Treatment for childhood acute lymphoblastic leukaemia (ALL)
Acute lymphoblastic leukaemia (ALL) is a very treatable cancer in children and young adults. The aim of treatment for ALL is to get rid of the leukaemia cells and help the bone marrow to work normally again.
Your child’s treatment plan will involve chemotherapy (anti-cancer) drugs, steroids and other medicines. The particular treatment your child has will depend on their individual condition and general health. Doctors will explain their recommendations and you will be able to ask questions and make decisions as the parent or carer of a child under 16.
From 16 years old, young people have the right to make their own treatment choices, although most will want their family closely involved.
Your child will normally start treatment soon after being diagnosed. Chemotherapy is the main treatment for ALL and is usually very effective.
Your child will have a combination of chemotherapy drugs according to a treatment plan (your healthcare team may call this a protocol or regimen). We have more information on how chemotherapy works, and how it’s given.
Standard treatment is divided into five phases, or ‘blocks. Some children and young adults will need more chemotherapy than others, and your healthcare team will adjust your child’s treatment based on their test results. Any time there’s a change in the treatment plan, your healthcare team will discuss it with you.
Babies under one year old will have different treatment from older children. If your child is under one year old, your consultant will discuss the treatment options with you.
Many children and young adults in the UK who are diagnosed with any type of cancer are treated through a clinical trial. This is where treatment options are compared to see which brings the best results. They help researchers and doctors find new treatments and improve current ones.
The most recent clinical trial for ALL in children and young adults was called UKALL 2011. This closed to new participants in December 2018. A new trial called ALLTogether is due to start in 2020.
Until ALLTogether opens, children and young adults who are newly diagnosed with ALL will receive the best treatment based on their particular circumstances, and what doctors have learned from previous trials.
Treatment for childhood ALL
In each phase of treatment your child will have a combination of several different drugs. The drugs may be given in different ways.
- intravenous – a single injection or drip (infusion) into a blood vessel
- oral – by mouth as a tablet or liquid
- intrathecal – as an injection into the fluid around the spine and brain, using the same procedure as a lumbar puncture
- intramuscular – by injection into a muscle
Drug and how it's delivered:
- cyclophosphamide – intravenous
- cytarabine– intravenous
- daunorubicin– intravenous
- dexamethasone (a steroid) – oral
- doxorubicin – intravenous
- mercaptopurine – oral
- methotrexate – intrathecal OR oral
- pegaspargase/crisantaspase – intramuscular
- vincristine – intravenous
Based on your child’s age, their white cell count, and the results of tests they had when they were diagnosed, they will have one of three treatment plans, or regimens.
Regimen A uses the lowest intensity of treatment. This is the initial treatment plan offered to children under 10 years old and children with a low white cell count at diagnosis.
Regimen B is intermediate intensity. This is the initial treatment plan offered to children and young adults over 10 years old, and those with a higher white cell count at diagnosis.
Regimen C uses the highest intensity of treatment. It isn’t used at the start of treatment, but your child may be moved onto this regimen later if not enough leukaemia cells have been cleared after the first part of treatment on regimen A or B, or if cytogenetic tests show that there are certain genetic changes present in the leukaemia cells. If your child needs to be moved onto regimen C, they won’t be moved back to regimen A or B.
Phases of treatment
The total length of treatment is just over two years.
Your healthcare team will explain to you in detail which drugs your child will have and when and will give you a chart to show this. The treatment schedule is quite complicated, and you’ll need to follow it carefully during the outpatient stages of treatment, when your child is at home. If it’s difficult to make sure your child gets all of the treatment at the right time, ask your healthcare team for support.
Phase 1: induction
For the first five weeks of treatment, your child will have intensive chemotherapy treatment to get rid of as many leukaemia cells as possible. They will need to stay in hospital for at least the first week or two because the doctors will need to monitor them closely for any complications from treatment.
The doctors will do further bone marrow tests during and at the end of this first phase to see how your child is responding to the treatment. After two weeks, some children on regimen A will move to regimen C. This will happen if the results of cytogenetic tests show that they need stronger treatment.
