FENNEC PHARMACEUTICALS INC. CAUTIONARY STATEMENT
This section and other parts of this Quarterly Report on Form 10-Q contain forward-looking statements, within the meaning of the Private Securities Litigation Reform Act of 1995, that involve risks and uncertainties. Forward-looking statements provide current expectations of future events based on certain assumptions and include any statement that does not directly relate to any historical or current fact. Forward-looking statements can be identified by words such as "future," "anticipates," "believes," "estimates," "expects," "intends," "plans," "predicts," "will," "would," "could," "can," "may," and similar terms. Forward-looking statements are not guarantees of future performance and our actual results may differ significantly from the results discussed in the forward-looking statements. Factors that might cause such differences include, but are not limited to, those discussed in Part I, Item 1A of our Annual Report on Form 10-K for the year endedDecember 31, 2021 under the heading "Risk Factors." We assume no obligation to revise or update any forward-looking statements for any reason, except as required by law. The following discussion should be read in conjunction with our Annual Report on Form 10-K for the year endedDecember 31, 2021 and the condensed consolidated financial statements and accompanying notes included elsewhere in this report.
Overview
Product Candidate - PEDMARKTM
Our only product candidate in the clinical stage of development is:
PEDMARKTM (a unique formulation of sodium thiosulfate ("STS")). We have
announced results of two Phase 3 clinical trials for the prevention of cisplatin
induced hearing loss, or ototoxicity in children, including the pivotal Phase 3
study SIOPEL 6, "A Multicentre Open Label Randomised Phase 3 Trial of the
Efficacy of Sodium Thiosulfate in Reducing Ototoxicity in Patients Receiving
Cisplatin Chemotherapy for Standard Risk Hepatoblastoma," and the proof of
concept Phase 3 study in collaboration with the Children's Oncology Group ("COG
ACCL0431") "A Randomized Phase 3 Study of Sodium Thiosulfate for the Prevention
of Cisplatin-Induced Ototoxicity in Children". COG ACCL0431 final results were
published in the Lancet Oncology in 2016. SIOPEL 6 final results were published
in the New England Journal of Medicine in June 2018 .
We continue to focus our resources on the development of PEDMARKTM.
PEDMARKTM
We have licensed fromOregon Health & Science University ("OHSU") intellectual property rights for the use of PEDMARKTM as a chemoprotectant and are developing PEDMARKTM as a protectant against the hearing loss often caused by platinum-based anti-cancer agents in children. Preclinical and clinical studies conducted by OHSU and others have indicated that PEDMARKTM can effectively reduce the incidence of hearing loss caused by platinum-based anti-cancer agents. Hearing loss among children receiving platinum-based chemotherapy is frequent, permanent and often severely disabling. The incidence of hearing loss in these children depends upon the dose and duration of chemotherapy, and many of these children require lifelong hearing aids. In addition, adults undergoing chemotherapy for several common malignancies, including ovarian cancer, testicular cancer, and particularly head and neck cancer and brain cancer, often receive intensive platinum-based therapy and may experience severe, irreversible hearing loss, particularly in the high frequencies. In theU.S. andEurope , it is estimated that, annually, over 10,000 children may receive platinum-based chemotherapy. The incidence of ototoxicity depends upon the dose and duration of chemotherapy. There is currently no established preventive agent for this hearing loss and only expensive, technically difficult and sub-optimal cochlear (inner ear) implants have been shown to provide some benefit. Infants and young children that suffer ototoxicity at critical stages 20 Table of Contents
of development lack speech language development and literacy, and older children and adolescents lack social-emotional development and educational achievement.
