TREATMENT & MANAGEMENT

PHARMACOLOGICAL THERAPIES

What is Chemotherapy? Treatment Plan

Refers to treating and managing various
diseases with cytotoxic chemicals or drugs –
in this case, using cytotoxic drugs in the
management of acute lymphoblastic
leukaemia (Canadian Cancer Society [CCS],
2019)
Cytotoxic agents can be either “cell-cycle
specific” or “cell-cycle non-specific" (CCS,
2019)
Chemotherapy treatment consists of 3 phases:
induction, consolidation and maintenance (American
Cancer Society [ACS], 2019)
The duration of the treatment is approximately
around 2-3 years (ACS, 2019)
The initial phase of the treatment is often the most
invasive and advanced (ACS, 2019)
Before initiating treatment, clients are classified
based on risk groups to ensure the right cytotoxic
drug is given with the correct dose (ACS, 2019)
The intensity of the treatment is determined by
the risk group (ACS, 2019)

Risk Factors
Clients with ALL are often classified and placed into risk
groups: low, standard, high and very-high risk (ACS, 2019)
Treatment intensity and risk factors are directly
proportional – meaning, the higher the risk the more
intense the treatment will be (ACS, 2019)
Clients in the lowest risk group often have better prognosis
and survival rates – however, it’s important to acknowledge
that clients in high/very high risk groups can still enter
remission and eventually be cured (ACS, 2019)

What Do We Look For?

Initial WBC at time of Diagnosis dictates treatment
trajectory
Age at time of diagnosis (ACS, 2019)
Kids above the age of 10 and younger than 1 are
considered high risk, whereas kids between the ages of
1-9 are more low-moderate risk (ACS, 2019)
 TREATMENT & MANAGEMENT
PHASES OF CHEMOTHERAPY
PHASE 1 - Induction
The induction period is about 4 weeks. the goal of this phase is to
achieve remission – where leukemia cells are no longer present
in the bone marrow, CBC values return to normal, and normal
WBC returns (ACS, 2019; CCS< 2019)
Remission does not mean cure - >95% of clients enter remission
following 1 month of induction treatment (ACS, 2019).
This initial phase is intense and requires prolonged hospitalization
– as well as the clients are at increased risk of infections due to
their immunocompromised state (ACS 2019; CCS, 2019).

PHASE 2- Consolidation

This phase begins as soon as the patient enters remission after

cancer treatment, and it is given to prevent the cancerous cells
from coming back (ACS, 2019; CCS, 2019).
This phase is also known as intensification and tends to last from
around 4-8 weeks (ACS 2019; CCS, 2019).
This phase is critical due to the fact that many patients have
minimal residual disease (MRD), where a small number of
leukemic cells still remain and are often the cause of relapse
(ACS, 2019; CCS, 2019).
Different drugs may be used than the ones in induction phase –
depending on clients condition (ACS, 2019; CCS 2019).
Intrathecal chemotherapy is continued at this time – depending o
clients condition (ACS, 2019; CCS, 2019).

PHASE 3 - Maintenance

This phase can last between 2-3 years (ACS, 2019;

CCS, 2019).
If the patient remains in remission after phase 1 and 3 –
then the maintenance therapy can begin (ACS, 2019;
CCS, 2019).
In this phase, there is no detectable cancerous cells in
the bone marrow – however this stage is essential due to
the fact the cancerous cells may still remain in the blood
at undetectable level, leading to relapse (ACS, 2019;
CCS, 2019).
This phase is less intensive due to the fact that most
medication administration is orally, and can be continued
at home (ACS, 2019; CCS, 2019).
 TREATMENT & MANAGEMENT
PHASES OF CHEMOTHERAPY

Intrathecal Chemotherapy
When ALL is suspected, all children will get a lumbar puncture to
check if the leukemia cells have spread to the CSF (ACS, 2019).
A needle is inserted into the spine in the lower back, and some
fluid is removed (ACS, 2019).
When this is performed, all children will get chemotherapy into the
CSF as a prophylactic in order to kill any cancerous cells that
might have spread – this is known as intrathecal chemotherapy
Methotrexate is the cytotoxic agent that is often used for
intrathecal chemotherapy (ACS, 2019).
It is usually given twice (or more if cancerous cells have been
found in the CSF or patient is at high risk) during the first month,
and several times during the next 1-2 months (ACS, 2019).
IT chemotherapy is administered during all phases of
chemotherapy, depending on the prognosis (ACS, 2019).

ALTERNATIVE THERAPY

Radiation Therapy Stem-Cell Transplant

Radiation therapy is administered to the head
(cranial radiation therapy) (CCS, 2019).
This is sometimes used as part of CNS
therapy if leukocytes were found to in the
CSF (CCS, 2019).
However, this is avoided in children below the
age of 5 due to the cognitive and
developmental problems associated with it
(CCS, 2019).
This therapy is often performed for high-risk
clients or clients with cancerous cells found in
the CNS at time of diagnosis (CCS, 2019)
This is often a last resort
A stem-cell transplant allows clinicians to be able to
administer higher doses of chemo therapy
(sometimes performed with radiation) to maximize
cancer-cell kill (CCS, 2019).
After this is performed, the client gets a transplant
of blood-forming stem cells to restore their bone
marrow
Blood-forming stem cells are usually obtained from
blood from the bone marrow, or from an infant’s
umbilical cord blood (CCS, 2019).
Two types of stem-cell transfer:
Allogenic stem cell transplant – stem cells come
from someone else - this is the preferred type of
transplant when treating ALL (CCS, 2019).
Autologous stem cell transplant – where patient
gets back his or her own cells (CCS, 2019).
 TREATMENT & MANAGEMENT
DRUGS USED IN EACH PHASE

Phase 1 - Induction
Vincristine
Daunorubicin
Steroids (Dexamethasone)
L’asparaginase
(CCS, 2019; ACS, 2019)

Phase 2 - Consolidation
L' asparaginase
Vincristine
Cyclophosphamide (Cytoxan, Procytox)
Cytarabine (Cytosar, Ara-C)
Mercaptopurine (Purinethol, 6-MP)
(CCS, 2019; ACS, 2019)

Phase 3 - Maintenance
Mercaptopurine
Methotrexate
Vincristine
Intermittent dosage and combination therapy might
be administered*
(CCS, 2019; ACS, 2019)

Intrathecal Chemotherapy
Methotrexate
(ACS, 2019)

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