The treatment of ALL depends on many factors including but not limited to the type of disease, patient’s age, chromosomal mutations, CNS involvement, performance status of the patient, along with other factors. ALL treatment generally takes long (about 2 to 3 years) and mainly include the following phases:
1.Induction: The main aim of induction therapy is to achieve remission, that is, depletion of leukemia cells from the blood and bone marrow. However, this does not mean a cure as some leukemia cells may still exist that are undetectable by conventional diagnostic techniques. Thus, further treatment is usually recommended. Induction treatment usually includes multiagent chemotherapy and corticosteroid with or without a targeted agent.
The treatment for ALL usually includes CNS prophylaxis since the leukemia cells quickly spread to CNS. Thus, even when leukemia cells are not diagnosed in the CSF, treatment with radiotherapy, intrathecal chemotherapy (directly injected into the CSF), or high dose intravenous chemotherapy is given to all patients starting from induction and throughout the treatment.
2.Consolidation: The main aim of consolidation treatment is to wipe out any remaining leukemia cells from the body after induction treatment. Allogenic or autologous stem cell transplant (SCT) may be considered in patients with poor-prognostic factors who are good candidates for the same. CNS prophylaxis continues during this phase.
3.Maintenance: The main aim of maintenance treatment is to avoid disease recurrence after induction and consolidation therapy. The maintenance treatment regimen usually includes mild chemotherapy (especially anti-metabolites) with or without corticosteroid and targeted agent depending upon the type of ALL. The duration of maintenance therapy is generally about 1 to 2 years.
Based on the results obtained from various clinical research studies carried out so far, following are the preferred treatment approaches for different types of diseases and different patient populations:
|Risk Group||Preferred Treatment|
|Ph+ ALL in AYA patients
(age 15 to 39 years)
|The preferred induction treatment regimen includes multiagent chemotherapy with corticosteroid with a TKI. Allogenic SCT may be employed if a matched donor is available OR multiagent chemotherapy with a TKI should be employed during consolidation. Maintenance therapy for about 1-2 years with a TKI with or without chemotherapy is considered after consolidation. Periodic MRD assessment and CNS prophylaxis is recommended.|
|Ph+ ALL in Adult patients
(age >/=40 years)
|For patients with age less than 65 years and who are otherwise healthy (without any accompanying comorbidities), the preferred treatment approach is similar to that for AYA patients.
For patients with age more than 65 years OR who are not overall healthy (have accompanying comorbidities), the preferred induction treatment regimen includes low-intensity chemotherapy combined with a TKI. Chemotherapy (low-intensity) along with a TKI can be employed during consolidation. Maintenance therapy for about 1-2 years involving a TKI with or without chemotherapy is considered after consolidation. Periodic MRD assessment and CNS prophylaxis is recommended.
|Ph- ALL in AYA patients
(age 15 to 39 years)
|The preferred induction treatment regimen includes multiagent chemotherapy with corticosteroid. Allogenic SCT may be employed if a matched donor is available OR multiagent chemotherapy should be employed during consolidation. Maintenance therapy for about 1-2 years is considered after consolidation. Periodic MRD assessment and CNS prophylaxis is recommended.|
|Ph- ALL in Adult patients
(age >/=40 years)
|For patients with age less than 65 years and who are otherwise healthy (without any accompanying health problem), the preferred treatment approach is similar to that for AYA patients.
For patients with age more than 65 years OR who are not overall healthy (have accompanying comorbidities), the preferred induction treatment regimen includes low-intensity chemotherapy. Chemotherapy (low-intensity) can be employed during consolidation. Maintenance therapy for about 1-2 years is considered after consolidation. Periodic MRD assessment and CNS prophylaxis is recommended.
Following is the brief description of various treatment types employed for ALL:
1.Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly-growing cancer cells. Chemotherapy may be employed in combination with targeted drugs for the management of ALL having certain genetic abnormalities for which targeted drugs are available. It may also be combined with corticosteroids to accelerate the benefit achievement. Chemotherapy may also be injected directly in the CSF for CNS prophylaxis/treatment. Many pharmaceutical companies are conducting a number of clinical trials to find out new drugs and drug-combinations with increased efficacy and specificity to target ALL cells. Chemotherapy may be associated with side effects due to its effect on normal body cells apart from cancerous cells.
2.Corticosteroids: These are a category of drugs which are structurally similar to cortisone, a hormone produced by the adrenal cortex. Examples of corticosteroids include dexamethasone and prednisone that are generally employed in the treatment regimen for ALL. These drugs may have their own side effects like hyperglycemia, weight gain, mood changes, weakness in bones, etc.
3.Targeted Therapy: Targeted drugs are designed to target a specific gene or protein characteristic of the ALL cells. Examples of targeted drugs for ALL include TKIs (like imatinib, dasatininb, nilotinib, bosutininb, and ponatinib) that target Philadelphia chromosomal abnormality. These drugs can be used in combination with other therapeutic agents or alone for the treatment of Ph+ ALL.
4.Monoclonal Antibodies: Monoclonal antibodies are man-made antibodies which can be directed to certain proteins characteristic of cancer cells. For the treatment of ALL, Blinatumomab is one such molecule, which gets attached to the CD19 protein on ALL cells and the CD3 protein on the T-lymphocytes. This brings the T-cells close to the cancer cells, and thus, helps immune cells to destroy the cancer cells. It is generally employed for the treatment of ALL that is not responding to chemotherapy or targeted agents.
5.Radiation Therapy: Radiation therapy (or radiotherapy) uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill cancerous cells. For ALL, an external beam radiation therapy is generally employed for prophylaxis or treatment for CNS leukemia. Radiotherapy may be employed with high dose chemotherapy before SCT.
6.Stem Cell Transplant (SCT): SCT is the standard of care in patients with poor risk ALL. It is generally employed for the treatment of ALL in patients who are good candidates for it (younger patients in good health). Following are major types of stem cell transplant techniques:
- Autologous SCT: In this technique, the patient’s own stem cells are first collected from the bone marrow tissue or peripheral blood (preferred nowadays). Then, the patient receives high-dose chemotherapy with or without radiation therapy to kill the leukemia The collected stem cells are re-administered to the patient which slowly replenish the blood cells in the patient’s body.
- Allogeneic SCT: In this technique, healthy stem cells to be administered to the patient after high dose chemotherapy are obtained from another person known as the donor. It is very important that donor is a close blood relative (preferably a sibling) so that donor HLA closely matches with that of the patient.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes patient’s choice and health condition are also important to make a treatment choice. Following are ultimate goals of treating stomach cancer:
- Prolongation of life
- Reduction of symptoms
- Improvement in quality of life
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