In
We initiated our rolling New Drug Application ("NDA") for PEDMARKTM for the
prevention of ototoxicity induced by cisplatin chemotherapy patients 1 month to
< 18 years of age with localized, non-metastatic, solid tumors with the FDA in
December 2018 . We announced that we had submitted full completion of the NDA in
February 2020 . The FDA set a Prescription Drug User Fee Act ("PDUFA") target
action date of August 10, 2020 for the completion of the FDA's review. On
August 10, 2020 , we announced that we received a Complete Response Letter
("CRL") from the FDA regarding our NDA for PEDMARKTM, which identified
deficiencies in the third-party manufacturing facility that manufactures
PEDMARKTM on our behalf. Importantly, no clinical safety or efficacy issues were
identified during the review and there was no requirement for further clinical
data.
In May 2021 , we announced the resubmission of our NDA for PEDMARKTM and in June
2021 we further announced that the FDA accepted for filing the resubmission of
our NDA and set a PDUFA target action date of November 27, 2021 . On November 29,
2021 , we announced that we received a CRL from the FDA regarding our NDA for
PEDMARKTM, which identified deficiencies in the third-party manufacturing
facility that manufactures PEDMARKTM on our behalf. In March 2022 , we announced
the resubmission of our NDA for PEDMARKTM, and in April 2022 , we further
announced that the FDA accepted for filing the resubmission of our NDA and set a
PDUFA target action date of September 23, 2022 .
In August 2018 , the Pediatric Committee ("PDCO") of the European Medicines
Agency ("EMA") accepted our pediatric investigation plan ("PIP") for sodium
thiosulfate with the trade name Pedmarqsi for the condition of the prevention of
platinum-induced hearing loss. An accepted PIP is a prerequisite for filing a
Marketing Authorization Application ("MAA") for any new medicinal product
in Europe . The indication targeted by our PIP is for the prevention of
platinum-induced ototoxic hearing loss for standard risk hepatoblastoma
("SR-HB"). Additional tumor types of the proposed indication will be subject to
the Committee for Medicinal Products for Human Use ("CHMP") assessment at the
time of the MAA. No deferred clinical studies were required in the positive
opinion given by PDCO. We were also advised that sodium thiosulfate (tradename
to be determined) is eligible for submission of an application for a Pediatric
Use Marketing Authorization ("PUMA"). A PUMA is a dedicated marketing
authorization covering the indication and appropriate formulation for medicines
developed exclusively for use in the pediatric population and provides data and
market protection up to 10 years. Therefore, this decision allows us to proceed
with the submission of a PUMA in the European Union ("EU") with incentives of
automatic access to the centralized procedure and up to 10 years of data and
market protection. In February 2020 , we announced that we had submitted a MAA
for the prevention of ototoxicity induced by cisplatin chemotherapy patients
1 month to < 18 years of age with localized, non-metastatic, solid tumors. The
EMA continues its review of our MAA.
Clinical Studies
PEDMARKTM has been studied by cooperative groups in two Phase 3 clinical studies of survival and reduction of ototoxicity, COG ACCL0431 and SIOPEL 6. Both studies have been completed. The COG ACCL0431 protocol enrolled one of five childhood cancers typically treated with intensive cisplatin therapy for localized and disseminated disease, including newly diagnosed hepatoblastoma, germ cell tumor, osteosarcoma, neuroblastoma, and medulloblastoma. SIOPEL 6 enrolled only hepatoblastoma patients with localized tumors.
SIOPEL 6
InOctober 2007 , we announced that our collaborative partner, theInternational Childhood Liver Tumour Strategy Group , known as SIOPEL, a multi-disciplinary group of specialists under the umbrella of theInternational Society of Pediatric Oncology , had launched a randomized Phase 3 clinical trial SIOPEL 6 to investigate whether STS reduces hearing loss in standard risk hepatoblastoma (liver) cancer patients receiving cisplatin as a monotherapy. 21
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The study was initiated inOctober 2007 initially in theUnited Kingdom and completed enrollment at the end of 2014. 52 sites from 11 countries enrolled 109 evaluable patients. Under the terms of our agreement, SIOPEL conducted and funded all clinical activities and we provided drug, drug distribution and pharmacovigilance, or safety monitoring, for the study. SIOPEL 6 was completed inDecember 2014 and the final results of SIOPEL 6 were published inThe New England Journal of Medicine inJune 2018 .
