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Leukemia - Acute Lymphocytic - ALL - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Adult Acute Lymphocytic Leukemia. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Leukemia is a cancer of the blood. Leukemia begins when normal blood cells change and grow uncontrollably. Acute lymphocytic leukemia (ALL) is a cancer of the lymphocytes, a type of white blood cell involved in the body’s immune system. ALL is also called acute lymphoid leukemia or acute lymphoblastic leukemia. Acute means that the disease begins and gets worse quickly; patients with ALL usually need immediate treatment. ALL is most common in young children and adults older than 50, but people of any age can develop ALL.

About lymphocytes

Lymphocytes are made in the bone marrow, the spongy, red tissue in the inner part of the large bones. Lymphocytes are found in the blood, lymph nodes, and spleen. Healthy lymphocytes fight bacterial and viral infections. In people with ALL, new lymphocytes do not develop into mature cells, but stay as immature cells called lymphoblasts. There are three different types of lymphocytes: T cells, B cells, and natural killer (NK) cells. Generally, T cells fight infections by activating other cells in the immune system and by destroying infected cells, B cells make antibodies, and NK cells fight microbes and cancer cells. About 85% of people with ALL have the B-cell subtype and about 15% have the T-cell type. The NK-cell subtype is quite rare.

About ALL

In people with ALL, the abnormal cells crowd other types of cells in the bone marrow, preventing the production of red blood cells (which carry oxygen), other types of white blood cells, and platelets (parts of the blood needed for clotting). This means that people with ALL may be anemic (because they do not have enough red blood cells), more likely to get infections (because they do not have enough of the type of white blood cells called neutrophils that fight bacteria), and bruise or bleed easily (because of a low level of platelets). Lymphoblasts may also collect in a person’s lymphatic system and cause swelling of the lymph nodes. Some cells may invade other organs, including the brain, liver, spleen, or the testicles in men.

Unlike other types of cancer, the spread of ALL to other parts of the body does not mean the cancer is in an advanced stage because acute leukemia is usually found throughout the body when it is diagnosed.

This section is about ALL in adults. Read about childhood ALL.

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Leukemia - Acute Lymphocytic - ALL - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find information about how many people learn they have this type of leukemia each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 6,020 people of all ages (3,140 men and boys and 2,880 women and girls) in the United States will be diagnosed with ALL. About one-third of these will be adults. ALL is much more common in children, especially those younger than 5. An estimated 1,440 deaths (810 men and boys and 630 women and girls) will occur this year; about four out of five of these deaths will be among adults.

Advances in treatment have dramatically lengthened the lives of people with ALL. The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. The five-year survival rate of people of all ages with ALL increased from 41% for those diagnosed from 1975-1977 to 69% for those diagnosed from 2003 to 2009 (the most recent data available). It is important to note that how long a person with ALL lives depends on several factors, including biologic features of the disease and a person’s age.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with ALL. Because the survival statistics are measured in five-year intervals, they may not represent more recent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society’s publication, Cancer Facts & Figures 2014 and the ACS website.

To continue reading this guide, use the menu on the side of your screen to select another section.  

Leukemia - Acute Lymphocytic - ALL - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find out more about what factors increase the chance of ALL. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The cause of ALL is not known. In general, ALL is most likely to affect children and older adults. The following factors may raise a person’s risk of developing ALL:

Age. Children younger than 15 and adults older than 50 are more likely to develop ALL.

Race. White people are somewhat more likely than black people to develop ALL for reasons that are not understood.

Genetic disorders. People with Down syndrome, ataxia telangiectasia, Li-Fraumeni syndrome, Klinefelter syndrome, Fanconi anemia, Wiskott-Aldrich syndrome, and Bloom syndrome have a higher risk of developing ALL than the general population.

High doses of radiation. People who have been exposed to high levels of radiation, such as long-term survivors of atomic bombs, may be more likely to develop ALL. Exposure to electromagnetic fields or high-voltage electric lines has not been proven to increase a person’s risk of ALL.

Viruses. Occasionally, ALL or unique types of lymphoma can be associated with a previous viral infection, such as the human T-cell leukemia virus-1 or the Epstein-Barr virus.

