Comparison of Chemotherapy Before and After Surgery Versus After Surgery Alone for the Treatment of Gallbladder Cancer
- Conditions
- Stage II Gallbladder Cancer AJCC v8Stage III Gallbladder Cancer AJCC v8Stage IIIA Gallbladder Cancer AJCC v8Stage IIIB Gallbladder Cancer AJCC v8Stage IIB Gallbladder Cancer AJCC v8Stage IIA Gallbladder Cancer AJCC v8
- Interventions
- Drug: CisplatinDrug: Gemcitabine HydrochlorideProcedure: LymphadenectomyProcedure: Partial Hepatectomy
- Registration Number
- NCT04559139
- Lead Sponsor
- ECOG-ACRIN Cancer Research Group
- Brief Summary
This phase II/III trial compares the effect of adding chemotherapy before and after surgery versus after surgery alone (usual treatment) in treating patients with stage II-III gallbladder cancer. Chemotherapy drugs, such as gemcitabine and cisplatin, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy before surgery may make the tumor smaller; therefore, may reduce the extent of surgery. Additionally, it may make it easier for the surgeon to distinguish between normal and cancerous tissue. Giving chemotherapy after surgery may kill any remaining tumor cells. This study will determine whether giving chemotherapy before surgery increases the length of time before the cancer may return and whether it will increase a patient's life span compared to the usual approach.
- Detailed Description
PRIMARY OBJECTIVE:
I. To determine the difference in overall survival (OS) for patients given neoadjuvant gemcitabine hydrochloride (gemcitabine) and cisplatin prior to re-resection followed by adjuvant gemcitabine and cisplatin compared to patients who receive only adjuvant gemcitabine and cisplatin after re-resection for incidental gallbladder cancer (IGBC).
SECONDARY OBJECTIVES:
I. To compare the incidence of residual disease at the time of re-resection between patients with IGBC who receive perioperative chemotherapy prior to re-resection and those who receive only adjuvant chemotherapy after re-resection.
II. To assess the clinical effect of preoperative chemotherapy compared to upfront re-resection on resectability among 3 cohorts: all enrolled patients, all patients who undergo staging laparoscopy, and all patients who undergo laparotomy.
III. To determine the difference in progression-free survival (PFS) for patients with IGBC who receive perioperative chemotherapy prior to and after re-resection compared to patients who receive only adjuvant chemotherapy after re-resection.
OUTLINE: Patients are randomized to 1 of 2 arms.
ARM I: Within 4 weeks of randomization, patients undergo surgery to remove part of the liver, the lymph nodes around the liver, and possibly the bile ducts. Patients then receive gemcitabine intravenously (IV) over 30 minutes and cisplatin IV over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity.
ARM II: Patients receive gemcitabine IV over 30 minutes and cisplatin over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for 4 cycles in the absence of disease progression or unacceptable toxicity. Approximately 4-8 weeks after completion of chemotherapy, patients whose disease has not spread to other places in the body (metastasized) undergo surgery as in Arm I. Patients with successful surgery then resume treatment with gemcitabine IV and cisplatin IV on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.
