UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
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FORM 10-K
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(Mark One)
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ANNUAL REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
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TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
For the fiscal year ended December 31, 2022
or
For the transition period from to
Commission File Number 001-37565
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NovoCure Limited
(Exact Name of Registrant as Specified in Its Charter)
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Jersey
(State or Other Jurisdiction of
Incorporation or Organization)
98-1057807
(I.R.S. Employer
Identification No.)
No. 4 The Forum
Grenville Street
St. Helier, Jersey JE2 4UF
(Address of Principal Executive Offices, including zip code)
Registrant’s telephone number, including area code: +44 (0) 15 3475 6700
Securities registered pursuant to Section 12(b) of the Act:
Title of each class
Trading Symbol(s)
Name of each exchange on which registered
Ordinary shares, no par value per share
NVCR
NASDAQ Global Select Market
Securities registered pursuant to Section 12(g) of the Act:
None
(Title of Class)
______________________________________________________________________
Indicate by check mark if the registrant is a well-known seasoned issuer, as defined in Rule 405 of the Securities Act. Yes ☒ No ☐
Indicate by check mark if the registrant is not required to file reports pursuant to Section 13 or Section 15(d) of the Act. Yes ☐ No ☒
Indicate by check mark whether the registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding
12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past
90 days. Yes ☒ No ☐
Indicate by check mark whether the registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T (§
232.405 of this chapter) during the preceding 12 months (or for such shorter period that the registrant was required to submit such files). Yes ☒ No ☐
Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, a smaller reporting company or an emerging growth
company. See the definitions of "large accelerated filer," "accelerated filer," "smaller reporting company" and "emerging growth company" in Rule 12b-2 of the Exchange Act.
Large accelerated filer
Non-accelerated filer
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Accelerated filer
Smaller reporting company
Emerging Growth Company
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If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial
accounting standards provided pursuant to Section 13(a) of the Exchange Act. ☐
Indicate by check mark whether the registrant has filed a report on and attestation to its management’s assessment of the effectiveness of its internal control over financial
reporting under Section 404(b) of the Sarbanes-Oxley Act (15 U.S.C. 7262(b)) by the registered public accounting firm that prepared or issued its audit report. ☒
If securities are registered pursuant to Section 12(b) of the Act, indicate by check mark whether the financial statements of the registrant included in the filing reflect the
correction of an error to previously issued financial statements. ☐
Indicate by check mark whether any of those error corrections are restatements that required a recovery analysis of incentive-based compensation received by any of the
registrant’s executive officers during the relevant recovery period pursuant to §240.10D-1(b). ☐
Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act). Yes ☐ No ☒
The aggregate market value of the outstanding common equity of the registrant held by non-affiliates as of the last business day of the registrant’s most recently completed
second fiscal quarter was $2,830,918,480.
The number of shares of the registrant’s ordinary shares outstanding as of February 20, 2023 was 105,455,173.
DOCUMENTS INCORPORATED BY REFERENCE
Portions of the registrant’s definitive proxy statement for its 2023 annual meeting of shareholders are incorporated by reference into Items 10, 11, 12, 13, and 14 of Part III of this
Form 10-K. Such definitive proxy statement will be filed with the Securities and Exchange Commission within 120 days after the end of the registrant’s fiscal year ended December
31, 2022.
Cautionary Note Regarding Forward‑Looking Statements
Summary of Risk Factors
Item 1.
Item 1A.
Item 1B.
Item 2.
Item 3.
Item 4.
Item 5.
Item 6.
Item 7.
Item 7A.
Item 8.
Item 9.
Item 9A.
Item 9B.
Item 9C.
Item 10.
Item 11.
Item 12.
Item 13.
Item 14.
Business
Risk Factors
Unresolved Staff Comments
Properties
Legal Proceedings
Mine Safety Disclosures
PART I
PART II
Market for Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities
Reserved
Management’s Discussion and Analysis of Financial Condition and Results of Operations
Quantitative and Qualitative Disclosures About Market Risk
Financial Statements
Changes in and Disagreements With Accountants on Accounting and Financial Disclosure
Controls and Procedures
Other Information
Disclosure Regarding Foreign Jurisdictions that Prevent Inspections
Directors, Executive Officers and Corporate Governance
Executive Compensation
Security Ownership of Certain Beneficial Owners and Management and Related Stockholder Matters
Certain Relationships and Related Transactions, and Director Independence
Principal Accountant Fees and Services
PART III
Item 15.
Item 16.
SIGNATURES
Exhibits and Financial Statement Schedules
Form 10-K Summary
PART IV
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CAUTIONARY NOTE REGARDING FORWARD-LOOKING STATEMENTS
In addition to historical facts or statements of current condition, this report contains forward-looking statements within the meaning of Section
27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. Forward-looking
statements contained in this report are based on our current plans, expectations, hopes, beliefs, intentions or strategies concerning future
developments and their impact on us. Forward-looking statements contained in this report constitute our expectations or forecasts of future
events as of the date this report was filed with the Securities and Exchange Commission and are not statements of historical fact. You can
identify these statements by the fact that they do not relate strictly to historical or current facts. Such statements may include words such as
"anticipate," "will," "estimate," "expect," "project," "intend," "should," "plan," "believe," "hope," and other words and terms of similar meaning in
connection with any discussion of, among other things, future operating or financial performance, strategic initiatives and business strategies,
regulatory or competitive environments, our intellectual property and research and development related to our Tumor Treating Fields
("TTFields") devices marketed under various brand names, including "Optune," "Optune Lua," and software, tools and other items to support
and optimize the delivery of TTFields (collectively, the "Products"). In particular, these forward-looking statements include, among others,
statements about:
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our research and development, clinical study and commercialization activities and projected expenditures;
the further commercialization of our Products for current and future indications;
our business strategies and the expansion of our sales and marketing efforts in the United States ("U.S.") and in other countries;
the market acceptance of our Products for current and future indications by patients, physicians, third-party payers and others in the
healthcare and scientific community;
our plans to pursue the use of our Products for the treatment of indications other than glioblastoma ("GBM") and malignant pleural
mesothelioma ("MPM");
our estimates regarding revenues, expenses, capital requirements and needs for additional financing;
our ability to obtain regulatory approvals for the use of our Products in indications other than GBM and MPM;
our ability to acquire from third-party suppliers the supplies needed to manufacture our Products;
our ability to manufacture adequate supply of our Products;
our ability to secure and maintain adequate coverage from third-party payers to reimburse us for our Products for current and future
indications;
our ability to receive payment from third-party payers for use of our Products for current and future indications;
our ability to maintain and develop our intellectual property position;
our ability to manage the risks associated with business disruptions caused by natural disasters, extreme weather events, pandemics
such as COVID-19 (coronavirus) or international conflict or other disruptions outside of our control;
our cash needs; and
our prospects, financial condition and results of operations.
These forward-looking statements involve a number of risks and uncertainties (some of which are beyond our control) or other assumptions that
may cause actual results or performance to be materially different from those expressed or implied by these forward-looking statements. Should
one or more of these risks or uncertainties materialize, or should any of our assumptions prove incorrect, actual results may vary in material
respects from
those projected in these forward-looking statements. Factors which may cause such differences to occur include those risks and uncertainties
set forth under Part I, Item IA, Risk Factors, of this Annual Report on Form 10-K, as well as other risks and uncertainties set forth from time to
time in the reports we file with the U.S. Securities and Exchange Commission the ("SEC"). We do not intend to update publicly any forward-
looking statement, whether as a result of new information, future events or otherwise, except as required by law.
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Summary of Risk Factors
The following is a summary of some of the risks and uncertainties that could materially adversely affect our business, financial condition and
results of operations. You should read this summary together with the more detailed description of each risk factor contained below.
Risks relating to the manufacturing, marketing and sales of our products
• We currently have only two products approved for use for specific indications. Our ability to expand our product line and their uses
requires regulatory approval, which is costly and requires significant time and effort to obtain.
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To date, we have generated only limited and intermittent operating profits, and we have a history of incurring substantial operating
losses. As we expand, we may experience difficulties managing our growth.
To obtain approvals for new products and indications and to continue to market our existing products, we are required to conduct
preclinical and clinical studies and other testing. Our clinical studies could be delayed or otherwise adversely affected by many factors,
including difficulties in enrolling patients and problems with third-party providers. Continued testing of our products may not yield
successful results and could reveal currently unknown safety hazards associated with our products. We may choose to, or may be
required to, suspend, repeat or terminate our clinical studies if they are not conducted in accordance with regulatory requirements, the
results are negative or inconclusive or the studies are not well designed.
• Our products do not have a significant history in the marketplace, as a result we may have difficulty:
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developing an adequate sales and marketing organization or contracting with third parties to assist us in doing so;
achieving market acceptance of our products by healthcare professionals, patients and/or third-party payers; and
securing and maintaining adequate coverage and reimbursement from third-party payers, including governmental agencies in
the countries where we market our products.
• We depend on single-source suppliers for some of our components, the loss of which could prevent or delay shipments of our products
to customers or delay our clinical studies.
• Quality control problems with respect to materials supplied by third-party suppliers could prevent or delay shipments of our products to
customers or delay our clinical studies.
• We face competition from numerous competitors.
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Because of the specialized nature of our business, the termination of relationships with our key employees, consultants and advisors
may be detrimental to our business.
Product liability suits, whether or not meritorious, could be brought against us and result in expensive and time-consuming litigation,
payment of substantial damages and/or expenses and an increase in our insurance rates.
• Other future litigation and regulatory actions could have a material adverse impact on the Company.
• We are subject to fluctuations in global economic, political, environmental, and industry conditions, some of which may be unfavorable,
including as a result of the COVID-19 pandemic.
• Our products and infrastructure face certain risks, including from cyber security breaches and data leakage. We are also subject to
privacy and data security laws.
Risks relating to the regulation of our business
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Legislative and regulatory changes in the U.S. and in other countries regarding healthcare and government-sponsored programs may
adversely affect us.
• We are subject to extensive post-marketing regulation by the U.S. Federal Drug Administration ("FDA") and comparable authorities in
other jurisdictions, which could cause us to incur significant costs to maintain compliance.
• Modifications to our products may require regulatory approvals and our regulators may not agree with our conclusions regarding
whether new approvals are required. Regulatory authorities may require us to cease promoting or to recall the modified versions of our
products until such approvals are obtained.
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In addition to FDA requirements, we will spend considerable time and money complying with other federal, state, local and foreign
rules, regulations and guidance.
If we, our collaborative partners, our contract manufacturers, or our component suppliers fail to comply with regulations, the
manufacturing and distribution of our products could be interrupted.
• Our products could be subject to recalls that could harm our reputation and financial results.
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If our products cause or contribute to a death or a serious injury, or malfunction in certain ways, we will be subject to medical device
reporting regulations, which can result in voluntary corrective actions or agency enforcement actions.
• We are not permitted to promote the use of our products for unapproved or off-label uses.
• We pay taxes in multiple jurisdictions and adverse determinations by governmental authorities or changes in tax laws, rates or our
status under which tax jurisdictions apply to us could increase our tax burden or subject our shareholders to additional taxes.
• We are affected by and subject to environmental laws and regulations that could be costly to comply with or that may result in costly
liabilities.
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Safety issues concerning lithium-ion batteries could have a material adverse impact on our business.
Risks relating to intellectual property
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If we fail to protect, sustain, further build and enforce our intellectual property rights, competitors may be able to develop competing
therapies.
Intellectual property litigation and disputes may cause us to incur substantial costs, divert attention from the management of our
business, harm our reputation, or require us to remove certain products from the market.
• Changes in U.S. patent law could impair our ability to protect our devices.
Risks relating to our ordinary shares and capital structure
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The market price for our ordinary shares may be volatile, which could result in substantial losses.
• Our ordinary shares are issued under the laws of Jersey, which may not provide the level of legal certainty and transparency afforded
by incorporation in a U.S. state.
• U.S. shareholders may not be able to enforce civil liabilities against us.
• We have borrowed a significant amount of debt and have the ability to borrow additional debt in the future.
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Transactions relating to our convertible notes may dilute the ownership interest of existing shareholders, or may otherwise depress the
price of our ordinary shares.
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ITEM 1. BUSINESS
Overview
PART I
We are a global oncology company with a proprietary platform technology called Tumor Treating Fields ("TTFields"), which are electric fields
that exert physical forces to kill cancer cells via a variety of mechanisms. Our key priorities are to drive commercial adoption of Optune and
Optune Lua, our commercial TTFields devices, and to advance clinical and product development programs intended to extend overall survival
in some of the most aggressive forms of cancer.
Optune is approved by the U.S. Food and Drug Administration ("FDA") under the Premarket Approval ("PMA") pathway for the treatment of
adult patients with newly diagnosed glioblastoma ("GBM") together with temozolomide, a chemotherapy drug, and for adult patients with GBM
following confirmed recurrence after chemotherapy as monotherapy treatment. We also have a CE certificate to market Optune for the
treatment of GBM in the European Union ("EU"), as well as approval or local registration in the United Kingdom ("UK"), Japan, Canada and
certain other countries. Optune Lua is approved by the FDA under the Humanitarian Device Exemption ("HDE") pathway to treatment malignant
pleural mesothelioma ("MPM") together with standard chemotherapies. We have also received CE certification in the EU and approval or local
registration to market Optune Lua in certain other countries. We market Optune and Optune Lua in multiple countries around the globe with the
majority of our revenues coming from the use of Optune in the U.S., Germany and Japan. We are actively evaluating opportunities to expand
our international footprint.
We believe the physical mechanisms of action behind TTFields therapy may be broadly applicable to solid tumor cancers. We recently
completed patient follow-up and announced top line results from our pivotal LUNAR study evaluating the use of TTFields in the treatment of
non-small cell lung cancer ("NSCLC") together with standard therapies. Patients treated with TTFields and standard therapies demonstrated a
statistically significant and clinically meaningful improvement in overall survival over standard therapies alone. The LUNAR study also showed a
statistically significant and clinically meaningful improvement in overall survival when patients were treated with TTFields and immune
checkpoint inhibitors, as compared to those treated with immune checkpoint inhibitors alone, and a positive trend in overall survival when
patients were treated with TTFields and docetaxel versus docetaxel alone. We expect to present full results of the LUNAR study at a future
medical conference.
In addition to the LUNAR study, we are conducting pivotal studies evaluating the use of TTFields in the treatment of ovarian cancer, brain
metastases from NSCLC ("brain metastases") and pancreatic cancer. We are also conducting a pivotal study testing the potential survival
benefit of initiating Optune concurrent with radiation therapy versus following radiation therapy in patients with newly diagnosed GBM.
We have one ongoing pilot study evaluating the use of TTFields in the treatment of stage 3 NSCLC and are designing several additional pilot
and pivotal studies in partnership with oncology leaders to further explore the capabilities of TTFields. We anticipate expanding our clinical
pipeline over time to study the safety and efficacy of TTFields for additional solid tumor indications and combinations with other cancer
treatment modalities.
Our therapy is delivered through a medical device and we continue to advance our Products with the intention to extend survival and maintain
quality of life for patients. We have several product development programs underway that are designed to optimize TTFields delivery to the
target tumor and enhance patient ease of use. Our intellectual property portfolio contains hundreds of issued patents and numerous patent
applications pending worldwide. We believe we possess global commercialization rights to our Products in oncology and are well-positioned to
extend those rights into the future as we continue to find innovative ways to improve our Products.
In 2018, we granted Zai Lab (Shanghai) Co., Ltd. ("Zai") a license to commercialize Optune in China, Hong Kong, Macau and Taiwan ("Greater
China") under a License and Collaboration Agreement (the "Zai Agreement"). The Zai Agreement also establishes a development partnership
intended to accelerate the development of TTFields in multiple solid tumor cancer indications. For additional information, see Note 12 to the
Consolidated Financial Statements.
Our ordinary shares are quoted on the NASDAQ Global Select Market under the symbol "NVCR." We were incorporated in the Bailiwick of
Jersey in 2000. Daily management and control of the Company are located in Switzerland, with additional operating centers located around the
world.
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Our therapy
When cancer develops, rapid and uncontrolled division of unhealthy cells occurs. Electrically charged proteins within the cell are critical for cell
division, making the rapidly dividing cancer cells vulnerable to electrical interference. TTFields therapy is a treatment that uses electric fields
which exert physical forces to kill cancer via a variety of mechanisms.
All cells are surrounded by a bilipid membrane, which separates the interior of the cell, or cytoplasm, from the space around it. This membrane
prevents low frequency electric fields from entering the cell. TTFields, however, have a unique frequency range, between 100 to 500 kHz,
enabling the electric fields to penetrate the cancer cell membrane. As healthy cells differ from cancer cells in their division rate, geometry and
electric properties, the frequency of TTFields can be tuned to specifically affect the cancer cells while leaving healthy cells mostly unaffected.
Whether cells are healthy or cancerous, cell division, or mitosis, is the same. When mitosis starts, charged proteins within the cell, or
microtubules, form the mitotic spindle. The spindle is built on electric interaction between its building blocks. During division, the mitotic spindle
segregates the chromosomes, pulling them in opposite directions. As the daughter cells begin to form, electrically polarized molecules migrate
towards the midline to make up the mitotic cleavage furrow. The furrow contracts and the two daughter cells separate. TTFields can interfere
with these conditions. When TTFields are present in a dividing cancer cell, they cause the electrically charged proteins to align with the
directional forces applied by the field, thus preventing the mitotic spindle from forming. Electrical forces also interrupt the migration of key
proteins to the cell midline, disrupting the formation of the mitotic cleavage furrow. Interfering with these key processes disrupts mitosis and can
lead to cell death.
Our track record of fundamental scientific research extends across more than two decades and, in all of our preclinical research to date, the
application of TTFields has demonstrated a consistent anti-mitotic effect. Recent preclinical work suggests that the well-established impairment
created by the physical effect of TTFields to tumor cells results in a series of changes to cell processes that downregulate DNA damage
response, interfere with cell movement and migration, and increase anti-tumor immunity. Research is ongoing to further refine and build upon
our understanding of TTFields' several mechanisms of action. Beyond our internal research efforts, we provide independent researchers with
preclinical laboratory bench systems, known as inovitro™ and inovivo™, and we grant funding to support basic and translational research on
TTFields. We also support independent research through our Investigator-Sponsored Trials and Preclinical Material Transfer Agreement
programs in order to enhance our understanding of the optimal use of TTFields.
TTFields is intended principally for use together with other standard-of-care cancer treatments. There is a growing body of evidence that
supports TTFields' broad applicability with certain other cancer therapies, including radiation therapy, certain chemotherapies and certain
immunotherapies. In our clinical research and commercial experience to date, TTFields has exhibited no systemic toxicity, with mild to moderate
skin irritation being the most common side effect.
Our technology
TTFields therapy is delivered through a portable medical device. The complete devices, called Optune and Optune Lua (for GBM and MPM
treatment, respectively), include a portable electric field generator, arrays, rechargeable batteries and accessories. Sterile, single-use arrays are
placed directly on the skin in the region surrounding the tumor and connected to the electric field generator to deliver therapy. Arrays are
changed when hair growth or the hydrogel reduces array adhesion to the skin. The therapy is designed to be delivered continuously throughout
the day and night, and efficacy is strongly correlated to time on therapy. When the device is turned on, TTFields are continuously generated
within the specific region of the body covered by the arrays. Healthy tissues located outside of this region remain unaffected by the therapy. The
electric field generator can be run from a standard power outlet or carried with a battery in a specially designed bag that we provide to patients.
We plan to use the same field generator technology across all indications for which our Products are approved. We plan to specifically target
individual solid tumor types by optimizing field generator parameters such as frequency and power output. Our arrays have been developed and
are in use, either commercially or clinically, for application on the head, thorax and abdomen.
Through engineering efforts, we plan to continue to advance our Products to optimize TTFields therapy for patients. We have several product
development programs underway designed to extend survival and enhance quality of life. Our product development programs are primarily
focused on enhancements to the field generator, arrays and software applications. Our product development initiatives include, but are not
limited to: next generation arrays that
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are thinner, lighter and more flexible, next generation array layout mapping software, development of a third generation device that optimizes
the use of electric fields to treat tumors, and patient-centered software that enables scaled patient support as we prepare to treat larger patient
populations across multiple indications. Our ultimate goal is to optimize the energy delivered to patients' tumors, potentially improving efficacy.
Any enhancements will be subject to applicable regulatory reviews and approvals.
Our commercial business
Optune is currently marketed for the treatment of GBM, the most common form of primary brain cancer and an aggressive disease for which
there are few effective treatment options. Optune Lua is currently marketed for the treatment of MPM, a rare cancer that has been strongly
linked to asbestos exposure. We market Optune and Optune Lua in multiple countries around the globe with the majority of our revenues
coming from the use of Optune in the U.S., Germany and Japan.
Treatment of newly diagnosed GBM
In 2015, we received FDA approval to market Optune for the treatment of adult patients with newly diagnosed supratentorial GBM in
combination with temozolomide. The FDA approved Optune for newly diagnosed GBM based on the EF-14 study ("EF-14"), which was a
randomized pivotal clinical study which compared, post radiation, Optune plus temozolomide versus temozolomide alone for the treatment of
newly diagnosed GBM. The primary endpoint of the study was progression-free survival and a powered secondary endpoint was overall
survival.
In EF-14, Optune plus temozolomide demonstrated unprecedented five-year survival results. Median overall survival was extended by nearly
five months (median overall survival of 20.9 months versus 16.0 months for temozolomide alone). Median progression-free survival was
extended by 2.7 months to 6.7 months for Optune plus temozolomide from 4.0 months for temozolomide alone. The final EF-14 data were
published in the Journal of the American Medical Association in 2017.
The following graph presents the overall survival data in the intent-to-treat population from our five-year analysis:
The extension of progression-free and overall survival in patients receiving Optune in combination with temozolomide in EF-14 was not specific
to any prognostic subgroup or tumor genetic marker and was consistent regardless of MGMT methylation status, extent of resection, age,
performance status or gender. Optune was safely combined with temozolomide with no significant increase in serious adverse events compared
with temozolomide alone. The most common side effect related to Optune was mild to moderate skin irritation.
Quality of life data from a pre-specified analysis of EF-14 demonstrated that patients treated with Optune and temozolomide maintained quality
of life over time and across predefined daily-functioning domains. Both healthcare professionals and patients reported stable quality of life
evaluation scores up to one year of Optune use. Physical, role, social, emotional and cognitive functioning for patients treated with Optune and
temozolomide all remained stable and comparable with patients treated with temozolomide alone.
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The National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology® (NCCN Guidelines®) for Central Nervous Systems
Cancers were updated to include alternating electric fields therapy (Optune) in combination with temozolomide following standard brain
radiation therapy with concurrent temozolomide as a Category 1 recommended postoperative adjuvant treatment option for patients with newly
diagnosed supratentorial GBM.
A post-hoc analysis of EF-14 showed that more time on Optune predicted increased survival in GBM patients. An Optune monthly usage
threshold as low as 50 percent correlated with significantly improved outcomes in patients treated with Optune together with temozolomide
compared to patients treated with temozolomide alone. The greater the patients’ monthly usage of Optune, the better their outcomes. Patients
who used Optune more than 90 percent of the time (n=43) had the greatest chance of survival: a median survival of 24.9 months from
randomization and a five-year probability of survival of 29.3 percent.
A separate post-hoc analysis of EF-14 showed that higher intensities at the tumor bed were associated with increased survival in GBM patients.
Patients treated with Optune at higher intensities (greater than or equal to 1.06 V/cm; n=119) had a median overall survival of 24.3 months
compared to a median overall survival of 21.6 months for patients treated with Optune at lower intensities (less than 1.06 V/cm; n=221).
In these analyses, both time on therapy and higher intensity were associated with improved overall survival, independent of each other. In
addition, patients who used Optune at least 18 hours per day at higher intensity levels (n=78) had a median overall survival of 25.1 months
(95% CI 20.8-39.4).
Treatment of recurrent GBM
We initially received FDA approval for Optune in 2011 for use as a monotherapy treatment for adult patients with GBM, following confirmed
recurrence after chemotherapy. The FDA approved Optune based on the EF-11 study ("EF-11"), a randomized, pivotal clinical study.
EF-11 was a multi-center, active controlled clinical study of 237 adults with recurrent GBM. Participants received either Optune as a
monotherapy (n=120) or the physician’s choice of chemotherapy (n=117). Chemotherapies chosen for the active control arm included mainly
bevacizumab, nitrosoureas and temozolomide. The primary endpoint was superiority in overall survival. Overall survival for patients treated with
Optune alone and active chemotherapy was 6.6 months and 6.0 months, respectively (p=0.27: HR = 0.86). The study demonstrated that
Optune provided clinically comparable survival with an overall better quality of life.
More objective radiological responses were observed in the Optune group than in the active control chemotherapy group (14 patients versus 7
patients). Three patients in the Optune alone arm had a complete response versus no patients in the active chemotherapy arm.
In 2020, the EF-19 post-approval registry, which was a post-approval study required as a condition of FDA approval, confirmed the
effectiveness and safety of Optune as monotherapy and further strengthened Optune's clinical profile in recurrent GBM. The EF-19 study
studied Optune as a monotherapy for the treatment of recurrent GBM in 192 patients compared to the 117 recurrent GBM patients who received
best standard of care chemotherapy in Novocure’s EF-11 registration study. Optune as monotherapy reduced the risk of death with fewer
adverse events compared to best standard of care chemotherapy. For patients who received at least one course of therapy, Optune prolonged
survival by a median 1.7 months. No new safety signals were noted.
Treatment of MPM
In 2019, we received FDA approval via the HDE pathway to market Optune Lua (then known as NovoTTF-100L) for the treatment of adult
patients with unresectable, locally advanced or metastatic MPM concurrent with pemetrexed and platinum-based chemotherapy. The FDA
approved Optune Lua for MPM based on the STELLAR study ("STELLAR"). STELLAR was a single-arm, open-label, multi-center study
designed to test the safety and efficacy of Optune Lua in combination with pemetrexed combined with cisplatin or carboplatin in patients with
unresectable, previously untreated MPM. The study was powered to prospectively determine the overall survival in patients treated with Optune
Lua plus chemotherapy. Secondary endpoints included overall response rate (per mRECIST criteria), progression-free survival and safety.
STELLAR investigated safety and efficacy among 80 patients treated with Optune Lua plus standard of care chemotherapy. In STELLAR, the
median overall survival was 18.2 months (95% CI, 12.1-25.8 months) across all patients treated with Optune Lua plus chemotherapy. The
median overall survival was 21.2 months for patients with epithelioid MPM (n=53) and 12.1 months for patients with non-epithelioid MPM
(n=27). 62% of patients enrolled in STELLAR who used Optune Lua plus chemotherapy were still alive at one year, with 42% of patients alive at
two
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years. The disease control rate in patients with at least one follow-up CT scan performed (n=72) was 97%. 40% of patients had a partial
response, 57% had stable disease, and 3% had progressive disease. The median progression-free survival was 7.6 months (95% CI, 6.7-8.6
months).
There was no increase in serious systemic adverse events when Optune Lua was added to chemotherapy. Mild-to-moderate skin irritation was
the only device-related side effect with Optune Lua. The STELLAR data were published in The Lancet Oncology in 2019.
Our commercial markets
We have built a commercial organization and market Optune and Optune Lua for the treatment of GBM and MPM in multiple countries in North
America, Europe and Asia.
In 2023, we estimate that approximately:
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15,000 people will be diagnosed with GBM or tumors that typically progress to GBM in the U.S. Of this population, we estimate that
approximately 8,200 patients who are candidates for treatment with Optune based upon the rate of disease progression and medical
eligibility will actively seek treatment.
4,600 people will be diagnosed with GBM or tumors that typically progress to GBM in Germany. Of this population, we estimate that
approximately 2,500 patients who are candidates for treatment with Optune based upon the rate of disease progression and medical
eligibility will actively seek treatment.
2,200 people will be diagnosed with GBM or tumors that typically progress to GBM in Japan. Of this population, we estimate that
approximately 1,200 patients who are candidates for treatment with Optune based upon the rate of disease progression and medical
eligibility will actively seek treatment.
In 2023, we estimate that approximately 3,000 people are diagnosed with malignant plural mesothelioma in the U.S. each year. Of this
population, we estimate that approximately 1,600 patients are candidates for treatment with Optune Lua based upon the rate of disease
progression and medical eligibility.
We believe there are many more patients who could benefit from treatment with TTFields than are currently on therapy. We continue to focus on
increasing penetration for GBM and MPM. In the future, we anticipate strategically expanding into additional geographic markets and additional
indications, pending regulatory approval.
Commercial execution
As of December 31, 2022, we had 102 sales force colleagues globally. Healthcare providers must undergo a certification training in order to
prescribe our Products.
With respect to the treatment of GBM, our sales and marketing efforts are principally focused on driving adoption with both neuro-oncologists
and radiation oncologists. In certain countries, neurosurgeons and medical oncologists also drive adoption. We continue to focus on driving key
academic center engagements.
With respect to the treatment of MPM, our sales and marketing efforts are principally focused on certification training, supporting the required
Institutional Review Board approval process in certain geographies, and driving awareness among radiation oncologists and thoracic
oncologists. We believe the benefit of our education efforts will extend beyond MPM to future indications treated by the same prescribers.
We currently operate as a direct-to-patient distributor of our Products, except for Japan. In Japan, we distribute Optune through hospitals and
provide patient support services under a contractual arrangement with the hospital. Once an eligible patient is identified by a certified prescriber,
the healthcare provider’s office submits a prescription order form and supporting documentation to us. We employ a team of Device Support
Specialists who provide technical training to the patient and any caregivers. Once treatment is initiated, we provide 24/7 technical support for
patients and caregivers as well as assistance with insurance reimbursement. We also provide the healthcare provider and the patient with a
usage report for monitoring patient time on therapy. We believe we have the experience and expertise to scale our sales and marketing efforts.
Billing and reimbursement
We provide our Products directly to patients following receipt of a prescription order and a signed patient service agreement (except in Japan as
described above). The number of active patients on therapy and the amount of net
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revenue recognized per active patient are our principal revenue drivers. An active patient is a patient who is receiving treatment under a
commercial prescription order as of the measurement date, including patients who may be on a temporary break from treatment and who plan
to resume treatment in less than 60 days. Growth in the number of active patients is a factor of both new patient starts and treatment duration.
We bill payers a single monthly fee for a month of therapy and we bear the financial risk of securing payment from third-party payers and
patients in all markets except for Japan. We distribute our Products through hospitals in Japan with the hospitals receiving reimbursement from
the government-mandated insurance program and in turn contracting with us for the equipment, supplies and services necessary to treat
patients with our Product.
We maintain a monthly list price for our therapy in the U.S. and set list prices outside of the United States that are approximately equivalent to
this price, subject to currency fluctuations. We typically negotiate discounts from our list price with healthcare payers, and in certain cases we
accept government-mandated discounts from our list prices in order to secure reimbursement for our Products.
We continue to work with payers to expand access to Optune for patients with GBM. As of December 31, 2022, we have received national
reimbursement for Optune in Austria, Germany, Israel, Japan, Sweden and Switzerland. In February 2023, we finalized contract terms to
establish national reimbursement in France for the treatment of adult patients with newly diagnosed GBM, pending official signatures and final
publication in the Journal Officiel.
In the U.S., a substantial majority of Americans with private health insurance had coverage of Optune for newly diagnosed GBM and/or
recurrent GBM as of December 31, 2022. As of September 2019, Americans who are beneficiaries of the Medicare fee-for-service program also
have coverage of Optune for newly diagnosed GBM. We believe we have completed our administrative ramp-up towards processing Medicare
claims and are efficiently pursuing appeals. We are actively appealing Medicare fee-for-service coverage denials up to and including the
Administrative Law Judge ("ALJ") process with Centers for Medicare and Medicaid Services ("CMS").
We are engaged in an initial dialogue with certain payers regarding access to Optune Lua for patients with MPM. We anticipate that MPM
claims during initial commercialization will go through an appeal process with payers, similar to our early experience with GBM. We anticipate
that our ability to gain meaningful coverage for Optune Lua will be dependent on inclusion in the relevant clinical guidelines for MPM.
Our development pipeline
Based on the results of our preclinical research, we have developed a pipeline strategy to advance TTFields through pilot and pivotal studies
across multiple solid tumor types. We anticipate expanding our clinical pipeline over time to include additional solid tumor cancer indications.
Current Development Pipeline
The solid tumor cancers
subject to our pilot and pivotal studies, as well as the studies themselves, are described in greater detail below. In addition to our studies in
tumors of the head, thorax and abdomen, we continue to conduct
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research in our approved indications to further advance the scientific evidence supporting the use of TTFields in GBM and to gather additional
information about our therapy's optimal use.
Glioblastoma
GBM is the most common and aggressive form of primary brain cancer. It is estimated that approximate 15,000 patients are diagnosed with
GBM or tumors that typically progress to GBM each year in the U.S. Following diagnosis, standard of care treatment includes surgical resection,
followed by radiotherapy with concomitant chemotherapy, followed TTFields together with maintenance chemotherapy.
2-THE-TOP pilot study
In 2021, Dr. David Tran, Chief of the Division of Neuro-Oncology at the University of Southern California Keck School of Medicine and co-
Director of the USC Keck Brain Tumor Center, presented updated data from the pilot 2-THE-TOP study testing the safety and efficacy of
TTFields together with pembrolizumab and temozolomide for the treatment of adult patients with newly diagnosed GBM. As of May 24, 2021, 25
patients with a median age of 61 years were enrolled in the study, with a median follow-up of 14.7 months. 32% had biopsy only and 16% had
partial resection. 72% had unmethylated MGMT and 12% had an IDH mutation. 48% were progression-free, and 60% were still alive. Of the 19
patients with follow-up greater than 9 months, the median progression-free survival was at least 11.2 months compared to 6.7 months from the
historical control study, EF-14, in which patients received TTFields and adjuvant temozolomide. 24% patients with measurable tumors achieved
partial or complete response. 193,760 peripheral blood mononuclear cells were sequenced in 12 patients before pembrolizumab and detected
robust post-TTFields T cell activation in 11 of 12 patients via the T1IFN trajectory with a strong correlation with the TCRαβ clonal expansion
Simpson index (Spearman coefficient r=-0.8, P=0.014). The study defined a T cell-based gene signature of TTFields effects on TCRαβ clonal
expansion. The most common adverse events were thrombosis (16%), seizure (12%), and metabolic disturbances (8%).
In March 2022, Dr. Tran presented updated results from the 2-THE-TOP study. These preliminary results, which are based on a median follow-
up time of 16.8 months, compared outcomes for 26 patients in the ongoing 2-THE-TOP study versus a historical, matched-control group of 26
patients from the EF-14 study. For patients in the 2-THE-TOP study, median progression-free survival was 12.1 months, compared with 7.9
months for the matched-control patients in EF-14 (hazard ratio=0.46, p=0.033). Patients in 2-THE-TOP had a median overall survival of 25.2
months, compared with 15.9 months for the matched-control patients in EF-14 (hazard ratio=0.38, p=0.020). Of the 15 patients in 2-THE-TOP
with measurable target lesions, six (40%) achieved partial to complete response and eight (53%) had stable disease.
The 2-THE-TOP study concluded that the triple combination of TTFields, temozolomide, and pembrolizumab is well tolerated and shows early
evidence of efficacy in newly diagnosed GBM patients. Patients will continue follow-up with survival and molecular data to be updated. In 2022,
we entered into a clinical collaboration agreement with MSD, a tradename of Merck & Co., Inc., ("MSD") to conduct the double-blind, placebo-
controlled pivotal KEYNOTE D58 study of TTFields concomitant with pembrolizumab and maintenance temozolomide for the treatment of newly
diagnosed GBM.
EF-33 pilot study
In October 2022, we announced preliminary data from our EF-33 pilot study, an open-label, single-arm study evaluating whether TTFields
delivered at 200 kHz to the brain using high-intensity arrays in the treatment of recurrent GBM significantly improves the clinical outcomes of
patients compared to using standard transducer arrays in 25 patients. Among patients who used Optune as directed with for at least one month,
median progression-free survival was 4.5 months compared to 2.2 months in the historical control, our pivotal EF-11 study. Further,
notwithstanding the increased dosage, EF-33 patients reported no TTFields-related toxicity.
TRIDENT pivotal study
In 2020, we enrolled the first patient in our TRIDENT study ("TRIDENT"), a pivotal study testing the potential survival benefit of initiating Optune
concurrent with radiation therapy in patients with newly diagnosed GBM. The primary endpoint is overall survival. Secondary endpoints include
progression-free survival, survival rates at one and two years, overall radiological response, severity and frequency of adverse effects,
pathological changes in
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resected GBM tumors post treatment, quality of life, and correlation of overall survival to TTFields dose. TRIDENT is designed to accrue 950
patients with a 24-month minimum follow-up period after the last patient enrolled.
Non-small cell lung cancer
Lung cancer is the most common cause of cancer-related death worldwide, and NSCLC accounts for approximately 85% of all lung cancers. It
is estimated that approximately 193,000 patients are diagnosed with NSCLC each year in the U.S.
Physicians use different combinations of surgery, radiation and pharmacological therapies to treat NSCLC, depending on the stage of the
disease. Surgery, which may be curative in a subset of patients, is usually used in early stages of the disease. A combination of radiation,
platinum-based chemotherapies, and immune checkpoint inhibitors, or targeted therapies, are the first line standard of care treatment for locally
advanced or metastatic NSCLC. Today, the standard of care for second line treatment is evolving and often includes immune checkpoint
inhibitors, docetaxel, platinum-based chemotherapy or pemetrexed.
EF-15 pilot study
In 2013, we published the results of our pilot study, the EF-15 study ("EF-15"), evaluating the safety and efficacy of TTFields in the treatment of
advanced NSCLC. EF-15 focused on the effects of treatment with TTFields in combination with standard of care pemetrexed chemotherapy.
Results of the pemetrexed pivotal FDA registration study were used as a historical control in this study.
A total of 42 patients were recruited to the study with a minimum follow-up of six months. Efficacy results based on 41 evaluable patients
showed both progression-free survival and overall survival for patients receiving TTFields in combination with pemetrexed increased compared
to historical control data for pemetrexed alone. Median time to in-field progression in the TTFields-treated group was 6.5 months (compared to
2.9 months in the historical control) and median overall survival was 13.8 months (compared to 8.3 months in the historical control). Adverse
events reported in this combination study were comparable to those reported with pemetrexed alone, suggesting minimal added toxicities due
to TTFields.
LUNAR pivotal study
In 2017, we enrolled the first patient in our LUNAR study ("LUNAR"), a pivotal study testing the effectiveness of TTFields in combination with
immune checkpoint inhibitors or docetaxel versus immune checkpoint inhibitors or docetaxel alone for patients with stage 4 NSCLC who
progressed during or after platinum-based therapy. It is estimated that approximately 46,000 patients receive second-line treatment for stage 4
NSCLC each year in the U.S. The primary endpoint is superior overall survival of patients treated with TTFields plus immune checkpoint
inhibitors or docetaxel versus immune checkpoint inhibitors or docetaxel alone. We believe our protocol incorporates the evolving standard of
care for second-line treatment of NSCLC. TTFields is intended principally for use in combination with other standard-of-care treatments, and
LUNAR was designed to generate data that contemplates multiple outcomes, all of which we believe will be clinically meaningful.
In 2021, we announced that an independent Data Monitoring Committee ("DMC") informed us that the pre-specified interim analysis for the
LUNAR study was accelerated given the length of accrual and the number of events observed, to date. The interim analysis included data from
210 patients accrued through February 2021. After review of the interim analysis, the DMC concluded that the LUNAR study should continue
with no evidence of increased systemic toxicity. The DMC went on to comment that the continued accrual to 534 patients as proposed in the
original protocol, given the current rate of accrual and the interim data presented, is likely unnecessary and possibly unethical for patients
randomized to control. For this reason, the DMC recommended an adjustment of accrual to approximately 276 patients with a 12-month follow-
up following the enrollment of the last patient. The DMC believed this amended protocol would provide adequate data regarding toxicity and
efficacy, providing sufficient overall power, as well as potentially providing important information regarding efficacy within treatment subgroups.
In May 2021, the FDA approved our investigational device exemption supplement incorporating the recommended protocol changes and we
enrolled our last LUNAR patient in November 2021.
In January 2023, we announced the LUNAR study met its primary endpoint, demonstrating a statistically significant and clinically meaningful
improvement in overall survival for patients treated with TTFields and standard therapies compared to those treated with standard therapies
alone. The LUNAR study also showed a statistically significant and clinically meaningful improvement in overall survival when patients were
treated with TTFields and immune checkpoint inhibitors, as compared to those treated with immune checkpoint inhibitor alone, and a positive
trend in
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overall survival when patients were treated with TTFields and docetaxel versus docetaxel alone. Patient enrollment was well balanced between
the immune checkpoint inhibitor and docetaxel cohorts of the experimental and control arms, and the control arms performed in line with prior
studies. TTFields therapy was well tolerated by patients enrolled in the experimental arm of the study. The publication of full data from the
LUNAR study is anticipated in 2023.
KEYNOTE B36 pilot study
In June 2022, we enrolled the first patient in our KEYNOTE B36 study, a pilot study evaluating the safety and efficacy of TTFields together with
the anti-PD-1 therapy pembrolizumab for the treatment of first-line NSCLC, expanding our research in the lung cancer space. This study is the
result of a clinical study collaboration with MSD.
Brain metastases
Metastatic cancer is cancer that has spread from the place where it first started to another place in the body. In metastasis, cancer cells break
away from where they first formed (the primary cancer), travel through the blood or lymph system, and form new tumors (the metastatic tumors)
in other parts of the body. The exact incidence of brain metastases is unknown because no national cancer registry documents brain
metastases, and estimates from scientific literature vary greatly based on the study methodology applied. It is estimated that between 100,000
and 240,000 new cases are diagnosed in the U.S. each year with brain metastases estimated to occur in between 10% to 40% of all cancer
patients.
Brain metastases are commonly treated with a combination of surgery and radiation. Chemotherapy is often given for the primary tumor, but
many chemotherapy agents do not cross the blood brain barrier and are thus ineffective in the treatment of brain metastases. When brain
metastases appear, they are either surgically removed or treated with radiation using stereotactic radiosurgery ("SRS") when possible. Whole
brain radiation therapy, although effective in delaying progression or recurrence of brain metastases when given either before or after SRS, is
associated with neurotoxicity and a significant decline in cognitive functioning. Thus, whole brain radiation therapy is often delayed until later in
the disease course and is often used as a last resort. This practice results in a window of unmet need after localized surgery and SRS are used
and before whole brain radiation therapy is administered to delay or prevent the additional spread of brain metastases.
