Overview
In the United States, most children with ALL are treated with protocols developed by the Children's Cancer Group (CCG) or the Pediatric Oncology Group (POG). Recently, these two groups have joined to form the Children's Oncology Group (COG). Future portocols will come through COG.
Children with ALL often have low blood counts and may need transfusions to relieve symptoms and antibiotics to treat infections.
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The first step in treatment is remission induction, which is aimed at achieving a state in which there is no visible evidence of disease and blood counts are normal. Hospitalization may be required for this step. A common approach is a four-week course of weekly vincristine and prednisone along with L-asparaginase. Doxorubicin, daunorubicin, or cyclophosphamide may be added for high-risk patients. Patients at standard or low risk may need only three drugs. Other drugs maybe given for supportive care. For example, allopurinol may be given to reduce the uric acid that may be formed and trimethoprim/sulfa to try to prevent Pneumocystis pneumonia.
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Treatment targeting the central nervous system - the brain and spinal cord (CNS) - is usually given during the remission induction phase and during the first three of treatment when remission is well established. The drug methotrexate is usually given intrathecally, which is aninjection into the cerebrospinal fluid, the liquid that bathes the central nervous system. The procedure to do this, a lumbar puncture, is repeated up to 18 times during the early and later phases of treatment. Cytarabine, hydrocortisone, or both may be added to methotrexate. Radiation therapy to the head is necessary if the disease is present in the CNS. Radiation may be used to prevent the disease from spreading there in very high-risk patients. In this case, the treatment is called prophylactic, which means preventive.
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Continuation or maintenance therapy generally lasts two to three years after remission is attained. For low-risk patients, this treatment is less intensive than remission induction. A common approach is intermittent methotrexate and daily 6-mercaptopurine with monthly vincristine and prednisone.
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About one quarter of children with ALL will relapse, but most will respond to reinduction therapy. Bone marrow transplantation should be considered after a second remission is achieved, especially in patients who relapse less than 36 months after diagnosis.
Drugs that might be used to treat ALL are listed at the bottom of the page. Click on the drug(s) you will be receiving to get more information.
Side effects during remission induction can be significant and patients usually remain in the hospital for three to six weeks. Treatment for ALL is aimed at the leukemic blood cells, but normal blood cells are also affected. All patients will have lowered blood counts that lead to a variety of symptoms. Low white blood cell counts put patients at increased risk of infection. Treatment with antibiotics to prevent or treat infections is likely. In some situations, your child will be in isolation and visitors to the room may need to wear gowns, masks, and gloves. Low white blood cell counts generally also lead to inflammation of the mucous membranes in the mouth and gastrointestinal tract. This is called mucositis. The tissues become very dry and may crack or bleed. Specific oral care regimens help minimize discomfort and prevent secondary infections. Mouth sores can make eating painful. The mouth sores themselves can cause pain that requires pain medication. Nausea and vomiting and diarrhea are side effects for which effective treatments exist. Hair may fall out and this is can be an especially upsetting side effect. Wigs and scarves may help minimize the distress hair loss causes. Low platelet counts lead to easy bruising and bleeding. Care to prevent injuries is very important. Low red blood cell counts causing anemia make patients feel tired and weak. Sometimes, patients are short of breath or have a fast heart rate. Transfusions will be necessary to replace red blood cells and platelets. Many patients are given stimulating factors called G-CSF or GM-CSF. These stimulate the development of new white blood cells so that cell counts are low for a shorter period of time. The initial treatment and the severity of side effects can be very difficult and wearing. While blood counts are low, your child may find it difficult to carry on normal activities. Simple exercise, such as walking, may seem overwhelming. Your doctors and nurses will do everything in their power to minimize the discomfort, sadness, and boredom that are common during this initial phase of treatment. Social workers, psychiatrists, and psychologists can help you and your child with depression and the ups and downs commonly experienced during treatment. Social workers can also help with financial issues related to treatment. Finally, all hospitals have clergy who are available to speak to you and provide spiritual guidance.
Resuming Activities
After the initial hospitalization, your child will slowly begin to resume your normal activities, but work and school may have to be postponed. Strength and stamina will return gradually. The doctors and nurses will provide more specific guidelines on what to expect based on individual treatment regimens and responses.
Clinical Trials
Many leukemia patients are asked to participate in a clinical trial. A clinical trial is a research program that attempts to find better treatments. A phase I clinical trial aims to find the safest way to give a new treatment. Patients are watched closely for side effects. Once the phase I trial is completed, the new treatment may be evaluated in a phase II clinical trial. At this stage the doctors are looking for anti-cancer activity, as well as side effects. After that, a phase III clinical trial will compare the new treatment to a standard treatment, randomly assigning patients to either group. Patients may be offered the chance to take part in any of the three types of trials. Some people worry that they will receive only a placebo, such as an ineffective sugar pill, in a clinical trial, but that is very rarely done in cancer treatment clinical trials.Patients are not required to take part in clinical trials. Those who choose to, however, may gain satisfaction from helping to evaluate new treatments, and may also have access to therapies that are not yet available to the general public. Patients may leave a clinical trial at any time, for any reason. Your doctor will explain why you may or may not be a candidate for a clinical trial. For a listing of current clinical trials, see the following website: http://www.nci.nih.gov/clinical_trials/
