Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia
- Conditions
- Acute Myeloid Leukemia With Multilineage Dysplasia Following Myelodysplastic SyndromeAdult Acute Minimally Differentiated Myeloid Leukemia (M0)Adult Acute Monoblastic Leukemia (M5a)Adult Acute Megakaryoblastic Leukemia (M7)Adult Acute Myeloblastic Leukemia Without Maturation (M1)Adult Acute Myeloid Leukemia With 11q23 (MLL) AbnormalitiesAdult Acute Myeloid Leukemia With Del(5q)Adult Pure Erythroid Leukemia (M6b)Secondary Acute Myeloid LeukemiaAdult Acute Myeloblastic Leukemia With Maturation (M2)
- Interventions
- Other: ObservationProcedure: Allogeneic hematopoietic stem cell transplantation
- Registration Number
- NCT02085408
- Lead Sponsor
- ECOG-ACRIN Cancer Research Group
- Brief Summary
This randomized phase III trial studies clofarabine to see how well it works compared with daunorubicin hydrochloride and cytarabine when followed by decitabine or observation in treating older patients with newly diagnosed acute myeloid leukemia. Drugs used in chemotherapy, such as clofarabine, daunorubicin hydrochloride, cytarabine, and decitabine, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) may kill more cancer cells. It is not yet known which chemotherapy regimen is more effective in treating acute myeloid leukemia.
- Detailed Description
PRIMARY OBJECTIVES:
I. To evaluate the effect of clofarabine induction and consolidation therapy on overall survival in comparison with standard therapy (daunorubicin \[daunorubicin hydrochloride\] \& cytarabine) in newly-diagnosed acute myeloid leukemia (AML) patients age \>= 60 years.
SECONDARY OBJECTIVES:
I. To evaluate complete remission (CR) rates, duration of remission, and toxicity/treatment-related mortality of clofarabine in comparison with standard therapy (daunorubicin \& cytarabine) in newly-diagnosed AML patients age \>= 60 years.
II. To evaluate the feasibility of consolidation with reduced-intensity conditioning and allogeneic hematopoietic stem cell transplantation from human leukocyte antigen (HLA)-identical donors in patients who achieve a response to induction therapy, including the incidence of successful engraftment, acute and chronic graft-versus-host disease, transplant-related mortality, and its impact on overall survival in comparison to patients receiving chemotherapy.
III. To evaluate the duration of remission and disease-free survival of patients in complete remission following completion of consolidation therapy who are subsequently randomized to receive scheduled low-dose decitabine maintenance in comparison with observation.
IV. To perform expression and methylation profiling on all patients receiving decitabine and to correlate their integrated epigenetic signatures with response to decitabine.
V. To examine the epigenetic profiles of remission marrow in patients randomized to observation vs. decitabine to determine whether epigenetic signature of apparently morphologically normal bone marrow is predictive of relapse or response to decitabine maintenance.
VI. To explore the possible association of response to clofarabine with ABC-transporter P-glycoprotein (Pgp).
VII. To assess the intensity of expression of CXC chemokine receptor type 4 (CXCR4) on diagnostic leukemia cells and to correlate this parameter with other established prognostic factors.
VIII. To assess the entire spectrum of somatic mutations and affected pathways at diagnosis of AML and elucidate the association between gene mutation and outcome.
IX. To examine the impact of smoking, obesity, regular acetaminophen use, regular aspirin use, benzene exposure, living in a rural/farm environment and some other underlying exposures and lifestyle factors associated with AML development on overall survival (OS).
X. To investigate potential correlative results between array comparative genomic hybridization (CGH) findings and acute myeloid leukemia patient characteristics.
TERTIARY OBJECTIVES:
I. To compare health-related quality of life (QOL) (physical, functional, leukemia-specific well-being) and fatigue in elderly AML patients receiving standard induction therapy with those receiving clofarabine.
II. To measure the change in health-related QOL that occurs over time (within treatment groups).
III. To comprehensively assess patient function at the time of study enrollment.
IV. To determine if components of a comprehensive geriatric assessment or QOL scales predict ability to complete AML treatment.
V. To describe the impact of transplant on QOL in AML patients above age 60.
OUTLINE:
INDUCTION THERAPY: Patients are randomized to 1 of 2 treatment arms.
