Five or Ten Year Colonoscopy for 1-2 Non-Advanced Adenomatous Polyps
- Conditions
- Adenocarcinoma of the ColonAdenocarcinoma of the Rectum
- Interventions
- Procedure: 5-year and 10 Year Surveillance Colonoscopy after Qualifying Colonoscopy
- Registration Number
- NCT05080673
- Lead Sponsor
- NRG Oncology
- Brief Summary
This trial examines colorectal cancer incidence in participants with 1 to 2 non-advanced adenomas randomized to surveillance colonoscopy at 10 years compared to participants randomized to surveillance colonoscopy at 5 and 10 years.
- Detailed Description
Colorectal cancer (CRC) is the fourth most common cancer and the second leading cause of cancer death among men and women in the United States (US). The lifetime risk of colorectal cancer in both men and women in the US is approximately 6%. About 93% of colorectal cancer (CRC) diagnoses are in patients older than 50 years (Siegel 2014). Randomized controlled trials show that screening for CRC significantly decreases CRC incidence and mortality (Schoen 2012, Atkin 2010, Mandel 1999, Mandel 2000). CRC screening has received a Grade A recommendation from the US Preventive Services Task Force.
In the U.S., colonoscopy is the most utilized screening modality for CRC. On a population basis, screening rates, which were around 40-50%, have now increased to 65%, and a goal to increase to 80% compliance is being promoted (CDC 2011, CDC 2013, Meester 2015).
Adenomatous polyps are the acknowledged precursors of colorectal cancer. Identification and removal of adenomas is the mechanism by which screening is effective in reducing CRC incidence and subsequent mortality. "Advanced" adenomas are adenomas which are greater than or equal to 1 cm, or have a "villous" component (tubulovillous or villous), or have foci of high grade dysplasia. Advanced adenomas are associated with increased long-term risk of cancer, even years after colonoscopy (Click 2018). The prevalence of advanced adenomas at screening colonoscopy is 5-10% (Ferlitsch 2011, Imperiale 2014). Non-advanced adenomas are adenomas greater than 1 cm with neither villous components nor high grade dysplasia. Non-advanced adenomas are much more common than advanced adenomas, present in around 30% of colonoscopy exams (Ferlitsch 2011, Imperiale 2014).
After detection of adenomas, patients are advised to return periodically for surveillance colonoscopy. Patients with 1-2 non-advanced adenomas are recommended by guidelines to return in 5 - 10 years for follow-up surveillance colonoscopy (Lieberman 2012). However, there are no guidelines on how to triage individuals to 5 as opposed to 10 years. Furthermore, there is limited evidence supporting the effectiveness of surveillance colonoscopy in reducing CRC incidence. A retrospective study in patients with advanced adenomas demonstrated benefit (Atkin 2017), but the study was not randomized and did not include patients with 1-2 non-advanced adenomas. The only randomized trial of surveillance colonoscopy was reported in the early 1990's, when participants were randomized to 3 vs. 1- and 3- year surveillance (Winawer 1993). No difference in advanced adenoma detection was observed when comparing participants examined at the two screening intervals, and as a result, guidelines were modified with participants advised to return every 3 years after adenomatous polyp detection. The recommended interval for non-advanced adenomas was gradually lengthened to the current standard, but there is no randomized, controlled data to support that interval. Furthermore, observational data of surveillance colonoscopy practice in the U.S. demonstrate that recommended intervals are often not adhered to, and individuals return for repeat testing well ahead of guideline recommendations (Schoen 2010, Lieberman 2014).
Furthermore, if anything, retrospective, natural history studies of non-advanced adenomas do not support the association of non-advanced adenoma with a higher risk of subsequent colorectal cancer (Atkin 1992, Spencer 1984, Loberg 2014). For example, in a classic study from the United Kingdom, patients with small rectosigmoid adenomas, even if multiple, did not have an increased risk of CRC compared to the general population, over a 14-year mean follow-up time (Atkin 1992). In a recent observational study from Norway, participants with a low-risk adenoma followed over a median of 7.7 years (maximum 19 years) without subsequent surveillance colonoscopy, had a lower CRC mortality than the general population (Loberg 2014), implying that although the initial colonoscopy may be protective, subsequent follow-up colonoscopy was not required. More recently, several studies have reported that individuals with non-advanced adenomas do not have an increased risk of colorectal cancer compared to those with no adenomas (Click 2018, Lieberman 2019, Lee 2019).
Another recent major development affecting screening is that practitioners of colonoscopy are now recommended to monitor and insure their adenoma detection rates are high. Data from Poland (Kaminski 2010) and Kaiser Permanente in California (Corley 2014) have demonstrated that a higher adenoma detection rate (ADR) is associated with a lower long-term risk of interval CRC, or cancer occurring after colonoscopy. Our understanding of these observations is premised on the notion that leaving pre-neoplastic tissue (adenomas) in situ, (such as what occurs with a lower ADR), increases the chance that an adenoma left behind will subsequently transform into cancer. The concern over interval cancers has stimulated quality concerns about the practice of colonoscopy. Guidelines for a recommended ADR at screening colonoscopy are rising, from the initial targets of 15% in women and 25% in men (Lieberman 2012) to 20% in women and 30% in men or 25% overall. ADRs in clinical studies are now commonly over 30% and some practitioners report rates exceeding 50%. However, adenomas that are detected when the ADR is high or as it increases over time are generally small, non-advanced adenomas.
