Paclitaxel and Trastuzumab With or Without Lapatinib in Treating Patients With Stage II or Stage III Breast Cancer That Can Be Removed by Surgery
- Conditions
- Male Breast CarcinomaStage IIA Breast Cancer AJCC v6 and v7Stage IIIC Breast Cancer AJCC v7Stage IIB Breast Cancer AJCC v6 and v7Stage IIIA Breast Cancer AJCC v7Stage IIIB Breast Cancer AJCC v7
- Interventions
- Other: Laboratory Biomarker Analysis
- Registration Number
- NCT00770809
- Lead Sponsor
- National Cancer Institute (NCI)
- Brief Summary
This randomized phase III trial studies paclitaxel and trastuzumab with or without lapatinib to see how well they work in treating patients with stage II or stage III breast cancer that can be removed by surgery. Drugs used in chemotherapy, such as paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Monoclonal antibodies, such as trastuzumab, 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. Lapatinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Giving paclitaxel with trastuzumab and/or lapatinib before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. It is not yet known which regimen is more effective in treating patients with breast cancer.
- Detailed Description
PRIMARY OBJECTIVE:
I. To determine if the pathologic complete response (pCR) in the breast to neoadjuvant weekly paclitaxel with trastuzumab plus lapatinib (THL) is 20% greater than the pCR to weekly paclitaxel with trastuzumab alone (TH).
SECONDARY OBJECTIVES:
I. To determine the pathologic complete response in the breast and axilla, using American Joint Committee on Cancer (AJCC) Tumor, Lymph Nodes and Metastasis (TMN) criteria (version 6), to neoadjuvant weekly paclitaxel plus human epidermal growth factor 2 (HER2)- targeted therapy in patients with HER2-positive operable breast cancer.
II. To evaluate residual cancer burden (RCB) as a predictor of long term relapse free survival (RFS) and overall survival (OS).
III. To document the toxicity of all chemotherapeutic regimens (THL, TH). IV. To determine the correlation between clinical, radiographic and pathologic response.
V. To compare overall survival (OS), relapse free survival (RFS) and time to first failure (TFF) among the treatment groups.
VI. To obtain blood, fresh frozen and fixed tumor tissue to test specific hypotheses for which biomarker data exist and to evaluate biomarkers in blood, serum and tissue that are likely to influence response to and toxicity of trastuzumab alone or trastuzumab plus lapatinib, when given with paclitaxel.
VII. To determine the surgical practice patterns for breast conservation and sentinel lymphadenectomy in patients undergoing neoadjuvant chemotherapy.
VIII. To determine the radiotherapy practice patterns for post-mastectomy and regional nodal irradiation in patients undergoing neoadjuvant chemotherapy.
IX. To evaluate pharmacogenomic determinants of toxicity.
OUTLINE: Patients are randomized to 1 of 3 treatment arms.
ARM I: Patients receive trastuzumab IV over 30-90 minutes and paclitaxel IV over 1 hour once weekly and lapatinib ditosylate orally (PO) once daily for 16 weeks in the absence of disease progression or unacceptable toxicity.
ARM II: Patients receive trastuzumab and paclitaxel as in arm I.
ARM III: Patients receive paclitaxel and lapatinib ditosylate as in arm I. (Discontinued as of 6-15-11) Within 42 days after completion of neoadjuvant therapy, patients in both arms undergo definitive surgery (breast conservation or total mastectomy).
