Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy the leukaemia cells. These work by disrupting the production of the leukaemia cells. The drugs circulate all over the body in the bloodstream.

As some of these drugs cannot get into the fluid around the brain and spinal cord (cerebrospinal fluid – CSF) they need to be injected directly into the fluid through a lumbar puncture. This is done even if leukaemia cells cannot be detected in the CSF, since research has shown that there will almost always be some leukaemia cells in the CSF which need to be destroyed.

When chemotherapy is given for acute lymphoblastic leukaemia it is divided into three different phases.

Induction

This is the initial intensive treatment, aimed at destroying as many leukaemia cells as possible. It usually achieves a remission of the disease, which means that the leukaemia cells can no longer be seen when a sample of bone marrow is examined under the microscope.

Drugs that are often used in this phase include:

• daunorubicin
• vincristine (Oncovin®)
• methotrexate
• cyclophosphamide
• cytarabine (Ara C)
• mercaptopurine (Puri-Nethol®).

Steroids and drugs such as allopurinol and folinic acid may also be given.

Intensification (consolidation)

A second, third or occasionally fourth intensive course of chemotherapy is usually given to increase the chance of a cure. The drugs that may be used in this phase include:

• high-dose methotrexate
• vincristine
• cytarabine
• etoposide
• daunorubicin
• cyclophosphamide
• tioguanine (Lanvis®).

Steroids may also be given. Some people who have the Philadelphia chromosome may be given a drug called imatinib (Glivec®). Imatinib may be given alongside, or instead of, chemotherapy in the intensification phase as part of research trials.

Continuing therapy (maintenance)

This is a less intensive course of chemotherapy given for a long time, mainly as tablets. It is aimed at killing any remaining leukaemia cells. The drugs used may include:

• mercaptopurine
• methotrexate tablets
• vincristine
• cytarabine (given into the fluid around the spinal cord).

Steroids and antibiotics may also be given. Imatinib (Glivec®) may continue to be given in this phase.

Instead of standard-dose maintenance chemotherapy some people may have high-dose chemotherapy with a stem cell transplant, as part of research trials. The high-dose treatment may include radiotherapy to the whole body (known as total body irradiation or TBI) and high doses of a chemotherapy drug such as etoposide or busulfan.

If you have standard continuing chemotherapy, your complete chemotherapy course is likely to last for at least two years. If you have high-dose chemotherapy after the induction and intensification phases the treatment time may be shorter and may finish in less than a year.

Some drugs may be given as tablets, but the main induction and intensification treatments consist of a combination of three or four drugs given by injection into a vein (intravenously).

Central lines

To make having chemotherapy easier and to prevent you from having frequent injections, a plastic tube (called a central line) can be put into a vein in your chest.

The tube is put in under a general or local anaesthetic. Usually a small cut (incision) will be made in the skin over your chest, and a narrow flexible plastic tube will be placed under your skin and into a large vein in your neck. The other end of the tube stays outside your body and has a screw cap at the end. The tube can be used to give drugs, fluids, stem cells or bone marrow, and also to collect blood samples.

You may feel sore and uncomfortable for a couple of days after the line has been put in, but it should then be painless. It can stay in for as long as it is needed, which may be more than two years. The nurses will show you how to look after it to prevent blockages or infections.

PICC lines and implantable ports

Instead of a central line, a PICC line (peripherally inserted central venous catheter) or an implantable port may be used. A PICC line is a long, thin tube put into a vein in the crook of the arm. An implantable port is a thin, soft plastic tube that is put into a vein in the chest and has an opening (port) just under the skin of the chest or arm.

Your doctor or chemotherapy nurse will explain the procedure to you. You will be given a local anaesthetic before the line is put in.

Intrathecal chemotherapy

As well as by injection into a vein, chemotherapy for acute lymphoblastic leukaemia is often given directly into the fluid around the brain and spinal cord (cerebrospinal fluid). Giving chemotherapy in this way is known as intrathecal chemotherapy. This is done using a similar procedure to the lumbar puncture. After giving a local anaesthetic, the doctor gently puts a needle into the fluid in the spine, a small amount of fluid is drawn off and the drugs are injected. The drugs will help to destroy any leukaemia cells in the fluid.

The induction and intensification chemotherapy is given as several sessions (cycles) of treatment, each normally lasting for a few days, followed by a rest period of a few weeks. The rest period allows your body to get over the side effects of treatment and your normal bone marrow cells to recover so that they can make new blood cells.

The number of cycles you have will depend on how your leukaemia responds to the drugs. Nowadays, most people have about four cycles of intensive chemotherapy.

Once you have finished the initial course of chemotherapy, which usually takes several months, your doctor may prescribe further chemotherapy, often as tablets, to be taken for at least two years. This is known as maintenance or continuation therapy. During this time you will need to make regular visits to the outpatients department of the hospital so that your doctor can check that the drugs are working.

