Stepped-Care Telehealth for Distress in Cancer Survivors
- Conditions
- Depressive SymptomsCancerAnxietyFatigueQuality of LifeSleep DisturbanceRecurrent Disease
- Interventions
- Other: Enhanced Usual Care Control
- Registration Number
- NCT03060096
- Lead Sponsor
- Wake Forest University Health Sciences
- Brief Summary
Mental health issues in post-treatment adult cancer survivors are associated with multiple adverse outcomes and may represent a cancer health disparity for rural survivors. The purpose of this study is to test a stepped-care approach tailored to symptom severity based on recent American Society of Clinical Oncology guidelines for reducing emotional distress (anxiety and/or depressive symptoms) and improving secondary outcomes (sleep disturbance, fatigue, fear of recurrence, quality of life) in rural, post-treatment cancer survivors in community oncology settings and to examine intervention costs. The resultant intervention will have great potential for widespread dissemination since it will be manualized, delivered by telephone, and comprised of modules to allow customized treatments for individuals with different cancer types.
- Detailed Description
Noting the need for evidence-based cancer survivorship care, the American Society of Clinical Oncology (ASCO) published guidelines for screening, assessment, and care of psychosocial distress (anxiety, depression) in adults with cancer. These guidelines recommend screening all adults with cancer for distress and treating those with moderate or severe symptoms using a stepped-care approach tailored to distress severity. While these guidelines apply to survivors with all cancer types across the cancer treatment and survivorship continuum, we have chosen to focus on survivors with non-metastatic breast, colorectal, prostate, uterine, and cervical cancers , as well as those with any stage lymphoma (Hodgkin's or non-Hodgkin's). Further, we have focused on the post-treatment survivorship period 6 months-5 years post-treatment because distress may be more likely to be assessed and addressed after treatment completion. A significant minority of post-treatment survivors is at risk for anxiety and depression symptoms during the five years following the end of treatment and accessible interventions are needed to treat them.
The purpose of this study is to test a method of implementing this stepped-care approach in community oncology practices caring for cancer survivors, using self-directed and stepped-care telehealth approaches based on cognitive-behavioral theory. Our approach is based on a previous trial of telephone-based cognitive behavioral therapy for rural older adults with Generalized Anxiety Disorder (NIMH 1R01MH083664: The Tranquil Moments Study; PI: Brenes), which has demonstrated high acceptability and efficacy for reducing anxiety, worry, and depressive symptoms in a rural geriatric population. This protocol adapts the methods of the previous trial to bring psychosocial care to underserved cancer survivors, many of whom have minimal or no access to mental health providers. Cancer survivors will be recruited through multiple NCI Community Oncology Research Program (NCORP) sites through the NCI-funded Wake Forest NCORP Research Base (WF NCORP RB).
We will obtain data on feasibility, outcome variability, and efficacy for designing a subsequent fully powered randomized controlled trial (RCT) assessing the effects of the intervention on distress in cancer survivors. In the planned larger study, we anticipate that this intervention will: (a) reduce treatment barriers for post-treatment cancer survivors; (b) enhance availability of psychosocial treatment (through use of telephone sessions and a workbook); and (c) result in reductions in anxiety and depressive symptoms in cancer survivors.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 68
- Age ≥18 years
- Score ≥10 on the GAD-7 and/or a score ≥8 on the PHQ-9, indicating clinically significant anxiety or depressive symptoms, respectively.
- Past history of treated Stage I, II, or III (newly diagnosed or recurrent) breast, colorectal, prostate, gynecologic (to include uterine and cervical) cancers and non-Hodgkin's lymphoma.
- 6-60 months post-treatment (surgery, chemotherapy, and/or radiation therapy) for cancer. Time frame applies to most recent completion of treatment if participant had a cancer recurrence. It is acceptable to be on maintenance or hormonal therapies.
- Participant resides in California, Georgia, Illinois, Kansas, Michigan, Minnesota, Missouri, New Mexico, North Carolina, North Dakota, South Carolina, Virginia, Tennessee, or Wisconsin
- Study-trained therapist in the state where the participant resides.
