NCCN Guidelines for Patients
Acute Lymphoblastic Leukemia, Version 1.2017
Regimens for AYAs and older adults
A protocol is a detailed outline or plan of a medical
treatment, study, or procedure. A treatment protocol
covers all phases of ALL treatment. It states which
drugs and regimens will be used during each
phase of treatment. A protocol often includes many
chemotherapy regimens that are given at different
times over the course of ALL treatment.
Treatments designed for children with ALL are called
pediatric protocols. The chemotherapy regimens
used for children are often called pediatric regimens.
Treatments designed for older adults with ALL are
called adult protocols and adult regimens.
Many of the same drugs are used for children and
older adults with ALL. But, the doses and schedules
are different. AYAs are patients aged 15 to 39 years.
Importantly, studies show that AYAs have much
better outcomes when treated more like children.
Experts recommend that treatment for AYAs should
be based on pediatric protocols. This is referred to
as a pediatric-inspired protocol. The main differences
between pediatric and adult treatments are described
Differences between pediatric and adult
Pediatric regimens are more intense and complex
than those given to older adults. They use high
(intensified) doses of certain chemotherapy drugs
that can be hard for older adults to tolerate.
Pediatric regimens tend to use more pegaspargase,
vincristine, and steroids such as dexamethasone and
prednisone. Overall, the doses of these drugs are
higher than what is given to adults. Some patients
may develop an allergy to pegaspargase. If this
happens, asparaginase erwinia chrysanthemi may be
In contrast, adult regimens tend to use more
cyclophosphamide and anthracyclines such
as doxorubicin and daunorubicin. These drugs
lower (suppress) the bone marrow’s ability to
make new blood cells. Thus, they are also called
myelosuppressive drugs. Adult regimens also use
allogeneic SCT (
ransplant) more often.
Intensified doses of drugs are given at certain
points during treatment for children and adults. But,
pediatric protocols give intensified doses more often
throughout the course of treatment. In contrast, adult
regimens tend to be less intense. The types and
doses of drugs used in adult regimens are meant
to be tolerable for people across a wide age range.
AYAs treated with these regimens may be under-
Length of treatment
In pediatric protocols, treatment is given for a longer
period of time overall. CNS (
preventive treatment is started earlier and given
longer. Children often receive maintenance therapy
for about 3 years. Adult regimens tend to give
maintenance for about 2 years.
Side effects of chemotherapy
A side effect is an unhealthy or unpleasant physical
or emotional condition caused by treatment. Each
treatment for ALL can cause side effects. The
reactions to chemotherapy differ between people.
Some people have many side effects. Others have
few. Some side effects can be very serious while
others can be unpleasant but not serious.
Often, doctors give IV chemotherapy through a thin,
soft tube called a central venous line or catheter.
One end of the central line will be inserted into a
large vein in your chest or upper arm. The other end
of the central line may stay outside of your body.
Or, it may be attached to a port that is placed just
under your skin.
See Figure 9
on page 33.