Acute lymphoblastic leukemia

Treatment for acute lymphoblastic leukemia

Today, there are more treatment options than ever before to put ALL into remission. Unlike many other cancers, ALL is both treatable and curable, so there’s plenty of reason for hope.

Our ALL specialists work closely with you, your family and each other to help get you back to health. At Fred Hutchinson Cancer Center, we provide all available standard therapies for ALL as well as targeted therapy, immunotherapy and bone marrow transplants. We also offer you access to the latest treatments through clinical trials.

Bone marrow The soft, spongy material in the center of your bones that produces all your blood cells, such as white blood cells, red blood cells and platelets. Immunotherapy A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. A therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. Some immunotherapies only target certain cells of the immune system. Others affect the immune system in a general way. Types of immunotherapy include cytokines, vaccines, bacillus Calmette-Guerin (BCG) and some monoclonal antibodies. Remission A decrease in, or disappearance of, signs and symptoms of cancer. A decrease in, or disappearance of, signs and symptoms of cancer. In partial remission, some (but not all) signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body. Standard care A treatment or other intervention currently being used and considered to be of proven effectiveness based on past studies. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies.

“We see the patient on the day that they're meant to start treatment. That would also allow us to educate them on potential side effects to look out for. Typically, they'll meet with one of our pharmacists on that day as well — again, just for another layer of support and information.”

— Christen N. Martino, ARNP, lymphoma survivor

Treatment plan

Treatment for ALL is different for each person. When it comes to treatment options, we think about every detail of your disease, from type to subtype, along with your goals and priorities.

“Your treatment is mainly coordinated through hematology-oncology. We often work with hematopathology as well. If you have complications from treatment, we have infectious disease experts, pulmonologists, gastroenterologists, and other supports, who all have very unique expertise in complications.”

— Ryan Cassaday, MD, hematologist-oncologist

How do we create your treatment plan?

Fred Hutch offers medical oncologists and hematologists who specialize in ALL . We offer the most advanced diagnostic, treatment and recovery programs, as well as extensive, holistic support.

We think about treatment as a collaborative effort. Your Fred Hutch physician will explain all your options and recommend a treatment plan based on your ALL subtype and classification, health, lifestyle and preferences.

Your personal team includes a hematologist-oncologist, advanced practice provider, nurse case manager and patient care coordinator. Other experts who specialize in treating people with cancer will join your team if needed. Our team approach means you can easily get help from experts like an infectious disease physician, pulmonologist, palliative care professional, geneticist, social worker, physical therapist or dietitian.

With support from the larger team, your physician will:

Figure out if there’s anything special we need to keep in mind because of your subtype and classification
Explain the standard therapy for your subtype
Tell you about any clinical trials that match your needs, so you can think about joining one

You are part of the care team, too. Your hematologist-oncologist will talk with you and your caregiver about your personal preferences and each of your options. We decide how to move forward together.

Caregiver A person who gives care to people who need help, such as children, older people or patients who have chronic illnesses or disabilities. A person who gives care to people who need help taking care of themselves, such as children, older people or patients who have chronic illnesses or disabilities. Caregivers may be health professionals, family members, friends, social workers or members of the clergy. They may give care at home, in a hospital or in another health care setting. Hematologist A physician who specializes in diseases of the blood and blood-forming tissues. Hematologist A physician who specializes in diseases of the blood and blood-forming tissues. Pulmonologist A physician who has special training in diagnosing and treating diseases of the lungs. Standard care A treatment or other intervention currently being used and considered to be of proven effectiveness based on past studies. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

Why do treatment plans differ?

For ALL, treatment plans are different from person to person. The treatment plan we design for you depends on many things, including:

Your subtype of ALL, because different subtypes start, grow and respond to treatments differently
The classification of your disease
If you’ve had treatment for ALL in the past
Your age and overall health
Your values, needs and preferences, like what type of treatment schedule works in your life and whether you want to join a clinical trial

Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

What is the standard therapy for ALL?

Treatment for ALL is highly complex and intense. It is usually done in three phases.

Phase 1: ALL induction therapy

Because ALL progresses so quickly, intense treatment to put the disease in remission often starts very soon after diagnosis — sometimes within hours or just a few days. This means getting a combination of chemotherapy drugs along with a steroid during an inpatient stay at the University of Washington Medical Center that lasts for a few days.

After your initial hospital visit, we know you’d rather be in the comfort of your own home. So we provide as much of your care as possible as an outpatient. We offer infusion services 365 days a year at SCCA South Lake Union campus so you can stay at home instead of at the hospital.

