Breast-Conserving Surgery and Radiation Therapy in Patients With Multiple Ipsilateral Breast Cancer

Phase 2

Completed

Conditions: Breast Cancer

Interventions: Procedure: therapeutic conventional surgery
Radiation: whole breast irradiation

Registration Number: NCT01556243

Lead Sponsor: Alliance for Clinical Trials in Oncology

Brief Summary: RATIONALE: Breast-conserving surgery is a less invasive type of surgery for breast cancer and may have fewer side effects and improve recovery. Radiation therapy uses high-energy x rays to kill tumor cells. Giving radiation therapy after surgery may kill any tumor cells that remain after surgery.

PURPOSE: This phase II trial studies how well breast-conserving surgery and radiation therapy work in treating patients with multiple ipsilateral breast cancer

Detailed Description: OBJECTIVES:

Primary

* To assess the local recurrence (LR) rate with breast-conservation in patients with multiple ipsilateral primary breast cancer (MIBC).

Secondary

* To examine the conversion rate to mastectomy secondary to persistent positive margins; poor cosmesis within the first year of attempting breast-conservation surgery (BCS) or inability to satisfy the radiation dose constraints on the boost to the lumpectomy bed of each site of disease.

* To assess whether patients who did not undergo re-excision for close margins (\< 2 mm) have a higher local recurrence (LR) rate than patients for whom negative margins were achieved.

* To assess patient's perception of cosmesis and incidence of breast lymphedema.

* To assess incidence of breast lymphedema

* To examine the type and severity of adverse effects of breast conserving surgery and radiation for women with multiple ipsilateral primary breast cancer (MIBC).

* To examine the radiation-related side effects of whole-breast radiation with a boost to 1 large or \> 1 lumpectomy site.

OUTLINE: This is a multicenter study.

Patients undergo breast-conserving surgery (BCS) with all lesions resected to negative margins using 1 lumpectomy or 2-3 separate lumpectomy incisions at the discretion of the surgeon. Patients receive adjuvant chemotherapy and/or endocrine therapy at the discretion of the treating medical oncologist based on tumor characteristics.

Recruitment & Eligibility

Status: COMPLETED

Sex: Female

Target Recruitment: 270

Inclusion Criteria

Age ≥ 40 years per National Comprehensive Cancer Network (NCCN) recommendations for breast conservation.
Life Expectancy of at least 5 years, excluding diagnosis of breast cancer (Comorbid conditions should be taken into consideration, but breast cancer diagnosis is not a consideration)
Female Gender - Men are excluded from this study. Male breast cancer is a rare event.

Men are rarely candidates for breast conservation surgery due to small breast size. Men are less likely to be candidates for breast conservation surgery if found to have MIBC.

Men are rarely candidates for breast conservation surgery due to small breast size. Men are less likely to be candidates for breast conservation surgery if found to have MIBC.
Foci of Breast Cancer

4.1 Upon clinical exam and pre-operative imaging by mammogram +/- MRI, two or three foci of biopsy proven breast cancer separated by > 2 cm of normal breast tissue.

4.2 Foci must include at least one focus of invasive breast carcinoma with another focus of either invasive breast carcinoma or ductal carcinoma in situ (DCIS).

No more than 2 quadrants with biopsy proven breast cancer.

4.3 Note: The shortest distance between lesions must be reported on mammogram +/- MRI and eligibility criteria must be met on both, if both are obtained.

4.4 Note: Patient is eligible for study if lesion is not visualized on all imaging modalities (i.e., any of the lesion(s) is/are visualized on MRI but not on mammogram OR visualized on mammogram but not on MRI).

4.5 Ultrasound cannot be used to determine patient eligibility; eligibility to be determined by bilateral mammogram +/- MRI only.

4.6 Fine needle aspirate of the second or third lesion to document malignancy is allowed if the first focus is shown to be invasive by core needle biopsy.

4.7 Patient may remain on study if, upon pathological assessment, two or three lesions identified on pre-operative imaging represent one contiguous lesion.
Patients may be registered AFTER surgery and PRIOR TO radiation therapy if either of the criteria is met:

5.1 An area of atypia > 2cm from the index lesion excised at the time of cancer operation is upgraded to DCIS or invasive carcinoma thereby identifying MIBC. OR

5.2 Patient underwent resection of two or three foci of malignancy by breast conservation surgery with a minimum of one invasive focus of breast cancer and a minimum of 2 cm of normal breast tissue between the lesions on final pathology.
Mammogram Imaging - Bilateral mammogram ≤ 90 days prior to date of surgery.

