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Cancer Interviews

Sharing the Journey

Type 1

The information below is provided with the permission of the National Cancer Institute (cancer.gov) which is a great public resource for information about cancer.


Definition of leukemia: A cancer that starts in the blood-forming tissue such as bone marrow and causes large numbers of blood cells to be produced and enter into the bloodstream.

..

There are two types of Acute Lymphoblastic Leukemia:

1. Adult Acute Lymphoblastic Leukemia.

2. Childhood Acute Lymphoblastic Leukemia.

ADULT ACUTE LYMPHOBLASTIC LEUKEMIA (ALL):

Adult acute lymphoblastic leukemia (ALL) is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell).

Adult acute lymphoblastic leukemia (ALL; also called acute lymphocytic leukemia) is a cancer of the blood and bone marrow. This type of cancer usually gets worse quickly if it is not treated.

Normally, the bone marrow makes blood stem cells (immature cells) that become mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid stem cell.

A myeloid stem cell becomes one of three types of mature blood cells:

Red blood cells that carry oxygen and other substances to all tissues of the body.

Platelets that form blood clots to stop bleeding.

Granulocytes (white blood cells) that fight infection and disease.

A lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes (white blood cells):

B lymphocytes that make antibodies to help fight infection.

T lymphocytes that help B lymphocytes make the antibodies that help fight infection.

Natural killer cells that attack cancer cells and viruses.

In ALL, too many stem cells become lymphoblasts, B lymphocytes, or T lymphocytes. These cells are also called leukemia cells. These leukemia cells are not able to fight infection very well. Also, as the number of leukemia cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may cause infection, anemia, and easy bleeding. The cancer can also spread to the central nervous system (brain and spinal cord).

Previous chemotherapy and exposure to radiation may increase the risk of developing ALL.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Possible risk factors for ALL include the following:

Being male.

Being white.

Being older than 70.

Past treatment with chemotherapy or radiation therapy.

Being exposed to radiation from an atomic bomb.

Having certain genetic disorders, such as Down syndrome.

Possible signs of adult ALL include fever, feeling tired, and easy bruising or bleeding.

The early signs of ALL may be like the flu or other common diseases. Check with your doctor if you have any of the following problems:

Weakness or feeling tired.

Fever or night sweats.

Easy bruising or bleeding.

Petechiae (flat, pinpoint spots under the skin, caused by bleeding).

Shortness of breath.

Weight loss or loss of appetite.

Pain in the bones or stomach.

Pain or feeling of fullness below the ribs.

Painless lumps in the neck, underarm, stomach, or groin.

Having many infections.

These and other symptoms may be caused by adult acute lymphoblastic leukemia or by other conditions.

Tests that examine the blood and bone marrow are used to detect (find) and diagnose adult ALL.

Once adult ALL has been diagnosed, tests are done to find out if the cancer has spread to the central nervous system (brain and spinal cord) or to other parts of the body.

The extent or spread of cancer is usually described as stages. It is important to know whether the leukemia has spread outside the blood and bone marrow in order to plan treatment. The following tests and procedures may be used to determine if the leukemia has spread:

Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Lumbar puncture : A procedure used to collect cerebrospinal fluid from the spinal column. This is done by placing a needle into the spinal column. This procedure is also called an LP or spinal tap.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of the abdomen, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

There is no standard staging system for adult ALL.

The disease is described as untreated, in remission, or recurrent.

Untreated adult ALL

The ALL is newly diagnosed and has not been treated except to relieve symptoms such as fever, bleeding, or pain.

The complete blood count is abnormal.

More than 5% of the cells in the bone marrow are blasts (leukemia cells).

There are signs and symptoms of leukemia.

Adult ALL in remission

The ALL has been treated.

The complete blood count is normal.

5% or fewer of the cells in the bone marrow are blasts (leukemia cells).

There are no signs or symptoms of leukemia other than in the bone marrow.

Recurrent Adult Acute Lymphoblastic Leukemia

Recurrent adult acute lymphoblastic leukemia (ALL) is cancer that has recurred (come back) after going into remission. The ALL may come back in the blood, bone marrow, or other parts of the body.

There are different types of treatment for patients with adult ALL.

Different types of treatment are available for patients with adult acute lymphoblastic leukemia (ALL). Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

The treatment of adult ALL usually has two phases.