METIS pivotal study
In 2016, we enrolled the first patient in our METIS study ("METIS"), a pivotal study testing the effectiveness of SRS plus TTFields compared to
SRS alone in patients with brain metastases resulting from NSCLC. It is estimated that between 20 to 40% of patients with NSCLC develop
brain metastases, with an estimated 38,000 to 77,000 patients diagnosed each year in the U.S. with brain metastases resulting from NSCLC.
The primary endpoint of METIS is time to first intracranial progression. Secondary endpoints include, among others, time to neurocognitive
failure, overall survival and radiological response rate following study treatments. The study is designed to accrue 270 patients with a minimum
12-month follow-up period following the final patient enrollment. We anticipate completing enrollment of the METIS study in the first quarter of
2023.
Ovarian cancer
In the U.S., ovarian cancer ranks fifth in cancer deaths among women, with approximately 24,000 women diagnosed each year. Ovarian cancer
incidence increases with age, and the median age at time of diagnosis is 63 years old.
Physicians use different combinations of surgery and pharmacological therapies to treat ovarian cancer, depending on the stage of the disease.
Surgery is usually used in early stages of the disease and is usually combined with chemotherapy, including paclitaxel and platinum-based
chemotherapy. Unfortunately, the majority of patients are diagnosed at an advanced stage when the cancer has spread outside of the ovaries to
include regional tissue involvement and/or metastases. Platinum-based chemotherapy remains part of the standard of care in advanced ovarian
cancer, but most patients with advanced ovarian cancer will have tumor progression or, more commonly, recurrence. Almost all patients with
recurrent disease ultimately develop platinum resistance, and the prognosis for this population remains poor.
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INNOVATE pilot study
In 2018, we published the results of our pilot study in recurrent ovarian cancer, the INNOVATE study ("INNOVATE"), examining TTFields in
combination with standard of care chemotherapy. INNOVATE was a multi-center, non-randomized, open-label study designed to test the
feasibility, safety and preliminary efficacy of TTFields in combination with weekly paclitaxel. The paclitaxel control arm from the bevacizumab
pivotal FDA registration study was used as a historical control in this study.
A total of 31 patients were recruited to the study with a minimum follow-up of six months. Safety results suggested that TTFields in combination
with weekly paclitaxel may be tolerable and safe as second-line treatment for patients with recurrent ovarian cancer. Median progression-free
survival in the TTFields-treated group was 8.9 months (compared to 3.9 months in the paclitaxel-alone historical control), and median overall
survival was not yet reached. The one-year survival rate was 61%. Efficacy results based on the 31 evaluable patients suggested more than
doubling of the progression-free survival and an improvement in overall survival among patients who received TTFields therapy with paclitaxel
compared to paclitaxel alone.
INNOVATE-3 pivotal study
In 2019, we enrolled the first patient in our INNOVATE-3 study ("INNOVATE-3"), a pivotal study testing the effectiveness of TTFields with
paclitaxel in patients with platinum-resistant ovarian cancer. It is estimated that approximately 16,000 patients are diagnosed with platinum-
resistant ovarian cancer each year in the U.S. The primary endpoint of INNOVATE-3 is overall survival. Secondary endpoints include
progression-free survival, objective response rate, severity and frequency of adverse events, time to undisputable deterioration in health-related
quality of life or death, and quality of life. The study is designed to accrue 540 patients with 18-month follow-up after the last patient in. In 2021,
we announced that the final patient was enrolled in the pivotal INNOVATE-3 study. In March 2022, we announced that an independent DMC
conducted a pre-specified interim analysis for the study. As part of the interim analysis, the DMC reviewed the safety data for all enrolled
patients and completed an analysis of overall survival on the first 540 patients randomized in the study. The interim analysis did not indicate a
need to increase the patient sample size and the DMC recommended that the study should continue to final analysis as planned. We anticipate
that final data will be released in 2023, following completion of a minimum 18-month follow-up period. The European Network for
Gynaecological Oncological Trial groups ("ENGOT") and The GOG Foundation, Inc. ("GOG"), third-party clinical study networks, are
collaborating with us on the study.
Pancreatic cancer
Pancreatic cancer is one of the most lethal cancers and is the third most frequent cause of death from cancer in the U.S. While overall cancer
incidence and death rates are remaining stable or declining, the incidence and death rates for pancreatic cancer are increasing. It is estimated
that approximately 53,000 patients are diagnosed with pancreatic cancer each year in the U.S. Pancreatic cancer has a five-year relative
survival rate of just 10 percent.
Physicians use different combinations of surgery, radiation and pharmacological therapies to treat pancreatic cancer, depending on the stage of
the disease. For patients with locally advanced pancreatic cancer involving encasement of arteries but no extra-pancreatic disease, the
standard of care is surgery followed by chemotherapy with or without radiation. Unfortunately, the majority of locally advanced cases are
diagnosed once the cancer is no longer operable, generally leaving chemotherapy with or without radiation as the only treatment option.
PANOVA pilot study
In 2018, we published the results of our pilot study in advanced pancreatic adenocarcinoma, the PANOVA study ("PANOVA"), examining
TTFields in combination with standard of care chemotherapy.
PANOVA was a multicenter, non-randomized, open-label study. The study included 40 patients with locally advanced or metastatic pancreatic
cancer whose tumors could not be removed surgically and who had not received chemotherapy or radiation therapy prior to the clinical study.
Patients were enrolled between 2014 and 2016 in two cohorts: The first cohort of 20 patients received TTFields with standard doses of
gemcitabine alone. The second cohort of 20 patients received TTFields with standard doses of nab-paclitaxel plus gemcitabine.
In the first cohort, efficacy results showed that progression-free survival and overall survival of patients treated with TTFields combined with
gemcitabine were more than double those of gemcitabine-treated historical controls. Median progression-free survival in the TTFields-treated
group was 8.3 months (compared to 3.7 months in the gemcitabine historical control), with locally advanced patients reaching a median
progression-free survival of 10.3
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months and patients with metastatic disease reaching a median progression-free survival of 5.7 months. The median overall survival for all
patients was 14.9 months (compared to 6.7 months in the gemcitabine historical control). Median overall survival was not reached in locally
advanced patients and 86% of patients were alive at end of follow up. Patients with metastatic disease experienced a median overall survival of
8.3 months. One-year survival was 55% (compared to 22% in the gemcitabine historical control). Of 11 patients with available CT scans, 5
(45%) had a partial response (compared to 7% with gemcitabine alone), 5 (45%) had stable disease, which means that the cancer is neither
decreasing nor increasing in extent or severity, and 1 (10%) had progressive disease.
In the second cohort, efficacy results showed that progression-free survival and overall survival of patients treated with TTFields combined with
nab-paclitaxel plus gemcitabine were more than double those of nab-paclitaxel plus gemcitabine-treated historical controls. Median
progression-free survival in the TTFields-treated group was 12.7 months (compared to 5.5 months in the nab-paclitaxel plus gemcitabine
historical control) and median overall survival was not yet reached. The one-year survival rate was 72% (compared to 35% in nab-paclitaxel
plus gemcitabine historical control). Of the 15 patients with available CT scans, 6 (40%) had a partial response (compared to 23% with the nab-
paclitaxel plus gemcitabine alone), 7 (47%) had stable disease and 2 (13%) had progressive disease.
Safety results from both cohorts suggested that TTFields plus first-line chemotherapies nab-paclitaxel and/or gemcitabine may be tolerable and
safe in patients with advanced pancreatic cancer. Patients reported no serious adverse events related to TTFields.
PANOVA-3 pivotal study
In 2018, we enrolled the first patient in our PANOVA-3 study ("PANOVA-3"), a pivotal study testing the effectiveness of TTFields with nab-
paclitaxel and gemcitabine versus nab-paclitaxel and gemcitabine alone as a front-line treatment for unresectable locally advanced pancreatic
cancer. It is estimated that approximately 43,000 patients are diagnosed with unresectable pancreatic cancer each year in the U.S. The primary
endpoint of PANOVA-3 is overall survival. Secondary endpoints include progression-free survival, local progression-free survival, objective
response rate, one-year survival rate, quality of life, pain-free survival, resectability rate and toxicity.
The study is designed to accrue 556 patients. In February 2023, we announced that the final patient was enrolled in the pivotal PANOVA-3
study, beginning the minimum 18-month follow-up period. A DMC will conduct a pre-specified interim analysis pursuant to the study protocol
and final data is anticipated in 2024.
Liver cancer
Liver cancer is a leading cause of cancer deaths worldwide and is the sixth leading cause of cancer deaths annually in the U.S. The incidence
of liver cancer is approximately 42,000 new cases annually in the U.S. The five-year survival rate with existing standards of care is less than
20%.
Hepatocellular carcinoma is the most widespread type of cancer that originates from the liver. Advanced liver cancer has spread either to the
lymph nodes or to other organs and, because these cancers are widespread, they cannot be treated with surgery. The current common
standard treatment for patients with advanced disease and those who progressed on loco-regional therapy is systemic therapy with sorafenib,
lenvatinib, or atezolizumab plus bevacizumab.
In 2021, we announced that the FDA granted breakthrough designation to the NovoTTF-200T System, a TTFields device intended for use
together with atezolizumab and bevacizumab for the first-line treatment of patients with unresectable or metastatic liver cancer. The designation
offers us an opportunity to interact with FDA experts throughout the premarket review phase and allows for prioritized review of regulatory
submissions.
HEPANOVA pilot study
In 2021, we announced the final results of our HEPANOVA study, a single-arm pilot study evaluating the safety and efficacy of TTFields in
combination with sorafenib for the treatment of advanced hepatocellular cancer. In 21 evaluable patients, HEPANOVA showed a 9.5% objective
response rate and 76% disease control rate, as well as 5.8 months of progression free survival, compared to historical control data showing a
4.5% objective response rate and 43% disease control rate for patients treated with sorafenib alone. These results are even more encouraging
when considering the poor prognosis of the study population. 52% of the patients in HEPANOVA were categorized as Child-Pugh Class B,
compared to 5% in the historical control, indicating significant liver functional compromise. Additionally, research conducted to date has shown
that TTFields anti-mitotic effect requires extended exposure to
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the therapy for maximum impact. This was a challenge given median patient treatment duration of only 10 weeks during the study. Of the
patients who received at least 12 weeks of therapy, the disease control rate reached 91% with an objective response rate of 18%. These data
demonstrate that TTFields have the potential to extend survival in advanced liver cancer.
Gastric cancer
Gastric cancer is the third leading cause of cancer deaths worldwide and the third leading cause of cancer deaths in China. The incidence of
gastric cancer is approximately 478,500 new cases annually in China, and approximately 26,000 new cases annually in the U.S. The five-year
overall survival rate of gastric cancer is approximately 36%.
Current therapies include surgery, chemotherapy, radiotherapy and targeted therapy. A commonly used chemotherapy regimen in treating
gastric cancer is XELOX, a combination of oxaliplatin and capecitabine. In patients diagnosed with advanced gastric cancer that is no longer
operable, combination chemotherapy extends progression-free survival and overall survival to 3-6 months and 8-14 months, respectively.
EF-31 pilot study
In June 2022, we announced the results from our EF-31 pilot study, a single-arm study evaluating the safety and efficacy of TTFields together
with XELOX chemotherapy (and trastuzumab for HER2-positive patients) as first-line treatment for patients with unresectable gastric
adenocarcinoma or gastroesophageal junction adenocarcinoma in partnership with Zai. In 26 evaluable patients, the primary endpoint,
confirmed objective response rate, was 50%, median progression-free survival was 7.8 months, duration of response was 10.3 months and
median overall survival had not yet been reached with a one-year survival rate of 72%.
Zai License and Collaboration Agreement
In 2018, we announced a strategic collaboration with Zai. The collaboration agreement grants Zai a license to commercialize our Products in
Greater China and establishes a development partnership intended to accelerate the development of TTFields in multiple solid tumor cancer
indications. Zai has launched Optune for the treatment of newly diagnosed GBM in Hong Kong and mainland China and is seeking marketing
authorization for GBM in Taiwan. Zai has also launched Optune Lua for the treatment of MPM in Hong Kong and has filed a Marketing
Authorization Application for MPM in mainland China. For additional information, see Note 12 to the Consolidated Financial Statements.
Manufacturing and supply chain
We outsource production of all of our system components to qualified partners. Disposable array manufacturing, the dominant activity in our
manufacturing supply chain, includes several specialized processes. Production of the durable system components follows standard electronic
medical device methodologies.
We have supply agreements in place with our third-party manufacturing partners. While we currently obtain some critical materials for use in
certain jurisdictions from single source suppliers, we have developed or are in the process of developing and obtaining regulatory approval for
second sources for critical materials in all jurisdictions. We hold safety stocks of single source components in quantities that we believe are
sufficient to protect against possible supply chain disruptions. We anticipate that the diversification of our supply chain will both ensure a
continuity of supply and reduce costs.
Intellectual property
We believe we possess global commercialization rights to our Products in oncology and are well-positioned to extend those rights into the future
as we continue to find innovative ways to improve our Products. Our robust global patent and intellectual property portfolio consists of hundreds
of issued patents in multiple jurisdictions covering various aspects of our devices and related technology. In the U.S., our patents have expected
expiration dates between 2023 and 2041. We have also filed several hundred additional patent applications worldwide, that, if issued, may
protect aspects of our platform beyond the current last-to-expire patent in the relevant market. These pending applications cover innovations
relating to our arrays, field generators and software platform, in addition to other topics related to TTFields. Our reliance on intellectual property
involves certain risks, as described under the heading "Risk factors—Risks relating to intellectual property."
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In addition to our patent portfolio, we further protect our intellectual property by maintaining the confidentiality of our trade secrets, know-how
and other confidential information. Given the length of time and expense associated with bringing device candidates through development and
regulatory approval to the market place, the healthcare industry has traditionally placed considerable importance on obtaining patent protection
and maintaining trade secrets, know-how and other confidential information for significant new technologies, products and processes.
Our policy is to require each of our employees, consultants and advisors to execute a confidentiality agreement before beginning their
employment, consulting or advisory relationship with us. These agreements generally provide that the individual must keep confidential and not
disclose to other parties any confidential information developed or learned by the individual during the course of their relationship with us except
in limited circumstances. These agreements also generally provide that we own, or the individual is required to assign to us, all inventions
conceived by the individual in the course of rendering services to us. Despite measures taken to protect our intellectual property, unauthorized
parties may copy certain aspects of our products or obtain and use information that we believe is proprietary.
Pursuant to our strategic collaboration with Zai, we granted Zai a license to commercialize TTFields in Greater China. For additional
information, see Note 12 to the Consolidated Financial Statements.
Competition
The market for cancer treatments is intensely competitive, subject to rapid change and significantly affected by new product and treatment
introductions and other activities of industry participants. The general bases of competition are overall effectiveness, side effect profile, cost,
availability of reimbursement and general market acceptance of a product as a suitable cancer treatment.
Our intellectual property portfolio is continuously expanding as we find new and unique ways to improve TTFields therapy. We believe these
intellectual property rights would provide an obstacle to the introduction of state of the art TTFields devices by a competitor. However,
competitors may be able to offer less sophisticated TTFields devices that utilize technology described in expired patents and/or choose to
market their system(s) in countries where we have limited or no enforceable intellectual property rights. Competitors could also pursue
alternative technologies for the application of TTFields into a patient that we did not foresee or protect. We are aware of a few third parties in
the United States and China developing devices and filing for intellectual property protection related to TTFields.
Beginning in 2021, several of our early patents covering technology included in our Products began expiring in the U.S. and elsewhere. Even
after the expiration of our patents, we believe that potential market entrants applying low-intensity, alternating electric fields to solid tumors will
have to undertake their own clinical studies and regulatory submissions to prove equivalence to our Products, a necessary step in receiving
regulatory approvals for a competing product, all while avoiding infringing our unexpired patents.
Presently, the traditional biotechnology, pharmaceutical and medical technology industries expend significant resources in developing novel and
proprietary therapies for the treatment of solid tumors, including GBM, MPM and other indications that we are currently investigating. As we
work to increase market acceptance of our Products, we compete with companies commercializing or investigating other anti-cancer therapies,
some of which are in clinical studies for GBM or MPM that currently specifically exclude patients who have been or are being treated with our
Products. The introduction of competing therapies could materially impact our business and financial results.
Government regulation
In the U.S., our Products and our operations are subject to extensive regulation by the FDA under the Federal Food, Drug, and Cosmetic Act
("FDCA"). In the EU member states where we market our Products and operate, we are currently subject to, inter alia, the Medical Device
Regulation ("MDR") as implemented into national legislation by the EU member states, and as amended from time to time, as well as local
applicable law. The MDR replaced the Medical Device Directive ("MDD") on May 26, 2021. In Switzerland, our Products and operations are
subject to, inter alia, the Medical Devices Ordinance, which implements the MDR into Swiss law (See "Foreign approvals and CE mark" below).
In Japan, our Products and operations are subject to regulation by the Pharmaceuticals and Medical Device Agency ("PMDA") under the
Pharmaceuticals and Medical Devices Act ("PMD Act"). In the UK, our Products and operations are subject to, inter alia, the Medical Devices
Regulations 2002 and the Medical Devices (Amendment etc.) (EU Exit) Regulations 2020 (the "UK Regulations"), which implements the MDR
and MDR like provisions into UK law. In addition, our Products must meet the requirements of a large and growing body of national, regional
and international standards that govern the preclinical and clinical testing, manufacturing, labeling,
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certification, storage, recordkeeping, advertising, promotion, export and marketing and distribution, among other things, of our Products for
current and future indications.
In the U.S., advertising and promotion of medical devices, in addition to being regulated by the FDA, is also regulated by the Federal Trade
Commission and by state regulatory and enforcement authorities. In the EU, advertising and promotion is subject to not only the general
provisions of the MDR, but also general EU advertising rules on misleading and comparative advertising and unfair commercial practices, as
implemented at the EU member state level, such as the Heilmittelwerbegesetz in Germany. In the UK, advertising and promotion is subject to
the UK Regulations, general guidance and enforcement of the Medicines and Healthcare products Regulatory Agency (MHRA), and adherence
to the Association of British HealthTech Industries (ABHI) Code of Ethical Business Practices. Promotional activities for FDA-regulated products
of other companies have been the subject of government enforcement actions brought under healthcare laws and consumer protection statutes.
In addition, we are required to meet analogous regulatory requirements in countries outside the U.S., which can change rapidly with relatively
short notice. Competitors can also initiate litigation alleging false advertising for our promotional efforts under the Lanham Act, or under similar
state laws.
Our research, development and clinical programs, as well as our manufacturing and marketing operations, are also subject to extensive
regulation.
Failure by us or by our suppliers to comply with applicable regulatory requirements can result in enforcement action by the FDA or other
regulatory authorities, which may result in any number of regulatory enforcement actions, or civil or criminal liability.
Food and Drug Administration
The FDA regulates the development, testing, manufacturing, labeling, storage, recordkeeping, promotion, marketing, distribution and service of
medical devices in the U.S. to ensure that medical products distributed domestically are safe and effective for their intended uses. In addition,
the FDA regulates the export of medical devices manufactured in the U.S. to international markets and the importation of medical devices
manufactured abroad. The FDA has broad post-market and regulatory enforcement powers to ensure compliance with the FDCA.
The FDA governs the following activities that we perform or that are performed on our behalf:
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product design, development and manufacture;
product safety, testing, labeling and storage;
record keeping procedures;
product marketing, sales and distribution; and
post-marketing surveillance, complaint handling, medical device reporting, reporting of deaths, serious injuries or device malfunctions
and repair or recall of products.
We have registered three of our facilities with the FDA. We are subject to announced and unannounced inspections by the FDA to determine
our compliance with the Quality System Regulation ("QSR") and other regulations and these inspections include the manufacturing facilities of
our suppliers.
FDA’s premarket clearance and approval requirements
Unless an exemption applies, before we can commercially distribute medical devices in the U.S., we must obtain, depending on the type of
device, either prior 510(k) clearance or premarket approval ("PMA") from the FDA. The FDA classifies medical devices into one of three
classes. Devices deemed to pose lower risks are placed in either class I or II, which typically requires the manufacturer to submit to the FDA a
premarket notification requesting permission to commercially distribute the device. This process is generally known as 510(k) clearance. Some
low-risk devices are exempted from this requirement. Devices deemed by the FDA to pose the greatest risks, such as life-sustaining, life-
supporting or implantable devices, or devices deemed not substantially equivalent to a previously cleared 510(k) device, are placed in class III,
generally requiring PMA.
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Premarket approval (PMA) and Humanitarian Device Exemption (HDE) pathways
Optune and Optune Lua are classified as Class III devices as they are deemed to be life-sustaining devices. Accordingly, we were required to
receive PMA for Optune, which the FDA granted in April 2011 and October 2015 for the treatment of recurrent and newly diagnosed
supratentorial GBM, respectively, in adult patients. We expect that we will be required to receive PMA for the use of our Products for future
indications.
A PMA must be supported by extensive data, including from technical tests, preclinical studies and clinical studies, manufacturing information
and intended labeling to demonstrate, to the FDA’s satisfaction, the safety and effectiveness of a medical device for its intended use. During the
PMA review period, the FDA will typically request additional information or clarification of the information already provided. Also, an advisory
panel of experts from outside the FDA may be convened to review and evaluate the application and provide recommendations to the FDA as to
the approvability of the device. The FDA may or may not accept the panel’s recommendation. In addition, the FDA will generally conduct a pre-
approval inspection of the manufacturing facility or facilities to ensure compliance with the QSR. Prior to approval of the Optune PMA for the
treatment of recurrent GBM, we and our critical component suppliers were each inspected by the FDA.
New PMAs or PMA supplements are required for modifications that affect the safety or effectiveness of our devices, including, for example,
certain types of modifications to a device’s indication for use, manufacturing process, labeling and design. PMA supplements often require
submission of the same type of information as a PMA, except that the supplement is limited to information needed to support any changes from
the device covered by the original PMA and may not require any or as extensive clinical data as the original PMA required, or the convening of
an advisory panel. The FDA requires a company to make the determination as to whether a new PMA or PMA supplement application is to be
filed. If a company determines that neither a new PMA nor a PMA supplement application is required for modifications, it must nevertheless
notify the FDA of these modifications in its PMA Annual Report. The FDA may review a company’s decisions when reviewing the PMA Annual
Report and require the filing of an application.
As is typical with medical device companies, we have received approval for a number of post-approval PMA supplements for GBM, including for
modifications to Optune’s electric field generator, arrays, software, manufacturing processes and labeling. Future modifications may be
considered by us as the need arises, some of which we may deem to require a PMA supplement application and others to require reporting in
our PMA Annual Report.
For class III devices intended to treat disease affecting 8,000 individuals or less per year in the U.S., called Humanitarian Use Devices ("HUD"),
the FDA has a separate marketing authorization pathway called the HDE. Approval basis for an HDE is a "reasonable assurance of safety" and
that the probable benefit to health outweighs risk of injury from its use, which means a traditional pivotal study usually is not required to support
approval.
In 2019, the FDA approved Optune Lua (then known as "NovoTTF-100L") for the treatment of MPM under the HDE pathway. Devices approved
through an HDE application are subject to certain requirements, including specific labeling restrictions and the requirement that a facility’s
institutional review board ("IRB") or Local Committee approve the use of the device before it can be distributed in that facility. In addition, there
is a general prohibition on profiting from sales of devices approved under the HDE standard. As part of the approval process, we applied for an
exemption from this limitation, which the FDA granted. Otherwise, HDE approved devices are generally required to follow the same
requirements as PMA approved devices, including the supplement process.
Clinical studies
Clinical studies are generally required to support approval of a PMA or HDE. Such studies generally require an Investigational Device
Exemption ("IDE") approval from the FDA for a specified number of patients and study sites, unless the product is deemed a non-significant risk
device eligible for more abbreviated IDE requirements. Clinical studies are subject to extensive monitoring, recordkeeping and reporting
requirements. Clinical studies must be conducted under the oversight of an IRB for the relevant clinical study sites and must comply with FDA
regulations, including those relating to current Good Clinical Practices ("cGCPs"). To conduct a clinical study, we also are required to obtain the
patients’ informed consent in form and substance that complies with both FDA requirements and state and federal privacy and human subject
protection regulations. We, the FDA or the respective IRB could suspend a clinical study at any time for various reasons, including a belief that
the risks to study subjects outweigh the anticipated benefits. Even if a study is completed, the results of clinical testing may not adequately
demonstrate the safety and efficacy of the device or may otherwise not be sufficient to obtain FDA approval to market the product in the U.S.
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Post-approval studies are also typically required as a condition of PMA to reinforce the reasonable assurance of safety and effectiveness. Such
studies are conducted in the post-market setting with the approved device, often to address the long-term use of the device or other discrete
questions that may have been raised based on the clinical data from the IDE clinical study. The FDA required a post-approval registry study as
a condition of approval for Optune for recurrent GBM, which we completed.
Clinical studies involving pharmacological/immunological therapy candidates may be regulated under FDA’s drug regulations, Unless exempt,
such studies require authorization from FDA of an Investigational New Drug Application ("IND") for a specified number of patients and study
sites. As with IDE studies, IND studies are subject to extensive monitoring, recordkeeping and reporting requirements, must be conducted
under the oversight of an IRB, must comply with FDA drug or biologic regulations, and are required to obtain informed consent that complies
with FDA requirements and state and federal privacy and human subject protection regulations. IND clinical studies can be suspended at any
time by us, the FDA or an IRB for various reasons, including a belief that the risks to study subjects outweigh the anticipated benefits. Even if an
IND study is completed, the results of clinical testing may not be sufficient to obtain FDA approval to market the product.
Foreign approvals and CE mark
Market access, sales and marketing of medical devices outside of the U.S. are subject to foreign regulatory requirements that vary widely from
country to country. In the European Economic Area (“EEA”), for Novocure’s devices these include the requirement to obtain a CE Certificate
and to affix a CE mark to our Products. In the EEA, whether or not we have obtained FDA approval, our devices must be subject to conformity
assessment procedure involving an EEA notified body, a private organization accredited by an EEA member state to conduct conformity
assessment procedures under the MDR. Apart from low risk medical devices (Class I with no measuring function and which are not sterile), a
conformity assessment procedure requires the intervention of a notified body. The notified body typically audits and examines the device’s
technical documentation, including the clinical evaluation, and the quality system for the manufacture, design and final inspection of our devices
before issuing a CE Certificate demonstrating compliance with the relevant requirements or the quality system requirements laid down in the
relevant Annexes to the MDR. Following the issuance of this CE Certificate, we can draw up a declaration of conformity and affix the CE mark
to the devices covered by this CE Certificate. The time required to CE mark our devices or to obtain approval from other non-U.S. authorities
may be longer or shorter than that required for FDA approval. Moreover, the MDR, which became applicable on May 26, 2021, with transitional
provisions for "legacy" devices under the MDD, imposed new, stricter requirements that we must comply with in order to obtain CE Certificates
for new devices, and to renew the CE Certificates for our MDD-Products when these expire, or at the latest, December 31, 2027 or 2028,
depending on the device, whichever comes first. In addition, as of May 25, 2021, in the absence of a new MRA, Switzerland is now considered
a non-EU “third country” with respect to medical devices, meaning that movement of our Products bearing a CE mark from the EEA to
Switzerland is subject to additional requirements. In the UK, we may continue to market and sell our Products under the CE mark until June
2023. Thereafter, our Products will be regulated under the UK Regulations.
In the EEA, before carrying out a clinical investigation with a non-CE marked device to assess its safety or performance when in accordance
with its intended use, the study sponsor must receive a positive opinion from the local ethics committee and approval from the national
competent authority in the relevant EEA member states in which the clinical investigation will be conducted. When a CE marked medical device
is used in a clinical study in accordance with its intended use, the approval of the national competent authorities is not required for the use of
such medical device in the study. In Japan, we must obtain approvals from the Ministry of Health, Labour, and Welfare ("MHLW") to market our
devices. Each regulatory approval process outside of the U.S. includes all the risks associated with FDA regulation, as well as country-specific
regulations.
Pervasive and continuing regulation
After a device is placed on the market, numerous regulatory requirements apply depending upon the country in which the device is being
marketed. These may include:
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product listing and establishment registration, which helps facilitate FDA inspections and other regulatory action;
• QSR, which requires manufacturers, including third-party manufacturers, to follow stringent design, testing, control, documentation and
other quality assurance procedures during all aspects of the manufacturing process for products marketed in the U.S.;
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labeling regulations and FDA and equivalent competent authority in other jurisdictions requiring promotion be truthful and non-
misleading and prohibiting the promotion of products for uncleared, unapproved or off-label uses;
approval of product modifications that affect the safety or effectiveness of one of our devices that has been approved or is the subject of
a CE Certificate;
• Medical Device Reporting regulations of the FDCA and medical device vigilance, which require that manufacturers comply with FDA or
equivalent competent authority requirements in other jurisdictions to report if their device may have caused or contributed to a death or
serious injury, or has malfunctioned in a way that would likely cause or contribute to a death or serious injury if the malfunction of the
device or a similar device were to recur;
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post-approval restrictions or conditions, including post-approval study commitments;
post-market surveillance regulations, which apply when necessary to protect the public health or to provide additional safety and
effectiveness data for the device;
the FDA’s and equivalent competent authority’s recall authority, whereby they can ask, or under certain conditions order, device
manufacturers to recall from the market a product that is in violation of governing laws and regulations;
regulations pertaining to voluntary recalls; and
notices of corrections or removals.
Our devices could be subject to voluntary recall if we, the FDA or another applicable regulatory authority determine, for any reason, that our
devices pose a risk of injury or are otherwise defective. Moreover, the FDA and other applicable regulatory authorities can order a mandatory
recall if there is a reasonable probability that our device would cause serious adverse health consequences or death.
The FDA has broad post-market and regulatory enforcement powers. We are subject to unannounced inspections by the FDA to determine our
compliance with the QSR and other regulations and these inspections include the manufacturing facilities of our subcontractors. We are also
subject to FDA’s broad regulatory enforcement power around promotional activities. Failure by us or by our suppliers to comply with applicable
regulatory requirements can result in enforcement action by the FDA or other applicable regulatory authorities, which may result in sanctions,
including, but not limited to:
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untitled letters, warning letters, fines, injunctions, consent decrees and civil penalties;
unanticipated expenditures to address or defend such actions;
customer notifications for repair, replacement and/or refunds;
recall, detention or seizure of our devices;
operating restrictions or partial suspension or total shutdown of production;
refusing or delaying our requests for approval of device candidates or a modified version of Optune;
• withdrawal of PMA/HDE approvals or suspension, variation or withdrawal of CE Certificates that have already been granted;
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refusal to grant export approval for our devices; or
civil and/or criminal prosecution by the U.S. Department of Justice or other enforcement authorities outside of the U.S.
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To date, our facilities and those of our critical suppliers have been inspected by several relevant regulatory authorities in order to obtain
regulatory approval of our Products. No inspectional observations were identified were issued following these inspections.
Durable medical equipment accreditation and licensing and other requirements
In the U.S., we are subject to accreditation and licensing requirements as a durable medical equipment ("DME") supplier in most states and
must meet the supplier standards of Medicare, Medicaid and other federal healthcare programs. Certain states require that DME providers
maintain an in-state location. Although we believe we are in compliance with all applicable federal and state regulations regarding accreditation
and licensure requirements and similar requirements in other jurisdictions, if we are found to be noncompliant, we could lose our accreditation
or licensure in such states or our supplier rights under such federal healthcare programs, which could prohibit us from selling our current or
future devices to patients in such state or to that federal healthcare program.
Healthcare regulatory matters
In addition to FDA restrictions on the marketing of medical devices, several other U.S. federal and state laws have been applied to restrict
certain business practices in the healthcare industry and penalize unlawful conduct. These laws include the federal Anti-Kickback Statute, the
federal prohibition on physician self-referrals (commonly known as the "Stark Law") and the federal False Claims Act.
The U.S. federal Anti-Kickback Statute is a criminal, intent-based statute that prohibits, among other things, knowingly and willfully offering,
paying, soliciting or receiving any remuneration to induce or in return for purchasing, leasing, ordering, recommending or arranging for the
purchase, lease, order or recommendation of any healthcare item or service that may be paid for, in whole or in part, by Medicare, Medicaid or
another federal healthcare program. Among other arrangements, this statute has been interpreted to apply to financial arrangements between
medical device manufacturers on one hand and prescribers and purchasers on the other. Although there are a number of statutory exceptions
and regulatory safe harbors that protect certain common activities from prosecution under the law, the exceptions and safe harbors are drawn
narrowly and practices that involve the provision of remuneration intended to induce ordering, purchasing, leasing or recommending of a
medical device may be subject to scrutiny if they do not qualify for an exception or safe harbor. In some cases, our practices may not meet all of
the technical elements for protection under a federal Anti-Kickback Statute exception or safe harbor. Similarly, as a supplier, we are also subject
to the federal beneficiary anti-inducement statute, which prohibits us from offering any remuneration to a beneficiary of Medicare or Medicaid
that is likely to influence that beneficiary’s choice of therapy, unless an exception applies. This can include, but is not limited to, the provision of
inappropriate financial assistance to purchase our Products. Recent government investigations and enforcement actions have focused on the
provision of financial assistance to patients by providers and suppliers. As noted, there are established exceptions from liability, but we cannot
guarantee that all of our practices will fall squarely within those exceptions.
As a DME supplier, we also are subject to the Stark law, which is a strict liability law that prohibits Medicare payments for certain "designated
health services" ("DHS") including DME ordered by physicians who, personally or through an immediate family member, have an ownership
interest in or a compensation arrangement with the furnishing DHS entity. The Stark law contains a number of specific exceptions that, if met,
permit physicians who have certain financial relationships with a DHS entity to make referrals to that entity and for that entity to bill Medicare for
such services.
The False Claims Act prohibits any person from knowingly presenting, or causing to be presented, a false claim for payment to the federal
government, or knowingly making, or causing to be made, a false statement to get a false claim paid. The government has pursued numerous
cases under the False Claims Act in connection with the off-label promotion of medical products and various other health care law violations.
Notably, the government may assert that a claim including items or services resulting from a violation of the federal Anti-Kickback Statute
constitutes a false or fraudulent claim for purposes of the federal civil False Claims Act.
The majority of states also have statutes or regulations similar to the federal Anti-Kickback Statute, Stark Law and False Claims Act laws, which
apply to items and services reimbursed under Medicaid and other state programs, or, in several states, that apply regardless of the payer (e.g.,
including private/commercial payors or cash-pay scenarios).
Numerous federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 as amended by the
Health Information Technology for Economic and Clinical Health Act ("HITECH" and collectively "HIPAA"), govern the collection, dissemination,
use, security and privacy of individually identifiable
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health information. We believe we are in substantial compliance with such applicable laws and regulations, including HIPAA.
HIPAA also includes a number of federal criminal provisions, including for healthcare fraud and for false statements relating to healthcare
matters. The healthcare fraud provision prohibits knowingly and willfully executing a scheme to defraud any healthcare benefit program,
including private third-party payers. The false statements provision prohibits knowingly and willfully falsifying, concealing or covering up a
material fact or making any materially false, fictitious or fraudulent statement in connection with the delivery of or payment for healthcare
benefits, items or services. Many states have similar healthcare fraud laws or insurance fraud laws that apply to claims for healthcare
reimbursement.
Sanctions under these federal and state laws may include civil monetary penalties, exclusion of a manufacturer’s products from reimbursement
under government programs, criminal fines and imprisonment.
Legislation similar to the federal Anti-Kickback Statute, the Stark Law and False Claims Act has been adopted in foreign countries, including a
number of EU member states.
In the EU, the General Data Protection Regulation ("GDPR") has applied since May 25, 2018. The GDPR harmonizes data privacy laws and
rules for the processing of personal data, including patient and employee data, across the EU and repeals and replaces Directive 95/46/EC of
the European Parliament and of the Council of October 24, 1995, and applicable national laws. The GDPR has added a number of strict data
protection and security requirements for companies processing personal data of EU residents, including when such data is transferred outside
the EU.
In the U.S., the federal Physician Payment Sunshine Act ("Sunshine Act") requires certain manufacturers of drugs, medical devices, biologicals
or medical supplies that participate in U.S. federal health care programs to track and then report certain payments and transfers of value given
to "Covered Recipients." The term "Covered Recipients" currently includes U.S.-licensed physicians and teaching hospitals, and, for reports
submitted on or after January 1, 2022, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and
certified nurse-midwives. The Sunshine Act requires that manufacturers collect this information on a yearly basis and then report it to Centers
for Medicare & Medicaid Services by the 90th day of each subsequent year. We have adopted policies and codes of conduct regarding our
interactions with Covered Recipients and believe we are in material compliance with the Sunshine Act. However, our failure to adhere to these
requirements could materially adversely impact our business and financial results. Additionally, a number of states have transparency reporting
requirements similar to (and in some cases broader than) the Sunshine Act, and regulations similar to the Sunshine Act have been adopted in
foreign countries including a number of EU member states.
In addition, the U.S. Foreign Corrupt Practices Act ("FCPA") prohibits corporations and individuals from engaging in certain activities to obtain or
retain business outside the U.S. or to influence a person working in an official capacity in a foreign country. It is illegal to pay, offer to pay or
authorize the payment of anything of value to any official of another country, government staff member, political party or political candidate in an
attempt to obtain or retain business or to otherwise influence a person working in that capacity. Legislation similar to the FCPA has been
adopted in foreign countries, including a number of EU member states.
Human Capital Resources
As of December 31, 2022, we had 1,320 employees, compared to 1,167 employees as of December 31, 2021. We believe relations with our
employees are good.
To achieve commercial success for our Products, we believe we must continue to develop and grow our sales and marketing, patient support
and research and development teams, along with the necessary staff to support it. This need accounts for the significant increase in the number
of employees in 2021. Developing and managing a growing organization is a difficult, expensive and time consuming process. To be successful
we must:
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recruit and retain adequate numbers of effective and experienced sales and marketing, patient support and research and development
personnel;
effectively train our personnel on the benefits and risks of our Products and healthcare compliance; and
• manage geographically disbursed business operations.
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We compete with other medical device, pharmaceutical and life sciences companies to recruit, hire, train and retain the personnel that we
anticipate we will need. Because our current Products require, and we anticipate our future Products will require, physician training and
education, we expect that our sales and marketing and patient support teams will continue to grow substantially as we expand our approved
indications and markets.
The ongoing COVID-19 pandemic also creates challenges to our ability to recruit and retain effective and experienced employees. In 2021, we
instituted a COVID-19 vaccine mandate for all employees (subject to certain exceptions). Some employees chose to leave our company in
response to this mandate and while the pandemic continues, this mandate may limit our ability to recruit new employees.
Available information
Our corporate website address is www.novocure.com. Our website is an inactive textual reference and nothing on our website is incorporated
by reference in this Annual Report. Our Annual Reports on Form 10-K, Quarterly Reports on Form 10-Q, Current Reports on Form 8-K, and
amendments to reports filed pursuant to Sections 13(a) and 15(d) of the Securities Exchange Act of 1934, as amended, or the Exchange Act,
are available free of charge on our website as soon as reasonably practicable after we electronically file such material with, or furnish it to, the
SEC. These filings are also available on the SEC’s website at www.sec.gov.
We may use our website as a means of disclosing material information and for complying with our disclosure obligations under Regulation Fair
Disclosure promulgated by the SEC. Accordingly, investors should monitor our website, in addition to following our press releases, SEC filings,
public conference calls, webcasts and our social media accounts.
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ITEM 1A. RISK FACTORS
An investment in our ordinary shares involves a high degree of risk. Investors and prospective investors should carefully consider all of the
information in this Annual Report on Form 10-K, including the risks and uncertainties described below. Any of the following risks could have a
material adverse effect on our business, prospects, financial condition and results of operations. In any such case, the trading price of our
ordinary shares could decline, and you could lose all or part of your investment. In assessing these risks, you should also refer to the other
information contained in this Annual Report on Form 10-K, including our consolidated financial statements and the related notes thereto.
Risks relating to our business and our Products
Our business and prospects depend heavily on Optune, which is currently approved only for the treatment of GBM, and Optune Lua,
which is currently approved only for the treatment of MPM. If we are unable to increase sales of our Products, obtain further
regulatory approvals and commercialize our Products for the treatment of additional indications, or are significantly delayed or
limited in doing so, our business and prospects will be materially harmed.
To date we have received FDA regulatory approval under the PMA pathway and certain approvals in other jurisdictions for the use of Optune for
the treatment of adult patients with newly diagnosed GBM in combination with certain forms of chemotherapy and for the treatment of adult
patients with recurrent GBM as monotherapy. Optune has a CE mark affixed for the treatment of GBM in the EU and Switzerland. We have also
received FDA approval under the HDE pathway to market Optune Lua for unresectable, locally advanced or metastatic, MPM in combination
with standard chemotherapies. Optune Lua is also CE Certified for the same indication in the EU and Switzerland. However, such approvals
and maintaining the CE Certificates of Conformity, and related CE marking, of our Products, as applicable, do not guarantee future revenues for
these indications. Further, until we receive FDA and analogous approval in other jurisdictions for the use of our Products for other indications,
almost all of our revenues will derive from sales and royalties from sales of Optune for the treatment of newly diagnosed and recurrent GBM
and Optune Lua for MPM. The commercial success of our Products and our ability to generate and maintain revenues from the sale of our
Products will depend on a number of factors, including:
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our ability to develop and obtain additional regulatory approvals and further commercialize our Products for additional indications;
our ability to expand into new markets and future indications;
the acceptance of our Products by patients and the healthcare community, including physicians and third-party payers (both private and
governmental), as therapeutically effective and safe;
the accomplishment of various scientific, engineering, clinical, regulatory and other goals, which we sometimes refer to as milestones,
on our anticipated timeline;
the relative cost, safety and efficacy of alternative therapies;
our ability to obtain and maintain sufficient coverage or reimbursement by private and governmental third-party payers and to comply
with applicable health care laws and regulations;
the ability of our third-party manufacturers to manufacture our Products in sufficient quantities with acceptable quality;
our ability to provide marketing, distribution and customer support for our Products;
the presence of competitive products in our active indications;
results of future clinical studies relating to our Products or other competitor products for similar indications;
compliance with applicable laws and regulatory requirements, in particular in the EU;
the maintenance of our existing regulatory approvals; and
the consequences of any reportable adverse events involving our Products.
