Testing Whether Treating Breast Cancer Metastases With Surgery or High-Dose Radiation Improves Survival
- Conditions
- Metastatic Malignant Neoplasm in the LungMetastatic Malignant Neoplasm in the Lymph NodesMetastatic Malignant Neoplasm in the SpinePrognostic Stage IV Breast Cancer AJCC v8Anatomic Stage IV Breast Cancer AJCC v8Metastatic Breast CarcinomaAnatomic Stage IV Breast Cancer American Joint Committee on Cancer (AJCC) v8Metastatic Malignant Neoplasm in the BoneMetastatic Malignant Neoplasm in the Liver
- Interventions
- Radiation: Stereotactic Body RadiotherapyProcedure: Surgery
- Registration Number
- NCT02364557
- Lead Sponsor
- NRG Oncology
- Brief Summary
This randomized phase II/III trial studies how well standard of care therapy with stereotactic radiosurgery and/or surgery works and compares it to standard of care therapy alone in treating patients with breast cancer that has spread to one or two locations in the body (limited metastatic) that are previously untreated. Standard of care therapy comprising chemotherapy, hormonal therapy, biological therapy, and others may help stop the spread of tumor cells. Radiation therapy and/or surgery is usually only given with standard of care therapy to relieve pain; however, in patients with limited metastatic breast cancer, stereotactic radiosurgery, also known as stereotactic body radiation therapy, may be able to send x-rays directly to the tumor and cause less damage to normal tissue and surgery may be able to effectively remove the metastatic tumor cells. It is not yet known whether standard of care therapy is more effective with stereotactic radiosurgery and/or surgery in treating limited metastatic breast cancer.
- Detailed Description
PRIMARY OBJECTIVES:
I. Phase II: To determine whether ablation \[through stereotactic body radiation therapy (SBRT) (stereotactic radiosurgery) and/or surgical resection of all known metastases\] in oligometastatic breast cancer patients provides a sufficient signal for improved progression-free survival (PFS) to warrant full accrual to the Phase III portion of the trial.
II. Phase III: To determine whether ablation (through SBRT and/or surgical resection of all known metastases) in oligometastatic breast cancer patients significantly improves overall survival (OS).
SECONDARY OBJECTIVES:
I. To evaluate treated metastasis control according to tumor receptor status \[estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2)\], use of chemotherapy, surgery versus (vs.) ablative therapy, and number of metastases.
II. To evaluate whether the addition of ablative metastasis directed therapy significantly reduces the number of distant recurrences (new metastases) in patients who progress according to tumor receptor status (ER, PR, HER-2); use of chemotherapy, and number of metastases.
III. To evaluate adverse events in patients who receive ablative metastasis-directed therapy to all known metastases in addition to standard medical therapy compared with those treated with standard medical therapy alone.
EXPLORATORY OBJECTIVE:
I. To explore the most appropriate and clinically relevant technological parameters to ensure quality and effectiveness throughout the radiation therapy processes, including imaging, simulation, target and critical structure definition, treatment planning, image guidance, and delivery.
TRANSLATIONAL RESEARCH OBJECTIVES:
I. To determine whether \< 5 circulating tumor cells (CTCs) (per 7.5 ml of blood) is an independent prognostic (outcome) marker for improved PFS and OS in oligometastatic breast cancer.
II. To determine whether \< 5 CTCs (per 7.5 ml of blood) is an independent predictive (response to therapy) marker for improved PFS and OS in oligometastatic breast cancer.
III. To determine whether eliminating CTCs (0/7.5 ml of blood in patients with at least 2 CTCs at registration) is both a prognostic and predictive marker for improved PFS and OS.
IV. To evaluate the prognostic and predictive properties of CTC count as a continuous measure of PFS and OS.
V. To store material for retrospective analysis of circulating tumor deoxyribonucleic acid (ctDNA).
VI. To store material for retrospective analysis of circulating micro-ribonucleic acid (RNA).
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- Female
- Target Recruitment
- 129
-
A patient cannot be considered eligible for this study unless all of the following conditions are met.
