High-Dose or Standard-Dose Radiation Therapy and Chemotherapy With or Without Cetuximab in Treating Patients With Newly Diagnosed Stage III Non-Small Cell Lung Cancer That Cannot Be Removed by Surgery
- Conditions
- Lung CancerRadiation Toxicity
- Interventions
- Registration Number
- NCT00533949
- Lead Sponsor
- Radiation Therapy Oncology Group
- Brief Summary
RATIONALE: Radiation therapy uses high-energy x-rays to kill tumor cells. Drugs used in chemotherapy, such as paclitaxel, carboplatin work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. 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 high-dose radiation therapy is more effective than standard-dose radiation therapy when given together with combination chemotherapy with or without cetuximab in treating patients with non-small cell lung cancer.
PURPOSE: This randomized phase III trial is studying high-dose or standard-dose radiation therapy given together with chemotherapy with or without cetuximab to see how well they work in treating patients with newly diagnosed stage III non-small cell lung cancer that cannot be removed by surgery.
- Detailed Description
OBJECTIVES:
Primary
* To compare the overall survival of patients with newly diagnosed, unresectable stage IIIA or IIIB non-small cell lung cancer treated with high- versus standard-dose conformal radiotherapy with concurrent and consolidation chemotherapy comprising carboplatin and paclitaxel.
* To compare the overall survival of patients treated with versus without cetuximab in the setting of concurrent chemotherapy
Secondary
* To compare progression-free survival and local-regional tumor control in patients treated with these regimens.
* To compare the toxicity of high- versus standard-dose conformal radiotherapy and concurrent chemotherapy with versus without cetuximab in these patients.
* To investigate the prognostic and predictive effects of gross tumor volume on overall survival of patients treated with these regimens.
* To compare the quality of life of patients treated with these regimens.
* To correlate outcomes (i.e., survival, toxicity, or QOL) in these patients with biological parameters.
* To analyze the predictive value of pre-treatment standardized uptake value (SUV) of positron emission tomography (PET) scan in predicting survival, distant metastasis, and local-regional control in patients treated with these regimens.
* To explore biological markers to predict clinical outcome including survival, distant metastasis, local-regional control, and QOL (including toxicity) in patients treated with these regimens.
* To prospectively collect and bank tissue, blood, and urine specimens for future biomarker analyses in predicting clinical outcome in patients treated with these regimens.
* To investigate associations between epidermal growth factor receptor (EGFR) expression and toxicity, response, overall survival, and progression-free survival.
OUTLINE: This is a multicenter study. Patients are stratified according to PET staging (yes vs no), radiotherapy technique (3-dimensional conformal radiotherapy vs intensity-modulated radiotherapy), Zubrod performance status (0 vs 1), and histology (squamous vs non-squamous). Patients are randomized to 1 of 4 treatment arms. (Arms II and IV closed to accrual effective 6/17/11)
Patients may undergo tumor tissue, blood, and urine collection periodically during study for tissue banking or biomarker correlative studies.
Patients may undergo quality-of-life assessment at baseline and periodically during study.
After completion of study therapy, patients are followed periodically for 5 years and then annually thereafter.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 544
Not provided
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N3 supraclavicular disease;
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Greater than minimal, exudative, or cytologically positive pleural effusions;
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Involved contralateral hilar nodes (i.e. greater than 1.5 cm on short axis or positive on PET scan);
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≥ 10% weight loss within the past month;
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Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free for a minimum of 3 years; non-invasive conditions such as carcinoma in situ of the breast, oral cavity, or cervix are all permissible.
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Prior systemic chemotherapy for the study cancer; note that prior chemotherapy for a different cancer is allowable.
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Prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields;
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Prior therapy that specifically and directly targets the epidermal growth factor receptor (EGFR) pathway;
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Prior severe infusion reaction to a monoclonal antibody;
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Severe, active co-morbidity, defined as follows:
- Significant history of uncontrolled cardiac disease; i.e., uncontrolled hypertension, unstable angina, myocardial infarction within the last 6 months, uncontrolled congestive heart failure, and cardiomyopathy with decreased ejection fraction.
