Testing Ramipril to Prevent Memory Loss in People With Glioblastoma
- Conditions
- Cognitive DeclineGlioblastomaRadiotherapy; ComplicationsChemoradiation
- Interventions
- Registration Number
- NCT03475186
- Lead Sponsor
- Wake Forest University Health Sciences
- Brief Summary
This study is to determine if an oral drug called Ramipril can lower the chance of memory loss in patients with glioblastoma getting chemoradiation. Patients will take Ramipril during chemoradiation and continue until 4 months post-treatment. Memory loss will be assessed using several neurocognitive tests throughout the duration of the study.
- Detailed Description
This is a pilot study of an oral drug Ramipril to prevent cognitive decline in glioblastoma patients receiving partial brain radiation and concurrent and adjuvant temozolomide . Ramipril will be titrated to the highest tolerable dose during chemoradiation (2.5-5 mg). Once this dose is determined, the patient will continue at this dose for 4 months after the completion of chemoradiation. Patients will be followed until 5 months post chemoradiation for compliance, toxicity, cognitive decline and participant reported outcomes (PRO).
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 75
- Histologically proven diagnosis of glioblastoma or gliosarcoma (World Health Organization [WHO] grade IV) obtained at the time of a partial or gross total resection of the tumor. Patients who undergo a stereotactic needle biopsy alone are not eligible.
- The tumor must have a supratentorial component.
- History/physical examination within 14 days prior to enrollment.
- The patient must have recovered from the effects of surgery, postoperative infection, and other complications before enrollment
- Patient planning to receive brain RT, and concurrent and adjuvant temozolomide chemotherapy for six weeks as per standard of care therapy. Use of the Optune® (also known as Tumor Treating Fields or TTFields) device is allowed at provider discretion, but must begin after the Month 1 Post RT (10 week [wk]) Neurocognitive-PRO assessment.
- Study drug (Ramipril) must be given >= 21 days and ≤ 42 days after surgery.
- All available brain magnetic resonance imaging (MRI) or computed tomography (CT) imaging reports from surgery to study completion must be submitted. This includes any post-operative or pre-radiation scan reports.
- Eastern Cooperative Oncology Group (ECOG) 0, 1 or 2
- Absolute neutrophil count (ANC) >= 1,500 cells/mm^3 (obtained within 14 days prior to enrollment)
- Platelets >= 100,000 cells/mm^3 (obtained within 14 days prior to enrollment)
- Hemoglobin >= 10.0 g/dl (Note: The use of transfusion or other intervention to achieve hemoglobin [Hgb] >= 10.0 g/dl is acceptable) (obtained within 14 days prior to enrollment)
- Blood urea nitrogen (BUN) =< 30 mg/dl within 14 days prior to enrollment
- Creatinine =< 1.7 mg/dl within 14 days prior to enrollment
- Total bilirubin =< 2.0 mg/dl within 14 days prior to enrollment
- Alanine aminotransferase (ALT)/aspartate aminotransferase (AST) =< 3 x normal range within 14 days prior to enrollment
- Patient must provide study specific informed consent prior to study entry
- Baseline potassium level <5.0 mEq/L. High potassium values that are thought to be a result of sample hemolysis may be repeated to determine an accurate potassium level and to determine potential study eligibility. Likewise high potassium values thought to be a result of potassium supplementation may be repeated at an appropriate time (5 half-lives after supplement discontinuation) to determine potential study eligibility.
Patient must be able to complete neurocognitive tests in the English language
- Women of childbearing potential and male participants must practice adequate contraception
- For females of child-bearing potential, negative serum or urine pregnancy test within 14 days of enrollment
- Local site must be follow the standard GBM radiation treatment dosimetry plan
- For patients who will be treated with the Optune® device in addition to standard of care radiation plus concurrent and adjuvant temozolomide, the following inclusion criteria also apply:
- Patients must have only a supratentorial glioblastoma
- The treating physician must be a qualified provider having successfully completed the training course provided by Novocure, the device manufacturer
- Patients with prior malignancies if all treatment for that malignancy was completed at least 2 years before registration and the patient has no evidence of disease.
- Prior allergic reaction or intolerance to angiotensin-converting-enzyme (ACE) inhibitor
- Hypotension (< 110 mg Hg systolic) at the time of enrollment
- Renal insufficiency with creatinine clearance of < 40 ml/min (at time of enrollment)
- Solitary kidney or known renal artery stenosis
- Current ACE inhibitor or angiotensin receptor blocker use. Patients can come off ACE inhibitors or angiotensin receptor blockers for 1 week to be eligible for this study.
- Prior invasive malignancy (except for non-melanomatous skin cancer) unless disease free for ≥ 2 years. (For example, carcinoma in situ of the breast, oral cavity, and cervix are all permissible).
