Early Surgery or Standard Palliative Therapy in Treating Patients With Stage IV Breast Cancer
- Conditions
- Breast CancerStage IV Breast Cancer
- Interventions
- Procedure: palliative surgeryProcedure: therapeutic conventional surgeryRadiation: palliative radiation therapyRadiation: radiation therapy
- Registration Number
- NCT01242800
- Lead Sponsor
- Eastern Cooperative Oncology Group
- Brief Summary
RATIONALE: The primary tumor might be a source of re-seeding of distant sites and therefore elimination of this source of metastasizing cells by early local therapy may be of benefit.
PURPOSE: This randomized phase III trial is studying early surgery to see how well it works compared to standard palliative therapy in treating patients with stage IV breast cancer.
- Detailed Description
OBJECTIVES:
Primary
* To evaluate whether early local therapy of intact primary disease in patients with Stage IV breast cancer whose disease does not progress during initial optimal systemic therapy, will result in prolonged survival, compared to patients who receive local therapy for palliation only.
Secondary
* To compare the time to uncontrolled chest wall disease between patients who receive early local therapy versus patients who receive palliative local therapy.
* To determine whether there is a difference in health-related quality-of-life (HRQOL) between patients who receive early local therapy versus patients who receive palliative local therapy.
* To determine whether the absolute value of circulating tumor cells (CTC) burden at 6 months following randomization (time +6) will be lower in the palliative therapy arm than in early local therapy arm, and whether this value is inversely related to survival (lower CTC, longer survival).
Exploratory
* To collect tumor and blood specimens for future exploration of the biological interactions between the primary tumor and metastatic lesions and the effect of primary tumor resection.
OUTLINE: This is a multicenter study. Patients are stratified according to hormone receptor and treatment plan (ER+ or PR+, HER2-, endocrine therapy alone vs ER+ or PR+, and HER2-, chemotherapy and/or endocrine therapy vs ER- or PR-, and HER2- vs HER2+), and number of involved organ systems with distant disease (regional nodes in the axillary, supraclavicular, and internal mammary locations are not considered distant sites) (1 vs \> 1). Patients are randomized to 1 of 2 treatment arms in 1:1 ratio.
* Arm I: Patients receive standard palliative therapy, if needed, to address symptoms such as tumor ulceration, pain, bulky adenopathy causing arm symptoms, and other similar situations. Therapy may consist of radiotherapy alone, surgery alone, or a combination of both.
* Arm II: Patients undergo surgery comprising breast-conserving therapy (BCT) or total mastectomy according to patient and treating physician preference. Surgery is to occur no later than 10 weeks after completion of 32 weeks of systemic therapy. Free surgical margins must be achieved with re-excision or mastectomy for patients undergoing BCT. After completion of BCT, patients undergo radiotherapy once a day, 5 days per week. Patients who had mastectomy undergo radiotherapy at the discretion of treating physician.
Patients may undergo blood and tumor tissue sample collection for circulating tumor cells (CTC) burden and future studies.
Patients complete the Functional Assessment of Cancer Therapy - Breast Trial Outcome Index (FACT- TOI) and FACT - General (22) and the Breast Cancer Subscale (FACT-B) quality-of-life questionnaires at baseline and periodically during study.
After completion of study therapy, patients are followed up periodically for 5 years.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 390
-
Diagnosis of intact primary (not recurrent) invasive carcinoma of the breast
- Stage IV disease
- Confirmation of the primary tumor should be by needle biopsy (preferred)
- Incisional surgical biopsy allowed as long as there is residual palpable or tumor image in the breast
-
Patients must be judged to be candidates for complete resection with free margins followed by radiation therapy (if radiation therapy is indicated)
-
For women not undergoing axillary dissection, sentinel node biopsy should document an axillary nodal burden of 1-2 involved lymph nodes (i.e., ACOSOG Z-11 criteria may be applied)
-
Prior non-invasive (Ductal Carcinoma In Situ) cancer allowed provided there has been no recurrence
-
Prior ipsilateral invasive cancer allowed if more than 5 years previous
-
Patients should have at least one organ system involved with distant metastatic disease
- If patient has only one metastatic lesion/focus, this must be proven by biopsy and the pathology report confirming the diagnosis of primary breast cancer, as well as the metastatic site, must be available
-
Must have available radiologic reports documenting disease status within the past 6 weeks prior to initiating systemic therapy
-
CNS metastases allowed provided projected survival > 6 months
-
Patients must have completed at least 16 weeks of optimal systemic therapy (appropriate to the tumor biological profile and the patient's age and menopausal status)
- If systemic therapy is discontinued for toxicity, but there is no distant progression and at least 12 weeks of therapy have been delivered, then the patient remains eligible
