Sorafenib Tosylate in Treating Patients With Desmoid Tumors or Aggressive Fibromatosis

Phase 3

Completed

Conditions: Desmoid Fibromatosis

Interventions: Other: Laboratory Biomarker Analysis
Other: Placebo Administration
Drug: Sorafenib Tosylate
Other: Quality-of-Life Assessment

Registration Number: NCT02066181

Lead Sponsor: National Cancer Institute (NCI)

Brief Summary: This randomized phase III trial compares the effects, good and/or bad, of sorafenib tosylate in treating patients with desmoid tumors or aggressive fibromatosis. Sorafenib tosylate may stop the growth of tumor cells by blocking some of the proteins needed for cell growth. \[Funding Source - FDA OOPD\]

Detailed Description: PRIMARY OBJECTIVES:

I. To compare the progression-free survival (PFS) rates of patients with desmoid tumors (DT)/deep fibromatosis (DF) who receive either sorafenib (sorafenib tosylate) or placebo using a double-blinded randomized phase III study.

SECONDARY OBJECTIVES:

I. To assess toxicity. II. To assess time to surgical intervention. III. To assess tumor response rates and survival.

TERTIARY OBJECTIVES:

I. To evaluate changes in magnetic resonance imaging (MRI) Tesla (T)2 to predict (or correlate) with a biological effect such as tumor growth (by Response Evaluation Criteria in Solid Tumors \[RECIST\] version \[v\]1.1), and pain palliation. (Correlative companion study) II. The mechanism of action of sorafenib in DT/DF remains unknown. In patients consenting to undergo the paired tumor biopsies (A091105-ST1), treatment induced changes will be quantified by histology, gene expression profiling, proteomic changes and selected interrogation of key pathways by western blot and reverse transcription-polymerase chain reaction (RT-PCR). (Correlative companion study) III. To collect archival tissue, baseline (tumor, blood) and day 8 (tumor, blood) specimens for basic science research (A091105-ST1). (Correlative companion study) IV. To assess patient-reported adverse events and quality of life (QOL) as measured by the Patient-Reported Outcomes-Common Terminology Criteria for Adverse Events (PRO-CTCAE) and the single-item overall Linear Analogue Self-Assessment (LASA) (A091105-HO1). (Correlative companion study) V. To assess pain palliation measured by the "worst pain" item of the Brief Pain Inventory Short Form (A091105-HO1). (Correlative companion study)

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM I: Patients receive sorafenib tosylate orally (PO) once daily (QD) on days 1-28.

ARM II: Patients receive placebo PO QD on days 1-28. Patients may crossover to Arm I upon disease progression.

In both arms, courses repeat every 28 days in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up annually for up to 3 years.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 87