Current clinical practice favoring colonoscopy-based screening with increased emphasis on detection of adenomas, most of which will turn out to be small, non-advanced adenomas, will greatly increase demand for utilization of surveillance colonoscopy exams in the coming decades. Yet, the evidence for determining the benefit, optimal timing, and recommended frequency of surveillance colonoscopy is unknown. A randomized, clinical trial to demonstrate the difference in yield between 5- or 10-year surveillance for participants with non-advanced adenoma is needed to guide clinical practice. Only a randomized trial will be authoritative enough to define good clinical practice and directly influence clinical care.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 9500
-
• The participant must have signed and dated an IRB-approved consent form that conforms to federal and institutional guidelines.
- Participants with a first-time diagnosis of 1-2 non-advanced tubular adenomas (less than 10 mm without tubulovillous or villous changes or high grade or severe dysplasia) from the qualifying colonoscopy within 4 years prior to randomization.
- Sessile serrated polyps/adenomas, as long as they do not meet the criteria for advanced adenomas, will be considered as non-advanced adenomas.
- Qualifying colonoscopy must be a complete colonoscopy with visualization of the cecum and with adequate cleansing within 4 years prior to randomization.
- Complete excision of all observed polyps in qualifying colonoscopy
- Participants must be able to read or understand English or Spanish.
-
• Prior history of colorectal cancer or colorectal adenomas including sessile serrated polyps/adenomas excluding those found on the qualifying colonoscopy.
- Prior history of a hyperplastic polyp measuring greater than or equal to 1 cm in size.
- Traditional serrated adenomas found on the qualifying colonoscopy.
- Hyperplastic polyp measuring greater than or equal to 1 cm in size found on the qualifying colonoscopy.
- Previous malignancies unless the patient has been disease-free for 5 or more years prior to randomization and is deemed by the physician to be at low risk for recurrence. Patients with the following cancers are eligible if diagnosed and treated within the past 5 years: all in situ cancers and basal cell and squamous cell carcinoma of the skin.
- Colonoscopy performed after the qualifying colonoscopy but prior to randomization.
- Incomplete qualifying colonoscopy (e.g., cecum not visualized).
- Incomplete endoscopic excision of adenomatous polyps based on colonoscopist impression at qualifying colonoscopy. (Excision of all hyperplastic rectosigmoid polyps is not required.)
- Sub-total colectomy or total proctocolectomy. (Segmental resections are allowed.)
- Family history of CRC diagnosed at greater than or equal to 60 years of age in a first degree relative (mother, father, child, sibling) or in two first degree relatives with CRC at any age.
- Participants with a clinical diagnosis of a significant heritable risk for colorectal cancer (Familial Adenomatous Polyposis, Hereditary Nonpolyposis Colorectal Cancer [Lynch Syndrome]).
- Participants tested positive for a Familial Adenomatous Polyposis, Hereditary Nonpolyposis Colorectal Cancer [Lynch Syndrome] genetic mutation that increases risk of colorectal cancer.
- Inflammatory bowel disease (e.g., Crohn's Disease, ulcerative colitis).
- Life expectancy less than 10 years due to comorbid conditions in the opinion of the investigator.
- Other comorbid conditions that would prevent the participant from having colonoscopies or would prevent required follow-up.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm 1 5-year and 10 Year Surveillance Colonoscopy after Qualifying Colonoscopy 5-Year and 10-Year Surveillance Colonoscopy after Qualifying Colonoscopy Arm 2 5-year and 10 Year Surveillance Colonoscopy after Qualifying Colonoscopy 10-Year Surveillance Colonoscopy after Qualifying Colonoscopy
- Primary Outcome Measures
Name Time Method Incidence of colorectal cancer 10 years To examine colorectal cancer incidence in participants with 1 to 2 non-advanced adenomas randomized to surveillance colonoscopy at 10 years compared to participants randomized to surveillance colonoscopy at 5 and 10 years.