-
Pathologically confirmed metastatic breast cancer
-
Known estrogen, progesterone, and HER2 status of either primary tumor or metastasis;
- Note: estrogen, progesterone and HER2 status of metastasis preferred for stratification
-
Number of allowable metastases:
-
=< 4 metastases seen on standard imaging within 60 days prior to registration when all metastatic disease is located within the following sites:
- Peripheral lung
- Osseous (bone)
- Spine
- Central lung
- Abdominal-pelvic metastases (lymph node/adrenal gland)
- Liver
- Mediastinal/cervical lymph node
-
-
All known disease amenable to metastasis-directed therapy with either SBRT or resection
- Note: Symptomatic bone metastasis are allowed if ablative therapy can be delivered
- Note: Sites for possible surgical excision include lung, liver, adrenal gland, bone, small intestine, large intestine, ovary, and amenable nodal disease sites
- Note: Surgical stabilization is allowed for a metastasis if it is followed by conventionally fractionated external beam radiotherapy
-
Maximum diameter of individual metastasis in any dimension =< 5 cm
-
There are no restrictions on distance between the metastases
-
Patients must be registered within 365 days of the initial metastatic breast cancer diagnosis; first-line standard systemic therapy (chemotherapy, anti-endocrine therapy, anti-HER2, or other standard targeted therapy) for metastatic breast cancer must be given or planned to be given; if given before study entry, it cannot have exceeded a duration of 12 months at the time of registration (Note: sequencing of ablative therapy [surgery or SBRT] relative to systemic therapy, for patients randomized to Arm 2, is at the discretion of the treating physician)
-
The primary tumor site must be controlled prior to registration
- For those who present with synchronous primary and oligometastatic disease, primary must be controlled prior to registration
- The definition of control is definitive surgery by excision or mastectomy (+/- radiotherapy) per institution preference For those who present with local recurrence and oligometastatic disease, local recurrence must be controlled prior to registration
- The definition of control is definitive surgery by excision or mastectomy (+/- radiotherapy) per institution preference
-
Appropriate stage for study entry based on the following diagnostic workup:
- History/physical examination within 60 days prior to registration
- Clinical grade computed tomography (CT) scans of the chest, abdomen, and pelvis with radionuclide bone scan OR whole body positron emission tomography (PET)/CT within 60 days prior to study registration
-
Zubrod performance status =< 2 within 60 days prior to registration
-
Blood cell count (CBC)/differential obtained within 60 days prior to registration on study
-
Absolute neutrophil count (ANC) >= 500 cells/mm^3
-
Platelets >= 50,000 cells/mm^3
-
Hemoglobin >= 8.0 g/dl (note: the use of transfusion or other intervention to achieve hemoglobin [Hgb] >= 8.0 g/dl is acceptable)
-
For females of child-bearing potential, negative serum or urine pregnancy test within 14 days prior to study registration
-
The patient or a legally authorized representative must provide study-specific informed consent prior to study entry
-
Patients with any of the following conditions are NOT eligible for this study.
