SWOG-9239 Reduction of Immunosuppression Plus Interferon Alfa and Combination Chemotherapy in Treating Patients With Malignant Tumors That Develop After Organ Transplant

Phase 2

Completed

• Conditions: Lymphoma; Multiple Myeloma and Plasma Cell Neoplasm
• Interventions: Biological: bleomycin sulfate; Biological: recombinant interferon alfa; Drug: cyclophosphamide; Drug: cytarabine; Drug: doxorubicin hydrochloride; Drug: etoposide; Drug: methotrexate; Drug: prednisone; Drug: vincristine sulfate; Procedure: conventional surgery; Radiation: radiation therapy

• Registration Number: NCT00002657
• Lead Sponsor: SWOG Cancer Research Network

Brief Summary

RATIONALE: Reducing the amount of drugs used to prevent transplant rejection may help a person's body kill tumor cells. Giving biological therapy, such as interferon alfa, which may interfere with the growth of cancer cells, or combination chemotherapy, which uses different ways to stop tumor cells from dividing so they stop growing or die, may kill more tumor cells.

PURPOSE: Phase II trial to study the effectiveness of reducing immunosuppression, and giving interferon alfa and combination chemotherapy, in treating patients who have malignant tumors that develop after organ transplant.

Detailed Description

OBJECTIVES: I. Evaluate the complete remission rate and survival of patients with lymphoproliferation following organ transplantation treated with a defined sequential approach: modification of immunosuppression, with surgery or limited radiotherapy for an isolated site of disease; interferon alfa; and chemotherapy (ProMACE-CytaBOM; cyclophosphamide, doxorubicin, etoposide, prednisone, cytarabine, bleomycin, vincristine, methotrexate).

OUTLINE: All patients receive modification of immunocompetence, unless rejection is present at outset. These patients proceed directly to interferon treatment. Group 1 (see Disease Characteristics): Patients receive reduced doses of their current immunosuppressive therapy for 10 days. Group 2: Patients receive reduced doses of some of their current immunosuppressive therapy and discontinue some of the other therapy for 14 days. Immunosuppressive therapy then resumes on day 15. Immunosuppressive therapy continues throughout other therapy, unless otherwise noted. Some patients may then undergo surgery or radiotherapy. Interferon therapy: Patients receive interferon alfa (IFNA) subcutaneously or intramuscularly on days 1-28 for a maximum of 3 courses. Patients then receive maintenance therapy with IFNA 3 days a week for 4 weeks for up to 6 courses. Chemotherapy (ProMACE-CytaBOM): Immunosuppressive therapy is stopped on days 1-20. Patients receive cyclophosphamide IV, doxorubicin IV, and etoposide IV over 60 minutes on day 1, oral prednisone on days 1-14, and cytarabine IV, bleomycin IV, vincristine IV, and methotrexate IV on day 8. Treatment is repeated every 21 days for up to 6 courses. Patients with positive CSF cytology receive intrathecal methotrexate or cytarabine on days 1, 3, 5, 7, and 14. Some patients may continue this therapy on day 21 , then every 3 weeks for 5 doses, or may receive cranial irradiation. Patients are followed monthly for 1 year, every 2 months for 1 year, every 4 months for 1 year, then every 6 months thereafter.

PROJECTED ACCRUAL: A total of 50 patients will be accrued for this study within 4-5 years.

Study Timeline

• Study Start: 1995-05
• Study First Submitted: 1999-11-01
• Primary Completion: 2003-11
• Study First Submitted QC: 2004-06-21
• Study First Posted: 2004-06-22
• Study Completion: 2011-07
• Status Verified: 2013-01
• Last Update Submitted: 2013-01-22
• Last Update Posted: 2013-01-24

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 20

Inclusion Criteria

Not provided

Exclusion Criteria

Not provided

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Immumosuppression, IFN-a, ProMACE-CytaBOM	bleomycin sulfate	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	recombinant interferon alfa	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	conventional surgery	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	radiation therapy	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	vincristine sulfate	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	cytarabine	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	cyclophosphamide	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	doxorubicin hydrochloride	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	etoposide	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	prednisone	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.
Immumosuppression, IFN-a, ProMACE-CytaBOM	methotrexate	Doses and schedules of immunosuppressive drugs (cyclosporin (or FK506), prednisone, and acyclovir) will depend on whether patients are judged to have clinically urgent disease or not. Patients who do not have a CR after initial immunosuppression will receive 3 cycles (28 days each) Interferon alpha 2b at 3.0 x 10\^6 IU/m\^2 on days 1-28. Patients who have a CR will then receive 6 additional cycles with 3 doses per week, then go onto observation. Patients who do not have a CR will then receive a maximum of 6 21-day cycles of chemotherapy, consisting of: cyclophosphamide 650 mg/m\^2 on day 1, adriamycin 25 mg/m\^2 on day 1, etoposide 120 mg/m\^2 on day 1, prednisone 60 mg/m\^2 on days 1-14, cytosine arabinoside 300 mg/m\^2 on day 8, bleomycin 5 mg/m\^2 on day 8, vincristine 1.4 mg/m\^2 on day 8, methotrexate 120 mg/m\^2 on day 8, leucovorin 25 mg/m\^2 q 6 hours on days 8-9, G-CSF 5 ug/kg/day on days 2-14, and one double strength tablet trimethoprim-sulfamethoxazole 3 times per week.