- Radiation therapy (if indicated) must begin within 12 weeks of final therapeutic surgical procedure (including re-excision for free margins and completion of axillary dissection)
-
Patients may register at any time from the time of diagnosis of stage IV breast cancer (if eligibility criteria met) to the time when a maximum of 30 weeks of induction systemic therapy has been completed
- Patients must be randomized within 16-32 weeks after the start of systemic therapy
-
Patients must not have experienced disease progression since the start of systemic therapy, as evidenced by radiographic documentation of disease status before treatment and within 4 weeks +/- 2 weeks prior to randomization, including:
- No new sites of disease
- No enlargement of existing sites by 20% or more in longest diameter
- No symptomatic deterioration
-
Patients who require radiotherapy to bone metastases during induction systemic therapy are eligible
-
Local disease at the primary site must be asymptomatic
-
Hormone receptor status known
-
Menopausal status not specified
-
Patients must have adequate organ function to undergo local therapy 4 weeks +/- 2 weeks prior to randomization per investigator discretion and institutional guidelines
-
More than 5 years since other primary cancers that were curatively treated
-
Negative pregnancy test
-
Fertile patients must use an accepted and effective contraception method
Exclusion criteria:
- Synchronous contralateral breast cancer
- Pregnant or nursing
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm I palliative surgery Patients receive standard palliative therapy, if needed, to address symptoms such as tumor ulceration, pain, bulky adenopathy causing arm symptoms, and other similar situations. Therapy may consist of radiotherapy alone, surgery alone, or a combination of both. Arm I palliative radiation therapy Patients receive standard palliative therapy, if needed, to address symptoms such as tumor ulceration, pain, bulky adenopathy causing arm symptoms, and other similar situations. Therapy may consist of radiotherapy alone, surgery alone, or a combination of both. Arm II therapeutic conventional surgery Patients undergo surgery comprising breast-conserving therapy (BCT) or total mastectomy according to patient and treating physician preference. Surgery is to occur no later than 10 weeks after completion of 32 weeks of systemic therapy. Free surgical margins must be achieved with re-excision or mastectomy for patients undergoing BCT. After completion of BCT, patients undergo radiotherapy once a day, 5 days per week. Patients who had mastectomy undergo radiotherapy at the discretion of treating physician. Arm II radiation therapy Patients undergo surgery comprising breast-conserving therapy (BCT) or total mastectomy according to patient and treating physician preference. Surgery is to occur no later than 10 weeks after completion of 32 weeks of systemic therapy. Free surgical margins must be achieved with re-excision or mastectomy for patients undergoing BCT. After completion of BCT, patients undergo radiotherapy once a day, 5 days per week. Patients who had mastectomy undergo radiotherapy at the discretion of treating physician.
- Primary Outcome Measures
Name Time Method 3-year Overall Survival Rate Assessed at baseline, then every 3 months within 2 years and every 6 months between 2-5 years, up to 5 years Overall survival (OS) was defined as time from randomization to death from any cause. All patients will be followed for survival through 5 years. Cases with incomplete follow-up or without record of vital status will be censored at the date of last contact. 3-year OS rate was estimated using Kaplan-Meier method.
- Secondary Outcome Measures
Name Time Method 3-year Cumulative Incidence of Locoregional Recurrence/Progression Assessed at baseline, then every 3 months within 2 years and every 6 months between 2-5 years, up to 5 years For patients in arm II (early local therapy), time to locoregional recurrence was defined as time from randomization to date of locoregional recurrence; for patients in arm A (continued systemic therapy), time to locoregional progression was defined as time from randomization to date of locoregional progression. In this study, locoregional recurrence was defined as the new development or clinically significant increase in size of any supraclavicular, infraclavicular, internal mammary or axillary adenopathy or chest wall disease or invasive in-breast recurrence for patients on arm B; for patients on arm A, locoregional progression was defined as the development of symptoms leading to a decision for local therapy. Locoregional recurrence/progression and distant progression were followed separately in the study, and the occurrence of one did not preclude the other getting reported. 3-year cumulative incidence of locoregional recurrence/progression was estimated.
Health-related Quality of Life (HRQL) Assessed at 18 months after randomization The Functional Assessment of Cancer Therapy-Breast Trial Outcome Index (FACT-B TOI) was used as the primary HRQL endpoint, measured by the prorated aggregate score of the 24 items from the FACT-B (7 functional well-being, 7 physical well-being, 10 breast cancer specific items). The theoretical range of the prorated aggregate score was 0-96, higher scores indicate better quality of life.
