Large B-cell Lymphoma (LBCL)

BREYANZI is indicated for the treatment of adult patients with large B-cell lymphoma (LBCL), including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B who have:

•

refractory disease to first-line chemoimmunotherapy or relapse within 12 months of first-line chemoimmunotherapy; or

•

refractory disease to first-line chemoimmunotherapy or relapse after first-line chemoimmunotherapy and are not eligible for hematopoietic stem cell transplantation (HSCT) due to comorbidities or age; or

•

relapsed or refractory disease after 2 or more lines of systemic therapy.

Limitations of Use: BREYANZI is not indicated for the treatment of patients with primary central nervous system (CNS) lymphoma [see Clinical Studies ( 14.1)].

Chronic Lymphocytic Leukemia (CLL) or Small Lymphocytic Lymphoma (SLL)

BREYANZI is indicated for the treatment of adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) who have received at least 2 prior lines of therapy including, a Bruton tyrosine kinase (BTK) inhibitor and a B-cell lymphoma 2 (BCL-2) inhibitor.

This indication is approved under accelerated approval based on response rate and duration of response [see Clinical Studies ]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s).

Follicular Lymphoma (FL)

BREYANZI is indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma (FL) who have received 2 or more prior lines of systemic therapy.

This indication is approved under accelerated approval based on response rate and duration of response [see Clinical Studies ]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s).

Mantle Cell Lymphoma (MCL)

BREYANZI is indicated for the treatment of adult patients with relapsed or refractory mantle cell lymphoma (MCL) who have received at least 2 prior lines of systemic therapy, including a Bruton tyrosine kinase (BTK) inhibitor.

Dose

See the respective Certificate of Release for Infusion (RFI Certificate) for each component, for the actual cell counts and volumes to be infused [see Dosage and Administration and Dosage Forms and Strengths ].

A single dose of BREYANZI contains CAR-positive viable T cells (consisting of 1:1 CAR-positive viable T cells of the CD8 and CD4 components), with each component supplied separately in one to four single-dose vials. See Table 1 for dose range per indication.

Table 1: Dose Range

Administration

BREYANZI is for autologous use only. The patient’s identity must match the patient identifiers on the BREYANZI cartons, vials, and syringe labels. Do not infuse BREYANZI if the information on the patient-specific labels does not match the intended patient.

Preparing BREYANZI

Before thawing the vials

•

Confirm the patient’s identity with the patient identifiers on the RFI Certificate.

•

Read the RFI Certificate (affixed inside the shipper) for information on the number of syringes you will need to administer the CD8 and CD4 components (syringe labels are provided with the RFI Certificate). There is a separate RFI Certificate for each cell component.

•

Confirm tocilizumab and emergency equipment are available prior to infusion and during the recovery period.

•

Confirm the infusion time in advance and adjust the start time of BREYANZI thaw such that it will be available for infusion when the patient is ready.

Thawing the vials

1.

Confirm the patient’s identity with the patient identifiers on the outer carton and on the syringe labels.
Once the vials of CAR-positive viable T cells (CD8 component and CD4 component) are removed from frozen storage, the thaw must be carried to completion and the cells administered within 2 hours.

2.

Remove the CD8 component carton and CD4 component carton from the outer carton.

3.

Confirm the patient’s identity with the patient identifiers on the inner carton.

4.

Open each inner carton and visually inspect the vial(s) for damage. If the vials are damaged, contact Bristol-Myers Squibb at 1-888-805-4555.

5.

Confirm the patient’s identity with the patient identifiers on the vials.

6.

Carefully remove the vials from the cartons, place vials on a protective barrier pad, and thaw at room temperature until there is no visible ice in the vials. Thaw all of the vials at the same time. Keep the CD8 and CD4 components separate.

Dose preparation

•

Prepare BREYANZI using sterile technique.

•

Based on the concentration of CAR-positive viable T cells for each component, more than one vial of each of the CD8 and CD4 components may be required to complete a dose. A separate syringe should be prepared for each CD8 or CD4 component vial received.
Note: The volume to be drawn up and infused may differ for each component as indicated on the RFI Certificate. Do NOT draw up excess volume into the syringe.

•

Each vial contains 5 mL with a total extractable volume of 4.6 mL of CD8 or CD4 component T cells. The RFI Certificate for each component indicates the volume (mL) of cells to be drawn up into each syringe. Use the smallest Luer-lock tip syringe necessary (1, 3, or 5 mL) to draw up the specified volume from each vial. A 5 mL syringe should not be used for volumes less than 3 mL.

7.

Prepare the syringe(s) of the CD8 component first. Affix the CD8 syringe labels to the syringe(s) prior to pulling the required volume into the syringe(s).
Note: It is important to confirm that the volume drawn up for each component matches the volume specified in the respective RFI Certificate. Do NOT draw up excess volume into the syringe.

Withdrawal of the required volume of cells from each vial into a separate syringe should be carried out using the following instructions:

8.

Hold the thawed vial(s) upright and gently invert the vial(s) 5 times to mix the cell product. If any clumping is apparent, continue to invert the vial(s) until clumps have dispersed and cells appear to be evenly resuspended.

9.

Visually inspect the thawed vial(s) for damage or leaks. Do not use if the vial is damaged or if the clumps do not disperse; contact Bristol-Myers Squibb at 1-888-805-4555. The liquid in the vials should be slightly opaque to opaque, colorless to yellow or brownish-yellow.

10.

Remove the polyaluminum cover (if present) from the bottom of the vial and swab the septum with an alcohol wipe. Allow to air dry before proceeding.
NOTE: The absence of the polyaluminum cover does not impact the sterility of the vial.

11.

Keeping the vial(s) upright, cut the seal on the tubing line on the top of the vial immediately above the filter to open the air vent on the vial.
NOTE: Be careful to select the correct tubing line with the filter. Cut ONLY the tubing with a filter.

12.

Hold a 20-gauge, 1-1 ½ inch needle, with the opening of the needle tip away from the retrieval port septum.

a.

Insert the needle into the septum at a 45°- 60° angle to puncture the retrieval port septum.

b.

Increase the angle of the needle gradually as the needle enters the vial.

a	b

13.

WITHOUT drawing air into the syringe, slowly withdraw the target volume (as specified in the RFI Certificate). Carefully inspect the syringe for signs of debris prior to proceeding. If there is debris, contact Bristol-Myers Squibb at 1-888-805-4555.

14.

Verify that the volume of CD8/CD4 component matches the volume specified for the relevant component in the RFI Certificate.
Once the volume is verified, remove the syringe/needle from the vial, carefully detach the needle from the syringe and cap the syringe.

15.

Continue to keep the vial horizontal and return it to the carton to avoid leaking from the vial.

16.

Dispose of any unused portion of BREYANZI (according to local biosafety guidelines).

17.

Repeat the process steps 7-16 for the CD4 Component.

18.

Transport the labeled CD8 and CD4 syringes to the bedside by placing with protective barrier pad inside an insulated room temperature container.

Management of Severe Adverse Reactions

Pregnancy

Lactation

Females and Males of Reproductive Potential

Pediatric Use

The safety and efficacy of BREYANZI have not been established in pediatric patients.

