Direct Oral Anticoagulants (DOACs) Versus LMWH +/- Warfarin for VTE in Cancer

Not Applicable

Completed

Conditions: Cancer
Venous Thromboembolism
Deep Vein Thrombosis (DVT)
Pulmonary Embolism (PE)
Blood Clot

Interventions: Drug: Rivaroxaban
Drug: Warfarin
Drug: Apixaban
Drug: Dalteparin
Drug: Edoxaban
Drug: Enoxaparin
Drug: Dabigatran
Drug: Fondaparinux

Registration Number: NCT02744092

Lead Sponsor: Alliance Foundation Trials, LLC.

Brief Summary: The overarching objective of the study is to determine the effectiveness of LMWH/ warfarin vs. DOAC anticoagulation for preventing recurrent VTE in cancer patients. The intervention strategy is Direct Oral AntiCoagulants (DOAC) therapy with edoxaban, apixaban, rivaroxaban, or dabigatran. The comparator is low molecular weight heparin (LMWH) alone or with warfarin. The information gained will empower cancer patients and physicians to make more informed choices about anticoagulation strategies to manage VTE.

Detailed Description: Venous blood clots affect nearly a million Americans each year. Venous clots in the legs are called deep venous thrombosis (DVT) and are dangerous because they travel to the lungs where they cause blockages known as pulmonary emboli (PE). DVT and PE are called venous thromboemboli (VTE). Cancer is a risk factor with nearly 200,000 VTEs in cancer patients each year. The purpose of VTE treatment is to prevent the initial clot from spreading and to prevent new clots from forming. This is accomplished by thinning the blood, or anticoagulation. Without anticoagulation, VTEs recur and are often fatal.

Recently, the FDA has approved 4 new Direct Oral AntiCoagulants (DOACs) for preventing VTE recurrence. Few cancer patients were included in the efficacy trials, and practice guidelines fall silent on whether switching to DOAC therapy is advisable. To fill this knowledge gap, the Alliance Foundation Trials LLC, a research network of academic and community practices across the US, is conducting a pragmatic randomized effectiveness trial.

The overarching objective of the study is to determine the effectiveness of LMWH/ warfarin vs. DOAC anticoagulation for preventing recurrent VTE in cancer patients. The investigators will conduct a trial of 811 cancer patients followed for 6 months. The intervention strategy is DOAC therapy with edoxaban, apixaban, rivaroxaban, or dabigatran. The comparator is LMWH alone or with warfarin. Within each arm, patients can choose the agent they prefer based on side effects, drug interactions, and practical issues such as co-pays. The trial compares these two strategies in terms of treatment: 1) benefits based on VTE recurrence; 2) harms based on bleeding rates; 3) burdens based on patients' reports of their experiences; and 4) mortality rates.

The investigators hypothesize that the benefits, harms and burdens of DOAC treatment will be non-inferior to, or better than, usual care with LMWH/ warfarin among cancer patients. The information gained will empower cancer patients and physicians to make more informed choices about anticoagulation strategies to manage VTE.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 811

Inclusion Criteria

Diagnosis of advanced solid tumor cancer, lymphoma, or myeloma (no time restrictions or limitations) -OR- diagnosis of early stage solid tumor cancer, lymphoma, or myeloma <= 12 months prior to study enrollment
Diagnosis of VTE <= 30 days prior to study enrollment for which potential benefits of anticoagulation therapy to prevent recurrence of VTE are felt by the treating physician to exceed the potential harms
- Any anticoagulation drug/strategy may be used to treat the index VTE; protocol treatment will begin <= 30days after the index VTE diagnosis date
Treating physician intends to put participant on anticoagulation therapy for at least three months.
Age >= 18 years
Platelet count is >= 50,000/mm^3 (<= 7 days prior to enrollment)
CrCl (Creatinine Clearance) is >= 15 ml/min (<= 7 days prior to enrollment)