After completion of study treatment, patients are followed up every 3 months for 2 years, then every 6 months for 1 year after surgery or until disease recurrence, whichever comes first, for up to 5 years.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 186
-
Patient must have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1
-
Patient must have histologically-confirmed T2 or T3 gallbladder cancer discovered incidentally at the time of or following routine cholecystectomy for presumed benign disease
- NOTE: Patients with histologically-confirmed Tis, T1a, T1b, or T4 tumors are not eligible
-
Patient must have undergone initial cholecystectomy within 12 weeks prior to randomization
-
Patient must have the ability to understand and the willingness to sign a written informed consent document
-
Leukocytes >= 3,000/mcL (obtained =< 28 days prior to randomization)
-
Absolute neutrophil count >= 1,500/mcL (obtained =< 28 days prior to randomization)
-
Platelets >= 100,000/mcL (obtained =< 28 days prior to randomization)
-
Total bilirubin =< institutional upper limit of normal (ULN) except in patients with Gilbert's syndrome. Patients with Gilbert's syndrome are eligible if direct bilirubin < 1.5 x ULN of the direct bilirubin (obtained =< 28 days prior to randomization)
-
Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 2.5 x institutional ULN (obtained =< 28 days prior to randomization)
-
Serum creatinine =< institutional ULN OR creatinine clearance >= 50 mL/min/1.73 m^2 (Based on Cockcroft Gault estimation) (obtained =< 28 days prior to randomization)
-
Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months of randomization are eligible for this trial
-
For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
-
Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
-
Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial
-
Patients with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association functional classification. To be eligible for this trial, patients should be class 2B or better
-
Patient must not have any evidence of metastatic disease or inoperable loco-regional disease based on high-quality, preoperative, cross-sectional imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) of the chest, abdomen, and pelvis (C/A/P) obtained within 6 weeks prior to randomization, defined as
- No radiographic evidence of distant disease (M1 disease)
- No radiographic evidence of tumor invasion into multiple extrahepatic organs (T4 disease)
- No radiographic evidence of distant lymph node involvement (celiac, para-aortic, para-caval lymph nodes)
- No evidence of new-onset ascites
- Soft tissue thickening within or in direct communication with the gallbladder fossa, peri-portal lymph node involvement, involvement of one extrahepatic organ, and other disease within the confines of what constitutes 'localized resectable' disease are allowable
-
Women must not be pregnant or breast feeding due to the potential harm to unborn fetus and possible risk for adverse events in nursing infants with the treatment regimens being used. All females of child bearing potential must have a serum or urine pregnancy test to rule out pregnancy within 14 days prior to randomization. A female of childbearing potential is defined as any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has achieved menarche at some point, 2) has not undergone a hysterectomy or bilateral oophorectomy; or 3) has not been naturally postmenopausal (amenorrhea following cancer therapy does not rule out childbearing potential) for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
-
Women of childbearing potential and sexually active males must not expect to conceive or father children by being strongly advised to use accepted and effective method(s) of contraception or to abstain from sexual intercourse for the duration of their participation in the study
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Arm I (surgery, adjuvant therapy) Gemcitabine Hydrochloride Within 4 weeks of randomization, patients undergo surgery to remove part of the liver, the lymph nodes around the liver, and possibly the bile ducts. Patients then receive gemcitabine IV over 30 minutes and cisplatin IV over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity. Arm II (neoadjuvant therapy, surgery, adjuvant therapy) Lymphadenectomy Patients receive gemcitabine IV over 30 minutes and cisplatin over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for 4 cycles in the absence of disease progression or unacceptable toxicity. Approximately 4-8 weeks after completion of chemotherapy, patients whose disease has not spread to other places in the body (metastasized), then undergo surgery as in Arm I. Patients with successful surgery then resume treatment with gemcitabine IV and cisplatin IV on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Arm I (surgery, adjuvant therapy) Lymphadenectomy Within 4 weeks of randomization, patients undergo surgery to remove part of the liver, the lymph nodes around the liver, and possibly the bile ducts. Patients then receive gemcitabine IV over 30 minutes and cisplatin IV over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity. Arm II (neoadjuvant therapy, surgery, adjuvant therapy) Gemcitabine Hydrochloride Patients receive gemcitabine IV over 30 minutes and cisplatin over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for 4 cycles in the absence of disease progression or unacceptable toxicity. Approximately 4-8 weeks after completion of chemotherapy, patients whose disease has not spread to other places in the body (metastasized), then undergo surgery as in Arm I. Patients with successful surgery then resume treatment with gemcitabine IV and cisplatin IV on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Arm I (surgery, adjuvant therapy) Partial Hepatectomy Within 4 weeks of randomization, patients undergo surgery to remove part of the liver, the lymph nodes around the liver, and possibly the bile ducts. Patients then receive gemcitabine IV over 30 minutes and cisplatin IV over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity. Arm II (neoadjuvant therapy, surgery, adjuvant therapy) Partial Hepatectomy Patients receive gemcitabine IV over 30 minutes and cisplatin over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for 4 cycles in the absence of disease progression or unacceptable toxicity. Approximately 4-8 weeks after completion of chemotherapy, patients whose disease has not spread to other places in the body (metastasized), then undergo surgery as in Arm I. Patients with successful surgery then resume treatment with gemcitabine IV and cisplatin IV on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Arm I (surgery, adjuvant therapy) Cisplatin Within 4 weeks of randomization, patients undergo surgery to remove part of the liver, the lymph nodes around the liver, and possibly the bile ducts. Patients then receive gemcitabine IV over 30 minutes and cisplatin IV over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity. Arm II (neoadjuvant therapy, surgery, adjuvant therapy) Cisplatin Patients receive gemcitabine IV over 30 minutes and cisplatin over 30 minutes-24 hours on days 1 and 8. Treatment repeats every 21 days for 4 cycles in the absence of disease progression or unacceptable toxicity. Approximately 4-8 weeks after completion of chemotherapy, patients whose disease has not spread to other places in the body (metastasized), then undergo surgery as in Arm I. Patients with successful surgery then resume treatment with gemcitabine IV and cisplatin IV on days 1 and 8. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity.
