Bendamustine Hydrochloride and Rituximab With or Without Bortezomib Followed by Rituximab With or Without Lenalidomide in Treating Patients With High-Risk Stage II, Stage III, or Stage IV Follicular Lymphoma
- Conditions
- Lymphoma
- Interventions
- Registration Number
- NCT01216683
- Lead Sponsor
- ECOG-ACRIN Cancer Research Group
- Brief Summary
RATIONALE: Drugs used in chemotherapy, such as bendamustine hydrochloride, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as rituximab, can block cancer growth in different ways. Some block the ability of cancer cells to grow and spread. Others find cancer cells and help kill them or carry cancer-killing substances to them. Bortezomib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Biological therapies, such as lenalidomide, may stimulate the immune system in different ways and stop cancer cells from growing. It is not yet known whether giving bendamustine hydrochloride and rituximab together alone is more effective than giving bendamustine hydrochloride and rituximab together with bortezomib or lenalidomide in treating follicular lymphoma.
PURPOSE: This randomized phase II trial is studying giving bendamustine hydrochloride and rituximab together with or without bortezomib followed by rituximab with or without lenalidomide to see how well they work in treating patients with high-risk stage II, stage III, or stage IV follicular lymphoma.
- Detailed Description
OBJECTIVES:
Primary
* To compare the complete remission rate in patients with high-risk follicular lymphoma receiving induction therapy comprising bendamustine hydrochloride and rituximab with vs without bortezomib.
* To compare the 1-year post-induction disease-free survival rate in patients receiving continuation therapy comprising rituximab with vs without lenalidomide.
Secondary
* To determine the 3-year progression-free survival and the 5-year overall survival of these patients.
* To evaluate patient-reported outcomes at baseline and during treatment to determine differences in symptom palliation, treatment-related symptoms, and overall health-related quality of life.
* To examine the association between baseline Follicular Lymphoma International Prognostic Index (FLIPI) information and outcome of these patients.
* To examine the association between baseline and end-of-treatment patient comorbidities assessed by the Cumulative Illness Rating Scale (CIRS) and outcome.
* To create an image and tissue bank including serial PET/CT scans, diagnostic paraffin-embedded tissue, germline DNA, and serial blood and bone marrow samples sufficient to support proposed and future studies of tumor and host characteristics that may predict for clinical outcome, including treatment arm effects, and enhance existing prognostic indices. (exploratory)
* To evaluate the rate of peripheral neuropathy associated with subcutaneous and intravenous bortezomib.
OUTLINE: Patients are stratified according to FLIPI-1score (0-2 vs 3 vs 4-5) and Groupe d'Etude des Lymphomes Folliculaires (GELF) tumor burden (low vs high). Patients are randomized to 1 of 3 treatment arms.
* Arm A then Arm D
* Arm A (induction): Patients receive rituximab intravenously (IV) on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity.
* Arm D (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity.
* Arm B then Arm E
* Arm B (induction): Patients receive rituximab IV on day 1; bortezomib IV on days 1, 4, 8, and 11; and bendamustine hydrochloride IV over 1 hour on days 1 and 4. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity.
* Arm E (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab as in arm D.
* Arm C then Arm F
* Arm C (induction): Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity.
* Arm F (continuation): Immediately after completing induction therapy, patients who have stable disease or better at time of post-induction restaging receive oral lenalidomide on days 1-21. Treatment repeats every 4 weeks for 13 courses in the absence of disease progression or unacceptable toxicity. Beginning 4 weeks after the completion of induction therapy, these patients receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity.
Quality of life (including fatigue, neurotoxicity, anxiety, and depression) is assessed by questionnaire at baseline and periodically during study therapy.
Blood, bone marrow, and tissue samples may be collected periodically for correlative studies and for a repository.
