Hypofractionated Radiation Therapy or Conventional Radiation Therapy After Surgery in Treating Patients With Prostate Cancer

Phase 3

Active, not recruiting

Conditions: Prostate Adenocarcinoma
Stage I Prostate Adenocarcinoma AJCC v7
Stage II Prostate Adenocarcinoma AJCC v7
Stage III Prostate Adenocarcinoma AJCC v7

Interventions: Radiation: Hypofractionated radiation therapy
Radiation: Conventional radiation therapy
Drug: Optional androgen deprivation therapy

Registration Number: NCT03274687

Lead Sponsor: NRG Oncology

Brief Summary: This randomized phase III trial studies how well hypofractionated radiation therapy works compared to conventional radiation therapy after surgery in treating patients with prostate cancer. Hypofractionated radiation therapy delivers higher doses of radiation therapy over a shorter period of time and may kill more tumor cells and have fewer side effects. Conventional radiation therapy uses high energy x-rays, gamma rays, neutrons, protons, or other sources to kill tumor cells and shrink tumors. It is not yet known whether giving hypofractionated radiation therapy or conventional radiation therapy after surgery may work better in treating patients with prostate cancer.

Detailed Description: PRIMARY OBJECTIVES:

I. To demonstrate that hypofractionated post-prostatectomy radiotherapy (HYPORT) does not increase patient-reported gastrointestinal (GI) or genitourinary (GU) symptoms over conventionally fractionated post-prostatectomy (COPORT) at the 2-year time point.

SECONDARY OBJECTIVES:

I. To compare patient-reported GI symptoms using the Expanded Prostate Cancer Index Composite (EPIC)-26 at end of radiation therapy (RT) and 6, 12, 24, and 60 months from end of treatment.

II. To compare patient-reported GU symptoms using the EPIC-26 at end of RT and 6, 12, 24, and 60 months from end of treatment.

III. To compare time to progression (TTP) where progression is defined as the first occurrence of biochemical failure (BF), local failure, regional failure, distant metastasis (DM), institution of new unplanned anticancer treatment, or death from prostate cancer (prostate cancer specific mortality \[PCSM\]).

IV. To compare freedom from biochemical failure (FFBF) and TTP rates with an alternate prostate specific antigen (PSA) \>= PSA nadir + 2 ng/mL definition of BF.

V. To compare local failure, regional failure, salvage therapy (i.e. institution of new unplanned anticancer treatment), DM, PCSM, and overall survival (OS) rates.

VI. Assessment of adverse events.

EXPLORATORY OBJECTIVES:

I. To compare utilities for health outcomes using the EuroQol five dimensions questionnaire (EQ-5D).

II. Paraffin-embedded tissue block, serum, plasma, whole blood, and urine for future translational research analyses for predictors of toxicity following hypofractionated or conventionally fractionated post-prostatectomy radiotherapy.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM I: Patients undergo conventional radiation therapy for 37 fractions over 7 weeks in the absence of disease progression or unacceptable toxicity. Patients may also receive androgen deprivation therapy for up to 6 months as per doctor recommendation.

ARM II: Patients undergo hypofractionated radiation therapy for 25 fractions over 5 weeks in the absence of disease progression or unacceptable toxicity. Patients may also receive androgen deprivation therapy for up to 6 months as per doctor recommendation.

After completion of study treatment, patients are followed up every 6 months for 2 years and every year for 3 years and thereafter.

