Testing Radiation and HER2-targeted Therapy Versus HER2-targeted Therapy Alone for Low-risk HER2-positive Breast Cancer
- Conditions
- HER2-positive Breast Cancer
- Interventions
- Radiation: Standard of Care Adjuvant Breast RadiationDrug: Standard of Care HER2-targeted Therapy Without Adjuvant Breast Radiation
- Registration Number
- NCT05705401
- Lead Sponsor
- NRG Oncology
- Brief Summary
This Phase III trial compares the recurrence-free interval (RFI) among patients with early-stage, low risk HER2+ breast cancer who undergo breast conserving surgery and receive HER2-directed therapy, and are randomized to not receive adjuvant breast radiotherapy versus those who are randomized to receive adjuvant radiotherapy per the standard of care.
- Detailed Description
The landmark trials that established breast conservation therapy (BCT) (breast-conserving surgery followed by adjuvant breast irradiation) as a suitable alternative to mastectomy were conducted in an era that predated biological subtyping of breast cancer and the use of HER2-directed therapies in patients with HER2+ cancers. These trials established adjuvant radiotherapy following breast-conserving surgery as necessary to maximize local control, yet, in the intervening years, overall outcomes have improved significantly owing to widespread adoption of screening mammography, resulting in a substantial reduction in average tumor size at diagnosis, as well as improvements in surgical techniques and, crucial for this proposal, the development of highly active systemic therapies.
Before the development of HER2-targeted therapies, patients with HER2-driven localized breast cancer had among the highest rates of local recurrence. However, with improved identification of these patients and the advent of HER2-directed therapies, outcomes have improved significantly, and trials have sought to optimize treatment to reduce the morbidity of both local and systemic treatment. Among the most salient of these examples is the APT trial, a single-arm adjuvant study that enrolled 410 breast cancer patients with HER2+ tumors ≤ 3cm in size and negative axillary nodes, who received adjuvant systemic therapy with weekly paclitaxel and trastuzumab for 12 weeks (TH) followed by 9 months of trastuzumab monotherapy. In addition to demonstrating a very low incidence of distant recurrence, among those on the trial who underwent BCT (lumpectomy and radiation, n = 244), only 2 local recurrence (LR) events have been reported after 7 years of follow-up (7-year LR = 1.2%), representing among the most favorable local outcomes of any breast cancer cohort studied to date. Confirmatory results are forthcoming from the ATEMPT trial, which evaluated the antibody-drug conjugate T-DM1 (ado-trastuzumab emtansine) (n=383) vs the TH regimen from the APT trial (n = 114), thus far showing only 3 LRs in each arm with a median 3-years of follow-up. Importantly, per the current standard of care for HER2+ patients undergoing BCT, all patients presumably received adjuvant breast radiotherapy.
The balance of the BCT literature, including a landmark meta-analysis by the Early Breast Cancer Trialists' Collaborative Group, suggests that adjuvant radiotherapy approximately halves the risk of local recurrence following lumpectomy across all analyzable subgroups. While the relative benefit appears constant across subgroups, the absolute benefit of adjuvant radiotherapy varies with the underlying risk. Taking the favorable results of the APT trial (1.2% 7-year LR), if one presumes that omission of radiotherapy yields a doubling or tripling of local recurrence (based on the observed RR of 0.5 - 0.66 for those receiving radiotherapy across the preponderance of historical trials), this population might have manifested a LR rate of 2.4 - 3.6% with the omission of radiotherapy. That is to say, the hypothesis is that administration of RT to APT patients undergoing BCT may have reduced the 7-year absolute risk of LR by only 1.2-2.4%. Through the identification of patients who are at low risk of LR, it may be acceptable for such patients to forego radiation. This hypothesis will be studied by evaluating omission of radiotherapy among patients with pT1N0 disease at breast-conserving surgery who receive adjuvant HER2-directed therapy (trastuzumab/paclitaxel preferred, other options per protocol), or with clinical tumors ≤ 3 cm and clinically negative axillary nodes (cN0) who achieve a pathologic complete response (pCR; ypT0N0) following preoperative (neoadjuvant) administration of HER2-directed therapy (trastuzumab/paclitaxel preferred, other options per protocol). It is expcted that the 5-year LR rate for this population omitting radiotherapy will be 2% or less, and that omission of radiation will not have a measurable impact on regional and distant recurrences or overall survival.
The practice of breast radiation oncology has benefited immensely from practice-changing trials that have refined the application of adjuvant radiotherapy since the early surgical studies determined whole breast radiotherapy to be necessary following lumpectomy. There are now several favorable breast cancer subtypes in which patients routinely forego radiotherapy after trials demonstrating modest benefits in terms of local recurrence and no impact on distant recurrence or survival, such as among small, low grade luminal cancers in older women and "good-risk" DCIS. Therefore, this will study the omission of radiotherapy among a population of HER2+ breast cancer patients who are now appreciated to also have favorable risk, so as to similarly weigh the attendant inconveniences, cost and morbidity of radiotherapy in light of an established absolute benefit, which may prove to be modest.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 1300
-
The patient or a legally authorized representative must provide study-specific informed consent prior to study entry and, for patients treated in the U.S., authorization permitting release of personal health information.