After completion of study treatment, patients are followed every 6 months for 2 years and then annually for up to 10 years.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 305
-
Pathologic confirmation of invasive breast cancer; patients with inflammatory breast cancer are not eligible
-
Clinical stage II-III operable invasive breast cancer with intent to perform surgical resection after neoadjuvant therapy
- Patients with multicentric or bilateral disease are eligible as long as the target lesion meets the eligibility criteria for this study
- Staging to rule out metastatic disease is recommended for clinical stage III patients
-
Tumors must be HER2 positive defined as HER2 3+ by immunohistochemical (IHC) assays or gene amplification by fluorescence in situ hybridization (FISH) with a ratio of >= 2 on invasive tumor
-
Estrogen receptor (ER) and progesterone receptor (PgR) status must be known
-
The target lesion in the breast must be >= 1 cm on physical examination or by radiographic measurement; palpable axillary adenopathy will be documented but not serve as measurable disease for the primary endpoint; patients with axillary disease only are not eligible to participate
-
Patient agrees to provide pretreatment biopsies
-
No prior chemotherapy, hormone therapy, biologic, or radiation therapy with therapeutic intent for this cancer
-
Cardiac ejection fraction must be >= 50% by echocardiogram or multiple gated acquisition (MUGA) scan
-
Eastern Cooperative Oncology Group (ECOG) (Zubrod) performance status 0-1
-
Patients must not be pregnant or nursing
-
Absolute neutrophil count (ANC) >= 1,000/ul
-
Platelet count >= 100,000/ul
-
Bilirubin =< 1.5 times upper limit of normal
-
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 times upper limit of normal (ULN)
-
Serum beta-human chorionic gonadotropin (HCG) negative (in female patients unless status-post (s/p) hysterectomy or menopausal or no menses for 24 consecutive months); assay must have a sensitivity of at least 50 mIU/mL
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm I (THL) Lapatinib Ditosylate Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 750 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm III (TL) Lapatinib Ditosylate Patients receive paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 15000 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. (Discontinued as of 6-15-11) Arm I (THL) Laboratory Biomarker Analysis Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 750 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm I (THL) Paclitaxel Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 750 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm I (THL) Trastuzumab Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 750 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm II (TH) Laboratory Biomarker Analysis Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm II (TH) Paclitaxel Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm II (TH) Trastuzumab Patients receive trastuzumab 2 mg/kg IV over 30-90 minutes and paclitaxel 80 mg/m\^2 IV over 1 hour once weekly for 16 weeks in the absence of disease progression or unacceptable toxicity. Arm III (TL) Paclitaxel Patients receive paclitaxel 80 mg/m\^2 IV over 1 hour once weekly and lapatinib ditosylate 15000 mg PO once daily for 16 weeks in the absence of disease progression or unacceptable toxicity. (Discontinued as of 6-15-11)
- Primary Outcome Measures
Name Time Method pCR Rate At time of surgery Complete pathological response is defined as the absence of residual invasive carcinoma in the breast at the time of definitive surgical removal. Pathologic complete response in the lymph nodes is defined as no detectable invasive tumor by H\&E. Analysis will use a chi-square test for the difference in proportions of patients on the THL arm versus the TH arm who achieve a pCR. Exact binomial methods will be used to construct 95% confidence intervals around the pCR incidence for each arm.
- Secondary Outcome Measures
Name Time Method Radiographic Response Rate (at Completion of Neoadjuvant Therapy) Week 16 Response was defined by the Response Evaluation Criteria in Solid Tumors (RECIST). A responding participant had either a complete response (disappearance of all target lesions) or partial response (30% decrease in sum of longest diameter of target lesions).
Time to First Failure Time from study entry to any recurrence ( up to 10 years) Time to first failure is defined as the interval from study entry to ipsilateral invasive breast tumor recurrence, regional invasive breast cancer recurrence, distant recurrence or death from any cause. Patients who have not experienced any of these events will be censored at the date of last clinical assessment. Distribution was estimated using the Kaplan Meier product-limit method.
Overall Survival Time from randomization to death or last follow-up (up to 10 years) Overall survival was measured as the interval from study entry until death, from any cause, or last contact. Distribution was estimated using the Kaplan Meier product-limit method
Pathologic Stage in the Breast and Axilla At time of surgery Stage will be determined by the American Joint Committee on Cancer (AJCC) TNM (tumor, lymph nodes, metastasis) staging system.
Incidence of Adverse Events as Graded by the National Cancer Institute Common Terminology Criteria for Adverse Events Version 3 Up to 30 days post-treatment The type and grade of treatment-related toxicity will be tabulated by treatment arm.
Relapse-free Survival (RFS) Time from surgery to any recurrence (up to 10 years) Relapse free survival is defined as the interval from definitive surgery to ipsilateral invasive breast tumor recurrence, regional invasive breast cancer recurrence, distant recurrence, or death from any cause, whichever occurs first. Patients who have not experienced any of these events will be censored at the date of last clinical assessment. Patients who do not undergo definitive surgery will not be assessable for RFS. Distribution was estimated using the Kaplan Meier product-limit method.