- Recurrent or multifocal malignant gliomas
- Metastases detected below the tentorium or beyond the cranial vault
- Prior chemotherapy or radiosensitizers for cancers of the head and neck region; note that prior chemotherapy for a different cancer is allowable, except prior temozolomide. Prior use of Gliadel wafers or any other intratumoral or intracavitary treatment are not permitted.
- Prior radiotherapy to the head or neck (except for T1 glottic cancer), resulting in overlap of radiation fields.
- Severe active co-morbidity, defined as follows:
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time of enrollment
- Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of enrollment.
- Known HIV positivity or acquired immune deficiency syndrome (AIDS) based upon current CDC definition; note, however, that HIV testing is not required for entry into this protocol. The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive.
- Active connective tissue disorders, such as lupus or scleroderma, that in the opinion of the treating physician may put the patient at high risk for radiation toxicity.
- Any other major medical illnesses or psychiatric impairments that in the investigator's opinion will prevent administration or completion of protocol therapy.
- Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic.
- Patients treated on any other therapeutic clinical protocols within 30 days prior to study entry or during participation in the study unless they involve standard of care or over the counter therapies or do not involve a drug therapy.
- Patients planning to receive therapeutic antitumor agents (excluding use of the Tumor Treating Fields (TTFields or Optune®) device after the Month 1 Post RT (10 wk) Neurocognitive-PRO assessment.) in addition to standard radiation and concurrent and adjuvant temozolomide are not eligible to participate in this study.
- Patients with impaired decision-making capacity; this exclusion is necessary because such patients may not be able to adequately give informed consent.
- Pregnant or lactating women, due to possible adverse effect on the developing fetus or infant due to study drug.
- For patients who will be treated with the Optune® device in addition to standard of care radiation plus concurrent and adjuvant temozolomide, the following exclusion criteria also apply:
- Optune® is not permitted in patients who have an active implanted medical device, skull defect (such as, missing bone with no replacement) or bullet fragments. Examples of active electronic devices include deep brain stimulators, spinal cord stimulators, vagus nerve stimulators, pacemakers, defibrillators, and programmatic shunts.
- Optune® is not permitted in patients who are known to be sensitive to conductive hydrogels. Examples of conductive hydrogels are gels used on electrocardiogram (ECG) stickers or transcutaneous electrical nerve stimulation (TENS) electrodes.
- Patients being treated with Memantine, Donepezil, and/or medications prescribed to enhance cognition.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- SINGLE_GROUP
- Arm && Interventions
Group Intervention Description Ramipril Ramipril Ramipril will be taken once daily by mouth. It will be titrated during the first 3 weeks of chemoradiation to the highest tolerable dose (2.5-5 mg). This dose will be taken each day until 4 months post-chemoradiation treatment (22 weeks).
- Primary Outcome Measures
Name Time Method Change from Baseline Neurocognitive Function at 10 weeks - Hopkins Verbal Learning Test-Revised (HVLT-R) Baseline,10 weeks HVLT-R measures verbal learning and memory. It consists of a 12-item word list which is read to subjects on three successive learning trials. Free recall scores are recorded for each learning trial. Scores for immediate recall (total of three trials), delayed recall (total number of words recalled after 20 minutes), and recognition (total number of words correctly identified) will be the variables derived from the HVLT-R.
Change from Baseline Neurocognitive Function at 10 weeks - Trail Making Test Part A and B (TMT A & B) Baseline,10 weeks Part A of the TMT measures attention and visual motor skills and processing speed and requires subjects to connect 25 numbered circles in the proper sequence (1-2-3-...) as quickly as possible. TMT-B is similar except subjects are required to connect dots in an alternating numerical and alphabetical sequence (1-A-2-B-...). TMT-B with its added complexity and set shifting requirements is a widely used measure of executive function. The score for TMT-A and TMT-B is the total time in seconds required to complete the task. Scores can also be generated for number of errors and number of circles correctly connected.
Change from Baseline Neurocognitive Function at 10 weeks - Controlled Oral Word Association Test (COWA) Baseline,10 weeks The COWA measures speed of mental processing, verbal fluency, and executive function. Subjects are asked to name as many words as possible all beginning with a specified letter. A total of three trials are administered, each with a different letter (F-A-S). The score on the COWA is the total number of words named across the three trials minus repetitions.
Efficacy of Ramipril of Neurocognitive Function at Baseline - Shipley Institute of Living Scale-Version 2 Vocabulary Baseline Provides an assessment of premorbid intellectual functioning comparable to a verbal IQ and thus is a proxy for cognitive reserve. This vocabulary test requires respondents to read a target word and select one of four words that most closely means the same thing. Score is total correct of 40 items and will be used in conjunction with the other neurocognitive results.