Trial Locations
- Locations (376)
Fox Chase Cancer Center - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Robert H. Lurie Comprehensive Cancer Center at Northwestern University
🇺🇸Chicago, Illinois, United States
Resurrection Medical Center
🇺🇸Chicago, Illinois, United States
CCOP - Columbus
🇺🇸Columbus, Ohio, United States
Herbert D. Kerman Regional Oncology Center - Daytona Beach
🇺🇸Daytona Beach, Florida, United States
CCOP - Bay Area Tumor Institute
🇺🇸Oakland, California, United States
California Cancer Care, Incorporated - Greenbrae
🇺🇸Greenbrae, California, United States
El Camino Hospital Cancer Center
🇺🇸Mountain View, California, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
University of South Alabama Mitchell Cancer Institute
🇺🇸Mobile, Alabama, United States
St. Joseph Hospital Regional Cancer Center - Orange
🇺🇸Orange, California, United States
Stanford Cancer Center
🇺🇸Stanford, California, United States
Mayo Clinic - Jacksonville
🇺🇸Jacksonville, Florida, United States
Doctors Medical Center - San Pablo Campus
🇺🇸San Pablo, California, United States
Todd Cancer Institute at Long Beach Memorial Medical Center
🇺🇸Long Beach, California, United States
Norwalk Hospital
🇺🇸Norwalk, Connecticut, United States
Northside Hospital Cancer Center
🇺🇸Atlanta, Georgia, United States
Mountain States Tumor Institute - Meridian
🇺🇸Meridian, Idaho, United States
Memorial Hospital
🇺🇸Carthage, Illinois, United States
John H. Stroger, Jr. Hospital of Cook County
🇺🇸Chicago, Illinois, United States
Medical Oncology and Hematology Associates - West Des Moines
🇺🇸Clive, Iowa, United States
John B. Amos Cancer Center
🇺🇸Columbus, Georgia, United States
Saint Luke's Mountain States Tumor Institute - Fruitland
🇺🇸Fruitland, Idaho, United States
St. Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Louis A. Weiss Memorial Hospital
🇺🇸Chicago, Illinois, United States
Kellogg Cancer Care Center
🇺🇸Highland Park, Illinois, United States
Galesburg Clinic, PC
🇺🇸Galesburg, Illinois, United States
Illinois Valley Community Hospital
🇺🇸Peru, Illinois, United States
Cancer Treatment Center at Pekin Hospital
🇺🇸Pekin, Illinois, United States
Michiana Hematology-Oncology, PC - South Bend
🇺🇸Mishawaka, Indiana, United States
Proctor Hospital
🇺🇸Peoria, Illinois, United States
Cancer Center of Kansas, PA - Wellington
🇺🇸Wellington, Kansas, United States
CCOP - Northern Indiana CR Consortium
🇺🇸South Bend, Indiana, United States
OSF St. Francis Medical Center
🇺🇸Peoria, Illinois, United States
Elkhart General Hospital
🇺🇸Elkhart, Indiana, United States
Reid Hospital & Health Care Services
🇺🇸Richmond, Indiana, United States
Saint Joseph Regional Medical Center
🇺🇸Mishawaka, Indiana, United States
Cancer Center of Kansas, PA - Winfield
🇺🇸Winfield, Kansas, United States
Howard Community Hospital
🇺🇸Kokomo, Indiana, United States
Union Hospital of Cecil County
🇺🇸Elkton, Maryland, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
St. Agnes Hospital Cancer Center
🇺🇸Baltimore, Maryland, United States
Tulane Cancer Center Office of Clinical Research
🇺🇸Alexandria, Louisiana, United States
St. Elizabeth Medical Center
🇺🇸Edgewood, Kentucky, United States
Hickman Cancer Center at Bixby Medical Center
🇺🇸Adrian, Michigan, United States
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
🇺🇸Baltimore, Maryland, United States
St. Mary Mercy Hospital
🇺🇸Livonia, Michigan, United States
DeCesaris Cancer Institute at Anne Arundel Medical Center
🇺🇸Annapolis, Maryland, United States
Sparrow Regional Cancer Center
🇺🇸Lansing, Michigan, United States
Community Cancer Center of Monroe
🇺🇸Monroe, Michigan, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
CCOP - Metro-Minnesota
🇺🇸Saint Louis Park, Minnesota, United States
Norris Cotton Cancer Center at Catholic Medical Center
🇺🇸Manchester, New Hampshire, United States
Licking Memorial Cancer Care Program at Licking Memorial Hospital
🇺🇸Newark, Ohio, United States
Community Hospital of Springfield and Clark County
🇺🇸Springfield, Ohio, United States
Mercy Hospital of Tiffin
🇺🇸Tiffin, Ohio, United States
St. Anne Mercy Hospital
🇺🇸Toledo, Ohio, United States
Fredericksburg Oncology, Incorporated
🇺🇸Fredericksburg, Virginia, United States
Doctor's Hospital of Laredo
🇺🇸Laredo, Texas, United States
Marshfield Clinic - Wausau Center
🇺🇸Wausau, Wisconsin, United States
Green Bay Oncology, Limited at St. Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Aurora Medical Center
🇺🇸Summit, Wisconsin, United States
Fox Valley Surgical Associates at Appleton Medical Center
🇺🇸Appleton, Wisconsin, United States
London Regional Cancer Program at London Health Sciences Centre
🇨🇦London, Ontario, Canada
Marshfield Clinic Cancer Care at Regional Cancer Center
