Azacitidine and Gemtuzumab Ozogamicin in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia
- Conditions
- Acute Myeloid LeukemiaAdult Acute Myeloid Leukemia With t(9;11)(p21.3;q23.3); MLLT3-KMT2AAdult Acute Myeloid Leukemia Without MaturationAdult Acute Megakaryoblastic LeukemiaAdult Acute Myeloid Leukemia With t(16;16)(p13.1;q22); CBFB-MYH11Adult Acute Monoblastic LeukemiaAdult Acute Myeloid Leukemia With Inv(16)(p13.1q22); CBFB-MYH11Adult Acute Monocytic LeukemiaAdult Acute Myeloid Leukemia With t(8;21); (q22; q22.1); RUNX1-RUNX1T1Adult Pure Erythroid Leukemia
- Interventions
- Registration Number
- NCT00658814
- Lead Sponsor
- National Cancer Institute (NCI)
- Brief Summary
This phase II trial is studying the side effects of giving azacitidine together with gemtuzumab ozogamicin to see how well it works in treating older patients with previously untreated acute myeloid leukemia. Drugs used in chemotherapy, such as azacitidine, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Azacitidine may also stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Monoclonal antibodies, such as gemtuzumab ozogamicin, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Giving azacitidine together with gemtuzumab ozogamicin may kill more cancer cells.
- Detailed Description
PRIMARY OBJECTIVES:
I. To test whether outcomes of patients of age 60 or older with previously untreated non-M3 acute myeloid leukemia treated with azacitidine plus gemtuzumab ozogamicin are sufficient to warrant phase III investigation.
II. To estimate the frequency and severity of toxicities of this regimen in the good- and poor-risk groups of patients.
III. To investigate in a preliminary manner the disease-free survival of patients who achieve complete remission and receive post-remission therapy on this study.
IV. To investigate in a preliminary manner the cytogenetic response rates of patients treated with this regimen.
V. To investigate in a preliminary manner the effects of cytogenetic abnormalities, promoter and global methylation changes, and multidrug resistance on overall survival and response to azacitidine plus gemtuzumab ozogamicin therapy.
OUTLINE: Patients are stratified according to risk status (good \[60-69 years of age OR Zubrod performance status \[PS\] 0-1\] vs poor \[\>= 70 years of age AND Zubrod PS 2-3\]).
REMISSION INDUCTION THERAPY: Patients receive azacitidine intravenously (IV) over 10-40 minutes or subcutaneously (SC) once daily (QD) on days 1-7 and gemtuzumab ozogamicin IV over 2 hours on day 8. Patients with residual leukemia (blast count \>= 5%) receive a second course of induction therapy beginning between days 15-29. Patients achieving complete remission (CR) or morphologic complete remission with incomplete blood count recovery (CRi) go on to receive consolidation therapy.
CONSOLIDATION THERAPY: Patients receive one course of azacitidine and gemtuzumab ozogamicin as in induction therapy (with azacitidine given SC only).
MAINTENANCE THERAPY: Patients receive azacitidine SC on days 1-7. Treatment repeats every 28 days for 4 courses in the absence of disease progression or unacceptable toxicity. Patients undergo bone marrow biopsies for cytogenetic studies at baseline, remission, and relapse or progression (and at completion of treatment if it does not correspond to one of these time points). Marrow and blood samples are submitted to correlatives studies and submitted to Southwest Oncology Group (SWOG) acute lymphoblastic leukemia (ALL)/chronic lymphocytic leukemia (CLL)/chronic myelogenous leukemia (CML) Repository in Seattle, WA.