Retention Rate at 10 weeks 10 weeks Measured by the percent of patients who took 75% of the Ramipril doses and completed the neurocognitive battery of tests
- Secondary Outcome Measures
Name Time Method Efficacy of Ramipril on Non-Memory Cognitive Functions-EORTC Quality of Life Questionnaire-Core 30/Brain Cancer Module-20 (EORTCQLQ30/BN20) Baseline, 6 weeks, 10 weeks, 22 weeks A 50-item questionnaire with a 20-item brain cancer specific section, used to assess the physical and psychosocial functioning and symptom experience. All of the scales and single-item measures range in score from 0 to 100 with standardization.
Estimate Time of Neurocognitive Decline- HVLT-R Baseline - 22 weeks Measured by the first significant decline of the HVLT-R.
Estimate Time of Neurocognitive Decline- TMT A & B Baseline - 22 weeks Measured by the first significant decline of the TMT A \& B
Estimate Time of Neurocognitive Decline- COWA Baseline - 22 weeks Measured by the first significant decline of the COWA
Determine Presence of Apolipoprotein Epsilon (ApoE) Baseline Measured by quantitative polymerase chain reaction (PCR) using patient serum via a blood test
Efficacy of neurocognitive function in surviving patients- HVLT-R 22 weeks Comparison of HVLT-R results between groups at study end.
Efficacy of neurocognitive function in surviving patients- COWA 22 weeks Comparison of COWA results between groups at study end.
Efficacy of neurocognitive function in surviving patients- EORTCQLQ30/BN20 22 weeks Comparison of EORTCQLQ30/BN20 results between groups at study end.
Efficacy of neurocognitive function in surviving patients- TMT A & B 22 weeks Comparison of TMT A \& B results between groups at study end.
Trial Locations
- Locations (420)
John H Stroger Jr Hospital of Cook County
🇺🇸Chicago, Illinois, United States
Swedish Medical Center-Ballard Campus
🇺🇸Seattle, Washington, United States
Swedish Medical Center-Cherry Hill
🇺🇸Seattle, Washington, United States
TriHealth Cancer Institute-Anderson
🇺🇸Cincinnati, Ohio, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Health Partners Inc
🇺🇸Minneapolis, Minnesota, United States
Cancer Center at Saint Joseph's
🇺🇸Phoenix, Arizona, United States
Mercy Hospital Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸Omaha, Nebraska, United States
Aurora Saint Luke's Medical Center
🇺🇸Milwaukee, Wisconsin, United States
Anchorage Associates in Radiation Medicine
🇺🇸Anchorage, Alaska, United States
Alaska Breast Care and Surgery LLC
🇺🇸Anchorage, Alaska, United States
Anchorage Oncology Centre
🇺🇸Anchorage, Alaska, United States
Providence Alaska Medical Center
🇺🇸Anchorage, Alaska, United States
Katmai Oncology Group
🇺🇸Anchorage, Alaska, United States
Mercy Hospital Fort Smith
🇺🇸Fort Smith, Arkansas, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸Hot Springs, Arkansas, United States
Mission Hope Medical Oncology - Arroyo Grande
🇺🇸Arroyo Grande, California, United States
Kaiser Permanente Los Angeles Medical Center
🇺🇸Los Angeles, California, United States
Pacific Central Coast Health Center-San Luis Obispo
🇺🇸San Luis Obispo, California, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸Colorado Springs, Colorado, United States
Columbus NCI Community Oncology Research Program
🇺🇸Columbus, Colorado, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Mercy Medical Center
🇺🇸Durango, Colorado, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Southwest Oncology PC
🇺🇸Durango, Colorado, United States
Parker Adventist Hospital
🇺🇸Parker, Colorado, United States
Beebe Medical Center
🇺🇸Lewes, Delaware, United States
Rocky Mountain Cancer Centers-Thornton
🇺🇸Thornton, Colorado, United States
Helen F Graham Cancer Center
🇺🇸Newark, Delaware, United States
Carle Cancer Institute Normal
🇺🇸Atlanta, Georgia, United States
Holy Cross Hospital
🇺🇸Fort Lauderdale, Florida, United States
Regional Cancer Center-Lee Memorial Health System
🇺🇸Fort Myers, Florida, United States
Northside Hospital
🇺🇸Atlanta, Georgia, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸Savannah, Georgia, United States
Northside Hospital - Gwinnett
🇺🇸Lawrenceville, Georgia, United States
Northside Hospital - Duluth
🇺🇸Duluth, Georgia, United States
Hawaii Cancer Care - Westridge
🇺🇸'Aiea, Hawaii, United States
Queen's Cancer Center - Pearlridge
🇺🇸'Aiea, Hawaii, United States
The Queen's Medical Center - West Oahu
🇺🇸'Ewa Beach, Hawaii, United States
Island Urology-Hilo