Phase 2: ALL consolidation therapy

About 80 percent of people with newly diagnosed ALL enter remission (the disease goes away) after induction therapy. Next, we do consolidation therapy to prevent a relapse (the disease coming back). This involves chemotherapy, steroids and targeted therapy and usually lasts a few weeks to a few months.

If your leukemia does not respond well to induction therapy, your physicians will recommend different treatments. If this happens, or if your leukemia has some features that might be harder to treat, your physicians may also recommend a bone marrow transplant — a treatment that our own physicians and scientists pioneered.

Phase 3: ALL maintenance therapy

If you’re in remission, you will then go on maintenance therapy to lower the risk of a recurrence. This phase may last a few years. It often involves lower doses of chemotherapy and targeted therapies. It's still treatment, but patients can usually go back to their normal lives during this phase.

Bone marrow The soft, spongy material in the center of your bones that produces all your blood cells, such as white blood cells, red blood cells and platelets. Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Infusion An injection of medications or fluids into a vein over a period of time. Recurrence Cancer that has come back, usually after a period during which it could not be detected. It may come back to the same place as the original (primary) tumor or someplace else. Also called recurrent cancer. Relapse The recurrence (return) of disease after an apparent recovery. Remission A decrease in, or disappearance of, signs and symptoms of cancer. A decrease in, or disappearance of, signs and symptoms of cancer. In partial remission, some (but not all) signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body. Steroid A type of drug used to relieve swelling and inflammation. Some steroid drugs may also have antitumor effects. Steroid A type of drug used to relieve swelling and inflammation. Some steroid drugs may also have antitumor effects. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies.

Learn about subtypes

To help plan your treatment, your team will use your test results to tell which subtype of ALL you have.

ALL is divided into subtypes based on:

Which type of lymphocyte the leukemic cells come from (B cells or T cells)
How mature the leukemic cells are
If the cells have chromosomal abnormalities (mutations)

Most people with ALL (about 80 percent) have a B-cell subtype. Some subtypes have an unusual number of chromosomes. In other subtypes, two chromosomes exchange DNA, which is called a translocation.

Chromosome Part of a cell that contains genetic information. Except for sperm and eggs, all human cells contain 46 chromosomes. Lymphocyte A type of immune cell that is made in the bone marrow and is found in the blood and in lymph tissue. The two main types of lymphocytes are B lymphocytes and T lymphocytes. A type of immune cell that is made in the bone marrow and is found in the blood and in lymph tissue. The two main types of lymphocytes (white blood cells) are B lymphocytes and T lymphocytes. B lymphocytes make antibodies, and T lymphocytes help kill tumor cells and help control immune responses. T cell A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. Also called T lymphocyte and thymocyte.

B-cell ALL

B-cell ALL starts in immature cells that would otherwise develop into B-cell lymphocytes, a part of our immune system that (among other things) makes antibodies. B-cell is the most common subtype of ALL.

Antibody A protein made by immune system cells and released into the blood. Antibodies defend the body against foreign substances, such as bacteria. Lymphocyte A type of immune cell that is made in the bone marrow and is found in the blood and in lymph tissue. The two main types of lymphocytes are B lymphocytes and T lymphocytes. A type of immune cell that is made in the bone marrow and is found in the blood and in lymph tissue. The two main types of lymphocytes (white blood cells) are B lymphocytes and T lymphocytes. B lymphocytes make antibodies, and T lymphocytes help kill tumor cells and help control immune responses.

T-cell lymphoma

T cells are a type of white blood cell and part of the immune system. Like the B-cell subtype, T-cell ALL starts in immature cells. It’s a less common subtype that happens more often in adults than children. Among adults, this subtype is about 25 percent of cases.

T cell A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. Also called T lymphocyte and thymocyte. White blood cell A type of blood cell that is made in the bone marrow and found in the blood and lymph tissue. White blood cells are part of the body’s immune system and help the body fight infection and other diseases. A type of blood cell that is made in the bone marrow and found in the blood and lymph tissue. White blood cells are part of the body’s immune system. They help the body fight infection and other diseases. Types of white blood cells include granulocytes (neutrophils, eosinophils and basophils), monocytes and lymphocytes (T cells and B cells). Checking the number of white blood cells in the blood is usually part of a complete blood cell (CBC) test. It may be used to look for conditions such as infection, inflammation, allergies and leukemia. Also called leukocyte and WBC.

