Treatment


Patients with ALL need to start chemotherapy right away. It is important to get medical care in a center where doctors are experienced in treating patients with ALL.


The goal of treatment for ALL is to cure the disease. Children with ALL are likely to be cured of their disease. The number of adult patients who have remissions has increased. The length of remissions in adults has improved.


There are two parts of treatment for ALL, called induction therapy and post-induction therapy. The aim of induction therapy is to:


Kill as many ALL cells as possible

Get blood counts back to normal

And to get rid of all signs of the disease for an extended period of time.

This is called a remission.

Some drugs used to treat ALL are given by mouth. Other drugs are given by placing a catheter in a vein - usually in the patient's upper chest. During induction therapy most patients are treated with more than one drug and they may be given several drugs in combination. Each drug type works in a different way to kill the cells. Combining drug types can strengthen the effects of the drugs. Some of the drugs used to treat ALL are clofarabine, cytarabine, daunorubicin, methotrexate, mitoxantrone, cyclophosphamide, vincristine, pegaspargase, imatinib mesylate, prednisone and dexamethasone.

Patients with ALL often have leukemic cells in the lining of the spinal cord and brain. The procedure used to check the spinal fluid for leukemic cells is called a spinal tap. The cells cannot always be found in an exam of the spinal fluid.


To prevent leukemia in the central nervous system (CNS) leukemia, all patients who are in remission have the lining of the spinal cord and brain treated. In some cases, treatment is needed for ALL that has already affected the lining of the spinal cord and brain (CNS leukemia) and is causing problems such as headache, nausea and vomiting, and blurred vision. Parts of the body that aren't easily reached with chemotherapy given by mouth or IV - such as the lining of the spinal cord and brain - are treated by injection into the spinal fluid. Drugs such as methotrexate or cytarabine are injected into the spinal fluid either to prevent or treat CNS leukemia.


When the treatment is for CNS leukemia, a spinal tap is done. Then spinal fluid is removed and chemotherapy is injected into the spinal canal.

Radiation therapy may be given to the spine or brain. Spinal taps are done from time to time to check if leukemic cells are being killed and to give more doses of chemotherapy. Sometimes both chemotherapy and radiation therapy are used.

Many ALL patients build up uric acid in their blood from their disease. Uric acid is a chemical made in the body. The use of chemotherapy also increases the uric acid. A high level of uric acid can cause kidney stones. Patients with high uric acid levels may be given a drug called allopurinol (Aloprim®, Zyloprim®) by mouth or IV. Another drug used to treat high uric acid levels is called rasburicase (Elitek®).


Post-Induction Therapy


More treatment is needed even after a patient with ALL is in remission. This is called post-induction therapy. It is given in cycles for two to three years. Post-induction therapy is given because some ALL cells remain that are not found by common blood or marrow tests. For most people, the postremission therapy drugs used are not the same drugs used during induction therapy. The doctor considers many things to decide the kind of post-induction therapy a patient needs, such as:

The patient's response to induction therapy.

Whether the patient has certain chromosomal abnormalities.

High-risk types of ALL - such as T-cell ALL, infant ALL and adult ALL - are usually treated with higher doses of drugs during induction and post-induction therapy. One treatment plan is to use higher doses of drugs and give them for a longer time. Allogeneic stem cell transplant may be a good treatment for some high-risk ALL patients.


Ph-Positive ALL-Induction/Post-Induction


About one out of five adults with ALL and a small number of children with ALL have a type called Ph-positive (or Philadelphia-positive) ALL.


Ph-positive ALL may be treated with imatinib mesylate, also called Gleevec® or with other related drugs, such as dasatinib (Sprycel®) or nilotinib (Tasigna®). These drugs are given with chemotherapy. Gleevec® (or Sprycel® or Tasigna®) is given by mouth. Doctors are studying how well this treatment works in patients with Ph-positive ALL.


During post-induction therapy, Gleevec® (or another related drug) is given with other drugs. Usually people with Ph-positive ALL stay on Gleevec® (or another related drug) after post-induction therapy is completed.


Allogeneic Stem Cell Transplant


Allogeneic stem cell transplant is a treatment used for some patients with ALL.

The main purpose of doing the transplant is to give strong doses of chemotherapy or radiation therapy to kill the ALL cells. This will also kill the healthy stem cells in the marrow. The transplanted donor stem cells help start a new supply of red cells, white cells and platelets.


Allogeneic stem cell transplant is a high-risk procedure. For this reason, it may not be a good treatment for some ALL patients. Allogeneic stem cell transplant may be a choice for adult ALL patients if:


They are not doing well with other treatments. The expected benefits of stem cell transplant exceed the risks. There is a donor.