- Must be able to speak and understand English.
- Must have access to a telephone
- Current psychotherapy [regular appointment(s) with a psychologist, counselor, or therapist within the last 30 days prior to randomization].
- Self-reported active alcohol or substance abuse within the last 30 days.
- Past history of prostate cancer or non-Hodgkin's lymphoma with only active surveillance (i.e., no surgery, chemotherapy, or radiation therapy).
- Diagnosis of a second malignancy (except for non-melanoma skin cancers) after a previous diagnosis of breast, colorectal, gynecologic cancers and non-Hodgkin's lymphoma
- Progressive cancer (must be considered no evidence of disease or stable)
- Self -reported history of a diagnosis of dementia from a healthcare provider.
- Self -reported psychotic symptoms in the last 30 days prior to randomization
- Active suicidal ideation (currently reported suicidal plan and intent).
- Any change in psychotropic medications within the last 30 days.
- Hearing loss that would preclude participating in telephone sessions (determined by brief hearing assessment administered by research staff)
- Failure/inability/unwillingness to provide names and contact information for two family members or friends to serve as emergency contacts during the course of the study.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Enhanced Usual Care Control (EUC) Enhanced Usual Care Control Participants randomized to EUC will receive information about local referrals/resources (support groups, mental health providers, etc.). They will also be provided "Facing Forward: Life after Cancer Treatment," a book developed by the NCI to assist with transition from active treatment to survivorship. Participants will receive information on self-help workbooks for anxiety \& depressive symptoms. EUC control will receive a copy of the CBT workbook on completion of the study.
- Primary Outcome Measures
Name Time Method Feasibility of Study Intervention Measured by Recruitment Rate Screening through end of study at week 13 Recruitment rate will be determined by the number of eligible participants who met all eligibility criteria and percent who agreed to participate.
Feasibility of Study Intervention Measured by Accrual Rate Start of study screening time to end of study accrual The accrual rate is determined by dividing the overall number of participants recruited in each arm by the total span of 38 months between the start of the first screening for enrollment and the time the study closed to accrual.
Feasibility of Study Intervention Measured by Retention Randomization through completion of study at week 13 Study retention will be estimated by the number of participants who complete the Week 7 and 13 visits
Feasibility of Study Intervention Measured by Adherence to Intervention Randomization through completion of study at week 13 Intervention adherence will be estimated as the mean proportion of therapy (high-intensity intervention) or check-in (low-intensity intervention) sessions each participant completes.
- Secondary Outcome Measures
Name Time Method Longitudinal Changes in the PROMIS Fatigue Scale From Baseline to 13 Weeks Baseline (Week 0), Week 13 The Patient Reported Outcomes Measurement Information System (PROMIS) Fatigue Short Form 8a is a measure of the experience of fatigue and the impact of fatigue on activities across multiple domains. There are eight items rated on a scale of 1(never) to 5 (always) based on how often fatigue was experienced over the last 7 days. The sum of these eight items ranges from a minimum of 8 to a maximum of 40, with higher scores representing more fatigue. This total score is then converted into a t-score based on the PROMIS 8a adult conversion table. The smallest t score is 33.1 and the largest t score is 77.8. A higher t score indicates greater fatigue.
Number of Participants With Moderate of Severe Depression (PHQ-9) or Anxiety (GAD-7) at 13 Weeks Week 13 A combined variable will be created that indicates if a participant had moderate/severe depression or anxiety at mid- or post-intervention. This is defined as either PHQ-9 or GAD-7 greater than or equal to 15.
Longitudinal Changes in the Fear of Recurrence Inventory Severity Subscale From Baseline to 13 Weeks Baseline (Week 0), Week 13 The Fear of Cancer Recurrence Inventory (FCRI; severity subscale) will be used to measure self-reported fear of recurrence. This 9-item subscale measures the presence and severity of the intrusive thoughts or images associated with the fear of cancer recurrence. Range is 0 to 36 with higher values representing higher fear of recurrence.