6.1 Note: For patients undergoing more than 1 breast operation, this is the date of the first breast surgery for breast cancer treatment.
Staging of Cancer - cN0 or cN1 disease
ECOG Performance Status (PS) - 0, 1, or 2.
Ability to Complete Questionnaires - Ability to complete questionnaire(s) by themselves or with assistance
Ability to Provide Written Informed Consent
Willing to Return to Enrolling Institution - Willing to return to enrolling institution for follow-up during the Active Monitoring Phase (the active treatment and observation portions) of the study. Patients are encouraged to return to the enrolling institution; however, patients may receive radiation therapy at a different institution other than the enrolling institution.

Registration

Exclusion Criteria

Pregnancy, Nursing and Requirement for Contraception - Pregnant women, nursing women and women of childbearing potential who are unwilling to employ adequate contraception (as determined by the treating physician) are excluded from participation.

This study involves radiation therapy (WBI) that has known genotoxic, mutagenic and teratogenic effects.
Size of Single Focus of Disease on Preoperative Imaging - Largest single focus of disease > 5 centimeters by either mammogram or MRI or both. Note: Measurement of the largest single focus should include any satellite lesions within 1 centimeter of the index lesion.
Prior Staging Procedure - Surgical axillary staging procedure prior to first definitive breast operation. Note: FNA or core needle biopsy of axillary node is permitted.
Evidence of Metastatic Disease - Clinical or radiographic evidence of metastatic disease
Prior History of Breast Cancer - Prior history of ipsilateral breast cancer [DCIS, LCIS (lobular cancer in situ) or invasive]
Staging of Cancer - cNX, cN2, or cN3 disease
Breast Implants - Breast implants at time of diagnosis. Note: Patients who have had implants previously removed prior to diagnosis are eligible.
Systemic Illnesses or Concurrent Disease - Co-morbid systemic illnesses or other severe concurrent disease which, in the judgment of the investigator, would interfere significantly with whole breast irradiation (such as connective tissue disorders, lupus, scleroderma).
Uncontrolled Intercurrent Illness - Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.
Bilateral Breast Cancer - Prior or current LCIS, DCIS or invasive breast cancer in the opposite breast (i.e., bilateral disease is not allowed).
Disallowed Prior Treatments - Treatment including radiation therapy, chemotherapy, biotherapy, hormonal therapy for this cancer prior to surgery (i.e., any neoadjuvant chemotherapy or endocrine therapy is not allowed). Patients who undergo surgical resection with breast conservation and then are treated with adjuvant systemic therapy are eligible to enroll prior to the start of radiotherapy.
Partial Breast Radiation - Planned partial breast radiation.
Known BRCA Mutations - Patients with known BRCA mutations. Patients who are not tested or whose testing result is not returned at the time of registration are not excluded from registering to this study.
Other Active Malignancies - Other active malignancy ≤ 5 years prior to registration.

14.1 Exceptions: Non-melanotic skin cancer or carcinoma-in-situ of the cervix.

14.2 Note: If there is a history of prior malignancy, they must not be receiving other specific treatment for their cancer.

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Breast conservation surgery and radiation therapy	whole breast irradiation	Patients undergo breast conserving surgery. Patients receive adjuvant chemotherapy at the physician's discretion. Patients receiving chemotherapy will start treatment within 12 weeks following surgery. Patients receive radiation therapy within 8 weeks following the last dose of chemotherapy or within 10 weeks following surgery if not receiving chemotherapy. Patients receive endocrine therapy at the physician's discretion. Patient observation will occur every 6 months until 5 years after the end of radiation therapy.
Breast conservation surgery and radiation therapy	therapeutic conventional surgery	Patients undergo breast conserving surgery. Patients receive adjuvant chemotherapy at the physician's discretion. Patients receiving chemotherapy will start treatment within 12 weeks following surgery. Patients receive radiation therapy within 8 weeks following the last dose of chemotherapy or within 10 weeks following surgery if not receiving chemotherapy. Patients receive endocrine therapy at the physician's discretion. Patient observation will occur every 6 months until 5 years after the end of radiation therapy.

Primary Outcome Measures

Name	Time	Method
Local Recurrence	5 years	Local recurrence(LR) defined as histologic evidence of ductal carcinoma in situ or invasive breast cancer in the ipsilateral breast or chest wall assessed up to 5 years. The estimated 5-year cumulative incidence of LR will be reported as a percentage of patients expected to experience a LR at 5 years.