- Transmural myocardial infarction within the last 6 months;
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration;
- Chronic Obstructive Pulmonary Disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy within 30 days before registration;
- Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects;
- Acquired Immune Deficiency Syndrome (AIDS) based upon current Centers for Disease Control and Prevention (CDC) definition; note, however, that human immunodeficiency virus (HIV) testing is not required for entry into this protocol. The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive. Protocol-specific requirements may also exclude immuno-compromised patients.
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Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic.
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Any history of allergic reaction to paclitaxel or other taxanes, or to carboplatin;
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Uncontrolled neuropathy grade 2 or greater regardless of cause.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- CROSSOVER
- Arm && Interventions
Group Intervention Description 60 Gy RT 60 Gy RT 60 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 74 Gy RT 74 Gy RT 74 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 60 Gy RT + Cetuximab Cetuximab 60 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 60 Gy RT + Cetuximab 60 Gy RT 60 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 74 Gy RT + Cetuximab 74 Gy RT 74 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 74 Gy RT + Cetuximab Cetuximab 74 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 60 Gy RT Carboplatin 60 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 60 Gy RT Paclitaxel 60 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 74 Gy RT Paclitaxel 74 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 74 Gy RT Carboplatin 74 Gy Radiation therapy with concurrent paclitaxel and carboplatin followed by consolidation paclitaxel and carboplatin 60 Gy RT + Cetuximab Carboplatin 60 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 60 Gy RT + Cetuximab Paclitaxel 60 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 74 Gy RT + Cetuximab Carboplatin 74 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin 74 Gy RT + Cetuximab Paclitaxel 74 Gy Radiation therapy with concurrent cetuximab, paclitaxel, and carboplatin followed by consolidation cetuximab, paclitaxel, and carboplatin
- Primary Outcome Measures
Name Time Method Overall Survival From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. Survival time is defined as time from randomization to date of death from any cause and is estimated by the Kaplan-Meier method. Patients last known to be alive are censored at the date of last contact.
- Secondary Outcome Measures
Name Time Method Prognostic Value of Pre-treatment Standardized Uptake Value (SUV) of Positron Emission Tomography (PET) Scan in Predicting Survival, Distant Metastasis, and Local-regional Failure From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. Standardized uptake value (SUV) is a simple way of determining activity in PET imaging. It is a mathematically derived ratio of tissue radioactivity concentration at a point in time and the injected dose of radioactivity per kilogram of the patient's body weight. All event times are time from randomization to date of event or censoring. A survival event is death from any cause, patients without events are censored at the date of last contact, and survival rates are estimated by Kaplan-Meier method. Local-regional and distant metastasis events are the first development of progressive disease locally/regionally or distant metastasis, respectively, patients who do not have an event are censored at the date of death or last contact, and event rates are estimated by cumulative incidence. Two-year rates are presented. PET SUV was evaluated as a continuous variable therefore the outcome variables are not summarized by PET SUV.
Percentage of Patients With Decline From Baseline to 3 Months in the Lung Cancer Subscale (LCS) of the Functional Assessment of the Cancer Therapy Trial Outcome Index (FACT-TOI). At baseline and 3 months. A decline of 2 points in the LCS from baseline to 3 months was considered a clinically meaningful change indicating a decline in quality of life. Comparisons are only made between radiation therapy dosing levels because the cetuximab regimen was known to be safe in combination with radiation therapy.
Local-regional Failure (Reported as Two-year Estimates) From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. A failure for local-regional failure is the first occurrence of local or regional progression. Time is measured from the date of randomization to the date of first failure. Patients alive without local or regional failure at the time of last follow-up are censored. Patients who died without local or regional failure are considered as having competing risk at the time of death. Local-regional failure was estimated by the cumulative incidence method and 2 year estimates are reported.
Percentage of Participants With Grade 3-5 Esophagitis and Pneumonitis Adverse Events as Assessed by NCI Common Toxicity Criteria for Adverse Effects (CTCAE) v3.0 From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. Treatment-related esophagitis and pneumonitis were assessed graded using the CTCAE v3.0. Comparisons are only made between radiation therapy dosing levels because the cetuximab regimen was known to be safe in combination with radiation therapy.
