Relapsed or refractory acute lymphoblastic leukaemia (ALL)

The figures we give here are averages. They cannot tell you what will happen to you. They’re based on what happened to groups of people with a similar diagnosis in the past. These people may not have had the same treatment as you.

Response to treatment for ALL is usually good.

• Around 9 in every 10 adults with ALL do respond to their first treatment.
• Around 1 in every 10 adults with ALL do not respond to their first treatment.

The figures vary more for relapse. We cannot give you an exact figure. We can only give you a range.

• Around 3 to 6 in every 10 adults with ALL do experience relapse.
• Around 4 to 7 in every 10 adults with ALL do not experience relapse.

Your haematology team may suggest treatment as part of a clinical trial, if there is one suitable for you. This is where new treatments or different ways of using existing treatments are tested to find out if they are better than standard treatments.

If there is a clinical trial suitable for you, your team should explain what it involves and the risks and benefits of it. They will give you the information you need to decide if it’s something you’d like to do. It is your choice whether to take part.

If you are fit enough to have it, your team might recommend more chemotherapy. This is often more intensive than the chemotherapy you may have had before. You usually have to stay in hospital to have it. It is sometimes called ‘salvage chemotherapy’ or ‘reinduction chemotherapy’.

Common chemotherapy options include medicines called:

• FLAG-Ida. This is a combination of four different medicines: fludarabine, cytarabine, granulocyte colony-stimulating factor (G-CSF) and idarubicin. You have fludarabine, cytarabine and idarubicin through a drip into a vein. You have G-CSF as an injection just under your skin, usually in your tummy, leg or arm.
• Hyper-CVAD. This is a combination of six different medicines: cyclophosphamide, vincristine, doxorubicin, dexamethasone, methotrexate and cytarabine. You have most of them through a drip into a vein.
• Etoposide. You usually have this in combination with other chemotherapy medicines. You have it through a drip into a vein.
• Cyclophosphamide. You usually have this in combination with other chemotherapy medicines. You have it through a drip into a vein.
• Cytarabine. You usually have this in combination with other chemotherapy medicines. You have it as an injection just under your skin.
• Nelarabine. You might have this if you have T-cell ALL. You have it through a drip into a vein. You might have it on its own or alongside other chemotherapy medicines.

You may also have steroids with your chemotherapy.

Your team might suggest a different combination of medicines. They will let you know exactly what you will have and what to expect.

If intensive chemotherapy is not suitable for you, your team might recommend non-intensive chemotherapy. This aims to lower your leukaemia cell counts rather than get rid of the leukaemia completely. It is sometimes called cytoreductive chemotherapy.

Common chemotherapy options include medicines called:

• Hydroxycarbamide. It comes as capsules that you take by mouth.
• Etoposide. It comes as capsules that you take by mouth.
• Vincristine. You have this as an injection or through a drip into a vein. You usually have it once a week at hospital on a day unit. You can usually go home afterwards.

You may also have steroids with your chemotherapy.

Your team will let you know exactly what medicines you may have, how often, and what to expect.

Depending on the genetic changes and proteins in your leukaemia cells, you might have targeted medicines as part of your treatment. You might have more than one targeted treatment, depending on your exact type of ALL.

• If you have Philadelphia-chromosome positive ALL, you might have a targeted medicine called a TKI. Examples include dasatinib and ponatinib. These are tablets or capsules that you take by mouth. If you have already had a TKI as part of your earlier treatment, you will probably swap to a different one.
• If your ALL cells make a protein called CD22, you might have a targeted medicine called inotuzumab ozogamicin. This is an antibody treatment joined to a chemotherapy drug. The antibody part sticks to the CD22 protein on leukaemia cells. The chemotherapy part then kills the cells. You have it through a drip into a vein.
• If your ALL cells make a protein called CD19, you might have an antibody therapy called blinatumomab. It sticks to the CD19 protein on leukaemia cells and to a protein on healthy T cells. This helps the T cells find and kill the leukaemia cells. You have it through a drip into a vein.
• If you have B-cell ALL, you might have an antibody therapy called rituximab. It sticks to the CD20 protein on leukaemia cells. This helps your own immune system recognise it and kill it. You have rituximab through a drip into a vein.

A stem cell transplant may be an option for you if other treatments get you back into remission. It involves having high-dose chemotherapy and sometimes radiotherapy. This kills the blood-forming cells in your bone marrow, called stem cells. These are then replaced by healthy stem cells from a donor.

A stem cell transplant is very intensive. You’ll have tests to check it’s suitable for you and that you’re fit enough to have one.

Your medical team will let you know if it is an option for you. They will discuss it with you and give you a chance to ask questions.

You usually stay in hospital for several weeks to have it, and it can take many months to recover.

CAR T-cell therapy is an intensive type of treatment. It involves modifying your own blood cells so they can recognise and kill cancer cells. You have it at specialist centres that have the facilities and staff to do it safely. This might not be your usual hospital.

If CAR T-cell therapy might be an option for you, your team will explain the benefits and risks.

Most people stay in hospital for a few weeks to have CAR T-cell therapy. You need to stay close to the hospital for around a month after treatment, in case you have any complications.