Exclusion Criteria

Diagnosis of acute leukemia
Has ever received or is scheduled to receive an Allogeneic Hematopoietic Stem Cell Transplantation (alloHSCT)
- Patients who have ever received an Autologous Hematopoietic Stem Cell Transplantation (autoHSCT) ARE eligible.
- Patients who are scheduled to receive an Autologous Hematopoietic Stem Cell Transplantation (autoHSCT) are NOT eligible
Ongoing, clinically significant bleeding (CTCAE grade 3 or 4)
Ongoing therapy with a P-gp inhibitor (e.g., nelfinavir, indinavir, or saquinavir-protease inhibitors for HIV) as these drugs interact with the factor Xa inhibitors
Therapy with any azole antifungals (e.g., itraconazole, ketaconazole, voriconazole) at the time of enrollment

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Randomized Arm 1 (DOACs)	Rivaroxaban	Randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC). There are four FDA-approved DOAC drugs that may be used for this study: Rivaroxaban, Apixaban, Edoxaban, or Dabigatran. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 1 (DOACs)	Apixaban	Randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC). There are four FDA-approved DOAC drugs that may be used for this study: Rivaroxaban, Apixaban, Edoxaban, or Dabigatran. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 1 (DOACs)	Edoxaban	Randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC). There are four FDA-approved DOAC drugs that may be used for this study: Rivaroxaban, Apixaban, Edoxaban, or Dabigatran. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 1 (DOACs)	Dabigatran	Randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC). There are four FDA-approved DOAC drugs that may be used for this study: Rivaroxaban, Apixaban, Edoxaban, or Dabigatran. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 2 (LMWH)	Warfarin	Randomized Arm 2 will get anticoagulation therapy with low molecular weight heparin (LMWH) with or without a transition to warfarin. There are three FDA-approved LMWH drugs that may be used for this study: Dalteparin, Enoxaparin, or Fondaparinux. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Preference Cohort 1 (DOACs)	Rivaroxaban	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC).
Randomized Arm 2 (LMWH)	Enoxaparin	Randomized Arm 2 will get anticoagulation therapy with low molecular weight heparin (LMWH) with or without a transition to warfarin. There are three FDA-approved LMWH drugs that may be used for this study: Dalteparin, Enoxaparin, or Fondaparinux. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 2 (LMWH)	Dalteparin	Randomized Arm 2 will get anticoagulation therapy with low molecular weight heparin (LMWH) with or without a transition to warfarin. There are three FDA-approved LMWH drugs that may be used for this study: Dalteparin, Enoxaparin, or Fondaparinux. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Randomized Arm 2 (LMWH)	Fondaparinux	Randomized Arm 2 will get anticoagulation therapy with low molecular weight heparin (LMWH) with or without a transition to warfarin. There are three FDA-approved LMWH drugs that may be used for this study: Dalteparin, Enoxaparin, or Fondaparinux. The treatment (including dosage form, dosage, frequency and duration) should be administered in accordance with the drug's FDA package insert, and all modifications are at the discretion of the treating investigator.
Preference Cohort 1 (DOACs)	Apixaban	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC).
Preference Cohort 1 (DOACs)	Edoxaban	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC).
Preference Cohort 1 (DOACs)	Dabigatran	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 1 will get anticoagulation therapy with a Direct Oral AntiCoagulant (DOAC).
Preference Cohort 2 (LMWH)	Dalteparin	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 2 will get anticoagulation therapy with Low Molecular Weight Heparin (LMWH) with or without a transition to warfarin.
Preference Cohort 2 (LMWH)	Warfarin	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 2 will get anticoagulation therapy with Low Molecular Weight Heparin (LMWH) with or without a transition to warfarin.
Preference Cohort 2 (LMWH)	Fondaparinux	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 2 will get anticoagulation therapy with Low Molecular Weight Heparin (LMWH) with or without a transition to warfarin.
Preference Cohort 2 (LMWH)	Enoxaparin	If an eligible participant is offered randomization and declines randomization, then a limited number of participants (up to N=190) will be allowed to enroll in the Preference Cohort. In this case, the treating physician and patient choose Arm 1 or Arm 2 (non-randomized). Preference cohort: Non-randomized Arm 2 will get anticoagulation therapy with Low Molecular Weight Heparin (LMWH) with or without a transition to warfarin.