-
female and male patients who have undergone breast conserving surgery and completed a minimum of 4 cycles (12 weeks) of neoadjuvant or adjuvant chemotherapy in combination with HER2-targeted therapy.
-≥ 40 years of age
-
ECOG performance status of 0 ,1, or 2/Karnofsky performance status above 60
-
Histologically or cytologically confirmed invasive breast carcinoma.
-
tumor must have been determined to be HER2-positive by current ASCO/CAP guidelines based on local testing results.
-
Patient must have undergone axillary staging, either sentinel node biopsy (SNB) or axillary lymph nodal dissection (ALND). In neoadjuvant patients, SNB following neoadjuvant therapy is strongly recommended. SNB prior to neoadjuvant therapy is discouraged, but patients are permitted if node negative (pN0).
-
The following staging criteria must be met according to AJCC 8th edition criteria:
Adjuvant cohort : By pathologic evaluation, the patient's primary tumor must be </= 2 cm and ipsilateral nodes must be pN0. Surgical lumpectomy margins must be negative for invasive cancer and ductal carcinoma in situ (no ink on tumor).
Neoadjuvant cohort: Prior to neoadjuvant therapy, the patient's primary tumor must be < 3 cm by imaging studies, with negative axillary nodes (cN0) based on axillary U/S, CT, PET or MRI. Physical examination is not sufficient documentation of cN0 status; • Must be ypT0N0 at surgery (lumpectomy); patients with residual non-invasive disease (DCIS) in the surgical specimen (ypTis), are NOT eligible.
- For the Adjuvant cohort, adjuvant therapy must have consisted of a minimum of 4 cycles (12 weeks) of chemotherapy in combination with HER2-targeted therapy.
- For the Neoadjuvant cohort, neoadjuvant therapy must have consisted of a minimum of 4 cycles (12 weeks) of chemotherapy in combination with HER2-targeted therapy.- ; Patients who did not receive chemotherapy in the neoadjuvant setting are not eligible, even if they achieved pCR with their preoperative treatment; nor would these patients become eligible by receiving chemotherapy after surgery.
- In patients assigned to radiation therapy, treatment should start ≤ 12 weeks from surgery on the Neoadjuvant cohort and ≤ 8 weeks from the completion of chemotherapy on the Adjuvant cohort. Patients should continue HER2-targeted therapy during assigned study treatment (radiation or observation).
- Bilateral mammogram or MRI within 52 weeks prior to randomization.
- HIV-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months of randomization are eligible for this trial.
- Definitive clinical or radiologic evidence of metastatic disease.
- On the Adjuvant cohort, patients with a primary tumor >2 cm on pathologic examination of the surgical specimen. On the Neoadjuvant cohort, patients with a primary tumor > 3 cm or with abnormal or suspicious ipsilateral axillary nodes by pretreatment imaging, unless demonstrated to be negative by cytologic or histologic examination.
- Pathologically positive axillary nodes at any time including of pN0(i+) or pN0(mol+) ypN0(i+) or ypN0(mol+) disease.
- Patient planning for or status-post mastectomy.
- Radiographically suspicious ipsilateral or contralateral axillary, supraclavicular, infraclavicular, or internal mammary lymph nodes, unless there is histological confirmation that these nodes are negative for metastatic disease.
- Suspicious microcalcifications, densities, or palpable abnormalities (in the ipsilateral or contralateral breast), or mass or non-mass enhancement on MRI (if performed) aside from the known cancer, unless biopsied and found to be benign.
- Non-epithelial breast malignancies such as sarcoma or lymphoma.
- Multicentric carcinoma (invasive cancer or DCIS) in more than one quadrant or separated by > 4 centimeters. If multifocal, all foci should be confined to a maximum tumor bed of 3 cm determined by pathological assessment.
- Paget's disease of the nipple.
- Synchronous (unilateral or bilateral) invasive breast cancer or DCIS. (Patients with synchronous and/or previous contralateral LCIS are eligible.)
- On the Adjuvant cohort, surgical margins that cannot be microscopically assessed or are positive at pathologic evaluation. (If surgical margins are rendered free of disease by re-excision, the patient is eligible).
- Treatment plan that includes regional nodal irradiation.
- Patients treated for a prior invasive breast malignancy are excluded. Contralateral DCIS ≥ 10 years prior to enrollment is permissible.
- Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial.
- Patients on oral, transdermal, or subdermal estrogen replacement (including all estrogen only and estrogen-progesterone formulas) are not eligible unless discontinued prior to randomization.
- Prior ipsilateral breast or thoracic RT for any condition (contralateral RT for DCIS ≥ 10 years prior to randomization is permitted).
- Active collagen vascular disease, specifically dermatomyositis with a CPK level above normal or with an active systemic lupus erythematosus, or scleroderma.
- Clinicians should consider whether any conditions would make this protocol unreasonably hazardous for the patient.
- Pregnancy or lactation at the time of randomization or intention to become pregnant during treatment. (Note: Pregnancy testing according to institutional standards for patients of childbearing potential must be performed within 14 days prior to randomization.)
