Acute lymphoblastic leukaemia

What is it?

Acute lymphoblastic leukaemia (ALL) is a cancer of the blood and bone marrow.^1,5 The marrow makes too many immature white blood cells (lymphoblasts) that do not work properly.^5,3 It usually develops quickly and gets worse fast if it is not treated.^5,1

It is rare overall, but it is the most common cancer in children, about 1 in 4 childhood cancers in the United States.^1,3 It is most common in children aged 1 to 4.³ Adults can get it too.⁶ The cause is often unclear.⁷ The risk is higher with Down's syndrome, after some kinds of chemotherapy or radiotherapy in the past, after high levels of radiation or of the chemical benzene, and with a weak immune system, for example from HIV.⁷

The first signs

Signs usually appear over a few weeks and can look like flu or other common illnesses.^2,5

• tiredness or weakness, and looking unusually pale;²
• bruising or bleeding easily;²
• fever, and getting ill often or slowly getting better;²
• swollen glands, pain in the bones or joints, or a swollen tummy;²
• breathlessness, poor appetite or losing weight without trying.²

How doctors find out

A specialist does blood tests and may take a small sample of bone marrow with a needle (a biopsy). You usually have a local anaesthetic, and young children may be given a general anaesthetic.⁸ Results can take a few weeks.⁸ More tests are usually needed, such as a lumbar puncture (a sample of fluid taken from the lower spine) and scans such as an X-ray, CT scan, MRI scan or ultrasound scan.⁸

Current treatment

Treatment is steroids and combination chemotherapy given in phases, with chemotherapy to protect the brain, plus targeted or immune medicines or a stem cell transplant for some types or if it comes back.Source: NHS

Will it get worse?

Without treatment it gets worse quickly, so treatment starts straight away.^5,1,4 It is often treatable.⁴ How it goes depends on the type of ALL, gene changes in the leukaemia cells (such as the Philadelphia chromosome), whether it has reached the brain or spinal cord, your age and your general health.^1,5 Children usually do better than adults.⁶ If it cannot be cured, treatment aims to keep it down, ease symptoms and help you live longer.⁴

Medicines: what helps, and what to watch for

Treatment usually starts with steroids for up to a week before chemotherapy. You usually have a combination of chemotherapy medicines, which is the main treatment.⁴ It comes in phases: first to clear the leukaemia from the blood and marrow (remission), then to kill any cells left.³ Children then have a phase of maintenance treatment.³ Chemotherapy is also given into the fluid around the spine, so it reaches leukaemia cells in the brain.³ Targeted medicines such as imatinib or dasatinib, and immune medicines such as blinatumomab, are used for some types of ALL or if it comes back.³

Good to know:

• Your team explains the benefits and side effects and helps you manage them;⁴
• You may get antibiotics against infections, blood transfusions, medicines that help the marrow make blood cells, and vaccines such as flu and COVID-19;⁴
• During maintenance, taking the medicine exactly as the doctor says lowers the chance that the leukaemia comes back;³

A transplant, for some people

A stem cell or bone marrow transplant replaces damaged blood cells with healthy ones.⁴ It may be used when the leukaemia has come back or is likely to come back.⁴ CAR T-cell therapy changes a person's T-cells (immune cells) in a lab so they attack certain proteins on cancer cells. It is being studied for childhood ALL that has come back a second time.³ Radiotherapy may be given to the brain and spinal cord if the leukaemia has spread there or may do so, or to the whole body before a transplant.^3,5

Is there a cure?

Treatment gives children with ALL a good chance of a cure.⁶ In adults the outlook is less good: with intensive treatment, about 4 in 10 stay free of leukaemia in the long term.⁶ Clinical trials are testing new treatments, and some take only people who have not started treatment yet.⁵

Sources

1. NHS: Acute lymphoblastic leukaemia – What is acute lymphoblastic leukaemia?
2. NHS: Acute lymphoblastic leukaemia – Symptoms
3. NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®) – Patient Version
4. NHS: Acute lymphoblastic leukaemia – Treatment
5. NCI PDQ: Adult Acute Lymphoblastic Leukemia Treatment (PDQ®) – Patient Version
6. NCI PDQ: Adult Acute Lymphoblastic Leukemia Treatment (PDQ®) – Health Professional Version
7. NHS: Acute lymphoblastic leukaemia – Causes
8. NHS: Acute lymphoblastic leukaemia – Tests and next steps