Radiation Therapy in Treating Patients With Stage II Prostate Cancer
- Conditions
- Prostate Cancer
- Interventions
- Radiation: Conventional 3D-CRT or IMRTRadiation: Hypofractionated 3D-CRT or IMRT
- Registration Number
- NCT00331773
- Lead Sponsor
- Radiation Therapy Oncology Group
- Brief Summary
RATIONALE: Giving radiation therapy that uses a 3-dimensional (3-D) image of the tumor to help focus thin beams of radiation directly on the tumor, and giving hypofractionated radiation therapy (higher doses over a shorter period of time), may be less costly with fewer side effects and just as effective in treating prostate cancer.
PURPOSE: This randomized phase III trial is studying several different radiation therapy regimens to compare how well they work in treating patients with stage II prostate cancer.
- Detailed Description
OBJECTIVES:
Primary
* Compare the disease-free survival (DFS) of patients with favorable-risk stage II prostate cancer treated with hypofractionated vs conventionally fractionated three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT).
Secondary
* Compare time to local progression, freedom from biochemical recurrence, and disease-specific and overall survival of patients treated with these regimens.
* Determine the incidence of gastrointestinal and genitourinary toxic effects in patients treated with these regimens.
* Compare the degree, duration, and significant differences in disease-specific health-related quality of life (HRQOL) decrements, using the Expanded Prostate Cancer Index Composite (EPIC), in patients treated with these regimens.
* Determine whether anxiety and/or depression, as measured by the Hopkins Symptom Checklist-25 (HSCL-25), are decreased with therapy that improves DFS of these patients .
* Determine whether the incremental gain in DFS outweighs decrements in the generic domains of HRQOL (i.e., mobility, self care, usual activities, pain/discomfort, and anxiety/depression) in patients treated with these regimens.
* Conduct a cost-utility analysis of hypofractionated 3D-CRT or IMRT as a prostate cancer therapy if this regimen is shown to be as effective as conventionally fractionated 3D-CRT or IMRT in improving DFS.
OUTLINE: This is a randomized, controlled, multicenter study. Patients are stratified according to Gleason score (2-4 vs 5-6), prostate-specific antigen (PSA) level (\< 4 ng/mL vs 4-\<9 ng/mL), and planned radiotherapy modality (three-dimensional conformal radiotherapy \[3D-CRT\] vs intensity-modulated radiotherapy \[IMRT\]). Patients are randomized to 1 of 2 treatment arms.
* Arm I: Patients undergo conventionally fractionated 3D-CRT or IMRT once daily 5 days a week for 8.2 weeks (total of 41 treatments).
* Arm II: Patients undergo hypofractionated 3D-CRT or IMRT once daily 5 days a week for 5.6 weeks (total of 28 treatments).
Quality of life, anxiety, and depression are assessed at baseline and then at 6 months and 1, 2, and 5 years after the start of radiotherapy.
After completion of study treatment, patients are followed every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.
PROJECTED ACCRUAL: A total of 1,067 patients will be accrued to this study.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- Male
- Target Recruitment
- 1116
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Conventional 3D-CRT Conventional 3D-CRT or IMRT Conventional 3D-CRT or IMRT to 73.8 Gy in 41 fractions Hypofractionated 3D-CRT Hypofractionated 3D-CRT or IMRT Hypofractionated 3D-CRT or IMRT to 70 Gy in 28 fractions
- Primary Outcome Measures
Name Time Method Five-year Disease-free Survival (DFS) Rate Analysis occurs after all patients have been followed for five years. Five-year rates are estimated by the Kaplan-Meier method. DFS events included local progression, distant metastatic progression, biochemical recurrence as defined by the Radiation Therapy Oncology Group (RTOG) Phoenix definition, or death from any cause. Patients who experienced second primary cancers remained under observation for DFS events.
- Secondary Outcome Measures
Name Time Method Five-year Local Progression Rate Analysis occurs after all patients have been followed for five years. Clinical criteria for local recurrence are progression (increase in palpable abnormality) at any time, failure of regression of the palpable tumor by 2 years, and redevelopment of a palpable abnormality after complete disappearance of previous abnormalities. Histologic criteria for local recurrence are presence of prostatic carcinoma upon biopsy and positive biopsy of the palpably normal prostate more than 2 years after the start of treatment. The arms were not statistically compared because of an insufficient number of events.
