Phases of treatment for acute lymphoblastic leukaemia (ALL)

Treatment for acute lymphoblastic leukaemia (ALL) is divided into different phases.

The phases are:

• steroid pre phase
• induction 
• consolidation
• intensification 
• maintenance 

Standard ALL treatment usually takes between 2 to 3 years. The maintenance phase takes up most of this time as it lasts 2 years. During the maintenance phase people often go 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, general health and age. Your team will explain your treatment plan and each phase to you. 

Before you start treatment your doctor may also talk to you about your fertility and how your treatment might affect it. Do ask if this is a concern and it hasn't been mentioned. Most hospitals who treat ALL have fertility experts they can refer you to for more information and support. 

This section is about the phases of treatment for ALL in adults. We have separate information about childhood ALL.

Steroid pre phase

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

You start treatment quickly after being diagnosed. Most people have steroids first. This often helps people to feel better quite quickly.  

You usually start taking steroids up to a week before you start chemotherapy. It helps get rid of some of the leukaemia cells. And this gives your doctor time to get the results from some important genetic tests. This helps them to plan your treatment.

The most common steroids to have are prednisolone or dexamethasone. You may also have a chemotherapy drug and supportive medicine with the steroid.

Induction

In the induction phase, you have several chemotherapy drugs which you have over a few days as a chemotherapy regimen . 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. Treatment usually takes about 4 to 8 weeks. There are different combinations of drugs you might have.

You also have supportive medicine, such as:

• medicine and fluid through a drip to protect your kidneys

• antibiotics if you have an infection

• 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. 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.

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. 

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 the area

You may also have radiotherapy to your head and spine.

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

Testing how well treatment has worked

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. 

Your doctor will tell you if you are in remission.

You are in 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

You will usually move on to the next phase of treatment if you are in remission. 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 (recur). 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 risk of recurrence, your doctors 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
• a targeted cancer drug called a tyrosine kinase inhibitor (TKI)
• a targeted cancer drug called a monoclonal antibody
• a stem cell transplant using cells from a donor
• CAR T-cell therapy 

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 cycles , 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. 

Stem cell or bone marrow transplant

In ALL treatment, you have a transplant using another person's stem cells.  This is called an allogeneic transplant or allograft.

Ideally, your donated stem cells need to match your own. A brother or sister is most likely to be a close match. If you don't have a brother or sister who is a match, you have stem cells from a donor. This could be a donor who is not related to you but whose stem cells are similar to yours. This is called a matched unrelated donor (MUD) transplant.

Before the transplant you 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:

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

Myeloablative conditioning (MAC)

You have either: 

• high amounts of chemotherapy, this is called high dose chemotherapy or
• radiotherapy to the whole body (total body irradiation or TBI ) and high dose chemotherapy

Reduced intensity conditioning (RIC)

With this type of conditioning you have lower doses of chemotherapy than in a traditional stem cell transplant. Some healthy cells and cancer cells are left behnid after treatment has finished.

You might also have an immunotherapy drug, such as a monoclonal antibody called alemtuzumab. 

If you have a stem cell 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.

Maintenance

The last phase of ALL treatment is maintenance therapy. It helps to keep the leukaemia away (in remission).

You usually have low dose chemotherapy every day, which you take as a tablet. You usually have short courses of steroids over a few days also known as pulses. You 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 count . 

Follow up after maintenance treatment

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.