ARM A (STANDARD THERAPY): Patients receive daunorubicin hydrochloride at 60 mg/m\^2 intravenously (IV) over 10-15 minutes on days 1-3 and cytarabine at 100 mg/m\^2 IV continuously on days 1-7. Patients with residual disease or those who do not achieve an aplastic bone marrow on day 12-14 (i.e., \< 5% blasts and \< 20% cellularity or markedly/moderately hypocellular) may receive a second course of induction therapy beginning no sooner than day 14.
ARM B: Patients receive clofarabine at 30 mg/m\^2 IV over 1 hour on days 1-5. Patients with residual disease or those who do not achieve an aplastic bone marrow on day 12-14 (i.e., \< 5% blasts and \< 20% cellularity or markedly/moderately hypocellular) may receive a second course of induction therapy beginning no sooner than day 21 and no later than day 56.
Patients who achieve a complete remission (CR) or CR with incomplete marrow recovery (CRi) after induction therapy proceed to consolidation therapy (Arms C and D). Patients who are 60-69 years of age who achieve a "morphologic leukemia-free state" after induction therapy and who have an HLA-identical donor proceed to allogeneic stem cell transplantation.
CONSOLIDATION THERAPY: Beginning within 60 days after documentation of CR or CRi, patients receive consolidation therapy in the same arm they were randomized to for induction therapy.
ARM C (STANDARD THERAPY): Patients receive cytarabine at 1500 mg/m\^2 IV over 1 hour once or twice daily on days 1-6. Treatment repeats every 4-6 weeks for 2 courses.
ARM D: Patients receive clofarabine at 20 mg/m\^2 IV over 1 hour on days 1-5. Treatment repeats every 4-6 weeks for 2 courses.
Patients who remain in CR after completion of consolidation therapy are randomized to one of the two maintenance therapy arms (Arms E and F).
MAINTENANCE THERAPY: Beginning within 60 days after completion of consolidation therapy, patients receive maintenance therapy and are randomized to 1 of 2 arms. Patients not eligible for randomization to decitabine maintenance after recovery from consolidation will be followed according to Arm E.
ARM E: Patients undergo observation monthly for 12 months.
ARM F: Patients receive decitabine at 20 mg/m\^2 IV over 1 hour on days 1-3. Treatment repeats every 4 weeks for 12 months the absence of unacceptable toxicity.
ALLOGENEIC STEM CELL TRANSPLANTATION WITH REDUCED-INTENSITY CONDITIONING REGIMEN (Arm G): Patients begin reduced-intensity conditioning 30-90 days after the initiation of induction therapy.
CONDITIONING REGIMEN: Patients receive fludarabine phosphate at 30 mg/m\^2 IV over 30 minutes on days -7 to -3, busulfan at 0.8 mg/kg IV over 2 hours every 6 hours on days -4 and -3 (for a total of 8 doses), and anti-thymocyte globulin at 2.5 mg/kg/day IV over 4-6 hours on days -4 to -2.
TRANSPLANTATION: Patients undergo allogeneic peripheral blood stem cell transplantation on day 0.
After completion of study treatment, patients are followed up every 3 months for 4 years, every 6 months for 1 year, and then annually thereafter.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 727
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description A (Induction:daunorubicin/cytarabine; consolidation:cytarabine; maintenance:observation/transplant) Observation See Detailed Description A (Induction:daunorubicin/cytarabine; consolidation:cytarabine; maintenance:observation/transplant) Allogeneic hematopoietic stem cell transplantation See Detailed Description B (Induction: clofarabine; Consolidation: clofarabine; Maintenance: decitabine or transplant) Allogeneic hematopoietic stem cell transplantation See Detailed Description A (Induction:daunorubicin/cytarabine; consolidation:cytarabine; maintenance:observation/transplant) Daunorubicin See Detailed Description A (Induction:daunorubicin/cytarabine; consolidation:cytarabine; maintenance:observation/transplant) Cytarabine See Detailed Description B (Induction: clofarabine; Consolidation: clofarabine; Maintenance: decitabine or transplant) Clofarabine See Detailed Description B (Induction: clofarabine; Consolidation: clofarabine; Maintenance: decitabine or transplant) Decitabine See Detailed Description
- Primary Outcome Measures
Name Time Method Overall Survival Assessed every 3 months for 4 years and then every 6 months for 1 year Overall survival is defined as the time from randomization to death or date last known alive.
- Secondary Outcome Measures
Name Time Method Proportion of Patients With Complete Remission Assessed every 3 months for 4 years and then every 6 months for 1 year Patients are required to have all of the following to be considered as having a completion remission (CR).