Trial Locations
- Locations (316)
Banner University Medical Center - Tucson
🇺🇸Tucson, Arizona, United States
Sparks Regional Medical Center
🇺🇸Fort Smith, Arkansas, United States
Providence Saint Joseph Medical Center/Disney Family Cancer Center
🇺🇸Burbank, California, United States
East Bay Radiation Oncology Center
🇺🇸Castro Valley, California, United States
Eden Hospital Medical Center
🇺🇸Castro Valley, California, United States
Valley Medical Oncology Consultants-Castro Valley
🇺🇸Castro Valley, California, United States
Bay Area Breast Surgeons Inc
🇺🇸Emeryville, California, United States
Valley Medical Oncology Consultants-Fremont
🇺🇸Fremont, California, United States
Contra Costa Regional Medical Center
🇺🇸Martinez, California, United States
El Camino Hospital
🇺🇸Mountain View, California, United States
Palo Alto Medical Foundation-Camino Division
🇺🇸Mountain View, California, United States
Highland General Hospital
🇺🇸Oakland, California, United States
Alta Bates Summit Medical Center - Summit Campus
🇺🇸Oakland, California, United States
Bay Area Tumor Institute
🇺🇸Oakland, California, United States
Hematology and Oncology Associates-Oakland
🇺🇸Oakland, California, United States
Tom K Lee Inc
🇺🇸Oakland, California, United States
Desert Regional Medical Center
🇺🇸Palm Springs, California, United States
Palo Alto Medical Foundation Health Care
🇺🇸Palo Alto, California, United States
Valley Care Health System - Pleasanton
🇺🇸Pleasanton, California, United States
Valley Medical Oncology Consultants
🇺🇸Pleasanton, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸Sacramento, California, United States
Saint Helena Hospital
🇺🇸Saint Helena, California, United States
Salinas Valley Memorial
🇺🇸Salinas, California, United States
Zuckerberg San Francisco General Hospital
🇺🇸San Francisco, California, United States
UCSF Medical Center-Mount Zion
🇺🇸San Francisco, California, United States
Doctors Medical Center- JC Robinson Regional Cancer Center
🇺🇸San Pablo, California, United States
The Medical Center of Aurora
🇺🇸Aurora, Colorado, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
AdventHealth Porter
🇺🇸Denver, Colorado, United States
Presbyterian - Saint Lukes Medical Center - Health One
🇺🇸Denver, Colorado, United States
Saint Joseph Hospital - Cancer Centers of Colorado
🇺🇸Denver, Colorado, United States
Rose Medical Center
🇺🇸Denver, Colorado, United States
Western States Cancer Research NCORP
🇺🇸Denver, Colorado, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Saint Mary's Hospital and Regional Medical Center
🇺🇸Grand Junction, Colorado, United States
Banner North Colorado Medical Center
🇺🇸Greeley, Colorado, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
AdventHealth Littleton
🇺🇸Littleton, Colorado, United States
Sky Ridge Medical Center
🇺🇸Lone Tree, Colorado, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Banner McKee Medical Center
🇺🇸Loveland, Colorado, United States
AdventHealth Parker
🇺🇸Parker, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Intermountain Health Lutheran Hospital
🇺🇸Wheat Ridge, Colorado, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸Hartford, Connecticut, United States
Manchester Memorial Hospital
🇺🇸Manchester, Connecticut, United States
Middlesex Hospital
🇺🇸Middletown, Connecticut, United States
Beebe Medical Center
🇺🇸Lewes, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
MedStar Georgetown University Hospital
🇺🇸Washington, District of Columbia, United States
Halifax Health Medical Center-Centers for Oncology
🇺🇸Daytona Beach, Florida, United States
Holy Cross Hospital
🇺🇸Silver Spring, Maryland, United States
Florida Cancer Specialists-Gainesville Cancer Center
🇺🇸Gainesville, Florida, United States
Jupiter Medical Center
🇺🇸Jupiter, Florida, United States
Mount Sinai Medical Center
🇺🇸Miami Beach, Florida, United States
Cleveland Clinic-Weston
🇺🇸Weston, Florida, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Atlanta Regional CCOP
🇺🇸Atlanta, Georgia, United States
Emory Saint Joseph's Hospital
🇺🇸Atlanta, Georgia, United States
Northside Hospital
🇺🇸Atlanta, Georgia, United States
WellStar Cobb Hospital