Five-year PSA Failure Rate Analysis occurs after all patients have been followed for five years. Five-year rates are shown (cumulative incidence estimates). Note, although the protocol calls this endpoint "Freedom from biochemical recurrence", it defines the endpoint as "The time to PSA failure". An event for PSA, i.e. biochemical, failure was the first of the following: initiation of non-protocol (e.g., salvage) hormone therapy, or an increase in PSA of at least 2 ng/mL. Time to biochemical failure was measured from study entry until the date of failure.
Frequency of Patients With GU and GI Acute and Late Toxicity Acute toxicity is measured from start of treatment to 90 days from the completion of treatment. Late toxicity is defined as toxicity occuring after 90 days from completion of treatment. Analysis occured at the time of the primary endpoint analysis. The frequency of genitourinary (GU) and gastrointestinal (GI) adverse events as defined and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 3) were compared between treatment arms. Acute toxicity was defined as any toxicity beginning within 90 days of completion of RT, and late toxicity was defined as any toxicity beginning more than 90 days after the completion of RT. Acute and late GU and GI toxicity rates were tabulated and reported in two ways: dichotomized as \< grade 2 vs ≥ grade 2, and dichotomized as \< grade 3 vs ≥ grade 3. Higher grade indicates more severity.
The Utilization of Sexual Medications/Devices Questionaire Baseline, 6, 12, and 24 months, and 5 years The Utilization of Sexual Medications/Devices questionaire is designed to assess the use of erectile aids among patients treated for prostate cancer. This instrument is used to complement the sexual symptom domain in the EPIC. The percentage of "Yes" responses to the following questions are reported: "Do you have a penile prosthesis", "Have you used an medications or devices to aid or improve erections?".
Assessment of Trade-off Between Disease-free Survival and Quality of Life. From baseline to 5 years from the start of treatment To examine trade-offs between the survival time and QOL, we were to combine them for each patient into two single measurements: quality adjusted live year (QALY) and quality adjusted disease-free survival year (QADFSY). We were to use Glasziou's multiple health-state (Q-TWiST) models to use the repeated measures of EQ-5D.
Five-year Disease-specific Survival Rate Analysis occurs after all patients have been followed for five years. An event was death in association with any of the following conditions:
* Primary cause of death certified as due to prostate cancer
* Further clinical tumor progression occurring after initiation of "salvage" anti-tumor (e.g., (androgen suppression) therapy
* A rise (that exceeds 1.0 ng/mL) in the serum prostate-specific antigen (PSA) level on at least two consecutive occasions that occurs during or after "salvage" androgen suppression therapy
* Disease progression in the absence of any anti-tumor therapy
* Death from a complication of therapy, irrespective of disease status. The arms were not statistically compared because of an insufficient number of events.Change From Baseline in Assessment of Anxiety and Depression Using the HSCL-25 Baseline, 6 months, 12 months, 24 months, and 5 years Anxiety and depression were measured with the Hopkins Symptom Checklist (HSCL-25). It consists of 25 items: Part I of the HSCL-25 has 10 items for anxiety symptoms; Part II has 15 items for depression symptoms. The scale for each question includes four categories of response ("Not at all," "A little," "Quite a bit," "Extremely," rated 1 to 4, respectively). Two scores are calculated: the total score is the average of all 25 items and ranges from 0 to 100. A higher score indicates worse symptoms. The HSCL-25 tool was assessed at baseline, 6 months, 12 months, 24 months, and 5 years. For each patient, the change in score from baseline to the time point is calculated by subtracting the baseline value from the time point value.
EQ-5D Scores Baseline, 6 months, 12 months, 24 months, and 5 years The EQ-5D is a 2-part self-assessment questionnaire. First part is 5 items (mobility, self care, usual activities, pain/discomfort, anxiety/depression) each with 3 problem levels (1-none, 2-moderate, 3-extreme). Health states are defined by the combination of the leveled responses to the 5 dimensions, generating 243 health states to which unconsciousness and death are added. The 2nd part is a visual analogue scale (VAS) valuing current health state, measured on a 20-cm 10-point interval scale. Worst imaginable health state is scored as 0 at the bottom of the scale, and best imaginable health state is scored as 100 at the top. Both the 5-item index score and the VAS score are transformed into a utility score between 0 -Worst health stat and 1 -Best health state. A two-sided Wilcoxon test with alpha 0.05 was used due to the skewed, thus non-normal, nature of the data.
