Studying the Physical Function and Quality of Life Before and After Surgery in Patients With Stage I Cervical Cancer
- Conditions
- Cervical Squamous Cell CarcinomaLymphedemaStage IA1 Cervical Cancer AJCC v6 and v7Cervical Adenosquamous CarcinomaStage IB1 Cervical Cancer AJCC v6 and v7Cervical AdenocarcinomaStage IA2 Cervical Cancer AJCC v6 and v7
- Interventions
- Procedure: ConizationOther: Quality-of-Life AssessmentOther: Questionnaire AdministrationProcedure: Therapeutic Conventional SurgeryProcedure: Therapeutic Lymphadenectomy
- Registration Number
- NCT01649089
- Lead Sponsor
- GOG Foundation
- Brief Summary
This clinical trial studies the physical function and quality-of-life before and after surgery in patients with stage I cervical cancer. Studying quality-of-life in patients undergoing surgery for cervical cancer may help determine the intermediate-term and long-term effects of surgery.
- Detailed Description
PRIMARY OBJECTIVES:
I. To examine the changes before and after non-radical surgical treatment (simple hysterectomy or cone biopsy \[fertility preservation\] and pelvic lymphadenectomy) on functional outcomes of bladder, bowel, and sexual function for stage IA1 (lymphatic vessel invasion positive \[LVSI+\]) and IA2-IB1 (=\< 2 cm) carcinoma of the cervix.
II. To evaluate incidence and severity of lymphedema after non-radical surgery (simple hysterectomy or cone biopsy \[fertility preservation\] and pelvic lymphadenectomy) for stage IA1 (LVSI+) and IA2-IB1 (=\< 2 cm) carcinoma of the cervix.
SECONDARY OBJECTIVES:
I. To investigate if non-radical surgery (simple hysterectomy or cone biopsy \[fertility preservation\] with pelvic lymphadenectomy) demonstrates greater physical function and less toxicity in comparison to historical data on radical surgery (radical hysterectomy or radical trachelectomy).
II. To evaluate incidence and severity of treatment-related adverse events, including surgical complications, among the entire cohort and by treatment type.
III. To evaluate changes in quality of life (QOL) (Functional Assessment of Cancer Therapy-Cervix \[FACT-Cx\]), cancer worries (Impact of Events Scale \[IES\]) and sexual (Female Sexual Function Index \[FSFI\])/reproductive concerns (RCS) among the entire cohort and by treatment type.
IV. To explore relationships (correlation, interaction, independence) between functional outcomes (i.e., bladder function, bowel function, sexual function), adverse events (including and surgical complication lymphedema \[Gynecologic Cancer Lymphedema Questionnaire (GCLQ)\]), cancer worry (IES), surgical complications, and overall quality of life (FACT-Cx).
V. To determine participants' intention for conception \& fertility rates (Integrative Care for Fertility \[ICF\]) and assess the reproductive concerns (RCS) of women following cone biopsy and pelvic lymphadenectomy for stage IA1 (LVSI+) and IA2-IB1 (=\< 2 cm) carcinoma of the cervix.
VI. To estimate the efficacy of non-radical surgery (simple hysterectomy or cone biopsy \[fertility preservation\] and pelvic lymphadenectomy) for stage IA1 (LVSI+) and IA2-IB1 (=\< 2 cm) carcinoma of the cervix.
OUTLINE:
Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy.
Patients complete the FACT-Cx, the IES, the FSFI, the GCLQ, and the Patient Reported Outcomes Measurement Information System (PROMIS) questionnaires at baseline, 4-6 weeks after surgery, and then every 6 months for 3 years. Patients undergoing cone biopsy and pelvic lymphadenectomy also complete the ICF and RCS questionnaires.
