Melphalan and Dexamethasone With or Without Bortezomib in Treating Patients With Previously Untreated Systemic Light-Chain Amyloidosis
- Conditions
- Light Chain Deposition DiseasePrimary Systemic Amyloidosis
- Interventions
- Registration Number
- NCT01078454
- Lead Sponsor
- National Cancer Institute (NCI)
- Brief Summary
This randomized phase III trial is studying melphalan and dexamethasone to see how well they work with or without bortezomib in treating patients with previously untreated systemic amyloidosis. Drugs used in chemotherapy, such as melphalan and dexamethasone, work in different ways to stop the growth of plasma cells, either by killing the cells or by stopping them from dividing. Bortezomib may stop the growth of plasma cells by blocking some of the enzymes needed for cell growth. It is not yet known whether giving melphalan together with dexamethasone is more effective with or without bortezomib in treating systemic amyloidosis.
- Detailed Description
PRIMARY OBJECTIVES:
I. To compare hematologic overall response (partial response \[PR\], very good PR, amyloid complete hematologic response \[ACR\], and stringent complete response \[sCR\]) after 3 courses of therapy in patients with previously untreated systemic light-chain amyloidosis treated with melphalan and dexamethasone with vs without bortezomib.
SECONDARY OBJECTIVES:
I. To evaluate the ACR rate after 3 courses of therapy and at completion of therapy.
II. To evaluate organ response rates after 3 courses of therapy and at 6, 9, and 12 months.
III. To evaluate treatment-related mortality.
IV. To evaluate toxicity.
V. To evaluate progression-free and overall survival.
VI. To evaluate PR or better at completion of therapy.
VII. To evaluate time to hematologic and organ response.
VIII. To evaluate the duration of hematologic and organ response.
IX. To assess quality of life (QOL) at baseline, at 3, 6, and 9 months during the therapy, at completion of therapy, and 3 and 6 months after therapy.
TERTIARY OBJECTIVES:
I. To determine the prognostic impact of t(11;14) translocation and cyclin D1 overexpression on response and overall survival.
II. (Correlative) To compare sCR rates and to determine the impact of sCR on the outcomes.
III. (Correlative) To perform a descriptive analysis of amyloid typing and proteomic composition of amyloid tissues.
OUTLINE: This is a multicenter study. Patients are stratified according to amyloid cardiac stage (stage I/II vs. better risk stage III) and are randomized to 1 of 2 treatment arms.
ARM A (Mel-Dex): Patients receive melphalan 0.22 mg/kg orally (PO) and dexamethasone 40 mg PO on days 1-4 every 4 weeks. Treatment repeats every 4 weeks for up to 9 courses in the absence of disease progression or unacceptable toxicity.
ARM B (B-Mel-Dex): Patients receive melphalan 0.22 mg/kg PO and dexamethasone 40 mg PO on days 1-4 and bortezomib 1.3 mg/m2 intravenously (IV) on days 1, 4, 8, and 11 every 4 weeks. Treatment repeats every 4 weeks for 2 cycles. Patients then receive melphalan PO and dexamethasone PO on days 1-4 and bortezomib IV on days 1, 8, 15, and 22 every 5 weeks. Treatment repeats every 5 weeks for up to 6 cycles in the absence of disease progression or unacceptable toxicity.
