Castle Biosciences Inc (CSTL) 2021 Q1 法說會逐字稿

Good afternoon, and welcome to Castle Biosciences First Quarter 2021 Conference Call. As a reminder, today's call is being recorded. (Operator Instructions)

I would like to turn the call over to Camilla Zuckero, Executive Director, Investor Relations and Corporate Communications. Please go ahead.

Thank you, operator. Good afternoon, everyone. Welcome to Castle Biosciences First Quarter 2021 Financial Results Conference Call. Joining me today is Castle's Founder, President and Chief Executive Officer, Derek Maetzold; and Chief Financial Officer, Frank Stokes.

Information recorded on this call speaks only as of today, May 10, 2021. Therefore, if you are listening to the replay or reading the transcript of this call, any time-sensitive information may no longer be accurate. A recording of today's call will be available on the Investor Relations page of the company's website for approximately 3 weeks.

Before we begin, I would like to remind you that some of the information discussed today may contain projections or other forward-looking statements regarding future events or the future financial performance of the company, including expectations and assumptions related to the impact of the COVID-19 pandemic and are made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. Forward-looking statements are based on current expectations and involve inherent risks and uncertainties, and there can be no assurances that the results contemplated in these statements will be realized.

A number of factors and risks could cause actual results to differ materially from those contained in these forward-looking statements. These factors and other risks and uncertainties are described in detail in the company's quarterly report on Form 10-Q for the quarter ended March 31, 2021, and in the company's other documents and reports filed with the Securities and Exchange Commission. These forward-looking statements speak only as of today, and we assume no obligation to update or revise these forward-looking statements as circumstances change.

I'll now turn the call over to Derek.

Thank you, Camilla, and good afternoon, everyone. This afternoon, I will discuss the highlights of our first quarter results and provide an overview of developments on our key priorities. Frank will then provide additional detail on our financial results and company performance.

I would like to start today's call by thanking the Castle team for their dedication and commitment to improving the lives of patients with skin cancer and other dermatologic diseases with high unmet clinical need. They continue to execute on our growth strategy at a very high level, including furthering our evidence development, progressing on our commercial team expansion, advancing our pipeline and providing strategic support for the pending acquisition of the Myriad myPath Melanoma laboratory.

We are off to a great start to the year. We delivered excellent top line growth with first quarter revenue of $22.8 million, a 31% increase over the first quarter of 2020. As we look forward to our growth potential in 2021, and although there remains continued uncertainty related to the impact of COVID-19 with regard to the timing of the return to historical levels of skin cancer diagnoses, we feel confident in providing 2021 revenue guidance of $80 million to $83 million. We expect continued investments in our growth initiatives, including our commercial team expansion, the expansion of our body of evidence and acceleration of our R&D efforts to support our continued growth.

In the first quarter of 2021, we delivered 5,142 total gene expression profile test reports. And we are encouraged by what we believe to be positive recovery trends, although melanoma diagnoses have not yet returned to pre-COVID levels. As we have discussed in the past, we expect that the majority of the estimated 26,000 patients who were not diagnosed in 2020 as well as those who are not diagnosed in early 2021 to be diagnosed later this year or in 2022, which could be impacted by the timing of both COVID vaccinations and the continued return to in-person medical care.

And as such, we anticipate continued improvement in our volume growth rate for the second half of 2021 and into 2022, but cannot predict the rate or progression of a full return to in-office visits or when all of our representatives will be allowed to visit all of their clinicians' offices.

We are seeing increased levels of in-person visits by our commercial team with just over 75% of our sales calls being live and in person. We're also seeing a return of in-person peer-to-peer activities. Despite the continued impact of COVID on both diagnoses of melanoma and office in-person visits, we delivered 4,060 DecisionDx-Melanoma test reports in the first quarter. Importantly, though, we saw order volume for DecisionDx-Melanoma increased by approximately 30% in March 2021 compared to January 2021. And in March, clinicians ordered DecisionDx-Melanoma more times than any other previous March. And the positive trends have continued through April, with April order volume exceeding that of March.

Turning to our DecisionDx-SCC test for patients diagnosed with high-risk squamous cell carcinoma and one or more risk factors, we delivered 527 test reports for this test. We launched DecisionDx-SCC on the last day of August in 2020. And in the fourth quarter of 2020, we delivered 428 test reports.

