S1415CD, Trial Assessing CSF Prescribing Effectiveness and Risk (TrACER)

Not Applicable

Completed

Conditions: Stage IIIA Breast Cancer
Stage IIIA Colorectal Cancer
Stage IIIB Colorectal Cancer
Stage IVB Colorectal Cancer
Stage 0 Breast Cancer
Stage IA Non-Small Cell Lung Carcinoma
Stage IIIB Non-Small Cell Lung Cancer
Stage IV Breast Cancer
Febrile Neutropenia
Stage I Colorectal Cancer

Interventions: Other: Preventive Intervention
Other: Quality-of-Life Assessment
Other: Questionnaire Administration

Registration Number: NCT02728596

Lead Sponsor: SWOG Cancer Research Network

Brief Summary: This randomized clinical trial studies prophylactic colony stimulating factor management in patients with breast, colorectal or non-small cell lung cancer receiving chemotherapy and with risk of developing febrile neutropenia. Patients receiving chemotherapy may develop febrile neutropenia. Febrile neutropenia is a condition that involves fever and a low number of neutrophils (a type of white blood cell) in the blood. Febrile neutropenia increases the risk of infection. Colony stimulating factors are medications sometimes given to patients receiving chemotherapy to prevent febrile neutropenia. Colony stimulating factors are given to patients based on guidelines. Some clinics have an automated system that helps doctors decide when to prescribe them when there is a high risk of developing febrile neutropenia. Gathering information about the use of an automated system to prescribe prophylactic colony stimulating factor may help doctors use colony stimulating factor when it is needed.

Detailed Description: PRIMARY OBJECTIVES:

I. To compare the use of primary prophylactic colony stimulating factor (PP-CSF) according to recommended clinical practice guidelines among patients registered at intervention components versus usual care components.

II. To compare the rate of febrile neutropenia (FN) among patients registered at intervention components versus usual care components.

III. To compare the rate of FN among intermediate risk patients registered at intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

SECONDARY OBJECTIVES:

I. To compare the rate of FN among low-risk patients registered at intervention components versus usual care components.

II. To compare the FN-related health-related quality of life (HRQOL) among low-risk patients registered at intervention components versus usual care components.

III. To compare patient adherence to PP-CSF prescribing among patients registered at intervention components versus usual care components.

IV. To compare patient knowledge of the indications for, efficacy of, and side effects associated with PP-CSF between the initiation and conclusion of the first cycle of myelosuppressive systemic therapy among patients registered at intervention components versus usual care components.

V. To compare the proportion of patients completing the initial systemic therapy regimen at planned duration and at planned dose intensity among patients registered at intervention components versus usual care components.

VI. To compare antibiotic use both as prophylaxis and as treatment for FN among patients registered at intervention components versus usual care components.

VII. To compare the rate of FN-related emergency department visits and hospitalizations among intermediate risk patients registered to Intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

VIII. To compare the FN-related health-related quality of life (HRQOL) among intermediate risk patients registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

IX. To compare overall survival among intermediate risk patients registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk patients versus not).

TERTIARY OBJECTIVES:

I. To characterize and descriptively report the differences among cohort components and the intervention and usual care components.

II. To evaluate the time to invasive recurrence in non-metastatic patients by component treatment assignment

OUTLINE: Patients are randomized to 1 of 4 clinic groups.

CLINIC GROUP 1 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.

CLINIC GROUP 2 (CLINIC WITH NO AUTOMATED SYSTEM): Patients receive CSF based on clinical practice guidelines.

CLINIC GROUP 3 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high or moderate risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSFs not be used for drugs that have a low risk of FN.

CLINIC GROUP 4 (CLINIC WITH AUTOMATED SYSTEM): Patients with a high risk of developing FN receive CSF based on the automated system recommendations. The automated system suggests that CSF not be used for drugs that have a moderate risk of FN.