Blood, urine, bone marrow, and fat samples may be collected periodically for laboratory analysis. Health-related quality of life is assessed periodically before, during, and after therapy. After completion of study treatment, patients are followed up periodically for 5 years.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 11
-
Histologically confirmed diagnosis of systemic light-chain amyloidosis
- Histologic diagnosis of disease must be confirmed by pathology (positive Congo red stain with green birefringence on polarized light microscopy)
- Genetic testing must be negative for transthyretin mutations associated with hereditary amyloidosis (required in patients who are African-American or who present with peripheral neuropathy as the dominant organ involvement)
-
Measurable disease, defined by >= 1 of the following:
- Serum M-protein >= 1 g/dL by serum protein electrophoresis (SPEP)
- Difference between involved and uninvolved free light chain be >4.0mg/dL provided the kappa to lambda free light chain (FLC) ratio is abnormal
-
Symptomatic organ involvement* (heart, kidney, liver/gastrointestinal tract, peripheral nervous system, or soft tissue), defined as any of the following:
- NOTE: *Carpal tunnel syndrome skin purpura or the presence of vascular amyloid on a bone marrow biopsy alone are not sufficient to meet criteria for "symptomatic organ involvement"
- Renal involvement is defined as proteinuria (predominantly albumin) > 0.5 g/day by 24-hour urine collection
- Cardiac involvement is defined as the presence of a mean left ventricular wall thickness of > 12 mm by echocardiogram in the absence of a history of hypertension or valvular heart disease or in the presence of unexplained low voltage (< 0.5 mV) by electrocardiogram
- Hepatic involvement is defined as hepatomegaly or an alkaline phosphatase > 1.5 times upper limit of normal (ULN)
- Peripheral nerve involvement is defined by clinical history or abnormal sensory and/or motor findings on neurologic exam
- Gastrointestinal (GI) involvement is defined as gross GI bleeding or diarrhea (at least 4 stools per day over baseline); a positive GI biopsy is not sufficient to document clinical involvement
- Autonomic nerve involvement is defined as orthostasis, symptoms of nausea or dysgeusia, gastric atony by gastric emptying scan, diarrhea, or constipation
- Soft tissue and lymphatic involvement may be ascertained based on classic physical exam findings (macroglossia, shoulder pad sign, raccoon eyes, carpal tunnel syndrome, synovial enlargement, firm enlarged lymph nodes) or biopsy
-
Ineligible for autologous stem cell transplantation with melphalan 200 mg/m^2 or refuses to undergo transplantation
-
Eastern Cooperative Oncology Group (ECOG) performance status 0-2
-
Amyloid cardiac biomarker stage I or II disease
- The amyloid cardiac staging system is based on NT-proBNP and troponin-T levels. If troponin T (cTnT) is not available at local institution then troponin I (cTnI) may be used. Thresholds for cTnT, cTnI, and NT-proBNP are < 0.035 ug/L, < 0.1 ug/L, and < 332 ng/L, respectively. Stage I patients have both troponin-T (or I) and NT-proBNP below the threshold. Stage II patients have either troponin-T (I) or NT-proBNP above the threshold. Stage III patients have troponin-T (or I) and simultaneous NT-proBNP above the threshold. Stage III patients are further classified as "better risk" if NT-proBNP is over 332 ng/L but less than 6000 ng/L
-
Negative pregnancy test
-
Fertile patients must use effective contraception
-
The absence of supine systolic blood pressure < 100 mmHg and difficult to manage symptomatic orthostatic hypotension
-
Absolute neutrophil count (ANC) > 1,500/mm^3
-
Platelet count > 140,000/mm^3
-
Hemoglobin > 10 g/dL
-
Total bilirubin < 2.5 mg/dL
-
Alkaline phosphatase < 5 times upper limit of normal (ULN)
-
Aspartate aminotransferase (AST) < 3 times ULN
-
Creatinine clearance > 30 mL/min
-
Bone marrow plasma cells < 30%
-
Human immunodeficiency virus (HIV)-positivity allowed provided the following criteria are met:
- No history of acquired immunodeficiency syndrome (AIDS)-defining events including history of CD4 cell count < 200/mm^3
- Current CD4 cell count >= 350/mm^3
- Not receiving zidovudine or stavudine
- No secondary amyloidosis
-
More than 3 weeks since radiotherapy
- Enrollment of subjects who require radiotherapy (which must be localized in field size) should be deferred until the radiotherapy is completed and 3 weeks have elapsed since the last date of therapy
-
More than 14 days since prior and no concurrent participation in clinical trials with other investigational agents not included in this trial
- Pregnant or nursing
- Clinically overt myeloma (hypercalcemia or lytic bone lesions)
- Prior chemotherapy or radiotherapy for the treatment of myeloma or systemic light-chain amyloidosis
- History of sustained ventricular tachycardias
- Cardiac syncope
