RT With or Without Cetuximab in Treating Patients Who Have Undergone Surgery for Locally Advanced Head and Neck Cancer
- Conditions
- Head and Neck Cancer
- Interventions
- Biological: cetuximabRadiation: intensity-modulated radiation therapy
- Registration Number
- NCT00956007
- Lead Sponsor
- Radiation Therapy Oncology Group
- Brief Summary
RATIONALE: Giving radiation therapy that uses a 3-dimensional (3-D) image of the tumor to help focus thin beams of radiation directly on the tumor, and giving radiation therapy in higher doses over a shorter period of time, may kill more tumor cells and have fewer side effects. Monoclonal antibodies, such as cetuximab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. It is not yet known whether radiation therapy is more effective when given alone or together with cetuximab in treating patients with head and neck cancer that has been removed by surgery.
PURPOSE: This randomized phase III trial is studying radiation therapy to see how well it works compared with radiation therapy given together with cetuximab in treating patients who have undergone surgery for locally advanced head and neck cancer.
- Detailed Description
OBJECTIVES:
Primary
* Determine whether the addition of cetuximab to postoperative intensity-modulated radiotherapy (IMRT) will improve overall survival (OS) in patients with locally advanced squamous cell carcinoma of the head and neck at intermediate risk following surgery.
Secondary
* Assess the impact of the addition of cetuximab to postoperative IMRT on disease-free survival (DFS) of these patients.
* Assess the impact of the addition of cetuximab to postoperative IMRT on acute and late dysphagia, xerostomia, skin toxicity, and other toxicities according to common Toxicity Criteria for Adverse Effects (CTCAE), v. 4 and their relationships with patient-reported outcomes at 3, 12, and 24 months.
* Analyze tumor for epidermal growth factor receptor (EGFR), specifically the extent of EGFR overexpression by immuno-histochemistry (IHC) and Fluorescence in situ hybridization (FISH) analysis, EGFRvIII expression, as well as the association of these assay data with OS and DFS.
* Analyze tumor for human papillomavirus (HPV) infection (as defined by in situ hybridization), specifically, within the cohort of patients with oropharynx cancer, to perform an exploratory analysis of the impact of HPV on DFS and OS of this patient subset.
* Analyze tumor DNA for TP53 mutations as a predictor of response to cetuximab and prognosis.
* Analyze germline DNA of polymorphic variants in EGFR intron repeats as a predictor of response to cetuximab.
Tertiary
* Assess the impact of the addition of cetuximab to postoperative IMRT on loco-regional control.
* Assess the impact of the addition of cetuximab to postoperative IMRT on patient-reported quality of life, swallowing, xerostomia, and skin toxicity based on head and neck specific instruments, including the Performance Status Scale for Head and Neck Cancer (PSS-HN), the Functional Assessment of Cancer Therapy-Head \& Neck (FACT-H\&N), the University of Michigan Xerostomia-Related Quality of Life Scale (XeQOLS), and the Dermatology Life Quality Index (DLQI).
* Assess the impact of the addition of cetuximab to postoperative IMRT on cost-utility analysis using the EuroQol (EQ-5D).
* Evaluate the utility of image-guided radiotherapy (IGRT) as a means of enhancing the efficacy (i.e., loco-regional control) of IMRT while reducing the acute and/or late toxicity (particularly xerostomia) and improving patient-reported outcomes (particularly XeQOLS scores).
* Retrospectively compare the loco-regional control rate in patients treated with IMRT alone (no IGRT or cetuximab) with similar patients treated with external beam radiotherapy alone in the postoperative clinical trial Radiation Therapy Oncology Group (RTOG)-95 01.
OUTLINE: This is a multicenter study. Patients are stratified according to clinical stage (T1-3 vs T4a), EGFR expression (high \[≥ 80% of cells staining positive\] vs low \[\< 80% of cells staining positive\] vs not evaluable), primary site of disease (oral cavity vs larynx vs oropharynx p16+ vs oropharynx p16- vs oropharynx, p16 not evaluable), and use of image-guided radiotherapy (yes vs no). Patients are randomized to 1 of 2 treatment arms.