Geriatric Use

In clinical trials of BREYANZI, 111 (41%) of 268 patients with two or more prior lines of therapy for LBCL, and 89 (59%) of 150 patients with one prior line of therapy for LBCL, were 65 years of age or older; 27 (10%) and 28 (19%) were 75 years of age or older, respectively. In patients with CLL/SLL, 51 (57%) of 89 were 65 years of age or older, and 9 (10%) were 75 years of age or older. In patients with FL, 42 (39%) of 107 were 65 years of age or older, and 10 (9%) were 75 years of age or older. In patients with MCL, 64 (73%) of 88 patients were 65 years of age or older, and 18 (21%) were 75 years of age or older. No clinically important differences in safety or effectiveness of BREYANZI were observed between patients aged ≥ 65 and younger patients.

Cytokine Release Syndrome

Cytokine release syndrome (CRS), including fatal or life-threatening reactions, occurred following treatment with BREYANZI.

In clinical trials of BREYANZI, which enrolled a total of 702 patients with non-Hodgkin lymphoma (NHL), CRS occurred in 54% of patients, including ≥ Grade 3 CRS (Lee grading system1) in 3.2% of patients. The median time to onset was 5 days (range: 1 to 63 days). CRS resolved in 98% of patients with a median duration of 5 days (range: 1 to 37 days). One patient had fatal CRS and 5 patients had ongoing CRS at the time of death. The most common manifestations of CRS (≥ 10%) included fever, hypotension, chills, tachycardia, hypoxia, and headache.

Serious events that may be associated with CRS include cardiac arrhythmias (including atrial fibrillation and ventricular tachycardia), cardiac arrest, cardiac failure, diffuse alveolar damage, renal insufficiency, capillary leak syndrome, hypotension, hypoxia, and hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS) [see Adverse Reactions ].

Ensure that 2 doses of tocilizumab are available prior to infusion of BREYANZI.

Monitor patients daily for at least 7 days following BREYANZI infusion at a REMS-certified healthcare facility for signs and symptoms of CRS. Monitor patients for signs or symptoms of CRS for at least 4 weeks after infusion. At the first sign of CRS, institute treatment with supportive care, tocilizumab, or tocilizumab and corticosteroids as indicated [see Dosage and Administration ].

Counsel patients to seek immediate medical attention should signs or symptoms of CRS occur at any time [see Patient Counseling Information ].

Neurologic Toxicities

Neurologic toxicities that were fatal or life-threatening, including immune effector cell-associated neurotoxicity syndrome (ICANS), occurred following treatment with BREYANZI. Serious events including cerebral edema and seizures occurred with BREYANZI. Fatal and serious cases of leukoencephalopathy, some attributable to fludarabine, also occurred.

In clinical trials of BREYANZI, CAR T cell-associated neurologic toxicities occurred in 31% of patients, including ≥ Grade 3 cases in 10% of patients. The median time to onset of neurotoxicity was 8 days (range: 1 to 63 days). Neurologic toxicities resolved in 88% of patients with a median duration of 7 days (range: 1 to 119 days). Of patients developing neurotoxicity, 82% also developed CRS.

The most common neurologic toxicities (≥ 5%) included encephalopathy, tremor, aphasia, delirium, and headache.

Monitor patients daily for at least 7 days following BREYANZI infusion at a REMS-certified healthcare facility for signs and symptoms of neurologic toxicities and assess for other causes of neurological symptoms. Monitor patients for signs or symptoms of neurologic toxicities for at least 4 weeks after infusion and treat promptly. Manage neurologic toxicity with supportive care and/or corticosteroid as needed [see Dosage and Administration ].

Counsel patients to seek immediate medical attention should signs or symptoms of neurologic toxicity occur at any time [see Patient Counseling Information ].

BREYANZI REMS

Because of the risk of CRS and neurologic toxicities, BREYANZI is available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS) called the BREYANZI REMS [see Boxed Warning and Warnings and Precautions ]. The required components of the BREYANZI REMS are:

•

Healthcare facilities that dispense and administer BREYANZI must be enrolled and comply with the REMS requirements.

•

Certified healthcare facilities must have on-site, immediate access to tocilizumab.

•

Ensure that a minimum of 2 doses of tocilizumab are available for each patient for infusion within 2 hours after BREYANZI infusion, if needed for treatment of CRS.

Further information is available at www.BreyanziREMS.com or contact Bristol-Myers Squibb at 1-866-340-7332.

Hypersensitivity Reactions

Allergic reactions may occur with the infusion of BREYANZI. Serious hypersensitivity reactions, including anaphylaxis, may be due to dimethyl sulfoxide (DMSO).

Serious Infections

Severe infections, including life-threatening or fatal infections, have occurred in patients after BREYANZI infusion.

In clinical trials of BREYANZI, infections of any grade occurred in 34% of patients, with Grade 3 or higher infections occurred in 12% of all patients. Grade 3 or higher infections with an unspecified pathogen occurred in 7%, bacterial infections in 3.7%, viral infections in 2%, and fungal infections in 0.7% of patients. One patient with FL, who received four prior lines of therapy developed a fatal case of John Cunningham (JC) virus progressive multifocal leukoencephalopathy four months after treatment with BREYANZI. One patient with MCL, who received three prior lines of therapy, developed a fatal case of cryptococcal meningoencephalitis 35 days after treatment with BREYANZI.

Febrile neutropenia developed after BREYANZI infusion in 8% of patients. Febrile neutropenia may be concurrent with CRS. In the event of febrile neutropenia, evaluate for infection and manage with broad‑spectrum antibiotics, fluids, and other supportive care as medically indicated.

Monitor patients for signs and symptoms of infection before and after BREYANZI administration and treat appropriately. Administer prophylactic antimicrobials according to standard institutional guidelines.

Avoid administration of BREYANZI in patients with clinically significant, active systemic infections.

Viral Reactivation

Hepatitis B virus (HBV) reactivation, in some cases resulting in fulminant hepatitis, hepatic failure, and death, can occur in patients treated with drugs directed against B cells.

In clinical trials of BREYANZI, 35 of 38 patients with a prior history of HBV were treated with concurrent antiviral suppressive therapy. Perform screening for HBV, HCV, and HIV in accordance with clinical guidelines before collection of cells for manufacturing. In patients with prior history of HBV, consider concurrent antiviral suppressive therapy to prevent HBV reactivation per standard guidelines.

Prolonged Cytopenias

Patients may exhibit cytopenias not resolved for several weeks following lymphodepleting chemotherapy and BREYANZI infusion.

In clinical trials of BREYANZI, Grade 3 or higher cytopenias persisted at Day 29 following BREYANZI infusion in 35% of patients, and included thrombocytopenia in 25%, neutropenia in 22%, and anemia in 6% of patients.

Monitor complete blood counts prior to and after BREYANZI administration.

Hypogammaglobulinemia

B-cell aplasia and hypogammaglobulinemia can occur in patients receiving BREYANZI.

In clinical trials of BREYANZI, hypogammaglobulinemia was reported as an adverse reaction in 10% of patients. Hypogammaglobulinemia, either as an adverse reaction or laboratory IgG level below 500 mg/dL after infusion, was reported in 30% of patients.

Monitor immunoglobulin levels after treatment with BREYANZI and manage using infection precautions, antibiotic prophylaxis, and immunoglobulin replacement as clinically indicated.