- Uncompensated New York Heart Association (NYHA) class III or IV congestive heart failure
- Uncontrolled infection
- Active malignancy within the past 5 years except for adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, or adequately treated stage I cancer currently in complete remission
- Serious medical or psychiatric illness likely to interfere with study participation, including recent myocardial infarction (within the past 6 months) or poorly controlled diabetes mellitus
- Hypersensitivity to bortezomib, boron, or mannitol
- Grade 2 or higher peripheral neuropathy
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description ARM A (Mel-Dex) melphalan Patients receive melphalan 0.22 mg/kg orally (PO) and dexamethasone 40 mg PO on days 1-4 every 4 weeks. Treatment repeats every 4 weeks for up to 9 courses in the absence of disease progression or unacceptable toxicity. ARM A (Mel-Dex) dexamethasone Patients receive melphalan 0.22 mg/kg orally (PO) and dexamethasone 40 mg PO on days 1-4 every 4 weeks. Treatment repeats every 4 weeks for up to 9 courses in the absence of disease progression or unacceptable toxicity. ARM B (B-Mel-Dex) melphalan Patients receive melphalan 0.22 mg/kg PO and dexamethasone 40 mg PO on days 1-4 and bortezomib 1.3 mg/m\^2 intravenously (IV) on days 1, 4, 8, and 11 every 4 weeks. Treatment repeats every 4 weeks for 2 cycles. Patients then receive melphalan PO and dexamethasone PO on days 1-4 and bortezomib IV on days 1, 8, 15, and 22 every 5 weeks. Treatment repeats every 5 weeks for up to 6 cycles in the absence of disease progression or unacceptable toxicity. ARM B (B-Mel-Dex) bortezomib Patients receive melphalan 0.22 mg/kg PO and dexamethasone 40 mg PO on days 1-4 and bortezomib 1.3 mg/m\^2 intravenously (IV) on days 1, 4, 8, and 11 every 4 weeks. Treatment repeats every 4 weeks for 2 cycles. Patients then receive melphalan PO and dexamethasone PO on days 1-4 and bortezomib IV on days 1, 8, 15, and 22 every 5 weeks. Treatment repeats every 5 weeks for up to 6 cycles in the absence of disease progression or unacceptable toxicity. ARM B (B-Mel-Dex) dexamethasone Patients receive melphalan 0.22 mg/kg PO and dexamethasone 40 mg PO on days 1-4 and bortezomib 1.3 mg/m\^2 intravenously (IV) on days 1, 4, 8, and 11 every 4 weeks. Treatment repeats every 4 weeks for 2 cycles. Patients then receive melphalan PO and dexamethasone PO on days 1-4 and bortezomib IV on days 1, 8, 15, and 22 every 5 weeks. Treatment repeats every 5 weeks for up to 6 cycles in the absence of disease progression or unacceptable toxicity.
- Primary Outcome Measures
Name Time Method Proportion of Patients With Hematologic Overall Response (Partial Response [PR]+ Very Good PR [VGPR]+ Amyloid Complete Response [ACR]+ Stringent Complete Response [sCR]) After 3 Months (3 Cycles) of Therapy Assessed at 3 months sCR: ACR and no clonal cells in bone marrow (BM) ACR: Negative serum/urine immunofixation (IF), \<5% plasma cells in BM, and normal serum FLC ratio VGPR: 1. PR and any of the following; 2. serum/urine M-protein detectable by IF but not measurable (NM) on electrophoresis (EP); (3) ≥90% reduction in serum M-component and urine M-protein \<100 mg/24 hr if baseline serum measurable; (4) urine M-component \<100 mg/24 hr and NM serum M-protein on serum protein EP if baseline urine measurable; (5) ≥90% drop in the difference between involved and uninvolved FLC levels if only FLC measurable PR: (1) ≥50% drop of serum M-protein and 24-hr urinary M-protein drop by ≥90% or to \<200 mg/24 hr if baseline serum/urine measurable; or (2) ≥50% drop of serum M-protein if only serum measurable at baseline; or (3) 24-hr urinary M-protein drop by ≥90% or to \<200 mg/24 hr if baseline urine measurable; or (4) ≥ 50% drop in the difference between involved and uninvolved FLC if only FLC measu
- Secondary Outcome Measures
Name Time Method
Trial Locations
- Locations (209)
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Emory University/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Eureka Hospital
🇺🇸Eureka, Illinois, United States
Illinois CancerCare Galesburg
🇺🇸Galesburg, Illinois, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
Memorial Hospital
🇺🇸Carthage, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Mason District Hospital
🇺🇸Havana, Illinois, United States
Mcdonough District Hospital
🇺🇸Macomb, Illinois, United States
Great Falls Clinic
🇺🇸Great Falls, Montana, United States
Marshfield Clinic - Weston Center
🇺🇸Weston, Wisconsin, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Green Bay Oncology - Oconto Falls
🇺🇸Oconto Falls, Wisconsin, United States
Waukesha Memorial Hospital - ProHealth Care
🇺🇸Waukesha, Wisconsin, United States
Diagnostic and Treatment Center
🇺🇸Weston, Wisconsin, United States
Marshfield Clinic Cancer Care at Saint Michael's Hospital
🇺🇸Stevens Point, Wisconsin, United States
Boston Medical Center
🇺🇸Boston, Massachusetts, United States