Recent genetic research has shown that many young children who develop ALL may have had changes that are signs of the disease in a very small number of cells before they were born, although it may take several years before the disease develops and causes symptoms. More research is being done to try to understand this finding in more detail.

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Leukemia - Acute Lymphocytic - ALL - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with ALL may experience the following symptoms or signs. Sometimes, people with ALL do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

  • Fatigue
  • Weakness
  • Easy bruising or bleeding
  • Pale skin
  • Red, pinhead-sized spots on the skin
  • Weight loss
  • Fever
  • Bone or abdominal pain
  • Difficulty breathing or shortness of breath
  • Frequent infections
  • Swollen lymph nodes (glands)
  • Enlarged liver or spleen

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If leukemia is diagnosed, relieving symptoms and side effects remains an important part of care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and learn more about the disease. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may also be used. This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The following tests may be used to diagnose ALL:

Blood tests. If the doctor believes a person has ALL based on the symptoms, he or she will examine the levels of different types of cells in the patient’s blood through a test called a complete blood count (CBC). Low levels of red blood cells and platelets and high levels of white blood cells are common in people with ALL but can also be a sign of other medical problems. In addition, the blood may be examined under a microscope to find out if there are lymphoblasts or other abnormal cells in the blood.

Bone marrow biopsy and aspiration. If the blood test shows abnormalities in the number or appearance of the white blood cells, a bone marrow biopsy and aspiration will be done. These two procedures are similar and often done at the same time. Bone marrow has both a solid and a liquid part. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle. An aspiration removes a sample of fluid with a needle. The sample(s) are then analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). The sample is used to look for leukemia, and molecular testing and immunophenotyping (see below) may also be done. A common site for a bone marrow biopsy and aspiration is the pelvic bone, which is located in the lower back by the hip. The skin in that area is usually numbed with medication beforehand, and other types of anesthesia (medication to block the awareness of pain) may be used.

Molecular testing. Your doctor may recommend running laboratory tests on the leukemia cells to identify specific genes, proteins, and other factors unique to the leukemia. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy (see Treatment Options).

  • Flow cytometry and cytochemistry (immunophenotyping) are tests that use chemicals or dyes on the cancer cells to provide information about the leukemia and its subtype. ALL cells have distinctive markers on their surface called cell surface proteins. The pattern of these markers is called the immunophenotype. These tests are used to distinguish ALL from normal blood cells and from other types of leukemia, which can also involve lymphocytes. Both tests can be done from a blood sample.
  • Karyotyping (or cytogenetics) is a test that is used to examine a cell’s chromosomes (long pieces of DNA that contain genes). People with ALL may have specific chromosomal changes, including the addition or loss of certain chromosomes, as well as translocations, which means that parts of one chromosome have been moved to another chromosome. These changes can be seen under a microscope using special methods.

About 20% to 30% of adults with ALL have a particular change in their chromosomes called the Philadelphia chromosome. The Philadelphia chromosome is an example of a translocation, which, in this instance, means that genetic material from chromosome 9 breaks off and attaches to chromosome 22 [t(9;22)]. In this way, two specific genes called BCR and ABL are brought together to make one gene called BCR-ABL. Some people may have other types of translocations. For example, many children with ALL have a translocation between chromosomes 12 and 21 [t(12;22)]. These genes are called TEL and AML1.

Lumbar puncture (spinal tap). A lumbar puncture is a procedure in which a doctor uses a needle to take a sample of cerebral spinal fluid (CSF) to look for cancer cells, blood, or tumor markers (substances found in higher than normal amounts in the blood, urine, or body tissues of people with certain kinds of cancer). Because ALL tends to spread to the CSF surrounding the brain, lumbar punctures are done regularly during ALL treatment, and chemotherapy (see Treatment Options) may be given in the CSF. Doctors generally give an anesthetic to numb the lower back before the procedure.

Imaging tests. A computed tomography (CT or CAT) scan (test that creates a three-dimensional picture of the inside of the body) or magnetic resonance imaging (MRI, a test that uses magnetic fields, not x-rays, to produce detailed images of the body) may be used to learn more about the cause of symptoms or to help diagnose infections in patients with ALL. They are not regularly used for assigning a classification (see Classification) to ALL since the disease has usually spread throughout the bone marrow and blood when it is diagnosed.