🇺🇸Eau Claire, Wisconsin, United States
St. Mary's Hospital Medical Center - Green Bay
🇺🇸Green Bay, Wisconsin, United States
Pretoria Academic Hospital
🇿🇦Pretoria, South Africa
Riverview UW Cancer Center at Riverview Hospital
🇺🇸Wisconsin Rapids, Wisconsin, United States
Vince Lombardi Cancer Clinic - Oshkosh
🇺🇸Oshkosh, Wisconsin, United States
Saint Joseph's Hospital
🇺🇸Marshfield, Wisconsin, United States
Marshfield Clinic - Lakeland Center
🇺🇸Minocqua, Wisconsin, United States
Swedish Cancer Institute at Swedish Medical Center - First Hill Campus
🇺🇸Seattle, Washington, United States
Indiana University Melvin and Bren Simon Cancer Center
🇺🇸Indianapolis, Indiana, United States
William N. Wishard Memorial Hospital
🇺🇸Indianapolis, Indiana, United States
East Bay Radiation Oncology Center
🇺🇸Castro Valley, California, United States
Enloe Cancer Center at Enloe Medical Center
🇺🇸Chico, California, United States
North Bay Cancer Center
🇺🇸Fairfield, California, United States
Contra Costa Regional Medical Center
🇺🇸Martinez, California, United States
Community Hospital of the Monterey Peninsula Comprehensive Cancer Center
🇺🇸Monterey, California, United States
Penrose Cancer Center at Penrose Hospital
🇺🇸Colorado Springs, Colorado, United States
Exempla Lutheran Medical Center
🇺🇸Wheat Ridge, Colorado, United States
Eastern Connecticut Hematology and Oncology Associates
🇺🇸Norwich, Connecticut, United States
Saint Joseph's Hospital of Atlanta
🇺🇸Atlanta, Georgia, United States
Kennestone Cancer Center at Wellstar Kennestone Hospital
🇺🇸Marietta, Georgia, United States
Nancy N. and J. C. Lewis Cancer and Research Pavilion at St. Joseph's/Candler
🇺🇸Savannah, Georgia, United States
Saint Alphonsus Cancer Care Center at Saint Alphonsus Regional Medical Center
🇺🇸Boise, Idaho, United States
University of Chicago Cancer Research Center
🇺🇸Chicago, Illinois, United States
Elmhurst Memorial Hospital
🇺🇸Elmhurst, Illinois, United States
Eureka Community Hospital
🇺🇸Eureka, Illinois, United States
Cancer Care and Hematology Specialists of Chicagoland - Niles
🇺🇸Niles, Illinois, United States
Cardinal Bernardin Cancer Center at Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Community Hospital of Ottawa
🇺🇸Ottawa, Illinois, United States
Oncology Hematology Associates of Central Illinois, PC - Ottawa
🇺🇸Ottawa, Illinois, United States
Oncology Hematology Associates of Central Illinois, PC - Peoria
🇺🇸Peoria, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Hematology Oncology Associates - Skokie
🇺🇸Skokie, Illinois, United States
West Suburban Center for Cancer Care
🇺🇸River Forest, Illinois, United States
Swedish-American Regional Cancer Center
🇺🇸Rockford, Illinois, United States
Center for Cancer Therapy at LaPorte Hospital and Health Services
🇺🇸La Porte, Indiana, United States
McFarland Clinic, PC
🇺🇸Ames, Iowa, United States
Siouxland Hematology-Oncology Associates, LLP
🇺🇸Sioux City, Iowa, United States
Cancer Center of Kansas, PA - Kingman
🇺🇸Kingman, Kansas, United States
Cancer Center of Kansas, PA - Liberal
🇺🇸Liberal, Kansas, United States
Greater Baltimore Medical Center Cancer Center
🇺🇸Baltimore, Maryland, United States
Shore Regional Cancer Center at Memorial Hospital - Easton
🇺🇸Easton, Maryland, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Oakwood Cancer Center at Oakwood Hospital and Medical Center
🇺🇸Dearborn, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Green Bay Oncology, Limited - Escanaba
🇺🇸Escanaba, Michigan, United States
Van Elslander Cancer Center at St. John Hospital and Medical Center
🇺🇸Grosse Pointe Woods, Michigan, United States
Butterworth Hospital at Spectrum Health
🇺🇸Grand Rapids, Michigan, United States
Dickinson County Healthcare System
🇺🇸Iron Mountain, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
Mercy Memorial Hospital - Monroe
🇺🇸Monroe, Michigan, United States
Mercy Regional Cancer Center at Mercy Hospital
🇺🇸Port Huron, Michigan, United States
Seton Cancer Institute at Saint Mary's - Saginaw
🇺🇸Saginaw, Michigan, United States
Spectrum Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Lakeland Regional Cancer Care Center - St. Joseph
🇺🇸Saint Joseph, Michigan, United States
William Beaumont Hospital - Royal Oak Campus
🇺🇸Royal Oak, Michigan, United States
Providence Cancer Institute at Providence Hospital - Southfield Campus
🇺🇸Southfield, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
St. John Macomb Hospital
🇺🇸Warren, Michigan, United States
Mercy and Unity Cancer Center at Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Mercy and Unity Cancer Center at Unity Hospital
🇺🇸Fridley, Minnesota, United States
Hutchinson Area Health Care
🇺🇸Hutchinson, Minnesota, United States