After completion of study treatment, patients are followed up at 4-6 weeks, every 3 months for 1 year, and then every 6 months for 2 years.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- Female
- Target Recruitment
- 224
- Patient must consent for the appropriate surgery
- Patients with a histologic diagnosis of squamous cell carcinoma, adenocarcinoma, or adenosquamous cell carcinoma of the cervix, stage IA1 (lymph-vascular space invasion [LVSI]+), IA2, and IB1 (tumor size [maximum visible or palpable]) =< 2 cm), any grade
- All patients must have undergone a cone biopsy or loop electrosurgical excision procedure (LEEP); depth of invasion must be =< 10 mm
- Patients must have no evidence of metastasis on positron emission tomography (PET) scan or magnetic resonance imaging (MRI) or computed tomography (CT) scan of the pelvis and chest imaging
- Patients who have met the pre-entry requirements
- Patients must have signed an approved informed consent and authorization permitting release of personal health information
- Patient must have Gynecologic Oncology Group (GOG) performance status of 0, 1, or 2
- Patients with stage IA1 disease who are LVSI negative
- Patients with stage IB1 with tumor size (maximum visible or palpable) > 2 cm
- Patients with >= stage IB2 disease
- Patients with clear cell or neuroendocrine cell types
- Patients with depth of invasion > 10 mm on first cone biopsy (or LEEP)
- Patients with a history of other invasive malignancies, with the exception of non-melanoma skin cancer, are excluded if there is any evidence of other malignancy being present within the last five years; patients are also excluded if their previous cancer treatment contraindicates this protocol therapy
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- SINGLE_GROUP
- Arm && Interventions
Group Intervention Description Treatment (cone biopsy/lymphadenectomy or hysterectomy) Quality-of-Life Assessment Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy. Treatment (cone biopsy/lymphadenectomy or hysterectomy) Conization Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy. Treatment (cone biopsy/lymphadenectomy or hysterectomy) Questionnaire Administration Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy. Treatment (cone biopsy/lymphadenectomy or hysterectomy) Therapeutic Lymphadenectomy Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy. Treatment (cone biopsy/lymphadenectomy or hysterectomy) Therapeutic Conventional Surgery Patients undergo cone biopsy and pelvic lymphadenectomy or simple hysterectomy and pelvic lymphadenectomy.
- Primary Outcome Measures
Name Time Method Change in bladder and bowel function score based on supplemental bladder and bowel questions plus 4 items from the Functional Assessment of Cancer Therapy-Cervix (3 bladder and 1 bowel question) Baseline to 3 years Analysis of variance methods with repeated measurements and a time component will initially be used to determine whether there are significant changes over time.
Change in sexual function and activity based on Female Sexual Function Index (19 items) score plus 2 Patient Reported Outcomes Measurement Information System screener items Baseline to 3 years Analysis of variance methods with repeated measurements and a time component will initially be used to determine whether there are significant changes over time.
Lymphedema Up to 3 years Based on Cancer Lymphedema Questionnaire score.
Maximum grade and duration of severe adverse events associated with bladder, bowel, and sexual dysfunction and lymphedema Up to 3 years after non-radical surgical procedure Graded according to Common Terminology Criteria for Adverse Events version 4.0 (version 5.0 will be used staring April 1, 2018).
- Secondary Outcome Measures
Name Time Method Maximum grade of treatment-related adverse events Up to 30 days after surgical procedure Graded according to Common Terminology Criteria for Adverse Events version 4.0 (version 5.0 will be used staring April 1, 2018).
Change in overall quality of life Baseline to 3 years Will be assessed based on Functional Assessment of Cancer Therapy-Cervix (15 items) score. Analysis of variance methods with repeated measurements and a time component will initially be used to determine whether there are significant changes over time.
Site of first recurrence Up to 3 years Classified as either local (pelvis regions, including vaginal) or distant (abdomen, lung, bone, brain, and other).
Change in cancer worries based on Impact of Events score Baseline to 3 years Analysis of variance methods with repeated measurements and a time component will initially be used to determine whether there are significant changes over time.
Change in reproductive concerns based on reproductive concerns (14 items) score Baseline to 3 years Analysis of variance methods with repeated measurements and a time component will initially be used to determine whether there are significant changes over time.
Recurrence-free survival Up to 3 years Product-limit estimates according to the method of Kaplan and Meier will be used to estimate recurrence-free survival. In addition, Cox proportional hazard regression will be employed to evaluate relative risk (hazard ratio) adjusting for known prognostic factors. Trellis plots will be used to display point estimates of hazard ratio and respective 95% confidence intervals from subgroup analyses. Local recurrence will be summarized using frequency tables and plot of cumulative incidence of local recurrence over time.
