Types of Treatment for Childhood Acute Lymphoblastic Leukemia

Executive Summary

Treatment for Childhood Acute Lymphoblastic Leukemia recommendations depends upon the state of Acute Lymphoblastic Leukemia of the individual. Appropriate treatment continues to control leukemia from recurring. Recurrent ALL is leukemia that recurs while or after remission. Leukemia may recur in the bone marrow, spinal fluid, and testicles, or less commonly, in other body areas. Refractory ALL did not go into remission, despite remission induction treatment.

Treatment recommendations depend on the size, grade, and type of tumor, metastasis, possible side effects, preferences, and overall health of the patient. The common treatments for childhood ALL radiation therapy are chemotherapy (Remission induction therapy, central nervous system directed therapy, consolidation therapy, maintenance therapy), and bone marrow transplantation/ stem cell transplantation. Some children will also require radiation therapy or bone marrow transplantation/stem cell transplantation. Palliative care includes medication, nutritional changes, emotional and spiritual support, and other relaxation therapies.

Treatment for Childhood Acute Lymphoblastic Leukemia

The following are used to describe the state of Acute Lymphoblastic Leukemia for each child.

Untreated ALL – The child has not yet received any treatment.

ALL in remission – There are normal white cells and other blood cells post-treatment. Blood counts, physical examinations, and bone marrow aspirations show no detectable leukemia. Remission is the absence of symptoms or signs of leukemia. However, continuing treatment to keep leukemia from coming back even when a child is in remission is essential.

Recurrent ALL – Recurrent ALL is leukemia that comes back after the child has had some period of remission. Leukemia may recur in the bone marrow, spinal fluid, testicles, or less commonly, in other areas of the body.

Refractory ALL – Leukemia did not go into remission, despite remission induction treatment 

“Standard to care” refers to the best-known treatment. In cancer care, different doctors work together to bring out an overall treatment plan for the patient, and such a team is called a multidisciplinary team. 

Treatments recommendations depend on many factors

• The size, grade and type of tumour
• Whether the tumour is applying pressure on vital parts of the brain
• If the tumour has increased to other parts of the body
• Possible side effects
• The patient’s preferences and overall health

Generally, cancer is not very common in children. This means it can be challenging for doctors to plan treatments unless they know what has been most influential in other children. This is why more than 60% of children with cancer take part in clinical trials.

The child’s care plan also includes treatment for symptoms and side effects, essential for cancer care. The three types of treatments used to treat childhood ALL are radiation therapy, chemotherapy, and bone marrow transplantation/ stem cell transplantation ^​1​. All children with ALL receive chemotherapy. Some children will also require radiation therapy or bone marrow transplantation/stem cell transplantation. These are some of the common treatment methods for Childhood Acute Lymphoblastic Leukemia.

Chemotherapy

Chemotherapy uses medicine to kill or stop the growth of cancerous cells. The point that makes a difference is how the chemotherapy enters the body and which cells it affects. A chemotherapy schedule usually consists of a certain number of cycles over a fixed period. A patient can be given one drug at a time or a combination of different drugs given simultaneously. Chemotherapy is the primary treatment for children with ALL ^​2​. It may be given by mouth, injected into a vein or muscle, or injected into the cerebral spinal fluid. It is generally in four phases-

• Remission induction therapy uses chemotherapy to kill as many leukemia cells as possible to cause cancer to remission.
• Central nervous system-directed therapy destroys any leukemia cells in the central nervous system and prevents the spread to the spinal fluid.
• Consolidation therapy begins when the child’s leukemia has gone into remission. Higher doses of chemotherapy, or drugs not used during previous treatment, destroy most of the remaining leukemia cells.
• Maintenance therapy continues for 2 to 3 years to destroy any remaining leukemia cells.

Side effects

The side effects of chemotherapy depend on the patient and the dose used. Still, they can include short-term side effects like hair loss, fatigue, loss of appetite, nausea and vomiting, diarrhea, and kidney and liver problems. If a drug called vincristine (Vincasar, Oncovin) is part of the child’s chemotherapy, there may be nerve pain and muscle weakness. However, these side effects are manageable with proper care. Other side effects related to chemotherapy that may last longer or develop after treatment include bone and joint problems. The severity of the side effects depends upon the type of drug, dose, and duration of the medication.

Radiation Therapy

Radiation therapy uses high-energy X-rays or particles to destroy cancer cells. The most common radiation treatment type is external-beam radiation therapy. In this method, the radiation is given from a machine outside the body. A radiation therapy schedule consists typically of a specific number of treatments offered over a set period.

Side effects

Side effects may include mild skin reactions, upset stomach, hair loss, fatigue, and loose bowel movements. Talk to the child’s doctor about what side effects and manage them. Most side effects go soon after treatment ends. However, long-term side effects of radiation treatment to the body and brain can occur and may include hormone problems affecting metabolism and growth, learning problems, and an increased risk of developing second cancer, including a brain tumor, or skin, salivary gland, and thyroid cancers can also occur after radiation treatment for ALL.

Bone Marrow Transplantation/stem cell transplantation

Bone marrow transplantation, also known as stem cell transplantation, is most often used to treat recurrent or refractory ALL. Sometimes, transplantation may be recommended as part of the initial therapy when leukemia is linked with very high-risk features. 

This type of transplant is a medical process in which bone marrow that contains the cancer is replaced by highly specialized cells ^​3​. These cells, known as hematopoietic stem cells, develop into healthy bone marrow. Hematopoietic stem cells are the blood-forming cells found in the bloodstream and the bone marrow.

Before suggesting transplantation, doctors talk to the patient and family members regarding the risks of this treatment. They will also consider several other factors, like the age and general health of the patient, the type of cancer, results of any previous treatment, and.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells – autologous (AUTO) and allogeneic (ALLO). AUTO uses the stem cells of the patient, while ALLO uses donated stem cells. In both types, the target is to destroy all cancer cells in the blood, marrow, and other body parts using high doses of chemotherapy or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow.

Side effects depend on the child’s general health, the type of transplant, and other factors.

Palliative Care 

Cancer and its treatment have side effects that can be mental, physical, or financial, and managing the effects are palliative or supportive care. Palliative care includes medication, nutritional changes, emotional and spiritual support, and other relaxation therapies.  Palliative care focuses on alleviating how you feel during treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of cancer and age, any person may receive this type of care.

Remission and Chance of recurrence

When cancer cannot be detected in the body, and there are no symptoms, this is known as remission. This may be called having ‘no evidence of disease. A remission can be temporary or permanent. Many people worry about the recurrence of cancer. The doctor performs another round of tests to know the extent of the recurrence. Mainly the treatment plan includes the treatments explained above, like surgery, chemotherapy, radiation therapy, and targeted therapy. Treatment of recurrent ALL depends on several factors such as the previous treatment of the child, the interval between the initial diagnosis and the recurrence, and whether leukemia cells are found in the CSF, bone marrow, testicles, or in more than one of these sites when it recurs.  

If we do not treat cancer, it leads to advanced or terminal cancer. It is vital to have conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important.

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