Immanuel St. Joseph's
🇺🇸Mankato, Minnesota, United States
Minnesota Oncology - Maplewood
🇺🇸Maplewood, Minnesota, United States
HealthEast Cancer Care at St. John's Hospital
🇺🇸Maplewood, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Humphrey Cancer Center at North Memorial Outpatient Center
🇺🇸Robbinsdale, Minnesota, United States
Regions Hospital Cancer Care Center
🇺🇸Saint Paul, Minnesota, United States
Park Nicollet Cancer Center
🇺🇸Saint Louis Park, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
St. Francis Cancer Center at St. Francis Medical Center
🇺🇸Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Willmar Cancer Center at Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Minnesota Oncology - Woodbury
🇺🇸Woodbury, Minnesota, United States
University of Mississippi Cancer Clinic
🇺🇸Jackson, Mississippi, United States
Regional Cancer Center at Singing River Hospital
🇺🇸Pascagoula, Mississippi, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Mercy Clinic Cancer and Hematology - Rolla
🇺🇸Rolla, Missouri, United States
Heartland Regional Medical Center
🇺🇸Saint Joseph, Missouri, United States
Saint Joseph Oncology, Incorporated
🇺🇸Saint Joseph, Missouri, United States
St. Anthony's Cancer Center
🇺🇸Saint Louis, Missouri, United States
David C. Pratt Cancer Center at St. John's Mercy
🇺🇸Saint Louis, Missouri, United States
St. John's Regional Health Center
🇺🇸Springfield, Missouri, United States
Hulston Cancer Center at Cox Medical Center South
🇺🇸Springfield, Missouri, United States
Billings Clinic - Downtown
🇺🇸Billings, Montana, United States
CCOP - Montana Cancer Consortium
🇺🇸Billings, Montana, United States
Big Sky Oncology
🇺🇸Great Falls, Montana, United States
Great Falls Clinic - Main Facility
🇺🇸Great Falls, Montana, United States
Sletten Cancer Institute at Benefis Healthcare
🇺🇸Great Falls, Montana, United States
Cancer Resource Center - Lincoln
🇺🇸Lincoln, Nebraska, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center
🇺🇸Lebanon, New Hampshire, United States
Hunterdon Regional Cancer Center at Hunterdon Medical Center
🇺🇸Flemington, New Jersey, United States
Radiation Oncology Center at Kennedy Health System - Sewell
🇺🇸Sewell, New Jersey, United States
J. Phillip Citta Regional Cancer Center at Community Medical Center
🇺🇸Toms River, New Jersey, United States
Fox Chase Virtua Health Cancer Program at Virtua West Jersey
🇺🇸Voorhees, New Jersey, United States
University of New Mexico Cancer Center - South
🇺🇸Las Cruces, New Mexico, United States
Roswell Park Cancer Institute
🇺🇸Buffalo, New York, United States
Bassett Healthcare Regional Cancer Program at Mary Imogene Bassett Hospital
🇺🇸Cooperstown, New York, United States
Winthrop University Hospital
🇺🇸Mineola, New York, United States
Beth Israel Medical Center - Petrie Division
🇺🇸New York, New York, United States
St. Luke's - Roosevelt Hospital Center - St.Luke's Division
🇺🇸New York, New York, United States
Mount Sinai Medical Center
🇺🇸New York, New York, United States
Memorial Sloan-Kettering Cancer Center
🇺🇸New York, New York, United States
Dyson Center for Cancer Care at Vassar Brothers Medical Center
🇺🇸Poughkeepsie, New York, United States
Nalitt Cancer Institute at Staten Island University Hospital
🇺🇸Staten Island, New York, United States
Dickstein Cancer Treatment Center at White Plains Hospital Center
🇺🇸White Plains, New York, United States
Blumenthal Cancer Center at Carolinas Medical Center
🇺🇸Charlotte, North Carolina, United States
Batte Cancer Center at Northeast Medical Center
🇺🇸Concord, North Carolina, United States
Iredell Memorial Hospital
🇺🇸Statesville, North Carolina, United States
Medcenter One Hospital Cancer Care Center
🇺🇸Bismarck, North Dakota, United States
St. Alexius Medical Center Cancer Center
🇺🇸Bismarck, North Dakota, United States
McDowell Cancer Center at Akron General Medical Center
🇺🇸Akron, Ohio, United States
Summa Center for Cancer Care at Akron City Hospital
🇺🇸Akron, Ohio, United States
Wood County Oncology Center
🇺🇸Bowling Green, Ohio, United States
Case Comprehensive Cancer Center
🇺🇸Cleveland, Ohio, United States
Grant Medical Center Cancer Care
🇺🇸Columbus, Ohio, United States
Riverside Methodist Hospital Cancer Care
🇺🇸Columbus, Ohio, United States
Mount Carmel Health - West Hospital
🇺🇸Columbus, Ohio, United States
Doctors Hospital at Ohio Health
🇺🇸Columbus, Ohio, United States
Grady Memorial Hospital
🇺🇸Delaware, Ohio, United States
Hematology Oncology Center
🇺🇸Elyria, Ohio, United States
Blanchard Valley Medical Associates
🇺🇸Findlay, Ohio, United States
Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Fairfield Medical Center
🇺🇸Lancaster, Ohio, United States
Lima Memorial Hospital