The treatment of adult ALL is done in phases:

Remission induction therapy: This is the first phase of treatment. The goal is to kill the leukemia cells in the blood and bone marrow. This puts the leukemia into remission.

Post-remission therapy: This is the second phase of treatment. It begins once the leukemia is in remission. The goal of post-remission therapy is to kill any remaining leukemia cells that may not be active but could begin to regrow and cause a relapse. This phase is also called remission continuation therapy.

Treatment called central nervous system (CNS) sanctuary therapy is usually given during each phase of therapy. Because standard doses of chemotherapy may not reach leukemia cells in the CNS (brain and spinal cord), the cells are able to "find sanctuary" (hide) in the CNS. High doses of certain anticancer drugs, intrathecal chemotherapy, and radiation therapy to the brain are able to reach leukemia cells in the CNS. They are given to kill the leukemia cells and keep the cancer from recurring (coming back). CNS sanctuary therapy is also called CNS prophylaxis.

Four types of standard treatment are used:

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid (intrathecal chemotherapy), an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is treatment using more than one anticancer drug. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Intrathecal chemotherapy may be used to treat adult ALL that has spread, or may spread, to the brain and spinal cord. When used to prevent cancer from spreading to the brain and spinal cord, it is called central nervous system (CNS) sanctuary therapy or CNS prophylaxis. Intrathecal chemotherapy is given in addition to chemotherapy by mouth or vein.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. External radiation therapy may be used to treat adult ALL that has spread, or may spread, to the brain and spinal cord. When used this way, it is called central nervous system (CNS) sanctuary therapy or CNS prophylaxis.

Chemotherapy with stem cell transplant

Stem cell transplant is a method of giving chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Targeted therapy drugs called tyrosine kinase inhibitors are used to treat some types of adult ALL. These drugs block the enzyme, tyrosine kinase, that causes stem cells to develop into more white blood cells (blasts) than the body needs. Three of the drugs used are imatinib mesylate (Gleevec), dasatinib, and nilotinib.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Patients with ALL may have late effects after treatment.

Side effects from cancer treatment that begin during or after treatment and continue for months or years are called late effects. Late effects of treatment for ALL may include the risk of second cancers (new types of cancer). Regular follow-up exams are very important for long-term survivors.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Untreated Adult Acute Lymphoblastic Leukemia

Standard treatment of adult acute lymphoblastic leukemia (ALL) during the remission induction phase includes the following:

Combination chemotherapy.

Tyrosine kinase inhibitor therapy with imatinib mesylate, in certain patients. Some of these patients will also have combination chemotherapy.

Supportive care including antibiotics and red blood cell and platelet transfusions.

CNS prophylaxis therapy including chemotherapy (intrathecal and/or systemic) with or without radiation therapy to the brain.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with untreated adult acute lymphoblastic leukemia. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.

Adult Acute Lymphoblastic Leukemia in Remission

Standard treatment of adult ALL during the post-remission phase includes the following:

Chemotherapy.

Tyrosine kinase inhibitor therapy.

Chemotherapy with stem cell transplant.

CNS prophylaxis therapy including chemotherapy (intrathecal and/or systemic) with or without radiation therapy to the brain.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with adult acute lymphoblastic leukemia in remission. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.

Recurrent Adult Acute Lymphoblastic Leukemia

Standard treatment of recurrent adult ALL may include the following:

Combination chemotherapy followed by stem cell transplant.

Low-dose radiation therapy as palliative care to relieve symptoms and improve the quality of life.

Tyrosine kinase inhibitor therapy with dasatinib for certain patients.

Some of the treatments being studied in clinical trials for recurrent adult ALL include the following:

A clinical trial of stem cell transplant using the patient's stem cells.

A clinical trial of biologic therapy.

A clinical trial of new anticancer drugs.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent adult acute lymphoblastic leukemia. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.

The following tests and procedures may be used:

Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as infection or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.

Complete blood count (CBC) with differential : A procedure in which a sample of blood is drawn and checked for the following:

The number of red blood cells and platelets.

The number and type of white blood cells.

The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.

The portion of the blood sample made up of red blood cells.

Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

Peripheral blood smear : A procedure in which a sample of blood is checked for blast cells, the number and kinds of white blood cells, the number of platelets, and changes in the shape of blood cells.

Bone marrow aspiration and biopsy : The removal of bone marrow, blood, and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow, blood, and bone under a microscope to look for abnormal cells.

