Treatment for ALL

Treatments for Acute Lymphoblastic Leukemia at Fred Hutch

Today, there are more treatment options than ever before to put ALL into remission. Unlike many other cancers, ALL is both treatable and curable, so there’s plenty of reason for hope.

Our ALL specialists work closely with you, your family and each other to help get you back to health. At Fred Hutchinson Cancer Center, we provide all available standard therapies for ALL as well as targeted therapy, immunotherapy and bone marrow transplants. We also offer you access to the latest treatments through clinical trials.

The safest, most effective and most widely accepted therapies for cancer are known as the “standard of care.” For many patients, these therapies will be a large part of their treatment. At Fred Hutch, we provide all standard therapies for ALL. We know how to choose the right ones for you and how to deliver them to give you the best chance at a full recovery.

Treatment Plan

Treatment for ALL is different for each person. When it comes to treatment options, we think about every detail of your disease, from type to subtype, along with your goals and priorities.

How Do We Create Your Treatment Plan?

Fred Hutch offers medical oncologists and hematologists who specialize in ALL . We offer the most advanced diagnostic, treatment and recovery programs, as well as extensive, holistic support. 

We think about treatment as a collaborative effort. Your Fred Hutch physician will explain all your options and recommend a treatment plan based on your ALL subtype and classification, health, lifestyle and preferences.

Your personal team includes a hematologist-oncologist, advanced practice provider, nurse case manager and patient care coordinator. Other experts who specialize in treating people with cancer will join your team if needed. Our team approach means you can easily get help from experts like an infectious disease physician, pulmonologist, palliative care professional, geneticist, social worker, physical therapist or registered dietitian. 

With support from the larger team, your physician will:

  • Figure out if there’s anything special we need to keep in mind because of your subtype and classification 
  • Explain the standard therapy for your subtype
  • Tell you about any clinical trials that match your needs, so you can think about joining one

You are part of the care team, too. Your hematologist-oncologist will talk with you and your caregiver about your personal preferences and each of your options. We decide how to move forward together.

Why Do Treatment Plans Differ?

For ALL, treatment plans are different from person to person. The treatment plan we design for you depends on many things, including:

  • Your subtype of ALL, because different subtypes start, grow and respond to treatments differently
  • The classification of your disease
  • If you’ve had treatment for ALL in the past
  • Your age and overall health
  • Your values, needs and preferences, like what type of treatment schedule works in your life and whether you want to join a clinical trial

Treatment Process

Different subtypes of ALL progress and respond to treatments in different ways. We choose, combine and schedule your treatments based on what works for your subtype and how your body responds. Your care team will make sure you understand each type of treatment and all of your choices.

Standard Therapy

Treatment for ALL is highly complex and intense. It is usually done in three phases.

Induction Therapy

Because ALL progresses so quickly, intense treatment to put the disease in remission often starts very soon after diagnosis — sometimes within hours or just a few days. This means getting a combination of chemotherapy drugs along with a steroid during an inpatient stay at the University of Washington Medical Center that lasts for a few days. 

After your initial hospital visit, we know you’d rather be in the comfort of your own home. So we provide as much of your care as possible as an outpatient. We offer infusion services 365 days a year at the South Lake Union campus so you can stay at home instead of at the hospital. 

Consolidation Therapy

About 80 percent of people with newly diagnosed ALL enter remission (the disease goes away) after induction therapy. Next, we do consolidation therapy to prevent a relapse (the disease coming back). This involves chemotherapy, steroids and targeted therapy and usually lasts a few weeks to a few months. 

If your leukemia does not respond well to induction therapy, your physicians will recommend different treatments. If this happens, or if your leukemia has some features that might be harder to treat, your physicians may also recommend a bone marrow transplant — a treatment that our own physicians and scientists pioneered.

Maintenance Therapy

If you’re in remission, you will then go on maintenance therapy to lower the risk of a recurrence. This phase may last a few years. It often involves lower doses of chemotherapy and targeted therapies. It's still treatment, but patients can usually go back to their normal lives during this phase.

Treatment Types

Chemotherapy

Most people with ALL start by getting intense chemotherapy and follow up with more treatments of phased chemotherapy.

Chemotherapy uses medicines to kill fast-growing cells (like cancer cells) or to keep them from dividing (which is how cancers grow). Chemotherapy drugs are usually given through an intravenous (IV) line in repeating cycles every two to six weeks. 

Your care team will talk with you about which drugs we recommend for you, how you will take them, your treatment schedule and what to expect. We will also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout Fred Hutch.

