Overview
The type of therapy recommended depends on many things, including the subtype of leukemia, what chromosomal alterations are present, and the patient's age and overall health. Some current drugs and drug combinations follow. Some patients will be offered the chance to take part in a clinical trial if appropriate.
Treatment for ALL is multiple chemotherapy drugs, usually involving several phases. It may last as long as three years.
Treatment Phases
- "Induction" is the first phase. Several chemotherapy drugs are used to achieve a remission, the state in which there is no evidence of disease and blood counts are normal. A commonly used five-drug regimen is vincristine, prednisone, Cytoxan, doxorubicin (Adriamycin®), and asparaginase. However, many different chemotherapy agents have been combined using various doses and schedules and the effort to find the optimal treatment is ongoing.
- In some patients, the leukemia cells will have already entered the central nervous system (CNS) by the time the diagnosis is confirmed. In some centers it will be treated with drugs; other centers recommend whole brain radiation.
- Even if the disease is not present in the CNS at diagnosis, it spreads there in up to 30% of patients. Since CNS leukemia is easier to prevent than to treat, prophylactic or preventative treatment is usually begun during the remission induction phase. Several approaches are possible. Methotrexate can be given intrathecally, which is a direct injection into the cerebrospinal fluid, the liquid that bathes the central nervous system. This is done with lumbar punctures or spinal taps. It can also be given by vein, in which case it circulates throughout the body. Another possible drug to use intrathecally is cytarabine. No matter which drug is used, many injections will be needed over three years.
- Some patients will have an Ommaya reservoir placed to eliminate the need for repeated lumbar punctures. The Ommaya reservoir is a soft plastic dome connected to a ventricular catheter, a flexible tube that is inserted into a cavity of the brain. It will be used to withdraw fluid and to deliver treatments.
- The consolidation, or intensification, phase follows the remission induction phase. Here, doctors aim to rid the body of any leukemia cells that remain after the initial treatment. It usually involves one or more types of chemotherapy sometimes at higher doses than in the remission induction phase.
- Next is the maintenance phase. Chemotherapy drugs are used at lower doses over long periods of time to treat any trace leukemia cells that remain, even if they are not detectable in laboratory tests. The drugs most commonly used are methotrexate, 6-mercaptopurine, vincristine, and prednisone. This phase may last two years.
- A bone marrow or stem cell transplant is also an option for some patients. This is very patient and disease specific. You will need to discuss this option with your doctor.
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.
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 Clinical Trials.gov as well the clinical trials listing at this web site and other comprehensive or clinical NCI-designated cancer center websites.
During Treatment
Side effects during remission induction can be significant and patients usually remain in the hospital for four to six weeks. Treatment for ALL is aimed at the leukemic blood cells, but normal blood cells are also effected. 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, you 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 can be an especially upsetting side effect. Wigs and scarves may help minimize the distress hair loss causes. Low platelet counts led 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 bone marrow 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, you 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, anxiety, and boredom that are common during this initial phase of treatment. Social workers, psychiatrists, and psychologists can help you and your family with depression and the ups and downs you will experience during treatment. Social workers can also help with financial issues related to treatment. Make sure your children's teachers are aware that you are sick, so they can be alert to the child's fears. Ask if your hospital has patient-to-patient volunteers. Often, these are volunteers who have been through the same treatments you are having. It can be especially helpful to speak with them. Finally, all hospitals have clergy who are available to speak to you and provide spiritual guidance during this very stressful time.
Resuming Activities
After the initial hospitalization, you 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 in individual treatment regimes and responses.