-
Pathologic evidence of active primary disease or local/regional breast tumor recurrence at the time of registration;
-
Co-existing or prior invasive malignancy (except non-melanomatous skin cancer), unless disease free for a minimum of 3 years; previous RT dose, date, fraction size, must be reported
-
Metastases with indistinct borders making targeting not feasible
- Note: A potential issue with bone metastases is that they often are not discrete; since many patients on this protocol will have bone metastases, this will be an important issue; theoretically, Houndsfield units might provide an appropriate measure; however, a sclerotic lesion against dense cortical bone will not have a sharp demarcation based on Houndsfield units (HU); therefore, we acknowledge that such determinations will pose a challenge and thus the physician's judgment will be required
-
Prior palliative radiation treatment for metastatic disease to be treated on the protocol (including radiopharmaceuticals)
-
Metastases located within 3 cm of the previously irradiated structures:
- Spinal cord previously irradiated to > 40 Gy (delivered in =< 3 Gy/fraction)
- Brachial plexus previously irradiated to > 50 Gy (delivered in =< 3 Gy/fraction)
- Small intestine, large intestine, or stomach previously irradiated to > 45 Gy (delivered in =< 3 Gy/fraction)
- Brainstem previously irradiated to > 50 Gy (delivered in =< 3 Gy/fraction)
- Whole lung previously irradiated with prior percent volume receiving greater than or equal to 20 Gy (V20Gy)> 30% (delivered in =< 3 Gy/fraction)
- Primary tumor irradiated with SBRT
- Metastasis irradiated with SBRT
-
Brain metastases
-
Exudative, bloody, or cytological proven malignant effusions
-
Severe, active co-morbidity defined as follows:
- Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months
- Transmural myocardial infarction within the last 6 months
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
- Chronic obstructive pulmonary disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at the time of registration
-
Pregnancy; lactating females must cease expression of milk prior to signing consent to be eligible
-
Human immunodeficiency virus (HIV) positive with cluster of differentiation (CD)4 count < 200 cells/microliter; note that patients who are HIV positive are eligible, provided they are under treatment with highly active antiretroviral therapy (HAART) and have a cluster of differentiation 4 (CD4) count >= 200 cells/microliter within 30 days prior to registration; note also that HIV testing is not required for eligibility for this protocol
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Standard of Care + Ablation Surgery Standard of care systemic therapy plus ablation of all metastases by stereotactic body radiotherapy or surgery at the discretion of the treating physician. Standard of Care + Ablation Stereotactic Body Radiotherapy Standard of care systemic therapy plus ablation of all metastases by stereotactic body radiotherapy or surgery at the discretion of the treating physician.
- Primary Outcome Measures
Name Time Method Progression-free Survival (Phase II) From randomization to last follow-up. Follow-up schedule: 3 mos after randomization and every 3 months to 24 months, then every six months to five years, then annually. Maximum follow-up at time of analysis was 63 months. Progression (failure) is defined as any of the following: progression of metastases, new metastases, or death. Progression-free survival (PFS) time is defined as time from randomization to the date of first progression, death, or last contact when participant had a documented clinical assessment (censored). PFS rates are estimated using the Kaplan-Meier method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Median PFS is provided.
Overall Survival (Phase III) From randomization to last follow-up. Follow-up schedule: 3 mos after randomization and every 3 months to 24 months and then annually. Maximum follow-up at time of analysis was 63 months. Overall survival time is defined as time from randomization to the date of death from any cause or last known follow-up (censored).
- Secondary Outcome Measures
Name Time Method Percentage of Participants With New Metastases From randomization to last follow-up. Follow-up schedule: 3 months after randomization, every 3 months up to 24 months, every six months up to five years, then annually. Maximum follow-up at time of analysis was 63 months.Two-year rates are provided here. New metastases (failure) is defined as the appearance of any new metastases. Failure time is measured from randomization to the date of first failure, last contact when participant had a documented clinical assessment (censored), or death without failure (competing risk). Failure rates are estimated using the cumulative incidence method. The protocol specifies that the distributions of failure times be compared between the arms, which is reported in the statistical analysis results. Two-year failure rates are provided here
Percentage of Participants With Treated Metastasis Progression on the SOC + Ablation Arm From randomization to last follow-up. Follow-up schedule: 3 months after randomization, every 3 months up to 24 months, every six months up to five years, then annually. Maximum follow-up at time of analysis was 63 months. Two-year rates are provide here. Metastasis progression (failure) is defined as the clearance and subsequent recurrence or the development of new metastases in the treated area. Failure time is defined as time from randomization to the date of first failure, last contact when participant had a documented clinical assessment (censored), or death without failure (competing risk). Failure rates are estimated using the cumulative incidence method. Two-year failure rates are provided here.
Number of Patients by Highest Grade Adverse Event Reported From randomization to last follow-up. Follow-up schedule: Arm 1: 3 mos. after randomization / Arm 2: weekly during SBRT and the last day of SBRT; both arms: then every 3 mos. to 24 mos., then annually. Maximum follow-up at time of analysis was 63 months. Common Terminology Criteria for Adverse Events (version 4.0) grades adverse event severity from 1=mild to 5=death. Summary data is provided in this outcome measure; see Adverse Events Module for specific adverse event data.