- Secondary Outcome Measures
Name Time Method
Trial Locations
- Locations (451)
Fairbanks Memorial Hospital
🇺🇸Fairbanks, Alaska, United States
CTCA at Western Regional Medical Center
🇺🇸Goodyear, Arizona, United States
Kingman Regional Medical Center
🇺🇸Kingman, Arizona, United States
Cancer Center at Saint Joseph's
🇺🇸Phoenix, Arizona, United States
University of Arizona Cancer Center - Prevention Research Clinic
🇺🇸Tucson, Arizona, United States
Mercy Hospital Fort Smith
🇺🇸Fort Smith, Arkansas, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸Hot Springs, Arkansas, United States
CARTI Cancer Center
🇺🇸Little Rock, Arkansas, United States
Kaiser Permanente-Anaheim
🇺🇸Anaheim, California, United States
Mission Hope Medical Oncology - Arroyo Grande
🇺🇸Arroyo Grande, California, United States
PCR Oncology
🇺🇸Arroyo Grande, California, United States
Kaiser Permanente-Baldwin Park
🇺🇸Baldwin Park, California, United States
Kaiser Permanente-Bellflower
🇺🇸Bellflower, California, United States
Mercy Cancer Center - Carmichael
🇺🇸Carmichael, California, United States
Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
Epic Care-Dublin
🇺🇸Dublin, California, United States
Mercy Cancer Center - Elk Grove
🇺🇸Elk Grove, California, United States
Bay Area Breast Surgeons Inc
🇺🇸Emeryville, California, United States
Epic Care Partners in Cancer Care
🇺🇸Emeryville, California, United States
Kaiser Permanente-Fontana
🇺🇸Fontana, California, United States
Kaiser Permanente South Bay
🇺🇸Harbor City, California, United States
Kaiser Permanente-Irvine
🇺🇸Irvine, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸Los Angeles, California, United States
Kaiser Permanente West Los Angeles
🇺🇸Los Angeles, California, United States
UCLA / Jonsson Comprehensive Cancer Center
🇺🇸Los Angeles, California, United States
Contra Costa Regional Medical Center
🇺🇸Martinez, California, United States
Mercy Cancer Center
🇺🇸Merced, California, United States
Alta Bates Summit Medical Center - Summit Campus
🇺🇸Oakland, California, United States
Bay Area Tumor Institute
🇺🇸Oakland, California, United States
Kaiser Permanente-Ontario
🇺🇸Ontario, California, United States
Stanford Cancer Institute Palo Alto
🇺🇸Palo Alto, California, United States
Kaiser Permanente - Panorama City
🇺🇸Panorama City, California, United States
Kaiser Permanente-Riverside
🇺🇸Riverside, California, United States
Mercy Cancer Center - Rocklin
🇺🇸Rocklin, California, United States
Mercy Cancer Center - Sacramento
🇺🇸Sacramento, California, United States
Kaiser Permanente-San Diego Mission
🇺🇸San Diego, California, United States
Kaiser Permanente-San Diego Zion
🇺🇸San Diego, California, United States
Pacific Central Coast Health Center-San Luis Obispo
🇺🇸San Luis Obispo, California, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Kaiser Permanente-San Marcos
🇺🇸San Marcos, California, United States
Mission Hope Medical Oncology - Santa Maria
🇺🇸Santa Maria, California, United States
Saint Joseph's Medical Center
🇺🇸Stockton, California, United States
Kaiser Permanente-Vallejo
🇺🇸Vallejo, California, United States
Epic Care Cyberknife Center
🇺🇸Walnut Creek, California, United States
BASS Medical Group - Lennon
🇺🇸Walnut Creek, California, United States
Kaiser Permanente-Woodland Hills
🇺🇸Woodland Hills, California, United States
Woodland Memorial Hospital
🇺🇸Woodland, California, United States
Rocky Mountain Cancer Centers-Aurora
🇺🇸Aurora, Colorado, United States
Rocky Mountain Regional VA Medical Center
🇺🇸Aurora, Colorado, United States
UCHealth University of Colorado Hospital
🇺🇸Aurora, Colorado, United States
Boulder Community Foothills Hospital
🇺🇸Boulder, Colorado, United States
Rocky Mountain Cancer Centers-Boulder
🇺🇸Boulder, Colorado, United States
Rocky Mountain Cancer Centers - Centennial
🇺🇸Centennial, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸Colorado Springs, Colorado, United States
Saint Francis Cancer Center
🇺🇸Colorado Springs, Colorado, United States
Kaiser Permanente-Franklin
🇺🇸Denver, Colorado, United States
The Women's Imaging Center
🇺🇸Denver, Colorado, United States
AdventHealth Porter
🇺🇸Denver, Colorado, United States
Colorado Blood Cancer Institute
🇺🇸Denver, Colorado, United States
Presbyterian - Saint Lukes Medical Center - Health One
🇺🇸Denver, Colorado, United States
Rocky Mountain Cancer Centers-Midtown
🇺🇸Denver, Colorado, United States
Rocky Mountain Cancer Centers-Rose
🇺🇸Denver, Colorado, United States
Mercy Medical Center
🇺🇸Durango, Colorado, United States
Southwest Oncology PC
🇺🇸Durango, Colorado, United States
Mountain Blue Cancer Care Center - Swedish
🇺🇸Englewood, Colorado, United States
Rocky Mountain Cancer Centers - Swedish
🇺🇸Englewood, Colorado, United States
The Melanoma and Skin Cancer Institute