🇺🇸Austell, Georgia, United States
John B Amos Cancer Center
🇺🇸Columbus, Georgia, United States
Emory Decatur Hospital
🇺🇸Decatur, Georgia, United States
Piedmont Fayette Hospital
🇺🇸Fayetteville, Georgia, United States
Northside Hospital - Gwinnett
🇺🇸Lawrenceville, Georgia, United States
Atrium Health Navicent
🇺🇸Macon, Georgia, United States
Wellstar Kennestone Hospital
🇺🇸Marietta, Georgia, United States
Southern Regional Medical Center
🇺🇸Riverdale, Georgia, United States
Harbin Clinic Medical Oncology and Clinical Research
🇺🇸Rome, Georgia, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸Savannah, Georgia, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸Boise, Idaho, United States
OSF Saint Anthony's Health Center
🇺🇸Alton, Illinois, United States
Mount Sinai Hospital Medical Center
🇺🇸Chicago, Illinois, United States
University of Illinois
🇺🇸Chicago, Illinois, United States
Presence Resurrection Medical Center
🇺🇸Chicago, Illinois, United States
University of Chicago Comprehensive Cancer Center
🇺🇸Chicago, Illinois, United States
Weiss Memorial Hospital
🇺🇸Chicago, Illinois, United States
Advocate Good Samaritan Hospital
🇺🇸Downers Grove, Illinois, United States
Duly Health and Care Joliet
🇺🇸Joliet, Illinois, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
SSM Health Good Samaritan
🇺🇸Mount Vernon, Illinois, United States
Advocate Christ Medical Center
🇺🇸Oak Lawn, Illinois, United States
Swedish American Hospital
🇺🇸Rockford, Illinois, United States
Franciscan Saint Francis Health-Beech Grove
🇺🇸Beech Grove, Indiana, United States
Fort Wayne Medical Oncology and Hematology Inc-Parkview
🇺🇸Fort Wayne, Indiana, United States
Reid Health
🇺🇸Richmond, Indiana, United States
McFarland Clinic - Ames
🇺🇸Ames, Iowa, United States
University of Iowa Healthcare Cancer Services Quad Cities
🇺🇸Bettendorf, Iowa, United States
UI Health Care Mission Cancer and Blood - West Des Moines Clinic
🇺🇸Clive, Iowa, United States
Mercy Capitol
🇺🇸Des Moines, Iowa, United States
Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
Iowa-Wide Oncology Research Coalition NCORP
🇺🇸Des Moines, Iowa, United States
UI Health Care Mission Cancer and Blood - Des Moines Clinic
🇺🇸Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
UI Health Care Mission Cancer and Blood - Laurel Clinic
🇺🇸Des Moines, Iowa, United States
Iowa Lutheran Hospital
🇺🇸Des Moines, Iowa, United States
University of Iowa/Holden Comprehensive Cancer Center
🇺🇸Iowa City, Iowa, United States
Siouxland Regional Cancer Center
🇺🇸Sioux City, Iowa, United States
Mercy Medical Center-Sioux City
🇺🇸Sioux City, Iowa, United States
Saint Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
HaysMed
🇺🇸Hays, Kansas, United States
Hutchinson Regional Medical Center
🇺🇸Hutchinson, Kansas, United States
University of Kansas Cancer Center
🇺🇸Kansas City, Kansas, United States
Mercy Hospital Pittsburg
🇺🇸Pittsburg, Kansas, United States
Salina Regional Health Center
🇺🇸Salina, Kansas, United States
Cotton O'Neil Cancer Center / Stormont Vail Health
🇺🇸Topeka, Kansas, United States
University of Kansas Health System Saint Francis Campus
🇺🇸Topeka, Kansas, United States
Harold Alfond Center for Cancer Care
🇺🇸Augusta, Maine, United States
Eastern Maine Medical Center
🇺🇸Bangor, Maine, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸Baltimore, Maryland, United States
Walter Reed National Military Medical Center
🇺🇸Bethesda, Maryland, United States
Christiana Care - Union Hospital
🇺🇸Elkton, Maryland, United States
TidalHealth Peninsula Regional
🇺🇸Salisbury, Maryland, United States
Sturdy Memorial Hospital
🇺🇸Attleboro, Massachusetts, United States
Tufts Medical Center
🇺🇸Boston, Massachusetts, United States
Massachusetts General Hospital Cancer Center
🇺🇸Boston, Massachusetts, United States
Brigham and Women's Hospital
🇺🇸Boston, Massachusetts, United States
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Dana-Farber Cancer Institute
🇺🇸Boston, Massachusetts, United States
Steward Saint Elizabeth's Medical Center
🇺🇸Brighton, Massachusetts, United States
Dana-Farber/Brigham and Women's Cancer Center at Milford Regional