Statistical Modeling of Genomic Biomarkers Baseline biomarker collection. Analysis would occur after the primary endpoint analysis. Five-year Overall Survival Rate Analysis occurs after all patients have been followed for five years. Five-year rates Kaplan-Meier estimates. Overall survival (OS) was measured from study entry until the date of death. Patients still alive at the time of analysis were censored at the date of last follow-up
Comparison of Disease-specific HRQOL Change in Expanded Prostate Cancer Index Composite (EPIC); the Utilization of Sexual Medications/Devices Supplements the EPIC Baseline, 6, 12, and 24 months, and 5 years Prostate cancer (PC) Health-Related Quality of Life (HRQOL) outcomes as measured by change over time in the Expanded Prostate Cancer Index Composite \[EPIC\], a PC HRQOL instrument measuring a broad spectrum of urinary, bowel, and sexual symptoms related to radiotherapy, is compared between arms. The EPIC questionnaire was grouped into four domains (bowel, urinary, sexual, hormonal), each with a score ranging from 0 (worst) to 100 (best), and was assessed at baseline, 6, 12, and 24 months, and 5 years. The difference in score from baseline to each time point was calculated and the Wilcoxon test statistic was used to test the null hypothesis that responses are the same across the two treatment arms vs. the alternative hypothesis that they are different, using a 2-sided alpha of 0.05 at each timepoint, resulting in an alpha of 0.0125 for each domain. Each row refers to a separate analysis.
Trial Locations
- Locations (294)
Winship Cancer Institute of Emory University
🇺🇸Atlanta, Georgia, United States
Naval Medical Center - Portsmouth
🇺🇸Portsmouth, Virginia, United States
Mercy Cancer Center at Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
Big Sky Oncology
🇺🇸Great Falls, Montana, United States
Fox Chase Virtua Health Cancer Program at Virtua West Jersey
🇺🇸Voorhees, New Jersey, United States
West Virginia University Health Sciences Center - Charleston
🇺🇸Charleston, West Virginia, United States
Saint John Regional Hospital
🇨🇦Saint John, New Brunswick, Canada
Massachusetts General Hospital
🇺🇸Boston, Massachusetts, United States
Dana-Farber/Brigham and Women's Cancer Center
🇺🇸Boston, Massachusetts, United States
Dana-Farber/Harvard Cancer Center at Dana Farber Cancer Institute
🇺🇸Boston, Massachusetts, United States
Methodist Cancer Center at Methodist Hospital
🇺🇸Indianapolis, Indiana, United States
Central Indiana Cancer Centers - East
🇺🇸Indianapolis, Indiana, United States
Virginia Piper Cancer Institute at Abbott - Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Hennepin County Medical Center - Minneapolis
🇺🇸Minneapolis, Minnesota, United States
Cancer Therapy and Research Center
🇺🇸San Antonio, Texas, United States
Kaiser Permanente Medical Center - San Francisco Geary Campus
🇺🇸San Francisco, California, United States
Utah Cancer Specialists at UCS Cancer Center
🇺🇸Salt Lake City, Utah, United States
LDS Hospital
🇺🇸Salt Lake City, Utah, United States
Kansas Masonic Cancer Research Institute at the University of Kansas Medical Center
🇺🇸Kansas City, Kansas, United States
Kansas City Cancer Centers - Southwest
🇺🇸Overland Park, Kansas, United States
BCCA - Fraser Valley Cancer Centre
🇨🇦Surrey, British Columbia, Canada
Great Falls Clinic - Main Facility
🇺🇸Great Falls, Montana, United States
Bozeman Deaconess Cancer Center
🇺🇸Bozeman, Montana, United States
Community Cancer Center at Rutland Regional Medical Center
🇺🇸Rutland, Vermont, United States
Columbia-Saint Mary's Cancer Care Center
🇺🇸Milwaukee, Wisconsin, United States
Medical College of Wisconsin Cancer Center
🇺🇸Milwaukee, Wisconsin, United States
Veterans Affairs Medical Center - Milwaukee
🇺🇸Milwaukee, Wisconsin, United States
Arizona Oncology Services Foundation
🇺🇸Phoenix, Arizona, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
St. Joseph Hospital
🇺🇸Denver, Colorado, United States
Presbyterian - St. Luke's Medical Center
🇺🇸Denver, Colorado, United States
Oklahoma University Cancer Institute