- Primary Outcome Measures
Name Time Method Difference in overall survival Time from randomization to death or last follow-up, assessed up to 5 years Will compare patients with incidental gallbladder cancer (IGBC) who receive perioperative chemotherapy prior to and after re-resection with patients who receive only adjuvant chemotherapy after re-resection. Will be evaluated by stratified log rank test, and Kaplan-Meier analyses will be used to calculate and display the overall survival distributions among all randomized patients on the two study arms (intention-to-treat analysis).
- Secondary Outcome Measures
Name Time Method Incidence of residual disease At the time of re-resection, through study completion, an average of 5 years. Will compare the incidence of residual disease which is defined as the presence of either microscopic or gross malignancy based on pathologic analysis of the re-resection specimen at the time of re-resection between patients with IGBC who receive perioperative chemotherapy prior to re-resection and those who receive only adjuvant chemotherapy after re-resection. Residual disease is defined as the presence of either microscopic or gross malignancy based on pathologic analysis of the re-resection specimen.
Resectability rate At the time of laparotomy, through study completion, an average of 5 years. Will be defined as the proportion of patients who successfully undergo a re-resection versus all patients who undergo laparotomy. Descriptive statistics will be performed to calculate the number, proportion of patients, and 95% confidence intervals for the resectability and residual disease outcomes. Patients who do not undergo reoperation or re-resection, have incomplete resections (R2), or who have gross evidence of distant metastases and/or T4 disease will be considered as unresectable for resectability analyses.
Overall resectability rate Up to 5 years Will be defined as the proportion of patients who successfully undergo a re-resection versus all enrolled patients. Descriptive statistics will be performed to calculate the number, proportion of patients, and 95% confidence intervals for the resectability and residual disease outcomes. Patients who do not undergo reoperation or re-resection, have incomplete resections (R2), or who have gross evidence of distant metastases and/or T4 disease will be considered as unresectable for resectability analyses.
Difference in progression-free survival From randomization to first observed radiographic disease progression that is inoperable (either locoregional or distant metastatic), or death from any cause, assessed up to 5 years Will compare patients given neoadjuvant gemcitabine and cisplatin with patients who receive only adjuvant gemcitabine and cisplatin after re-resection for IGCB. A stratified log rank test, along with Kaplan-Meier curves, will be used to analyze progression-free survival among all evaluable patients.