As you may recall, we are focusing our commercial incentives on our DecisionDx-Melanoma test. Within this context, we remain extremely pleased with its early adoption as the DecisionDx-SCC test continues to exceed our expectations. We believe this performance is due in part to the high unmet clinical need that this test is filling. Equally important to know is the value that we are seeing through leveraging our dermatologic commercial channels.

Specifically, more than 80% of clinicians who have ordered this test for SCC have also ordered our DecisionDx-Melanoma test from the last 2.5 years. In other words, we believe being able to walk into an office of a current customer, one has adopted DecisionDx-Melanoma as an important tool in the management of their patients with melanoma, makes it easier for us to lay out the clinical need and the value of our DecisionDx-SCC test in those patients with high-risk squamous cell carcinoma.

The technical assessment dossier for our DecisionDx-SCC test was submitted to Palmetto and Noridian in the second quarter of 2020. We received confirmation of acceptance of the submission as being complete in the third quarter of 2020 and believe, although there can be no assurances that a draft LCD should be posted in 2021. We believe that the LCD could be posted in 2021, but I'll remind you that there is no specific time frame under which Palmetto and Noridian must operate.

Now let's discuss our comprehensive test solutions for difficult-to-diagnose melanocytic lesions. In the first quarter of 2021, we delivered 218 DecisionDx DiffDx-Melanoma test reports. Similar to what we are seeing with DecisionDx-SCC, the early uptake of our DiffDx-Melanoma test is exceeding our expectations. And you may have seen our important milestone announcement from April 27 regarding the definitive agreement we signed to acquire the Myriad myPath Melanoma laboratory.

We believe this acquisition will add incremental value to both myPath Melanoma and DiffDx-Melanoma by leveraging the strength of these 2 validated tests. Through this acquisition, we believe that more patients will receive actionable results, more of the time, enabling a more confident diagnosis and a clearer treatment path. We expect this transaction to close in late May 2021.

Evidence development remains a key component of our near- and long-term growth strategy. We expanded our significant body of evidence in 2020 with 11 supportive peer-reviewed publications published for our proprietary gene expression profile test. And in the first quarter of 2021, we added 2 additional articles for DecisionDx-Melanoma, which is now supported by 30 peer-reviewed publications.

In March, you may recall that we announced our integrated test results or ITR, for DecisionDx-Melanoma. The ITR is calculated by the independently validated integrated 31-GEP or i31-GEP algorithm, designed to provide a more precise and personalized prediction of sentinel lymph node positivity in order to guide discussions and recommendations within current risk-based guidelines for the sentinel lymph node biopsy surgical procedure.

i31-GEP is an artificial intelligence-based neural network algorithm that integrates the DecisionDx-Melanoma test result with the patient's traditional, clinical and pathologic features. The algorithm has been validated in a cohort of 1,674 tested patients with T1-T4 cutaneous melanoma. We presented data on the validation study at the World Congress of Melanoma in April. The independent validation phase show that the i31-GEP test provides a highly concordant prediction of sentinel lymph node positivity rate compared to the actual observed rates with a linear regression slope of 0.999, with a slope of 1.0, representing complete concordance.

Additionally, a patient's originally classified with a 5% to 10% likelihood of sentinel lymph node positivity using clinical or pathologic features only, the i31-GEP was able to reclassify 63% of those patients, whose actual risk of sentinel lymph node positivity was either below 5% or above 10%. Finally, the i31-GEP has a high negative predictive value of 98% in patients with T1-T4 melanomas. We plan to continue investing in development for all of our GEP tests as it remains a key component of our growth strategy, supporting adoption of our tests, both by clinicians as well as reimbursement by commercial payers.

We are a data-driven, evidence-based company, and we invest heavily in evidence development, supporting not only our existing tests, but also our pipeline tests as well. And earlier today, we announced one of our innovative pipeline programs. The program's initiative is to develop and validate a genomic test aimed at predicting systemic therapy response for patients with moderate to severe psoriasis, atopic dermatitis and related conditions. Essentially, those patients with inflammatory skin conditions that have reached the severity of disease to be considered for systemic therapy.

