Other treatments for acute lymphoblastic leukaemia

Stem cell transplant

Some people may be offered a stem cell transplant after consolidation chemotherapy. This involves a further course of intensive chemotherapy and/or radiation therapy followed by a transplant of stem cells. A stem cell transplant is not suitable for everyone, especially people with other health problems.

Stem cells are unspecialised, blood-forming cells that can be taken from the bloodstream (peripheral blood stem cell transplant), bone marrow (bone marrow transplant), or umbilical cord blood (cord blood transplant).

For ALL, stem cells are usually collected from another person. This is known as an allogeneic transplant. A suitably matched donor could be a relative or an unrelated person found through the Stem Cell Donors Australia registry.

It can sometimes be hard to find a suitable donor. In this case, an overseas donor, a partially matched donor or a cord blood transplant may be considered. Half-matched family donors are increasingly being used (this is known as a haploidentical transplant).

Learn more about main steps in an allogeneic stem cell transplant.

CAR-T cell immunotherapy

Some people with ALL may be offered a special type of immunotherapy called CAR (chimeric antigen receptor) T-cell therapy. T-cells are part of the immune system and their job is to hunt down and attack abnormal cells in the body. CAR T-cell immunotherapy modifies a person’s own T-cells so they are better able to do this.

First, a small plastic tube (cannula) is inserted into a vein in each arm. Blood is taken from one arm and fed through a special machine that separates out the T-cells. The remaining blood is then returned to you through the cannula in the other arm.

Chimeric antigen receptor is added to the T-cells to make them into CAR T-cells. This happens in a laboratory and may take 2–3 weeks. The CAR T-cells are then injected back into your body to attack the leukaemia cells.

CAR T-cell therapy is now available in Australia for some people with relapsed B-cell ALL. If CAR T-cell therapy is suitable for you, you may be referred to a specialist centre for treatment.

Side effects

These may include:

• a high temperature
• fast heart rate
• low blood pressure and dizziness
• nausea and/or vomiting (feeling and/or being sick)
• muscle and joint pain
• breathing difficulties.

These side effects usually occur in the first 10 days after treatment and can be managed, but it’s important to let your doctor know about them.

In the 4–8 weeks after treatment, there may also be side effects in the brain, including headaches, loss of balance and confusion. These side effects usually get better in 1–2 weeks and can be managed.

Targeted therapy

Targeted therapy uses drugs that attack specific features of leukaemia cells to stop the leukaemia growing and spreading.

Tyrosine kinase inhibitors (TKIs)

These targeted therapy drugs are often used to treat people with ALL who have the Philadelphia chromosome. They work by blocking a protein called tyrosine kinase, which tells the leukaemia cells to grow and multiply. Without this signal, the leukaemia cells die.

TKIs such as imatinib, dasatinib and ponatinib are taken as tablets. You may have TKIs on their own or in combination with chemotherapy.

Side effects

These may include:

• fatigue
• nausea and vomiting
• diarrhoea
• skin rashes
• facial, hand or leg swelling
• anaemia, bruising or infections.

Monoclonal antibodies

Monoclonal antibodies are made in a laboratory but behave like natural antibodies that fight infection and disease. They lock onto specific proteins on the surface of leukaemia cells to interfere with how they grow and survive.

Monoclonal antibodies such as rituximab, blinatumomab and inotuzumab ozogamicin are sometimes used for particular types of ALL. These drugs are given through a drip into a vein (intravenously), either on their own or in combination with chemotherapy.

Side effects

These may include:

• flu-like symptoms
• nausea and vomiting
• increased risk of infections
• fatigue.

Radiation therapy

Also known as radiotherapy, radiation therapy uses targeted radiation to kill or damage leukaemia cells so they cannot grow, multiply or spread. The radiation is usually in the form of x-ray beams.

Radiation therapy may be given to the:

• brain or spine when ALL has spread, or is likely to spread, to the cerebrospinal fluid
• whole body (total body irradiation) before a stem cell transplant.

If you are having radiation therapy to the brain, you will be fitted for a special mask. This keeps your head still during treatment.

Side effects

Radiation therapy most commonly causes tiredness, dry or itchy skin, and hair loss from your body and head. These side effects are usually temporary and there are ways to reduce discomfort.

Total body irradiation will cause reduced sperm production in men and early menopause in premenopausal women. This means you will not be able to have a child (infertility, see Prognosis and Managing side effects).

Steroids

Steroids (also known as corticosteroids) are made naturally in the body, but they can also be produced artificially and used as drugs. They are often given with chemotherapy to help destroy leukaemia cells or to reduce allergic reactions to some chemotherapy drugs.

The most commonly used steroids for ALL include prednisolone and dexamethasone. Steroids are usually given as tablets. They are often taken for a few weeks, but sometimes need to be taken for months.

Side effects

Possible side effects include hyperactivity, difficulty sleeping, mood changes, heartburn and high blood glucose levels. You may also experience increased appetite, weight gain, high blood pressure and muscle weakness, as well as fluid retention that can cause puffy eyelids, face, hands, fingers and feet, and may blur your vision. If used for a long period, steroids may cause diabetes and contribute to thinning of the bones (osteoporosis).

Taking steroids in the morning with food or milk can reduce the risk of sleeplessness at night and stomach irritation. Tell your treatment team if you experience heartburn, as it can be relieved with medicines.

Some types of steroids can affect blood sugar levels, so people with diabetes need to monitor their blood sugars more often and may need to have their diabetes medicines adjusted. Discuss these changes with your treatment team and GP. You can also call the National Diabetes Services Scheme (NDSS) Helpline on 1800 637 700.

Palliative treatment

Palliative treatment can be used at any stage of advanced ALL to improve quality of life. As well as slowing the spread of leukaemia, it can relieve pain, nausea and other symptoms. Many people think palliative treatment is for people at the end of their life; however, it can help people at any stage. Treatment may include chemotherapy and/or radiation therapy.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs. The team also provides support to families and carers.