Primary Outcome Measures

Name	Time	Method
Response	every 3 months while on protocol treatment

Secondary Outcome Measures

Name	Time	Method
overall survival	every 3 months while on treatment, then every 6 months thereafter

Trial Locations

Locations (86)

Providence Hospital - Southfield; 🇺🇸 Southfield, Michigan, United States

CCOP - Dayton; 🇺🇸 Kettering, Ohio, United States

Boston Medical Center; 🇺🇸 Boston, Massachusetts, United States

CCOP - Virginia Mason Research Center; 🇺🇸 Seattle, Washington, United States

Swedish Cancer Institute; 🇺🇸 Seattle, Washington, United States

Veterans Affairs Medical Center - Cincinnati; 🇺🇸 Cincinnati, Ohio, United States

Veterans Affairs Medical Center - San Antonio (Murphy); 🇺🇸 San Antonio, Texas, United States

Veterans Affairs Medical Center - Tucson; 🇺🇸 Tucson, Arizona, United States

Beckman Research Institute, City of Hope; 🇺🇸 Los Angeles, California, United States

Cancer Research Center of Hawaii; 🇺🇸 Honolulu, Hawaii, United States

David Grant Medical Center; 🇺🇸 Travis Air Force Base, California, United States

Arizona Cancer Center; 🇺🇸 Tucson, Arizona, United States

CCOP - Bay Area Tumor Institute; 🇺🇸 Oakland, California, United States

CCOP - Central Illinois; 🇺🇸 Decatur, Illinois, United States

CCOP - Atlanta Regional; 🇺🇸 Atlanta, Georgia, United States

Veterans Affairs Medical Center - Wichita; 🇺🇸 Wichita, Kansas, United States

Veterans Affairs Medical Center - Lexington; 🇺🇸 Lexington, Kentucky, United States

CCOP - Montana Cancer Consortium; 🇺🇸 Billings, Montana, United States

Veterans Affairs Medical Center - Jackson; 🇺🇸 Jackson, Mississippi, United States

CCOP - Wichita; 🇺🇸 Wichita, Kansas, United States

Veterans Affairs Medical Center - Shreveport; 🇺🇸 Shreveport, Louisiana, United States

Albert B. Chandler Medical Center, University of Kentucky; 🇺🇸 Lexington, Kentucky, United States

Veterans Affairs Medical Center - Biloxi; 🇺🇸 Biloxi, Mississippi, United States

Veterans Affairs Medical Center - New Orleans; 🇺🇸 New Orleans, Louisiana, United States

Louisiana State University Health Sciences Center - Shreveport; 🇺🇸 Shreveport, Louisiana, United States

CCOP - Metro-Minnesota; 🇺🇸 Saint Louis Park, Minnesota, United States

Brooke Army Medical Center; 🇺🇸 Fort Sam Houston, Texas, United States

St. Louis University Health Sciences Center; 🇺🇸 Saint Louis, Missouri, United States

Veterans Affairs Medical Center - Dayton; 🇺🇸 Dayton, Ohio, United States

Herbert Irving Comprehensive Cancer Center; 🇺🇸 New York, New York, United States

CCOP - Columbus; 🇺🇸 Columbus, Ohio, United States

Vanderbilt Cancer Center; 🇺🇸 Nashville, Tennessee, United States

University of Mississippi Medical Center; 🇺🇸 Jackson, Mississippi, United States

CCOP - Greater Phoenix; 🇺🇸 Phoenix, Arizona, United States

Veterans Affairs Medical Center - Phoenix (Hayden); 🇺🇸 Phoenix, Arizona, United States

