If the leukemia is refractory -- that is, if it doesn't go away with the first treatment (which happens in about 10% to 20% of cases) -- then newer or more intensive doses of drugs may be tried, although they are less likely to work. A stem cell transplant may be tried if the leukemia can be put into at least partial remission. Clinical trials of new treatment approaches may also be considered.
If leukemia comes back (recurs) after initial treatment, it will most often do so in the bone marrow and blood. Occasionally, the brain or spinal fluid will be the first place it recurs.
In these cases, it is sometimes possible to put the leukemia into remission again with more chemotherapy, although this remission is not likely to last. For ALL patients with the Philadelphia chromosome, switching to or adding a newer targeted drug such as dasatinib (Sprycel) may be helpful. If a second remission can be achieved, most doctors will advise some type of stem cell transplant if possible.
If the leukemia doesn't go away or keeps coming back, eventually chemotherapy treatment will not be very helpful. If a stem cell transplant is not an option, a patient may want to consider taking part in a clinical trial of newer treatments.
Those who want to continue treatment to fight the leukemia as long as they can need to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects. Everyone has his or her own way of looking at this. In many cases, the doctor can estimate the response rate for the treatment being considered. Some people are tempted to try more chemotherapy, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, it is important to think about and understand your reasons for choosing this plan.
Palliative treatment
If a clinical trial is not an option, it is important at this time to focus on relieving the symptoms of the leukemia. This is known as palliative treatment. For example, the doctor may advise less intensive chemotherapy to try to slow the leukemia growth instead of trying to cure it.
As the leukemia grows in the bone marrow it may cause pain. It is important that you be as comfortable as possible. Treatments that may be helpful include radiation and appropriate pain-relieving medicines. If medicines such as aspirin and ibuprofen don't help with the pain, stronger opioid medicines such as morphine are likely to be helpful.
Other common symptoms from leukemia are low blood counts and fatigue. Medicines or blood transfusions may be needed to help correct these problems. Nausea and loss of appetite can be treated with medicines and high-calorie food supplements. Infections that occur may be treated with antibiotics.
At some point, you may benefit from hospice care. Most of the time, this can be given at home. The leukemia may be causing symptoms or problems that need attention, and hospice focuses on your comfort. Receiving hospice care doesn't mean you can't have treatment for the problems caused by the cancer or other health conditions. It just means that the focus of care is on living life as fully as possible and feeling as well as one can at this difficult stage.
Remember also that maintaining hope is important. The hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that can bring happiness and meaning. In a way, pausing at this time in your cancer treatment is an opportunity to refocus on the most important things in your life. This is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do.
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