Efficacy of Oral Azacitidine Plus Best Supportive Care as Maintenance Therapy in Subjects With Acute Myeloid Leukemia (AML) in Complete Remission
- Registration Number
- NCT01757535
- Lead Sponsor
- Celgene
- Brief Summary
This study enrolled 472 participants, aged 55 or older, with a diagnosis of de novo acute myeloid leukemia (AML) or AML secondary to prior myelodysplastic disease or chronic myelomonocytic leukemia (CMML), and who have achieved first complete remission (CR)/ complete remission with incomplete blood count recovery (CRi) following induction with or without consolidation chemotherapy.
The study is amended to include an extension phase (EP). The EP allows participants who are currently receiving oral azacitidine and who are demonstrating clinical benefit as assessed by the investigator, to continue receiving oral azacitidine after unblinding by sponsor until the participant meets the criteria for study discontinuation or until oral azacitidine becomes commercially available and reimbursed. In addition, all participants in the placebo arm and participants who had been discontinued from the treatment phase (irrespective of randomization arm) and continuing in the follow-up phase will be followed for survival in the EP.
- Detailed Description
This is an international, multicenter, placebo-controlled, Phase 3 study with a double-blind, randomized, parallel-group design in subjects with de novo AML or AML secondary to prior diagnosis of myelodysplastic syndromes (MDS) or chronic myelomonocytic leukemia (CMML) aged ≥ 55 years, who are in first CR/CRi following induction therapy with or without consolidation chemotherapy. The study consists of 3 phases; the pre-randomization phase (screening phase), the treatment phase, and the follow-up phase.
The study is amended to include an extension phase (EP). The EP allows participants who are currently receiving oral azacitidine and who are demonstrating clinical benefit as assessed by the Investigator, to continue receiving oral azacitidine after unblinding by sponsor until they meet the criteria for study discontinuation or until oral azacitidine becomes commercially available and reimbursed. In addition, all participants in the placebo arm and participants who had been discontinued from the treatment phase (irrespective of randomization arm) and continuing in the follow-up phase will be followed for survival in the EP.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 472
- Male or female participants ≥ 55 years of age
- Newly diagnosed, histologically confirmed de novo acute myeloid leukemia (AML) or AML secondary to prior myelodysplastic disease or CMML (Chronic myelomonocytic leukemia)
- First complete remission (CR)/ complete remission with incomplete blood count recovery (CRi) with induction therapy with intensive chemotherapy with or without consolidation therapy within 4 months (+/- 7 days of achieving CR or CRi)
- Eastern Cooperative Oncology Group (ECOG) performance status - 0, 1, 2, 3
Key Inclusion Criteria in the Extended Phase of the study:
At the Investigator's discretion and with approval of the sponsor, participants meeting all of the following eligibility criteria are eligible to enter the extension phase:
-
All participants randomized into the oral azacitidine or placebo arm and are continuing in either the treatment phase or follow-up phase of the CC-486-AML-001 study;
- Participants randomized to oral azacitidine treatment arm and continuing in the treatment phase demonstrating clinical benefit as assessed by the investigator are eligible to receive oral azacitidine in the extension phase (EP);
- Participants randomized into placebo arm of the study will not receive oral azacitidine in the EP, but will be followed for survival in the EP;
- Participants currently in the follow-up phase will continue to be followed for survival in the EP;
-
Participants who have signed the informed consent for the EP of the study;
-
Participants who do not meet any of the criteria for study discontinuation
Key
- AML with inversion (inv)(16), translocation = t(8;21), t(16;16), t(15;17), or t(9;22) or molecular evidence of such translocations
- Prior bone marrow or stem cell transplantation
- Have achieved CR/CRi following therapy with hypomethylating agents
- Diagnosis of malignant disease within the previous 12 months
- Proven central nervous system (CNS) leukemia
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Oral Azacitidine Oral Azacitidine 300 mg oral azacitidine on days 1 to 14 of each 28-day treatment cycle. Placebo Placebo Identically matching placebo tablets on days 1 to 14 of each 28-day treatment cycle.
- Primary Outcome Measures
Name Time Method Kaplan-Meier (K-M) Estimate for Overall Survival (OS) Day 1 (randomization) up to data cut off date of 15 July 2019; median follow-up for OS estimated by the reverse K-M method was 41.2 months for all participants. Overall survival was defined as time from randomization to death from any cause; participants surviving at the end of the follow-up period, or who withdraw consent, or who were lost to follow up were censored at the date last known alive.