Recruitment & Eligibility

Status: ACTIVE_NOT_RECRUITING

Sex: Male

Target Recruitment: 296

Inclusion Criteria

PRIOR TO STEP 1 REGISTRATION
Adenocarcinoma of the prostate treated primarily with radical prostatectomy
- Any type of radical prostatectomy will be permitted, including retropubic, perineal, laparoscopic, or robotically assisted; there is no time limit for the date of radical prostatectomy
One of the following pathologic T-classifications: pT2 or pT3
- Patients with positive surgical margins are eligible
One of the following pathologic N-classifications: pN0, pNX
- If a lymph node dissection is performed, the number of lymph nodes removed per side of the pelvis and the extent of the pelvic lymph node dissection (obturator versus [vs.] extended lymph node dissection) should be noted whenever possible
No clinical evidence of regional lymph node metastasis
- Computed tomography (CT) (with contrast if renal function is acceptable; a noncontrast CT is permitted if the patient is not a candidate for contrast), magnetic resonance imaging (MRI), nodal sampling, or dissection of the pelvis within 120 days prior to step 1 registration
- Patients with pelvic lymph nodes equivocal or questionable by imaging are eligible if the nodes are =< 1 cm in the short axis
A post-radical prostatectomy study entry PSA >= 45 days after prostatectomy and within 30 days prior to step 1, < 2.0 ng/mL
No evidence of a local recurrence in the prostate fossa based on a digital rectal examination (DRE) within 60 days prior to step 1 registration
- Patients with equivocal or questionable DRE findings should have an MRI of the pelvis to exclude the presence of a prostate fossa mass
- Patients with equivocal or questionable exam findings by DRE or MRI are eligible if a biopsy of the lesion is negative for tumor
No evidence of bone metastases (M0) on bone scan (Na F positron emission tomography (PET)/CT is an acceptable substitute) within 120 days prior to step 1 registration
- Equivocal bone scan findings are allowed if plain films and/or MRI are negative for metastasis
Zubrod performance status 0-1 within 60 days prior to step 1 registration
The patient or a legally authorized representative must provide study-specific informed consent prior to step 1 registration
Willingness and ability to complete the Expanded Prostate Cancer Index Composite (EPIC) questionnaire
Only English and French-speaking patients are eligible to participate as these are the only language the EPIC has been validated in
PRIOR TO STEP 2 REGISTRATION
The EPIC must be completed in full and entered within 10 business days after step 1 registration; NRG Oncology Statistical and Data Management Center has 3 business days to score the results and send a notification to the site to proceed to step 2 randomization

Exclusion Criteria

A post-prostatectomy PSA nadir >= 0.2 ng/mL AND Gleason >= 7 (Considered for NRG-GU002, principal investigator [PI]: Hurwitz)
pT2 with a negative surgical margin and PSA < 0.1 ng/mL
Androgen deprivation therapy started prior to prostatectomy for > 6 months (180 days) duration;
- Note: The use of finasteride or dutasteride (+/- tamsulosin) for longer periods prior to prostatectomy is acceptable
Androgen deprivation therapy started after prostatectomy and prior to step 1 registration for > 6 weeks (42 days)
Neoadjuvant chemotherapy before or after prostatectomy
Prior invasive (except non-melanoma skin cancer) malignancy unless disease-free for a minimum of 3 years and not in the pelvis; (for example, carcinoma in situ of the oral cavity is permissible if disease free for a minimum of 3 years; however, patients with prior history of bladder cancer are not allowed no matter the disease free duration); prior hematological (e.g., leukemia, lymphoma, myeloma) malignancy is not allowed
Previous chemotherapy for any other disease site if given within 3 years prior to step 1
Prior radiotherapy, including brachytherapy, to the region of the study cancer that would result in overlap of radiation therapy treatment volumes
Severe, active co-morbidity, defined as follows:
- Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months
- Transmural myocardial infarction within the last 6 months
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time of step 1 registration
- Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of step 1 registration
- Severe hepatic disease, defined as a diagnosis of Child-Pugh class B or C hepatic disease
- Human immunodeficiency virus (HIV) positive with cluster of differentiation (CD)4 count < 200 cells/microliter; note that patients who are HIV positive are eligible, provided they are under treatment with highly active antiretroviral therapy (HAART) and have a CD4 count >= 200 cells/microliter within 30 days prior to registration; note also that HIV testing is not required for eligibility for this protocol
- End-stage renal disease (ie, on dialysis or dialysis has been recommended)
Prior allergic reaction to the study drugs involved in this protocol
History of inflammatory bowel disease, prior bowel surgeries (or colostomy) for any reason, or prior partial/radical cystectomy for any reason