Mixed phenotype acute leukemia

Mixed phenotype acute leukemia is a very rare subtype that is only about 2–5 percent of cases. It is diagnosed when someone has more than one type of leukemia at the same time or if their cancer cells have features of more than one type: both acute lymphoblastic leukemia and acute myeloid leukemia (AML).

Philadelphia chromosome-positive ALL (Ph+ ALL)

About 25 percent of adult ALL patients have this subtype. The Philadelphia chromosome is the most common translocation (when two chromosomes exchange DNA) in adult ALL. This means parts of chromosomes 9 and 22 get rearranged. Two genes called BCR and ABL join together in chromosome 22 to make one gene called BCR-ABL. Because this subtype is caused by the Philadelphia chromosome, it is called Philadelphia chromosome-positive ALL (Ph+ ALL).

Chromosome Part of a cell that contains genetic information. Except for sperm and eggs, all human cells contain 46 chromosomes. Chromosome Part of a cell that contains genetic information. Except for sperm and eggs, all human cells contain 46 chromosomes. Gene The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein. Gene The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein. PH+ ALL The most common sub-type of acute lymphoblastic leukemia, it's the subtype diagnosed in 20 to 25 percent of ALL patients.

Treatment process

Different subtypes of ALL start, progress and respond to treatments in different ways. We choose, combine and schedule your treatments based on what works for your subtype and how your body responds. Your care team will make sure you understand each type of treatment and all your choices.

“There are a few different ways we customize treatment. One way is that certain features of the disease will allow for targeted therapies. Age and medical comorbidities are another factor. Your goals, personal beliefs about your disease and your life play a role in treatment, too. We find a balance that works for you.”

— Ryan Cassaday, MD, hematologist-oncologist

Chemotherapy for ALL

Chemotherapy uses medicines to kill fast-growing cells (like cancer cells) or to keep them from dividing (which is how cancers grow). Chemotherapy drugs are usually given through an intravenous (IV) line in repeating cycles every two to six weeks.

Your care team will talk with you about which drugs we recommend for you, how you will take them, your treatment schedule and what to expect. We will also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout Fred Hutch.

Some of the chemotherapy drugs that are used most often to treat ALL are:

Cyclophosphamide
Cytarabine
Doxorubicin or daunorubicin
Mercaptopurine
Methotrexate
Nelarabine
Pegaspargase
Vincristine

Learn More About Chemotherapy

Chemotherapy for ALL

Most people with ALL start by getting intense chemotherapy and follow up with more treatments of phased chemotherapy.

Targeted therapy for ALL

Targeted therapies work in one of three ways:

They target a gene or protein that causes cancer growth.
They damage cancer cells directly.
They tell your immune system to attack certain cells. This is also called immunotherapy.

Therapies called Abelson tyrosine kinase inhibitors (ABL TKIs) are used for Ph+ ALL. They block the leukemia-causing effects of the protein made by the BCR-ABL gene — an abnormal gene in the Philadelphia chromosome.

The targeted drugs used for Ph+ ALL are usually taken daily as pills. They include:

Dasatinib
Imatinib
Nilotinib
Ponatinib

For some people with B-cell ALL, antibody-based treatments may be an option. Antibodies are a different kind of targeted therapy because they are proteins that your immune system normally makes to target a specific protein (called an antigen). Researchers have found ways to take advantage of this by making antibodies that can attack cancer if the leukemia cells have certain antigens. One example is rituximab, which may be added to chemotherapy if your leukemia has a protein called CD20. Another targeted therapy called inotuzumab ozogamicin may be an option. It uses an antibody to deliver an anti-cancer drug to your cancerous B cells.

Learn More About Targeted Therapy

Antibody A protein made by immune system cells and released into the blood. Antibodies defend the body against foreign substances, such as bacteria. Antibody A protein made by immune system cells and released into the blood. Antibodies defend the body against foreign substances, such as bacteria. Antigen A foreign substance, such as bacteria, that causes the body’s immune system to respond by making antibodies. Antibodies defend the body against antigens. B cell A type of white blood cell that makes antibodies. B cells are part of the immune system and develop from stem cells in the bone marrow. Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Chromosome Part of a cell that contains genetic information. Except for sperm and eggs, all human cells contain 46 chromosomes. Gene The functional and physical unit of heredity passed from parent to offspring. Genes are pieces of DNA, and most genes contain the information for making a specific protein. Immunotherapy A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. A therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. Some immunotherapies only target certain cells of the immune system. Others affect the immune system in a general way. Types of immunotherapy include cytokines, vaccines, bacillus Calmette-Guerin (BCG) and some monoclonal antibodies. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies.