- Secondary Outcome Measures
Name Time Method Mean Change in the Functional Assessment of Chronic Illness Therapy (FACIT-Fatigue Scale V 4.0) Score From Baseline Baseline to Cycle 2, Day 1 (C2D1), C3D1, C4D1, C5D1, C6D1, C7D1, C8D1, C9D1C3, C10D1, C11D1, C12D1, C13D1, C14D1, C15D1, C15D1, C16D1, C17D1, C18D1, C19D1, C20D1, C21D1, C22D1, C23D1, C24D1, C25D1 and continued on day 1 at each cycle through C33D1 The functional assessment of chronic illness therapy (FACIT-Fatigue Scale V 4.0) is a subscale of the FACIT-F and has been validated in the oncology setting. The FACIT-Fatigue Scale is a short, 13-item, self-administered tool that measures the level of fatigue in an individual during usually daily activities over the past week. The level of fatigue is measured on a 5-point Likert scale (0 = not at all; 4 = very much. The scores range from 0 to 52, with higher scores indicating less fatigue. If there were missing items, but the participant answered at least 50% of the items, then subscores were prorated.
Time to Definitive Clinically Meaningful Deterioration for ≥ 2 Consecutive Visits as Measured Using the Functional Assessment of Chronic Illness Therapy (FACIT-Fatigue Scale V 4.0) From day 1 (randomization) up to data cut off date of 15 July 2019; approximately 74 months Clinically meaningful deterioration was defined as at least 3 points of deterioration from baseline for at least 2 consecutive visits for the FACIT--Fatigue. The FACIT-Fatigue Scale V 4.0) is a subscale of the FACIT-F and has been validated in the oncology setting. The FACIT-Fatigue Scale is a short, 13-item, self-administered tool that measures the level of fatigue in an individual during usually daily activities over the past week. The level of fatigue is measured on a 5-point Likert scale (0 = not at all to 4 = very much. The scores that range from 0 to 52, with higher scores indicating less fatigue. If there were missing items, but the participant answered at least 50% of the items, subscores were prorated.
Kaplan-Meier Estimate of Time to Relapse Day 1 (randomization) to the date of the data cut off date of 15 July 2019; approximately 74 months Time to relapse was defined as the interval (in months) from the date of randomization to the date of documented relapse. Estimates of relapse rate were based on the cumulative incidence function from a competing risk analysis with death as a competing risk for relapse from complete remission (CR)/ complete remission with incomplete blood count recovery (CRi).
Documented relapse was defined as, the earliest date of the following:
* ≥ 5% bone marrow blasts (myeloblasts) from Central Pathology report, or
* appearance of \> 0% blasts in the peripheral blood with a later bone marrow confirmation (bone marrow blast \[myeloblasts\] ≥ 5%) within 100 days, or
* at least 2 peripheral blasts ≥ 5% within 30 days.Kaplan-Meier Estimates of Time to Discontinuation From Treatment From day 1 (randomization) up to data cut off date of 15 July 2019; approximately 74 months Time to discontinuation from treatment was assessed and defined as the interval from the date of randomization to the date of discontinuation from study drug. Participants who were receiving treatment at the time of study closure were censored at the date of last visit. Estimates of relapse rate were based on the cumulative incidence function from a competing risk analysis with death as a competing risk for relapse from CR/ CRi.
Number of Participants With Treatment Emergent Adverse Events (TEAEs) Day 1 (randomization) to the data cut off date of 15 July 2019; the median treatment duration was 11.6 months (range: 0.5 to 74.3 months) for the oral aza arm and 5.7 months (range: 0.7 to 68.5 months) for the placebo arm. TEAEs include AEs that started between first dose date and 28 days after the last dose of study drug.
