Chemotherapy Before Surgery and Radiation Therapy or Surgery and Radiation Therapy Alone in Treating Patients With Nasal and Paranasal Sinus Cancer That Can Be Removed by Surgery

Phase 2

Recruiting

• Conditions: Stage III Nasal Cavity and Paranasal Sinus Squamous Cell Carcinoma AJCC v6 and v7; Stage IVA Nasal Cavity and Paranasal Sinus Squamous Cell Carcinoma AJCC v7
• Interventions: Drug: Carboplatin; Drug: Cisplatin; Radiation: Image Guided Radiation Therapy; Drug: Docetaxel; Other: Laboratory Biomarker Analysis; Radiation: Intensity-Modulated Radiation Therapy; Other: Questionnaire Administration; Procedure: Therapeutic Conventional Surgery

• Registration Number: NCT03493425
• Lead Sponsor: ECOG-ACRIN Cancer Research Group

Brief Summary

This randomized phase II trial studies how well chemotherapy before surgery and radiation therapy works compared to surgery and radiation therapy alone in treating patients with nasal and paranasal sinus cancer that can be removed by surgery. Drugs used in chemotherapy, such as docetaxel, cisplatin, and carboplatin 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. Radiation therapy uses high-energy x-rays to kill tumor cells and shrink tumors. Giving chemotherapy before surgery and radiation therapy may make the tumor smaller and reduce the amount of normal tissue that needs to be removed and treated with radiation.

Detailed Description

PRIMARY OBJECTIVES:

I. Evaluate the structure preservation rate for patients with locally advanced resectable nasal and paranasal sinus squamous cell carcinoma (NPNSCC) with or without neoadjuvant therapy; all patients will undergo surgical resection and postoperative standard care.

II. Evaluate overall survival (OS) for patients with locally advanced resectable NPNSCC with or without neoadjuvant therapy followed by surgical resection and postoperative standard care.

SECONDARY OBJECTIVES:

I. Evaluate progression-free survival (PFS) for this patient population. II. Examine the rate of structure preservation for the orbit (freedom from orbital exenteration).

III. Evaluate site reported p16 data and correlate with outcome. IV. Determine the accuracy of baseline/post-chemotherapy magnetic resonance imaging (MRI) and fludeoxyglucose F-18 positron emission tomography/computed tomography (FDG PET/CT)-based prediction of orbit and skull base preservation.

V. Determine the accuracy of baseline/post-chemotherapy MRI and/or FDG PET/CT-based prediction of 2-year overall survival.

TERTIARY OBJECTIVES:

I. To determine the effects of tobacco, operationalized as combustible tobacco (1a), other forms of tobacco (1b), and environmental tobacco exposure (ETS) (1c) on provider-reported cancer-treatment toxicity (adverse events \[both clinical and hematologic\] and dose modifications).

II. To determine the effects of tobacco on patient-reported physical symptoms and psychological symptoms.

III. To examine quitting behaviors and behavioral counseling/support and cessation medication utilization.

IV. To explore the effect of tobacco use and exposure on treatment duration, relative dose intensity, and therapeutic benefit.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM A: Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided intensity modulated radiation therapy (IMRT) once daily (QD) for 5 fractions per week for 30 fractions. Patients with positive margins/positive extracapsular spread (ECS) in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin intravenously (IV) over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months if \< 2 years from study entry and then every 6 months if 2-5 years from study entry.

Study Timeline

• Study First Submitted: 2018-01-26
• Study First Submitted QC: 2018-04-03
• Study First Posted: 2018-04-10
• Study Start: 2019-03-12
• Status Verified: 2024-12
• Last Update Submitted: 2024-12-19
• Last Update Posted: 2024-12-24
• Primary Completion: 2029-03-31
• Study Completion: 2029-03-31

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 82

Inclusion Criteria

• Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1

• General physical condition compatible with the proposed chemotherapy and surgery

• Stage T3 or T4a, histologically-confirmed NPNSCC requiring orbital or skull base resection:

  • Stages T3 and T4a disease will be included regardless of nodal status (N0 or N1-3), provided that surgical therapy would require orbital or skull base resection

  • The surgical oncologist in each institution will determine the need for resection of the orbit OR base of skull at baseline for patients on both Arms A and B and following neo-adjuvant chemotherapy for patients on Arm B

    • Resection of skull base will be deemed necessary according to skull base bone erosion by CT or marrow involvement by MRI is noted; for any disease abutting the skull base; or for ethmoid sinus or frontal sinus involvement
    • Resection of orbital contents will be deemed necessary according to skull base society guidelines, based on involvement of periorbital fat documented by MRI imaging