The following tests may be done on the samples of blood or bone marrow tissue that are removed:

Cytogenetic analysis: A laboratory test in which the cells in a sample of blood or bone marrow are looked at under a microscope to find out if there are certain changes in the chromosomes in the lymphocytes. For example, sometimes in ALL, part of one chromosome is moved to another chromosome. This is called the Philadelphia chromosome. Other tests, such as fluorescence in situ hybridization (FISH), may also be done to look for certain changes in the chromosomes.

Immunophenotyping : A process used to identify cells, based on the types of antigens or markers on the surface of the cell. This process is used to diagnose the subtype of ALL by comparing the cancer cells to normal cells of the immune system. For example, a cytochemistry study may test the cells in a sample of tissue using chemicals (dyes) to look for certain changes in the sample. A chemical may cause a color change in one type of leukemia cell but not in another type of leukemia cell.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

The age of the patient.

Whether the cancer has spread to the brain or spinal cord.

Whether there are certain changes in the genes, including the Philadelphia chromosome.

Whether the cancer has been treated before or has recurred (come back).

CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA (ALL):

Childhood acute lymphoblastic leukemia (ALL) is a type of cancer in which the bone marrow makes too many immature lymphocytes (a type of white blood cell).

Childhood acute lymphoblastic leukemia (also called ALL or acute lymphocytic leukemia) is a cancer of the blood and bone marrow. This type of cancer usually gets worse quickly if it is not treated.

ALL is the most common type of cancer in children.

In a healthy child, the bone marrow makes blood stem cells (immature cells) that become mature blood cells over time. A blood stem cell may become a myeloid stem cell or a lymphoid stem cell.

A myeloid stem cell becomes one of three types of mature blood cells:

Red blood cells that carry oxygen and other substances to all tissues of the body.

Platelets that form blood clots to stop bleeding.

White blood cells that fight infection and disease.

A lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes (white blood cells):

B lymphocytes that make antibodies to help fight infection.

T lymphocytes that help B lymphocytes make the antibodies that help fight infection.

Natural killer cells that attack cancer cells and viruses.

In a child with ALL, too many stem cells become lymphoblasts, B lymphocytes, or T lymphocytes. These cells are cancer (leukemia) cells. The leukemia cells do not work like normal lymphocytes and are not able to fight infection very well. Also, as the number of leukemia cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may lead to infection, anemia, and easy bleeding.

Family history and being exposed to radiation may affect the risk of having childhood ALL.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your child's doctor if you think your child may be at risk.

Possible risk factors for ALL include the following:

Being exposed to x-rays before birth.

Being exposed to radiation.

Past treatment with chemotherapy.

Having certain changes in the genes.

Having certain genetic conditions, such as:

Down syndrome.

Neurofibromatosis type 1 (NF1).

Shwachman syndrome.

Bloom syndrome.

Ataxia-telangiectasia.

Signs of childhood ALL include fever and bruising.

These and other signs and symptoms may be caused by childhood ALL or by other conditions. Check with your child's doctor if your child has any of the following:

Fever.

Easy bruising or bleeding.

Petechiae (flat, pinpoint, dark-red spots under the skin caused by bleeding).

Bone or joint pain.

Painless lumps in the neck, underarm, stomach, or groin.

Pain or feeling of fullness below the ribs.

Weakness, feeling tired, or looking pale.

Loss of appetite.

Tests that examine the blood and bone marrow are used to detect (find) and diagnose childhood ALL.

The following tests and procedures may be used to diagnose childhood ALL and find out if leukemia cells have spread to other parts of the body such as the brain or testicles:

Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.

Complete blood count (CBC) with differential : A procedure in which a sample of blood is drawn and checked for the following:

The number of red blood cells and platelets.

The number and type of white blood cells.

The amount of hemoglobin (the protein that carries oxygen) in the red blood cells.

The portion of the sample made up of red blood cells.

Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

Bone marrow aspiration and biopsy : The removal of bone marrow and a small piece of bone by inserting a hollow needle into the hipbone or breastbone. A pathologist views the bone marrow and bone under a microscope to look for signs of cancer.

The following tests may be done on the tissue that is removed:

Cytogenetic analysis : A laboratory test in which the cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes in the lymphocytes. For example, in Philadelphia chromosome –positive ALL, part of one chromosome is moved to another chromosome. This is called the “Philadelphia chromosome.” Other tests, such as fluorescence in situ hybridization (FISH), may also be done to look for certain changes in the chromosomes.

