Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team.

Some forms of leukaemia don’t need treatment straight away, and some may never need treatment.

Treatment for leukaemia depends on:

• the stage of the disease
• the location of the cancer
• the severity of symptoms
• your general health and wishes.

Treatment may involve the following.

Surgery

Surgery is not useful in treating leukaemia because the cancer cells are spread throughout the bone marrow and often in many other organs.

However, the spleen may need to be removed in CLL, CML or hairy cell leukaemia if it becomes so enlarged that it is pressing on nearby organs, or if it is removing too many blood cells from the bloodstream. The spleen is removed to relieve symptoms, rather than to cure the leukaemia.

Chemotherapy

Some people with leukaemia may receive chemotherapy.

Chemotherapy is the main treatment for people with acute leukaemia (ALL and AML). It may be given over several years. People with ALL usually receive chemotherapy in 3 main phases over 1 to 3 years (the first 2 phases involve high dose chemotherapy) . People with AML usually receive 2 phases of high-dose chemotherapy. Chemotherapy may be used for CLL, sometimes combined with targeted therapy. Different medicines and combinations may be used depending on your age, health and personal preferences.

Some people with CML may receive chemotherapy before starting targeted therapy, or as an alternative if they can’t take the targeted therapy medicines.

Using chemotherapy to treat leukaemia may cause a side effect called tumour lysis syndrome. This occurs when the large number of leukaemia cells in the body break open after they are killed by the chemotherapy medications, releasing their contents into the bloodstream. This can overwhelm the kidneys and cause serious problems. Extra fluids and certain medicines may be given to avoid this syndrome.

 

Steroids

Steroids are hormones naturally made in the body. They can also be made in a lab and used as drugs. Steroids may be used to increase the effect of chemotherapy, help destroy leukaemia cells, or to reduce allergic reactions to some chemotherapy drugs. They are usually given as a pill.

The most common steroids for ALL include prednisolone and dexamethasone.

Steroids may also be used to treat CLL with chemotherapy, or if there is a sudden drop in the amount of red blood cells.

Radiation therapy

Some people with leukaemia may receive radiation therapy.

Radiation therapy is not usually a major treatment for leukaemia. However, it may be used to treat leukaemia that has spread to the central nervous system or testicles, or to treat symptoms caused when swollen internal organs, such as the spleen, press on other organs. It may also be used before a stem cell transplant. Radiation therapy can be used to relieve bone pain where the leukaemia has spread to.

 

Targeted therapy

 

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells. Different types of targeted therapy may be used for different types of leukaemia.

Targeted therapy for ALL usually includes a group of drugs called tyrosine kinase inhibitors. These drugs work by blocking a protein that leukaemia cells need to grow and divide. Some of these medicines include imatinib, dasatinib, nilotinib, bosutinib and ponatinib.  Some subtypes of ALL may be treated with a group of drugs called monoclonal antibodies. These work by targeting a protein on the surface of leukaemia cells. Monoclonal antibodies used to treat ALL include rituximab and blinatumomab.

Targeted therapy for some subtypes of AML may be available through clinical trials. The most common type of targeted therapy for CLL is monoclonal antibodies, including the drugs rituximab, obinutuzumab, ofatumumab and alemtuzumab. Tyrosine kinase inhibitors may be used to treat CLL, including the drugs ibrutinib and idelalisib.

Targeted therapy using tyrosine kinase inhibitors is the main treatment to control CML symptoms (they can’t cure the disease). These include the drugs imatinib, dasatinib, nilotinib and ponatinib.

CAR-T therapy is a term for a type of immunotherapy that changes your child’s own T-cells so they can attack the cancer cells. Currently, CAR-T therapy is only used for some forms of acute lymphoblastic leukaemia (ALL).

During CAR-T some of your child’s blood will taken and sent to a laboratory. In the laboratory, your child’s cells will be changed so that they have structures called chimeric antigen receptors on the surface. After growing enough of the new cells, they are injected back into your child. In the body, the cells will replicate and grow. The ‘new’ T cells may be able to find and attack the cancer cells. The T cells are taken and re-injected intravenously (in a vein).

 

Stem cell transplant

Chemotherapy may be given in high doses to treat leukaemia, followed by a stem cell transplant to restore the bone marrow that has been destroyed by the chemotherapy treatment. The transplanted cells may come from a donor or from the patient’s own body. They may be taken from the blood, the bone marrow or umbilical cord blood.

A stem cell transplant from another person (a donor) is only possible if that person has a tissue type that closely matches that of the person with leukaemia. The best donor is often a close relative.

Leukapheresis

If large numbers of leukaemia cells in the bloodstream are causing problems with normal circulation, a procedure called leukapheresis may be used. This involves passing the blood through a machine that removes white blood cells and then returns the treated blood back into the bloodstream.

Immunotherapy

Immunotherapy involves treatment with medicines that boost the ability of the immune system to attack cancer cells. Interferon-alpha may be used as immunotherapy to treat CML, although tyrosine kinase inhibitors are now preferred.

Follow-up

Treatment for leukaemia often lasts for years. Some people may require ongoing chemotherapy or radiotherapy to keep the leukamia under control. CLL and CML are rarely cured, and treatment may continue at intervals for life.

After treatment for leukaemia, you will need regular follow-up examinations and tests to look for return of the cancer or side effects from treatment.

Advanced disease

If leukaemia treatment is unsuccessful, palliative treatment to control the symptoms of the disease may be the best option. This might include:

• radiation therapy, chemotherapy, or both
• pain-relieving medicines to reduce pain from leukaemia in the bones
• blood transfusions to treat fatigue
• food supplements and medicines to treat nausea and loss of appetite.

Recurrent cancer

Leukaemia may recur (come back) after treatment. Secondary cancer is when the cancer spreads to another part of the body.

Treatment options for recurrent leukaemia include further chemotherapy, possibly using different medicines or higher doses, targeted treatment with blinatumomab (for some types of ALL) or a stem cell transplant.

Active monitoring

Some forms of leukaemia may not need to be treated straight away, or at all. Instead, you may have regular check-ups and blood tests to monitor the cancer (called active monitoring, watchful waiting, or watch and wait). Active monitoring can be better than treating the cancer straight away, because early treatment can cause side effects or make your body resistant to treatment.

Other treatments

Other treatments may be used for different types of leukaemia, but these are not used as often as the main treatments:

•       Treatment for acute promyelocytic leukaemia (APML) is different from most other AML treatments and consists of 3 phases – some people with APML may not need to go through all 3 phases. This treatment involves different types of drugs, including chemotherapy drugs

•       Low‑dose drug therapy may be used for AML if you aren’t healthy enough for intensive chemotherapy or a stem cell transplant. Drugs used for this therapy include azacytidine and cytarabine.

•       Allopurinol is drug that may be used to treat some symptoms of CML

•       Human leukocyte antigen (HLA) typing may be used if a stem cell transplant is an option for treatment. This test is used to make sure the donor is a suitable match.