Secondary Malignancies

Patients treated with BREYANZI may develop secondary malignancies. T cell malignancies have occurred following treatment of hematologic malignancies with BCMA- and CD19-directed genetically modified autologous T cell immunotherapies, including BREYANZI. Mature T cell malignancies, including CAR-positive tumors, may present as soon as weeks following infusion, and may include fatal outcomes [see Boxed Warning, Adverse Reactions ( 6.2), Patient Counseling Information ].  Monitor lifelong for secondary malignancies. In the event that a secondary malignancy occurs, contact Bristol-Myers Squibb at 1-888-805-4555 for reporting and to obtain instructions on collection of patient samples for testing.

Effects on Ability to Drive and Use Machines

Due to the potential for neurologic events, including altered mental status or seizures, patients receiving BREYANZI are at risk for developing altered or decreased consciousness or impaired coordination in the 8 weeks following BREYANZI administration. Advise patients to refrain from driving and engaging in hazardous occupations or activities, such as operating heavy or potentially dangerous machinery, for at least 8 weeks.

Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome (IEC-HS)

Immune Effector Cell-Associated Hemophagocytic Lymphohistiocytosis-Like Syndrome (IEC-HS), including fatal or life-threatening reactions, occurred following treatment with BREYANZI. Three of 89 (3%) safety evaluable patients with R/R CLL/SLL developed IEC-HS. Time to onset of IEC-HS ranged from 7 to 18 days. Two of the 3 patients developed IEC-HS in the setting of ongoing CRS and 1 in the setting of ongoing neurotoxicity. IEC-HS was fatal in 2 of 3 patients. One patient had fatal IEC-HS and one had ongoing IEC-HS at time of death.

IEC-HS is a life-threatening condition with a high mortality rate if not recognized and treated early. Treatment of IEC-HS should be administered per current practice guidelines.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The safety data described in the WARNINGS and PRECAUTIONS (N=702) and in this section reflect exposure to a single dose of BREYANZI in one randomized, open-label study with 89 patients (TRANSFORM) with relapsed or refractory LBCL, and five open-label, single-arm studies with 61 patients (PILOT) and 268 patients (TRANSCEND) with relapsed or refractory LBCL, 89 patients with relapsed or refractory CLL/SLL (TRANSCEND-CLL), 107 patients with relapsed or refractory FL (TRANSCEND-FL), and 88 patients with relapsed or refractory MCL (TRANSCEND-MCL Cohort).

Relapsed or Refractory LBCL After One Line of Therapy

TRANSFORM

The safety of BREYANZI was evaluated in the TRANSFORM, a randomized, open-label, multicenter study, in which patients with primary refractory LBCL or relapse within 1 year of first-line chemoimmunotherapy received BREYANZI (N=89) or standard therapy (N=91) [see Clinical Studies ]. Patients had not yet received treatment for relapsed or refractory lymphoma and were potential candidates for autologous HSCT. The trial excluded patients who were ineligible for transplant or who had age > 75 years, Eastern Cooperative Oncology Group (ECOG) performance status >1, history of central nervous system (CNS) disorders (such as seizures or cerebrovascular ischemia), uncontrolled infection, CrCl < 45 mL/min, alanine aminotransferase (ALT) > 5 times the upper limit of normal (ULN), left ventricular ejection fraction (LVEF) < 40%, or absolute neutrophil count (ANC) < 1.0 × 109 cells/L or platelets < 50 × 109 cells/L in the absence of bone marrow involvement.

The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells. The median age of the BREYANZI-treated population was 59 years (range: 20 to 74 years); 47% were male; 58% were White, 11% were Asian, and 5% were Black.

Serious adverse reactions occurred in 38% of patients. The most common nonlaboratory serious adverse reactions (> 2%) were CRS, sepsis, fever, febrile neutropenia, headache, aphasia, COVID-19 infection, and pulmonary embolism.

Table 4 presents selected nonlaboratory adverse reactions in patients treated with BREYANZI, and Table 5 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were fever, CRS, musculoskeletal pain, headache, fatigue, nausea, constipation, and dizziness.

Other clinically important adverse reactions in < 10% of patients treated with BREYANZI included the following:

•

Immune system disorders: Hemophagocytic lymphohistiocytosis (1.1%)

•

Infections and infestations: Viral infection (9%), fungal infection (4.5%), pneumonia (2.2%)

•

Nervous system disorders: Encephalopathy (8%), aphasia (4.5%), peripheral neuropathy (4.5%), ataxia (3.4%), paresis (1.1%)

•

Psychiatric disorders: Delirium (2.2%)

•

Renal and urinary disorders: Renal failure (3.4%)

•

Respiratory, thoracic, and mediastinal disorders: Dyspnea (8%)

•

Vascular disorders: Thrombosis (8%), hypertension (7%)

Grade 4 laboratory abnormalities in ≥ 10% of patients were lymphocyte decrease (64%), neutrophil decrease (66%), and platelet decrease (34%).

PILOT

The safety of BREYANZI was evaluated in the PILOT study, a single-arm open-label study in transplant-ineligible patients with R/R LBCL after one line of chemoimmunotherapy [see Clinical Studies ( 14.1)]. The study enrolled patients who were ineligible for high-dose therapy and autologous HSCT due to organ function or age, but who had adequate organ function for CAR-T cell therapy. Patients with a history of relevant CNS disorders (such as seizures or cerebrovascular ischemia), ECOG performance status > 2, or uncontrolled infection were ineligible. The trial required LVEF ≥ 40%, adequate oxygen saturation on room air with ≤ Grade 1 dyspnea, AST, and ALT ≤ 5 x ULN, total bilirubin < 2.0 mg/dL, creatinine clearance > 30 mL/min, and adequate bone marrow function to receive lymphodepleting chemotherapy. The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells.

The median age was 74 years (range: 53 to 84 years), 90% were age ≥ 65 years, 61% were male. The ECOG performance status was 0 or 1 in 74% of patients and 2 in 26% of patients; 25% had CrCl < 60 ml/min; 20% had a baseline ANC < 1000/μL.

Serious adverse reactions occurred in 33% of patients. The most common nonlaboratory, serious adverse reactions (> 2%) were CRS, confusional state, gastrointestinal hemorrhage, muscular weakness, musculoskeletal pain, pulmonary embolism, and sepsis.

Table 6 presents selected nonlaboratory adverse reactions, and Table 7 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were fatigue, CRS, fever, nausea, encephalopathy, hypotension, musculoskeletal pain, and edema.

Other clinically important adverse reactions in < 10% of patients included the following:

•

Blood and lymphatic system disorders: Febrile neutropenia (1.6%)

•

Eye disorders: Vision blurred (3.3%)

•

Gastrointestinal disorders: Vomiting (8%), abdominal pain (7%), gastrointestinal hemorrhage (4.9%)

•

Infections and infestations: Fungal infection (4.9%), sepsis (3.3%), viral infection (3.3%)

•

Nervous system disorders: Motor dysfunction (7%), aphasia (4.9%), ataxia (4.9%), peripheral neuropathy (4.9%)

•

Psychiatric disorders: Delirium (3.3%)

•

Renal and urinary disorders: Renal failure (7%)

•

Respiratory, thoracic, and mediastinal disorders: Hypoxia (4.9%)

•

Skin and subcutaneous tissue disorders: Rash (7%)

•

Vascular disorders: Thrombosis (7%)

Grade 4 laboratory abnormalities in ≥ 10% of patients were lymphocyte decrease (95%), neutrophil decrease (57%), and platelet decrease (20%).