- Use of any investigational product within 30 days prior to randomization.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Standard of Care Adjuvant Breast Radiation Standard of Care Adjuvant Breast Radiation Patients continue to receive their current planned adjuvant breast radiation and systemic HER2-targeted therapies Standard of Care HER2-targeted Therapy Without Adjuvant Breast Radiation Standard of Care HER2-targeted Therapy Without Adjuvant Breast Radiation Patients continue to receive their current systemic HER2-targeted therapy without breast adjuvant radiation
- Primary Outcome Measures
Name Time Method recurrence-free interval (RFI) From randomization to first recurrence event or censoring for the duration of the trial, at 10.5 years Time to recurrence event or censoring
- Secondary Outcome Measures
Name Time Method ipsilateral breast recurrence (IBR) by treatment arm From randomization to first recurrence event or censoring for the duration of the trial at 10.5 years. Time to ipsilateral breast recurrence (IBR) by treatment arm.
patient-reported worry about recurrence by treatment arm using a the three-item worry about recurrence score At 3 years after randomization To evaluate whether there is a difference in patient-reported worry about recurrence in patients who do and do not receive breast radiation in cohort A and cohort B. The worry about recurrence score has a range from 1-5 with higher scores indicating more worry.
disease-free survival (DFS) by treatment arm. From the time of randomization for the duration of the trial at 10.5 years. To determine disease-free survival (DFS) by treatment arm.
overall survival (OS) by treatment arm. From the time of randomization for the duration of the trial at 10.5 years. To determine overall survival (OS) by treatment arm.
local regional recurrence (LRR) by treatment arm From randomization to first recurrence event or censoring for the duration of the trial at 10.5 years. Time to local regional recurrence (LRR) by treatment arm.
patient-reported breast pain by treatment arm using the Breast Cancer Treatment Outcome Scale (BCTOS) At 3 years after randomization To evaluate whether there is a difference in patient-reported breast pain in patients who do and do not receive breast radiation in cohort A and cohort B. The BCTOS pain score has a range from 1-5 with higher scores indicating worse pain.
ipsilateral breast recurrence (IBR) for radiation omitting arm From randomization to first recurrence event or censoring for the duration of the trial , measured at year 7 Time to IBTR event or censoring
Trial Locations
- Locations (409)
Kent Hospital
🇺🇸Warwick, Rhode Island, United States
Morton Plant Hospital
🇺🇸Clearwater, Florida, United States
Cancer Center at Saint Joseph's
🇺🇸Phoenix, Arizona, United States
Banner University Medical Center - Tucson
🇺🇸Tucson, Arizona, United States
University of Arizona Cancer Center-North Campus
🇺🇸Tucson, Arizona, United States
Kaiser Permanente-Deer Valley Medical Center
🇺🇸Antioch, California, United States
Mission Hope Medical Oncology - Arroyo Grande
🇺🇸Arroyo Grande, California, United States
PCR Oncology
🇺🇸Arroyo Grande, California, United States
Sutter Auburn Faith Hospital
🇺🇸Auburn, California, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
🇺🇸Auburn, California, United States
Tower Cancer Research Foundation
🇺🇸Beverly Hills, California, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
🇺🇸Cameron Park, California, United States
City of Hope Comprehensive Cancer Center
🇺🇸Duarte, California, United States
Kaiser Permanente Dublin
🇺🇸Dublin, California, United States
Kaiser Permanente-Fremont
🇺🇸Fremont, California, United States
Palo Alto Medical Foundation-Fremont
🇺🇸Fremont, California, United States
Fresno Cancer Center
🇺🇸Fresno, California, United States
Kaiser Permanente-Fresno
🇺🇸Fresno, California, United States
UCI Health - Chao Family Comprehensive Cancer Center and Ambulatory Care
🇺🇸Irvine, California, United States
City of Hope at Irvine Lennar
🇺🇸Irvine, California, United States
City of Hope Antelope Valley
🇺🇸Lancaster, California, United States
Los Angeles General Medical Center
🇺🇸Los Angeles, California, United States
USC / Norris Comprehensive Cancer Center
🇺🇸Los Angeles, California, United States
Cedars Sinai Medical Center
🇺🇸Los Angeles, California, United States
Memorial Medical Center
🇺🇸Modesto, California, United States
Kaiser Permanente-Modesto
🇺🇸Modesto, California, United States
Palo Alto Medical Foundation-Camino Division
🇺🇸Mountain View, California, United States
Kaiser Permanente Oakland-Broadway
🇺🇸Oakland, California, United States
Kaiser Permanente-Oakland
🇺🇸Oakland, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
🇺🇸Orange, California, United States
Palo Alto Medical Foundation Health Care
🇺🇸Palo Alto, California, United States
Stanford Cancer Institute Palo Alto