With our industry-leading position as the only diagnostics company with a suite of commercially available test for dermatologic cancer, we have demonstrated our ability to successfully develop, validate and bring to market clinically actionable, innovative genomic tests. We start by identifying dermatologic diseases with high unmet clinical need. We then use the gene expression profile of individual patient's biology in effort to develop a gene expression profile test designed to assist clinicians and their patients by better informing treatment to optimize both health outcomes and reduce health care costs.

This pipeline test has the potential to expand our reach into nonskin cancer medical dermatology diseases and is expected to provide additional value for our clinical customers and their patients. We recently launched the 4,800-patient prospective multicenter trial to develop and validate this pipeline test and plan to enroll approximately 50 centers with leading experts in the field. This pipeline test, along with our other pipeline products has the potential to increase our U.S. total addressable market to slightly more than $5.5 billion.

Another important component of our growth strategy is the expansion of our commercial team. I am pleased to say that we have completed our expansion ahead of schedule with all new outside sales territories field. And we expect to enter the third quarter of 2021 with a total of 60 to 65 sales representatives, all calling on dermatologists as a primary call point, followed by Mohs surgeons, surgeons who work in skin cancer, including surgical oncologists and head and neck surgeons and dermatopathologists.

This expansion will nearly double our dermatology-focused sales efforts compared to the 32 outside sales territories we had before the expansion and in time for the expected continued positive trends of offices opening back up for in-person sales calls and in-person peer-to-peer programs. We expect that each of our 60 to 65 sales representatives will sell all 4 dermatologic tests: DecisionDx-Melanoma, DecisionDx-SCC, myPath Melanoma and DiffDX-Melanoma.

Additionally, we have seen that our market is promotionally responsive. So we expect that as offices open more fully, our sales force expansion efforts should have a positive impact on our 2021 exit volume and should position us well for growth in 2022.

Before I turn the call over to Frank, let me summarize our takeaways. We delivered an excellent quarter of financial performance with strong execution on our growth initiatives. We increased investments in these initiatives during COVID to ensure resiliency and are seeing the benefits of those actions, which we believe furthers our position as a leading dermatologic diagnostics company, strengthening our value proposition and continuing to create shareholder value.

I will now turn the call over to Frank, who will provide additional details relating to our financial results.

Thank you, Derek. As Derek stated, we're pleased with the investments we have made in our growth initiatives, along with solid execution from the team, enabled us to develop -- deliver a strong start to the year. We reported revenue of $22.8 million in the first quarter of 2021 compared to $17.4 million in the first quarter of 2020, a 31% increase primarily due to higher revenue adjustments related to prior periods and higher per unit revenues and partially offset by lower test report volumes for DecisionDx-Melanoma and DecisionDx-UM. Positive prior period revenue adjustments for the first quarter of 2021 were $5.3 million compared to $3.2 million for the same period in 2020.

Our gross margin in the first quarter was 87% compared to 86% for the first quarter of 2020. Our operating expenses for the quarter ended March 31, 2021, were $24.1 million compared to $14 million for the same period last year. This increase was driven primarily by higher SG&A expense, which increased by $7.1 for the quarter, attributable in part to the expansion of our sales and marketing teams for the launch of our DiffDx-Melanoma test, administrative support functions and higher personnel costs associated with our increased headcount, which includes salaries, bonuses, benefits and stock-based compensation.

R&D expense increased by $3 million in 2021 compared to 2020 and was primarily associated with increases in personnel costs attributable to additional headcount and costs incurred in our clinical studies. We expect our R&D expense to increase further as we continue to invest in activities that support our commercial products and pipeline initiatives and position us well for near and long-term growth.

Noncash stock-based compensation expense, which is allocated among cost of sales, R&D and SG&A, totaled $4.9 million for the quarter ended March 31, 2021, compared to $1.6 million for the quarter ended March 31, 2020. We expect material increases in stock-based compensation expense in future periods, reflecting both higher post-IPO stock option valuations as well as additional awards outstanding due to our growth in headcount.

Our net loss for the first quarter of 2021 was $4.3 million compared to net income of $0.6 million for the first quarter of 2020. Diluted loss per share attributable to common stockholders for the first quarter of 2021 was $0.17 compared to diluted earnings per share attributable to common stockholders of $0.03 for the first quarter of 2020.

