Intensity-Modulated Radiation Therapy and Paclitaxel With or Without Pazopanib Hydrochloride in Treating Patients With Anaplastic Thyroid Cancer

Phase 2

Completed

Conditions: Thyroid Gland Anaplastic Carcinoma

Interventions: Radiation: Intensity-Modulated Radiation Therapy
Drug: Paclitaxel
Drug: Pazopanib Hydrochloride
Other: Placebo Administration

Registration Number: NCT01236547

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This randomized phase II trial studies the side effects and how well intensity-modulated radiation therapy (IMRT) and paclitaxel with or without pazopanib hydrochloride works in treating patients with anaplastic thyroid cancer. Specialized radiation therapy that delivers a high dose of radiation directly to the tumor may kill more tumor cells and cause less damage to normal tissue. Drugs used in chemotherapy, such as paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Pazopanib hydrochloride may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether radiation therapy and paclitaxel are more effective when given with pazopanib hydrochloride in treating thyroid cancer.

Detailed Description: PRIMARY OBJECTIVES:

I. To evaluate the safety of IMRT, paclitaxel, and pazopanib (pazopanib hydrochloride) suspension. (Run-in component) II. To evaluate and compare overall survival at 1 year from study registration. (Phase II component)

SECONDARY OBJECTIVES:

I. To evaluate local-regional control at 6 and 12 months. (Phase II component) II. To evaluate the rate of grade 4 (Common Terminology Criteria for Adverse Events version 4.0 \[CTCAE, v. 4.0\]) hemorrhage, grade 4 febrile neutropenia, or any grade 5 adverse event assessed to be definitely, probably, or possibly related to the induction or concurrent treatment components of the protocol regimen. (Phase II component) III. To evaluate the rates of other adverse events (CTCAE, v. 4.0) assessed to be definitely, probably, or possibly related to the induction or concurrent treatment components of the protocol regimen. (Phase II component) IV. To evaluate the rate of treatment discontinuation due to toxicity during the induction or concurrent treatment components of the protocol regimen. (Phase II component) V. To evaluate response (as per Response Evaluation Criteria in Solid Tumors \[RECIST\]) of the primary site following the treatment component in subjects with measurable disease prior to chemoradiation. (Phase II component)

OUTLINE:

RUN-IN COMPONENT: Patients receive paclitaxel intravenously (IV) over 1 hour once weekly and pazopanib hydrochloride orally (PO) once daily (QD) for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 6-7 weeks (or until radiation treatment is completed) and intensity-modulated radiotherapy (IMRT) 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).

RANDOMIZED PHASE II COMPONENT: Patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).

ARM II: Patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and placebo PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).

After completion of study treatment, patients are followed up every 3 months for 2 years, every 6 months for 1 year, and then annually thereafter.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 123