🇺🇸Palo Alto, California, United States
Pomona Valley Hospital Medical Center
🇺🇸Pomona, California, United States
Kaiser Permanente-Rancho Cordova Cancer Center
🇺🇸Rancho Cordova, California, United States
Kaiser Permanente- Marshall Medical Offices
🇺🇸Redwood City, California, United States
Kaiser Permanente-Richmond
🇺🇸Richmond, California, United States
Rohnert Park Cancer Center
🇺🇸Rohnert Park, California, United States
Kaiser Permanente-Roseville
🇺🇸Roseville, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
🇺🇸Roseville, California, United States
Sutter Roseville Medical Center
🇺🇸Roseville, California, United States
The Permanente Medical Group-Roseville Radiation Oncology
🇺🇸Roseville, California, United States
Kaiser Permanente Downtown Commons
🇺🇸Sacramento, California, United States
Sutter Medical Center Sacramento
🇺🇸Sacramento, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸Sacramento, California, United States
Kaiser Permanente-South Sacramento
🇺🇸Sacramento, California, United States
South Sacramento Cancer Center
🇺🇸Sacramento, California, United States
California Pacific Medical Center-Pacific Campus
🇺🇸San Francisco, California, United States
Kaiser Permanente-San Francisco
🇺🇸San Francisco, California, United States
Kaiser Permanente-Santa Teresa-San Jose
🇺🇸San Jose, California, United States
Stanford Cancer Center South Bay
🇺🇸San Jose, California, United States
Kaiser Permanente San Leandro
🇺🇸San Leandro, California, United States
Pacific Central Coast Health Center-San Luis Obispo
🇺🇸San Luis Obispo, California, United States
Kaiser San Rafael-Gallinas
🇺🇸San Rafael, California, United States
Ridley-Tree Cancer Center
🇺🇸Santa Barbara, California, United States
Kaiser Permanente Medical Center - Santa Clara
🇺🇸Santa Clara, California, United States
Mission Hope Medical Oncology - Santa Maria
🇺🇸Santa Maria, California, United States
Kaiser Permanente-Santa Rosa
🇺🇸Santa Rosa, California, United States
Sutter Pacific Medical Foundation
🇺🇸Santa Rosa, California, United States
City of Hope South Pasadena
🇺🇸South Pasadena, California, United States
Kaiser Permanente Cancer Treatment Center
🇺🇸South San Francisco, California, United States
Kaiser Permanente-South San Francisco
🇺🇸South San Francisco, California, United States
Kaiser Permanente-Stockton
🇺🇸Stockton, California, United States
Palo Alto Medical Foundation-Sunnyvale
🇺🇸Sunnyvale, California, United States
Cedars-Sinai Cancer - Tarzana
🇺🇸Tarzana, California, United States
City of Hope South Bay
🇺🇸Torrance, California, United States
Torrance Memorial Physician Network - Cancer Care
🇺🇸Torrance, California, United States
City of Hope Upland
🇺🇸Upland, California, United States
Kaiser Permanente Medical Center-Vacaville
🇺🇸Vacaville, California, United States
Kaiser Permanente-Vallejo
🇺🇸Vallejo, California, United States
Kaiser Permanente-Walnut Creek
🇺🇸Walnut Creek, California, United States
UCHealth University of Colorado Hospital
🇺🇸Aurora, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸Colorado Springs, Colorado, United States
UCHealth Memorial Hospital Central
🇺🇸Colorado Springs, Colorado, United States
Memorial Hospital North
🇺🇸Colorado Springs, Colorado, United States
Saint Francis Cancer Center
🇺🇸Colorado Springs, Colorado, United States
Poudre Valley Hospital
🇺🇸Fort Collins, Colorado, United States
Cancer Care and Hematology-Fort Collins
🇺🇸Fort Collins, Colorado, United States
UCHealth Greeley Hospital
🇺🇸Greeley, Colorado, United States
UCHealth Highlands Ranch Hospital
🇺🇸Highlands Ranch, Colorado, United States
Medical Center of the Rockies
🇺🇸Loveland, Colorado, United States
John Fitzgerald Kennedy Medical Center
🇺🇸Atlantis, Florida, United States
Lee Memorial Health System
🇺🇸Fort Myers, Florida, United States
Regional Cancer Center-Lee Memorial Health System
🇺🇸Fort Myers, Florida, United States
Sarasota Memorial Hospital-Venice
🇺🇸N. Venice, Florida, United States
Health Central
🇺🇸Ocoee, Florida, United States
Orlando Health Cancer Institute
🇺🇸Orlando, Florida, United States
GenesisCare USA - Plantation
🇺🇸Plantation, Florida, United States
Florida Cancer Specialists - Sarasota
🇺🇸Sarasota, Florida, United States
Intercoastal Medical Group - Cattleridge II
🇺🇸Sarasota, Florida, United States
Florida Cancer Specialists - Sarasota Downtown
🇺🇸Sarasota, Florida, United States
First Physicians Group - Urology Robotic and Minimally Invasive Surgery
🇺🇸Sarasota, Florida, United States
First Physicians Group-Sarasota
🇺🇸Sarasota, Florida, United States
Sarasota Memorial Hospital
🇺🇸Sarasota, Florida, United States
Sarasota Memorial Health Care Center at University Parkway
🇺🇸Sarasota, Florida, United States
Moffitt Cancer Center-International Plaza
🇺🇸Tampa, Florida, United States
Moffitt Cancer Center - McKinley Campus
🇺🇸Tampa, Florida, United States
Moffitt Cancer Center
🇺🇸Tampa, Florida, United States
Florida Cancer Specialists - Venice Pinebrook
