Tadalafil in Preventing Erectile Dysfunction in Patients With Prostate Cancer Treated With Radiation Therapy

Phase 3

Completed

Conditions: Sexual Dysfunction
Prostate Cancer

Interventions: Other: Placebo
Drug: Tadalafil

Registration Number: NCT00931528

Lead Sponsor: Radiation Therapy Oncology Group

Brief Summary: RATIONALE: Tadalafil may help prevent erectile dysfunction (ED) in patients with prostate cancer that has been treated with radiation therapy. It is not yet known whether tadalafil is more effective than a placebo in preventing erectile dysfunction.

PURPOSE: This randomized phase III trial is studying tadalafil to see how well it works compared with a placebo in preventing erectile dysfunction in patients with prostate cancer treated with radiation therapy.

Detailed Description: OBJECTIVES:

Primary

* To determine whether tadalafil maintains spontaneous (off-drug) erectile function, as measured by the International Index of Erectile Function (IIEF) as compared to placebo at weeks 28-30 after initiation of radiotherapy in patients with prostate cancer.

Secondary

* Determine the difference in spontaneous (off-drug) erectile function between tadalafil and placebo at 1 and 2 years.

* Determine the difference in overall sexual function as measured by the IIEF between tadalafil and placebo at weeks 28-30 and at 1 and 2 years.

* Determine differences in patient and partner overall sexual satisfaction as measured by the Sexual Adjustment Questionnaire (SAQ) between tadalafil and placebo at weeks 28-30 and at 1 and 2 years.

* Determine differences in patient and partner marital adjustment as measured by Locke's Marital Adjustment Test (LMAT) between tadalafil and placebo at weeks 28-30 and at 1 and 2 years.

* Determine associations between patient and partner overall sexual satisfaction as measured by SAQ and patient and partner marital adjustment as measured by LMAT at weeks 28-30 and at 1 and 2 years.

* Determine patient-related factors (i.e., age, pretreatment sexual response, tobacco use, and comorbidities) that may predict response to tadalafil therapy at weeks 28-30 and at 1 and 2 years.

* Determine the difference in adverse events between tadalafil and placebo as assessed by Common Toxicity Criteria for Adverse Effects (CTCAE) v3.0 criteria.

Tertiary

* Characterization of preference and erectile function among patients who choose to stay on (or if on placebo, to start) tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor other than tadalafil, a non-PDE5-inhibitor erectile aide, or no PDE5 inhibitor or erectile aide at 28-30 weeks and at 1 and 2 years.

* Identification of radiotherapy factors (i.e., modality, prescribed total dose, planning target volume margin, penile bulb dose-volume parameters) associated with erectile function.

* Evaluation of the number of patients screened for eligibility, the number eligible that are presented the study, the number who refuse, and the number who are accrued.

OUTLINE: This is a multicenter study. Patients are stratified according to age (≤ 65 years vs \> 65 years) and radiotherapy treatment (external beam radiation therapy vs brachytherapy\*). Patients are randomized to 1 of 2 treatment arms.

Note: \* Radiotherapy start date for brachytherapy patients is the date of the procedure.

All patients undergo either external beam radiotherapy alone to the prostate ± seminal vesicles only or low-dose rate permanent brachytherapy alone.

* Arm I: Beginning ≤ 7 days after the start of radiotherapy, patients receive oral tadalafil once daily for 24 weeks in the absence of disease progression or unacceptable toxicity.

* Arm II: Beginning ≤ 7 days after the start of radiotherapy, patients receive oral placebo once daily for 24 weeks in the absence of disease progression or unacceptable toxicity.

Patients complete the International Index of Erectile Function (IIEF), the Sexual Adjustment Questionnaire (SAQ), the Locke's Marital Adjustment Test (LMAT) (if applicable), and the Expanded Prostate Cancer Index Composite Sexual Medications and Devices Evaluations Supplement questionnaires periodically. Partners or spouses complete the SAQ-Partner, LMAT (if applicable), and IIEF questionnaires periodically.

After completion of study treatment, patients are followed at 28-30 weeks, and annually for up to 2 years.