Secondary Outcome Measures

Name	Time	Method
Type and Severity of Adverse Effects of Breast-conserving Surgery and Radiation as Assessed by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0	Up to 30 days post-treatment
Radiation-related Side Effects	17 months	Radiation-related side effects of whole-breast radiation with a boost to 1 large or \> 1 lumpectomy site as assessed by NCI CTCAE version 4.0.
Conversion Rate to Mastectomy	5 years	The conversion rate to mastectomy secondary to persistent positive margins; poor cosmesis within the first year of attempting BCS; or inability to satisfy the radiation dose constraints on the boost to the lumpectomy bed of each site of disease.
Patient's Perception of Cosmesis	24 months	Patient's perception of cosmesis will be assessed at their initial post-operative visit as well as 24 months following completion of WBI using the BREAST-Q subscales: satisfaction with breasts, satisfaction with overall outcome, and physical well-being. Patients registered after surgery will not partake in the pre-operative assessment but will be asked to complete subsequent cosmesis surveys. The total score for each of these subscales will be determined using the BREAST-Q scoring module (http://www.mskcc.org/mskcc/shared/Breast-Q/scoreBQ.html). The BREAST-Q has multiple domains, and each domain score is obtained by transforming the raw scale item responses with the Q-Score software program. Each domain results in an independent score from 0 to 100 (higher scores indicate greater satisfaction or quality of life).

