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 is generally done in two parts:
- Induction therapy
- Post-remission (consolidation and maintenance) therapy
- Central Nervous System Prophylaxis
The first phase of treatment is induction therapy. Its goal is to "induce" (bring on) remission - when no evidence of the disease is left. Several drugs are combined. Induction therapy attempts to:
- Kill as many ALL cells as possible
- Get blood cell counts back to normal
- Get rid of all signs of the disease for an extended time
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.
Chemotherapy Drugs Used for ALL
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:
- Clofarabine (Clolar®)
- Cyclophosphamide (Cytoxan®)
- Cytarabine (ara-C, Cytosar-U®)
- Dasatinib (Sprycel®)
- Daunorubicin (Cerubidine®)
- Dexamethasone (Decadron®)
- Imatinib mesylate (Gleevec®)
- Methotrexate (Rheumatrex®, Trexall®)
- Mitoxantrone (Novantrone®)
- Nelarabine (Arranon®)
- Pegaspargase (Oncaspar®)
- Ponatinib (Iclusig®)
- Vincristine (Oncovin®)
- Vincristine sulfate liposome injection (Marqibo®)
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.
- 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.
Minimal Residual Disease
Some people with ALL have a very low level of remaining ALL cells after treatment. This is called minimal residual disease (MRD). Sensitive molecular techniques permit the identification of small amounts of residual leukemia cells at times when blood and marrow appear normal. Your doctor may consider giving you additional treatment if MRD is detected at the end of your induction therapy (day 29). In some pediatric institutions, doctors are checking for MRD on day eight as an indicator of slow early-responders. The molecular test can also be used for patients in remission to help determine whether more treatment is needed.
After you finish induction therapy and are in remission, you'll begin the second phase of treatment called post-remission therapy (consolidation and maintenance therapy). Without this second step, your cancer will likely return.
Consolidation therapy is usually given in cycles for four to six months. You'll continue to receive therapy for two to three years. Maintenance therapy is usually given for about two years. Its purpose is to destroy stray ALL cells that blood or marrow tests can't detect. For most people, post-remission therapy includes different drugs than those used during induction therapy.
Some factors your doctor considers when deciding the type of post-remission 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 and consolidation and maintenance therapy.
Cancer cells often collect in the lining of the spinal canal or brain (the meninges) in patients with acute lymphocytic leukemia (ALL). This results in central nervous system (CNS) leukemia, which causes headache, nausea, vomiting and blurred vision. Even if cancerous cells aren't detected once you're in remission, you must still undergo central nervous system prophylaxis as the majority of patients will develop CNS leukemia if not treated.
Intrathecal therapy is used to kill ALL cells in the central nervous system. During this procedure, chemotherapy drugs are delivered directly into your spinal canal.
When you undergo intrathecal therapy, your doctor performs a lumbar puncture (spinal tap) by inserting a needle into your spinal canal; this can be done with either local anesthesia or with sedation/anesthesia. He or she removes spinal fluid, which is examined for leukemic cells, and replaces it by injecting fluid containing chemotherapy drugs such as methotrexate (Rheumatrex®, Trexall®), cytarabine (Cytosar-U®, cytosine arabinoside, ara-C) or hydrocortisone.
Because the drugs go directly into your spinal canal, the therapy treats hard-to-reach spine and brain cells more effectively than injecting chemotherapy into a vein. In some cases, radiation therapy to the spine or brain may be used.
You'll need to undergo a lumbar puncture periodically to ensure that ALL cells are being killed.