🇺🇸Lima, Ohio, United States
Strecker Cancer Center at Marietta Memorial Hospital
🇺🇸Marietta, Ohio, United States
Northwest Ohio Oncology Center
🇺🇸Maumee, Ohio, United States
Knox Community Hospital
🇺🇸Mount Vernon, Ohio, United States
St. Charles Mercy Hospital
🇺🇸Oregon, Ohio, United States
Southern Ohio Medical Center Cancer Center
🇺🇸Portsmouth, Ohio, United States
Toledo Clinic - Oregon
🇺🇸Oregon, Ohio, United States
Flower Hospital Cancer Center
🇺🇸Sylvania, Ohio, United States
Toledo Hospital
🇺🇸Toledo, Ohio, United States
St. Vincent Mercy Medical Center
🇺🇸Toledo, Ohio, United States
Medical University of Ohio Cancer Center
🇺🇸Toledo, Ohio, United States
CCOP - Toledo Community Hospital
🇺🇸Toledo, Ohio, United States
UVMC Cancer Care Center at Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Toledo Clinic, Incorporated - Main Clinic
🇺🇸Toledo, Ohio, United States
Fulton County Health Center
🇺🇸Wauseon, Ohio, United States
Mount Carmel St. Ann's Cancer Center
🇺🇸Westerville, Ohio, United States
Genesis - Good Samaritan Hospital
🇺🇸Zanesville, Ohio, United States
St. Luke's Cancer Network at St. Luke's Hospital
🇺🇸Bethlehem, Pennsylvania, United States
Easton Regional Cancer Center at Easton Hospital
🇺🇸Easton, Pennsylvania, United States
Cherry Tree Cancer Center
🇺🇸Hanover, Pennsylvania, United States
Penn State Hershey Cancer Institute at Milton S. Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Lancaster General Hospital
🇺🇸Lancaster, Pennsylvania, United States
Lewistown Hospital
🇺🇸Lewistown, Pennsylvania, United States
St. Mary Regional Cancer Center
🇺🇸Langhorne, Pennsylvania, United States
Charles A. & Betty Bott Cancer Center at Holy Redeemer Hospital
🇺🇸Meadowbrook, Pennsylvania, United States
Kimmel Cancer Center at Thomas Jefferson University - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Mount Nittany Medical Center
🇺🇸State College, Pennsylvania, United States
UPMC Cancer Centers
🇺🇸Pittsburgh, Pennsylvania, United States
Virginia Piper Cancer Institute at Abbott - Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Hennepin County Medical Center - Minneapolis
🇺🇸Minneapolis, Minnesota, United States
York Cancer Center at Apple Hill Medical Center
🇺🇸York, Pennsylvania, United States
Susquehanna Cancer Center at Divine Providence Hospital
🇺🇸Williamsport, Pennsylvania, United States
CCOP - Upstate Carolina
🇺🇸Spartanburg, South Carolina, United States
Gibbs Regional Cancer Center at Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
Sanford Cancer Center at Sanford USD Medical Center
🇺🇸Sioux Falls, South Dakota, United States
Avera Cancer Institute
🇺🇸Sioux Falls, South Dakota, United States
University of Texas Medical Branch
🇺🇸Galveston, Texas, United States
West Tennessee Cancer Center at Jackson-Madison County General Hospital
🇺🇸Jackson, Tennessee, United States
Methodist Hospital
🇺🇸Houston, Texas, United States
M. D. Anderson Cancer Center at University of Texas
🇺🇸Houston, Texas, United States
Baylor Medical Center at Irving
🇺🇸Irving, Texas, United States
CCOP - Scott and White Hospital
🇺🇸Temple, Texas, United States
Harrison Medical Center
🇺🇸Bremerton, Washington, United States
St. Joseph Cancer Center
🇺🇸Bellingham, Washington, United States
University Cancer Center at University of Washington Medical Center
🇺🇸Seattle, Washington, United States
St. Mary Regional Cancer Center at St. Mary Medical Center
🇺🇸Walla Walla, Washington, United States
St. Mary's Regional Cancer Center at St. Mary's Medical Center
🇺🇸Huntington, West Virginia, United States
Langlade Memorial Hospital
🇺🇸Antigo, Wisconsin, United States
Fox Valley Hematology and Oncology - East Grant Street
🇺🇸Appleton, Wisconsin, United States
Theda Care Cancer Institute
🇺🇸Appleton, Wisconsin, United States
Marshfield Clinic - Chippewa Center
🇺🇸Chippewa Falls, Wisconsin, United States
Center for Cancer Treatment & Prevention at Sacred Heart Hospital
🇺🇸Eau Claire, Wisconsin, United States
Green Bay Oncology, Limited at St. Vincent Hospital Regional Cancer Center
🇺🇸Green Bay, Wisconsin, United States
St. Vincent Hospital Regional Cancer Center
🇺🇸Green Bay, Wisconsin, United States
Vince Lombardi Cancer Clinic - Green Bay at Aurora BayCare Medical Center
🇺🇸Green Bay, Wisconsin, United States
UW Cancer Center Johnson Creek
🇺🇸Johnson Creek, Wisconsin, United States
Gundersen Lutheran Center for Cancer and Blood
🇺🇸La Crosse, Wisconsin, United States
Holy Family Memorial Medical Center Cancer Care Center
🇺🇸Manitowoc, Wisconsin, United States
Bay Area Cancer Care Center at Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Vince Lombardi Cancer Clinic - Marinette
🇺🇸Marinette, Wisconsin, United States
Regional Cancer Center at Oconomowoc Memorial Hospital