After completion of study treatment, patients are followed up for 12 months.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 3665

Inclusion Criteria

Patients must have a current diagnosis of breast cancer, non-small cell lung cancer, or colorectal cancer; the current diagnosis may be an initial diagnosis or recurrence and/or progression of previously diagnosed disease; cancer may be metastatic or non-metastatic
Patients must be registered prior to or on the same day as their first cycle of chemotherapy for their current disease and stage 9or disease setting).
Patients must not have had any systemic therapy (chemotherapy or combination regimens) in the 180 days just prior to registration. Prior biologic therapy, immunotherapy, tyrosine kinase inhibitors, and hormonal therapy are allowed.
Patients must be planning to receive one of the study-allowed regimens as their initial treatment for their current disease; myelosuppressive therapy must follow the standard regimen, although a dose reduction of up to 10% is permitted. This treatment may be neoadjuvant or adjuvant chemotherapy.
Patients must not be receiving or planning to receive concurrent radiation during systemic treatment.
Patients must not have any known contraindication to CSFs prior to registration, including prior hypersensitivity to Escherichia coli-derived proteins, filgrastim, pegfilgrastim, or tbo-filgrastim
Patients must be able to understand and provide information for the patient-completed study forms in either English or Spanish
Patients may have had a prior malignancy
Patients must not be participating or plan to participate in other clinical trials that involve investigational systemic cancer treatments or investigational uses of CSF during their first 6 months after registration
Patients must be informed of the investigational nature of this study and must sign and give written informed consent in accordance with institutional and federal guidelines
As a part of the Oncology Patient Enrollment Network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Clinic group 1 (clinics with existing automated system for CSF prescribing)	Preventive Intervention	CSF prescribing for patients taking anti-cancer drugs is based on existing automated system recommendations: CSF is recommended for drugs with high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 3 (clinics with automated system for CSF prescribing)	Preventive Intervention	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drugs with intermediate or high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 1 (clinics with existing automated system for CSF prescribing)	Quality-of-Life Assessment	CSF prescribing for patients taking anti-cancer drugs is based on existing automated system recommendations: CSF is recommended for drugs with high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 1 (clinics with existing automated system for CSF prescribing)	Questionnaire Administration	CSF prescribing for patients taking anti-cancer drugs is based on existing automated system recommendations: CSF is recommended for drugs with high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 2 (clinics with no automated system for CSF prescribing)	Questionnaire Administration	CSF prescribing for patients taking anti-cancer drugs is based on existing clinical practice guidelines.
Clinic group 2 (clinics with no automated system for CSF prescribing)	Quality-of-Life Assessment	CSF prescribing for patients taking anti-cancer drugs is based on existing clinical practice guidelines.
Clinic group 3 (clinics with automated system for CSF prescribing)	Quality-of-Life Assessment	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drugs with intermediate or high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 2 (clinics with no automated system for CSF prescribing)	Preventive Intervention	CSF prescribing for patients taking anti-cancer drugs is based on existing clinical practice guidelines.
Clinic group 3 (clinics with automated system for CSF prescribing)	Questionnaire Administration	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drugs with intermediate or high risk of FN; CSF is not recommended for drugs with low risk of FN.
Clinic group 4 (clinics with automated system for CSF prescribing)	Preventive Intervention	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drug with high risk of FN; CSF is not recommended for drugs with intermediate or low risk of FN.
Clinic group 4 (clinics with automated system for CSF prescribing)	Quality-of-Life Assessment	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drug with high risk of FN; CSF is not recommended for drugs with intermediate or low risk of FN.
Clinic group 4 (clinics with automated system for CSF prescribing)	Questionnaire Administration	CSF prescribing for patients taking anti-cancer drugs is based on automated system recommendations: CSF is recommended for drug with high risk of FN; CSF is not recommended for drugs with intermediate or low risk of FN.