Minor and James Medical PLLC
🇺🇸Seattle, Washington, United States
Fred Hutchinson Cancer Research Center/University of Washington Cancer Consortium
🇺🇸Seattle, Washington, United States
Group Health Cooperative-Seattle
🇺🇸Seattle, Washington, United States
Indiana University Medical Center
🇺🇸Indianapolis, Indiana, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Illinois Valley Hospital
🇺🇸Peru, Illinois, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
MetroHealth Medical Center
🇺🇸Cleveland, Ohio, United States
Greene Memorial Hospital
🇺🇸Xenia, Ohio, United States
Geisinger Medical Center-Cancer Center Hazelton
🇺🇸Hazleton, Pennsylvania, United States
PeaceHealth Saint Joseph Medical Center
🇺🇸Bellingham, Washington, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Swedish Cancer Institute-Issaquah
🇺🇸Issaquah, Washington, United States
Cancer Care Northwest - Spokane South
🇺🇸Spokane, Washington, United States
The Polyclinic
🇺🇸Seattle, Washington, United States
United General Hospital
🇺🇸Sedro-Woolley, Washington, United States
University of Washington Medical Center
🇺🇸Seattle, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Compass Oncology Vancouver
🇺🇸Vancouver, Washington, United States
Wenatchee Valley Medical Center
🇺🇸Wenatchee, Washington, United States
Tufts Medical Center
🇺🇸Boston, Massachusetts, United States
Fox Chase Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Hutchinson Area Health Care
🇺🇸Hutchinson, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Minnesota Oncology and Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Castle Medical Center
🇺🇸Kailua, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸Lihue, Hawaii, United States
Pali Momi Medical Center
🇺🇸'Aiea, Hawaii, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
Littleton Adventist Hospital
🇺🇸Littleton, Colorado, United States
Parker Adventist Hospital
🇺🇸Parker, Colorado, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Oncare Hawaii Inc-Pali Momi
🇺🇸'Aiea, Hawaii, United States
Exempla Lutheran Medical Center
🇺🇸Wheat Ridge, Colorado, United States
University of Mississippi Medical Center
🇺🇸Jackson, Mississippi, United States
Graham Hospital Association
🇺🇸Canton, Illinois, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Presbyterian - Saint Lukes Medical Center - Health One
🇺🇸Denver, Colorado, United States
Exempla Saint Joseph Hospital
🇺🇸Denver, Colorado, United States
Rose Medical Center
🇺🇸Denver, Colorado, United States
Colorado Cancer Research Program CCOP
🇺🇸Denver, Colorado, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Western Oncology Research Consortium
🇺🇸Portland, Oregon, United States
Adventist Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Saint Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
Union Hospital of Cecil County
🇺🇸Elkton, Maryland, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
Green Bay Oncology - Iron Mountain
🇺🇸Iron Mountain, Michigan, United States
Fairview-Southdale Hospital
🇺🇸Edina, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Metro-Minnesota CCOP
🇺🇸Saint Louis Park, Minnesota, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸Great Falls, Montana, United States
Kalispell Medical Oncology
🇺🇸Kalispell, Montana, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
Montana Cancer Specialists
🇺🇸Missoula, Montana, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Clinton Memorial Hospital
🇺🇸Wilmington, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Arthur G. James Cancer Hospital and Solove Research Institute at Ohio State University Medical Center
🇺🇸Columbus, Ohio, United States
The Jewish Hospital
🇺🇸Cincinnati, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
Providence Milwaukie Hospital
🇺🇸Milwaukie, Oregon, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Cancer Care Center at Island Hospital
🇺🇸Anacortes, Washington, United States
Geisinger Medical Group
🇺🇸State College, Pennsylvania, United States
Geisinger Wyoming Valley
🇺🇸Wilkes-Barre, Pennsylvania, United States
Harrison HealthPartners Hematology and Oncology-Bremerton
🇺🇸Bremerton, Washington, United States
Harborview Medical Center
🇺🇸Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
Columbia Basin Hematology and Oncology PLLC
🇺🇸Kennewick, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸Poulsbo, Washington, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Skagit Valley Hospital
🇺🇸Mount Vernon, Washington, United States
Marshfield Clinic-Chippewa Center
🇺🇸Chippewa Falls, Wisconsin, United States
Marshfield Clinic Cancer Center at Sacred Heart
🇺🇸Eau Claire, Wisconsin, United States
Green Bay Oncology at Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Gundersen Lutheran
🇺🇸La Crosse, Wisconsin, United States
Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Holy Family Memorial Hospital
🇺🇸Manitowoc, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸Minocqua, Wisconsin, United States