• Patients must be deemed surgically resectable by the surgical teams at each institution and must have a determination of degree of anticipated structure preservation of orbit and skull base; this needs to be determined prior to randomization

• Patients may not be receiving investigational agents at time of registration, or at any time while on study and during the 4 weeks preceding enrollment

• Patients with a history of allergic reactions attributed to compounds of similar chemical or biologic composition to docetaxel and/or both platinum-based chemotherapy agents are excluded; patient must be able to receive at least one of the two proposed chemotherapy regimens

• Patients with evidence of distant metastases or leptomeningeal disease (LMD) are excluded

• Patients must not have received previous irradiation for head and neck tumor, skull base, or brain tumors

• Patients with uncontrolled inter-current illnesses which in the opinion of the investigator will interfere with the ability to undergo therapy including chemotherapy are excluded

• Patients with a history of a different malignancy are excluded, unless the disease has not progressed for >= 2 years

• Absolute neutrophil count (ANC) > 1500/mm^3 =< 2 weeks prior to randomization

• Hemoglobin (Hgb) > 8.0 g/dL =< 2 weeks prior to randomization

• Platelet count > 100,000/mm^3 =< 2 weeks prior to randomization

• Creatinine clearance of > 60 ml/min; creatinine clearance may be measured or calculated; if calculating, creatinine clearance, use the Cockroft-Gault formula =< 2 weeks prior to randomization

• Total bilirubin within normal limits (must be obtained =< 2 weeks prior to randomization)

• Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) must be within the range allowing for eligibility, must be obtained < 2 weeks prior to randomization

• Alkaline phosphatase must be within the range allowing for eligibility, must be obtained < 2 weeks prior to randomization

• Patients with a prior history of squamous cell or basal carcinoma of the skin or in situ cervical cancer must have been curatively treated

• No current peripheral neuropathy > grade 2 at time of randomization

• Patients must not have any co-existing condition that would preclude full compliance with the study; no prior history of severe hypersensitivity reaction to docetaxel or other drugs formulated with polysorbate 80

• Women must not be pregnant or breast-feeding

  • All females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy
  • A female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)

• Women of childbearing potential and sexually active males must be strongly advised to use an accepted and effective method of contraception or to abstain from sexual intercourse for the duration of their participation in the study

• Patients must have measurable disease; MRI and/or PET/CT scans need to be performed within 2 weeks prior to registration

Read More

Exclusion Criteria

Not provided

Read More

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Arm A (surgery, IMRT, cisplatin, carboplatin)	Laboratory Biomarker Analysis	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Image Guided Radiation Therapy	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Image Guided Radiation Therapy	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Intensity-Modulated Radiation Therapy	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Intensity-Modulated Radiation Therapy	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Questionnaire Administration	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Therapeutic Conventional Surgery	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Therapeutic Conventional Surgery	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Laboratory Biomarker Analysis	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Questionnaire Administration	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Carboplatin	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm A (surgery, IMRT, cisplatin, carboplatin)	Cisplatin	Patients undergo standard of care surgery. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV over 1-2 hours or carboplatin IV over 30 minutes (for patients who are ineligible to receive cisplatin) weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Carboplatin	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Docetaxel	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.
Arm B (docetaxel, cisplatin, carboplatin, surgery, IMRT)	Cisplatin	Patients receive docetaxel IV over 1 hour and cisplatin IV over 1-2 hours on day 1. Patients who are ineligible to receive cisplatin receive carboplatin IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 3 courses in the absence of disease progression or unacceptable toxicity. Patients then undergo standard of care surgery no later than 6 weeks following the last dose of chemotherapy. Beginning 4-6 weeks after surgery, patients undergo image guided IMRT QD for 5 fractions per week for 30 fractions. Patients with positive margins/positive ECS in lymph nodes undergo image guided IMRT QD for 5 fractions per week for 30 fractions and cisplatin IV or carboplatin IV weekly for 6 weeks in the absence of disease progression or unacceptable toxicity.

Primary Outcome Measures

Name	Time	Method
Overall survival (OS)	From date of randomization, censoring follow-up at last date of contact, assessed for up to 5 years	Log rank test will be used to compare OS between the two arms. The comparison between the two arms for OS will be conducted separately (each at one-sided 0.05 significance level).
Structure preservation rate defined as both skull base and orbit being preserved	Up to 5 years	Fisher?s exact test will be used to compare the structure preservation rate between the two arms. The comparison between the two arms for structure preservation will be conducted separately (each at one-sided 0.05 significance level).