Primary Outcome Measures

Name	Time	Method
Incidence of Febrile Neutropenia Among Intermediate Risk Participants	Within 6 months post registration	To compare the rate of FN among intermediate risk participants registered at intervention components by component treatment assignment (administer PP-CSF to intermediate risk participants versus not). Febrile neutropenia is defined by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0) as an absolute neutrophil count (ANC) \< 1000/µL and a single temperature of \> 38.3°C (101°F) or a sustained temperature of ≥ 38°C (101°F) for more than one hour.
Percentage of Participants With CSF Prescribed as Primary Prophylaxis	Baseline to up to 14 days	To compare the use of primary prophylactic colony stimulating factor (PP-CSF) according to recommended clinical practice guidelines among participants registered at intervention components versus usual care components. Primary prophylaxis of CSF (PP-CSF) is defined as the initiation of granulocyte CSFs during the first cycle of myelosuppressive systemic therapy, given 24 to 72 hours after cessation of systemic therapy. Separate mixed effects logistic models will be fit to assess the effect of the intervention on PP-CSF use. The rate of CSF prescribing is defined as the percent of participants prescribed CSF as primary prophylaxis out of the total number of participants within each arm.
Incidence of Febrile Neutropenia	Within 6 months post registration	To compare the rate of febrile neutropenia (FN) among participants, at any risk level, registered at intervention components versus usual care components. Febrile neutropenia is defined by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0) as an absolute neutrophil count (ANC) \< 1000/µL and a single temperature of \> 38.3°C (101°F) or a sustained temperature of ≥ 38°C (101°F) for more than one hour.

Secondary Outcome Measures

Name	Time	Method
Incidence of Febrile Neutropenia Among Low Risk Participants	Within 6 months of registration	To compare the rate of FN among low-risk participants registered at intervention components versus usual care components. Febrile neutropenia is defined by the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0) as an absolute neutrophil count (ANC) \< 1000/µL and a single temperature of \> 38.3°C (101°F) or a sustained temperature of ≥ 38°C (101°F) for more than one hour.
FN-related Health-Related Quality of Life (HRQOL) Among Low Risk Participants	Baseline to up to 14 days	To compare the FN-related health-related quality of life (HRQOL) among low-risk participants registered at intervention components versus usual care components. Assessed using the Functional Assessment of Cancer Therapy - Febrile Neutropenia (Version 4) (FACT-N). Includes FACT general cancer score and FN-related score. A linear mixed effects model will be fit to assess the effect of the intervention on HRQOL. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Proportion Completing Initial Systemic Therapy Regimen: a) at Planned Duration and b) at Planned Dose Intensity (Clinical)	Up to 12 months	To compare the proportion of participants completing the initial systemic therapy regimen at planned duration and at planned dose intensity among participants registered at intervention components versus usual care components.Two separate mixed effects logistic models will be used to assess the effect of the intervention on completion of the initial systemic therapy regimen (i) at planned duration and (ii) at planned dose intensity. Component-level characteristics, patient-level clinical and demographic variables will be adjusted.
Participant Adherence Rates to PP-CSF Prescription	Within 14 days after the completion of first course of therapy	To compare adherence to PP-CSF prescribing among participants registered at intervention components versus usual care components. Participant adherence rates are obtained from the proportion receiving PP-CSF among those for whom PP-CSF was ordered by the physician. The primary adherence measure will be obtained from the participant's chart; secondary adherence will be measured via self-report on the Follow-Up Participant Survey. For the home and clinic settings, separate mixed effects logistic models will be used to assess the effect of the intervention on adherence to PP-CSF orders, treating adherence after the start of the study. Component-level characteristics, participant-level clinical and demographic variables will be adjusted.
