CC BY-NC-ND 4.0 · Indian J Med Paediatr Oncol 2021; 42(06): 584-594
DOI: 10.1055/s-0041-1731979
How I Treat

How I Treat Adult Acute Lymphoblastic Leukemia in India

1   Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
Smita Kayal
1   Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
› Author Affiliations
Funding No external sources of funding


Survival in pediatric acute lymphoblastic leukemia (ALL) has improved from less than 10% (in the 1960s) to over 90% in developed countries.[1] These improvements were driven by optimized, risk-stratified chemotherapy and enhanced supportive care. The incorporation of tyrosine kinase inhibitors (TKIs) in Philadelphia chromosome-positive (Ph+ve) ALL has improved survival in this subset.[2] However, older age makes significant impacts on survival in ALL. Though the survival among adolescents and younger adults (AYA, 19–40 years) has improved (5-year survival: 50–70%), gains in older adults (41–60 years) with ALL have been more modest (5-year survival: 30–40%).[3] [4] Even in the best centers in the world, till recently, survival among “elderly” ALL (>60–65 years) was poor, and only 10 to 15% were being “cured” with conventional chemotherapy.[3] [5]

Adverse disease biology partly explains the drop in survival with age.[6] Older patients have higher proportions of Ph-positivity, and “Ph-like” changes, with a lesser proportion with “good risk” cytogenetics like the t(12;21) translocation. Better outcomes are demonstrated in AYA ALL with intensive (“pediatric-type”) chemotherapy protocols.[7] [8] However, these regimens have increased toxicity and treatment-related mortality (TRM), especially in older individuals and “real-world” patients.[9] [10] [11] [12] India has the highest population of adolescent and young adults globally, and most centers see a significant proportion of patients in this age group.[13] [14] Indian centers report a high incidence of infectious complications (including multidrug resistant bacterial infections) during delivery of intense therapies for acute leukemias.[15] [16] Even if minimal residual disease (MRD) assessment is done, there is limited access to stem cell transplantation.[14] Thus, multiple factors contribute to poorer outcomes in adult ALL, and the challenges are country and center specific.

In this review, we use a series of representative case scenarios to discuss the management process in adult ALL. The discussions focus on presenting the standard of care while simultaneously highlighting issues specific to India. The broad principles of the decision-making process are outlined without too much detailing of the features of individual protocols.

Publication History

Article published online:
23 September 2021

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