Relapsed or Refractory LBCL After Two or More Lines of Therapy

TRANSCEND

The safety of BREYANZI was evaluated in the TRANSCEND study, in which 268 adult patients with R/R LBCL after 2 or more prior lines of therapy received a single dose of CAR-positive viable T cells [see Clinical Studies ( 14.1)]. Patients with a history of CNS disorders (such as seizures or cerebrovascular ischemia) or autoimmune disease requiring systemic immunosuppression were ineligible. The median age of the study population was 63 years (range: 18 to 86 years); 65% were male. The ECOG performance status at screening was 0 in 41% of patients, 1 in 58% of patients, and 2 in 1.5% of patients.

Serious adverse reactions occurred in 46% of patients. The most common nonlaboratory serious adverse reactions (> 2%) were CRS, encephalopathy, sepsis, febrile neutropenia, aphasia, pneumonia, fever, hypotension, dizziness, and delirium. Fatal adverse reactions occurred in 4% of patients.

Table 8 presents selected nonlaboratory adverse reactions reported in patients treated with BREYANZI, and Table 9 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were fatigue, CRS, musculoskeletal pain, nausea, headache, encephalopathy, infections (pathogen unspecified), decreased appetite, diarrhea, hypotension, tachycardia, dizziness, cough, constipation, abdominal pain, vomiting, and edema.

Other clinically important adverse reactions in < 10% of patients included the following:

•

Cardiac disorders: Arrhythmia (6%), cardiomyopathy (1.5%)

•

Gastrointestinal disorders: Gastrointestinal hemorrhage (4.1%)

•

Infections and infestations: Pneumonia (8%), fungal infection (8%), sepsis (4.5%), urinary tract infection (4.1%)

•

Metabolism and nutrition disorders: Tumor lysis syndrome (0.7%)

•

Nervous system disorders: Ataxia or gait disturbance (7%), visual disturbance (5%), paresis (2.6%), cerebrovascular events (1.9%), seizure (1.1%), brain edema (0.4%)

•

Procedural complications: Infusion-related reaction (1.9%)

•

Respiratory, thoracic, and mediastinal disorders: Pleural effusion (7%), hypoxia (6%)

•

Vascular disorder: Thrombosis (7%)

Relapsed or Refractory CLL/SLL

TRANSCEND-CLL

The safety of BREYANZI was evaluated in the TRANSCEND-CLL study, which included 89 adult patients with R/R CLL/SLL who had received at least 2 prior lines of therapy including a BTK inhibitor and a BCL-2 inhibitor before receiving a single dose of CAR‑positive viable T cells [see Clinical Studies ]. Patients with a history of CNS disorders (such as seizures or cerebrovascular ischemia) or autoimmune disease requiring systemic immunosuppression, Richter’s transformation, ECOG performance status >1 were ineligible. The trial required LVEF ≥ 40%, adequate oxygen saturation on room air with ≤ Grade 1 dyspnea, ALT ≤ 5 x ULN, total bilirubin < 2.0 mg/dL, creatinine clearance > 30 mL/min, and adequate bone marrow function to receive lymphodepleting chemotherapy.

The median age of the study population was 66 years (range: 49 to 82 years); 69% were male, 84% were White, 3% were Black, 1% were Asian. Two percent were Hispanic, and 89% were non-Hispanic. The ECOG performance status at screening was 0 in 40% of patients, and 1 in 60% of patients.

Serious adverse reactions occurred in 60% of patients. The most common nonlaboratory serious adverse reactions (> 2%) were CRS, encephalopathy, febrile neutropenia, pneumonia, hemorrhage, fever, renal failure, aphasia, abdominal pain, delirium, tumor lysis syndrome, upper respiratory tract infection, and hemophagocytic lymphohistiocytosis [IEC-HS]. Fatal adverse reactions occurred in 1.1% of patients.

Table 10 presents selected nonlaboratory adverse reactions reported in patients treated with BREYANZI, and Table 11 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were CRS, encephalopathy, fatigue, musculoskeletal pain, nausea, edema, diarrhea, dyspnea, headache, fever, decreased appetite, constipation, tremor, dizziness, Infection with pathogen unspecified, rash, tachycardia, cough, and delirium.

Other clinically important adverse reactions in < 10% of patients included the following:

•

Cardiac disorders: Chest discomfort (4.5%), Arrhythmia (2.2%).

•

Eye disorders: Vision blurred (4.5%).

•

Gastrointestinal disorders: Dyspepsia (9%), abdominal distension (7%).

•

Immune system disorders: Hemophagocytic lymphohistiocytosis [IEC-HS] (3.4%).

•

Infections and infestations: Fungal infection (9%), pneumonia (7%), urinary tract infection (7%), bacterial infectious disorders (4.5%), sepsis (2.2%).

•

Injury, poisoning and procedural complications: Infusion related reaction (1.1%).

•

Nervous system disorders: Aphasia (8%), Ataxia (3.4%), Paresis (3.4%), Seizure (1.1%).

•

Psychiatric disorders: Affective disorder (7%).

•

Respiratory, thoracic, and mediastinal disorders: Oral pain (8%), hypoxia (8%).

•

Skin and subcutaneous tissue disorders: Ecchymosis (8%), xerosis (7%), pruritus (6%).

•

Vascular disorder: Thrombosis (6%).

Grade 4 laboratory abnormalities in ≥ 10% of patients were neutrophil count decreased (81%), lymphocyte count decreased (73%), white blood cell decreased (72%), and platelet count decreased (30%).

Relapsed or Refractory FL

TRANSCEND-FL

The safety of BREYANZI was evaluated in the TRANSCEND-FL study, in which 107 adult patients with relapsed or refractory FL after two or more prior lines of therapy received a single dose of BREYANZI [see Clinical Studies (14.3)]. Patients with a history of CNS disorders and active autoimmune disease requiring immunosuppressive therapy were ineligible. The median age was 62 years (range: 23 to 80 years), 38 % were female, and ECOG performance status was 0 in 61% and 1 in 39% of patients; 56% were White, 3% were Black, 9% were Asian; 5% were Hispanic and 69% were non-Hispanic.

Serious adverse reactions occurred in 26% of patients. The most common nonlaboratory serious adverse reactions (> 2%) were CRS, aphasia, febrile neutropenia, fever, and tremor.

Table 12 presents selected nonlaboratory adverse reactions reported in patients treated with BREYANZI, and Table 13 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were CRS, headache, musculoskeletal pain, fatigue, constipation, and fever.

Other clinically important adverse reactions in < 10% of patients included the following:

•

Blood and lymphatic system disorders: Febrile neutropenia (6%).

•

Cardiac disorders: Tachycardia (2.8%).

•

Eye disorders: Vision blurred (1.9%).

•

Gastrointestinal disorders: Nausea (9%), abdominal pain (4.7%), vomiting (3.7%).

•

General disorders and administration site conditions: Edema (4.7%), chills (3.7%).