After completion of study therapy, patients are followed every 2 months for 2 years, every 3 months for 1 year, every 4 months for 1 year, and then every 6 months thereafter.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 133
-
Morphologically confirmed diagnosis of acute myeloid leukemia (AML) with classification other than WHO acute promyelocytic leukemia (FAB M3), based on bone marrow examination performed within 14 days prior to registration; patients with World Health Organization (WHO) acute promyelocytic leukemia (FAB M3) or blastic transformation of chronic myelogenous leukemia are not eligible
-
Zubrod performance status 0-3
-
No known hypersensitivity to azacitidine, mannitol, hydroxyurea, orgemtuzumab ozogamicin
-
No prior systemic chemotherapy for acute leukemia with the exception of hydroxyurea; administration of hydroxyurea to control high white blood cell (WBC) count prior to registration is permitted
-
Patients with a history of prior myelodysplastic syndrome (MDS) are eligible according to the following criteria:
- No prior treatment of MDS with AML induction-type chemotherapy or high-dose chemotherapy with hematopoietic stem cell support
- Prior cytarabine allowed if dose < 100 mg/m^2/day
- Prior hematopoietic growth factors, thalidomide, lenalidomide, arsenic trioxide, and signal transduction inhibitors for treatment of MDS allowed
- No prior treatment with azacitidine, decitabine, or gemtuzumab ozogamicin
- At least 30 days since prior therapy for MDS and recovered
-
Bilirubin =< 2.0 x institutional upper limit of normal (IULN) within 14 days to registration, unless the elevation is believed to be due to hepatic infiltration by AML
- Hyperbilirubinemia due primarily to elevated unconjugated hyperbilirubinemia secondary to Gilbert syndrome or hemolysis is allowed
-
Serum glutamic oxaloacetic transaminase (SGOT) aspartate aminotransferase (AST) =< 2 x IULN, or serum glutamic pyruvate transaminase (SGPT) alanine aminotransferase (ALT) =< 2.0 x IULN , unless the elevation is believed to be due to hepatic infiltration by AML
-
Serum creatinine =< 1.5 x IULN
-
Left ventricle ejection fraction (LVEF) >= 40% by multi-gated acquisition scan (MUGA) or echocardiogram (ECHO) AND no clinical evidence of congestive heart failure within the past 56 days
-
Pretreatment cytogenetics must be performed on all patients; collection of pretreatment specimens must be completed within 14 days prior to registration to S0703; specimens must be submitted to the site's preferred cytogenetics laboratory
-
Patients must consent to submit specimens to the Southwest Oncology Group (SWOG) acute lymphoblastic leukemia (ALL)/chronic lymphocytic leukemia (CLL)/chronic myelogenous leukemia (CML) repository for cellular and molecular studies; collection of pretreatment blood and/or marrow specimens must be completed within 14 days prior to registration; if a marrow specimen is available, either from the diagnostic marrow or a repeat pre-registration marrow, then it must be submitted along with a peripheral blood specimen; otherwise peripheral blood alone must be submitted; residual specimens will only be banked if the patient provides separate consent; sites are required to offer patients the opportunity to participate in banking
-
No central nervous system (CNS) involvement; if central nervous involvement is clinically suspected, it must be ruled out by a lumbar puncture
-
Women of reproductive potential must have a pregnancy test within 28 days prior to registration; patients must not be pregnant or nursing because of the teratogenic potential of the drugs used in this study; women/men of reproductive potential must have agreed to use an effective contraceptive method
-
Patients not known to be human immunodeficiency virus positive (HIV+) must be tested for HIV infection within 14 days prior to registration
-
HIV-positive patients must meet the following criteria:
- No history of acquired immunodeficiency syndrome (AIDS)-defining events
- CD4 cells >= 500/mm^3
- Viral load of < 50 copies HIV messenger ribonucleic acid (mRNA)/mm^3 if on cART or < 25,000 copies HIV mRNA if not on cART
- No zidovudine or stavudine as part of cART Patients who are HIV+ and do not meet all of these criteria will not be eligible for this study
-
No other prior malignancy except for a) adequately treated basal cell or squamous cell skin cancer or b) any diagnosis of malignancy made within the past 2 years earlier, of which there is no clinically evident cancer, and for which the patient has completed all chemotherapy and radiotherapy at least 6 months prior to study registration; prior treatment with AML induction-type chemotherapy is not allowed; concurrent hormonal therapy is allowed
-
All patients must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines
-
At the time of patient registration, the treating institution's name and identification (ID) number must be provided to the Data Operations Center in Seattle in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered into the data base
-
Patients must have complete remission (CR) or CRi, documented by blood and marrow examinations performed within 42 days before this registration
-
Following completion of induction therapy, the blood counts must recover to absolute neutrophil count (ANC) >= 1,000/mcL and platelets >= 90,000/mcL (without transfusion), and must be maintained at these levels during the 7 days prior to registration
-
Patients must have serum creatinine =< 1.5 x IULN and SGOT or SGPT =< 1.5 x IULN within 28 days before registration
-
Patients must have recovered to =< Grade 2 from any induction cycle non-hematologic toxicities
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- SINGLE_GROUP
- Arm && Interventions
Group Intervention Description Treatment (azacitidine, gemtuzumab) Azacitidine See Detailed Description Treatment (azacitidine, gemtuzumab) Gemtuzumab Ozogamicin See Detailed Description
- Primary Outcome Measures
Name Time Method Complete Response Up to 60 days Morphologic complete remission (CR): ANC \>=1,000/mcL, platelet count \>=100,000/mcL, \<5% bone marrow blasts, no Auer rods, no evidence of extramedullary disease. Morphologic complete remission with incomplete blood count recovery (CRi): Same as CR but ANC may be \<1,000/mcL and/or platelet count \<100,000/mcL.