Change in Participant Knowledge of PP-CSF Indications	Baseline to up to 14 days	To compare participant knowledge of the indications for, efficacy of, and side effects associated with PP-CSF between the initiation and conclusion of the first cycle of myelosuppressive systemic therapy among participants registered at intervention components versus usual care components. Linear mixed effects model with a time variable and an interaction between randomized group and time will be used to analyze change in the patient knowledge score. Random effects will be used to accommodate both the correlation among measures from the same patient as well as the correlation among patients from the same component. Component-level characteristics, participant-level clinical and demographic variables will be adjusted.
Rate of FN-Related Emergency Department Visits and Hospitalizations	At 6 months	To compare the rate of FN-related emergency department (ED) visits and hospitalizations among intermediate risk participants registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk participants versus not). FN-related ED visits and hospitalizations are defined as admission to ED or hospital with documentation of fever and decreased ANC. A mixed effects Poisson model will be used to assess the effect of the intervention on FN-related ED visits and hospitalizations. Robust variance estimation will be used to relax the strong assumptions about the variance made by Poisson regression. If a large number of zero counts is observed, then zero-inflated Poisson regression will be used.
FN-related Health-Related Quality of Life (HRQOL) Among Intermediate Risk Participants	Baseline to up to 14 days	To compare the FN-related health-related quality of life (HRQOL) among intermediate risk participants registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk participants versus not). Assessed using the Functional Assessment of Cancer Therapy - Febrile Neutropenia (Version 4) (FACT-N). Includes FACT general cancer score and FN-related score. A linear mixed effects model will be fit to assess the effect of the intervention on HRQOL. Component-level characteristics, participant-level clinical and demographic variables will be adjusted.
Prophylactic and FN-Related Antibiotic Use	Within 30 days of therapy	To compare antibiotic use both as prophylaxis and as treatment for FN among participants registered at intervention components versus usual care components. Prophylactic and FN-related antibiotic use will be measured as total number of antibiotic agents used and duration of antibiotic use. A linear mixed effects model will be fit to assess the effect of the intervention on duration of antibiotics use with number of days. Mixed effects Poisson models will be used to assess the effect of the intervention on total number of antibiotics agents used. Three separate models will be fit, with the following outcomes: (i) the number of times antibiotics were used as prophylaxis, (ii) the number of times antibiotics were used as treatment for FN, and (iii) t
Overall Survival (OS)	Time from date of registration to date of death due to any cause, assessed up to 12 months	To compare overall survival among intermediate risk participants registered to intervention components by component treatment assignment (administer PP-CSF to intermediate risk participants versus not). A Cox proportional hazards model will be used to model survival. Component-level characteristics, participant-level clinical and demographic variables will be adjusted. A separate analysis of cause-specific survival to address FN-related deaths will also be conducted.

