Chemotherapy for acute lymphoblastic leukaemia (ALL)

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in the bloodstream.

Chemotherapy is the main treatment for acute lymphoblastic leukaemia (ALL). You have several different chemotherapy drugs over a few days. Many people find having a copy of the treatment timetable very helpful. You may have treatment as part of a clinical trial.

Your exact treatment depends on a number of factors such as your type of ALL, general health and age. But you can usually divide it into phases. These are:

• steroid pre phase

• induction

• consolidation

• intensification

• maintenance

You usually start chemotherapy in the induction phase of your treatment.

You might have other treatment alongside chemotherapy. We have more information about the treatments you might have in each phase. 

This section is about chemotherapy for adults. We have separate information about childhood ALL.

Induction

The aim of the induction phase is to destroy as many leukaemia cells as possible.

What treatment do I have?

You start treatment quite quickly after getting diagnosed and you have several chemotherapy drugs over a few days.

Chemotherapy damages healthy bone marrow cells as well as the leukaemia cells. So you will generally need to stay in hospital until you have recovered. This is usually about 4 to 8 weeks. 

Some of the chemotherapy drugs you might have include:

• vincristine

• doxorubicin

• daunorubicin

• cyclophosphamide

• cytarabine

• asparaginase

• methotrexate

• mercaptopurine

• idarubicin

You usually have a combination of chemotherapy drugs over a few weeks called a chemotherapy regime. We have specific information about each of these drugs on our cancer drugs A to Z list.

Chemotherapy into the fluid around the spinal cord and brain

Leukaemia cells can sometimes travel to the brain and spinal cord (the central nervous system or CNS). So as part of your induction treatment your doctor injects chemotherapy directly into the fluid that circulates around the spinal cord and brain. This is called intrathecal chemotherapy.

You have intrathecal chemotherapy to prevent leukaemia cells spreading to the CNS (CNS directed prophylaxis). You have intrathecal chemotherapy during all phases of your treatment.

You have extra intrathecal chemotherapy injections if:

• you have leukaemia cells in your CNS at diagnosis or

• your doctor thinks you have a high risk of developing leukaemia in this area

You may also have radiotherapy to your head and spine.

You have intrathecal chemotherapy in the same way you have a lumbar puncture.

Steroids alongside chemotherapy

Steroids are naturally made by our bodies in small amounts. They help to control many functions. But steroids can also be made artificially and used as drugs to treat ALL.

You usually have a type of steroid called corticosteroids. These are man-made versions of the hormones produced by the adrenal glands  just above the kidneys.

Corticosteroids include:

• prednisolone

• dexamethasone

• methylprednisolone

• hydrocortisone

You usually start taking steroids up to a week before you start chemotherapy for induction treatment. Steroids are very good at getting rid of the leukaemia cells. It also gives your doctor time before starting chemotherapy to get the results of important genetic tests. These results help them to plan your treatment.

Immunotherapy and targeted cancer drugs alongside chemotherapy

Some people with ALL have certain proteins on their leukaemia cells. A type of drug treatment called monoclonal antibodies (MABs) aim to find these proteins and kill the leukaemia cells. If your leukaemia has these proteins, you might have a MAB, such as rituximab or blinatumomab with your chemotherapy.

If you have Philadelphia positive ALL you have a type of targeted cancer drug called a tyrosine kinase inhibitor (TKI) alongside your chemotherapy treatment. Most commonly, this is imatinib. You take this as a tablet every day. This will continue throughout all phases of your treatment.

You can watch this short video that explains what Philadelphia positive ALL is. It is just over 2 minutes long.

There is also a type of immunotherapy called CAR T-cell therapy. You might have this if you have B cell ALL that has come back or is no longer responding to treatment.

Consolidation and intensification

After induction treatment, you have a test called a bone marrow biopsy . A doctor called a pathologist looks at the biopsy to see if there is any sign of leukaemia in your bone marrow. If there is no sign of leukaemia and your blood count levels have returned to normal, it’s called complete remission (CR).

The aims of the consolidation and intensification phases are to get rid of any leukaemia cells that might still be there and to reduce the risk of the leukaemia coming back.

In these phases you're likely to have some of the same chemotherapy drugs you had in the induction phase. And you will also have some other cancer drugs. You usually have higher amounts (doses) of the drugs so the treatment is stronger.

Common chemotherapy drugs for these phases include:

• doxorubicin
• asparaginase
• methotrexate
• mercaptopurine
• cytarabine
• vincristine
• etoposide
• daunorubicin
• cyclophosphamide
• darubicin

You usually have a combination of chemotherapy drugs.