🇺🇸Venice, Florida, United States
Moffitt Cancer Center at Wesley Chapel
🇺🇸Wesley Chapel, Florida, United States
Grady Health System
🇺🇸Atlanta, Georgia, United States
Emory Proton Therapy Center
🇺🇸Atlanta, Georgia, United States
Emory University Hospital Midtown
🇺🇸Atlanta, Georgia, United States
Emory University Hospital/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Emory Saint Joseph's Hospital
🇺🇸Atlanta, Georgia, United States
Emory Decatur Hospital
🇺🇸Decatur, Georgia, United States
Emory Johns Creek Hospital
🇺🇸Johns Creek, Georgia, United States
CTCA at Southeastern Regional Medical Center
🇺🇸Newnan, Georgia, United States
South Georgia Medical Center/Pearlman Cancer Center
🇺🇸Valdosta, Georgia, United States
Hawaii Cancer Care - Westridge
🇺🇸'Aiea, Hawaii, United States
Pali Momi Medical Center
🇺🇸'Aiea, Hawaii, United States
Queen's Cancer Center - Pearlridge
🇺🇸'Aiea, Hawaii, United States
The Cancer Center of Hawaii-Pali Momi
🇺🇸'Aiea, Hawaii, United States
The Queen's Medical Center - West Oahu
🇺🇸'Ewa Beach, Hawaii, United States
Hawaii Cancer Care Inc - Waterfront Plaza
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Cenrer - POB I
🇺🇸Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
🇺🇸Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸Honolulu, Hawaii, United States
Castle Medical Center
🇺🇸Kailua, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸Lihue, Hawaii, United States
Saint Luke's Cancer Institute - Boise
🇺🇸Boise, Idaho, United States
Saint Luke's Cancer Institute - Fruitland
🇺🇸Fruitland, Idaho, United States
Saint Luke's Cancer Institute - Meridian
🇺🇸Meridian, Idaho, United States
Saint Luke's Cancer Institute - Nampa
🇺🇸Nampa, Idaho, United States
Saint Luke's Cancer Institute - Twin Falls
🇺🇸Twin Falls, Idaho, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Centralia Oncology Clinic
🇺🇸Centralia, Illinois, United States
Saint Mary's Hospital
🇺🇸Centralia, Illinois, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
John H Stroger Jr Hospital of Cook County
🇺🇸Chicago, Illinois, United States
University of Chicago Comprehensive Cancer Center
🇺🇸Chicago, Illinois, United States
Carle at The Riverfront
🇺🇸Danville, Illinois, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸Decatur, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Northwestern Medicine Cancer Center Kishwaukee
🇺🇸DeKalb, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Crossroads Cancer Center
🇺🇸Effingham, Illinois, United States
Elmhurst Memorial Hospital
🇺🇸Elmhurst, Illinois, United States
Northwestern Medicine Cancer Center Delnor
🇺🇸Geneva, Illinois, United States
Northwestern Medicine Glenview Outpatient Center
🇺🇸Glenview, Illinois, United States
Northwestern Medicine Grayslake Outpatient Center
🇺🇸Grayslake, Illinois, United States
Ingalls Memorial Hospital
🇺🇸Harvey, Illinois, United States
Northwestern Medicine Lake Forest Hospital
🇺🇸Lake Forest, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Edward Hospital/Cancer Center
🇺🇸Naperville, Illinois, United States
UC Comprehensive Cancer Center at Silver Cross
🇺🇸New Lenox, Illinois, United States
Carle Cancer Institute Normal
🇺🇸Normal, Illinois, United States
Cancer Care Center of O'Fallon
🇺🇸O'Fallon, Illinois, United States
HSHS Saint Elizabeth's Hospital
🇺🇸O'Fallon, Illinois, United States
Northwestern Medicine Orland Park
🇺🇸Orland Park, Illinois, United States
University of Chicago Medicine-Orland Park
🇺🇸Orland Park, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸Springfield, Illinois, United States
Springfield Clinic
🇺🇸Springfield, Illinois, United States
Springfield Memorial Hospital
🇺🇸Springfield, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Northwestern Medicine Cancer Center Warrenville
🇺🇸Warrenville, Illinois, United States
Midwestern Regional Medical Center
🇺🇸Zion, Illinois, United States
Northwest Cancer Center - Main Campus
🇺🇸Crown Point, Indiana, United States
UChicago Medicine Northwest Indiana
🇺🇸Crown Point, Indiana, United States
Northwest Oncology LLC
🇺🇸Dyer, Indiana, United States
Goshen Center for Cancer Care
🇺🇸Goshen, Indiana, United States
Northwest Cancer Center - Hobart
🇺🇸Hobart, Indiana, United States
Saint Mary Medical Center
🇺🇸Hobart, Indiana, United States
The Community Hospital
🇺🇸Munster, Indiana, United States
Women's Diagnostic Center - Munster
🇺🇸Munster, Indiana, United States
Reid Health
🇺🇸Richmond, Indiana, United States
Memorial Hospital of South Bend
🇺🇸South Bend, Indiana, United States
Northwest Cancer Center - Valparaiso
🇺🇸Valparaiso, Indiana, United States
Mary Greeley Medical Center
🇺🇸Ames, Iowa, United States
McFarland Clinic - Ames
🇺🇸Ames, Iowa, United States
UI Health Care Mission Cancer and Blood - Ankeny Clinic
🇺🇸Ankeny, Iowa, United States
Physicians' Clinic of Iowa PC
🇺🇸Cedar Rapids, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸Clive, Iowa, United States