Targeted therapy for ALL

For some subtypes or classifications of ALL, you may get targeted therapies. These therapies are newer cancer treatments that are more exact than standard chemotherapy.

Immunotherapy for ALL

For ALL that has come back or didn’t respond to other treatments (relapsed or refractory ALL), your physician may recommend a form of treatment that uses your immune system, such as:

Blinatumomab, a type of antibody therapy that helps your body’s T cells recognize and destroy cancerous B cells
Tisagenlecleucel (Kymriah®) or brexucabtagene autoleucel (Tecartus®), or CAR T-cell therapy

Fred Hutch is one of the first cancer centers in the nation to offer FDA-approved cellular immunotherapy for ALL. Tisagenlecleucel, known as the brand name Kymriah®, and brexucabtagene autoleucel, known as the brand name Tecartus®, are two different CAR T-cell therapies available only at certified treatment centers.

Learn More About Immunotherapy

Antibody A protein made by immune system cells and released into the blood. Antibodies defend the body against foreign substances, such as bacteria. Chimeric antigen receptor T-cell therapy A type of treatment in which a patient's T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells. A type of treatment in which a patient's T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells. T cells are taken from a patient’s blood. Then, in the laboratory, the gene for a special receptor that binds to a certain protein on the patient’s cancer cells is added to the T cells. This special receptor is called a chimeric antigen receptor (CAR). Large numbers of the CAR T cells are grown in the laboratory and given to the patient by infusion. Chimeric antigen receptor T-cell therapy is used to treat certain blood cancers, and it is being studied in the treatment of other types of cancer. Also called CAR T-cell therapy. Refractory In medicine, refractory disease is a disease or condition that does not respond to treatment. T cell A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. A type of white blood cell. T cells are part of the immune system and develop from stem cells in the bone marrow. They help protect the body from infection and may help fight cancer. Also called T lymphocyte and thymocyte.

Immunotherapy for ALL

Immunotherapies are some of the latest innovations in ALL care. They use the power of your immune system to fight your cancer.

Blood or marrow transplant for ALL

For ALL, most people who have a transplant get stem cells from a donor. This is called an allogeneic transplant, and it works in two ways:

After you receive strong chemotherapy to get rid of the ALL, the donor’s healthy stem cells restart your body’s ability to make blood cells.
White blood cells from the donor may recognize any leukemia cells that are still in your body and attack them.

More people are eligible for allogeneic transplants than ever before, because of advances available at Fred Hutch, including:

Non-myeloablative (lower-intensity) transplants, which use lower-dose chemotherapy
Transplants using stem cells from donated umbilical cord blood or haploidentical (half-matched) donors

Sometimes, physicians transplant the patient’s own stem cells, which were taken out earlier and had the leukemic cells removed (autologous transplant). This doesn’t happen very often with ALL.

Learn More About Blood and Marrow Transplants

Allogeneic stem cell transplant Uses bone marrow or stem cells from a related or unrelated donor whose tissue type closely matches the patient’s. Replaces blood-forming cells that have been destroyed by disease or cancer treatment. Uses bone marrow or stem cells from a donor whose tissue type closely matches the patient’s to replace blood-forming cells that have been destroyed by disease or cancer treatment. This can be from a related or unrelated donor. Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Stem cell A cell from which other types of cells develop. For example, blood cells develop from blood-forming stem cells.

Blood or marrow transplant for ALL

A blood or bone marrow transplant resets your body’s ability to make healthy blood cells. Researchers at Fred Hutch, pioneered this form of treatment.

Your physicians may recommend a transplant if your first treatment doesn’t put your ALL into complete remission or if your disease comes back.

Caregiving for transplant patients

Caregivers have a special role in bone marrow transplants. This intense treatment involves strong chemotherapy with serious side effects. During the initial recovery period, which often takes at least a month, your loved one will need daily help. We have classes to help transplant caregivers get ready. During recovery, a transplant registered nurse is available by phone 24 hours a day, 7 days a week, to help you.

Monitoring your health

While you’re in active treatment, your ALL care team will see you regularly for exams and tests to check:

How well your treatment is working
If there’s any reason to change your treatment
If you need help with side effects or supportive care services, like nutrition care or mental health counseling

We update your treatment plan based on the best scientific evidence as well as how your disease responds and what you prefer.

Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

What are the possible results of treatment?

