net revenue, adding about $9 million of revenues to what we had as a record quarter in Q2, right? So thinking about Q4 revenue guidance, if we do in Q4, what we did in Q3, less the $4.4 million onetime revenue in Q3 that we pointed out, that essentially gets you to $740 million, which is around the midpoint of our guidance. And that was the thinking here. And then we accounted for some potential risk on collection side and some opportunities that we have.

Operator

Our next question comes from Kevin DeGeeter with Ladenburg Thalmann.

Kevin DeGeeter

I just had one on the Verastem collaboration or a clinical trial you announced yesterday. And from the NovoCure perspective, what's the more important learning from that study? Is it really kind of appreciating the patient sort of antitumor clinical benefit of a combination with the KRAS inhibitor? Or does it really learn more about how the skin toxicities kind of play together? I just kind of want to understand, I guess this is an NovoCure-funded study kind of from your perspective, what are we trying to learn?

Frank Leonard

Excellent. Thank you for the question. I'll start off, and then I'll turn it over to my colleague, Dr. Weinberg, to speak to some of the specifics of the trial. First, I just want to note that we are very pleased to have this collaboration in place with Verastem. We think that this asset has the potential to be best-in-class, and we are excited to work with them. I think I would also highlight that I think this trial being done in locally advanced pancreatic cancer, first line, which is our FDA-approved indication, is strong validation of Tumor Treating Fields as an effective therapy in that indication already. And that really drove our ability to get a top-tier partner to work with us on a study here. So my thanks to our partner, our collaborators at Verastem. And I'll turn it over to Dr. Weinberg to talk a little bit about what we hope to see and how it dovetails off some of the things we've already seen in preclinical research.

Uri Weinberg

Thank you. So the PANOVA-5 study is going to focus on our approved indication in pancreatic cancer, namely locally advanced unresectable patients. And it will incorporate the Verastem's G12D VS-7375 inhibitor, KRAS inhibitor concomitantly with gemcitabine, nab-paclitaxel and of course, Optune Pax.

This study will include around 25 patients. And we have also announced that we are opening the PANOVA-6 study that will use daraxonrasib in its approved indication of metastatic pancreatic adenocarcinoma concomitantly with Optune Pax enrolling a similar number of patients. So we are being very attentive to the developments in the field and dynamic in our approach to that, considering everything that we have done in pancreatic cancer so far.

And these two smaller single-arm studies intend to give the first experience showing feasibility and tolerability and toxicity of the concomitant use of Optune Pax with KRAS inhibition in the disease. And as you mentioned, the first and foremost goal of these two studies is to give physicians with the right level of confidence and experience to see the feasibility of this.

We will learn about toxicity, but we're not particularly concerned about this considering the local nature of our therapy and the nature of the skin toxicity that we observed so far in pancreatic adenocarcinoma. And I would just remind everybody that preclinically, we have seen a very important activity of TTFields affecting downstream transcription factors to KRAS, which suggests that the concomitant use of our device with KRAS inhibitors of any kind might be very interesting and even could be synergistic, hopefully.

Operator

I'm showing no other questions. I'd like to turn the call over to Bill Doyle for closing remarks.

William Doyle

Thank you very much. I'd like to conclude today with a big thank you to the NovoCure team. This was an exceptionally strong quarter. And as Frank noted, it was strong across the board. Our emerging markets performed very well. But importantly, our established markets really showed growth across the board.

We've said for years that there are many more patients who can benefit from Tumor Treating Fields than have been currently prescribed. And our teams have begun to figure out the ways to get to those patients and their clinicians at the moment that decisions are made so that they can benefit from the therapy, and we saw it in the numbers.

We're focused on Pax, as you described. There's a tremendous amount of change in the pancreatic market. We're all aware of this. As Frank described in detail, it's creating quite a bit of work within the practices. And that work involves learning how to use the new therapy, learning how to guide patients through the reimbursement process. But we also know that the KRAS therapies are not cures, and we're going to see a wave of recurrence later this year as well if the data that we've seen in the clinical trials bears out, which we expect it to.

That's where we're really going to see, I think, the opportunity to, one, get back into the practices, but really find the sweet spot for Tumor Treating Fields in this emerging landscape, along with the activities that Uri described, really studying the concomitant use of the therapies together. And then finally, we are a company that's committed to profitability. And I think we have shown tangible progress on that path over the last few quarters. And we're very pleased to be able to increase our guidance, both in terms of revenue, but importantly, in terms of adjusted EBITDA today. So thank you very much for your interest in NovoCure, and we look forward to our next report.

Operator

Thank you for your participation. This does conclude the program. You may now disconnect. Good day.