Overall survival Up to 3 years Product-limit estimates according to the method of Kaplan and Meier will be used to estimate overall survival. In addition, cox proportional hazard regression will be employed to evaluate relative risk (hazard ratio) adjusting for known prognostic factors. Trellis plots will be used to display point estimates of hazard ratio and respective 95% confidence intervals from subgroup analyses. Gompertz hazard regression will also be employed to evaluate relative risk (hazard ratio) and cure rates, adjusting for known prognostics factors.
Trial Locations
- Locations (185)
The Mark H Zangmeister Center
🇺🇸Columbus, Ohio, United States
Doctors Hospital
🇺🇸Columbus, Ohio, United States
Good Samaritan Regional Health Center
🇺🇸Mount Vernon, Illinois, United States
Cleveland Clinic Foundation
🇺🇸Cleveland, Ohio, United States
Jackson Memorial Hospital-Holtz Children's Hospital
🇺🇸Miami, Florida, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸Miami, Florida, United States
Sutter Auburn Faith Hospital
🇺🇸Auburn, California, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
🇺🇸Auburn, California, United States
Mills-Peninsula Medical Center
🇺🇸Burlingame, California, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸Berkeley, California, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
🇺🇸Cameron Park, California, United States
Eden Hospital Medical Center
🇺🇸Castro Valley, California, United States
Sutter Davis Hospital
🇺🇸Davis, California, United States
Palo Alto Medical Foundation-Fremont
🇺🇸Fremont, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸Los Angeles, California, United States
UC San Diego Moores Cancer Center
🇺🇸La Jolla, California, United States
Memorial Medical Center
🇺🇸Modesto, California, United States
Palo Alto Medical Foundation-Gynecologic Oncology
🇺🇸Mountain View, California, United States
Palo Alto Medical Foundation-Camino Division
🇺🇸Mountain View, California, United States
Palo Alto Medical Foundation Health Care
🇺🇸Palo Alto, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
🇺🇸Roseville, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
🇺🇸Orange, California, United States
Sutter Roseville Medical Center
🇺🇸Roseville, California, United States
Palo Alto Medical Foundation-Santa Cruz
🇺🇸Santa Cruz, California, United States
Palo Alto Medical Foundation-Sunnyvale
🇺🇸Sunnyvale, California, United States
Sutter Pacific Medical Foundation
🇺🇸Santa Rosa, California, United States
Olive View-University of California Los Angeles Medical Center
🇺🇸Sylmar, California, United States
Sutter Cancer Centers Radiation Oncology Services-Vacaville
🇺🇸Vacaville, California, United States
Sutter Solano Medical Center/Cancer Center
🇺🇸Vallejo, California, United States
UM Sylvester Comprehensive Cancer Center at Deerfield Beach
🇺🇸Deerfield Beach, Florida, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸Savannah, Georgia, United States
UM Sylvester Comprehensive Cancer Center at Plantation
🇺🇸Plantation, Florida, United States
Northwestern Medicine Cancer Center Delnor
🇺🇸Geneva, Illinois, United States
Sudarshan K Sharma MD Limited-Gynecologic Oncology
🇺🇸Hinsdale, Illinois, United States
Cancer Center of Kansas - Newton
🇺🇸Newton, Kansas, United States
Cancer Center of Kansas-Manhattan
🇺🇸Manhattan, Kansas, United States
Cancer Center of Kansas - McPherson
🇺🇸McPherson, Kansas, United States
Baptist Health Corbin
🇺🇸Corbin, Kentucky, United States
Baptist Health Lexington
🇺🇸Lexington, Kentucky, United States
Baptist Health Madisonville/Merle Mahr Cancer Center
🇺🇸Madisonville, Kentucky, United States
Baptist Health Paducah
🇺🇸Paducah, Kentucky, United States
Woman's Hospital
🇺🇸Baton Rouge, Louisiana, United States
Hematology/Oncology Clinic PLLC
🇺🇸Baton Rouge, Louisiana, United States
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Brigham and Women's Hospital
🇺🇸Boston, Massachusetts, United States