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In addition, the promotion of our Products is limited to approved indications, which vary by geography. The labelling for Optune in the U.S. is
limited in certain respects (for example, it is approved specifically for glioblastomas of the supratentorial region of the brain, is indicated for use
in the treatment of newly diagnosed GBM only when used together with temozolomide, and limited to use by adults ages 22 and older), which
may limit the number of patients to whom it is prescribed. Similarly, the label for Optune Lua also contains certain limitations that may adversely
affect adoption, including the requirement in the United States (applicable to all HDE-approved devices) to display on all marketing materials
that the efficacy of the Product has not been established, as well as a limitation for use by adults ages 22 and older, and the absence of pivotal
clinical data.
Our ability to generate future revenues will also depend on achieving regulatory approval of, and eventual commercialization of, our Products
for additional indications and in additional geographies, which is not guaranteed. Our near-term prospects are substantially dependent on our
ability to obtain regulatory approvals on the timetable we have anticipated, and thereafter to further successfully commercialize our Products for
additional indications. Regulatory changes or actions in areas in which we operate or propose to operate may further affect our ability to obtain
regulatory approvals on our anticipated timetable. If we are not able to receive such approvals, meet other anticipated milestones, or further
commercialize our Products, or are significantly delayed or limited in doing so, our business and prospects will be materially harmed and we
may need to reduce expenses by delaying, reducing or curtailing the development of our Products and we may need to raise additional capital
to fund our operations, which we may not be able to obtain on favorable terms, if at all.
To date, we have generated only limited and intermittent operating profits, and we have a history of incurring substantial operating
losses.
We were founded in 2000 and have only recently and intermittently started generating limited operating profits. We have otherwise had a history
of incurring substantial operating losses. We anticipate continuing to incur significant costs associated with commercializing our Products for
approved indications including product sales, marketing, manufacturing, and distribution expenses. We expect our research, development, and
clinical study expenses to increase in connection with our ongoing activities and as additional indications enter late-stage clinical development
and as we advance our product development. Our expenses could increase beyond expectations if, for example, we are required by the FDA,
or other regulatory agencies or similar governing bodies, to change manufacturing processes for our Products or to perform clinical, nonclinical
or other types of studies in addition to those that we currently anticipate. Our revenues are dependent, in part, upon the size of the markets in
the jurisdictions in which we receive regulatory approval, the accepted price for our Products and the ability to obtain reimbursement at the
accepted applicable price. If the number of addressable patients is not as significant as we estimate, the indications approved by regulatory
authorities are narrower than we expect or the eligible population for treatment is narrowed by competition, regulatory approvals, physician
choice or treatment guidelines, we may not generate significant revenues. If we are not able to generate significant revenues, we may never be
sustainably profitable.
Our clinical studies could be delayed or otherwise adversely affected by many factors, including difficulties in enrolling patients.
Clinical testing can be costly and take many years, and the outcome is uncertain and susceptible to varying interpretations. Moreover, success
in preclinical and early clinical studies does not ensure that large-scale studies will be successful or predict final results. Acceptable results in
early studies may not be replicable in later studies. A number of companies in the oncology industry have suffered significant setbacks in
advanced clinical studies, even after promising results in earlier studies. Negative or inconclusive results or adverse events or incidents during a
clinical study could cause the clinical study to be redone or terminated. In addition, failure to appropriately construct clinical studies could result
in high rates of adverse events or incidents, which could cause a clinical study to be suspended, redone or terminated. Our failure or the failure
of third-party participants in our studies to comply with their obligations to follow protocols and/or legal requirements may also result in our
inability to use the affected data in our submissions to regulatory authorities.
The timely completion of clinical studies depends, among other things, on our ability to enroll a sufficient number of patients who remain in the
study until its conclusion. We may experience difficulties in patient enrollment in our clinical studies for a variety of reasons, including:
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the severity of the disease under investigation;
the limited size and nature of the patient population;
the patient eligibility criteria defined in our protocol and other clinical study protocols;
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the nature of the study protocol, including the attractiveness of, or the discomforts and risks associated with, the treatments received by
enrolled subjects;
difficulties and delays in clinical studies that may occur as a result of the COVID-19 pandemic;
the ability to obtain IRB approval at clinical study locations;
clinicians’ and patients’ perceptions as to the potential advantages, disadvantages and side effects of our Products in relation to other
available therapies, including any new drugs or treatments that may be approved for the indications we are pursuing;
availability of other clinical studies that exclude use of our Products;
the possibility or perception that enrolling in a Product’s clinical study may limit the patient’s ability to enroll in future clinical studies for
other therapies due to protocol restrictions;
the possibility or perception that our software is not secure enough to maintain patient privacy;
patient referral practices of physicians;
the ability to monitor patients adequately during and after treatment;
the availability of appropriate clinical study investigators, support staff, drugs and other therapeutic supplies and proximity of patients to
clinical sites;
physicians’ or our ability to obtain and maintain patient consents; and
the risk that patients enrolled in clinical studies will choose to withdraw from or otherwise not be able to complete a clinical study.
If we have difficulty enrolling and retaining a sufficient number or diversity of patients to conduct our clinical studies as planned, or encounter
other difficulties, we may need to delay, terminate or modify ongoing or planned clinical studies, any of which would have an adverse effect on
our business.
If we are unable to continue the development of an adequate sales and marketing organization or contract with third parties to assist
us, we may not be able to successfully commercialize our Products for current and future indications.
To achieve commercial success for our Products, we must continue to compliantly develop and grow our sales and marketing organization and,
as necessary, enter into sales and distribution relationships with third parties to market and sell our Products. Developing and managing a sales
and marketing organization is a difficult, expensive and time consuming process. We may not be able to successfully develop adequate sales
and marketing capabilities to achieve our growth objectives. We compete with other medical device, pharmaceutical and life sciences
companies to recruit, hire, train and retain the sales and marketing personnel that we anticipate we will need, and the nature of our Products
may make it more difficult to compete for sales and marketing personnel. In addition, because our current Products require, and we anticipate
our future Products will require, physician training and education, our sales and marketing organization may need to grow substantially as we
expand our approved indications and markets. As a consequence, our expenses associated with building up and maintaining our sales force
and marketing capabilities may be disproportionate to the revenues we may be able to generate on sales of our Products.
If we are unable to establish adequate sales and marketing capabilities or successful sales and distribution relationships, we may fail to realize
the full revenue potential of our Products for current and future indications, and we may not be able to achieve the necessary growth in a cost-
effective manner or realize a positive return on our investment. In our current and future sales and distribution agreements with other
companies, we generally do not and may not have control over the resources or degree of effort that any of these third parties may devote to
our Products, and if they fail to devote sufficient time and resources to the marketing of our Products, or if their performance is substandard, our
revenues may be adversely affected.
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The success of our business may be dependent on the actions of our collaborative partners.
Our global business strategy includes, in part, the consummation of collaborative arrangements with companies who will support the
development and commercialization of our Products and technology. For example, we have exclusively licensed rights to commercialize our
Products in the field of oncology in Greater China to Zai pursuant to an agreement that also establishes a development partnership for Tumor
Treating Fields (“TTFields”) in multiple solid tumor indications. Zai is responsible for the development and commercialization of our Products in
Greater China at its sole cost with certain assistance from us. We have also entered into several clinical collaborations with third parties to test
our Products and technology together with other products and technologies.
When we collaborate with a third party for development and commercialization of a Product in a particular territory, we can expect to relinquish
some or all of the control over the future success of that Product to the third party in that territory. In addition, our collaborative partners may
have the right to abandon research or development projects and terminate applicable agreements, including payment obligations, prior to or
upon the expiration of the agreed-upon terms. We may not be successful in establishing or maintaining collaborative arrangements on
acceptable terms or at all, collaborative partners may terminate funding before completion of projects, our Products may not achieve the criteria
for milestone payments, our collaborative arrangements may not result in successful product commercialization, our Products may not receive
acceptable pricing and we may not derive any revenue from such arrangements. Additionally, our collaborators may not perform their
obligations as expected or in compliance with study protocols or applicable laws. Our collaborators may also be subject to additional risks in
their particular territories, such as a lack of intellectual property protections and/or enforcement or the possibility of nationalization. Acts or
omissions by collaborators may disqualify study data for use in regulatory submissions and/or create liability for us in the jurisdictions in which
we operate. Any disagreements with collaborators, including disagreements over proprietary rights, contract interpretation or the preferred
course of development or commercialization, might cause delays or termination of the research, development or commercialization of Products,
might lead to additional responsibilities for us with respect to developing or commercializing Products, or might result in litigation or arbitration,
any of which would be time-consuming and expensive. To the extent that we are not able to develop and maintain collaborative arrangements,
we would need to devote substantial capital to undertake development and commercialization activities on our own in order to further expand
our global reach, and we may be forced to limit the territories in which we commercialize our Products.
We may not be successful in achieving market acceptance of our Products by healthcare professionals, patients and/or third-party
payers in the timeframes we anticipate, or at all, which could have a material adverse effect on our business, prospects, financial
condition and results of operations.
Our business model is predicated on achieving market acceptance of our Products as a monotherapy or in combination with well-established
cancer treatment modalities like surgery, radiation, pharmacological and immunocologic therapies. We may not achieve market acceptance of
our Products for current or future indications within the timeframes we have anticipated, or at all, for a number of different reasons, including the
following factors:
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it may be difficult to gain broad acceptance of our Products because they are new technologies and involve a novel mechanism of
action and, as such, physicians may be reluctant to prescribe our Products without prior experience or additional data or training;
physicians may be reluctant to prescribe our Products due to their perception that the supporting clinical study designs have limitations,
as they are, for example, unblinded;
physicians at large academic universities and medical centers may prefer to enroll patients into clinical studies instead of prescribing
our Products;
it may be difficult to gain broad acceptance at community hospitals where the number of patients seeking treatment may be more
limited than at larger medical centers, and such community hospitals may not be willing to invest in the resources necessary for their
physicians to become trained to use our Products, which could lead to reluctance to prescribe our Products;
patients may be reluctant to use our Products for various reasons, including a perception that the treatment is untested or difficult to use
(for example, they will need to shave the areas on their bodies where the arrays are applied) or a perception that our software is not
secure;
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our Products may have side effects (for example, dermatitis where the arrays are placed) and our Products cannot be worn in all
circumstances (for example, they cannot get wet and are difficult to wear in high temperatures); and
the price of our Products includes a monthly fee for use of the device and therefore, as the duration of the treatment course increases,
the overall price will increase correspondingly and, when used in combination with other treatments, the overall cost of treatment will be
greater than using a single type of treatment.
In particular, our Products may not achieve market acceptance for current or future indications because of the following additional factors:
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achieving patient acceptance could be difficult because we are targeting devastating diseases with poor prognoses, and not all patients
with potentially short lifespans are willing to comply with requirements of treatment with our Products, such as the need to use our
Products for at least 18 hours per day, carrying around a device and shaving the area where the arrays are worn, and other patients
may forego our Products for financial, privacy, cosmetic, visibility or mobility reasons;
achieving patient compliance is difficult because the recommended use of our currently marketed Products is throughout the day,
requiring patients to wear the device nearly continuously, which to some extent restricts physical mobility because the battery must be
frequently exchanged and recharged, and the patient or a caregiver must ensure that it remains continuously operable and this may
also impact the pool of patients to whom physicians may be willing to prescribe our Products;
certain patients are contraindicated to using our Products due to a variety of factors, including, but not limited to, those who have an
active implanted medical device, those who have a skull defect, and those who are sensitive to conductive hydrogels;
there are certain perceived limitations to our study designs or data obtained from our clinical studies;
efficacy may also be limited in instances where patients take a break from the device when experiencing skin rashes, while bathing or
swimming (because our Products should not get wet), or while traveling; and
patients may decline therapy or prescribers may be unwilling to prescribe our Products due to certain adverse events reported in clinical
studies by patients treated with our Products as monotherapy include medical device site reaction, headache, malaise, muscle
twitching, fall and skin ulcer; additional adverse events reported in clinical studies by patients treated with our Products in combination
with chemotherapies in addition to the above, were thrombocytopenia, nausea, constipation, vomiting, fatigue and other side effects
consistent with treatment with chemotherapies.
In addition, even if we are successful in achieving market acceptance of our Products for GBM or MPM, we may be unsuccessful in achieving
market acceptance of our Products for other indications, such as brain metastases, NSCLC, pancreatic cancer, ovarian cancer and other solid
tumor cancers, because certain radiation, chemotherapies and/or systemic medical therapies may become or remain the preferred standard of
care for these indications.
There may be other factors that are presently unknown to us that also may negatively impact our ability to achieve market acceptance of our
Products. If we do not achieve market acceptance of our Products in the timeframes we anticipate, or are unable to achieve market acceptance
at all, our business, prospects, financial condition and results of operations could be materially adversely affected.
Failure to secure and maintain adequate coverage and reimbursement from third-party payers could adversely affect acceptance of
our Products and reduce our revenues.
We expect that the vast majority of our revenues will come from third-party payers either directly to us in markets where we provide our
Products or plan to provide our device candidates to patients or indirectly via payments made to hospitals or other entities providing our
Products or which may in the future provide our device candidates to patients.
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In the U.S., private payers cover the largest segment of the population, with the remainder either uninsured or covered by governmental payers.
The majority of the third-party payers outside the U.S. are government agencies, government sponsored entities or other payers operating
under significant regulatory requirements from national or regional governments.
Third-party payers may decline to cover and reimburse certain procedures, supplies or services. Additionally, some third-party payers may
decline to cover and reimburse our Products for a particular patient even if the payer has a favorable coverage policy addressing our Products
or previously approved reimbursement for our Products. Additionally, private and government payers may consider the cost of a treatment in
approving coverage or in setting reimbursement for the treatment.
Private and government payers around the world are increasingly challenging the prices charged for medical products and services.
Additionally, the containment of healthcare costs has become a priority of governments around the world. Adoption of additional price controls
and cost-containment measures, and adoption of more restrictive policies in jurisdictions with existing controls and measures by both private
and public payers, could further limit our revenues and operating results. If third-party payers do not consider our Products or the combination of
our Products with additional treatments to be cost-justified under a required cost-testing model, they may not cover our Products for their
populations or, if they do, the level of reimbursement may not be sufficient to allow us to sell our Products on a profitable basis.
Reimbursement for the treatment of patients with medical devices around the world is governed by complex mechanisms established on a
national or sub-national level in each country. These mechanisms vary widely among countries, can be informal, somewhat unpredictable, and
evolve constantly, reflecting the efforts of these countries to reduce public spending on healthcare. As a result, obtaining and maintaining
reimbursement for the treatment of patients with medical devices has become more challenging globally. We cannot guarantee that the use of
our Products will receive reimbursement approvals and cannot guarantee that our existing reimbursement approvals will be maintained in any
country.
We provide financial assistance to certain patients in certain markets who qualify based on established financial and other criteria. Primarily, we
provide financial assistance to patients where we have or are actively pursuing coverage and reimbursement. This financial assistance is
intended to defray out-of-pocket costs for our Products for patients who begin treatment but who are unable to pay for the costs of their
treatment not covered by insurance. Our costs associated with this program could increase if payers increase the cost-sharing burden of
patients or we do not obtain coverage and reimbursement and we elect to continue providing financial assistance in those markets. Additionally
we provide charitable donations to foundations that can then provide financial assistance to those receiving health care coverage from federal
or state funded programs. Enforcement actions and changes to government regulations related to manufacturer-sponsored and independent
charitable patient assistance programs could reduce our ability to support patients financially in the future.
Our failure to secure or maintain adequate coverage or reimbursement for our Products by third-party payers in the U.S. or in the other
jurisdictions in which we market our Products could have a material adverse effect on our business, revenues and results of operations and
cause our stock price to decline.
We may not be successful in securing and maintaining reimbursement codes necessary to facilitate accurate and timely billing for
our Products or physician services attendant to our Products.
Third-party payers, healthcare systems, government agencies or other groups often issue reimbursement codes to facilitate billing for products
and physician services used in the delivery of healthcare. Within the U.S., the billing codes most directly related to our Products are contained
in the Healthcare Common Procedure Coding System ("HCPCS code set"). The HCPCS code set contains Level I codes that describe
physician services, also known as Common Procedural Terminology codes ("CPT codes") and Level II codes that primarily describe products.
CMS is responsible for issuing the HCPCS Level II codes. The American Medical Association issues HCPCS Level I codes.
We have secured unique HCPCS Level II codes that describe Optune and we are able to use these codes in the U.S. to bill third-party payers.
Loss of these codes or any alteration in the reimbursement amounts attached to these codes would materially impact our operating results. We
do not have a unique HCPCS Level II code for Optune Lua at this time.
No CPT codes currently exist to describe physician services related to the delivery of therapy using our Products. We may not be able to secure
CPT codes for physician services related to our Products. Our future revenues and results may be affected by the absence of CPT codes, as
physicians may be less likely to prescribe the therapy when there is no certainty that adequate reimbursement will be available for the time,
effort, skill, practice expense and malpractice costs required to provide the therapy to patients.
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Outside the U.S., but excluding Germany and Japan, we have not secured codes to describe our Products or to document physician services
related to the delivery of therapy using our Products. The failure to obtain and maintain these codes could affect the future growth of our
business.
There is no assurance that Medicare or the Medicare Administrative Contractors will provide, or continue to provide, coverage or
adequate payment rates for our Products.
We anticipate that a significant portion of patients using our Products will be beneficiaries under the Medicare fee-for-service program. Failure to
secure or maintain coverage or maintain adequate reimbursement from Medicare would reduce our revenues and may also affect the coverage
and reimbursement decisions of other third-party payers in the U.S. and elsewhere.
Medicare classifies Optune as durable medical equipment ("DME"). Medicare has the authority to issue national coverage determinations or to
defer coverage decisions to its regional Medicare Administrative Contractors ("MACs"). The fact that only two MACs administer the entire DME
program may negatively affect our ability to petition individual medical policy decision-makers at the MACs for coverage. The absence of a
positive coverage determination or a future restriction to existing coverage from Medicare or the DME MACs would materially affect our future
revenues.
Additionally, Medicare has the authority to publish the reimbursement amounts for DME products. Medicare has published a reimbursement
amount for Optune that falls below the median reimbursement that we have established with non-Medicare payers. Medicare may in the future
publish reimbursement amounts for our Products that do not reflect then-current prices for our Products or Medicare may decrease existing
reimbursement amounts published for our Products. Medicare fee schedules are frequently referenced by private payers in the U.S. and around
the world. Medicare's publication of reimbursement amounts for our Products that are below our Products’ established prices could materially
reduce our revenues and operating results with respect to non-Medicare payers in the U.S. and our other active markets.
Medicare has assigned the billing codes describing Optune to the DME category for products that require frequent and substantial servicing.
DME items in this billing category are billed monthly and payment is not capped after a time period. If Medicare revises its payment category
classifications for our Products, this action could materially reduce our revenues and operating results.
CMS requires prior authorization for certain DME items. Claims for such items that did not receive prior authorization before they were furnished
to a beneficiary will be automatically denied. In the event Medicare adds one of our Products to the list of items requiring prior authorization, our
ability to bill and secure reimbursement for patients who would otherwise be covered to use our Product under the Medicare fee-for-service
program may be reduced.
The Medicare fee-for-service program has denied coverage for all claims prior to the September 1, 2019 effective date for the DME MAC LCD,
which provides coverage for Optune for the treatment of newly diagnosed GBM subject to certain conditions and restrictions. We expect that
Medicare will continue to deny essentially all claims that do not meet the coverage policy terms. Although we are actively appealing these
coverage denials, we are unable to bill the vast majority of our existing Medicare fee-for-service patients for amounts not paid by Medicare.
Therefore, we are absorbing and may continue to absorb the costs of treatment for amounts not paid by Medicare.
We appeal Medicare coverage denials through the Medicare appeals process: redetermination by a MAC, reconsideration by a Qualified
Independent Contractor, hearing before an Administrative Law Judge (“ALJ”) at the Office of Medicare Hearings and Appeals, review by the
Medicare Appeals Council, and judicial review in U.S. District Court. Currently, there is a considerable backlog of appeals at the ALJ level and
there are significant delays in the assignment of ALJ cases. We cannot provide any assurance that our outstanding ALJ appeals will be
favorably decided. Further, we anticipate that, even if we are successful in winning our appeals, we will experience a significant delay in
securing reimbursement for Medicare patients when Medicare’s DME MACs deny coverage for patients who start therapy.
While we have obtained Medicare coverage for our existing Products, we cannot provide any assurance that we can access transitional,
expedited, or expanded Medicare coverage for our future Products. CMS is expected to issue rules regarding coverage of emerging
technologies; however, no specific information is available about the content of the expected rules and we cannot provide any assurance that
any new rules regarding emerging technologies would be applicable to our future Products.
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We depend on single-source suppliers for some of our components. The loss of these suppliers could prevent or delay shipments of
our Products, delay our clinical studies or otherwise adversely affect our business.
In certain jurisdictions, we source some of the components of our Products from only a single vendor. If any one of these single-source
suppliers were to fail to continue to provide components to us on a timely basis, or at all, our business and reputation could be harmed. Our
policy is to seek and maintain second-source suppliers, but we can provide no assurance that we will secure or maintain such suppliers. We
have developed or are in the process of developing and obtaining regulatory approval for second sources for components in all jurisdictions.
Various steps must be taken before securing these suppliers, including qualifying these suppliers in accordance with regulatory requirements,
but we may never receive such approvals. The risks associated with the failure of our suppliers to comply with strictly enforced regulatory
requirements as described below are exacerbated by our dependence on single-source suppliers.
If we experience any deficiency in the quality of, delay in or loss of availability of any components supplied to us by third-party suppliers, or if we
switch suppliers or components, we may face additional regulatory delays and the manufacture and delivery of our Products would be
interrupted for an extended period of time, which could materially adversely affect our business, prospects, financial condition and results of
operations. If we are required to obtain prior regulatory approval from the FDA or regulatory authorities or similar governing bodies in other
jurisdictions or to conduct a new conformity assessment procedure and obtain new CE Certificates of Conformity in the EU to use different
suppliers or components for our Products, regulatory approval or the CE Certificates of Conformity for our Products may not be received on a
timely basis, or at all, which would have a material adverse effect on our business, prospects, financial condition and results of operations.
Quality control problems with respect to devices and components supplied by third-party suppliers could have a material adverse
effect on our reputation, our clinical studies or the commercialization of our Products and, as a result, a material adverse effect on
our business, prospects, financial condition and results of operations.
Our Products, which are manufactured by third parties, are highly technical and are required to meet exacting specifications. Any quality control
problems that we experience with respect to the devices and components supplied by third-party suppliers could have a material adverse effect
on our reputation, our attempts to complete our clinical studies, our operating expenses or the commercialization of our Products. The failure of
our suppliers to comply with strictly enforced regulatory requirements could expose us to regulatory action, including warning letters, product
recalls, suspension or termination of distribution, product seizures or civil penalties. If we experience any delay in the receipt or deficiency in the
quality of products supplied to us by third-party suppliers, or if we have to switch to replacement suppliers, we may face additional regulatory
delays and the manufacture and delivery of our Products would be interrupted for an extended period of time, which would materially adversely
affect our business, prospects, financial condition and results of operations.
If the third parties on which we rely to conduct our preclinical and clinical studies and to assist us with research and development do
not perform as contractually required or expected, we may not be able to obtain regulatory approvals for or commercialize our
Products.
We do not have the ability to independently conduct certain of our preclinical and development activities or any of our clinical studies for our
Products; therefore, we must rely on third parties, such as contract research organizations, medical institutions, clinical investigators, contract
laboratories and collaborative partners, to conduct such studies. We and these third parties are required to comply with current good clinical
practices ("cGCPs"), which are regulations and guidelines enforced by the FDA under the medical device Quality System Regulation ("QSR")
and comparable regulatory authorities in other jurisdictions for clinical development. We and these third parties are also required to comply with
current good laboratory practices ("cGLPs"), which are regulations and guidelines enforced by the FDA and comparable regulatory authorities in
other jurisdictions for nonclinical laboratory studies. If we or any of these third parties fail to comply with applicable cGLP and cGCP regulations,
the data generated in our nonclinical studies and clinical studies may be deemed unreliable and the FDA or regulatory authorities in other
jurisdictions may require us to perform additional nonclinical or clinical studies before approving our applications. We cannot be certain that,
upon inspection or review of our data, such regulatory authorities will determine that any of our nonclinical studies or clinical studies comply with
the applicable cGLP or cGCP regulations.
Additionally, any third parties conducting our preclinical, clinical and other development programs are not and will not be our employees and,
except for remedies available to us under our agreements with such third parties, we
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cannot control whether or not they devote sufficient time and resources to our ongoing preclinical, clinical and other development programs. If
these third parties do not successfully carry out their contractual duties or regulatory obligations or meet expected deadlines, if these third
parties need to be replaced or if the quality or accuracy of the data they obtain is compromised due to the failure to adhere to our clinical
protocols or regulatory requirements or for other reasons, our development activities or clinical studies may be extended, delayed, suspended
or terminated, and we may not be able to obtain regulatory approval for our Products or successfully commercialize our Products on a timely
basis, if at all, and our business, prospects and results of operations may be adversely affected.
Continued testing of our Products may not yield successful results and could reveal currently unknown aspects or safety hazards
associated with our Products.
Our research and development programs are designed to test the safety and efficacy of our Products and TTFields through extensive preclinical
and clinical testing. Even if our ongoing and future preclinical and clinical studies are completed as planned, we cannot be certain that their
results will support our claims or that the FDA and other regulatory authorities will agree with our conclusions. Success in preclinical studies and
early clinical studies does not ensure that later clinical studies will be successful, and we cannot be sure that the later studies will replicate the
results of prior studies and preclinical studies. The clinical study process may fail to demonstrate that our device candidates are safe and
effective for the proposed indicated uses, which could cause us to abandon a device candidate and may delay development of others. It is also
possible that patients enrolled in clinical studies will experience adverse side effects that have not been previously observed. In addition, our
preclinical and clinical studies for our device candidates involve a relatively small patient population and, as a result, these studies may not be
indicative of future results.
We may experience numerous unforeseen events during, or as a result of, the testing process that could delay or prevent further
commercialization of our Products, including the following:
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Preclinical and clinical testing for our Products may not produce the desired effect, may be inconclusive or may not be predictive of
safety or efficacy results obtained in future clinical studies, following long-term use or in much larger populations;
unanticipated adverse events or other side effects that are not currently known may occur during our clinical studies that may preclude
additional regulatory approval or result in additional limitations to commercial use if approved; and
the data collected from our clinical studies may not reach statistical significance or otherwise not be sufficient to support FDA or other
regulatory approval.
If unacceptable side effects arise in the development of our Products for future indications, we could suspend or terminate our clinical studies or
the FDA or other regulatory authorities could order us to cease clinical studies or deny approval of our device candidates for any or all targeted
indications, narrow the approved indications for use or otherwise require restrictive product labeling or marketing or require further clinical
studies, which may be time-consuming and expensive and may not produce results supporting FDA or other regulatory approval of our
Products in a specific indication. Treatment-related side effects could also affect patient recruitment or the ability of enrolled patients to complete
the study or result in potential product liability claims. In addition, these side effects may not be appropriately recognized or managed by the
treating medical staff. We expect to have a need to train medical personnel using our device candidates to understand the side effect profiles for
our clinical studies and upon any commercialization of our Products for future indications. Inadequate training in recognizing or managing the
potential side effects of our Products could result in patient injury or death. Any of these occurrences may harm our business, prospects and
financial condition significantly.
Any delay or termination of our clinical studies will delay the filing of submissions for regulatory approvals of our Products and ultimately our
ability to commercialize our Products and generate revenues. Furthermore, we may abandon our Products for indications that we previously
believed to be promising. Over time, we expect to make modifications to our Products that are designed to improve efficacy, reduce side effects,
enhance the user experience and other purposes. It is possible that our patients will not accept these developments or see them as
improvements, necessitating abandoning the development or spending additional development efforts to refine the modification. Any of these
events could have a material adverse effect on our business, prospects, financial condition and results of operations and cause our stock price
to decline.
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We face competition from numerous competitors, which may make it more difficult for us to achieve significant market penetration
and which may allow our competitors to develop additional oncology treatments to compete with our Products.
The oncology market is intensely competitive, subject to rapid change and significantly affected by new product introductions and other market
activities of industry participants. Our Products primarily compete with radiation and pharmacological therapies. We may face additional
competition as advancements are made in the field of anti-cancer therapies and as we enter additional oncological markets. To date, we have
conducted clinical studies where our Products are used together with a certain subset of other anti-cancer therapies. Many of our competitors
are large, well-capitalized companies with significantly greater market share and resources than we have. As a consequence, they are able to
spend more aggressively on product development, marketing, sales and other initiatives than we can. Many of these competitors could have:
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significantly greater name recognition and experience;
established distribution networks and/or relationships with government agencies, healthcare professionals, patients and third-party
payers;
additional product lines, and the ability to offer rebates or bundle products to offer higher discounts or more competitive pricing or other
incentives to gain a competitive advantage; and
greater financial and human resources for research and development, sales and marketing, patent litigation and/or acquisitions.
Although we believe our Products represent a treatment modality that can be used together with other cancer treatment modalities, our current
and future competitors may at any time develop additional drugs, biologics or devices for the treatment of GBM, MPM, or other solid tumors that
could be more effective from a therapeutic or cost-basis perspective than using our Products. In our currently-approved indications, if current or
future competitors develop a product that proves to be superior or comparable to our Products, our revenues may decline. In addition, some of
our competitors may compete by lowering the price of their cancer treatments. If these competitors’ products were to gain acceptance by
healthcare professionals, patients or third-party payers, a downward pressure on prices could result. If prices were to fall, we may not be able to
improve our gross margins or sales growth sufficiently to be sustainably profitable. For future indications, other companies could view us as a
competitor and attempt to block our market entry or otherwise hinder our Product growth in a market. We are aware of third parties in the United
States and China developing devices and filing for intellectual property protection related to TTFields, which, if approved, may directly compete
with our Products. Competitors could also pursue lawsuits to invalidate our patents or develop alternative technologies for the application of
TTFields into a patient that we did not foresee or protect.
As we expand, we may experience difficulties managing our growth.
Our anticipated growth will place a significant strain on our management and on our operational and financial resources and systems. We could
face challenges inherent in efficiently managing a more complex business with an increased number of employees over large geographic
distances, including the need to implement appropriate systems, policies, benefits and compliance programs. Failure to manage our growth
effectively could materially adversely affect our business. Additionally, our anticipated growth will increase the demands placed on our third-
party suppliers, resulting in an increased need to carefully monitor the available supply of components and services and to scale up our quality
assurance programs. There is no guarantee that our suppliers will be able to support our anticipated growth. Any failure by us to manage our
growth effectively could have an adverse effect on our ability to achieve our development and commercialization goals.
Because of the specialized nature of our business, the termination of relationships with our key employees, consultants and advisors
may prevent us from successfully operating our business, including developing our Products, conducting clinical studies,
commercializing our Products and obtaining any necessary financing.
We are highly dependent on the members of our executive team, the loss of whose services may adversely impact the achievement of our
objectives. While we have entered into employment agreements with each of our key executives, any of them could leave our employment at
any time. We do not have "key person" insurance on any of our employees. The loss of the services of one or more of our current employees
might impede the achievement of our business objectives.
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The competition for qualified personnel in the oncology and medical device fields is intense, and we rely heavily on our ability to attract and
retain qualified scientific, technical and managerial personnel. Our future success depends upon our ability to attract, retain and motivate highly
skilled employees. In order to commercialize our Products successfully, we will be required to expand our workforce, particularly in the areas of
research and development and clinical studies, sales and marketing and supply chain management. These activities will require the addition of
new personnel and the development of additional expertise by existing management personnel. We face intense competition for qualified
individuals from numerous pharmaceutical, biopharmaceutical and biotechnology companies, as well as academic and other research
institutions. We may not be able to attract and retain these individuals on acceptable terms or at all. Failure to do so could materially harm our
business.
Product liability suits, whether or not meritorious, could be brought against us due to alleged defective devices or for the misuse of
our Products, which could result in expensive and time-consuming litigation, payment of substantial damages and/or expenses and
an increase in our insurance rates.
If our current or future devices are defectively designed or manufactured, contain defective components or are misused, or if someone claims
any of the foregoing, whether or not meritorious, we may become subject to substantial and costly litigation. For example, we may be sued if
our Products cause or are perceived to cause injury or are found to be otherwise unsuitable during clinical testing, manufacturing, marketing or
sale. This may occur if our Products are misused or damaged, have a sudden failure or malfunction (including with respect to safety features) or
are otherwise impaired due to wear and tear. Even absent a product liability suit, malfunctions of our Products or misuse by physicians or
patients would need to be remedied swiftly in order to maintain continuous use and ensure efficacy of our Products.
Any product liability claims may include allegations of defects in manufacturing, defects in design, a failure to warn of dangers inherent in the
device, negligence, strict liability or a breach of warranties. Claims could also be asserted under state consumer protection acts. If we cannot
successfully defend ourselves against product liability claims, we may incur substantial liabilities or be required to limit commercialization of our
Products. Even successful defense may require significant financial and management resources. Regardless of the merits or eventual outcome,
liability claims may result in:
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decreased demand for our Products;
injury to our reputation;
• withdrawal of clinical study participants and inability to continue clinical studies;
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initiation of investigations by regulators;
costs to prepare for and defend the related litigation;
a diversion of management’s time and our resources;
substantial monetary awards to study participants or patients;
product recalls, withdrawals or labeling, marketing or promotional restrictions;
loss of revenues;
exhaustion of any available insurance and our capital resources;
the inability to commercialize any device candidate; and
a decline in our share price.
Product liability claims could divert management’s attention from our core business, be expensive to defend and result in sizable damage
awards against us. We may not have sufficient insurance coverage for all claims. Any product liability claims brought against us, with or without
merit, could increase our product liability insurance rates or prevent us from securing continuing coverage, could harm our reputation in the
industry and could reduce revenues. Product liability claims in excess of our insurance coverage would be paid out of cash reserves, if any,
which could have a material adverse effect on our business, prospects, financial condition and results of operations and cause our stock price
to decline. Even if our agreements with our third-party manufacturers and suppliers entitle us to indemnification against losses, such
indemnification may not be available or adequate should any claim arise.
Other future litigation and regulatory actions could have a material adverse impact on the Company.
From time to time, we may be subject to litigation and other legal and regulatory proceedings relating to our business or investigations or other
actions by governmental agencies, including as described in Part I, Item 3 "Legal
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Proceedings" of this Annual Report on Form 10-K. No assurances can be given that the results of these or new matters will be favorable to us.
An adverse resolution of lawsuits, arbitrations, investigations or other proceedings or actions could have a material adverse effect on our
financial condition and results of operations, including as a result of non-monetary remedies. Defending ourselves in these matters may be
time-consuming, expensive and disruptive to normal business operations and may result in significant expense and a diversion of
management’s time and attention from the operation of our business, which could impede our ability to achieve our business objectives.
Additionally, any amount that we may be required to pay to satisfy a judgment, settlement, fine or penalty may not be covered by insurance.
Subject to the Jersey Companies Law, our articles of association permit us to indemnify any director against any liability, to purchase and
maintain insurance against any liability for any director and to provide any director with funds (whether by loan or otherwise) to meet
expenditures incurred or to be incurred by such director in defending any criminal, regulatory or civil proceedings or in connection with an
application for relief (or to enable any such director to avoid incurring such expenditure). In addition, we have entered into indemnification
agreements with each of our directors and officers to indemnify them against certain liabilities and expenses arising from their being a director
or officer to the maximum extent permitted by Jersey law. In the event we are required to make such payments to our directors and officers,
there can be no assurance that any of these payments will not be material.
Global economic, political and industry conditions constantly change and unfavorable conditions may have a material adverse effect
on our business and results of operations.
We are a global company with worldwide operations. Volatile economic, political and market conditions, such as political or economic instability,
civil unrest, trade sanctions, majority hostilities or acts of terrorism in the regions in which we operate may have a negative impact on our
operating results and our ability to achieve our business objectives. We may not have insight into economic and political trends that could
emerge and negatively affect our business. In addition, significant or volatile changes in exchange rates between the U.S. dollar and other
currencies may have a material adverse impact upon our liquidity, revenues, costs and operating results.
In particular, we have research facilities located in Israel, and certain key suppliers manufacture their goods in Israel. Due to the high-conflict
nature of this area, Israel could be subject to additional political, economic and military confines, which could result in a material adverse effect
on our operations. Parties with whom we do business have sometimes declined to travel to Israel during periods of heightened unrest or
tension, forcing us to make alternative arrangements when necessary. In addition, the political and security situation in Israel may result in
parties with whom we have agreements involving performance in Israel claiming that they are not obligated to perform their commitments under
those agreements pursuant to force majeure provisions in the agreements.
Additionally, natural disasters and public health emergencies, such as extreme weather events and the COVID-19 pandemic, could have a
significant adverse effect on our business, including interruption of our commercial and clinical operations, supply chain disruption,
endangerment of our personnel, fewer patient visits, increased patient drop-out rates, delays in recruitment of new patients, and other delays or
losses of materials and results.
The COVID-19 pandemic could materially adversely impact our business.
As the COVID-19 pandemic continues around the globe, we have experienced and will likely continue to experience disruptions that could
severely impact our business and clinical studies, which could include:
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delays and/or difficulties in onboarding active patients and enrolling patients in our clinical studies;
delays and/or difficulties in clinical site initiation, including difficulties in recruiting clinical site investigators and clinical site staff;
declines in prescriptions written due to a perception that our Products are difficult to administer remotely or if patients are unwilling to
travel to treatment sites or receive in-home treatment assistance from us or other caregivers;
reductions in third-party reimbursements, which could materially affect our revenue, as most of our patients rely on third-party payers to
cover the cost of our Products and a material number of our patients could lose access to their private health insurance plan if they or
someone in their family lose their job;
diversion of healthcare resources away from conducting clinical studies, including the diversion of hospitals serving as our clinical study
sites and hospital staff supporting the conduct of our clinical studies;
interruption of key clinical study activities, such as clinical study site monitoring, due to limitations on travel imposed or recommended
by federal or state governments, employers and others;
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staff disruptions and turnover internally and at treatment sites and third-party providers who provide support, either directly as a result of
illness or indirectly as a result of vaccine mandates and other changes in terms of employment;
delays in receiving approval from local regulatory authorities or IRBs to initiate our planned clinical studies;
delays in clinical sites receiving the supplies and materials needed to conduct our clinical studies;
interruption in global shipping that may affect the transport of active patient and clinical study materials;
changes in local regulations as part of a response to the COVID-19 outbreak that may require us to change the ways in which our
clinical studies are conducted, which may result in unexpected costs, or to discontinue the clinical studies altogether;
delays in necessary interactions with local regulators, ethics committees and other important agencies and contractors due to
limitations in employee resources or forced furlough of government employees;
disruption of our supply chain as our suppliers and common carriers are unable to meet our requirements to provide us the materials
we need for clinical study and active patient care needs;
indirect consequences of the COVID-19 pandemic on the global economy in general, such as an increase in bankruptcies of our key
suppliers, or the inability of our third-party payers to meet their obligations reimburse us in a timely fashion or at all;
postponements and cancellations of key conferences and meetings and travel restrictions could interfere with our ability to interact with
key thought leaders in the field, leading to a disruption in the rate of adoption of our technology;
access restrictions at offices, hospitals, and treatment centers, and stakeholder illness could interfere with the ability of our sales force
to engage in face-to-face visits with providers, leading to a disruption in the rate of adoption of our technology;
increases in expenditures for technology and other tools necessary to provide patient care in an environment where both patient and
care-giver travel is restricted and access to in-person interaction is limited;
refusal of the FDA to accept data from clinical studies in affected geographies outside the United States; and
patient delays in seeking or receiving treatment, either due to fear of infection or lack of access to treatment and study sites, leading to
fewer diagnoses of the indications our Products are approved to treat or more advanced procession of the disease, which may
contraindicate the use of our Products or disqualify the patient from participating in a given study.
The global status of the COVID-19 pandemic continues to rapidly evolve. The extent to which the pandemic may impact our business and
clinical studies will depend on future developments, which are highly uncertain and cannot be predicted with confidence, such as the ultimate
geographic spread of the disease, the duration of the pandemic, travel restrictions and social distancing guidelines, business closures or
business disruptions and the effectiveness of actions taken to contain and treat the disease. The response to the pandemic may result in
permanent changes to the environment in which we operate as described above in ways we are unable to predict. The COVID-19 pandemic
may also have the effect of heightening many of the other risks described herein.
We are increasingly dependent on information technology systems and subject to privacy and security laws. Our Products and our
systems and infrastructure face certain risks, including from cyber security breaches and data leakage.
We increasingly rely upon technology systems and infrastructure. Our technology systems, including our Products, are potentially vulnerable to
breakdown or other interruption by fire, power loss, system malfunction, unauthorized access and other events. Likewise, data privacy breaches
by employees and others with both permitted and unauthorized access to our Products and our systems may pose a risk that protected patient
information ("PI") may be exposed to unauthorized persons or to the public, or may be permanently lost. The increasing use and evolution of
technology, including cloud-based computing, creates additional opportunities for the unintentional dissemination of information, intentional
destruction of confidential information stored in our systems or in non-encrypted portable media or storage devices. We could also experience a
business interruption, information theft of confidential information, or reputational damage from industrial espionage attacks, malware or other
cyber incidents, which may
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compromise our system infrastructure or lead to data leakage, either internally or at our third-party service providers or other business partners.
