Chemotherapy for Acute Lymphocytic Leukemia (ALL)

(Note: This information is about treating acute lymphocytic leukemia (ALL) in adults. To learn about ALL in children, see Leukemia in Children.)

Chemotherapy (chemo) is the use of drugs to treat cancer. Chemo drugs travel through the bloodstream to reach cancer cells all over the body. This makes chemo useful for cancers such as leukemia that has spread throughout the body.

Chemo is the main treatment for just about all people with acute lymphocytic leukemia (ALL). Because of its potential side effects, chemo might not be recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemo.

How is chemo given?

Chemo treatment for ALL is typically divided into 3 phases:

• Induction, which is short and intensive, usually lasts about a month.
• Consolidation (intensification), which is also intensive, typically lasts for a few months.
• Maintenance (post-consolidation), which is less intensive, typically lasts for about 2 years.

During the more intensive phases of treatment, people can often have serious side effects from chemo, so they might need to spend time in the hospital. For more on the different phases of treatment, see Typical Treatment of Acute Lymphocytic Leukemia.

Chemo is typically given in cycles, with each period of treatment followed by a rest period to allow the body time to recover.

Most often, chemo drugs are injected into a vein (IV), into a muscle, or under the skin, or are taken by mouth. These drugs enter the blood and can reach leukemia cells all over the body.

Most chemo drugs have trouble reaching the area around the brain and spinal cord, so chemo may need to be injected into the cerebrospinal fluid (CSF) to kill cancer cells in that area. This is called intrathecal chemo. Intrathecal chemo can be given during a spinal tap or by using a special catheter called an Ommaya reservoir.

Which chemo drugs are used to treat ALL?

Chemo for ALL uses a combination of anti-cancer drugs. The most commonly used chemo drugs include:

• Vincristine or liposomal vincristine (Marqibo)
• Daunorubicin (daunomycin) or doxorubicin (Adriamycin)
• Cytarabine (cytosine arabinoside, ara-C)
• L-asparaginase or PEG-L-asparaginase (pegaspargase or Oncaspar)
• 6-mercaptopurine (6-MP)
• Methotrexate
• Cyclophosphamide
• Prednisone
• Dexamethasone
• Nelarabine (Arranon) 

People typically get several of these drugs at different times during the course of treatment, but they do not get all of them.

Possible side effects

Chemo drugs can affect some normal cells in the body, which can lead to side effects. The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. Common side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation

Chemo drugs also affect the normal cells in bone marrow, which can lower blood cell counts. This can lead to:

• Increased risk of infections (from having too few normal white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue and shortness of breath (from having too few red blood cells)

Most side effects from chemo go away once treatment is finished. Low blood cell counts can last weeks, but then should return to normal. There are often ways to lessen chemo side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Be sure to ask your cancer care team about medicines to help reduce side effects, and let your doctor or nurse know when you do have side effects so they can be managed effectively.

Low white blood cell counts: Some of the most serious side effects of chemo are caused by low white blood cell counts.

You may get antibiotics and drugs that help prevent fungal and viral infections before before you have signs of infection or at the earliest sign that an infection may be developing (such as a fever).

Drugs known as growth factors, such as filgrastim (Neupogen), pegfilgrastim (Neulasta), and sargramostim (Leukine), are sometimes given to increase the white blood cell counts after chemo, to help lower the chance of infection. However, it’s not clear if they have an effect on treatment success.

There are also steps that you can take to lower your risk of infection, such as washing your hands often. These are discussed in Infections in People With Cancer.

Low platelet counts: If your platelet counts are low, you may be given drugs or platelet transfusions to help protect against bleeding.

Low red blood cell counts: Shortness of breath and extreme fatigue caused by low red blood cell counts (anemia) may be treated with drugs or with red blood cell transfusions.

Decisions about when a patient can leave the hospital are often influenced by their blood counts. Some people find it helpful to keep track of their counts. If you are interested in this, ask your doctor or nurse about your blood cell counts and what these numbers mean.

Side effects of specific drugs: Certain drugs might cause specific side effects. For example:

• Cytarabine (ara-C), especially when used at high doses, can cause dryness in the eyes and can affect certain parts of the brain, which can lead to problems with coordination and balance.
• Vincristine can damage nerves, which can lead to numbness, tingling, or weakness in hands or feet.
• Anthracyclines (such as daunorubicin or doxorubicin) can damage the heart, so the total dose needs to be watched closely, and these drugs might not be used in someone who already has heart problems.

Other organs that could be damaged by certain chemo drugs include the kidneys, liver, testicles, ovaries, and lungs. Doctors and nurses carefully monitor treatment to reduce the risk of these side effects as much as possible. If serious side effects occur, the chemo may have to be reduced or stopped, at least for a time.

Second cancers: One of the most serious side effects of ALL therapy is an increased risk of getting acute myeloid leukemia (AML) at a later time. This occurs in a small portion of patients after they have received certain chemo drugs. Less often, people cured of leukemia may later develop non-Hodgkin lymphoma or other cancers. Of course, the risk of getting these second cancers must be balanced against the obvious benefit of treating a life-threatening disease such as leukemia with chemotherapy.

Tumor lysis syndrome: This side effect of chemo is most common in patients who have large numbers of leukemia cells in the body, so it is seen most often in the first (induction) phase of treatment. When chemo kills the leukemia cells, they break open and release their contents into the bloodstream. This can overwhelm the kidneys, which aren’t able to get rid of all of these substances at once. Excess amounts of certain minerals can also affect the heart and nervous system. This can often be prevented by giving extra fluids during treatment and by giving certain drugs, such as bicarbonate, allopurinol, and rasburicase, which help the body get rid of these substances.