Inclusion Criteria

Patients must have confirmation of DT/DF by local pathologist prior to registration
Patients may have been treated with locoregional therapies such as major surgery, radiation, radiofrequency ablation, or cryosurgery provided this has been completed at least 4 weeks prior to registration and recovered from therapy related toxicity to less than CTCAE grade 2
Patients may have been treated with cytotoxic, biologic (antibody), immune or experimental therapy, tyrosine kinase inhibitors, hormone inhibitors or nonsteroidal anti-inflammatory drugs (NSAIDs) provided this has been completed at least 4 weeks prior to registration (6 weeks for mitomycin and nitrosoureas) and recovered from any therapy related toxicity to less than CTCAE grade 2
Patients with prior or current treatment of sorafenib are excluded
No concomitant treatment, in therapeutic doses, with anticoagulants such as warfarin or warfarin-related agents, heparin, thrombin or Factor Xa inhibitors, or antiplatelet agents (e.g., clopidogrel); low dose aspirin (=< 81 mg/day), low-dose warfarin (=< 1 mg/day), and prophylactic low molecular weight heparin (LMWH) are permitted; please note that drugs that strongly induce or inhibit cytochrome P450, family 3, subfamily A, polypeptide 4 (CYP3A4) or are associated with a risk of torsades are not allowed; chronic concomitant treatment of CYP3A4 inducers is not allowed (e.g., dexamethasone, phenytoin, carbamazepine, rifampin, rifabutin, rifapentin, phenobarbital, and St. John's wort); as part of the enrollment/informed consent procedures, the patient will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the patient is considering a new over-the-counter medicine or herbal product; the following drugs are strong inhibitors of CYP3A4 and are not allowed during the treatment with sorafenib:
- Boceprevir
- Indinavir
- Nelfinavir
- Lopinavir/ritonavir
- Saquinavir
- Telaprevir
- Ritonavir
- Clarithromycin
- Conivaptan
- Itraconazole
- Ketoconazole
- Mibefradil
- Nefazodone
- Posaconazole
- Voriconazole
- Telithromycin
  - Drugs with possible or conditional risk of torsades should be used with caution knowing that sorafenib could prolong the QT interval
Chronic daily NSAID use as treatment for controlling desmoid tumors is not allowed, and should be stopped >= 3 days prior to registration; NSAIDS are allowed when used for desmoid tumor-related pain or for symptoms that are unrelated to desmoid disease (eg. headache, arthritis)
Patients must have measurable disease
Patients have to meet one of the following criteria to be eligible:
- Disease determined unresectable or entailing unacceptably morbid surgery based on 1 or more of the following characteristics:
  - Multifocal disease
  - Disease in which there is involvement or inadequate plane from: neurovascular bundle, bone, skin, or viscera
  - Large size in relationship to location OR multi-compartment involvement
- Progression by radiographic imaging (10% increase in size by RECIST v1.1 within 6 months of registration)
- Patients with symptomatic disease which meets the following criteria Brief Pain Inventory (BPI) score greater than or equal to 3 AND one of the following:
  - Inability to control pain with NSAIDs and considering addition of narcotics OR
  - > 30% increase in current use of narcotics OR
  - Addition of a new opioid narcotic
Eastern Cooperative Oncology Group (ECOG) performance status =< 2
Patients who are pregnant or nursing are not eligible
No patients with a history of cardiac disease: congestive heart failure > class II New York Heart Association (NYHA); active coronary artery disease (CAD) (myocardial infarction or unstable angina within 6 months prior to study entry)
No patients with inadequately controlled hypertension (defined as a blood pressure of >= 150 mmHg systolic and/or >= 90 mmHg diastolic), or any prior history of hypertensive crisis or hypertensive encephalopathy
No patients with clinically significant gastrointestinal (GI) bleeding or bleeding diathesis within 30 days prior to registration
Absolute neutrophil count >= 1,500/mm^3
Hemoglobin >= 8 g/dl
Platelets >= 75,000/mm^3
Total bilirubin =< 1.5 x upper limits of normal (ULN)
Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST])/serum glutamate pyruvate transaminase (SGPT) (aspartate aminotransferase [ALT]) =< 1.5 x ULN
Calculated creatinine clearance >= 50 mL/min using the Cockcroft-Gault equation

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: CROSSOVER

Arm && Interventions

Group	Intervention	Description
Arm I (sorafenib tosylate)	Laboratory Biomarker Analysis	Patients receive sorafenib tosylate PO QD on days 1-28.
Arm I (sorafenib tosylate)	Sorafenib Tosylate	Patients receive sorafenib tosylate PO QD on days 1-28.
Arm II (placebo)	Laboratory Biomarker Analysis	Patients receive placebo PO QD on days 1-28. Patients may crossover to Arm I upon disease progression.
Arm II (placebo)	Placebo Administration	Patients receive placebo PO QD on days 1-28. Patients may crossover to Arm I upon disease progression.
Arm II (placebo)	Quality-of-Life Assessment	Patients receive placebo PO QD on days 1-28. Patients may crossover to Arm I upon disease progression.
Arm I (sorafenib tosylate)	Quality-of-Life Assessment	Patients receive sorafenib tosylate PO QD on days 1-28.