Stem cell transplant is usually not considered for a child unless:

Doctors have determined that the child's type of ALL is not likely to respond well to chemotherapy.

Chemotherapy has not worked well.

The child has relapsed ALL.


Side Effects of Treatment


Not all patients have treatment side effects. Patients who experience side effects should speak to their treatment teams about how to manage their side effects.


Possible side effects of treatment for ALL include:

The number of red cells may decrease (called anemia). Transfusions of red cells (blood cells that are donated and given to the patient) may be needed to increase red cells.

Patients also may have a drop in the number of platelets. If a patient's platelet count is very low he or she may need a platelet transfusion to prevent bleeding.

A big drop in white cells may lead to an infection. Such infections are usually treated with antibiotics, until the white cell count goes up and the infection clears up. For adults, growth factors are sometimes given to increase white cells. G-CSF (Neulasta® or Neupogen®) and GM-CSF (Leukine®) are drugs that increase the number of white cells. The doctor may talk about the absolute neutrophil count or ANC, which is the number of neutrophils, a type of white cell a person has to fight an infection. Fever or chills may be the only signs of infection. Patients with an infection may also have:

Coughing


Sore throat

Pain when urinating

Frequent loose bowel movements.

To lower the risk of infection:


The patient, the patient's visitors and medical staff need to wash their hands well.

The patient's central line must be kept clean. Patients on chemotherapy should take good care of their teeth and gums.

Chemotherapy affects the parts of the body where new cells form quickly. This includes the inside of mouth and bowel, and the skin and hair. Some other chemotherapy side effects are:

Mouth sores

Diarrhea

Hair loss

Rashes

Nausea

Vomiting.

Drugs and other therapies can be given to prevent or treat nausea or vomiting.


Follow-up Visits


Patients who have finished all of their therapy still need to go to their doctors regularly for exams and tests. The doctor may recommend longer periods of time between follow-up visits if a patient continues to be disease free.


Treatment for ALL can cause long-term or late effects. Children should be checked for treatment effects on growth or learning that may not take place right away. It is important to identify problems early. Talk to the doctor about when your child's learning skills should be assessed. Some children will need special help with schoolwork during and after treatment.


Relapsed or Refractory ALL


Some patients have a remission after treatment but then ALL cells return later - this is called a relapse. Other patients with ALL may still have ALL cells in the marrow even after treatment (refractory leukemia).


For patients who relapse, the same or different drugs may be given, or be used. A drug called clofarabine (Clolar®) is being used to treat some children (ages 1 to 21) with relapsed and refractory ALL.


In refractory leukemia, drugs that were not used to treat the patient's ALL in the first round of treatment may be given. Allogeneic stem cell transplantation also may be used.


Clinical Trials


Clinical trials are used to study new drugs, new treatments or new uses for approved drugs or treatments. These are some of the types of trials under way:


Leukemia-specific therapy, based on a patient's specific type of leukemia - such as the type of chromosome changes - is being studied.

The ALL cells of some patients are not as easily killed by drugs as those of other patients. This is called drug resistance. Scientists are trying to understand why some ALL cells are resistant to the effects of chemotherapy. This will help them develop better treatments.

Scientists are studying ways to boost the body's natural defenses, called immunotherapy. The goal is to kill or prevent the growth of ALL cells.


Blood cell growth factors can be used to help restore normal blood cells during treatment.

Scientists are studying the exact genetic changes that cause a normal cell to become an ALL cell. This research is leading to the development of new treatments. These treatments could block the effects of cancer-causing genes called oncogenes.

Gene profiling will be used more in the future to design more specific treatments for the different types of leukemia. New targeted treatments are being developed for ALL.


Many therapies, such as nilotinib, are being studied in clinical trials for Ph-positive ALL and other high-risk types of ALL. T-cell ALL, infant ALL and adult ALL are other high-risk types of ALL.


Doctors are studying a type of stem cell transplant, called a nonmyeloablative stem cell transplant (also called a reduced-intensity transplant).


Talk to the Doctor


It may be helpful to write down questions to ask your doctor. You can also write down or record your doctor's answers and review them later. You may want to bring a family member or friend with you to the doctor. This person can listen, take notes and offer support. Some patients record information and listen to it at home.

Questions to Ask Your Doctor

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Get More Information


The Leukemia & Lymphoma Society offers ongoing education programs featuring leading leukemia specialists discussing the latest issues in the diagnosis and treatment of leukemia. Visit the Leukemia Education Series page to find out about upcoming and archived programs. These programs are offered at no charge.

Further details of treatment and supportive care and the beneficial and adverse effects of treatment may be obtained from the free LLS informational booklets Acute Lymphocytic Leukemia and Acute Lymphocytic Leukemia: A Guide for Patients and Caregivers.