Trial Locations

Locations (160): Saint John Macomb-Oakland Hospital
🇺🇸
Warren, Michigan, United States
Dayton Physicians LLC-Atrium
🇺🇸
Franklin, Ohio, United States
MultiCare Good Samaritan Hospital
🇺🇸
Puyallup, Washington, United States
Marshfield Clinic-Wausau Center
🇺🇸
Wausau, Wisconsin, United States
NEA Baptist Memorial Hospital
🇺🇸
Jonesboro, Arkansas, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
Baptist Memorial Hospital and Fowler Family Cancer Center - Jonesboro
🇺🇸
Jonesboro, Arkansas, United States
Contra Costa Regional Medical Center
🇺🇸
Martinez, California, United States
Illinois CancerCare-Macomb
🇺🇸
Macomb, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸
Mattoon, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸
Peoria, Illinois, United States
Carle Physician Group-Effingham
🇺🇸
Effingham, Illinois, United States
Cancer Care Specialists of Illinois-Swansea
🇺🇸
Swansea, Illinois, United States
Saint Luke's Mountain States Tumor Institute
🇺🇸
Boise, Idaho, United States
Saint Alphonsus Cancer Care Center-Boise
🇺🇸
Boise, Idaho, United States
Saint Luke's Mountain States Tumor Institute - Nampa
🇺🇸
Nampa, Idaho, United States
Illinois CancerCare-Princeton
🇺🇸
Princeton, Illinois, United States
Saint Luke's Mountain States Tumor Institute - Fruitland
🇺🇸
Fruitland, Idaho, United States
Carle on Vermilion
🇺🇸
Danville, Illinois, United States
Cancer Center of Kansas-Independence
🇺🇸
Independence, Kansas, United States
Saint Luke's Mountain States Tumor Institute - Meridian
🇺🇸
Meridian, Idaho, United States
Centralia Oncology Clinic
🇺🇸
Centralia, Illinois, United States
Augusta University Medical Center
🇺🇸
Augusta, Georgia, United States
Cancer Center of Kansas - Parsons
🇺🇸
Parsons, Kansas, United States
Cancer Center of Kansas - Pratt
🇺🇸
Pratt, Kansas, United States
Crossroads Cancer Center
🇺🇸
Effingham, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸
Pekin, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸
Eureka, Illinois, United States
Sanford Thief River Falls Medical Center
🇺🇸
Thief River Falls, Minnesota, United States
Illinois CancerCare-Galesburg
🇺🇸
Galesburg, Illinois, United States
John H Stroger Jr Hospital of Cook County
🇺🇸
Chicago, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸
Ottawa, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸
Kewanee, Illinois, United States
Cancer Center of Kansas - Newton
🇺🇸
Newton, Kansas, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸
Decatur, Illinois, United States
Louisiana State University Health Sciences Center Shreveport
🇺🇸
Shreveport, Louisiana, United States
Illinois CancerCare-Canton
🇺🇸
Canton, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸
Carthage, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸
Bloomington, Illinois, United States
Illinois CancerCare-Peru
🇺🇸
Peru, Illinois, United States
CoxHealth South Hospital
🇺🇸
Springfield, Missouri, United States
Carle Cancer Center
🇺🇸
Urbana, Illinois, United States
Novant Health Oncology Specialists-Kernersville
🇺🇸
Kernersville, North Carolina, United States
Saint Joseph Mercy Chelsea
🇺🇸
Chelsea, Michigan, United States
West Michigan Cancer Center
🇺🇸
Kalamazoo, Michigan, United States
Sanford Cancer Center Worthington
🇺🇸
Worthington, Minnesota, United States
Baptist Cancer Center-Grenada
🇺🇸
Grenada, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Desoto
🇺🇸
Southhaven, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Golden Triangle
🇺🇸
Columbus, Mississippi, United States
Essentia Health Cancer Center
🇺🇸
Duluth, Minnesota, United States
Cancer Center of Kansas - Wellington
🇺🇸
Wellington, Kansas, United States
Saint Mary Mercy Hospital
🇺🇸
Livonia, Michigan, United States
Novant Health Oncology Specialists-Mount Airy
🇺🇸
Mount Airy, North Carolina, United States
Presbyterian Rust Medical Center/Jorgensen Cancer Center
🇺🇸
Rio Rancho, New Mexico, United States
Dayton Physicians LLC-Wayne