Operating cash flow for the 3 months ended March 31, 2021, was negative $3.6 million compared to negative $0.3 million for the same period in 2020. Finally, we had cash and cash equivalents at March 31, 2021, of $407 million and no debt.

Although we can't predict the trajectory of continued COVID recovery, our core business and underlying fundamentals remain strong. And we are initiating 2021 revenue guidance of $80 million to $83 million. We are excited about the opportunities that lie ahead and remain committed to building a dermatologic diagnostics company, focused on making a positive impact on patient outcomes.

I'll now turn the call back over to Derek.

Thank you, Frank. In summary, we delivered strong execution in the first quarter with strong top line growth and significant positive trends in order volume in March 2021 compared to January 2021. We saw excellent progress on our key growth initiatives, including expanding our body of evidence, completion of our commercial team expansion and initiation of our development and validation study for psoriasis, atopic dermatitis and related conditions pipeline tests.

Before we move on to Q&A, I want to again express my gratitude to our employees for their hard work and dedication to improving the lives of patients with skin cancer and other dermatologic diseases with high unmet clinical needs.

This concludes our remarks. Thank you for your continued interest in Castle. Operator, we are now ready for Q&A.

(Operator Instructions) Our first question comes from the line of Thomas Flaten with Lake Street Capital Markets.

Frank, just a quick clarification on the guidance. Does that include any contribution from myPath? Or is that a TBD at this point?

We've gotten -- we're including a little bit of contribution there. Keep in mind, we'll own that business a little more than 6 months this year, and we'll be new with it. But yes, we do have a little bit of benefit from myPath.

And then flipping to the new pipeline product, I'm -- just out of curiosity, could you share maybe some thoughts on what the overlap in potential gene expression? I think you characterized to that between the 2 disease states. Are there significant numbers of genes that are present in both disease states? And are those -- is gene expression typically the vehicle you would use? Or are there other, for example, noncoding regions that would be important in better understanding those diseases?

Thomas, this is Derek. I think we'll have an answer for that question specifically towards the end of 2022. Our belief is that there's enough literature out there to go ahead and demonstrate that there is a -- that we should be able to identify a gene expression profile signature that will assist in predicting treatment response. I don't know how much overlap we're going to see between sort of classical atopic dermatitis as well as classical psoriasis.

But I think that if we view these as sort of inflammatory syndrome or inflammatory skin diseases rather than sort of partial is in a 2 different programs. Initially, our belief in working with our steering committee is that the approach that we should be taking is let's go after this in a significant manner, which is why we are initiating this with roughly just under 5,000-patient study, to go ahead and answer those questions. So today, I don't have a definitive answer for you except that we've seen a good proof-of-concept work in the literature in our own hands and say we can move forward here.

And then just one quick one to finish up on the field force. Congrats on getting that done early. I was curious if you had any anecdotal feedback from the sales reps that have been carrying all 3 products in the bag to date. What are common objections? What are the kind of unique selling points? I know you touched on it a little bit in the prepared comments, but I'm just curious to get some qualitative understanding of how they've kind of experienced that in the field to date.

Yes. Let me separate one comment there. We have 32 dermatologically focused sales representatives. So maybe 80% call volume is on dermatologists, which would include dermatological physicians, NPs and PAs who work on their practices, Mohs surgeons. And then the remaining part of their calls are largely on surgeons who do skin cancer work like surgical oncologists, and a smattering of dermatopathology and medical oncology, more information. And they're only covering 2 tests today. So they're only offering the DecisionDx-Melanoma test and the DecisionDx-SCC test.

So in that context, I think maybe to answer your question here, which I think you were asking, what we find is that when we are introducing the DecisionDx-SCC test after we've gone through our Melanoma test, you sort of get head nodding, there's an agreement that there is a significant unmet clinical need in these because of one or more risk factors that there was sort of a wide range of treatment options, everything to kind of do nothing to do everything. And that the tools they have pathologically and clinically aren't that good.