Trial Locations

Locations (350): Cedars-Sinai Medical Center
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Los Angeles, California, United States
Mount Carmel Health Center West
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Columbus, Ohio, United States
The Mark H Zangmeister Center
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Columbus, Ohio, United States
Knox Community Hospital
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Mount Vernon, Ohio, United States
University of Illinois
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Chicago, Illinois, United States
CHI Health Good Samaritan
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Kearney, Nebraska, United States
Morton Plant Hospital
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Clearwater, Florida, United States
Saint Agnes Hospital
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Baltimore, Maryland, United States
Regional Hematology and Oncology PA
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Newark, Delaware, United States
Dana-Farber/Brigham and Women's Cancer Center at South Shore
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South Weymouth, Massachusetts, United States
Genesys Hurley Cancer Institute
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Flint, Michigan, United States
CHI Health Saint Francis
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Grand Island, Nebraska, United States
Cancer and Blood Specialists-Henderson
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Henderson, Nevada, United States
Dartmouth Hitchcock Medical Center
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Lebanon, New Hampshire, United States
Memorial Hospital
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Chattanooga, Tennessee, United States
Memorial Sloan Kettering Cancer Center-Basking Ridge
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Basking Ridge, New Jersey, United States
North Shore University Hospital
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Manhasset, New York, United States
Levine Cancer Institute-Rock Hill
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Rock Hill, South Carolina, United States
Lexington Medical Center
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West Columbia, South Carolina, United States
Gundersen Lutheran Medical Center
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La Crosse, Wisconsin, United States
University of Vermont College of Medicine
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Burlington, Vermont, United States
Virginia Mason Medical Center
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Seattle, Washington, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
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Miami, Florida, United States
Naval Medical Center-San Diego
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San Diego, California, United States
University Medical Center of Southern Nevada
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Las Vegas, Nevada, United States
Nevada Cancer Research Foundation NCORP
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Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Central
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Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Maryland Parkway
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Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-San Martin
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Las Vegas, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
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Las Vegas, Nevada, United States
Cancer Therapy and Integrative Medicine
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Las Vegas, Nevada, United States
Cancer and Blood Specialists-Tenaya
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Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
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Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
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Las Vegas, Nevada, United States
Good Samaritan Hospital-Cincinnati
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Cincinnati, Ohio, United States
Las Vegas Cancer Center-Medical Center
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Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Centennial Hills
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Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Central Valley
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Las Vegas, Nevada, United States
University of Cincinnati
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Cincinnati, Ohio, United States
Memorial Medical Center
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Springfield, Illinois, United States
Valley Radiation Oncology
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Peru, Illinois, United States
Bronson Battle Creek
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Battle Creek, Michigan, United States
Hurley Medical Center
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Flint, Michigan, United States
Eastern Maine Medical Center
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Bangor, Maine, United States
Mercy Health Saint Mary's
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Grand Rapids, Michigan, United States
Radiation Oncology of Northern Illinois
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Ottawa, Illinois, United States
Sinai Hospital of Baltimore
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Baltimore, Maryland, United States
William Beaumont Hospital-Royal Oak
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Royal Oak, Michigan, United States
Dana-Farber Cancer Institute
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Boston, Massachusetts, United States
Flaget Memorial Hospital
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Bardstown, Kentucky, United States
Mercy Medical Center-West Lakes
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West Des Moines, Iowa, United States
Eastern Maine Medical Center Cancer Care
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Brewer, Maine, United States