Immunophenotyping : A laboratory test in which the antigens or markers on the surface of a blood or bone marrow cell are checked to see if they are lymphocytes or myeloid cells. If the cells are malignant lymphocytes (cancer) they are checked to see if they are B lymphocytes or T lymphocytes.

Lumbar puncture : A procedure used to collect a sample of cerebrospinal fluid from the spinal column. This is done by placing a needle into the spinal column. The sample of fluid is checked for leukemia cells. This procedure is also called an LP or spinal tap. This procedure is done after leukemia is diagnosed to find out if leukemia cells have spread to the brain and spinal cord. Intrathecal chemotherapy is given after the sample of fluid is removed to treat any leukemia cells that may have spread to the brain and spinal cord.

Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. The chest x-ray is done to see if leukemia cells have formed a mass in the middle of the chest.

Testicular biopsy : The removal of cells or tissues from the testicles so they can be viewed under a microscope by a pathologist to check for signs of cancer. This procedure is done only if there seems to be anything unusual about the testicles during the physical exam.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on:

Age at diagnosis, gender, and race.

The number of white blood cells in the blood at diagnosis.

Whether the leukemia cells began from B lymphocytes or T lymphocytes.

Whether there are certain changes in the chromosomes or genes of the lymphocytes with cancer.

Whether the child has Down syndrome.

Whether leukemia cells are found in the cerebrospinal fluid.

How quickly and how low the leukemia cell count drops after initial treatment.

Treatment options depend on:

Whether the leukemia cells began from B lymphocytes or T lymphocytes.

Whether the child has standard-risk or high-risk ALL.

The age of the child at diagnosis.

Whether there are certain changes in the chromosomes of lymphocytes, such as the Philadelphia chromosome.

How quickly and how low the leukemia cell count drops after initial treatment.

For leukemia that relapses (comes back) after initial treatment, the prognosis and treatment options depend partly on the following:

How long it is between diagnosis and when the leukemia comes back after initial treatment.

Whether the leukemia comes back in the bone marrow or in other parts of the body.

In childhood ALL, risk groups are used to plan treatment.

There are two risk groups in childhood ALL. They are described as:

Standard (low) risk: Includes children aged 1 to younger than 10 years who have a white blood cell count of less than 50,000/µL at diagnosis.

High risk: Includes children 10 years and older and/or children who have a white blood cell count of 50,000/µL or more at diagnosis.

Other factors that affect the risk group include the following:

Whether the leukemia cells began from B lymphocytes or T lymphocytes.

Whether there are certain changes in the chromosomes or genes of the lymphocytes.

How quickly and how low the leukemia cell count drops after initial treatment.

Whether leukemia cells are found in the cerebrospinal fluid at diagnosis.

It is important to know the risk group in order to plan treatment. Children with high-risk ALL usually receive more anticancer drugs and higher doses of anticancer drugs than children with standard-risk ALL.

Relapsed Childhood Acute Lymphoblastic Leukemia

Relapsed childhood ALL is cancer that has come back after it has been treated. The leukemia may come back in the blood and bone marrow, brain, spinal cord, testicles, or other parts of the body.

Treatment Option Overview

There are different types of treatment for childhood acute lymphoblastic leukemia (ALL).

Different types of treatment are available for children with acute lymphoblastic leukemia (ALL). Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Because cancer in children is rare, taking part in a clinical trial should be considered. Some clinical trials are open only to patients who have not started treatment.

Children with ALL should have their treatment planned by a team of doctors with expertise in treating childhood leukemia.

Treatment will be overseen by a pediatric oncologist, a doctor who specializes in treating children with cancer. The pediatric oncologist works with other pediatric health professionals who are experts in treating children with leukemia and who specialize in certain areas of medicine. These may include the following specialists:

Hematologist.

Medical oncologist.

Pediatric surgeon.

Radiation oncologist.

Neurologist.

Pathologist.

Radiologist.

Pediatric nurse specialist.

Social worker.

Rehabilitation specialist.

Psychologist.

Child-life specialist.

Regular follow-up exams are very important. Treatment can cause side effects long after it has ended. These are called late effects. Radiation therapy to the brain may cause changes in mood, feelings, thinking, learning, or memory. Children younger than 4 years have a higher risk of side effects from radiation therapy to the brain.