And so you sort of start get head nodding along with the unmet clinical need, the limitations of current staging features, and the conversation more quickly goes into now, let's talk about the right patients to use your testing, what are my peers doing in terms of adjusting treatment plan decisions. So we are seeing a nice leverage effect off of our melanoma reputation, those same practice. I think that's also why we're seeing about 80% of the physicians who have ordered our DecisionDx-SCC test have ordered the DecisionDx-Melanoma test in the last couple of years.

The other small sales force of 10 individuals, we trained up and let them go in early November of 2020, just focusing on our DiffDx-Melanoma test with 2 dermatopathologists. And the reason for that was to introduce carefully that test to that specialty group. And then following this expansion, the kind of 60 to 65 representatives will then have each individual representative selling all 3 products in a smaller geography. So that question will have to hold off until we get past July 1.

Our next question comes from the line of Catherine Schulte with Baird.

Guys, congrats on the quarter. I guess first on guidance, can you just walk through what that assumes for the rebound you'll see in volumes in the second quarter, maybe how melanoma diagnoses improve for the balance of the year? And what's baked in there for the impact of the newly expanded sales force?

Catherine, thank you. So we're assuming that the current, I guess, environment or climate is steady state. We'll get some of the misdiagnoses coming in over time. We don't expect a big rush or to see that true up all at once. And so we're optimistic that things will continue to thaw and get better and better. And of course, it's very regional around the country. Some places are catching up with others.

As it relates to sales force, we have always assumed sort of a 6-month ramp to average productivity. And so with the new folks starting now, we'll see some benefit from their efforts, but we certainly won't see full efforts. So we would expect that the benefit of that expansion will start to be felt in the back half of '21 and then be nicely felt in '22.

Okay. Great. And then I think the NCCN non-melanoma skin cancer panel is meeting this month. How should we think about the path to guideline inclusion there for SCC? And is there any data that you've submitted to the panel for this meeting?

So we think that the pathways similar to, I guess, other disease states and tests, the NCCN SCC panel is relatively new. I can't remember when they started reviewing SCC individually, but it's not more than a couple of years ago. And they're still trying to kind of wrestle with how do you bucket or bin different risk groups. We are pleased to go ahead and see the increased clarity that came about in January of 2021 when they sort of went from just a low-risk bucket and a high-risk bucket to now having a low-risk, a high-risk and what they call a very high-risk bucket.

And it just so happens that if you happen to have an aggressive Class IIb test result from our DecisionDx-SCC test, your risk of metastasizing is like you're very, very high risk. So the fact they've already been stratified a little more finer going from 2 to 3 bins, I think will be helpful for us.

We have engaged, as part of our normal investigator work and publication work with a number of the NCCN community members for SCC and the ones we have talked to are favorably disposed to looking at rolling in genomic testing information to help provide high clarity or accuracy improvements. Unlike melanoma, where I think there historically is a higher barrier because they've been -- pathologists have been looking at melanoma for several decades. That really -- that sort of level of sort of legacy ownership is really not there in squamous cell carcinoma. That really happens to be a tumor, which just has -- the pathology and clinical features just aren't as informative as you see in other disease states.

So I think the opportunity to have that move quicker is certainly there. And I think the team, if they haven't already, they'll be submitting shortly the packet of the upcoming review cycle. I think I answered the question.

Yes. Very helpful. And then last one for me, a pretty strong quarter for prior period collections. Any movement on the commercial payer side? And any thoughts on the outlook there for incremental coverage decisions?

Yes. So as it relates to the prior period revenue, Catherine, we did have a larger amount that we have had on trend, and we wouldn't expect that to be continued. There were some reasonable buckets of appeals that we had negotiated with payers that were -- I guess we were successful in. And so although those tests were from last year, largely speaking, we were able to successfully collect on those through the appeals process in a sort of a basket fashion.

That, of course, doesn't impact commercial payer policy. We continue to just chip away at those and make small progress. And what's important, I think, is -- as important is not only those policy progress and the policy moves we're winning, but the continued success on appeals.

Our next question comes from the line of Max Masucci with Canaccord Genuity.

First one, did the expanded Medicare payments for DecisionDx-Melanoma just flow into the model as expected in Q1? And if so, how should we think about any sort of sequential increase we could see in DecisionDx-Melanoma ASPs in Q2 and beyond?

Yes, Max, it did flow as we'd expected. We are getting paid on the percentage of those cases that we had expected to. So that trend is playing out as we had anticipated.