After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is ALL, these results also help the doctor describe the disease; this is called classification.

The next section helps explain the different subtypes and classifications for this type of cancer. Use the menu on the side of your screen to select Subtypes and Clasification, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Subtypes and Classification

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will learn about how doctors describe ALL. This is called subtype and classification. To see other pages, use the menu on the side of your screen.

To help plan treatment and predict prognosis (chance of recovery), doctors divide ALL into subtypes and classify the disease based on the type of lymphocytes that are affected (such as T cells or B cells). For example, flow cytometry (see Diagnosis) distinguishes between ALL involving T cells or B cells. Specific chromosomal or genetic changes in the cancer cells are used to help predict how well the disease will respond to treatment and may guide the treatment choices.

Subtypes include:

  • Acute precursor B-cell (pre B-cell) lymphoblastic leukemia
  • Acute B-cell lymphoblastic leukemia
  • Precursor T-cell acute lymphoblastic leukemia
  • Philadelphia chromosome positive (BCR-ABL fusion) acute lymphoblastic leukemia (see below)

About 5% of people with the B-cell type have a unique subtype called Burkitt leukemia or Burkitt lymphoma. ALL can also be described by what the cells look like when viewed with a microscope (called L1, L2, and L3), although this is less important than the results of the flow cytometry or cytogenetic tests.

As described in Diagnosis, about 20% to 30% of adults with ALL have a genetic change or mutation called the Philadelphia chromosome, causing two genes, BCR and ABL, to become one fusion gene called BCR-ABL. This mutation is found only in the cancerous blood-forming cells, not in other organs of the body, and is not inherited. Therefore, there is no concern about an increased risk of ALL for other family members.

The BCR-ABL gene causes specific types of white blood cells called B lymphoblasts to grow out of control. It is important to test for the Philadelphia chromosome because it helps the doctor predict a patient’s prognosis and recommend treatment.

ALL classification

In a cancer where a solid tumor forms, doctors agree on a set of stages that describe how big the tumor is and where it has spread. Because leukemia usually does not form a solid tumor and is found throughout the body when diagnosed, there is no formal staging system for ALL. Instead, there are general classifications used to describe ALL:

Newly diagnosed and untreated. A patient has decreased numbers of normal white blood cells, red blood cell, and platelets. Often there are many abnormal lymphoblasts in the blood. The bone marrow contains abnormal lymphoblasts, and the person usually is experiencing symptoms of ALL (listed in the Symptoms section).

In remission. A patient has received treatment for ALL. The bone marrow contains less than 5% blasts, and the patient has no symptoms. The numbers of normal white blood cells, red blood cells, and platelets are normal.

Recurrent. Recurrent leukemia has come back after being in remission.

Refractory. Refractory leukemia means that the disease has not responded to treatment.

Information about the cancer’s subtype and classification will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will learn about the different ways doctors use to treat people with ALL. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Descriptions of the most common treatment options for ALL are listed below. Treatment options and recommendations depend on several factors, including the subtype of ALL, its classification, possible side effects, and the patient’s preferences and overall health. Take time to learn about your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist, a doctor who specializes in treating blood disorders. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time.

Patients with ALL receive several different drugs throughout their treatment, some of which are given orally (by mouth) as a pill, while others are injected into a vein (intravenously, IV). A patient may receive chemotherapy during different stages of treatment:

Remission Induction therapy. This is the first round of treatment given during the first three to four weeks after diagnosis. It is designed to destroy most of the leukemia cells, stop symptoms of the disease, and return the blood counts to normal levels.

The specific treatments used may include:

  • Doxorubicin (Adriamycin), cyclophosphamide (Neosar), or vincristine (Vincasar), given by an injection into a vein
  • Asparaginase (Elspar), given by injection into a muscle, under the skin or into a vein
  • Dexamethasone (multiple brand names) or prednisone (multiple brand names) by mouth
  • Methotrexate (multiple brand names) or cytarabine (Cytosar-U) as an injection into the spinal fluid

The goal of induction therapy is a complete remission (CR), which means that the blood counts have returned to normal, the leukemia cannot be seen when a bone marrow sample is examined under the microscope, and the signs and symptoms of the ALL are gone. More than 95% of children and 75% to 80% of adults with ALL will have a CR. However, small amounts of leukemia can remain after treatment even if it cannot be seen with a microscope, and it is necessary to give additional therapy to prevent the ALL from coming back. 