Late effects of treatment for ALL also include the risk of second cancers (new types of cancer), especially brain tumors.

Some late effects may be treated or controlled. It is important to talk with your child's doctors about the possible late effects caused by some treatments.

The treatment of childhood ALL usually has three phases.

The treatment of childhood ALL is done in phases:

Remission induction: This is the first phase of treatment. The goal is to kill the leukemia cells in the blood and bone marrow. This puts the leukemia into remission.

Consolidation /intensification: This is the second phase of treatment. It begins once the leukemia is in remission. The goal of consolidation/intensification therapy is to kill any leukemia cells that remain in the body and may cause a relapse.

Maintenance: This is the third phase of treatment. The goal is to kill any remaining leukemia cells that may regrow and cause a relapse. Often the cancer treatments are given in lower doses than those used during the remission induction and consolidation/intensification phases. Not taking medication as ordered by the doctor during maintenance therapy increases the chance the cancer will come back. This is also called the continuation therapy phase.

Four types of standard treatment are used:

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid (intrathecal), an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is treatment using more than one anticancer drug.

The way the chemotherapy is given depends on the child's risk group. Children with high-risk ALL receive more anticancer drugs and higher doses of anticancer drugs than children with standard-risk ALL.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. External radiation therapy may be used to treat childhood ALL that has spread, or may spread, to the brain and spinal cord.

Chemotherapy with stem cell transplant

Stem cell transplant is a method of giving high doses of chemotherapy and sometimes total-body irradiation, and then replacing the blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of a donor. After the patient receives treatment, the donor's stem cells are given to the patient through an infusion. These reinfused stem cells grow into (and restore) the patient's blood cells. The stem cell donor doesn't have to be related to the patient.

Stem cell transplant is rarely used as initial treatment for children and teenagers with ALL. It is used more often as part of treatment for ALL that relapses (comes back after treatment).

Targeted therapy

Targeted therapy is a treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Tyrosine kinase inhibitors (TKIs) are targeted therapy drugs that block the enzyme, tyrosine kinase, which causes stem cells to become more white blood cells or blasts than the body needs. Imatinib mesylate (Gleevec) is a TKI used in the treatment of children with Philadelphia chromosome –positive ALL.

New kinds of targeted therapies are also being studied in the treatment of childhood ALL.

Treatment is given to kill leukemia cells that have spread or may spread to the brain, spinal cord, or testicles.

Treatment to kill leukemia cells or prevent the spread of leukemia cells to the brain and spinal cord is called CNS-directed therapy. Chemotherapy may be used to treat leukemia cells that have spread, or may spread, to the brain and spinal cord. Because standard chemotherapy may not reach leukemia cells in the CNS (brain and spinal cord), the cells are able to hide in the CNS. Systemic chemotherapy given in high doses or intrathecal chemotherapy (into the cerebrospinal fluid) is able to reach leukemia cells in the CNS. Sometimes external radiation therapy to the brain is also given.

These treatments are given in addition to treatment that is used to kill leukemia cells in the rest of the body. All children with ALL receive CNS-directed therapy as part of induction therapy and consolidation/intensification therapy and sometimes during maintenance therapy.

If the leukemia cells spread to the testicles, treatment includes high doses of chemotherapy and sometimes radiation therapy.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI Web site.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your child's condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Bone marrow aspiration and biopsy is done during all phases of treatment to see how well the treatment is working.

Treatment Options for Childhood Acute Lymphoblastic Leukemia

Newly Diagnosed Childhood Acute Lymphoblastic Leukemia (Standard Risk)

The treatment of standard-risk childhood acute lymphoblastic leukemia (ALL) during the remission induction, consolidation /intensification, and maintenance phases always includes combination chemotherapy. Children who are not in remission after having combination chemotherapy during the induction phase may be helped by more chemotherapy. When they are in remission, a stem cell transplant using stem cells from a donor may be done.

Intrathecal chemotherapy is given to prevent the spread of leukemia cells to the brain and spinal cord.

Treatments being studied in clinical trials for standard-risk ALL include new chemotherapy regimens.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with untreated childhood acute lymphoblastic leukemia. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your child's doctor about clinical trials that may be right for your child. General information about clinical trials is available from the NCI Web site.