🇺🇸
Greenville, Ohio, United States
Greater Dayton Cancer Center
🇺🇸
Kettering, Ohio, United States
Billings Clinic Cancer Center
🇺🇸
Billings, Montana, United States
Sanford Roger Maris Cancer Center
🇺🇸
Fargo, North Dakota, United States
Sanford Joe Lueken Cancer Center
🇺🇸
Bemidji, Minnesota, United States
Baptist Memorial Hospital and Cancer Center-Union County
🇺🇸
New Albany, Mississippi, United States
Centerpoint Medical Center LLC
🇺🇸
Independence, Missouri, United States
Marshfield Medical Center-Rice Lake
🇺🇸
Rice Lake, Wisconsin, United States
Novant Health Oncology Specialists-Wilkesboro
🇺🇸
Wilkesboro, North Carolina, United States
Dayton Physicians LLC-Upper Valley
🇺🇸
Troy, Ohio, United States
Baptist Memorial Hospital and Cancer Center-Oxford
🇺🇸
Oxford, Mississippi, United States
University of New Mexico Cancer Center
🇺🇸
Albuquerque, New Mexico, United States
Geisinger Medical Center-Cancer Center Hazleton
🇺🇸
Hazleton, Pennsylvania, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States
CHI Health Saint Francis
🇺🇸
Grand Island, Nebraska, United States
Sanford Bismarck Medical Center
🇺🇸
Bismarck, North Dakota, United States
Geisinger Wyoming Valley/Henry Cancer Center
🇺🇸
Wilkes-Barre, Pennsylvania, United States
Marshfield Clinic Stevens Point Center
🇺🇸
Stevens Point, Wisconsin, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
Geisinger Cancer Services-Pottsville
🇺🇸
Pottsville, Pennsylvania, United States
Essentia Health Cancer Center-South University Clinic
🇺🇸
Fargo, North Dakota, United States
Christus Saint Vincent Regional Cancer Center
🇺🇸
Santa Fe, New Mexico, United States
Baptist Memorial Hospital and Cancer Center-Collierville
🇺🇸
Collierville, Tennessee, United States
Greenville Health System Cancer Institute-Seneca
🇺🇸
Seneca, South Carolina, United States
Greenville Health System Cancer Institute-Butternut
🇺🇸
Greenville, South Carolina, United States
Lewistown Hospital
🇺🇸
Lewistown, Pennsylvania, United States
Greenville Health System Cancer Institute-Faris
🇺🇸
Greenville, South Carolina, United States
Marshfield Clinic Cancer Center at Sacred Heart
🇺🇸
Eau Claire, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸
Minocqua, Wisconsin, United States
Geisinger Medical Oncology-Selinsgrove
🇺🇸
Selinsgrove, Pennsylvania, United States
Geisinger Medical Group
🇺🇸
State College, Pennsylvania, United States
Marshfield Medical Center-Marshfield
🇺🇸
Marshfield, Wisconsin, United States
Greenville Health System Cancer Institute-Eastside
🇺🇸
Greenville, South Carolina, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸
Sioux Falls, South Dakota, United States
Swedish Cancer Institute-Issaquah
🇺🇸
Issaquah, Washington, United States
MultiCare Auburn Medical Center
🇺🇸
Auburn, Washington, United States
Marshfield Clinic - Ladysmith Center
🇺🇸
Ladysmith, Wisconsin, United States
Doctors Cancer Center
🇵🇷
Manati, Puerto Rico
Swedish Medical Center-Ballard Campus
🇺🇸
Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸
Seattle, Washington, United States
Swedish Medical Center-Cherry Hill
🇺🇸
Seattle, Washington, United States
Cancer Center of Kansas - Dodge City
🇺🇸
Dodge City, Kansas, United States
Cancer Center of Kansas - El Dorado
🇺🇸
El Dorado, Kansas, United States
Menorah Medical Center
🇺🇸
Overland Park, Kansas, United States
Cancer Center of Kansas - Chanute
🇺🇸
Chanute, Kansas, United States
Cancer Center of Kansas-Kingman
🇺🇸
Kingman, Kansas, United States
Cancer Center of Kansas - Fort Scott
🇺🇸
Fort Scott, Kansas, United States
Saint Luke's Mountain States Tumor Institute-Twin Falls
🇺🇸
Twin Falls, Idaho, United States
Cancer Center of Kansas-Liberal
🇺🇸
Liberal, Kansas, United States
Cancer Center of Kansas - Salina
🇺🇸
Salina, Kansas, United States
Cancer Center of Kansas - Wichita
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas-Wichita Medical Arts Tower
🇺🇸
Wichita, Kansas, United States
Cancer Center of Kansas - Winfield