Inclusion Criteria

Pathologically (histologically or cytologically) proven diagnosis of anaplastic thyroid cancer (a diagnosis that is noted to be "consistent with anaplastic thyroid cancer" with the presence of a thyroid mass is acceptable)
- Note: Tissue collection for central review is mandatory, but central review is not required for eligibility; due to the aggressiveness of this disease, treatment will be started prior to central review
If there was a total or partial thyroidectomy completed within 3 months of enrollment, the surgical specimen must show the area of anaplastic thyroid cancer to be at least 1 cm in greatest dimension
The following minimum diagnostic workup is required:
- History/physical examination within 2 weeks prior to registration
- Imaging of neck and brain (computed tomography [CT] scan or magnetic resonance imaging [MRI]) and chest/abdominal imaging (chest x-ray or chest CT scan, or full body positron emission tomography [PET]/CT are acceptable) within 4 weeks prior to registration
- Note: The CT scan of the neck must be done with contrast or if an MRI is done, with gadolinium; therefore, the CT portion of a full body PET/CT has to be a high resolution CT to be acceptable for eligibility
- Abdominal imaging must cover the liver and adrenal glands; therefore, separate imaging is not required if these areas are covered by a chest CT scan
- Electrocardiogram within 10 days prior to registration
Zubrod performance status 0-2
Absolute neutrophil count (ANC) >= 1,500 cells/mm^3 (within 10 days prior to registration on study)
Platelets >= 100,000 cells/mm^3 (within 10 days prior to registration on study)
Hemoglobin (Hgb) >= 9.0 g/dl (within 10 days prior to registration on study) (Note: the use of transfusion or other intervention to achieve Hgb >= 9.0 g/dL is acceptable)
Total bilirubin < 1.5 x institutional upper limit of normal (ULN) (except for patients with Gilbert's syndrome and elevations of indirect bilirubin) (within 10 days prior to registration)
Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 2.5 x institutional ULN (within 10 days prior to registration); Note: patients who have both bilirubin > ULN and AST/ALT > ULN are not eligible (unless they have Gilbert's syndrome and elevations of indirect bilirubin)
Spot urine protein to creatinine ratio (UPCR) < 1 or a 24-hour urine protein collection < 1 gm within 10 days prior to registration
Creatinine < 1.5 mg/dL or within normal institutional limits within 10 days prior to registration; Note: if neither criteria is met, the creatinine clearance must be > 50 mL/min/1.73 m^2 per either the Cockcroft-Gault equation, Jeliffe method, or 12- or 24-hour urine collection
Serum electrolytes including sodium, potassium, blood urea nitrogen (BUN), creatinine, glucose, magnesium, phosphate, and calcium within 10 days prior to registration
Documentation of the patient's history of corrected QT interval (QTc) prolongation, family history of prolonged QTc, and relevant cardiac disease within 10 days prior to registration
Evaluation of the patient's medications within 10 days prior to registration with attempt to change any medication that affects cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A4)
Blood pressure =< 140/90 within 10 days of registration (must be taken and recorded by a health care professional); Note: if the systolic blood pressure is > 140 and/or diastolic blood pressure is > 90 at the time of registration, the patient's blood pressure must be controlled; systolic blood pressure must be < 140 and diastolic blood pressure must be < 90 on at least 2 separate measurements prior to the start of treatment, and the treating physician must believe that this is feasible in order to enroll the patient
Prothrombin time (PT)/international normalized ratio (INR)/partial thromboplastin time (PTT) within 1.2 x the upper limit of normal within 10 days prior to registration unless the patient is receiving coumadin and has a stable INR that is in range for the desired level of anticoagulation
Negative pregnancy test (serum or urine) within 10 days of registration in women of child-bearing potential
Women of childbearing potential and male participants who are sexually active must agree to practice adequate contraception during treatment and for 6 months post-treatment
The patient must provide study specific informed consent prior to study entry

Exclusion Criteria

Known active invasive malignancy (except for non-melanomatous skin cancer or anaplastic thyroid cancer; the presence of prostate cancer confined to the prostate with a prostate-specific antigen [PSA] =< 1 ng/mL for more than 6 months also is allowed)
Prior systemic chemotherapy for anaplastic thyroid cancer
- Patients who have had chemotherapy or radiotherapy within 4 weeks of registration (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered > 4 weeks previously
- Patients receiving other investigational agents
Prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields
Patients with any of the following cardiovascular conditions within the past 6 months:
- Cerebrovascular accident (CVA) or transient ischemic attack (TIA)
- Admission for unstable angina
- Myocardial Infarction
- Cardiac angioplasty or stenting
- Coronary artery bypass graft surgery
- Pulmonary embolism, untreated deep venous thrombosis (DVT), or DVT which has been treated with therapeutic anticoagulation for less than 6 weeks
- Arterial thrombosis
- Symptomatic peripheral vascular disease
- Class III or IV heart failure as defined by the New York Heart Association (NYHA) functional classification system; Note: a patient who has a history of class III heart failure and is asymptomatic on treatment may be considered eligible for the study
Certain medications that are associated with a risk for QTc prolongation and/or torsades de pointes, although not prohibited, should be avoided or replaced with medications that do not carry these risks, if possible
Patients who require heparin (other than low-molecular weight heparin)
Patients with any condition that may impair the ability to absorb oral medications/investigational product including:
- Prior surgical procedures affecting absorption including, but not limited to, major resection of stomach or small bowel
- Active peptic ulcer disease
- Malabsorption syndrome
Patients with any condition that may increase the risk of gastrointestinal bleeding or gastrointestinal perforation, including:
- Active peptic ulcer disease
- Known intraluminal metastatic lesions
- Inflammatory bowel disease (e.g., ulcerative colitis, Crohn's disease) or other gastrointestinal conditions which increase the risk of perforation
- History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within 28 days prior to beginning study treatment
History of hemoptysis within 30 days of registration; Note: patients who have minimal bleeding from the mouth, which is clearly not related to a source in the lungs, i.e., surgery such as a non-lung biopsy, are eligible only after good hemostasis has been documented
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection or psychiatric illness/social situations that would limit compliance with study requirements
Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic
Prior allergic reaction to the study drug(s) involved in this protocol
QTc prolongation defined as a QTc interval >= 480 msecs or other significant electrocardiogram (EKG) abnormalities are ineligible; Note: if unsure about EKG abnormality, the treating physician should discuss this with Drs. Sherman or Bible
Known brain metastasis
Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy because of the potential for pharmacokinetic interactions with pazopanib; in addition, these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy; appropriate studies will be undertaken in patients receiving combination antiretroviral therapy when indicated
Certain medications that act through the cytochrome P450 (CYP450) system are specifically prohibited in patients receiving pazopanib and others should be avoided or administered with extreme caution
- Strong inhibitors of CYP3A4 such as ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, voriconazole may increase pazopanib concentrations and are prohibited; although, in exceptional circumstances, they may be administered in conjunction with lowering the dose of pazopanib by 50% of what would otherwise be administered; grapefruit juice is also an inhibitor of CYP450 and should not be taken with pazopanib
- Strong inducers of CYP3A4, such as rifampin, may decrease pazopanib concentrations, are strictly prohibited
- Medications that have narrow therapeutic windows and are substrates of CYP3A4, cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6), or cytochrome P450, family 2, subfamily C, polypeptide 8 (CYP2C8) should be avoided and, if necessary, administered with caution