Primary Outcome Measures

Name	Time	Method
Cumulative Non-Fatal VTE Recurrence at 6 Months (%)	6 months	To compare the effectiveness of anticoagulation with a DOAC (intervention) with LMWH/warfarin (comparator) for preventing VTE recurrence in patients with cancer based on cumulative VTE recurrence reported by patients or clinicians at 6 months. Only VTEs that were nonfatal were considered because of the challenges of attributing cause of death in cancer patients to tumor progression vs. VTE.

Secondary Outcome Measures

Name	Time	Method
Cumulative Rates of Major Bleeding	6 months	To compare the harms of DOAC vs. LMWH/warfarin therapy for cancer patients with VTE based on the cumulative rate of major bleeding at 6 months. d. Major bleeding was defined as Grade \>=3 on the Common Terminology Criteria for Adverse Events from the National Cancer Institute (NCI CTCAE) criteria version 5.0 (i.e., severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self care activities of daily living).
Health Related Quality of Life Reported by Participants Via the Optum SF-12v2 Health Survey Questionnaire	6 months	Change in physical health at 6 months. Health-related quality of life was measured using the 12-Item Short Form Health Survey (SF-12) sub-scales for physical and mental health (score range, 0-100; higher scores indicate better physical and mental health functioning). Survey content included minor verbiage changes for clarity. The presented scores in this results section indicate the change (difference) in mean scores between the baseline and 6-month follow-up assessment.
Burden of Anticoagulation Therapy Reported by Participants Via the Anti-Clot Treatment Scale (ACTS) Questionnaire	6 months	To compare the burden of anticoagulation therapy with DOAC vs. with LMWH/warfarin for cancer patients with VTE at 6 months. The burden scale has12 items and patients are asked to rate their experiences on a 5-point scale of intensity (1=not at all, 2=a little, 3=moderately, 4=quite a bit, 5=extremely). The ACTS burden tool is then scored using the totals from each question with a total score from 12 to 60 possible. Higher scores signify greater satisfaction (lower burden).
Mortality Reported by Participants' Surrogates (Via Study-specific Questionnaire) or Clinicians (Via Study-specific Case Report Form)	6 months	To compare the impact of DOAC vs. LMWH/warfarin therapy on mortality in cancer patients with VTE based on survival at 6 months. Mortality was reported by participants' surrogates (via study-specific questionnaire) or clinicians (via study-specific case report form)
Benefit of Anticoagulation Therapy Reported by Participants Via the Anti-Clot Treatment Scale (ACTS) Questionnaire	6-months	To compare the benefit of anticoagulation therapy with DOAC vs. with LMWH/warfarin for cancer patients with VTE at 6 months. The benefits scale has 3 items and patients are asked to rate their experiences on a 5-point scale of intensity (1=not at all, 2=a little, 3=moderately, 4=quite a bit, 5=extremely). The ACTS benefits tool is then scored using the totals from each question with a total score from 3 to 15 possible. Higher scores signify greater satisfaction (greater benefits).
Health Related Quality of Life (Mental Health) Reported by Participants Via the Optum SF-12v2 Health Survey Questionnaire at 3-months	3-months	Change in mental health at 3 months from baseline. Health-related quality of life was measured using the 12-Item Short Form Health Survey (SF-12) sub-scales for physical and mental health (score range, 0-100; higher scores indicate better physical and mental health functioning). Survey content included minor verbiage changes for clarity. The scores indicate change in score from baseline.
Health Related Quality of Life (Mental Health) Reported by Participants Via the Optum SF-12v2 Health Survey Questionnaire at 6-months	6-months	Change in mental health at 6 months from baseline. Health-related quality of life was measured using the 12-Item Short Form Health Survey (SF-12) sub-scales for physical and mental health (score range, 0-100; higher scores indicate better physical and mental health functioning). Survey content included minor verbiage changes for clarity. The scores indicate change in score from baseline.