The primary objectives of SIOPEL 6 were:
? To assess the efficacy of STS to reduce the hearing impairment caused by
cisplatin.
? To carefully monitor any potential impact of STS on response to cisplatin and
survival. SIOPEL 6 - Results Background / Objectives: Bilateral high-frequency hearing loss is a serious permanent side-effect of cisplatin therapy, particularly debilitating when occurring in young children. STS has been shown to reduce cisplatin induced hearing loss. SIOPEL 6 was a Phase 3 randomized trial to assess the efficacy of STS in reducing ototoxicity in young children treated with cisplatin (Cis) for SR-HB.
Design / Methods:
Newly diagnosed patients with SR-HB, defined as tumor limited to PRETEXT I, II or III, no portal or hepatic vein involvement, no intra-abdominal extrahepatic disease, AFP >100ng/ml and no metastases, were randomized to Cis or Cis+STS for 4 preoperative and 2 postoperative courses. Cisplatin 80mg/m2 was administered over 6 hours, STS 20g/m2 was administered intravenously over 15 minutes exactly 6 hours after stopping cisplatin. Tumor response was assessed after 2 and 4 preoperative cycles with serum AFP and liver imaging. In case of progressive disease (PD), STS was to be stopped and doxorubicin 60mg/m2 combined with cisplatin. The primary endpoint was centrally reviewed absolute hearing threshold, at the age of ?3.5 years by pure tone audiometry.
Results:
109 randomized patients (52 Cisplatin only ("Cis") and 57 Cis+STS) were
evaluable. The combination of Cis+STS was generally well tolerated. With a
patient follow-up time of 52 months, the three-year Event Free Survival ("EFS")
for Cis was 78.8% and 82.1% for the Cis + STS. The three-year Overall Survival
("OS") is 92.3% for Cis and 98.2% for Cis + STS. Treatment failure defined as
Progressive Disease ("PD") at 4 cycles was equivalent in both arms. Among the
first 101 evaluable patients, hearing loss occurred in 29/46=63.0% under Cis and
in 18/55=32.7% under Cis +STS, corresponding to a relative risk of
0.52(P=0.002).
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[[Image Removed: Graphic]]
Conclusions:
This randomized Phase 3 trial in SR-HB of cisplatin versus cisplatin plus STS shows that the addition of STS significantly reduces the incidence of cisplatin-induced hearing loss without any evidence of tumor protection.
COG ACCL0431
InMarch 2008 , we announced the activation of a Phase 3 trial with STS to prevent hearing loss in children receiving cisplatin-based chemotherapy in collaboration with theChildren's Oncology Group . The goal of this Phase 3 study was to evaluate in a multi-centered, randomized trial whether STS is an effective and safe means of preventing hearing loss in children receiving cisplatin-based chemotherapy for newly diagnosed germ cell, liver (hepatoblastoma), brain (medulloblastoma), nerve tissue (neuroblastoma) or bone (osteosarcoma) cancers. Eligible children, one to eighteen years of age, were to receive cisplatin according to their disease-specific regimen and, upon enrollment in this study, were randomized to receive STS or not. Efficacy of STS was determined through comparison of hearing sensitivity at follow-up relative to baseline measurements using standard audiometric techniques.The Children's Oncology Group was responsible for funding the clinical activities for the study and we were responsible for providing the drug, drug distribution and pharmacovigilance, or safety monitoring, for the study. The trial completed enrollment of 131 pediatric patients in the first quarter of 2012. The final results of COG ACCL0431 were published in Lancet Oncology inDecember 2016 .
COG ACCL0431 - Results
COG Study ACCL0431, "A Randomized Phase 3 Study of Sodium Thiosulfate for the Prevention of Cisplatin-Induced Ototoxicity in Children," finished enrollment of 131 patients of which 125 were eligible patients. The patients had been previously diagnosed with childhood cancers.
