Chemotherapy for Acute Lymphocytic Leukemia (ALL)

Chemotherapy (chemo) is the main treatment for most people with acute lymphocytic leukemia (ALL), also known as acute lymphoblastic leukemia.

Chemo is the use of drugs to treat cancer. Chemo drugs travel through your bloodstream to reach cancer cells all over your body. This makes chemo useful for cancers like leukemia that spread throughout the body.

Less intense chemo might be recommended for people with other serious health issues, but advanced age by itself is not a barrier to getting chemo for ALL.

• Note: This information is about treating acute lymphocytic leukemia (ALL) in adults. To learn about ALL in children, see Leukemia in Children.

Phases of chemo treatment for ALL

Chemo treatment for ALL is typically divided into 3 phases:

• Induction (remission induction): short and intensive, usually lasts about a month
• Consolidation (intensification): also intensive, usually lasts a few months
• Maintenance (post-consolidation): less intensive, usually lasts about 2 years

During the more intensive phases of treatment, people can often have serious side effects from chemo. You might need to stay in the hospital during this time.

For more on the different phases of treatment, see Typical Treatment of Acute Lymphocytic Leukemia.

How is chemo given for ALL?

Chemo is typically given in cycles, with each period of treatment followed by a rest period to allow your body time to recover.

Systemic chemo

Chemo drugs for ALL treatment are usually injected or infused into a vein (IV). Some drugs can be injected into a muscle or under your skin, or taken by mouth. These drugs enter your blood and can reach leukemia cells all over your body.

Intrathecal chemo

Most chemo drugs have trouble reaching the area around the brain and spinal cord. You may need chemo injected into your cerebrospinal fluid (CSF) to kill cancer cells in that area.

This is called intrathecal chemo.

Intrathecal chemo can be given during a lumbar puncture (spinal tap) or by using a special catheter called an Ommaya reservoir.

Which chemo drugs are used to treat ALL?

Chemo for ALL uses a combination of anticancer drugs. The most commonly used chemo drugs include:

• Vincristine or liposomal vincristine (Marqibo)
• Daunorubicin (daunomycin) or doxorubicin (Adriamycin)
• Cytarabine (cytosine arabinoside, ara-C)
• PEG-L-asparaginase (pegaspargase)
• 6-mercaptopurine (6-MP)
• Methotrexate
• Cyclophosphamide
• Prednisone
• Dexamethasone
• Nelarabine (Arranon)

People typically get several of these drugs at different times during the course of treatment, but they do not get all of them. Sometimes, targeted drugs or immunotherapy are given along with chemo.

Possible side effects

Chemo drugs can affect some normal cells in your body, which can lead to side effects. The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken.

Common side effects include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation

There are often ways to lessen these side effects. For example, you can take medicines to help prevent or reduce nausea and vomiting. Ask your cancer care team about this, and let them know when you have side effects so they can be managed.

Most of these side effects go away once treatment is finished.

Side effects from low blood cell counts

Chemo drugs also affect the normal cells in bone marrow. This can lower your blood cell counts, leading to:

• Increased risk of infections (from having too few normal white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue and shortness of breath (from having too few red blood cells)

Low blood cell counts can last weeks but should then return to normal.

To manage your low blood counts, you may need medicines or transfusions. Your blood cell counts could affect when you are allowed to leave the hospital. Some people find it helpful to keep track of their counts. If you are interested in this, ask your cancer care team about your blood cell counts and what these numbers mean.  

Learn more about managing low blood counts in Side Effects: Blood-related Problems.

Side effects of specific chemo drugs

Certain drugs might cause specific side effects. For example:

• Cytarabine (ara-C), especially at high doses, can cause dry eyes and affect certain parts of your brain. This can lead to problems with coordination and balance.
• Vincristine can damage nerves, leading to numbness, tingling, or weakness in hands or feet.
• Anthracyclines (such as daunorubicin or doxorubicin) can damage your heart, so the total dose must be watched closely. These drugs might not be used if you already have heart problems.

Other organs that could be damaged by certain chemo drugs include the kidneys, liver, testicles, ovaries, and lungs.

Your cancer care team will carefully monitor your treatment to reduce your risk as much as possible. If serious side effects happen, you might have to reduce or stop chemo, at least for a time.

Tumor lysis syndrome

This chemo side effect is most common in people who have large numbers of leukemia cells in the body, so it’s seen most often in the first (induction) phase of treatment.

When chemo kills the leukemia cells, they break open and release their contents into your bloodstream. This can overwhelm your kidneys, which aren’t able to get rid of it all at once. Excess amounts of certain minerals can also affect your heart and nervous system.

Getting extra fluids during treatment can often prevent this. Taking certain medicines that help your body get rid of these substances can also help.

Second cancers

One of the most serious side effects of ALL therapy is an increased risk of getting acute myeloid leukemia (AML) at a later time. This happens to a small portion of people after they get certain chemo drugs.

Less often, people cured of leukemia may later develop non-Hodgkin lymphoma or other cancers. The risk of these second cancers must be balanced against the obvious benefit of treating a life-threatening disease such as leukemia.