🇺🇸Englewood, Colorado, United States
Kaiser Permanente-Rock Creek
🇺🇸Lafayette, Colorado, United States
Rocky Mountain Cancer Centers-Lakewood
🇺🇸Lakewood, Colorado, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
Rocky Mountain Cancer Centers-Littleton
🇺🇸Littleton, Colorado, United States
AdventHealth Littleton
🇺🇸Littleton, Colorado, United States
Kaiser Permanente-Lone Tree
🇺🇸Lone Tree, Colorado, United States
Rocky Mountain Cancer Centers-Sky Ridge
🇺🇸Lone Tree, Colorado, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Rocky Mountain Cancer Centers-Longmont
🇺🇸Longmont, Colorado, United States
AdventHealth Parker
🇺🇸Parker, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
Rocky Mountain Cancer Centers-Thornton
🇺🇸Thornton, Colorado, United States
Saint Anthony North Hospital
🇺🇸Westminster, Colorado, United States
Yale-New Haven Hospital Saint Raphael Campus
🇺🇸New Haven, Connecticut, United States
Yale University
🇺🇸New Haven, Connecticut, United States
Yale-New Haven Hospital North Haven Medical Center
🇺🇸North Haven, Connecticut, United States
Veterans Affairs Connecticut Healthcare System-West Haven Campus
🇺🇸West Haven, Connecticut, United States
Kaiser Permanente-Capitol Hill Medical Center
🇺🇸Washington, District of Columbia, United States
MedStar Georgetown University Hospital
🇺🇸Washington, District of Columbia, United States
Mount Sinai Comprehensive Cancer Center at Aventura
🇺🇸Aventura, Florida, United States
Veterans Administration Hospital
🇺🇸Bay Pines, Florida, United States
Malcom Randall Veterans Administration Medical Center
🇺🇸Gainesville, Florida, United States
Mount Sinai Medical Center
🇺🇸Miami Beach, Florida, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸Miami, Florida, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Augusta University Medical Center
🇺🇸Augusta, Georgia, United States
Low Country Cancer Care
🇺🇸Savannah, Georgia, United States
Memorial Health University Medical Center
🇺🇸Savannah, Georgia, United States
Pali Momi Medical Center
🇺🇸'Aiea, Hawaii, United States
Queen's Cancer Center - Pearlridge
🇺🇸'Aiea, Hawaii, United States
Hawaii Cancer Care Inc - Waterfront Plaza
🇺🇸Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
🇺🇸Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸Honolulu, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸Lihue, Hawaii, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸Boise, Idaho, United States
Saint Alphonsus Cancer Care Center-Caldwell
🇺🇸Caldwell, Idaho, United States
Kootenai Health - Coeur d'Alene
🇺🇸Coeur d'Alene, Idaho, United States
Walter Knox Memorial Hospital
🇺🇸Emmett, Idaho, United States
Idaho Urologic Institute-Meridian
🇺🇸Meridian, Idaho, United States
Saint Alphonsus Cancer Care Center-Nampa
🇺🇸Nampa, Idaho, United States
Kootenai Clinic Cancer Services - Post Falls
🇺🇸Post Falls, Idaho, United States
Kootenai Clinic Cancer Services - Sandpoint
🇺🇸Sandpoint, Idaho, United States
OSF Saint Anthony's Health Center
🇺🇸Alton, Illinois, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Saint Mary's Hospital
🇺🇸Centralia, Illinois, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
John H Stroger Jr Hospital of Cook County
🇺🇸Chicago, Illinois, United States
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
Carle at The Riverfront
🇺🇸Danville, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
SSM Health Good Samaritan
🇺🇸Mount Vernon, Illinois, United States
The Carle Foundation Hospital
🇺🇸Urbana, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸Yorkville, Illinois, United States
Midwestern Regional Medical Center
🇺🇸Zion, Illinois, United States
Northwest Cancer Center - Main Campus
🇺🇸Crown Point, Indiana, United States
Saint Clare Hospital
🇺🇸Lakewood, Washington, United States
Northwest Oncology LLC
🇺🇸Dyer, Indiana, United States
Northwest Cancer Center - Hobart
🇺🇸Hobart, Indiana, United States
Saint Mary Medical Center
🇺🇸Hobart, Indiana, United States
Saint Catherine Hospital
🇺🇸Indianapolis, Indiana, United States
The Community Hospital
🇺🇸Munster, Indiana, United States
Women's Diagnostic Center - Munster
🇺🇸Munster, Indiana, United States
Reid Health
🇺🇸Richmond, Indiana, United States
Northwest Cancer Center - Valparaiso
🇺🇸Valparaiso, Indiana, United States
Mercy Cancer Center-West Lakes
🇺🇸Clive, Iowa, United States
UI Health Care Mission Cancer and Blood - West Des Moines Clinic
🇺🇸Clive, Iowa, United States
Alegent Health Mercy Hospital
🇺🇸Council Bluffs, Iowa, United States
Greater Regional Medical Center
🇺🇸Creston, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
UI Health Care Mission Cancer and Blood - Laurel Clinic
🇺🇸Des Moines, Iowa, United States
Mercy Medical Center-West Lakes
🇺🇸West Des Moines, Iowa, United States