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Hypofractionated radiation therapy	Hypofractionated radiation therapy	Hypofractionated post-prostatectomy radiation therapy (HYPORT) over 5 weeks. Patients may also receive optional androgen deprivation therapy per doctor recommendation.
Conventional radiation therapy	Conventional radiation therapy	Conventional post-prostatectomy radiation therapy (COPORT) over 7 weeks. Patients may also receive optional androgen deprivation therapy per doctor recommendation.
Conventional radiation therapy	Optional androgen deprivation therapy	Conventional post-prostatectomy radiation therapy (COPORT) over 7 weeks. Patients may also receive optional androgen deprivation therapy per doctor recommendation.
Hypofractionated radiation therapy	Optional androgen deprivation therapy	Hypofractionated post-prostatectomy radiation therapy (HYPORT) over 5 weeks. Patients may also receive optional androgen deprivation therapy per doctor recommendation.

Primary Outcome Measures

Name	Time	Method
Change in Urinary Domain of the Expanded Prostate Cancer Index (EPIC) at Two Years	Baseline (randomization), 2 years	The EPIC is a prostate cancer health-related quality of life (HRQOL) self-administered instrument measuring patient-reported urinary, bowel, sexual, and hormonal symptoms related to prostate cancer treatments. Response options for each item form a Likert scale with scores transformed linearly to a 0-100 scale. Domain scores are also on a 0-100 scale with higher scores representing better HRQOL. The urinary domain contains 12 items. Change from baseline is calculated by subtracting baseline from later score, with a positive change score indicating increased HRQOL.
Change in Bowel Domain of the Expanded Prostate Cancer Index (EPIC) at Two Years	Baseline, 2 years	The EPIC is a prostate cancer health-related quality of life (HRQOL) self-administered instrument measuring patient-reported urinary, bowel, sexual, and hormonal symptoms related to prostate cancer treatments. Response options for each item form a Likert scale with scores transformed linearly to a 0-100 scale. Domain scores are also on a 0-100 scale with higher scores representing better HRQOL. The bowel domain contains 14 items. Change from baseline is calculated by subtracting baseline from later score, with a positive change score indicating increased HRQOL.