Percentage of Participants With Other Grade 3-5 Adverse Events as Assessed by NCI CTCAE v3.0 From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. Treatment-related adverse events other than esophagitis and pneumonitis were assessed graded using the CTCAE v3.0. Comparisons are only made between radiation therapy dosing levels because the cetuximab regimen was known to be safe in combination with radiation therapy.
Death During or Within 30 Days of Discontinuation of Protocol Treatment From start of protocol treatment to 24 months. Deaths regardless of cause and occuring during or within 30 days of discontinuation of protocol treatment were evaluated.
Patient-reported Swallowing Score (Area Under the Curve) From randomization to 6 weeks after start of radiation therapy (6-10 weeks from randomization) Patients completed a swallowing diary prior to the start of treatment and then daily during treatment. Patients recorded a score to indicate problems with swallowing on that day (1-None, 2-Mild soreness only, 3-Can swallow solids with some difficulty, 4-Cannot swallow solids, 5-Cannot swallow liquids). These scores were then plotted across time and the area under the curve from baseline until the end of week 6 was calculated. A lower area under the curve indicates better swallowing ability. Comparisons are only made between radiation therapy dosing levels because the cetuximab regimen was known to be safe in combination with radiation therapy.
EuroQoL (EQ5D) Visual Analog Scale (VAS) Through One Year (Area Under the Curve) From randomization to one year The visual analogue scale is a self-assessment of current health state, measured on a 20-cm scale ranging from 0 for the worst imaginable health state to 100 for best imaginable health state, marked at 10-point intervals. The area under the curve of each subject's EQ5D visual analog scale (VAS) response trajectory within 1 year was calculated. The EQ5D VAS utility was normalized by the baseline score. The trajectory included all available time points through one year. If a subject died within one year, the EQ5D VAS was reduced to 0 at the time of death. If subject was censored within one year, the EQ5D utility curve was truncated at the time of censoring. The scores were plotted across time and the area under the curve was calculated. A greater area under the curve indicates a better health state. Comparisons are only made between radiation therapy dosing levels because the cetuximab regimen was known to be safe in combination with radiation
Overall Survival and Local-regional Failure by Epithelial Growth Factor Receptor (EGFR) Group From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. EGFR is a protein that is present on the surface of both normal cells and cancer cancer cells. EGFR H-Score is a measure of staining intensity ranging from 0 to 300 where a higher value indicates greater intensity of EGFR. Available tumor samples were evaluated for EGFR and given an H-Score. Patients were divided into two groups based on H-Score values dichotomized at 200. All event times are time from randomization to date of event or censoring. A survival event is death from any cause, patients without events are censored at the date of last contact, and survival rates are estimated by Kaplan-Meier method. A local-regional event is the first development of progressive disease locally or regionally, patients who do not have an event are censored at the date of death or last contact, and event rates are estimated by cumulative incidence. Two-year rates are reported.
Percentage of Patients With Grade 3+ Adverse Events by Epithelial Growth Factor Receptor (EGFR) Group From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. EGFR is a protein that is present on the surface of both normal cells and cancer cancer cells. EGFR H-Score is a measure of staining intensity ranging from 0 to 300 where a higher value indicates greater intensity of EGFR. Available tumor samples were evaluated for EGFR and given an H-Score. Patients were divided into two groups based on H-Score values dichotomized at 200. Worst toxicity as determined by adverse events was used as a measure of a patient's quality of life (QOL). Adverse events were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v3.0. Grade refers to the severity of the AE. The CTCAE v3.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE. Highest grade (worst) adverse event (AE) per subject was counted.