🇺🇸Milford, Massachusetts, United States
Newton-Wellesley Hospital
🇺🇸Newton, Massachusetts, United States
Michigan Cancer Research Consortium NCORP
🇺🇸Ann Arbor, Michigan, United States
Trinity Health Saint Joseph Mercy Hospital Ann Arbor
🇺🇸Ann Arbor, Michigan, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Corewell Health Dearborn Hospital
🇺🇸Dearborn, Michigan, United States
Henry Ford Health Saint John Hospital
🇺🇸Detroit, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Genesys Regional Medical Center-West Flint Campus
🇺🇸Flint, Michigan, United States
Genesys Regional Medical Center
🇺🇸Grand Blanc, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Ascension Borgess Hospital
🇺🇸Kalamazoo, Michigan, United States
University of Michigan Health - Sparrow Lansing
🇺🇸Lansing, Michigan, United States
Trinity Health Saint Mary Mercy Livonia Hospital
🇺🇸Livonia, Michigan, United States
Trinity Health Saint Joseph Mercy Oakland Hospital
🇺🇸Pontiac, Michigan, United States
Lake Huron Medical Center
🇺🇸Port Huron, Michigan, United States
MyMichigan Medical Center Saginaw
🇺🇸Saginaw, Michigan, United States
Henry Ford Health Providence Southfield Hospital
🇺🇸Southfield, Michigan, United States
Henry Ford Health Warren Hospital
🇺🇸Warren, Michigan, United States
Mayo Clinic Health Systems-Mankato
🇺🇸Mankato, Minnesota, United States
Southeast Missouri Hospital
🇺🇸Cape Girardeau, Missouri, United States
Mercy Cancer Center - Cape Girardeau
🇺🇸Cape Girardeau, Missouri, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
MU Health Care Goldschmidt Cancer Center
🇺🇸Jefferson City, Missouri, United States
University Health Truman Medical Center
🇺🇸Kansas City, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Center for Cancer Care and Research
🇺🇸Saint Louis, Missouri, United States
Comprehensive Cancer Care PC
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Saint Louis-Cape Girardeau CCOP
🇺🇸Saint Louis, Missouri, United States
Billings Clinic Cancer Center
🇺🇸Billings, Montana, United States
Northern Rockies Radiation Oncology Center
🇺🇸Billings, Montana, United States
Saint Vincent Healthcare
🇺🇸Billings, Montana, United States
Montana Cancer Consortium NCORP
🇺🇸Billings, Montana, United States
Saint Vincent Frontier Cancer Center
🇺🇸Billings, Montana, United States
Bozeman Health Deaconess Hospital
🇺🇸Bozeman, Montana, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸Butte, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸Great Falls, Montana, United States
Berdeaux, Donald MD (UIA Investigator)
🇺🇸Great Falls, Montana, United States
Great Falls Clinic
🇺🇸Great Falls, Montana, United States
Northern Montana Hospital
🇺🇸Havre, Montana, United States
Saint Peter's Community Hospital
🇺🇸Helena, Montana, United States
Glacier Oncology PLLC
🇺🇸Kalispell, Montana, United States
Kalispell Medical Oncology
🇺🇸Kalispell, Montana, United States
Logan Health Medical Center
🇺🇸Kalispell, Montana, United States
Montana Cancer Specialists
🇺🇸Missoula, Montana, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Community Medical Center
🇺🇸Missoula, Montana, United States
Guardian Oncology and Center for Wellness
🇺🇸Missoula, Montana, United States
Nebraska Cancer Research Center
🇺🇸Lincoln, Nebraska, United States
Missouri Valley Cancer Consortium
🇺🇸Omaha, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
University Medical Center of Southern Nevada
🇺🇸Las Vegas, Nevada, United States
Nevada Cancer Research Foundation NCORP
🇺🇸Las Vegas, Nevada, United States
Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
New Hampshire Oncology Hematology PA-Concord
🇺🇸Concord, New Hampshire, United States
Cheshire Medical Center-Dartmouth-Hitchcock Keene
🇺🇸Keene, New Hampshire, United States
LRGHealthcare-Lakes Region General Hospital
🇺🇸Laconia, New Hampshire, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸Lebanon, New Hampshire, United States
Dartmouth Cancer Center - Manchester
🇺🇸Manchester, New Hampshire, United States
Elliot Hospital
🇺🇸Manchester, New Hampshire, United States
Solinsky Center for Cancer Care
🇺🇸Manchester, New Hampshire, United States
Foundation Medical Partners