30-Day Survival 30 days Patients surviving more than 30 days after study registration
- Secondary Outcome Measures
Name Time Method Number of Patients With Grade 3 Through 5 Adverse Events That Are Related to Study Drug Up to 5 years Only adverse events that are possibly, probably or definitely related to study drug are reported.
Relapse-free Survival Up to 5 years Relapse-free survival (RFS) is defined for all patients who achieve CR or CRi. RFS is measured from the date CR or CRi is first achieved until relapse or death form any cause, with observation censored on the date of last contact for patients last known to be alive without report of relapse. Relapse from CR/CRi is defined as reappearance of leukemic blasts in the peripheral blood; or \> 5% blasts in the bone marrow not attributable to another cause; or appearance or reappearance of extramedullary disease.
Trial Locations
- Locations (177)
Stanford Cancer Institute Palo Alto
🇺🇸Palo Alto, California, United States
Providence Saint Joseph Medical Center/Disney Family Cancer Center
🇺🇸Burbank, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸Sacramento, California, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸Hartford, Connecticut, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸Boise, Idaho, United States
OSF Saint Anthony's Health Center
🇺🇸Alton, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Heartland Cancer Research NCORP
🇺🇸Decatur, Illinois, United States
Advocate Sherman Hospital
🇺🇸Elgin, Illinois, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
SSM Health Good Samaritan
🇺🇸Mount Vernon, Illinois, United States
Springfield Memorial Hospital
🇺🇸Springfield, Illinois, United States
Franciscan Saint Francis Health-Beech Grove
🇺🇸Beech Grove, Indiana, United States
Reid Health
🇺🇸Richmond, Indiana, United States
Hospital District Sixth of Harper County
🇺🇸Anthony, Kansas, United States
Cancer Center of Kansas - Chanute
🇺🇸Chanute, Kansas, United States
Cancer Center of Kansas - Dodge City
🇺🇸Dodge City, 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-Independence
🇺🇸Independence, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸Kingman, Kansas, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Southwest Medical Center
🇺🇸Liberal, Kansas, United States
Cancer Center of Kansas-Liberal
🇺🇸Liberal, Kansas, United States
Cancer Center of Kansas - Newton
🇺🇸Newton, Kansas, United States
Menorah Medical Center
🇺🇸Overland Park, Kansas, United States
Saint Luke's South Hospital
🇺🇸Overland Park, Kansas, United States
Cancer Center of Kansas - Parsons
🇺🇸Parsons, Kansas, United States
Kansas City NCI Community Oncology Research Program
🇺🇸Prairie Village, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸Pratt, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸Salina, Kansas, United States
Salina Regional Health Center
🇺🇸Salina, Kansas, United States
AdventHealth Shawnee Mission
🇺🇸Shawnee Mission, Kansas, United States
Cotton O'Neil Cancer Center / Stormont Vail Health
🇺🇸Topeka, Kansas, United States
Cancer Center of Kansas - Wellington
🇺🇸Wellington, Kansas, United States
Associates In Womens Health
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸Wichita, Kansas, United States
Ascension Via Christi Hospitals Wichita
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Wichita
🇺🇸Wichita, Kansas, United States
Wesley Medical Center
🇺🇸Wichita, Kansas, United States
Wichita NCI Community Oncology Research Program
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸Winfield, Kansas, United States
University of Kentucky/Markey Cancer Center
🇺🇸Lexington, Kentucky, United States
Hematology/Oncology Clinic PLLC
🇺🇸Baton Rouge, Louisiana, United States
Tulane University School of Medicine
🇺🇸New Orleans, Louisiana, United States
Michigan Cancer Research Consortium NCORP
🇺🇸Ann Arbor, Michigan, United States
Trinity Health Saint Joseph Mercy Hospital Ann Arbor