Recruitment & Eligibility

Status: COMPLETED

Sex: Male

Target Recruitment: 242

Inclusion Criteria

Clinical stage T1b-T2b (AJCC, 6th ed.) adenocarcinoma of the prostate within 6 months of registration
Clinically negative lymph nodes as established by imaging (pelvic ± abdominal CT or MR), nodal sampling, or dissection within 3 months prior to registration. Patients with lymph nodes equivocal or questionable by imaging are eligible if the nodes are ≤ 1.5 cm. Lymph node assessment is optional, and at investigator discretion, for patients with Gleason Score <7.
No evidence of bone metastases (M0) on bone scan within 3 months prior to registration. Equivocal bone scan findings are allowed if plain films are negative for metastasis. Bone metastases assessment is optional, and at investigator discretion, for patients with Gleason Score <7.
Baseline serum prostatic specific antigen (PSA) value performed with an FDA-approved assay (e.g., Abbott, Hybritech) within 3 months prior to registration.

-4.1 Any of the following combinations of factors (NOTE: tumor found in 1 or both lobes on biopsy, but not palpable, will not alter T stage):
- T1b-T2b disease, Gleason Score <7 and serum total PSA that is <20 ng/ml or
- T1b-T2b disease, Gleason Score ≥7 and PSA that is <15 ng/ml
Serum total testosterone level prior to the initiation of radiation therapy (RT) within normal range according to institutional guidelines
Zubrod Performance Status 0 or 1 (Appendix III)
Age ≥ 18 years
Treatment that will consist of either external beam RT alone to the prostate ± seminal vesicles only at a dose between 75 Gy and 79.2 Gy or brachytherapy alone (NOTE: treatment with combined external RT and brachytherapy excludes patient participation)
Pretreatment (before starting prostate cancer treatment) erectile function as measured by IIEF Question 1, "How often were you able to get an erection during sexual activity?" - with responses of:
- "sometimes (about half the time)" [response 3] or
- "most times (much more than half the time)" [response 4] or
- "almost always/always" [response 5]
History of prior tadalafil use: Document usual dosage per sexual encounter, date of last dose, and patient's response (No; Yes-Unsatisfactory Response; Yes-Satisfactory Response). Regardless of past experience, the patient is eligible if he agrees to adhere to protocol and take only tadalafil or placebo prescribed on study.
Although patients with partners are targeted for recruitment, patients without partners or without partners willing to participate are eligible. Patients (and spouses/partners, if willing to participate) must be able to provide study-specific informed consent.

Exclusion Criteria

The patient's participation in another medical research study that involves the treatment of ED
Previous or concomitant invasive cancer (American Joint Committee on Cancer [AJCC] Stage >0), other than localized basal cell or squamous cell skin carcinoma (AJCC Stage 0-II), or a hematological malignancy (e.g., leukemia, lymphoma, myeloma) unless continually disease free for at least 5 years
History of myocardial infarction within the last year
Heart failure in the last 6 months
Uncontrolled arrhythmias, hypotension (<90/50mm Hg), or uncontrolled hypertension (>170/100 mm Hg)
Stroke within the last 6 months
Use of luteinizing hormone-releasing hormone (LHRH) agonist androgen suppression (e.g., Lupron, Zoladex), anti-androgen (e.g., Casodex, Eulexin, Nilandron), or estrogenic (e.g., diethylstilbestrol) agents within the last 6 months
Current use of any organic nitrate or as needed nitrates (e.g., use of nitroglycerin)
Current use of cimetidine, ketoconazole, itraconazole, erythromycin, or ritonavir
Known moderate to severe renal insufficiency or end-stage renal disease
Known severe hepatic impairment
Use of mechanical (vacuum) devices, intracorporeal, intraurethral, topical, or oral (sildenafil, tadalafil, vardenafil) agents as therapy for ED or supplements to enhance sexual function within 5-7 days prior to the start of RT. Patients who discontinue these therapies remain eligible if they can meet eligibility criteria
Pretreatment (before starting prostate cancer treatment) ED as measured by IIEF Question 1, "How often were you able to get an erection during sexual activity?" - with responses of:
- "no sexual activity" [response 0] or
- "almost never/never" [response 1] or
- "a few times (much less than half the time)" [response 2]
Prior penile implant or history of bilateral orchiectomy
Prior prostatectomy, prostatic cryosurgery or high-intensity focused ultrasound (HIFU), radionuclide prostate brachytherapy, or chemotherapy for prostate cancer
Prior or anticipated combined external RT and brachytherapy
Prior or anticipated external RT to the pelvic ± para-aortic lymph nodes
Acquired Immune Deficiency Syndrome (AIDS) based upon current Centers for Disease Control and Prevention (CDC) definition; note, however, that HIV testing is not required for entry into this protocol. The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive. Protocol-specific requirements may also exclude immunocompromised patients.
Anatomical genital abnormalities or concurrent conditions that in the estimation of the physician would prohibit sexual intercourse or prevent study completion
Major medical or psychiatric illness which, in the opinion of the investigator, would prevent completion of treatment or would interfere with follow-up

