The first 60 days: Acute lymphoblastic leukaemia
Acute lymphoblastic leukaemia is the childhood cancer success story, and was the first disease treated with CAR-T and with a T-cell engager. Below, week by week, is what OnCo's record of Acute lymphoblastic leukaemia says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
- Ph-positive ALL, newly diagnosedNCCN category Category 2A (ponatinib preferred TKI), NCCN ALL 2026
Ponatinib (PhALLCON) or dasatinib with reduced-intensity chemotherapy, or chemotherapy-free TKI + blinatumomab (D-ALBA); BCR::ABL1 PCR monitoring; transplant for MRD persistence or IKZF1-plus, increasingly omitted for MRD-negative patients.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Children, standard risk B-ALL, Adolescents and young adults (15-39), Ph-negative.
- Medical oncologistNamed in the standard of care for: Frontline, Relapsed, Children, standard risk B-ALL, Children, high risk or MRD-positive and 7 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Children, standard risk B-ALL.
- Transplant and cell therapy teamNamed in the standard of care for: Relapsed, Children, high risk or MRD-positive, Infants (<1 year), KMT2A-rearranged, Adolescents and young adults (15-39), Ph-negative and 5 more.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
- 1.Children, standard risk B-ALLNCCN category Category 1 (blinatumomab in consolidation), NCCN Pediatric ALL 2026
Risk-adapted multi-agent chemotherapy (induction, consolidation, interim maintenance, delayed intensification, 2-3 years maintenance) with two cycles of blinatumomab in consolidation (AALL1731, approved June 2024); intrathecal CNS prophylaxis; cranial radiation abandoned for most.
- 2.Infants (<1 year), KMT2A-rearrangedNCCN category Clinical trial preferred, NCCN Pediatric ALL 2026
Interfant-21 backbone with blinatumomab; transplant for high-risk; menin inhibitors in trials.
Intensified chemotherapy; blinatumomab for MRD persistence (AALL1331 in relapse); inotuzumab and CAR-T (tisagenlecleucel) for relapse; allogeneic transplant for very high risk or MRD persistence.
Risk-adapted chemotherapy + blinatumomab consolidation; TKI if Ph+.
- 5.Adolescents and young adults (15-39), Ph-negativeNCCN category Category 1 (blinatumomab consolidation), NCCN ALL 2026
Paediatric-inspired regimens (CALGB 10403, GRAALL, UKALL) with asparaginase; blinatumomab consolidation (E1910); MRD-guided transplant.
Hyper-CVAD or age-adapted multi-agent chemotherapy with blinatumomab interleaved in consolidation (E1910); inotuzumab-containing lower-intensity regimens (Mini-hyper-CVD + InO ± blinatumomab) for older adults; MRD-driven transplant.
Blinatumomab (BLAST; full approval 2018) to convert to MRD negativity, then transplant or continued blinatumomab-based therapy.
Intensive paediatric-type chemotherapy with nelarabine for high-risk (AALL0434); relapse: nelarabine, venetoclax combinations, CD7 CAR-T and daratumumab in trials; transplant in CR2.
CAR-T (tisagenlecleucel, obe-cel), inotuzumab, transplant.
Blinatumomab (TOWER) or inotuzumab (INO-VATE) as salvage and bridge; CD19 CAR-T (tisagenlecleucel ≤25 years; obe-cel or brexucabtagene in adults) for second salvage or as definitive therapy; transplant for those not previously transplanted; CD22 or dual CAR-T for CD19-negative relapse in trials.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example BCR-ABL, KMT2A, Ph-like signature, MRD, MRD by flowor clonoSEQ/PCRat end of induction and consolidation), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include B-cell precursor ALL: ETV6::RUNX1, high hyperdiploidy; Ph-positive BCR::ABL1; Ph-like/CRLF2; KMT2A-rearranged; hypodiploid, iAMP21, TCF3::HLF, DUX4/ZNF384 fusions, T-cell ALL: early T-precursorsubtype adverse; NOTCH1 mutated majority, Mixed-phenotype acute leukaemia.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Frontline
- For my situation (frontline), which of the standard options do you recommend and why?Guideline options include: Risk-adapted chemotherapy + blinatumomab consolidation; TKI if Ph+.