Primary Outcome Measures

Name	Time	Method
Progression-free Survival(PFS) Rate	Time from randomization to the first occurrence of progression or death due to any cause, assessed up to 3 years	PFS is defined as the time from randomization to the first occurrence of progression or death due to any cause. If no event exists, the PFS will be censored at the last disease assessment. Data following cross over will be analyzed and summarized separately from the data from the main course of treatment for these patients in an exploratory and hypothesis generating manner. Intention to treat principles will be used. Patient disease status was evaluated using RECSIT v1.1. Patients ending treatment for symptomatic deterioration without radiographic evidence of PD, were classified as having PD. Otherwise, patients not yet showing disease progression were classified as having no progression at the most recent disease assessment and in the following cases: crossing over to receive sorafenib, date of first non-protocol directed anti-cancer therapy, lost to follow-up, withdrawal of consent, and changing imaging methods from that which was used at study entry.

Secondary Outcome Measures

Name	Time	Method
Best Objective Status Between the Two Treatment Arms According to Response Evaluation Criteria in Solid Tumors Version 1.1	Up to 3 years	Compared between the two treatment arms and using the Cochran-Mantel-Haenszel test. Complete Response (CR): All of the following must be true: a. Disappearance of all target lesions. b. Each target lymph node must have reduction in short axis to \<1.0 cm. Partial Response (PR): At least a 30% decrease in PBSD (sum of the longest diameter for all target lesions plus the sum of the short axis of all the target lymph nodes at current evaluation) taking as reference the BSD. Patients on Arm II (placebo) who crossover are censored for Best Objective Status at the time of crossover.
Incidence of Adverse Events, Using the Patient Reported Outcomes-Common Terminology Criteria in Adverse Events Version 4.0	Up to 3 years	INCLUDED IN THE ADVERSE EVENTS PORTION OF THE RESULTS SECTION. Frequency tables, summary statistics, and categorical analysis will be used to compare the distributions of toxicity for patients treated with sorafenib tosylate vs placebo. Data for patients who have crossed over or having received surgical or radiotherapy intervention will be summarized independently from their primary course of study treatment in an exploratory and hypothesis generating manner.
Overall Survival	Time between the date of randomization to until death, assessed up to 3 years	Kaplan-Meier methodology and log rank tests will be used to compare overall survival between the groups at various time points (eg, 1 year rate, 2 year rate, etc) and 95% confidence intervals will be calculated for these estimates. Data following crossover will be analyzed and summarized separately from the main course of treatment for these patients in an exploratory and hypothesis generating manner.
Time to Surgical Intervention During Treatment	Time between randomization to the patient undergoing therapeutic surgical resection for this disease, assessed up to 3 years	A log rank test will be used to compare the distributions of time to surgical intervention between the two arms using a 2-sided test and alpha=0.05 level of significance. Kaplan-Meier methodology will be used to estimate various time points and 95% confidence intervals will be calculated for these estimates. Surgery will be classified by outcome (eg, complete-macroscopic, complete-microscopic, or partial), type, location (eg, limb), thereafter analyzed by categorical analysis and descriptive statistics. Non-parametric methods will be used, as appropriate. Too few patients had surgery during treatment to perform analysis.
Duration of Response	Time between first tumor response and progression, assessed up to 3 years	Kaplan Meier methodology will be used to estimate the distribution of duration of response and the log-rank test will be used to test for a difference in duration of response between the two arms. Patients on Arm II (placebo) who crossover are censored for Duration of Response at the time of crossover.