•

Infections and infestations: Upper respiratory tract infection (8%), bacterial infectious disorders (6%), urinary tract infection (4.7%), viral infectious disorders (1.9%), pneumonia (1.9%), sepsis (0.9%).

•

Nervous system disorders: Encephalopathy (7%), aphasia (8%), dizziness (4.7%), motor dysfunction (3.7%), ataxia (3.7%), neuropathy peripheral (4.7%).

•

Psychiatric disorders: Insomnia (4.7%), delirium (4.7%), anxiety (1.9%).

•

Renal and urinary disorders: Acute kidney injury (0.9%).

•

Respiratory, thoracic and mediastinal disorders: Cough (7%), dyspnea (1.9%), hypoxia (1.9%).

•

Vascular disorders: Hypotension (8%), hypertension (6%), thrombosis (4.7%).

•

Skin and subcutaneous tissue disorders: Rash (7%).

Grade 4 laboratory abnormalities in ≥ 10% of patients were lymphocyte count decreased  (78%), neutrophil count decreased (61%), white blood cell decreased (41%), and platelet count decreased (11%).

Relapsed or Refractory MCL

TRANSCEND-MCL Cohort

The safety of BREYANZI was evaluated in the TRANSCEND Study-MCL Cohort, in which 88 adult patients with relapsed or refractory MCL received a single dose of CAR-positive viable T cells [see Clinical Studies ]. Patients with a history of CNS disorders (such as seizures or cerebrovascular ischemia) or autoimmune disease requiring systemic immunosuppression were ineligible. The trial required left ventricular ejection fraction ≥ 40%, adequate oxygen saturation on room air with ≤ Grade 1 dyspnea, ALT ≤ 5 x ULN, total bilirubin < 2.0 mg/dL, creatinine clearance > 30 mL/min, and adequate bone marrow function to receive lymphodepleting chemotherapy. The median age of the study population was 69 years (range: 36 to 86 years); 76% were male, 88% were White, 6% were Asian and 2.3% were Black. Four percent were Hispanic, and 92% were non-Hispanic. The ECOG performance status at screening was 0 in 54% of patients, and 1 in 46% of patients.

Serious adverse reactions occurred in 53% of patients. The most common nonlaboratory serious adverse reactions (> 2%) were CRS, confusional state, fever, encephalopathy, mental status changes, pleural effusion, upper respiratory tract infection, and decreased appetite. Fatal adverse reactions occurred in 4.5% of patients.

Table 14 presents selected nonlaboratory adverse reactions reported in patients treated with BREYANZI, and Table 15 describes selected new or worsening Grade 3 or 4 laboratory abnormalities.

The most common nonlaboratory adverse reactions (≥ 20%) were CRS, fatigue, musculoskeletal pain, encephalopathy, edema, headache, and decreased appetite.

Other clinically important adverse reactions in < 10% of patients included the following:

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Blood and lymphatic system disorders: Febrile neutropenia (6%).

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Cardiac disorders: Arrhythmia (2.3%).

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Eye disorders: Vision blurred (3.4%).

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Gastrointestinal disorders: Vomiting (6%).

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Infections and infestations: Bacterial infection (9%), viral infection (9%), fungal infection (8%), urinary tract infection (6%), sepsis (3.4%), pneumonia (2.3%).

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Injury, poisoning and procedural complications: Infusion related reaction (4.5%).

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Metabolism and nutrition disorders: Tumor lysis syndrome (2.3%).

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Nervous system disorders: Neuropathy peripheral (9%), aphasia (8%), ataxia (4.5%), cerebral infarction (1.1%), seizure (1.1%).

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Psychiatric disorders: Delirium (7%).

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Respiratory, thoracic, and mediastinal disorders: Hypoxia (3.4%).

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Vascular disorder: Thrombosis (4.5%).

Grade 4 laboratory abnormalities in ≥ 10% of patients were lymphocyte count decreased (84%), neutrophil count decreased (52%), white blood cell decreased (52%), and platelet count decreased (22%).

Postmarketing Experience

Because adverse events to marketed products are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to product exposure.

The following adverse events have been identified during postmarketing use of BREYANZI.

Nervous System Disorder: Immune effector cell-associated neurotoxicity syndrome (ICANS).

Neoplasms: T cell malignancies

Drug-Laboratory Test Interactions

HIV and the lentivirus used to make BREYANZI have limited, short spans of identical genetic material (RNA). Therefore, some commercial HIV nucleic acid tests may yield false-positive results in patients who have received BREYANZI.

Mechanism of Action

BREYANZI is a CD19-directed genetically modified autologous cell immunotherapy administered as a defined composition to reduce variability in CD8-positive and CD4-positive T cell dose. The CAR is comprised of an FMC63 monoclonal antibody-derived single chain variable fragment (scFv), IgG4 hinge region, CD28 transmembrane domain, 4-1BB (CD137) costimulatory domain, and CD3 zeta activation domain. CD3 zeta signaling is critical for initiating activation and antitumor activity, while 4-1BB (CD137) signaling enhances the expansion and persistence of BREYANZI.

CAR binding to CD19 expressed on the cell surface of tumor and normal B cells induces activation and proliferation of CAR T cells, release of pro-inflammatory cytokines, and cytotoxic killing of target cells.

Pharmacodynamics

Following BREYANZI infusion, pharmacodynamic responses were evaluated over a 4-week period by measuring transient elevation of soluble biomarkers such as cytokines, chemokines, and other molecules. Peak elevation of soluble biomarkers was observed within the first 14 days after BREYANZI infusion and returned to baseline levels within 28 days.

B-cell aplasia, defined as CD19+ B cells comprising less than 3% of peripheral blood lymphocytes, is an on-target effect of BREYANZI. B-cell aplasia was observed in the majority of patients for up to 1 year following BREYANZI infusion.

Pharmacokinetics

Following infusion, BREYANZI exhibited an initial expansion followed by a bi-exponential decline.

Relapsed or Refractory LBCL

The median time of maximal expansion in peripheral blood occurred 10-12 days after infusion. BREYANZI was present in peripheral blood for an estimated median of 12.1 months (range: 0.1+ to 24.2+ months).

Among patients who received two or more prior lines of therapy for LBCL (TRANSCEND), responders (N=135) had a 2.3-fold higher median Cmax than nonresponders (N=37) (35,335 vs. 15,527 copies/µg). Responders had a 1.8-fold higher median AUC0-28d than nonresponders (273,552 vs. 155,240 day*copies/µg).

Patients < 65 years old (N=142) had a 3.1-fold and 2.3-fold higher median Cmax and AUC0-28d, respectively, compared to patients ≥ 65 years old (N=96). Sex, race, ethnicity, and body weight did not show clear relationships to Cmax and AUC0-28d.

Relapsed or Refractory CLL/SLL

The median time of maximal expansion in peripheral blood occurred 14 days after infusion. BREYANZI was present in peripheral blood for an estimated median of 12.0 months (range: 0.1+ to 30.1+ months).

Among patients who received prior therapy for CLL/SLL (TRANSCEND-CLL), responders (N=27) had a 2.0-fold higher median Cmax than nonresponders (N=25) (99,559 vs. 48,948 copies/µg). Responders had a 1.9-fold higher median AUC0-28d than nonresponders (793,893 vs. 408,307 day*copies/µg).

