Welcome to the fifteenth part of a series on Hemato-oncology.
Question: Dr. Chiragbhai, thank you for explaining to us about diagnosis of ALL – Acute Lymphoid Leukemia. It was good to know that this leukemia has a cure rate as high as 60-90%. Diagnostic methods are same as AML. But what about treatment?
Answer: Right, cure rates are high, and yet treatment is comparatively easier, cheaper and mainly as outpatient. Unlike AML, however, there are many different protocols for ALL treatment. Some of the most common ones are BFM 90 or 95, UKALL, various protocols from USA or Europe, and from St Jude Children Hospital.
Que: What is the Best protocol?
Ans: Since there is no direct comparison of these protocols, it is not possible to answer which protocol is best. However, most protocols have good cure rates. Some are more aggressive with likely somewhat higher cure rates.
Most important concept however is to decide one protocol and follow it as it is. The treating team should become comfortable and confident with one protocol, to know its schedule, side effects, common problems etc. ALL protocols are very long and complicated in comparison to most other malignancies. Hence familiarity with a protocol is important and using more than one protocol in one institute is not advisable.
We use BFM 95 protocol for all our patients. This is the German protocol with one of the best cure rates, and importantly most of it can be done as outpatient, thus making it convenient and reducing cost.
Basic concept of all major protocols is same i.e. induction, consolidation, CNS prophylaxis, and maintenance. Main medicines are also same, but in different schedules i.e. prednisone or dexamethasone, vincristine, daunorubicin, L-asparaginase, cyclophosphamide, andintrathecal chemotherapy as well as high dose methotrexate or radiotherapy for CNS prophylaxis, and6-MP, methotrexate for maintenance.
Que: Do these patients also need Stem Cell Transplant?
Ans: Yes, but much less common compared to AML. Since cure rates are very good in children with standard therapy, transplant has less role. However, in high risk cases and in adults (over age 18), where results are not very good with standard chemotherapy, more aggressive regimens including Transplant are recommended by most guidelines as part of initial therapy. But it is possible only in few patients in India due to inability to find a matched brother or sister, cost, risks, and smaller benefit compared to AML transplant.
One of the high risk subsets is Philadelphia chromosome positive ALL, where now Imatinib gives good results, and transplant may be avoided as first line therapy.
Children with ALL must be treated as the cure rates are so high.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496
Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad.