Phases of treatment for acute lymphoblastic leukaemia (ALL)
Treatment for acute lymphoblastic leukaemia (ALL) is divided into different phases. These are:
- steroid pre phase
- induction
- consolidation
- intensification
- maintenance
The names of the phases of ALL treatment aren't very important. They have been this way for a very long time. But it's good to know what your treatment team might be referring to when they explain your treatment to you.
Standard ALL treatment usually takes between 2 to 3 years altogether. The maintenance phase takes up most of this time as it lasts 2 years. During the maintenance phase people are often back to work or college. If you have a stem cell or bone marrow transplant the treatment time is shorter but more intensive.
Doctors work out your treatment based on your type of ALL, age and level of fitness. Your treatment team will explain your treatment plan and each phase to you.
Before you start treatment your doctor will also talk to you about your fertility and how ALL treatment might affect it. Most hospitals who treat ALL will have fertility experts they can refer you to for more detailed information.
Steroid pre phase
The aim of the steroid pre phase is to destroy as many the leukaemia cells as possible. After treatment, your doctor calls it a complete remission (CR) if:
- there is no sign of leukaemia in your bone marrow when looked at under a microscope
- your blood count has returned to normal
What treatment do I have?
You start treatment quite quickly after getting diagnosed. Most people receive steroids first. This is known as the pre phase. Steroids are very good at getting rid of the leukaemia cells. It also often helps people to feel better quite quickly.
You usually start taking steroids for up to a week before you start chemotherapy. As well as helping get rid of some of the leukaemia cells, this gives your doctor time to get the results from some important genetic tests. This helps them to plan your treatment.
Induction
In induction you have several chemotherapy drugs which you have over a few days. You can ask for a copy of your treatment timetable to help you follow your treatment plan and know what to expect next.
Chemotherapy damages healthy cells as well as the leukaemia cells. So you will generally need to stay in hospital until you have recovered from induction treatment. This usually takes about 4 to 6 weeks. There are different combinations of drugs you might have.
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 alongside your treatment. Most commonly, this is imatinib (Glivec). 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 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.
If you have leukaemia cells in your CNS at diagnosis, you will receive extra intrathecal chemotherapy injections to clear the leukaemia from this area.
You have intrathecal chemotherapy in the same way you have a lumbar puncture.
What happens next
After you've finished the induction phase and your blood count has recovered, you have another 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 will usually move on to the next phase of treatment if you are in 
. If you’re not in remission after your first cycle of treatment, there will usually be a change of your treatment plan.
Consolidation and intensification
Doctors know that even if your leukaemia is in remission after the first cycle of treatment, you have to continue treatment or it will come back. So the aims of consolidation and intensification are to get rid of any leukaemia cells that might still be there and to stop them from coming back.
To work out the next part of your treatment your doctor looks at how likely your leukaemia is to come back. For this they look at what genetic changes you have. And if you have any minimal residual disease (MRD).
Depending on this risk, you might have one or more of the following:
- more chemotherapy
- continue to take targeted cancer drugs called
tyrosine kinase inhibitors (TKI) if you have a type of leukaemia called Philadelphia positive leukaemia - blinatumomab which is a type of cancer drug called a
monoclonal antibody - usually for people with high levels of MRD after induction - a bone marrow or stem cell transplant using cells from a donor - usually a brother or sister if you are matched or you might have an unrelated donor
You may also have treatment with CAR T-cell therapy if you are taking part in a clinical trial.
The treatment you have also depends on other 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
- your general health and level of fitness
Chemotherapy
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 , also known as blocks. After each block you will have time off to recover. You might need to stay in hospital for some of these if you get too unwell. The number of consolidation blocks you have may be different to someone else with ALL. This is usually based on your general health and level of fitness.
Your treatment team will go into the detail of your treatment plan with you.
Bone marrow or stem cell transplant
This means having bone marrow from someone else. This is also known as an allogeneic transplant or allograft. Before the transplant you have to have treatment 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:
- myeloablative conditioning
- reduced intensity conditioning (RIC)
Myeloablative conditioning
You might have either:
- high amounts (doses) chemotherapy
- radiotherapy to the whole body (total body irradiation or TBI) and high dose chemotherapy
Reduced intensity conditioning
This is also known as a mini transplant. With this type of conditioning you have lower doses of chemotherapy than in a traditional stem cell transplant. You might also have a type of drug called a monoclonal antibody. An example of this is alemtuzumab (Campath, MabCampath). This monoclonal antibody therapy targets a certain type of white blood cell. For example with alemtuzumab, it's CD52.
If you have a transplant you won't need the next phase which is maintenance 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.
Maintenance
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 everyday, which you take as a tablet. You usually have short courses of steroids over a few days also known as pulses. You'll also have injections of chemotherapy every 3 months. This lasts 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 see your doctor at least monthly to check how you are getting on and to keep an eye on your blood counts.
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.
Clinical trials
Your doctor may offer you treatment 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.