The size and complexity of our computer systems, and scope of our geographic reach, make us potentially vulnerable to information technology
system breakdowns, internal and external malicious intrusion, cyberattacks and computer viruses. Because the techniques used to obtain
unauthorized access, or to sabotage systems, change frequently and generally are not recognized until launched against a target, we may be
unable to anticipate these techniques or to implement adequate preventative measures. If we do not allocate and effectively manage the
resources necessary to build and sustain the proper technology infrastructure or properly manage third-party contractors who perform data
management services on our behalf, then a security breach could subject us to, among other things, transaction errors, business process
inefficiencies, the loss of customers, damage to our reputation, business disruptions or the loss of or damage to intellectual property. Such
security breaches could expose us to a risk of loss of information, litigation, penalties, remediation costs and potentially significant liability to
customers, employees, business partners and regulatory authorities, including, for example, under the Health Insurance Portability and
Accountability Act of 1996 (“HIPAA”) in the United States and Regulation 2016/679 on the protection of natural persons with regard to the
processing of personal data and on the free movement of such data under GDPR in the EU. If our data management systems (including third
party data management systems) do not effectively collect, secure, store, process and report relevant data for the operation of our business,
whether due to equipment malfunction or constraints, software deficiencies, or human error, our ability to effectively plan, forecast and execute
our business plan and comply with applicable laws and regulations will be impaired. Any such impairment could materially and adversely affect
our financial condition and results of operations.
While we have invested heavily in the protection of data and information technology and in related training, there can be no assurance that our
efforts will prevent significant breakdowns, breaches in our systems or other cyber incidents or ensure compliance with all applicable security
and privacy laws, regulations and standards, including with respect to third-party service providers that utilize sensitive personal information,
including PI, on our behalf.
A security breach, whether of our Products, systems or third-party hosting services we utilize, could disrupt treatments being provided by our
Products, disrupt access to our customers’ stored information, such as patient treatment data and health information, and could lead to the loss
of, damage to or public disclosure of such data and information, including patient health information. Such an event could have serious negative
consequences, including possible patient injury, regulatory action, fines, penalties and damages, reduced demand for our Products, an
unwillingness of customers to use our Products, harm to our reputation and brand and time-consuming and expensive litigation, any of which
could have a material adverse effect on our financial results. We carry a limited amount of insurance for cybersecurity liability, and our insurance
coverage may be inadequate. In the future, our insurance coverage may be expensive or not be available on acceptable terms or in sufficient
amounts, if at all.
Risks relating to the regulation of our business
Our device candidates must undergo rigorous preclinical and clinical testing and we must obtain regulatory approvals, which could
be costly and time-consuming and subject us to unanticipated delays or prevent us from marketing any devices.
Our research and development activities, as well as the manufacturing and marketing of our Products, are subject to regulation, including
regulation for safety, efficacy and quality, by the FDA in the U.S. In the EU member states where we market our Products and operate, we are
subject to, inter alia, the Medical Device Regulation ("MDR"), which applies directly in all EU member states. In Switzerland, our Products and
operations are subject to, inter alia, the Medical Devices Ordinance, which implements the MDR into Swiss law. In the United Kingdom, our
Products and operation are subject to, inter alia, the Medical Devices Regulations 2002 and the Medical Devices (Amendment etc.) (EU Exit)
Regulations 2020 (the "UK Re, which implements the MDR and MDR like provisions into UK law. We are regulated by comparable authorities in
other countries. Regulations promulgated by the regulatory authorities in our applicable jurisdictions are wide-ranging and govern, among other
things:
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the conduct of preclinical and clinical studies;
product design, development, manufacturing, testing, storage and shipping;
product labeling, advertising and promotion;
premarket clearance, approval and conformity assessment procedures, as well as for modifications introduced in marketed products;
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post-market surveillance and monitoring;
reporting of adverse events or incidents and implementation of corrective actions, including product recalls;
interactions with healthcare professionals and patients; and
product sales and distribution.
We cannot be certain if or when the FDA, comparable regulatory agencies in other jurisdictions or our notified body might request additional or
modified studies on our Products, under what conditions such studies might be requested, or the required size or length of any such studies.
The data collected from our clinical studies may not be sufficient to support regulatory approval in the U.S., Japan and other countries or to
obtain a CE Certificate in the EU for our various future device candidates. Even if we believe the data collected from our clinical studies are
sufficient, the FDA and comparable regulatory bodies in other jurisdictions have substantial discretion in the assessment and approval or
conformity assessment processes and may disagree with our interpretation of the data. Our failure to adequately demonstrate the safety and
efficacy of any of our device candidates would delay or prevent regulatory approval in the U.S., Japan and other countries or delay or prevent a
CE Certificate in the EU (and therefore be unable to affix the CE mark) for our device candidates, which could prevent us from being sustainably
profitable. In addition, any change in the laws or regulations that govern the clearance and approval processes relating to our current and future
devices could make it more difficult and costly to obtain clearance or approval for new devices, or to produce, market and distribute our
Products. Significant delays in receiving clearance or approval, or the failure to receive clearance or approval for our new devices would have
an adverse effect on our ability to expand our business.
We intend to market our Products in a number of international markets in addition to our current markets. In order to market our Products in any
jurisdiction and for other indications or purposes, we may be required to obtain separate regulatory approvals or CE Certificates for our
Products, as applicable. The requirements governing the conduct of clinical studies and manufacturing and marketing of our device candidates
outside the U.S. vary widely from country to country. CE Certificates and regulatory approvals in other jurisdictions may take longer to obtain
than FDA approvals and can require, among other things, additional testing and different clinical study designs. CE Certification processes and
regulatory approvals in other jurisdictions include essentially all of the risks associated with the FDA approval processes. Some regulatory
agencies in other jurisdictions must also approve prices of our Products. Approval of a Product by the FDA does not guarantee approval of the
same product by the health authorities of other countries or CE marking of our Products in the EU and vice versa. In addition, changes in
regulatory policy in the U.S. or in other countries for the approval or CE marking of a medical device during the period of product development
and regulatory agency review or notified body review of each submitted new application may cause delays or rejections.
In the European Economic Area (“EEA”), we are required to obtain a CE Certificate and to affix a CE mark to our Products. In the EEA, our
devices must be subject to conformity assessment procedure involving an EEA notified body, a private organization accredited by an EEA
member state to conduct conformity assessment procedures under the MDR. The notified body typically audits and examines the device’s
technical documentation, including the clinical evaluation, and the quality system for the manufacture, design and final inspection of our devices
before issuing a CE Certificate demonstrating compliance with the relevant requirements or the quality system requirements laid down in the
relevant Annexes to the MDR. The MDR became active on May 26, 2021 and replaced Council Directive 93/42/EEC concerning medical
devices (“MDD”) with transitional provisions for "legacy" devices under the MDD. The MDR introduced significant changes to the regulatory
framework for medical devices in the EU. including new, stricter requirements that we must comply with in order to obtain CE Certificates for
new product candidates, and to renew the CE Certificates for our "legacy" MDD-Products when they expire or by December 31, 2027 or 2028,
depending on device class, whichever occurs first. These changes may prevent or delay the CE Certification of our device candidates or impact
our ability to modify our Products on a timely basis. In particular, the delay in the publication of key MDR guidance documents at EU level and
the limited availability of qualified notified bodies might affect our ability to timely comply and demonstrate such compliance with the new
requirements or delay the MDR CE Certification of our device candidates. Further, as a result of the implementation of the MDR, our notified
body (as well as many other notified bodies throughout the EEA) has suffered a significant backlog in issuing CE Certificate renewals. In the
UK, we may continue to market and sell our Products under the CE mark until June 2023. Thereafter, our Products will be regulated under the
UK Regulations. There can be no assurance that the UK Regulations will be interpreted by UK regulators in the same manner as the MDR in
the future, which may prevent or delay the UK CE certification of our device candidates or impact our ability to modify our Products on a timely
basis
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We may choose to, or may be required to, suspend, repeat or terminate our clinical studies if they are not conducted in accordance
with regulatory requirements, the results are negative or inconclusive or the studies are not well designed.
Clinical studies must be conducted in accordance with the FDA’s cGCPs and the equivalent laws and regulations applicable in other
jurisdictions in which the clinical studies are conducted. The clinical studies are subject to oversight by the FDA, regulatory agencies in other
jurisdictions, ethics committees and institutional review boards at the medical institutions where the clinical studies are conducted. In addition,
clinical studies must be conducted with device candidates produced under the FDA’s QSR and in accordance with the applicable regulatory
requirements in the other jurisdictions in which the clinical studies are conducted. The conduct of clinical studies may require large numbers of
test patients.
The FDA or regulatory agencies in other jurisdictions might delay or terminate our clinical studies of a device candidate for various reasons,
including:
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the device candidate may have unforeseen adverse side effects or may not appear to be more effective than current therapies;
• we may not agree with the FDA, a regulatory authority in another jurisdiction or an ethics committee regarding the protocol for the
conduct of a clinical study;
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new therapies may become the standard of care while we are conducting our clinical studies, which may require us to revise or amend
our clinical study protocols or terminate a clinical study; or
fatalities may occur during a clinical study due to medical problems that may or may not be related to clinical study treatments.
Furthermore, the process of obtaining and maintaining regulatory approvals in the U.S. and other jurisdictions and CE Certification in the EU for
new therapeutic products is lengthy, expensive and uncertain. It can vary substantially, based on the type, complexity and novelty of the product
involved. Accordingly, any of our device candidates could take a significantly longer time than we expect to, or may never, gain regulatory
approval or obtain CE Certification in the EU, which could have a material adverse effect on our business, prospects, financial condition and
results of operations and cause our stock price to decline.
The process of obtaining and maintaining regulatory approvals may be further complicated when we seek approval for indications involving the
use of our products together with pharmacological/immunological therapies and therapy candidates. If our regulators determine that the
predominant questions stem from the pharmacological/immunological therapy in the study, they may require us and our partners to conduct the
study under trial rules and regulations governing pharmacological/immunological therapies, which may differ significantly from medical device
requirements. Adhering to pharmacological/immunological regulations and requirements governing clinical trials could make it more difficult to
enroll study sites and patients, increase compliance costs and lengthen the time it takes to complete the study.
Legislative and regulatory changes in the U.S. and in other countries regarding healthcare insurance and government-sponsored
reimbursement programs (such as Medicare in the United States) may adversely affect our business and financial results.
We rely to a material degree on highly regulated private and government-run health insurance programs for our revenue in most of the
countries in which we operate. The laws and regulations regarding health care programs, both public and private, are driven by public policy
considerations that may be unrelated to the direct provision of patient care, such as lowering costs or requiring or limiting access to healthcare
options. These laws and regulations are very complicated and there are many requirements we must satisfy in order for our Products to
become and remain eligible for reimbursement under these programs. In many cases we may have limited negotiating power when negotiating
reimbursement rates for our Products.
In the future, lawmakers and regulators could also pass additional healthcare laws and implement other regulatory changes at both the national
and local levels. These laws and regulations could potentially affect coverage and reimbursement for our Products. However, we cannot predict
the ultimate content, timing or effect of any future healthcare initiatives or the impact any future legislation or regulation will have on us.
With respect to countries outside the U.S., the national competent authorities in the EU member states, the UK, Switzerland, Israel, Japan, and
other jurisdictions are also increasingly active in their goal of reducing public spending on healthcare. We cannot, therefore, guarantee that the
treatment of patients with our Products would be
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reimbursed in any particular country or, if successfully included on reimbursement lists, whether we will remain on such lists.
We are subject to extensive post-marketing regulation by the FDA and comparable authorities in other jurisdictions, which could
impact the sales and marketing of our Products and could cause us to incur significant costs to maintain compliance. In addition, we
may become subject to additional regulation in other jurisdictions as we increase our efforts to market and sell Optune or Optune Lua
and future Products outside of the U.S.
We market and sell our Products, and expect to market and sell future Products, subject to extensive regulation by the FDA and numerous
other federal, state and governmental authorities in other jurisdictions. These regulations are broad and relate to, among other things, the
conduct of preclinical and clinical studies, product design, development, manufacturing, labeling, testing, product storage and shipping,
premarket clearance and approval, conformity assessment procedures, premarket clearance and approval of modifications introduced in
marketed products, post-market surveillance and monitoring, reporting of adverse events and incidents, pricing and reimbursement, interactions
with healthcare professionals, interactions with patients, information security, advertising and promotion and product sales and distribution.
Although we have received FDA approval to market Optune in the U.S. for the treatment of adult patients with newly diagnosed GBM (together
with temozolomide) and recurrent GBM and approval to market Optune Lua for adults patients with MPM, we will require additional FDA
approval to market our Products for other indications. We may be required to obtain approval of a new PMA, HDE or PMA/HDE supplement
application for modifications made to our Products. This approval process is costly and uncertain, and it could take one to three years, or longer,
from the time the application is filed with the FDA. We may make modifications in the future that we believe do not or will not require additional
approvals. If the FDA disagrees, and requires new PMAs, HDEs, or PMA/HDE supplements for the modifications, we may be required to recall
and to stop marketing the modified versions of our Products.
In addition, before our Products can be marketed in the EU, our Products must obtain a CE Certificate from a notified body. New intended uses
of CE marked medical devices falling outside the scope of the current CE Certificate require a completely new conformity assessment before
the device can be CE marked and marketed in the EU for the new intended use. The process required to gather necessary information and
draw up documentation in order to obtain CE Certification of a medical device in the EU can be expensive and lengthy and its outcome can be
uncertain. We may make modifications to our Products in the future that we believe do not or will not require notifications to our notified body or
new conformity assessments to permit the maintenance of our current CE Certificate. If the competent authorities of the EU member states or
our notified body disagree and require the conduct of a new conformity assessment, the modification of the existing CE Certificate or the
issuance of a new CE Certificate, we may be required to recall or suspend the marketing of the modified versions of our Products.
In Japan, new medical devices or new therapeutic uses of medical devices falling outside the scope of the existing approval by the MHLW
require a new assessment and approval for each such new device or use. Accordingly, we may be required to obtain a new approval from
MHLW before we launch a modified version of our Products or the use of our Products for additional indications. Approval time frames from the
MHLW vary from simple notifications to review periods of one or more years, depending on the complexity and risk level of the device. In
addition, importation into Japan of medical devices is subject to "Quality Management System (QMS) Ordinance," which includes the equivalent
of "Good Import" regulations in the U.S. As with any highly regulated market, significant changes in the regulatory environment could adversely
affect our ability to commercialize Optune in Japan.
In the U.S. and other jurisdictions, we also are subject to numerous post-marketing regulatory requirements, which include regulations under
the QSR related to the manufacturing of our Products, labeling regulations and medical device reporting regulations, which require us to report
to the FDA or comparable regulatory authorities in other jurisdictions and our notified body if our Products cause or contributes to a death or
serious injury, or malfunction in a way that would likely cause or contribute to a death or serious injury. In addition, these regulatory
requirements may in the future change in a way that adversely affects us. If we fail to comply with present or future regulatory requirements that
are applicable to us, we may be subject to enforcement action by the FDA or comparable regulatory authorities in other jurisdictions and notified
bodies, which may include any of the following sanctions:
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untitled letters, warning letters, fines, injunctions, consent decrees and civil penalties;
unanticipated expenditures to address or defend such actions;
patient notification, or orders for repair, replacement or refunds;
voluntary or mandatory recall, withdrawal or seizure of our current or future devices;
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administrative detention by the FDA or other regulatory authority in another jurisdiction of medical devices believed to be adulterated or
misbranded;
operating restrictions, suspension or shutdown of production;
refusal or delay of our requests for PMA or analogous approval for new intended uses for or modifications to our Products or for
approval of new devices;
refusal or delay in obtaining CE Certificates for new intended uses for or modifications to our Products;
suspension, variation or withdrawal of the CE Certificates granted by our notified body in the EU;
prohibition or restriction of Products being placed on the market;
operating restrictions;
suspension or withdrawal of PMA or analogous approvals that have already been granted;
refusal to grant export approval for our Products or any device candidates; or
criminal prosecution.
The occurrence of any of these events could have a material adverse effect on our business, prospects, financial condition and results of
operations and cause our stock price to decline.
Over time, we expect to make modifications to our Products that are designed to improve efficacy, reduce side effects, enhance the
user experience and other purposes. Modifications to our Products may require approvals of new PMAs, HDEs, or PMA/HDE
supplement applications, modified or new CE Certificates and analogous regulatory approvals in other jurisdictions or even require
us to cease promoting or to recall the modified versions of our Products until such clearances, approvals or modified or new CE
Certificates are obtained, and the FDA, comparable regulatory authorities in other jurisdictions or our notified body may not agree
with our conclusions regarding whether new approvals are required.
Any modification to a device approved through the PMA or HDE pathway that impacts the safety or effectiveness of the device requires
submission to the FDA and FDA approval of a PMA supplement application or even a new PMA or HDE application, as the case may be. The
FDA requires a company to make the determination as to whether a new PMA, HDE or PMA/HDE supplement application is to be filed, but the
FDA may review the company’s decision. For example, in the past, we have made initial determinations that certain modifications did not
require the filing of a new PMA or PMA/HDE supplement application and have notified the FDA of these changes in our PMA Annual Report,
but after its review of our PMA Annual Report, the FDA requested that we submit these modifications to the FDA as a PMA supplement
application. From time to time, we may make other changes to the devices, software, packaging, manufacturing facilities and manufacturing
processes and may submit additional PMA/HDE supplement applications for these changes. FDA may conduct a facility inspection as part of its
review and approval process. In addition, it is possible that the FDA will require a human factors (user interface) study. It is also possible that
the FDA may require additional clinical data. We can provide no assurance that we will receive FDA approval for these changes on a timely
basis, or at all. We also may make additional changes in the future that we may determine do not require the filing of a new PMA, HDE or
PMA/HDE supplement application. The FDA may not agree with our decisions regarding whether the filing of new PMAs, HDEs or PMA/HDE
supplement applications are required.
In addition, any substantial change introduced to a medical device or to the quality system certified by our notified body requires a new
conformity assessment of the device and can lead to changes to the CE Certificates or the preparation of a new CE Certificate of Conformity.
Substantial changes may include, among others, the introduction of a new intended use of the device, a change in its design or a change in the
company’s suppliers. Responsibility for determination that a modification constitutes a substantial change lies with the manufacturer of the
medical device. We must inform the notified body that conducted the conformity assessment of the Products we market or sell in the EU of any
planned substantial changes to our quality system or changes to our Products that could, among other things, affect compliance with the MDR
or the devices’ intended use. The notified body will then assess the changes and verify whether they affect the Product’s conformity with the
Essential Requirements laid down in Annex I to the MDR or the conditions for the use of the device. If the assessment is favorable, the notified
body will issue a new CE Certificate or an addendum to the existing CE Certificate attesting compliance with the Essential Requirements laid
down in Annex I to the MDR. There is a risk that the competent authorities of the EU member states or our notified body may disagree with our
assessment of the changes introduced to our Products. The competent authorities of the EU member states or our notified body also may come
to a different conclusion than the FDA on any given product modification.
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In addition, "legacy" medical devices that have obtained a CE Certification under the MDD may in principle continue to be marketed under such
CE Certificate until the CE Certificate expires but at the latest by December 31, 2027 or 2028, depending on device class, under transitional
provisions as amended in February 2023, provided that the manufacturer complies with the MDR’s additional requirements related to post-
marketing surveillance, market surveillance, vigilance, and registration of economic operators and of devices. However, if such medical devices
undergo a significant change in their design or intended use, we would need to obtain a new CE Certificate under the MDR for these devices.
If the FDA disagrees with us and requires us to submit a new PMA, HDE, or PMA/HDE supplement application for then-existing modifications
and/or the competent authorities of the EU member states or our notified body disagree with our assessment of the change introduced in a
product, its design or its intended use, we may be required to cease promoting or to recall the modified product until we obtain approval and/or
until a new conformity assessment has been conducted in relation to the product, as applicable. In addition, we could be subject to significant
regulatory fines or other penalties. Furthermore, our Products could be subject to recall if the FDA, comparable regulatory authorities in other
jurisdictions, or our notified body determine, for any reason, that our Products are not safe or effective or that appropriate regulatory
submissions were not made. Any recall or requirement that we seek additional approvals or clearances could result in significant delays, fines,
increased costs associated with modification of a product, loss of revenues and potential operating restrictions imposed by the FDA,
comparable foreign regulatory authorities in other jurisdictions, or our notified body. Delays in receipt or failure to receive approvals/certification,
or the failure to comply with any other existing or future regulatory requirements, could reduce our sales, profitability and future growth
prospects.
In addition to FDA requirements, we will spend considerable time and money complying with other federal, state, local and foreign
rules, regulations and guidance and, if we are unable to fully comply with such rules, regulations and guidance, we could face
substantial penalties.
We are subject to extensive regulation by the U.S. federal government and the states and other countries in which we conduct our business.
U.S. federal government healthcare laws apply when we submit a claim on behalf of a U.S. federal healthcare program beneficiary, or when a
customer submits a claim for an item or service that is reimbursed under a U.S. federal government-funded healthcare program, such as
Medicare or Medicaid. The laws that affect our ability to operate our business in addition to the Federal Food, Drug, and Cosmetic Act and FDA
regulations include, but are not limited to, the following:
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the Federal Anti-Kickback Statute, an intent-based federal criminal statute which prohibits knowingly and willfully offering, providing,
soliciting or receiving remuneration of any kind to induce or reward, or in return for, referrals or the purchase, lease, order or
recommendation or arranging of any items or services reimbursable by a federal healthcare program;
the Federal Civil False Claims Act, which imposes civil penalties, including through civil whistleblower or "qui tam" actions, for knowingly
submitting or causing the submission of false or fraudulent claims of payment to the federal government, knowingly making, using or
causing to be made or used a false statement or record material to payment of a false claim or avoiding, decreasing or concealing an
obligation to pay money to the federal government;
the Federal Criminal False Claims Act, which is similar to the Federal Civil False Claims Act and imposes criminal liability on those that
make or present a false, fictitious or fraudulent claim to the federal government;
• Medicare laws and regulations that prescribe requirements for coverage and reimbursement, including the conditions of participation for
DME suppliers, and laws prohibiting false claims or unduly influencing selection of products for reimbursement under Medicare and
Medicaid;
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healthcare fraud statutes that prohibit false statements and improper claims to any third-party payer;
the Federal Physician Self-Referral Law, commonly known as the Stark law, which, absent an applicable exception, prohibits physicians
from referring Medicare and Medicaid patients to an entity for the provision of certain designated health services (“DHS”), including
DME, if the physician (or a member of the physician’s immediate family) has an impermissible financial relationship with that entity and
prohibits the DHS entity from billing for such improperly referred services;
the Federal Beneficiary Anti-Inducement Statute, which prohibits the offering of any remuneration to a beneficiary of Medicare or
Medicaid that is likely to influence that beneficiary’s choice of provider or supplier. This can include, but is not limited to, inappropriate
provision of patient services including financial
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assistance. Recent government investigations have focused on this particular prohibition. There are established exceptions from
liability, but we cannot guarantee that all of our practices will fall squarely within those exceptions;
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similar state anti-kickback, false claims, insurance fraud and self-referral laws, which may not be limited to government-reimbursed
items, as well as state laws that require us to maintain permits or licenses to distribute DME;
federal and state accreditation and licensing requirements applicable to DME providers and equivalent requirements in other
jurisdictions;
the U.S. Foreign Corrupt Practices Act, which can be used to prosecute companies in the U.S. for arrangements with physicians or
other parties outside the U.S. if the physician or party is a government official of another country and the arrangement violates the law
of that country;
the Federal Trade Commission Act, the Lanham Act and similar federal and state laws regulating truthfulness in advertising and
consumer protection; and
the Federal Physician Payments Sunshine Act, the French Sunshine Act and similar state and foreign laws, which require periodic
reporting of payments and other transfers of value made to U.S. and French-licensed physicians, teaching hospitals, and in the U.S.,
physician assistants, nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse-midwives.
Similar laws exist in the EU, individual EU member states and other countries. These laws are complemented by EU or national professional
codes of practices.
HIPAA provides data privacy and security provisions for safeguarding medical information. Additionally, states in the U.S. are enacting local
privacy laws (e.g., California). In the EU, the GDPR harmonizes data privacy laws and rules on the processing of personal data, including
patient and employee data, across the EU. The GDPR has a number of strict data protection and security requirements for companies
processing data of EU residents, including when such data is transferred outside of the EU. Additionally, we need to comply with analogous
privacy laws in other jurisdictions in which we operate, such as the Israeli Privacy Protection Law, the Asia Pacific Economic Cooperation
Privacy Framework, and Japan’s Act on the Protection of Personal Information.
The laws and codes of practices applicable to us are subject to evolving interpretations. Moreover, certain U.S. federal and state laws regarding
healthcare fraud and abuse and certain laws in other jurisdictions regarding interactions with healthcare professionals and patients are broad
and we may be required to restrict certain of our practices to be in compliance with these laws. Healthcare fraud and abuse laws also are
complex and even minor, inadvertent irregularities, or even the perception of impropriety, can potentially give rise to claims that a statute has
been violated.
Any violation of these laws could have a material adverse effect on our business, prospects, financial condition and results of operations and
cause our stock price to decline. Similarly, if there is a change in law, regulation or administrative or judicial interpretations, we may have to
change our business practices or our existing business practices could be challenged as unlawful, which likewise could have a material adverse
effect on our business, prospects, financial condition and results of operations and cause our stock price to decline. Fines and penalties for
violations of these laws and regulations could include severe criminal and civil penalties, including, for example, significant monetary damages,
exclusion from participation in the federal healthcare programs and permanent disbarment of key employees. Any penalties, damages, fines,
curtailment or restructuring of our operations would adversely affect our ability to operate our business, our prospects and our financial results.
In addition, any action against us for violation of these laws, even if we successfully defend against it, could cause us to incur significant legal
expenses, divert our management’s attention from the operation of our business and damage our reputation.
In addition, although we believe that we have the required licenses, permits and accreditation to dispense our Products in the future, a regulator
could find that we need to obtain additional licenses or permits. We also may be subject to mandatory reaccreditation and other requirements in
order to maintain our billing privileges. Failure to satisfy those requirements could cause us to lose our privileges to bill governmental and
private payers. If we are required to obtain permits or licenses that we do not already possess, we also may become subject to substantial
additional regulation or incur significant expense.
To ensure compliance with Medicare, Medicaid and other regulations, federal and state governmental agencies and their agents, including DME
MACs, may conduct audits of our operations to support our claims submitted for reimbursement of items furnished to beneficiaries and health
care providers. Depending on the nature of the conduct found in such audits and whether the underlying conduct could be considered systemic,
the resolution of these audits could adversely impact our revenue, financial condition and results of operations.
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If we, our collaborative partners, our contract manufacturers or our component suppliers fail to comply with the FDA’s QSR or
equivalent regulations established in other countries, the manufacturing and distribution of our Products could be interrupted, and
our Product sales and results of operations could suffer.
We, our collaborative partners, our contract manufacturers and our component suppliers are required to comply with the FDA’s QSR and the
equivalent quality system requirements imposed by the laws and regulations in other jurisdictions, which are a complex regulatory framework
that covers the procedures and documentation of the design, testing, production, control, quality assurance, labeling, packaging, sterilization,
storage and shipping of our Products. We cannot assure you that our facilities or our contract manufacturers’ or component suppliers’ facilities
would pass any future quality system inspection. If our or any of our contract manufacturers’ or component suppliers’ facilities fails a quality
system inspection, the manufacturing or distribution of our Products could be interrupted and our operations disrupted. Failure to take adequate
and timely corrective action in response to an adverse quality system inspection could force a suspension or shutdown of our packaging and
labeling operations or the manufacturing operations of our contract manufacturers, and lead to suspension, variation or withdrawal of our
regulatory approvals or a recall of our Products. If any of these events occurs, we may not be able to provide our customers with our Products
on a timely basis, our reputation could be harmed and we could lose customers, any or all of which could have a material adverse effect on our
business, prospects, financial condition and results of operations and cause our stock price to decline.
Our Products may in the future be subject to recalls that could harm our reputation, business and financial results.
The FDA and similar governmental authorities in other jurisdictions have the authority to require the recall of commercialized products in the
event of material deficiencies or defects in design or manufacture. In the case of the FDA, the authority to require a recall must be based on an
FDA finding that there is a reasonable probability that the device would cause serious injury or death. In addition, governmental bodies in other
jurisdictions have the authority to require the recall of our Products in the event of material deficiencies or defects in design or manufacture.
Distributors and manufacturers may, under their own initiative, recall a product if any material deficiency in a device is found. A government-
mandated or voluntary recall by us or one of our manufacturers could occur as a result of component failures, manufacturing errors, design or
labeling defects or other deficiencies and issues. The FDA requires that certain classifications of recalls be reported to the FDA within ten
working days after the recall is initiated. Requirements for the reporting of product recalls to the competent authorities are imposed in other
jurisdictions in which our Products are or would be marketed in the future. Companies are required to maintain certain records of recalls, even if
they are not reportable to the FDA or to the competent authorities of other countries. In the future, we may initiate voluntary recalls involving our
Products that we determine do not require notification of the FDA or to other equivalent non-U.S. authorities. If the FDA or the equivalent non-
U.S. authorities disagree with our determinations, they could require us to report those actions as recalls. A future recall announcement could
harm our reputation with customers and negatively affect our sales. In addition, the FDA and the equivalent non-U.S. authorities could take
enforcement action if we fail to report the recalls when they were conducted. Recalls of our Products would divert managerial and financial
resources and could have a material adverse effect on our business, prospects, financial condition and results of operations and cause our
stock price to decline.
If our Products cause or contribute to a death or a serious injury, or malfunction in certain ways, we will be subject to medical device
reporting regulations, which can result in voluntary corrective actions or agency enforcement actions.
Under the FDA Medical Device Reporting regulations and the equivalent regulations applicable in other jurisdictions in which our Products are
or may be marketed in the future, medical device manufacturers are required to report to the FDA and to the equivalent non-U.S. authorities
information that a device has or may have caused or contributed to a death or serious injury or has malfunctioned in a way that would likely
cause or contribute to death or serious injury if the malfunction of the device or one of our similar devices were to recur. If we fail to report these
events to the FDA or to the equivalent authorities in other jurisdictions within the required time frames, or at all, the FDA or the equivalent
authorities in other jurisdictions could take enforcement action against us. Any such adverse event involving our Products also could result in
future voluntary corrective actions, such as recalls or customer notifications, or agency action, such as inspection or enforcement action. Any
corrective action, whether voluntary or involuntary, as well as defending ourselves in a lawsuit, will require the dedication of our time and capital,
distract management from operating our business, and may harm our reputation and financial results.
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We may be subject to fines, penalties or injunctions if we are determined to be promoting the use of our Products for unapproved or
off-label uses.
Medical devices may be marketed only for the indications for which they are approved. Our promotional materials and training materials must
comply with FDA regulations and other applicable laws and regulations governing the promotion of our Products in the U.S. and other
jurisdictions. Currently, Optune is approved for treatment of adult patients with newly diagnosed GBM (together with temozolomide) and
recurrent GBM in the U.S. and is approved for treatment of adult patients with GBM in Japan. In the EU and Switzerland, we have CE marked
the Optune for the treatment of newly diagnosed GBM (together with temozolomide), recurrent GBM, and advanced NSCLC (together with
standard-of-care chemotherapy). Optune is also approved in Israel and in Australia for the treatment of recurrent GBM and newly diagnosed
GBM (together with temozolomide). The Optune Lua System is only approved in the U.S., the EU and Switzerland for the treatment of
unresectable, locally advanced or metastatic MPM.
If the FDA or the competent authorities in other jurisdictions, including the EU member states, determine that our promotional materials or
training constitutes promotion of an unapproved use, they could request that we modify our training or promotional materials or subject us to
regulatory or enforcement actions, including the issuance of an untitled or warning letter, an injunction, seizure, civil fines and criminal penalties.
It is also possible that authorities in other federal, state or national enforcement in other jurisdictions might take action if they consider our
promotional or training materials to constitute promotion of an unapproved use, which could result in significant fines or penalties under other
statutory authorities, such as laws prohibiting false claims for reimbursement. In that event, our reputation could be damaged and the
commercialization of our Products could be impaired.
We pay taxes in multiple jurisdictions and adverse determinations by taxing or other governmental authorities or changes in tax laws,
rates or our status under which tax jurisdictions apply to us could increase our tax burden or otherwise affect our financial condition
or results of operations, as well as subject our shareholders to additional taxes.
The amount of taxes we pay is subject to a variety of tax laws in the various jurisdictions in which we and our subsidiaries are organized and
operate. Our domestic and international tax liabilities are dependent on the location of earnings among these various jurisdictions. Such tax
liabilities could be affected by changes in tax or other laws, treaties, and regulations, as well as the interpretation or enforcement thereof by tax
or other governmental entities in any relevant jurisdiction. The amount we pay in tax to any particular jurisdiction depends, in part, on the correct
interpretation of the tax laws in such jurisdiction, and we have made a number of determinations as to the effect of such tax laws in our
particular circumstances. In some cases, the determinations we have made as to the effect of the tax laws in a particular jurisdiction depend on
the continuing effectiveness of administrative rulings we have received from the tax authorities in that jurisdiction, while in other cases, our
determinations are based on the reasoned judgment of our tax advisors. Although we believe that we are in compliance with the administrative
rulings we have received, that the assumptions made by our tax advisors in rendering their advice remain correct, and that as a result we are in
compliance with applicable tax laws in the jurisdictions where we and our subsidiaries are organized and operate, a taxing authority in any such
jurisdiction may challenge our interpretation of those laws and assess us or any of our subsidiaries with additional taxes, penalties, fees and
interest.
Additionally, from time to time, proposals can be made and legislation can be introduced to change the tax laws, regulations or interpretations
thereof (possibly with retroactive effect) of various jurisdictions or limit tax treaty benefits that, if enacted, could materially increase our tax
burden, increase our effective tax rate or otherwise have a material adverse impact on our financial condition and results of operations. It is
possible that these changes could adversely affect our business. While we monitor proposals and other developments that would materially
impact our tax burden and effective tax rate and investigate our options accordingly, we could still be subject to increased taxation on a going
forward and retroactive basis no matter what action we undertake if certain legislative proposals or regulatory changes are enacted, certain tax
treaties are amended and/or our interpretation of applicable tax or other laws is challenged and determined to be incorrect. Any alternative
interpretations of applicable tax laws asserted by a tax authority or changes in tax laws, regulations or accounting principles that limit our ability
to take advantage of tax treaties between jurisdictions, modify or eliminate the deductibility of various currently deductible payments, increase
the tax burden of operating or being resident in a particular country, result in transfer pricing adjustments or otherwise require the payment of
additional taxes, may have a material adverse effect on our cash flows, financial condition and results of operations. The termination or revision
of any of our tax rulings or indirect tax exemptions that we have or may have in the future may have a material adverse effect on our cash flows,
financial condition and results of operations.
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We are affected by and subject to environmental laws and regulations that could be costly to comply with or that may result in costly
liabilities.
We are subject to environmental laws and regulations, including those that impose various environmental controls on the manufacturing,
transportation, storage, use and disposal of batteries and hazardous chemicals and other materials used in, and hazardous waste produced by,
the manufacturing of our Products. We incur and expect to continue to incur costs to comply with these environmental laws and regulations.
Additional or modified environmental laws and regulations, including those relating to the manufacture, transportation, storage, use and disposal
of materials used to manufacture our Products or restricting disposal or transportation of batteries, may be imposed that may result in higher
costs.
In addition, we cannot predict the effect that additional or modified environmental laws and regulations may have on us, our third-party suppliers
of equipment, batteries and our Products or our customers. For example, we and our suppliers rely on the exemption in European Directive
2011/65/EU relating to the restriction of the use of certain hazardous substances in electrical and electronic equipment, set out in Annex IV,
relating to lead content in our arrays. To the extent this exemption is revoked or amended, it may have a material impact on our business and
results of operations.
Safety issues concerning lithium-ion batteries could have a material adverse impact on our business.
Our Products use lithium-ion batteries. On rare occasions, lithium-ion cells can rapidly release the energy they contain by venting smoke, heat,
and flames in a manner that can ignite nearby materials as well as other lithium-ion cells. A failure in the lithium-ion battery contained in a
Product could occur, which could result in accidents, casualty or damages, and subject us to lawsuits, product recalls, or redesign efforts. In
addition, we store a significant number of lithium-ion cells at our facilities. Any failure of battery cells or a safety issue or fire related to the cells
could disrupt our operations. Such damage or injury could lead to adverse publicity and potentially a safety recall. The transportation of lithium
and lithium-ion batteries is regulated worldwide.
Laws regulating the transportation of batteries have been and may be enacted which could impose additional costs that could harm our ability to
be profitable. If additional restrictions are put in place that limit our ability to ship our Products by air freight or on water borne cargo, such
restrictions could have an adverse effect on our supply chain, our inventory management procedures and processes and our ability to fill
prescriptions and service patients in a timely manner, which could have a material adverse effect on our business, prospects, financial condition
and results of operations. In addition, compliance with future worldwide or International Air Transport Association approval process and
regulations could require significant time and resources from our technical staff and, if redesign were necessary, could delay the introduction of
new Products.
Risks relating to intellectual property
If we fail to protect, sustain, further build and enforce our intellectual property rights, including to our proprietary technology, trade
secrets or know how, competitors may be able to develop competing therapies.
Our success depends, in part, on our ability to obtain and maintain protection for our Products and technologies under the patent laws or other
intellectual property laws of the U.S. and other countries. The standards that the U.S. Patent and Trademark Office ("USPTO") and its
counterparts in other jurisdictions use to grant patents are not always applied predictably or uniformly and can change. Consequently, we
cannot be certain as to whether pending patent applications will result in issued patents, and we cannot be certain as to the type and extent of
patent claims that may be issued to us in the future. Any issued patents may not contain claims that will permit us to stop competitors from
using similar technology.
Our current intellectual property portfolio consists of hundreds of issued patents in multiple jurisdictions covering various aspects of our devices
and related technology. The legal scope of our patents vary, with some having broad coverage and others having narrow coverage, for example
being limited to certain intensities and frequencies. Our patent position is generally uncertain and involves complex legal and factual questions.
In the U.S., our patents have expected expiration dates between 2023 and 2041. In 2021, several patents covering technology included in our
Products expired in the U.S. and elsewhere. Patent expiration could adversely affect our ability to protect our Products and future product
development and our competitors may develop and market competing products. We have also filed additional patent applications in several
countries that may never be issued. Consequently, our operating results and financial position could be materially adversely affected. In
addition, due to the extensive time needed to develop, test and obtain regulatory approval for our treatment therapies, any patents
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that protect our Product candidates may expire early during commercialization. This may reduce or eliminate any market advantages that such
patents may give us and harm our financial position. If we fail to develop and successfully launch new Products prior to the expiration of patents
for our existing Products, our sales and achieving patient acceptance with respect to those Products could decline significantly. We may not be
able to develop and successfully launch more advanced replacement Products before these and other patents expire.
We have limited intellectual property rights outside of our key markets. In some countries outside the U.S., we do not have any intellectual
property rights, and our intellectual property rights in other countries outside the U.S. have a different scope and strength compared to our
intellectual property rights in the U.S. Consequently, we may not be able to prevent third parties from practicing our inventions in all countries
outside the U.S. Competitors may use our technologies in jurisdictions where we have not obtained patent protection to develop their own
products and further, may export otherwise infringing products to territories where we have patent protection, but where enforcement rights are
not as strong as those in the U.S. These products may compete with our devices, and our patents or other intellectual property rights may not
be effective or adequate to prevent such competition.
For a variety of reasons, we may decide not to file for patent protection for certain of our intellectual property. Our patent rights underlying
TTFields and our Products may not be adequate, and our competitors or customers may design around our proprietary technologies or
independently develop similar or alternative technologies or products that are equal or superior to ours without infringing on any of our patent
rights. In addition, the patents licensed or issued to us may not provide a competitive advantage, and may be insufficient to prevent others from
commercializing products similar or identical to ours. The occurrence of any of these events could have a material adverse effect on our
business, prospects, financial condition and results of operations and cause our stock price to decline.
Our existing and future patent portfolio also may be vulnerable to legal challenges worldwide. The standards that courts use to interpret patents
are not always applied predictably or uniformly and can change from country to country, particularly as new technologies develop. As a result of
the uncertainties of patent law in general, we cannot predict how much protection, if any, will be given to our patents if we attempt to enforce
them and they are challenged in court. Any attempt to enforce our intellectual property rights may also be time-consuming and costly, may divert
the attention of management from our business, may ultimately be unsuccessful or may result in a remedy that is not commercially valuable.
Such attempts may also provoke third parties to assert claims against us or result in our intellectual property being narrowed in scope or
declared to be invalid or unenforceable.
In addition, we rely on certain proprietary trade secrets, know-how and other confidential information. We have taken measures to protect our
unpatented trade secrets, know-how and other confidential information, including the use of confidentiality and assignment of inventions
agreements with our employees, consultants and certain contractors. It is possible, however, that these persons may breach or challenge the
agreements, that our trade secrets may otherwise be misappropriated or that competitors may independently develop or otherwise discover our
trade secrets. There is therefore no guarantee that we will be able to obtain, maintain and enforce the intellectual property rights that may be
necessary to protect and grow our business and to provide us with a meaningful competitive advantage, and our failure to do so could have a
material adverse effect on our business, prospects, financial condition and results of operations and cause our stock price to decline.
The oncology and medical device industries are characterized by patent and other intellectual property litigation and disputes, and
any litigation, dispute or claim against us may cause us to incur substantial costs, could place a significant strain on our financial
resources, divert the attention of management from our business, harm our reputation and require us to remove certain devices from
the market.
Whether a product infringes a patent or violates other intellectual property rights involves complex legal and factual issues, the determination of
which is often uncertain. Any intellectual property dispute, even a meritless or unsuccessful one, would be time consuming and expensive to
defend and could result in the diversion of our management’s attention from our business and result in adverse publicity, the disruption of
research and development and marketing efforts, injury to our reputation and loss of revenues. Any of these events could negatively affect our
business, prospects, financial condition and results of operations.
Third parties may assert that TTFields, our Products, the methods employed in the use of our Products or other activities infringe on their
patents. Such claims may be made by competitors seeking to obtain a competitive advantage or by other parties, many of whom have
significantly larger intellectual property portfolios than we have. Additionally, in recent years, individuals and groups have begun purchasing
intellectual property assets for the purpose of making claims of infringement and attempting to extract settlements from companies like ours.