* Arm I: Patients undergo intensity-modulated radiotherapy (IMRT) once daily 5 days a week for 6 weeks in the absence of disease progression or unacceptable toxicity.
* Arm II: Patients undergo IMRT as in arm I. Patients also receive cetuximab IV over 1-2 hours once weekly beginning at least 5 days prior to the start of IMRT and continuing for 4 weeks after the completion of IMRT (for a total of 11 doses) in the absence of disease progression or unacceptable toxicity.
Quality of life is assessed at baseline and at 3, 12, and 24 months.
Tissue samples are collected periodically for further laboratory analysis.
After completion of study treatment, patients are followed up at 1 and 3 months, every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 702
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm II: IMRT plus cetuximab cetuximab Radiation therapy (RT): 60 Gy IMRT, 2 Gy/day in 30 fractions (5 days a week for 6 weeks). Cetuximab: 400 mg/m\^2 intravenously (IV) at least 5 days prior to IMRT; 250 mg/m\^2 IV once a week for 6 weeks during RT and continuing 4 weeks after RT. Arm I: Intensity-Modulated Radiotherapy intensity-modulated radiation therapy Radiation therapy: 60 Gy intensity-modulated radiotherapy (IMRT), 2 Gy/day in 30 fractions (5 days a week for 6 weeks). Arm II: IMRT plus cetuximab intensity-modulated radiation therapy Radiation therapy (RT): 60 Gy IMRT, 2 Gy/day in 30 fractions (5 days a week for 6 weeks). Cetuximab: 400 mg/m\^2 intravenously (IV) at least 5 days prior to IMRT; 250 mg/m\^2 IV once a week for 6 weeks during RT and continuing 4 weeks after RT.
- Primary Outcome Measures
Name Time Method Percentage of Participants Alive (Overall Survival) From randomization to date of death or last follow-up. Maximum follow-up at time of analysis was 12.1 years. Overall survival time is defined as time from registration/randomization to the date of death from any cause or last known follow-up (censored). Overall survival rates are estimated by the Kaplan-Meier method. Analysis occurred after all participants had potentially been on study for at least 5 years. The distributions of survival times are compared, which is reported in the statistical analysis results. Five-year rates are provided.
- Secondary Outcome Measures
Name Time Method Percentage of Participants With Other ≥ Grade 3 Adverse Events Related to Protocol Treatment From start of radiation therapy to 90 days. Adverse events other than dysphagia, dermatitis radiation, and rash acneiform. Common Terminology Criteria for Adverse Events (version 4.0) grades adverse event severity from 1=mild to 5=death. Adverse events (AEs) assessed to be definitely, probably, or possibly related to protocol treatment were included. If relationship was missing, it was assumed to be definitely, probably, or possibly related to protocol treatment. Acute adverse events are those occurring within 90 days of the start of radiation therapy.
Percentage of Participants With Other ≥ Grade 3 Late Adverse Events Related to Protocol Treatment From 91 days after start of radiation therapy to date of last reported follow-up. Maximum follow-up at time of analysis was 12.1 years. Adverse events other than dysphagia, dermatitis radiation, and rash acneiform. Common Terminology Criteria for Adverse Events (version 4.0) grades adverse event severity from 1=mild to 5=death. Adverse events (AEs) assessed to be definitely, probably, or possibly related to protocol treatment were included. If relationship was missing, it was assumed to be definitely, probably, or possibly related to protocol treatment. Late adverse events are those occurring after days from the start of radiation therapy.
Percentage of Participants With ≥ Grade 3 Acute Dysphagia, Dry Mouth, or Skin Toxicity Related to Protocol Treatment From start of radiation therapy to 90 days Common Terminology Criteria for Adverse Events (version 4.0) grades adverse event severity from 1=mild to 5=death. Adverse events (AEs) assessed to be definitely, probably, or possibly related to protocol treatment were included. If relationship was missing, it was assumed to be definitely, probably, or possibly related to protocol treatment. Acute adverse events are those occurring within 90 days of the start of radiation therapy.