William Beaumont Hospital-Troy
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Troy, Michigan, United States
Allegiance Health
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Jackson, Michigan, United States
Saint Mary Mercy Hospital
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Livonia, Michigan, United States
Liberty Radiation Oncology Center
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Liberty, Missouri, United States
Sparrow Hospital
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Lansing, Michigan, United States
Saint James Community Hospital and Cancer Treatment Center
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Butte, Montana, United States
Washington University School of Medicine
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Saint Louis, Missouri, United States
Sainte Genevieve County Memorial Hospital
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Sainte Genevieve, Missouri, United States
Montana Cancer Consortium NCORP
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Billings, Montana, United States
Benefis Healthcare-Sletten Cancer Institute
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Great Falls, Montana, United States
Bozeman Deaconess Hospital
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Bozeman, Montana, United States
Saint Vincent Healthcare
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Billings, Montana, United States
Saint Elizabeth Regional Medical Center
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Lincoln, Nebraska, United States
The Christ Hospital
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Cincinnati, Ohio, United States
Levine Cancer Institute-Tryon
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Charlotte, North Carolina, United States
Carolinas Medical Center/Levine Cancer Institute-University
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Charlotte, North Carolina, United States
Memorial Sloan Kettering Cancer Center-Rockville Centre
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Rockville Centre, New York, United States
Columbus NCI Community Oncology Research Program
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Columbus, Ohio, United States
Carolinas Medical Center/Levine Cancer Institute
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Charlotte, North Carolina, United States
21st Century Oncology
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Las Vegas, Nevada, United States
Memorial Sloan Kettering Cancer Center-Commack
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Commack, New York, United States
Vassar Brothers Medical Center
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Poughkeepsie, New York, United States
Levine Cancer Institute-Ballantyne
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Charlotte, North Carolina, United States
North Shore-LIJ Health System/Center for Advanced Medicine
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New Hyde Park, New York, United States
Comprehensive Cancer Centers of Nevada-Northwest
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Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Tenaya
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Las Vegas, Nevada, United States
CaroMont Breast Surgical Specialists-Gastonia
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Gastonia, North Carolina, United States
Carolinas HealthCare System Union
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Monroe, North Carolina, United States
Oncology Specialists of Charlotte
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Charlotte, North Carolina, United States
Memorial Sloan Kettering Cancer Center-West Harrison
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Harrison, New York, United States
Saint Peter's University Hospital
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New Brunswick, New Jersey, United States
Memorial Sloan Kettering Cancer Center
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New York, New York, United States
Memorial Sloan Kettering Cancer Center-Sleepy Hollow
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Sleepy Hollow, New York, United States
Randolph Hospital
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Asheboro, North Carolina, United States
CaroMont Regional Medical Center
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Gastonia, North Carolina, United States
Grant Medical Center
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Columbus, Ohio, United States
TriHealth Cancer Institute-Westside
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Cincinnati, Ohio, United States
Delaware Radiation Oncology
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Delaware, Ohio, United States
Saint Ann's Hospital
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Westerville, Ohio, United States
Fairfield Medical Center
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Lancaster, Ohio, United States
Doctors Hospital
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Columbus, Ohio, United States
Central Vermont Medical Center
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Berlin, Vermont, United States
Marietta Memorial Hospital
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Marietta, Ohio, United States
Licking Memorial Hospital
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Newark, Ohio, United States
Newark Radiation Oncology
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Newark, Ohio, United States
UT Southwestern/Simmons Cancer Center-Dallas
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Dallas, Texas, United States
M. D. Anderson Cancer Center
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Houston, Texas, United States
Pulmonary Medicine Center of Chattanooga-Hixson
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Hixson, Tennessee, United States
Avera Cancer Institute
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Sioux Falls, South Dakota, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
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Poulsbo, Washington, United States
Memorial GYN Plus
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Ooltewah, Tennessee, United States