Trial Locations

Locations (148): Washington Hospital
🇺🇸
Fremont, California, United States
Memorial Cancer Institute at Memorial Regional Hospital
🇺🇸
Hollywood, Florida, United States
Saint Joseph's Medical Center
🇺🇸
Stockton, California, United States
Dartmouth Hitchcock Medical Center
🇺🇸
Lebanon, New Hampshire, United States
Roswell Park Cancer Institute
🇺🇸
Buffalo, New York, United States
South County Hematology
🇺🇸
Chula Vista, California, United States
Cancer Center Oncology Medical Group
🇺🇸
La Mesa, California, United States
St. Elizabeth's Medical Center
🇺🇸
Brighton, Massachusetts, United States
Bozeman Health
🇺🇸
Bozeman, Montana, United States
Dana-Farber/New Hampshire Oncology Hematology
🇺🇸
Londonderry, New Hampshire, United States
Onslow Medical Center
🇺🇸
Richlands, North Carolina, United States
WellSpan Health York Cancer Center
🇺🇸
York, Pennsylvania, United States
Green Bay Oncology, Ltd./HSHS St. Mary's Hospital Medical Center
🇺🇸
Green Bay, Wisconsin, United States
MultiCare Regional Cancer Center - Tacoma
🇺🇸
Tacoma, Washington, United States
University of Maryland Medical Center
🇺🇸
Baltimore, Maryland, United States
East Carolina University
🇺🇸
Greenville, North Carolina, United States
MultiCare Regional Cancer Center - Puyallup
🇺🇸
Puyallup, Washington, United States
Western Pennsylvania Hospital
🇺🇸
Pittsburgh, Pennsylvania, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
Ann M Wierman MD LTD
🇺🇸
Las Vegas, Nevada, United States
Sharp Memorial Hospital
🇺🇸
San Diego, California, United States
Henry Ford Health System
🇺🇸
Detroit, Michigan, United States
Community Hospital of Anaconda
🇺🇸
Anaconda, Montana, United States
Benefis Sletten Cancer Institute
🇺🇸
Great Falls, Montana, United States
Kalispell Regional Medical Center
🇺🇸
Kalispell, Montana, United States
Montana Cancer Consortium
🇺🇸
Billings, Montana, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
Walter Reed National Military Medical Center
🇺🇸
Bethesda, Maryland, United States
WellSpan Health Adams Cancer Center
🇺🇸
Gettysburg, Pennsylvania, United States
Sharp Rees-Stealy
🇺🇸
San Diego, California, United States
Washington Hospital Healthcare System
🇺🇸
Fremont, California, United States
VA Central California Fresno Medical Center
🇺🇸
Fresno, California, United States
Medical Oncology Associates- San Diego
🇺🇸
San Diego, California, United States
UCSF Medical Center - Mission Bay
🇺🇸
San Francisco, California, United States
Morton Plant Hospital
🇺🇸
Clearwater, Florida, United States
Breast Cancer Center at Memorial Regional Hospital
🇺🇸
Hollywood, Florida, United States
Middlesex Hospital
🇺🇸
Middletown, Connecticut, United States
Memorial Regional Hospital
🇺🇸
Hollywood, Florida, United States
Breast Cancer Center at Memorial Hospital West
🇺🇸
Pembroke Pines, Florida, United States
Hollis Cancer Center
🇺🇸
Lakeland, Florida, United States
Memorial Hospital West
🇺🇸
Pembroke Pines, Florida, United States
Memorial Cancer Institute at Memorial Hospital West
🇺🇸
Pembroke Pines, Florida, United States
The Center for Cancer Care-Snellville
🇺🇸
Snellville, Georgia, United States
The Center for Cancer Care-Duluth
🇺🇸
Duluth, Georgia, United States
Gwinnett Medical Center
🇺🇸
Lawrenceville, Georgia, United States
University of Illinois
🇺🇸
Chicago, Illinois, United States
Advocate Illinois Masonic Medical Center
🇺🇸
Chicago, Illinois, United States
Carle on Vermillion
🇺🇸
Danville, Illinois, United States
Kootenai Health
🇺🇸
Post Falls, Idaho, United States
NorthShore University HealthSystem Evanston Hospital
🇺🇸