The primary endpoint was to evaluate the efficacy of STS for prevention of hearing loss in children receiving cisplatin chemotherapy (hypothesis: 50% relative reduction in hearing loss).
Secondary endpoints included:
? Compare change in mean hearing thresholds.
? Compare incidence of other Grade 3/4 toxicities (renal and hematological).
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? Monitor Event Free Survival (EFS) and Overall Survival (OS) in two groups.
125 eligible subjects were enrolled with germ cell tumor (32), osteosarcoma (29), neuroblastoma (26), medulloblastoma/pnet (26), hepatoblastoma (7), or other (5). Of these, 104 subjects (64 male and 29 <5 years old) were evaluable for the primary endpoint.
Subjects were randomized either to no treatment (control) or treatment with STS 16 grams/m2 IV over 15 minutes, 6 hours after each cisplatin dose. Hearing was measured using standard audiometry for age and data was reviewed centrally usingAmerican Speech-Language-Hearing Association criteria.
The proportion of subjects with hearing loss assessed at 4 weeks post the final cisplatin dose (primary endpoint):
? The proportion of hearing loss for STS vs. Control was 28.6% (14/49) vs. 56.4%
(31/55), respectively (p=0.004).
In a predefined subgroup of patients less than 5 years old with 29 eligible
? subjects: STS vs. Control was 21.4% (3/14) vs. 73.3% (11/15), respectively
(p=0.005). Conclusions:
STS protects against cisplatin-induced hearing loss in children across a
? heterogeneous range of tumor types, with even stronger efficacy in the protocol
predefined subgroup of patients under five years old, and is not associated
with serious adverse events attributed to its use.
? Further potential clinical use will be informed by the final results of SIOPEL
6 study. Capital Funding We have not received and do not expect to have significant revenues from our product candidate until we are either able to sell our product candidate after obtaining applicable regulatory approvals or we establish collaborations that provide us with up-front payments, licensing fees, milestone payments, royalties or other revenue. We generated a net loss of approximately$8.8 million for the six months endedJune 30, 2022 , and a net loss of$8.7 million for the six months endedJune 30, 2021 . As ofJune 30, 2022 , our accumulated deficit was approximately$188.3 million ($179.5 million atDecember 31, 2021 ). We believe that our cash and cash equivalents as ofJune 30, 2022 , which totaled$14.9 million , plus the Bridge Bank Loan and Security Agreement orPetrichor Agreement, will be sufficient to meet our cash requirements through at least the next twelve months, including anticipated NDA approval and, if approved, the first commercial launch of PEDMARKTM inthe United States . Our projections of our capital requirements are subject to substantial uncertainty, and more capital than we currently anticipate may be required thereafter. To finance our continuing operations, we may need to raise substantial additional funds through either the sale of additional equity, the issuance of debt, the establishment of collaborations that provide us with funding, the out-license or sale of certain aspects of our intellectual property portfolio or from other sources. We may not be able to raise the necessary capital, or such funding may not be available on financially acceptable terms if at all. If we cannot obtain adequate funding in the future, we might be required to further delay, scale back or eliminate certain research and development studies, consider business combinations, or even shut down some, or all, of our operations. Our operating expenses will depend on many factors, including the progress of our drug development efforts and efficiency of our operations and current resources. Our research and development expenses, which include expenses associated with our clinical trials, drug manufacturing to support clinical programs, consulting fees, sponsored research costs, toxicology studies, license fees, milestone payments, and other fees and costs related to the development of our product candidate, will depend on the availability of financial resources, the results of our clinical trials, and any directives from regulatory agencies, which are difficult to predict. Our general and administration expenses include expenses associated with the 24 Table of Contents
compensation of employees, stock-based compensation, professional fees, consulting fees, insurance and other administrative matters associated in support of our drug development programs.