Secondary Outcome Measures

Name	Time	Method
Percentage of Participants With Biochemical Failure	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years.	Biochemical failure was analyzed using two different definitions. The protocol definition of biochemical failure is a PSA measurement ≥ 0.4 ng/mL and rising (i.e. PSA ≥ 0.4 ng/mL followed by a value higher than the first by any amount) or followed by initiation of salvage hormones. The Phoenix definition of biochemical failure is a PSA measurement ≥ PSA nadir + 2 ng/mL where nadir is the lowest post-RT PSA value. Time to biochemical failure is defined as time from randomization to the date of first biochemical failure, last known follow-up (censored), or death without biochemical failure (competing risk). Biochemical failure rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Two-year rates are provided.
Number of Participants With Grade 3+ Adverse Events	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Common Terminology Criteria for Adverse Events (CTCAE) version 4 grades adverse event severity from 1=mild to 5=death. Summary data is provided in this outcome measure; see Adverse Events Module for specific adverse event data. Counts of participants with any grade 3 or higher adverse event, any grade 3 or higher gastrointestinal adverse events, and any grade 3 or higher genitourinary adverse events are reported. Adverse events of any attribution are included.
Change in Urinary Domain Score of the Expanded Prostate Cancer Index (EPIC) at End of Radiation Therapy (RT), 6 Months, 1 and 5 Years	Baseline, end of RT, then 6 months,1 and 5 years from the start of RT (5 year time point has not yet been reached). RT dates depend on timing and duration of androgen deprivation therapy (ADT) (optional) and RT.	The EPIC is a prostate cancer health-related quality of life (HRQOL) self-administered instrument measuring patient-reported urinary, bowel, sexual, and hormonal symptoms related to prostate cancer treatments. Response options for each item form a Likert scale with scores transformed linearly to a 0-100 scale. Domain scores are also on a 0-100 scale with higher scores representing better HRQOL. The urinary domain contains 12 items. Change from baseline is calculated by subtracting baseline from later score, with a positive change score indicating increased HRQOL.
Percentage of Participants With Local-Regional Failure	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Local-regional failure is defined as local or regional failure. Local failure is defined as the development of a new biopsy-proven mass in the prostate bed. Regional failure is defined as radiographic evidence (CT or MRI) of lymphadenopathy (lymph node size ≥ 1.0 cm in the short axis) in a patient without the diagnosis of a hematologic/lymphomatous disorder associated with adenopathy. Time to local-regional failure is defined as time from randomization to the date of first local-regional failure, last known follow-up (censored), or death without local-regional (competing risk). Local-regional failure rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Two-year rates are provided.
Percentage of Participants Receiving Salvage Therapy	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Salvage therapy is defined as the initiation of new unplanned anticancer treatment. Time to salvage therapy initiation is defined as time from randomization to the date of first salvage therapy, last known follow-up (censored), or death without salvage therapy (competing risk). Salvage therapy rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of salvage initiation times be compared between the arms, which is reported in the statistical analysis results. Two-year rates are provided.
Change in Bowel Domain Score of the Expanded Prostate Cancer Index (EPIC) at End of RT, 6 Months, 1 and 5 Years	Baseline, end of RT, then 6 months,1 and 5 years from the start of RT (5 year time point has not yet been reached). RT dates depend on timing and duration of ADT (optional) and RT.	The EPIC is a prostate cancer health-related quality of life (HRQOL) self-administered instrument measuring patient-reported urinary, bowel, sexual, and hormonal symptoms related to prostate cancer treatments. Response options for each item form a Likert scale with scores transformed linearly to a 0-100 scale. Domain scores are also on a 0-100 scale with higher scores representing better HRQOL. The bowel domain contains 14 items. Change from baseline is calculated by subtracting baseline from later score, with a positive change score indicating increased HRQOL.
Percentage of Participants With Progression	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Progression (failure) is defined as the first occurrence of biochemical failure, local failure, regional failure, distant failure, institution of new unplanned anticancer treatment, or death from prostate cancer. Time to progression is defined as time from randomization to the date of progression, last known follow-up (censored), or death without progression (competing risk). Progression rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Two-year rates are provided.
Percentage of Participants With Distant Metastasis	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Distant metastasis (failure) is defined as radiographic evidence of hematogenous spread evaluated by bone scan, CT, or MRI. Time to distant metastasis is defined as time from randomization to the date of first distant metastasis, last known follow-up (censored), or death without local recurrence (competing risk). Distant metastasis rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Two-year rates are provided.
Percentage of Participants Who Died From Prostate Cancer (Prostate Cancer Specific Mortality)	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Cause of death was centrally reviewed. Count and percentage at time of analysis are reported.
Percent of Participants Alive (Overall Survival)	From randomization to last follow-up. Maximum follow-up at time of analysis was 3.0 years. Two-year rates reported here. Follow-up schedule: end of RT, then 6, 12, 18, 24 months from start of RT, then yearly.	Overall survival time is defined as time from registration/randomization to the date of death (failure) from any cause or last known follow-up (censored). Overall survival rates are estimated by the Kaplan-Meier method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. 2-year rates are provided.