🇺🇸Hilo, Hawaii, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸Lihue, Hawaii, United States
Castle Medical Center
🇺🇸Kailua, Hawaii, United States
Straub Medical Center - Kahului Clinic
🇺🇸Kahului, Hawaii, United States
Saint Luke's Cancer Institute - Fruitland
🇺🇸Fruitland, Idaho, United States
Rush-Copley Medical Center
🇺🇸Aurora, Illinois, United States
Saint Luke's Cancer Institute - Twin Falls
🇺🇸Twin Falls, Idaho, United States
OSF Saint Anthony's Health Center
🇺🇸Alton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸Carbondale, Illinois, United States
Carle on Vermilion
🇺🇸Danville, Illinois, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸Decatur, Illinois, United States
Heartland Cancer Research NCORP
🇺🇸Decatur, Illinois, United States
Crossroads Cancer Center
🇺🇸Effingham, Illinois, United States
Illinois CancerCare-Dixon
🇺🇸Dixon, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Good Samaritan Regional Health Center
🇺🇸Mount Vernon, Illinois, United States
Cancer Care Center of O'Fallon
🇺🇸O'Fallon, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸Springfield, Illinois, United States
Valley Radiation Oncology
🇺🇸Peru, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Illinois CancerCare - Washington
🇺🇸Washington, Illinois, United States
The Carle Foundation Hospital
🇺🇸Urbana, Illinois, United States
Saint Anthony Regional Hospital
🇺🇸Carroll, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸Clive, Iowa, United States
Medical Oncology and Hematology Associates-West Des Moines
🇺🇸Clive, Iowa, United States
Alegent Health Mercy Hospital
🇺🇸Council Bluffs, Iowa, United States
Central Care Cancer Center - Great Bend
🇺🇸Great Bend, Kansas, United States
Ascension Via Christi Hospitals Wichita
🇺🇸Wichita, Kansas, United States
Flaget Memorial Hospital
🇺🇸Bardstown, Kentucky, United States
Saint Joseph London
🇺🇸London, Kentucky, United States
Jewish Hospital Medical Center South
🇺🇸Shepherdsville, Kentucky, United States
Culicchia Neurological Clinic LLC
🇺🇸Marrero, Louisiana, United States
IHA Hematology Oncology Consultants-Canton
🇺🇸Canton, Michigan, United States
Saint Joseph Mercy Canton
🇺🇸Canton, Michigan, United States
Great Lakes Cancer Management Specialists-Doctors Park
🇺🇸East China Township, Michigan, United States
Genesee Hematology Oncology PC
🇺🇸Flint, Michigan, United States
Mercy Health Saint Mary's
🇺🇸Grand Rapids, Michigan, United States
Academic Hematology Oncology Specialists
🇺🇸Grosse Pointe Woods, Michigan, United States
Great Lakes Cancer Management Specialists-Van Elslander Cancer Center
🇺🇸Grosse Pointe Woods, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Mercy Health Mercy Campus
🇺🇸Muskegon, Michigan, United States
Michigan Breast Specialists-Macomb Township
🇺🇸Macomb, Michigan, United States
Ascension Borgess Cancer Center
🇺🇸Oshtemo, Michigan, United States
Cancer and Hematology Centers of Western Michigan - Norton Shores
🇺🇸Norton Shores, Michigan, United States
Newland Medical Associates-Pontiac
🇺🇸Pontiac, Michigan, United States
Oncology Hematology Associates of Saginaw Valley PC
🇺🇸Saginaw, Michigan, United States
Lakeland Medical Center Saint Joseph
🇺🇸Saint Joseph, Michigan, United States
Bhadresh Nayak MD PC-Sterling Heights
🇺🇸Sterling Heights, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
Ascension Saint Joseph Hospital
🇺🇸Tawas City, Michigan, United States
Michigan Breast Specialists-Warren
🇺🇸Warren, Michigan, United States
Saint John Macomb-Oakland Hospital
🇺🇸Warren, Michigan, United States
Saint Mary's Oncology/Hematology Associates of West Branch
🇺🇸West Branch, Michigan, United States
Huron Gastroenterology PC
🇺🇸Ypsilanti, Michigan, United States
Metro Health Hospital
🇺🇸Wyoming, Michigan, United States
Riverwood Healthcare Center
🇺🇸Aitkin, Minnesota, United States
Sanford Joe Lueken Cancer Center
🇺🇸Bemidji, Minnesota, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸Brainerd, Minnesota, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Essentia Health Saint Mary's - Detroit Lakes Clinic
🇺🇸Detroit Lakes, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Lake Region Healthcare Corporation-Cancer Care
🇺🇸Fergus Falls, Minnesota, United States
Essentia Health - Fosston
🇺🇸Fosston, Minnesota, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
Essentia Health Hibbing Clinic
🇺🇸Hibbing, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
New Ulm Medical Center
🇺🇸New Ulm, Minnesota, United States
Monticello Cancer Center
🇺🇸Monticello, Minnesota, United States
Essentia Health - Park Rapids