University of Kansas Clinical Research Center
🇺🇸Fairway, Kansas, United States
Central Care Cancer Center - Garden City
🇺🇸Garden City, Kansas, United States
Central Care Cancer Center - Great Bend
🇺🇸Great Bend, Kansas, United States
University of Kansas Cancer Center
🇺🇸Kansas City, Kansas, United States
University of Kansas Hospital-Indian Creek Campus
🇺🇸Overland Park, Kansas, United States
Cotton O'Neil Cancer Center / Stormont Vail Health
🇺🇸Topeka, Kansas, United States
University of Kansas Hospital-Westwood Cancer Center
🇺🇸Westwood, Kansas, United States
Robert J Dole VA Medical Center
🇺🇸Wichita, Kansas, United States
Flaget Memorial Hospital
🇺🇸Bardstown, Kentucky, United States
Commonwealth Cancer Center-Corbin
🇺🇸Corbin, Kentucky, United States
Saint Elizabeth Healthcare Edgewood
🇺🇸Edgewood, Kentucky, United States
Saint Elizabeth Healthcare Fort Thomas
🇺🇸Fort Thomas, Kentucky, United States
Saint Joseph Hospital
🇺🇸Lexington, Kentucky, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸Lexington, Kentucky, United States
Saint Joseph London
🇺🇸London, Kentucky, United States
Jewish Hospital
🇺🇸Louisville, Kentucky, United States
Saints Mary and Elizabeth Hospital
🇺🇸Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸Louisville, Kentucky, United States
Saint Joseph Mount Sterling
🇺🇸Mount Sterling, Kentucky, United States
Mercy Health - Paducah Cancer Center
🇺🇸Paducah, Kentucky, United States
Jewish Hospital Medical Center South
🇺🇸Shepherdsville, Kentucky, United States
MaineHealth Maine Medical Center- Scarborough
🇺🇸Scarborough, Maine, United States
Kaiser Permanente-Woodlawn Medical Center
🇺🇸Baltimore, Maryland, United States
Kaiser Permanente-Gaithersburg Medical Center
🇺🇸Gaithersburg, Maryland, United States
Kaiser Permanente - Kensington Medical Center
🇺🇸Kensington, Maryland, United States
Kaiser Permanente - Largo Medical Center
🇺🇸Largo, Maryland, United States
Kaiser Permanente Lutherville - Timonium Medical Center
🇺🇸Lutherville, Maryland, United States
Boston Veteran's Affairs Medical Center
🇺🇸Jamaica Plain, Massachusetts, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
🇺🇸Grand Rapids, Michigan, United States
Corewell Health Grand Rapids Hospitals - Helen DeVos Children's Hospital
🇺🇸Grand Rapids, Michigan, United States
Trinity Health Grand Rapids Hospital
🇺🇸Grand Rapids, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Ascension Borgess Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Ascension Borgess Hospital
🇺🇸Kalamazoo, Michigan, United States
Trinity Health Muskegon Hospital
🇺🇸Muskegon, Michigan, United States
Corewell Health Lakeland Hospitals - Niles Hospital
🇺🇸Niles, Michigan, United States
Cancer and Hematology Centers of Western Michigan - Norton Shores
🇺🇸Norton Shores, Michigan, United States
Corewell Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Corewell Health Lakeland Hospitals - Marie Yeager Cancer Center
🇺🇸Saint Joseph, Michigan, United States
Corewell Health Lakeland Hospitals - Saint Joseph Hospital
🇺🇸Saint Joseph, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
University of Michigan Health - West
🇺🇸Wyoming, Michigan, United States
Riverwood Healthcare Center
🇺🇸Aitkin, Minnesota, United States
Essentia Health - Baxter Clinic
🇺🇸Baxter, Minnesota, United States
Sanford Joe Lueken Cancer Center
🇺🇸Bemidji, Minnesota, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸Brainerd, Minnesota, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Minnesota Oncology - Burnsville
🇺🇸Burnsville, Minnesota, United States
Cambridge Medical Center
🇺🇸Cambridge, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Essentia Health - Deer River Clinic
🇺🇸Deer River, Minnesota, United States
Essentia Health Saint Mary's - Detroit Lakes Clinic
🇺🇸Detroit Lakes, Minnesota, United States
Essentia Health Cancer Center
🇺🇸Duluth, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Essentia Health - Ely Clinic
🇺🇸Ely, Minnesota, United States
Lake Region Healthcare Corporation-Cancer Care
🇺🇸Fergus Falls, Minnesota, United States
Essentia Health - Fosston
🇺🇸Fosston, Minnesota, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Essentia Health Hibbing Clinic
🇺🇸Hibbing, Minnesota, United States
Essentia Health - International Falls Clinic
🇺🇸International Falls, Minnesota, United States
Fairview Clinics and Surgery Center Maple Grove
🇺🇸Maple Grove, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Minneapolis VA Medical Center
🇺🇸Minneapolis, Minnesota, United States
Health Partners Inc
🇺🇸Minneapolis, Minnesota, United States
Monticello Cancer Center
🇺🇸Monticello, Minnesota, United States
Essentia Health - Moose Lake Clinic
🇺🇸Moose Lake, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Essentia Health - Park Rapids