Trial Locations

Locations (241): Iowa Methodist Medical Center
🇺🇸
Des Moines, Iowa, United States
Mayo Clinic in Florida
🇺🇸
Jacksonville, Florida, United States
University of Alabama at Birmingham Cancer Center
🇺🇸
Birmingham, Alabama, United States
University of South Alabama Mitchell Cancer Institute
🇺🇸
Mobile, Alabama, United States
University of Arkansas for Medical Sciences
🇺🇸
Little Rock, Arkansas, United States
Marin Cancer Care Inc
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Greenbrae, California, United States
Marin General Hospital
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Greenbrae, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸
Los Angeles, 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
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Los Angeles, California, United States
Fremont - Rideout Cancer Center
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Marysville, California, United States
Kaiser Permanente Oakland-Broadway
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Oakland, California, United States
Stanford Cancer Institute Palo Alto
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Palo Alto, California, United States
Pomona Valley Hospital Medical Center
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Pomona, California, United States
Kaiser Permanente-Rancho Cordova Cancer Center
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Rancho Cordova, California, United States
Rohnert Park Cancer Center
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Rohnert Park, California, United States
The Permanente Medical Group-Roseville Radiation Oncology
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Roseville, California, United States
University of California Davis Comprehensive Cancer Center
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Sacramento, California, United States
South Sacramento Cancer Center
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Sacramento, California, United States
Kaiser Permanente Medical Center - Santa Clara
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Santa Clara, California, United States
Kaiser Permanente Cancer Treatment Center
🇺🇸
South San Francisco, California, United States
Gene Upshaw Memorial Tahoe Forest Cancer Center
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Truckee, California, United States
UCHealth University of Colorado Hospital
🇺🇸
Aurora, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸
Colorado Springs, Colorado, United States
UCHealth Memorial Hospital Central
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Colorado Springs, Colorado, United States
Yale University
🇺🇸
New Haven, Connecticut, United States
Helen F Graham Cancer Center
🇺🇸
Newark, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸
Newark, Delaware, United States
Beebe Health Campus
🇺🇸
Rehoboth Beach, Delaware, United States
TidalHealth Nanticoke / Allen Cancer Center
🇺🇸
Seaford, Delaware, United States
UM Sylvester Comprehensive Cancer Center at Coral Gables
🇺🇸
Coral Gables, Florida, United States
UM Sylvester Comprehensive Cancer Center at Deerfield Beach
🇺🇸
Deerfield Beach, Florida, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸
Miami, Florida, United States
Cleveland Clinic-Weston
🇺🇸
Weston, Florida, United States
Grady Health System
🇺🇸
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
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
The Cancer Center of Hawaii-Pali Momi
🇺🇸
'Aiea, Hawaii, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
SIH Cancer Institute
🇺🇸
Carterville, Illinois, United States
University of Chicago Comprehensive Cancer Center
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Chicago, Illinois, United States
Decatur Memorial Hospital
🇺🇸
Decatur, Illinois, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Loyola University Medical Center
🇺🇸
Maywood, Illinois, United States
UC Comprehensive Cancer Center at Silver Cross
🇺🇸
New Lenox, Illinois, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸
Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
UW Health Carbone Cancer Center Rockford
🇺🇸
Rockford, Illinois, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Goshen Center for Cancer Care
🇺🇸
Goshen, Indiana, United States
McFarland Clinic - Ames
🇺🇸
Ames, 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