Trial Locations

Locations (140)

UM Sylvester Comprehensive Cancer Center at Deerfield Beach; 🇺🇸 Deerfield Beach, Florida, United States

UM Sylvester Comprehensive Cancer Center at Plantation; 🇺🇸 Plantation, Florida, United States

Emory University Hospital/Winship Cancer Institute; 🇺🇸 Atlanta, Georgia, United States

NorthShore University HealthSystem-Evanston Hospital; 🇺🇸 Evanston, Illinois, United States

NorthShore University HealthSystem-Glenbrook Hospital; 🇺🇸 Glenview, Illinois, United States

Saint Alphonsus Medical Center-Nampa; 🇺🇸 Nampa, Idaho, United States

Carle Physician Group-Mattoon/Charleston; 🇺🇸 Mattoon, Illinois, United States

Mercy Hospital Joplin; 🇺🇸 Joplin, Missouri, United States

Good Samaritan Regional Health Center; 🇺🇸 Mount Vernon, Illinois, United States

Henry Ford Medical Center-Columbus; 🇺🇸 Novi, Michigan, United States

Mercy Clinic-Rolla-Cancer and Hematology; 🇺🇸 Rolla, Missouri, United States

Heartland Regional Medical Center; 🇺🇸 Saint Joseph, Missouri, United States

Delbert Day Cancer Institute at PCRMC; 🇺🇸 Rolla, Missouri, United States

CoxHealth South Hospital; 🇺🇸 Springfield, Missouri, United States

Kalispell Regional Medical Center; 🇺🇸 Kalispell, Montana, United States

Community Medical Hospital; 🇺🇸 Missoula, Montana, United States

Diagnostic and Treatment Center; 🇺🇸 Weston, Wisconsin, United States

Sanford Bismarck Medical Center; 🇺🇸 Bismarck, North Dakota, United States

Marshfield Medical Center-Marshfield; 🇺🇸 Marshfield, Wisconsin, United States

Marshfield Clinic Stevens Point Center; 🇺🇸 Stevens Point, Wisconsin, United States

Marshfield Clinic-Wausau Center; 🇺🇸 Wausau, Wisconsin, United States

Northwestern University; 🇺🇸 Chicago, Illinois, United States

Rush University Medical Center; 🇺🇸 Chicago, Illinois, United States

University of Pittsburgh Cancer Institute (UPCI); 🇺🇸 Pittsburgh, Pennsylvania, United States

Massachusetts General Hospital Cancer Center; 🇺🇸 Boston, Massachusetts, United States

Banner University Medical Center - Tucson; 🇺🇸 Tucson, Arizona, United States

University of Arizona Cancer Center-North Campus; 🇺🇸 Tucson, Arizona, United States

Mercy Hospital Fort Smith; 🇺🇸 Fort Smith, Arkansas, United States

Memorial Sloan Kettering Bergen; 🇺🇸 Montvale, New Jersey, United States

University of Miami Miller School of Medicine-Sylvester Cancer Center; 🇺🇸 Miami, Florida, United States

University of Cincinnati Cancer Center-UC Medical Center; 🇺🇸 Cincinnati, Ohio, United States

Olathe Health Cancer Center; 🇺🇸 Olathe, Kansas, United States

University of Kansas Cancer Center; 🇺🇸 Kansas City, Kansas, United States

Central Care Cancer Center - Garden City; 🇺🇸 Garden City, Kansas, United States

University of Kansas Cancer Center-Overland Park; 🇺🇸 Overland Park, Kansas, United States

Lawrence Memorial Hospital; 🇺🇸 Lawrence, Kansas, United States

Welch Cancer Center; 🇺🇸 Sheridan, Wyoming, United States

Sanford Roger Maris Cancer Center; 🇺🇸 Fargo, North Dakota, United States

Central Care Cancer Center - Great Bend; 🇺🇸 Great Bend, Kansas, United States

University of Kansas Hospital-Westwood Cancer Center; 🇺🇸 Westwood, Kansas, United States

Sanford Broadway Medical Center; 🇺🇸 Fargo, North Dakota, United States

University of Kansas Health System Saint Francis Campus; 🇺🇸 Topeka, Kansas, United States

Ascension Via Christi - Pittsburg; 🇺🇸 Pittsburg, Kansas, United States

Salina Regional Health Center; 🇺🇸 Salina, Kansas, United States

University of Rochester; 🇺🇸 Rochester, New York, United States

Washington University School of Medicine; 🇺🇸 Saint Louis, Missouri, United States

Wayne State University/Karmanos Cancer Institute; 🇺🇸 Detroit, Michigan, United States

