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NCCN Guidelines for Patients



Acute Lymphoblastic Leukemia, Version 1.2017


Cancer treatments


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

treatment regimens

Drug dosage

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.

Drugs used

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

given instead.

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.

Dose intensification

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.