D N Greenwald Center
🇺🇸Mukwonago, Wisconsin, United States
Rocky Mountain Oncology
🇺🇸Casper, Wyoming, United States
Welch Cancer Center
🇺🇸Sheridan, Wyoming, United States
Green Bay Oncology - Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
The Medical Center of Aurora
🇺🇸Aurora, Colorado, United States
University of Michigan
🇺🇸Ann Arbor, Michigan, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Oncare Hawaii Inc-Kuakini
🇺🇸Honolulu, Hawaii, United States
Oncare Hawaii Inc-POB II
🇺🇸Honolulu, Hawaii, United States
North Colorado Medical Center
🇺🇸Greeley, Colorado, United States
Sky Ridge Medical Center
🇺🇸Lone Tree, Colorado, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
Cleveland Clinic Florida - Weston
🇺🇸Weston, Florida, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
Eastern Connecticut Hematology and Oncology Associates
🇺🇸Norwich, Connecticut, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Beebe Medical Center
🇺🇸Lewes, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
Mayo Clinic in Florida
🇺🇸Jacksonville, Florida, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Saint Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Illinois CancerCare-Havana
🇺🇸Havana, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Holy Family Medical Center
🇺🇸Monmouth, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Illinois CancerCare-Monmouth
🇺🇸Monmouth, Illinois, United States
Bromenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Ottawa Regional Hospital and Healthcare Center
🇺🇸Ottawa, Illinois, United States
Community Cancer Center Foundation
🇺🇸Normal, Illinois, United States
Illinois CancerCare-Community Cancer Center
🇺🇸Normal, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Proctor Hospital
🇺🇸Peoria, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Illinois Oncology Research Association CCOP
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Pekin Cancer Treatment Center
🇺🇸Pekin, Illinois, United States
Perry Memorial Hospital
🇺🇸Princeton, Illinois, United States
Saint Francis Hospital and Health Centers
🇺🇸Beech Grove, Indiana, United States
Illinois CancerCare-Spring Valley
🇺🇸Spring Valley, Illinois, United States
McFarland Clinic PC-William R Bliss Cancer Center
🇺🇸Ames, Iowa, United States
Reid Hospital and Health Care Services
🇺🇸Richmond, Indiana, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
University of Iowa Hospitals and Clinics
🇺🇸Iowa City, Iowa, United States
Mercy Medical Center-Sioux City
🇺🇸Sioux City, Iowa, United States
Siouxland Hematology Oncology Associates
🇺🇸Sioux City, Iowa, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Kalispell Regional Medical Center
🇺🇸Kalispell, Montana, United States
Bozeman Deaconess Hospital
🇺🇸Bozeman, Montana, United States
Cooper Hospital University Medical Center
🇺🇸Camden, New Jersey, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
University of Arkansas for Medical Sciences
🇺🇸Little Rock, Arkansas, United States
Mayo Clinic in Arizona
🇺🇸Scottsdale, Arizona, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Glacier Oncology PLLC
🇺🇸Kalispell, Montana, United States
Providence Hospital
🇺🇸Southfield, Michigan, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸Butte, Montana, United States
Montana Cancer Consortium CCOP
🇺🇸Billings, Montana, United States
Green Bay Oncology - Escanaba
🇺🇸Escanaba, Michigan, United States
Saint Vincent Healthcare
🇺🇸Billings, Montana, United States
Hematology-Oncology Centers of the Northern Rockies PC
🇺🇸Billings, Montana, United States
Billings Clinic
🇺🇸Billings, Montana, United States
Bozeman Deaconess Cancer Center
🇺🇸Bozeman, Montana, United States
Saint Peter's Community Hospital
🇺🇸Helena, Montana, United States
Northern Montana Hospital
🇺🇸Havre, Montana, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Saint Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸Wisconsin Rapids, Wisconsin, United States
Providence Willamette Falls Medical Center
🇺🇸Oregon City, Oregon, United States
Marshfield Clinic at James Beck Cancer Center
🇺🇸Rhinelander, Wisconsin, United States
Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Marshfield Clinic
🇺🇸Marshfield, Wisconsin, United States
Marshfield Clinic-Rice Lake Center
🇺🇸Rice Lake, Wisconsin, United States
Oconomowoc Memorial Hospital-ProHealth Care Inc
🇺🇸Oconomowoc, Wisconsin, United States
Straub Clinic and Hospital
🇺🇸Honolulu, Hawaii, United States
University of Hawaii
🇺🇸Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
OnCare Hawaii-Liliha
🇺🇸Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸Honolulu, Hawaii, United States
Grandview Hospital
🇺🇸Dayton, Ohio, United States
Samaritan North Health Center
🇺🇸Dayton, Ohio, United States
Dayton CCOP
🇺🇸Dayton, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Evergreen Hematology and Oncology PS
🇺🇸Spokane, Washington, United States
Saint Mary's Hospital and Regional Medical Center
🇺🇸Grand Junction, Colorado, United States