Prognostic and Predictive Effects of Gross Tumor Volume (GTV) on Overall Survival From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. Gross tumor volume (GTV) is defined as the combined volume (cubic centimeters) of the primary tumor and clinically positive lymph nodes seen either on the planning computed tomography (CT) scan or the pretreatment positron emission tomography (PET) scan. Survival time is defined as time from randomization to date of death from any cause and is estimated by the Kaplan-Meier method. Patients last known to be alive are censored at the date of last contact. GTV was evaluated as a continuous variable therefore overall survival time is not summarized by GTV. "Prognostic" refers to the main effect and "predictive" refers to the interaction between GTV and treatment arm.
Progression-free Survival From randomization to last follow-up. Analysis occured after all patients were on study for 18 months. Maximum follow-up at time of analysis was 61.5 months. A failure for progression-free survival (PFS) is the first occurrence of local or regional progression, distant metastases, or death from any cause. Progression is defined using Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a nontarget lesion, or the appearance of new lesions. Time is measured from the date of randomization to the date of first failure. Patients without failure are censored at the date of last follow-up.
Trial Locations
- Locations (213)
Shore Regional Cancer Center at Memorial Hospital - Easton
🇺🇸Easton, Maryland, United States
CCOP - Christiana Care Health Services
🇺🇸Newark, Delaware, United States
Mountain States Tumor Institute at St. Luke's Regional Medical Center
🇺🇸Boise, Idaho, United States
Mary Bird Perkins Cancer Center - Baton Rouge
🇺🇸Baton Rouge, Louisiana, United States
Renown Institute for Cancer at Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
Fox Chase Virtua Health Cancer Program at Virtua Memorial Hospital Marlton
🇺🇸Marlton, New Jersey, United States
Center for Cancer Care at Exeter Hospital
🇺🇸Exeter, New Hampshire, United States
Cancer Institute of New Jersey at Cooper - Voorhees
🇺🇸Voorhees, New Jersey, United States
Cancer Centers of the Carolinas - Faris Road
🇺🇸Greenville, South Carolina, United States
University of Chicago Cancer Research Center
🇺🇸Chicago, Illinois, United States
Community Regional Cancer Care at Community Hospital North
🇺🇸Indianapolis, Indiana, United States
Virginia Piper Cancer Institute at Abbott - Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Cancer Care Centers of South Texas - Northeast
🇺🇸San Antonio, Texas, United States
Utah Cancer Specialists at UCS Cancer Center
🇺🇸Salt Lake City, Utah, United States
UCSF Helen Diller Family Comprehensive Cancer Center
🇺🇸San Francisco, California, United States
Barbara Ann Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Josephine Ford Cancer Center at Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Mayo Clinic Cancer Center
🇺🇸Rochester, Minnesota, United States
Medical College of Wisconsin Cancer Center
🇺🇸Milwaukee, Wisconsin, United States
Stanford Cancer Center
🇺🇸Stanford, California, United States
UAB Comprehensive Cancer Center
🇺🇸Birmingham, Alabama, United States
Poudre Valley Radiation Oncology
🇺🇸Fort Collins, Colorado, United States
CCOP - Mount Sinai Medical Center
🇺🇸Miami Beach, Florida, United States
St. Joseph Hospital Regional Cancer Center - Orange
🇺🇸Orange, California, United States
Feather River Hospital Cancer Center
🇺🇸Paradise, California, United States
Memorial Medical Center
🇺🇸Modesto, California, United States
Arizona Oncology - Tucson
🇺🇸Tucson, Arizona, United States