Henry Ford Hospital; 🇺🇸 Detroit, Michigan, United States

University of Oklahoma Health Sciences Center; 🇺🇸 Oklahoma City, Oklahoma, United States

Mercy Hospital Oklahoma City; 🇺🇸 Oklahoma City, Oklahoma, United States

University of Arizona Cancer Center-Orange Grove Campus; 🇺🇸 Tucson, Arizona, United States

UC San Diego Moores Cancer Center; 🇺🇸 La Jolla, California, United States

Stanford Cancer Institute Palo Alto; 🇺🇸 Palo Alto, California, United States

VA Palo Alto Health Care System; 🇺🇸 Palo Alto, California, United States

UM Sylvester Comprehensive Cancer Center at Coral Gables; 🇺🇸 Coral Gables, Florida, United States

Emory Proton Therapy Center; 🇺🇸 Atlanta, Georgia, United States

Emory University Hospital Midtown; 🇺🇸 Atlanta, Georgia, United States

Saint Alphonsus Cancer Care Center-Boise; 🇺🇸 Boise, Idaho, United States

Kootenai Health - Coeur d'Alene; 🇺🇸 Coeur d'Alene, Idaho, United States

Saint Alphonsus Cancer Care Center-Caldwell; 🇺🇸 Caldwell, Idaho, United States

Kootenai Clinic Cancer Services - Post Falls; 🇺🇸 Post Falls, Idaho, United States

Rush - Copley Medical Center; 🇺🇸 Aurora, Illinois, United States

Carle on Vermilion; 🇺🇸 Danville, Illinois, United States

NorthShore University HealthSystem-Highland Park Hospital; 🇺🇸 Highland Park, Illinois, United States

Carle Physician Group-Effingham; 🇺🇸 Effingham, Illinois, United States

Carle Cancer Center; 🇺🇸 Urbana, Illinois, United States

The Carle Foundation Hospital; 🇺🇸 Urbana, Illinois, United States

Saint Anthony Regional Hospital; 🇺🇸 Carroll, Iowa, United States

Iowa Methodist Medical Center; 🇺🇸 Des Moines, Iowa, United States

Broadlawns Medical Center; 🇺🇸 Des Moines, Iowa, United States

Medical Oncology and Hematology Associates-Des Moines; 🇺🇸 Des Moines, Iowa, United States

Iowa Lutheran Hospital; 🇺🇸 Des Moines, Iowa, United States

Methodist West Hospital; 🇺🇸 West Des Moines, Iowa, United States

Henry Ford Medical Center-Fairlane; 🇺🇸 Dearborn, Michigan, United States

Henry Ford Macomb Hospital-Clinton Township; 🇺🇸 Clinton Township, Michigan, United States

Henry Ford Cancer Institute-Downriver; 🇺🇸 Brownstown, Michigan, United States

Weisberg Cancer Treatment Center; 🇺🇸 Farmington Hills, Michigan, United States

Allegiance Health; 🇺🇸 Jackson, Michigan, United States

Sanford Joe Lueken Cancer Center; 🇺🇸 Bemidji, Minnesota, United States

Henry Ford Macomb Health Center - Shelby Township; 🇺🇸 Shelby, Michigan, United States

Henry Ford West Bloomfield Hospital; 🇺🇸 West Bloomfield, Michigan, United States

Saint Louis Cancer and Breast Institute-Ballwin; 🇺🇸 Ballwin, Missouri, United States

Central Care Cancer Center - Bolivar; 🇺🇸 Bolivar, Missouri, United States

Siteman Cancer Center at West County Hospital; 🇺🇸 Creve Coeur, Missouri, United States

Freeman Health System; 🇺🇸 Joplin, Missouri, United States

University of Kansas Cancer Center at North Kansas City Hospital; 🇺🇸 North Kansas City, Missouri, United States

Mercy Hospital South; 🇺🇸 Saint Louis, Missouri, United States

Siteman Cancer Center-South County; 🇺🇸 Saint Louis, Missouri, United States

Siteman Cancer Center at Christian Hospital; 🇺🇸 Saint Louis, Missouri, United States

Siteman Cancer Center at Saint Peters Hospital; 🇺🇸 Saint Peters, Missouri, United States

Mercy Hospital Saint Louis; 🇺🇸 Saint Louis, Missouri, United States

Benefis Healthcare- Sletten Cancer Institute; 🇺🇸 Great Falls, Montana, United States