Progression-free Survival in the Presence or Absence of Circulating Tumor Cells (CTCs) From randomization to last follow-up. Follow-up schedule: 3 months after randomization, every 3 months up to 24 months, every six months up to five years, then annually. Maximum follow-up at time of analysis was 63 months.Two-year rates are provided here. The presence of CTCs is defined as ≥ 5 CTCs (per 7.5ml of blood). Progression (failure) is defined as any of the following: progression of metastases, new metastases, or death. Progression-free survival (PFS) time is defined as time from randomization to the date of first progression, death, or last contact when participant had a documented clinical assessment (censored). PFS rates are estimated using the Kaplan-Meier method. The protocol specifies that the distributions of failure times be compared between the groups, which is reported in the statistical analysis results. Two-year PFS rates are provided here
Trial Locations
- Locations (165)
Emory University Hospital Midtown
🇺🇸Atlanta, Georgia, United States
Emory Saint Joseph's Hospital
🇺🇸Atlanta, Georgia, United States
Alta Bates Summit Medical Center-Herrick Campus
🇺🇸Berkeley, California, United States
Central Maryland Radiation Oncology in Howard County
🇺🇸Columbia, Maryland, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸Great Falls, Montana, United States
Virtua Voorhees
🇺🇸Voorhees, New Jersey, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸Dallas, Texas, United States
Ogden Regional Medical Center
🇺🇸Ogden, Utah, United States
Greater Baltimore Medical Center
🇺🇸Baltimore, Maryland, United States
Allegheny General Hospital
🇺🇸Pittsburgh, Pennsylvania, United States
UPMC-Shadyside Hospital
🇺🇸Pittsburgh, Pennsylvania, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
University of Illinois
🇺🇸Chicago, Illinois, United States
M D Anderson Cancer Center
🇺🇸Houston, Texas, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
The Cancer Center of Hawaii-Liliha
🇺🇸Honolulu, Hawaii, United States
Texas Oncology-Austin Midtown
🇺🇸Austin, Texas, United States
Arizona Center for Cancer Care-Peoria
🇺🇸Peoria, Arizona, United States
CTCA at Western Regional Medical Center
🇺🇸Goodyear, Arizona, United States
USC / Norris Comprehensive Cancer Center
🇺🇸Los Angeles, California, United States
Banner University Medical Center - Tucson
🇺🇸Tucson, Arizona, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
The Permanente Medical Group-Roseville Radiation Oncology
🇺🇸Roseville, California, United States
Naval Medical Center -San Diego
🇺🇸San Diego, California, United States
Duke University Medical Center
🇺🇸Durham, North Carolina, United States
Huntsman Cancer Institute/University of Utah
🇺🇸Salt Lake City, Utah, United States
University of Alabama at Birmingham Cancer Center
🇺🇸Birmingham, Alabama, United States
Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Mayo Clinic in Rochester
🇺🇸Rochester, Minnesota, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸Portland, Oregon, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
University of Nebraska Medical Center
🇺🇸Omaha, Nebraska, United States
Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Los Angeles General Medical Center
🇺🇸Los Angeles, California, United States
UC San Diego Moores Cancer Center
🇺🇸La Jolla, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
🇺🇸Orange, California, United States
Cedars Sinai Medical Center
🇺🇸Los Angeles, California, United States
Kaiser Permanente Cancer Treatment Center
🇺🇸South San Francisco, California, United States
Saint Joseph's Medical Center
🇺🇸Stockton, California, United States
Gene Upshaw Memorial Tahoe Forest Cancer Center
🇺🇸Truckee, California, United States
UCHealth Memorial Hospital Central
🇺🇸Colorado Springs, Colorado, United States
Poudre Valley Hospital
🇺🇸Fort Collins, Colorado, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
Mayo Clinic in Florida