Mayo Clinic Scottsdale
🇺🇸Scottsdale, Arizona, United States
Rebecca and John Moores UCSD Cancer Center
🇺🇸La Jolla, California, United States
Mercy Cancer Center at Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
Ella Milbank Foshay Cancer Center at Jupiter Medical Center
🇺🇸Jupiter, Florida, United States
Central Indiana Cancer Centers - East
🇺🇸Indianapolis, Indiana, United States
Lacks Cancer Center at Saint Mary's Health Care
🇺🇸Grand Rapids, Michigan, United States
Mercy Regional Cancer Center at Mercy Medical Center
🇺🇸Cedar Rapids, Iowa, United States
Radiation Oncology Associates Southwest
🇺🇸Fort Wayne, Indiana, United States
Barnes-Jewish West County Hospital
🇺🇸Saint Louis, Missouri, United States
Minnesota Oncology Hematology, PA - Maplewood
🇺🇸Maplewood, Minnesota, United States
Broward General Medical Center Cancer Center
🇺🇸Fort Lauderdale, Florida, United States
Baptist Cancer Institute - Jacksonville
🇺🇸Jacksonville, Florida, United States
Integrated Community Oncology Network
🇺🇸Jacksonville Beach, Florida, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Emory Crawford Long Hospital
🇺🇸Atlanta, Georgia, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Cancer Treatment Center at Pekin Hospital
🇺🇸Pekin, Illinois, United States
Cancer Center at Ball Memorial Hospital
🇺🇸Muncie, Indiana, United States
Saint Alphonsus Cancer Care Center at Saint Alphonsus Regional Medical Center
🇺🇸Boise, Idaho, United States
Integrated Community Oncology Network - Orange Park
🇺🇸Orange Park, Florida, United States
Georgia Cancer Center for Excellence at Grady Memorial Hospital
🇺🇸Atlanta, Georgia, United States
Winship Cancer Institute of Emory University
🇺🇸Atlanta, Georgia, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Peninsula Regional Medical Center
🇺🇸Salisbury, Maryland, United States
Community Cancer Center
🇺🇸Normal, Illinois, United States
Community Regional Cancer Care at Community Hospital East
🇺🇸Indianapolis, Indiana, United States
Center for Cancer Care at Goshen General Hospital
🇺🇸Goshen, Indiana, United States
St. Agnes Hospital Cancer Center
🇺🇸Baltimore, Maryland, United States
Baystate Regional Cancer Program at D'Amour Center for Cancer Care
🇺🇸Springfield, Massachusetts, United States
Tulane Cancer Center Office of Clinical Research
🇺🇸Alexandria, Louisiana, United States
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis
🇺🇸Saint Louis, Missouri, United States
UMDNJ University Hospital
🇺🇸Newark, New Jersey, United States
Greenebaum Cancer Center at University of Maryland Medical Center
🇺🇸Baltimore, Maryland, United States
Humphrey Cancer Center at North Memorial Outpatient Center
🇺🇸Robbinsdale, Minnesota, United States
Van Elslander Cancer Center at St. John Hospital and Medical Center
🇺🇸Grosse Pointe Woods, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
CentraCare Clinic - River Campus
🇺🇸Saint Cloud, Minnesota, United States
Regions Hospital Cancer Care Center
🇺🇸Saint Paul, Minnesota, United States
Regional Cancer Center at Singing River Hospital
🇺🇸Pascagoula, Mississippi, United States
Methodist Estabrook Cancer Center
🇺🇸Omaha, Nebraska, United States
Saint Elizabeth Cancer Institute at Saint Elizabeth Regional Medical Center
🇺🇸Lincoln, Nebraska, United States
CCOP - Nevada Cancer Research Foundation
🇺🇸Las Vegas, Nevada, United States
Siteman Cancer Center at Barnes-Jewish St. Peters Hospital - St. Peters
🇺🇸Saint Peters, Missouri, United States
Saint Mary's Regional Medical Center
🇺🇸Reno, Nevada, United States
Payson Center for Cancer Care at Concord Hospital
🇺🇸Concord, New Hampshire, United States
New York Oncology Hematology, PC at Albany Regional Cancer Care