* Peripheral Blood Counts
1. Neutrophil count \> 1.0 x 10\^9 /L
2. Platelet count ≥ 100 x 10\^9 /L
3. Reduced hemoglobin concentration or hematocrit has no bearing on remission status
4. Leukemic blasts must not be present in the peripheral blood
* Bone Marrow Aspirate and Biopsy
1. Cellularity of bone marrow biopsy must be \> 20% with maturation of all cell lines
2. \< 5% blasts by morphologic review
3. Auer rods must not be detectable
* Extramedullary leukemia, such as CNS or soft tissue involvement, must not be presentOverall Survival by Donor Status Assessed every 3 months for 4 years and then every 6 months for 1 year Overall survival is defined as time between achieving leukemia-free state after induction therapy to death from any cause or date last known alive. The association between overall survival and donor status was evaluated regardless of assigned treatment arms. Patients with transplant donor information (either had donor or did not have a donor) reported after achieving CR/Cri/leukemia-free state post induction therapy were included in this analysis.
Disease-free Survival for Maintenance Assessed every 3 months for 4 years and then every 6 months for 1 year DFS for maintenance comparison is defined as the time from maintenance randomization until relapse or death of any cause. The censored follow-up time for patients without relapse and death information is the date of last contact. Only patients who remained in CR or CRi after completion of consolidation therapy that were randomized to either observation or decitabine in the maintenance Step were included in this analysis.
Trial Locations
- Locations (269)
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
Beth Israel Deaconess Medical Center
🇺🇸Boston, Massachusetts, United States
Nevada Cancer Research Foundation CCOP
🇺🇸Las Vegas, Nevada, United States
Penn State Milton S Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Lewistown Hospital
🇺🇸Lewistown, Pennsylvania, United States
Arizona Cancer Center at University Medical Center North
🇺🇸Tucson, Arizona, United States
University of Arizona Health Sciences Center
🇺🇸Tucson, Arizona, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
North Colorado Medical Center
🇺🇸Greeley, Colorado, United States
Littleton Adventist Hospital
🇺🇸Littleton, Colorado, United States
Sky Ridge Medical Center
🇺🇸Lone Tree, Colorado, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Parker Adventist Hospital
🇺🇸Parker, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Exempla Lutheran Medical Center
🇺🇸Wheat Ridge, Colorado, United States
Beebe Medical Center
🇺🇸Lewes, Delaware, United States
Saint Francis Hospital and Medical Center
🇺🇸Hartford, Connecticut, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
Mayo Clinic in Florida
🇺🇸Jacksonville, Florida, United States
Piedmont Hospital
🇺🇸Atlanta, Georgia, United States
Atlanta Regional CCOP
🇺🇸Atlanta, Georgia, United States
Northside Hospital
🇺🇸Atlanta, Georgia, United States
Saint Joseph's Hospital of Atlanta
🇺🇸Atlanta, Georgia, United States
Georgia Regents University
🇺🇸Augusta, Georgia, United States
Well Star Cobb Hospital
🇺🇸Austell, Georgia, United States
Dekalb Medical Center
🇺🇸Decatur, Georgia, United States
John B Amos Cancer Center
🇺🇸Columbus, Georgia, United States
Gwinnett Medical Center
🇺🇸Lawrenceville, Georgia, United States
Piedmont Fayette Hospital
🇺🇸Fayetteville, Georgia, United States
Southern Regional Medical Center
🇺🇸Riverdale, Georgia, United States
Wellstar Kennestone Hospital
🇺🇸Marietta, Georgia, United States
Harbin Clinic Medical Oncology and Clinical Research
🇺🇸Rome, Georgia, United States
Oncare Hawaii Inc - Kapiolani Medical Center at Pali Momi
🇺🇸'Aiea, Hawaii, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸Lihue, Hawaii, United States
Saint Alphonsus Regional Medical Center
🇺🇸Boise, Idaho, United States
Saint Anthony's Health
🇺🇸Alton, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Saint Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Memorial Hospital
🇺🇸Carthage, Illinois, United States
Mount Sinai Hospital Medical Center
🇺🇸Chicago, Illinois, United States
Hematology and Oncology Associates
🇺🇸Chicago, Illinois, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