Some of the chemotherapy drugs that are used most often to treat ALL are:

  • Cyclophosphamide
  • Cytarabine
  • Doxorubicin or daunorubicin
  • Mercaptopurine
  • Methotrexate
  • Nelarabine
  • Pegaspargase
  • Vincristine
Learn More About Chemotherapy

Targeted Therapy

For some subtypes or classifications of ALL, you may get targeted therapies. These therapies are newer cancer treatments that are more exact than standard chemotherapy.

Targeted therapies work in one of three ways:

  • They target a gene or protein that causes cancer growth.
  • They damage cancer cells directly.
  • They tell your immune system to attack certain cells. This is also called immunotherapy.

Therapies called Abelson tyrosine kinase inhibitors (ABL TKIs) are used for Ph+ ALL. They block the leukemia-causing effects of the protein made by the BCR-ABL gene — an abnormal gene in the Philadelphia chromosome.

The targeted drugs used for Ph+ ALL are usually taken daily as pills. They include:

  • Dasatinib 
  • Imatinib 
  • Nilotinib 
  • Ponatinib 

For some people with B-cell ALL, antibody-based treatments may be an option. Antibodies are a different kind of targeted therapy because they are proteins that your immune system normally makes to target a specific protein (called an antigen). Researchers have found ways to take advantage of this by making antibodies that can attack cancer if the leukemia cells have certain antigens. One example is rituximab, which may be added to chemotherapy if your leukemia has a protein called CD20. Another targeted therapy called inotuzumab ozogamicin may be an option. It uses an antibody to deliver an anti-cancer drug to your cancerous B cells.

Learn More About Targeted Therapy

Immunotherapy

Immunotherapies are some of the latest innovations in ALL care. They use the power of your immune system to fight your cancer.

For ALL that has come back or didn’t respond to other treatments (relapsed or refractory ALL), your physician may recommend a form of treatment that uses your immune system, such as:

  • Blinatumomab, a type of antibody therapy that helps your body’s T cells recognize and destroy cancerous B cells
  • Tisagenlecleucel (Kymriah®) or brexucabtagene autoleucel (Tecartus®), or CAR T-cell therapy

Fred Hutch is one of the first cancer centers in the nation to offer FDA-approved cellular immunotherapy for ALL. Tisagenlecleucel, known as the brand name Kymriah®, and brexucabtagene autoleucel, known as the brand name Tecartus®, are two different CAR T-cell therapies available only at certified treatment centers.

Learn More About Immunotherapy

Blood or Marrow Transplant

Immunotherapies are some of the latest innovations in ALL care. They use the power of your immune system to fight your cancer.

For ALL, most people who have a transplant get stem cells from a donor. This is called an allogeneic transplant, and it works in two ways:

  1. After you receive strong chemotherapy to get rid of the ALL, the donor’s healthy stem cells restart your body’s ability to make blood cells.
  2. White blood cells from the donor may recognize any leukemia cells that are still in your body and attack them. 

More people are eligible for allogeneic transplants than ever before, because of advances available at Fred Hutch, including:

  • Non-myeloablative (lower-intensity) transplants, which use lower-dose chemotherapy
  • Transplants using stem cells from donated umbilical cord blood or haploidentical (half-matched) donors

Sometimes, physicians transplant the patient’s own stem cells, which were taken out earlier and had the leukemic cells removed (autologous transplant). This doesn’t happen very often with ALL.

Learn More About Blood and Marrow Transplants

Monitoring Your Health

While you’re in active treatment, your ALL care team will see you regularly for exams and tests to check:

  • How well your treatment is working
  • If there’s any reason to change your treatment
  • If you need help with side effects or supportive care services, like nutrition care or mental health counseling

We update your treatment plan based on the best scientific evidence as well as how your disease responds and what you prefer.

Possible Results of Treatment

Throughout treatment, your care team looks for signs of:

  • Remission: Fewer signs and symptoms of cancer. Partial remission means some signs and symptoms remain. Complete remission means there are no signs or symptoms.
  • Disease progression: The disease is getting worse or spreading.
  • Relapse: The disease, signs or symptoms have come back after they had improved.
  • Refractory disease: The disease does not respond to treatment.

What about “cured”? Sometimes physicians use the word “cured” if you have been in complete remission for at least five years. After five years, cancer is less likely to come back (recur), but recurrence is still possible. 

Managing Side Effects

You might be wondering about possible side effects from treatment, like hair loss or nausea from chemotherapy. If you are, it might be helpful to know that many of today’s treatments are more targeted to cancer cells, so they don’t cause as many side effects as standard chemotherapy.