With respect to our current Products, the risk of infringement claims is exacerbated by the fact that there are numerous
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issued and pending patents relating to the treatment of cancer. Because patent applications can take many years to issue, and in many cases
remain unpublished for many months after filing, there may be applications now pending of which we are unaware that may later result in issued
patents that our Products may infringe.
There could also be existing patents that one or more components of our Products or other device candidates may inadvertently infringe. As the
number of competitors in the market or other device candidates grows, the possibility of inadvertent patent infringement by us or a patent
infringement claim against us increases. To the extent we gain greater market visibility, our risk of being subject to such claims is also likely to
increase. If a third party’s patent was upheld as valid and enforceable and we were found to be infringing, we could be prevented from making,
using, selling, offering to sell or importing our Products or other device candidates, unless we were able to obtain a license under that patent or
to redesign our systems to avoid infringement. A license may not be available at all or on terms acceptable to us, and we may not be able to
redesign our Products to avoid any infringement. Modification of our Products or development of device candidates to avoid infringement could
require us to conduct additional clinical studies and to revise our filings with the FDA and other regulatory bodies, which would be time-
consuming and expensive. If we are not successful in obtaining a license or redesigning our devices, we may be unable to make, use, sell, offer
to sell or import our devices and our business could suffer. We may also be required to pay substantial damages and undertake remedial
activities, which could cause our business to suffer.
We may also be subject to claims alleging that we infringe or violate other intellectual property rights, such as copyrights or trademarks, may
have to defend against allegations that we misappropriated trade secrets, and may face claims based on competing claims of ownership of our
intellectual property. The confidentiality and assignment of inventions agreements that our employees, consultants and other third parties sign
may not in all cases be enforceable or sufficient to protect our intellectual property rights. In addition, we may face claims from third parties
based on competing claims to ownership of our intellectual property.
We also employ individuals who were previously employed at other medical device companies, and as such we may be subject to claims that
such employees have inadvertently or otherwise used or disclosed the alleged trade secrets or other proprietary information of their former
employers. Any such litigation, dispute or claim could be costly to defend and could subject us to substantial damages, injunctions or other
remedies, which could have a material adverse effect on our business, prospects, financial condition and results of operations and cause our
stock price to decline.
Changes in U.S. patent law could diminish the value of patents in general, thereby impairing our ability to protect our devices.
As is the case with other medical device companies, our success is heavily dependent on our intellectual property rights, and particularly on our
patent rights. Obtaining and enforcing patents in the medical device industry involves both technological and legal complexity, and is therefore
costly, time consuming and inherently uncertain. In addition, the U.S. has recently enacted and is currently implementing wide-ranging patent
reform legislation. Certain U.S. Supreme Court rulings have narrowed the scope of patent protection available in certain circumstances and
weakened the rights of patent owners in certain situations. In addition to increasing uncertainty with regard to our ability to obtain patents in the
future, this combination of events has created uncertainty with respect to the value of patents once obtained. Depending on decisions by the
U.S. Congress, the federal courts and the USPTO, the laws and regulations governing patents could change in unpredictable ways that could
further negatively impact the value of our patents, narrow the scope of available patent protection or weaken the rights of patent owners.
Risks relating to our ordinary shares and capital structure
The market price for our ordinary shares may be volatile, which could result in substantial losses.
The market price for our ordinary shares may be volatile and subject to wide fluctuations in response to factors such as publication of clinical
studies relating to our Products, our system candidates or a competitor’s product, actual or anticipated fluctuations in our quarterly results of
operations, changes in financial estimates by securities research analysts, negative publicity, studies or reports, changes in the economic
performance or market valuations of other companies that operate in our industry, changes in the availability of third-party reimbursement in the
U.S. or other countries, changes in governmental regulations or in the status of our regulatory approvals or applications, announcements by us
or our competitors of material acquisitions, strategic partnerships, joint ventures or capital commitments, intellectual property litigation, release
of transfer restrictions on our outstanding ordinary shares, and economic or political conditions in the U.S. or elsewhere.
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Our ordinary shares are issued under the laws of Jersey, which may not provide the level of legal certainty and transparency afforded
by incorporation in a U.S. state.
We are incorporated under the laws of the Bailiwick of Jersey, Channel Islands. Jersey legislation regarding companies is largely based on
English corporate law principles. However, there can be no assurance that Jersey law will not change in the future or that it will serve to protect
investors in a similar fashion afforded under corporate law principles in the U.S., which could adversely affect the rights of investors.
U.S. shareholders may not be able to enforce civil liabilities against us.
We are a Jersey entity with most of our assets located outside of the U.S. Although we have appointed an agent for service of process in the
U.S. for purposes of U.S. federal securities laws, a number of our directors and executive officers and a number of directors of each of our
subsidiaries are not residents of the U.S., and all or a substantial portion of the assets of such persons are located outside the U.S. As a result,
it may not be possible for investors to effect service of process within the U.S. upon such persons or to enforce against them judgments
obtained in U.S. courts predicated upon the civil liability provisions of the federal securities laws of the U.S.
We have been advised by our Jersey lawyers that the courts of Jersey would recognize any final and conclusive judgment under which a sum of
money is payable (not being a sum payable in respect of taxes or other charges of a like nature or in respect of a fine or other penalty) obtained
against us in the courts of any other territory in respect of certain enforceable obligations in accordance with the principles of private
international law as applied by Jersey law (which are broadly similar to the principles accepted under English common law) and such judgment
would be sufficient to form the basis of proceedings in the Jersey courts for a claim for liquidated damages in the amount of such judgment. In
such proceedings, the Jersey courts would not re-hear the case on its merits save in accordance with such principles of private international
law. Obligations may not necessarily be enforceable in Jersey in all circumstances or in accordance with their terms; and in particular, but
without limitation: (i) any agreement purporting to provide for a payment to be made in the event of a breach of such agreement would not be
enforceable to the extent that the Jersey courts were to construe such payment to be a penalty that was excessive, in that it unreasonably
exceeds the maximum damages that an obligee could have suffered as a result of the breach of an obligation; (ii) the Jersey courts may refuse
to give effect to any provision in an agreement that would involve the enforcement of any revenue or penal laws in other jurisdictions; and (iii)
the Jersey courts may refuse to allow unjust enrichment or to give effect to any provisions of an agreement (including provisions relating to
contractual interest on a judgment debt) that it considers usurious.
We have borrowed a significant amount of debt and have the ability to borrow additional debt in the future, which could adversely
affect our financial condition and results of operations and our ability to react to changes in our business.
We currently have two significant debt arrangements outstanding. On November 5, 2020, we issued $575 million of 0% Convertible Senior
Notes due 2025 (the “Convertible Notes”). The Convertible Notes are senior unsecured obligations. The Convertible Notes do not bear regular
interest, and mature on November 1, 2025, unless earlier repurchased, redeemed or converted. The Notes are not redeemable prior to
November 6, 2023 and are convertible into a combination of cash and ordinary shares on or after August 1, 2025, or earlier upon certain
events.
Our existing indebtedness and any additional indebtedness we may incur otherwise could require us to divert funds identified for other purposes
for debt service and impair our liquidity position.
The fact that a substantial portion of our cash flow from operations could be needed to make payments on our indebtedness could have
important consequences, including the following:
•
•
•
•
increasing our vulnerability to general adverse economic and industry conditions or increased interests rates;
limiting the availability of our cash flow for other purposes and our flexibility in planning for or reacting to changes in our business and
the markets in which we operate, which would place us at a competitive disadvantage compared to our competitors that may have less
exposure to debt;
limiting our ability to borrow additional funds for working capital, capital expenditures and other investments; and
failing to comply with the covenants in our debt agreements could result in all of our indebtedness becoming immediately due and
payable.
46
Our ability to obtain necessary funds through borrowing, as well as our ability to service our indebtedness, will depend on our ability to generate
cash flow from operations. Our ability to generate cash is subject to general economic, financial, competitive, legislative, regulatory and other
factors that are beyond our control. If our business does not generate sufficient cash flow from operations or if future borrowings are not
available to us under our outstanding borrowings or otherwise in amounts sufficient to enable us to fund our liquidity needs, our financial
condition and results of operations may be adversely affected. Our inability to make scheduled payments on our debt obligations in the future
would require us to refinance all or a portion of our indebtedness on or before maturity, sell assets or seek additional equity investment. We may
not be able to take any of such actions on a timely basis, on terms satisfactory to us or at all.
Transactions relating to our Convertible Notes may dilute the ownership interest of existing shareholders, or may otherwise depress
the price of our ordinary shares.
The conversion of some or all of our Convertible Notes would dilute the ownership interests of existing shareholders to the extent we deliver
shares upon conversion of any of such notes. Our Convertible Notes are convertible at the option of their holders prior to their scheduled terms
under certain circumstances. In connection with the conversion of our Convertible Notes, we may deliver to the holders of such notes a
significant number of our ordinary shares. Any sales in the public market of our ordinary shares issuable upon such conversion could adversely
affect prevailing market prices of our ordinary shares. In addition, the existence of our Convertible Notes may encourage short selling by market
participants because the conversion of such notes could be used to satisfy short positions, or anticipated conversion of such notes into our
ordinary shares could depress the price of our ordinary shares.
47
ITEM 1B. UNRESOLVED STAFF COMMENTS
None.
ITEM 2. PROPERTIES
Our global headquarters and operating center is located in Root, Switzerland, our U.S. operating center is located in Portsmouth, New
Hampshire, and our research and development operations are located in Haifa, Israel, all of which are leased. In December 2021 we acquired a
property in downtown Portsmouth, New Hampshire that will become our U.S. flagship location. Construction on the property is expected to be
completed in 2023. We also lease additional office and warehouse space across North America, Europe, Israel and Japan. We believe that our
current facilities are adequate for our present purposes, but we may need additional space as we continue to grow and expand our operations.
We believe that suitable additional or alternative office, laboratory, and manufacturing space would be available as required in the future on
commercially reasonable terms.
ITEM 3. LEGAL PROCEEDINGS
From time to time, we are involved in various legal proceedings, claims, investigations and litigation that arise in the ordinary course of our
business. Litigation is inherently uncertain. Accordingly, we cannot predict with certainty the outcome of these matters. After considering a
number of factors, including (but not limited to) the views of legal counsel, the nature of contingencies to which the Company is subject and
prior experience, management believes that the ultimate disposition of these legal actions will not materially affect its consolidated financial
position or results of operations.
ITEM 4. MINE SAFETY DISCLOSURES
None.
48
PART II
ITEM 5. MARKET FOR REGISTRANT’S COMMON EQUITY, RELATED STOCKHOLDER MATTERS AND ISSUER PURCHASES OF
EQUITY SECURITIES
Our ordinary shares are quoted on the NASDAQ Global Select Market under the symbol "NVCR."
Holders of Ordinary Shares
As of February 17, 2023, there were 17 holders of record of our ordinary shares. On February 17, 2023, the last reported sale price of our
ordinary shares on the NASDAQ Global Select Market was $84.74 per share.
Dividend Policy
We have not paid any dividends on our ordinary shares since our inception and do not anticipate paying any dividends on our ordinary shares in
the foreseeable future.
Performance Graph
The following performance graph is being furnished as part of this annual report and shall not be deemed "filed" with the SEC or incorporated
by reference into any of our filings under the Securities Act of 1933, as amended (the "Securities Act"), or the Exchange Act, whether made
before or after the date hereof and irrespective of any general incorporation language in any such filing.
The graph below matches our cumulative 5-Year total shareholder return on our ordinary shares with the cumulative total returns of the Russell
2000 index and the Nasdaq Biotechnology index. The graph tracks the performance of a $100 investment in our ordinary shares and in each
index (with the reinvestment of all dividends) from December 31, 2017 to December 31, 2022. Pursuant to applicable SEC rules, all values
assume reinvestment of the full amount of all dividends; however, no dividends have been declared on our ordinary shares to date. The
shareholder return shown on the graph below is not necessarily indicative of future performance, and we do not make or endorse any
predictions as to future stockholder returns.
49
NovoCure Ltd
Russell 2000
NASDAQ Biotechnology
12/17
100.00
100.00
100.00
12/18
165.74
88.99
91.14
12/19
417.18
111.70
114.02
12/20
856.63
134.00
144.15
12/21
371.68
153.85
144.18
12/22
363.12
122.41
129.59
Recent Sales of Unregistered Securities
Not applicable
Issuer Purchases of Equity Securities
Not applicable.
Securities Authorized for Issuance Under Equity Compensation Plans
The following table gives information about our ordinary shares that may be issued upon the exercise of stock options and vesting of restricted
stock units, as applicable, under all of our existing equity compensation plans as of December 31, 2022, including the 2003 Share Option Plan
(the "2003 Plan"), the 2013 Share Option Plan (the "2013 Plan"), the 2015 Omnibus Incentive Plan (the "2015 Plan") and the Employee Share
Purchase Plan (the "ESPP"). Each of the 2003 Plan, the 2013 Plan, the 2015 Plan and the ESPP has been approved by the Company’s
shareholders.
Equity Compensation Plan Information
(a)
Number of Securities to
be Issued Upon Exercise
of Outstanding Options,
Warrants and Rights
(b)
Weighted Average
Exercise Price of
Outstanding
Options, Warrants
and Rights
(c)
Number of Securities
Remaining Available for
Future Issuance (Excludes
Securities Reflected in
Column (a))
14,163,823 $
—
14,163,823 $
23.12
—
23.12
25,499,056
—
25,499,056
Plan Category
Equity compensation plans approved by
shareholders
Equity compensation plans not approved by
shareholders
Total
ITEM 6. [RESERVED]
50
ITEM 7. MANAGEMENT’S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS
Management’s Discussion and Analysis of Financial Condition and Results of Operations ("MD&A") is intended to provide information to assist
you in better understanding and evaluating our financial condition and results of operations. We encourage you to read this MD&A in
conjunction with our consolidated financial statements and the notes thereto included in Part II, Item 8 of this Annual Report on Form 10-K. This
discussion contains forward-looking statements that involve risks and uncertainties. Please refer to the information under the heading
"Cautionary Note Regarding Forward-Looking Statements" elsewhere in this report. References to the words "we," "our," "us," and the
"Company" in this report refer to NovoCure Limited, including its consolidated subsidiaries.
Overview
We are a global oncology company with a proprietary platform technology called Tumor Treating Fields ("TTFields"), which are electric fields
that exert physical forces to kill cancer cells via a variety of mechanisms. Our key priorities are to drive commercial adoption of Optune and
Optune Lua, our commercial TTFields devices, and to advance clinical and product development programs intended to extend overall survival
in some of the most aggressive forms of cancer.
Optune is approved by the U.S. Food and Drug Administration ("FDA") under the Premarket Approval ("PMA") pathway for the treatment of
adult patients with newly diagnosed glioblastoma ("GBM") together with temozolomide, a chemotherapy drug, and for adult patients with GBM
following confirmed recurrence after chemotherapy as monotherapy treatment. We also have a CE certificate to market Optune for the
treatment of GBM in the European Union ("EU"), as well as approval or local registration in the United Kingdom ("UK"), Japan, Canada and
certain other countries. Optune Lua is approved by the FDA under the Humanitarian Device Exemption ("HDE") pathway to treatment malignant
pleural mesothelioma ("MPM") together with standard chemotherapies. We have also received CE certification in the EU and approval or local
registration to market Optune Lua in certain other countries. We market Optune and Optune Lua in multiple countries around the globe with the
majority of our revenues coming from the use of Optune in the U.S., Germany and Japan. We are actively evaluating opportunities to expand
our international footprint.
We believe the physical mechanisms of action behind TTFields therapy may be broadly applicable to solid tumor cancers. We recently
completed patient follow-up and announced top line results from our pivotal LUNAR study evaluating the use of TTFields in the treatment of
non-small cell lung cancer ("NSCLC") together with standard therapies. Patients treated with TTFields and standard therapies demonstrated a
statistically significant and clinically meaningful improvement in overall survival over standard therapies alone. The LUNAR study also showed a
statistically significant and clinically meaningful improvement in overall survival when patients were treated with TTFields and immune
checkpoint inhibitors, as compared to those treated with immune checkpoint inhibitors alone, and a positive trend in overall survival when
patients were treated with TTFields and docetaxel versus docetaxel alone. We expect to present full results of the LUNAR study at a future
medical conference.
In addition to the LUNAR study, we are conducting pivotal studies evaluating the use of TTFields in the treatment of ovarian cancer, brain
metastases from NSCLC ("brain metastases") and pancreatic cancer. We are also conducting a pivotal study testing the potential survival
benefit of initiating Optune concurrent with radiation therapy versus following radiation therapy in patients with newly diagnosed GBM.
We have one ongoing pilot study evaluating the use of TTFields in the treatment of stage 3 NSCLC and are designing several additional pilot
and pivotal studies in partnership with oncology leaders to further explore the capabilities of TTFields. We anticipate expanding our clinical
pipeline over time to study the safety and efficacy of TTFields for additional solid tumor indications and combinations with other cancer
treatment modalities.
The table below presents the current status of the ongoing clinical studies in our pipeline and anticipated timing of data.
51
Our therapy is delivered
through a medical device and we continue to advance our Products with the intention to extend survival and maintain quality of life for patients.
We have several product development programs underway that are designed to optimize TTFields delivery to the target tumor and enhance
patient ease of use. Our intellectual property portfolio contains hundreds of issued patents and numerous patent applications pending
worldwide. We believe we possess global commercialization rights to our Products in oncology and are well-positioned to extend those rights
into the future as we continue to find innovative ways to improve our Products.
In 2018, we granted Zai Lab (Shanghai) Co., Ltd. ("Zai") a license to commercialize Optune in China, Hong Kong, Macau and Taiwan ("Greater
China") under a License and Collaboration Agreement (the "Zai Agreement"). The Zai Agreement also establishes a development partnership
intended to accelerate the development of TTFields in multiple solid tumor cancer indications. For additional information, see Note 12 to the
Consolidated Financial Statements.
Impact of COVID-19
In March 2020, the World Health Organization (“WHO”) declared COVID-19 a global pandemic. Since the pandemic began, we have been
following the guidance of the WHO, the U.S. Centers for Disease Control and Prevention, and local health authorities in all of our active markets
and we have adjusted the way we conduct business to adapt to the evolving situation. The COVID-19 pandemic did not have a material impact
on our financial results throughout 2022. The pandemic has had and is having an impact on our day-to-day operations, which varies by region
based on factors such as geographical spread, stage of containment and recurrence of the pandemic in each region. We believe the prolonged
disruption caused by COVID-19 is resulting in increased volatility across global health care systems, such as fluctuations in patient volumes and
changes in patterns of care in certain regions, which is currently impacting and might continue to impact our business and clinical studies in the
future. For example, outside the U.S., localized lockdowns are causing disruptions in the ability to monitor clinical studies. TTFields is an
emerging modality in cancer care and requires significant educational effort to drive awareness and acceptance of our therapy. We have relied
heavily on virtual engagement to manage these educational efforts since the onset of the pandemic, which poses challenges to our ability to
effectively communicate and engage with our customers and partners around the world.
Given the aggressive nature of the cancers that we treat, we believe that the fundamental value proposition of the TTFields platform remains
unchanged. We continue to evaluate and plan for the potential effects of COVID-19 on our business moving forward. The extent to which the
COVID-19 pandemic may impact our business and clinical studies in the future will depend on further developments, which are highly uncertain
and cannot be predicted with confidence. The COVID-19 pandemic may also heighten many of the other risks described in our risk factors
disclosed in this Annual Report.
We view our operations and manage our business in one operating segment. Our net revenues were $537.8 million for the year ended
December 31, 2022, $535.0 million for the year ended December 31, 2021 and $494.4 million for the year ended December 31, 2020. Our net
loss was $92.5 million for the year ended December 31, 2022, net loss was $58.4 million for the year ended December 31, 2021 and net
income was $19.8 million for the year ended December 31, 2020. As of December 31, 2022, we had an accumulated deficit of $778.5 million.
52
Commentary on Results of Operations
Net revenues
Our revenues are primarily derived from patients using our Products in our active markets. We charge for treatment with our Products on a
monthly basis. Our potential net revenues per patient are determined by our ability to secure payment, the monthly fee we collect and the
number of months that the patient remains on therapy.
We also receive revenues pursuant to the Zai Agreement. For additional information regarding the Zai Agreement, see Note 12 to the
Consolidated Financial Statements.
Cost of revenues
We contract with third parties to manufacture our Products. Our cost of revenues is primarily comprised of the following:
•
•
•
disposable arrays;
depreciation expense for the field equipment, including the electric field generator used by patients; and
personnel and overhead costs such as facilities, freight and depreciation of property, plant and equipment associated with managing
our inventory, warehousing and order fulfillment functions.
Operating expenses
Our operating expenses consist of research, development and clinical studies, sales and marketing and general and administrative expenses.
Personnel costs are a significant component for each category of operating expenses and consist of wages, benefits and bonuses. Personnel
costs also include share-based compensation.
Research, development and clinical studies
Our research, development and clinical studies activity is focused on advancing TTFields through clinical studies across multiple solid tumor
types and improving the efficacy and usability of our devices. Research, development and clinical studies costs, including direct and allocated
expenses, are expensed as incurred and consist primarily of the following:
•
•
personnel costs for those employees involved in our preclinical and basic research, clinical development programs, clinical affairs,
product development and regulatory activities;
costs to conduct research, product development and clinical study activity through agreements with contract research organizations and
other third parties;
• manufacturing expenses associated with our Products, including durable components and disposable arrays, utilized in clinical studies
and other research;
•
•
•
costs associated with medical grants, publications, presentations and investigator-sponsored trials;
professional fees related to regulatory approvals and conformity assessment procedures; and
facilities, depreciation and other allocated expenses, which include direct and allocated expenses for rent and maintenance of facilities,
depreciation of leasehold improvements and equipment and laboratory and other supplies.
53
The following table summarizes our research, development and clinical study expenses by program for the years ended December 31, 2022,
2021 and 2020:
U.S. dollars in thousands
Preclinical and basic research
Clinical development programs:
LUNAR
INNOVATE - 3
METIS
PANOVA - 3
TRIDENT
Other clinical studies
Clinical administration
Product development
Clinical affairs
Other research and development costs (1)
Share based compensation
Research, development and clinical studies
Year ended December 31,
2022
2021
2020
$
16,922 $
15,580 $
12,079
6,905
9,494
8,480
22,185
12,162
5,524
22,690
15,323
19,891
35,719
30,790
206,085 $
9,069
17,708
7,056
15,026
12,588
4,634
19,764
15,248
24,486
32,547
27,597
201,303 $
8,261
14,190
5,147
7,033
3,709
2,764
13,158
9,710
21,058
16,776
18,125
132,010
$
(1) Other research, development and clinical study costs include regulatory affairs, quality assurance, intellectual property, product safety,
allocated facilities and other overhead costs.
We are committed to investing strategically to maximize the growth potential of the TTFields platform. We expect growth in our research and
development investments to continue into 2023 as we work to advance our pipeline programs and increase acceptance of Tumor Treating
Fields across the global oncology community.
Sales and marketing
Sales and marketing expenses consist primarily of personnel costs, travel, marketing and promotional activities, medical education, commercial
shipping and facilities costs. Over the next few years, we expect to continue to make significant expenditures associated with selling and
marketing our Products, primarily in connection with continued commercialization in North America, the EU and Japan for the treatment of our
approved indications.
General and administrative
General and administrative expenses consist primarily of personnel, professional fees and facilities costs. General and administrative personnel
costs include our executive, finance, human resources, information technology and legal functions. These costs also include our contributions to
support industry and patient groups. Our professional fees consist primarily of accounting, information technology, legal and other consulting
costs. We expect that general and administrative expenses will increase to support our growth. In addition, we incur significant legal and
accounting costs related to compliance with SEC rules and regulations, including the costs of achieving and maintaining compliance with
Section 404 of the Sarbanes-Oxley Act of 2002 and compliance with rules of the NASDAQ Stock Market, as well as insurance, investor
relations and other costs associated with being a public company.
Financial expenses, net
Financial expenses, net primarily consists of credit facility interest expense and related debt issuance costs, interest income from cash balances
and short-term investments and gains (losses) from foreign currency transactions. Our reporting currency is the U.S. dollar. We have historically
held substantially all of our cash balances in U.S. dollar denominated accounts to minimize the risk of translational currency exposure.
54
Critical accounting policies and estimates
In accordance with U.S. GAAP, in preparing our financial statements we must make estimates and assumptions that affect the reported
amounts of assets and liabilities, the disclosure of contingent assets and liabilities as of the date of the financial statements and the reported
amounts of net revenues and expenses during the reporting period. We develop and periodically change these estimates and assumptions
based on historical experience and on various other factors that we believe are reasonable under the circumstances. Actual results may differ
from these estimates.
The critical accounting policies requiring estimates, assumptions and judgments that we believe have the most significant impact on our
consolidated financial statements are described below.
Revenue recognition
In May 2014, the Financial Accounting Standards Board ("FASB") issued Accounting Standards Update ("ASU") 2014-09, Revenue from
Contracts with Customers (Topic 606) (ASU 2014-09), an updated standard on revenue recognition and issued subsequent amendments to the
initial guidance in March 2016, April 2016, May 2016 and December 2016 within ASU 2016-08, 2016-10, 2016-12 and 2016-20, respectively.
The Company adopted the standard effective January 1, 2018 using the modified retrospective method for all contracts. The reported results for
2018 and thereafter reflect the application of Accounting Standards Codification ("ASC") 606 guidance. The amount of revenue recognized
reflects the consideration to which we expect to be entitled to receive in exchange for our Products. For additional information, see Note 2(m) to
the Consolidated Financial Statements.
We also receive revenues pursuant to the Zai Agreement. For additional information regarding the Zai Agreement, see Note 12 to the
Consolidated Financial Statements.
Share-based compensation
Under the FASB's ASC 718, Compensation-Stock Compensation, we measure and recognize compensation expense for share options granted
to our employees and directors and for our ESPP based on the fair value of the awards on the date of grant. The fair value of share options is
estimated at the date of grant using the Black-Scholes option pricing model and for market condition awards we also use the Monte-Carlo
simulation model. Both models requires management to apply judgment and make estimates, including:
•
•
•
•
beginning with the first quarter of 2022, the computation of expected volatility is based on the historical volatility the Company's shares,
beginning with the first quarter of 2021 and prior to the first quarter of 2022, the computation of expected volatility is based on a
combination of actual historical share price volatility of comparable publicly-traded companies and the historical volatility the Company's
shares. Prior to the first quarter of 2021, due to the lack of sufficient historical information for the Company, the computation was based
on actual historical volatility of comparable publicly-traded companies;
beginning with the first quarter of 2021, the expected term of options granted is calculated using the Company's historical and future
exercise behavior. Prior to the first quarter of 2021, it was calculated using the average between the vesting period and the contractual
term to the expected term of the options in effect at the time of grant;
the risk-free interest rate, which we base on the yield curve of U.S. Treasury securities with periods commensurate with the expected
term of the options being valued; and
the expected dividend yield, which we estimate to be zero based on the fact that we have never paid cash dividends and have no
present intention to pay cash dividends.
For information about our ESPP, see Note 14 to the Consolidated Financial Statements.
We recognize share-based compensation costs only for those shares expected to vest over the requisite vesting period of the award, which is
generally the option vesting term of four years, using the accelerated method.
We recognize compensation costs for the value of performance stock units ("PSU") over the performance period when the vesting conditions
become probable in accordance with ASC 718.
55
The table below summarizes the assumptions that were used to estimate the fair value of the options granted to employees during the periods
presented:
Expected term (years)
Expected volatility
Risk-free interest rate
Dividend yield
Year ended December 31,
2022
5.33-5.83
60%-62%
1.58%-4.23%
0.00%
2021
5.50-6.00
60%-63%
0.78%-1.27%
0.00%
2020
5.50-6.00
54%-56%
0.30%-0.86%
0.00%
If any of the assumptions used in the Black-Scholes option pricing model change significantly, share-based compensation for future awards may
differ materially from the awards granted previously.
So long as our ordinary shares are publicly traded in a liquid market, we will rely on the daily trading price of our ordinary shares when we
estimate the fair value of options granted.
We incurred share-based compensation expense of $107.0 million, $94.9 million and $75.7 million during the years ended December 31, 2022,
2021 and 2020, respectively. As of December 31, 2022, we have unrecognized compensation expense of $125.6 million, which is expected to
be recognized over a weighted average period of approximately 2.38 years. We expect to continue to grant equity awards in the future, and to
the extent that we do, our recognized share-based compensation expense will likely increase. For additional information, see Note 14 to the
Consolidated Financial Statements.
Long-lived assets
Property and equipment and field equipment are stated at cost, net of accumulated depreciation. Depreciation is calculated using the straight-
line method over the estimated useful life of the relevant asset. We make estimates of the useful life of our property and equipment and field
equipment, based on similar assets purchased in the past and our historical experience with such similar assets, in order to determine the
depreciation expense to be recorded for each reporting period.
Our field equipment consists of equipment being utilized under rental agreements accounted for on a monthly basis as an operating lease, as
well as service pool equipment. Service pool equipment is equipment owned and maintained by us that is swapped for equipment that needs
repair or maintenance by us while being used by a patient. We record a provision for any excess, lost or damaged equipment when warranted
based on an assessment of the equipment.
We assess impairment whenever events or changes in circumstances indicate that the carrying amount of the asset is impaired or the
estimated useful life is no longer appropriate. Circumstances such as changes in technology or in the way an asset is being used may trigger an
impairment review. For additional information, see Notes 2(i) and 2(j) to the Consolidated Financial Statements.
Inventories
Inventories are stated at the lower of cost or net realizable value. We regularly evaluate the ability to realize the value of inventory. If the
inventories are deemed damaged, if actual demand for our devices declines, or if market conditions are less favorable than those projected,
inventory write-offs may be required. For additional information, see Note 2(h) to the Consolidated Financial Statements.
Income taxes
As part of the process of preparing our consolidated financial statements, we are required to calculate our income taxes based on taxable
income by jurisdiction. We make certain estimates and judgments in determining our income taxes, including assessment of our uncertain tax
positions, for financial statement purposes. Significant changes to these estimates may result in an increase or decrease to our tax provision in
the subsequent period when such a change in estimate occurs.
Uncertain tax positions are based on estimates and assumptions that have been deemed reasonable by management. Our estimates of
unrecognized tax benefits and potential tax benefits may not be representative of actual outcomes.
For additional information, see Note 13 to the Consolidated Financial Statements.
56
Results of operations
The following discussion provides an analysis of our results of operations and reasons for material changes therein for 2022 as compared to
2021. See "Results of Operations" in Part II, Item 7, Management's Discussion and Analysis of Financial Condition and Results of Operations in
the Company's 2021 Annual Report on Form 10-K, filed with the SEC on February 24, 2022, for an analysis of the 2021 results as compared to
2020.
The following table sets forth our consolidated statements of operations data:
U.S. dollars in thousands, except share and per share data
Net revenues
Cost of revenues
Gross profit
Operating costs and expenses:
Research, development and clinical studies
Sales and marketing
General and administrative
Total operating costs and expenses
Operating income (loss)
Financial (expenses) income, net
Income (loss) before income tax
Income tax
Net income (loss)
Basic net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing basic net income
(loss) per share
Diluted net income (loss) per ordinary share
Year ended December 31,
2022
2021
2020
537,840 $
114,867
422,973
206,085
173,658
132,753
512,496
(89,523)
7,677
(81,846)
10,688
(92,534) $
535,031 $
114,877
420,154
201,303
137,057
126,127
464,487
(44,333)
(7,742)
(52,075)
6,276
(58,351) $
494,366
106,501
387,865
132,010
118,017
107,437
357,464
30,401
(12,299)
18,102
(1,706)
19,808
(0.88) $
(0.56) $
0.20
104,660,476
103,433,274
100,930,866
(0.88) $
(0.56) $
0.18
$
$
$
$
Weighted average number of ordinary shares used in computing diluted net income
(loss) per share
104,660,476
103,433,274
108,877,648
The following table details the share-based compensation expense included in costs and expenses:
U.S. dollars in thousands
Cost of revenues
Research, development and clinical studies
Sales and marketing
General and administrative
Total share-based compensation expense
Key performance indicators
2022
Year ended December 31,
2021
2020
$
$
4,690 $
30,790
28,826
42,649
106,955 $
3,471 $
27,597
22,673
41,159
94,900 $
2,221
18,125
17,672
37,703
75,721
We believe certain commercial operating statistics are useful to investors in evaluating our commercial business as they help investors evaluate
and compare the adoption of our Products from period to period. The number of active patients on therapy is our principal revenue driver. An
"active patient" is a patient who is receiving treatment under a commercial prescription order as of the measurement date, including patients
who may be on a temporary break from treatment and who plan to resume treatment in less than 60 days. Prescriptions are a leading indicator
of
57
demand. A "prescription received" is a commercial order for Optune or Optune Lua that is received from a physician certified to treat patients
with our Products for a patient not previously on Optune or Optune Lua. Orders to renew or extend treatment are not included in this total.
The
following
table
includes certain commercial operating statistics
for and as of
the end of
the periods presented.
Operating statistics
Active patients at period end
North America (1)
EMEA:
Germany
Other EMEA
Japan
Total
Prescriptions received in period
North America (1)
EMEA:
Germany
Other EMEA
Japan
Total
2022
December 31,
2021
2020
2,191
467
403
369
3,430
2,272
563
445
307
3,587
2,193
562
391
265
3,411
Year ended December 31,
2022
2021
2020
3,823
830
495
381
5,529
3,781
924
521
436
5,662
3,871
910
467
365
5,613
(1) North America includes data for the United States and Canada for the second half of 2021 and all of 2022, and the United States only for the
first half of 2021 and 2020.
Worldwide, there were 7 active MPM patients on therapy as of December 31, 2022 and 33 MPM prescriptions were received in the year ended
December 31, 2022.
Year ended December 31, 2022 compared to year ended December 31, 2021
Net revenues
Year ended December 31,
2022
2021
Change
% Change
$
537,840 $
535,031 $
2,809
1 %
Net revenues. Net revenues increased by $2.8 million, or 1%, to $537.8 million for the year ended December 31, 2022 from $535.0 million for
the year ended December 31, 2021. This was primarily due to an increase in collections from previously denied and appealed claims in the U.S.
offset by a reduction in German approval rates as a result of updated coverage criteria, and the impact of foreign exchange rate fluctuations.
In 2022, we recorded $32 million in revenue from the successful appeal of previously denied claims for Medicare fee-for-service beneficiaries
billed prior to established coverage. We continue to actively appeal and pursue previously denied claims for beneficiaries billed prior to
established coverage, but the cadence and amount of these Medicare payments are impossible to predict. We believe collections from those
claims which were most accessible were largely exhausted in 2022 and the remaining outstanding claims will take time to collect. As a result,
we expect future net revenue to more closely reflect core drivers of net revenue: number of active patients on therapy, duration of therapy, and
net realized price per month.
Cost of revenues
Year ended December 31,
2022
2021
Change
% Change
$
114,867 $
114,877 $
(10)
— %
Cost of revenues. Our cost of revenues were $114.9 million for the year ended December 31, 2022, virtually unchanged from $114.9 million for
the year ended December 31, 2021. Excluding sales to Zai, cost of revenues per
58
active patient per month were $2,481 for the year ended December 31, 2022 compared to $2,474 for the year ended December 31, 2021.
Cost of revenues per active patient is calculated by dividing the cost of revenues for the year less product sales to Zai for the year by the
average of the active patients at the end of the each quarter in the current year and the end of the year active patients from the prior year. This
annual figure is then divided by twelve to estimate the monthly cost of revenues per active patient. Sales to Zai are deducted because they are
made at burdened cost and in anticipation of future royalties from Zai, and Zai patient counts are not included in our active patient population.
Product's cost sold to Zai totaled $11.1 million for the year ended December 31, 2022 compared to $11.3 million for the year ended
December 31, 2021.
Gross margin was 79% for the year ended December 31, 2022 and 79% for the year ended December 31, 2021. Our gross margins are
affected by our ability to achieve efficiencies of scale, the number of active patients and array usage within a given period, product mix, and
product modifications. Increased product sales to Zai have the effect of tempering gross margin, as those products are sold at cost.
Operating expenses:
Research, development and clinical studies
Sales and marketing
General and administrative
Total operating expenses
2022
2021
Change
% Change
Year ended December 31,
$
$
206,085 $
173,658
132,753
512,496 $
201,303 $
137,057
126,127
464,487 $
4,782
36,601
6,626
48,009
2 %
27 %
5 %
10 %
Research, development and clinical studies expenses. Research, development and clinical studies expenses increased by $4.8 million, or 2%,
to $206.1 million for the year ended December 31, 2022 from $201.3 million for the year ended December 31, 2021. The change is driven by an
increase of $4.8 million in product development and regulatory affairs expenses.
We expect growth in our research and development investments to continue into 2023 as we work to advance our pipeline programs and
increase acceptance of TTFields across the global oncology community. We balance our investments in research and development with our
organizational capacity to effectively execute our strategic initiatives.
Sales and marketing expenses. Sales and marketing expenses increased by $36.6 million, or 27%, to $173.7 million for the year ended
December 31, 2022 from $137.1 million for the year ended December 31, 2021. The change primarily was due to increases of $22.7 million,
$2.9 million and $2.9 million in marketing, health policy, and sales expenses, respectively, which are intended to increase awareness and
acceptance of TTFields in our approved indications and enhance our commercial capabilities in anticipation of potential future approvals in new
indications. Additionally, we are investing in market access capabilities in order to evaluate opportunities, identify optimal access pathways, and
successfully gain reimbursement in new geographies.
General and administrative expenses. General and administrative expenses increased by $6.6 million, or 5%, to $132.8 million for the year
ended December 31, 2022 from $126.1 million for the year ended December 31, 2021. The change primarily was due to increases of $5.0
million and $2.5 million in information technology infrastructure and supply chain optimization, respectively, and offset by a decrease in
expenses associated with personnel costs and professional services.
Financial (expenses) income, net
Year ended December 31,
2022
2021
Change
% Change
$
7,677 $
(7,742) $
15,419
(199)%
Financial (expenses) income, net. Financial expenses, net, decreased by $15.4 million, or 199%, to $7.7 million income for the year ended
December 31, 2022 from $7.7 million expense for the year ended December 31, 2021. In 2022, financial income was primary driven by interest
income and amortization of investment premiums on our cash, cash equivalents and short term investments. In 2021, financial expenses were
primarily driven by foreign exchange expenses.
59
Income tax
Year ended December 31,
2022
2021
Change
% Change
$
10,688 $
6,276 $
4,412
70 %
Income taxes. Income tax expenses increased by $4.4 million, or 70%, resulting in a tax expense of $10.7 million for the year ended
December 31, 2022 compared to a tax expense of $6.3 million for the year ended December 31, 2021. The increase was primarily due to an
increase in income before taxes in the U.S.
Non-GAAP financial measures
We also measure our performance based upon a non-U.S. GAAP measurement of earnings before interest, taxes, depreciation, amortization
and shared-based compensation ("Adjusted EBITDA"). We believe Adjusted EBITDA is useful to investors in evaluating our operating
performance because it helps investors evaluate and compare the results of our operations from period to period by removing the impact of
earnings attributable to our capital structure, tax rate and material non-cash items, specifically share-based compensation.
We calculate Adjusted EBITDA as operating income before financial expenses and income taxes, net of depreciation, amortization and share-
based compensation. The following table reconciles net loss (which is the most directly comparable U.S. GAAP operating performance
EBITDA.
measure)
Adjusted
to
Net income (loss)
Add: Income tax
Add: Financial expenses (income), net
Add: Depreciation and amortization
EBITDA
Add: Share-based compensation
Adjusted EBITDA
Year ended December 31,
2022
2021
2020
$
$
$
(92,534) $
10,688
(7,677)
10,624
(78,899) $
106,955
28,056 $
(58,351) $
6,276
7,742
10,251
(34,082) $
94,900
60,818 $
19,808
(1,706)
12,299
9,150
39,551
75,721
115,272
Adjusted EBITDA decreased by $32.8 million, or 54%, to $28.1 million for the year ended December 31, 2022 from $60.8 million for the year
ended December 31, 2021. This decrease was primarily driven by an increase in sales and marketing expenses intended to increase
awareness and acceptance of TTFields in our approved indications, enhance our commercial capabilities in anticipation of potential future
approvals in new indications, and expand our international footprint.
Liquidity and capital resources
We have incurred significant losses and cumulative negative cash flows from operations with only limited and intermittent operating profits since
our founding in 2000. As of December 31, 2022, we had an accumulated deficit of $778.5 million. To date, we primarily have financed our
operations through the issuance and sale of equity and the proceeds from long-term loans.
At December 31, 2022, we had $115.3 million in cash and cash equivalents and $854.1 million in short-term investments. At December 31,
2022, our cash, cash equivalents and short-term investments totaled $969.4 million, an increase of $31.7 million compared to $937.7 million at
December 31, 2021. The increase was primarily due to net cash generated by operating activities and the exercise of options.
We believe our cash, cash equivalents and short-term investments as of December 31, 2022 are sufficient for our operations for at least the
next 12 months based on our existing business plan and our ability to control the timing of significant expense commitments. We expect that our
research, development and clinical expenses, sales and marketing expenses and general and administrative expenses will continue to increase
over the next several years and may outpace our gross profit. As a result, we may need to raise additional capital to fund our operations.
60
The following summary of our cash flows for the periods indicated has been derived from our consolidated financial statements, which are
included elsewhere in this Annual Report:
U.S. dollars in thousands
Net cash provided by (used in) operating activities
Net cash provided by (used in) investing activities
Net cash provided by (used in) financing activities
Effect of exchange rate changes on cash and cash equivalents
Net increase (decrease) in cash, cash equivalents and restricted cash
Operating activities
Year ended December 31,
2022
2021
2020
$
$
30,788 $
(139,957)
15,491
(97)
(93,775) $
82,756 $
(144,834)
25,702
(188)
(36,564) $
99,148
(472,847)
440,209
247
66,757
Net cash provided by operating activities primarily represents our net income for the periods presented. Adjustments to net income for non-cash
items include share-based compensation, depreciation, amortization and asset write-downs. Operating cash flows are also impacted by
changes in operating assets and liabilities, principally trade payables, deferred revenues, other payables, prepaid expenses, inventory and
trade receivables.