🇺🇸Albany, New York, United States
Barberton Citizens Hospital
🇺🇸Barberton, Ohio, United States
Trinity CancerCare Center
🇺🇸Minot, North Dakota, United States
Blumenthal Cancer Center at Carolinas Medical Center
🇺🇸Charlotte, North Carolina, United States
Alamance Cancer Center at Alamance Regional Medical Center
🇺🇸Burlington, North Carolina, United States
McDowell Cancer Center at Akron General Medical Center
🇺🇸Akron, Ohio, United States
CCOP - MeritCare Hospital
🇺🇸Fargo, North Dakota, United States
Cancer Centers of North Carolina - Raleigh
🇺🇸Raleigh, North Carolina, United States
FirstHealth Moore Regional Community Hospital Comprehensive Cancer Center
🇺🇸Pinehurst, North Carolina, United States
Altru Cancer Center at Altru Hospital
🇺🇸Grand Forks, North Dakota, United States
Presbyterian Cancer Center at Presbyterian Hospital
🇺🇸Charlotte, North Carolina, United States
Case Comprehensive Cancer Center
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Taussig Cancer Center
🇺🇸Cleveland, Ohio, United States
Summa Center for Cancer Care at Akron City Hospital
🇺🇸Akron, Ohio, United States
Kinston Medical Specialists
🇺🇸Kinston, North Carolina, United States
Flower Hospital Cancer Center
🇺🇸Sylvania, Ohio, United States
Geisinger Cancer Institute at Geisinger Health
🇺🇸Danville, Pennsylvania, United States
Aultman Cancer Center at Aultman Hospital
🇺🇸Canton, Ohio, United States
Southwest General Health Center
🇺🇸Middleburg Heights, Ohio, United States
Hillcrest Cancer Center at Hillcrest Hospital
🇺🇸Mayfield Heights, Ohio, United States
Charles M. Barrett Cancer Center at University Hospital
🇺🇸Cincinnati, Ohio, United States
St. Anne Mercy Hospital
🇺🇸Toledo, Ohio, United States
Oklahoma University Cancer Institute
🇺🇸Oklahoma City, Oklahoma, United States
Willamette Valley Cancer Center - Eugene
🇺🇸Eugene, Oregon, United States
Natalie Warren Bryant Cancer Center at St. Francis Hospital
🇺🇸Tulsa, Oklahoma, United States
Bryn Mawr Hospital
🇺🇸Bryn Mawr, Pennsylvania, United States
Fox Chase Cancer Center - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Regional Cancer Center - Erie
🇺🇸Erie, Pennsylvania, United States
Kimmel Cancer Center at Thomas Jefferson University - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Northeast Radiation Oncology Center
🇺🇸Dunmore, Pennsylvania, United States
Dale and Frances Hughes Cancer Center at Pocono Medical Center
🇺🇸East Stroudsburg, Pennsylvania, United States
Sanford Cancer Center at Sanford USD Medical Center
🇺🇸Sioux Falls, South Dakota, United States
Gibbs Regional Cancer Center at Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
West Texas Cancer Center
🇺🇸Odessa, Texas, United States
McGlinn Family Regional Cancer Center at Reading Hospital and Medical Center
🇺🇸Reading, Pennsylvania, United States
Texas Oncology, PA at Harris Center HEB
🇺🇸Bedford, Texas, United States
Texas Oncology, PA at Texas Cancer Center - Arlington South
🇺🇸Arlington, Texas, United States
CCOP - Greenville
🇺🇸Greenville, South Carolina, United States
Cancer Centers of the Carolinas - Seneca
🇺🇸Seneca, South Carolina, United States
Lankenau Cancer Center at Lankenau Hospital
🇺🇸Wynnewood, Pennsylvania, United States
Theda Care Cancer Institute
🇺🇸Appleton, Wisconsin, United States
Hopital Notre-Dame du CHUM
🇨🇦Montreal, Quebec, Canada
CancerCare Manitoba
🇨🇦Winnipeg, Manitoba, Canada
Texas Oncology, PA at Texas Cancer Center - Denton South
🇺🇸Denton, Texas, United States
Christine LaGuardia Phillips Cancer Center at Wellmont Holston Valley Medical Center
🇺🇸Kingsport, Tennessee, United States
Cancer Care Northwest - Spokane South
🇺🇸Spokane, Washington, United States
University of Virginia Cancer Center