Green Bay Oncology at Saint Vincent Hospital
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Green Bay, Wisconsin, United States
Lehigh Valley Hospital-Muhlenberg
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Bethlehem, Pennsylvania, United States
Hennepin County Medical Center
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Minneapolis, Minnesota, United States
Huntsman Cancer Institute/University of Utah
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Salt Lake City, Utah, United States
Contra Costa Regional Medical Center
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Martinez, California, United States
Stanford Cancer Institute
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Palo Alto, California, United States
Crossroads Cancer Center
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Effingham, Illinois, United States
Centralia Oncology Clinic
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Centralia, Illinois, United States
Cancer Care Specialists of Central Illinois
🇺🇸
Decatur, Illinois, United States
Decatur Memorial Hospital
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Decatur, Illinois, United States
Ingalls Memorial Hospital
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Harvey, Illinois, United States
Illinois CancerCare-Eureka
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Eureka, Illinois, United States
Illinois CancerCare-Galesburg
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Galesburg, Illinois, United States
Illinois CancerCare-Kewanee Clinic
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Kewanee, Illinois, United States
OSF Saint Francis Radiation Oncology at Pekin Cancer Treatment Center
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Pekin, Illinois, United States
Illinois CancerCare-Ottawa Clinic
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Ottawa, Illinois, United States
Illinois CancerCare-Macomb
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Macomb, Illinois, United States
Methodist Medical Center of Illinois
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Peoria, Illinois, United States
Illinois CancerCare-Peru
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Peru, Illinois, United States
Illinois CancerCare-Princeton
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Princeton, Illinois, United States
Indiana University-Melvin and Bren Simon Cancer Center
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Indianapolis, Indiana, United States
IU Health Methodist Hospital
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Indianapolis, Indiana, United States
Sidney and Lois Eskenazi Hospital
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Indianapolis, Indiana, United States
Saint Joseph Regional Medical Center-Mishawaka
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Mishawaka, Indiana, United States
Michiana Hematology Oncology PC-South Bend
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South Bend, Indiana, United States
McFarland Clinic PC-Boone
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Boone, Iowa, United States
Saint Elizabeth Medical Center South
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Edgewood, Kentucky, United States
Saint Elizabeth-Fort Thomas
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Fort Thomas, Kentucky, United States
Jewish Hospital Medical Center South
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Shepherdsville, Kentucky, United States
Research Medical Center
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Kansas City, Missouri, United States
Centerpoint Medical Center LLC
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Independence, Missouri, United States
Saint Luke's East-Lee's Summit
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Lee's Summit, Missouri, United States
Novant Health Presbyterian Medical Center
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Charlotte, North Carolina, United States
Carolina Surgical Clinic of Charlotte PA
🇺🇸
Charlotte, North Carolina, United States
Carolinas Medical Center/Levine Cancer Institute-Pineville
🇺🇸
Charlotte, North Carolina, United States
Matthews Radiation Oncology Center
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Matthews, North Carolina, United States
Cone Health Cancer Center
🇺🇸
Greensboro, North Carolina, United States
Novant Health Cancer Specialists-Matthews
🇺🇸
Matthews, North Carolina, United States
Bethesda North Hospital
🇺🇸
Cincinnati, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸
Cincinnati, Ohio, United States
Mount Carmel East Hospital
🇺🇸
Columbus, Ohio, United States
Riverside Methodist Hospital
🇺🇸
Columbus, Ohio, United States
OhioHealth MedCentral Hospital
🇺🇸
Mansfield, Ohio, United States
Delaware Health Center-Grady Cancer Center
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Delaware, Ohio, United States
Grady Memorial Hospital
🇺🇸
Delaware, Ohio, United States
Springfield Regional Medical Center
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Springfield, Ohio, United States
OhioHealth Marion General Hospital
🇺🇸
Marion, Ohio, United States
University Pointe
🇺🇸
West Chester, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸
Zanesville, Ohio, United States
University of Pittsburgh Cancer Institute (UPCI)
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Pittsburgh, Pennsylvania, United States
Roger Williams Medical Center
🇺🇸
Providence, Rhode Island, United States
Texas Tech University Health Sciences Center-Amarillo
🇺🇸
Amarillo, Texas, United States
Bryn Mawr Hospital
🇺🇸
Bryn Mawr, Pennsylvania, United States
The Methodist Hospital System
🇺🇸
Houston, Texas, United States
Harrison HealthPartners Hematology and Oncology-Bremerton
🇺🇸
Bremerton, Washington, United States
Doctor's Hospital of Laredo
🇺🇸
Laredo, Texas, United States
Saint Elizabeth Hospital
🇺🇸
Enumclaw, Washington, United States
Mary Washington Hospital
🇺🇸
Fredericksburg, Virginia, United States
Saint Clare Hospital
🇺🇸
Lakewood, Washington, United States
Franciscan Research Center-Northwest Medical Plaza
🇺🇸
Tacoma, Washington, United States
Northwest Medical Specialties PLLC
🇺🇸
Tacoma, Washington, United States
Abbott-Northwestern Hospital
🇺🇸