UI Health Care Mission Cancer and Blood - West Des Moines Clinic
🇺🇸Clive, Iowa, United States
Greater Regional Medical Center
🇺🇸Creston, Iowa, United States
Iowa Methodist Medical Center
🇺🇸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
UI Health Care Mission Cancer and Blood - Waukee Clinic
🇺🇸Waukee, Iowa, United States
Mercy Medical Center-West Lakes
🇺🇸West Des Moines, Iowa, United States
University of Kansas Cancer Center
🇺🇸Kansas City, Kansas, United States
The University of Kansas Cancer Center - Olathe
🇺🇸Olathe, Kansas, United States
University of Kansas Cancer Center-Overland Park
🇺🇸Overland Park, Kansas, United States
University of Kansas Hospital-Indian Creek Campus
🇺🇸Overland Park, Kansas, United States
Salina Regional Health Center
🇺🇸Salina, Kansas, United States
University of Kansas Health System Saint Francis Campus
🇺🇸Topeka, Kansas, United States
University of Kansas Hospital-Westwood Cancer Center
🇺🇸Westwood, Kansas, United States
The James Graham Brown Cancer Center at University of Louisville
🇺🇸Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸Louisville, Kentucky, United States
Greater Baltimore Medical Center
🇺🇸Baltimore, Maryland, United States
UM Upper Chesapeake Medical Center
🇺🇸Bel Air, Maryland, United States
University of Maryland Shore Medical Center at Easton
🇺🇸Easton, Maryland, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Henry Ford Cancer Institute-Downriver
🇺🇸Brownstown, Michigan, United States
Caro Cancer Center
🇺🇸Caro, Michigan, United States
Michigan Healthcare Professionals Clarkston
🇺🇸Clarkston, Michigan, United States
Henry Ford Macomb Hospital-Clinton Township
🇺🇸Clinton Township, Michigan, United States
Henry Ford Medical Center-Fairlane
🇺🇸Dearborn, Michigan, United States
Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
OSF Saint Francis Hospital and Medical Group
🇺🇸Escanaba, Michigan, United States
Michigan Healthcare Professionals Farmington
🇺🇸Farmington Hills, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
🇺🇸Grand Rapids, Michigan, United States
Corewell Health Grand Rapids Hospitals - Helen DeVos Children's Hospital
🇺🇸Grand Rapids, Michigan, United States
Trinity Health Grand Rapids Hospital
🇺🇸Grand Rapids, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
Michigan Healthcare Professionals Macomb
🇺🇸Macomb, Michigan, United States
Michigan Healthcare Professionals Madison Heights
🇺🇸Madison Heights, Michigan, United States
Saint Mary's Oncology/Hematology Associates of Marlette
🇺🇸Marlette, Michigan, United States
Henry Ford Medical Center-Columbus
🇺🇸Novi, Michigan, United States
Trinity Health Saint Joseph Mercy Oakland Hospital
🇺🇸Pontiac, Michigan, United States
Corewell Health William Beaumont University Hospital
🇺🇸Royal Oak, Michigan, United States
MyMichigan Medical Center Saginaw
🇺🇸Saginaw, Michigan, United States
Oncology Hematology Associates of Saginaw Valley PC
🇺🇸Saginaw, Michigan, United States
MyMichigan Medical Center Tawas
🇺🇸Tawas City, Michigan, United States
Corewell Health Beaumont Troy Hospital
🇺🇸Troy, Michigan, United States
Michigan Healthcare Professionals Troy
🇺🇸Troy, Michigan, United States
Henry Ford West Bloomfield Hospital
🇺🇸West Bloomfield, Michigan, United States
Saint Mary's Oncology/Hematology Associates of West Branch
🇺🇸West Branch, Michigan, United States
University of Michigan Health - West
🇺🇸Wyoming, Michigan, United States
Sanford Joe Lueken Cancer Center
🇺🇸Bemidji, Minnesota, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸Brainerd, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Essentia Health - Deer River Clinic
🇺🇸Deer River, Minnesota, United States
Essentia Health Cancer Center
🇺🇸Duluth, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Saint Luke's Hospital of Duluth
🇺🇸Duluth, Minnesota, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Essentia Health Hibbing Clinic
🇺🇸Hibbing, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Monticello Cancer Center
🇺🇸Monticello, Minnesota, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸Saint Cloud, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Essentia Health Sandstone
🇺🇸Sandstone, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Essentia Health Virginia Clinic
🇺🇸Virginia, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Baptist Memorial Hospital and Cancer Center-Golden Triangle
🇺🇸Columbus, Mississippi, United States
Baptist Cancer Center-Grenada
🇺🇸Grenada, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Union County
🇺🇸New Albany, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Oxford
🇺🇸Oxford, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Desoto
🇺🇸Southhaven, Mississippi, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Parkland Health Center - Farmington
🇺🇸Farmington, Missouri, United States
University of Kansas Cancer Center - North
🇺🇸Kansas City, Missouri, United States
University of Kansas Cancer Center - Lee's Summit
