Acute lymphoblastic leukemia (ALL) is a type of blood cancer that can occur in both adults and children. ALL grows and spreads quickly, so if you are diagnosed with this disease, it is important to begin treatment as soon as possible.

There are many different treatments available for people with ALL, including chemotherapy, targeted therapy, radiation therapy, and stem cell transplants. Various considerations can go into determining which leukemia treatment is right for you. Your doctor will base their recommendation on factors including:

• The subtype of ALL you have
• Which genetic mutations your cancer cells contain
• Whether you have any other health conditions
• Your age
• The types of symptoms you are experiencing
• Whether you have had cancer in the past

When receiving ALL treatments, you will likely have a health care team, which can include a number of different types of health care professionals. These may include:

• Hematologist-oncologists, doctors who specialize in blood cancer
• Pathologists, doctors who are experts at diagnosing diseases
• Radiologists, doctors who can read imaging tests

Other team members may include oncology nurses, nurse practitioners, surgeons, social workers, pharmacists, and counselors.

Types of Treatment for Acute Lymphoblastic Leukemia

ALL treatment is usually delivered in multiple phases. You may receive different therapies during each phase. Each phase also has different goals:

• Induction therapy — This first phase aims to kill as many cancer cells as possible.
• Consolidation or post-remission therapy — Once most of the cancer has been removed from the body, consolidation therapy aims to remove all possible remaining cancer cells. Stem cell transplantation may be used as consolidation.
• Maintenance therapy — These treatments help keep the cancer from coming back.

If treatment is effective, you may go into remission. Complete remission means that no cancer cells can be detected and you have no remaining leukemia symptoms. In some cases, leukemia returns after a person has gone into remission. This is known as a relapse.

Chemotherapy

Chemotherapy uses medication to kill cancer cells or prevent them from multiplying. Different chemotherapy drugs can be delivered in different ways. Some medications may be taken orally, some are injected under your skin, and others are delivered with an intravenous tube into a vein. These methods can’t effectively deliver chemotherapy to the central nervous system (brain and spinal cord), so you may also need to have chemotherapy drugs injected into your spinal fluid in order to kill cancer cells that have spread there.

There are several different types of chemotherapy drugs, which can kill cancer cells in different ways:

• DNA-damaging drugs — such as Cytoxan (cyclophosphamide) and Paraplatin (carboplatin) — damage or attach to a cell’s DNA in order to kill it or stop it from growing.
• Antitumor antibiotics, like Cerubidine (daunorubicin) and Adriamycin (doxorubicin), prevent cancer cells from multiplying.
• Antimetabolites — including Trexall (methotrexate), Fludara (fludarabine), and Cytosar-U (cytarabine) — prevent cancer cells from making new DNA, leading to their death.
• DNA repair enzyme inhibitors, like VP-16 (etoposide) and Hycamtin (topotecan), prevent leukemic cells from healing themselves, making them more sensitive to damage.
• Steroids like Decadron (dexamethasone) and Deltasone (prednisone) can kill leukemia cells in various ways.
• Antimitotic drugs such as Oncovin (vincristine) prevent cancer cells from making copies of themselves.

New chemotherapy drugs are being developed and tested. For example, Clolar (clofarabine) is approved to treat childhood ALL and has shown promise in studies of adults with this disease. Arranon (nelarabine) is a newer drug that can be used to treat T-cell ALL.

Chemotherapy is usually given in cycles, which includes one or more doses of the medication, plus a period of rest. Induction therapy often lasts for three to four weeks and commonly requires a hospital stay. Consolidation will consist of several more cycles. They may include the same chemotherapy drugs and doses used during induction therapy, or you may receive new drugs. You may also need a stem cell transplant during consolidation chemotherapy.

Finally, maintenance treatment usually consists of lower-dose chemotherapy for two to three years.

Targeted Therapy

Targeted therapies are drugs that recognize and attack specific proteins or cells. You may receive these medications in combination with chemotherapy. Targeted therapies are less likely to affect your body’s normal cells, and therefore tend to cause fewer side effects than do other cancer treatments.

Some targeted therapies are used to treat ALL cells that have the Philadelphia chromosome. This genetic change, found in about 20 percent to 30 percent of people with ALL, occurs when two different chromosomes become abnormally attached together. This change forms a new gene, BCR-ABL, that makes cancer cells multiply too quickly.

Targeted therapy medications called tyrosine kinase inhibitors can kill leukemia cells that contain BCR-ABL. Examples of drugs in this category include:

• Gleevec (imatinib)
• Sprycel (dasatinib)
• Tasigna (nilotinib)
• Iclusig (ponatinib)
• Bosulif (bosutinib)

Other targeted therapy drugs are currently being studied in clinical trials and may eventually be more widely available to treat ALL.