Disease-free Survival From randomization to date of LRR, DM, death or last known follow-up, whichever occurred first. Maximum follow-up at time of analysis was 12.1 years. Disease is defined as local-regional progression/recurrence (LRR) or distant metastasis (DM). LRR is defined as recurrent cancer in the tumor bed and/or neck not clearly attributable to a second primary neoplasm; both imaging and biopsy confirmation are strongly recommended. DM is defined as clear evidence of distant metastases; biopsy is recommended where possible. Disease-free survival time is defined as time from randomization to the date of first disease, death, or last known follow-up (censored), whichever occurred first. Disease-free survival rates are estimated using the Kaplan-Meier method. Analysis occurred after all participants had potentially been on study for at least 5 years. The distributions of disease-free survival times are compared, which is reported in the statistical analysis results. Five-year rates are provided.
Percentage of Participants With ≥ Grade 3 Late Dysphagia, Dry Mouth, or Skin Toxicity Related to Protocol Treatment From 91 days after start of radiation therapy to date of last reported follow-up. Maximum follow-up at time of analysis was 12.1 years. Common Terminology Criteria for Adverse Events (version 4.0) grades adverse event severity from 1=mild to 5=death. Adverse events assessed to be definitely, probably, or possibly related to protocol treatment were included. If relationship was missing, it was assumed to be definitely, probably, or possibly related to protocol treatment. Late adverse events are those occurring after days from the start of radiation therapy.
Trial Locations
- Locations (263)
John H Stroger Jr Hospital of Cook County
🇺🇸Chicago, Illinois, United States
Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
University of Southern California/Norris Cancer Center
🇺🇸Los Angeles, California, United States
Los Angeles County-USC Medical Center
🇺🇸Los Angeles, California, United States
Albert Einstein Medical Center
🇺🇸Philadelphia, Pennsylvania, United States
Texas Oncology Cancer Center Sugar Land
🇺🇸Sugar Land, Texas, United States
Texas Oncology - Round Rock Cancer Center
🇺🇸Round Rock, Texas, United States
Sentara Virginia Beach General Hospital
🇺🇸Virginia Beach, Virginia, United States
Memorial Health University Medical Center
🇺🇸Savannah, Georgia, United States
Tufts Medical Center
🇺🇸Boston, Massachusetts, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Foundation
🇺🇸Cleveland, Ohio, United States
Cancer Care Northwest - Spokane South
🇺🇸Spokane, Washington, United States
Health Sciences North
🇨🇦Sudbury, Ontario, Canada
M D Anderson Cancer Center
🇺🇸Houston, Texas, United States
Baptist Hospital of Miami
🇺🇸Miami, Florida, United States
IU Health Methodist Hospital
🇺🇸Indianapolis, Indiana, United States
Community Regional Cancer Care-East Radiation Oncology
🇺🇸Indianapolis, Indiana, United States
Community Regional Cancer Care-North
🇺🇸Indianapolis, Indiana, United States
University of Texas Health Science Center at San Antonio
🇺🇸San Antonio, Texas, United States
UC San Diego Moores Cancer Center
🇺🇸La Jolla, California, United States
Radiation Oncology Associates PC
🇺🇸Fort Wayne, Indiana, United States
IU Health Ball Memorial Hospital
🇺🇸Muncie, Indiana, United States
University of Pennsylvania/Abramson Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Pocono Medical Center
🇺🇸East Stroudsburg, Pennsylvania, United States
Maimonides Medical Center
🇺🇸Brooklyn, New York, United States
UCSF-Mount Zion
🇺🇸San Francisco, California, United States
Vanderbilt-Ingram Cancer Center
🇺🇸Nashville, Tennessee, United States
Huntsman Cancer Institute/University of Utah