🇺🇸Park Rapids, Minnesota, United States
Fairview Northland Medical Center
🇺🇸Princeton, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Mayo Clinic in Rochester
🇺🇸Rochester, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Essentia Health Sandstone
🇺🇸Sandstone, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Sanford Thief River Falls Medical Center
🇺🇸Thief River Falls, Minnesota, United States
Essentia Health Virginia Clinic
🇺🇸Virginia, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Sanford Cancer Center Worthington
🇺🇸Worthington, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸Wyoming, Minnesota, United States
Saint Louis Cancer and Breast Institute-Ballwin
🇺🇸Ballwin, Missouri, United States
Central Care Cancer Center - Bolivar
🇺🇸Bolivar, Missouri, United States
Cox Cancer Center Branson
🇺🇸Branson, Missouri, United States
Mercy Cancer Center - Cape Girardeau
🇺🇸Cape Girardeau, Missouri, United States
Freeman Health System
🇺🇸Joplin, Missouri, United States
Mercy Hospital Joplin
🇺🇸Joplin, Missouri, United States
Kansas City Veterans Affairs Medical Center
🇺🇸Kansas City, Missouri, United States
Lake Regional Hospital
🇺🇸Osage Beach, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸Rolla, Missouri, United States
Phelps Health Delbert Day Cancer Institute
🇺🇸Rolla, 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 South
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Mercy Hospital Washington
🇺🇸Washington, Missouri, United States
Community Hospital of Anaconda
🇺🇸Anaconda, Montana, 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
Great Falls Clinic
🇺🇸Great Falls, Montana, United States
Hi-Line Sletten Cancer Center
🇺🇸Havre, Montana, United States
Logan Health Medical Center
🇺🇸Kalispell, Montana, United States
Community Medical Center
🇺🇸Scranton, Pennsylvania, United States
CHI Health Saint Francis
🇺🇸Grand Island, Nebraska, United States
Nebraska Cancer Specialists/Oncology Hematology West PC
🇺🇸Grand Island, Nebraska, United States
CHI Health Good Samaritan
🇺🇸Kearney, Nebraska, United States
Saint Elizabeth Regional Medical Center
🇺🇸Lincoln, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
Midlands Community Hospital
🇺🇸Papillion, Nebraska, United States
Carson Tahoe Regional Medical Center
🇺🇸Carson City, Nevada, United States
Comprehensive Cancer Centers of Nevada - Henderson
🇺🇸Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada-Horizon Ridge
🇺🇸Henderson, Nevada, United States
OptumCare Cancer Care at Seven Hills
🇺🇸Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada-Southeast Henderson
🇺🇸Henderson, Nevada, United States
GenesisCare USA - Henderson
🇺🇸Henderson, Nevada, United States
Las Vegas Urology - Green Valley
🇺🇸Henderson, Nevada, United States
Las Vegas Urology - Pebble
🇺🇸Henderson, Nevada, United States
Urology Specialists of Nevada - Green Valley
🇺🇸Henderson, Nevada, United States
Las Vegas Urology - Pecos
🇺🇸Las Vegas, Nevada, United States
OptumCare Cancer Care at Charleston
🇺🇸Las Vegas, Nevada, United States
University Medical Center of Southern Nevada
🇺🇸Las Vegas, Nevada, United States
Hope Cancer Care of Nevada
🇺🇸Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Central
🇺🇸Las Vegas, Nevada, United States
Urology Specialists of Nevada - Central
🇺🇸Las Vegas, Nevada, United States
Women's Cancer Center of Nevada
🇺🇸Las Vegas, Nevada, United States
GenesisCare USA - Las Vegas
🇺🇸Las Vegas, Nevada, United States
Sunrise Hospital and Medical Center
🇺🇸Las Vegas, Nevada, United States
Las Vegas Urology - Sunset
🇺🇸Las Vegas, Nevada, United States
Urology Specialists of Nevada - Southwest
🇺🇸Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
🇺🇸Las Vegas, Nevada, United States
Ann M Wierman MD LTD
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Northwest
🇺🇸Las Vegas, Nevada, United States
GenesisCare USA - Vegas Tenaya
🇺🇸Las Vegas, Nevada, United States
Las Vegas Urology - Cathedral Rock
🇺🇸Las Vegas, Nevada, United States
Las Vegas Urology - Smoke Ranch
🇺🇸Las Vegas, Nevada, United States
OptumCare Cancer Care at MountainView
🇺🇸Las Vegas, Nevada, United States
Urology Specialists of Nevada - Northwest
🇺🇸Las Vegas, Nevada, United States
Alliance for Childhood Diseases/Cure 4 the Kids Foundation
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Town Center
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
🇺🇸Las Vegas, Nevada, United States
Summerlin Hospital Medical Center
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸Las Vegas, Nevada, United States
GenesisCare USA - Fort Apache
🇺🇸Las Vegas, Nevada, United States
OptumCare Cancer Care at Fort Apache
🇺🇸Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Central Valley
🇺🇸Las Vegas, Nevada, United States
Hope Cancer Care of Nevada-Pahrump