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm I (paclitaxel, pazopanib hydrochloride, IMRT)	Pazopanib Hydrochloride	Patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).
Arm II (paclitaxel, placebo, IMRT)	Intensity-Modulated Radiation Therapy	Patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and placebo PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).
Arm II (paclitaxel, placebo, IMRT)	Placebo Administration	Patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and placebo PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).
Arm I (paclitaxel, pazopanib hydrochloride, IMRT)	Intensity-Modulated Radiation Therapy	Patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).
Arm II (paclitaxel, placebo, IMRT)	Paclitaxel	Patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and placebo PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and placebo PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).
Arm I (paclitaxel, pazopanib hydrochloride, IMRT)	Paclitaxel	Patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 2-3 weeks. Patients then receive concurrent paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD for 6-7 weeks (or until radiation treatment is completed) and IMRT 5 days per week for 6.5 weeks (total of 66 Gy in 33 fractions). Beginning 25-31 days after the completion of IMRT, patients receive paclitaxel IV over 1 hour once weekly and pazopanib hydrochloride PO QD. Treatment repeats every 3 weeks for 4 cycles (for patients with no measurable disease) or continues in the absence of disease progression or unacceptable toxicity (for patients with measurable disease).

Primary Outcome Measures

Name	Time	Method
(Phase II) Overall Survival	From randomization to last follow-up.Maximum follow-up for phase II participants at time of analysis was 4.2 years.	Overall survival time is defined as time from 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. One-year rates are provided. Analysis occurred after all eligible participants were potentially followed for 3 years.
(Phase I) Number of Participants With Treatment-related Grade 4 Hemorrhage, Grade 4 Febrile Neutropenia, or Grade 5 Adverse Event (AE), or Discontinuation of Treatment Due to Toxicity [Adverse Events of Concern (AEC)]	From registration to last follow-up. Maximum follow-up for run-in and phase II participants at time of analysis was 7.4 years.	Common Terminology Criteria for AEs (version 4.0) grades AE severity from 1=mild to 5=death. Discontinuation of treatment due to toxicity is defined as \< 75% of planned radiation therapy delivered. "Treatment-related" = definitely, probably, or possibly related to treatment. A single run-in arm was originally planned, but additional run-in arms were added due to amendments to the protocol regimen unrelated to toxicities. A two-stage design based on the binomial distribution was used in which the 1st stage analyzes the run-in arm and the 2nd stage analyzes run-in and phase II pazopanib arm participants combined. Because there were multiple run-in arms, only the last is used in the 2nd stage analysis. 1st stage: If ≤4 of 9 participants experience AEC, then conclude treatment is safe. 2nd stage: If ≤8 of 24 participants experience AEC, then conclude treatment safe. Otherwise conclude the treatment is too toxic. Summary data is provided here, see AE Module for specific AE data.