A serious adverse event (SAE) is:
* Death
* Life-threatening event
* Inpatient hospitalization or prolongation of existing hospitalization
* Persistent or significant disability or incapacity
* Congenital anomaly or birth defect
* Other important medical event The severity of AEs were assessed by the investigator according to the Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0: Grade 1 (Mild): asymptomatic/mild symptoms; clinical or diagnostic observations only; intervention not indicated. Grade 2 (Moderate): minimal, local or noninvasive intervention indicated; limiting age-appropriate activities of daily living. Grade 3: Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self care Grade 4: Life-threatening; urgent intervention indicated. Grade 5: Death due to AE.Percentage of Participants Experiencing a Clinically Meaningful Change (Improvement, No Change and Deterioration) in the FACIT-Fatigue Scale From Baseline Baseline to Cycle 2, Day 1 (C2D1), C3D1, C4D1, C5D1, C6D1, C7D1, C8D1, C9D1C3, C10D1, C11D1, C12D1, C13D1, C14D1, C15D1, C15D1, C16D1, C17D1, C18D1, C19D1, C20D1, C21D1, C22D1, C23D1, C24D1, C25D1 and continued on day 1 at each cycle through C33D1 A clinically meaningful improvement or worsening was defined as at least 3 points of improvement or worsening from baseline, respectively, for FACIT-Fatigue. The functional assessment of chronic illness therapy (FACIT-Fatigue Scale V 4.0) is a subscale of the FACIT-F and has been validated in the oncology setting. The FACIT-Fatigue Scale is a short, 13-item, self-administered tool that measures the level of fatigue in an individual during usually daily activities over the past week. The level of fatigue is measured on a 5-point Likert scale (0 = not at all; 4 = very much. The scores range from 0 to 52, with higher scores indicating less fatigue. If there were missing items, but the participant answered at least 50% of the items, then subscores were prorated.
Kaplan-Meier Estimate of Relapse Free Survival (RFS) From day 1 (randomization) up to data cut off date of 15 July 2019; approximately 74 months RFS was defined as the time from the date of randomization to the date of documented relapse or death from any cause, whichever occurred first. Participants who were still alive without documented relapse, or who were lost to follow-up or withdrew consent without documented relapse, were censored at the date of their last bone marrow assessment, prior to receiving any other therapy for AML.
Documented relapse was defined as the earliest date of the following:
* ≥ 5% bone marrow blasts (myeloblasts) from Central Pathology report, or
* appearance of \> 0% blasts in the peripheral blood with a later bone marrow confirmation (bone marrow blast \[myeloblasts\] ≥ 5%) within 100 days, or
* at least 2 peripheral blasts ≥ 5% within 30 days.Mean Change in the European Quality of Life-Five Dimensions-Three Levels (EQ-5D-3L) Score From Baseline Baseline to Cycle 2, Day 1 (C2D1), C3D1, C4D1, C5D1, C6D1, C7D1, C8D1, C9D1C3, C10D1, C11D1, C12D1, C13D1, C14D1, C15D1, C15D1, C16D1, C17D1, C18D1, C19D1, C20D1, C21D1, C22D1, C23D1, C24D1, C25D1 and continued on day 1 at each cycle through C33D1 The EQ-5D-3L is a self-administered questionnaire consisting of 5 questions, pertaining to specific health dimensions (ie, mobility, self-care, pain, usual activities, and anxiety/depression) and a health status scale. Each question has 3 levels of severity, corresponding to no problems, moderate problems and severe problems. Canadian population sample weights were used to derive health utility scores. A higher utility score represents a better health state. A clinically meaningful improvement or worsening was defined as at least 0.08 points of improvement or 0.10 points of worsening from baseline, respectively, for the EQ-5D-3L Health Utility Index. The instrument is scored using the United Kingdom (UK) index ranges from -0.594 to 1, where 0 equates to death and 1 equates to full health; -0.594 is considered 'worse than death'.
Time to Definitive Clinically Meaningful Deterioration for ≥ 2 Consecutive Visits as Measured Using the EQ-5D HRQoL Scale From day 1 (randomization) up to data cut off date of 15 July 2019; approximately 74 months Clinically meaningful deterioration was defined at least 0.10 point of deterioration from baseline for at least 2 consecutive visits for the EQ-5D Health Utility Index. The EQ-5D-3L is a self-administered questionnaire consisting of 5 questions, pertaining to specific health dimensions (ie, mobility, self-care, pain, usual activities, and anxiety/depression) and a health status scale. Each question has 3 levels of severity, corresponding to no problems, moderate problems and severe problems. Canadian population sample weights were used to derive health utility scores. A higher utility score represents a better health state. A clinically meaningful improvement or worsening was defined as at least 0.08 points of improvement or 0.10 points of worsening from baseline, respectively, for the EQ-5D-3L Health Utility Index. The EQ-5D-3L is scored using the UK index ranges from -0.594 to 1, where 0 equates to death and 1 equates to full health; -0.594 is considered 'worse than death'.