Remission Consolidation or Intensification therapy. This stage of therapy refers to the use of different drugs given in doses similar to or higher than the doses used to achieve remission. Depending on the subtype of the ALL, the doctor may recommend several courses of consolidation therapy.

Remission Maintenance or Continuation therapy. Treatment is given both orally and intravenously over a two-year to three-year period to keep the ALL from returning. These drugs are usually given in lower doses and have fewer side effects.

Re-induction chemotherapy. This stage is used to treat ALL if it has come back after treatment.

Central nervous system (CNS) prophylaxis (preventive treatment). This is the use of drugs, given directly in the spinal fluid by spinal tap (lumbar puncture; see Diagnosis) and/or by vein, to prevent the leukemia from spreading from the blood to the brain or spinal cord. This treatment is often given in combination with radiation therapy (see below) to the head. 

Side effects of chemotherapy

Induction therapy usually begins in the hospital, and patients will often need to stay in the hospital for three to four weeks during treatment. However, depending on the situation, many patients can leave the hospital and are monitored closely with regular visits to the doctor. Sometimes, patients will need to stay in the hospital for consolidation therapy, but most patients are able to go home. Many patients with ALL can return to school or work while receiving maintenance therapy.

Because chemotherapy attacks rapidly dividing cells, including those in normal tissue such as the hair, lining of the mouth, intestines, and bone marrow, patients receiving chemotherapy may lose their hair, develop mouth sores, or have nausea and vomiting. Because of changes in the blood counts, most patients will need transfusions of red blood cells and platelets at some point during their treatment. Treatment with antibiotics to prevent or treat infection is usually needed as well. Chemotherapy may lower the body’s resistance to infection by reducing the number of neutrophils, lead to increased bruising and bleeding because of the decrease in the number of platelets and other problems with blood clotting, and cause fatigue by lowering the number of red blood cells.

Chemotherapy may affect fertility (ability to have a child in the future) and increase the risk of developing a second cancer. Patients may want to talk with a fertility specialist before treatment begins.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells.

Recent studies show that not all cancers have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors involved in your leukemia. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about targeted treatments.

For ALL, targeted therapy is recommended in addition to standard chemotherapy for patients with Philadelphia chromosome-positive ALL (Ph+ ALL). Such drugs include imatinib (Gleevec), dasatinib (Sprycel), nilotinib (Tasigna), ponatinib (Iculsig) for Philadelphia chromosome-positive ALL. Currently, the safety of ponatinib is being re-evaluated by the FDA because of the risk of life-threatening blood clots and narrowing of blood vessels. Patients taking this drug should talk with their doctors about the risks and benefits of continuing to take the drug, as other treatment options may be available.

Nelarabine (Arranon) is a new drug that targets T-cell ALL. Monoclonal antibodies such as rituximab (Rituxan) are used in addition to chemotherapy for the treatment of B-cell ALL. Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Radiation therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen usually consists of a specific number of treatments given over a set period of time. For ALL, radiation therapy to the brain is sometimes used to destroy cancerous cells around the brain and spinal column.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Learn more about radiation therapy.

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which bone marrow that contains leukemia is destroyed and then replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. These stem cells make all of the normal cells in the blood. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and patient’s age and general health.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). However, AUTO transplants are generally not used to treat ALL.

In both types, the goal of transplantation is to destroy cancer cells in the marrow, blood, and other parts of the body and allow replacement blood stem cells to create healthy bone marrow. In most stem cell transplants, the patient is treated with high doses of chemotherapy and/or radiation therapy to destroy as many cancer cells as possible. Learn more about bone marrow and stem cell transplantation.

Getting care for symptoms and side effects

ALL and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the disease, an important part of care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the leukemia and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the leukemia, such as chemotherapy and radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.

Recurrent ALL

A remission is when ALL cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the disease will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the leukemia returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the disease does return. Learn more about coping with the fear of recurrence.   

If the leukemia does return after the original treatment, it is called recurrent or relapsed leukemia. When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the leukemia’s subtype and classification have changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as chemotherapy, targeted therapy, and radiation therapy) but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat recurrent ALL.

