In Search of Long-Term Disease Control: CAR T-Cell Therapy With Axicabtagene Ciloleucel or Allogeneic Hematopoietic Cell Transplantation Against Relapsed/Refractory Large B-Cell Lymphoma.

BACKGROUND: CD19-directed chimeric antigen receptor (CAR) T-cell therapy has become the preferred cellular immunotherapy for relapsed/refractory (r/r) large B-cell lymphoma (LBCL), whereas allogeneic hematopoietic cell transplantation (allo-HCT) remains a potential salvage option. Comparative real-world data between both approaches are limited. PATIENTS AND METHODS: We conducted a retrospective single-center real-world analysis comparing outcomes of allo-HCT and CD19-directed CAR T-cell therapy with axicabtagene ciloleucel (axi-cel). A total of 187 patients with r/r large B-cell lymphoma (r/r LBCL) were included. Primary endpoints were progression-free survival (PFS) and overall survival (OS). Secondary endpoints included relapse incidence (RI), non-relapse mortality (NRM), and treatment-related toxicities. Propensity score matching (PSM) was performed to adjust for baseline differences. RESULTS: Response rates and relapse incidence were comparable between groups. However, NRM was significantly higher after allo-HCT (12% vs. 36%; P = < .001), mainly driven by infections and graft-versus-host disease. Consequently, axi-cel was associated with superior survival, with 12-month PFS of 50.1% versus 33.8% and OS of 60.5% versus 43.2% (both P < .05). These findings were confirmed in subgroup analyses (≥ 3rd line) and propensity score-matched cohorts. Multivariable analyses identified primary refractoriness and poor performance status as adverse prognostic factors, while treatment modality mainly impacted NRM rather than relapse risk. CONCLUSION: In conclusion, axi-cel provided superior PFS and OS to patients with r/r LBCL compared with allo-HCT, primarily due to lower treatment-related mortality and improved disease control in patients with chemorefractory disease prior to cellular therapy.