Healthcare Resource Utilization (HRU): Rate of Hospital Events Per Person Year Day 1 (randomization) to the date of the data cut off date of 15 July 2019; approximately 74 months HRU is defined as any consumption of healthcare resources directly or indirectly related to the treatment of the patient. HRU is a key component to understand treatment costs and budget impact of new treatments from a provider perspective.
Percentage of Participants Experiencing a Clinically Meaningful Change (Improvement, No Change and Deterioration) in the EQ-5D-3L Scale From Baseline Baseline to Cycle 2, Day 1 (C2D1), C3D1, C4D1, C5D1, C6D1, C7D1, C8D1, C9D1C3, C10D1, C11D1, C12D1, C13D1, C14D1, C15D1, C15D1, C16D1, C17D1, C18D1, C19D1, C20D1, C21D1, C22D1, C23D1, C24D1, C25D1 and continued on day 1 at each cycle through C33D1 The EQ-5D-3L is a self-administered questionnaire consisting of 5 questions, pertaining to specific health dimensions (ie, mobility, self-care, pain, usual activities, and anxiety/depression) and a health status scale. Each question has 3 levels of severity, corresponding to no problems, moderate problems and severe problems. Canadian population sample weights were used to derive health utility scores. A higher utility score represents a better health state. A clinically meaningful improvement or worsening was defined as at least 0.08 points of improvement or 0.10 points of worsening from baseline, respectively, for the EQ-5D-3L Health Utility Index. The instrument is scored using the United Kingdom (UK) index ranges from -0.594 to 1, where 0 equates to death and 1 equates to full health; -0.594 is considered 'worse than death'.
Healthcare Resource Utilization (HRU): Number of Days Hospitalized Per Person-Year Day 1 (randomization) to the date of the data cut off date of 15 July 2019; approximately 74 months HRU is defined as any consumption of healthcare resources directly or indirectly related to the treatment of the patient. HRU is a key component to understand treatment costs and budget impact of new treatments from a provider perspective.
Trial Locations
- Locations (223)
Swedish Cancer Inst
🇺🇸Seattle, Washington, United States
Local Institution - 039
🇺🇸San Antonio, Texas, United States
Arizona Oncology Associates, P.C.
🇺🇸Phoenix, Arizona, United States
University of Oklahoma Peggy and Charles Stephenson Cancer Center
🇺🇸Oklahoma City, Oklahoma, United States
Local Institution - 653
🇹🇷Ankara, Turkey
Local Institution - 271
🇦🇹Graz, Austria
Local Institution - 006
🇺🇸Los Angeles, California, United States
Massachusetts General Hospital
🇺🇸Boston, Massachusetts, United States
Sharp Memorial Hospital
🇺🇸San Diego, California, United States
University of Southern California Norris Cancer Center
🇺🇸Los Angeles, California, United States
Northwestern University Medical Center
🇺🇸Chicago, Illinois, United States
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Franciscan St. Francis Health
🇺🇸Indianapolis, Indiana, United States
Innovative Clinical Research Institute
🇺🇸Whittier, California, United States
Local Institution - 010
🇺🇸Southington, Connecticut, United States
UPMC Cancer Pavillion
🇺🇸Pittsburgh, Pennsylvania, United States
Local Institution - 016
🇺🇸Cleveland, Ohio, United States
John Theurer Cancer Center at Hackensack University Medical Center
🇺🇸Hackensack, New Jersey, United States
Local Institution - 011
🇺🇸Nashville, Tennessee, United States
Local Institution - 510
🇦🇺Wollongong, New South Wales, Australia