Minneapolis, Minnesota, United States
Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Regions Hospital
🇺🇸
Saint Paul, Minnesota, United States
Catholic Health Initiatives NCORP
🇺🇸
Englewood, Colorado, United States
Mercy Hospital
🇺🇸
Coon Rapids, Minnesota, United States
Fairview-Southdale Hospital
🇺🇸
Edina, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸
Maplewood, Minnesota, United States
Ridgeview Medical Center
🇺🇸
Waconia, Minnesota, United States
United Hospital
🇺🇸
Saint Paul, Minnesota, United States
Park Nicollet Clinic-Saint Louis Park
🇺🇸
Saint Louis Park, Minnesota, United States
North Memorial Medical Health Center
🇺🇸
Robbinsdale, Minnesota, United States
Health Partners Inc
🇺🇸
Minneapolis, Minnesota, United States
New Ulm Medical Center
🇺🇸
New Ulm, Minnesota, United States
Unity Hospital
🇺🇸
Fridley, Minnesota, United States
Saint John's Hospital-Healtheast
🇺🇸
Maplewood, Minnesota, United States
Billings Clinic-Cody
🇺🇸
Cody, Wyoming, United States
Menorah Medical Center
🇺🇸
Overland Park, Kansas, United States
Minnesota Oncology and Hematology PA-Woodbury
🇺🇸
Woodbury, Minnesota, United States
Kansas City NCI Community Oncology Research Program
🇺🇸
Prairie Village, Kansas, United States
Rice Memorial Hospital
🇺🇸
Willmar, Minnesota, United States
Metro Minnesota Community Oncology Research Consortium
🇺🇸
Saint Louis Park, Minnesota, United States
Welch Cancer Center
🇺🇸
Sheridan, Wyoming, United States
Coborn Cancer Center at Saint Cloud Hospital
🇺🇸
Saint Cloud, Minnesota, United States
Lakeview Hospital
🇺🇸
Stillwater, Minnesota, United States
Big Horn Basin Cancer Center
🇺🇸
Cody, Wyoming, United States
Oncare Hawaii, Incorporated-Pali Momi
🇺🇸
'Aiea, Hawaii, United States
Pali Momi Medical Center
🇺🇸
'Aiea, Hawaii, United States
Saint John Hospital and Medical Center
🇺🇸
Detroit, Michigan, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Mercy Hospital Oklahoma City
🇺🇸
Oklahoma City, Oklahoma, United States
Mayo Clinic Cancer Center
🇺🇸
Rochester, Minnesota, United States
Alegent Health Immanuel Medical Center
🇺🇸
Omaha, Nebraska, United States
Hematology and Oncology Consultants PC
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸
Omaha, Nebraska, United States
Froedtert and the Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
Aurora Sinai Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Fairview Ridges Hospital
🇺🇸
Burnsville, Minnesota, United States
University of Colorado Cancer Center-Anschutz Cancer Pavilion
🇺🇸
Aurora, Colorado, United States
Saint Joseph Mercy Hospital
🇺🇸
Ann Arbor, Michigan, United States
Greater Regional Medical Center
🇺🇸
Creston, Iowa, United States
Kalispell Regional Medical Center
🇺🇸
Kalispell, Montana, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸
Hot Springs, Arkansas, United States
Epic Care-Dublin
🇺🇸
Dublin, California, United States
Bay Area Breast Surgeons, Incorporated
🇺🇸
Emeryville, California, United States
Cedars Sinai Medical Center
🇺🇸
Los Angeles, California, United States
UC San Diego Moores Cancer Center
🇺🇸
La Jolla, California, United States
Epic Care Partners in Cancer Care
🇺🇸
Emeryville, California, United States
Alta Bates Summit Medical Center-Summit Campus
🇺🇸
Oakland, California, United States
Bay Area Tumor Institute
🇺🇸
Oakland, California, United States
Smilow Cancer Hospital Care Center at Saint Francis
🇺🇸
Hartford, Connecticut, United States
Beebe Medical Center
🇺🇸
Lewes, Delaware, United States
Christiana Gynecologic Oncology LLC
🇺🇸
Newark, Delaware, United States
Delaware Clinical and Laboratory Physicians PA
🇺🇸
Newark, Delaware, United States
Beebe Health Campus
🇺🇸
Rehoboth Beach, Delaware, United States
Helen F. Graham Cancer Center
🇺🇸
Newark, Delaware, United States
Medical Oncology Hematology Consultants PA
🇺🇸
Newark, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸
Newark, Delaware, United States
Nanticoke Memorial Hospital
🇺🇸
Seaford, Delaware, United States
Christiana Care Health System-Wilmington Hospital
🇺🇸
Wilmington, Delaware, United States
Mount Sinai Medical Center
🇺🇸
Miami Beach, Florida, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
The Cancer Center of Hawaii-Leeward
🇺🇸
'Ewa Beach, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸
Lihue, Hawaii, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Kootenai Medical Center
🇺🇸
Coeur d'Alene, Idaho, United States
Kootenai Cancer Center
🇺🇸
Post Falls, Idaho, United States
Saint Joseph Medical Center
🇺🇸
Bloomington, Illinois, United States
Kootenai Cancer Clinic
🇺🇸
Sandpoint, Idaho, United States
Illinois CancerCare-Bloomington
🇺🇸
Bloomington, Illinois, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸
Carbondale, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸
Galesburg, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸
Peoria, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸
Pekin, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸
Peoria, Illinois, United States
Central Illinois Hematology Oncology Center
🇺🇸
Springfield, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸
Springfield, Illinois, United States
IU Health West Hospital
🇺🇸
Avon, Indiana, United States
Springfield Clinic
🇺🇸
Springfield, Illinois, United States
Cancer Care Specialists of Illinois-Swansea
🇺🇸
Swansea, Illinois, United States
IU Health Central Indiana Cancer Centers-Fishers
🇺🇸
Fishers, Indiana, United States
IU Health North Hospital
🇺🇸
Carmel, Indiana, United States
Memorial Regional Cancer Center-Day Road
🇺🇸
Mishawaka, Indiana, United States
Memorial Hospital of South Bend
🇺🇸
South Bend, Indiana, United States
Mary Greeley Medical Center
🇺🇸
Ames, Iowa, United States
McFarland Clinic PC-William R Bliss Cancer Center
🇺🇸
Ames, Iowa, United States
Medical Oncology and Hematology Associates-West Des Moines
🇺🇸
Clive, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸
Clive, Iowa, United States
Alegent Health Mercy Hospital
🇺🇸
Council Bluffs, Iowa, United States
McFarland Clinic PC-Trinity Cancer Center
🇺🇸
Fort Dodge, Iowa, United States
Methodist West Hospital
🇺🇸
West Des Moines, Iowa, United States
McFarland Clinic PC-Jefferson
🇺🇸
Jefferson, Iowa, United States
McFarland Clinic PC-Marshalltown
🇺🇸
Marshalltown, Iowa, United States
Commonwealth Cancer Center-Corbin
🇺🇸