We have specific information about each of these drugs on our cancer drugs A to Z list.

Chemotherapy before a stem cell or bone marrow transplant

Some people have a transplant using another person's stem cells. This is called an allogeneic transplant. 

Before the transplant you have chemotherapy to prepare your body to receive the stem cells. You might hear this called conditioning treatment. 

There are two main types of conditioning treatment. These are:

• full intensity conditioning (myeloablative)
• reduced intensity conditioning (RIC)

For myeloablative conditioning you have very high doses of chemotherapy. With reduced intensity conditioning you have lower doses of chemotherapy. 

The treatment kills the leukaemia cells as well as the healthy cells in your bone marrow. This makes space in your bone marrow for the donor stem cells. And dampens down your immune system so you don’t reject the donor cells.

Maintenance

Maintenance treatment aims to help keep the leukaemia away (in remission). You have more chemotherapy, but in lower amounts (doses) than in the other phases of treatment. You usually have short courses of steroids over a few days also known as pulses. 

The chemotherapy and steroid drugs that you are likely to have during maintenance include:

• methotrexate
• vincristine
• mercaptopurine
• dexamethasone or prednisolone (steroids)

The maintenance phase lasts for 2 to 3 years. You usually have this as an outpatient, and most people can go back to work, college or university during this phase.

Growth factors

Granulocyte colony stimulating factor or G-CSF is a type of growth factor that you might have during ALL treatment. Growth factors are natural substances that stimulate the bone marrow to make blood cells.

After chemotherapy your white blood cell count drops, so you’re at an increased risk of getting an infection. The longer your white cell count is low the greater your risk. Having a growth factor such as G-CSF helps your white cell count go up more quickly. This could lower the risk of infection.

The different types of G-CSF are called:

• filgrastim

• lenograstim

• pegfilgrastim

Chemotherapy for ALL that comes back or resists treatment

If your ALL comes back it is called relapsed ALL. If your leukaemia is difficult to get rid of after treatment, it is called refractory ALL.

Treatment for refractory or relapsed ALL can include some of the following:

• more chemotherapy

• targeted cancer drugs

• immunotherapy, such as CAR T-cell therapy

• a stem cell transplant

Chemotherapy drugs for relapsed ALL include:

• FLAG-Ida – fludarabine, high dose ara-C (cytarabine), GCSF and idarubicin

• nelarabine, cyclophosphamide and etoposide

• nelarabine on its own

• clofarabine, cyclophosphamide and etoposide

How you have chemotherapy

Chemotherapy for leukaemia treatment comes in many different forms. These include tablets that you take by mouth, an injection into your muscle, or a drip into your bloodstream (intravenous). You might also have it as an injection into the fluid around the spinal cord and brain.

Chemotherapy into a vein

You have treatment through a thin short tube (a cannula) that goes into a vein in your arm each time you have treatment.

Or you might have it through a long plastic tube that goes into a large vein in your chest. This might be a:

• central line

• PICC line

• Portacath - although this is rare

The aim is to keep your line in place throughout the course of your treatment. Some people need to have their line replaced a number of times during their treatment. This could be because of an infection for instance. 

Chemotherapy into the fluid around the spinal cord and brain

You have intrathecal chemotherapy in the same way you have a lumbar puncture. You lie on your side. Your doctor gives you a small injection to numb an area in your back. They then inject the drug between 2 of your spinal bones into the spinal fluid. It takes from 1 to 5 minutes. Afterwards you need to lie flat for an hour.

Side effects of chemotherapy

Chemotherapy for ALL can cause side effects and these can vary from person to person. It depends on the chemotherapy drugs you are having, the amount you have and if you have them with other cancer drugs. 

Some of the common side effects include:

• an increased risk of infection

• breathlessness and looking pale

• bruising, bleeding gums or nosebleeds

• feeling or being sick

• diarrhoea

• tiredness and weakness

• hair thinning or loss

• sore mouth and ulcers

• tumour lysis syndrome - this is when there are changes to the levels of substances in your blood due to the breakdown of cancer cells. It usually happens when you first start treatment

Loss of fertility

Many people keep their fertility after ALL treatment. But chemotherapy can affect some people making it harder to get pregnant or father a child. Talk to your doctor before starting treatment if this is a concern for you. They can explain how this could affect you and may refer you to a fertility specialist.

Support at home

Chemotherapy for ALL can be difficult to cope with. Tell your doctor or nurse about any problems or side effects that you have. Your nurse will give you telephone numbers to call if you have any problems at home.