🇺🇸Lee's Summit, Missouri, United States
University of Kansas Cancer Center at North Kansas City Hospital
🇺🇸North Kansas City, Missouri, United States
Mercy Hospital South
🇺🇸Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸Sainte Genevieve, Missouri, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸Sullivan, Missouri, United States
BJC Outpatient Center at Sunset Hills
🇺🇸Sunset Hills, Missouri, United States
Billings Clinic Cancer Center
🇺🇸Billings, Montana, United States
Bozeman Health Deaconess Hospital
🇺🇸Bozeman, Montana, United States
Nebraska Medicine-Bellevue
🇺🇸Bellevue, Nebraska, United States
CHI Health Good Samaritan
🇺🇸Kearney, Nebraska, United States
Cancer Partners of Nebraska
🇺🇸Lincoln, Nebraska, United States
Nebraska Medicine-Village Pointe
🇺🇸Omaha, Nebraska, United States
Northwell Health Cancer Institute at Huntington
🇺🇸Greenlawn, New York, United States
University of Nebraska Medical Center
🇺🇸Omaha, Nebraska, United States
OptumCare Cancer Care at Seven Hills
🇺🇸Henderson, Nevada, United States
OptumCare Cancer Care at Charleston
🇺🇸Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Central
🇺🇸Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
🇺🇸Las Vegas, Nevada, United States
OptumCare Cancer Care at MountainView
🇺🇸Las Vegas, Nevada, United States
Alliance for Childhood Diseases/Cure 4 the Kids Foundation
🇺🇸Las Vegas, Nevada, United States
Summerlin Hospital Medical Center
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸Las Vegas, Nevada, United States
OptumCare Cancer Care at Fort Apache
🇺🇸Las Vegas, Nevada, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸Lebanon, New Hampshire, United States
Memorial Sloan Kettering Basking Ridge
🇺🇸Basking Ridge, New Jersey, United States
Memorial Sloan Kettering Monmouth
🇺🇸Middletown, New Jersey, United States
Memorial Sloan Kettering Bergen
🇺🇸Montvale, New Jersey, United States
Northwell Health Imbert Cancer Center
🇺🇸Bay Shore, New York, United States
Montefiore Medical Center-Einstein Campus
🇺🇸Bronx, New York, United States
Montefiore Medical Center-Weiler Hospital
🇺🇸Bronx, New York, United States
Montefiore Medical Center - Moses Campus
🇺🇸Bronx, New York, United States
Sands Cancer Center
🇺🇸Canandaigua, New York, United States
Memorial Sloan Kettering Commack
🇺🇸Commack, New York, United States
Noyes Memorial Hospital/Myers Cancer Center
🇺🇸Dansville, New York, United States
Memorial Sloan Kettering Westchester
🇺🇸Harrison, New York, United States
Northwell Health/Center for Advanced Medicine
🇺🇸Lake Success, New York, United States
Northern Westchester Hospital
🇺🇸Mount Kisco, New York, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸New York, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸New York, New York, United States
Upstate Cancer Center at Oswego
🇺🇸Oswego, New York, United States
Wilmot Cancer Institute Radiation Oncology at Greece
🇺🇸Rochester, New York, United States
Highland Hospital
🇺🇸Rochester, New York, United States
Pluta Cancer Center
🇺🇸Rochester, New York, United States
University of Rochester
🇺🇸Rochester, New York, United States
Phelps Memorial Hospital Center
🇺🇸Sleepy Hollow, New York, United States
Staten Island University Hospital
🇺🇸Staten Island, New York, United States
Stony Brook University Medical Center
🇺🇸Stony Brook, New York, United States
State University of New York Upstate Medical University
🇺🇸Syracuse, New York, United States
SUNY Upstate Medical Center-Community Campus
🇺🇸Syracuse, New York, United States
Memorial Sloan Kettering Nassau
🇺🇸Uniondale, New York, United States
Upstate Cancer Center at Verona
🇺🇸Verona, New York, United States
Wilmot Cancer Institute at Webster
🇺🇸Webster, New York, United States
East Carolina University
🇺🇸Greenville, North Carolina, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Sanford Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Indu and Raj Soin Medical Center
🇺🇸Beavercreek, Ohio, United States
Cleveland Clinic Mercy Hospital
🇺🇸Canton, Ohio, United States
Dayton Physicians LLC-Miami Valley South
🇺🇸Centerville, Ohio, United States
Miami Valley Hospital South
🇺🇸Centerville, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Riverside Methodist Hospital
🇺🇸Columbus, Ohio, United States
Grant Medical Center
🇺🇸Columbus, Ohio, United States
Doctors Hospital
🇺🇸Columbus, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Premier Blood and Cancer Center
🇺🇸Dayton, Ohio, United States
Dayton Physician LLC - Englewood
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital North
🇺🇸Dayton, Ohio, United States
Delaware Health Center-Grady Cancer Center
🇺🇸Delaware, Ohio, United States
Grady Memorial Hospital
🇺🇸Delaware, Ohio, United States
Dublin Methodist Hospital
🇺🇸Dublin, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Dayton Physicians LLC-Atrium
🇺🇸Franklin, Ohio, United States
Miami Valley Cancer Care and Infusion
🇺🇸Greenville, Ohio, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