After completion of study therapy, patients are followed up periodically for 15 years.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 289
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm B then Arm E (Induction with Bendamustine + Rituximab + Bortezomib; Continuation with Rituximab) rituximab Arm B (induction): Patients receive rituximab IV on day 1; bortezomib IV on days 1, 4, 8, and 11; and bendamustine hydrochloride IV over 1 hour on days 1 and 4. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm E (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab as in arm D. Arm A then Arm D (Induction with Bendamustine + Rituximab; Continuation with Rituximab) rituximab Arm A (induction): Patients receive rituximab intravenously (IV) on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm D (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity. Arm A then Arm D (Induction with Bendamustine + Rituximab; Continuation with Rituximab) Bendamustin Arm A (induction): Patients receive rituximab intravenously (IV) on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm D (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity. Arm B then Arm E (Induction with Bendamustine + Rituximab + Bortezomib; Continuation with Rituximab) Bendamustin Arm B (induction): Patients receive rituximab IV on day 1; bortezomib IV on days 1, 4, 8, and 11; and bendamustine hydrochloride IV over 1 hour on days 1 and 4. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm E (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab as in arm D. Arm C then Arm F (Induction with Bendamustine+Rituximab; Continuation with Lenalidomide + Rituximab) rituximab Arm C (induction): Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm F (continuation): Immediately after completing induction therapy, patients who have stable disease or better at time of post-induction restaging receive oral lenalidomide on days 1-21. Treatment repeats every 4 weeks for 13 courses in the absence of disease progression or unacceptable toxicity. Beginning 4 weeks after the completion of induction therapy, these patients receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity. Arm C then Arm F (Induction with Bendamustine+Rituximab; Continuation with Lenalidomide + Rituximab) Bendamustin Arm C (induction): Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm F (continuation): Immediately after completing induction therapy, patients who have stable disease or better at time of post-induction restaging receive oral lenalidomide on days 1-21. Treatment repeats every 4 weeks for 13 courses in the absence of disease progression or unacceptable toxicity. Beginning 4 weeks after the completion of induction therapy, these patients receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity. Arm B then Arm E (Induction with Bendamustine + Rituximab + Bortezomib; Continuation with Rituximab) bortezomib Arm B (induction): Patients receive rituximab IV on day 1; bortezomib IV on days 1, 4, 8, and 11; and bendamustine hydrochloride IV over 1 hour on days 1 and 4. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm E (continuation): Beginning 4 weeks after the completion of induction therapy, patients who have stable disease or better at time of post-induction restaging receive rituximab as in arm D. Arm C then Arm F (Induction with Bendamustine+Rituximab; Continuation with Lenalidomide + Rituximab) lenalidomide Arm C (induction): Patients receive rituximab IV on day 1 and bendamustine hydrochloride IV over 1 hour on days 1 and 2. Treatment repeats every 28 days for 6 courses in the absence of disease progression or unacceptable toxicity. Arm F (continuation): Immediately after completing induction therapy, patients who have stable disease or better at time of post-induction restaging receive oral lenalidomide on days 1-21. Treatment repeats every 4 weeks for 13 courses in the absence of disease progression or unacceptable toxicity. Beginning 4 weeks after the completion of induction therapy, these patients receive rituximab IV on day 1. Treatment repeats every 8 weeks for 2 years in the absence of disease progression or unacceptable toxicity.
- Primary Outcome Measures
Name Time Method 1-year Post-induction Disease-free Survival (DFS) Rate Assessed at 1 year post-induction, approximately 1.5 years 1-year post induction disease-free survival rate is defined as the proportion of patients achieving complete remission during induction treatment and are alive and maintaining complete remission at 1 year after induction completion.
The purpose of this analysis is to compare the 1-year post-induction disease-free survival (DFS) rate with rituximab plus lenalidomide to rituximab alone as continuation therapy following induction treatment of bendamustine+rituximab, therefore, patients with induction treatment of bendamustine + rituximab + bortezomib were not included in this analysis.Complete Remission (CR) Rate Assessed every 4 weeks during induction treatment and every 8 weeks during continuation treatment, up to 2 years Complete remission is defined as complete disappearance of all detectable clinical evidence of disease and disease-related symptoms if present prior to therapy.