Secondary Outcome Measures

Name	Time	Method
(Phase II) Local-regional Control	From randomization to last follow-up.Maximum follow-up for phase II participants at time of analysis was 4.2 years. (Statistical analysis compares full distributions therefore all available follow-up was used.)	Local-regional failure is defined as local-regional relapse/progression in the thyroid bed or regional lymph nodes. Time to local-regional failure is defined as time from randomization to the date of first local-regional recurrence, last known follow-up (censored), or death without local recurrence (competing risk). Failure rates are estimated using the cumulative incidence method. The protocol specifies 6- and 12-month estimates to be reported and for the full distributions of failure times to be compared between the arms. Analysis occurred after all eligible participants were potentially followed for 3 years.
(Phase II) Percentage of Participants With Treatment-related Grade 4 Hemorrhage, Grade 4 Febrile Neutropenia, or Grade 5 Adverse Event, or Discontinuation of Treatment Due to Toxicity [Adverse Events of Concern]	From start of treatment to last follow-up.Maximum follow-up for phase II participants at time of analysis was 4.2 years.	Common Terminology Criteria for Adverse Events (CTCAE, v. 4.0) grades adverse event severity from 1=mild to 5=death. Discontinuation of treatment due to toxicity is defined as \< 75% of planned radiation therapy delivered. Adverse events rated as definitely, probably, or possibly related to treatment were considered treatment-related. Summary data is provided in this outcome measure.; See Adverse Events Module for specific adverse event data.
(Phase II) Percentage of Participants With Treatment-related Grade 3 or 4 Adverse Events Other Than Grade 4 Hemorrhage or Grade 4 Febrile Neutropenia [Not Adverse Events of Concern]	From start of treatment to last follow-up.Maximum follow-up for phase II participants at time of analysis was 4.2 years.	Common Terminology Criteria for Adverse Events (CTCAE, v. 4.0) grades adverse event severity from 1=mild to 5=death. Adverse events rated as definitely, probably, or possibly related to treatment were considered treatment-related. Summary data is provided in this outcome measure.; See Adverse Events Module for specific adverse event data.
(Phase II) Percentage of Participants With Complete or Partial Response of the Primary Site After Chemoradiation Per Response Evaluation Criteria in Solid Tumors (RECIST) Version 1.1	2-4 weeks after treatment (approximately week 10-14)	Complete Response: Disappearance of all target lesions; Any pathological lymph nodes (whether target or non-target) must have reduction in short axis to \<10 mm. Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum diameters.