🇺🇸
Winfield, Kansas, United States
William Beaumont Hospital-Royal Oak
🇺🇸
Royal Oak, Michigan, United States
Bozeman Deaconess Hospital
🇺🇸
Bozeman, Montana, United States
Presbyterian Kaseman Hospital
🇺🇸
Albuquerque, New Mexico, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸
New York, New York, United States
Novant Health Oncology Specialists-Statesville
🇺🇸
Statesville, North Carolina, United States
Adena Regional Medical Center
🇺🇸
Chillicothe, Ohio, United States
Dayton Physicians LLC-Signal Point
🇺🇸
Middletown, Ohio, United States
Dayton Physicians LLC-Wilson
🇺🇸
Sidney, Ohio, United States
Geisinger Medical Center
🇺🇸
Danville, Pennsylvania, United States
Gibbs Cancer Center-Gaffney
🇺🇸
Gaffney, South Carolina, United States
Greenville Health System Cancer Institute-Greer
🇺🇸
Greer, South Carolina, United States
Greenville Memorial Hospital
🇺🇸
Greenville, South Carolina, United States
Gibbs Cancer Center-Pelham
🇺🇸
Greer, South Carolina, United States
MGC Hematology Oncology-Union
🇺🇸
Union, South Carolina, United States
Baptist Memorial Hospital and Cancer Center-Memphis
🇺🇸
Memphis, Tennessee, United States
Meharry Medical College
🇺🇸
Nashville, Tennessee, United States
Family Cancer Center-Memphis
🇺🇸
Memphis, Tennessee, United States
Logan Regional Hospital
🇺🇸
Logan, Utah, United States
MultiCare Tacoma General Hospital
🇺🇸
Tacoma, Washington, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸
Eau Claire, Wisconsin, United States
Marshfield Clinic - Weston Center
🇺🇸
Weston, Wisconsin, United States
Marshfield Clinic - Wisconsin Rapids Center
🇺🇸
Wisconsin Rapids, Wisconsin, United States
McKay-Dee Hospital Center
🇺🇸
Ogden, Utah, United States
Dixie Medical Center Regional Cancer Center
🇺🇸
Saint George, Utah, United States
Sanford Broadway Medical Center
🇺🇸
Fargo, North Dakota, United States
Essentia Health Saint Joseph's Medical Center
🇺🇸
Brainerd, Minnesota, United States
Ascension Saint John Hospital
🇺🇸
Detroit, Michigan, United States
Oncology Associates at Mercy Medical Center
🇺🇸
Cedar Rapids, Iowa, United States
Saint Joseph Mercy Brighton
🇺🇸
Brighton, Michigan, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
Saint Joseph Mercy Canton
🇺🇸
Canton, Michigan, United States
Dayton Physicians LLC-Miami Valley South
🇺🇸
Centerville, Ohio, United States
William Beaumont Hospital - Troy
🇺🇸
Troy, Michigan, United States
Community Medical Center
🇺🇸
Scranton, Pennsylvania, United States
Novant Health Oncology Specialists-Davidson County
🇺🇸
Thomasville, North Carolina, United States
Dayton Physician LLC-Miami Valley Hospital North
🇺🇸
Dayton, Ohio, United States
Spartanburg Medical Center
🇺🇸
Spartanburg, South Carolina, United States
Greenville Health System Cancer Institute-Spartanburg
🇺🇸
Spartanburg, South Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸
Sioux Falls, South Dakota, United States
MultiCare Gig Harbor Medical Park
🇺🇸
Gig Harbor, Washington, United States
Swedish Cancer Institute-Edmonds
🇺🇸
Edmonds, Washington, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
Tripler Army Medical Center
🇺🇸
Honolulu, Hawaii, United States
Medical Oncology and Hematology Associates-Des Moines
🇺🇸
Des Moines, Iowa, United States
Louisiana State University Health Science Center
🇺🇸
New Orleans, Louisiana, United States
University Medical Center New Orleans
🇺🇸
New Orleans, Louisiana, United States
Saint Joseph Mercy Hospital
🇺🇸
Ann Arbor, Michigan, United States
Research Medical Center
🇺🇸
Kansas City, Missouri, United States
Novant Health Forsyth Medical Center
🇺🇸
Winston-Salem, North Carolina, United States
Novant Health Oncology Specialists
🇺🇸
Winston-Salem, North Carolina, United States
Geisinger Medical Oncology-Lewisburg
🇺🇸
Lewisburg, Pennsylvania, United States
Marshfield Clinic-Chippewa Center
🇺🇸
Chippewa Falls, Wisconsin, United States
Integrity Oncology PLLC-Collierville
🇺🇸
Collierville, Tennessee, United States