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Placebo	Placebo	Placebo
Tadalafil	Tadalafil	Tadalafil

Primary Outcome Measures

Name	Time	Method
Percentage of Patients Maintaining Spontaneous (Off-drug) Erectile Function (EF) at Weeks 28-30 After Initiation of Radiation Therapy (RT)	Baseline and 30 weeks from the start of radiation therapy	EF is measured by Question 1 of the International Index of Erectile Function (IIEF). The IIEF is a validated 15-item for measuring patient-reported erectile function. Question 1 asks "How often were you able to get an erection during sexual activity?" Responses ranged from 0=no sexual activity, to 5=Almost always or always. Higher scores indicated better functioning. All patients have erectile function prior to initiation of RT, indicated by a score of 3, 4, or 5 on IIEF Q1. Patients with a lower IIEF Q1 score at weeks 28-30 than at baseline will have less erectile function and be categorized as nonresponders. Patients with similar or improved erectile function will be categorized as responders (maintaining). Patient-related predictors of at erectile function at this time point are also reported with this outcome measure.

Secondary Outcome Measures

Name	Time	Method
Percentage of Patients Maintaining Spontaneous (Off-drug) EF at Years 1 and 2 After Initiation of RT	Baseline, 1 and 2 years from the start of tadalafil or placebo	The International Index of Erectile Function (IIEF) is a validated 15-item for measuring patient-reported erectile function. Question 1 asks "How often were you able to get an erection during sexual activity?" Responses ranged from 0=no sexual activity, to 5=Almost always or always. Higher scores indicated better functioning. All patients have erectile function prior to initiation of RT, indicated by a score of 3, 4, or 5. Patients with a lower IIEF Q1 score at weeks 28-30 than at baseline will have less erectile function and be categorized as nonresponders. Patients with similar or improved erectile function will be categorized as responders (maintaining). Patient-related predictors of at erectile function at Years 1 and 2 are also reported with this outcome measure.
Overall Patient Sexual Satisfaction as Measured by Change From Baseline in the Sexual Adjustment Questionnaire (SAQ) Score	Baseline, week 30 and years 1 and 2 after the start of treatment	The Sexual Adjustment Questionnaire (SAQ) is a 20-item questionnaire with an overall score range between 8 and 100 including the following domains: desire, ranging between 5 and 30; dysfunction, 0 and 25; activity, 0 and 10; satisfaction, 1 and 10; and fatigue, 1 and 5. The change in SAQ score is calculated by subtracting the baseline score from the follow-up score. A positive change indicates an improvement in sexual well-being.
Overall Sexual Function as Measured by Change From Baseline in the International Index of Erectile Function (IIEF)	Baseline, week 30, and years 1 and 2 from start of treatment	The IIEF is a validated 15-item for measuring patient-reported erectile function. A score of 0-5 is given to each of the 15 questions that examine 5 main domains of male sexual function: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Domain scores are the sum of each item. The erectile function domain has 5 items with a score range of 1-30, orgasmic function has 2 items with a score range of 0-10, sexual desire has 2 items with a score range of 0-10, intercourse satisfaction has 3 items with a score range of 0-15, and overall satisfaction has 2 items with a score range of 2-10. Total score ranges from 0-70, with higher scores indicated better functioning. Change from baseline is calculated by subtracting baseline score from score at the time point of interest.
Overall Partner Sexual Satisfaction as Measured by Change From Baseline in the Sexual Adjustment Questionnaire-Partner (SAQ-P) Score	Baseline, week 30 and years 1 and 2 after the start of treatment	The SAQ-P is an 18-item questionnaire with an overall score range between 0 and 90 including the following domains: desire, dysfunction, activity, satisfaction, and fatigue. The change in SAQ score is calculated by subtracting the baseline score from the follow-up score. A positive change indicates an improvement in sexual well-being.
Partner Marital Adjustment as Measured by the Locke's Marital Adjustment Test	Baseline, week 30 and years 1 and 2 after the start of treatment	The Locke Marital Adjustment Test (LMAT) is a 16-item questionnaire with scores ranging from 48 to 138 for participants. Higher scores indicate greater sexual function, sexual wellbeing, or marital adjustment. The change in LMAT score is calculated by subtracting the baseline score from the follow-up score.
Patient Marital Adjustment as Measured by the Locke's Marital Adjustment Test	Baseline, week 30 and years 1 and 2 after the start of treatment	The Locke Marital Adjustment Test (LMAT) is a 16-item questionnaire with scores ranging from 48 to 138 for participants. Higher scores indicate greater sexual function, sexual wellbeing, or marital adjustment. The change in LMAT score is calculated by subtracting the baseline score from the follow-up score.