Trial Locations
- Locations (367)
UMass Memorial Medical Center - University Campus
🇺🇸Worcester, Massachusetts, United States
NYU Langone Hospital - Long Island
🇺🇸Mineola, New York, United States
Roper Hospital
🇺🇸Charleston, South Carolina, United States
Charleston Oncology - Roper
🇺🇸Charleston, South Carolina, United States
Bon Secours Saint Francis Hospital
🇺🇸Charleston, South Carolina, United States
Charleston Oncology - Saint Francis
🇺🇸Charleston, South Carolina, United States
University of Alabama at Birmingham Cancer Center
🇺🇸Birmingham, Alabama, United States
Anchorage Associates in Radiation Medicine
🇺🇸Anchorage, Alaska, United States
Anchorage Radiation Therapy Center
🇺🇸Anchorage, Alaska, United States
Alaska Breast Care and Surgery LLC
🇺🇸Anchorage, Alaska, United States
Alaska Oncology and Hematology LLC
🇺🇸Anchorage, Alaska, United States
Alaska Women's Cancer Care
🇺🇸Anchorage, Alaska, United States
Anchorage Oncology Centre
🇺🇸Anchorage, Alaska, United States
Katmai Oncology Group
🇺🇸Anchorage, Alaska, United States
Providence Alaska Medical Center
🇺🇸Anchorage, Alaska, United States
Cancer Center at Saint Joseph's
🇺🇸Phoenix, Arizona, United States
Mercy Hospital Fort Smith
🇺🇸Fort Smith, Arkansas, United States
CHI Saint Vincent Cancer Center Hot Springs
🇺🇸Hot Springs, Arkansas, United States
NEA Baptist Memorial Hospital and Fowler Family Cancer Center - Jonesboro
🇺🇸Jonesboro, Arkansas, United States
CARTI Cancer Center
🇺🇸Little Rock, Arkansas, United States
University of Arkansas for Medical Sciences
🇺🇸Little Rock, Arkansas, United States
Mission Hope Medical Oncology - Arroyo Grande
🇺🇸Arroyo Grande, California, United States
Providence Saint Joseph Medical Center/Disney Family Cancer Center
🇺🇸Burbank, California, United States
Mercy Cancer Center - Carmichael
🇺🇸Carmichael, California, United States
Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
Mercy Cancer Center - Elk Grove
🇺🇸Elk Grove, California, United States
Cedars Sinai Medical Center
🇺🇸Los Angeles, California, United States
Providence Queen of The Valley
🇺🇸Napa, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
🇺🇸Orange, California, United States
Stanford Cancer Institute Palo Alto
🇺🇸Palo Alto, California, United States
Mercy Cancer Center - Rocklin
🇺🇸Rocklin, California, United States
Mercy Cancer Center - Sacramento
🇺🇸Sacramento, California, United States
Pacific Central Coast Health Center-San Luis Obispo
🇺🇸San Luis Obispo, California, United States
Torrance Memorial Medical Center
🇺🇸Torrance, California, United States
Woodland Memorial Hospital
🇺🇸Woodland, California, United States
Penrose-Saint Francis Healthcare
🇺🇸Colorado Springs, Colorado, United States
University of California Davis Comprehensive Cancer Center
🇺🇸Sacramento, California, United States
Providence Santa Rosa Memorial Hospital
🇺🇸Santa Rosa, California, United States
Torrance Memorial Physician Network - Cancer Care
🇺🇸Torrance, California, United States
Rocky Mountain Cancer Centers-Longmont
🇺🇸Longmont, Colorado, United States
Parker Adventist Hospital
🇺🇸Parker, Colorado, United States
Mission Hope Medical Oncology - Santa Maria
🇺🇸Santa Maria, California, United States
Providence Medical Foundation - Santa Rosa
🇺🇸Santa Rosa, California, United States
Saint Francis Cancer Center
🇺🇸Colorado Springs, Colorado, United States
Rocky Mountain Cancer Centers-Penrose
