Published on September 10, 2020
Treating Adult Acute Leukemia (ALL) with Multi-Agent Chemotherapy
"What has been shown for newly diagnosed patients to have the highest cure rates, multi-agent chemotherapy over a pretty prolonged period of time, followed then by a lower intensity maintenance program" Dr. Gail Roboz from Weill Cornell joins Patient Power host and advocate, Ruth Fein to discuss the importance of testing and knowing what the best treatment protocol is for your type of ALL. Dr. Roboz emphasizes the importance of great communication with your doctor because treatment for adult acute lymphoblastic leukemia may often include multiple drugs that can change over the months of therapy.
Transcript | Multi-Agent Therapies for Acute Lymphoblastic Leukemia
Determining Treatment Protocol for ALL Patients
Whether a person is newly diagnosed with adult ALL, or if the cancer has returned, I would imagine it's important to know if it's spread to other parts of the body, in this case most commonly the brain or the spinal cord. Right? And once you know that, how might treatments be different?
So, regular cancers that are tumors are staged kind of one, two, three, four. Leukemias aren't like that, but ALL is a disease that actually hides in the central nervous system and it can hide in the testes in men. So, there are what are called watershed or protected areas that have to be looked at carefully, and whether or not you're documented, for example, to have leukemic cells in the spinal fluid, you actually get, routinely as a part of all ALL therapy, spinal taps with what's called intrathecal or into the spinal fluid chemotherapy as part of the treatment regimen. Even if you've never had a leukemic cell ever found there, we have to prophylactically treat that area because otherwise leukemic cells have a nasty tendency of showing up there even when they weren't there to begin with. The number of spinal taps that you get is generally different if you have cells in the liquid or if you don't.
So, that's a change in the treatment. And also, sometimes for patients who are going onto STEM cell transplant, there may be radiation therapy to the brain or, for example, if there was a mass in the chest. If there were sites of extra medullary or outside of the bone marrow disease, sometimes there might be an extra boost of radiation incorporated as part of a STEM cell transplant. That said, there are some patients, and this is where things get really messed up and complicated in ALL, but in T-cell ALL, there's something called lymphoblastic lymphoma, where the disease might present only as a mass in the chest. And in that case, for some patients, T-cell ALL and T-cell lymphoblastic lymphoma may actually be the same thing even though that terminology sounds very different. So, it's super important to get that all straightened out with your doctor, T-cell versus B-cell. Do you have one site of disease that's outside of the bone marrow or do you have more than one site and what might be the treatment adaptations to specifically address those areas that are outside of the bone marrow?
So everyone doesn't get the same treatment for lots of the reasons you were just talking about, and it doesn't matter what stage of the disease they're in. There just might be all kinds of differences from the disease itself. So, it depends on so many factors and that, I would imagine, leads to the importance of so many different kinds of tests. How do you know what therapy is best for which patients and what tests give you that information?
It's super complicated for patients, but the good news is we know what we're doing. So, as a patient, of course, we want to get you onto a treatment regimen that is associated with the best possible outcomes. And to do that, what we need to do is understand exactly what is the nature of the disease you have and what are the clinical trials that have been done to date that would give us a protocol that is best for your type of ALL. ALL is generally multi-agent therapy. So, in pretty much every ALL protocol, there are different chemotherapies. They're given sequentially at different times through a period for newly diagnosed patients that might actually be two or three years if you include the intensive chemotherapy portions upfront followed by the lower intensity maintenance. The good news is that for the different subgroups of ALL, there are well worked out protocols that kind of we can give the patients with a calendar, showing them what we anticipate the next months to years are going to look like.
And then, for some patients, there are also clinical trial options that may say, "Well, this is what we've done up to now, and this is how the success rates are. But in this clinical trial, we might be changing one agent or adding a new one." So, some patients actually are very interested in participating in a clinical trial because there might be something new. That said, it's complicated in that there are likely to be multiple drugs that change over the months of therapy. And most of my patients I actually have, they have a calendar, and we follow through the calendar so that they know what to expect week to week because it's not just remembering, "Okay, I'm getting drug A and drug B four times in a row and then I'm done."
It's more complicated than that, and the reason is you want to give that one-two punch to the leukemic cells. You want to keep showing them different agents throughout the course of the chemotherapy treatment. That's what's been shown for newly diagnosed patients to have the highest cure rates is multi-agent chemotherapy over a pretty prolonged period of time, followed then by a lower intensity maintenance program, which is typically a combination of pills and monthly IV drugs like vincristine (Oncovin) that people can go back to work. They go back to their lives, but they're still proceeding with this maintenance for a prolonged period after they go into remission.
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