Trial Locations

Locations (150): Minnesota Oncology Hematology PA-Woodbury
🇺🇸
Woodbury, Minnesota, United States
Johns Hopkins University/Sidney Kimmel Cancer Center
🇺🇸
Baltimore, Maryland, United States
University Health Network-Princess Margaret Hospital
🇨🇦
Toronto, Ontario, Canada
Northwestern University
🇺🇸
Chicago, Illinois, United States
Dana-Farber Cancer Institute
🇺🇸
Boston, Massachusetts, United States
Cancer and Blood Specialists-Shadow
🇺🇸
Las Vegas, Nevada, United States
Las Vegas Cancer Center-Medical Center
🇺🇸
Las Vegas, Nevada, United States
Oncology Hematology Care Inc-Anderson
🇺🇸
Cincinnati, Ohio, United States
Radiation Oncology Centers of Nevada Central
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Maryland Parkway
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-San Martin
🇺🇸
Las Vegas, Nevada, United States
Cancer Therapy and Integrative Medicine
🇺🇸
Las Vegas, Nevada, United States
Cancer and Blood Specialists-Tenaya
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada-Summerlin
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Northwest
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada
🇺🇸
Las Vegas, Nevada, United States
Nevada Cancer Research Foundation NCORP
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Tenaya
🇺🇸
Las Vegas, Nevada, United States
Oncology Hematology Care Inc-Blue Ash
🇺🇸
Cincinnati, Ohio, United States
GenesisCare USA - Fort Apache
🇺🇸
Las Vegas, Nevada, United States
HealthCare Partners Medical Group Oncology/Hematology-Centennial Hills
🇺🇸
Las Vegas, Nevada, United States
Oncology Hematology Care Inc-Mercy West
🇺🇸
Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸
Cincinnati, Ohio, United States
M D Anderson Cancer Center
🇺🇸
Houston, Texas, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸
Rolla, Missouri, United States
GenesisCare USA - Vegas Tenaya
🇺🇸
Las Vegas, Nevada, United States
Summerlin Hospital Medical Center
🇺🇸
Las Vegas, Nevada, United States
Hennepin County Medical Center
🇺🇸
Minneapolis, Minnesota, United States
Health Partners Inc
🇺🇸
Minneapolis, Minnesota, United States
Duke University Medical Center
🇺🇸
Durham, North Carolina, United States
University of Oklahoma Health Sciences Center
🇺🇸
Oklahoma City, Oklahoma, United States
Fox Chase Cancer Center
🇺🇸
Philadelphia, Pennsylvania, United States
University of Alabama at Birmingham Cancer Center
🇺🇸
Birmingham, Alabama, United States
Mercy Hospital Joplin
🇺🇸
Joplin, Missouri, United States
Mercy Hospital Springfield
🇺🇸
Springfield, Missouri, United States
Mayo Clinic in Rochester
🇺🇸
Rochester, Minnesota, United States
Missouri Valley Cancer Consortium
🇺🇸
Omaha, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸
Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸
Omaha, Nebraska, United States
Nebraska Cancer Specialists - Omaha
🇺🇸
Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸
Omaha, Nebraska, United States
Oncology Hematology West PC
🇺🇸
Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸
Omaha, Nebraska, United States
Saint Francis Regional Medical Center
🇺🇸
Shakopee, Minnesota, United States
Lakeview Hospital
🇺🇸
Stillwater, Minnesota, United States
PCR Oncology
🇺🇸
Arroyo Grande, California, United States
Beebe Medical Center
🇺🇸
Lewes, Delaware, United States
Christiana Gynecologic Oncology LLC
🇺🇸
Newark, Delaware, United States
Medical Oncology Hematology Consultants PA
🇺🇸
Newark, Delaware, United States
Delaware Clinical and Laboratory Physicians PA
🇺🇸
Newark, Delaware, United States
Helen F Graham Cancer Center
🇺🇸
Newark, Delaware, United States
Beebe Health Campus