🇺🇸Pahrump, Nevada, United States
Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
Saint Mary's Regional Medical Center
🇺🇸Reno, Nevada, United States
Radiation Oncology Associates
🇺🇸Reno, Nevada, United States
Morristown Medical Center
🇺🇸Morristown, New Jersey, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Laura and Isaac Perlmutter Cancer Center at NYU Langone
🇺🇸New York, New York, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸New York, New York, United States
Southeastern Medical Oncology Center-Clinton
🇺🇸Clinton, North Carolina, United States
Southeastern Medical Oncology Center-Goldsboro
🇺🇸Goldsboro, North Carolina, United States
Southeastern Medical Oncology Center-Jacksonville
🇺🇸Jacksonville, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Essentia Health Cancer Center-South University Clinic
🇺🇸Fargo, North Dakota, United States
Sanford South University Medical Center
🇺🇸Fargo, North Dakota, United States
Southpointe-Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Sanford Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Altru Cancer Center
🇺🇸Grand Forks, North Dakota, United States
Essentia Health - Jamestown Clinic
🇺🇸Jamestown, North Dakota, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸Beachwood, Ohio, United States
Indu and Raj Soin Medical Center
🇺🇸Beavercreek, Ohio, United States
Saint Elizabeth Boardman Hospital
🇺🇸Boardman, Ohio, United States
Dayton Physicians LLC-Miami Valley South
🇺🇸Centerville, Ohio, United States
Miami Valley Hospital South
🇺🇸Centerville, Ohio, United States
University of Cincinnati Cancer Center-UC Medical Center
🇺🇸Cincinnati, Ohio, United States
Good Samaritan Hospital - Cincinnati
🇺🇸Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸Cincinnati, Ohio, United States
Bethesda North Hospital
🇺🇸Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸Cincinnati, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸Cincinnati, Ohio, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
Louis Stokes Cleveland VA Medical Center
🇺🇸Cleveland, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Premier Blood and Cancer Center
🇺🇸Dayton, Ohio, United States
Dayton Physician LLC - Englewood
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital North
🇺🇸Dayton, Ohio, United States
Armes Family Cancer Center
🇺🇸Findlay, Ohio, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Orion Cancer Care
🇺🇸Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Dayton Physicians LLC-Atrium
🇺🇸Franklin, Ohio, United States
Dayton Physicians LLC-Wayne
🇺🇸Greenville, Ohio, United States
Miami Valley Cancer Care and Infusion
🇺🇸Greenville, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
Greater Dayton Cancer Center
🇺🇸Kettering, Ohio, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Dayton Physicians LLC - Troy
🇺🇸Troy, Ohio, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Saint Joseph Warren Hospital
🇺🇸Warren, Ohio, United States
University of Cincinnati Cancer Center-West Chester
🇺🇸West Chester, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸Westlake, Ohio, United States
Saint Elizabeth Youngstown Hospital
🇺🇸Youngstown, Ohio, United States
Veterans Administration Medical Center - Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Mercy Hospital Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Saint Alphonsus Cancer Care Center-Baker City
🇺🇸Baker City, Oregon, United States
Saint Alphonsus Cancer Care Center-Ontario
🇺🇸Ontario, Oregon, United States
Oregon Health and Science University
🇺🇸Portland, Oregon, United States
Saint Luke's Cancer Center - Allentown
🇺🇸Allentown, Pennsylvania, United States
Saint Luke's University Hospital-Bethlehem Campus
🇺🇸Bethlehem, Pennsylvania, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Saint Luke's Hospital-Anderson Campus
🇺🇸Easton, Pennsylvania, United States
Geisinger Medical Oncology-Lewisburg
🇺🇸Lewisburg, Pennsylvania, United States
UPMC-Presbyterian Hospital
🇺🇸Pittsburgh, Pennsylvania, United States
Geisinger Cancer Services-Pottsville
🇺🇸Pottsville, Pennsylvania, United States
Saint Luke's Hospital - Upper Bucks Campus
🇺🇸Quakertown, Pennsylvania, United States
Saint Luke's Hospital - Monroe Campus
🇺🇸Stroudsburg, Pennsylvania, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸Wilkes-Barre, Pennsylvania, United States
Providence Veterans Administration Hospital
🇺🇸Providence, Rhode Island, United States
Ralph H Johnson VA Medical Center
🇺🇸Charleston, South Carolina, United States
Gibbs Cancer Center-Gaffney
🇺🇸Gaffney, South Carolina, United States
Prisma Health Greenville Memorial Hospital
🇺🇸Greenville, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸Greer, South Carolina, United States
North Grove Medical Park
🇺🇸Spartanburg, South Carolina, United States