🇺🇸Park Rapids, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Sanford Cancer Center Worthington
🇺🇸Worthington, Minnesota, United States
Fairview Lakes Medical Center
🇺🇸Wyoming, Minnesota, United States
Minnesota Oncology Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Central Care Cancer Center - Bolivar
🇺🇸Bolivar, Missouri, United States
Cox Cancer Center Branson
🇺🇸Branson, Missouri, United States
Southeast Cancer Center
🇺🇸Cape Girardeau, Missouri, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Freeman Health System
🇺🇸Joplin, Missouri, United States
Capital Region Southwest Campus
🇺🇸Jefferson City, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸Rolla, Missouri, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸Rolla, Missouri, United States
Mercy Hospital Joplin
🇺🇸Joplin, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸Sullivan, Missouri, United States
Missouri Baptist Outpatient Center-Sunset Hills
🇺🇸Sunset Hills, Missouri, United States
Mercy Hospital Washington
🇺🇸Washington, Missouri, United States
Alegent Health Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
Midlands Community Hospital
🇺🇸Papillion, Nebraska, United States
AtlantiCare Health Park-Cape May Court House
🇺🇸Cape May Court House, New Jersey, United States
Lovelace Radiation Oncology
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
AtlantiCare Surgery Center
🇺🇸Egg Harbor Township, New Jersey, United States
Cancer Center of Kansas - Wichita
🇺🇸Wichita, Kansas, United States
Northwell Health Imbert Cancer Center
🇺🇸Bay Shore, New York, United States
Cone Health Cancer Center at Asheboro
🇺🇸Asheboro, North Carolina, United States
Northwell Health/Center for Advanced Medicine
🇺🇸Lake Success, New York, United States
Cone Health Cancer Center at Alamance Regional
🇺🇸Burlington, North Carolina, United States
Central Carolina Surgery
🇺🇸Greensboro, North Carolina, United States
Cone Health Cancer Center
🇺🇸Greensboro, North Carolina, United States
Cone Heath Cancer Center at Mebane
🇺🇸Mebane, North Carolina, United States
Margaret R Pardee Memorial Hospital
🇺🇸Hendersonville, North Carolina, United States
Novant Health Cancer Institute - Thomasville
🇺🇸Thomasville, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Wake Forest Baptist Health - Wilkes Medical Center
🇺🇸Wilkesboro, North Carolina, United States
Southpointe-Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Essentia Health Cancer Center-South University Clinic
🇺🇸Fargo, North Dakota, United States
Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Essentia Health - Jamestown Clinic
🇺🇸Jamestown, North Dakota, United States
Sanford Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Strecker Cancer Center-Belpre
🇺🇸Belpre, Ohio, United States
Adena Regional Medical Center
🇺🇸Chillicothe, Ohio, United States
Bethesda North Hospital
🇺🇸Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸Cincinnati, Ohio, United States
Columbus Oncology and Hematology Associates Inc
🇺🇸Columbus, Ohio, United States
Mount Carmel East Hospital
🇺🇸Columbus, Ohio, United States
Grant Medical Center
🇺🇸Columbus, Ohio, United States
Mount Carmel Health Center West
🇺🇸Columbus, Ohio, United States
The Mark H Zangmeister Center
🇺🇸Columbus, Ohio, United States
Riverside Methodist Hospital
🇺🇸Columbus, Ohio, United States
Doctors Hospital
🇺🇸Columbus, Ohio, United States
Delaware Health Center-Grady Cancer Center
🇺🇸Delaware, Ohio, United States
Columbus Oncology and Hematology Associates
🇺🇸Dublin, Ohio, United States
Grady Memorial Hospital
🇺🇸Delaware, Ohio, United States
Dublin Methodist Hospital
🇺🇸Dublin, Ohio, United States
Fairfield Medical Center
🇺🇸Lancaster, Ohio, United States
Mount Carmel Grove City Hospital
🇺🇸Grove City, Ohio, United States
Saint Rita's Medical Center
🇺🇸Lima, Ohio, United States
OhioHealth Mansfield Hospital
🇺🇸Mansfield, Ohio, United States
OhioHealth Marion General Hospital
🇺🇸Marion, Ohio, United States
Marietta Memorial Hospital
🇺🇸Marietta, Ohio, United States
Mercy Health - Perrysburg Hospital
🇺🇸Perrysburg, Ohio, United States
Mercy Health - Saint Anne Hospital
🇺🇸Toledo, Ohio, United States
Mercy Health Sylvania Radiation Oncology Center
🇺🇸Toledo, Ohio, United States
Genesis Healthcare System Cancer Care Center
🇺🇸Zanesville, Ohio, United States
Saint Charles Health System
🇺🇸Bend, Oregon, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Bay Area Hospital
🇺🇸Coos Bay, Oregon, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Saint Charles Health System-Redmond