Trial Locations

Locations (192): Providence Hospital
🇺🇸
Mobile, Alabama, United States
Arizona Center for Cancer Care-Peoria
🇺🇸
Peoria, Arizona, United States
Mayo Clinic in Arizona
🇺🇸
Scottsdale, Arizona, United States
Arizona Oncology Services Foundation
🇺🇸
Scottsdale, Arizona, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸
Berkeley, California, United States
Saint Agnes Medical Center
🇺🇸
Fresno, California, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
🇺🇸
Auburn, California, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
🇺🇸
Cameron Park, California, United States
Mercy San Juan Medical Center
🇺🇸
Carmichael, California, United States
Enloe Medical Center
🇺🇸
Chico, California, United States
Veterans Administration Long Beach Medical Center
🇺🇸
Long Beach, California, United States
Northridge Hospital Medical Center
🇺🇸
Northridge, California, United States
Kaiser Permanente Oakland-Broadway
🇺🇸
Oakland, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
🇺🇸
Roseville, California, United States
Kaiser Permanente Cancer Treatment Center
🇺🇸
South San Francisco, California, United States
Sutter Solano Medical Center
🇺🇸
Vallejo, California, United States
Sutter Cancer Centers Radiation Oncology Services-Vacaville
🇺🇸
Vacaville, California, United States
Penrose-Saint Francis Healthcare
🇺🇸
Colorado Springs, Colorado, United States
The Hospital of Central Connecticut
🇺🇸
New Britain, Connecticut, United States
Washington Hospital Center
🇺🇸
Washington, District of Columbia, United States
Broward Health North
🇺🇸
Deerfield Beach, Florida, United States
University of Florida
🇺🇸
Gainesville, Florida, United States
Cancer Specialists of North Florida-Beaches
🇺🇸
Jacksonville Beach, Florida, United States
Baptist Cancer Institute
🇺🇸
Jacksonville, Florida, United States
University of Florida Health Science Center
🇺🇸
Jacksonville, Florida, United States
Mayo Clinic in Florida
🇺🇸
Jacksonville, Florida, United States
Cancer Specialists of North Florida-Baptist South
🇺🇸
Jacksonville, Florida, United States
21st Century Oncology-Orange Park
🇺🇸
Orange Park, Florida, United States
21st Century Oncology-Palatka
🇺🇸
Palatka, Florida, United States
Cancer Specialists of North Florida-Saint Augustine
🇺🇸
Saint Augustine, Florida, United States
Atlanta VA Medical Center
🇺🇸
Decatur, Georgia, United States
John B Amos Cancer Center
🇺🇸
Columbus, Georgia, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Saint John's Hospital
🇺🇸
Springfield, Illinois, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Advocate Lutheran General Hospital.
🇺🇸
Park Ridge, Illinois, United States
Advocate Illinois Masonic Medical Center
🇺🇸
Chicago, Illinois, United States
IU Health Bloomington
🇺🇸
Bloomington, Indiana, United States
Saint Vincent Anderson Regional Hospital/Cancer Center
🇺🇸
Anderson, Indiana, United States
Parkview Hospital Randallia
🇺🇸
Fort Wayne, Indiana, United States
Radiation Oncology Associates PC
🇺🇸
Fort Wayne, Indiana, United States
IU Health Goshen Center for Cancer Care
🇺🇸
Goshen, Indiana, United States
Memorial Hospital of South Bend
🇺🇸
South Bend, Indiana, United States
Northern Indiana Cancer Research Consortium
🇺🇸
South Bend, Indiana, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸
Baltimore, Maryland, United States
Baptist Health Lexington