Evanston, Illinois, United States
NorthShore University HealthSystem Glenbrook Hospital
🇺🇸
Glenview, Illinois, United States
Carle - Effingham
🇺🇸
Effingham, Illinois, United States
NorthShore University HealthSystem Highland Park Hospital
🇺🇸
Highland Park, Illinois, United States
Carle - Mattoon/Charleston
🇺🇸
Mattoon, Illinois, United States
NorthShore University HealthSystem Skokie ACC
🇺🇸
Skokie, Illinois, United States
Loyola University Medical Center
🇺🇸
Maywood, Illinois, United States
The Carle Foundation Hospital/Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Franciscan St. Francis Health - Mooresville
🇺🇸
Mooresville, Indiana, United States
Franciscan St. Francis Health - Indianapolis
🇺🇸
Indianapolis, Indiana, United States
Woodland Cancer Care Center
🇺🇸
Michigan City, Indiana, United States
Union Hospital
🇺🇸
Terre Haute, Indiana, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Memorial Hospital at South Bend
🇺🇸
South Bend, Indiana, United States
Saint Elizabeth Medical Center Fort Thomas
🇺🇸
Fort Thomas, Kentucky, United States
Saint Elizabeth Medical Center South
🇺🇸
Edgewood, Kentucky, United States
Chandler Medical Center - University of Kentucky
🇺🇸
Lexington, Kentucky, United States
Eastern Maine Medical Center
🇺🇸
Bangor, Maine, United States
DF/BWCC at Milford Regional Medical Center
🇺🇸
Boston, Massachusetts, United States
Massachusetts General Hospital
🇺🇸
Boston, Massachusetts, United States
Brigham & Women's Hospital
🇺🇸
Boston, Massachusetts, United States
Lowell General Hospital
🇺🇸
Lowell, Massachusetts, United States
South Shore Hospital
🇺🇸
South Weymouth, Massachusetts, United States
Green Bay Oncology, Ltd./St. Francis Hospital
🇺🇸
Escanaba, Michigan, United States
Masonic Cancer Center University of Minnesota Medical Center
🇺🇸
Minneapolis, Minnesota, United States
University of Minnesota Health: Clinics and Surgery Center
🇺🇸
Minneapolis, Minnesota, United States
University of Minnesota Medical Center, Fairview
🇺🇸
Minneapolis, Minnesota, United States
Veterans Administration/Harry S Truman Memorial Hospital
🇺🇸
Columbia, Missouri, United States
Ellis Fischel Cancer Center University of Missouri Healthcare
🇺🇸
Columbia, Missouri, United States
Siteman Cancer Center - West County
🇺🇸
Saint Louis, Missouri, United States
Siteman Cancer Center - St. Peters
🇺🇸
Saint Peters, Missouri, United States
Billings Clinic
🇺🇸
Billings, Montana, United States
Nevada Cancer Specialists - Oakey
🇺🇸
Las Vegas, Nevada, United States
Community Medical Center
🇺🇸
Missoula, Montana, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
Nevada Cancer Specialists - Tenaya
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Central Valley
🇺🇸
Las Vegas, Nevada, United States
Nevada Cancer Specialists - Fort Apache
🇺🇸
Las Vegas, Nevada, United States
New Hampshire Oncology - Hematology PA
🇺🇸
Concord, New Hampshire, United States
New Hampshire Oncology-Hematology PA
🇺🇸
Hooksett, New Hampshire, United States
John Theurer Cancer Center at Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
SUNY Upstate Medical University
🇺🇸
New York, New York, United States
Southeastern Medical Oncology Center
🇺🇸
Jacksonville, North Carolina, United States
Mission Hospital - Memorial Campus
🇺🇸
Asheville, North Carolina, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Lenoir Memorial Hospital
🇺🇸
Kinston, North Carolina, United States
Duke University Health System
🇺🇸
Durham, North Carolina, United States
Kenansville Medical Center
🇺🇸
Kenansville, North Carolina, United States
The James Cancer Hospital and Solove Research Institute