🇺🇸Nashua, New Hampshire, United States
Cooper Hospital University Medical Center
🇺🇸Camden, New Jersey, United States
Morristown Medical Center
🇺🇸Morristown, New Jersey, United States
Rutgers New Jersey Medical School
🇺🇸Newark, New Jersey, United States
Overlook Hospital
🇺🇸Summit, New Jersey, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸Albuquerque, New Mexico, United States
Hematology Oncology Associates
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Roswell Park Cancer Institute
🇺🇸Buffalo, New York, United States
Hematology Oncology Associates of Central New York-East Syracuse
🇺🇸East Syracuse, New York, United States
Elmhurst Hospital Center
🇺🇸Elmhurst, New York, United States
Queens Hospital Center
🇺🇸Jamaica, New York, United States
Northwell Health NCORP
🇺🇸Lake Success, New York, United States
Northwell Health/Center for Advanced Medicine
🇺🇸Lake Success, New York, United States
North Shore University Hospital
🇺🇸Manhasset, New York, United States
Garnet Health Medical Center
🇺🇸Middletown, New York, United States
Long Island Jewish Medical Center
🇺🇸New Hyde Park, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸New York, New York, United States
Vassar Brothers Medical Center
🇺🇸Poughkeepsie, New York, United States
State University of New York Upstate Medical University
🇺🇸Syracuse, New York, United States
Mission Hospital
🇺🇸Asheville, North Carolina, United States
Cone Health Cancer Center at Alamance Regional
🇺🇸Burlington, North Carolina, United States
UNC Lineberger Comprehensive Cancer Center
🇺🇸Chapel Hill, North Carolina, United States
Atrium Health Cabarrus/LCI-Concord
🇺🇸Concord, North Carolina, United States
Duke University Medical Center
🇺🇸Durham, North Carolina, United States
Wayne Memorial Hospital
🇺🇸Goldsboro, North Carolina, United States
East Carolina University
🇺🇸Greenville, North Carolina, United States
ECU Health Oncology Kinston
🇺🇸Kinston, North Carolina, United States
FirstHealth of the Carolinas-Moore Regional Hospital
🇺🇸Pinehurst, North Carolina, United States
UNC Rex Healthcare
🇺🇸Raleigh, North Carolina, United States
Marion L Shepard Cancer Center - ECU Health Beaufort Hospital
🇺🇸Washington, North Carolina, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Mid Dakota Clinic
🇺🇸Bismarck, North Dakota, United States
Saint Alexius Medical Center
🇺🇸Bismarck, North Dakota, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Cleveland Clinic Akron General
🇺🇸Akron, Ohio, United States
Cleveland Clinic Cancer Center Beachwood
🇺🇸Beachwood, Ohio, United States
Aultman Health Foundation
🇺🇸Canton, Ohio, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Foundation
🇺🇸Cleveland, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Grandview Hospital
🇺🇸Dayton, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital North
🇺🇸Dayton, Ohio, United States
Dayton NCI Community Oncology Research Program
🇺🇸Dayton, Ohio, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
Cleveland Clinic Cancer Center Independence
🇺🇸Independence, Ohio, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Saint Rita's Medical Center
🇺🇸Lima, Ohio, United States
Hillcrest Hospital Cancer Center
🇺🇸Mayfield Heights, Ohio, United States
University Hospitals Parma Medical Center
🇺🇸Parma, Ohio, United States
Cleveland Clinic Cancer Center Strongsville
🇺🇸Strongsville, Ohio, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Clinton Memorial Hospital/Foster J Boyd Regional Cancer Center
🇺🇸Wilmington, Ohio, United States
Cleveland Clinic Wooster Family Health and Surgery Center
🇺🇸Wooster, Ohio, United States
Greene Memorial Hospital
🇺🇸Xenia, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Cancer Care Associates
🇺🇸Oklahoma City, Oklahoma, United States
UPMC Hillman Cancer Center Erie
🇺🇸Erie, Pennsylvania, United States
Penn State Milton S Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Lewistown Hospital
🇺🇸Lewistown, Pennsylvania, United States
Guthrie Medical Group PC-Robert Packer Hospital
🇺🇸Sayre, Pennsylvania, United States
Mount Nittany Medical Center
🇺🇸State College, Pennsylvania, United States
Kent Hospital