🇺🇸Colorado Springs, Colorado, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Longmont United Hospital
🇺🇸Longmont, Colorado, United States
Regional Cancer Center-Lee Memorial Health System
🇺🇸Fort Myers, Florida, United States
Mercy Medical Center
🇺🇸Durango, Colorado, United States
Southwest Oncology PC
🇺🇸Durango, Colorado, United States
Saint Anthony Hospital
🇺🇸Lakewood, Colorado, United States
Littleton Adventist Hospital
🇺🇸Littleton, Colorado, United States
UM Sylvester Comprehensive Cancer Center at Coral Gables
🇺🇸Coral Gables, Florida, United States
Saint Mary Corwin Medical Center
🇺🇸Pueblo, Colorado, United States
University of Florida Health Science Center - Gainesville
🇺🇸Gainesville, Florida, United States
University of Miami Miller School of Medicine-Sylvester Cancer Center
🇺🇸Miami, Florida, United States
UM Sylvester Comprehensive Cancer Center at Aventura
🇺🇸Aventura, Florida, United States
UM Sylvester Comprehensive Cancer Center at Deerfield Beach
🇺🇸Deerfield Beach, Florida, United States
UM Sylvester Comprehensive Cancer Center at Kendall
🇺🇸Miami, Florida, United States
UM Sylvester Comprehensive Cancer Center at Plantation
🇺🇸Plantation, Florida, United States
Emory University Hospital Midtown
🇺🇸Atlanta, Georgia, United States
Emory University Hospital/Winship Cancer Institute
🇺🇸Atlanta, Georgia, United States
Emory Saint Joseph's Hospital
🇺🇸Atlanta, Georgia, United States
Northeast Georgia Medical Center Braselton
🇺🇸Braselton, Georgia, United States
Northeast Georgia Medical Center-Gainesville
🇺🇸Gainesville, Georgia, United States
Low Country Cancer Care
🇺🇸Savannah, Georgia, United States
Memorial Health University Medical Center
🇺🇸Savannah, Georgia, United States
Summit Cancer Care-Memorial
🇺🇸Savannah, Georgia, United States
Saint Luke's Cancer Institute - Boise
🇺🇸Boise, Idaho, United States
Saint Luke's Cancer Institute - Fruitland
🇺🇸Fruitland, Idaho, United States
Saint Luke's Cancer Institute - Meridian
🇺🇸Meridian, Idaho, United States
Saint Luke's Cancer Institute - Nampa
🇺🇸Nampa, Idaho, United States
Saint Luke's Cancer Institute - Twin Falls
🇺🇸Twin Falls, Idaho, United States
Saint Anthony's Health
🇺🇸Alton, Illinois, United States
Rush - Copley Medical Center
🇺🇸Aurora, Illinois, United States
Illinois CancerCare-Canton
🇺🇸Canton, Illinois, United States
Illinois CancerCare-Bloomington
🇺🇸Bloomington, Illinois, United States
Memorial Hospital of Carbondale
🇺🇸Carbondale, Illinois, United States
SIH Cancer Institute
🇺🇸Carterville, Illinois, United States
Illinois CancerCare-Carthage
🇺🇸Carthage, Illinois, United States
Centralia Oncology Clinic
🇺🇸Centralia, Illinois, United States
Saint Mary's Hospital
🇺🇸Centralia, Illinois, United States
Northwestern University
🇺🇸Chicago, Illinois, United States
University of Chicago Comprehensive Cancer Center
🇺🇸Chicago, Illinois, United States
University of Illinois
🇺🇸Chicago, Illinois, United States
Carle at The Riverfront
🇺🇸Danville, Illinois, United States
Cancer Care Specialists of Illinois - Decatur
🇺🇸Decatur, Illinois, United States
Decatur Memorial Hospital
🇺🇸Decatur, Illinois, United States
Northwestern Medicine Cancer Center Kishwaukee
🇺🇸DeKalb, Illinois, United States
Illinois CancerCare-Dixon
🇺🇸Dixon, Illinois, United States
Carle Physician Group-Effingham
🇺🇸Effingham, Illinois, United States
Crossroads Cancer Center
🇺🇸Effingham, Illinois, United States
Elmhurst Memorial Hospital
🇺🇸Elmhurst, Illinois, United States