Throughout treatment, your care team looks for signs of:

Remission: Fewer signs and symptoms of cancer. Partial remission means some signs and symptoms remain. Complete remission means there are no signs or symptoms.
Disease progression: The disease is getting worse or spreading.
Relapse: The disease, signs or symptoms have come back after they had improved.
Refractory disease: The disease does not respond to treatment.

What about “cured”? Sometimes physicians use the word “cured” if you have been in complete remission for at least five years. After five years, cancer is less likely to come back (recur), but recurrence is still possible.

Disease progression When the disease is getting worse or spreading. Recurrence Cancer that has come back, usually after a period during which it could not be detected. It may come back to the same place as the original (primary) tumor or someplace else. Also called recurrent cancer. Refractory In medicine, refractory disease is a disease or condition that does not respond to treatment. Relapse The recurrence (return) of disease after an apparent recovery. Remission A decrease in, or disappearance of, signs and symptoms of cancer. A decrease in, or disappearance of, signs and symptoms of cancer. In partial remission, some (but not all) signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body. Sign In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. Some examples of signs are fever, swelling, skin rash, high blood pressure and high blood glucose. Symptom A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. Some examples of symptoms are headache, fatigue, nausea and pain.

Caregiving during treatment

If your loved one is getting chemotherapy, targeted therapy or immunotherapy, there are many ways you can help. Caregiving during active treatment for ALL often means doing tasks like these:

Keeping track of their appointments and driving them to and from treatment
Watching for changes in their condition and telling their care team about any symptoms
Providing physical care, like helping them take medicines
Spending time with them and encouraging them
Taking care of things at home that they may not be able to do, like grocery shopping and cleaning

Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Immunotherapy A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. A therapy that uses substances to stimulate or suppress the immune system to help the body fight cancer, infection and other diseases. Some immunotherapies only target certain cells of the immune system. Others affect the immune system in a general way. Types of immunotherapy include cytokines, vaccines, bacillus Calmette-Guerin (BCG) and some monoclonal antibodies. Targeted therapy A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. A type of treatment that uses drugs or other substances to identify and attack specific types of cancer cells while causing less harm to normal cells. Some targeted therapies block the action of certain enzymes, proteins or other molecules involved in the growth and spread of cancer cells. Other types of targeted therapies help the immune system kill cancer cells, or they deliver toxic substances directly to cancer cells and kill them. Targeted therapy may have fewer side effects than other types of cancer treatment. Most targeted therapies are either small molecule drugs or monoclonal antibodies.

Supportive care services

Along with treating your ALL, Fred Hutch provides a range of services to support you and your caregiver before, during and after treatment. This is part of how we take care of you — not just your disease.
From dietitians to our Spiritual Health team, we have experts who specialize in caring for people with cancer. We understand this may be one of the most intense and challenging experiences you and your family ever go through. We are here to provide the care you need.

“It's important, and much more convenient for patients, to offer all these services in-house. We all work together, so it's easy to communicate. We don't want to wait, so having access to the same information benefits the patient immensely.”

— Ryan Cassaday, MD, hematologist-oncologist

Managing side effects

You might be wondering about possible side effects from treatment, like hair loss or nausea from chemotherapy. If you are, it might be helpful to know that many of today’s treatments are more targeted to cancer cells, so they don’t cause as many side effects as standard chemotherapy.

You are always at the center of everything we do. Our physicians, nurses and advanced practice providers are here to help prevent or manage the side effects of treatment.

How to get help with side effects

Before you begin treatment, we talk with you in advance about what to expect, based on your treatment plan, and what can help if you do have side effects.

At your appointments, we want you to tell us about any side effects you are having. If you have questions or concerns between appointments, you can call or email us. We will make sure you know how to reach care providers at Fred Hutch after hours, if that’s when you need us.

We have many tools to help you feel better, such as:

Antibiotics, vaccines and antiviral drugs to prevent or treat infections
Transfusions, steroids and medicines that help the immune system treat low levels of blood cells (low blood counts)
Nutrition care and medicines to help with digestive problems
Conventional and integrative therapies for pain

Coping with Side Effects

Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Steroid A type of drug used to relieve swelling and inflammation. Some steroid drugs may also have antitumor effects. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

Common side effects of ALL treatment

Side effects are different depending on which treatment you receive. They also depend on other things, like how strong your immune system is. These are some of the common side effects of ALL treatment:

Higher risk of infection (due to low levels of white blood cells)
Low numbers of red blood cells (anemia), which can cause unusual tiredness (fatigue) and is treated with transfusions
Low numbers of platelets, which can cause bruising and bleeding and is treated with transfusions
Mouth sores
Diarrhea
Hair loss
Nausea
Vomiting
Headache
Rash or other skin changes
Numbness, tingling or pain from nerve damage (neuropathy)

ALL treatment can also have long-term effects, like fatigue, and late effects (that start long after treatment ends), like heart disease. Not everyone who is treated for ALL develops long-term or late effects. It often depends on your age, overall health and your specific treatment. But no matter if or when late side effects show up, we’re here to help.