Local Institution - 009
🇺🇸New York, New York, United States
Cancer Care Centers of South Texas - Loop
🇺🇸San Antonio, Texas, United States
Local Institution - 503
🇦🇺Heidelberg, Australia
Columbia University Irving Medical Center
🇺🇸New York, New York, United States
Local Institution - 504
🇦🇺Woodville South, South Australia, Australia
Local Institution - 507
🇦🇺Liverpool, Australia
Local Institution - 502
🇦🇺Hobart, Australia
Mount Sinai Comprehensive Cancer Center
🇺🇸Miami Beach, Florida, United States
University of California San Francisco Fresno Campus
🇺🇸Fresno, California, United States
Providence St Joseph Medical Center Cancer Center
🇺🇸Burbank, California, United States
Loyola University Chicago
🇺🇸Maywood, Illinois, United States
Duke University Medical Center
🇺🇸Durham, North Carolina, United States
Local Institution - 001
🇺🇸Houston, Texas, United States
Local Institution - 034
🇺🇸Fort Sam Houston, Texas, United States
Local Institution - 002
🇺🇸New York, New York, United States
Local Institution - 500
🇦🇺Melbourne, Australia
Local Institution - 013
🇺🇸Indianapolis, Indiana, United States
Local Institution - 041
🇺🇸Dallas, Texas, United States
Greenville Hospital System
🇺🇸Greenville, South Carolina, United States
Local Institution - 007
🇺🇸Nashville, Tennessee, United States
Local Institution - 506
🇦🇺St Leonards, Australia
Local Institution - 505
🇦🇺Perth, Australia
Local Institution - 300
🇧🇪Brugge, Belgium
Local Institution - 231
🇧🇷Porto Alegre, Rio Grande Do Sul, Brazil
Local Institution - 230
🇧🇷Sao Paulo, Brazil
Local Institution - 512
🇦🇺Perth, Australia
Local Institution - 270
🇦🇹Salzburg, Austria
Local Institution - 607
🇨🇦Toronto, Ontario, Canada
Local Institution - 273
🇦🇹Vienna, Austria
Local Institution - 403
🇩🇪Keil, Germany
Local Institution - 321
🇨🇿Praha, Czechia
Local Institution - 460
🇫🇷Clamart Cedex, France
Local Institution - 703
🇮🇹Palermo, Italy
Local Institution - 860
🇪🇸Valencia, Spain
Local Institution - 416
🇩🇪Schweiler, Germany
Local Institution - 401
🇩🇪Ulm, Germany
Washington University School Of Medicine
🇺🇸Saint Louis, Missouri, United States
Local Institution - 535
🇰🇷Busan, Korea, Republic of
Local Institution - 501
🇦🇺Woolloongabba, Australia
Local Institution - 004
🇺🇸Rochester, New York, United States
Local Institution - 014
🇺🇸Valhalla, New York, United States
Local Institution - 709
🇮🇹Roma, Italy
Stanford Cancer Center
🇺🇸Stanford, California, United States
Rocky Mountain Cancer Center
🇺🇸Denver, Colorado, United States
Local Institution - 037
🇺🇸Rochester, Minnesota, United States
Kaiser Permanente Northwest Oncology Hematology
🇺🇸Portland, Oregon, United States
Local Institution - 057
🇺🇸Omaha, Nebraska, United States
Froedtert Hospital BMT Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Local Institution - 044
🇺🇸Orlando, Florida, United States
Local Institution - 058
🇺🇸Louisville, Kentucky, United States
Local Institution - 049
🇺🇸Louisville, Kentucky, United States
Local Institution - 050
🇺🇸Orange, California, United States
City Of Hope
🇺🇸Duarte, California, United States
George Washington University Cancer Center
🇺🇸Washington, District of Columbia, United States
Cancer Care and Hematology Specialists of Chicagoland, P.C. - Niles, IL
🇺🇸Niles, Illinois, United States
Local Institution - 003
🇺🇸Westwood, Kansas, United States
Local Institution - 015
🇺🇸Worcester, Massachusetts, United States
Winthrop University Hospital
🇺🇸Mineola, New York, United States
Local Institution - 025