🇺🇸Ann Arbor, Michigan, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Spectrum Health Big Rapids Hospital
🇺🇸Big Rapids, Michigan, United States
Corewell Health Dearborn Hospital
🇺🇸Dearborn, Michigan, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Henry Ford Health Saint John Hospital
🇺🇸Detroit, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Genesys Regional Medical Center-West Flint Campus
🇺🇸Flint, Michigan, United States
Cancer Research Consortium of West Michigan NCORP
🇺🇸Grand Rapids, Michigan, United States
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
🇺🇸Grand Rapids, Michigan, United States
Trinity Health Grand Rapids Hospital
🇺🇸Grand Rapids, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
University of Michigan Health - Sparrow Lansing
🇺🇸Lansing, Michigan, United States
Trinity Health Saint Mary Mercy Livonia Hospital
🇺🇸Livonia, Michigan, United States
Trinity Health Muskegon Hospital
🇺🇸Muskegon, Michigan, United States
Trinity Health Saint Joseph Mercy Oakland Hospital
🇺🇸Pontiac, Michigan, United States
Lake Huron Medical Center
🇺🇸Port Huron, Michigan, United States
MyMichigan Medical Center Saginaw
🇺🇸Saginaw, Michigan, United States
Henry Ford Health Providence Southfield Hospital
🇺🇸Southfield, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
Henry Ford Health Warren Hospital
🇺🇸Warren, Michigan, United States
University of Michigan Health - West
🇺🇸Wyoming, Michigan, United States
University of Mississippi Medical Center
🇺🇸Jackson, Mississippi, United States
Southeast Missouri Hospital
🇺🇸Cape Girardeau, Missouri, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
University Health Truman Medical Center
🇺🇸Kansas City, Missouri, United States
Saint Luke's Hospital of Kansas City
🇺🇸Kansas City, Missouri, United States
Saint Joseph Health Center
🇺🇸Kansas City, Missouri, United States
North Kansas City Hospital
🇺🇸Kansas City, Missouri, United States
Heartland Hematology and Oncology Associates Incorporated
🇺🇸Kansas City, Missouri, United States
Research Medical Center
🇺🇸Kansas City, Missouri, United States
Saint Luke's East - Lee's Summit
🇺🇸Lee's Summit, Missouri, United States
Liberty Hospital
🇺🇸Liberty, Missouri, United States
Heartland Regional Medical Center
🇺🇸Saint Joseph, 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
Saint Louis-Cape Girardeau CCOP
🇺🇸Saint Louis, Missouri, United States
Billings Clinic Cancer Center
🇺🇸Billings, Montana, United States
Northern Rockies Radiation Oncology Center
🇺🇸Billings, Montana, United States
Saint Vincent Healthcare
🇺🇸Billings, Montana, United States
Montana Cancer Consortium NCORP
🇺🇸Billings, Montana, United States
Saint Vincent Frontier Cancer Center
🇺🇸Billings, Montana, United States
Bozeman Health Deaconess Hospital
🇺🇸Bozeman, Montana, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸Butte, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸Great Falls, Montana, United States
Berdeaux, Donald MD (UIA Investigator)
🇺🇸Great Falls, Montana, United States
Great Falls Clinic
🇺🇸Great Falls, Montana, United States
Northern Montana Hospital
🇺🇸Havre, Montana, United States
Saint Peter's Community Hospital
🇺🇸Helena, Montana, United States
Glacier Oncology PLLC
🇺🇸Kalispell, Montana, United States
Kalispell Medical Oncology
🇺🇸Kalispell, Montana, United States
Logan Health Medical Center
🇺🇸Kalispell, Montana, United States
Montana Cancer Specialists
🇺🇸Missoula, Montana, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Community Medical Center
🇺🇸Missoula, Montana, United States
Guardian Oncology and Center for Wellness
🇺🇸Missoula, Montana, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
University of Rochester
🇺🇸Rochester, New York, United States
Novant Health Presbyterian Medical Center
🇺🇸Charlotte, North Carolina, United States
Wayne Memorial Hospital
🇺🇸Goldsboro, North Carolina, United States
Margaret R Pardee Memorial Hospital
🇺🇸Hendersonville, North Carolina, United States
Rutherford Hospital
🇺🇸Rutherfordton, North Carolina, United States