This analysis was conducted among 222 evaluable patients for the primary analysis. The purpose of this analysis is to compare the complete remission rate of rituximab + bendamustine vs. bortezomib + rituximab + bendamustine as induction therapy, therefore, the proportion of patients with complete remission was compared between Arm B (bortezomib + rituximab + bendamustine) and Arms A and C combined (rituximab + bendamustine).
- Secondary Outcome Measures
Name Time Method Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) Subscale Score at Baseline Assessed at baseline The Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) subscale is comprised of 11 items that assess neurotoxicity with a scale of 0-4. The FACT-GOG-NTX subscale score ranges between 0 and 44. The higher the score, the better the quality of life.
3-year Progression-free Survival Rate Assessed every cycle during treatment and every 6 months between 2 and 5 years from study entry Progression-free survival is defined as the time from registration of induction treatment to progression, relapse or death, whichever occurs first. Patients alive without documented progression are censored at last disease assessment. 3-year progression-free survival rate is the proportion of patients who were progression-free and alive at 3 years estimated using the method of Kaplan-Meier.
Progression/relapse is defined as appearance of any new lesion more than 1.5 cm in any axis during or at the end of therapy, \>=50% increase from nadir in the SPD of any previously involved nodes or extranodal masses or the size of other lesions, or \>=50% increase in the longest diameter of any single previously identified node or extranodal mass more than 1 cm in its short axis.
The 3-year progression-free survival rate is reported by Cumulative Illness Rating Scale (CIRS) score (\<10 vs. \>=10). Higher CIRS scores indicate higher severity with max score of 56 points.5-year Overall Survival Rate Assessed every cycle during treatment and every 6 months between 2 and 5 years from study entry Overall survival is defined as the time from randomization to death or date last known alive. 5-year overall survival rate is the proportion of patients who were alive at 5 years estimated using the method of Kaplan-Meier.
The 5-year overall survival rate is reported by Cumulative Illness Rating Scale (CIRS) score (\<10 vs. \>=10). Higher CIRS scores indicate higher severity with max score of 56 points.1-year Disease-free Survival (DFS) Rate Assessed at 1 year post-induction, approximately 1.5 years 1-year post induction disease-free survival rate is defined as the proportion of patients achieving complete remission during induction treatment and are alive and maintaining complete remission at 1 year after induction completion.
This analysis was conducted among 250 evaluable patients with Cumulative Illness Rating Scale (CIRS) data available. The proportion of patients disease-free and alive at 1 year post induction treatment was compared between patients with CIRS \<10 and patients with CIRS \>=10. Higher CIRS scores indicate higher severity with max score of 56 points.Progression-free Survival Assessed every cycle during treatment and every 6 months between 2 and 5 years from study entry Progression-free survival is defined as the time from registration of induction treatment to progression, relapse or death, whichever occurs first. Patients alive without documented progression are censored at last disease assessment. Progression/relapse is defined as appearance of any new lesion more than 1.5 cm in any axis during or at the end of therapy, \>=50% increase from nadir in the SPD of any previously involved nodes or extranodal masses or the size of other lesions, or \>=50% increase in the longest diameter of any single previously identified node or extranodal mass more than 1 cm in its short axis.
The five FLIPI risk factors were: age \> 60 years, Ann Arbor stage III-IV, hemoglobin level \< 12 gm/dL, \>4 nodal areas, and serum LDH level above normal. The FLIPI score was calculated by summing the number of risk factors. The higher the FLIPI score, the worse the prognosis.Proportion of Patients With Grade 3 or Higher Peripheral Neuropathy Assessed every cycle during treatment and for 30 days after discontinuation of treatment, up to 15 years Peripheral neuropathy was assessed using NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Proportion of patients with grade 3 or higher peripheral neuropathy was compared between patients with subcutaneous bortezomib and patients with intravenous bortezomib.
Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) Subscale Score at Mid-induction Treatment Assessed at cycle 3 or cycle 4, approximately 3 or 4 months The Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) is comprised of 13 items that assess fatigue and its impact with a scale of 0-4. The FACIT-Fatigue subscale score ranges between 0 and 52. The higher the score, the better the quality of life.