Longitudinal Changes in the Generalized Anxiety Disorder (GAD)-7 Score for Anxiety From Baseline to 13 Weeks Screening or baseline (if >30 days since screening), Week 13 The Generalized Anxiety Disorder (GAD) -7 is a self-report measure of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) symptoms of Generalized Anxiety Disorder (GAD). Longitudinal changes in the GAD-7 will be measured in participants to evaluate the effectiveness of the intervention in reducing anxiety. Patients select 1 of 4 numbers with "0" indicating not all, to "3" indicating nearly everyday. The first 7 questions are summed to create a total score ranging from 0 to 21. Higher scores reflect greater anxiety severity. Scores above 10 are considered to be in the clinical range. GAD-7 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe anxiety, respectively.
Longitudinal Changes in the Patient Health Questionnaire (PHQ-9) Score for Depression From Baseline to 13 Weeks Screening or baseline (if >30 days since screening), Week 13 The PHQ-9 is a self-report measure of DSM-IV symptoms of Major Depressive Disorder where participants rate how often they experienced 9 symptoms over past 2 weeks. Patients select 1 of 4 numbers with "0" indicating not all, to "3" indicating nearly everyday. Longitudinal changes in the PHQ-9 will be measured in participants to evaluate the effectiveness of the intervention in reducing depression. The possible range is 0-27. A larger score represents more severe depression level.
Longitudinal Changes in the Insomnia Severity Index (ISI) From Baseline to 13 Weeks. Baseline (Week 0), Week 13 Measure Description: The Insomnia Severity Index (ISI) is 7-item self-report measure of type and severity of insomnia symptoms, including problems with sleep onset, sleep maintenance, or early morning awakening; satisfaction with current sleep pattern; interference with daily functioning; noticing impairment attributed to sleep problems; and level of concern or distress caused by the sleep problem. Each of the seven items is scored on a 5-point scale, ranging from 0 (lowest) to 4 (highest). The sum of the scores for all seven items yields a total score, which falls within a range of 0 to 28. A higher score indicates a greater level of sleep impairment.
Longitudinal Changes in the Health Status Questionnaire (SF-36) From Baseline to 13 Weeks Baseline (Week 0), Week 13 The Health Status Questionnaire (SF-36) functions as a self-reporting tool designed to evaluate an individual's quality of life. It consists of 36 items and is organized into eight subscales. Each subscale score is then translated into a linear scale that spans from 0 to 100. A higher score means enhanced quality of life. Additionally, the questionnaire incorporates two domains as mental health component and physical health component. These domains are the results of linear aggregation from the 8 subscales and transforming into T score metric. In these metrics, the t score has a mean of 50 and a standard deviation of 10 based on the characteristics of U.S. general population for both mental and physical health sub scores. A higher T-score corresponds to a higher quality of life for that subscale.
Longitudinal Changes in the Impact of Events Scale-Revised (IES-R) From Baseline to 13 Weeks Baseline (Week 0), Week 13 The Impact of Events Scale - Revised (IES-R) is a 22-item self-report measure of cancer related distress. The IES-R assesses the frequency with which respondents experience intrusive thoughts, avoidant behaviors, and autonomic arousal specific to one's thoughts and feelings about cancer over the past week. Each item is rated on a 5-point scale ranging from 0("not at all") to 4("extremely"). The higher grade indicates greater stress. IES- R total score is the sum of the means of the three subscale scores. IES- R total score ranges from 0 to 12. The higher scores indicate higher cancer distress.