Trial Locations

Locations (130): Greater Baltimore Medical Center
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Baltimore, Maryland, United States
Sinai Hospital of Baltimore
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Baltimore, Maryland, United States
North Memorial Medical Health Center
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Robbinsdale, Minnesota, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
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Green Bay, Wisconsin, United States
UNC Lineberger Comprehensive Cancer Center
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Chapel Hill, North Carolina, United States
University of Wisconsin Carbone Cancer Center
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Madison, Wisconsin, United States
Saint Vincent Hospital Cancer Center Green Bay
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Green Bay, Wisconsin, United States
Bay Area Medical Center
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Marinette, Wisconsin, United States
American Fork Hospital / Huntsman Intermountain Cancer Center
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American Fork, Utah, United States
Holy Family Memorial Hospital
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Manitowoc, Wisconsin, United States
Ohio State University Comprehensive Cancer Center
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Columbus, Ohio, United States
UPMC-Saint Margaret
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Pittsburgh, Pennsylvania, United States
UPMC-Saint Clair Hospital Cancer Center
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Pittsburgh, Pennsylvania, United States
UPMC-Shadyside Hospital
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Pittsburgh, Pennsylvania, United States
UPMC Jefferson Regional Radiation Oncology
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Pittsburgh, Pennsylvania, United States
Boston Medical Center
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Boston, Massachusetts, United States
Hennepin County Medical Center
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Minneapolis, Minnesota, United States
Case Western Reserve University
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Cleveland, Ohio, United States
Cleveland Clinic Foundation
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Cleveland, Ohio, United States
M D Anderson Cancer Center
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Houston, Texas, United States
California Pacific Medical Center-Pacific Campus
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San Francisco, California, United States
UCSF Medical Center-Mount Zion
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San Francisco, California, United States
UCSF Medical Center-Parnassus
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San Francisco, California, United States
Utah Cancer Specialists-Salt Lake City
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Salt Lake City, Utah, United States
LDS Hospital
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Salt Lake City, Utah, United States
Cancer Center at Saint Joseph's
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Phoenix, Arizona, United States
Saint Joseph's Hospital and Medical Center
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Phoenix, Arizona, United States
Arizona Oncology-Deer Valley Center
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Phoenix, Arizona, United States
Mayo Clinic in Rochester
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Rochester, Minnesota, United States
University of Oklahoma Health Sciences Center
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Oklahoma City, Oklahoma, United States
Medical College of Wisconsin
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Milwaukee, Wisconsin, United States
McKay-Dee Hospital Center
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Ogden, Utah, United States
The Kirklin Clinic at Acton Road
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Birmingham, Alabama, United States
University of Alabama at Birmingham Cancer Center
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Birmingham, Alabama, United States
Sutter Cancer Centers Radiation Oncology Services-Auburn
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Auburn, California, United States
Arizona Oncology Services Foundation
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Scottsdale, Arizona, United States
Alta Bates Summit Medical Center-Herrick Campus
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Berkeley, California, United States
Eden Hospital Medical Center
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Castro Valley, California, United States
Mills-Peninsula Medical Center
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Burlingame, California, United States
Sutter Cancer Centers Radiation Oncology Services-Roseville
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Roseville, California, United States
Sutter Cancer Centers Radiation Oncology Services-Cameron Park
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Cameron Park, California, United States
Sutter Cancer Centers Radiation Oncology Services-Vacaville
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Vacaville, California, United States
Christiana Gynecologic Oncology LLC
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Newark, Delaware, United States
Sutter Solano Medical Center/Cancer Center
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Vallejo, California, United States
Delaware Clinical and Laboratory Physicians PA
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Newark, Delaware, United States
Helen F Graham Cancer Center
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Newark, Delaware, United States
Christiana Care Health System-Christiana Hospital
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Newark, Delaware, United States
Medical Oncology Hematology Consultants PA
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Newark, Delaware, United States
Christiana Care Health System-Wilmington Hospital
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Wilmington, Delaware, United States
Beebe Health Campus
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Rehoboth Beach, Delaware, United States
Mayo Clinic in Florida
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Jacksonville, Florida, United States
Emory University Hospital/Winship Cancer Institute
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Atlanta, Georgia, United States
Emory University Hospital Midtown
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Atlanta, Georgia, United States
Radiation Oncology Associates PC
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Fort Wayne, Indiana, United States
Parkview Hospital Randallia
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Fort Wayne, Indiana, United States
University of Kansas Cancer Center
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Kansas City, Kansas, United States
Touro Infirmary
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New Orleans, Louisiana, United States
Mary Bird Perkins Cancer Center
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Baton Rouge, Louisiana, United States
Henry Ford Macomb Hospital-Clinton Township
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Clinton Township, Michigan, United States
Henry Ford Medical Center-Fairlane