🇺🇸Charlottesville, Virginia, United States
Bellin Memorial Hospital
🇺🇸Green Bay, Wisconsin, United States
All Saints Cancer Center at Wheaton Franciscan Healthcare
🇺🇸Racine, Wisconsin, United States
St. Vincent Hospital Regional Cancer Center
🇺🇸Green Bay, Wisconsin, United States
Veterans Affairs Medical Center - Milwaukee
🇺🇸Milwaukee, Wisconsin, United States
D.N. Greenwald Center
🇺🇸Mukwonago, Wisconsin, United States
Allan Blair Cancer Centre at Pasqua Hospital
🇨🇦Regina, Saskatchewan, Canada
Door County Cancer Center at Door County Memorial Hospital
🇺🇸Sturgeon Bay, Wisconsin, United States
Saskatoon Cancer Centre at the University of Saskatchewan
🇨🇦Saskatoon, Saskatchewan, Canada
Tom Baker Cancer Centre - Calgary
🇨🇦Calgary, Alberta, Canada
Waukesha Memorial Hospital Regional Cancer Center
🇺🇸Waukesha, Wisconsin, United States
SUNY Upstate Medical University Hospital
🇺🇸Syracuse, New York, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Mercy Regional Cancer Center at Mercy Hospital
🇺🇸Port Huron, Michigan, United States
Siouxland Hematology-Oncology Associates, LLP
🇺🇸Sioux City, Iowa, United States
UHHS Chagrin Highlands Medical Center
🇺🇸Orange Village, Ohio, United States
St. Charles Mercy Hospital
🇺🇸Oregon, Ohio, United States
UHHS Westlake Medical Center
🇺🇸Westlake, Ohio, United States
Cleveland Clinic - Wooster
🇺🇸Wooster, Ohio, United States
Frankford Hospital Cancer Center - Torresdale Campus
🇺🇸Philadelphia, Pennsylvania, United States
Albert Einstein Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Frank M. and Dorothea Henry Cancer Center at Geisinger Wyoming Valley Medical Center
🇺🇸Wilkes-Barre, Pennsylvania, United States
Texas Oncology, PA at Texas Oncology Cancer Center Sugar Land
🇺🇸Sugar Land, Texas, United States
M. D. Anderson Cancer Center at University of Texas
🇺🇸Houston, Texas, United States
CCOP - Virginia Mason Research Center
🇺🇸Seattle, Washington, United States
Harrington Cancer Center
🇺🇸Amarillo, Texas, United States
Longview Cancer Center
🇺🇸Longview, Texas, United States
Klabzuba Cancer Center at Harris Methodist Fort Worth Hospital
🇺🇸Fort Worth, Texas, United States
Integrated Community Oncology Network at Southside Cancer Center
🇺🇸Jacksonville, Florida, United States
Baptist Medical Center South
🇺🇸Jacksonville, Florida, United States
Baptist-South Miami Regional Cancer Program
🇺🇸Miami, Florida, United States
Flagler Cancer Center
🇺🇸Saint Augustine, Florida, United States
Sacred Heart Cancer Center at Sacred Heart Hospital
🇺🇸Pensacola, Florida, United States
Texas Oncology, PA at Texas Cancer Center - Sherman
🇺🇸Sherman, Texas, United States
Enloe Cancer Center at Enloe Medical Center
🇺🇸Chico, California, United States
OSF St. Francis Medical Center
🇺🇸Peoria, Illinois, United States
Florida Cancer Center - Palatka
🇺🇸Palatka, Florida, United States
Memorial Cancer Institute at Memorial Regional Hospital
🇺🇸Hollywood, Florida, United States
Riverview UW Cancer Center at Riverview Hospital
🇺🇸Wisconsin Rapids, Wisconsin, United States
Veterans Affairs Medical Center - Albany
🇺🇸Albany, New York, United States
St. Mary Mercy Hospital
🇺🇸Livonia, Michigan, United States
Cleveland Clinic Cancer Center at Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Mayo Clinic - Jacksonville
🇺🇸Jacksonville, Florida, United States
Riverside Methodist Hospital Cancer Care
🇺🇸Columbus, Ohio, United States
Luther Midlelfort Hospital
🇺🇸Eau Claire, Wisconsin, United States
Tyler Cancer Center
🇺🇸Tyler, Texas, United States
St. Mary's Hospital Medical Center - Green Bay
🇺🇸Green Bay, Wisconsin, United States
Dixie Regional Medical Center - East Campus
🇺🇸Saint George, Utah, United States
