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Medical Supportive Care for Treatment-Related Toxicity in Childhood ALL

  • Etan Orgel
  • Deepa BhojwaniEmail author
Chapter

Abstract

As discussed elsewhere in this textbook, increased treatment intensity over the past decades for childhood acute lymphoblastic leukemia (ALL) has improved outcomes and 90% of children with newly diagnosed with ALL are now expected to become long-term survivors [1–3]. Concurrently, the burden of intensified therapeutic regimens has become evident; treatment-related toxicity (TRT) not only leads to long-term morbidity and late effects in survivors of childhood ALL [4], but also compromises optimal delivery of otherwise curative chemotherapy [5–9]. Early efforts to reduce TRT focused on refinements in risk-stratification to better identify groups that may benefit from high morbidity treatment modalities. This approach led to significant mitigation in the use of cranial radiation and anthracyclines with reduction of late mortality [10]. However, the prevalence of TRT during therapy has nevertheless remained relatively constant. Despite an increased focus on medical supportive care, severe grade 3 or 4 toxicity is reported in ~40–75% of those treated on recent ALL consortia trials [11–13]. Non-disease related treatment related mortality (TRM) continues to be problematic on current regimens, affecting 1–3% of children treated for pediatric ALL irrespective of the specific regimen or consortia [6, 14–17]. While relapse of disease remains the number one cause of death in children with ALL, improvement in disease response has reduced the number of relapse-related deaths. As a result, the relatively constant rate for TRM over the years now constitutes an increasing proportion of mortality; approximately one in five deaths on therapy are now due to TRM rather than the disease itself [1]. The highest risk for TRM occurs within the initial Induction phase, with up to 50% of non-disease related deaths occurring within those first 28 days [6, 16]. The Induction phase of ALL chemotherapy is therefore not only critical for obtaining a remission for eventual cure [18], but also the period of greatest risk for a life-threatening event. In the following chapter, we provide an overview of the key toxicities that occur during ALL treatment with an emphasis on the current states of the science and future directions. The overall goal of this chapter is to provide insight into common supportive care issues impacting therapy and to aid the clinician in providing anticipatory supportive care and prompt recognition and intervention for serious toxicity.

Keywords

Acute Lymphoblastic Leukemia Chimeric Antigen Receptor Posterior Reversible Encephalopathy Syndrome Treatment Related Mortality Central Nervous System Toxicity 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Childrens Hospital Los AngelesLos AngelesUSA

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