Dana-Farber Cancer Institute
🇺🇸Boston, Massachusetts, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Hutchinson Area Health Care
🇺🇸Hutchinson, Minnesota, United States
Fairview Clinics and Surgery Center Maple Grove
🇺🇸Maple Grove, Minnesota, United States
Health Partners Inc
🇺🇸Minneapolis, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸Wyoming, Minnesota, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Mercy Hospital Joplin
🇺🇸Joplin, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸Rolla, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Women's Cancer Center of Nevada
🇺🇸Las Vegas, Nevada, United States
Memorial Sloan Kettering Cancer Center
🇺🇸New York, New York, United States
Memorial Sloan Kettering Westchester
🇺🇸Harrison, New York, United States
Memorial Sloan Kettering Commack
🇺🇸Commack, New York, United States
Memorial Sloan Kettering Basking Ridge
🇺🇸Basking Ridge, New Jersey, United States
Memorial Sloan Kettering Nassau
🇺🇸Uniondale, New York, United States
Summa Health System - Akron Campus
🇺🇸Akron, Ohio, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
Strecker Cancer Center-Belpre
🇺🇸Belpre, Ohio, United States
University of Cincinnati Cancer Center-UC Medical Center
🇺🇸Cincinnati, Ohio, United States
Adena Regional Medical Center
🇺🇸Chillicothe, Ohio, United States
Aultman Health Foundation
🇺🇸Canton, Ohio, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Columbus Oncology and Hematology Associates Inc
🇺🇸Columbus, Ohio, United States
Mount Carmel East Hospital
🇺🇸Columbus, Ohio, United States
Grant Medical Center
🇺🇸Columbus, Ohio, United States
Riverside Methodist Hospital
🇺🇸Columbus, Ohio, United States
Mount Carmel Health Center West
🇺🇸Columbus, Ohio, United States
Grandview Hospital
🇺🇸Dayton, Ohio, United States
Delaware Health Center-Grady Cancer Center
🇺🇸Delaware, Ohio, United States
Delaware Radiation Oncology
🇺🇸Delaware, Ohio, United States
Dublin Methodist Hospital
🇺🇸Dublin, Ohio, United States
Mount Carmel Grove City Hospital
🇺🇸Grove City, Ohio, United States
Grady Memorial Hospital
🇺🇸Delaware, Ohio, United States
Central Ohio Breast and Endocrine Surgery
🇺🇸Gahanna, Ohio, United States
Marietta Memorial Hospital
🇺🇸Marietta, Ohio, United States
Saint Rita's Medical Center
🇺🇸Lima, Ohio, United States
OhioHealth Mansfield Hospital
🇺🇸Mansfield, Ohio, United States
OhioHealth Marion General Hospital
🇺🇸Marion, Ohio, United States
Hillcrest Hospital Cancer Center
🇺🇸Mayfield Heights, Ohio, United States
UH Seidman Cancer Center at Lake Health Mentor Campus
🇺🇸Mentor, Ohio, United States
Licking Memorial Hospital
🇺🇸Newark, Ohio, United States
Knox Community Hospital
🇺🇸Mount Vernon, Ohio, United States
Newark Radiation Oncology
🇺🇸Newark, Ohio, United States
ProMedica Toledo Hospital/Russell J Ebeid Children's Hospital
🇺🇸Toledo, Ohio, United States
Southern Ohio Medical Center
🇺🇸Portsmouth, Ohio, United States
Mercy Health Perrysburg Cancer Center
🇺🇸Perrysburg, Ohio, United States
Saint Vincent Mercy Medical Center
🇺🇸Toledo, Ohio, United States
Saint Ann's Hospital
🇺🇸Westerville, Ohio, United States
Mercy Health - Saint Anne Hospital
🇺🇸Toledo, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸Zanesville, Ohio, United States
Oklahoma Cancer Specialists and Research Institute-Tulsa
🇺🇸Tulsa, Oklahoma, United States
Jefferson Abington Hospital
🇺🇸Abington, Pennsylvania, United States
Paoli Memorial Hospital
🇺🇸Paoli, Pennsylvania, United States
Asplundh Cancer Pavilion
🇺🇸Willow Grove, Pennsylvania, United States
Lankenau Medical Center
🇺🇸Wynnewood, Pennsylvania, United States
Women and Infants Hospital
🇺🇸Providence, Rhode Island, United States
Parkland Memorial Hospital
🇺🇸Dallas, Texas, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸Dallas, Texas, United States
Memorial Hermann Texas Medical Center
🇺🇸Houston, Texas, United States
Monongalia Hospital
🇺🇸Morgantown, West Virginia, United States
Naval Medical Center - Portsmouth