Trial Locations
- Locations (166)
Prisma Health Cancer Institute - Easley
🇺🇸Easley, South Carolina, United States
Kaiser Permanente-Santa Rosa
🇺🇸Santa Rosa, California, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸Savannah, Georgia, United States
Pacific Central Coast Health Center-San Luis Obispo
🇺🇸San Luis Obispo, California, United States
Augusta University Medical Center
🇺🇸Augusta, Georgia, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Kaiser Permanente-Stockton
🇺🇸Stockton, California, United States
Kaiser San Rafael-Gallinas
🇺🇸San Rafael, California, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Carle on Vermilion
🇺🇸Danville, Illinois, United States
Fairview Northland Medical Center
🇺🇸Princeton, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸Carbondale, Illinois, United States
Spectrum Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Central Care Cancer Center - Bolivar
🇺🇸Bolivar, Missouri, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸Decatur, Illinois, United States
Virginia Cancer Institute
🇺🇸Richmond, Virginia, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Illinois CancerCare-Galesburg
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Monticello Cancer Center
🇺🇸Monticello, Minnesota, United States
Cox Cancer Center Branson
🇺🇸Branson, Missouri, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Good Samaritan Regional Health Center
🇺🇸Mount Vernon, Illinois, United States
Springfield Clinic
🇺🇸Springfield, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸Springfield, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Fairview Clinics and Surgery Center Maple Grove
🇺🇸Maple Grove, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Sanford Thief River Falls Medical Center
🇺🇸Thief River Falls, Minnesota, United States
Saint Louis Cancer and Breast Institute-Ballwin
🇺🇸Ballwin, Missouri, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Sanford Joe Lueken Cancer Center
🇺🇸Bemidji, Minnesota, United States
Parkland Health Center-Bonne Terre
🇺🇸Bonne Terre, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
AdventHealth Hendersonville
🇺🇸Hendersonville, North Carolina, United States
Southwest VA Regional Cancer Center
🇺🇸Norton, Virginia, United States
Freeman Health System
🇺🇸Joplin, Missouri, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸Rolla, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸Rolla, Missouri, United States
Prisma Health Cancer Institute - Eastside
🇺🇸Greenville, South Carolina, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸Wisconsin Rapids, Wisconsin, United States
Missouri Baptist Sullivan Hospital
🇺🇸Sullivan, Missouri, United States
AdventHealth Infusion Center Asheville
🇺🇸Asheville, North Carolina, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
VCU Community Memorial Health Center
🇺🇸South Hill, Virginia, United States
AdventHealth Infusion Center Haywood
🇺🇸Clyde, North Carolina, United States
Gibbs Cancer Center-Gaffney
🇺🇸Gaffney, South Carolina, United States
Sovah Health Martinsville
🇺🇸Martinsville, Virginia, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Marshfield Clinic Stevens Point Center
🇺🇸Stevens Point, Wisconsin, United States
Langlade Hospital and Cancer Center
🇺🇸Antigo, Wisconsin, United States
Holy Family Memorial Hospital
🇺🇸Manitowoc, Wisconsin, United States
Aspirus Medford Hospital
🇺🇸Medford, Wisconsin, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Wellmont Medical Associates-Bristol
🇺🇸Bristol, Virginia, United States
Marshfield Medical Center - Weston
🇺🇸Weston, Wisconsin, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸Eau Claire, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Marinette
🇺🇸Marinette, Wisconsin, United States
Prisma Health Cancer Institute - Laurens
🇺🇸Clinton, South Carolina, United States
Marshfield Clinic-Chippewa Center
🇺🇸Chippewa Falls, Wisconsin, United States
VCU Massey Cancer Center at Stony Point
🇺🇸Richmond, Virginia, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸Richmond, Virginia, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸Green Bay, Wisconsin, United States
Marshfield Clinic-Wausau Center
🇺🇸Wausau, Wisconsin, United States
Kaiser Permanente-Fresno
🇺🇸Fresno, California, United States
Kaiser Permanente-Modesto
🇺🇸Modesto, California, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸Galesburg, Illinois, United States
Cambridge Medical Center
🇺🇸Cambridge, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Parkland Health Center - Farmington
🇺🇸Farmington, Missouri, United States
Southeast Cancer Center
🇺🇸Cape Girardeau, Missouri, United States