Net cash provided by operating activities was $30.8 million for the year ended December 31, 2022 compared to $82.8 million for the year ended
December 31, 2021 a decrease of $ 52.0 million. The decrease in net cash provided by operating activities was primarily driven by a $43.2
million increase in sales, marketing, general and administrative expenses to enhance our capabilities in anticipation of potential future approvals
of new indications and entry into potential new markets, and a $4.8 million increase in research and development expenses. In addition, finance
income increased by $15.4 million and tax expenses increased by $ 4.4 million, offsetting a $2.8 million increase in gross profit and a $17.0
million change in working capital.
Upcoming use of cash in operations will include payments in the normal course of business of $42.1 million in purchase obligations with certain
of our suppliers, primarily for the purchase of Product components along with other commitments to purchase goods or services. These
amounts include approximately $30.6 million of commitments with three major suppliers. We make such commitments through a combination of
purchase orders, supplier contracts, and open orders based on projected demand information. We also have employment agreements with
certain employees that require the funding of a specific level of payments if certain events, such as a change in control or termination without
cause, occur. In the course of normal business operations, we also have agreements with contract service providers to assist in the
performance of our research and development (including clinical studies) and manufacturing activities. We could also enter into additional
collaborative research, contract research, manufacturing and supplier agreements in the future, which may require up-front payments and even
long-term commitments of cash.
Investing activities
Our investing activities primarily consist of capital expenditures to purchase property and equipment and field equipment, as well as
investments in and redemptions of our short-term investments.
Net cash used in investing activities was $140.0 million for the year ended December 31, 2022 compared to net cash used in investing activities
of $144.8 million for the year ended December 31, 2021. The net cash used in investing activities for 2022 was primarily attributable to $21.4
million in property and equipment and the net purchase of $118.6 million in short-term investments. The net cash used in investing activities for
2021 was primary attributable to $24.2 million in property and equipment and the net purchase of $120.7 million in short-term investments.
Financing activities
To date, our primary financing activities have been the sale of equity and the proceeds from long-term loans.
Net cash provided by financing activities was $15.5 million for the year ended December 31, 2022 compared to $25.7 million for the year ended
December 31, 2021. The net cash provided by financing activities for 2022 was primarily attributable to $10.3 million in proceeds from the
exercise of options and $5.2 million in proceeds from the issuance of shares pursuant to the ESPP. The net cash provided by financing activities
for 2021 was primarily attributable to $21.2 million in proceeds from the exercise of options and $4.5 million in proceeds from the issuance of
shares pursuant to the ESPP.
61
Convertible Notes
On November 5, 2020, we issued $575.0 million aggregate principal amount of 0% Convertible Senior Notes due 2025 (the “Notes”). The net
proceeds from the offering were approximately $558.4 million. We intend to use the net proceeds to further advance our clinical and product
development programs and to invest in associated pre-commercial and commercial activities, as well as for general corporate purposes.
The Notes are senior unsecured obligations. The Notes do not bear regular interest, and the principal amount of the Notes will not accrete.
Special interest, if any, payable in accordance with the terms of the Notes will be payable in cash semi-annually in arrears on May 1 and
November 1 of each year, beginning on May 1, 2021. The Notes mature on November 1, 2025, unless earlier repurchased, redeemed or
converted.
The Notes are convertible at an initial conversion rate of 5.9439 ordinary shares per $1,000 principal amount of the Notes, which is equivalent
to an initial conversion price of approximately $168.24 per ordinary share. In January 2021, we irrevocably elected to settle all conversions of
Notes by a combination of cash and our ordinary shares and that the cash portion per $1,000 principal amount of Notes for all conversion
settlements shall be $1,000, Accordingly, from and after the date of the election, upon conversion of any Notes, holders of Notes will receive,
with respect to each $1,000 principal amount of Notes converted, cash in an amount up to $1,000 and the balance of the conversion value, if
any, in our ordinary shares
The Notes are not redeemable prior to November 6, 2023, except in the event of certain tax law changes. We may redeem for cash all or any
portion of the Notes, at our option, on or after November 6, 2023 if the last reported sale price of our ordinary shares has been at least 130% of
the conversion price then in effect for at least 20 trading days (whether or not consecutive) during any 30 consecutive trading day period
(including the last trading day of such period) ending on, and including, the trading day immediately preceding the date on which we provide
notice of redemption at a redemption price equal to 100% of the principal amount of the Notes to be redeemed, plus accrued and unpaid special
interest, if any, to, but excluding, the redemption date. No sinking fund is provided for the Notes.
Prior to the close of business on the business day immediately preceding August 1, 2025, the Notes are convertible at the option of the holders
only upon the satisfaction of certain conditions and during certain periods and if we exercise our right to redeem the Notes as permitted or
required by the indenture. On or after August 1, 2025 until the close of the business on the business day immediately preceding the maturity
date, holders may convert all or any portion of their Notes at the conversion rate at any time irrespective of the foregoing conditions.
Term loan credit facility
On November 6, 2020, we entered into a new three-year $150.0 million senior secured revolving credit facility with a syndicate of relationship
banks (the "2020 Credit Facility"). We may, subject to certain conditions and limitations, increase the revolving credit commitments outstanding
under the 2020 Credit Facility or incur new incremental term loans in an aggregate principal amount not to exceed $250.0 million in total.
The commitments under the 2020 Credit Facility are guaranteed by certain of our subsidiaries and secured by a first lien on our and certain of
our subsidiaries’ assets. Outstanding loans will bear interest per annum at a sliding scale based on the our secured leverage ratio from 2.75%
to 3.25% above the applicable interbank borrowing reference rate for the currency in which the loan is denominated. Additionally, the 2020
Credit Facility contains a fee for the unused revolving credit commitments at a sliding scale based on our secured leverage ratio from 0.35% to
0.45%. The 2020 Credit Facility contains financial covenants requiring maintenance of a minimum fixed charge coverage ratio and specifying a
maximum senior secured net leverage ratio, as well as customary events of default which include a change of control.
As of December 31, 2022, we had no outstanding balance borrowed under the 2020 Credit Facility.
On February 17, 2023, we gave irrevocable notice to the administrative agent under the 2020 Credit Facility that we terminated all
commitments, effective February 22, 2023. This effectively terminated the 2020 Credit Facility, as our ability to borrow and our obligations to
comply with all covenants ended on such date. The liens and guaranties in favor of the lenders are released. There are no early termination
fees payable and as of February 22, 2023 we had no outstanding balance borrowed under the 2020 Credit Facility.
2020 Prepayment of 2018 term loan
In 2018, we entered into a Loan and Security Agreement ("2018 Loan Agreement") pursuant to which we borrowed a term loan in the aggregate
principal amount of $150 million (the "2018 Credit Facility"). The term loan, which was drawn in full upon execution of the 2018 Loan
Agreement, bore interest at 9.0% per annum, payable quarterly in arrears. In 2020, we terminated the 2018 Credit Facility and prepaid the
principal amount in full. The prepayment
62
included $150 million in principal repayment and $3.0 million in prepayment premium, plus accrued and unpaid interest and expenses payable
through the payoff date.
ITEM 7A. QUANTITATIVE AND QUALITATIVE DISCLOSURES ABOUT MARKET RISK
We are exposed to various market risks in the ordinary course of our business. Market risk represents the risk of loss that may impact our
financial position due to adverse changes in financial market prices and rates. Our market risk exposure is primarily a result of fluctuations in
interest rates and foreign currency exchange rates. We do not hold or issue financial instruments for trading purposes. There were no material
quantitative changes in our market risk exposures between the year ended December 31, 2022 and the year ended December 31, 2021.
Interest rate sensitivity
Our exposure to market risk for changes in interest rates relates primarily to our investment portfolio. Our cash, cash equivalents and short-term
investment accounts as of December 31, 2022 totaled $969.4 million and consist of cash, cash equivalents and short-term investments with
maturities of less than one year from the date of purchase. Our primary exposure to market risk is interest income sensitivity, which is affected
by changes in the general level of the interest rates in the United States. We are subject to interest rate fluctuation exposure through our
investment in money market instruments which bear a variable interest rate. However, because of portfolio diversification, the short-term nature
of the instruments in our portfolio and our intent to hold non-money market instruments to maturity, a 10% change in market interest rates would
not be expected to have a material impact on our financial condition or our results of operations.
Foreign currency exchange risk
Our consolidated results of operations and cash flow are subject to fluctuations due to changes in foreign currency exchange rates. All of our
revenues are generated in the local currency for commercial markets. Our expenses are generally denominated in the currencies in which our
operations are located, which is primarily in the United States, Switzerland, Germany, Israel and Japan. Our consolidated results of operations
and cash flows are, therefore, subject to fluctuations due to changes in foreign currency exchange rates and may be adversely affected in the
future due to changes in foreign exchange rates. The effect of a hypothetical 10% change in foreign currency exchange rates applicable to our
business would not have a material impact on our historical consolidated financial statements. We do not hedge our foreign currency exchange
risk.
63
ITEM 8. FINANCIAL STATEMENTS
NovoCure Limited
Index to consolidated financial statements
Report of Independent Registered Public Accounting Firm (PCAOB ID Number 1281)
Consolidated Balance Sheets as of December 31, 2022 and 2021
Consolidated Statements of Operations for the years ended December 31, 2022, 2021 and 2020
Consolidated Statements of Comprehensive Income (Loss) for the years ended December 31, 2022, 2021 and 2020
Statements of Changes in Shareholders’ Equity for the years ended December 31, 2022, 2021 and 2020
Consolidated Statements of Cash Flows for the years ended December 31, 2022, 2021 and 2020
Notes to Consolidated Financial Statements
Page
65
68
70
71
72
73
75
64
Report of Independent Registered Public Accounting Firm
To the Shareholders and the Board of Directors of NovoCure Limited
Opinion on the Financial Statements
We have audited the accompanying consolidated balance sheets of NovoCure Limited and subsidiaries (the Company) as of December 31,
2022 and 2021, the related consolidated statements of operations, comprehensive income (loss), changes in shareholders’ equity and cash
flows for each of the three years in the period ended December 31, 2022 and the related notes (collectively referred to as the "consolidated
financial statements"). In our opinion, the consolidated financial statements present fairly, in all material respects, the financial position of the
Company at December 31, 2022 and 2021, and the results of its operations and its cash flows for each of the three years in the period ended
December 31, 2022, in conformity with U.S. generally accepted accounting principles.
We also have audited, in accordance with the standards of the Public Company Accounting Oversight Board (United States) ("PCAOB"), the
Company's internal control over financial reporting as of December 31, 2022, based on criteria established in Internal Control-Integrated
Framework issued by the Committee of Sponsoring Organizations of the Treadway Commission (2013 framework) and our report dated
February 23, 2023 expressed an unqualified opinion thereon.
Basis for Opinion
These financial statements are the responsibility of the Company’s management. Our responsibility is to express an opinion on the Company’s
financial statements based on our audits. We are a public accounting firm registered with the PCAOB and are required to be independent with
respect to the Company in accordance with the U.S. federal securities laws and the applicable rules and regulations of the Securities and
Exchange Commission and the PCAOB.
We conducted our audits in accordance with the standards of the PCAOB. Those standards require that we plan and perform the audit to obtain
reasonable assurance about whether the financial statements are free of material misstatement, whether due to error or fraud. Our audits
included performing procedures to assess the risks of material misstatement of the financial statements, whether due to error or fraud, and
performing procedures that respond to those risks. Such procedures included examining, on a test basis, evidence regarding the amounts and
disclosures in the financial statements. Our audits also included evaluating the accounting principles used and significant estimates made by
management, as well as evaluating the overall presentation of the financial statements. We believe that our audits provide a reasonable basis
for our opinion.
Critical Audit Matter
The critical audit matter communicated below is a matter arising from the current period audit of the financial statements that was
communicated or required to be communicated to the audit committee and that: (1) relates to accounts or disclosures that are material to the
consolidated financial statements and (2) involved our especially challenging, subjective or complex judgments. The communication of a critical
audit matter does not alter in any way our opinion on the consolidated financial statements, taken as a whole, and we are not, by
communicating the critical audit matter below, providing a separate opinion on the critical audit matter or on the accounts or disclosures to
which it relates.
65
Revenue recognition – Measuring variable consideration
Description of the Matter
As per the Company's consolidated statements of operations, the net revenues recognized during the fiscal year
of 2022 amounted to a sum of $538 million, which included variable consideration estimates. As described in Note
2 to the consolidated financial statements, the transaction price is determined based on the consideration to which
the Company will be entitled to in exchange for providing Optune solution. The company provides certain patients
with implicit price concessions, which results in variable consideration. According to historical records, the
Company expects to receive, in aggregate for a given portfolio, less than the gross revenue net of explicit
discounts.
How We Addressed the
Matter in Our Audit
Auditing the Company's measurement of variable consideration involved challenging judgment because the
calculation involves uncertainty and subjective management assumptions about estimates of expected price
concessions. The implicit discount includes both an estimate of claims that will pay at an amount less than billed
and an estimate of claims that will not pay within a given time horizon. The implicit discount adjustments to the
transaction price are due to concessions, not collectability concerns driven by payer credit risk.
We obtained an understanding, evaluated the design and tested the operating effectiveness of internal controls
over the Company's process to calculate variable consideration, including the underlying assumptions about
estimates of expected price concessions.
Our audit procedures included, among others, evaluating the methodology used, analyzing the significant
assumptions discussed above, and testing the accuracy and completeness of the underlying data used in
management's calculation. This included testing inputs of the calculation by reconciliation of the data between the
various information systems performing independent recalculation of the Company's estimate and evaluating the
historical accuracy of management's estimates by comparing such estimates to subsequent actual results.
KOST FORER GABBAY & KASIERER
A Member of Ernst & Young Global
We have served as the Company‘s auditor since 2003.
Tel-Aviv, Israel
February 23, 2023
66
Report of Independent Registered Public Accounting Firm
To the Shareholders and the Board of Directors of NovoCure Limited
Opinion on Internal Control over Financial Reporting
We have audited NovoCure Limited and subsidiaries' internal control over financial reporting as of December 31, 2022, based on criteria
established in Internal Control–Integrated Framework issued by the Committee of Sponsoring Organizations of the Treadway Commission
(2013 framework) (the COSO Criteria). In our opinion, NovoCure Limited and subsidiaries (the Company) maintained, in all material respects,
effective internal control over financial reporting as of December 31, 2022, based on the COSO criteria.
We also have audited, in accordance with the standards of the Public Company Accounting Oversight Board (United States) (PCAOB), the
consolidated balance sheets of the Company as of December 31, 2022 and 2021, the related consolidated statements of operations,
comprehensive income (loss) changes in shareholders’ equity and cash flows for each of the three years in the period ended December 31,
2022 and the related notes, and our report dated February 23, 2023 expressed an unqualified opinion thereon.
Basis for Opinion
The Company’s management is responsible for maintaining effective internal control over financial reporting and for its assessment of the
effectiveness of internal control over financial reporting included in the accompanying Management's Annual Report on Internal Control over
Financial Reporting. Our responsibility is to express an opinion on the Company’s internal control over financial reporting based on our audit.
We are a public accounting firm registered with the PCAOB and are required to be independent with respect to the Company in accordance
with the U.S. federal securities laws and the applicable rules and regulations of the Securities and Exchange Commission and the PCAOB.
We conducted our audit in accordance with the standards of the PCAOB. Those standards require that we plan and perform the audit to obtain
reasonable assurance about whether effective internal control over financial reporting was maintained in all material respects.
Our audit included obtaining an understanding of internal control over financial reporting, assessing the risk that a material weakness exists,
testing and evaluating the design and operating effectiveness of internal control based on the assessed risk, and performing such other
procedures as we considered necessary in the circumstances. We believe that our audit provides a reasonable basis for our opinion.
Definition and Limitations of Internal Control Over Financial Reporting
A company’s internal control over financial reporting is a process designed to provide reasonable assurance regarding the reliability of financial
reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles. A
company’s internal control over financial reporting includes those policies and procedures that (1) pertain to the maintenance of records that, in
reasonable detail, accurately and fairly reflect the transactions and dispositions of the assets of the company; (2) provide reasonable assurance
that transactions are recorded as necessary to permit preparation of financial statements in accordance with generally accepted accounting
principles, and that receipts and expenditures of the company are being made only in accordance with authorizations of management and
directors of the company; and (3) provide reasonable assurance regarding prevention or timely detection of unauthorized acquisition, use, or
disposition of the company’s assets that could have a material effect on the financial statements.
Because of its inherent limitations, internal control over financial reporting may not prevent or detect misstatements. Also, projections of any
evaluation of effectiveness to future periods are subject to the risk that controls may become inadequate because of changes in conditions, or
that the degree of compliance with the policies or procedures may deteriorate.
KOST FORER GABBAY & KASIERER
A Member of Ernst & Young Global
Tel-Aviv, Israel
February 23, 2023
67
NovoCure Limited and subsidiaries
Consolidated balance sheets
U.S. dollars in thousands
Assets
Current assets:
Cash and cash equivalents
Short-term investments
Restricted cash
Trade receivables, net
Receivables and prepaid expenses
Inventories
Total current assets
Long-term assets:
Property and equipment, net
Field equipment, net
Right-of-use assets
Other long-term assets
Total long-term assets
Total assets
The accompanying notes are an integral part of the consolidated financial statements.
68
December 31,
2022
2021
$
$
115,326 $
854,099
508
86,261
25,959
29,376
1,111,529
32,678
12,684
23,596
11,161
80,119
1,191,648 $
208,802
728,898
807
93,567
17,025
24,427
1,073,526
22,693
12,923
18,267
12,086
65,969
1,139,495
NovoCure Limited and subsidiaries
Consolidated balance sheets
U.S. dollars in thousands, except share and per share data
Liabilities and shareholders’ equity
Current liabilities:
Trade payables
Other payables, lease liabilities and accrued expenses
Total current liabilities
Long-term liabilities:
Long-term debt, net
Deferred revenues
Long term leases
Employee benefit liabilities
Other long-term liabilities
Total long-term liabilities
Total liabilities
Commitments and contingencies
Shareholders’ equity:
Share capital -
Ordinary shares - No par value, Unlimited shares authorized; Issued and outstanding: 105,049,411
shares and 103,971,263 shares at December 31, 2022 and December 31, 2021 respectively;
Additional paid-in capital
Accumulated other comprehensive income (loss)
Retained earnings (accumulated deficit)
Total shareholders’ equity
Total liabilities and shareholders’ equity
The accompanying notes are an integral part of the consolidated financial statements.
69
December 31,
2022
2021
$
85,197 $
73,580
158,777
565,509
2,878
18,762
4,404
148
591,701
750,478
72,600
70,002
142,602
562,216
6,477
12,997
4,543
166
586,399
729,001
—
1,222,063
(2,433)
(778,460)
441,170
1,191,648 $
—
1,099,589
(3,169)
(685,926)
410,494
1,139,495
$
NovoCure Limited and subsidiaries
Consolidated statements of operations
U.S. dollars in thousands, except share and per share data
Net revenues
Cost of revenues
Gross profit
Operating costs and expenses:
Research, development and clinical studies
Sales and marketing
General and administrative
Total operating costs and expenses
Operating income (loss)
Financial (expenses) income, net
Income (loss) before income taxes
Income tax
Net income (loss)
Basic net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing
basic net income (loss) per share
Diluted net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing
diluted net income (loss) per share
The accompanying notes are an integral part of the consolidated financial statements.
70
$
$
$
$
Year ended December 31,
2022
2021
2020
537,840 $
114,867
422,973
535,031 $
114,877
420,154
494,366
106,501
387,865
206,085
173,658
132,753
512,496
(89,523)
7,677
201,303
137,057
126,127
464,487
(44,333)
(7,742)
(81,846)
10,688
(92,534) $
(52,075)
6,276
(58,351) $
132,010
118,017
107,437
357,464
30,401
(12,299)
18,102
(1,706)
19,808
(0.88) $
(0.56) $
0.20
104,660,476
103,433,274
100,930,866
(0.88) $
(0.56) $
0.18
104,660,476
103,433,274
108,877,648
NovoCure Limited and subsidiaries
Consolidated statements of comprehensive income (loss)
U.S. dollars in thousands
Net income (loss)
Other comprehensive income (loss), net of tax :
Change in foreign currency translation adjustments
Unrealized gain (loss) from debt securities
Pension benefit plan
Total comprehensive income (loss)
The accompanying notes are an integral part of the consolidated financial statements.
71
Year ended December 31,
2022
2021
2020
$
(92,534) $
(58,351) $
19,808
1,425
(445)
(244)
(91,798) $
302
—
361
(57,688) $
(85)
—
(980)
18,743
$
NovoCure Limited and subsidiaries
Statements of changes in shareholders’ equity
Ordinary
shares
U.S. dollars in thousands, except share data
Balance as of December 31, 2019
(Shares)
99,528,435 $
Additional
paid-in
capital
Accumulated other
comprehensive
income (loss)
Retained
earnings
(accumulated
deficit)
Total
shareholders’
equity
871,442 $
(2,767) $
(650,885) $
217,790
Share-based compensation
Exercise of options
Issuance of shares in connection with
employee stock purchase plan
Conversion feature of convertible note, net
Other comprehensive income (loss) net of tax
expense of $0
Net income (loss)
Balance as of December 31, 2020
Share-based compensation
Exercise of options
Issuance of shares in connection with
employee stock purchase plan
Cumulative effect adjustment resulting from
ASU 2020-06 early adoption (see Note 2(y))
Other comprehensive income (loss) net of tax
expense of $0
Net income (loss)
Balance as of December 31, 2021
Share-based compensation
Exercise of options
Issuance of shares in connection with
employee stock purchase plan
Other comprehensive income (loss), net of
tax expense of $0
Net income (loss)
—
2,739,150
66,691
—
—
—
102,334,276
—
1,585,617
51,370
75,721
28,428
3,370
132,474
—
—
1,111,435
94,900
21,182
4,546
—
(132,474)
—
—
103,971,263
—
—
1,099,589
—
991,884
106,955
10,295
86,264
5,224
—
—
—
—
Balance as of December 31, 2022
105,049,411 $
1,222,063 $
The accompanying notes are an integral part of the consolidated financial statements.
72
—
—
—
—
—
—
—
—
(1,065)
—
(3,832)
—
19,808
(631,077)
—
—
—
—
663
—
(3,169)
—
—
—
—
—
—
—
(58,351)
(685,926)
—
—
—
736
—
(2,433) $
—
(92,534)
(778,460) $
75,721
28,428
3,370
132,474
(1,065)
19,808
476,526
94,900
21,182
4,546
663
(58,351)
410,494
106,955
10,295
5,224
736
(92,534)
441,170
3,502
(128,972)
NovoCure Limited and subsidiaries
Consolidated statements of cash flows
U.S. dollars in thousands
Cash flows from operating activities:
Net income (loss)
Adjustments to reconcile net income (loss) to net cash provided by (used in)
operating activities:
Depreciation and amortization
Accrued interest
Asset write-downs and impairment of field equipment
Share-based compensation
Foreign currency remeasurement loss (gain)
Decrease (increase) in accounts receivables
Amortization of discount (premium)
Decrease (increase) in inventories
Decrease (increase) in other long-term assets
Increase (decrease) in accounts payables and accrued expenses
Increase (decrease) in other long-term liabilities
Net cash provided by (used in) operating activities
Cash flows from investing activities:
Purchase of property, equipment and field equipment
Proceeds from maturity of short-term investments
Purchase of short-term investments
Net cash provided by (used in) investing activities
Year ended December 31,
2022
2021
2020
$
(92,534) $
(58,351) $
19,808
10,624
(2,216)
955
106,955
(3,256)
2,547
(1,536)
(4,342)
7,107
14,257
(7,773)
30,788 $
10,251
(94)
649
94,900
3,231
5,270
3,101
2,483
4,519
27,777
(10,980)
82,756 $
(21,358)
1,179,289
(1,297,888)
(24,170)
958,000
(1,078,664)
(139,957) $
(144,834) $
$
$
9,150
—
429
75,721
(699)
(30,354)
3,260
(2,935)
(1,366)
25,470
664
99,148
(14,968)
150,000
(607,879)
(472,847)
The accompanying notes are an integral part of the consolidated financial statements.
73
NovoCure Limited and subsidiaries
Consolidated statements of cash flows
U.S. dollars in thousands
Cash flows from financing activities:
Proceeds from issuance of shares, net
Proceeds from convertible note, net
Repayment of long-term debt
Exercise of options
Net cash provided by (used in) financing activities
Effect of exchange rate changes on cash, cash equivalents and restricted cash
Increase (decrease) in cash, cash equivalents and restricted cash
Cash, cash equivalents and restricted cash at the beginning of the year
Cash, cash equivalents and restricted cash at the end of the year
Supplemental cash flow activities:
Cash paid during the year for:
Income taxes paid (refunded), net
Interest paid
Non-cash activities:
Right-of-use assets obtained in exchange for lease liabilities
The accompanying notes are an integral part of the consolidated financial statements.
74
Year ended December 31,
2022
2021
2020
5,224 $
—
(28)
10,295
15,491 $
4,546 $
—
(26)
21,182
25,702 $
3,370
558,439
(150,028)
28,428
440,209
(97) $
(188) $
247
(93,775)
209,609
115,834 $
(36,564)
246,173
209,609 $
66,757
179,416
246,173
5,480 $
41 $
3,110 $
101 $
(3,261)
8,686
12,117 $
5,387 $
5,617
$
$
$
$
$
$
$
Table of Contents
NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Note 1: Organization
NovoCure Limited (including its consolidated subsidiaries, the "Company") was incorporated in the Bailiwick of Jersey and is principally
engaged in the development, manufacture and commercialization of Tumor Treating Fields ("TTFields") devices, including Optune and Optune
Lua (collectively, our "Products"), for the treatment of solid tumor cancers. The Company currently markets Optune in the United States ("U.S."),
Germany, Japan and certain other countries. The Company currently markets Optune Lua in the U.S. and European Union. The Company also
has a License and Collaboration Agreement (the "Zai Agreement") with Zai Lab (Shanghai) Co., Ltd. ("Zai") to market Optune in China, Hong
Kong, Macau and Taiwan ("Greater China"). See Note 12.
During the year ended December 31, 2019, the Company implemented changes to its corporate entity operating structure, including transferring
certain intellectual property to its Swiss subsidiary, primarily to align corporate entities with the Company’s evolving operations and business
model. As of January 1, 2022, the effective place of daily management and control of the Company moved to Switzerland and the Company
has become a Swiss tax resident.
Note 2: Basis of presentation and significant accounting policies
The consolidated financial statements are prepared in accordance with accounting principles generally accepted in the United States (“U.S.
GAAP”).
a. Use of estimates:
The preparation of financial statements in conformity with U.S. GAAP requires management to make estimates and assumptions that affect the
amounts reported in the consolidated financial statements and accompanying notes. The Company evaluates on an ongoing basis its
assumptions, including those related to contingencies, deferred taxes, tax liabilities, useful-life of field equipment, right-of-use assets and lease
liabilities, convertible notes, pension liabilities, revenue recognition, accrued expenses and share-based compensation costs. The Company’s
management believes that the estimates, judgment and assumptions used are reasonable based upon information available at the time they
are made. These estimates, judgments and assumptions can affect the reported amounts of assets and liabilities at the dates of the
consolidated financial statements, and the reported amounts of net revenue and expenses during the reporting period. Actual results could
differ from those estimates.
b. Financial statements in U.S. dollars:
The accompanying financial statements have been prepared in U.S. dollars in thousands, except for share and per-share data.
The Company finances its operations in U.S. dollars and a substantial portion of its costs and revenues from its primary markets is incurred in
U.S. dollars. As such, the Company’s management believes that the U.S. dollar is the currency of the primary economic environment in which
NovoCure Limited and certain subsidiaries operate. The Company’s reporting currency is U.S. dollars.
Transactions and balances denominated in U.S. dollars are presented at their original amounts. Monetary accounts maintained in currencies
other than the U.S. dollar are re-measured into dollars in accordance with Accounting Standards Codification (ASC) No. 830-10, "Foreign
Currency Matters." All transaction gains and losses of the re-measurement of monetary balance sheet items are reflected in the consolidated
statements of operations as financial income or expenses, as applicable.
For a subsidiary whose functional currency has been determined to be its local currency, assets and liabilities are translated at year-end
exchange rates and statement of operations items are translated at average exchange rates prevailing during the year. Such translation
adjustments are recorded as a separate component of accumulated other comprehensive income (loss) in shareholders' equity.
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
c. Principles of consolidation:
The consolidated financial statements include the accounts of the Company and its wholly owned subsidiaries. Intercompany transactions and
balances, including unrealized profits from intercompany sales, have been eliminated upon consolidation.
d. Cash equivalents:
Cash equivalents are short-term, highly liquid investments that are readily convertible into cash with a maturity of three months or less at the
date acquired.
e. Short-term investments:
The Company accounts for investments in debt securities in accordance with ASC 320, "Investments—Debt and Equity Securities."
Management determines the appropriate classification of its investments in marketable debt securities at the time of purchase and reevaluates
such determinations at each balance sheet date. Investments in marketable debt securities can be classified as available-for-sale ("AFS") and
held-to-maturity ("HTM") when the Company has the intent and ability to hold the securities to maturity. As of December 31, 2022 and 2021, all
securities are classified as held-to-maturity since the Company has the intent and ability to hold the securities to maturity and, accordingly, debt
securities are stated at amortized cost.
Available-for-sale debt securities are carried at fair value, with the unrealized gains and losses, net of tax, reported in accumulated other
comprehensive income (loss) in shareholders’ equity. Realized gains and losses on sale of investments are included in financial income, net
and are derived using the specific identification method for determining the cost of securities sold.
The amortized cost of debt securities is adjusted for amortization of premiums and accretion of discounts to maturity. Such amortization together
with interest on securities is included in financial income, net.
Each reporting period, the Company evaluates whether declines in fair value below amortized cost are due to expected credit losses, as well as
the Company’s ability and intent to hold the investment until a forecasted recovery occurs. Allowance for credit losses on available-for-sale debt
securities are recognized in the Company’s consolidated statements of income, and any remaining unrealized losses, net of taxes, are included
in accumulated other comprehensive income (loss) in stockholders’ equity.
Held-to-maturity debt securities are stated at amortized cost of which is adjusted for amortization of premiums and accretion of discounts to
maturity and any credit losses. Such amortization, interest or credit losses are included in the consolidated statement of operations as financial
income or expenses, as appropriate.
For the years ended December 31, 2022, 2021 and 2020, no credit losses have been identified.
f. Restricted cash
The Company has restricted cash used as security for the use of Company credit cards and cash management, presented in short-term assets.
Additionally, the Company has pledged bank deposits to cover bank guarantees related to facility rental agreements, fleet lease agreements
and customs payments presented in other long-term assets (see Note 12).
g. Trade receivables:
The Company’s trade receivables balance contains billed and unbilled commercial activities. The Company records an allowance for credit
losses, if identified. The Company periodically reviews its customers’ credit risk and payment history. To date, the Company has not
experienced any material credit losses related to counter-party risk.
h. Inventories:
Inventories are stated at the lower of cost or net realizable value. Cost is determined using the weighted average method. The Company
regularly evaluates its ability to realize the value of inventory. If the inventories are deemed
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
damaged, if actual demand for the Company’s devices deteriorates, or if market conditions are less favorable than those projected, inventory
write-offs may be required.
Inventory write-offs of $917, $1,045 and $616, respectively, were recorded for the years ended December 31, 2022, 2021 and 2020.
i. Property and equipment:
Property and equipment are stated at cost, net of accumulated depreciation. Depreciation is calculated using the straight-line method over the
rates:
estimated
following
assets
useful
lives
the
the
of
at
Computers and laboratory equipment
Office furniture
Production equipment
Leasehold improvements
%
15 - 33
6 - 33
20
Over the shorter of the term of the lease or its useful life
Land and assets held within construction in progress are not depreciated. Construction in progress is related to the construction or development
of property and equipment that is not yet ready for its intended use.
j. Field equipment:
Field equipment is stated at cost, net of accumulated depreciation. Depreciation is calculated using the straight-line method over the estimated
useful life of the field equipment, which was determined to be 18 to 36 months. Field equipment is equipment being utilized under service
agreements, and accounted for in accordance with ASC 842 on a monthly basis as an operating lease (see Note 2(x)). The Company records a
write-off provision for any excess, lost or damaged equipment when warranted based on an assessment of the equipment. Write-offs for
equipment are included in cost of revenues (see Note 7).
k. Impairment of long-lived assets:
The Company’s long-lived assets are reviewed for impairment in accordance with ASC 360-10, "Property, Plant and Equipment," whenever
events or changes in circumstances indicate that the carrying amount of the asset may not be recoverable. Recoverability of an asset to be held
and used is measured by a comparison of the carrying amount of an asset to the future undiscounted cash flows expected to be generated by
the asset. If such asset is considered to be impaired, the impairment to be recognized is measured by the amount by which the carrying amount
of the asset exceeds its fair value. During the three years ended December 31, 2022, no impairment losses have been identified.
l. Other long-term assets:
Restricted deposits, long-term lease deposits associated with office rent and vehicles under operating leases, prepaid and vendors down
payments are presented in other long-term assets.
m. Revenue recognition:
Our Products are comprised of two main components: (1) an electric field generator and (2) arrays and related accessories. We retain title to
the electric field generator, and the patient is provided replacement arrays and technical support for the device during the term of treatment. The
electric field generator and arrays are always supplied and function together and are not sold on a standalone basis.
The Company uses the portfolio approach to apply the standard to portfolios of contracts with similar characteristics.
To recognize revenue under ASC 606, the Company applies the following five steps:
1.
Identify the contract with a patient. A contract with a patient exists when (i) the Company enters into an enforceable contract
with a patient that defines each party’s rights regarding delivery of and payment for a Product, (ii) the contract has commercial
substance and (iii) the Company determines that collection of substantially all consideration for such Product is probable based on the
payer’s intent and ability to pay the promised consideration. The evidence of a contract generally consists of a prescription, a patient
service agreement and the verification of the assigned payer for the contract and intention to collect.
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
2.
Identify the performance obligations in the contract. Our contracts include the lease of the device, the supply obligation of
disposable arrays and technical support for the term of treatment. To the extent a contract includes multiple promised products and/or
services, the Company must apply judgment to determine whether those products and/or services are capable of being distinct in the
context of the contract. If these criteria are not met the promised products and/or services are accounted for as a combined
performance obligation. In the Company’s case, the device, support, and disposables are provided as one inseparable package of
monthly treatment for a single monthly fee. For more information, see Note 2(x).
3.
Determine the transaction price. The transaction price is determined based on the consideration to which the Company will be
entitled in exchange for providing a Product to the patient. To the extent the transaction price includes variable consideration, the
Company estimates the amount of variable consideration that should be included in the transaction price utilizing either the expected
value method or the most likely amount method depending on the nature of the variable consideration. Variable consideration is
included in the transaction price if, in the Company’s judgment, it is probable that a significant future reversal of cumulative revenue
under the contract will not occur. The Company has agreements with many payers that define explicit discounts off the gross
transaction price. In addition to the explicit discounts negotiated with each payer, the Company expects to receive, in aggregate for a
given portfolio, less than the gross revenue net of explicit discounts. ASC 606 requires that the Company recognize this variable
consideration as an implicit discount in the billing period. The implicit discount includes both an estimate of claims that will pay at an
amount less than billed and an estimate of claims that will not pay within a given time horizon. The implicit discount adjustments to the
transaction price are due to concessions, not collectability concerns driven by payer credit risk.
Allocate the transaction price to performance obligations in the contract. If a contract contains a single performance obligation,
4.
the entire transaction price is allocated to the single performance obligation. As discussed above, there is a combined performance
obligation under the Company’s contracts and, therefore, the monthly transaction price determined for the performance obligation will
be recognized over time ratably over the monthly term of the treatment.
Recognize revenue when or as the Company satisfies a performance obligation. The Company satisfies performance
5.
obligations over time. Revenue is recognized at the time the related performance obligation is satisfied by transferring a promised
service to a patient. The patient consumes the benefits of treatment on a daily basis over the monthly term. As this criterion is met, the
revenues will be recognized over the monthly term. For more information, see Note 2(x).
Revenues are presented net of indirect taxes.
Net revenues in the years ended December 31, 2022, 2021 and 2020 also include amounts recognized pursuant to the Zai Agreement. For
additional information, see Note 12.
n. Charitable care:
The Company provides treatment at no charge to patients who meet certain criteria under its charitable care policy. Because the Company does
not pursue collection of amounts determined to qualify as charity, they are not reported as revenue. The Company's costs of care provided
under charitable care were $3,009, $4,204 and $3,653 for the years ended December 31, 2022, 2021 and 2020, respectively. These amounts
were determined by applying charitable care as a percentage of gross billings to total cost of goods sold.
o. Shipping and handling costs:
The Company does not separately bill its customers for shipping and handling costs associated with shipping Products to its customers. These
direct shipping and handling costs of $3,211, $2,958 and $3,224 for the years ended December 31, 2022, 2021 and 2020, respectively, are
included in Sales and Marketing costs.
p. Accounting for share-based compensation:
The Company accounts for share-based compensation in accordance with ASC 718, "Compensation—Stock Compensation." ASC 718 requires
companies to estimate the fair value of share-based compensation awards on the date of grant using an option-pricing model. The value of the
award is recognized as an expense over the
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
requisite service periods in the Company’s consolidated statements of operations. The Company's policy is to account for forfeitures as they
occur.
The Company recognizes compensation costs for the value of awards granted using the accelerated method over the requisite service period of
the award, which for restricted share units is two or three years and and for option awards, which is two or four years.
The Company recognizes compensation costs for the value of performance stock units ("PSU") over the performance period when the vesting
conditions become probable in accordance with ASC 718.
The Company applies the Black-Scholes model as it believes it is the most appropriate fair value method for all equity awards and for the
Employee Share Purchase Plan (the "ESPP"). For market condition awards, the Company also applies the Monte-Carlo simulation model. The
Black-Scholes model requires a number of assumptions, of which the most significant are the share price, expected volatility and the expected
award term.
Beginning with the first quarter of 2022, the computation of expected volatility is based on the historical volatility the Company's shares,
beginning with the first quarter of 2021 and prior to the first quarter of 2022, the computation of expected volatility is based on a combination of
actual historical share price volatility of comparable publicly-traded companies and the historical volatility the Company's shares. Prior to the
first quarter of 2021, due to the lack of sufficient historical information for the Company, the computation was based on actual historical volatility
of comparable publicly-traded companies. Beginning with the first quarter of 2021, the expected term of options granted is calculated using the
Company's historical and future exercise behavior. Prior to the first quarter of 2021, it was calculated using the average between the vesting
period and the contractual term to the expected term of the options in effect at the time of grant. The Company has historically not paid
dividends and has no foreseeable plans to pay dividends and, therefore, uses an expected dividend yield of zero in the option pricing model.
The risk-free interest rate is based on the yield of U.S. treasury bonds with equivalent terms.
q. Fair value of financial instruments:
The carrying amounts of cash and cash equivalents, short-term investments, restricted cash, receivables and prepaid expenses, trade
receivables, trade payables and other accounts payable and accrued expenses approximate their fair value due to the short-term maturity of
such instruments.
The Company accounts for certain assets and liabilities at fair value under ASC 820, "Fair Value Measurements and Disclosures." Fair value is
an exit price, representing the amount that would be received to sell an asset or paid to transfer a liability in an orderly transaction between
market participants. As such, fair value is a market-based measurement that should be determined based on assumptions that market
participants would use in pricing an asset or a liability.
The hierarchy below lists three levels of fair value based on the extent to which inputs used in measuring fair value are observable in the
market. The Company categorizes each of its fair value measurements in one of these three levels based on the lowest level input that is
significant to the fair value measurement in its entirety.
The three levels of inputs that may be used to measure fair value are as follows:
Level 1 - Observable inputs that reflect quoted prices (unadjusted) for identical assets or liabilities in active markets;
Level 2 - Includes other inputs that are directly or indirectly observable in the marketplace, other than quoted prices included in Level 1, such as
quoted prices for similar assets or liabilities in active markets, quoted prices for identical or similar assets or liabilities in markets with insufficient
volume or infrequent transactions, or other inputs that are observable (model-derived valuations in which significant inputs are observable), or
can be derived principally from or corroborated by observable market data; and
Level 3 - Unobservable inputs which are supported by little or no market activity.
The availability of observable inputs can vary from instrument to instrument and is affected by a wide variety of factors, including, for example,
the type of instrument, the liquidity of markets and other characteristics particular to the transaction. To the extent that valuation is based on
models or inputs that are less observable or unobservable in the market, the determination of fair value requires more judgment and the
instrument is categorized as Level 3.
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
r. Basic and diluted net loss per share:
Basic net income (loss) per share is computed based on the weighted average number of ordinary shares outstanding during each period.
Diluted net income per share is computed based on the weighted average number of ordinary shares outstanding during the period, plus
potential dilutive shares considered outstanding during the period, in accordance with ASC 260-10, as determined under the treasury stock
method.
s. Income taxes:
The Company accounts for income taxes in accordance with ASC 740-10, "Income Taxes." ASC 740-10 prescribes the use of the liability
method whereby deferred tax asset and liability account balances are determined based on differences between the financial reporting and tax
bases of assets and liabilities and are measured using the enacted tax rates and laws that will be in effect when the differences are expected to
reverse. The Company provides a valuation allowance, to reduce deferred tax assets to their estimated realizable value, if needed.
The Company established reserves for uncertain tax positions based on the evaluation of whether or not the Company’s uncertain tax position
is "more likely than not" to be sustained upon examination. The Company records interest and penalties pertaining to its uncertain tax positions
in the financial statements as income tax expense.
t. Concentration of risks:
Our cash, cash equivalents, short-term investments and trade receivables are potentially subject to a concentration of risk. Cash, cash
equivalents and short-term investments are invested at top tier financial institutions globally. As such, these investments may be in excess of
insured limitations or not insured in certain jurisdictions. Generally, these investments may be redeemed upon demand and therefore, bear
minimal risk.
Our trade receivables are due from numerous governments and federal and state agencies that are paid from their respective budgets, and
from hundreds of health insurance companies. The Company does not believe that there are significant default risks associated with these
governments, agencies and health insurance companies based upon the Company's historical experience with them.