Corbin, Kentucky, United States
Oakwood Hospital and Medical Center
🇺🇸
Dearborn, Michigan, United States
Wayne State University/Karmanos Cancer Institute
🇺🇸
Detroit, Michigan, United States
Spectrum Health at Butterworth Campus
🇺🇸
Grand Rapids, Michigan, United States
Borgess Medical Center
🇺🇸
Kalamazoo, Michigan, United States
Bronson Methodist Hospital
🇺🇸
Kalamazoo, Michigan, United States
West Michigan Cancer Center
🇺🇸
Kalamazoo, Michigan, United States
Munson Medical Center
🇺🇸
Traverse City, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸
Pontiac, Michigan, United States
Saint Mary's of Michigan
🇺🇸
Saginaw, Michigan, United States
Mercy Health Mercy Campus
🇺🇸
Muskegon, Michigan, United States
Saint John Macomb-Oakland Hospital
🇺🇸
Warren, Michigan, United States
Saint Francis Regional Medical Center
🇺🇸
Shakopee, Minnesota, United States
Saint Francis Medical Center
🇺🇸
Cape Girardeau, Missouri, United States
Parkland Health Center-Bonne Terre
🇺🇸
Bonne Terre, Missouri, United States
Southeast Cancer Center
🇺🇸
Cape Girardeau, Missouri, United States
Capital Region Medical Center-Goldschmidt Cancer Center
🇺🇸
Jefferson City, Missouri, United States
Missouri Baptist Medical Center
🇺🇸
Saint Louis, Missouri, United States
Missouri Baptist Outpatient Center-Sunset Hills
🇺🇸
Sunset Hills, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸
Sullivan, Missouri, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Saint Peter's Community Hospital
🇺🇸
Helena, Montana, United States
Community Medical Hospital
🇺🇸
Missoula, Montana, United States
Saint Patrick Hospital-Community Hospital
🇺🇸
Missoula, Montana, United States
Heartland Hematology and Oncology
🇺🇸
Kearney, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸
Omaha, Nebraska, United States
Midlands Community Hospital
🇺🇸
Papillion, Nebraska, United States
Las Vegas Cancer Center-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada-Henderson
🇺🇸
Henderson, Nevada, United States
21st Century Oncology-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada-Southeast Henderson
🇺🇸
Henderson, Nevada, United States
Cancer and Blood Specialists-Shadow
🇺🇸
Las Vegas, Nevada, United States
21st Century Oncology-Fort Apache
🇺🇸
Las Vegas, Nevada, United States
21st Century Oncology-Vegas Tenaya
🇺🇸
Las Vegas, Nevada, United States
Cancer and Blood Specialists-Fort Apache
🇺🇸
Las Vegas, Nevada, United States
Lake Norman Hematology Oncology Specialists-Huntersville
🇺🇸
Huntersville, North Carolina, United States
Southern Oncology Specialists-Huntersville
🇺🇸
Huntersville, North Carolina, United States
Lake Norman Hematology Oncology Specialists-Mooresville
🇺🇸
Mooresville, North Carolina, United States
Strecker Cancer Center-Belpre
🇺🇸
Belpre, Ohio, United States
Annie Penn Memorial Hospital
🇺🇸
Reidsville, North Carolina, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
Columbus Oncology and Hematology Associates Inc
🇺🇸
Columbus, Ohio, United States
Oregon Health and Science University
🇺🇸
Portland, Oregon, United States
Lehigh Valley Hospital-Cedar Crest
🇺🇸
Allentown, Pennsylvania, United States
Hilton Head Regional Medical Center
🇺🇸
Hilton Head Island, South Carolina, United States
Lankenau Medical Center
🇺🇸
Wynnewood, Pennsylvania, United States
Parkland Memorial Hospital
🇺🇸
Dallas, Texas, United States
Norris Cotton Cancer Center-North
🇺🇸
Saint Johnsbury, Vermont, United States
Harrison Medical Center
🇺🇸
Bremerton, Washington, United States
Highline Medical Center-Main Campus
🇺🇸
Burien, Washington, United States
Saint Francis Hospital
🇺🇸
Federal Way, Washington, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸
Green Bay, Wisconsin, United States
Saint Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Saint Mary's Hospital
🇺🇸
Green Bay, Wisconsin, United States
Aurora Saint Luke's Medical Center
🇺🇸
Milwaukee, Wisconsin, United States
Westfields Hospital/Cancer Center of Western Wisconsin
🇺🇸
New Richmond, Wisconsin, United States
Vince Lombardi Cancer Clinic-Oshkosh
🇺🇸
Oshkosh, Wisconsin, United States
Aurora Medical Center in Summit
🇺🇸
Summit, Wisconsin, United States
Aurora West Allis Medical Center
🇺🇸
West Allis, Wisconsin, United States
Jewish Hospital
🇺🇸
Louisville, Kentucky, United States
The James Graham Brown Cancer Center at University of Louisville
🇺🇸
Louisville, Kentucky, United States
Saints Mary and Elizabeth Hospital
🇺🇸
Louisville, Kentucky, United States
Jewish Hospital Medical Center Northeast
🇺🇸
Louisville, Kentucky, United States
Saint Luke's Hospital of Kansas City
🇺🇸
Kansas City, Missouri, United States
Heartland Hematology and Oncology Associates Incorporated
🇺🇸
Kansas City, Missouri, United States
Saint Luke's South Hospital
🇺🇸
Overland Park, Kansas, United States
Aurora BayCare Medical Center
🇺🇸
Green Bay, Wisconsin, United States
Iowa Methodist Medical Center
🇺🇸
Des Moines, Iowa, United States
Oncare Hawaii Inc-POB II
🇺🇸
Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸
Honolulu, Hawaii, United States
OnCare Hawaii, Incorporated-Kuakini
🇺🇸
Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸
Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸
Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸
Honolulu, Hawaii, United States
OnCare Hawaii-Liliha
🇺🇸
Honolulu, Hawaii, United States
Virginia Commonwealth University/Massey Cancer Center
🇺🇸
Richmond, Virginia, United States
Iowa-Wide Oncology Research Coalition NCORP
🇺🇸
Des Moines, Iowa, United States
Medical Oncology and Hematology Associates-Des Moines
🇺🇸
Des Moines, Iowa, United States
Medical Oncology and Hematology Associates-Laurel
🇺🇸
Des Moines, Iowa, United States
Mercy Medical Center-Des Moines
🇺🇸
Des Moines, Iowa, United States
Iowa Lutheran Hospital
🇺🇸
Des Moines, Iowa, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸
Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸
Lexington, Kentucky, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Lovelace Women's Hospital
🇺🇸
Albuquerque, New Mexico, United States
University of Rochester
🇺🇸
Rochester, New York, United States
Southern Oncology Specialists-Charlotte
🇺🇸
Charlotte, North Carolina, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸
Peoria, Illinois, United States
Southern Ohio Medical Center
🇺🇸
Portsmouth, Ohio, United States