Illinois CancerCare-Eureka
🇺🇸Eureka, Illinois, United States
Western Illinois Cancer Treatment Center
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Galesburg
🇺🇸Galesburg, Illinois, United States
Illinois CancerCare-Macomb
🇺🇸Macomb, Illinois, United States
Northwestern Medicine Cancer Center Delnor
🇺🇸Geneva, Illinois, United States
Illinois CancerCare-Kewanee Clinic
🇺🇸Kewanee, Illinois, United States
Carle Physician Group-Mattoon/Charleston
🇺🇸Mattoon, Illinois, United States
Good Samaritan Regional Health Center
🇺🇸Mount Vernon, Illinois, United States
Edward Hospital/Cancer Center
🇺🇸Naperville, Illinois, United States
UC Comprehensive Cancer Center at Silver Cross
🇺🇸New Lenox, Illinois, United States
Cancer Care Center of O'Fallon
🇺🇸O'Fallon, Illinois, United States
HSHS Saint Elizabeth's Hospital
🇺🇸O'Fallon, Illinois, United States
University of Chicago Medicine-Orland Park
🇺🇸Orland Park, Illinois, United States
Illinois CancerCare-Ottawa Clinic
🇺🇸Ottawa, Illinois, United States
Illinois CancerCare-Pekin
🇺🇸Pekin, Illinois, United States
OSF Saint Francis Radiation Oncology at Pekin
🇺🇸Pekin, Illinois, United States
Illinois CancerCare-Peoria
🇺🇸Peoria, Illinois, United States
OSF Saint Francis Radiation Oncology at Peoria Cancer Center
🇺🇸Peoria, Illinois, United States
Methodist Medical Center of Illinois
🇺🇸Peoria, Illinois, United States
OSF Saint Francis Medical Center
🇺🇸Peoria, Illinois, United States
Illinois CancerCare-Peru
🇺🇸Peru, Illinois, United States
Valley Radiation Oncology
🇺🇸Peru, Illinois, United States
Edward Hospital/Cancer Center?Plainfield
🇺🇸Plainfield, Illinois, United States
Illinois CancerCare-Princeton
🇺🇸Princeton, Illinois, United States
Southern Illinois University School of Medicine
🇺🇸Springfield, Illinois, United States
Springfield Clinic
🇺🇸Springfield, Illinois, United States
Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Carle Cancer Center
🇺🇸Urbana, Illinois, United States
Northwestern Medicine Cancer Center Warrenville
🇺🇸Warrenville, Illinois, United States
Illinois CancerCare - Washington
🇺🇸Washington, Illinois, United States
Rush-Copley Healthcare Center
🇺🇸Yorkville, Illinois, United States
Reid Health
🇺🇸Richmond, Indiana, United States
Mission Cancer and Blood - Ankeny
🇺🇸Ankeny, Iowa, United States
Saint Anthony Regional Hospital
🇺🇸Carroll, Iowa, United States
Mercy Cancer Center-West Lakes
🇺🇸Clive, Iowa, United States
Mission Cancer and Blood - West Des Moines
🇺🇸Clive, Iowa, United States
Alegent Health Mercy Hospital
🇺🇸Council Bluffs, Iowa, United States
Greater Regional Medical Center
🇺🇸Creston, Iowa, United States
Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
Mission Cancer and Blood - Des Moines
🇺🇸Des Moines, Iowa, United States
Broadlawns Medical Center
🇺🇸Des Moines, Iowa, United States
Mercy Medical Center - Des Moines
🇺🇸Des Moines, Iowa, United States
Mission Cancer and Blood - Laurel
🇺🇸Des Moines, Iowa, United States
Iowa Lutheran Hospital
🇺🇸Des Moines, Iowa, United States
Trinity Regional Medical Center
🇺🇸Fort Dodge, Iowa, United States
Methodist West Hospital
🇺🇸West Des Moines, Iowa, United States
Mercy Medical Center-West Lakes
🇺🇸West Des Moines, Iowa, United States
Central Care Cancer Center - Garden City
🇺🇸Garden City, Kansas, United States
Central Care Cancer Center - Great Bend
🇺🇸Great Bend, Kansas, United States
Flaget Memorial Hospital
🇺🇸Bardstown, Kentucky, United States