The Company has no off-balance sheet concentrations of credit risk such as foreign exchange contracts, option contracts or other foreign
hedging arrangements.
u. Retirement, pension and severance plans:
The Company has a 401(k) retirement savings plan for its U.S. employees. Each eligible employee may elect to contribute a portion of the
employee’s compensation to the plan. Company contributions to the plan are at the sole discretion of the Company's Board of Directors.
Currently, the Company provides a matching contribution of 50% of the employee's contributions, up to a maximum of three percent (3%) of the
employee's annual salary. The Company began making matching contributions as of January 1, 2019. For the years ended December 31, 2022,
2021 and 2020, the Company had made matching contributions in the amount of $2,083 and $1,967 and $1,589, respectively, pursuant to the
plan.
The Company sponsors a defined benefit plan (the "Swiss Plan") for all its employees in Switzerland for retirement benefits, as well as benefits
on death or long-term disability, whereby the employee and the Company contribute a portion of the employee's compensation to the plan. The
Swiss Plan is part of a collective pension foundation “AXA Foundation for Occupational Benefits”. This is a semi-autonomous pension
foundation, meaning that the underlying investment risk and the longevity are born by the pension foundation itself. Disability and death risks
are reinsured with AXA insurance. Notwithstanding, the Company and its employees bear the risk of having to pay recovery contributions in a
financial distress situation. The Company accounts for this risk in accordance with ASC 715, "Compensation – Retirement Benefits" (see Note
9). The pension expense for the years ended December 31, 2022, 2021 and 2020 was $2,104, $1,494 and $1,588, respectively.
Israeli law generally requires payment of severance pay upon dismissal of an employee or upon termination of employment in certain other
circumstances. The Company contributes to employee pension plans to fund its severance liabilities. According to Section 14 of Israel
Severance Pay Law, the Company makes deposits on behalf of its employees with respect to the Company’s severance liability and therefore
no obligation is provided for in the financial statements. Severance pay liabilities with respect to employees who are not subject to Section 14,
are provided for in the financial statements based upon the number of years of service and the latest monthly salary and
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
the related deposits are recorded as an asset based on the cash surrender value. Contributions pursuant to these obligations for the years
ended December 31, 2022, 2021 and 2020 amounted to $1,594, $1,466 and $1,130, respectively.
v. Contingent liabilities:
The Company accounts for its contingent liabilities in accordance with ASC 450, "Contingencies." A provision is recorded when it is both
probable that a liability has been incurred and the amount of the loss can be reasonably estimated.
With respect to legal matters, provisions are reviewed and adjusted to reflect the impact of negotiations, estimated settlements, legal rulings,
advice of legal counsel and other information and events pertaining to a particular matter.
w. Other comprehensive income (loss):
The Company accounts for comprehensive income (loss) in accordance with ASC 220, "Comprehensive Income." ASC 220 establishes
standards for the reporting and display of comprehensive income (loss) and its components. Comprehensive income (loss) generally represents
all changes in shareholders' equity during the period except those resulting from investments by, or distributions to, shareholders. The
accumulated other comprehensive income (loss), net of taxes, relates to a pension liability, unrealized loss from debt securities and foreign
currency translation adjustments.
x. Leases:
1.
Lessee accounting:
The Company determines if an arrangement is a lease and the classification of that lease at inception based on: (1) whether the contract
involves the use of a distinct identified asset, (2) whether the Company obtains the right to substantially all the economic benefits from the use
of the asset throughout the period, and (3) whether the Company has a right to direct the use of the asset. The Company elected to not
recognize a lease liability or right-of-use ("ROU") asset for leases with a term of twelve months or less. The Company also elected the practical
expedient to not separate lease and non-lease components for its leases.
ROU assets represent the right to use an underlying asset for the lease term and lease liabilities represent the obligation to make minimum
lease payments arising from the lease. ROU assets are initially measured at amounts, which represents the discounted present value of the
lease payments over the lease, plus any initial direct costs incurred. The ROU assets are reviewed for impairment. The lease liability is initially
measured at lease commencement date based on the discounted present value of minimum lease payments over the lease term. The implicit
rate within the operating leases are generally not determinable; therefore, the Company uses the Incremental Borrowing Rate ("IBR") based on
the information available at commencement date in determining the present value of lease payments. The Company’s IBR is estimated to
approximate the interest rate on similar terms and payments and in economic environments where the leased asset is located.
Certain leases include options to extend or terminate the lease. An option to extend the lease is considered in connection with determining the
ROU asset and lease liability when it is reasonably certain that the Company will exercise that option. An option to terminate is considered
unless it is reasonably certain that the Company will not exercise the option.
2. Lessor accounting - Operating leases:
ASC 842 provides lessors with an optional practical expedient, by class of underlying asset, not to separate non-lease components from the
associated lease component and, instead, to account for those components as a single component if the non-lease components otherwise
would be accounted for under the new revenue guidance (ASC 606) and both of the following criteria are met:
a. The timing and pattern of transfer of the lease component and the non-lease component(s) are the same; and
b. The lease component would be classified as an operating lease if it were accounted for separately.
The Company's product supply agreements include the right to use the device (lease component), the supply obligation of disposable arrays
and technical support for the term of treatment (non-lease component).
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
If the lease component is the predominant component, the Company accounts for all revenues under such lease as a single component in
accordance with the new lease accounting standard. Conversely, if the non-lease component is the predominant component, all revenues under
such lease are accounted for in accordance with the revenue recognition accounting standard. The Company's operating leases qualify for the
single component accounting, and the non-lease component in each of the Company's leases is predominant. Therefore, The Company
accounts for all revenues from its operating leases in accordance with the revenue recognition accounting standard.
y. Convertible note:
Prior to January 1, 2021, the Company accounted for its convertible senior notes in accordance with ASC 470-20 "Debt with Conversion and
Other Options". Pursuant to ASC Subtopic 470-20, issuers of certain convertible debt instruments, such as the convertible senior notes, that
have a net settlement feature and may be settled wholly or partially in cash upon conversion are required to separately account for the liability
(debt) and equity (conversion option) components of the instrument. The Company allocated the proceeds from issuance between the liability
component and the embedded conversion option, or equity component. The liability component at issuance is recognized at fair value, based
on the fair value of a similar instrument of similar credit rating and maturity that does not have a conversion feature. The equity component is
based on the excess of the principal amount of the convertible senior notes over the fair value of the liability component and is recorded in
additional paid-in capital. The equity component, net of issuance costs is presented within additional paid-in-capital and is not remeasured as
long as it continues to meet the conditions for equity classification. The Company allocated the total issuance costs incurred to the liability and
equity components of the convertible senior notes based on the same proportions as the proceeds from the notes.
In August 2020, the Financial Accounting Standards Board ("FASB") issued Accounting Standards Update ("ASU") No. 2020-06, Accounting for
Convertible Instruments and Contracts in an Entity’s Own Equity (ASU 2020-06), which simplifies the accounting for certain financial
instruments with characteristics of liabilities and equity, including convertible instruments and contracts in an entity’s own equity. Among other
changes, ASU 2020-06 removes from GAAP the liability and equity separation model for convertible instruments with a cash conversion
feature, and as a result, after adoption, entities will no longer separately present in equity an embedded conversion feature for such debt.
Similarly, the embedded conversion feature will no longer be amortized into income as interest expense over the life of the instrument. Instead,
entities will account for a convertible debt instrument wholly as debt unless (1) a convertible instrument contains features that require bifurcation
as a derivative under Accounting Standards Codification ("ASC Topic 815"), Derivatives and Hedging, or (2) a convertible debt instrument was
issued at a substantial premium. Additionally, ASU 2020-06 requires the application of the if-converted method to calculate the impact of
convertible instruments on diluted earnings per share (EPS), which is consistent with the Company’s accounting treatment under the current
standard. ASU 2020-06 is effective for fiscal years beginning after December 15, 2021, with early adoption permitted for fiscal years beginning
after December 15, 2020, and can be adopted on either a fully retrospective or modified retrospective basis. The Company early adopted ASU
2020-06, effective January 1, 2021 on a modified retrospective basis.
Commencing January 1, 2021, the Company early adopted ASU 2020-06. The impact of the Company’s adoption of ASU 2020-06 on the
balance sheet as of January 1, 2021 was an increase in long term debt, net of $128,972, a decrease in additional paid-in capital of $132,474,
and a decrease in accumulated deficit of $3,502. Interest expense recognized in future periods will be reduced as a result of accounting for the
convertible debt instrument as a single liability measured at its amortized cost. For additional information see Note 10 of these audited
consolidated financial statements.
Note 3: Cash and Cash equivalents and Short-term investments
Cash equivalents include items almost as liquid as cash with maturity periods of three months or less when purchased, and short-term
investments include items with maturity dates between three months and one year when purchased. As of December 31, 2022 and 2021, the
Company’s cash and cash equivalents and short-term investments were composed of:
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Fair value
level
Adjusted
cost basis
Unrealized
gains
Unrealized
losses
Fair market
value
Recorded basis
Cash and cash
equivalents
Short-term
investments
December 31, 2022
Cash
Money market funds
Certificate of deposits
and term deposits
HTM securities (1)
$
9,697 $
Level 1
105,629
Level 2
316,946
— $
—
—
— $
—
9,697 $
9,697 $
9,697 $
105,629
105,629
105,629
—
—
—
316,946
316,946
—
316,946
U.S. Treasury bills
Government and
governmental agencies Level 2
Corporate debt securities Level 2
Level 1
Total
$
$
$
$
$
188,030 $
8 $
(540) $
187,498 $
188,030 $
— $
188,030
44,357 $
304,766 $
12 $
1,066 $
(12) $
(587) $
44,357 $
305,245 $
44,357 $
304,766 $
— $
— $
44,357
304,766
537,153 $
1,086 $
(1,139) $
537,100 $
537,153 $
— $
537,153
969,425 $
1,086 $
(1,139) $
969,372 $
969,425 $
115,326 $
854,099
December 31, 2021
Fair value
level
Adjusted
cost basis
Unrealized
gains
Unrealized
losses
Fair market
value
Recorded
basis
Cash and cash
equivalents
Short-term
investment
Cash
Money market funds
$
3,139 $
Level 1
64,668
Certificate of deposits, notes
and term deposits
HTM securities (1)
Level 2
565,089
U.S. Treasury bills
Corporate debt securities
Level 1
Level 2
Total
199,981
104,823
304,804 $
937,700 $
$
$
— $
—
—
8
—
8 $
8 $
— $
—
3,139 $
3,139 $
3,139 $
64,668
64,668
64,668
—
—
—
565,089
565,089
140,995
424,09
—
—
— $
199,989
104,823
304,812 $
199,981
104,823
304,804 $
—
—
— $
199,98
104,82
304,80
— $
937,708 $
937,700 $
208,802 $
728,89
(1) Changes in fair value of HTM securities are presented for disclosure purposes as required by ASC 320 and are recorded as finance
expenses only if the unrealized loss is identified as a credit loss.
In November 2022, the Company transferred all of its AFS portfolio to HTM as part of the Company's investment strategy. Such transfers are
made at fair value at the date of transfer, The net unrealized loss on these securities at the date of transfer was $911. These securities continue
to be reported in accumulated comprehensive income (loss) and are amortized over the remaining lives of the securities as an adjustment to
the yield. As of December 31, 2022, the unamortized unrealized loss balance was $445 and is reported in accumulated other comprehensive
income (loss).
In accordance with ASC No. 820, the Company measures its money market funds and marketable securities at fair value. Money market funds
and marketable securities are classified within Level 1 or Level 2. This is because these
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
assets are valued using quoted market prices or alternative pricing sources and models utilizing market observable inputs.
As of December 31, 2022 and 2021, all investments and equivalents mature in one year or less.
Unrealized losses from debt securities are primarily attributable to changes in interest rates. The Company does not believe any remaining
unrealized losses represent impairments based on the evaluation of available evidence.
Debt securities with continuous unrealized losses for less than 12 months and their related fair values were as follows:
U.S. Treasury bills
Government and governmental agencies
Corporate debt securities
Total
As of December 31, 2022, no continuous unrealized losses for 12 months or greater was identified.
Note 4: Receivables and prepaid expenses
The following table sets forth the Company’s receivables and prepaid expenses:
Advances to and receivables from suppliers
Government authorities
Prepaid expenses
Others
Note 5: Inventories
December 31, 2022
Less than 12 months
Fair value
Unrealized loss
162,813
38,477
162,085
363,375 $
(540)
(12)
(587)
(1,139)
December 31,
2022
2021
7,151 $
12,389
6,195
224
25,959 $
3,843
8,421
4,711
50
17,025
$
$
$
Inventories are stated at the lower of cost or net realizable value. The weighted average methodology is applied to determine cost. The
following table sets forth the Company’s inventories:
Raw materials
Work in process
Finished goods
December 31,
2022
2021
$
$
4,314 $
9,321
15,741
29,376 $
1,485
8,274
14,668
24,427
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Note 6: Property and equipment, net
The following table sets forth the Company’s property and equipment, net:
Cost:
Computers and laboratory equipment
Office furniture
Production equipment
Land and building
Leasehold improvements
Total cost
Accumulated depreciation and amortization
Depreciated cost
December 31,
2022
2021
$
$
$
$
24,804 $
2,627
3,513
15,988 $
9,346
56,278 $
(23,600)
32,678 $
21,135
3,044
2,377
11,155
7,076
44,787
(22,094)
22,693
The Company capitalized software costs according to FASB's ASC 350-40, "Accounting for the Costs of Computer Software Developed or
Obtained for Internal Use." Cumulative capitalization as of December 31, 2022 and 2021 was $13,192 and $9,979, respectively. Amortization of
capitalized software costs for the years ended December 31, 2022, 2021 and 2020 was $1,056, $1,084 and $1,398, respectively.
Depreciation expense was $3,105, $2,812 and $2,635 for the years ended December 31, 2022, 2021 and 2020, respectively.
Write downs of $344, $10 and $20 were identified for the years ended December 31, 2022, 2021 and 2020, respectively.
Note 7: Field equipment, net
The following table sets forth the Company’s field equipment, net:
Field equipment
Accumulated depreciation
Field equipment, net
December 31,
2022
2021
$
$
36,727 $
(24,043)
12,684 $
33,789
(20,866)
12,923
Depreciation expense was $6,463, $6,355 and $5,117 for the years ended December 31, 2022, 2021 and 2020, respectively. Write downs of
$611, $639 and $409 were identified for the years ended December 31, 2022, 2021 and 2020, respectively.
Note 8: Other payables, lease liabilities and accrued expenses
The following table sets forth the Company’s other payables and accrued expenses:
Employees and payroll accruals
Deferred revenues
Government authorities
Other
85
December 31,
2022
2021
$
$
40,778 $
18,028
8,660
6,114
73,580 $
39,590
17,762
5,797
6,853
70,002
Table of Contents
NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Note 9: Employee benefit obligations
The Company's liability in respect of the Swiss Plan (see Note 2(u)) is the projected benefit obligation calculated using the projected unit credit
method. The projected benefit obligation as of December 31, 2022 represents the actuarial present value of the estimated future payments
required to settle the obligation that is attributable to employee service rendered before that date. Swiss Plan assets are recorded at fair value.
Pension expense is presented in the payroll expenses in the various functions in which the employees are engaged. Actuarial gains and losses
arising from differences between the actual and the expected return on the Swiss Plan assets are recognized in accumulated other
comprehensive income (loss) and amortized over the requisite service period. The Swiss Plan is part of a collective pension foundation of
pooled investments managed by a top tier insurance company. The Company and the employees pay retirement contributions, which are
defined as a percentage of the employees’ covered salaries.The basis for the determination of the interest on employee’s savings account is
the return on plan assets, considering legal minimum requirements. The targeted allocation for these funds is as follows:
Asset Allocation by Category as of December 31, 2022:
Asset Category:
Debt Securities
Real Estate
Equity Securities
Others
Total
86
Asset
allocation (%)
32%
26%
34%
8%
100%
Table of Contents
NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
The following table sets forth the Swiss Plan’s funded status and amounts recognized in the consolidated financial statements for the year
ended December 31, 2022 and 2021:
Change in Benefit Obligation
Projected benefit obligation at beginning of year
Interest cost
Company service cost
Employee contributions
Prior service cost
Benefits paid
Actuarial loss
Projected benefit obligation at end of year
Change in Plan Assets
Fair value of plan assets at beginning of year
Actual return on plan assets
Employer contributions
Employee contributions
Benefits paid
Fair value of plan assets at end of year
Funded Status at End of year
Excess of obligation over assets
Change in Accrued Benefit Liability
Accrued benefit liability at beginning of year
Company contributions made during year
Net periodic benefit cost for year
Net decrease (increase) in accumulated other comprehensive loss
Accrued benefit liability at end of year
Non-current plan assets
Non-current liability
Accrued benefit liability at end of year
Projected Benefit Payments
Projected year 1
Projected year 2
Projected year 3
Projected year 4
Projected year 5
Projected years 6-10
$
$
$
$
$
$
$
$
$
$
December 31,
2022
2021
29,975 $
62
2,725
1,631
484
423
(5,865)
29,435 $
25,967 $
(4,937)
2,446
1,631
424
25,531 $
22,753
48
1,915
1,167
(923)
2,976
2,039
29,975
18,082
1,992
1,750
1,167
2,976
25,967
3,904 $
4,008
(4,008) $
2,446
(2,078)
(264)
(3,904) $
(4,671)
1,750
(1,310)
223
(4,008)
December 31,
2022
2021
25,531 $
29,435
(3,904) $
539 $
744
983
1,065
578
16,940
25,967
29,975
(4,008)
567
454
819
765
452
13,816
The fair value of the plan assets is the estimated cash surrender value of the insurance contract at December 31, 2022. The level of inputs used
to measure fair value was Level 2.
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Net Periodic Benefit Cost
Service cost
Interest cost (income)
Expected return on plan assets
Amortization of actuarial (gain) loss
Amortization of prior service costs
Total net periodic benefit cost
Weighted average assumptions:
Discount rate as of December 31
Expected long-term rate of return on assets
Rate of compensation increase
Mortality and disability assumptions (*)
(*) Mortality data used for actuarial calculation.
Note 10: Long-term debt, net
The following table sets forth the Company’s long-term debt, net:
0% Convertible Senior Notes (a)
Credit facility (b)
a. Convertible Notes
Year ended
December 31,
2022
2021
$
$
2,725 $
62
(701)
117
(99)
2,104 $
1,915
48
(508)
133
(94)
1,494
2.30%
3.50%
1.50%
0.20%
2.50%
1.00%
BVG 2020 GT
BVG 2020 GT
December 31,
2022
2021
565,509 $
562,216
—
565,509 $
—
562,216
$
$
On November 5, 2020, the Company issued $575,000 aggregate principal amount of 0% Convertible Senior Notes due 2025 (the “Notes”). The
net proceeds from the offering were approximately $558,400.
The Notes are senior unsecured obligations of the Company. The Notes do not bear regular interest, and the principal amount of the Notes will
not accrete. Special interest, if any, payable in accordance with the terms of the Notes will be payable in cash semi-annually in arrears on May 1
and November 1 of each year, beginning on May 1, 2021. The Notes mature on November 1, 2025, unless earlier repurchased, redeemed or
converted.
The Notes are convertible into cash, the Company’s ordinary shares or a combination of cash and the Company’s ordinary shares at the
Company’s election at an initial conversion rate of 5.9439 ordinary shares per $1,000 principal amount of the Notes, which is equivalent to an
initial conversion price of approximately $168.24 per ordinary share.
In January 2021, the Company irrevocably elected to settle all conversions of Notes by a combination of cash and the Company's ordinary
shares and that the cash portion per $1,000 principal amount of Notes for all conversion settlements shall be $1,000. Accordingly, from and
after the date of the election, upon conversion of any Notes,
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
holders of Notes will receive, with respect to each $1,000 principal amount of Notes converted, cash in an amount up to $1,000 and the balance
of the conversion value, if any, in ordinary shares (the "Conversion Shares").
The Notes are not redeemable prior to November 6, 2023, except in the event of certain tax law changes. The Company may redeem for cash
all or any portion of the Notes, at the Company’s option, on or after November 6, 2023 if the last reported sale price of the Company’s ordinary
shares has been at least 130% of the conversion price then in effect for at least 20 trading days (whether or not consecutive) during any 30
consecutive trading day period (including the last trading day of such period) ending on, and including, the trading day immediately preceding
the date on which the Company provides notice of redemption at a redemption price equal to 100% of the principal amount of the Notes to be
redeemed, plus accrued and unpaid special interest, if any, to, but excluding, the redemption date. No sinking fund is provided for the Notes.
Prior to the close of business on the business day immediately preceding August 1, 2025, the Notes are convertible at the option of the holders
only upon the satisfaction of certain conditions and during certain periods as described below and if the Company exercises its right to redeem
the Notes as permitted or required by the Indenture as described below. On or after August 1, 2025 until the close of the business on the
business day immediately preceding the maturity date, holders may convert all or any portion of their Notes at the conversion rate at any time
irrespective of the foregoing conditions.
If holders of at least $3,000 aggregate principal amount of the Notes provide the Company with reasonable evidence that the trading price per
$1,000 principal amount of Notes (the “Note Trading Price”) on any trading day would be less than 98% of the product of the last reported sale
price of the Ordinary Shares on such trading day and the conversion rate on such trading day (the “Trigger Note Price”), the Company shall
follow the process for obtaining the Note Trading Price as provided in the Indenture on a daily basis until the Note Trading Price exceeds the
Trigger Notice Price. During this time, if during any five consecutive trading day period (the “Measurement Period”) the Note Trading Price is
less than 98% of the Trigger Notice Price, the Company must notify the holders and the trustee of such an event and the holders may convert
their Notes into Ordinary Shares at any time during the five business day period immediately after.
If the Company intends to (i) issue warrants/rights/options to existing shareholders with an exercise price less than the ten-day trailing last
trading price average or (ii) distribute to shareholders assets, securities or rights with a value per share greater than 10% of the last reported
trading price, then the Company must give holders of the Notes thirty-five (35) trading days’ notice of such event, at which time a holder may
convert their Notes during such 35 trading day period (or until the Company revokes its decision to issue/distribute the securities, whichever
comes sooner).
In addition, upon the occurrence of a fundamental change (as defined in the indenture), holders may require the Company to repurchase for
cash all or any portion of their Notes at a fundamental change repurchase price equal to 100% of the principal amount of the Notes to be
repurchased, plus accrued and unpaid special interest, if any, to, but excluding, the fundamental change repurchase date. In addition, following
certain corporate events that occur prior to the maturity date or if the Company delivers a notice of redemption, the Company will, in certain
circumstances, increase the conversion rate for a holder who elects to convert its Notes in connection with such a corporate event or notice of
redemption, as the case may be.
As of December 31, 2022, the conditions allowing holders of the Notes to convert were not met. The Notes are therefore not convertible as of
December 31, 2022 and are classified as long-term liability.
The net carrying amount of the liability and equity components of the Convertible Notes (see note 2(z) for additional information) as of
December 31, 2022 and 2021 are as follows:
Liability component, net:
Principal amount
Unamortized issuance costs
Net carrying amount of liability component (1)
December 31,
2022
2021
$
$
575,000 $
(9,491)
565,509 $
575,000
(12,784)
562,216
) An effective interest rate determines the fair value of the Notes, therefore they are categorized as Level 3 in accordance with ASC 820, "Fair
Value Measurements and Disclosures." The estimated fair value of the Net
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
carrying amount of liability component of the Notes as of December 31, 2022 and 2021 were $455,091 and $467,469, respectively.
Finance expense related to the Notes were as follows:
Amortization of debt issuance costs
Amortization of debt discount
Total finance expense recognized
b. Loan and Security Agreement
Year ended December 31,
2022
2021
2020
$
$
$
3,293 $
— $
3,293 $
3,339 $
— $
3,339 $
333
3,605
3,938
On February 7, 2018, the Company and certain of its subsidiaries entered into a Loan and Security Agreement ("2018 Loan Agreement") with
BioPharma Credit PLC pursuant to which such lender made a term loan to the Company in the principal amount of $150,000 (the "2018 Credit
Facility"). The term loan, which was drawn in full upon execution of the 2018 Loan Agreement, bore interest at 9.0% per annum, payable
quarterly in arrears.
On August 18, 2020, the Company terminated the 2018 Credit Facility. The prepayment included $150,000 in principal repayment and $3,000 in
prepayment premium, plus accrued and unpaid interest and expenses payable through the payoff date. The un-amortized issuance costs in the
amount of $478 that were fully amortized upon the repayment and the prepayment premium were reported in the Company’s finance expenses.
Note 11: Other long-term liabilities
Leasehold improvements financing and other
Unrecognized tax benefits (Note 13(e))
Note 12: Commitments and contingent liabilities
a.
Operating leases
December 31,
2022
2021
$
$
72 $
76
148 $
12
154
166
The facilities of the Company are leased under various operating lease agreements for periods ending no later than 2044. The Company also
has the option to extend the term of certain facility lease agreements and these are included in the calculation of right-of-use assets. The
Company also leases motor vehicles under various operating leases, which expire on various dates, the latest of which is in 2025.
Under ASC 842, all leases with durations greater than 12 months, including non-cancelable operating leases, are recognized on the balance
sheet. The aggregated present value of lease payments is recorded as a long-term asset titled right-of-use assets. The corresponding lease
liabilities are split between other payables and long-term lease liabilities, and as of December 31, 2022, are as follows:
Future minimum lease payments:
2023
2024
90
December 31,
2022
$
6,228
5,254
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
2025
2026
2027
Thereafter
Total future minimum lease payments
Less imputed interest
Net present value of future minimum lease payments
Current year end
Short-term lease liabilities
Long-term lease liabilities
Net present value of future minimum lease payments
Weighted average of remaining operating lease term (years)
Weighted average of operating lease discount rate
$
$
$
$
4,484
4,085
3,272
5,089
28,412
(3,846)
24,566
5,804
18,762
24,566
5.66
5.38 %
Lease and rental expense for the years ended December 31, 2022, 2021 and 2020 was $7,108, $7,349, and $5,950, respectively.
b. Bank guarantee and pledges
As of December 31, 2022 and 2021 the Company pledged bank deposits of $2,296 and $2,350, respectively, to cover bank guarantees in
respect of its leases of operating facilities and obtained guarantees by the bank for the fulfillment of the Company’s lease commitments of
$2,459 and $2,698, respectively.
c. Senior secured revolving credit facility
On November 6, 2020, the Company entered into a new three-year $150,000 senior secured revolving credit facility with a syndicate of
relationship banks (the "Credit Facility"). The Company may, subject to certain conditions and limitations, increase the revolving credit
commitments outstanding under the revolving credit facility or incur new incremental term loans in aggregate principal amount not to exceed
$250.0 million in total.
The commitments under the Credit Facility are guaranteed by certain of the Company's subsidiaries and secured by a first lien on the
Company's and certain of the Company's subsidiaries’ assets. Outstanding loans will bear interest per annum at a sliding scale based on the
Company's secured leverage ratio from 2.75% to 3.25% above the applicable interbank borrowing reference rate for the currency in which the
loan is denominated. Additionally, the facility contains a fee for the unused revolving credit commitments at a sliding scale based on the
Company's secured leverage ratio from 0.35% to 0.45%. The Credit Facility contains financial covenants requiring maintenance of a minimum
fixed charge coverage ratio and specifying a maximum senior secured net leverage ratio, as well as customary events of default which include a
change of control.
As of December 31, 2022, the Company had no outstanding balance borrowed under the Credit Facility.
On February 17, 2023, the Company gave irrevocable notice to the administrative agent under the Credit Facility that the Company terminated
all commitments, effective February 22, 2023. This effectively terminated the Credit Facility, as the Company's ability to borrow and the
Company's obligations to comply with all covenants ended on such date. The liens and guaranties in favor of the lenders are released. There
was no early termination fee payable and as of February 22, 2023 the Company had no outstanding balance borrowed under the Credit Facility.
d. Zai License and Collaboration Agreement
On September 10, 2018, the Company entered into the Zai Agreement. Under the Zai Agreement, the Company granted Zai exclusive rights to
commercialize Optune in the field of oncology in China, Hong Kong, Macau and
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Taiwan ("Greater China"). The Zai Agreement also established a development partnership for Optune in multiple solid tumor indications. In
partial consideration for the license grant to Zai for Greater China, the Company was entitled to a non-refundable, up-front license fee in the
amount of $15,000 (the "License Fee"). The Zai Agreement also provides for certain development, regulatory and commercial milestone
payments totaling up to $78,000. Furthermore, pursuant to the Zai Agreement, Zai will pay the Company tiered royalties at percentage rates
from 10 up to the mid-teens on the net sales of the licensed products in Greater China. Zai is purchasing licensed products for commercial use
exclusively from the Company at the Company’s fully burdened manufacturing cost.
The Company recognizes revenue pursuant to the License Agreement with Zai in accordance with ASC 606, "Revenue Recognition from
Customers." The License Fee is deferred and recognized over related six year performance period commencing September 10, 2018 ("Zai
Performance Period"). Revenue from commercial milestone payments will be recognized upon the achievement of such milestones and future
clinical or regulatory milestone payments will be recognized in a straight line over the applicable performance period, in accordance with ASC
606. Revenue from royalty payments are recognized in accordance with ASC 606 in the period accrued. Revenues from sales of product or
rendering services are recognized upon shipping the products or rendering the services and satisfying the performance obligation.
During the year ended December 31, 2020, the Company triggered an aggregate $10,000 of milestone payments, which, with the License Fee,
are deferred and recognized over the remainder of the Zai Performance Period ending in September 2024 on a straight-line basis, resulting in
revenue of $4,389 $6,308 and $3,981 for the years ended December 31, 2022, 2021 and 2020, respectively.
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Note 13: Income taxes
a. Tax provision:
As of January 1, 2022, the effective place of daily management and control of the Company moved to Switzerland and the Company has
become a Swiss tax resident. As a result, the income tax disclosures have been presented in accordance with the Company’s current country of
tax residency.
Income (loss) before income taxes is as follows:
Swiss
Non-Swiss
Total income (loss) before income taxes
The provision (benefit) for income taxes from continuing operations is comprised of:
Current:
Swiss
Non-Swiss
Total current
Deferred:
Swiss
Non-Swiss
Total deferred
Total income tax provision
Year ended December 31,
2022
(269,621) $
187,775
2021
(145,591) $
93,516
2020
32,010
(13,908)
(81,846) $
(52,075) $
18,102
Year ended December 31,
2022
2021
2020
469 $
10,219
10,688 $
—
—
—
10,688 $
281 $
5,995
6,276 $
— $
—
—
6,276 $
3,105
(4,811)
(1,706)
—
—
—
(1,706)
$
$
$
$
$
$
b. Theoretical tax
The Company's effective tax rate is affected by the tax rates in the various jurisdictions in which the Company operates. Under Swiss law, the
Company is subject to income tax at the federal level at a statutory rate of 8.5%, as well as at the cantonal and communal levels, resulting in an
aggregate corporate tax rate of 12.0%.
For purposes of comparability, the Company used the Swiss federal statutory rate for the 2022, 2021 and 2020 tax years when presenting the
Company's reconciliation of the income tax provision.
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
A reconciliation of the provision for income taxes compared with the amounts at the Swiss rate was:
Income (loss) before income taxes
Swiss federal statutory rate
Income tax at federal Swiss rate
Foreign taxes rate differential
Change in valuation allowance
Effect of tax law change
Share based compensation
Research and development credits
Return to provision true-ups
Withholding taxes
Other
Income tax
Effective tax rate
c. Deferred income tax
$
$
$
2022
(81,846)
Year ended December 31,
2021
(52,075)
$
$
8.5 %
8.5 %
(6,957)
25,716
(14,238)
5,681
5,318
(4,898)
(1,020)
548
538
10,688
$
$
(4,426)
1,601
11,643
—
(4,636)
(2,216)
2,416
273
1,621
6,276
$
$
2020
18,102
8.5 %
1,539
2,517
6,821
(8,694)
(1,615)
(5,243)
—
2,366
603
(1,706)
(13.1)%
(12.1)%
(9.4)%
Deferred income taxes reflect the net tax effects of temporary differences between the carrying amounts of assets and liabilities for financial
purposes and the amounts used for income tax purposes. Significant components of the Company’s deferred tax assets and liabilities are
as follows:
Deferred tax assets:
Unamortized intangible assets
Impact of revenue recognition
Net operating loss carryforwards
Share based compensation
Capitalized research and development
Research and development credits
Lease liabilities
Interest limitations
Other temporary differences
Total gross deferred tax assets
Less: valuation allowance
Total deferred tax assets
Deferred tax liabilities:
Right of use assets
Fixed assets
Other liabilities
Total gross deferred tax liabilities
Net deferred taxes assets (liability)
d. Carryforward loss:
December 31,
2022
2021
153,450 $
82,972 $
65,472 $
30,009 $
16,730 $
8,992 $
5,846 $
— $
7,089 $
370,560 $
(361,358)
9,202
5,785
1,730
1,687
9,202 $
138,978
112,251
77,664
25,644
—
12,146
4,836
7,948
3,032
382,499
(375,717)
6,782
4,559
2,214
9
6,782
— $
—
$
$
$
$
$
$
$
$
$
$
$
$
In Switzerland, the Company had $525,131 of net operating carryforwards (NOLs) available at the Federal level, of which $497,371 are
available at the cantonal and communal level as well. These NOLs expire from 2026 through
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
2029. Additionally, the Company had $37,105 of non-Swiss NOLs as of December 31, 2022, of which $4,942 carry forward indefinitely. The
remainder expire from 2026 through 2041.
e. Uncertain tax benefits:
A reconciliation of the beginning and ending balances of uncertain tax benefits is as follows:
Balance at beginning of the year
Additions (reductions) for taxes positions related to prior years
Balance at the end of the year
2022
December 31,
2021
2020
$
$
154 $
(78)
76 $
297 $
(143)
154 $
116
181
297
The Company recognizes interest and penalties related to unrecognized tax benefits in tax expense. During the years ended December 31,
2022, 2021 and 2020, the Company accrued $2, $5 and $21, respectively, for interest and penalties expenses related to uncertain tax positions.
The Company files income tax returns in the Switzerland and various foreign jurisdictions. Currently, the Company is under examination by the
tax authorities in Israel for the tax years 2018, 2019 and 2020 and is not under examination by any other tax authority. Additional tax years
within the period 2016 to 2021 remain subject to examination by Swiss, U.S. and other tax authorities.
Note 14: Share capital
Share capital is composed as follows:
Ordinary shares no par value
Equity incentive plans:
Stock option plan
Issued and outstanding
Number of shares
December 31,
2022
2021
105,049,411
103,971,263
Until the IPO in October 2015, the Company maintained and granted option awards under the 2003 Share Option Plan (the "2003 Plan") and
the 2013 Equity Incentive Share Option Plan (the "2013 Plan") for the Company’s officers, directors, employees and advisors. The 2003 Plan
and the 2013 Plan terminated as of the IPO as to future awards, but they continue to govern option awards previously granted thereunder.
In September 2015, the Company adopted the 2015 Omnibus Incentive Plan (the "2015 Plan"). The Company’s shareholders approved the
2015 Plan in September 2015. Under the 2015 Plan, the Company can issue various types of equity compensation awards such as restricted
shares, performance shares, restricted stock units ("RSUs"), performance share units ("PSUs"), long-term cash award and other share-based
awards. Options granted under the 2015 Plan generally have a vesting period of two or four years and expire ten years after the date of grant.
RSUs granted under the 2015 Plan vest in equal installments over two or three years. PSUs granted under the 2015 Plan generally vest have a
vesting period between three and six years, as performance targets are attained. Options, RSUs and PSUs granted under the 2015 Plan that
are canceled before expiration become available for future grants.
On December 31, 2022, in accordance with the terms of the 2015 Plan, the number of shares available for issuance under the 2015 Plan
automatically increased by 4% of the Company’s outstanding ordinary shares as of December 30, 2022. As a result, the number of shares
available for issuance under the 2015 Plan increased from 39,264,853 shares to 43,465,227 shares. As of December 31, 2022,20,630,323
ordinary shares are available for grant under the 2015 Plan.
Employee Stock Purchase Plan
In September 2015, the Company adopted an ESPP to encourage and enable eligible employees to acquire ownership of the Company’s
ordinary shares purchased through accumulated payroll deductions on an after-tax
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
basis. The ESPP is intended to be an "employee stock purchase plan" within the meaning of Section 423 of the Code and the provisions of the
ESPP will be construed in a manner consistent with the requirements of such section. The Company began its offerings under the ESPP on
August 1, 2016. The Company issued 86,264 ordinary shares for the plan period from January 1, 2022 through December 31, 2022.
The terms of the ESPP provide that on December 31 of each year, the number of shares available for purchase by eligible employees who
participate in the ESPP automatically increases by 1% of the Company’s outstanding ordinary shares outstanding, unless the Company
determines that such an increase is not necessary. The Company determined that an such increase was not necessary and no such increase
took place. As of December 31, 2022, 4,868,733 ordinary shares are available for offering under the ESPP.
The fair value of share-based awards was estimated using the Black-Scholes model for all equity grants and for market condition awards. The
Company also applied the Monte-Carlo simulation model, with the following underlying assumptions:
Stock Option Plans
Expected term (years)
Expected volatility
Risk-free interest rate
Dividend yield
ESPP
Expected term (years)
Expected volatility
Risk-free interest rate
Dividend yield
Year ended December 31,
2022
2021
2020
5.33-5.83
60%-62%
1.58%-4.23%
0.00 %
0.50
51%-77%
0.19%-2.52%
0.00 %
5.50-6.00
60%-63%
0.78%-1.27%
0.00 %
0.50
54%-81%
0.05%-0.09%
0.00 %
5.50-6.00
54%-56%
0.30%-0.86%
0.00 %
0.50
47%-66%
0.17%-1.57%
0.00 %
A summary of the status of the Company’s options to purchase ordinary shares as of December 31, 2022 and changes during the year ended
on that date is presented below:
Outstanding at beginning of year
Granted
Exercised
Forfeited and cancelled
Outstanding at end of year
Exercisable options
Year ended December 31, 2022
Number of
options
8,549,322 $
857,077
(474,116)
(145,919)
8,786,364 $
7,103,058 $
Weighted
average
exercise
price
Aggregate
intrinsic
value
33.09
78.69
21.55
86.79
37.27 $
25.53 $
355,931
350,025
A summary of the status of the Company’s RSUs and PSUs as of December 31, 2022 and changes during the year ended on that date is
presented below:
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NovoCure Limited and subsidiaries
Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
Unvested at beginning of year
Granted
Vested
Forfeited and cancelled
Unvested at end of year (1)
Year ended December 31, 2022
Number of
RSUs/PSUs
4,459,107 $
1,572,203
(517,768)
(136,083)
5,377,459 $
Aggregate
intrinsic
value
Weighted
average
grant date
fair value
price
65.56
79.45
86.56
94.21
66.87 $
394,437
) Includes PSUs that have a mix of service, market and other milestone performance vesting conditions which are vested upon achievements
of market and performance conditions which are not probable, as of December 31, 2022, in accordance with ASC 718 as follows:
December 31, 2022
Number of
PSUs
2,703,852 $
108,113
124,701
17,712
7,605 $
10,532
189,626 $
3,162,141
Fair value at grant
date per PSU
Total fair value at
grant date
48.16 $
69.37
80.59
84.68
87.66 $
94.94
114.26 $
$
130,218
7,500
10,050
1,500
667
1,000
21,667
172,602
These PSUs will be expensed over the performance period when the vesting conditions become probable in accordance with ASC 718.
The total equity-based compensation expense related to all of the Company’s equity incentive plans recognized for the years ended
December 31, 2022, 2021 and 2020, was comprised as follows:
Cost of revenues
Research, development and clinical studies
Sales and marketing
General and administrative
Total share-based compensation expense
Year ended December 31,
2022
2021
2020
$
$
4,690 $
30,790
28,826
42,649
106,955 $
3,471 $
27,597
22,673
41,159
94,900 $
2,221
18,125
17,672
37,703
75,721
As of December 31, 2022, unamortized share-based compensation costs amounted to $125,600 and are expected to be recognized over a
weighted average period of approximately 2.38 years.
The weighted average grant date exercise price of the Company’s options granted during the years ended December 31, 2022, 2021 and 2020
were $78.69, $149.96 and $71.87 per share, respectively.
The weighted average grant date fair value of the Company’s options granted during the years ended December 31, 2022, 2021 and 2020 were
$44.70, $81.93 and $37.12 per share, respectively.
The weighted average grant date fair values of the Company’s options forfeited and cancelled during the years ended December 31, 2022,
2021 and 2020 were $86.79, $62.77 and $22.98, respectively.
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
The aggregate intrinsic values for the options exercised during the years ended December 31, 2022, 2021 and 2020 were $26,436, $143,695
and $156,910, respectively. The aggregate intrinsic value is calculated as the difference between the per share exercise price and the deemed
fair value of the Company’s ordinary shares for each share subject to an option multiplied by the number of shares subject to options at the date
of exercise. The Company deemed the fair value of the Company’s ordinary shares to be $73.35, $75.08 and $173.04 per share as of
December 31, 2022, 2021, and 2020, respectively.
Options outstanding as of December 31, 2022 are as follows:
Exercise price
$
0.00 - 10.00
10.01 - 20.00
20.01 - 30.00
30.01 - 40.00
40.01 - 60.00
60.01 - 100.00
100.01 - 160.00
160.01 - 220.00
Note 15: Financial (expenses) income, net
The following table sets forth the Company’s total financial expenses, net:
Financial expenses:
Interest expense
Revolving credit facility fee
Amortization of discount and issuance costs
Foreign currency translation losses
Others
Financial income:
Amortization of investments premium
Foreign currency translation gains
Interest income
Total financial (expenses) income, net
Number
of options
outstanding
971,356
2,570,427
1,773,039
263,141
1,148,810
1,620,734
429,595
9,262
8,786,364
Weighted
average
remaining
contractual
term
(years)
3.68
3.97
4.51
5.54
6.29
8.23
8.21
8.42
5.4
Number
of options
exercisable
971,356
2,570,427
1,773,039
263,141
984,817
417,461
114,879
7,938
7,103,058
Weighted
average
remaining
contractual
term
(years)
3.68
3.97
4.51
5.54
6.30
7.01
8.06
8.44
4.7
Year ended December 31,
2022
2021
2020
$
$
$
$
$
(41) $
(558)
(3,293)
(3,523)
(698)
(8,113) $
4,829 $
—
10,961
15,790 $
7,677 $
(101) $
(588)
(3,339)
(4,032)
(779)
(8,839) $
306 $
—
791
1,097 $
(7,742) $
(13,068)
(79)
(4,514)
—
(389)
(18,050)
1,316
2,648
1,787
5,751
(12,299)
Note 16: Basic and diluted net income (loss) per share
Basic net income (loss) per share is computed based on the weighted average number of ordinary shares outstanding during each period.