🇺🇸Salt Lake City, Utah, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Saint Luke's Hospital of Duluth
🇺🇸Duluth, Minnesota, United States
Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
CancerCare Manitoba
🇨🇦Winnipeg, Manitoba, Canada
University of Mississippi Medical Center
🇺🇸Jackson, Mississippi, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
Central Maine Medical Center
🇺🇸Lewiston, Maine, United States
Peninsula Regional Medical Center
🇺🇸Salisbury, Maryland, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
Greenville Health System Cancer Institute/Greenville CCOP
🇺🇸Greenville, South Carolina, United States
Mary Bird Perkins Cancer Center
🇺🇸Baton Rouge, Louisiana, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Boston Medical Center
🇺🇸Boston, Massachusetts, United States
Mayo Clinic in Florida
🇺🇸Jacksonville, Florida, United States
Lahey Hospital and Medical Center
🇺🇸Burlington, Massachusetts, United States
Dartmouth Hitchcock Medical Center
🇺🇸Lebanon, New Hampshire, United States
Saint Peter's University Hospital
🇺🇸New Brunswick, New Jersey, United States
Arizona Oncology Associates-West Orange Grove
🇺🇸Tucson, Arizona, United States
Saint John Macomb-Oakland Hospital
🇺🇸Warren, Michigan, United States
University of Miami Sylvester Comprehensive Cancer Center at Deerfield Beach
🇺🇸Deerfield Beach, Florida, United States
William Backus Hospital
🇺🇸Norwich, Connecticut, United States
Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
Oakwood Hospital
🇺🇸Dearborn, Michigan, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
Saint Vincent's Medical Center
🇺🇸Bridgeport, Connecticut, United States
Sparta Cancer Treatment Center
🇺🇸Sparta, New Jersey, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸Miami, Florida, United States
University of Cincinnati
🇺🇸Cincinnati, Ohio, United States
Exeter Hospital
🇺🇸Exeter, New Hampshire, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸Baltimore, Maryland, United States
AnMed Health Cancer Center
🇺🇸Anderson, South Carolina, United States
Saint Alphonsus Regional Medical Center
🇺🇸Boise, Idaho, United States
Wheeling Hospital
🇺🇸Wheeling, West Virginia, United States
University Health Network-Princess Margaret Hospital
🇨🇦Toronto, Ontario, Canada
Allan Blair Cancer Centre
🇨🇦Regina, Saskatchewan, Canada
Sanford Cancer Center-Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Rapid City Regional Hospital
🇺🇸Rapid City, South Dakota, United States
Intermountain Medical Center
🇺🇸Murray, Utah, United States
Fox Chase Cancer Center at Virtua Memorial Hospital of Burlington County
🇺🇸Mount Holly, New Jersey, United States
UMDNJ - New Jersey Medical School
🇺🇸Newark, New Jersey, United States
Memorial Sloan-Kettering Cancer Center
🇺🇸New York, New York, United States
MD Anderson Cancer Center at Cooper-Voorhees
🇺🇸Voorhees, New Jersey, United States
McGill University Department of Oncology
🇨🇦Montreal, Quebec, Canada
LDS Hospital
🇺🇸Salt Lake City, Utah, United States
Greenville Health System Cancer Institute-Spartanburg
🇺🇸Spartanburg, South Carolina, United States
Centre Hospitalier Universitaire de Sherbrooke-Fleurimont
🇨🇦Sherbrooke, Quebec, Canada
Gibbs Cancer Center-Pelham
🇺🇸Greer, South Carolina, United States
Gundersen Lutheran
🇺🇸La Crosse, Wisconsin, United States
Dixie Medical Center Regional Cancer Center
🇺🇸Saint George, Utah, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Salem Hospital
🇺🇸Salem, Oregon, United States
Fox Chase Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Wellmont Holston Valley Hospital and Medical Center
🇺🇸Kingsport, Tennessee, United States
Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
Utah Cancer Specialists-Salt Lake City
🇺🇸Salt Lake City, Utah, United States
CHUQ - Pavilion Hotel-Dieu de Quebec
🇨🇦Quebec City, Quebec, Canada