FACIT-Fatigue subscale score at cycle 3 is considered as mid-treatment score. If FACIT-Fatigue subscale score at cycle 3 is not available, the score at cycle 4 will be used as the mid-treatment score.Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) Subscale Score at Mid-induction Treatment Assessed at cycle 3, approximately 3 months The Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) subscale is comprised of 11 items that assess neurotoxicity with a scale of 0-4. The FACT-GOG-NTX subscale score ranges between 0 and 44. The higher the score, the better the quality of life.
Complete Remission (CR) Rate Assessed every 4 weeks during induction treatment and every 8 weeks during continuation treatment, up to 2 years Complete remission is defined as complete disappearance of all detectable clinical evidence of disease and disease-related symptoms if present prior to therapy.
This analysis was conducted among 250 evaluable patients with Cumulative Illness Rating Scale (CIRS) data available. The proportion of patients with complete remission was compared between patients with CIRS \<10 and patients with CIRS \>=10. Higher CIRS scores indicate higher severity with max score of 56 points.Functional Assessment of Cancer Therapy - General (FACT-G) Total Score at Baseline Assessed at baseline The Functional Assessment of Cancer Therapy - General (FACT-G) is a 27-item questionnaire that has four areas of measurements (physical well-being, social/family well-being, emotional well-being and functional well-being) with a scale of 0-4. The FACT-G total score ranges between 0 and 108. The higher the score, the better the quality of life.
Functional Assessment of Cancer Therapy - General (FACT-G) Total Score at Mid-treatment Assessed at cycle 3 or cycle 4, approximately 3 or 4 months The Functional Assessment of Cancer Therapy - General (FACT-G) is a 27-item questionnaire that has four areas of measurements (physical well-being, social/family well-being, emotional well-being and functional well-being) with a scale of 0-4. The FACT-G total score ranges between 0 and 108. The higher the score, the better the quality of life.
FACT-G total score at cycle 3 is considered as mid-treatment score. If FACT-G total score at cycle 3 is not available, the score at cycle 4 will be used as the mid-treatment score.Functional Assessment of Cancer Therapy - General (FACT-G) Total Score at End of Induction Treatment Assessed at cycle 6, approximately 6 months The Functional Assessment of Cancer Therapy - General (FACT-G) is a 27-item questionnaire that has four areas of measurements (physical well-being, social/family well-being, emotional well-being and functional well-being) with a scale of 0-4. The FACT-G total score ranges between 0 and 108. The higher the score, the better the quality of life.
Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) Subscale Score at End of Induction Treatment Assessed at cycle 6, approximately 6 months The Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) is a 15-item questionnaire that evaluates disease-related symptoms and concerns specific to lymphoma with a scale of 0-4. The FACT-Lym subscale score ranges between 0 and 60. The higher the score, the better the quality of life.
Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) Subscale Score at End of Induction Treatment Assessed at cycle 6, approximately 6 months The Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) is comprised of 13 items that assess fatigue and its impact with a scale of 0-4. The FACIT-Fatigue subscale score ranges between 0 and 52. The higher the score, the better the quality of life.
Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) Subscale Score at Baseline Assessed at baseline The Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) is a 15-item questionnaire that evaluates disease-related symptoms and concerns specific to lymphoma with a scale of 0-4. The FACT-Lym subscale score ranges between 0 and 60. The higher the score, the better the quality of life.
Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) Subscale Score at Mid-induction Treatment Assessed at cycle 3 or cycle 4, approximately 3 or 4 months The Functional Assessment of Cancer Therapy - Lymphoma (FACT-Lym) is a 15-item questionnaire that evaluates disease-related symptoms and concerns specific to lymphoma with a scale of 0-4. The FACT-Lym subscale score ranges between 0 and 60. The higher the score, the better the quality of life.
FACT-Lym subscale score at cycle 3 is considered as mid-treatment score. If FACT-Lym subscale score at cycle 3 is not available, the score at cycle 4 will be used as the mid-treatment score.Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) Subscale Score at Baseline Assessed at baseline The Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue) is comprised of 13 items that assess fatigue and its impact with a scale of 0-4. The FACIT-Fatigue subscale score ranges between 0 and 52. The higher the score, the better the quality of life.
Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) Subscale Score at the End of Induction Treatment Assessed at end of induction treatment (cycle 6), approximately 6 months The Functional Assessment of Cancer Therapy/Gynecologic Oncology Group - Neurotoxicity (FACT-GOG-NTX) subscale is comprised of 11 items that assess neurotoxicity with a scale of 0-4. The FACT-GOG-NTX subscale score ranges between 0 and 44. The higher the score, the better the quality of life.
Trial Locations
- Locations (226)
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Graham Hospital Association
🇺🇸Canton, Illinois, United States
Mcdonough District Hospital
🇺🇸Macomb, Illinois, United States
Minnesota Oncology and Hematology PA-Woodbury
🇺🇸Woodbury, Minnesota, United States
Mount Nittany Medical Center
🇺🇸State College, Pennsylvania, United States
Marshfield Clinic
🇺🇸Marshfield, Wisconsin, United States
Saint Joseph's Hospital
🇺🇸Marshfield, Wisconsin, United States
Case Western Reserve University
🇺🇸Cleveland, Ohio, United States
MetroHealth Medical Center
🇺🇸Cleveland, Ohio, United States
Tufts Medical Center
🇺🇸Boston, Massachusetts, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Vanderbilt-Ingram Cancer Center
🇺🇸Nashville, Tennessee, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Diagnostic and Treatment Center
🇺🇸Weston, Wisconsin, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
Marshfield Clinic - Weston Center
🇺🇸Weston, Wisconsin, United States
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
Illinois CancerCare Galesburg
🇺🇸Galesburg, Illinois, United States
Riverview Hospital
🇺🇸Wisconsin Rapids, Wisconsin, United States
Crossroads Cancer Center
🇺🇸Effingham, Illinois, United States
Eureka Hospital
🇺🇸Eureka, Illinois, United States
North Shore Hematology Oncology
🇺🇸Libertyville, Illinois, United States
Pekin Cancer Treatment Center
🇺🇸Pekin, Illinois, United States
Hinsdale Hematology Oncology Associates Incorporated
🇺🇸Hinsdale, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Illinois Cancer Specialists-Niles
🇺🇸Niles, Illinois, United States
Community Cancer Center Foundation
🇺🇸Normal, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
The Carle Foundation Hospital
🇺🇸Urbana, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Ottumwa Regional Health Center
🇺🇸Ottumwa, Iowa, United States
Siouxland Hematology Oncology Associates
🇺🇸Sioux City, Iowa, United States
Mercy Medical Center-Sioux City
🇺🇸Sioux City, Iowa, United States
Lawrence Memorial Hospital
🇺🇸Lawrence, Kansas, United States
Greater Baltimore Medical Center
🇺🇸Baltimore, Maryland, United States
Dana-Farber Harvard Cancer Center
🇺🇸Boston, Massachusetts, United States
Green Bay Oncology - Iron Mountain
🇺🇸Iron Mountain, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
Allegiance Health
🇺🇸Jackson, Michigan, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸Brainerd, Minnesota, United States
Saint Mary's of Michigan
🇺🇸Saginaw, Michigan, United States
Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
Essentia Health Cancer Center
🇺🇸Duluth, Minnesota, United States
Essentia Health Saint Mary's Medical Center
🇺🇸Duluth, Minnesota, United States
Miller-Dwan Hospital
🇺🇸Duluth, Minnesota, United States
Unity Hospital
🇺🇸Fridley, Minnesota, United States
Hutchinson Area Health Care
🇺🇸Hutchinson, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸Minneapolis, Minnesota, United States
Lakeview Hospital
🇺🇸Stillwater, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸Saint Louis Park, Minnesota, United States
Metro-Minnesota CCOP
🇺🇸Saint Louis Park, Minnesota, United States
Regions Hospital
🇺🇸Saint Paul, Minnesota, United States