Billings Clinic Cancer Center; 🇺🇸 Billings, Montana, United States

Great Falls Clinic; 🇺🇸 Great Falls, Montana, United States

Northwell Health Imbert Cancer Center; 🇺🇸 Bay Shore, New York, United States

Memorial Sloan Kettering Basking Ridge; 🇺🇸 Basking Ridge, New Jersey, United States

Memorial Sloan Kettering Monmouth; 🇺🇸 Middletown, New Jersey, United States

Montefiore Medical Center - Moses Campus; 🇺🇸 Bronx, New York, United States

Long Island Jewish Medical Center; 🇺🇸 New Hyde Park, New York, United States

Northwell Health/Center for Advanced Medicine; 🇺🇸 Lake Success, New York, United States

Montefiore Medical Center-Weiler Hospital; 🇺🇸 Bronx, New York, United States

Roswell Park Cancer Institute; 🇺🇸 Buffalo, New York, United States

Mount Sinai Hospital; 🇺🇸 New York, New York, United States

Lenox Hill Hospital; 🇺🇸 New York, New York, United States

Memorial Sloan Kettering Cancer Center; 🇺🇸 New York, New York, United States

University of Cincinnati Cancer Center-West Chester; 🇺🇸 West Chester, Ohio, United States

UPMC Cancer Centers - Arnold Palmer Pavilion; 🇺🇸 Greensburg, Pennsylvania, United States

UPMC Pinnacle Cancer Center/Community Osteopathic Campus; 🇺🇸 Harrisburg, Pennsylvania, United States

UPMC-Heritage Valley Health System Beaver; 🇺🇸 Beaver, Pennsylvania, United States

UPMC Jameson; 🇺🇸 New Castle, Pennsylvania, United States

Thomas Jefferson University Hospital; 🇺🇸 Philadelphia, Pennsylvania, United States

UPMC-Presbyterian Hospital; 🇺🇸 Pittsburgh, Pennsylvania, United States

UPMC-Shadyside Hospital; 🇺🇸 Pittsburgh, Pennsylvania, United States

UPMC-Passavant Hospital; 🇺🇸 Pittsburgh, Pennsylvania, United States

Sanford Cancer Center Oncology Clinic; 🇺🇸 Sioux Falls, South Dakota, United States

UPMC Washington Hospital Radiation Oncology; 🇺🇸 Washington, Pennsylvania, United States

Parkland Memorial Hospital; 🇺🇸 Dallas, Texas, United States

Sanford USD Medical Center - Sioux Falls; 🇺🇸 Sioux Falls, South Dakota, United States

UT Southwestern/Simmons Cancer Center-Dallas; 🇺🇸 Dallas, Texas, United States

UT Southwestern Clinical Center at Richardson/Plano; 🇺🇸 Richardson, Texas, United States

Inova Fairfax Hospital; 🇺🇸 Falls Church, Virginia, United States

Marshfield Medical Center-EC Cancer Center; 🇺🇸 Eau Claire, Wisconsin, United States

Inova Schar Cancer Institute; 🇺🇸 Fairfax, Virginia, United States

Marshfield Clinic-Minocqua Center; 🇺🇸 Minocqua, Wisconsin, United States

Marshfield Medical Center-Rice Lake; 🇺🇸 Rice Lake, Wisconsin, United States

Marshfield Medical Center - Weston; 🇺🇸 Weston, Wisconsin, United States

Mercy Hospital Springfield; 🇺🇸 Springfield, Missouri, United States

Smilow Cancer Center/Yale-New Haven Hospital; 🇺🇸 New Haven, Connecticut, United States

Moffitt Cancer Center; 🇺🇸 Tampa, Florida, United States

Yale University; 🇺🇸 New Haven, Connecticut, United States

Moffitt Cancer Center-International Plaza; 🇺🇸 Tampa, Florida, United States

Moffitt Cancer Center - McKinley Campus; 🇺🇸 Tampa, Florida, United States

The James Graham Brown Cancer Center at University of Louisville; 🇺🇸 Louisville, Kentucky, United States

University of Michigan Comprehensive Cancer Center; 🇺🇸 Ann Arbor, Michigan, United States

Medical College of Wisconsin; 🇺🇸 Milwaukee, Wisconsin, United States

University of Kansas Cancer Center - North; 🇺🇸 Kansas City, Missouri, United States

UNC Lineberger Comprehensive Cancer Center; 🇺🇸 Chapel Hill, North Carolina, United States

Montefiore Medical Center-Einstein Campus; 🇺🇸 Bronx, New York, United States

Idaho Urologic Institute-Meridian; 🇺🇸 Meridian, Idaho, United States

Bozeman Deaconess Hospital; 🇺🇸 Bozeman, Montana, United States