You are always at the center of everything we do. Our physicians, nurses and advanced practice providers are here to help prevent or manage the side effects of treatment. 

Get Help with Side Effects

Before you begin treatment, we talk with you in advance about what to expect, based on your treatment plan, and what can help if you do have side effects.

At your appointments, we want you to tell us about any side effects you are having. If you have questions or concerns between appointments, you can call or email us. We will make sure you know how to reach care providers at Fred Hutch after hours, if that’s when you need us. 

We have many tools to help you feel better, such as:

  • Antibiotics, vaccines and antiviral drugs to prevent or treat infections
  • Transfusions, steroids and medicines that help the immune system treat low levels of blood cells (low blood counts)
  • Nutrition care and medicines to help with digestive problems
  • Conventional and integrative therapies for pain

Coping with Side Effects

Common Side Effects

Side effects are different depending on which treatment you receive. They also depend on other things, like how strong your immune system is. These are some of the common side effects of ALL treatment:

  • Higher risk of infection (due to low levels of white blood cells)
  • Low numbers of red blood cells (anemia), which can cause unusual tiredness (fatigue) and is treated with transfusions
  • Low numbers of platelets, which can cause bruising and bleeding and is treated with transfusions
  • Mouth sores
  • Diarrhea
  • Hair loss
  • Nausea
  • Vomiting 
  • Headache
  • Rash or other skin changes
  • Numbness, tingling or pain from nerve damage (neuropathy)

ALL treatment can also have long-term effects, like fatigue, and late effects (that start long after treatment ends), like heart disease. Not everyone who is treated for ALL develops long-term or late effects. It often depends on your age, overall health and your specific treatment. But no matter if or when late side effects show up, we’re here to help. 

“We see the patient on the day that they're meant to start treatment. That would also allow us to educate them on potential side effects to look out for. Typically, they'll meet with one of our pharmacists on that day as well — again, just for another layer of support and information.”

— Christen N. Martino, ARNP, lymphoma survivor

Supportive Care Services

Along with treating your ALL, Fred Hutch provides a range of services to support you and your caregiver before, during and after treatment. This is part of how we take care of you — not just your disease.

From dietitians to our Spiritual Health team, we have experts who specialize in caring for people with cancer. We understand this may be one of the most intense and challenging experiences you and your family ever go through. We are here to provide the care you need. 

Learn more about Supportive Care

Caregiving During Treatment

If your loved one is getting chemotherapy, targeted therapy or immunotherapy, there are many ways you can help. Caregiving during active treatment for ALL often means doing tasks like these:

  • Keeping track of their appointments and driving them to and from treatment
  • Watching for changes in their condition and telling their care team about any symptoms
  • Providing physical care, like helping them take medicines
  • Spending time with them and encouraging them
  • Taking care of things at home that they may not be able to do, like grocery shopping and cleaning

Caregiving for Transplant Patients

Caregivers have a special role in bone marrow transplants. This intense treatment involves strong chemotherapy with serious side effects. During the initial recovery period, which often takes at least a month, your loved one will need daily help. We have classes to help transplant caregivers get ready. During recovery, a transplant registered nurse is available by phone 24 hours a day, 7 days a week, to help you.

Continuing Care

When your disease is in remission and your active treatment ends, it’s still important to get follow-up care on a regular basis. At follow-up visits, you’ll see the same team who treated your ALL. They will check:

  • For signs that your disease has come back (signs of recurrence)
  • If you need help with long-term side effects (which go on after treatment ends)
  • If you need help with late effects (which may start long after treatment is over)
  • Your overall health

Schedule For Follow-up Visits

Just like we personalize your treatment plan for you, we personalize your follow-up schedule, too. Your hematologist-oncologist will schedule your follow-ups based on many things, including:

  • Your ALL subtype
  • Which treatments you had and how your disease responded 
  • How the disease and treatments affected you 
  • How long it’s been since your treatment ended

Most patients are followed for at least five years for ALL. It’s common to have visits more often at first and then less often later. This will depend on your exact needs. 

What Happens at Follow-up Visits

Follow-up for ALL usually means seeing your hematologist-oncologist for a physical exam and having blood tests to check your blood cell levels. If there are any changes, you might have tests to check the health of your bone marrow.  

Your physician will let you know if you need any imaging tests. You might have tests like a CT (computed tomography) scan or PET (positron-emission tomography) scan. These can help check for recurrence (if the cancer has come back), but they also expose you to some radiation. Together, you and your physician will decide on the benefits and risks.

Meet the Acute Lymphoblastic Leukemia Care Team

ALL Team at Fred Hutch