Eureka Hospital
🇺🇸Eureka, Illinois, United States
University of Illinois
🇺🇸Chicago, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Illinois CancerCare Galesburg
🇺🇸Galesburg, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Havana
🇺🇸Havana, Illinois, United States
Mason District Hospital
🇺🇸Havana, Illinois, United States
Hematology Oncology Associates of Illinois-Highland Park
🇺🇸Highland Park, Illinois, United States
Hinsdale Hematology Oncology Associates Incorporated
🇺🇸Hinsdale, Illinois, United States
Presence Saint Mary's Hospital
🇺🇸Kankakee, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
North Shore Hematology Oncology
🇺🇸Libertyville, Illinois, United States
Mcdonough District Hospital
🇺🇸Macomb, Illinois, United States
Holy Family Medical Center
🇺🇸Monmouth, Illinois, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Illinois CancerCare-Monmouth
🇺🇸Monmouth, Illinois, United States
Illinois Cancer Specialists-Niles
🇺🇸Niles, Illinois, United States
Bromenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Community Cancer Center Foundation
🇺🇸Normal, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Illinois CancerCare-Community Cancer Center
🇺🇸Normal, Illinois, United States
Ottawa Regional Hospital and Healthcare Center
🇺🇸Ottawa, Illinois, United States
Pekin Cancer Treatment Center
🇺🇸Pekin, Illinois, United States
Proctor Hospital
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸Peoria, Illinois, United States
Illinois Oncology Research Association CCOP
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Illinois Valley Hospital
🇺🇸Peru, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Perry Memorial Hospital
🇺🇸Princeton, Illinois, United States
Swedish American Hospital
🇺🇸Rockford, Illinois, United States
Hematology Oncology Associates of Illinois - Skokie
🇺🇸Skokie, Illinois, United States
Illinois CancerCare-Spring Valley
🇺🇸Spring Valley, Illinois, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Fort Wayne Medical Oncology and Hematology Inc - State Boulevard
🇺🇸Fort Wayne, Indiana, United States
Saint Francis Hospital and Health Centers
🇺🇸Beech Grove, Indiana, United States
Franciscan St. Francis Health
🇺🇸Indianapolis, Indiana, United States
Reid Hospital and Health Care Services
🇺🇸Richmond, Indiana, United States
McFarland Clinic
🇺🇸Ames, Iowa, United States
Siouxland Hematology Oncology Associates
🇺🇸Sioux City, Iowa, United States
Mercy Medical Center-Sioux City
🇺🇸Sioux City, Iowa, United States
Saint Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
Ochsner Clinic Foundation-Baton Rouge
🇺🇸Baton Rouge, Louisiana, United States
Eastern Maine Medical Center
🇺🇸Bangor, Maine, United States
Harold Alfond Center for Cancer Care
🇺🇸Augusta, Maine, United States
Johns Hopkins University
🇺🇸Baltimore, Maryland, United States
Union Hospital of Cecil County
🇺🇸Elkton, Maryland, United States
Tufts Medical Center
🇺🇸Boston, Massachusetts, United States
Caritas Saint Elizabeth's Medical Center
🇺🇸Brighton, Massachusetts, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
Mecosta County Medical Center
🇺🇸Big Rapids, Michigan, United States
Oakwood Hospital
🇺🇸Dearborn, Michigan, United States
Hurley Medical Center
🇺🇸Flint, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Genesys Regional Medical Center-West Flint Campus
🇺🇸Flint, Michigan, United States
Genesys Regional Medical Center
🇺🇸Grand Blanc, Michigan, United States
Grand Rapids Clinical Oncology Program
🇺🇸Grand Rapids, Michigan, United States
Saint Mary's Health Care
🇺🇸Grand Rapids, Michigan, United States
Spectrum Health at Butterworth Campus
🇺🇸Grand Rapids, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Sparrow Hospital
🇺🇸Lansing, Michigan, United States
Saint Mary Mercy Hospital
🇺🇸Livonia, Michigan, United States
Mercy Health Partners-Mercy Campus
🇺🇸Muskegon, Michigan, United States
Saint Joseph Mercy Port Huron
🇺🇸Port Huron, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
Spectrum Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Saint Mary's of Michigan
🇺🇸Saginaw, Michigan, United States
Providence Hospital
🇺🇸Southfield, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
Sanford Clinic North-Bemidgi
🇺🇸Bemidji, Minnesota, United States