🇺🇸Oklahoma City, Oklahoma, United States
Barbara Ann Karmanos Cancer Institute
🇺🇸Detroit, Michigan, United States
Josephine Ford Cancer Center at Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Peninsula Medical Center
🇺🇸Burlingame, California, United States
Arizona Oncology - Tucson
🇺🇸Tucson, Arizona, United States
Alta Bates Summit Comprehensive Cancer Center
🇺🇸Berkeley, California, United States
Marin Cancer Institute at Marin General Hospital
🇺🇸Greenbrae, California, United States
Valley Medical Oncology
🇺🇸Fremont, California, United States
Valley Medical Oncology Consultants - Castro Valley
🇺🇸Castro Valley, California, United States
Providence Saint Joseph Medical Center - Burbank
🇺🇸Burbank, California, United States
Alta Bates Summit Medical Center - Summit Campus
🇺🇸Oakland, California, United States
Radiation Oncology Centers - Cameron Park
🇺🇸Cameron Park, California, United States
Kaiser Permanente Medical Center - Los Angeles
🇺🇸Los Angeles, California, United States
Veterans Affairs Medical Center - Long Beach
🇺🇸Long Beach, California, United States
California Pacific Medical Center - California Campus
🇺🇸San Francisco, California, United States
Kaiser Permanente Medical Center - Richmond
🇺🇸Richmond, California, United States
Kaiser Permanente Medical Center - Santa Rosa
🇺🇸Santa Rosa, California, United States
Radiation Oncology Center - Roseville
🇺🇸Roseville, California, United States
Kaiser Permanente Medical Center - Rancho Cordova
🇺🇸Rancho Cordova, California, United States
Doctors Medical Center - San Pablo Campus
🇺🇸San Pablo, California, United States
Rohnert Park Cancer Center
🇺🇸Rohnert Park, California, United States
Kaiser Permanente Medical Center - Santa Clara Kiely Campus
🇺🇸Santa Clara, California, United States
Solano Radiation Oncology Center
🇺🇸Vacaville, California, United States
Emory Crawford Long Hospital
🇺🇸Atlanta, Georgia, United States
Baptist-South Miami Regional Cancer Program
🇺🇸Miami, Florida, United States
University of Florida Shands Cancer Center
🇺🇸Gainesville, Florida, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Kaiser Permanente Medical Center - Walnut Creek
🇺🇸Walnut Creek, California, United States
Sutter Solano Medical Center
🇺🇸Vallejo, California, United States
Decatur Memorial Hospital Cancer Care Institute
🇺🇸Decatur, Illinois, United States
Mayo Clinic - Jacksonville
🇺🇸Jacksonville, Florida, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
OSF St. Francis Medical Center
🇺🇸Peoria, Illinois, United States
Veterans Affairs Medical Center - Atlanta (Decatur)
🇺🇸Decatur, Georgia, United States
Poudre Valley Radiation Oncology
🇺🇸Fort Collins, Colorado, United States
St. Mary - Corwin Regional Medical Center
🇺🇸Pueblo, Colorado, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
CCOP - Christiana Care Health Services
🇺🇸Newark, Delaware, United States
University of Chicago Cancer Research Center
🇺🇸Chicago, Illinois, United States
BroMenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Cancer Treatment Center at Pekin Hospital
🇺🇸Pekin, Illinois, United States
Saint Anthony's Hospital at Saint Anthony's Health Center
🇺🇸Alton, Illinois, United States
Oncology Hematology Associates of Central Illinois, PC - Peoria
🇺🇸Peoria, Illinois, United States
St. Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Greenebaum Cancer Center at University of Maryland Medical Center
🇺🇸Baltimore, Maryland, United States
CCOP - St. Louis-Cape Girardeau
🇺🇸Saint Louis, Missouri, United States
Siouxland Hematology-Oncology Associates, LLP
🇺🇸Sioux City, Iowa, United States
Hubert H. Humphrey Cancer Center at North Memorial Outpatient Center
🇺🇸Robbinsdale, Minnesota, United States
Community Cancer Center
🇺🇸Normal, Illinois, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
CCOP - Illinois Oncology Research Association
🇺🇸Peoria, Illinois, United States
Mercy Cancer Center at Mercy Medical Center - North Iowa
🇺🇸Mason City, Iowa, United States
McFarland Clinic, PC
🇺🇸Ames, Iowa, United States
St. Francis Cancer Center at St. Francis Medical Center
🇺🇸Shakopee, Minnesota, United States