- Am I a candidate for Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Relapsed
- For my situation (relapsed), which of the standard options do you recommend and why?Guideline options include: CAR-T (tisagenlecleucel, obe-cel), inotuzumab, transplant.
- Am I a candidate for Revumenib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Children, standard risk B-ALL
- For my situation (children, standard risk b-all), which of the standard options do you recommend and why?Guideline options include: Risk-adapted multi-agent chemotherapy (induction, consolidation, interim maintenance, delayed intensification, 2-3 years maintenance) with two cycles of blinatumomab in consolidation (AALL1731, approved June 2024); intrathecal CNS prophylaxis; cranial radiation abandoned for most.
- Am I a candidate for Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of COG AALL1731 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Children, high risk or MRD-positive
- For my situation (children, high risk or mrd-positive), which of the standard options do you recommend and why?Guideline options include: Intensified chemotherapy; blinatumomab for MRD persistence (AALL1331 in relapse); inotuzumab and CAR-T (tisagenlecleucel) for relapse; allogeneic transplant for very high risk or MRD persistence.
- Am I a candidate for Blinatumomab, Inotuzumab ozogamicin, Tisagenlecleucel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Infants (<1 year), KMT2A-rearranged
- For my situation (infants (<1 year), kmt2a-rearranged), which of the standard options do you recommend and why?Guideline options include: Interfant-21 backbone with blinatumomab; transplant for high-risk; menin inhibitors in trials.
- Am I a candidate for Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of Interfant-06 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Adolescents and young adults (15-39), Ph-negative
- For my situation (adolescents and young adults (15-39), ph-negative), which of the standard options do you recommend and why?Guideline options include: Paediatric-inspired regimens (CALGB 10403, GRAALL, UKALL) with asparaginase; blinatumomab consolidation (E1910); MRD-guided transplant.
- Am I a candidate for Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ECOG-ACRIN E1910 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Adults 40-70, Ph-negative
- For my situation (adults 40-70, ph-negative), which of the standard options do you recommend and why?Guideline options include: Hyper-CVAD or age-adapted multi-agent chemotherapy with blinatumomab interleaved in consolidation (E1910); inotuzumab-containing lower-intensity regimens (Mini-hyper-CVD + InO ± blinatumomab) for older adults; MRD-driven transplant.
- Am I a candidate for Blinatumomab, Inotuzumab ozogamicin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ECOG-ACRIN E1910 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Ph-positive ALL, newly diagnosed
- For my situation (ph-positive all, newly diagnosed), which of the standard options do you recommend and why?Guideline options include: Ponatinib (PhALLCON) or dasatinib with reduced-intensity chemotherapy, or chemotherapy-free TKI + blinatumomab (D-ALBA); BCR::ABL1 PCR monitoring; transplant for MRD persistence or IKZF1-plus, increasingly omitted for MRD-negative patients.
- Am I a candidate for Ponatinib, Dasatinib, Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PhALLCON and D-ALBA (GIMEMA LAL2116) apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
MRD-positive after induction or consolidation
- For my situation (mrd-positive after induction or consolidation), which of the standard options do you recommend and why?Guideline options include: Blinatumomab (BLAST; full approval 2018) to convert to MRD negativity, then transplant or continued blinatumomab-based therapy.
- Am I a candidate for Blinatumomab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Relapsed or refractory B-ALL
- For my situation (relapsed or refractory b-all), which of the standard options do you recommend and why?Guideline options include: Blinatumomab (TOWER) or inotuzumab (INO-VATE) as salvage and bridge; CD19 CAR-T (tisagenlecleucel ≤25 years; obe-cel or brexucabtagene in adults) for second salvage or as definitive therapy; transplant for those not previously transplanted; CD22 or dual CAR-T for CD19-negative relapse in trials.
- Am I a candidate for Blinatumomab, Inotuzumab ozogamicin, Tisagenlecleucel or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of TOWER and INO-VATE ALL apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
T-cell ALL
- For my situation (t-cell all), which of the standard options do you recommend and why?Guideline options include: Intensive paediatric-type chemotherapy with nelarabine for high-risk (AALL0434); relapse: nelarabine, venetoclax combinations, CD7 CAR-T and daratumumab in trials; transplant in CR2.