Saint John Macomb-Oakland Hospital
🇺🇸Warren, Michigan, United States
Essentia Health Duluth Clinic CCOP
🇺🇸Duluth, Minnesota, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸Brainerd, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Lake Region Healthcare Corporation-Cancer Care
🇺🇸Fergus Falls, Minnesota, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Saint Louis University Hospital
🇺🇸Saint Louis, Missouri, United States
Montana Cancer Consortium CCOP
🇺🇸Billings, Montana, United States
Saint John's Mercy Medical Center
🇺🇸Saint Louis, Missouri, United States
Saint Louis-Cape Girardeau CCOP
🇺🇸Saint Louis, Missouri, United States
Saint Vincent Healthcare
🇺🇸Billings, Montana, United States
Hematology-Oncology Centers of the Northern Rockies PC
🇺🇸Billings, Montana, United States
Bozeman Deaconess Cancer Center
🇺🇸Bozeman, Montana, United States
Billings Clinic
🇺🇸Billings, Montana, United States
Bozeman Deaconess Hospital
🇺🇸Bozeman, Montana, United States
Northern Montana Hospital
🇺🇸Havre, Montana, United States
Saint Peter's Community Hospital
🇺🇸Helena, Montana, United States
Glacier Oncology PLLC
🇺🇸Kalispell, Montana, United States
Montana Cancer Specialists
🇺🇸Missoula, Montana, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Winthrop University Hospital
🇺🇸Mineola, New York, United States
Park Ridge Hospital Breast Health Center
🇺🇸Hendersonville, North Carolina, United States
Memorial Sloan Kettering Cancer Center
🇺🇸New York, New York, United States
Kinston Medical Specialists PA
🇺🇸Kinston, North Carolina, United States
Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Sanford Clinic North-Fargo
🇺🇸Fargo, North Dakota, United States
Summa Akron City Hospital
🇺🇸Akron, Ohio, United States
Summa Barberton Hospital
🇺🇸Barberton, Ohio, United States
Akron General Medical Center
🇺🇸Akron, Ohio, United States
Aultman Health Foundation
🇺🇸Canton, Ohio, United States
The Jewish Hospital
🇺🇸Cincinnati, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸Dayton, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Samaritan North Health Center
🇺🇸Dayton, Ohio, United States
Dayton CCOP
🇺🇸Dayton, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Greene Memorial Hospital
🇺🇸Xenia, Ohio, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Clinton Memorial Hospital
🇺🇸Wilmington, Ohio, United States
Saint Rita's Medical Center
🇺🇸Lima, Ohio, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Providence Milwaukie Hospital
🇺🇸Milwaukie, Oregon, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Providence Willamette Falls Medical Center
🇺🇸Oregon City, Oregon, United States
Lehigh Valley Hospital - Muhlenberg
🇺🇸Bethlehem, Pennsylvania, United States
Lehigh Valley Hospital
🇺🇸Allentown, Pennsylvania, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Geisinger Medical Center-Cancer Center Hazelton
🇺🇸Hazleton, Pennsylvania, United States
Abramson Cancer Center of The University of Pennsylvania
🇺🇸Philadelphia, Pennsylvania, United States
Fox Chase Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Geisinger Medical Group
🇺🇸State College, Pennsylvania, United States
Mount Nittany Medical Center
🇺🇸State College, Pennsylvania, United States
Geisinger Wyoming Valley
🇺🇸Wilkes-Barre, Pennsylvania, United States
York Hospital
🇺🇸York, Pennsylvania, United States
Saint Francis Hospital
🇺🇸Greenville, South Carolina, United States
AnMed Health Cancer Center
🇺🇸Anderson, South Carolina, United States
Carolina Blood and Cancer Care Associates PA
🇺🇸Rock Hill, South Carolina, United States
Carolina Blood and Cancer Care Associates PA-Lancaster
🇺🇸Lancaster, South Carolina, United States
Upstate Carolina CCOP
🇺🇸Spartanburg, South Carolina, United States
Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
Sanford Cancer Center-Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Medical X-Ray Center
🇺🇸Sioux Falls, South Dakota, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Jackson-Madison County General Hospital
🇺🇸Jackson, Tennessee, United States
Erlanger Medical Center
🇺🇸Chattanooga, Tennessee, United States
Northwest Cancer Specialists
🇺🇸Vancouver, Washington, United States
West Virginia University Charleston