🇺🇸Jacksonville, Florida, United States
Miami Cancer Institute
🇺🇸Miami, Florida, United States
Memorial Hospital West
🇺🇸Pembroke Pines, Florida, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Emory University Hospital/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Lewis Hall Singletary Oncology Center
🇺🇸Thomasville, Georgia, United States
John B Amos Cancer Center
🇺🇸Columbus, Georgia, United States
CTCA at Southeastern Regional Medical Center
🇺🇸Newnan, Georgia, United States
University of Chicago Comprehensive Cancer Center
🇺🇸Chicago, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Northwestern Medicine Cancer Center Delnor
🇺🇸Geneva, Illinois, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Northwestern Medicine Cancer Center Warrenville
🇺🇸Warrenville, Illinois, United States
Southwest Illinois Health Services LLP
🇺🇸Swansea, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Midwestern Regional Medical Center
🇺🇸Zion, Illinois, United States
Ascension Saint Vincent Anderson
🇺🇸Anderson, Indiana, United States
Parkview Hospital Randallia
🇺🇸Fort Wayne, Indiana, United States
Parkview Regional Medical Center
🇺🇸Fort Wayne, Indiana, United States
IU Health Ball Memorial Hospital
🇺🇸Muncie, Indiana, United States
Ascension Via Christi Hospitals Wichita
🇺🇸Wichita, Kansas, United States
MaineHealth Coastal Cancer Treatment Center
🇺🇸Bath, Maine, United States
Memorial Hospital of South Bend
🇺🇸South Bend, Indiana, United States
MaineHealth/SMHC Cancer Care and Blood Disorders-Biddeford
🇺🇸Biddeford, Maine, United States
Owensboro Health Mitchell Memorial Cancer Center
🇺🇸Owensboro, Kentucky, United States
Maine Medical Center-Bramhall Campus
🇺🇸Portland, Maine, United States
MaineHealth/SMHC Cancer Care and Blood Disorders-Sanford
🇺🇸Sanford, Maine, United States
MaineHealth Cancer Care Center of York County
🇺🇸Sanford, Maine, United States
Lahey Hospital and Medical Center
🇺🇸Burlington, Massachusetts, United States
Maine Medical Center- Scarborough Campus
🇺🇸Scarborough, Maine, United States
UM Upper Chesapeake Medical Center
🇺🇸Bel Air, Maryland, United States
University of Maryland/Greenebaum Cancer Center
🇺🇸Baltimore, Maryland, United States
Henry Ford Cancer Institute-Downriver
🇺🇸Brownstown, Michigan, United States
Michigan Healthcare Professionals Clarkston
🇺🇸Clarkston, Michigan, United States
Lowell General Hospital
🇺🇸Lowell, Massachusetts, United States
Henry Ford Macomb Hospital-Clinton Township
🇺🇸Clinton Township, Michigan, United States
Michigan Healthcare Professionals Farmington
🇺🇸Farmington Hills, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Henry Ford West Bloomfield Hospital
🇺🇸West Bloomfield, Michigan, United States
William Beaumont Hospital-Royal Oak
🇺🇸Royal Oak, Michigan, United States
GenesisCare USA - Troy
🇺🇸Troy, Michigan, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
Saint Luke's Hospital of Duluth
🇺🇸Duluth, Minnesota, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital South
🇺🇸Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Kalispell Regional Medical Center
🇺🇸Kalispell, Montana, United States
Wentworth-Douglass Hospital
🇺🇸Dover, New Hampshire, United States
Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
Virtua Memorial
🇺🇸Mount Holly, New Jersey, United States
Community Medical Center
🇺🇸Toms River, New Jersey, United States
Lovelace Radiation Oncology
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
New Mexico Oncology Hematology Consultants
🇺🇸Albuquerque, New Mexico, United States
Christus Saint Vincent Regional Cancer Center
🇺🇸Santa Fe, New Mexico, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸New York, New York, United States
University of Rochester
🇺🇸Rochester, New York, United States
Dickstein Cancer Treatment Center
🇺🇸White Plains, New York, United States
Rex Hematology Oncology Associates-Cary
🇺🇸Cary, North Carolina, United States
Rex Hematology Oncology Associates-Garner