Spartanburg Medical Center
🇺🇸Spartanburg, South Carolina, United States
Spartanburg Medical Center - Mary Black Campus
🇺🇸Spartanburg, South Carolina, United States
SMC Center for Hematology Oncology Union
🇺🇸Union, South Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Saint Joseph Regional Cancer Center
🇺🇸Bryan, Texas, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸Dallas, Texas, United States
Baylor College of Medicine/Dan L Duncan Comprehensive Cancer Center
🇺🇸Houston, Texas, United States
Kaiser Permanente-Burke Medical Center
🇺🇸Burke, Virginia, United States
Sovah Health Martinsville
🇺🇸Martinsville, Virginia, United States
Kaiser Permanente Tysons Corner Medical Center
🇺🇸McLean, Virginia, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸Richmond, Virginia, United States
Carilion Roanoke Memorial Hospital
🇺🇸Roanoke, Virginia, United States
Kaiser Permanente-Caton Hill Medical Center
🇺🇸Woodbridge, Virginia, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Saint Elizabeth Hospital
🇺🇸Enumclaw, Washington, United States
Saint Francis Hospital
🇺🇸Federal Way, Washington, United States
Jefferson Healthcare
🇺🇸Port Townsend, Washington, United States
Valley Medical Center
🇺🇸Renton, Washington, United States
Saint Michael Cancer Center
🇺🇸Silverdale, Washington, United States
Franciscan Research Center-Northwest Medical Plaza
🇺🇸Tacoma, Washington, United States
North Star Lodge Cancer Center at Yakima Valley Memorial Hospital
🇺🇸Yakima, Washington, United States
United Hospital Center
🇺🇸Bridgeport, West Virginia, United States
WVUH-Berkely Medical Center
🇺🇸Martinsburg, West Virginia, United States
West Virginia University Healthcare
🇺🇸Morgantown, West Virginia, United States
Camden Clark Medical Center
🇺🇸Parkersburg, West Virginia, United States
Princeton Community Hospital
🇺🇸Princeton, West Virginia, United States
Wheeling Hospital/Schiffler Cancer Center
🇺🇸Wheeling, West Virginia, United States
Ascension Saint Elizabeth Hospital
🇺🇸Appleton, Wisconsin, United States
Duluth Clinic Ashland
🇺🇸Ashland, Wisconsin, United States
Northwest Wisconsin Cancer Center
🇺🇸Ashland, Wisconsin, United States
Ascension Southeast Wisconsin Hospital - Elmbrook Campus
🇺🇸Brookfield, Wisconsin, United States
Ascension Calumet Hospital
🇺🇸Chilton, Wisconsin, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸Eau Claire, Wisconsin, United States
Ascension Saint Francis - Reiman Cancer Center
🇺🇸Franklin, Wisconsin, United States
Ascension Southeast Wisconsin Hospital - Franklin
🇺🇸Franklin, Wisconsin, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸Green Bay, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
🇺🇸Green Bay, Wisconsin, United States
Essentia Health-Hayward Clinic
🇺🇸Hayward, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸Marshfield, Wisconsin, United States
Ascension Columbia Saint Mary's Hospital Ozaukee
🇺🇸Mequon, Wisconsin, United States
Ascension Southeast Wisconsin Hospital - Saint Joseph Campus
🇺🇸Milwaukee, Wisconsin, United States
Ascension Columbia Saint Mary's Hospital - Milwaukee
🇺🇸Milwaukee, Wisconsin, United States
Ascension Saint Francis Hospital
🇺🇸Milwaukee, Wisconsin, United States
Zablocki Veterans Administration Medical Center
🇺🇸Milwaukee, Wisconsin, United States
Marshfield Medical Center - Minocqua
🇺🇸Minocqua, Wisconsin, United States
Cancer Center of Western Wisconsin
🇺🇸New Richmond, Wisconsin, United States
Ascension Mercy Hospital
🇺🇸Oshkosh, Wisconsin, United States
Ascension All Saints Hospital
🇺🇸Racine, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸Rice Lake, Wisconsin, United States
Essentia Health-Spooner Clinic
🇺🇸Spooner, Wisconsin, United States
Marshfield Medical Center-River Region at Stevens Point
🇺🇸Stevens Point, Wisconsin, United States
Essentia Health Saint Mary's Hospital - Superior
🇺🇸Superior, Wisconsin, United States
Marshfield Clinic-Wausau Center
🇺🇸Wausau, Wisconsin, United States
Ascension Medical Group Southeast Wisconsin - Mayfair Road
🇺🇸Wauwatosa, Wisconsin, United States
Marshfield Medical Center - Weston
🇺🇸Weston, Wisconsin, United States
Billings Clinic-Cody
🇺🇸Cody, Wyoming, United States
Welch Cancer Center
🇺🇸Sheridan, Wyoming, United States
Cancer Center-Metro Medical Center Bayamon
🇵🇷Bayamon, Puerto Rico
Puerto Rico Hematology Oncology Group
🇵🇷Bayamon, Puerto Rico
HIMA San Pablo Oncologic Hospital
🇵🇷Caguas, Puerto Rico
Doctors Cancer Center
🇵🇷Manati, Puerto Rico
Instituto Oncologia Moderna Ponce
🇵🇷Ponce, Puerto Rico
San Juan Community Oncology Group
🇵🇷San Juan, Puerto Rico
Primary Care Physician Group
🇵🇷San Juan, Puerto Rico
Centro Comprensivo de Cancer de UPR
🇵🇷San Juan, Puerto Rico
PROncology
🇵🇷San Juan, Puerto Rico
San Juan City Hospital
🇵🇷San Juan, Puerto Rico