AdventHealth Infusion Center Weaverville
🇺🇸Weaverville, North Carolina, United States
Tidelands Georgetown Memorial Hospital
🇺🇸Georgetown, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸Greer, South Carolina, United States
Regional Cancer Center at Indian Path Community Hospital
🇺🇸Kingsport, Tennessee, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
🇺🇸Green Bay, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸Marshfield, Wisconsin, United States
Marshfield Clinic - Ladysmith Center
🇺🇸Ladysmith, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Oconto Falls
🇺🇸Oconto Falls, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸Minocqua, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸Rice Lake, Wisconsin, United States
Cancer Center of Western Wisconsin
🇺🇸New Richmond, Wisconsin, United States
Aspirus Cancer Care - Wisconsin Rapids
🇺🇸Wisconsin Rapids, Wisconsin, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Health Partners Inc
🇺🇸Minneapolis, Minnesota, United States
Sanford Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
HaysMed University of Kansas Health System
🇺🇸Hays, Kansas, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Salina Regional Health Center
🇺🇸Salina, Kansas, United States
Olathe Health Cancer Center
🇺🇸Olathe, Kansas, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Sanford South University Medical Center
🇺🇸Fargo, North Dakota, United States
University of Kansas Health System Saint Francis Campus
🇺🇸Topeka, Kansas, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Ascension Via Christi - Pittsburg
🇺🇸Pittsburg, Kansas, United States
Mercy Hospital Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Mercy Hospital Fort Smith
🇺🇸Fort Smith, Arkansas, United States
Spartanburg Medical Center
🇺🇸Spartanburg, South Carolina, United States
Prisma Health Greenville Memorial Hospital
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸Seneca, South Carolina, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸Boiling Springs, South Carolina, United States
McLeod Regional Medical Center
🇺🇸Florence, South Carolina, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
Self Regional Healthcare
🇺🇸Greenwood, South Carolina, United States
Prisma Health Cancer Institute - Butternut
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸Greer, South Carolina, United States
Spartanburg Medical Center - Mary Black Campus
🇺🇸Spartanburg, South Carolina, United States
Wellmont Holston Valley Hospital and Medical Center
🇺🇸Kingsport, Tennessee, United States
Wellmont Bristol Regional Medical Center
🇺🇸Bristol, Tennessee, United States
MGC Hematology Oncology-Union
🇺🇸Union, South Carolina, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸Sainte Genevieve, Missouri, United States
Mercy Hospital Joplin
🇺🇸Joplin, Missouri, United States
Mercy Hospital South
🇺🇸Saint Louis, Missouri, United States
Heartland Regional Medical Center
🇺🇸Saint Joseph, Missouri, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Sanford Cancer Center Worthington
🇺🇸Worthington, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸Wyoming, Minnesota, United States
Aspirus Regional Cancer Center
🇺🇸Wausau, Wisconsin, United States
Summit Cancer Care-Candler
🇺🇸Savannah, Georgia, United States
Low Country Cancer Care Associates PC
🇺🇸Savannah, Georgia, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
SIH Cancer Institute
🇺🇸Carterville, Illinois, United States
Centralia Oncology Clinic
🇺🇸Centralia, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Illinois CancerCare-Dixon
🇺🇸Dixon, Illinois, United States
Crossroads Cancer Center
🇺🇸Effingham, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Cancer Care Center of O'Fallon
🇺🇸O'Fallon, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
Valley Radiation Oncology
🇺🇸Peru, Illinois, United States
The Carle Foundation Hospital
🇺🇸Urbana, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸Yorkville, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Kaiser Permanente-South Sacramento
🇺🇸Sacramento, California, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Mercy Hospital Washington
🇺🇸Washington, Missouri, United States
Missouri Baptist Outpatient Center-Sunset Hills
🇺🇸Sunset Hills, Missouri, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Truman Medical Centers
🇺🇸Kansas City, Missouri, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
HSHS Saint Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Capital Region Southwest Campus
🇺🇸Jefferson City, Missouri, United States
Wellmont Medical Associates Oncology and Hematology-Johnson City
🇺🇸Johnson City, Tennessee, United States