Relapsed or Refractory FL

The median time of maximal expansion in peripheral blood occurred 10 days after infusion. Median Cmax and AUC0-28d are 30,530 copies/µg and 253,400 day*copies/µg, respectively. BREYANZI was present in peripheral blood for an estimated median of 12.0 months (range: 0.3+ to 24.0+ months).

Relapsed or Refractory MCL

The median time of maximal expansion in peripheral blood occurred 10 days after infusion. Median Cmax and AUC0-28d were 30,968 copies/µg and 375,006 day*copies/µg, respectively. BREYANZI was present in peripheral blood for an estimated median of 17.9 months (range: 0.1+ to 24.2+ months).

Patients receiving medications for CRS and/or neurologic toxicities

In general, patients with higher CAR-T cell expansion tended to have higher rates of CRS and neurologic toxicities. Some patients required tocilizumab and/or corticosteroids for the management of CRS or neurologic toxicities [see Dosage and Administration ]. BREYANZI continued to expand and persist in patients who received tocilizumab and/or corticosteroids treatment. In TRANSCEND, patients treated with tocilizumab (N=49) had a 3.6-fold and 3.7-fold higher median Cmax and AUC0-28d of BREYANZI, respectively, compared to patients who did not receive tocilizumab (N=189). Similarly, patients who received corticosteroids (N=50) had a 3.8-fold and 3.7-fold higher median Cmax and AUC0‑28d of BREYANZI, respectively, compared to patients who did not receive corticosteroids (N=188).

Immunogenicity

BREYANZI has the potential to induce anti-product antibodies. The immunogenicity of BREYANZI has been evaluated using an electrochemiluminescence (ECL) immunoassay for the detection of binding antibodies against the extracellular CD19-binding domain of BREYANZI. Pre-existing anti-product antibodies were detected in 11% (28/261) in TRANSCEND, 1% (1/89) in TRANSFORM, 0% (0/51) in PILOT, 2% (2/86) in TRANSCEND-CLL, 2% (2/102) in TRANSCEND-FL, and 13% (11/87) in TRANSCEND-MCL Cohort of patients. Treatment-induced or treatment-boosted anti-product antibodies were detected in 11% (27/257) in TRANSCEND, 1% (1/89) in TRANSFORM, 2% (1/49) in PILOT, 7% (6/84) in TRANSCEND-CLL, 18% (18/100) in TRANSCEND-FL, and 18% (15/85) in TRANSCEND-MCL Cohort of patients. Due to the small number of patients who had anti-product antibodies, the relationship between anti-product antibody status and efficacy, safety, or pharmacokinetics was not conclusive.

Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity or genotoxicity studies have been conducted with BREYANZI. No studies have been conducted to evaluate the effects of BREYANZI on fertility. In vitro studies with BREYANZI manufactured from healthy donors and patients showed no evidence for transformation and/or immortalization and no preferential integration near genes associated with oncogenic transformation.

Relapsed or Refractory Large B-Cell Lymphoma

Relapsed or Refractory LBCL After One Line of Therapy

TRANSFORM

A randomized, open-label, multicenter trial evaluated the efficacy of BREYANZI in adult patients with relapsed or refractory LBCL after first-line chemoimmunotherapy (TRANSFORM; NCT03575351). Patients had not yet received treatment for relapsed or refractory lymphoma, were potential candidates for autologous HSCT, and were required to have primary refractory disease or relapse within 12 months from complete response (CR) to initial chemoimmunotherapy. Eligibility criteria required adequate organ function and blood counts for HSCT.

In total, 184 patients were randomized in a 1:1 ratio to receive a single infusion of BREYANZI (planned dose, 100 × 106 CAR-positive viable T cells) or to receive standard therapy consisting of 3 cycles of chemoimmunotherapy followed by high-dose therapy and autologous HSCT in patients who attained CR or PR. All patients underwent leukapheresis prior to randomization.

Patients randomized to BREYANZI were to receive lymphodepleting chemotherapy consisting of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days followed by BREYANZI infusion 2 to 7 days after completion of lymphodepleting chemotherapy. Bridging chemotherapy was permitted between leukapheresis and the start of lymphodepleting chemotherapy. BREYANZI was administered in the inpatient (79%) and outpatient (21%) setting.

In the overall study population, the median age was 59 years (range: 20 to 75 years), 57% were male, 59% were White, 10% were Asian, and 4% were Black. Diagnoses included de novo DLBCL NOS (55%), high-grade B-cell lymphoma (23%), primary mediastinal large B-cell lymphoma (10%), and DLBCL arising from indolent lymphoma (8%). Of these patients, 73% had primary refractory disease to last therapy and 27% had relapsed disease within 12 months of achieving CR to first-line therapy.

Of 92 patients randomized to receive BREYANZI, 89 (97%) received BREYANZI. The median time from leukapheresis to product availability was 26 days (range: 19 to 84 days), and the median time from leukapheresis to product infusion was 36 days (range: 25 to 91 days). Fifty-eight (63%) patients received bridging therapy. One patient received a nonconforming product (manufacturing failure; 1.1%).

Of the 92 patients randomized to receive standard therapy, 91 started treatment and 43 (47%) received high-dose therapy and HSCT. The most common reason for not receiving HSCT was lack of efficacy of the salvage chemotherapy.

The primary efficacy measure was event-free survival (EFS) as determined by an independent review committee (IRC). Other efficacy measures included progression-free survival. Efficacy is summarized in Table 16 and Figure 1. The estimated 1-year EFS was 45% [95% CI: 29, 59] in the BREYANZI arm and 24% [95% CI: 14, 35] in the standard therapy arm.

Of the 92 patients in the BREYANZI arm, the estimated median duration of response (DOR) was not reached (95% CI: 7.9 months, NR) in patients who achieved CR (N=61) and 2.3 months (95% CI: 2.1, NR) in patients who achieved a best response of PR (N=18).

An interim analysis of overall survival was conducted at the time of the primary EFS analysis. The interim analysis of overall survival did not meet the criteria for statistical significance. Forty-six patients randomized to the standard therapy arm (50%) subsequently received BREYANZI on protocol.

Figure 1: Kaplan-Meier Plot of IRC-Assessed Event-Free Survival (Intention-to- Treat Analysis)

PILOT

The efficacy of BREYANZI was evaluated in a single-arm, open-label, multicenter trial (PILOT; NCT03483103) in transplant-ineligible patients with relapsed or refractory LBCL after one line of chemoimmunotherapy. The study enrolled patients who were not eligible for high-dose therapy and autologous HSCT due to organ function or age, while also having adequate organ function for CAR-T cell therapy. The study required at least one of the following criteria: age ≥ 70 years, adjusted diffusing capacity of the lung for carbon monoxide (DLCO) ≤ 60%; LVEF < 50%; creatinine clearance < 60mL/min; AST or ALT greater than 2 × ULN, or ECOG performance status of 2. The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells. Bridging therapy for disease control was permitted between leukapheresis and the start of lymphodepleting chemotherapy. Of the 61 patients treated with BREYANZI, 32 (53%) received bridging therapy.

BREYANZI was administered 2 to 7 days following completion of lymphodepleting chemotherapy. The lymphodepleting chemotherapy regimen consisted of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days. BREYANZI was administered in the inpatient (67%) and outpatient (33%) setting.