🇺🇸Redmond, Oregon, United States
Lehigh Valley Hospital-Cedar Crest
🇺🇸Allentown, Pennsylvania, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸Bethlehem, Pennsylvania, United States
Christiana Care Health System-Concord Health Center
🇺🇸Chadds Ford, Pennsylvania, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Geisinger Medical Oncology-Lewisburg
🇺🇸Lewisburg, Pennsylvania, United States
Lankenau Medical Center
🇺🇸Wynnewood, Pennsylvania, United States
Prisma Health Cancer Institute - Easley
🇺🇸Easley, South Carolina, United States
Prisma Health Cancer Institute - Spartanburg
🇺🇸Boiling Springs, South Carolina, United States
Prisma Health Cancer Institute - Faris
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Eastside
🇺🇸Greenville, South Carolina, United States
Prisma Health Greenville Memorial Hospital
🇺🇸Greenville, South Carolina, United States
Prisma Health Cancer Institute - Greer
🇺🇸Greer, South Carolina, United States
South Carolina Cancer Specialists PC
🇺🇸Hilton Head Island, South Carolina, United States
The Radiation Oncology Center-Hilton Head/Bluffton
🇺🇸Hilton Head Island, South Carolina, United States
Prisma Health Cancer Institute - Seneca
🇺🇸Seneca, South Carolina, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Providence Regional Cancer System-Aberdeen
🇺🇸Aberdeen, Washington, United States
PeaceHealth Saint Joseph Medical Center
🇺🇸Bellingham, Washington, United States
Saint Elizabeth Hospital
🇺🇸Enumclaw, Washington, United States
Providence Regional Cancer System-Centralia
🇺🇸Centralia, Washington, United States
Swedish Cancer Institute-Edmonds
🇺🇸Edmonds, Washington, United States
Providence Regional Cancer Partnership
🇺🇸Everett, Washington, United States
Saint Francis Hospital
🇺🇸Federal Way, Washington, United States
Swedish Cancer Institute-Issaquah
🇺🇸Issaquah, Washington, United States
Kadlec Clinic Hematology and Oncology
🇺🇸Kennewick, Washington, United States
Saint Clare Hospital
🇺🇸Lakewood, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
Providence Regional Cancer System-Shelton
🇺🇸Shelton, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Providence Saint Mary Regional Cancer Center
🇺🇸Walla Walla, Washington, United States
Marshfield Clinic-Chippewa Center
🇺🇸Chippewa Falls, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States
Marshfield Clinic - Ladysmith Center
🇺🇸Ladysmith, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸Marshfield, Wisconsin, United States
Marshfield Clinic-Wausau Center
🇺🇸Wausau, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸Rice Lake, Wisconsin, United States
FHP Health Center-Guam
🇬🇺Tamuning, Guam
Marshfield Medical Center - Weston
🇺🇸Weston, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸Wisconsin Rapids, Wisconsin, United States
Straub Pearlridge Clinic
🇺🇸'Aiea, Hawaii, United States
Essentia Health - Deer River Clinic
🇺🇸Deer River, Minnesota, United States
Rocky Mountain Cancer Centers-Longmont
🇺🇸Longmont, Colorado, United States
Littleton Adventist Hospital
🇺🇸Littleton, Colorado, United States
Novant Health Cancer Institute - Kernersville
🇺🇸Kernersville, North Carolina, United States
Randolph Hospital
🇺🇸Asheboro, North Carolina, United States
Novant Health Breast Surgery - Greensboro
🇺🇸Greensboro, North Carolina, United States
Novant Health Cancer Institute - Wilkesboro
🇺🇸Wilkesboro, North Carolina, United States
Annie Penn Memorial Hospital
🇺🇸Reidsville, North Carolina, United States
Novant Health Cancer Institute - Statesville
🇺🇸Statesville, North Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Saint Michael Cancer Center
🇺🇸Bremerton, Washington, United States
PeaceHealth Saint John Medical Center
🇺🇸Longview, Washington, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Saint Luke's Cancer Institute - Meridian
🇺🇸Meridian, Idaho, United States
Saint Luke's Cancer Institute - Nampa
🇺🇸Nampa, Idaho, United States
Saint Joseph's/Candler - Bluffton Campus
🇺🇸Bluffton, South Carolina, United States
Greater Regional Medical Center
🇺🇸Creston, Iowa, United States
Pocono Medical Center
🇺🇸East Stroudsburg, Pennsylvania, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸Wilkes-Barre, Pennsylvania, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Caro Cancer Center
🇺🇸Caro, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Newland Medical Associates-Clarkston
🇺🇸Clarkston, Michigan, United States
Ascension Saint John Hospital
🇺🇸Detroit, Michigan, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