Throughout your treatment you will have regular blood tests and lumbar punctures to check for leukaemia cells. Depending on the results of these tests your doctor may need to change the treatment you are having.

Supportive care

During your treatment you will also have supportive care. This treats the symptoms that have been caused by a lack of normal blood cells due to the leukaemia itself and due to the chemotherapy. Drips (transfusions) of red blood cells and platelets are usually needed to replace the normal blood cells. These can also be given through your central line.

Risk of bruising and bleeding

Platelets help blood to clot. When you have leukaemia, the number of platelets in your blood is lower than normal, and chemotherapy may temporarily reduce the numbers even more. This means that you may bruise very easily, may develop blood spots (petechiae) or rashes (purpura), and may bleed heavily from even minor cuts and grazes.

You may need to have a drip (transfusion) of platelets before your chemotherapy begins, and at times during your treatment, to replace the missing platelets.

If you have any unexplained bruising or bleeding, contact the hospital immediately.

Low resistance to infection

While the chemotherapy drugs are acting on the leukaemia cells in your body, they also reduce the number of normal cells in your blood for a while. When these cells are in short supply, you are more likely to get an infection. During chemotherapy your blood will be tested regularly. You will probably be given tablets or other medicines to reduce the risk of infection. If you get an infection, you will be given medicines to treat it. Most infections are caused by bacteria or viruses already in your own body, but if your immunity is low it is best to avoid crowded places where you may come into contact with someone who may have an infection.

You may also be advised to be careful about what you eat, to guard against the risk of infection from raw, undercooked or contaminated food. The hospital will give you information on how to prepare foods and which foods to avoid.

If your temperature goes above 38ºC (100.5ºF) or you suddenly feel ill, even with a normal temperature, contact your doctor or the hospital straight away.

You may be given injections of a drug called G-CSF (granulocyte-colony stimulating factor). This is a type of protein that stimulates the bone marrow to produce more white blood cells. The injections are given under the skin (subcutaneously).

Anaemia

If the level of red blood cells (haemoglobin) in your blood is low you may become very tired and lethargic. You may also become breathless. These are all symptoms of anaemia - a lack of haemoglobin in the blood.

Anaemia can be treated very successfully by blood transfusions. You should quickly feel more energetic after a transfusion and the breathlessness will be eased. We can send you factsheets about blood transfusions.

Tiredness (fatigue)

This is a very common effect of chemotherapy. The fatigue may be due to anaemia, but may also occur as a result of chemotherapy, even if your blood count is normal. You may be especially aware of this when you are at home between courses of chemotherapy and for a few months after the treatment has finished.

Feeling sick

Some of the drugs used to treat acute lymphoblastic leukaemia may make you feel sick (nausea) and may sometimes cause vomiting. There are now very effective anti-sickness drugs (anti-emetics) to prevent or greatly reduce nausea and vomiting. Your doctor can prescribe these for you. Let your doctor or nurse know if the anti-emetics are not controlling your nausea as different ones can be prescribed. We can send you a factsheet about coping with nausea and vomiting, which gives some helpful advice on coping with these effects.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause mouth ulcers. Regular mouthwashes are important and the nurse will show you how to use these properly. If you don’t feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet. Our section on eating well has some useful tips on coping with eating problems.

Effects on the heart

Some of the drugs used to treat acute lymphoblastic leukaemia may affect the heart muscle. The doses of the chemotherapy drugs used are very carefully monitored, and heart tests (eg cardiac echograms) may be done from time to time to check your heart.

Hair loss

Unfortunately, hair loss is another common side effect of these drugs. If your hair falls out, you can cover up by wearing wigs, hats or scarves. Most patients are entitled to a free wig from the National Health Service and your doctor or one of the nurses on the ward can arrange for a wig specialist to visit you. If your hair falls out, it will grow back over a period of 3–6 months when the treatment ends.

Although they may be hard to deal with at the time, these side effects will disappear once your treatment is over.

Our section on chemotherapy discusses the treatment and its side effects in more detail. Information about individual drugs and their particular side effects are also available.

Chemotherapy affects different people in different ways. Some people find they are able to lead a fairly normal life during their treatment, but many find they feel very unwell at times, become very tired and have to take things much more slowly. Do as much as you feel like and rest whenever you need to.

Contraception

It is not advisable to become pregnant or father a child while taking any of the chemotherapy drugs used to treat ALL, as they may harm the developing foetus. It is important to use effective contraception during your treatment and for a few months afterwards. You can discuss this with your doctor or nurse.

Condoms should be used during sex within the first 48 hours after chemotherapy in order to protect your partner from any of the drug that may be present in semen or vaginal fluid.

Our section on chemotherapy discusses the treatment and its side effects in more detail. Information about individual drugs and their particular side effects are also available.