🇺🇸
Rehoboth Beach, Delaware, United States
Sibley Memorial Hospital
🇺🇸
Washington, District of Columbia, United States
Mayo Clinic in Florida
🇺🇸
Jacksonville, Florida, United States
Low Country Cancer Care
🇺🇸
Savannah, Georgia, United States
Queen's Cancer Center - Pearlridge
🇺🇸
'Aiea, Hawaii, United States
Pali Momi Medical Center
🇺🇸
'Aiea, Hawaii, United States
Lewis Cancer and Research Pavilion at Saint Joseph's/Candler
🇺🇸
Savannah, Georgia, United States
Wilcox Memorial Hospital and Kauai Medical Clinic
🇺🇸
Lihue, Hawaii, United States
Reid Health
🇺🇸
Richmond, Indiana, United States
Siouxland Regional Cancer Center
🇺🇸
Sioux City, Iowa, United States
University of Iowa/Holden Comprehensive Cancer Center
🇺🇸
Iowa City, Iowa, United States
Oncology Hematology Care Inc-Crestview
🇺🇸
Crestview Hills, Kentucky, United States
Brigham and Women's Hospital
🇺🇸
Boston, Massachusetts, United States
Fairview Ridges Hospital
🇺🇸
Burnsville, Minnesota, United States
Hutchinson Area Health Care
🇺🇸
Hutchinson, Minnesota, United States
Abbott-Northwestern Hospital
🇺🇸
Minneapolis, Minnesota, United States
New Ulm Medical Center
🇺🇸
New Ulm, Minnesota, United States
North Memorial Medical Health Center
🇺🇸
Robbinsdale, Minnesota, United States
Metro Minnesota Community Oncology Research Consortium
🇺🇸
Saint Louis Park, Minnesota, United States
Park Nicollet Clinic - Saint Louis Park
🇺🇸
Saint Louis Park, Minnesota, United States
Ridgeview Medical Center
🇺🇸
Waconia, Minnesota, United States
Central Care Cancer Center - Bolivar
🇺🇸
Bolivar, Missouri, United States
Cox Cancer Center Branson
🇺🇸
Branson, Missouri, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸
Rolla, Missouri, United States
Freeman Health System
🇺🇸
Joplin, Missouri, United States
Siteman Cancer Center-South County
🇺🇸
Saint Louis, Missouri, United States
Washington University School of Medicine
🇺🇸
Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸
Saint Louis, Missouri, United States
CoxHealth South Hospital
🇺🇸
Springfield, Missouri, United States
Nebraska Hematology and Oncology
🇺🇸
Lincoln, Nebraska, United States
Southeast Nebraska Cancer Center - 68th Street Place
🇺🇸
Lincoln, Nebraska, United States
Nebraska Cancer Research Center
🇺🇸
Lincoln, Nebraska, United States
Great Plains Health Callahan Cancer Center
🇺🇸
North Platte, Nebraska, United States
Faith Regional Health Services Carson Cancer Center
🇺🇸
Norfolk, Nebraska, United States
Regional West Medical Center Cancer Center
🇺🇸
Scottsbluff, Nebraska, United States
Cancer and Blood Specialists-Henderson
🇺🇸
Henderson, Nevada, United States
Comprehensive Cancer Centers of Nevada - Henderson
🇺🇸
Henderson, Nevada, United States
Radiation Oncology Centers of Nevada Southeast
🇺🇸
Las Vegas, Nevada, United States
Comprehensive Cancer Centers of Nevada - Central Valley
🇺🇸
Las Vegas, Nevada, United States
NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center
🇺🇸
New York, New York, United States
Memorial Sloan Kettering Cancer Center
🇺🇸
New York, New York, United States
Oncology Hematology Care Inc-Eden Park
🇺🇸
Cincinnati, Ohio, United States
Good Samaritan Hospital - Dayton
🇺🇸
Dayton, Ohio, United States
Miami Valley Hospital North
🇺🇸
Dayton, Ohio, United States
Dayton NCI Community Oncology Research Program
🇺🇸
Dayton, Ohio, United States
Oncology Hematology Care Inc-Healthplex
🇺🇸
Fairfield, Ohio, United States
Wayne Hospital
🇺🇸
Greenville, Ohio, United States
Kettering Medical Center
🇺🇸
Kettering, Ohio, United States
Springfield Regional Cancer Center
🇺🇸
Springfield, Ohio, United States
Wright-Patterson Medical Center