So there was a nice ASP increase. If you just look at in-period revenue and volume, this was a nice ASP increase for Q4 or Q1. Certainly, improvements through the rest of this year will be more measured. I don't think we'll see additional significant stepwise increases there. So more steady and more typical for our historical progress through the rest of the year.

Great. And then maybe a big picture question. Great to learn more about the test and your development pipeline. Can you just walk us through how you arrived at inflammatory skin disease as a new category of interest for your product portfolio? And at this point in time, I'd imagine that precision oncology hasn't quite made its way into inflammatory skin disease, the way it has for some other disease categories, which would make this another somewhat first of its kind market opportunity. Does that logic sound correct?

Correct. So Max, Derek here. One is that we've been looking at the inflammatory sort of skin disease as one of our potential pipeline opportunities once they got past the IPO, and that original recommendation came from some of our current customers and some KOLs that we seek counsel from around dermatology said, we've got some significant issues here. You've got this March of biologics and systemic therapies with psoriasis and psoriatic arthritis. In clinical trials, they perform remarkably well. Yet the majority of people actually end up switching from a wide reasons, either it's -- it didn't quite work as well in the real world. It doesn't in a controlled trial. It could be side effects. It could be cost or access issues.

But the way we're using these new therapies is it sort of as market share wins, whatever I used before, I kind of use now. And maybe that's the right way to approach it. But right now, we really have no objective data to make a better choice. And we've got so many options now in psoriasis and more coming now in atopic dermatitis. If you could assist us like you do in melanoma with figuring out, drug D may be a better choice than drug A, even though drug A is your go-to drug. And that could help do what, save patients an extra quarter or 2 of not getting full efficacy, significance sort of wasting of health care dollars if they don't respond well, et cetera, et cetera.

So I think the opportunity here to really go in hard in the next couple of years and come out at the other end, hopefully with a clinically validated test that will really help dermatologists take a more thoughtful is a little negative there, much more objective, informed decision-making process to get it right the first time, hopefully, rather than third time, has tremendous payback to both patient benefits, health care system cost reductions, improved satisfaction among dermatologists that when they prescribe a therapy for patient A and it happens to be drug A, there's a much higher chance that's a good match versus trying to figure it out empirically.

So we're quite excited about this. We've done some proof-of-concept work over the last couple of months and feel like our approach in terms of securing the actual specimen is a nice viable approach that flows well in the practice setting. So very, very excited to go and kick this off.

(Operator Instructions) Our next question comes from the line of Puneet Souda with SVB Leerink.

So first one, just wanted to -- and I apologize if this was covered. I just wanted to get in terms of the pipeline expansion for atopic dermatitis and related conditions. And how are you thinking about that data -- that large study, when do you expect that to read out? What should we expect in terms of the updates in terms of the data here?

Yes. Yes. Good questions there. So maybe the last one first. So I think we anticipate here that at this point in time and kind of first quarter of 2021, I think we should assume that our clinical research group could go ahead and marshal up, enrolling as we planned that as we work through this large, nearly 5,000 patient program, we should be able to have a test to the marketplace, we would think by the end of 2025 that could turn out to be conservative. But I think that's -- if that fits with what we've been talking about in the last 6 months or so, we'll know more as we get working through the summer and fall, certainly in terms of recruitment opportunities.

I think taking a step closer to today, when can we get sort of an indication of early data readouts, I think we'll have some genomic profiling work and discovery work nailed down by maybe in the first half of 2022. Maybe there's some preliminary data we'll discuss publicly in the second half of '22. I don't think it comes really earlier than that, just based upon how the protocol is going to be following patients that are managed on sequential systemic therapies. So we're going to want to get those cycles of that and enough patients in.

But I think what's exciting from our perspective in terms of confidence around the clinical trials is that nearly every clinical research site that we work with in our squamous cell carcinoma studies, in our DecisionDx-Melanoma studies, in our DiffDx-Melanoma studies, number one, do clinical research and dermatology conditions; and number two, a far more prevalent condition happens to be psoriasis and their atopic derm.