🇺🇸
Columbus, Ohio, United States
Dayton Physicians LLC, Miami Valley South
🇺🇸
Centerville, Ohio, United States
Kinston Medical Specialists, P.A.
🇺🇸
Kinston, North Carolina, United States
Dayton Physicians LLC, Samaritan North
🇺🇸
Dayton, Ohio, United States
Veteran Affairs Medical Center
🇺🇸
Dayton, Ohio, United States
Dayton Clincial Oncology Program
🇺🇸
Dayton, Ohio, United States
Dayton Physicians LLC, Atrium
🇺🇸
Franklin, Ohio, United States
Greater Dayton Cancer Center
🇺🇸
Kettering, Ohio, United States
Wright Patterson Medical Center
🇺🇸
Dayton, Ohio, United States
Dayton Physicians, Wayne
🇺🇸
Greenville, Ohio, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
Dayton Physicians LLC, Upper valley
🇺🇸
Troy, Ohio, United States
WellSpan Health Sechler Family Cancer Center
🇺🇸
Lebanon, Pennsylvania, United States
WellSpan Health Ephrata Cancer Center
🇺🇸
Ephrata, Pennsylvania, United States
Toledo Clinic Cancer Center - Maumee
🇺🇸
Maumee, Ohio, United States
Toledo Clinic Cancer Center - Toledo
🇺🇸
Toledo, Ohio, United States
University of Vermont Medical Center
🇺🇸
Burlington, Vermont, United States
Fort Belvoir Community Hospital
🇺🇸
Fort Belvoir, Virginia, United States
Augusta Health Cancer Center
🇺🇸
Fishersville, Virginia, United States
Bon Secours Cancer Institute Medical Oncology at Memorial Regional
🇺🇸
Mechanicsville, Virginia, United States
Bon Secours Cancer Institute Medical Oncology at St. Francis
🇺🇸
Midlothian, Virginia, United States
MultiCare Regional Cancer Center - Auburn
🇺🇸
Auburn, Washington, United States
MultiCare Regional Cancer Center - Gig Harbor Medical Park
🇺🇸
Gig Harbor, Washington, United States
HSHS St. Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Green Bay Oncology, Ltd./HSHS St. Vincent Hospital
🇺🇸
Green Bay, Wisconsin, United States
Multicare Institute for Research & Innovation
🇺🇸
Tacoma, Washington, United States
HSHS St. Mary's Hospital Medical Center
🇺🇸
Green Bay, Wisconsin, United States
University of Wisconsin
🇺🇸
Madison, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸
La Crosse, Wisconsin, United States
Green Bay Oncology, Ltd./HSHS St. Clare Memorial Hospital
🇺🇸
Oconto Falls, Wisconsin, United States
Green Bay Oncology, Ltd./Door County Memorial Hospital
🇺🇸
Sturgeon Bay, Wisconsin, United States
Siteman Cancer Center - South County
🇺🇸
Saint Louis, Missouri, United States
Baylor University Medical Center
🇺🇸
Dallas, Texas, United States
The Stamford Hospital
🇺🇸
Stamford, Connecticut, United States
Baylor Scott & White Research Institute
🇺🇸
Dallas, Texas, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
University of Texas Southwestern Medical Center
🇺🇸
Dallas, Texas, United States
James Graham Brown Cancer Center
🇺🇸
Louisville, Kentucky, United States
Norton Hospital
🇺🇸
Louisville, Kentucky, United States
University of Louisville Hospital
🇺🇸
Louisville, Kentucky, United States
University of Louisville Physicians, PSC
🇺🇸
Louisville, Kentucky, United States
University of Louisville, Division of Surgical Oncology
🇺🇸
Louisville, Kentucky, United States
Wake Forest Baptist Health
🇺🇸
Winston-Salem, North Carolina, United States
Bon Secours Cancer Institute Medical Oncology at St. Mary's
🇺🇸
Richmond, Virginia, United States
Hawaii Cancer Care POB II
🇺🇸
Honolulu, Hawaii, United States
Hawaii Oncology Inc Kuakini
🇺🇸
Honolulu, Hawaii, United States
Hawaii Oncology Inc POB I
🇺🇸
Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸
Honolulu, Hawaii, United States
Hawaii Cancer Care Liliha
🇺🇸
Honolulu, Hawaii, United States