Saint James Hospital and Health Centers Comprehensive Cancer Institute - Olympia Fields
🇺🇸Olympia Fields, Illinois, United States
Holden Comprehensive Cancer Center at University of Iowa
🇺🇸Iowa City, Iowa, United States
Central Maryland Oncology Center
🇺🇸Columbia, Maryland, United States
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Helen P. Denit Cancer Center at Montgomery General Hospital
🇺🇸Olney, Maryland, United States
Albert Lea Cancer Center at Albert Lea Medical Center
🇺🇸Albert Lea, Minnesota, United States
Foote Memorial Hospital
🇺🇸Jackson, Michigan, United States
Tate Cancer Center at Baltimore Washington Medical Center
🇺🇸Glen Burnie, Maryland, United States
Boston University Cancer Research Center
🇺🇸Boston, Massachusetts, United States
Great Lakes Cancer Institute at McLaren Regional Medical Center
🇺🇸Flint, Michigan, United States
MeritCare Bemidji
🇺🇸Bemidji, Minnesota, United States
Minnesota Oncology Hematology, PA - Woodbury
🇺🇸Woodbury, Minnesota, United States
St. John's Regional Medical Center
🇺🇸Joplin, Missouri, United States
Hudner Oncology Center at Saint Anne's Hospital - Fall River
🇺🇸Fall River, Massachusetts, United States
Lowell General Hospital
🇺🇸Lowell, Massachusetts, United States
Duluth Clinic Cancer Center - Duluth
🇺🇸Duluth, Minnesota, United States
Immanuel St. Joseph's
🇺🇸Mankato, Minnesota, United States
CCOP - Duluth
🇺🇸Duluth, Minnesota, United States
Miller - Dwan Medical Center
🇺🇸Duluth, Minnesota, United States
Park Nicollet Cancer Center
🇺🇸Saint Louis Park, Minnesota, United States
Lourdes Regional Cancer Center
🇺🇸Binghamton, New York, United States
Coborn Cancer Center
🇺🇸Saint Cloud, Minnesota, United States
Kansas City Cancer Centers - South
🇺🇸Kansas City, Missouri, United States
Methodist Estabrook Cancer Center
🇺🇸Omaha, Nebraska, United States
Dartmouth - Hitchcock Concord
🇺🇸Concord, New Hampshire, United States
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis
🇺🇸Saint Louis, Missouri, United States
Capital Health Regional Cancer Center
🇺🇸Trenton, New Jersey, United States
Cancer Institute of New Jersey at Cooper - Voorhees
🇺🇸Voorhees, New Jersey, United States
CaroMont Cancer Center at Gaston Memorial Hospital
🇺🇸Gastonia, North Carolina, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Northern Rockies Radiation Oncology Center
🇺🇸Billings, Montana, United States
Kingsbury Center for Cancer Care at Cheshire Medical Center
🇺🇸Keene, New Hampshire, United States
Cayuga Medical Center of Ithaca
🇺🇸Ithaca, New York, United States
Cancer Institute of New Jersey at Cooper University Hospital - Camden
🇺🇸Camden, New Jersey, United States
CCOP - Montana Cancer Consortium
🇺🇸Billings, Montana, United States
Siteman Cancer Center at Barnes-Jewish St. Peters Hospital - St. Peters
🇺🇸Saint Peters, Missouri, United States
Saint Mary's Regional Medical Center
🇺🇸Reno, Nevada, United States
Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center
🇺🇸Lebanon, New Hampshire, United States
CCOP - Nevada Cancer Research Foundation
🇺🇸Las Vegas, Nevada, United States
Cancer Institute of New Jersey at UMDNJ - Robert Wood Johnson Medical School
🇺🇸New Brunswick, New Jersey, United States
Fox Chase Virtua Health Cancer Program at Virtua Memorial Hospital Marlton
🇺🇸Marlton, New Jersey, United States
Newark Beth Israel Medical Center
🇺🇸Newark, New Jersey, United States
Roswell Park Cancer Institute
🇺🇸Buffalo, New York, United States
CCOP - Hematology-Oncology Associates of Central New York
🇺🇸East Syracuse, New York, United States
Bismarck Cancer Center
🇺🇸Bismarck, North Dakota, United States
Wayne Memorial Hospital, Incorporated
🇺🇸Goldsboro, North Carolina, United States
Duke Comprehensive Cancer Center
🇺🇸Durham, North Carolina, United States
Wayne Radiation Oncology
🇺🇸Goldsboro, North Carolina, United States
Saint Francis Hospital Cancer Center
🇺🇸Poughkeepsie, New York, United States
NYU Cancer Institute at New York University Medical Center
🇺🇸New York, New York, United States
CCOP - North Shore University Hospital
🇺🇸Manhasset, New York, United States
McDowell Cancer Center at Akron General Medical Center