Results of Operations
Three months ended
Three Months Ended Three Months Ended
In thousands of U.S. Dollars June 30, 2022 % June 30, 2021 % Change
Revenue $ - $ - $ -
Operating expenses:
Research and development 1,131 23 % 800 20 % 331
General and administration 3,878 77 % 3,120 80 % 758
Total operating expense 5,009 100 % 3,920 100 % 1,089
Loss from operations (5,009) (3,920) (1,089)
Unrealized (loss)/gain on
securities (8) (84) 76
Foreign currency transaction
gain/(loss) 1 - 1
Amortization expense (8) - (8)
Interest expense (57) (9) (48)
Interest income 9 12 (3)
Net loss $ (5,072) $ (4,001) $ (1,071)
Research and development expenses increased by $331 for the three months ended
June 30, 2022 , compared to the same period in 2021. The Company's research and
development activities during these three months increased as the Company's
efforts on a year over year basis were more focused on ongoing development and
regulatory activities. The difference is mainly due to the timing of the NDA
resubmission over the same period in 2021. General and administrative expenses
increased by $758 over same period in 2021. Legal expenses increased $367 over
same period in the prior year primarily as a result of the class action suits
and patent defense. Sales and marketing activities increased by $620 over the
same period in prior year as pre-commercialization activities increased. There
was a decrease in non-cash equity compensation of $290 for the three months
ended June 30, 2022 over the same period in 2021.
The Company holds shares of Processa (NASDAQ: PCSA) which are marked to market
each balance sheet date and unrealized gains or losses are recognized at that
time. The unrealized loss on those shares for the three months ended June 30,
2022 was $8 . The Company has vendors that transact in Euros, Great British
Pounds and Canadian Dollars. There was a foreign currency transaction gain of $1
for the three months ended June 30, 2022 , compared to zero for the same period
in 2021. Amortization expense is a non-cash expense and relates to amortization
of the deferred issuance cost of the loan facilities with Bridge Bank .
Amortization expense increased by $8 for the three months ended June 30, 2022
compared to the same period in 2021. Interest expense increased by $48 for the
three months ended June 30 2022, over the same period in 2021. The increase
relates to the interest being paid on the Bridge Bank loan facility. Interest
income was $3 lower for the three months ended June 30, 2022 , compared to the
same period in 2021. This was driven mainly by lower average cash balances for
the three months ended June 30, 2022 compared to the same period in 2021.
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Six months ended
Six Months Ended Six Months Ended
In thousands of U.S. Dollars June 30, 2022 % June 30, 2021 % Change
Revenue $ - $ - $ -
Operating expenses:
Research and development 2,568 30 % 3,216 36 % (648)
General and administration 5,987 70 % 5,627 64 % 360
Total operating expenses 8,555 100 % 8,843 100 % (288)
Loss from operations (8,555) (8,843) 288
Unrealized (loss)/gain on securities (99) 98 (197)
Foreign currency transaction gain/(loss) (2)
(8) 6
Amortization expense (15) - (15)
Interest expense (115) (9) (106)
Interest income 18 28 (10)
Net loss $ (8,768) $ (8,734) $ (34)
Research and development expenses decreased by $648 for the six months ended
June 30, 2022 , compared to the same period in 2021. The main drivers of this
decrease were a decline in manuafacturing activities ($384 ), and a decline in
regulatory expense ($165 ). General and administrative expenses increased by $360
over same period in 2021 primarily related to legal expenses.
The Company holds shares of Processa (NASDAQ: PCSA) which are marked to market
each balance sheet date and unrealized gains or losses are recognized at that
time. The unrealized loss on those shares for the six months ended on June 30,
2022 was $99 , which is in contrast to the $98 gain for the same period in 2021.