United Hospital
🇺🇸Saint Paul, Minnesota, United States
Ridgeview Medical Center
🇺🇸Waconia, Minnesota, United States
Rice Memorial Hospital
🇺🇸Willmar, Minnesota, United States
Veterans Adminstration New Jersey Health Care System
🇺🇸East Orange, New Jersey, United States
Cancer Institute of New Jersey At Hamilton
🇺🇸Hamilton, New Jersey, United States
Aria Health-Torresdale Campus
🇺🇸Philadelphia, Pennsylvania, United States
Ireland Cancer Center at Firelands Regional Medical Center
🇺🇸Sandusky, Ohio, United States
Essentia Health Cancer Center-South University Clinic
🇺🇸Fargo, North Dakota, United States
Cleveland Clinic Foundation
🇺🇸Cleveland, Ohio, United States
Lake University Ireland Cancer Center
🇺🇸Mentor, Ohio, United States
Geaugra Hospital
🇺🇸Chardon, Ohio, United States
Toledo Clinic Cancer Centers-Oregon
🇺🇸Oregon, Ohio, United States
Penn State Milton S Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Geisinger Medical Center
🇺🇸Danville, Pennsylvania, United States
Geisinger Medical Oncology at Evangelical Community Hospital
🇺🇸Lewisburg, Pennsylvania, United States
Pennsylvania Hospital
🇺🇸Philadelphia, Pennsylvania, United States
Geisinger Medical Oncology-Pottsville
🇺🇸Pottsville, Pennsylvania, United States
Geisinger Medical Group
🇺🇸State College, Pennsylvania, United States
Geisinger Wyoming Valley
🇺🇸Wilkes-Barre, Pennsylvania, United States
Reading Hospital
🇺🇸West Reading, Pennsylvania, United States
Vanderbilt-Ingram Cancer Center Cool Springs
🇺🇸Franklin, Tennessee, United States
Sanford Cancer Center-Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Marshfield Clinic-Chippewa Center
🇺🇸Chippewa Falls, Wisconsin, United States
University of Texas Southwestern Medical Center
🇺🇸Dallas, Texas, United States
West Virginia University Healthcare
🇺🇸Morgantown, West Virginia, United States
Langlade Hospital and Cancer Center
🇺🇸Antigo, Wisconsin, United States
Marshfield Clinic Cancer Center at Sacred Heart
🇺🇸Eau Claire, Wisconsin, United States
Green Bay Oncology at Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Saint Vincent Hospital
🇺🇸Green Bay, Wisconsin, United States
Salinas Valley Memorial
🇺🇸Salinas, California, United States
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
Marin Cancer Care Inc
🇺🇸Greenbrae, California, United States
Stanford University Hospitals and Clinics
🇺🇸Stanford, California, United States
Vince Lombardi Cancer Clinic-Marinette
🇺🇸Marinette, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸Minocqua, Wisconsin, United States
Saint Michael's Hospital
🇺🇸Stevens Point, Wisconsin, United States
Oconomowoc Memorial Hospital-ProHealth Care Inc
🇺🇸Oconomowoc, Wisconsin, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Green Bay Oncology - Oconto Falls
🇺🇸Oconto Falls, Wisconsin, United States
Poudre Valley Hospital
🇺🇸Fort Collins, Colorado, United States
Rocky Mountain Cancer Centers-Greenwood Village
🇺🇸Greenwood Village, Colorado, United States
Vince Lombardi Cancer Clinic - Oshkosh
🇺🇸Oshkosh, Wisconsin, United States
Vince Lombardi Cancer Clinic-Sheboygan
🇺🇸Sheboygan, Wisconsin, United States
Green Bay Oncology - Sturgeon Bay
🇺🇸Sturgeon Bay, Wisconsin, United States
Sky Ridge Medical Center
🇺🇸Lone Tree, Colorado, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸Wisconsin Rapids, Wisconsin, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Christiana Care Health System-Christiana Hospital
🇺🇸Newark, Delaware, United States
Georgia Regents University Medical Center
🇺🇸Augusta, Georgia, United States
Aurora Cancer Care-Milwaukee West
🇺🇸Wauwatosa, Wisconsin, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, 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
