Acute Lymphocytic Leukemia Health Article

Recurrent ALL

ADULTS.

Adults who relapse after initial remission and maintenance therapy often undergo reinduction chemotherapy and are then referred for bone marrow or stem cell transplant. Some receive transplants of umbilical cord blood. Such transplants carry the risk of graft versus host disease, but also carry the possibility of graft versus leukemia, in which the transplanted cells attack the residual leukemic cells. Unlike graft-versus-host disease, graft versus leukemia is useful.

New treatments for relapsed ALL include immunotherapies or biological response modifiers. Some reduce adverse effects of treatment and others are used to fight the leukemia. Some of these include cytokines, substances that stimulate the production of blood cells after treatment has suppressed the bone marrow, and colony-stimulating factors, which have the same effect. Other immunotherapies, such as monoclonal antibodies and interferon, have not yet been shown effective against ALL, but are still under study.

CHILDREN.

The treatment and prognosis of children who relapse depends on the timing of that relapse. Relapse that occurs within six months is often treated with bone marrow transplantation. Early relapse carries the least favorable prognosis, with only 10% to 20% chance of long-term survival. Relapse that occurs more than a year after initial treatment is finished can be treated with another full round of chemotherapy, and bone marrow transplant reserved for those children who relapse a second time. Those with such late relapses have a 30% to 40% chance of long-term survival.

Recurrent disease may occur in a sanctuary site, or a part of the body difficult to penetrate with chemotherapeutic drugs. The central nervous system is the most common site of such recurrences. Children who have an isolated central nervous system relapse during the first 18 months of treatment have a 45% likelihood of long-term survival. Children with central nervous system relapse after the first 18 months of treatment have up to an 80% chance of long-term survival. Treatment for relapse in the central nervous system includes intrathecal chemotherapy, and for most children, the use of radiation therapy to the brain and spinal cord.

The testicles are the second most common site of relapse. Early testicular relapse (within the first 18 months of treatment) carries a 40% chance of long-term survival, and late testicular relapse carries an 85% chance of long-term survival. Another sanctuary site is the eye, but isolated relapse here is unusual.

Coping with cancer treatment

The treatment of ALL can be particularly draining, not only due to adverse effects but due to its prolonged time course. Although much of the treatment can be given on an outpatient basis, many protocols utilize lengthy intravenous infusions of chemotherapy and require hospitalization.

ADULTS.

To prevent nausea and vomiting, adults can take oral anti-nausea medication an hour or so before scheduled treatments, including intrathecal treatments. To avoid headache, they should remain flat for at least 30 to 60 minutes after intrathecal chemotherapy. Nurses can give instructions in mouth care if mouth sores occur and skin care if rashes occur after radiation treatment. Books, music, and television can provide distraction and reduce anxiety during chemotherapy infusions.

Patients scheduled for inpatient stays can bring their own pillows, pajamas and even food, with their doctor's approval. Temporary issuance of handicapped parking stickers are often helpful.

CHILDREN.

The presence of parents during treatment is critical. While some hospitals exclude parents during treatments, others invite them to be present. Blood can be drawn and intravenous catheters placed while children sit in their parents' laps. If at all possible, a parent should spend the night during any hospitalizations.

Like adults, children can take anti-nausea drugs an hour or so before scheduled treatments. Children, and some adults, can apply topical anesthetic creams to sites of bone marrow aspirates or spinal taps. Favorite stuffed animals or blankets can be present for most procedures.

Play and fun are as important to children with cancer as to healthy children. Items such as board games, modeling clay, video games, dolls, and toy cars can be enjoyed even with intravenous lines in place. Play dates with friends should be encouraged, with proper screening to limit exposure to contagious illnesses.

School districts are required to accommodate the special needs of children. Children with ALL might require shorter school days or the provision of a tutor at home. Children who develop learning disabilities due to treatment might require the intervention of a special education team.