So I think we feel quite bullish that as sites get up and running, we'll be working largely with centers. We've worked over the last, what, 5, 6, 10 years. And we hopefully will know which one's to pick and can be good horses for us and which ones might take a bit longer. So that feels very exciting in terms of trial execution at this point in time.

Okay. That's very helpful, Derek. In terms of the access, I think you mentioned the 75% number today, with the reps sort of being in person. Do you expect that to -- given what you're seeing, do you expect that to recover completely to in-person sort of by the summertime? Or anything you can provide in terms of continued improvement of that rep access to the physicians to the dermatologists and the broader physician community that you're serving?

Yes. So I don't know if I -- so one, it's interesting. Before we know, we all know how to spell out a five-letter word called COVID, we were more interested in looking at interactions in the course of a day. We didn't really care if they were a really long phone call or an in-person visit as long as it was really moving customers from point A to point B. And now, of course, the last 9 months, we've been thinking about this sort of virtual versus telephone versus in-person mix.

So I don't have good sort of '19 -- 2019 data that I can rely upon to say what's 100% look like? Is that really 95% or not? I think I would be as aggressive as saying that our models show that by July 1, we're back to whatever 100% looks like. I think we should probably assume the summer works its way through maybe around Labor Day, would be we hopefully get back to whatever it used to be.

And I say that only because we're going to have different states with differences of regional openness happening, but -- so that next 5 months is like a reasonable approach to think about it. And that will happen to be timed well with our new representatives kind of hitting about 6 months in the field. So we're not going to be able to tell you which is the chicken or the egg, just that we've got both in hand, which is a good thing, of course at the end of the day.

I think we were really, really pleased to go ahead and see that 3/4 of our sales calls in the first quarter already were in-person. And I think that's a reflection of both the hope with the quality and the value that we bring to our dermatological and surgery customers. But I think it's also a reflection that clinicians value interactions. And after 9 months, there's only so much more time they're going to spend in front of their laptop at their office, talking over a video cam or a telephone.

So we see encouraging interest in, you know what, I'm willing to go ahead and see you, my staff is going to see you. I'm willing to come out with you. So if you have a peer-to-peer program going on, let me know about that. So it's a very interesting nice dynamic of our clinical base as saying, hey, this is one way I can show that I'm actually practicing medicine like I did before 2020.

Okay. That's great. And then last one, Frank, maybe this is for you. And just as we think about the second quarter, given what you're seeing as 3/4 of the reps in person and the recovery and the conversations that you're having, anything you can provide in terms of the 2Q volume pickup that we should be thinking about? And then broadly, that accelerating through the year?

And then lastly, if Derek could also -- I don't know if this was covered, but just wanted to get a gauge on how are you approaching the commercial payers today after having solid reimbursement and thinking about the broader pipeline as well?

Sure. So I think, Puneet, we're hopeful that we see physician interactions as it relates to skin cancer at least continue at the same pace, and it would be great if they accelerated some. And if that happens, and we're confident our commercial team can go out and continue to take increased penetration of those patient encounters or diagnoses.

Tough to really put a line in the sand on exactly what that pace will be. I know that other areas of the economy have seen nice acceleration here in terms of recovery. So we're -- I guess, the best I can say is we're optimistic or hopeful that medical commerce will have the same experience.

Are you talking about commercial? Or...

So on the commercial payer side, Puneet, we're continuing to just, I guess, politely overwhelm them with evidence. And the strategy is just to, at some point, have so much clinical evidence that there's just no way a straight-faced party cannot realize that there's real benefit to patients, benefit to their physicians and cost savings to the health care system by using our test in our skin cancer indication. And that's -- we all know it. We know it's good for patients, and it's a real shame that being good for patients isn't enough for the commercial payers. But unfortunately, they're less interested in what's good for patients and more interested in what's good for them.

Thank you. There are no further questions. I will now turn the call back to Derek Maetzold for closing remarks.

So in summary, we delivered strong execution in the first quarter with strong top line growth and significant positive trends in order volume in March of '21 compared to January of '21 with March being our highest-ever order volume month for DecisionDx-Melanoma and April exceeding that.

This concludes our first quarter earnings for 2021. We thank you again for joining us today and for your continued interest in Castle Biosciences.

Ladies and gentlemen, this concludes today's conference call. We thank you for your participation. You may now disconnect.