Cotton O'Neil Cancer Center / Stormont Vail Health
🇺🇸
Topeka, Kansas, United States
Ascension Via Christi Hospitals Wichita
🇺🇸
Wichita, Kansas, United States
Owensboro Health Mitchell Memorial Cancer Center
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Owensboro, Kentucky, United States
East Jefferson General Hospital
🇺🇸
Metairie, Louisiana, United States
Ochsner Medical Center Jefferson
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New Orleans, Louisiana, United States
MaineHealth Maine Medical Center - Portland
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Portland, Maine, United States
MaineHealth Maine Medical Center- Scarborough
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Scarborough, Maine, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸
Baltimore, Maryland, United States
Central Maryland Radiation Oncology in Howard County
🇺🇸
Columbia, Maryland, United States
University of Maryland Radiation Oncology Center at Union Hospital
🇺🇸
Elkton, Maryland, United States
UM Baltimore Washington Medical Center/Tate Cancer Center
🇺🇸
Glen Burnie, Maryland, United States
Boston Medical Center
🇺🇸
Boston, Massachusetts, United States
Lowell General Hospital
🇺🇸
Lowell, Massachusetts, United States
Beth Israel Deaconess Hospital-Plymouth
🇺🇸
Plymouth, Massachusetts, United States
Trinity Health Saint Joseph Mercy Hospital Ann Arbor
🇺🇸
Ann Arbor, Michigan, United States
Henry Ford Cancer Institute-Downriver
🇺🇸
Brownstown, Michigan, United States
McLaren Cancer Institute-Clarkston
🇺🇸
Clarkston, Michigan, United States
Michigan Healthcare Professionals Clarkston
🇺🇸
Clarkston, Michigan, United States
Henry Ford Macomb Hospital-Clinton Township
🇺🇸
Clinton Township, Michigan, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Henry Ford Hospital
🇺🇸
Detroit, Michigan, United States
Michigan Healthcare Professionals Farmington
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Farmington Hills, Michigan, United States
Weisberg Cancer Treatment Center
🇺🇸
Farmington Hills, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸
Flint, Michigan, United States
McLaren Cancer Institute-Flint
🇺🇸
Flint, Michigan, United States
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
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Grand Rapids, Michigan, United States
Trinity Health Grand Rapids Hospital
🇺🇸
Grand Rapids, Michigan, United States
West Michigan Cancer Center
🇺🇸
Kalamazoo, Michigan, United States
Karmanos Cancer Institute at McLaren Greater Lansing
🇺🇸
Lansing, Michigan, United States
University of Michigan Health - Sparrow Lansing
🇺🇸
Lansing, Michigan, United States
McLaren Cancer Institute-Lapeer Region
🇺🇸
Lapeer, Michigan, United States
Trinity Health Saint Mary Mercy Livonia Hospital
🇺🇸
Livonia, Michigan, United States
McLaren Cancer Institute-Macomb
🇺🇸
Mount Clemens, Michigan, United States
McLaren Cancer Institute-Central Michigan
🇺🇸
Mount Pleasant, Michigan, United States
McLaren Cancer Institute-Owosso
🇺🇸
Owosso, Michigan, United States
McLaren Cancer Institute-Northern Michigan
🇺🇸
Petoskey, Michigan, United States
Trinity Health Saint Joseph Mercy Oakland Hospital
🇺🇸
Pontiac, Michigan, United States
McLaren-Port Huron
🇺🇸
Port Huron, Michigan, United States
Michigan Healthcare Professionals Troy
🇺🇸
Troy, Michigan, United States
Henry Ford West Bloomfield Hospital
🇺🇸
West Bloomfield, Michigan, United States
University of Michigan Health - West
🇺🇸
Wyoming, Michigan, United States
Saint Luke's Hospital of Duluth
🇺🇸
Duluth, Minnesota, United States
Mayo Clinic Health Systems-Mankato
🇺🇸
Mankato, Minnesota, United States
Mayo Clinic in Rochester
🇺🇸
Rochester, Minnesota, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Mercy Cancer Center - Cape Girardeau
🇺🇸
Cape Girardeau, Missouri, United States
Siteman Cancer Center at West County Hospital
🇺🇸
Creve Coeur, Missouri, United States
North Kansas City Hospital
🇺🇸
Kansas City, Missouri, United States
Kansas City Veterans Affairs Medical Center
🇺🇸
Kansas City, Missouri, United States
The University of Kansas Cancer Center-South
🇺🇸
Kansas City, 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
Heartland Regional Medical Center
🇺🇸
Saint Joseph, Missouri, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
Siteman Cancer Center-South County
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Siteman Cancer Center at Saint Peters Hospital