Diluted net income per share is computed based on the weighted average number of ordinary shares outstanding during the period, plus
potential dilutive shares (deriving from options, RSUs, PSUs, convertible notes and the ESPP) considered outstanding during the period, in
accordance with ASC 260-10, as determined under the treasury stock method.
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Notes to consolidated financial statements
U.S. dollars in thousands (except share and per share data)
The
following
table sets
forth
the computation of
the Company’s basic and diluted net
loss per ordinary share:
Net income (loss) attributable to ordinary shares as reported
Net income (loss) used in computing basic net income (loss) per share
Adjustment needed in calculating diluted net income (loss) per share
Net income (loss) used in computing diluted net income (loss) per share
Weighted average number of ordinary shares used in computing basic net income
(loss) per share
Potentially dilutive shares that were excluded from the computation of basic net
income (loss) per share:
Options
Restricted share units
ESPP
Weighted average number of ordinary shares used in computing diluted net income
(loss) per share
Weighted anti-dilutive shares outstanding which were not included in the diluted
calculation
Basic net income (loss) per ordinary share
Diluted net income (loss) per ordinary share
Note 17: Subcontractor
Year ended December 31,
2022
2021
2020
(92,534) $
(58,351) $
19,808
(92,534) $
(58,351) $
—
—
(92,534) $
(58,351) $
19,808
—
19,808
104,660,476
103,433,274
100,930,866
—
—
—
—
—
—
6,967,554
945,612
33,616
104,660,476
103,433,274
108,877,648
7,272,606
8,524,922
1,307,762
(0.88) $
(0.56) $
(0.88) $
(0.56) $
0.20
0.18
$
$
$
$
$
In certain markets and for certain key components, the Company is currently dependent upon sole source suppliers used in its devices. The
Company’s management believes that in most cases other suppliers could provide similar components at comparable terms. A change of
suppliers which requires FDA or other regulatory approval, however, could cause a material delay in manufacturing and a possible loss of sales,
which could adversely affect the Company’s operating results and financial position.
99
Note 18: Supplemental information
The following table presents long-lived assets by location:
United States
Israel
Switzerland
Japan
Germany
Others
Total long-lived assets
December 31,
2022
2021
$
$
30,012 $
7,180
5,084
1,063
762
1,261
45,362 $
23,263
5,297
4,085
799
1,020
1,152
35,616
The Company’s net revenues by geographic region, based on the patient’s location are summarized as follows:
United States
EMEA:
Germany
Other EMEA
Japan
Greater China (1)
Total net revenues
Year ended December 31,
2022
2021
2020
$
406,894 $
353,110 $
340,782
46,120
30,713
32,781
21,332
537,840 $
93,939
30,577
34,640
22,765
535,031 $
93,264
18,654
29,076
12,590
494,366
$
(1) For additional information, see Note 12.
Note 19: Selected quarterly financial information (Unaudited)
The following table sets forth selected financial information for the Company:
2022
Three months ended
Net revenues
Gross profit
Operating income (loss)
Net income (loss)
Basic net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing basic
net income (loss) per share
Diluted net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing
diluted net income (loss) per share
$
$
$
December 31
September 30
June 30
March 31
128,429 $
99,541
(42,978)
(37,303)
(0.36) $
130,998 $
101,249
(24,611)
(26,576)
(0.25) $
140,866 $
112,363
(21,128)
(24,008)
(0.23) $
137,547
109,820
(806)
(4,647)
(0.04)
105,026,945
104,884,583
104,627,789
(0.36) $
(0.25) $
(0.23) $
104,186,120
(0.04)
105,026,945
104,884,583
104,627,789
104,186,120
100
Net revenues
Gross profit
Operating income (loss)
Net income (loss)
Basic net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing basic
net income (loss) per share
Diluted net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing
diluted net income (loss) per share
Net revenues
Gross profit
Operating income (loss)
Net income (loss)
Basic net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing basic
net income (loss) per share
Diluted net income (loss) per ordinary share
Weighted average number of ordinary shares used in computing
diluted net income (loss) per share
2021
Three months ended
December 31
September 30
June 30
March 31
133,213 $
103,526
(23,398)
(26,458)
(0.25) $
133,606 $
103,400
(8,552)
(13,124)
(0.13) $
133,517 $
104,918
(12,295)
(14,641)
(0.14) $
134,695
108,310
(88)
(4,128)
(0.04)
103,884,288
103,731,147
103,484,866
(0.25) $
(0.13) $
(0.14) $
102,633,545
(0.04)
103,884,288
103,731,147
103,484,866
102,633,545
2020
Three months ended
December 31
September 30
June 30
March 31
143,953 $
115,817
12,092
4,917
0.05 $
132,660 $
104,265
15,022
9,284
0.09 $
115,925 $
90,451
6,668
1,655
0.02 $
101,828
77,332
(3,381)
3,952
0.04
101,945,085
101,234,306
100,718,893
0.04 $
0.09 $
0.02 $
99,877,567
0.04
110,604,714
108,643,814
107,647,802
108,100,623
$
$
$
$
$
$
Note 20: Subsequent Event
On February 17, 2023, the Company gave irrevocable notice to the administrative agent under the Credit Facility that the Company terminated
all commitments, effective February 22, 2023. See Note 12c.
101
Table of Contents
ITEM 9. CHANGES IN AND DISAGREEMENTS WITH ACCOUNTANTS ON ACCOUNTING AND FINANCIAL DISCLOSURE
None.
ITEM 9A. CONTROLS AND PROCEDURES
(a) Evaluation of Disclosure Controls and Procedures
Our management, with the participation of our Chief Executive Officer and Chief Financial Officer, evaluated the effectiveness of our disclosure
controls and procedures as of the end of the period covered by this Annual Report on Form 10-K. Based on that evaluation, the Chief Executive
Officer and Chief Financial Officer concluded that our disclosure controls and procedures as of the end of the period covered by this Annual
Report on Form 10-K have been designed and are functioning effectively to provide reasonable assurance that the information required to be
disclosed by us in reports filed under the Securities Exchange Act of 1934 is recorded, processed, summarized and reported within the time
periods specified in the SEC’s rules and forms. We believe that a controls system, no matter how well designed and operated, cannot provide
absolute assurance that the objectives of the controls system are met, and no evaluation of controls can provide absolute assurance that all
control issues and instances of fraud, if any, within a company have been detected.
(b) Management’s Annual Report on Internal Control over Financial Reporting
Management is responsible for establishing and maintaining adequate internal control over financial reporting as defined in Rules 13a-15(f) and
15d- 15(f) under the Exchange Act. Our internal control over financial reporting is a process designed to provide reasonable assurance
regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with general
accepted accounting principles. Because of its inherent limitations, internal control over financial reporting may not prevent or detect
misstatements. Projections of any evaluation of effectiveness to future periods are subject to the risk that controls may become inadequate
because of changes in conditions, or that the degree of compliance with the policies or procedures may deteriorate.
Our management assessed the effectiveness of our internal control over financial reporting as of December 31, 2022. In making this
assessment, it used the criteria established in Internal Control- Integrated Framework (2013) issued by the Committee of Sponsoring
Organizations of the Treadway Commission (COSO). Based on such assessment, management has concluded that, as of December 31, 2022,
our internal control over financial reporting is effective based on those criteria.
(c) Attestation Report of the Registered Public Accounting Firm
The effectiveness of our internal control over financial reporting as of December 31, 2022, has been audited by Kost Forer Gabbay & Kasierer,
a member of Ernst & Young Global, an independent registered public accounting firm, as stated in their attestation report, which is included
herein.
(d) Changes in Internal Control over Financial Reporting
There have been no changes in our internal control over financial reporting during our most recent fiscal quarter that have materially affected, or
are reasonably likely to materially affect, our internal control over financial reporting.
ITEM 9B. OTHER INFORMATION
Election of New Director.
On February 22, 2023, the Board of Directors (the “Board”) of the Company elected Allyson J. Ocean, M.D., effective immediately, to fill an
existing vacancy on the Board. Dr. Ocean will receive compensation for her service on the Board as a non-employee member of the Board in
the same manner as other non-employee members of the Board. For a description of the Company’s director compensation programs, see
“Director Compensation” in the definitive proxy statement filed by the Company on April 25, 2022 in connection with its 2022 Annual Meeting of
Shareholders.
Allyson J. Ocean
Dr. Ocean, 51, is is an internationally recognized academic gastrointestinal medical oncologist specializing in translational and clinical research,
development of novel therapeutics, and patient advocacy. Dr. Ocean is currently an Associate Professor of Clinical Medicine at the Weill
Medical College of Cornell University, a position she has held since 2004. Dr. Ocean also currently serves as a medical oncologist and
attending physician in gastrointestinal
102
Table of Contents
oncology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, as well as a medical oncologist at The Jay Monahan Center for
Gastrointestinal Health. Dr. Ocean is co-founder and Scientific Advisory Board Chair of Let’s Win Pancreatic Cancer, an award-winning non-
profit organization missioned to increase access to treatment options and clinical trials for patients with pancreatic cancer. Additionally, Dr.
Ocean serves on several scientific advisory boards. Dr. Ocean graduated cum laude from Tufts University and received her M.D. with honors
from the Tufts University School of Medicine.
Dr. Ocean will be appointed to a Board committee at a later date.
Upon her election to the Board, and pursuant to the Company’s Non-Employee Director Plan, Dr. Ocean will be awarded an option under the
Company's 2015 Omnibus Incentive Plan as of February 28, 2023 ("Grant Date") to purchase ordinary shares of the Company with an
aggregate Grant Date fair value of $667,000 (subject to rounding of shares to the nearest whole number) using the Black-Scholes pricing model
and the valuation assumptions used by the Company in accounting for options as of the Grant Date at an exercise price per share equal to the
closing price of the Company’s ordinary shares on the Grant Date (the “Options”). The Options shall vest in equal amounts on the first, second
and third anniversary of the Grant Date.
There is no arrangement or understanding between Dr. Ocean and any other persons pursuant to which Dr. Ocean was elected to serve on the
Board.
Dr. Ocean does not have any direct or indirect material interest in any transaction or proposed transaction required to be reported under Item
404(a) of Regulation S-K or Item 5.02(d) of Form 8-K.
Termination of a Material Definitive Agreement.
On February 17, 2023, the Company gave irrevocable notice under the Company’s Credit Agreement, dated as of November 6, 2020, by and
among the Company, as borrower, JPMorgan Chase Bank, N.A., as administrative agent and the financial institutions party thereto, (“Lenders”)
(as amended, restated, supplemented or otherwise modified, the “Credit Agreement”) to terminate all commitments, effective February 22,
2023. This effectively terminated the Credit Facility, as the Company’s ability to borrow and its obligations to comply with all covenants ended on
such date. The liens and guaranties in favor of the Lenders are released. As of the date of termination, the Company had no outstanding
balance borrowed under the Credit Agreement. No early termination fees or penalties were payable in connection with the termination.
ITEM 9C. DISCLOSURE REGARDING FOREIGN JURISDICTIONS THAT PREVENT INSPECTIONS
Not applicable.
103
Table of Contents
ITEM 10. DIRECTORS, EXECUTIVE OFFICERS AND CORPORATE GOVERNANCE
PART III
The information required by Item 10 is incorporated herein by reference to the information contained under the captions "Proposal 1 — Election
of Directors,” “Corporate Governance,” “Delinquent Section 16(A) Reports” and “Proposal 2 – Approval and Ratification of Appointment of
Independent Registered Public Accounting Firm” in our definitive proxy statement related to the 2023 annual meeting of shareholders.
ITEM 11. EXECUTIVE COMPENSATION
The information required by this Item 11 is incorporated by reference to the information contained under the caption "2022 Director
Compensation," "Compensation Discussion and Analysis — Executive Compensation" and "Compensation Committee Report" in our definitive
proxy statement related to the 2023 annual meeting of shareholders.
ITEM 12. SECURITY OWNERSHIP OF CERTAIN BENEFICIAL OWNERS AND MANAGEMENT AND RELATED STOCKHOLDER MATTERS
The information required by Item 12 regarding the ownership of our ordinary shares is incorporated by reference to the information contained
under the caption "Information About Stock Ownership — Security Ownership of Certain Beneficial Owners And Management" in our definitive
proxy statement related to the 2023 annual meeting of shareholders.
The information required by Item 12 with respect to securities authorized for issuance under our equity compensation plans is provided under
the caption "Equity Compensation Plan Information" in Part II, Item 5 hereof.
ITEM 13. CERTAIN RELATIONSHIPS AND RELATED TRANSACTIONS, AND DIRECTOR INDEPENDENCE
The information required by Item 13 is incorporated by reference to the information contained under the captions "Proposal 1 – Election of
Directors," "Corporate Governance," and "Certain Relationships and Related Party Transactions" in our definitive proxy statement related to the
2023 annual meeting of shareholders.
ITEM 14. PRINCIPAL ACCOUNTING FEES AND SERVICES
The information required by Item 14 is incorporated by reference to the information contained under the caption "Proposal 2 – Approval and
Ratification of Appointment of Independent Registered Public Accounting Firm" in our definitive proxy statement related to the 2023 annual
meeting of shareholders.
104
Table of Contents
ITEM 15. EXHIBITS AND FINANCIAL STATEMENT SCHEDULES
(a) DOCUMENTS FILED AS PART OF THIS REPORT
PART IV
The following is a list of our consolidated financial statements and our subsidiaries and supplementary data included in this Annual Report on
Form
hereof:
Item
1. FINANCIAL STATEMENTS AND SUPPLEMENTAL DATA
under
10-K
Part
of
8
II
Report of Independent Registered Public Accounting Firm.
Consolidated Balance Sheets as of December 31, 2022, 2021 and 2020.
Consolidated Statements of Operations for the years ended December 31, 2022, 2021 and 2020.
Consolidated Statement of Comprehensive Loss for the years ended December 31, 2022, 2021 and 2020.
Consolidated Statements of Shareholders’ Equity for the years ended December 31, 2022, 2021 and 2020
Consolidated Statements of Cash Flows for the years ended December 31, 2022, 2021 and 2020.
Notes to Consolidated Financial Statements.
2. FINANCIAL STATEMENT SCHEDULES
Schedules are omitted because they are not applicable or are not required, or because the required information is included in the consolidated
financial statements or notes thereto.
(b) EXHIBITS
The following is a list of exhibits filed as part of this Annual Report on Form 10-K. Where so indicated by footnote, exhibits that were previously
filed are incorporated by reference. For exhibits incorporated by reference, the location of the exhibit in the previous filing is indicated.
EXHIBIT INDEX
Exhibit
Number
3.1
3.2
4.1
4.2
4.3
4.4
Exhibit Description
Memorandum of Association
Amended and Restated Articles of Association
Description of the Registrant’s Securities Registered Pursuant to Section
12 of the Securities Exchange Act of 1934
Eleventh Amended and Restated Investors Rights Agreement, dated
June 1, 2015
Tenth Amended and Restated Registration Rights Agreement, dated
June 1, 2015
Indenture, dated November 5, 2020, between NovoCure Limited. and
U.S. Bank National Association
105
Incorporated by Reference
Date
9/21/15
6/6/18
Number
3.3
3.2
Form
S-1/A
8-K
Filed
Herewith
X
DRS
DRS
8-K
6/24/15
6/24/15
11/5/20
4.2
4.3
4.1
Table of Contents
Exhibit
Number
4.5
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10
10.11
10.12
10.13
10.14
10.15
10.16
10.17
10.18
10.19
10.20
Exhibit Description
Form of 0% Convertible Senior Note due 2025 (included in Exhibit 4.4)
Credit Agreement dated November 6, 2020 among NovoCure Limited,
the subsidiary borrowers party thereto, the lenders party thereto and J.P.
Morgan Chase Bank, N.A., as administrative agent
License and Collaboration Agreement, dated as of September 10, 2018,
between NovoCure Limited and Zai Lab (Shanghai) Co., Ltd.
Settlement Agreement with the Technion, dated February 10, 2015
2003 Share Option Plan#
2013 Share Option Plan#
2015 Omnibus Incentive Plan#
Director Compensation Plan#
Employee Share Purchase Plan#
Form of Non-Qualified Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan (U.S. individuals)#
Form of Incentive Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan (U.S. individuals)#
2015 Omnibus Incentive Plan, including 2015 Omnibus Incentive Plan
Sub-Plan for Grantees Subject to Israeli Taxation and 2015 Omnibus
Incentive Plan Sub-Plan for Switzerland#
Form of Incentive Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan for use in connection with the 2015 Omnibus
Incentive Plan Sub-Plan for Grantees Subject to Israeli Taxation (non-
102(b) grants)#
Form of Incentive Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan for use in connection with the 2015 Omnibus
Incentive Plan Sub-Plan for Grantees Subject to Israeli Taxation (102(b)
grants)#
Form of Stock Option Award Agreement based on the 2015 Omnibus
Incentive Plan for use in connection with the 2015 Omnibus Incentive
Plan Sub-Plan for Switzerland#
Form of Incentive Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan for use in Japan#
Form of Stock Option Award Agreement based on the 2015 Omnibus
Incentive Plan for use in Germany#
Form of Incentive Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan#
Form of Non-Qualified Stock Option Agreement pursuant to the 2015
Omnibus Incentive Plan#
Form of Incentive Stock Option Agreement pursuant to the NovoCure
Limited 2015 Omnibus Incentive Plan – Form of Performance Option
Agreement for Israel#
NovoCure Limited Policy on Recoupment of Incentive Compensation#
106
Incorporated by Reference
Date
11/5/20
11/9/20
Number
4.2
10.1
Form
8-K
8-K
Filed
Herewith
10-Q
10/25/18
10.2
DRS/A
DRS
DRS
S-1/A
S-1/A
S-1/A
S-1/A
8/11/15
6/24/15
6/24/15
9/21/15
9/21/15
9/21/15
9/21/15
S-1/A
9/21/15
10.13
10.3
10.4
10.5
10.14
10.15
10.17
10.18
8-K
12/22/15
10.1
8-K
12/22/15
10.2
8-K
12/22/15
10.3
8-K
12/22/15
10.4
8-K
10-K
8-K
8-K
8-K
8-K
12/22/15
10.5
3/1/16
10.25
5/12/17
5/12/17
4/4/18
10.1
10.2
10.1
8/1/17
99.1
Table of Contents
Exhibit
Number
10.21
10.22
10.23
10.24
10.25
10.26
10.27
10.28
10.29
10.30
10.31
10.32
10.33
10.34
10.35
10.36
10.37
10.38
10.39
10.40
10.41
Exhibit Description
Form of Indemnification Agreement
Employment Agreement, dated as of May 11, 2016, by and between
Novocure USA LLC and William F. Doyle#
Amendment #1 to Employment Agreement between Novocure USA LLC
and William F. Doyle dated February 24, 2021#
Israeli SubPlan to the NovoCure Limited Employee Share Purchase
Plan#
Non-Employee Director Compensation Program#
Employment Agreement, dated as of October 10, 2016, by and between
NovoCure (Israel) Ltd. and Asaf Danziger#
Employment Agreement, dated as of October 10, 2016, by and between
Novocure USA LLC and Wilhelmus Groenhuysen#
Amended and Restated Employment Agreement dated as of September
1, 2020 by and between Novocure USA LLC and Wilhelmus
Groenhuysen#
Employment Agreement, dated as of October 10, 2016, by and between
NovoCure USA LLC and Michael J. Ambrogi#
Amended and Restated Employment Agreement, dated as of September
1, 2002, by and between NovoCure USA LLC and Michael J. Ambrogi#
Employment Agreement, dated as of September 1, 2020, by and
between NovoCure USA LLC and Ashley Cordova#
Employment Agreement, dated as of July 25, 2018, between Novocure
USA LLC and Pritesh Shah#
Form of Restricted Share Unit Award Notice pursuant to the 2015
Omnibus Incentive Plan – Form of Agreement for USA#
Form of Restricted Share Unit Award Notice pursuant to the 2015
Omnibus Incentive Plan – Form of Agreement for Israel#
Form of Restricted Share Unit Award Notice pursuant to the 2015
Omnibus Incentive Plan – Form of Agreement for Switzerland#
Form of Restricted Share Unit Award Notice pursuant to the 2015
Omnibus Incentive Plan – Form of Agreement for Japan#
Form of Restricted Share Unit Award Notice pursuant to the 2015
Omnibus Incentive Plan – Form of Agreement for Germany#
Form of Performance-Based Share Unit Award for Executive Chairman
and Chief Executive Officer#
Form of Performance-Based Share Unit Award for Certain Executive
Officers#
First Addendum dated June 9, 2020 to License and Collaboration
Agreement, dated as of September 10, 2018, between NovoCure
Limited and Zai Lab (Shanghai) Co., Ltd.**
Purchase and Sale Agreement dated December 1, 2021 by and
between 64 Vaughan Mall, LLC and Novocure Inc.
107
Incorporated by Reference
Date
3/22/16
5/13/16
Number
10.1
10.1
Form
8-K
8-K
Filed
Herewith
2/25/21
10.23
6/30/16
7/28/22
10/14/16
10/14/16
8/13/20
10.1
10.2
10.1
10.2
10.1
10/14/16
10.3
8/13/20
10.30
10-K
8-K
10-Q
8-K
8-K
8-K
8-K
8-K
8-K
8/13/20
10-Q
10/25/18
10-K
10-K
10-K
10-K
8-K
8-K
8-K
2/23/17
2/23/17
2/23/17
2/23/17
4/4/18
3/6/20
3/6/20
10.2
10.1
10.28
10.29
10.30
10.31
10.2
10.1
10.2
10-K
2/25/21
10.40
10-K
2/24/22
10.41
Table of Contents
Exhibit
Number
10.42
10.43
21
23.1
31.1
31.2
32.1*
32.2*
101.INS
101.SCH
101.CAL
101.DEF
101.LAB
101.PRE
104
Exhibit Description
Construction Agreement dated December 30, 2021 by and between
Hanover Development Corporation and Novocure Inc.**
Amendment No. 1 dated as of December 6, 2021 to Credit Agreement
dated as of November 6, 2020
Subsidiaries
Consent of Independent Registered Public Accounting Firm
Certification of Principal Executive Officer Required Under Rule 13a-
14(a) and 15d-14(a) of the Securities Exchange Act of 1934, as
amended
Certification of Principal Financial Officer Required Under Rule 13a-
14(a) and 15d-14(a) of the Securities Exchange Act of 1934, as
amended
Certification of Principal Executive Officer Required Under Rule 13a-
14(b) of the Securities Exchange Act of 1934, as amended, and 18
U.S.C. §1350
Certification of Principal Financial Officer Required Under Rule 13a-
14(b) of the Securities Exchange Act of 1934, as amended, and 18
U.S.C. §1350
Inline XBRL Instance Document
Inline XBRL Taxonomy Extension Schema Document
Inline XBRL Taxonomy Extension Calculation Linkbase Document
Inline XBRL Taxonomy Extension Definition Linkbase Document
Inline XBRL Taxonomy Extension Label Linkbase Document
Inline XBRL Extension Presentation Linkbase Document
Cover Page Interactive Data File (formatted as Inline XBRL and
contained in Exhibit 101)
Incorporated by Reference
Date
2/24/22
Number
10.42
Form
10-K
10-K
2/24/22
10.43
Filed
Herewith
X
X
X
X
X
X
X
X
X
X
X
X
X
*
†
#
**
The certifications attached as Exhibits 32.1 and 32.2 that accompany this Annual Report on Form 10-K are not deemed filed with the
Securities and Exchange Commission and are not to be incorporated by reference into any filing of NovoCure Limited under the
Securities Act of 1933, as amended, or the Securities Exchange Act of 1934, as amended, whether made before or after the date of
this Form 10-K, irrespective of any general incorporation language contained in such filing.
Confidential treatment has been granted for certain information set forth in this exhibit. Such information has been omitted and filed
separately with the Securities and Exchange Commission.
Compensation plans and arrangements for executive officers and others.
Portions of the referenced exhibit have been omitted pursuant to Item 601(b)(10) of Regulation S-K
This Annual Report on Form 10-K includes trademarks of NovoCure Limited and other persons. All trademarks or trade names referred to
herein are the property of their respective owners.
ITEM 16. FORM 10-K SUMMARY
None.
108
Table of Contents
Pursuant to the requirements of Section 13 or 15(d) of the Securities Exchange Act of 1934, the registrant has duly caused this report to be
signed on its behalf by the undersigned, thereunto duly authorized.
Date: February 23, 2023
SIGNATURES
NovoCure Limited
By:
/s/ Asaf Danziger
Asaf Danziger
Chief Executive Officer
Pursuant to the requirements of the Securities Exchange Act of 1934, this report has been signed below by the following persons on behalf of
indicated.
capacities
the
Signature
Registrant
dates
and
and
the
the
Date:
on
Title
in
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
February 23, 2023
/s/ Asaf Danziger
Asaf Danziger
/s/ Ashley Cordova
Ashley Cordova
/s/ William F. Doyle
William F. Doyle
/s/ Jeryl L. Hilleman
Jeryl L. Hilleman
/s/ David T. Hung
David T. Hung
/s/ Kinyip Gabriel Leung
Kinyip Gabriel Leung
/s/ Martin J. Madden
Martin J. Madden
/s/ Timothy J. Scannell
Timothy J. Scannell
/s/ William A. Vernon
William A. Vernon
109
Chief Executive Officer and Director (Principal
Executive Officer)
Chief Financial Officer (Principal Financial and
Accounting Officer)
Executive Chairman and Director
Director
Director
Director
Director
Director
Director
NOVOCURE LIMITED
DESCRIPTION OF SECURITIES REGISTERED PURSUANT TO
SECTION 12 OF THE SECURITIES EXCHANGE ACT OF 1934
Exhibit 4.1
NovoCure Limited, a Jersey corporation (“we,” “us” or “our”) has one class of securities registered pursuant to Section 12 of the
Securities Exchange Act of 1934: our ordinary shares, no par value per share. Our ordinary shares are listed on the NASDAQ Global Select
Market under the symbol “NVCR.”
The general terms and provisions of our ordinary shares are summarized below. This summary does not purport to be complete and is
qualified in all respects by reference to certain provisions of the Companies (Jersey) Law 1991 (the “Jersey Companies Law”) and our amended
and restated articles of association (our “articles of association”) and our memorandum of association, which have been filed as an exhibit to
our most recent Annual Report on Form 10-K filed with the Securities and Exchange Commission (the “SEC”) and are hereby incorporated by
reference. Our articles of association and our memorandum of association may be amended from time to time, with any such amendments to
be reflected by a document filed with one of our periodic or current reports filed with the SEC subsequent to the date of such Annual Report.
Our authorized share capital consists of an unlimited number of no par value shares, comprised of (i) an unlimited number of ordinary
shares, and (ii) an unlimited number of preferred shares, of which no preferred shares are currently outstanding. Our articles of association
provide that preferred shares may be issued from time to time in one or more classes. Our board of directors is authorized to fix the voting
rights, if any, designations, powers, preferences, the relative participating, optional or other special rights, and any qualifications, limitations and
restrictions thereof, applicable to the shares of each class. Our board of directors is able, without shareholder approval, to issue any authorized
but unissued preferred shares with voting and other rights that could adversely affect the voting power and other rights of the holders of the
ordinary shares. The ability of our board of directors to issue preferred shares without shareholder approval could have the effect of delaying,
deferring or preventing a change of control of us or the removal of existing management.
Description of Ordinary Shares
General
Voting rights
Holders of our ordinary shares are entitled to one vote per share on matters to be voted on by shareholders. The Jersey Companies
Law does not confer any pre-emptive rights to purchase our shares from our shareholders. There is no cumulative voting of shares.
Dividends and other distributions
Holders of our ordinary shares are entitled to receive such dividends, if any, as may be approved by our board of directors in its
discretion. In order to be able to declare any dividends, our directors must make a statutory solvency statement to the effect that we will be able
to discharge our liabilities as they fall due and that, having regard to our prospects as to the intention of the directors with respect to the
management of our business, and with the amount and character of the financial resources that will in the view of the directors be available to
us, we will be able to continue to carry on business and discharge our liabilities as they fall due for a 12-month period immediately following the
date on which the dividend is proposed to be paid (or until we are dissolved on a solvent basis, if earlier). Dividends must be apportioned and
paid pro rata according to the amounts paid on shares, unless otherwise specified in the
rights attached to a specific class or classes of shares. Dividends do not accrue interest and may, if unclaimed, be invested by our board of
directors on our behalf until claimed. Any dividend unclaimed after a period of seven years from the date of declaration of such dividend or the
date on which such dividend became due for payment is forfeited and becomes our property.
Our articles of association provide that our board of directors may offer our shareholders the right to receive in lieu of any cash dividend
(or part thereof) that we declare on our ordinary shares, such number of our ordinary shares that are (or nearly as possible) equivalent in value
to the cash dividend, based on the market price of such shares determined in accordance with our articles of association.
Winding up
If we are wound up (whether the liquidation is voluntary, under supervision or by the courts of Jersey), the liquidator (or the board of
directors, where no liquidator is appointed) may, with the authority of a special resolution of our shareholders, divide among our shareholders
part or all of our assets, or transfer any part of our assets to a trustee for the benefit of our shareholders.
Changes in capital and allotment of securities
We may, by special resolution of our shareholders, alter our memorandum of association to change the amount of our share capital,
consolidate all or any of our shares (whether issued or not) into fewer shares or divide all or any of our shares (whether issued or not) into more
shares, cancel any unissued shares or alter our share capital in any other way permitted by the Jersey Companies Law. Subject to the
provisions of the Jersey Companies Law, our board of directors has the discretion to issue authorized but unissued shares.
Variation of class rights
The rights attaching to any class of shares may only be altered by approval of holders of not less than two-thirds (2/3) of the number of
the issued shares of that class, or by special resolution of the relevant class passed at a class shareholder meeting by the holders of not less
than two-thirds (2/3) in number of the issued shares of such class, in each case, being voted in person or by proxy at such meeting. In addition,
unless otherwise expressly provided by the conditions of issue of, or statement of rights relating to, any shares or class of shares, the rights
conferred upon the holders of any shares or class of shares (regardless of whether they are issued with preferred, deferred or other special
rights) will not be deemed to be varied or abrogated by the creation or issue of further shares or classes of shares (including additional shares
of such class), the conversion and redemption of shares in accordance with our articles of association or any applicable statement of rights, or
the purchase or redemption by us of our own shares.
Special meetings
Under the Jersey Companies Law, only our board of directors or shareholders holding at least 10% of the total voting rights of our share
capital can requisition a shareholders’ meeting. A meeting requisitioned by shareholders must be held within two months of receipt by us of the
written request, but such shareholders may call the meeting if our board of directors does not call the meeting within 21 days of the date of
deposit of the written request at our registered office, in which event such meeting must be held within three months of the date of deposit of the
written request of our registered office. Our articles of association specifies the information that a shareholder requisitioning a shareholders’
meeting is required to provide with its written request for the requisition of a shareholders’ meeting.
Actions by written consent
Our Articles of Association permits the adoption of an ordinary or special resolution of shareholders by written consent; however, Jersey
law and our Articles of Association require that any ordinary or special resolution adopted by written consent be signed by all shareholders
entitled to vote on such resolution.
Shareholders may adopt an ordinary or special resolution in writing, if all of the following conditions are met:
1. All shareholders entitled to vote receive:
a. a copy of the ordinary or special resolution; and
b. a statement informing shareholders how to signify their agreement to the resolution (which may be by electronic
means) and the date by which the resolution must be passed if it is not to lapse twenty-eight days after the circulation
date; and
2.All shareholders entitled to vote:
a. sign a document; or
b. sign several documents in the like form each signed by one or more of the shareholders entitled to vote; and
c. the signed document is returned to us at the place and time indicated in the notice (which may be by electronic
means).
The notice to shareholders must be in addition to (if not already included in) any notice or proxy statement required to be distributed in
accordance with U.S. securities law or exchange regulation applicable to the class of shares being voted. Each shareholder has one vote for
each eligible share held by such shareholder, and, unless specified otherwise in the document transmitting the shareholder's approval of the
resolution, all such eligible shares will be voted for such resolution.
Directors
Our board of directors may vary the minimum or maximum number of directors (subject to a minimum of two and a maximum of 13
directors), and may appoint directors to fill any vacancies. In 2018, our articles of association were amended to declassify the board of directors.
In 2020, our Class I and Class II directors will be elected to one-year terms expiring at our annual meeting of shareholders in 2021 and,
beginning with our annual meeting of shareholders in 2021, all directors will be elected to one-year terms expiring at the subsequent annual
meeting of shareholders.
Shareholders are only able to appoint a person as a director at a shareholder meeting if (i) the relevant person has been recommended
by our board of directors or is a serving director who is retiring at that shareholder meeting; or (ii) if a shareholder (other than the person
proposed as a director) who is entitled to attend and vote at that shareholder meeting has submitted written notice to us of their intention to
nominate the relevant person no less than 90 and no more than 120 full days prior to the date of that shareholder meeting, along with a notice
from the relevant person confirming their willingness to be appointed.
Name of Subsidiary and Name
Under Which It Does Business
Novocure Austria GmbH
Novocure Canada, Inc.
Novocure Capital
Novocure Denmark ApS
NovoCure (Israel) Ltd.
Novocure France SAS
NovoCure GmbH
Novocure GmbH
Novocure Inc.
Novocure Italy S.r.L.
Novocure K.K.
Novocure Luxembourg S.à.r.l.
Novocure Netherlands B.V.
Novocure Poland Sp. z o.o.
Novocure Spain S.L.
Novocure USA LLC
Novocure UK Limited
SUBSIDIARIES OF NOVOCURE LIMITED
Jurisdiction of Incorporation
Exhibit 21
Austria
Canada
Luxembourg
Denmark
Israel
France
Germany
Switzerland
Delaware
Italy
Japan
Luxembourg
Netherlands
Poland
Spain
Delaware
United Kingdom
Exhibit 23.1
We consent to the incorporation by reference in the following Registration Statements:
(1) Registration Statement (Form S-8 No. 333-209854) pertaining to the NovoCure Limited Employee Share Purchase Plan, the NovoCure Limited 2015
Omnibus Incentive Plan, the NovoCure Limited 2013 Share Option Plan and the Standen Limited 2003 Share Option Plan,
(2) Registration Statement (Form S-8 No. 333-217619) pertaining to the NovoCure Limited Employee Share Purchase Plan and the NovoCure Limited
2015 Omnibus Incentive Plan,
(3) Registration Statement (Form S-8 No. 333-224606) pertaining to the NovoCure Limited 2015 Omnibus Incentive Plan,
(4) Registration Statement (Form S-8 No. 333-232896) pertaining to the NovoCure Limited Employee Share Purchase Plan, the NovoCure Limited 2015
Omnibus Incentive Plan,
(5) Registration Statement (Form S-8 No. 333-236862) pertaining to the NovoCure Limited Employee Share Purchase Plan, the NovoCure Limited 2015
Omnibus Incentive Plan,
(6) Registration Statement (Form S-8 No. 333-253499) pertaining to the NovoCure Limited Employee Share Purchase Plan, the NovoCure Limited 2015
Omnibus Incentive Plan, and
(7) Registration Statement (Form S-8 No. 333-262965) pertaining to the NovoCure Limited 2015 Omnibus Incentive Plan;
of our reports dated February 23, 2023, with respect to the consolidated financial statements of NovoCure Limited and the effectiveness of internal control
over financial reporting of NovoCure Limited included in this Annual Report (Form 10-K) of NovoCure Limited for the year ended December 31, 2022, filed
with the Securities and Exchange Commission.
Tel Aviv, Israel
February 23, 2023
/s/ KOST FORER GABBAY AND KASIERER
A member of Ernst & Young Global
I, Asaf Danziger, certify that:
Exhibit 31.1
1.
2.
3.
4.
5.
I have reviewed this Annual Report on Form 10-K of NovoCure Limited;
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact
necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with
respect to the period covered by this report;
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all
material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented
in this report;
The registrant’s other certifying officer(s) and I are responsible for establishing and maintaining disclosure controls and procedures
(as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange
Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:
(a)
(b)
(c)
(d)
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to
be designed under our supervision, to ensure that material information relating to the registrant,
including its consolidated subsidiaries, is made known to us by others within those entities, particularly
during the period in which this report is being prepared;
Designed such internal control over financial reporting, or caused such internal control over financial
reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability
of financial reporting and the preparation of financial statements for external purposes in accordance
with generally accepted accounting principles;
Evaluated the effectiveness of the registrant's disclosure controls and procedures and presented in this
report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of
the period covered by this report based on such evaluation; and
Disclosed in this report any change in the registrant's internal control over financial reporting that
occurred during the registrant's most recent fiscal quarter (the registrant's fourth fiscal quarter in the case
of an annual report) that has materially affected, or is reasonably likely to materially affect, the
registrant's internal control over financial reporting.
The registrant’s other certifying officers and I have disclosed, based on our most recent evaluation of internal control over financial
reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the
equivalent functions):
(a)
(b)
all significant deficiencies and material weaknesses in the design or operation of internal control over
financial reporting which are reasonably likely to adversely affect the registrant's ability to record,
process, summarize and report financial information; and
any fraud, whether or not material, that involves management or other employees who have a significant
role in the registrant's internal controls over financial reporting.
Date: February 23, 2023
/s/ Asaf Danziger
Asaf Danziger
Chief Executive Officer and Director
(Principal Executive Officer)
I, Ashley Cordova, certify that:
CERTIFICATIONS
Exhibit 31.2
1.
2.
3.
4.
5.
I have reviewed this Annual Report on Form 10-K of NovoCure Limited;
Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to
make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period
covered by this report;
Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material
respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;
The registrant’s other certifying officer(s) and I are responsible for establishing and maintaining disclosure controls and procedures (as
defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules
13a-15(f) and 15d-15(f)) for the registrant and have:
(a)
(b)
(c)
(d)
Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under
our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is
made known to us by others within those entities, particularly during the period in which this report is being prepared;
Designed such internal control over financial reporting, or caused such internal control over financial reporting to be
designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the
preparation of financial statements for external purposes in accordance with generally accepted accounting principles;
Evaluated the effectiveness of the registrant's disclosure controls and procedures and presented in this report our
conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this
report based on such evaluation; and
Disclosed in this report any change in the registrant's internal control over financial reporting that occurred during the
registrant's most recent fiscal quarter (the registrant's fourth fiscal quarter in the case of an annual report) that has
materially affected, or is reasonably likely to materially affect, the registrant's internal control over financial reporting.
The registrant’s other certifying officers and I have disclosed, based on our most recent evaluation of internal control over financial
reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent
functions):
(a)
(b)
all significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting
which are reasonably likely to adversely affect the registrant's ability to record, process, summarize and report financial
information; and
any fraud, whether or not material, that involves management or other employees who have a significant role in the
registrant's internal controls over financial reporting.
Date: February 23, 2023
/s/ Ashley Cordova
Ashley Cordova
Chief Financial Officer
(Principal Accounting and Financial Officer)
NOVOCURE LIMITED
CERTIFICATION PURSUANT TO
18 U.S.C. SECTION 1350,
AS ADOPTED PURSUANT TO
SECTION 906 OF THE SARBANES-OXLEY ACT OF 2002
Exhibit 32.1
In connection with the Annual Report of NovoCure Limited (the "Company") on Form 10-K for the fiscal year ended December 31, 2022, as filed with the
Securities and Exchange Commission on the date hereof (the "Report"), I, Asaf Danziger, Chief Executive Officer (Principal Executive Officer) of the
Company, certify, pursuant to 18 U.S.C. § 1350, as adopted pursuant to § 906 of the Sarbanes-Oxley Act of 2002, that:
(1)
(2)
The Report fully complies with the requirements of section 13(a) or 15(d) of the Securities Exchange Act of 1934; and
The information contained in the Report fairly presents, in all material respects, the financial condition and result of operations of the
Company.
/s/ Asaf Danziger
Asaf Danziger
Chief Executive Officer
(Principal Executive Officer)
Date: February 23, 2023
A signed original of this written statement required by Section 906 has been provided to the Company and will be retained by the Company and furnished to
the Securities and Exchange Commission or its staff on request.
This certification accompanies the Report to which it relates, is not deemed filed with the Securities and Exchange Commission and is not to be incorporated
by reference into any filing of NovoCure Limited under the Securities Act of 1933, as amended, or the Securities Exchange Act of 1934, as amended (whether
made before or after the date of the Report), irrespective of any general incorporation language contained in such filing.
NOVOCURE LIMITED
CERTIFICATION PURSUANT TO
18 U.S.C. SECTION 1350,
AS ADOPTED PURSUANT TO
SECTION 906 OF THE SARBANES-OXLEY ACT OF 2002
Exhibit 32.2
In connection with the Annual Report of NovoCure Limited (the "Company") on Form 10-K for the fiscal year ended December 31, 2022, as filed with the
Securities and Exchange Commission on the date hereof (the "Report"), I, Ashley Cordova, Chief Financial Officer (Principal Financial and Accounting
Officer) of the Company, certify, pursuant to 18 U.S.C. § 1350, as adopted pursuant to § 906 of the Sarbanes-Oxley Act of 2002, that:
(1)
(2)
The Report fully complies with the requirements of section 13(a) or 15(d) of the Securities Exchange Act of 1934; and
The information contained in the Report fairly presents, in all material respects, the financial condition and result of operations of the
Company.
/s/ Ashley Cordova
Ashley Cordova
Chief Financial Officer
(Principal Financial and Accounting Officer)
Date: February 23, 2023
A signed original of this written statement required by Section 906 has been provided to the Company and will be retained by the Company and furnished to
the Securities and Exchange Commission or its staff on request.
This certification accompanies the Report to which it relates, is not deemed filed with the Securities and Exchange Commission and is not to be incorporated
by reference into any filing of NovoCure Limited under the Securities Act of 1933, as amended, or the Securities Exchange Act of 1934, as amended (whether
made before or after the date of the Report), irrespective of any general incorporation language contained in such filing.