Platelet A tiny, disc-shaped piece of a cell that is found in the blood and spleen. Platelets help form blood clots to slow or stop bleeding and to help wounds heal. A tiny, disc-shaped piece of a cell that is found in the blood and spleen. Platelets are pieces of very large cells in the bone marrow called megakaryocytes. They help form blood clots to slow or stop bleeding and to help wounds heal. Having too many or too few platelets, or having platelets that do not work as they should, can cause problems. Checking the number of platelets in the blood may help diagnose certain diseases or conditions. Red blood cell A type of blood cell that carries oxygen in the body. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores.

Continuing care

When your disease is in remission and your active treatment ends, it’s still important to get follow-up care on a regular basis. At follow-up visits, you’ll see the same team who treated your ALL. They will check:

For signs that your disease has come back (signs of recurrence)
If you need help with long-term side effects (which go on after treatment ends)
If you need help with late effects (which may start long after treatment is over)
Your overall health

Recurrence Cancer that has come back, usually after a period during which it could not be detected. It may come back to the same place as the original (primary) tumor or someplace else. Also called recurrent cancer. Remission A decrease in, or disappearance of, signs and symptoms of cancer. A decrease in, or disappearance of, signs and symptoms of cancer. In partial remission, some (but not all) signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body. Side effects A problem that occurs when treatment affects healthy tissues or organs. Some side effects of cancer treatment are nausea, vomiting, fatigue, pain, decreased blood cell counts, hair loss and mouth sores. Sign In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. In medicine, a sign is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease. Some examples of signs are fever, swelling, skin rash, high blood pressure and high blood glucose.

“I get to see my patients for many years, and I think that's a really unique relationship we develop over time. We talk about each other's families, and we check in on life events outside of the clinic. I think the longevity of knowing our patients is a really special aspect of being a provider in oncology.”

— Christen N. Martino, ARNP, lymphoma survivor

Schedule for follow-up visits

Just like we personalize your treatment plan for you, we personalize your follow-up schedule, too. Your hematologist-oncologist will schedule your follow-ups based on many things, including:

Your ALL subtype
Which treatments you had and how your disease responded
How the disease and treatments affected you
How long it’s been since your treatment ended

Most patients are followed for at least five years for ALL. It’s common to have visits more often at first and then less often later. This will depend on your exact needs.

Hematologist A physician who specializes in diseases of the blood and blood-forming tissues. Treatment plan A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A detailed plan with information about a patient’s disease, the goal of treatment, the treatment options for the disease and the possible side effects and expected length of treatment. A treatment plan may also include information about how much the treatment is likely to cost and about regular follow-up care after treatment ends.

What happens at follow-up visits

Follow-up for ALL usually means seeing your hematologist-oncologist for a physical exam and having blood tests to check your blood cell levels. If there are any changes, you might have tests to check the health of your bone marrow.

Your physician will let you know if you need any imaging tests. You might have tests like a CT (computed tomography) scan or PET (positron-emission tomography) scan. These can help check for recurrence (if the cancer has come back), but they also expose you to some radiation. Together, you and your physician will decide on the benefits and risks.

Bone marrow The soft, spongy material in the center of your bones that produces all your blood cells, such as white blood cells, red blood cells and platelets. Computed tomography A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are used to create three-dimensional (3-D) views of tissues and organs. A procedure that uses a computer linked to an X-ray machine to make a series of detailed pictures of areas inside the body. The pictures are taken from different angles and are used to create three-dimensional (3-D) views of tissues and organs. A dye may be injected into a vein or swallowed to help the tissues and organs show up more clearly. This scan may be used to help diagnose disease, plan treatment or find out how well treatment is working. Hematologist A physician who specializes in diseases of the blood and blood-forming tissues. Imaging In medicine, a process that makes pictures of areas inside the body. Imaging uses methods such as X-rays (high-energy radiation), ultrasound (high-energy sound waves) and radio waves. Recurrence Cancer that has come back, usually after a period during which it could not be detected. It may come back to the same place as the original (primary) tumor or someplace else. Also called recurrent cancer.

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