Treatment for recurrent ALL depends on the length of the remission and is usually given in cycles for two to three years. If a recurrence occurs after a long remission, the leukemia may respond again to the original treatment. If the remission was short, then other drugs are used, often in the form of new drugs being tested in clinical trials. An ALLO stem cell transplant is generally recommended for patients whose leukemia has come back after a second remission is achieved. The drug clofarabine (Clolar) may be used for patients between ages 1 and 21 who have relapsed or refractory ALL after already receiving at least two types of chemotherapy. Supportive care will also be important to help relieve symptoms and side effects.

People with recurrent leukemia often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

Refractory ALL

Refractory ALL occurs when a complete remission is not achieved because the drugs did not kill enough leukemia cells. These patients often continue to have low blood counts, need transfusions, and have a risk of bleeding or infection.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this type of leukemia, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Your health care team may recommend a treatment plan that includes new drugs being tested in clinical trials or ALLO stem cell transplantation. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of refractory leukemia is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from leukemia is not always possible. If treatment is not successful, the disease may be called advanced or terminal leukemia.

This diagnosis is stressful because the disease is not curable, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced leukemia and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and bereavement.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with ALL. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments, such as new chemotherapy before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating ALL. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with ALL.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for ALL, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Cancer.Net offers a lot of information about clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of leukemia.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will read about the scientific research being done now to learn more about ALL and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about ALL, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Most cancer centers are actively involved in clinical trials aimed at increasing the rate of cure from ALL. Always talk with your doctor about the diagnostic and treatment options best for you.

New drugs and treatment regimens. Researchers are looking at the use of new types of chemotherapy, as well as different schedules and doses of current drugs. The drug clofarabine (Clolar) has been approved for children with recurrent ALL and is being researched for adults with ALL. In addition, several studies have shown that adolescents and younger to middle-aged adults benefit from the more intensive treatments most often used for younger children with ALL.

Immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to improve, target, or restore immune system function. Researchers are studying the use of different antibodies directed against ALL cells, including inotuzumab ozogamicin and blinatumomab. Inotuzumab ozogamicin is an antibody joined with a type of chemotherapy to more specifically direct the chemotherapy to the leukemia cell. Blinatumomab is called a bispecific antibody, meaning it is directed against the leukemia cells and helps the patient’s own T cells to attack the leukemia.

Stem cell/bone marrow transplantation. Different ways to make stem cell transplantation (see Treatment) safer and easier are also being studied.

Tests to detect small amounts of ALL after treatment. Researchers are studying other molecular or immunologic tests that can help find small amounts of ALL in patients in remission. Then, a change in treatment may prevent the ALL from coming back.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current ALL treatments in order to improve patients’ comfort and quality of life.

Looking for More about the Latest Research?

If you would like additional information about the latest areas of research regarding leukemia, explore these related items that take you outside of this guide:

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 06/2013

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of leukemia, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for ALL are described in detail within the Treatment section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the subtype and classification, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with ALL. Learn more about caregiving.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will read about your medical care after treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for ALL ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

It’s very important for people in remission to receive regular follow-up examinations for several years to watch for early signs of recurrence or late effects of chemotherapy. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

People recovering from ALL are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

  • What is my diagnosis? What does this mean?
  • What subtype of ALL do I have?
  • What classification is it?
  • Can you recommend a leukemia specialist?
  • Where is the best place for me to receive treatment?
  • What are my options for treatment?
  • What clinical trials are open to me?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the leukemia, manage the symptoms and side effects, or both?
  • How likely is it that my ALL will go into remission?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of this treatment, both in the short term and the long term?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before treatment begins?
  • How will the treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • Can you explain my pathology report (laboratory test results) to me?
  • Do I need to start treatment right away?
  • What follow-up tests will I need, and how often will I need them?
  • What support services are available to me? To my family?
  • Whom should I call for questions or problems?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.  

Leukemia - Acute Lymphocytic - ALL - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2013

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Adult Acute Lymphocytic Leukemia. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of leukemia, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

This is the end of Cancer.Net’s Guide to Adult Acute Lymphocytic Leukemia. Use the menu on the side of your screen to select another section, to continue reading this guide.