🇺🇸Charleston, West Virginia, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Green Bay Oncology at Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Holy Family Memorial Hospital
🇺🇸Manitowoc, Wisconsin, United States
Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Oconomowoc Memorial Hospital-ProHealth Care Inc
🇺🇸Oconomowoc, Wisconsin, United States
D N Greenwald Center
🇺🇸Mukwonago, Wisconsin, United States
Waukesha Memorial Hospital - ProHealth Care
🇺🇸Waukesha, Wisconsin, United States
Aurora Cancer Care-Milwaukee West
🇺🇸Wauwatosa, Wisconsin, United States
Saint Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Welch Cancer Center
🇺🇸Sheridan, Wyoming, United States
Rambam Medical Center
🇮🇱Haifa, Israel
Vanderbilt-Ingram Cancer Center
🇺🇸Nashville, Tennessee, United States
Sanford Medical Center-Fargo
🇺🇸Fargo, North Dakota, United States
Castle Medical Center
🇺🇸Kailua, Hawaii, United States
Kapiolani Medical Center at Pali Momi
🇺🇸'Aiea, Hawaii, United States
Rocky Mountain Oncology
🇺🇸Casper, Wyoming, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
Graham Hospital Association
🇺🇸Canton, Illinois, United States
University of Rochester
🇺🇸Rochester, New York, United States
West Virginia University
🇺🇸Morgantown, West Virginia, United States
The Hospital of Central Connecticut
🇺🇸New Britain, Connecticut, United States
Mayo Clinic in Arizona
🇺🇸Scottsdale, Arizona, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Kalispell Medical Oncology
🇺🇸Kalispell, Montana, United States
Cooper Hospital University Medical Center
🇺🇸Camden, New Jersey, United States
Saint James Community Hospital and Cancer Treatment Center
🇺🇸Butte, Montana, United States
Benefis Healthcare- Sletten Cancer Institute
🇺🇸Great Falls, Montana, United States
Baystate Medical Center
🇺🇸Springfield, Massachusetts, United States
University of Mississippi Medical Center
🇺🇸Jackson, Mississippi, United States
Great Falls Clinic
🇺🇸Great Falls, Montana, United States
Kalispell Regional Medical Center
🇺🇸Kalispell, Montana, United States
Shaare Zedek Medical Center
🇮🇱Jerusalem, Israel
Mayo Clinic Methodist Hospital
🇮🇳Nagpur, India
Saint John Hospital and Medical Center
🇺🇸Detroit, Michigan, United States
Wayne State University
🇺🇸Detroit, Michigan, United States
University of Oklahoma Health Sciences Center
🇺🇸Oklahoma City, Oklahoma, United States
University of Alabama at Birmingham
🇺🇸Birmingham, Alabama, United States
Saint Anthony Central Hospital
🇺🇸Denver, Colorado, United States
Exempla Saint Joseph Hospital
🇺🇸Denver, Colorado, United States
Presbyterian - Saint Lukes Medical Center - Health One
🇺🇸Denver, Colorado, United States
Rose Medical Center
🇺🇸Denver, Colorado, United States
Colorado Cancer Research Program CCOP
🇺🇸Denver, Colorado, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Columbia River Oncology Program
🇺🇸Portland, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Froedtert and the Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
The Medical Center of Aurora
🇺🇸Aurora, Colorado, United States
Walter Reed National Military Medical Center
🇺🇸Bethesda, Maryland, United States
Gundersen Lutheran
🇺🇸La Crosse, Wisconsin, United States
Saint Joseph Mercy Hospital
🇺🇸Ann Arbor, Michigan, United States
Michigan Cancer Research Consortium Community Clinical Oncology Program
🇺🇸Ann Arbor, Michigan, United States
Florida Hospital
🇺🇸Orlando, Florida, United States
University of Florida
🇺🇸Gainesville, Florida, United States
Straub Clinic and Hospital
🇺🇸Honolulu, Hawaii, United States
University of Hawaii
🇺🇸Honolulu, Hawaii, United States
OnCare Hawaii-Liliha
🇺🇸Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸Honolulu, Hawaii, United States
Oncare Hawaii Inc-POB II
🇺🇸Honolulu, Hawaii, United States
Oncare Hawaii Inc-Kuakini
🇺🇸Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸Honolulu, Hawaii, United States
Norton Health Care Pavilion - Downtown
🇺🇸Louisville, Kentucky, United States
Ochsner Baptist Medical Center
🇺🇸New Orleans, Louisiana, United States
Ochsner Clinic Foundation
🇺🇸New Orleans, Louisiana, United States
University of Kentucky
🇺🇸Lexington, Kentucky, United States
University of Wisconsin Hospital and Clinics
🇺🇸Madison, Wisconsin, United States
Grandview Hospital
🇺🇸Dayton, Ohio, United States