Newly Diagnosed Childhood Acute Lymphoblastic Leukemia (High Risk)

The treatment of high-risk childhood acute lymphoblastic leukemia (ALL) during the remission induction, consolidation /intensification, and maintenance phases always includes combination chemotherapy. Children in the high-risk ALL group are given more anticancer drugs and higher doses of anticancer drugs, especially during the consolidation/intensification phase, than children in the standard-risk group.

Intrathecal and systemic chemotherapy are given to prevent the spread of leukemia cells to the brain and spinal cord. Sometimes radiation therapy to the brain is also given.

Treatments being studied in clinical trials for high-risk ALL include new chemotherapy regimens and stem cell transplant.

Newly Diagnosed Childhood Acute Lymphoblastic Leukemia (Special Groups)

T-cell childhood acute lymphoblastic leukemia

The treatment of T-cell childhood acute lymphoblastic leukemia (ALL) during the remission induction, consolidation /intensification, and maintenance phases always includes combination chemotherapy. Children with T-cell ALL are given more anticancer drugs and higher doses of anticancer drugs than children with B-cell ALL in the standard-risk group.

Intrathecal and systemic chemotherapy are given to prevent the spread of leukemia cells to the brain and spinal cord. Sometimes radiation therapy to the brain is also given.

Treatments being studied in clinical trials for T-cell ALL include new anticancer agents and chemotherapy regimens.

Infants with ALL

The treatment of infants with ALL during the remission induction, consolidation /intensification, and maintenance phases always includes combination chemotherapy. Infants with ALL are given different anticancer drugs and higher doses of anticancer drugs than children 1 year and older in the standard-risk group. It is not clear whether a stem cell transplant during first remission improves survival.

Intrathecal and systemic chemotherapy are given to prevent the spread of leukemia cells to the brain and spinal cord.

Treatments being studied in clinical trials for infants with ALL include the following:

A clinical trial of chemotherapy followed by a donor stem cell transplant for infants with certain gene changes.

A clinical trial of combination chemotherapy and targeted therapy with a tyrosine kinase inhibitor.

Children 10 years and older and teenagers with ALL

The treatment of ALL in children and teenagers (10 years and older) during the remission induction, consolidation /intensification, and maintenance phases always includes combination chemotherapy. Children 10 years and older and teenagers with ALL are given more anticancer drugs and higher doses of anticancer drugs than children in the standard-risk group.

Intrathecal and systemic chemotherapy are given to prevent the spread of leukemia cells to the brain and spinal cord. Sometimes radiation therapy to the brain is also given.

Treatments being studied in clinical trials for children 10 years and older and teenagers with ALL include new anticancer agents and chemotherapy regimens.

Philadelphia chromosome–positive ALL

The treatment of Philadelphia chromosome –positive childhood ALL during the remission induction, consolidation /intensification, and maintenance phases may include the following:

Combination chemotherapy and targeted therapy with a tyrosine kinase inhibitor (imatinib mesylate) with or without a stem cell transplant using stem cells from a donor.

A clinical trial of combination chemotherapy and a new tyrosine kinase inhibitor, with or without stem cell transplant.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with T-cell childhood acute lymphoblastic leukemia and Philadelphia chromosome positive childhood precursor acute lymphoblastic leukemia. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your child's doctor about clinical trials that may be right for your child. General information about clinical trials is available from the NCI Web site.

Relapsed Childhood Acute Lymphoblastic Leukemia

Standard treatment of relapsed childhood acute lymphoblastic leukemia (ALL) that comes back in the bone marrow may include the following:

Combination chemotherapy.

Chemotherapy with or without total-body irradiation followed by a stem cell transplant, using stem cells from a donor.

Standard treatment of relapsed childhood acute lymphoblastic leukemia (ALL) that comes back outside the bone marrow may include the following:

Systemic chemotherapy and intrathecal chemotherapy with radiation therapy to the brain and/or spinal cord for cancer that comes back in the brain and spinal cord only.

Combination chemotherapy and radiation therapy for cancer that comes back in the testicles only.

Some of the treatments being studied in clinical trials for relapsed childhood ALL include:

New anticancer drugs and new combination chemotherapy treatments.

Combination chemotherapy and new kinds of targeted therapies.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent childhood acute lymphoblastic leukemia. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your child's doctor about clinical trials that may be right for your child. General information about clinical trials is available from the NCI Web site.

Source: The public domain information on this page was obtained with permission from the National Cancer Institute (cancer.gov).

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