The first 60 days: Standard-risk B-cell acute lymphoblastic leukaemia in children
Standard-risk acute lymphoblastic leukaemia is the commonest and most curable childhood cancer: a child aged one to nine with a modest white cell count and favourable genetics. Two to three years of chemotherapy cures about nine in ten, and adding the immune drug blinatumomab to the chemotherapy in the AALL1731 trial cut relapses further. Below, week by week, is what OnCo's record of Standard-risk B-cell acute lymphoblastic leukaemia in children 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.
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: Induction (four weeks).
- Medical oncologistNamed in the standard of care for: Induction (four weeks), Consolidation and interim maintenance, Delayed intensification and maintenance, Relapse.
- Transplant and cell therapy teamNamed in the standard of care for: Consolidation and interim maintenance, Delayed intensification and maintenance, Relapse.
- Palliative and supportive care teamNamed in the standard of care for: Induction (four weeks), Delayed intensification and maintenance.
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.Induction (four weeks)NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)
Vincristine, dexamethasone and pegylated asparaginase with intrathecal methotrexate; flow cytometry MRD at day 29 decides the post-induction arm.
Reinduction chemotherapy with blinatumomab for high- and intermediate-risk relapse; tisagenlecleucel or inotuzumab ozogamicin for later relapse (see the relapsed ALL page).
- 3.Consolidation and interim maintenanceNCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)
Cyclophosphamide, cytarabine and mercaptopurine, then escalating methotrexate; two cycles of blinatumomab added for standard-risk average and high disease (AALL1731).
- 4.Delayed intensification and maintenanceNCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)
One delayed intensification block with vincristine, dexamethasone, doxorubicin, asparaginase, cyclophosphamide, cytarabine and thioguanine; then daily mercaptopurine, weekly methotrexate and vincristine-steroid pulses to two years or more.
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 Age and presenting white cell count, ETV6::RUNX1 fusion, High hyperdiploidy with trisomies 4 and 10, Flow cytometry MRD at day 8 and day 29, CNS status at diagnosis), 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 Standard-risk favourable B-ALL, Standard-risk average B-ALL, Standard-risk high B-ALL.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Induction (four weeks)
- For my situation (induction (four weeks)), which of the standard options do you recommend and why?Guideline options include: Vincristine, dexamethasone and pegylated asparaginase with intrathecal methotrexate; flow cytometry MRD at day 29 decides the post-induction arm.
- Am I a candidate for Vincristine, Dexamethasone, Asparaginase (pegaspargase, calaspargase pegol, Erwinia asparaginase) or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Consolidation and interim maintenance
- For my situation (consolidation and interim maintenance), which of the standard options do you recommend and why?Guideline options include: Cyclophosphamide, cytarabine and mercaptopurine, then escalating methotrexate; two cycles of blinatumomab added for standard-risk average and high disease (AALL1731).
- Am I a candidate for Cyclophosphamide, Cytarabine, Mercaptopurine 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 COG AALL1731 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Delayed intensification and maintenance
- For my situation (delayed intensification and maintenance), which of the standard options do you recommend and why?Guideline options include: One delayed intensification block with vincristine, dexamethasone, doxorubicin, asparaginase, cyclophosphamide, cytarabine and thioguanine; then daily mercaptopurine, weekly methotrexate and vincristine-steroid pulses to two years or more.
- Am I a candidate for Vincristine, Dexamethasone, Doxorubicin or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Relapse
- For my situation (relapse), which of the standard options do you recommend and why?Guideline options include: Reinduction chemotherapy with blinatumomab for high- and intermediate-risk relapse; tisagenlecleucel or inotuzumab ozogamicin for later relapse (see the relapsed ALL page).
- Am I a candidate for Blinatumomab, Tisagenlecleucel, Inotuzumab ozogamicin, 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 Blinatumomab, COG AALL1731, NGS-based MRD (clonoSEQ and molecular MRD), Blinatumomab added to frontline chemotherapy?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 “Whether blinatumomab allows chemotherapy to be shortened rather than only added to”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Asparaginase hypersensitivity and silent inactivation, and osteonecrosis in older children”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Standard-risk B-cell acute lymphoblastic leukaemia in children: the full pageStandard-risk acute lymphoblastic leukaemia is the commonest and most curable childhood cancer: a child aged one to nine with a modest white cell count and favourable genetics. Two to three years of chemotherapy cures about nine in ten, and adding the immune drug blinatumomab to the chemotherapy in the AALL1731 trial cut relapses further.
- 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.
- Event-free / disease-free survival (EFS, DFS, iDFS, RFS): In early-stage cancer: how long patients stay free of recurrence, progression, or death.
- B-ALL risk groups (NCI criteria, ETV6::RUNX1, hyperdiploidy, hypodiploidy, iAMP21, IKZF1, CNS status): Childhood leukaemia treatment is chosen from a risk table built over fifty years: age and white count at diagnosis (the NCI criteria), the chromosome pattern in the blasts (favourable ETV6::RUNX1 and high hyperdiploidy, unfavourable hypodiploidy, iAMP21, KMT2A, Ph-positive and Ph-like), whether leukaemia cells are in the spinal fluid, and above all how fast the leukaemia clears in the first month.
- Minimal / molecular residual disease (MRD): Cancer still present after treatment but too small to see on scans, detected by blood or marrow tests.
Every term links to the glossary.