🇺🇸
Lexington, Kentucky, United States
Mary Bird Perkins Cancer Center
🇺🇸
Baton Rouge, Louisiana, United States
Central Maine Medical Center
🇺🇸
Lewiston, Maine, United States
Ochsner Clinic CCOP
🇺🇸
New Orleans, Louisiana, United States
Central Maryland Radiation Oncology in Howard County
🇺🇸
Columbia, Maryland, United States
Saint Agnes Hospital
🇺🇸
Baltimore, Maryland, United States
Johns Hopkins University/Sidney Kimmel Comprehensive Cancer Center
🇺🇸
Baltimore, Maryland, United States
Tate Cancer Center
🇺🇸
Glen Burnie, Maryland, United States
Saint Anne's Hospital
🇺🇸
Fall River, Massachusetts, United States
Bronson Battle Creek
🇺🇸
Battle Creek, Michigan, United States
Cape Cod Hospital
🇺🇸
Hyannis, Massachusetts, United States
Huron Valley-Sinai Hospital
🇺🇸
Commerce, Michigan, United States
McLaren-Flint
🇺🇸
Flint, Michigan, United States
Mercy Health Saint Mary's
🇺🇸
Grand Rapids, Michigan, United States
Spectrum Health at Butterworth Campus
🇺🇸
Grand Rapids, Michigan, United States
West Michigan Cancer Center
🇺🇸
Kalamazoo, Michigan, United States
William Beaumont Hospital-Royal Oak
🇺🇸
Royal Oak, Michigan, United States
Saint Mary's of Michigan
🇺🇸
Saginaw, Michigan, United States
Saint Luke's Hospital of Duluth
🇺🇸
Duluth, Minnesota, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
United Hospital
🇺🇸
Saint Paul, Minnesota, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
Saint Elizabeth Regional Medical Center
🇺🇸
Lincoln, Nebraska, United States
Siteman Cancer Center - Saint Peters
🇺🇸
Saint Peters, Missouri, United States
Barnes-Jewish West County Hospital
🇺🇸
Saint Louis, Missouri, United States
Exeter Hospital
🇺🇸
Exeter, New Hampshire, United States
Concord Hospital
🇺🇸
Concord, New Hampshire, United States
Wentworth-Douglass Hospital
🇺🇸
Dover, New Hampshire, United States
Elliot Hospital
🇺🇸
Manchester, New Hampshire, United States
Cooper Hospital University Medical Center
🇺🇸
Camden, New Jersey, United States
MD Anderson Cancer Center at Cooper-Voorhees
🇺🇸
Voorhees, New Jersey, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
New York Oncology Hematology PC - Albany
🇺🇸
Albany, New York, United States
Memorial Medical Center - Las Cruces
🇺🇸
Las Cruces, New Mexico, United States
Southside Hospital
🇺🇸
Bay Shore, New York, United States
Veteran Affairs New York Harbor Healthcare System-Brooklyn Campus
🇺🇸
Brooklyn, New York, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
Lourdes Hospital
🇺🇸
Binghamton, New York, United States
Long Island Jewish Medical Center
🇺🇸
New Hyde Park, New York, United States
Columbia University Medical Center
🇺🇸
New York, New York, United States
Mission Hospital-Memorial Campus
🇺🇸
Asheville, North Carolina, United States
High Point Regional Hospital
🇺🇸
High Point, North Carolina, United States
Coastal Carolina Radiation Oncology
🇺🇸
Wilmington, North Carolina, United States
CarolinaEast Health System-Medical Center
🇺🇸
New Bern, North Carolina, United States
The Coleman Radiation Center-Carteret General Hospital
🇺🇸
Morehead City, North Carolina, United States
South Atlantic Radiation Oncology
🇺🇸
Supply, North Carolina, United States
Summa Akron City Hospital/Cooper Cancer Center
🇺🇸
Akron, Ohio, United States
Case Western Reserve University
🇺🇸
Cleveland, Ohio, United States
Summa Barberton Hospital
🇺🇸