After four weeks, your child will have an MRD test to find out how many leukaemia cells are still in their bone marrow. If there are a low number of leukaemia cells present (this is called MRD low risk), your child will stay on the same treatment (regimen A or B). If there are a higher number of cells (this is called MRD risk), the treatment will move to regimen C.
Phase 2: consolidation
After the induction phase, your child will have more chemotherapy to clear remaining leukaemia cells from the blood and bone marrow and prevent leukaemia cells from spreading into the brain and spinal cord.
For most of this time your child will be able to stay at home and visit hospital for treatment or check-ups as outpatient. If they have an infection or become ill at any stage during their treatment, they may need to stay in hospital overnight or longer so doctors can monitor them closely.
The length of this phase and the type of chemotherapy your child will have is based on the results of the MRD test at the end of the induction phase.
If your child is MRD low risk, then consolidation will last for either three weeks (regimen A) or five weeks (regimen B).
If your child is MRD risk at the end of induction, then they’ll move onto regimen C and consolidation will last for 10 weeks.
If your child is on regimen B for induction, but the results of their cytogenetic tests during induction suggest that they need stronger treatment, then they’ll move onto regimen C at the start of consolidation.
If your child is MRD risk, your doctors will carry out extra MRD tests halfway through and at the end of consolidation. If the tests show that the disease isn’t responding to the treatment, the consultant will talk to you about which other treatment options might be most effective.
Phase 3: interim maintenance
For children and young adults on regimen A and B, this third phase lasts for about nine weeks and is less intensive. The main treatment during this phase will be oral chemotherapy (tablets or liquid), and your child will be able to stay at home most of the time.
Children and young adults on regimen C will have a more intensive course of chemotherapy which includes the drug methotrexate. This will last for around 8 weeks.
Phase 4: delayed intensification
Delayed intensification will last for seven or eight weeks depending on which regimen they’re on. The aim is to give intensive chemotherapy to clear as many as possible of the few leukaemia cells that are left. Your child will still mainly be an outpatient for this phase of treatment.
Phase 5: maintenance
This is the longest but gentlest phase of treatment. It lasts for two years for girls and three years for boys and reduces the risk of the disease coming back. Your child will mainly be an outpatient for this phase of treatment.
By the time your child has moved onto maintenance therapy they may be well enough to get back to their normal routine. School age children may be able to attend school regularly.
Recovery time varies a lot in children and so don’t be worried it takes a little while for your child to get back to their usual activities, even if they’re feeling much better physically.
Relapsed childhood ALL
Sometimes the ALL can return after treatment has finished. This is called relapse. Relapse can happen either during treatment or after treatment has finished.
Although relapse is often harder to treat, especially if it happens early during treatment, there are still effective treatment options. The consultant will discuss these in detail with you if your child experiences a relapse.
When a relapse happens late in treatment, or after treatment is complete, there’s a good chance that your child can be treated again successfully.
Relapse sometimes happens in the fluid around the brain and spinal cord. This is called a CNS relapse). It can also happen in the testicles in boys. This is called an extramedullary relapse.
Treatment for relapsed childhood ALL
Your child may be offered one of these treatments if the ALL doesn’t respond well to initial treatment or relapses:
- a stem cell transplant
- CAR-T therapy
Read more about treatments for childhood leukaemia.
At the end of the treatment, your child will have follow-up appointments to check there are no signs of relapse or treatment complications.
After their last treatment, your child will have a bone marrow test to check that the bone marrow has been cleared of leukaemia cells. This is called complete remission.
In the first year after treatment, your child will normally have a check-up every two to three months. They’ll have blood tests at these check-ups, but no more bone marrow tests will be needed if the blood test results are normal. The check-ups will get less and less frequent over time. After five years, they’ll be booked once a year.
It’s very important to make sure that your GP is aware of the treatment your child has had for ALL. If your child becomes ill later in life, it’s important to make sure that the doctors looking after them are aware of their medical history. Even for unrelated conditions, the diagnosis and choice of treatment may be more difficult if your child’s medical history isn’t available. Your healthcare team should give you an end of treatment summary when your child finishes their treatment.
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