Acute Lymphocytic Leukemia (ALL): Chemotherapy 

What is chemotherapy?

Chemotherapy uses anticancer medicines to kill cancer cells. The medicines are made to attack and kill cancer cells that grow quickly. Some normal cells also grow quickly. Because of this, chemotherapy can also harm those cells. This can cause side effects.

When might chemotherapy be used for ALL?

Chemotherapy is the main treatment for nearly all people with acute lymphocytic leukemia (ALL). 

If the first treatment with chemotherapy doesn't work, your doctor may advise another type of chemotherapy. This might be given in high doses along with a stem cell transplant. This depends on a variety of factors, such as your age and if the first treatment worked at all.

How is chemotherapy given for ALL?

If you get chemotherapy, you will meet with a hematologist/oncologist before treatment starts. This kind of doctor specializes in treating blood cancers like leukemia. The doctor will talk with you about your treatment and what you might expect. 

Chemotherapy for ALL is often given in phases. This gives the medicines a better chance of working well. The treatment phases of ALL include:

• Remission induction or induction therapy. The goal of this phase is to quickly kill as many leukemia cells in the blood and bone marrow as possible. This usually puts the leukemia into remission. Remission means you don't have signs or symptoms of the cancer.

• Consolidation (intensification) therapy. The goal of this phase is to kill any remaining leukemia cells and keep you in remission.

• Maintenance therapy. The goal of this phase is to keep the leukemia in remission over a long period of time.

Chemotherapy in the first two phases can be intense. You may need to spend a lot of time in the hospital. Younger patients often get stronger chemotherapy. Older patients may get slightly less strong treatment.

What is intrathecal chemotherapy?

Intrathecalchemotherapy may be needed for some people with ALL. The treatment sends medicine directly into the cerebrospinal fluid (CSF). This is the fluid that surrounds your brain and spinal cord. The medicine is given through a lumbar puncture. This is an injection in the lower part of your spine. A lumbar puncture can cause discomfort. This treatment is often used to treat ALL to kill or prevent the spread of cancer in your spine or brain. It's is often started during the induction phase of chemotherapy. It may continue throughout your treatment. You will likely get a combination of medicines, methotrexate and cytarabine.

If you need long-term treatment for your brain, a surgeon can insert a small, soft plastic dome just under the scalp with minor surgery. The plastic dome is called an Ommaya reservoir. It lets your health care providers easily send medicine into your CSF. It can also be used to take a sample of CSF. This can let your healthcare providers see if the treatment is working. It can also be used to check for signs of infection. When you no longer need the reservoir, the surgeon will remove it.

Treatment in the remission induction phase

This first phase of treatment lasts a month or so. You may be in the hospital for 4 to 6 weeks. You will likely get a combination of at least 3 chemotherapy medicines. This makes it more likely that the treatment will work. Which medicines you get and how long you receive them depends on many factors. They include your age and overall health, the subtype of ALL, and how well the leukemia responds to treatment.

The medicines most often used in this phase include: 

• Vincristine

• Dexamethasone or prednisone

• Doxorubicin or daunorubicin

• Cyclophosphamide

• L-asparaginase or peg-asparginase

• Cytarabine

• Methotrexate

• Etoposide

You may also get blood transfusions during this time if your blood cell counts get too low. Your healthcare team will check you closely for side effects. Side effects are more likely if you get high doses of medicine.

People whose leukemia cells have the Philadelphia chromosome will likely also get a targeted therapy medicine with chemotherapy. An example of this kind of medicine is imatinib. Targeted therapy medicine is taken daily as pills.

A few weeks after treatment, you will have a bone marrow biopsy and aspiration. This is to look for any leukemia cells that remain. If there are still leukemia cells in your bone marrow, you may have a second course of chemotherapy. This is done to try to put the leukemia into remission.

Treatment in the consolidation (intensification) phase

Once your leukemia is in remission, the next phase of treatment is consolidation. This is an intense course of chemotherapy. It’s done to try to kill any remaining cancer cells. This phase includes many of the same medicines used in the induction phase. This phase usually lasts for 4 to 6 months. Some people may have a stem cell transplant during this phase of treatment. Intrathecal chemotherapy may be continued during this phase. For people whose leukemia cells contain the Philadelphia chromosome, targeted therapy will continue through this phase.

Treatment in the maintenance phase

The maintenance phase may last 2 to 3 years. This phase is necessary for most types of ALL. It’s done because there still may be traces of leukemia cells in your body. The most common medicines for this phase of treatment are methotrexate and mercaptopurine. For people whose leukemia cells contain the Philadelphia chromosome, targeted therapy will continue through this phase. 

What are common side effects of chemotherapy?

Chemotherapy medicines are designed to attack and kill cells that divide quickly, including cancer cells. These medicines can also affect normal cells that grow quickly. These include hair, cells that line your mouth and throat, and bone marrow cells where new blood cells are made. The side effects of chemotherapy are different for everyone. They usually go away when the treatment ends.

Chemotherapy for ALL is typically given in high doses. This can often lead to serious side effects. These usually go away when the treatment ends. The side effects can be different for each person. The most common short-term side effects of chemotherapy for ALL include:

• Nausea and vomiting

• Loss of appetite 

• Easy bruising or bleeding, from low levels of blood platelets

• Tiredness, from having low levels of red blood cells

• Infections, from low levels of white blood cells

• Hair loss

• Headaches

• Loss of sexual desire

• Mouth sores

• Pain when swallowing

• Diarrhea

• Skin and nail changes

• Pain, numbness, or tingling in the hands or feet

Some side effects may not go away after treatment. For example, some medicines may damage the heart or other organs, or may affect your fertility. Doctors try to limit this damage by watching the doses of chemotherapy carefully. Some medicines may raise your risk of having other types of cancer later on. These risks need to be weighed against the benefits these medicines provide in treating your ALL.

Working with your healthcare provider

It's important to know which medicines you're taking. Write your medicines down, ask your healthcare team how they work, and what side effects they might have.

Talk with your healthcare providers about what signs to look for, and when to call them. Make sure you know what number to call with questions, even on evenings and weekends.

It may be helpful to keep a diary of your side effects. Write down physical, thinking, and emotional changes. A written list will make it easier for you to remember your questions when you go to your appointments. It will also make it easier for you to work with your medical team to make a plan to manage your side effects.