🇺🇸Portsmouth, Virginia, United States
ProHealth D N Greenwald Center
🇺🇸Mukwonago, Wisconsin, United States
ProHealth Waukesha Memorial Hospital
🇺🇸Waukesha, Wisconsin, United States
ProHealth Oconomowoc Memorial Hospital
🇺🇸Oconomowoc, Wisconsin, United States
Cancer Center of Western Wisconsin
🇺🇸New Richmond, Wisconsin, United States
Aurora West Allis Medical Center
🇺🇸West Allis, Wisconsin, United States
Odette Cancer Centre- Sunnybrook Health Sciences Centre
🇨🇦Toronto, Ontario, Canada
Seoul National University Bundang Hospital
🇰🇷Seongnam City, Kyeonggi-do, Korea, Republic of
Samsung Medical Center
🇰🇷Seoul, Korea, Korea, Republic of
Asan Medical Center
🇰🇷Seoul, Korea, Republic of
Catholic University of Korea-Seoul Saint Mary's Hospital
🇰🇷Seoul, Korea, Korea, Republic of
Gachon University Gil Hospital
🇰🇷Incheon, Korea, Republic of
Gangnam Severance Hospital
🇰🇷Seoul, Korea, Republic of
Seoul National University Hospital
🇰🇷Seoul, Korea, Republic of
Yonsei University Health System-Severance Hospital
🇰🇷Seoul, Korea, Republic of
Korea Cancer Center Hospital
🇰🇷Seoul, Korea, Republic of
Cancer Center of Kansas-Independence
🇺🇸Independence, Kansas, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Cancer Center of Kansas - Dodge City
🇺🇸Dodge City, Kansas, United States
University of Hawaii Cancer Center
🇺🇸Honolulu, Hawaii, United States
Associates In Womens Health
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - El Dorado
🇺🇸El Dorado, Kansas, United States
Cancer Center of Kansas - Fort Scott
🇺🇸Fort Scott, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸Winfield, Kansas, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸Honolulu, Hawaii, United States
Ascension Via Christi Hospitals Wichita
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Chanute
🇺🇸Chanute, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸Kingman, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸Salina, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Wichita
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Parsons
🇺🇸Parsons, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸Pratt, Kansas, United States
California Pacific Medical Center-Pacific Campus
🇺🇸San Francisco, California, United States
Baystate Medical Center
🇺🇸Springfield, Massachusetts, United States
University of Mississippi Medical Center
🇺🇸Jackson, Mississippi, United States
Memorial Sloan Kettering Monmouth
🇺🇸Middletown, New Jersey, United States
MD Anderson Cancer Center at Cooper-Voorhees
🇺🇸Voorhees, New Jersey, United States
Cooper Hospital University Medical Center
🇺🇸Camden, New Jersey, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
Kyung Hee University Hospital at Gangdong
🇰🇷Seoul, Korea, Republic of
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Northwestern Medicine Cancer Center Warrenville
🇺🇸Warrenville, Illinois, United States
Fairfield Medical Center
🇺🇸Lancaster, Ohio, United States
ProMedica Flower Hospital
🇺🇸Sylvania, Ohio, United States
UW Cancer Center at ProHealth Care
🇺🇸Waukesha, Wisconsin, United States
Cancer Center at Saint Joseph's
🇺🇸Phoenix, Arizona, United States
Saint Joseph's Hospital and Medical Center
🇺🇸Phoenix, Arizona, United States
Sutter Medical Center Sacramento
🇺🇸Sacramento, California, United States
Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Nebraska Methodist Hospital
🇺🇸Omaha, Nebraska, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Aurora Saint Luke's Medical Center
🇺🇸Milwaukee, Wisconsin, United States
AdventHealth Orlando
🇺🇸Orlando, Florida, United States
Tulane University Health Sciences Center
🇺🇸New Orleans, Louisiana, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸Richmond, Virginia, United States
University of Rochester
🇺🇸Rochester, New York, United States
Cancer Center of Kansas-Liberal
🇺🇸Liberal, Kansas, United States
Cancer Center of Kansas - Wellington
🇺🇸Wellington, Kansas, United States