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Dearborn, Michigan, United States
Henry Ford Cancer Institute-Downriver
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Brownstown, Michigan, United States
Henry Ford Hospital
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Detroit, Michigan, United States
West Michigan Cancer Center
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Kalamazoo, Michigan, United States
Henry Ford Medical Center-Columbus
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Novi, Michigan, United States
Fairview Ridges Hospital
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Burnsville, Minnesota, United States
Henry Ford West Bloomfield Hospital
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West Bloomfield, Michigan, United States
Mercy Hospital
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Coon Rapids, Minnesota, United States
Fairview Southdale Hospital
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Edina, Minnesota, United States
Unity Hospital
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Fridley, Minnesota, United States
Abbott-Northwestern Hospital
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Minneapolis, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
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Maplewood, Minnesota, United States
United Hospital
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Saint Paul, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
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Saint Louis Park, Minnesota, United States
Metro Minnesota Community Oncology Research Consortium
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Saint Louis Park, Minnesota, United States
Regions Hospital
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Saint Paul, Minnesota, United States
Rice Memorial Hospital
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Willmar, Minnesota, United States
Ridgeview Medical Center
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Waconia, Minnesota, United States
University of Mississippi Medical Center
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Jackson, Mississippi, United States
Billings Clinic Cancer Center
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Billings, Montana, United States
Memorial Sloan Kettering Basking Ridge
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Basking Ridge, New Jersey, United States
New York-Presbyterian/Brooklyn Methodist Hospital
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Brooklyn, New York, United States
Memorial Sloan Kettering Commack
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Commack, New York, United States
Memorial Sloan Kettering Cancer Center
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New York, New York, United States
Memorial Sloan Kettering Westchester
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Harrison, New York, United States
Summa Health System - Akron Campus
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Akron, Ohio, United States
Memorial Sloan Kettering Sleepy Hollow
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Sleepy Hollow, New York, United States
Memorial Sloan Kettering Nassau
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Uniondale, New York, United States
University of Cincinnati Cancer Center-UC Medical Center
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Cincinnati, Ohio, United States
Summa Health System - Barberton Campus
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Barberton, Ohio, United States
Mercy Cancer Center-Elyria
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Elyria, Ohio, United States
Summa Health Medina Medical Center
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Medina, Ohio, United States
UH Seidman Cancer Center at Lake Health Mentor Campus
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Mentor, Ohio, United States
UH Seidman Cancer Center at Southwest General Hospital
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Middleburg Heights, Ohio, United States
University Hospitals Parma Medical Center
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Parma, Ohio, United States
UH Seidman Cancer Center at Firelands Regional Medical Center
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Sandusky, Ohio, United States
University of Cincinnati Cancer Center-West Chester
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West Chester, Ohio, United States
UPMC-Heritage Valley Health System Beaver
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Beaver, Pennsylvania, United States
UPMC Cancer Centers - Arnold Palmer Pavilion
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Greensburg, Pennsylvania, United States
Penn State Milton S Hershey Medical Center
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Hershey, Pennsylvania, United States
UPMC-Johnstown/John P. Murtha Regional Cancer Center
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Johnstown, Pennsylvania, United States
UPMC Cancer Center-Natrona Heights
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Natrona Heights, Pennsylvania, United States
UPMC Cancer Center at UPMC McKeesport
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McKeesport, Pennsylvania, United States
UPMC-Coraopolis/Heritage Valley Radiation Oncology
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Moon, Pennsylvania, United States
UPMC Jameson
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New Castle, Pennsylvania, United States
Thomas Jefferson University Hospital
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Philadelphia, Pennsylvania, United States
UPMC-Presbyterian Hospital
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Pittsburgh, Pennsylvania, United States
UPMC-Passavant Hospital
🇺🇸
Pittsburgh, Pennsylvania, United States
Prisma Health Cancer Institute - Faris
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸
Boiling Springs, South Carolina, United States
UPMC Uniontown Hospital Radiation Oncology
🇺🇸
Uniontown, Pennsylvania, United States
UPMC Washington Hospital Radiation Oncology
🇺🇸
Washington, Pennsylvania, United States
UPMC Cancer Center at UPMC Northwest
🇺🇸
Seneca, Pennsylvania, United States
Prisma Health Cancer Institute - Eastside
🇺🇸
Greenville, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸
Greer, South Carolina, United States
Parkland Memorial Hospital
🇺🇸
Dallas, Texas, United States
Prisma Health Cancer Institute - Seneca
🇺🇸
Seneca, South Carolina, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸
Dallas, Texas, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States
Sandra L Maxwell Cancer Center
🇺🇸
Cedar City, Utah, United States
Logan Regional Hospital
🇺🇸
Logan, Utah, United States
Utah Valley Regional Medical Center
🇺🇸
Provo, Utah, United States
Saint George Regional Medical Center
🇺🇸
Saint George, Utah, United States
Sentara Virginia Beach General Hospital
🇺🇸
Virginia Beach, Virginia, United States
Sentara Cancer Institute at Sentara CarePlex Hospital
🇺🇸
Hampton, Virginia, United States
Sentara Norfolk General Hospital
🇺🇸
Norfolk, Virginia, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸
Green Bay, Wisconsin, United States
Green Bay Oncology at Saint Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Sutter Medical Center Sacramento
🇺🇸
Sacramento, California, United States
Moffitt Cancer Center
🇺🇸
Tampa, Florida, United States
The James Graham Brown Cancer Center at University of Louisville
🇺🇸
Louisville, Kentucky, United States