- Am I a candidate for Venetoclax, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Revumenib, MK-1045, UCART22, CRC01?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Adult ALL outcomes”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “CD19-negative relapse”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- A Study of Olverembatinib in Patients With Newly Diagnosed Ph+ ALL (POLARIS-1)Phase 3 · recruiting · NCT06051409A Pivotal Registrational Phase 3 Study of Olverembatinib Combined With Chemotherapy Versus Investigator's Choice of TKI Combined With Chemotherapy in Patients With Newly Diagnosed Ph+ ALL
- A Clinical Trial of MK-1045 in People With B-cell Acute Lymphoblastic Leukemia (MK-1045-005)Phase 2/3 · recruiting · NCT07570173A Phase 2/3, Randomized, Open-Label, Comparison Study of MK-1045 Versus Blinatumomab in Participants With Relapsed or Refractory CD19+ B-Cell Acute Lymphoblastic Leukemia (B-ALL)
- A Phase 2 Study of WU-CART-007, an Anti-CD7 Allogeneic CAR-T Cell Therapy in T-Cell Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma (T-RRex)Phase 2 · recruiting · NCT06514794A Phase 2 Study of WU-CART-007, an Anti-CD7 Allogeneic CAR-T Cell Therapy in Patients With Relapsed/Refractory Cell Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma (T-RRex)
- A Study of pCAR-19B in the Treatment of CD19-positive Relapsed/Refractory B-ALL in Children and AdolescentsPhase 2 · recruiting · NCT05334823A Phase II Clinical Study of Anti-CD19 CAR-T Therapy (pCAR-19B) in the Treatment of CD19-positive Relapsed/Refractory B-ALL
- A Study to Learn More About the Study Medicine Called Inotuzumab Ozogamicin (InO) in Children (1 to <18 Years) With First Relapse ALLPhase 2 · recruiting · NCT05748171A PROSPECTIVE, RANDOMIZED, OPEN-LABEL PHASE 2 STUDY TO EVALUATE THE SUPERIORITY OF INOTUZUMAB OZOGAMICIN MONOTHERAPY VERSUS ALLR3 FOR INDUCTION TREATMENT OF CHILDHOOD HIGH-RISK OR VERY HIGH-RISK FIRST RELAPSE B-CELL PRECURSOR ACUTE LYMPHOBLASTIC LEUKAEMIA
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Acute lymphoblastic leukaemia: the full pageAcute lymphoblastic leukaemia is the childhood cancer success story, and was the first disease treated with CAR-T and with a T-cell engager.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Ph-positive ALL: Ph-positive ALL is acute lymphoblastic leukaemia carrying the Philadelphia chromosome.
- Philadelphia chromosome (Ph+, BCR::ABL1): A swapped piece between chromosomes 9 and 22 that fuses two genes into BCR::ABL1, a runaway kinase.
- Aneuploidy and chromosomal instability as the cause of cancer: The oldest theory of cancer, from Theodor Boveri in 1914: tumours arise from cells with the wrong number or arrangement of chromosomes.
- Prophylactic cranial irradiation (PCI): Giving the brain a preventive dose of radiation (25 Gy in 10 sessions) before any metastasis can be seen, mainly in small-cell lung cancer, which spreads to the brain in over half of patients.
- ICANS (neurotoxicity): ICANS is confusion, speech difficulty, and rarely seizures after CAR-T or bispecific therapy.
- Allogeneic stem cell transplant (allo-SCT): Replacing a patient's blood system with a donor's: chemotherapy wipes out the marrow, donor stem cells rebuild it, and the donor's immune cells hunt down leftover leukaemia.
- MRD-negative complete remission: MRD-negative complete remission means not just no leukaemia visible under the microscope, but none detectable with tests a thousand times more sensitive.
- B cell: The immune cells that make antibodies.
- Leukaemia (tissue type): Cancer of the blood-forming cells in the bone marrow, which flood the blood with immature or abnormal white cells and crowd out normal blood production.
- Undetectable MRD (uMRD / MRD-negative): The test for leftover cancer cells found none, down to the sensitivity of the assay (often one cell in 100,000 or a million).
Every term links to the glossary.