🇺🇸Winston-Salem, North Carolina, United States
Yakima Valley Memorial Hospital/ North Star Lodge
🇺🇸Yakima, Washington, United States
Local Institution - 509
🇦🇺South Brisbane, Queensland, Australia
Local Institution - 511
🇦🇺Bedford Park, South Australia, Australia
Local Institution - 508
🇦🇺Adelaide, South Australia, Australia
Local Institution - 458
🇫🇷Le Chesnay Cedex, France
Local Institution - 233
🇧🇷Curitiba, Paraná, Brazil
Local Institution - 232
🇧🇷Rio de Janeiro, Brazil
Local Institution - 234
🇧🇷São Paulo, Brazil
Local Institution - 605
🇨🇦Edmonton, Alberta, Canada
Local Institution - 600
🇨🇦Winnipeg, Manitoba, Canada
Local Institution - 604
🇨🇦Halifax, Nova Scotia, Canada
Local Institution - 608
🇨🇦Montreal, Quebec, Canada
Local Institution - 602
🇨🇦Montreal, Quebec, Canada
Local Institution - 320
🇨🇿Brno, Jihomoravský Kraj, Czechia
Local Institution - 322
🇨🇿Praha, Czechia
Local Institution - 362
🇫🇮Tampere, Finland
Local Institution - 456
🇫🇷Amiens, France
Local Institution - 361
🇫🇮Helsinki, Finland
Local Institution - 465
🇫🇷Argenteuil, France
Local Institution - 360
🇫🇮Turku, Finland
Local Institution - 462
🇫🇷Boulognes Sur Mer, France
Local Institution - 457
🇫🇷Bobigny Cedex, France
Local Institution - 452
🇫🇷Creteil, France
Local Institution - 453
🇫🇷Lille, France
Local Institution - 463
🇫🇷Paris, France
Local Institution - 454
🇫🇷Paris, France
Local Institution - 461
🇫🇷Limoges Cedex, France
Local Institution - 450
🇫🇷Lyon cedex, France
Local Institution - 800
🇫🇷Paris Cedex 10, France
Local Institution - 464
🇫🇷Pontoise, France
Local Institution - 455
🇫🇷Rouen, France
Local Institution - 459
🇫🇷Saint-Cloud, France
Local Institution - 400
🇩🇪Dresden, Saxony, Germany
Local Institution - 451
🇫🇷Villejuif CEDEX, France
Local Institution - 413
🇩🇪Berlin, Germany
Local Institution - 406
🇩🇪Düsseldorf, Germany
Local Institution - 410
🇩🇪Bonn, Germany
Local Institution - 415
🇩🇪Erlangen, Germany
Local Institution - 404
🇩🇪Frankfurt am Main, Germany
Local Institution - 411
🇩🇪München, Germany
Local Institution - 412
🇩🇪Goch, Germany
Local Institution - 408
🇩🇪Heilbronn, Germany
Local Institution - 405
🇩🇪Hannover, Germany
Local Institution - 414
🇩🇪Jena, Germany
Local Institution - 409
🇩🇪Muenchen, Germany
Local Institution - 402
🇩🇪Mannheim, Germany
Local Institution - 407
🇩🇪Oldenburg, Germany
Local Institution - 717
🇮🇹Naples, Italy
Local Institution - 950
🇮🇪Dublin, Ireland
Local Institution - 381
🇮🇱Beer Sheva, Israel
Local Institution - 383
🇮🇱Jerusalem, Israel
Local Institution - 380
🇮🇱Haifa, Israel
Local Institution - 382
🇮🇱Petach Tikva, Israel
Local Institution - 701
🇮🇹Alessandria, Italy
Local Institution - 721
🇮🇹Bari, Italy
Local Institution - 720
🇮🇹Bologna, Italy
Local Institution - 710
🇮🇹Cagliari, Italy
Local Institution - 708
🇮🇹Firenze, Italy
Local Institution - 702
🇮🇹Cremona, Italy
Local Institution - 712
🇮🇹Genova, Italy
Local Institution - 716
🇮🇹Lecce, Italy
Local Institution - 726
🇮🇹Milano, Italy
Local Institution - 706
🇮🇹Milan, Italy
Local Institution - 704
🇮🇹Monza, Italy
Local Institution - 725
🇮🇹Naples, Italy
Local Institution - 705
🇮🇹Orbassano (TO), Italy
Local Institution - 719
🇮🇹Palermo, Italy
Local Institution - 724
🇮🇹Pesaro, Italy
Local Institution - 700
🇮🇹Reggio Calabria, Italy
Local Institution - 714
🇮🇹Roma, Italy
Local Institution - 723
🇮🇹Roma, Italy
Local Institution - 722
🇮🇹Rome, Italy
Local Institution - 718
🇮🇹Torino, Italy
Local Institution - 707
🇮🇹Varese, Italy
Local Institution - 715
🇮🇹Torino, Italy
Local Institution - 711