Barberton, Ohio, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Foundation
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Cancer Center Independence
🇺🇸
Independence, Ohio, United States
Arthur G. James Cancer Hospital and Solove Research Institute at Ohio State University Medical Center
🇺🇸
Columbus, Ohio, United States
Ohio State University Medical Center
🇺🇸
Columbus, Ohio, United States
Hillcrest Hospital Cancer Center
🇺🇸
Mayfield Heights, Ohio, United States
Toledo Clinic Cancer Centers-Maumee
🇺🇸
Maumee, Ohio, United States
Lake University Ireland Cancer Center
🇺🇸
Mentor, Ohio, United States
Southwest General Health Center Ireland Cancer Center
🇺🇸
Middleburg Heights, Ohio, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸
Orange Village, Ohio, United States
Cancer Care Center, Incorporated
🇺🇸
Salem, Ohio, United States
Flower Hospital
🇺🇸
Sylvania, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸
Westlake, Ohio, United States
Cancer Treatment Center
🇺🇸
Wooster, Ohio, United States
Cleveland Clinic Wooster Specialty Center
🇺🇸
Wooster, Ohio, United States
Willamette Valley Cancer Center
🇺🇸
Eugene, Oregon, United States
Three Rivers Community Hospital
🇺🇸
Grants Pass, Oregon, United States
Clackamas Radiation Oncology Center
🇺🇸
Clackamas, Oregon, United States
Providence Medford Medical Center
🇺🇸
Medford, Oregon, United States
Rogue Valley Medical Center
🇺🇸
Medford, Oregon, United States
Abington Memorial Hospital
🇺🇸
Abington, Pennsylvania, United States
Bryn Mawr Hospital
🇺🇸
Bryn Mawr, Pennsylvania, United States
Delaware County Memorial Hospital
🇺🇸
Drexel Hill, Pennsylvania, United States
Fox Chase Cancer Center Buckingham
🇺🇸
Furlong, Pennsylvania, United States
Adams Cancer Center
🇺🇸
Gettysburg, Pennsylvania, United States
Cherry Tree Cancer Center
🇺🇸
Hanover, Pennsylvania, United States
Academic Urology Prostate Center
🇺🇸
King Of Prussia, Pennsylvania, United States
Fox Chase Cancer Center
🇺🇸
Philadelphia, Pennsylvania, United States
Albert Einstein Medical Center
🇺🇸
Philadelphia, Pennsylvania, United States
Lankenau Medical Center
🇺🇸
Wynnewood, Pennsylvania, United States
WellSpan Health-York Hospital
🇺🇸
York, Pennsylvania, United States
Rapid City Regional Hospital
🇺🇸
Rapid City, South Dakota, United States
Spartanburg Regional Medical Center
🇺🇸
Spartanburg, South Carolina, United States
Texas Oncology-Denton South
🇺🇸
Denton, Texas, United States
The Klabzuba Cancer Center
🇺🇸
Fort Worth, Texas, United States
University of Texas Medical Branch at Galveston
🇺🇸
Galveston, Texas, United States
West Texas Cancer Center
🇺🇸
Odessa, Texas, United States
Texas Oncology Cancer Center Sugar Land
🇺🇸
Sugar Land, Texas, United States
Texas Cancer Center-Sherman
🇺🇸
Sherman, Texas, United States
Tyler Cancer Center
🇺🇸
Tyler, Texas, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States
Dixie Medical Center Regional Cancer Center
🇺🇸
Saint George, Utah, United States
Utah Valley Regional Medical Center
🇺🇸
Provo, Utah, United States
University of Virginia
🇺🇸
Charlottesville, Virginia, United States
Danville Regional Medical Center
🇺🇸
Danville, Virginia, United States
Compass Oncology Vancouver
🇺🇸
Vancouver, Washington, United States
Appleton Medical Center
🇺🇸
Appleton, Wisconsin, United States
Saint Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Gundersen Lutheran
