Henry Goldstein. Acute lymphoblastic leukaemia – treatment, Don't Forget the Bubbles, 2014. Available at:
Hamish will undergo treatment for his leukaemia, and this can be a hugely overwhelming prospect for the family. The best approach to begin with may be to just give an overview of the principles of ALL treatment.
When the blood film is reported, and CSF & BMA are obtained, the oncologist will confirm the diagnosis and advise a treatment protocol. There will be a number of consultations with the oncologist and parents within a relatively short period of time, during which a treatment course is plotted and a child may be enrolled onto a study.
This is a particularly tough time for both children and their parents, and more details are provided regarding prognosis and disease course.
A full treatise on the management of ALL is well beyond the scope of this site, but I’ll provide a brief overview of the principles. The aim of the first stage, induction therapy, is complete remission, that is, no leukaemic cells on BMA or in CSF at Day 29. Induction involves intensive chemotherapy and is aiming to achieve immunosuppresion. The patient is at the greatest risk of DIC or tumour lysis syndrome during induction.
On arrival, the patient will be admitted to the oncology ward, ideally in a single room.
Chemo treatment will depend on which Study protocol is being used. The aim of the chemotherapy is to kill the cancer cells. Consequently this will result in the death of some healthy cells too, for example hair cells – which is why most patients will lose their hair (it will grow back post-chemo). It also causes immunosuppression and a reduction in their three cell lines: Hb, WCC, and platelets. Patients will usually need packed red cells or platelet transfusions at some stage of their treatment. GCSF is used in some patients to help with WCC recovery.
While the patient is neutropenic, they are at increased risk of infection and should return to hospital with any temperatures, and be managed as febrile neutropenia.
Education & Allied Health is a key component of induction. A new diagnosis of childhood cancer is highly stressful for the child, their family (nuclear and extended) and community. It is important for the carers to ensure they have their own general practitioner.
Although B-ALL & T-ALL have differing lengths of treatment with a number of cycles, the overall treatment pattern is similar.
Cycles progress in the order Induction, Consolidation, Interim Maintenance II, Delayed Intensification, Interim Maintenance II, Maintenance, with a full course of treatment lasting around three years. CNS sanctuary therapy is usually included at each stage (intrathecal methotrexate).
Each cycle involves a different regimen of chemotherapy and varying intensity. A key point is that the aim is to achieve remission in induction, with the remainder of cycles reducing the risk of relapse.
If there is CNS involvement or testicular involvement then there may also be a period of radiotherapy.
After a few months, most families will be experts in their own treatment protocol. If you the general paed seeing a child with ALL in hospital, it will be helpful to find out some information from the family prior to calling their Oncologist:
- Which Study protocol are they on?
- What part of the protocol are they in?
- When was their last chemo (and what was it)?