OhioHealth Mansfield Hospital
🇺🇸Mansfield, Ohio, United States
OhioHealth Marion General Hospital
🇺🇸Marion, Ohio, United States
Dayton Physicians LLC - Troy
🇺🇸Troy, Ohio, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Mercy Hospital Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Saint Charles Health System
🇺🇸Bend, Oregon, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Providence Cancer Institute Clackamas Clinic
🇺🇸Clackamas, Oregon, United States
Legacy Mount Hood Medical Center
🇺🇸Gresham, Oregon, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Providence Willamette Falls Medical Center
🇺🇸Oregon City, Oregon, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸Portland, Oregon, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Legacy Meridian Park Hospital
🇺🇸Tualatin, Oregon, United States
Penn State Milton S Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
UPMC-Magee Womens Hospital
🇺🇸Pittsburgh, Pennsylvania, United States
Women and Infants Hospital
🇺🇸Providence, Rhode Island, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
Lexington Medical Center
🇺🇸West Columbia, South Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Baptist Memorial Hospital and Cancer Center-Collierville
🇺🇸Collierville, Tennessee, United States
Baptist Memorial Hospital and Cancer Center-Memphis
🇺🇸Memphis, Tennessee, United States
MD Anderson in The Woodlands
🇺🇸Conroe, Texas, United States
M D Anderson Cancer Center
🇺🇸Houston, Texas, United States
MD Anderson West Houston
🇺🇸Houston, Texas, United States
MD Anderson League City
🇺🇸League City, Texas, United States
MD Anderson in Sugar Land
🇺🇸Sugar Land, Texas, United States
Farmington Health Center
🇺🇸Farmington, Utah, United States
University of Utah Sugarhouse Health Center
🇺🇸Salt Lake City, Utah, United States
Huntsman Cancer Institute/University of Utah
🇺🇸Salt Lake City, Utah, United States
University of Vermont Medical Center
🇺🇸Burlington, Vermont, United States
University of Vermont and State Agricultural College
🇺🇸Burlington, Vermont, United States
Dartmouth Cancer Center - North
🇺🇸Saint Johnsbury, Vermont, United States
Bon Secours Memorial Regional Medical Center
🇺🇸Mechanicsville, Virginia, United States
Bon Secours Saint Francis Medical Center
🇺🇸Midlothian, Virginia, United States
Bon Secours Saint Mary's Hospital
🇺🇸Richmond, Virginia, United States
Bon Secours Cancer Institute at Reynolds Crossing
🇺🇸Richmond, Virginia, United States
Swedish Cancer Institute-Edmonds
🇺🇸Edmonds, Washington, United States
Swedish Cancer Institute-Issaquah
🇺🇸Issaquah, Washington, United States
Skagit Regional Health Cancer Care Center
🇺🇸Mount Vernon, Washington, United States
Swedish Medical Center-Ballard Campus
🇺🇸Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
Legacy Cancer Institute Medical Oncology and Day Treatment
🇺🇸Vancouver, Washington, United States
Legacy Salmon Creek Hospital
🇺🇸Vancouver, Washington, United States
Langlade Hospital and Cancer Center
🇺🇸Antigo, Wisconsin, United States
Duluth Clinic Ashland
🇺🇸Ashland, Wisconsin, United States
Northwest Wisconsin Cancer Center
🇺🇸Ashland, Wisconsin, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸Green Bay, Wisconsin, United States
Essentia Health-Hayward Clinic
🇺🇸Hayward, Wisconsin, United States
University of Wisconsin Carbone Cancer Center - University Hospital
🇺🇸Madison, Wisconsin, United States
Froedtert Menomonee Falls Hospital
🇺🇸Menomonee Falls, Wisconsin, United States
Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
ProHealth D N Greenwald Center
🇺🇸Mukwonago, Wisconsin, United States
Cancer Center of Western Wisconsin
🇺🇸New Richmond, Wisconsin, United States
Drexel Town Square Health Center
🇺🇸Oak Creek, Wisconsin, United States
ProHealth Oconomowoc Memorial Hospital
🇺🇸Oconomowoc, Wisconsin, United States
Aspirus Cancer Care - James Beck Cancer Center
🇺🇸Rhinelander, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Sheboygan
🇺🇸Sheboygan, Wisconsin, United States
Sheboygan Physicians Group
🇺🇸Sheboygan, Wisconsin, United States
Essentia Health-Spooner Clinic
🇺🇸Spooner, Wisconsin, United States
Aspirus Cancer Care - Stevens Point
🇺🇸Stevens Point, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
Essentia Health Saint Mary's Hospital - Superior
🇺🇸Superior, Wisconsin, United States
UW Cancer Center at ProHealth Care
🇺🇸Waukesha, Wisconsin, United States
Aspirus Regional Cancer Center
🇺🇸Wausau, Wisconsin, United States
Froedtert West Bend Hospital/Kraemer Cancer Center
🇺🇸West Bend, Wisconsin, United States
Aspirus Cancer Care - Wisconsin Rapids
🇺🇸Wisconsin Rapids, Wisconsin, United States
Cancer Center-Metro Medical Center Bayamon
🇵🇷Bayamon, Puerto Rico
Doctors Cancer Center
🇵🇷Manati, Puerto Rico
San Juan Community Oncology Group
🇵🇷San Juan, Puerto Rico
Centro Comprensivo de Cancer de UPR
🇵🇷San Juan, Puerto Rico
San Juan City Hospital
🇵🇷San Juan, Puerto Rico