King Faisal Specialist Hospital and Research Centre
🇸🇦Riyadh, Saudi Arabia
London Regional Cancer Program
🇨🇦London, Ontario, Canada
Ottawa Health Research Institute-General Division
🇨🇦Ottawa, Ontario, Canada
University of Alabama at Birmingham
🇺🇸Birmingham, Alabama, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Saint John Hospital and Medical Center
🇺🇸Detroit, Michigan, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Western Oncology Research Consortium
🇺🇸Portland, Oregon, United States
Oregon Health and Science University
🇺🇸Portland, Oregon, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Nebraska Methodist Hospital
🇺🇸Omaha, Nebraska, United States
The Nebraska Medical Center
🇺🇸Omaha, Nebraska, United States
Froedtert and the Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Clement J. Zablocki VA Medical Center
🇺🇸Milwaukee, Wisconsin, United States
University of Colorado Cancer Center - Anschutz Cancer Pavilion
🇺🇸Aurora, Colorado, United States
Saint Joseph Mercy Hospital
🇺🇸Ann Arbor, Michigan, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Sutter General Hospital
🇺🇸Sacramento, California, United States
University of California at Davis Cancer Center
🇺🇸Sacramento, California, United States
Rocky Mountain Cancer Centers-Aurora
🇺🇸Aurora, Colorado, United States
Mercy General Hospital Radiation Oncology Center
🇺🇸Sacramento, California, United States
University of Michigan
🇺🇸Ann Arbor, Michigan, United States
Florida Hospital
🇺🇸Orlando, Florida, United States
UF Cancer Center at Orlando Health
🇺🇸Orlando, Florida, United States
The James Graham Brown Cancer Center at University of Louisville
🇺🇸Louisville, Kentucky, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
🇺🇸Auburn, California, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
🇺🇸Cameron Park, California, United States
City of Hope
🇺🇸Duarte, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸Los Angeles, California, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Bay Area Tumor Institute CCOP
🇺🇸Oakland, California, United States
Pomona Valley Hospital Medical Center
🇺🇸Pomona, California, United States
The Permanente Medical Group-Roseville Radiation Oncology
🇺🇸Roseville, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
🇺🇸Roseville, California, United States
Saint Helena Hospital
🇺🇸Saint Helena, California, United States
Kaiser Permanente Medical Center - Santa Clara
🇺🇸Santa Clara, California, United States
Sutter Cancer Centers Radiation Oncology Services-Vacaville
🇺🇸Vacaville, California, United States
Stanford University Hospitals and Clinics
🇺🇸Stanford, California, United States
Rocky Mountain Cancer Centers-Littleton
🇺🇸Littleton, Colorado, United States
Emory University/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Saint Joseph's-Candler Health System
🇺🇸Savannah, Georgia, United States
Northeast Georgia Medical Center
🇺🇸Gainesville, Georgia, United States
University of Illinois
🇺🇸Chicago, Illinois, United States
Ingalls Memorial Hospital
🇺🇸Harvey, Illinois, United States
Hines Veterans Administration Hospital
🇺🇸Hines, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Saint John's Hospital
🇺🇸Springfield, Illinois, United States
Parkview Hospital Randallia
🇺🇸Fort Wayne, Indiana, United States
McFarland Clinic PC-William R Bliss Cancer Center
🇺🇸Ames, Iowa, United States
University of Iowa Hospitals and Clinics
🇺🇸Iowa City, Iowa, United States
Saint Mary's of Michigan
🇺🇸Saginaw, Michigan, United States
Cape Radiation Oncology
🇺🇸Cape Girardeau, Missouri, United States
University of Missouri - Ellis Fischel
🇺🇸Columbia, Missouri, United States
Singing River Hospital
🇺🇸Pascagoula, Mississippi, United States
Saint Louis University Hospital
🇺🇸Saint Louis, Missouri, United States
Siteman Cancer Center-South County
