Treatments for childhood ALL

If your child has acute lymphoblastic leukemia (ALL), the healthcare team will create a treatment plan just for your child. It will be based on your child’s health and specific information about the ALL. When deciding which treatments to offer for childhood ALL, the healthcare team will consider:

• the subtype of ALL
• chromosome and gene changes within the leukemia cells
• response to treatment
• whether there are leukemia cells in the brain and spinal cord (called the central nervous system, or CNS)
• the level of risk
• your child’s age
• your child’s overall health

The following treatments may be offered for childhood ALL.

Chemotherapy is the main treatment for childhood leukemia. Treatment of childhood ALL is usually given in 3 or 4 parts or phases, depending on the treatment plan (protocol). All of these phases involve chemotherapy. Overall treatment for childhood ALL usually takes 2 to 4 years. Chemotherapy is often given through a needle in a vein (intravenously). Children with high-risk or very high-risk ALL are usually given more chemotherapy drugs and higher doses of chemotherapy drugs than children with low-risk or standard-risk ALL.

Induction therapy is the first phase of treatment for childhood ALL. It is used to kill all the leukemia cells in the blood and bone marrow to put the leukemia into remission. Induction therapy usually lasts 4 to 6 weeks. Your child may have to stay in the hospital for part or all of induction chemotherapy. Most children with ALL go into remission after one month of induction therapy.

The drugs given during induction chemotherapy vary depending on the level of risk. The most common chemotherapy combination used for standard-risk or low-risk ALL include:

• vincristine (Oncovin)
• pegaspargase (Oncaspar), asparaginase (Kidrolase) or asparaginase erwinia (Erwinase)
• crisantaspase recombinant (Rylaze), if your child has an allergy or sensitivity to pegaspargase or asparaginase
• dexamethasone (Decadron, Dexasone) or prednisone

For high-risk ALL, one of the following drugs is added to the above combination:

• doxorubicin (Adriamycin)
• daunorubicin (Cerubidine, daunomycin)

Consolidation therapy is given after ALL is in remission. It is used to kill any leukemia cells that might still be in the blood or bone marrow to prevent ALL from coming back. Consolidation therapy is usually given for about 4 to 6 weeks. Different drugs are given during consolidation chemotherapy than those used during the induction phase. The intensity and type of consolidation chemotherapy can vary depending on the level of risk. Consolidation therapy is also called intensification therapy.

The most common drugs used during consolidation or intensification chemotherapy include:

• cyclophosphamide (Procytox)
• low-dose cytarabine (Cytosar)
• mercaptopurine (Purinethol)
• pegaspargase, asparaginase or asparaginase erwinia
• vincristine
• methotrexate
• thioguanine (Lanvis)
• dexamethasone

Other chemotherapy drugs that may be used during this phase for high-risk ALL include:

• doxorubicin
• daunorubicin
• vincristine
• etoposide (Vepesid, VP-16)
• cyclophosphamide
• high-dose cytarabine
• clofarabine (Clolar)
• nelarabine (Atriance)

Maintenance or continuation therapy lasts for about 1 and a half years for girls and 2 and a half years for boys. It is given to maintain remission, kill any remaining leukemia cells and prevent ALL from coming back. Maintenance therapy drugs are often given in lower doses than those given in the induction and consolidation phases. During this final phase, chemotherapy is given at a low level of intensity (lower doses given less frequently) over a longer period of time to maintain remission. Maintenance therapy usually involves taking chemotherapy drugs by mouth (orally) at home each day. Intravenous and intrathecal chemotherapy may also be given at certain times during this phase.

Chemotherapy drugs used during the maintenance phase include:

• daily oral mercaptopurine
• weekly oral methotrexate

Intermittent doses or pulses of other chemotherapy drugs are often added, such as:

• vincristine
• dexamethasone

Depending on the protocol, your child may receive induction, consolidation, interim maintenance, delayed intensification and then maintenance therapy. Interim maintenance is similar to a standard maintenance cycle. It allows the bone marrow to recover while maintaining remission. Delayed intensification is a reinduction phase that gives more intense chemotherapy before maintenance chemotherapy starts.

There are some subtypes of childhood ALL that are treated differently:

Children with T-cell ALL are treated with more chemotherapy drugs and higher doses of chemotherapy drugs.

Children with mature B-cell ALL are treated with more chemotherapy drugs and higher doses of chemotherapy drugs, usually for 6 to 8 months. This is a shorter time frame than chemotherapy treatments for other subtypes of ALL.

Children with Down syndrome and ALL may be treated with fewer drugs and lower doses of chemotherapy.

Find out more about chemotherapy for childhood leukemia.

Central nervous system (CNS) therapy is given to kill any leukemia cells in the CNS and prevent cancer cells from spreading to the CNS. CNS therapy may be given as intrathecal chemotherapy, where drugs are given directly into the cerebrospinal fluid (CSF) around the spinal cord.

CNS therapy usually starts at the beginning of the induction phase. It may be given 2 or more times during the first month of treatment. It is usually given more frequently during consolidation chemotherapy, and then continued during the maintenance phase.

The most common chemotherapy drug used for CNS therapy to treat low-risk or standard-risk ALL is intrathecal methotrexate. For high-risk groups, chemotherapy drugs may include intrathecal methotrexate, cytarabine and hydrocortisone.

Targeted therapy is sometimes used to treat certain subtypes of ALL, such Philadelphia chromosome–positive ALL.

Targeted therapy drugs used to treat ALL include:

• blinatumomab (Blincyto)
• bortezomib (Velcade)
• imatinib (Gleevec)

Find out more about targeted therapy for childhood leukemia.

A stem cell transplant is sometimes used to treat childhood ALL. It may be used for:

• ALL that doesn’t respond well to treatment
• ALL that is in remission but has a high risk of coming back
• children with Philadelphia chromosome–positive ALL who do not respond to targeted therapy
• rarer forms of ALL (after the first remission is reached with induction chemotherapy)
• T-cell ALL that does not respond well to chemotherapy

Childhood ALL is treated with an allogeneic stem cell transplant.

Find out more about stem cell transplants for childhood leukemia.

Radiation therapy to the testicles may be used for ALL that has spread to the testicles if there isn’t a complete response to systemic chemotherapy.

Cranial radiation (radiation therapy to the head) is sometimes used as part of CNS therapy in certain types of ALL that have spread to the CNS, such as pre-B ALL and high-risk T-cell ALL. It is usually avoided if possible because radiation therapy to the brain can affect growth and development in young children. It may be given to children who have leukemia that has spread to the brain and doesn’t respond to other treatments.

Find out more about radiation therapy for childhood leukemia.

Some children are very ill when they are diagnosed with ALL. Others become ill during treatment. Low blood cell counts can happen because of ALL or its treatment and cause serious problems, such as infections, bleeding and even heart failure. Supportive therapy, such as antibiotics, antifungals, blood products, growth factors or other drugs, may be given to treat or prevent some of these problems.

Find out more about supportive therapy for childhood leukemia.

Follow-up after treatment is an important part of cancer care. Your child will need to have regular follow-up visits, especially in the first few years after treatment has finished. These visits allow the healthcare team to monitor your child’s progress and recovery from treatment.

Find out more about follow-up after treatment for childhood leukemia.

Children with cancer may be treated in a clinical trial. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

To make the decisions that are right for your child, ask the healthcare team questions about treatment.