Immunotherapy for acute lymphoblastic leukemia

Immunotherapy helps to strengthen or restore the immune system's ability to fight cancer. This works to kill cancer cells and stop cancer cells from growing and spreading.

Immunotherapy may be used to treat B-cell acute lymphoblastic leukemia (ALL). If you have immunotherapy, your healthcare team will use what they know about the cancer and about your health to plan the drugs, doses and schedules. Immunotherapy may be the only treatment you have or it may be used along with other treatments.

You may have immunotherapy to:

• lower the risk that ALL will come back (recur or relapse)

• treat ALL that doesn't respond to other treatments (called refractory ALL) or recurs after treatment

Different types of immunotherapy can be used for B-cell ALL.

The monoclonal antibodies used for B-cell ALL trigger the immune system to attack and destroy leukemia cells. They are also considered a type of targeted therapy because they are made in a lab to recognize and lock onto particular protein markers on the surface of the leukemia cells.

Blinatumomab (Blincyto) may be used to treat CD19-positive B-cell ALL when there continues to be a low level of minimal residual disease (MRD) in the first complete remission after induction or consolidation treatment. MRD means there are leukemia cells in the bone marrow, but they can only be seen using sensitive tests.

Blinatumomab may also be used to treat relapsed or refractory B-cell ALL. Chemotherapy for CNS prophylaxis is usually given before and during blinatumomab treatment to prevent ALL from relapsing in the brain and spinal cord (called the central nervous system, or CNS).

This drug is given as a continuous intravenous infusion (through an IV) for 28 days. You will have a 14-day break from treatment, and then you may receive more 28-day cycles of treatment.

Blinatumomab is given in a hospital or clinic for the first 9 days of the first treatment cycle, and for the first 2 days of the second cycle. Your healthcare team will watch for side effects during this time. You may need to go back to a hospital or clinic if you receive further treatment cycles or if you stop and restart treatment.

Inotuzumab ozogamicin (Besponsa) may be used to treat relapsed or refractory CD22-positive B-cell ALL. This drug is given intravenously for an hour. It is given once a week for a cycle of 3 or 4 weeks. The number of cycles you need will depend on the response to treatment.

CAR T-cell therapy takes millions of T cells from a person with cancer. In the lab, they are changed so they have chimeric antigen receptors (CARs) on their surface. These receptors recognize a specific antigen (protein) found on the type of cancer being treated. The T cells are then given back to the person where they multiply, attack and destroy the cancer cells.

Tisagenlecleucel (Kymriah) is a CAR T-cell therapy approved to treat young adults (up to and including age 25) with CD19-positive B-cell ALL that is refractory or has relapsed after stem cell transplant or other treatments. It may also be used to treat young adults with B-cell ALL who can't have a stem cell transplant.

This drug is given intravenously as a single dose in a one-time treatment. It is given at a specialized treatment centre.

Chemotherapy is given before you receive tisagenlecleucel.

Side effects of immunotherapy for ALL will depend mainly on the type of drug or drug combination, the dose, how it's given and your overall health. Tell your healthcare team if you have side effects that you think might be from immunotherapy. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Monoclonal antibodies used to treat ALL may cause these side effects:

• bacterial, fungal and viral infections in the blood or other organs, including pneumonia and sepsis

• low blood cell counts

• cytokine release syndrome (CRS), which may include rapid heartbeat and low blood pressure

• nausea and vomiting

• fever

• headache

• rash

• breathing problems

• fatigue, weakness

• constipation

Monoclonal antibodies can cause serious and life-threatening side effects. Your healthcare team can tell you more about the specific side effects of blinatumomab and inotuzumab ozogamicin.

The CAR T-cell therapy drug tisagenlecleucel can also cause serious and life-threatening reactions such as CRS. This can occur days to weeks after you receive treatment. Symptoms can include high fever, chills, muscle aches and pain, joint stiffness, nausea and vomiting, sweating, and breathing problems. If you receive tisagenlecleucel, your healthcare team will check your blood counts regularly and watch for CRS, neurological problems and other side effects.

Other side effects can include:

• infections

• abdominal pain

• constipation

• weight loss

• muscle cramps

• emotional distress or anxiety

• sleep disturbances

• symptoms of high blood sugar such as thirst, low urine output, dark urine, dry flushed skin and irritability

• swelling of the arms or legs

Some people have serious reactions to immunotherapy drugs that are given intravenously. This is called an infusion reaction and may happen when the drug is going into your vein or soon after. If this happens, your healthcare team will give you medicines to reduce your side effects or stop your treatment to manage your reaction.

Find out more about immunotherapy. To make the decisions that are right for you, ask your healthcare team questions about immunotherapy.

Details about specific drugs change regularly. Find out more about sources of drug information and where to get details on specific drugs.