Saint John Hospital and Medical Center
🇺🇸Detroit, Michigan, United States
Rocky Mountain Cancer Centers-Midtown
🇺🇸Denver, Colorado, United States
Rocky Mountain Cancer Centers-Rose
🇺🇸Denver, Colorado, United States
Colorado Blood Cancer Institute
🇺🇸Denver, Colorado, United States
Colorado Cancer Research Program CCOP
🇺🇸Denver, Colorado, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
The Medical Center of Aurora
🇺🇸Aurora, Colorado, United States
Froedtert and the Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Rocky Mountain Cancer Centers-Boulder
🇺🇸Boulder, Colorado, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
Comprehensive Cancer Care and Research Institute of Colorado LLC
🇺🇸Englewood, Colorado, United States
Rocky Mountain Cancer Centers-Lakewood
🇺🇸Lakewood, Colorado, United States
Mountain Blue Cancer Care Center
🇺🇸Golden, Colorado, United States
Rocky Mountain Cancer Centers-Sky Ridge
🇺🇸Lone Tree, Colorado, United States
Parker Adventist Hospital
🇺🇸Parker, Colorado, United States
Littleton Adventist Hospital
🇺🇸Littleton, Colorado, United States
Rocky Mountain Cancer Centers-Parker
🇺🇸Parker, Colorado, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
Exempla Lutheran Medical Center
🇺🇸Wheat Ridge, Colorado, United States
Emory University/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸Boise, Idaho, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Saint Joseph Medical Center
🇺🇸Bloomington, Illinois, United States
Centralia Oncology Clinic
🇺🇸Centralia, Illinois, United States
Memorial Hospital
🇺🇸Carthage, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Cancer Care Center of Decatur
🇺🇸Decatur, Illinois, United States
Carle on Vermilion
🇺🇸Danville, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Mason District Hospital
🇺🇸Havana, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Illinois CancerCare-Monmouth
🇺🇸Monmouth, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
Bromenn Regional Medical Center
🇺🇸Normal, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Ottawa Regional Hospital and Healthcare Center
🇺🇸Ottawa, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
Proctor Hospital
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
Illinois Oncology Research Association CCOP
🇺🇸Peoria, Illinois, United States
Illinois Valley Hospital
🇺🇸Peru, Illinois, United States
SwedishAmerican Regional Cancer Center/ACT
🇺🇸Rockford, Illinois, United States
Perry Memorial Hospital
🇺🇸Princeton, Illinois, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Franciscan Saint Anthony Health-Michigan City
🇺🇸Michigan City, Indiana, United States
IU Health Arnett Cancer Care
🇺🇸Lafayette, Indiana, United States
McFarland Clinic PC-William R Bliss Cancer Center
🇺🇸Ames, Iowa, United States
Saint Luke's Regional Medical Center
🇺🇸Sioux City, Iowa, United States
Wesley Medical Center
🇺🇸Wichita, Kansas, United States
Ochsner Health Center-Summa
🇺🇸Baton Rouge, Louisiana, United States
Green Bay Oncology - Escanaba
🇺🇸Escanaba, Michigan, United States
University of Massachusetts Medical School
🇺🇸Worcester, Massachusetts, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
Saint Joseph Mercy Oakland
🇺🇸Pontiac, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Saint John Macomb-Oakland Hospital
🇺🇸Warren, Michigan, United States
Sanford Clinic North-Bemidgi
🇺🇸Bemidji, Minnesota, United States
Fairview Ridges Hospital
🇺🇸Burnsville, Minnesota, United States
Fairview-Southdale Hospital
🇺🇸Edina, Minnesota, United States
Saint John's Hospital - Healtheast
🇺🇸Maplewood, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸Maplewood, Minnesota, United States