Foreign currency transaction loss was $2 for the six months ended June 30, 2022
($8 loss for same period in 2021). Amortization expense was $15 for the six
months ended June 30, 2022 compared to $0 for the same period in 2021. In 2022,
the Company is amortizing the capitalized costs associated with the renegotiated
Bridge Bank loan facility. Interest expense increased $106 for the six months
ended June 30, 2022 over same period in 2021. The expense relates to interest on
the Bridge Bank loan facility. Interest income was $10 lower for the six months
ended June 30, 2022 , compared to the same period in 2021. This was driven mainly
by lower average cash balances for the six months ended June 30, 2022 compared
to the same period in 2021.
Liquidity and Capital Resources
As of As of
Selected Asset and Liability Data (thousands): June 30, 2022 December 31, 2021 Cash and equivalents$ 14,915 $ 21,100 Other current assets 639 1,287 Current liabilities 3,037 1,654 Working capital (1) 12,517 20,733
(1) [Current assets - current liabilities]
Selected Equity: Common stock and additional paid in capital 195,552
194,015
Accumulated deficit (188,254) (179,486)
Shareholders' equity 8,541 15,772
Cash and cash equivalents were $14,915 at June 30, 2022 and $21,100 at December
31, 2021 . The decrease in cash and cash equivalents between June 30, 2022 and
December 31, 2021 is the result of expenses related to the development and
preparation of the NDA resubmission of PEDMARKTM and general and administrative
expenses, which was offset by minimal cash inflows of $61 from various option
exercises. There was a decrease of $648 in other current assets between June 30,
2022 and December 31, 2021 . This is a result of a $463 decrease in deferred
charges related to the financing of
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our director and officer's insurance policy, a
Current liabilities increased by$1,383 betweenJune 30, 2022 andDecember 31, 2021 . The increase was driven mainly by the re-classification of$1,000 from long to short-term debt. Payables and accrued expenses increased$361 due to timing of select manufacturing and expenses associated with the PEDMARKTM pre-commercialization effort. Working capital decreased betweenDecember 31, 2021 andJune 30, 2022 by$8,216 . The decrease relates to cash expenditures for operating activities for the six months endedJune 30, 2022 , the$1,000 reclassification of long-term debt to current liability, offset by the$61 cash inflow from option exercises. The Company expects increases in cash outflows related to pre-commercialization and commercialization activities in the coming quarters upon potential NDA approval.
The following table illustrates a summary of cash flow data for the three and
six month periods ended
Selected Cash Flow Data Three Months Ended June 30, Six Months Ended June 30,
(dollars and shares in thousands) 2022 2021 2022 2021
Net cash used in operating activities $ (3,390) $ (4,426) $ (6,246) $ (8,019)
Net cash provided by investing activities - - - -
Net cash provided by financing activities 46
4,968 61 4,968
Net cash flow $ (3,344) $ 542 $ (6,185) $ (3,051)
Net cash used in operating activities for the three and six months ended June
30, 2022 primarily reflected a net loss of $5,072 and $8,768 , respectively.
These three and six month losses were adjusted for the add back of non-cash
items consisting of $1,043 and $1,476 , respectively, in stock-based compensation
expense, with unrealized loss on securities of $8 and $99 added back for the
three and six months ended June 30, 2022 , respectively. For the three and six
months ended June 30, 2022 , there was a net change in prepaid and other assets
of $221 and $548 , respectively; coupled with a net increase in current
liabilities for the three and six month periods ended June 30, 2022 of $401 and
$383 , respectively. Three and six month cash flows from operating activities
were negative $3,390 and $6,246 , respectively, for the period ended June 30,
2022 . Net cash provided by financing activities for the three and six months
ended June 30, 2022 was $46 and $61 , respectively. Financing activities
consisted of proceeds from the exercises of various options. Net cash flows from
the three and six month period ended June 30, 2022 were negative $3,344 and
$6,185 , respectively.