🇺🇸Warwick, Rhode Island, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸Boiling Springs, South Carolina, United States
Roper Hospital
🇺🇸Charleston, South Carolina, United States
Prisma Health Cancer Institute - Easley
🇺🇸Easley, South Carolina, United States
Greenville Health System Cancer Institute-Andrews
🇺🇸Greenville, South Carolina, United States
Saint Francis Hospital
🇺🇸Federal Way, Washington, United States
Prisma Health Cancer Institute - Butternut
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸Greenville, South Carolina, United States
Prisma Health Greenville Memorial Hospital
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Eastside
🇺🇸Greenville, South Carolina, United States
Self Regional Healthcare
🇺🇸Greenwood, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸Greer, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸Seneca, South Carolina, United States
Lexington Medical Center
🇺🇸West Columbia, South Carolina, United States
Erlanger Medical Center
🇺🇸Chattanooga, Tennessee, United States
Nashville Oncology Associates PC
🇺🇸Nashville, Tennessee, United States
Meharry Medical College
🇺🇸Nashville, Tennessee, United States
Doctor's Hospital of Laredo
🇺🇸Laredo, Texas, United States
Texas Tech University Health Sciences Center-Lubbock
🇺🇸Lubbock, Texas, United States
Central Vermont Medical Center/National Life Cancer Treatment
🇺🇸Berlin, Vermont, United States
University of Vermont and State Agricultural College
🇺🇸Burlington, Vermont, United States
Danville Regional Medical Center
🇺🇸Danville, Virginia, United States
Hematology Oncology Associates of Fredericksburg Inc
🇺🇸Fredericksburg, Virginia, United States
Centra Alan B Pearson Regional Cancer Center
🇺🇸Lynchburg, Virginia, United States
Cancer Care Center at Island Hospital
🇺🇸Anacortes, Washington, United States
MultiCare Auburn Medical Center
🇺🇸Auburn, Washington, United States
PeaceHealth Saint Joseph Medical Center
🇺🇸Bellingham, Washington, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Providence Regional Cancer System-Centralia
🇺🇸Centralia, Washington, United States
Kadlec Clinic Hematology and Oncology
🇺🇸Kennewick, Washington, United States
EvergreenHealth Medical Center
🇺🇸Kirkland, Washington, United States
Saint Clare Hospital
🇺🇸Lakewood, Washington, United States
Skagit Valley Hospital
🇺🇸Mount Vernon, Washington, United States
Providence - Saint Peter Hospital
🇺🇸Olympia, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸Poulsbo, Washington, United States
MultiCare Good Samaritan Hospital
🇺🇸Puyallup, Washington, United States
Virginia Mason Medical Center
🇺🇸Seattle, Washington, United States
Minor and James Medical PLLC
🇺🇸Seattle, Washington, United States
Pacific Medical Center-First Hill
🇺🇸Seattle, Washington, United States
Kaiser Permanente Washington
🇺🇸Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
University of Washington Medical Center - Montlake
🇺🇸Seattle, Washington, United States
PeaceHealth United General Medical Center
🇺🇸Sedro-Woolley, Washington, United States
Saint Michael Cancer Center
🇺🇸Silverdale, Washington, United States
Cancer Care Northwest - Spokane South
🇺🇸Spokane, Washington, United States
Providence Sacred Heart Medical Center and Children's Hospital
🇺🇸Spokane, Washington, United States
Providence Holy Family Hospital
🇺🇸Spokane, Washington, United States
Evergreen Hematology and Oncology PS
🇺🇸Spokane, Washington, United States
MultiCare Allenmore Hospital
🇺🇸Tacoma, Washington, United States
MultiCare Tacoma General Hospital
🇺🇸Tacoma, Washington, United States
Northwest NCI Community Oncology Research Program
🇺🇸Tacoma, Washington, United States
Saint Joseph Medical Center
🇺🇸Tacoma, Washington, United States
Wenatchee Valley Hospital and Clinics
🇺🇸Wenatchee, Washington, United States
Saint Mary's Medical Center
🇺🇸Huntington, West Virginia, United States
Camden Clark Medical Center
🇺🇸Parkersburg, West Virginia, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States
Ascension Southeast Wisconsin Hospital - Saint Joseph Campus
🇺🇸Milwaukee, Wisconsin, United States
Welch Cancer Center
🇺🇸Sheridan, Wyoming, United States
San Juan City Hospital
🇵🇷San Juan, Puerto Rico