🇺🇸Akron, Ohio, United States
MNAP Oncologic Center
🇺🇸Philadelphia, Pennsylvania, United States
Guthrie Cancer Center at Guthrie Clinic Sayre
🇺🇸Sayre, Pennsylvania, United States
Cleveland Clinic - Wooster
🇺🇸Wooster, Ohio, United States
Hillcrest Cancer Center at Hillcrest Hospital
🇺🇸Mayfield Heights, Ohio, United States
Carolina Regional Cancer Center
🇺🇸Myrtle Beach, South Carolina, United States
Summa Center for Cancer Care at Akron City Hospital
🇺🇸Akron, Ohio, United States
Precision Radiotherapy at University Pointe
🇺🇸West Chester, Ohio, United States
Charles M. Barrett Cancer Center at University Hospital
🇺🇸Cincinnati, Ohio, United States
Barberton Citizens Hospital
🇺🇸Barberton, Ohio, United States
Cancer Care Center, Incorporated
🇺🇸Salem, Ohio, United States
Kimmel Cancer Center at Thomas Jefferson University - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Fox Chase Cancer Center CCOP Research Base
🇺🇸Philadelphia, Pennsylvania, United States
Cleveland Clinic Taussig Cancer Center
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Cancer Center
🇺🇸Independence, Ohio, United States
Rosenfeld Cancer Center at Abington Memorial Hospital
🇺🇸Abington, Pennsylvania, United States
Geisinger Cancer Institute at Geisinger Health
🇺🇸Danville, Pennsylvania, United States
Celilo Cancer Center at Mid-Columbia Medical Center
🇺🇸The Dalles, Oregon, United States
Cancer Treatment Center
🇺🇸Wooster, Ohio, United States
Cancer Center of Paoli Memorial Hospital
🇺🇸Paoli, Pennsylvania, United States
CCOP - Main Line Health
🇺🇸Wynnewood, Pennsylvania, United States
Frankford Hospital Cancer Center - Torresdale Campus
🇺🇸Philadelphia, Pennsylvania, United States
Albert Einstein Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Rapid City Regional Hospital
🇺🇸Rapid City, South Dakota, United States
York Cancer Center at Apple Hill Medical Center
🇺🇸York, Pennsylvania, United States
CCOP - Upstate Carolina
🇺🇸Spartanburg, South Carolina, United States
Lankenau Cancer Center at Lankenau Hospital
🇺🇸Wynnewood, Pennsylvania, United States
INOVA Alexandria Hospital
🇺🇸Alexandria, Virginia, United States
Huntsman Cancer Institute at University of Utah
🇺🇸Salt Lake City, Utah, United States
Good Samaritan Cancer Center
🇺🇸Puyallup, Washington, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
David C. Pratt Cancer Center at St. John's Mercy
🇺🇸Saint Louis, Missouri, United States
Medcenter One Hospital Cancer Care Center
🇺🇸Bismarck, North Dakota, United States
Mid Dakota Clinic, PC
🇺🇸Bismarck, North Dakota, United States
St. Alexius Medical Center Cancer Center
🇺🇸Bismarck, North Dakota, United States
CCOP - MeritCare Hospital
🇺🇸Fargo, North Dakota, United States
MeritCare Broadway
🇺🇸Fargo, North Dakota, United States
Don Monti Comprehensive Cancer Center at North Shore University Hospital
🇺🇸Manhasset, New York, United States
Highland Hospital of Rochester
🇺🇸Rochester, New York, United States
Hudson Valley Oncology Associates
🇺🇸Poughkeepsie, New York, United States
Mercy and Unity Cancer Center at Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Mayo Clinic Cancer Center
🇺🇸Rochester, Minnesota, United States
Regions Hospital Cancer Care Center
🇺🇸Saint Paul, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Penrose Cancer Center at Penrose Hospital
🇺🇸Colorado Springs, Colorado, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
St. Mary's Regional Cancer Center at St. Mary's Hospital and Medical Center
🇺🇸Grand Junction, Colorado, United States
North Colorado Medical Center
🇺🇸Greeley, Colorado, United States
Sky Ridge Medical Center
🇺🇸Lone Tree, Colorado, United States
Hope Cancer Care Center at Longmont United Hospital
🇺🇸Longmont, Colorado, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Bay Area Breast Surgeons, Incorporated
🇺🇸Oakland, California, United States
CCOP - Bay Area Tumor Institute
🇺🇸Oakland, California, United States
Tom K Lee, Incorporated
🇺🇸Oakland, California, United States
Kaiser Permanente Medical Center - Roseville
🇺🇸Roseville, California, United States
Kaiser Permanente Medical Center - Santa Teresa