Commonwealth Cancer Center-Corbin
🇺🇸Corbin, Kentucky, United States
Saint Joseph Hospital
🇺🇸Lexington, Kentucky, United States
Saint Joseph Radiation Oncology Resource Center
🇺🇸Lexington, Kentucky, United States
Saint Joseph Hospital East
🇺🇸Lexington, Kentucky, United States
University of Kentucky/Markey Cancer Center
🇺🇸Lexington, Kentucky, United States
Saint Joseph London
🇺🇸London, Kentucky, United States
Jewish Hospital
🇺🇸Louisville, Kentucky, United States
The James Graham Brown Cancer Center at University of Louisville
🇺🇸Louisville, Kentucky, United States
Saints Mary and Elizabeth Hospital
🇺🇸Louisville, Kentucky, United States
UofL Health Medical Center Northeast
🇺🇸Louisville, Kentucky, United States
Saint Joseph Mount Sterling
🇺🇸Mount Sterling, Kentucky, United States
Jewish Hospital Medical Center South
🇺🇸Shepherdsville, Kentucky, United States
Lowell General Hospital
🇺🇸Lowell, Massachusetts, United States
University of Michigan Comprehensive Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Bronson Battle Creek
🇺🇸Battle Creek, Michigan, United States
University of Michigan - Brighton Center for Specialty Care
🇺🇸Brighton, Michigan, United States
Corewell Health Grand Rapids Hospitals - Butterworth Hospital
🇺🇸Grand Rapids, Michigan, United States
Baptist Memorial Hospital and Cancer Center-Desoto
🇺🇸Southhaven, Mississippi, United States
Corewell Health Grand Rapids Hospitals - Helen DeVos Children's Hospital
🇺🇸Grand Rapids, Michigan, United States
Trinity Health Grand Rapids Hospital
🇺🇸Grand Rapids, Michigan, United States
Bronson Methodist Hospital
🇺🇸Kalamazoo, Michigan, United States
West Michigan Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Ascension Borgess Cancer Center
🇺🇸Kalamazoo, Michigan, United States
Borgess Medical Center
🇺🇸Kalamazoo, Michigan, United States
Trinity Health Muskegon Hospital
🇺🇸Muskegon, Michigan, United States
Corewell Health Lakeland Hospitals - Niles Hospital
🇺🇸Niles, Michigan, United States
Cancer and Hematology Centers of Western Michigan - Norton Shores
🇺🇸Norton Shores, Michigan, United States
Corewell Health Reed City Hospital
🇺🇸Reed City, Michigan, United States
Corewell Health Lakeland Hospitals - Marie Yeager Cancer Center
🇺🇸Saint Joseph, Michigan, United States
Corewell Health Lakeland Hospitals - Saint Joseph Hospital
🇺🇸Saint Joseph, Michigan, United States
Munson Medical Center
🇺🇸Traverse City, Michigan, United States
University of Michigan Health - West
🇺🇸Wyoming, Michigan, United States
Sanford Joe Lueken Cancer Center
🇺🇸Bemidji, Minnesota, United States
Mayo Clinic in Rochester
🇺🇸Rochester, Minnesota, United States
Baptist Cancer Center-Grenada
🇺🇸Grenada, Mississippi, United States
Baptist Memorial Hospital and Cancer Center-Oxford
🇺🇸Oxford, Mississippi, United States
Sanford Thief River Falls Medical Center
🇺🇸Thief River Falls, Minnesota, United States
Sanford Cancer Center Worthington
🇺🇸Worthington, Minnesota, United States
Baptist Memorial Hospital and Cancer Center-Union County
🇺🇸New Albany, Mississippi, United States
Saint Louis Cancer and Breast Institute-Ballwin
🇺🇸Ballwin, Missouri, United States
Central Care Cancer Center - Bolivar
🇺🇸Bolivar, Missouri, United States
Cox Cancer Center Branson
🇺🇸Branson, Missouri, United States
Saint Francis Medical Center
🇺🇸Cape Girardeau, Missouri, United States
Southeast Cancer Center
🇺🇸Cape Girardeau, Missouri, United States