🇮🇹Udine, Italy
Local Institution - 533
🇰🇷Daegu, Korea, Republic of
Local Institution - 536
🇰🇷Seoul, Korea, Republic of
Local Institution - 530
🇰🇷Seoul, Korea, Republic of
Local Institution - 531
🇰🇷Seoul, Korea, Republic of
Local Institution - 532
🇰🇷Seoul, Korea, Republic of
Local Institution - 821
🇵🇱Warsaw, Poland
Local Institution - 841
🇵🇹Coimbra, Portugal
Local Institution - 252
🇲🇽Huixquilucan de Degollado, Mexico
Local Institution - 750
🇱🇹Klaipeda, Lithuania
Local Institution - 251
🇲🇽Mexico, Mexico
Local Institution - 250
🇲🇽Monterrey, Mexico
Local Institution - 824
🇵🇱Bydgoszcz, Poland
Local Institution - 820
🇵🇱Gdansk, Poland
Local Institution - 823
🇵🇱Wroclaw, Poland
Local Institution - 822
🇵🇱Lodz, Poland
Local Institution - 843
🇵🇹Lisboa, Portugal
Local Institution - 842
🇵🇹Porto, Portugal
Local Institution - 971
🇷🇺Moscow, Russian Federation
Local Institution - 844
🇵🇹Porto, Portugal
Local Institution - 970
🇷🇺Nizhniy Novgorod, Russian Federation
Local Institution - 972
🇷🇺Saint Petersburg, Russian Federation
Local Institution - 872
🇪🇸Palma de Mallorca, Baleares, Spain
Local Institution - 973
🇷🇺St Petersburg, Russian Federation
Local Institution - 869
🇪🇸Badalona (Barcelona), Spain
Local Institution - 871
🇪🇸Barcelona, Spain
Local Institution - 861
🇪🇸Salamanca, Spain
Local Institution - 870
🇪🇸Barcelona, Spain
Local Institution - 867
🇪🇸La Coruna, Spain
Local Institution - 866
🇪🇸Madrid, Spain
Local Institution - 873
🇪🇸Caceres, Spain
Local Institution - 868
🇪🇸Madrid, Spain
Local Institution - 865
🇪🇸Madrid, Spain
Local Institution - 863
🇪🇸Cordoba, Spain
Local Institution - 864
🇪🇸Oviedo, Spain
Local Institution - 599
🇨🇳Beitou District, Taipei City, Taiwan
Local Institution - 595
🇨🇳Niaosong District Kaohsiung City, Taiwan
Local Institution - 862
🇪🇸Sevilla, Spain
Local Institution - 597
🇨🇳Tainan, Taiana, Taiwan
Local Institution - 598
🇨🇳Taipei, Zhongzheng Dist., Taiwan
Local Institution - 650
🇹🇷Ankara, Turkey
Local Institution - 651
🇹🇷Istanbul, Turkey
Local Institution - 652
🇹🇷Samsun, Turkey
Local Institution - 903
🇬🇧Brighton East Sussex, United Kingdom
Local Institution - 902
🇬🇧Canterbury Kent, United Kingdom
Local Institution - 907
🇬🇧Boston, United Kingdom
Local Institution - 905
🇬🇧London, United Kingdom
Local Institution - 901
🇬🇧London, United Kingdom
Local Institution - 908
🇬🇧London, United Kingdom
Local Institution - 909
🇬🇧Maidstone, United Kingdom
Local Institution - 906
🇬🇧Romford, Essex, United Kingdom
Local Institution - 900
🇬🇧Manchester, United Kingdom
Cancer Institute of New Jersey
🇺🇸New Brunswick, New Jersey, United States
Local Institution - 601
🇨🇦Saint John, New Brunswick, Canada
Local Institution - 272
🇦🇹Wien, Austria
Local Institution - 301
🇧🇪Charleroi, Belgium
Local Institution - 603
🇨🇦St John's, Newfoundland and Labrador, Canada
Local Institution - 596
🇨🇳Taichung, Northern Dist., Taiwan
Local Institution - 302
🇧🇪Mons, Belgium
Local Institution - 951
🇮🇪Galway, Ireland
Local Institution - 840
🇵🇹Lisboa, Portugal
Local Institution - 274
🇦🇹Vienna, Austria
Local Institution - 904
🇬🇧Nottingham, Nottinghamshire, United Kingdom
Lancaster General Hospital
🇺🇸Lancaster, Pennsylvania, United States
Local Institution - 023
🇺🇸Kansas City, Missouri, United States
Local Institution - 047
🇺🇸New Orleans, Louisiana, United States
Ochsner Medical Center - Jefferson Highway
🇺🇸New Orleans, Louisiana, United States
Local Institution - 035
🇺🇸Richmond, Virginia, United States
Local Institution - 046
🇺🇸Gainesville, Florida, United States