🇺🇸San Jose, California, United States
General Robert Huyser Cancer Center at David Grant Medical Center
🇺🇸Travis Air Force Base, California, United States
Bryn Mawr Hospital
🇺🇸Bryn Mawr, Pennsylvania, United States
Mercy Fitzgerald Hospital
🇺🇸Darby, Pennsylvania, United States
Upper Delaware Valley Cancer Center
🇺🇸Milford, Pennsylvania, United States
Frederick R. and Betty M. Smith Cancer Treatment Center
🇺🇸Sparta, New Jersey, United States
Radiation Oncology Associates - Reno
🇺🇸Reno, Nevada, United States
Larry G Strieff MD Medical Corporation
🇺🇸Oakland, California, United States
Kaiser Permanente Medical Center - Sacramento
🇺🇸Sacramento, California, United States
Rocky Mountain Cancer Centers - Aurora
🇺🇸Aurora, Colorado, United States
Radiological Associates of Sacramento Medical Group, Incorporated
🇺🇸Sacramento, California, United States
University of California Davis Cancer Center
🇺🇸Sacramento, California, United States
Mercy General Hospital
🇺🇸Sacramento, California, United States
South Sacramento Cancer Center
🇺🇸Sacramento, California, United States
South Sacramento Kaiser-Permanente Medical Center
🇺🇸Sacramento, California, United States
Aurora Presbyterian Hospital
🇺🇸Aurora, Colorado, United States
Veterans Affairs Medical Center - Ann Arbor
🇺🇸Ann Arbor, Michigan, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Long Island Jewish Medical Center
🇺🇸New Hyde Park, New York, United States
HealthEast Cancer Care at St. John's Hospital
🇺🇸Maplewood, Minnesota, United States
Medical City Dallas Hospital
🇺🇸Dallas, Texas, United States
Norton Suburban Hospital
🇺🇸Louisville, Kentucky, United States
James Graham Brown Cancer Center at University of Louisville
🇺🇸Louisville, Kentucky, United States
Auburn Radiation Oncology
🇺🇸Auburn, California, United States
East Bay Radiation Oncology Center
🇺🇸Castro Valley, California, United States
Sutter Health - Western Division Cancer Research Group
🇺🇸Greenbrae, California, United States
Kaiser Permanente Medical Center - Hayward
🇺🇸Hayward, California, United States
Kaiser Permanente Medical Center - Oakland
🇺🇸Oakland, California, United States
Kaiser Permanente - Division of Research - Oakland
🇺🇸Oakland, California, United States
Valley Medical Oncology Consultants - Pleasanton
🇺🇸Pleasanton, California, United States
Kaiser Permanente Medical Center - Redwood City
🇺🇸Redwood City, California, United States
UCSF Helen Diller Family Comprehensive Cancer Center
🇺🇸San Francisco, California, United States
Kaiser Permanente Medical Center - South San Francisco
🇺🇸South San Francisco, California, United States
Kaiser Foundation Hospital - San Rafael
🇺🇸San Rafael, California, United States
Kaiser Permanente Medical Facility - Stockton
🇺🇸Stockton, California, United States
Exempla Lutheran Medical Center
🇺🇸Wheat Ridge, Colorado, United States
Bay Medical
🇺🇸Panama City, Florida, United States
Georgia Cancer Center for Excellence at Grady Memorial Hospital
🇺🇸Atlanta, Georgia, United States
MetroWest Medical Center - Framingham Union Hospital
🇺🇸Framingham, Massachusetts, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Mercy and Unity Cancer Center at Unity Hospital
🇺🇸Fridley, Minnesota, United States
Minnesota Oncology Hematology, PA - Maplewood
🇺🇸Maplewood, Minnesota, United States
CCOP - Metro-Minnesota
🇺🇸Saint Louis Park, Minnesota, United States
CentraCare Clinic - River Campus
🇺🇸Saint Cloud, Minnesota, United States
Billings Clinic - Downtown
🇺🇸Billings, Montana, United States
Kansas City Cancer Centers - North
🇺🇸Kansas City, Missouri, United States
Sletten Cancer Institute at Benefis Healthcare
🇺🇸Great Falls, Montana, United States
Center for Cancer Care at Exeter Hospital
🇺🇸Exeter, New Hampshire, United States
CentraState Medical Center
🇺🇸Freehold, New Jersey, United States
Princeton Radiation Oncology Center
🇺🇸Jamesburg, New Jersey, United States
University Medical Center at Princeton
🇺🇸Princeton, New Jersey, United States
Lovelace Medical Center - Downtown
🇺🇸Albuquerque, New Mexico, United States
New York Oncology Hematology, PC at Albany Regional Cancer Care