Of 74 patients who underwent leukapheresis, 61 (82%) received BREYANZI and comprise the main efficacy population; 1 (1.4%) received CAR-positive T cells that did not meet the product specifications for BREYANZI (manufacturing failure); and 12 (16%) did not receive CAR-positive T cells for other reasons.

Of the 61 patients who received BREYANZI, the median age was 74 years (range: 53 to 84 years), 61% were male, 89% were White, 3% were Asian, and 2% were Black. Diagnoses included de novo DLBCL NOS (51%), high-grade B-cell lymphoma (33%), and DLBCL arising from follicular lymphoma (15%). Of these patients, 53% had primary refractory disease, 23% had relapse within 12 months of completing first-line therapy, and 25% had relapse >12 months after first-line therapy.

Efficacy was based on CR rate and DOR, as determined by an independent review committee (IRC) using 2014 Lugano criteria (Tables 17 and 18). The median time to CR was 1 month (range 0.8 to 6.9 months).

Relapsed or Refractory LBCL After Two or More Lines of Therapy

TRANSCEND

The efficacy of BREYANZI was evaluated in an open-label, multicenter, single-arm trial (TRANSCEND; NCT02631044) in adult patients with relapsed or refractory large B-cell non-Hodgkin lymphoma after at least 2 lines of therapy. The study included patients with ECOG performance status ≤ 2, prior autologous and/or allogeneic HSCT, and secondary CNS lymphoma involvement. The study excluded patients with a creatinine clearance of less than 30 mL/min, ALT > 5 times the ULN, or LVEF < 40%. There was no prespecified threshold for blood counts; patients were eligible to enroll if they were assessed by the investigator to have adequate bone marrow function to receive lymphodepleting chemotherapy. Bridging therapy for disease control was permitted between apheresis and the start of lymphodepleting chemotherapy, including intrathecal chemotherapy or radiation therapy for treatment of CNS involvement with lymphoma.

BREYANZI was administered 2 to 7 days following completion of lymphodepleting chemotherapy. The lymphodepleting chemotherapy regimen consisted of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days. BREYANZI was administered in the inpatient and outpatient setting.

Of 299 patients who underwent leukapheresis for whom BREYANZI was manufactured in the dose range of 50 to 110 × 106 CAR-positive viable T cells:

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44 (15%) did not receive CAR-positive T cells either due to manufacturing failures (n=2), death (n=29), disease complications (n=6), or other reasons (n=7).

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204 (68%) received BREYANZI in the intended dose range, of whom 192 were evaluable for efficacy (main efficacy population); 12 were not evaluable due to absence of PET positive disease at study baseline or after bridging therapy.

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51 (17%) either received BREYANZI outside of the intended dose range (n=26) or received CAR-positive T cells that did not meet the product specifications for BREYANZI (manufacturing failures; n=25).

Of the 192 patients in the main efficacy population, the median age was 63 years (range: 18 to 86 years), 69% were male, 84% were White, 6% were Black, and 4.7% were Asian. The median number of prior therapies was 3 (range: 1 to 8). Diagnoses were de novo DLBCL (53%), DLBCL transformed from indolent lymphoma (25%), high-grade B-cell lymphoma (14%), primary mediastinal large B-cell lymphoma (7%), follicular lymphoma, grade 3B (1.0%). Of these patients, 64% had disease refractory to last therapy, 53% had primary refractory disease, 37% had prior HSCT and 2.6% had CNS involvement.

Efficacy was based on CR rate and DOR, as determined by an IRC using 2014 Lugano criteria (Tables 19 and 20). The median time to first response (CR or partial response [PR]) was 1.0 month (range: 0.7 to 8.9 months). The median time to first CR was 1.0 month (range 0.8 to 12.5 months). Of the 104 patients who achieved CR, 23 initially had stable disease (6 patients) or PR (17 patients), with a median time to improvement of 2.2 months (range: 0.7 to 11.6 months).

Response durations were longer in patients who achieved a CR, as compared to patients with a best response of PR (Table 20). Of the 104 patients who achieved CR, 68 (65%) had remission lasting at least 6 months and 64 (62%) had remission lasting at least 9 months.

Of the 287 patients who underwent leukapheresis and had radiographically evaluable disease, 27 additional patients achieved a response, apart from the responses noted in Table 19. The IRC-assessed overall response rate in the leukapheresed population (n=287) was 59% (95% CI: 53, 64), with a CR rate of 43% (95% CI: 37, 49) and PR rate of 15% (95% CI: 11, 20). These efficacy results include responses that may have been contributed solely by bridging therapy, responses after receipt of product outside of the intended dose range, and responses to product that did not meet release specifications.

Relapsed or Refractory Chronic Lymphocytic Lymphoma or Small Lymphocytic Lymphoma

TRANSCEND-CLL

The efficacy of BREYANZI was evaluated in a phase 1/2, open-label, multicenter, single-arm trial (TRANSCEND-CLL; NCT03331198) in adult patients with R/R CLL or SLL who had received at least 2 prior lines of therapy including a BTK inhibitor and a BCL-2 inhibitor. Patients with del(17p), complex karyotype, and unmutated immunoglobulin heavy chain variable region (IGHV) were included in the study. The study enrolled patients with ECOG performance status of ≤ 1. The study excluded patients with a creatinine clearance of less than 30 mL/min, ALT > 5 times the ULN (except for subjects with leukemic infiltration of the liver), or LVEF < 40%. There was no prespecified threshold for blood counts; patients were eligible to enroll if they were assessed by the investigator to have adequate bone marrow function to receive lymphodepleting chemotherapy. The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells. Bridging therapy for disease control was permitted between apheresis and the start of lymphodepleting chemotherapy.

Of the 89 patients, BREYANZI was administered 2 to 11 days following completion of lymphodepleting chemotherapy. The lymphodepleting chemotherapy regimen consisted of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days. BREYANZI was administered in the inpatient (88%) and outpatient (12%) settings.

Of 113 patients who underwent leukapheresis, 94 received BREYANZI. Of the 94, 84 received BREYANZI at 90 to 111 × 106 CAR-positive T cells and 10 received a cell-dose outside of this dose range; 3 received CAR-positive T cells that did not meet the product specifications for BREYANZI (manufacturing failure); and 16 other patients did not receive BREYANZI for other reasons.

The median time from leukapheresis to product availability was 24 days (range: 19 to 84 days), and the median time from leukapheresis to product infusion was 36 days (range: 28 to 384 days). Of the 89 patients treated with BREYANZI, 69 (78%) received bridging therapy.

Patients had measurable disease present before BREYANZI administration based on IRC assessment. Nineteen of 84 patients were not evaluable for efficacy (13 patients did not have baseline disease assessments performed after completion of bridging therapy, 1 patient lacked measurable disease, and 5 had Richter’s transformation). Of the 65 efficacy-evaluable patients, the median age was 66 years (range: 49 to 82 years), 68% were male, 80% were White, 3% were Black, 1% were Asian. Two‑percent were Hispanic and 89% were non-Hispanic. Eighty-three percent of patients had at least one high risk genetic attribute including 43% del(17p), 45% TP53 mutation, 45% unmutated IGHV, and 62% with complex karyotype. Fifty-one percent of the patients had bulky disease. The median number of prior therapies was 5 (range: 2 to 12). All 65 patients were exposed to a BTK inhibitor, of which 88% were refractory, 1.5% were relapsed, and 11% were intolerant. Of 65 patients who received a BCL-2 inhibitor, 92% were refractory, none relapsed, and 6% were intolerant. A total of 83% had disease refractory to last therapy.

