Treatment for acute lymphoblastic leukaemia (ALL) is divided into different phases. These are:
- induction also called remission induction
- intensification also called delayed intensification
Treatment for ALL usually takes between 2 and 3 years. The maintenance phase of treatment takes up most of this time. If you have a stem cell or bone marrow transplant the treatment time is much shorter.
ALL treatment is complicated, so the treatment varies. Your treatment team will talk to you about your treatment plan.
Induction or remission induction
The aim of the induction phase is to destroy as many the leukaemia cells as possible. If there is no sign of leukaemia in your blood and bone marrow after treatment it's called a complete remission (CR).
What treatment do I have?
You start treatment quite quickly after getting diagnosed. The main treatment is chemotherapy. You have several chemotherapy drugs over a few days.
Chemotherapy kills off many of your healthy bone marrow cells as well as the leukaemia cells. So you need to stay in hospital until you have recovered. This is usually about a month. There are different combinations of drugs you might have.
You usually start taking steroids for up to a week before you start chemotherapy. This starts to get rid of some of the leukaemia cells. This allows your doctor a bit of time to get all your test results and plans your treatment.
You also take medicine and have fluid through a drip to help protect your kidneys. You take antibiotics if you have an infection. You might need blood or platelet transfusions depending on your blood test results.
If you have Philadelphia positive ALL you have a targeted cancer drug. This drug is called imatinib (Glivec), and you have it alongside your chemotherapy. You take this as a tablet every day. This continues throughout your treatment.
You can watch this short video that explains what Philadelphia positive ALL is.
The human body is made up of trillions of cells. Inside each cell is a nucleus and within the nucleus are the cell’s chromosomes. There are 23 pairs in total.
Chromosomes are made up of DNA, which gives the instructions that tell a cell what to do. Sections of DNA are called genes. They carry the information that makes you you. For example, they tell your body what colour your hair will be or what colour your eyes will be.
Genes also tell your cells when to divide and grow, and when to die.
When cells divide to make new cells, they make exact copies of the chromosomes.
In Philadelphia chromosome positive leukaemia an abnormal change happens to chromosomes 9 and 22. Part of chromosome 9 breaks off where the gene ABL1 is located and part of chromosome 22 breaks off where the BCR gene is located. The broken parts swap places creating a new gene on chromosome 22.
This new chromosome is called the Philadelphia chromosome and the new gene is called BCR-ABL1. This new gene tells the cell to make a large quantity of a protein called tyrosine kinase which encourages leukaemia cells to grow.
There are targeted cancer drugs that can block the protein and stop the leukaemia from growing. These drugs are called tyrosine kinase blockers. You take them as tablets.
For more information about your type of leukaemia and treatments go to CRUK.org/about-cancer/leukaemia.
Chemotherapy into the spine
Leukaemia cells can sometimes travel to the brain and spinal cord (the central nervous system or CNS). So as part of your induction treatment you have chemotherapy into the fluid that circulates around the spinal cord and brain. This is called intrathecal chemotherapy. You may also have steroids into the CNS fluid.
Intrathecal chemotherapy treats leukaemia cells that are in the CNS. Or you have it to prevent leukaemia cells spreading to the CNS (CNS prophylaxis). You will also have this as part of other phases of your treatment.
You have intrathecal chemotherapy in the same way you have a lumbar puncture.
What happens next
After you finished the induction phase you have a bone marrow test. This is to check how well the treatment has worked. You might hear your doctors use the term MRD. This stands for minimal residual disease. This is a sensitive test to check if there are any remaining leukaemia cells in your body.
You move on to the next phase of treatment if you are in
Consolidation and intensification
The aim is to get rid of any leukaemia cells that might still be there and to stop them from coming back. You have one or more of the following treatments:
- more chemotherapy
- imatinib if you have a type of leukaemia called Philadelphia positive leukaemia
- a donor transplant
- a transplant with your own blood stem cells, but this is rare
You may also have treatment with CAR T-cell therapy if you are taking part in a clinical trial.
The treatment you have depends on many factors. These include:
- whether your lumbar puncture tests show leukaemia cells in the fluid around your brain and spinal cord
- whether your leukaemia is completely in remission
- how many times you had chemotherapy before your leukaemia went into remission
- whether you developed leukaemia after treatment for another cancer
- your general health and level of fitness
In these phases you're likely to have some of the same chemotherapy drugs you had in the induction phase. You will also have some others. You usually have higher amounts (doses) of the drugs so the treatment is stronger.
You have your treatment in
Your treatment team will go into the detail of your treatment plan with you.
A donor transplant means having bone marrow or stem cells from someone else. This is also known as an allogeneic transplant or allograft. Before the transplant you have either:
- high dose chemotherapy
- radiotherapy to the whole body (total body irradiation or TBI) and high dose chemotherapy.
If you have a transplant you won't need maintaince therapy. Your transplant team follows you up very closely once you are well enough to go home.
What happens next
You usually start maintenance therapy after finishing your consolidation therapy.
The last phase of ALL treatment is maintenance therapy. It helps to keep the leukaemia away (in remission).
What to expect
You usually have low dose chemotherapy and short courses of steroids for around 2 years. You might also have intrathecal chemotherapy. If you have Philadelphia positive leukaemia you continue to take imatinib until treatment ends. You have maintenance treatment as blocks.
You see your doctor every few months to check how you are getting on and to keep an eye on your blood counts.
Sometimes you may need blood transfusions or antibiotics if you have an infection.
If you are having treatment as part of a clinical trial, your maintenance treatment might include a targeted cancer drug such as inotuzumab ozogamicin.
What happens next
Your doctor follows you up closely after you finish maintenance treatment. You have regular blood tests and meet with your doctor to see how you are.
You can still contact your specialist nurse between appointments if you have any problems.
You usually have treatment for ALL as part of a clinical trial. Doctors and researchers do trials to:
- improve treatment
- make existing treatments better
- develop new treatments
Talk to your doctor or clinical nurse specialist if you are interested in joining a clinical trial.