Fletcher Allen Health Care - University Health Center Campus
🇺🇸Burlington, Vermont, United States
Midelfort Clinic - Luther
🇺🇸Eau Claire, Wisconsin, United States
Gundersen Lutheran Center for Cancer and Blood
🇺🇸La Crosse, Wisconsin, United States
Sands Cancer Center
🇺🇸Canandaigua, New York, United States
Cancer Care Center at John Muir Health - Concord Campus
🇺🇸Concord, California, United States
Saint Agnes Cancer Center at Saint Agnes Medical Center
🇺🇸Fresno, California, United States
Radiation Oncology Center - Roseville
🇺🇸Roseville, California, United States
Saint Helena Hospital
🇺🇸Saint Helena, California, United States
Penrose Cancer Center at Penrose Hospital
🇺🇸Colorado Springs, Colorado, United States
Washington Cancer Institute at Washington Hospital Center
🇺🇸Washington, District of Columbia, United States
Creticos Cancer Center at Advocate Illinois Masonic Medical Center
🇺🇸Chicago, Illinois, United States
Charles B. Eberhart Cancer Center at DeKalb Medical Center
🇺🇸Decatur, Georgia, United States
Parkview Regional Cancer Center at Parkview Health
🇺🇸Fort Wayne, Indiana, United States
Mercy Cancer Center at Mercy Medical Center - North Iowa
🇺🇸Mason City, Iowa, United States
Good Samaritan Cancer Center at Good Samaritan Hospital
🇺🇸Kearney, Nebraska, United States
University of Mississippi Cancer Clinic
🇺🇸Jackson, Mississippi, United States
St. Luke's - Roosevelt Hospital Center - St.Luke's Division
🇺🇸New York, New York, United States
J. Phillip Citta Regional Cancer Center at Community Medical Center
🇺🇸Toms River, New Jersey, United States
Penn State Hershey Cancer Institute at Milton S. Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Morgan Cancer Center at Lehigh Valley Hospital - Cedar Crest
🇺🇸Allentown, Pennsylvania, United States
Cleveland Clinic Cancer Center
🇺🇸Independence, Ohio, United States
Cancer Center of Paoli Memorial Hospital
🇺🇸Paoli, Pennsylvania, United States
Adena Regional Medical Center
🇺🇸Chillicothe, Ohio, United States
North Coast Cancer Care, Incorporated
🇺🇸Sandusky, Ohio, United States
Jon and Karen Huntsman Cancer Center at Intermountain Medical Center
🇺🇸Murray, Utah, United States
Utah Valley Regional Medical Center - Provo
🇺🇸Provo, Utah, United States
Princess Margaret Hospital
🇨🇦Toronto, Ontario, Canada
Bay Area Cancer Care Center at Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Radiological Associates of Sacramento Medical Group, Incorporated
🇺🇸Sacramento, California, United States
University of California Davis Cancer Center
🇺🇸Sacramento, California, United States
M.D. Anderson Cancer Center at Orlando
🇺🇸Orlando, Florida, United States
Saint Joseph Mercy Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill
🇺🇸Chapel Hill, North Carolina, United States
Hollings Cancer Center at Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
University of Florida Shands Cancer Center
🇺🇸Gainesville, Florida, United States
Mercy Cancer Center at Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
Central Baptist Hospital
🇺🇸Lexington, Kentucky, United States
MBCCOP - LSU Health Sciences Center
🇺🇸New Orleans, Louisiana, United States
CCOP - Ochsner
🇺🇸New Orleans, Louisiana, United States
University Radiation Oncology at Parkridge Hospital
🇺🇸Rochester, New York, United States
John Stoddard Cancer Center at Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
James P. Wilmot Cancer Center at University of Rochester Medical Center
🇺🇸Rochester, New York, United States
Highland Hospital of Rochester
🇺🇸Rochester, New York, United States
Billings Clinic - Downtown
🇺🇸Billings, Montana, United States
Elliot Regional Cancer Center at Elliot Hospital
🇺🇸Manchester, New Hampshire, United States