Efficacy was based on ORR (including CR and PR) and DOR as determined by an IRC using 2018 International Workshop CLL (iwCLL) criteria (Tables 21 and 22). The median time to first response (CR or PR) was 1.1 months (range: 0.8 to 17.4 months). The median time to first CR was 3.0 months (range 1.1 to 17.9 months).

Minimal residual disease (MRD) negative status was defined as less than one CLL cell per 104 leukocytes using ClonoSEQ, a next generation sequencing assay (NGS) at any time post infusion (MRD‑negativity rate). There was no statistical testing of MRD-negativity rate. In patients who achieved CR, the MRD-negativity rate was 100% (13/13, 95% CI: 75.3, 100) in peripheral blood and 92.3% (12/13, 95% CI: 64, 99.8) in the bone marrow.

Relapsed or Refractory Follicular Lymphoma

TRANSCEND-FL

The efficacy of BREYANZI was evaluated in a Phase 2, open-label, multicenter, single-arm trial (TRANSCEND‑FL; NCT04245839) in adult patients with relapsed or refractory FL after two or more lines of systemic therapy (including an anti-CD20 antibody and an alkylating agent). The study enrolled patients with ECOG performance status of ≤ 1. The study excluded patients with a creatinine clearance of ≤ 30 mL/min, ALT > 5 times the ULN, or LVEF < 40%. There was no prespecified threshold for blood counts; patients were eligible to enroll if they were assessed by the investigator to have adequate bone marrow function to receive lymphodepleting chemotherapy. The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells. Bridging therapy for disease control was permitted between apheresis and the start of lymphodepleting chemotherapy.

A single dose of BREYANZI was administered 2 to 7 days following completion of lymphodepleting chemotherapy. The lymphodepleting chemotherapy regimen consisted of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days. Six percent of patients were treated with BREYANZI in outpatient setting.

Of 114 patients who underwent leukapheresis, 107 received BREYANZI and the median dose administered was 100.02 x 106 CAR-positive viable T-cells (range: 93.4 to 109.2 x 106 CAR-positive viable T cells).The primary efficacy analysis included 94 patients who had PET-positive disease at study baseline or confirmation of PET-positive disease after bridging therapy, received conforming product in intended dose range and had at least 9 months of follow up from the date of first response.

The median time from leukapheresis to product availability was 29 days (range: 20 to 55 days), and the median time from leukapheresis to product infusion was 50 days (range: 31 to 313 days). Of the 107 patients treated with BREYANZI, 40 (40%) received bridging therapy.

The median age was 63 years (range: 23 to 80 years), 62% were male, ECOG performance status was 0 in 63% and 1 in 37% of patients; 55% were White, 3% were Black, 9% were Asian; 5% were Hispanic and 69% were non-Hispanic. The median number of prior systemic therapies was 3 (range: 2 to 10), with 46% receiving 2 prior lines, 22% receiving 3 prior lines and 32% receiving ≥ 4 prior lines. Twenty percent had received rituximab with lenalidomide, 25% had received a PI3K inhibitor, and 29% of patients had prior autologous HSCT. Eighty-nine percentage patients had Stage III-IV disease at study entry, 29% had bulky disease, 64% had progression within 6 months of the most recent regimen, and 50% had progression within 24 months of initial diagnosis (POD24).

Efficacy was based on ORR, defined as the percentage of patients with a best overall response (BOR) of CR or PR after BREYANZI infusion and duration of response as determined by an IRC (Tables 23 and 24). The median time to first response (CR or PR) was 1.0 month (range: 0.6 to 3.3 months). The median time to first CR was 3.0 months (range 0.6 to 18.0 months).

Relapsed or Refractory Mantle Cell Lymphoma

TRANSCEND-MCL Cohort

The efficacy of BREYANZI was evaluated in an open-label, multicenter, single-arm trial (TRANSCEND-MCL Cohort; NCT02631044) in adult patients with relapsed or refractory MCL who had received at least two prior lines of therapy including a BTK inhibitor, an alkylating agent, and an anti-CD20 agent. The study included patients with ECOG performance status of ≤ 1, prior autologous and/or allogeneic HSCT, and secondary CNS lymphoma involvement. The study excluded patients with a creatinine clearance ≤ 30 mL/min, alanine aminotransferase > 5 times the upper limit of normal or left ventricular ejection fraction (LVEF) < 40%. There was no prespecified threshold for blood counts; patients were eligible to enroll if they were assessed by the investigator to have adequate bone marrow function to receive lymphodepleting chemotherapy. The planned dose of BREYANZI was 100 × 106 CAR-positive viable T cells. Bridging therapy for disease control was permitted between apheresis and the start of lymphodepleting chemotherapy.

BREYANZI was administered 2 to 7 days following completion of lymphodepleting chemotherapy. The lymphodepleting chemotherapy regimen consisted of fludarabine 30 mg/m2/day and cyclophosphamide 300 mg/m2/day concurrently for 3 days. BREYANZI was administered in the inpatient (85%) and outpatient (15%) setting.

Of 89 patients who underwent leukapheresis, 71 received BREYANZI and the median dose administered was 99.8 x 106 CAR-positive viable T cells (range: 90 to 103 x 106 CAR-positive viable T cells). The primary efficacy analysis included a total of 68 patients with MCL who received at least 2 prior lines of therapy including a BTK inhibitor, had PET-positive disease at study baseline or after bridging therapy, received conforming product in the intended dose range, and had at least 6 months of follow up from the date of first response.

The median time from leukapheresis to product availability was 24 days (range: 17 to 80 days), and the median time from leukapheresis to product infusion was 36 days (range: 28 to 489 days). Of the 68 patients in the main efficacy population, 44 (65%) received bridging therapy.

The median age was 69 years (range: 36 to 86 years); 75% were male, ECOG performance status was 0 in 57% and 1 in 43% of patients; 87% were White, 1.5% were Black, 6% were Asian; 6% were Hispanic and 91% were non-Hispanic. The median number of prior therapies was 3 (range: 2 to 11) and 32% had received prior HSCT. Twenty-nine percent of patients had blastoid morphology and 10% had CNS lymphoma involvement at baseline. Sixty-nine percent of patients had disease refractory to their last therapy for MCL, defined as best response of partial response (PR), stable disease (SD), or progressive disease (PD) to last systemic or HSCT treatment with curative intent. All 68 patients were exposed to BTK inhibitor, of which 56% were refractory, defined as any response to prior BTK inhibitor that was less than PR.

Efficacy was based on ORR, defined as the percentage of patients with BOR of either CR or PR after BREYANZI infusion, as determined by an IRC using 2014 Lugano classification. Other efficacy measures included complete response rate and DOR, as determined by IRC (Tables 25 and Table 26).

Both the median time to first response (CR or PR) and the median time to first CR were 1 month (range: 0.7 to 3 months).