Veterans Affairs Medical Center - Denver; 🇺🇸 Denver, Colorado, United States

University of Colorado Cancer Center; 🇺🇸 Denver, Colorado, United States

Veterans Affairs Medical Center - Detroit; 🇺🇸 Detroit, Michigan, United States

Henry Ford Hospital; 🇺🇸 Detroit, Michigan, United States

Barbara Ann Karmanos Cancer Institute; 🇺🇸 Detroit, Michigan, United States

Oklahoma Medical Research Foundation; 🇺🇸 Oklahoma City, Oklahoma, United States

CCOP - Columbia River Program; 🇺🇸 Portland, Oregon, United States

MBCCOP - University of South Alabama; 🇺🇸 Mobile, Alabama, United States

Veterans Affairs Medical Center - Little Rock (McClellan); 🇺🇸 Little Rock, Arkansas, United States

USC/Norris Comprehensive Cancer Center; 🇺🇸 Los Angeles, California, United States

Jonsson Comprehensive Cancer Center, UCLA; 🇺🇸 Los Angeles, California, United States

Veterans Affairs Medical Center - Long Beach; 🇺🇸 Long Beach, California, United States

Veterans Affairs Outpatient Clinic - Martinez; 🇺🇸 Martinez, California, United States

Veterans Affairs Medical Center - Hines (Hines Junior VA Hospital); 🇺🇸 Hines, Illinois, United States

MBCCOP - LSU Medical Center; 🇺🇸 New Orleans, Louisiana, United States

Tulane University School of Medicine; 🇺🇸 New Orleans, Louisiana, United States

CCOP - Grand Rapids Clinical Oncology Program; 🇺🇸 Grand Rapids, Michigan, United States

Keesler Medical Center - Keesler AFB; 🇺🇸 Keesler AFB, Mississippi, United States

CCOP - St. Louis-Cape Girardeau; 🇺🇸 Saint Louis, Missouri, United States

Veterans Affairs Medical Center - Brooklyn; 🇺🇸 Brooklyn, New York, United States

MBCCOP - University of New Mexico HSC; 🇺🇸 Albuquerque, New Mexico, United States

Barrett Cancer Center, The University Hospital; 🇺🇸 Cincinnati, Ohio, United States

Cleveland Clinic Cancer Center; 🇺🇸 Cleveland, Ohio, United States

Oregon Cancer Center at Oregon Health Sciences University; 🇺🇸 Portland, Oregon, United States

Veterans Affairs Medical Center - Oklahoma City; 🇺🇸 Oklahoma City, Oklahoma, United States

Veterans Affairs Medical Center - Portland; 🇺🇸 Portland, Oregon, United States

CCOP - Upstate Carolina; 🇺🇸 Spartanburg, South Carolina, United States

Veterans Affairs Medical Center - Nashville; 🇺🇸 Nashville, Tennessee, United States

University of Texas Health Science Center at San Antonio; 🇺🇸 San Antonio, Texas, United States

University of Texas Medical Branch; 🇺🇸 Galveston, Texas, United States

Texas Tech University Health Science Center; 🇺🇸 Lubbock, Texas, United States

Veterans Affairs Medical Center - Temple; 🇺🇸 Temple, Texas, United States

CCOP - Scott and White Hospital; 🇺🇸 Temple, Texas, United States

Huntsman Cancer Institute; 🇺🇸 Salt Lake City, Utah, United States

Veterans Affairs Medical Center - Salt Lake City; 🇺🇸 Salt Lake City, Utah, United States

CCOP - Northwest; 🇺🇸 Tacoma, Washington, United States

Veterans Affairs Medical Center - Seattle; 🇺🇸 Seattle, Washington, United States

Puget Sound Oncology Consortium; 🇺🇸 Seattle, Washington, United States

University of Michigan Comprehensive Cancer Center; 🇺🇸 Ann Arbor, Michigan, United States

University of California Davis Medical Center; 🇺🇸 Sacramento, California, United States

Veterans Affairs Medical Center - Ann Arbor; 🇺🇸 Ann Arbor, Michigan, United States

Veterans Affairs Medical Center - Albuquerque; 🇺🇸 Albuquerque, New Mexico, United States

University of Arkansas for Medical Sciences; 🇺🇸 Little Rock, Arkansas, United States

Loyola University Medical Center; 🇺🇸 Maywood, Illinois, United States

CCOP - Kansas City; 🇺🇸 Kansas City, Missouri, United States

CCOP - Cancer Research for the Ozarks; 🇺🇸 Springfield, Missouri, United States

Veterans Affairs Medical Center - Boston (Jamaica Plain); 🇺🇸 Jamaica Plain, Massachusetts, United States

Veterans Affairs Medical Center - Kansas City; 🇺🇸 Kansas City, Missouri, United States

CCOP - Greenville; 🇺🇸 Greenville, South Carolina, United States

CCOP - Santa Rosa Memorial Hospital; 🇺🇸 Santa Rosa, California, United States

University of Kansas Medical Center; 🇺🇸 Kansas City, Kansas, United States