Southeast Clinical Oncology Research Consortium NCORP
🇺🇸Winston-Salem, North Carolina, United States
Cleveland Clinic Akron General
🇺🇸Akron, Ohio, United States
Mary Rutan Hospital
🇺🇸Bellefontaine, Ohio, United States
Adena Regional Medical Center
🇺🇸Chillicothe, Ohio, United States
University of Cincinnati Cancer Center-UC Medical Center
🇺🇸Cincinnati, Ohio, United States
Riverside Methodist Hospital
🇺🇸Columbus, Ohio, United States
Columbus NCI Community Oncology Research Program
🇺🇸Columbus, Ohio, United States
Grant Medical Center
🇺🇸Columbus, Ohio, United States
Mount Carmel Health Center West
🇺🇸Columbus, Ohio, United States
Doctors Hospital
🇺🇸Columbus, Ohio, United States
Grandview Hospital
🇺🇸Dayton, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital North
🇺🇸Dayton, Ohio, United States
Dayton NCI Community Oncology Research Program
🇺🇸Dayton, Ohio, United States
Grady Memorial Hospital
🇺🇸Delaware, Ohio, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
Spartanburg Medical Center
🇺🇸Spartanburg, South Carolina, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Fairfield Medical Center
🇺🇸Lancaster, Ohio, United States
Marietta Memorial Hospital
🇺🇸Marietta, Ohio, United States
Knox Community Hospital
🇺🇸Mount Vernon, Ohio, United States
Licking Memorial Hospital
🇺🇸Newark, Ohio, United States
Southern Ohio Medical Center
🇺🇸Portsmouth, Ohio, United States
Springfield Regional Medical Center
🇺🇸Springfield, Ohio, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Saint Ann's Hospital
🇺🇸Westerville, Ohio, United States
Clinton Memorial Hospital/Foster J Boyd Regional Cancer Center
🇺🇸Wilmington, Ohio, United States
Greene Memorial Hospital
🇺🇸Xenia, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸Zanesville, Ohio, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Legacy Mount Hood Medical Center
🇺🇸Gresham, Oregon, United States
Providence Milwaukie Hospital
🇺🇸Milwaukie, Oregon, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Providence Willamette Falls Medical Center
🇺🇸Oregon City, Oregon, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸Portland, Oregon, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Adventist Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Legacy Emanuel Hospital and Health Center
🇺🇸Portland, Oregon, United States
Salem Hospital
🇺🇸Salem, Oregon, United States
Legacy Meridian Park Hospital
🇺🇸Tualatin, Oregon, United States
AnMed Health Hospital
🇺🇸Anderson, South Carolina, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
The Don and Sybil Harrington Cancer Center
🇺🇸Amarillo, Texas, United States
Cancer Care Center at Island Hospital
🇺🇸Anacortes, Washington, United States
PeaceHealth Saint Joseph Medical Center
🇺🇸Bellingham, Washington, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Swedish Cancer Institute-Issaquah
🇺🇸Issaquah, Washington, United States
Kadlec Clinic Hematology and Oncology
🇺🇸Kennewick, Washington, United States
Skagit Valley Hospital
🇺🇸Mount Vernon, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸Poulsbo, Washington, United States
Harborview Medical Center
🇺🇸Seattle, Washington, United States
Minor and James Medical PLLC
🇺🇸Seattle, Washington, United States
Fred Hutchinson Cancer Center
🇺🇸Seattle, Washington, United States
Kaiser Permanente Washington
🇺🇸Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
University of Washington Medical Center - Montlake
🇺🇸Seattle, Washington, United States
PeaceHealth United General Medical Center
🇺🇸Sedro-Woolley, Washington, United States
Saint Michael Cancer Center
🇺🇸Silverdale, Washington, United States
Cancer Care Northwest - Spokane South
🇺🇸Spokane, Washington, United States
Evergreen Hematology and Oncology PS
🇺🇸Spokane, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Wenatchee Valley Hospital and Clinics
🇺🇸Wenatchee, Washington, United States
Rocky Mountain Oncology
🇺🇸Casper, Wyoming, United States
Welch Cancer Center
🇺🇸Sheridan, Wyoming, United States