Helen DeVos Children's Hospital at Spectrum Health
🇺🇸Grand Rapids, Michigan, United States
Sparrow Hospital
🇺🇸Lansing, Michigan, United States
21st Century Oncology-Pontiac
🇺🇸Pontiac, Michigan, United States
Hope Cancer Center
🇺🇸Pontiac, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
Ascension Saint Mary's Hospital
🇺🇸Saginaw, Michigan, United States
IHA Hematology Oncology Consultants-Ann Arbor
🇺🇸Ypsilanti, Michigan, United States
Providence Cancer Institute Clackamas Clinic
🇺🇸Clackamas, Oregon, United States
SIH Cancer Institute
🇺🇸Carterville, Illinois, United States
Springfield Clinic
🇺🇸Springfield, Illinois, United States
Carle Cancer Center NCI Community Oncology Research Program
🇺🇸Urbana, Illinois, United States
Saint Luke's Cancer Institute - Boise
🇺🇸Boise, Idaho, United States
Marshfield Clinic-Minocqua Center
🇺🇸Minocqua, Wisconsin, United States
Marshfield Clinic Stevens Point Center
🇺🇸Stevens Point, Wisconsin, United States
Saint Elizabeth Regional Medical Center
🇺🇸Lincoln, Nebraska, United States
Central Ohio Breast and Endocrine Surgery
🇺🇸Gahanna, Ohio, United States
Centralia Oncology Clinic
🇺🇸Centralia, Illinois, United States
Saint Joseph Regional Cancer Center
🇺🇸Bryan, Texas, United States
Sanford Thief River Falls Medical Center
🇺🇸Thief River Falls, Minnesota, United States
Saint Joseph Mercy Brighton
🇺🇸Brighton, Michigan, United States
IHA Hematology Oncology Consultants-Brighton
🇺🇸Brighton, Michigan, United States
Southern Ohio Medical Center
🇺🇸Portsmouth, Ohio, United States
Lehigh Valley Hospital-Hazelton
🇺🇸Hazleton, Pennsylvania, United States
Heartland Regional Medical Center
🇺🇸Saint Joseph, Missouri, United States
Paoli Memorial Hospital
🇺🇸Paoli, Pennsylvania, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Saint Louis Cancer and Breast Institute-Ballwin
🇺🇸Ballwin, Missouri, United States
Duluth Clinic Ashland
🇺🇸Ashland, Wisconsin, United States
Anchorage Radiation Therapy Center
🇺🇸Anchorage, Alaska, United States
Alaska Women's Cancer Care
🇺🇸Anchorage, Alaska, United States
Alaska Oncology and Hematology LLC
🇺🇸Anchorage, Alaska, United States
Aspirus Cancer Care - Wisconsin Rapids
🇺🇸Wisconsin Rapids, Wisconsin, United States
Providence Saint Joseph Medical Center/Disney Family Cancer Center
🇺🇸Burbank, California, United States
Aspirus Regional Cancer Center
🇺🇸Wausau, Wisconsin, United States
Mission Hope Medical Oncology - Santa Maria
🇺🇸Santa Maria, California, United States
Aspirus Langlade Hospital
🇺🇸Antigo, Wisconsin, United States
Saint Francis Cancer Center
🇺🇸Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Lakewood
🇺🇸Lakewood, Colorado, United States
Delaware Clinical and Laboratory Physicians PA
🇺🇸Newark, Delaware, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
Suburban Hematology Oncology Associates - Snellville
🇺🇸Snellville, Georgia, United States
Hawaii Cancer Care - Savio
🇺🇸'Aiea, Hawaii, United States
Pali Momi Medical Center
🇺🇸'Aiea, Hawaii, United States
The Cancer Center of Hawaii-Pali Momi
🇺🇸'Aiea, Hawaii, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸Yorkville, Illinois, United States
Springfield Memorial Hospital
🇺🇸Springfield, Illinois, United States
Saint Luke's Hospital
🇺🇸Cedar Rapids, Iowa, United States
Mercy Medical Center-West Lakes
🇺🇸West Des Moines, Iowa, United States
Central Care Cancer Center - Garden City
🇺🇸Garden City, Kansas, United States
Trinity Regional Medical Center
🇺🇸Fort Dodge, Iowa, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Commonwealth Cancer Center-Corbin
🇺🇸Corbin, Kentucky, United States
West Jefferson Medical Center
🇺🇸Marrero, Louisiana, United States
LSU Health Sciences Center at Shreveport
🇺🇸Shreveport, Louisiana, United States
Hematology Oncology Consultants-Clarkston
🇺🇸Clarkston, Michigan, United States
IHA Hematology Oncology Consultants-Chelsea
🇺🇸Chelsea, Michigan, United States
Genesee Cancer and Blood Disease Treatment Center
🇺🇸Flint, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Spectrum Health at Butterworth Campus
🇺🇸Grand Rapids, Michigan, United States
Saint Mary's Oncology/Hematology Associates of Marlette
🇺🇸Marlette, Michigan, United States
Saint Mary Mercy Hospital
🇺🇸Livonia, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
Michigan Breast Specialists-Grosse Pointe Woods
🇺🇸Grosse Pointe Woods, Michigan, United States
Great Lakes Cancer Management Specialists-Macomb Medical Campus
🇺🇸Macomb, Michigan, United States