🇺🇸
Saint Peters, Missouri, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Bozeman Health Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Logan Health Medical Center
🇺🇸
Kalispell, Montana, United States
Wentworth-Douglass Hospital
🇺🇸
Dover, New Hampshire, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸
Lebanon, New Hampshire, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Lovelace Radiation Oncology
🇺🇸
Albuquerque, New Mexico, United States
New Mexico Oncology Hematology Consultants
🇺🇸
Albuquerque, New Mexico, United States
Memorial Medical Center-Las Cruces
🇺🇸
Las Cruces, New Mexico, United States
Northwell Health Imbert Cancer Center
🇺🇸
Bay Shore, New York, United States
New York-Presbyterian/Brooklyn Methodist Hospital
🇺🇸
Brooklyn, New York, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
Mary Imogene Bassett Hospital
🇺🇸
Cooperstown, New York, United States
Arnot Ogden Medical Center/Falck Cancer Center
🇺🇸
Elmira, New York, United States
Northwell Health/Center for Advanced Medicine
🇺🇸
Lake Success, New York, United States
NYP/Weill Cornell Medical Center
🇺🇸
New York, New York, United States
Dickstein Cancer Treatment Center
🇺🇸
White Plains, New York, United States
UNC Lineberger Comprehensive Cancer Center
🇺🇸
Chapel Hill, North Carolina, United States
Novant Health Presbyterian Medical Center
🇺🇸
Charlotte, North Carolina, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
UNC Rex Healthcare
🇺🇸
Raleigh, North Carolina, United States
Novant Cancer Institute Radiation Oncology - Supply
🇺🇸
Supply, North Carolina, United States
Novant Health Cancer Institute Radiation Oncology - Wilmington
🇺🇸
Wilmington, North Carolina, United States
Novant Health Forsyth Medical Center
🇺🇸
Winston-Salem, North Carolina, United States
Cleveland Clinic Akron General
🇺🇸
Akron, Ohio, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸
Beachwood, Ohio, United States
Geauga Hospital
🇺🇸
Chardon, Ohio, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
Case Western Reserve University
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Cancer Center/Fairview Hospital
🇺🇸
Cleveland, Ohio, United States
Cleveland Clinic Foundation
🇺🇸
Cleveland, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸
Columbus, Ohio, United States
Mercy Cancer Center-Elyria
🇺🇸
Elyria, Ohio, United States
Cleveland Clinic Cancer Center Independence
🇺🇸
Independence, Ohio, United States
Cleveland Clinic Cancer Center Mansfield
🇺🇸
Mansfield, 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
UH Seidman Cancer Center at Southwest General Hospital
🇺🇸
Middleburg Heights, Ohio, United States
University Hospitals Parma Medical Center
🇺🇸
Parma, Ohio, United States
North Coast Cancer Care
🇺🇸
Sandusky, Ohio, United States
UH Seidman Cancer Center at Firelands Regional Medical Center
🇺🇸
Sandusky, Ohio, United States
Cleveland Clinic Cancer Center Strongsville
🇺🇸
Strongsville, Ohio, United States
ProMedica Flower Hospital
🇺🇸
Sylvania, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸
Westlake, Ohio, United States
Cleveland Clinic Wooster Family Health and Surgery Center
🇺🇸
Wooster, Ohio, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Jefferson Abington Hospital
🇺🇸
Abington, Pennsylvania, United States
Crozer-Keystone Regional Cancer Center at Broomall
🇺🇸
Broomall, Pennsylvania, United States
Christiana Care Health System-Concord Health Center
🇺🇸
Chadds Ford, Pennsylvania, United States
Geisinger Medical Center
🇺🇸
Danville, Pennsylvania, United States
Northeast Radiation Oncology Center
🇺🇸
Dunmore, Pennsylvania, United States
Crozer Regional Cancer Center at Brinton Lake
🇺🇸
Glen Mills, Pennsylvania, United States
UPMC Pinnacle Cancer Center/Community Osteopathic Campus
🇺🇸
Harrisburg, Pennsylvania, United States
Thomas Jefferson University Hospital
🇺🇸
Philadelphia, Pennsylvania, United States
Guthrie Medical Group PC-Robert Packer Hospital
🇺🇸
Sayre, Pennsylvania, United States
Reading Hospital
🇺🇸
West Reading, Pennsylvania, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸
Wilkes-Barre, Pennsylvania, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸
Boiling Springs, South Carolina, United States
Medical University of South Carolina
🇺🇸
Charleston, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸
Greenville, South Carolina, United States
Saint Francis Cancer Center