🇺🇸Saint Louis, Missouri, United States
Kansas City Cancer Center-Lee's Summit
🇺🇸Lee's Summit, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Siteman Cancer Center - Saint Peters
🇺🇸Saint Peters, Missouri, United States
Saint John's Mercy Medical Center
🇺🇸Saint Louis, Missouri, United States
Barnes-Jewish West County Hospital
🇺🇸Saint Louis, Missouri, United States
Saint Elizabeth Regional Medical Center
🇺🇸Lincoln, Nebraska, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Memorial Sloan Kettering Cancer Center at Basking Ridge
🇺🇸Basking Ridge, New Jersey, United States
Cooper Hospital University Medical Center
🇺🇸Camden, New Jersey, United States
New York Oncology Hematology PC - Albany
🇺🇸Albany, New York, United States
Memorial Sloan Kettering Cancer Center Commack
🇺🇸Commack, New York, United States
Beth Israel Medical Center
🇺🇸New York, New York, United States
Memorial Sloan-Kettering Cancer Center at Sleepy Hallow
🇺🇸Sleepy Hollow, New York, United States
Memorial Sloan-Kettering Cancer Center Rockville Centre
🇺🇸Rockville Centre, New York, United States
Mission Hospital-Memorial Campus
🇺🇸Asheville, North Carolina, United States
Wayne Radiation Oncology
🇺🇸Goldsboro, North Carolina, United States
Kinston Medical Specialists PA
🇺🇸Kinston, North Carolina, United States
Summa Akron City Hospital/Cooper Cancer Center
🇺🇸Akron, Ohio, United States
Akron General Medical Center
🇺🇸Akron, Ohio, United States
Summa Barberton Hospital
🇺🇸Barberton, Ohio, United States
Mercy Medical Center
🇺🇸Canton, Ohio, United States
Geaugra Hospital
🇺🇸Chardon, Ohio, United States
Ohio State University Medical Center
🇺🇸Columbus, Ohio, United States
Cleveland Clinic Cancer Center Independence
🇺🇸Independence, Ohio, United States
Mercy Cancer Center-Elyria
🇺🇸Elyria, Ohio, United States
Lake University Ireland Cancer Center
🇺🇸Mentor, Ohio, United States
Hillcrest Hospital Cancer Center
🇺🇸Mayfield Heights, Ohio, United States
Southwest General Health Center Ireland Cancer Center
🇺🇸Middleburg Heights, Ohio, United States
Summa Health Center at Lake Medina
🇺🇸Medina, Ohio, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸Orange Village, Ohio, United States
Cleveland Clinic Cancer Center-Strongsville
🇺🇸Strongsville, Ohio, United States
North Coast Cancer Care
🇺🇸Sandusky, Ohio, United States
Saint Charles Hospital
🇺🇸Oregon, Ohio, United States
Robinson Radiation Oncology
🇺🇸Ravenna, Ohio, United States
Flower Hospital
🇺🇸Sylvania, Ohio, United States
University Pointe
🇺🇸West Chester, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸Westlake, Ohio, United States
Cleveland Clinic Wooster Specialty Center
🇺🇸Wooster, Ohio, United States
Willamette Valley Cancer Center
🇺🇸Eugene, Oregon, United States
Adams Cancer Center
🇺🇸Gettysburg, Pennsylvania, United States
Portland Veterans Administration Medical Center
🇺🇸Portland, Oregon, United States
Cherry Tree Cancer Center
🇺🇸Hanover, Pennsylvania, United States
Northeast Radiation Oncology Center
🇺🇸Dunmore, Pennsylvania, United States
Thomas Jefferson University Hospital
🇺🇸Philadelphia, Pennsylvania, United States
Saint Mary Medical and Regional Cancer Center
🇺🇸Langhorne, Pennsylvania, United States
Reading Hospital
🇺🇸West Reading, Pennsylvania, United States
WellSpan Health-York Hospital
🇺🇸York, Pennsylvania, United States
Greenville Health System Cancer Institute-Faris
🇺🇸Greenville, South Carolina, United States
University of Texas Southwestern Medical Center
🇺🇸Dallas, Texas, United States
Texas Oncology PA - Bedford
🇺🇸Bedford, Texas, United States
Texas Oncology-Denton South
🇺🇸Denton, Texas, United States
Memorial Hermann Memorial City Medical Center
🇺🇸Houston, Texas, United States
Ben Taub General Hospital
🇺🇸Houston, Texas, United States
Texas Oncology-Seton Williamson