Lakeland Hospital Niles
🇺🇸Niles, Michigan, United States
Marie Yeager Cancer Center
🇺🇸Saint Joseph, Michigan, United States
Spectrum Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Advanced Breast Care Center PLLC
🇺🇸Warren, Michigan, United States
Macomb Hematology Oncology PC
🇺🇸Warren, Michigan, United States
Great Lakes Cancer Management Specialists-Macomb Professional Building
🇺🇸Warren, Michigan, United States
Cambridge Medical Center
🇺🇸Cambridge, Minnesota, United States
Minnesota Oncology - Burnsville
🇺🇸Burnsville, Minnesota, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Essentia Health Cancer Center
🇺🇸Duluth, Minnesota, United States
Fairview Clinics and Surgery Center Maple Grove
🇺🇸Maple Grove, Minnesota, United States
Fairview Northland Medical Center
🇺🇸Princeton, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
Essentia Health Sandstone
🇺🇸Sandstone, Minnesota, United States
Essentia Health Virginia Clinic
🇺🇸Virginia, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Parkland Health Center - Farmington
🇺🇸Farmington, Missouri, United States
Mercy Hospital South
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Nebraska Cancer Specialists/Oncology Hematology West PC
🇺🇸Grand Island, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
CHI Health Good Samaritan
🇺🇸Kearney, Nebraska, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸Albuquerque, New Mexico, United States
Lovelace Medical Center-Downtown
🇺🇸Albuquerque, New Mexico, United States
Mission Hospital
🇺🇸Asheville, North Carolina, United States
Wake Forest University at Clemmons
🇺🇸Clemmons, North Carolina, United States
Novant Health Cancer Institute - Mount Airy
🇺🇸Mount Airy, North Carolina, United States
Sanford South University Medical Center
🇺🇸Fargo, North Dakota, United States
Good Samaritan Hospital - Cincinnati
🇺🇸Cincinnati, Ohio, United States
Licking Memorial Hospital
🇺🇸Newark, Ohio, United States
Newark Radiation Oncology
🇺🇸Newark, Ohio, United States
Mercy Health - Saint Vincent Hospital
🇺🇸Toledo, Ohio, United States
Saint Ann's Hospital
🇺🇸Westerville, Ohio, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Prisma Health Cancer Institute - Butternut
🇺🇸Greenville, South Carolina, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸Eau Claire, Wisconsin, United States
PeaceHealth United General Medical Center
🇺🇸Sedro-Woolley, Washington, United States
Aspirus Medford Hospital
🇺🇸Medford, Wisconsin, United States
Cancer Center of Western Wisconsin
🇺🇸New Richmond, Wisconsin, United States
Saint Joseph Mercy Chelsea
🇺🇸Chelsea, Michigan, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸Wichita, Kansas, United States
Sainte Genevieve County Memorial Hospital
🇺🇸Sainte Genevieve, Missouri, United States
Providence Regional Cancer System-Yelm
🇺🇸Yelm, Washington, United States
Michigan Cancer Research Consortium NCORP
🇺🇸Ann Arbor, Michigan, United States
Saint Joseph Mercy Hospital
🇺🇸Ann Arbor, Michigan, United States
Novant Health Forsyth Medical Center
🇺🇸Winston-Salem, North Carolina, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Diagnostic and Treatment Center
🇺🇸Weston, Wisconsin, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Saints Mary and Elizabeth Hospital
🇺🇸Louisville, Kentucky, United States
Jewish Hospital
🇺🇸Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸Louisville, Kentucky, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
University Medical Center New Orleans
🇺🇸New Orleans, Louisiana, United States
Louisiana State University Health Science Center
🇺🇸New Orleans, Louisiana, United States
Hawaii Cancer Care Inc - Waterfront Plaza
🇺🇸Honolulu, Hawaii, United States
Island Urology
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Cenrer - POB I
🇺🇸Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸Honolulu, Hawaii, United States
Hawaii Diagnostic Radiology Services LLC
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
🇺🇸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
Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, 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
Broadlawns Medical Center
🇺🇸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
Medical Oncology and Hematology Associates-Laurel
🇺🇸Des Moines, Iowa, United States
Methodist West Hospital
🇺🇸West Des Moines, Iowa, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
Knox Community Hospital
🇺🇸Mount Vernon, Ohio, United States
Northwest Wisconsin Cancer Center
🇺🇸Ashland, Wisconsin, United States