🇺🇸Albany, New York, United States
James P. Wilmot Cancer Center at University of Rochester Medical Center
🇺🇸Rochester, New York, United States
Cleveland Clinic Cancer Center at Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Willamette Valley Cancer Center - Eugene
🇺🇸Eugene, Oregon, United States
Fox Chase Cancer Center - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
Frank M. and Dorothea Henry Cancer Center at Geisinger Wyoming Valley Medical Center
🇺🇸Wilkes-Barre, Pennsylvania, United States
Texas Oncology, PA at Texas Cancer Center Dallas Southwest
🇺🇸Dallas, Texas, United States
Texas Oncology, PA at Harris Center HEB
🇺🇸Bedford, Texas, United States
St. Joseph Regional Cancer Center
🇺🇸Bryan, Texas, United States
Texas Oncology, PA at Texas Cancer Center - Sherman
🇺🇸Sherman, Texas, United States
Klabzuba Cancer Center at Harris Methodist Fort Worth Hospital
🇺🇸Fort Worth, Texas, United States
University of Texas Health Science Center at San Antonio
🇺🇸San Antonio, Texas, United States
Texas Oncology, PA at Texas Oncology Cancer Center Sugar Land
🇺🇸Sugar Land, Texas, United States
Sandra L. Maxwell Cancer Center
🇺🇸Cedar City, Utah, United States
Jon and Karen Huntsman Cancer Center at Intermountain Medical Center
🇺🇸Murray, Utah, United States
Val and Ann Browning Cancer Center at McKay-Dee Hospital Center
🇺🇸Ogden, Utah, United States
Utah Valley Regional Medical Center - Provo
🇺🇸Provo, Utah, United States
Dixie Regional Medical Center - East Campus
🇺🇸Saint George, Utah, United States
Fletcher Allen Health Care - University Health Center Campus
🇺🇸Burlington, Vermont, United States
Norris Cotton Cancer Center - North
🇺🇸Saint Johnsbury, Vermont, United States
Danville Regional Medical Center
🇺🇸Danville, Virginia, United States
Sentara Cancer Institute at Sentara Norfolk General Hospital
🇺🇸Norfolk, Virginia, United States
Veterans Affairs Medical Center - Richmond
🇺🇸Richmond, Virginia, United States
Harrison Medical Center
🇺🇸Bremerton, Washington, United States
St. Francis Hospital
🇺🇸Federal Way, Washington, United States
Franciscan Cancer Center at St. Joseph Medical Center
🇺🇸Tacoma, Washington, United States
CCOP - Northwest
🇺🇸Tacoma, Washington, United States
MultiCare Regional Cancer Center at Tacoma General Hospital
🇺🇸Tacoma, Washington, United States
Theda Care Cancer Institute
🇺🇸Appleton, Wisconsin, United States
Franciscan Skemp Healthcare - La Crosse Campus
🇺🇸La Crosse, Wisconsin, United States
Community Memorial Hospital Cancer Care Center
🇺🇸Menomonee Falls, Wisconsin, United States
Columbia Saint Mary's Hospital - Ozaukee
🇺🇸Mequon, Wisconsin, United States
British Columbia Cancer Agency - Vancouver Cancer Centre
🇨🇦Vancouver, British Columbia, Canada
All Saints Cancer Center at Wheaton Franciscan Healthcare
🇺🇸Racine, Wisconsin, United States
Welch Cancer Center at Sheridan Memorial Hospital
🇺🇸Sheridan, Wyoming, United States
British Columbia Cancer Agency - Centre for the Southern Interior
🇨🇦Kelowna, British Columbia, Canada
British Columbia Cancer Agency - Vancouver Island Centre
🇨🇦Victoria, British Columbia, Canada
London Regional Cancer Program at London Health Sciences Centre
🇨🇦London, Ontario, Canada
Margaret and Charles Juravinski Cancer Centre
🇨🇦Hamilton, Ontario, Canada
Cancer Care Program at Thunder Bay Regional Health Sciences
🇨🇦Thunder Bay, Ontario, Canada
Hopital Notre-Dame du CHUM
🇨🇦Montreal, Quebec, Canada
McGill Cancer Centre at McGill University
🇨🇦Montreal, Quebec, Canada
Centre Hospitalier Universitaire de Quebec
🇨🇦Quebec City, Quebec, Canada
Saskatoon Cancer Centre at the University of Saskatchewan
🇨🇦Saskatoon, Saskatchewan, Canada
Allan Blair Cancer Centre at Pasqua Hospital
🇨🇦Regina, Saskatchewan, Canada
St. Luke's Hospital Cancer Care Center
🇺🇸Duluth, Minnesota, United States
Gibbs Regional Cancer Center at Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
Nova Scotia Cancer Centre
🇨🇦Halifax, Nova Scotia, Canada
St. Mary Regional Cancer Center
🇺🇸Langhorne, Pennsylvania, United States
Northeast Radiation Oncology Center
🇺🇸Dunmore, Pennsylvania, United States