🇺🇸
La Crosse, Wisconsin, United States
Mayo Clinic Health System-Franciscan Healthcare
🇺🇸
La Crosse, Wisconsin, United States
Bay Area Medical Center
🇺🇸
Marinette, Wisconsin, United States
Oconomowoc Memorial Hospital-ProHealth Care Inc
🇺🇸
Oconomowoc, Wisconsin, United States
Door County Cancer Center
🇺🇸
Sturgeon Bay, Wisconsin, United States
Tom Baker Cancer Centre
🇨🇦
Calgary, Alberta, Canada
Cross Cancer Institute
🇨🇦
Edmonton, Alberta, Canada
Aurora West Allis Medical Center
🇺🇸
West Allis, Wisconsin, United States
Waukesha Memorial Hospital - ProHealth Care
🇺🇸
Waukesha, Wisconsin, United States
BCCA-Vancouver Cancer Centre
🇨🇦
Vancouver, British Columbia, Canada
BCCA-Fraser Valley Cancer Centre
🇨🇦
Surrey, British Columbia, Canada
BCCA-Cancer Centre for the Southern Interior
🇨🇦
Kelowna, British Columbia, Canada
Juravinski Cancer Centre at Hamilton Health Sciences
🇨🇦
Hamilton, Ontario, Canada
CHUQ - Pavilion Hotel-Dieu de Quebec
🇨🇦
Quebec City, Quebec, Canada
London Regional Cancer Program
🇨🇦
London, Ontario, Canada
Allan Blair Cancer Centre
🇨🇦
Regina, Saskatchewan, Canada
Virginia Mason CCOP
🇺🇸
Seattle, Washington, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸
Miami, Florida, United States
University of Cincinnati
🇺🇸
Cincinnati, Ohio, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
University of Texas Health Science Center
🇺🇸
San Antonio, Texas, United States
UCSF-Mount Zion
🇺🇸
San Francisco, California, United States
California Pacific Medical Center
🇺🇸
San Francisco, California, United States
Utah Cancer Specialists-Salt Lake City
🇺🇸
Salt Lake City, Utah, United States
Huntsman Cancer Institute/University of Utah
🇺🇸
Salt Lake City, Utah, United States
University of Hawaii Cancer Center
🇺🇸
Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
University of Alabama at Birmingham
🇺🇸
Birmingham, Alabama, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Henry Ford Hospital
🇺🇸
Detroit, Michigan, United States
Saint John Hospital and Medical Center
🇺🇸
Detroit, Michigan, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Providence Portland Medical Center
🇺🇸
Portland, Oregon, United States
Western Oncology Research Consortium
🇺🇸
Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸
Portland, Oregon, United States
Mayo Clinic
🇺🇸
Rochester, Minnesota, United States
Nebraska Methodist Hospital
🇺🇸
Omaha, Nebraska, United States
Mercy General Hospital Radiation Oncology Center
🇺🇸
Sacramento, California, United States
Radiological Associates of Sacramento
🇺🇸
Sacramento, California, United States
University of Colorado Cancer Center - Anschutz Cancer Pavilion
🇺🇸
Aurora, Colorado, United States
Aurora Saint Luke's Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Clement J. Zablocki VA Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Christiana Care Health System-Christiana Hospital
🇺🇸
Newark, Delaware, United States
Maine Medical Center- Scarborough Campus
🇺🇸
Scarborough, Maine, United States
Good Samaritan Hospital
🇺🇸
Kearney, Nebraska, United States
Arizona Oncology Associates-West Orange Grove
🇺🇸
Tucson, Arizona, United States
Cancer Specialists of North Florida-Southside
🇺🇸
Jacksonville, Florida, United States
New Hanover Regional Medical Center
🇺🇸
Wilmington, North Carolina, United States