🇺🇸Garner, North Carolina, United States
Rex Hematology Oncology Associates-Blue Ridge
🇺🇸Raleigh, North Carolina, United States
UNC Rex Healthcare
🇺🇸Raleigh, North Carolina, United States
Novant Cancer Institute Radiation Oncology - Supply
🇺🇸Supply, North Carolina, United States
UNC Rex Cancer Center of Wakefield
🇺🇸Raleigh, North Carolina, United States
Novant Health Cancer Institute Radiation Oncology - Wilmington
🇺🇸Wilmington, North Carolina, United States
Novant Health New Hanover Regional Medical Center
🇺🇸Wilmington, North Carolina, United States
Cleveland Clinic Akron General
🇺🇸Akron, Ohio, United States
Legacy Mount Hood Medical Center
🇺🇸Gresham, Oregon, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
ProMedica Flower Hospital
🇺🇸Sylvania, Ohio, United States
UPMC Pinnacle Cancer Center/Community Osteopathic Campus
🇺🇸Harrisburg, Pennsylvania, United States
University of Pennsylvania/Abramson Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Guthrie Medical Group PC-Robert Packer Hospital
🇺🇸Sayre, Pennsylvania, United States
Self Regional Healthcare
🇺🇸Greenwood, South Carolina, United States
Reading Hospital
🇺🇸West Reading, Pennsylvania, United States
Gibbs Cancer Center-Pelham
🇺🇸Greer, South Carolina, United States
Spartanburg Medical Center
🇺🇸Spartanburg, South Carolina, United States
Inova Fairfax Hospital
🇺🇸Falls Church, Virginia, United States
Edwards Comprehensive Cancer Center
🇺🇸Huntington, West Virginia, United States
Legacy Salmon Creek Hospital
🇺🇸Vancouver, Washington, United States
Marshfield Medical Center-River Region at Stevens Point
🇺🇸Stevens Point, Wisconsin, United States
Saint Vincent Hospital Cancer Center at Saint Mary's
🇺🇸Green Bay, Wisconsin, United States
Froedtert West Bend Hospital/Kraemer Cancer Center
🇺🇸West Bend, Wisconsin, United States
Tom Baker Cancer Centre
🇨🇦Calgary, Alberta, Canada
Diagnostic and Treatment Center
🇺🇸Weston, Wisconsin, United States
Cross Cancer Institute
🇨🇦Edmonton, Alberta, Canada
The Research Institute of the McGill University Health Centre (MUHC)
🇨🇦Montreal, Quebec, Canada
CHUM - Hopital Notre-Dame
🇨🇦Montreal, Quebec, Canada
London Regional Cancer Program
🇨🇦London, Ontario, Canada
Ottawa Hospital and Cancer Center-General Campus
🇨🇦Ottawa, Ontario, Canada
McGill University Department of Oncology
🇨🇦Montreal, Quebec, Canada
CHUM - Centre Hospitalier de l'Universite de Montreal
🇨🇦Montreal, Quebec, Canada
Jewish General Hospital
🇨🇦Montreal, Quebec, Canada
Yonsei University Health System-Severance Hospital
🇰🇷Seoul, Korea, Republic of
King Faisal Specialist Hospital and Research Centre
🇸🇦Riyadh, Saudi Arabia
Sutter Medical Center Sacramento
🇺🇸Sacramento, California, United States
University of California Davis Comprehensive Cancer Center
🇺🇸Sacramento, California, United States
UCHealth University of Colorado Hospital
🇺🇸Aurora, Colorado, United States
Orlando Health Cancer Institute
🇺🇸Orlando, Florida, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Saint Vincent Hospital Cancer Center Green Bay
🇺🇸Green Bay, Wisconsin, United States
West Virginia University Healthcare
🇺🇸Morgantown, West Virginia, United States
Memorial Regional Hospital/Joe DiMaggio Children's Hospital
🇺🇸Hollywood, Florida, United States
Helen F Graham Cancer Center
🇺🇸Newark, Delaware, United States
Dartmouth Hitchcock Medical Center/Dartmouth Cancer Center
🇺🇸Lebanon, New Hampshire, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
UNC Lineberger Comprehensive Cancer Center
🇺🇸Chapel Hill, North Carolina, United States
University of Florida Health Science Center - Gainesville
🇺🇸Gainesville, Florida, United States
Montefiore Medical Center - Moses Campus
🇺🇸Bronx, New York, United States
Bon Secours Saint Mary's Hospital
🇺🇸Richmond, Virginia, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸Albuquerque, New Mexico, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Saint Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States