🇺🇸
Wright-Patterson Air Force Base, Ohio, United States
Upper Valley Medical Center
🇺🇸
Troy, Ohio, United States
Springfield Regional Medical Center
🇺🇸
Springfield, Ohio, United States
Christiana Care Health System-Concord Health Center
🇺🇸
Chadds Ford, Pennsylvania, United States
Cancer Center of Western Wisconsin
🇺🇸
New Richmond, Wisconsin, United States
MedStar Georgetown University Hospital
🇺🇸
Washington, District of Columbia, United States
MedStar Washington Hospital Center
🇺🇸
Washington, District of Columbia, United States
John B Amos Cancer Center
🇺🇸
Columbus, Georgia, United States
Christiana Care Health System-Wilmington Hospital
🇺🇸
Wilmington, Delaware, United States
TidalHealth Nanticoke / Allen Cancer Center
🇺🇸
Seaford, Delaware, United States
University of Arkansas for Medical Sciences
🇺🇸
Little Rock, Arkansas, United States
Mercy Hospital
🇺🇸
Coon Rapids, Minnesota, United States
Good Samaritan Regional Health Center
🇺🇸
Mount Vernon, Illinois, United States
Loyola University Medical Center
🇺🇸
Maywood, Illinois, United States
OptumCare Cancer Care at Fort Apache
🇺🇸
Las Vegas, Nevada, United States
United Hospital
🇺🇸
Saint Paul, Minnesota, United States
Fairview Southdale Hospital
🇺🇸
Edina, Minnesota, United States
GenesisCare USA - Las Vegas
🇺🇸
Las Vegas, Nevada, United States
Unity Hospital
🇺🇸
Fridley, Minnesota, United States
Minnesota Oncology Hematology PA-Maplewood
🇺🇸
Maplewood, Minnesota, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸
Saint Louis, Missouri, United States
Comprehensive Cancer Centers of Nevada-Southeast Henderson
🇺🇸
Henderson, Nevada, United States
Saint John's Hospital - Healtheast
🇺🇸
Maplewood, Minnesota, United States
Rice Memorial Hospital
🇺🇸
Willmar, Minnesota, United States
Regions Hospital
🇺🇸
Saint Paul, Minnesota, United States
Siteman Cancer Center at West County Hospital
🇺🇸
Creve Coeur, Missouri, United States
Las Vegas Cancer Center-Henderson
🇺🇸
Henderson, Nevada, United States
Saint Mary's Regional Medical Center
🇺🇸
Reno, Nevada, United States
GenesisCare USA - Henderson
🇺🇸
Henderson, Nevada, United States
Miami Valley Hospital
🇺🇸
Dayton, Ohio, United States
Hackensack University Medical Center
🇺🇸
Hackensack, New Jersey, United States
Miami Valley Hospital South
🇺🇸
Centerville, Ohio, United States
Blanchard Valley Hospital
🇺🇸
Findlay, Ohio, United States
Sovah Health Martinsville
🇺🇸
Martinsville, Virginia, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸
Franklin, Ohio, United States
Oklahoma Cancer Specialists and Research Institute-Tulsa
🇺🇸
Tulsa, Oklahoma, United States
Huntsman Cancer Institute/University of Utah
🇺🇸
Salt Lake City, Utah, United States
Medical College of Wisconsin
🇺🇸
Milwaukee, Wisconsin, United States
University of Michigan Comprehensive Cancer Center
🇺🇸
Ann Arbor, Michigan, United States
Christiana Care Health System-Christiana Hospital
🇺🇸
Newark, Delaware, United States
Yale University
🇺🇸
New Haven, Connecticut, United States
Hawaii Cancer Care Inc - Waterfront Plaza
🇺🇸
Honolulu, Hawaii, United States
Queen's Medical Center
🇺🇸
Honolulu, Hawaii, United States
Kuakini Medical Center
🇺🇸
Honolulu, Hawaii, United States
Kapiolani Medical Center for Women and Children
🇺🇸
Honolulu, Hawaii, United States
Straub Clinic and Hospital
🇺🇸
Honolulu, Hawaii, United States
University of Hawaii Cancer Center
🇺🇸
Honolulu, Hawaii, United States
Queen's Cancer Center - Kuakini
🇺🇸
Honolulu, Hawaii, United States
Hawaii Cancer Care Inc-Liliha
🇺🇸
Honolulu, Hawaii, United States
Siteman Cancer Center at Saint Peters Hospital
🇺🇸
Saint Peters, Missouri, United States