We continue to pursue various strategic alternatives including collaborations
with other pharmaceutical and biotechnology companies. Our projections of
further capital requirements are subject to substantial uncertainty. Our working
capital requirements may fluctuate in future periods depending upon numerous
factors, including: our ability to obtain additional financial resources; our
ability to enter into collaborations that provide us with up-front payments,
milestones or other payments; results of our research and development
activities; progress or lack of progress in our preclinical studies or clinical
trials; unfavorable toxicology in our clinical programs; our drug substance
requirements to support clinical programs; change in the focus, direction, or
costs of our research and development programs; headcount expense; the costs
involved in preparing, filing, prosecuting, maintaining, defending and enforcing
our patent claims; competitive and technological advances; the potential need to
develop, acquire or license new technologies and products; our business
development activities; new regulatory requirements implemented by regulatory
authorities; the timing and outcome of any regulatory review process; and
commercialization activities, if any.
Financial Instruments
We invest excess cash and cash equivalents in high credit quality investments held by financial institutions in accordance with our investment policy designed to protect the principal investment. AtJune 30, 2022 , we had approximately$278 in our cash accounts and$14,637 in savings and money market accounts. While we have never experienced any loss or write down of our money market investments since our inception, the amounts we hold in money market accounts are substantially above the$250 amount insured by theFDIC and may lose value. 27
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Our investment policy is to manage investments to achieve, in the order of importance, the financial objectives of preservation of principal, liquidity and return on investment. Investments may be made inU.S. or Canadian obligations and bank securities, commercial paper ofU.S. or Canadian industrial companies, utilities, financial institutions and consumer loan companies, and securities of foreign banks provided the obligations are guaranteed or carry ratings appropriate to the policy. Securities must have a minimum Dun & Bradstreet rating of A for bonds or R1 low for commercial paper. The policy also provides for investment limits on concentrations of securities by issuer and maximum-weighted average time to maturity of twelve months. This policy applies to all of our financial resources. The policy risks are primarily the opportunity cost of the conservative nature of the allowable investments. As our main purpose is research and development, we have chosen to avoid investments of a trading or speculative nature. Since our inception, we have not had any material off-balance sheet arrangements. In addition, we do not engage in trading activities involving non-exchange traded contracts. As such, we are not materially exposed to any financing, liquidity, market or credit risk that could arise if we had engaged in such activities. Research and Development
Our research and development efforts have been focused on the development of PEDMARKTM since 2013.
We have established relationships with contract research organizations, universities and other institutions, which we utilize to perform many of the day-to-day activities associated with our drug development. Where possible, we have sought to include leading scientific investigators and advisors to enhance our internal capabilities. Research and development issues are reviewed internally by our executive management and supporting scientific team. Research and development expenses for the three and six months endedJune 30, 2022 was$1,131 and$2,568 , respectively. For the same periods in 2021, research and development expense was$800 and$3,216 , respectively. We have decreased our research and development expenses related to PEDMARKTM as our efforts have shifted to pre-commercialization activities after the NDA resubmission inMarch 2022 . Our product candidate still requires significant, time-consuming and costly research and development, testing and regulatory clearances. In developing our product candidate, we are subject to risks of failure that are inherent in the development of products based on innovative technologies. For example, it is possible that our product candidate will be ineffective or toxic, or will otherwise fail to receive the necessary regulatory clearances. There is a risk that our product candidate will be uneconomical to manufacture or market or will not achieve market acceptance. There is also a risk that third parties may hold proprietary rights that preclude us from marketing our product candidate or that others will market a superior or equivalent product. As a result of these factors, we are unable to accurately estimate the nature, timing and future costs necessary to complete the development of this product candidate. In addition, we are unable to reasonably estimate the period when material net cash inflows could commence from the sale, licensing or commercialization of such product candidate, if ever.
Critical Accounting Policies and Use of Estimates
A summary of our critical accounting policies and use of estimates are presented in Part II, Item 7, "Management's Discussion and Analysis of Financial Condition and Results of Operation" of our Annual Report on Form 10-K for the fiscal year endedDecember 31, 2021 (filedFebruary 28, 2022 ). There have been no material changes to our critical accounting policies and use of estimates during the six months endedJune 30, 2022 .
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