Our CAR T away from home service can help with costs or accommodation if you need it.

If you have ALL in your brain or spinal fluid, you will have treatment for this. Your treatment may include:

• Radiotherapy. You usually have treatment from a radiotherapy machine. It looks similar to an X-ray or CT machine. You may have treatment on a day unit and go home afterwards, or you may stay in hospital.
• Intrathecal medicine. This is medicine you have through an injection into your lower back (a lumbar puncture). You usually have a chemotherapy medicine, sometimes with a steroid.

You might also need medicine to prevent or manage symptoms or side effects. This is called supportive care. It does not treat your ALL itself, but it helps you feel better. It aims to reduce your symptoms, extend your survival, and give you and your loved ones the best quality of life possible.

You might have supportive care on its own, or you might have it alongside treatment to control your ALL. Supportive care might include:

• Blood transfusions.
• Growth factor injections to boost your blood counts.
• Anti-sickness or anti-diarrhoeal medicines.
• Pain relief, if you need it.
• Medicine to prevent or treat infections.
• Medicines to protect your bladder, kidneys and gut.
• Mouthwashes to help with mouth ulcers, infections or a sore mouth.
• Food or drink supplements, if you are not able to eat or drink enough.
• Steroids, which help with many different symptoms and side effects. They are usually tablets you take by mouth.

Supportive care is not only limited to the physical impact of ALL. It can include:

• Emotional, psychological and social support
• Complementary therapies
• Physiotherapy
• Spiritual wellbeing and mindfulness
• Financial support and practical advice
• Tips to help you cope with side effects and late effects

We’re here if you need support. Call our freephone helpline on 08088 010 444, message us on WhatsApp at 07500 068 065 or email us at support@leukaemiacare.org.uk.

If your ALL does not respond to treatment, or comes back after treatment, your medical team will talk to you about your options. They may suggest trying a different treatment. But if there are no suitable treatment options left, they might suggest end of life care.

End of life care means you do not have any more treatment that aims to control or cure your ALL. But you still have treatment to relieve your symptoms and improve your quality of life. End of life care begins when you need it, and may last a few days, months or years.

End of life care helps you live as well as possible until you die. The aim is to help you have a good quality of life and die with dignity.

We’re here if you need support with end of life care. Call our freephone helpline on 08088 010 444, message us on WhatsApp at 07500 068 065 or email us at support@leukaemiacare.org.uk.

The following charities also provide support and information for people dealing with end of life care:

• Compassion in Dying
• Hospice UK
• Marie Curie

A study for older adults with acute lymphoblastic leukaemia (UKALL60+). Clinicaltrials.gov. NCT number NCT01616238. Updated 16/08/2023. Available at https://clinicaltrials.gov/study/NCT01616238 [Accessed May 2026]

Gökbuget N, Boissel N, Chiaretti S, Dombret H, Doubek M, Fielding A, Foà R, Giebel S, Hoelzer D, Hunault M, Marks DI. Diagnosis, prognostic factors, and assessment of ALL in adults: 2024 ELN recommendations from a European expert panel. Blood. 2024 May 9;143(19):1891-902. https://doi.org/10.1182/blood.2023020794

Gökbuget N, Boissel N, Chiaretti S, Dombret H, Doubek M, Fielding A, Foà R, Giebel S, Hoelzer D, Hunault M, Marks DI. Management of ALL in adults: 2024 ELN recommendations from a European expert panel. Blood. 2024 May 9;143(19):1903-30. https://doi.org/10.1182/blood.2023023568

Hoelzer D, Bassan R, Boissel N, Roddie C, Ribera JM, Jerkeman M, ESMO Guidelines Committee. ESMO Clinical Practice Guideline interim update on the use of targeted therapy in acute lymphoblastic leukaemia. Annals of Oncology. 2024 Jan 1;35(1):15-28. https://doi.org/10.1016/j.annonc.2023.09.3112

Rangel LC, Martínez MA, Solís-Huerta F, Ontiveros-Austria JL, Rodriguez-Rodriguez S, Demichelis R. Central nervous system relapse in adults with acute lymphoblastic leukemia: identifying key risk factors and survival outcomes. Blood. 2024 Nov 5;144:2807. https://doi.org/10.1182/blood-2024-208699

RM Partners West London Cancer Alliance, South East London Cancer Alliance, North Central and East London Cancer Alliance. Pan-London Haemato-Oncology Clinical Guidelines Acute leukaemias and myeloid neoplasms – part 1: acute lymphoblastic leukaemia [Internet]. 2020 Jan. Available from: https://rmpartners.nhs.uk/wp-content/uploads/2020/01/Pan-London-ALL-Guidelines-Jan-2020.pdf [Accessed May 2026].

Standard chemotherapy with or without nelarabine or rituximab in treating patients with newly diagnosed acute lymphoblastic leukaemia (UKALL14). Clinicaltrials.gov. NCT number NCT01085617. Updated 30/03/2025. Available at https://clinicaltrials.gov/study/NCT01085617 [Accessed May 2026]

Thames Valley Strategic Clinical Network NHS. Protocol: ALL maintenance (25-60 years) [Internet]. 2019. Available from https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-50-all-maintenance.pdf [Accessed May 2026]