Monoclonal antibodies are another type of targeted therapy for ALL. These drugs attach to proteins located on the outer surface of leukemia cells. One monoclonal antibody, Blincyto (blinatumomab), attaches to ALL cells and then sends signals to the body’s immune system to destroy these cells.

Another drug in this category, Besponsa (inotuzumab ozogamicin), includes an antibody connected to a chemotherapy drug. The antibody can attach to the cancer cells, delivering the chemotherapy directly to these cells.

Immunotherapy

Immunotherapy includes any treatments that help the body’s own immune system attack leukemia cells. Monoclonal antibodies can be considered both a targeted therapy and a form of immunotherapy.

Another form of immunotherapy for ALL is chimeric antigen receptor (CAR) T-cell therapy. This treatment uses the body’s own T-cells to kill cancer. T cells are a type of lymphocyte (white blood cell) that kill infected cells in order to protect the body. During CAR T-cell therapy, doctors remove some of your body’s T cells and change their genes. The new T cells have special proteins called CARs on their surface. Doctors then put the T cells back into your body. The CAR proteins attach to other proteins on the surface of leukemia cells, allowing the T cells to kill the cancer cells.

CAR T-cell therapy has been approved to treat ALL in children and young adults up to the age of 25. It is also currently being studied for older adults.

Radiation Therapy

During radiation therapy, high-energy X-rays are used to kill cancer cells. Radiation therapy is often used to treat ALL that has spread to a particular area of the body, such as the brain or spine. It can also help reduce symptoms such as bone pain. Radiation can also be used to prepare a person’s body for a stem cell transplant, although this is not as common in people with ALL.

Stem Cell Transplant

Your blood stem cells are capable of making all of the other types of blood cells found in your body. Certain cancer treatments, such as chemotherapy, can damage these stem cells. During a stem cell transplant, your cancer cells — along with normal blood stem cells — are destroyed with aggressive treatment, and new healthy stem cells are delivered back to your body through an IV. The healthy stem cells can then produce new, nonleukemic blood cells.

There are two types of stem cell transplants: In autologous transplants, a person’s own stem cells are taken out of their body, sometimes treated, and then replaced. In allogenic transplants, a donor provides healthy stem cells.

Also known as bone marrow transplants, stem cell transplants may be used for people with ALL that is refractory (resistant to treatment), relapsed, or hard to treat. Stem cell transplants may also be an option for infants with ALL.

Palliative Care

You can choose to receive palliative care treatments while receiving other treatments for ALL. Palliative care aims to prevent and reduce the physical, mental, and social side effects of cancer care. This type of care can help improve your quality of life and make it easier for you and your family to deal with other cancer treatments.

Palliative care is not the same as end-of-life care — you can receive it at any point during your treatment journey. Ask your care team about palliative care options before and while receiving other therapies.

Managing the Side Effects From ALL Treatment

Many leukemia treatments cause side effects. You may need additional treatments in order to address them. Reducing your side effects may make it possible for you to receive more aggressive treatments that have the greatest chance of killing as many cancer cells as possible.

Cancer cells are more sensitive to chemotherapy drugs than are normal, healthy cells. However, your body’s normal cells can still be damaged by chemotherapy, leading to side effects. These side effects often include hair loss, nausea, vomiting, and mouth sores.

In order to treat the side effects of chemotherapy, you may need to get a blood transfusion, in which blood cells from a donor are delivered to your blood vessels in order to raise your numbers of healthy blood cells. You may also need antibiotics to treat infection.

Radiation therapy can sometimes lead to skin problems, tiredness, nausea, and diarrhea. These side effects often go away once the treatments are done, but your cancer care team may be able to help you find ways to prevent or treat these side effects. Eating a healthy diet, drinking plenty of water, and getting extra rest may help you feel better while you are going through radiation treatments.

What Is the Outlook for ALL?

Certain factors can make it more likely that treatments will be effective and that you will have a good outlook, or prognosis. These factors include:

• Being younger in age
• Having a lower white blood cell count when you are first diagnosed
• Having certain genetic changes
• Going into remission more quickly

Many new ALL treatments are currently being studied. This means that the prognosis for people with ALL may continue to improve as better treatments become available.

Connect With Others Who Understand

MyLeukemiaTeam is the social network for people with leukemia and their loved ones. On MyLeukemiaTeam, members come together to ask questions, give advice, and share their stories with others who understand life with leukemia.

Have you undergone chemotherapy treatments for ALL? Is your doctor recommending that you have a stem cell transplant? Share your experiences in the comments below, or start a conversation by posting on your Activities page.