North Memorial Medical Health Center
🇺🇸Robbinsdale, Minnesota, United States
Saint Francis Regional Medical Center
🇺🇸Shakopee, Minnesota, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Hunterdon Medical Center
🇺🇸Flemington, New Jersey, United States
UMDNJ - New Jersey Medical School
🇺🇸Newark, New Jersey, United States
Rutgers Cancer Institute of New Jersey
🇺🇸New Brunswick, New Jersey, United States
Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
New York University Langone Medical Center
🇺🇸New York, New York, United States
Sanford Clinic North-Fargo
🇺🇸Fargo, North Dakota, United States
Sanford Medical Center-Fargo
🇺🇸Fargo, North Dakota, United States
Summa Akron City Hospital/Cooper Cancer Center
🇺🇸Akron, Ohio, United States
Mercy Medical Center
🇺🇸Canton, Ohio, United States
Toledo Clinic Cancer Centers-Bowling Green
🇺🇸Bowling Green, Ohio, United States
Ireland Cancer Center Landerbrook Health Center
🇺🇸Mayfield Heights, Ohio, United States
Southwest General Health Center Ireland Cancer Center
🇺🇸Middleburg Heights, Ohio, United States
Flower Hospital
🇺🇸Sylvania, Ohio, United States
UHHS-Chagrin Highlands Medical Center
🇺🇸Orange Village, Ohio, United States
Toledo Community Hospital Oncology Program CCOP
🇺🇸Toledo, Ohio, United States
UH-Seidman Cancer Center at Saint John Medical Center
🇺🇸Westlake, Ohio, United States
UHHS-Westlake Medical Center
🇺🇸Westlake, Ohio, United States
Toledo Clinic Cancer Centers-Toledo
🇺🇸Toledo, Ohio, United States
University Hospitals Sharon Health Center
🇺🇸Wadsworth, Ohio, United States
Abington Memorial Hospital
🇺🇸Abington, Pennsylvania, United States
Geisinger Medical Center-Cancer Center Hazleton
🇺🇸Hazleton, Pennsylvania, United States
Lewistown Hospital
🇺🇸Lewistown, Pennsylvania, United States
Thomas Jefferson University Hospital
🇺🇸Philadelphia, Pennsylvania, United States
Hematology and Oncology Associates of North East Pennsylvania
🇺🇸Scranton, Pennsylvania, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Parkland Memorial Hospital
🇺🇸Dallas, Texas, United States
West Virginia University Charleston
🇺🇸Charleston, West Virginia, United States
Fox Valley Hematology and Oncology
🇺🇸Appleton, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States
Saint Mary's Hospital
🇺🇸Rhinelander, Wisconsin, United States
Aurora BayCare Medical Center
🇺🇸Green Bay, Wisconsin, United States
Green Bay Oncology Limited at Saint Mary's Hospital
🇺🇸Green Bay, Wisconsin, United States
Bellin Memorial Hospital
🇺🇸Green Bay, Wisconsin, United States
UW Cancer Center Johnson Creek
🇺🇸Johnson Creek, Wisconsin, United States
Marshfield Clinic at James Beck Cancer Center
🇺🇸Rhinelander, Wisconsin, United States
Saint Nicholas Hospital
🇺🇸Sheboygan, Wisconsin, United States
Marshfield Clinic-Rice Lake Center
🇺🇸Rice Lake, Wisconsin, United States
Marshfield Clinic Cancer Care at Saint Michael's Hospital
🇺🇸Stevens Point, Wisconsin, United States
Waukesha Memorial Hospital - ProHealth Care
🇺🇸Waukesha, Wisconsin, United States
Vince Lombardi Cancer Clinic
🇺🇸Two Rivers, Wisconsin, United States
Aurora Medical Center in Summit
🇺🇸Summit, Wisconsin, United States
Aspirus Regional Cancer Center
🇺🇸Wausau, Wisconsin, United States
Saint Joseph Mercy Hospital
🇺🇸Ann Arbor, Michigan, United States
Ochsner Baptist Medical Center
🇺🇸New Orleans, Louisiana, United States
Ochsner Medical Center Jefferson
🇺🇸New Orleans, Louisiana, United States
Dean Hematology and Oncology Clinic
🇺🇸Madison, Wisconsin, United States
University of Wisconsin Hospital and Clinics
🇺🇸Madison, Wisconsin, United States
North Colorado Medical Center
🇺🇸Greeley, Colorado, United States