🇺🇸Round Rock, Texas, United States
Texas Oncology-Wichita Falls Texoma Cancer Center
🇺🇸Wichita Falls, Texas, United States
Texas Cancer Center-Sherman
🇺🇸Sherman, Texas, United States
Cancer Care Centers of South Texas- Northeast
🇺🇸San Antonio, Texas, United States
University of Virginia
🇺🇸Charlottesville, Virginia, United States
Sentara Hospitals
🇺🇸Norfolk, Virginia, United States
Sentara Cancer Institute at Sentara CarePlex Hospital
🇺🇸Hampton, Virginia, United States
Harrison Medical Center
🇺🇸Bremerton, Washington, United States
Tri-Cities Cancer Center
🇺🇸Kennewick, Washington, United States
Skagit Valley Hospital
🇺🇸Mount Vernon, Washington, United States
University of Washington Medical Center
🇺🇸Seattle, Washington, United States
Cancer Care Northwest-North Spokane
🇺🇸Spokane, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Northwest CCOP
🇺🇸Tacoma, Washington, United States
Compass Oncology Vancouver
🇺🇸Vancouver, Washington, United States
Wenatchee Valley Medical Center
🇺🇸Wenatchee, Washington, United States
West Virginia University Healthcare
🇺🇸Morgantown, West Virginia, United States
Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Fox Valley Hematology and Oncology
🇺🇸Appleton, Wisconsin, United States
Langlade Hospital and Cancer Center
🇺🇸Antigo, Wisconsin, United States
Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Aspirus Regional Cancer Center
🇺🇸Wausau, Wisconsin, United States
Cross Cancer Institute
🇨🇦Edmonton, Alberta, Canada
Doctor H. Bliss Murphy Cancer Centre
🇨🇦St. John's, Newfoundland and Labrador, Canada
Chinese University of Hong Kong-Prince of Wales Hospital
🇨🇳Shatin, Hong Kong, China
CHUM - Hopital Notre-Dame
🇨🇦Montreal, Quebec, Canada
Kansas City Cancer Centers - North
🇺🇸Kansas City, Missouri, United States
University of North Carolina
🇺🇸Chapel Hill, North Carolina, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
The Klabzuba Cancer Center
🇺🇸Fort Worth, Texas, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
NorthShore University HealthSystem-Evanston Hospital
🇺🇸Evanston, Illinois, United States
Siouxland Hematology Oncology Associates
🇺🇸Sioux City, Iowa, United States
Sands Cancer Center
🇺🇸Canandaigua, New York, United States
Lehigh Valley Hospital
🇺🇸Allentown, Pennsylvania, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
Atlanta VA Medical Center
🇺🇸Decatur, Georgia, United States
Cancer Centers of North Carolina
🇺🇸Raleigh, North Carolina, United States
Yale University
🇺🇸New Haven, Connecticut, United States
The Cancer Center of Hawaii-Liliha
🇺🇸Honolulu, Hawaii, United States
Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
Tulane University Health Sciences Center
🇺🇸New Orleans, Louisiana, United States
Touro Infirmary
🇺🇸New Orleans, Louisiana, United States
Texas Oncology-Austin Midtown
🇺🇸Austin, Texas, United States
Texas Oncology - Central Austin Cancer Center
🇺🇸Austin, Texas, United States
Texas Oncology - South Austin Cancer Center
🇺🇸Austin, Texas, United States
Hunter Holmes McGuire Veterans Administration Medical Center
🇺🇸Richmond, Virginia, United States
Virginia Commonwealth University
🇺🇸Richmond, Virginia, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
University of Hawaii
🇺🇸Honolulu, Hawaii, United States
University of Kentucky
🇺🇸Lexington, Kentucky, United States
University of Wisconsin Hospital and Clinics
🇺🇸Madison, Wisconsin, United States
University Radiation Oncology
🇺🇸Rochester, New York, United States
University of Rochester
🇺🇸Rochester, New York, United States
University of New Mexico
🇺🇸Albuquerque, New Mexico, United States
Highland Hospital
🇺🇸Rochester, New York, United States
Door County Cancer Center
🇺🇸Sturgeon Bay, Wisconsin, United States
University of Kansas Medical Center
🇺🇸Kansas City, Kansas, United States