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Eastside
🇺🇸
Greenville, South Carolina, United States
Self Regional Healthcare
🇺🇸
Greenwood, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸
Greer, South Carolina, United States
The Radiation Oncology Center-Hilton Head/Bluffton
🇺🇸
Hilton Head Island, South Carolina, United States
Carolina Regional Cancer Center
🇺🇸
Myrtle Beach, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸
Seneca, South Carolina, United States
Spartanburg Medical Center
🇺🇸
Spartanburg, South Carolina, United States
Vanderbilt University/Ingram Cancer Center
🇺🇸
Nashville, Tennessee, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸
Dallas, Texas, United States
University of Texas Medical Branch
🇺🇸
Galveston, Texas, United States
UTMB Cancer Center at Victory Lakes
🇺🇸
League City, Texas, United States
American Fork Hospital / Huntsman Intermountain Cancer Center
🇺🇸
American Fork, Utah, United States
Farmington Health Center
🇺🇸
Farmington, Utah, United States
Logan Regional Hospital
🇺🇸
Logan, Utah, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States
McKay-Dee Hospital Center
🇺🇸
Ogden, Utah, United States
Ogden Regional Medical Center
🇺🇸
Ogden, Utah, United States
Utah Valley Regional Medical Center
🇺🇸
Provo, Utah, United States
Riverton Hospital
🇺🇸
Riverton, Utah, 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
LDS Hospital
🇺🇸
Salt Lake City, Utah, United States
South Jordan Health Center
🇺🇸
South Jordan, Utah, United States
Dartmouth Cancer Center - North
🇺🇸
Saint Johnsbury, Vermont, United States
Augusta Health Center for Cancer and Blood Disorders
🇺🇸
Fishersville, Virginia, United States
Naval Medical Center - Portsmouth
🇺🇸
Portsmouth, Virginia, United States
Overlake Medical Center
🇺🇸
Bellevue, Washington, United States
Ascension Saint Elizabeth Hospital
🇺🇸
Appleton, Wisconsin, United States
Ascension Southeast Wisconsin Hospital - Elmbrook Campus
🇺🇸
Brookfield, Wisconsin, United States
Mayo Clinic Health System Eau Claire Hospital-Luther Campus
🇺🇸
Eau Claire, Wisconsin, United States
Ascension Saint Francis - Reiman Cancer Center
🇺🇸
Franklin, Wisconsin, United States
Aurora Cancer Care-Grafton
🇺🇸
Grafton, Wisconsin, United States
Aurora BayCare Medical Center
🇺🇸
Green Bay, Wisconsin, United States
Aurora Cancer Care-Kenosha South
🇺🇸
Kenosha, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸
La Crosse, Wisconsin, United States
Mayo Clinic Health System-Franciscan Healthcare
🇺🇸
La Crosse, Wisconsin, United States
University of Wisconsin Carbone Cancer Center - University Hospital
🇺🇸
Madison, Wisconsin, United States
Aurora Bay Area Medical Group-Marinette
🇺🇸
Marinette, Wisconsin, United States
Froedtert Menomonee Falls Hospital
🇺🇸
Menomonee Falls, Wisconsin, United States
Aurora Saint Luke's Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Sinai Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Zablocki Veterans Administration Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Ascension Mercy Hospital
🇺🇸
Oshkosh, Wisconsin, United States
Vince Lombardi Cancer Clinic - Oshkosh
🇺🇸
Oshkosh, Wisconsin, United States
Ascension All Saints Hospital
🇺🇸
Racine, Wisconsin, United States
Vince Lombardi Cancer Clinic-Sheboygan
🇺🇸
Sheboygan, Wisconsin, United States
Aurora Medical Center in Summit
🇺🇸
Summit, Wisconsin, United States
Vince Lombardi Cancer Clinic-Two Rivers
🇺🇸
Two Rivers, Wisconsin, United States
Aurora West Allis Medical Center
🇺🇸
West Allis, 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
Arthur J E Child Comprehensive Cancer Centre
🇨🇦
Calgary, Alberta, Canada
Juravinski Cancer Centre at Hamilton Health Sciences
🇨🇦
Hamilton, Ontario, Canada
London Regional Cancer Program
🇨🇦
London, Ontario, Canada
Centre De Sante Et De Services Sociaux De Chicoutimi
🇨🇦
Chicoutimi, Quebec, Canada
CIUSSSEMTL-Hopital Maisonneuve-Rosemont
🇨🇦
Montreal, Quebec, Canada
CHUM - Centre Hospitalier de l'Universite de Montreal
🇨🇦
Montreal, Quebec, Canada
The Research Institute of the McGill University Health Centre (MUHC)
🇨🇦
Montreal, Quebec, Canada
CHU de Quebec-L'Hotel-Dieu de Quebec (HDQ)
🇨🇦
Quebec City, Quebec, Canada
Centre Hospitalier Universitaire de Sherbrooke-Fleurimont
🇨🇦
Sherbrooke, Quebec, Canada
Allan Blair Cancer Centre
🇨🇦
Regina, Saskatchewan, Canada
Saskatoon Cancer Centre
🇨🇦
Saskatoon, Saskatchewan, Canada
Kantonsspital Aarau
🇨🇭
Aarau, Switzerland