The first phase of treatment is induction therapy. The goal of induction therapy is to destroy as many cancer cells as possible in order to achieve (induce) a remission. Typically, initial therapy requires a hospital stay of four to six weeks.
Induction regimens for ALL generally use a combination of drugs that include:
- Vincristine (Oncovin®)
- Anthracyclines (daunorubicin (Cerubidine®), doxorubicin (Adriamycin®))
- Corticosteroids (prednisone, dexamethasone)
The doctor may add additional drugs to induction based on the patient’s prognostic factors.
During induction, patients also receive treatment to prevent ALL from spreading to the central nervous system. This is called CNS-directed treatment.
At the end of induction therapy, doctors will check to see whether the patient has achieved a complete remission. A complete remission is achieved when you no longer have signs and symptoms of leukemia.
If you are in remission, you will continue on to the next phase of treatment called “consolidation.” If you are not in remission, another course of chemotherapy is usually given.
To see a list of standard drugs and drugs under clinical study to treat ALL, order or download our free booklet, Acute Lymphoblastic Leukemia (ALL) in Adults.
Minimal residual disease (MRD): Even when a complete remission is achieved, some leukemia cells that cannot be seen with a microscope may remain in the body. The presence of these cells is referred to as “minimal residual disease (MRD).”
Patients who have achieved remission after initial treatment for this type of ALL but have MRD are at increased risk of disease relapse.
It is important to get tested for MRD after achieving remission. The tests used most often to detect MRD are flow cytometry, polymerase chain reaction (PCR), and next-generation sequencing. These three tests typically use samples of bone marrow cells, but in some cases, blood samples can be used.
These tests are much more sensitive than standard tests that examine cell samples with a microscope. It is often recommended that MRD testing be done after the completion of induction therapy. Recommendations for additional MRD testing depend on the treatment regimen used.
Learn more about blood cancer tests that help doctors identify MRD:
For patients in remission but who test positive for MRD, blinatumomab (Blincyto®) may be prescribed. For information about the drugs listed on this page, visit our cancer drug listings.
The second phase of chemotherapy is called “consolidation” therapy or "intensification" therapy. The goal of consolidation is to kill any remaining leukemia cells. Consolidation treatment is often based on whether the patient is MRD positive after induction. For patients with B-cell ALL who are MRD positive, blinatumomab (Blincyto®) is often the recommended treatment.
For patients who are MRD negative after induction, consolidation is typically combination chemotherapy. Depending on the treatment regimen used, consolidation chemotherapy may use different drugs than those given during induction or some of the same drugs.
As part of consolidation therapy, some patients in remission may receive a stem cell transplantation.
The third phase of ALL chemotherapy treatment is called “maintenance.” The goal of maintenance therapy is to prevent disease relapse after induction and consolidation therapy. It usually lasts for about two years. Patients receive lower doses of chemotherapy drugs and, as a result, tend to have less severe side effects. Most maintenance therapy regimens include 6-mercaptopurine, methotrexate, vincristine, and corticosteroids.
ALL can spread to the central nervous system (the brain and spinal cord). A lumbar puncture (also called a spinal tap) is used to check the spinal fluid for ALL cells. At the time of diagnosis, it is uncommon for leukemia cells to be found in the central nervous system, occurring in only 3 percent to 7 percent of cases.
Even if ALL cells are not found in the spinal fluid, patients are still treated to prevent the spread of leukemia cells to the central nervous system. CNS-directed therapy is typically given to all patients throughout the entire course of ALL therapy, from induction to consolidation and throughout maintenance.
CNS-directed therapy may include:
- Intrathecal chemotherapy: In this treatment, chemotherapy is injected directly into the spinal canal
- Systemic chemotherapy: In this treatment, drugs are given through a vein
- Cranial irradiation: In this treatment, patients receive radiation therapy to the brain. In most practices, doctors do not routinely use cranial radiation except in patients who already have leukemia cells in their central nervous system. Some regimens for T-cell ALL still use cranial radiation, although this is becoming less common. When radiation therapy is used, the chance of long-term side effects is higher.
For information about the drugs listed on this page, visit our cancer drug listing.