🇺🇸Oconomowoc, Wisconsin, United States
Green Bay Oncology, Limited - Oconto Falls
🇺🇸Oconto Falls, Wisconsin, United States
Ministry Medical Group at Saint Mary's Hospital
🇺🇸Rhinelander, Wisconsin, United States
Marshfield Clinic - Indianhead Center
🇺🇸Rice Lake, Wisconsin, United States
Vince Lombardi Cancer Clinic - Sheboygan
🇺🇸Sheboygan, Wisconsin, United States
St. Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Marshfield Clinic at Saint Michael's Hospital
🇺🇸Stevens Point, Wisconsin, United States
Huntsman Cancer Institute at University of Utah
🇺🇸Salt Lake City, Utah, United States
Cancer Center of Kansas, PA - Salina
🇺🇸Salina, Kansas, United States
Cancer Center of Kansas, PA - Dodge City
🇺🇸Dodge City, Kansas, United States
CCOP - MeritCare Hospital
🇺🇸Fargo, North Dakota, United States
Cancer Center of Kansas, PA - Newton
🇺🇸Newton, Kansas, United States
Cancer Center of Kansas, PA - McPherson
🇺🇸McPherson, Kansas, United States
Leeward Radiation Oncology
🇺🇸'Ewa Beach, Hawaii, United States
Cancer Center of Kansas-Independence
🇺🇸Independence, Kansas, United States
Cancer Center of Kansas, PA - Chanute
🇺🇸Chanute, Kansas, United States
Cancer Center of Kansas - Fort Scott
🇺🇸Fort Scott, Kansas, United States
CCOP - Kansas City
🇺🇸Prairie Village, Kansas, United States
Trinity CancerCare Center
🇺🇸Minot, North Dakota, United States
Kapiolani Medical Center at Pali Momi
🇺🇸'Aiea, Hawaii, United States
Mid Dakota Clinic, PC
🇺🇸Bismarck, North Dakota, United States
Cancer Center of Kansas, PA - El Dorado
🇺🇸El Dorado, Kansas, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Cancer Center of Kansas, PA - Parsons
🇺🇸Parsons, Kansas, United States
Cancer Center of Kansas, PA - Pratt
🇺🇸Pratt, Kansas, United States
Graham Hospital
🇺🇸Canton, Illinois, United States
Newark Beth Israel Medical Center
🇺🇸Newark, New Jersey, United States
Barbara Ann Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Oklahoma University Cancer Institute
🇺🇸Oklahoma City, Oklahoma, United States
Presbyterian - St. Luke's Medical Center
🇺🇸Denver, Colorado, United States
Tunnell Cancer Center at Beebe Medical Center
🇺🇸Lewes, Delaware, United States
CCOP - Christiana Care Health Services
🇺🇸Newark, Delaware, United States
Mountain States Tumor Institute at St. Luke's Regional Medical Center
🇺🇸Boise, Idaho, United States
Providence Cancer Center
🇺🇸Anchorage, Alaska, United States
Mountain States Tumor Institute at St. Luke's
🇺🇸Twin Falls, Idaho, United States
Saint Francis/Mount Sinai Regional Cancer Center at Saint Francis Hospital and Medical Center
🇺🇸Hartford, Connecticut, United States
Saint Luke's Mountain States Tumor Institute
🇺🇸Nampa, Idaho, United States
Cancer Institute of New Jersey at Cooper - Voorhees
🇺🇸Voorhees, New Jersey, United States
King Faisal Specialist Hospital and Research Center
🇸🇦Riyadh, Saudi Arabia
McGill Cancer Centre at McGill University
🇨🇦Montreal, Quebec, Canada
Fox Chase Virtua Health Cancer Program at Virtua Memorial Hospital Marlton
🇺🇸Marlton, New Jersey, United States
Saint John Regional Hospital
🇨🇦Saint John, New Brunswick, Canada
Tel-Aviv Sourasky Medical Center
🇮🇱Tel Aviv, Israel
Mayo Clinic Cancer Center
🇺🇸Rochester, Minnesota, United States
Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
CCOP - Missouri Valley Cancer Consortium
🇺🇸Omaha, Nebraska, United States
Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Medical College of Wisconsin Cancer Center
🇺🇸Milwaukee, Wisconsin, United States
McCreery Cancer Center at Ottumwa Regional
🇺🇸Ottumwa, Iowa, United States
Mercy Medical Center - Sioux City
🇺🇸Sioux City, Iowa, United States
Georgia Cancer Center for Excellence at Grady Memorial Hospital
🇺🇸Atlanta, Georgia, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Hematology and Oncology Associates
🇺🇸Chicago, Illinois, United States
University of Illinois Cancer Center
🇺🇸Chicago, Illinois, United States
Emory Crawford Long Hospital
🇺🇸Atlanta, Georgia, United States
Winship Cancer Institute of Emory University
🇺🇸Atlanta, Georgia, United States
Southern Regional Medical Center
🇺🇸Riverdale, Georgia, United States
Charles B. Eberhart Cancer Center at DeKalb Medical Center
🇺🇸Decatur, Georgia, United States
Decatur Memorial Hospital Cancer Care Institute
🇺🇸Decatur, Illinois, United States
Ingalls Cancer Care Center at Ingalls Memorial Hospital
🇺🇸Harvey, Illinois, United States
Hinsdale Hematology Oncology Associates
🇺🇸Hinsdale, Illinois, United States
North Shore Oncology and Hematology Associates, Limited - Libertyville
🇺🇸Libertyville, Illinois, United States
Provena St. Mary's Regional Cancer Center - Kankakee
🇺🇸Kankakee, Illinois, United States
McDonough District Hospital
🇺🇸Macomb, Illinois, United States
BroMenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Community Cancer Center
🇺🇸Elyria, Ohio, United States
Trinity Cancer Center at Trinity Medical Center - 7th Street Campus
🇺🇸Moline, Illinois, United States
Regional Cancer Center at Memorial Medical Center
🇺🇸Springfield, Illinois, United States
St. Francis Hospital and Health Centers - Beech Grove Campus
🇺🇸Beech Grove, Indiana, United States
Memorial Hospital of South Bend
🇺🇸South Bend, Indiana, United States
Center for Cancer Care at Goshen General Hospital
🇺🇸Goshen, Indiana, United States
Foote Memorial Hospital
🇺🇸Jackson, Michigan, United States
MidMichigan Medical Center - Midland
🇺🇸Midland, Michigan, United States
Mercy General Health Partners
🇺🇸Muskegon, Michigan, United States
St. Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
Lakeside Cancer Specialists, PLLC
🇺🇸Saint Joseph, Michigan, United States
Saint Michael's Hospital Cancer Center
🇺🇸Stevens Point, Wisconsin, United States
Diagnostic and Treatment Center
🇺🇸Weston, Wisconsin, United States
Marshfield Clinic - Weston Center
🇺🇸Weston, Wisconsin, United States
University of Wisconcin Cancer Center at Aspirus Wausau Hospital
🇺🇸Wausau, Wisconsin, United States
Green Bay Oncology, Limited - Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
Oncology Alliance, SC - Milwaukee - West
🇺🇸Wauwatosa, Wisconsin, United States
Vince Lombardi Cancer Clinic - Two Rivers
🇺🇸Two Rivers, Wisconsin, United States
Waukesha Memorial Hospital Regional Cancer Center
🇺🇸Waukesha, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸Wisconsin Rapids, Wisconsin, United States
CancerCare Manitoba
🇨🇦Winnipeg, Manitoba, Canada
Saint Joseph Mercy Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Wake Forest University Comprehensive Cancer Center
🇺🇸Winston-Salem, North Carolina, United States
H. Lee Moffitt Cancer Center and Research Institute at University of South Florida
🇺🇸Tampa, Florida, United States
CCOP - Michigan Cancer Research Consortium
🇺🇸Ann Arbor, Michigan, United States
St. Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Florida Hospital Cancer Institute at Florida Hospital Orlando
🇺🇸Orlando, Florida, United States
M.D. Anderson Cancer Center at Orlando
🇺🇸Orlando, Florida, United States
Cancer Research Center of Hawaii
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Institute at Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Straub Clinic and Hospital, Incorporated
🇺🇸Honolulu, Hawaii, United States
Hawaii Medical Center - East
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
Lucille P. Markey Cancer Center at University of Kentucky
🇺🇸Lexington, Kentucky, United States
Saint Luke's Cancer Institute at Saint Luke's Hospital
🇺🇸Kansas City, Missouri, United States
CCOP - Iowa Oncology Research Association
🇺🇸Des Moines, Iowa, United States
John Stoddard Cancer Center at Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
Medical Oncology and Hematology Associates at John Stoddard Cancer Center
🇺🇸Des Moines, Iowa, United States
Medical Oncology and Hematology Associates at Mercy Cancer Center
🇺🇸Des Moines, Iowa, United States
Research Medical Center
🇺🇸Kansas City, Missouri, United States
Mercy Cancer Center at Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
John Stoddard Cancer Center at Iowa Lutheran Hospital
🇺🇸Des Moines, Iowa, United States
Roper St. Francis Cancer Center at Roper Hospital
🇺🇸Charleston, South Carolina, United States
Hollings Cancer Center at Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
Virginia Commonwealth University Massey Cancer Center
🇺🇸Richmond, Virginia, United States
University of Wisconsin Paul P. Carbone Comprehensive Cancer Center
🇺🇸Madison, Wisconsin, United States
Cancer Center of Kansas, PA - Medical Arts Tower
🇺🇸Wichita, Kansas, United States
Cancer Center of Kansas, PA - Wichita
🇺🇸Wichita, Kansas, United States
CCOP - Wichita
🇺🇸Wichita, Kansas, United States
Via Christi Cancer Center at Via Christi Regional Medical Center
🇺🇸Wichita, Kansas, United States
Lovelace Medical Center - Downtown
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Highland Hospital of Rochester
🇺🇸Rochester, New York, United States
James P. Wilmot Cancer Center at University of Rochester Medical Center
🇺🇸Rochester, New York, United States
Good Samaritan Hospital
🇺🇸Dayton, Ohio, United States
David L. Rike Cancer Center at Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Samaritan North Cancer Care Center
🇺🇸Dayton, Ohio, United States
Cross Cancer Institute at University of Alberta
🇨🇦Edmonton, Alberta, Canada
CCOP - Illinois Oncology Research Association
🇺🇸Peoria, Illinois, United States
Mayo Clinic Scottsdale
🇺🇸Scottsdale, Arizona, United States