Because of acute lymphoblastic leukemia's (ALL's) rapid growth, most patients need to start chemotherapy soon after diagnosis. During chemotherapy, you're given potent drugs that must be toxic enough to damage or kill leukemic cells. At the same time, they can take aim at normal cells and cause side effects. Yet, not everyone experiences side effects the same way.
ALL treatment consists of:
- Induction therapy
- Minimal Residual Disease (MRD)
- Postremission therapy
- Treatment to prevent central nervous system prophylaxis
The first phase of treatment is induction therapy. The goal of induction therapy is to achieve remission, which means all signs and symptoms of leukemia have disappeared from the blood and marrow, although there may still be some in the body. A remission is not a cure but it is a very important part of the process because it allows normal marrow cells to develop and the patient’s blood counts to return to normal levels. Generally, if blast cells are still evident after the first course of induction chemotherapy, a second course of chemotherapy, usually using different drugs, is given.
Induction therapy is usually done over four to six weeks. You will likely spend most of that time in the hospital. You may have to go through several rounds of induction therapy before all your ALL cells are destroyed and you go into remission.
Doctors commonly combine two or more chemotherapy drugs to treat ALL. Each drug type works in a different way to kill the cancerous cells. Combining drug types can strengthen their effectiveness.
Some drugs used to treat ALL are:
- Daunorubicin (Cerubidine®) or doxorubicin (Adriamycin®) by central line, port or PICC
- Asparaginase Erwinia chrysanthemi (Erwinaze®), calaspargase pegol-mknl (AsparlasTM), or pegaspargase (PEG-L-asparaginase; Oncaspar®) by injection
- Vincristine (Oncovin®) by central line, port or PICC
- Dexamethasone or prednisone (corticosteroids) by mouth
- Methotrexate by injection into the spinal fluid
- Cytarabine (cytosine arabinoside, ara-C, Cytosar-U®) by injection into the spinal fluid
- 6-mercaptopurine (6-MP) (Purinethol® given by mouth as a tablet and Purixan® given by mouth as a liquid)
ALL drugs are administered in several ways
- As pills to swallow
- By injection or through a catheter (a thin, flexible tube or intravenous line) surgically placed in a vein, normally in your upper chest.
The first round of chemotherapy usually does not get rid of all the ALL cells. Most patients will need more rounds of treatment. Usually the same drugs are used for the added rounds.
- To see a list of standard drugs and drugs under clinical study to treat ALL, order or download The Leukemia & Lymphoma Society's free booklet Acute Lymphoblastic Leukemia.
- For information about the drugs mentioned on this page, visit Drug Listings.
Sensitive testing techniques permit the identification of small amounts of residual leukemia cells, known as “minimal residual disease (MRD),” at times when blood and marrow appear normal. This approach can be used if the leukemia cells have a detectable molecular abnormality or immunophenotype. It can also permit more sensitive follow-up of patients in remission and can help determine whether additional treatment is necessary.
Studies in both children and adults with ALL have shown that persistence or reappearance of MRD after induction chemotherapy is the most powerful prognostic indicator for both children and adult patients with ALL, even in patients who have low-risk features at diagnosis. Most patients who have persistent MRD after chemotherapy experience a relapse despite continued chemotherapy treatment,
When there is no sign of ALL, this is called a remission. Unfortunately, more treatment is usually needed even after an ALL patient is in remission. Some ALL cells may remain. These are not found by common blood or marrow tests. This part of ALL treatment is called post-remission therapy. Without this second step, your cancer will likely return.
Post-remission therapy consists of consolidation (intensification) therapy and maintenance therapy.
- Consolidation therapy is usually given in cycles for four to six months.
- Maintenance therapy is usually given for about two years.
For most people, the drugs used during consolidation and maintenance therapy are different than the drugs used during induction therapy.
Some factors your doctor considers when deciding the type of postremission therapy you'll need include:
- Whether induction therapy killed your ALL cells
- Your ability to tolerate intensive treatment
- Cytogenetic findings and whether they reveal certain changes to your chromosomes
- The availability of a stem cell donor
Some types of ALL, such as T-cell ALL, infant ALL and adult ALL, are usually treated with higher doses of drugs during induction, consolidation and maintenance therapy.
Patients may have ALL cells in the lining of the spinal cord and brain. A spinal tap (also called a lumbar puncture) is used to check the spinal fluid for ALL cells. Every ALL patient gets treatment to prevent CNS leukemia. Even if ALL cells are not found in the spinal fluid, patients are still treated.
The spinal cord and brain are hard to reach with chemotherapy that is given through a vein in the arm. So, spinal fluid is removed and chemotherapy is injected right into the spinal canal. Drugs, such as methotrexate, are used.
Radiation therapy may be given to the spine or brain. Sometimes both chemotherapy and radiation therapy are used. In some practices, doctors are not using cranial radiation for pediatric patients except in patients who have CNS leukemia or CNS relapse. When radiation therapy is not used, the chance of long-term effects decreases.
Spinal taps are done from time to time throughout treatment. This test checks to see if the ALL cells are being killed.