Siteman Cancer Center at West County Hospital
🇺🇸Creve Coeur, Missouri, United States
Parkland Health Center - Farmington
🇺🇸Farmington, Missouri, United States
MU Health Care Goldschmidt Cancer Center
🇺🇸Jefferson City, Missouri, United States
Freeman Health System
🇺🇸Joplin, Missouri, United States
Mercy Hospital Joplin
🇺🇸Joplin, Missouri, United States
Lake Regional Hospital
🇺🇸Osage Beach, Missouri, United States
Delbert Day Cancer Institute at PCRMC
🇺🇸Rolla, Missouri, United States
Mercy Clinic-Rolla-Cancer and Hematology
🇺🇸Rolla, Missouri, United States
Heartland Regional Medical Center
🇺🇸Saint Joseph, Missouri, United States
Saint Louis Cancer and Breast Institute-South City
🇺🇸Saint Louis, Missouri, United States
Washington University School of Medicine
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital South
🇺🇸Saint Louis, Missouri, United States
Siteman Cancer Center-South County
🇺🇸Saint Louis, Missouri, United States
Missouri Baptist Medical Center
🇺🇸Saint Louis, Missouri, United States
Siteman Cancer Center at Christian Hospital
🇺🇸Saint Louis, Missouri, United States
Mercy Hospital Saint Louis
🇺🇸Saint Louis, Missouri, United States
Siteman Cancer Center at Saint Peters Hospital
🇺🇸Saint Peters, Missouri, United States
Sainte Genevieve County Memorial Hospital
🇺🇸Sainte Genevieve, Missouri, United States
Mercy Hospital Springfield
🇺🇸Springfield, Missouri, United States
CoxHealth South Hospital
🇺🇸Springfield, Missouri, United States
Missouri Baptist Sullivan Hospital
🇺🇸Sullivan, Missouri, United States
BJC Outpatient Center at Sunset Hills
🇺🇸Sunset Hills, Missouri, United States
Mercy Hospital Washington
🇺🇸Washington, Missouri, United States
Saint Patrick Hospital - Community Hospital
🇺🇸Missoula, Montana, United States
Nebraska Cancer Specialists/Oncology Hematology West PC
🇺🇸Grand Island, Nebraska, United States
CHI Health Good Samaritan
🇺🇸Kearney, Nebraska, United States
Saint Elizabeth Regional Medical Center
🇺🇸Lincoln, Nebraska, United States
Alegent Health Immanuel Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Bergan Mercy Medical Center
🇺🇸Omaha, Nebraska, United States
Alegent Health Lakeside Hospital
🇺🇸Omaha, Nebraska, United States
Creighton University Medical Center
🇺🇸Omaha, Nebraska, United States
Midlands Community Hospital
🇺🇸Papillion, Nebraska, United States
Memorial Sloan Kettering Basking Ridge
🇺🇸Basking Ridge, New Jersey, United States
Trinitas Hospital and Comprehensive Cancer Center - Williamson Street Campus
🇺🇸Elizabeth, New Jersey, United States
The Cancer Institute of New Jersey Hamilton
🇺🇸Hamilton, New Jersey, United States
Jersey City Medical Center
🇺🇸Jersey City, New Jersey, United States
Monmouth Medical Center Southern Campus
🇺🇸Lakewood, New Jersey, United States
Saint Barnabas Medical Center
🇺🇸Livingston, New Jersey, United States
Monmouth Medical Center
🇺🇸Long Branch, New Jersey, United States
Memorial Sloan Kettering Monmouth
🇺🇸Middletown, New Jersey, United States
Memorial Sloan Kettering Bergen
🇺🇸Montvale, New Jersey, United States
Rutgers Cancer Institute of New Jersey
🇺🇸New Brunswick, New Jersey, United States
Rutgers New Jersey Medical School
🇺🇸Newark, New Jersey, United States
Newark Beth Israel Medical Center
🇺🇸Newark, New Jersey, United States
Robert Wood Johnson University Hospital Somerset
🇺🇸Somerville, New Jersey, United States
Community Medical Center
🇺🇸Toms River, New Jersey, United States
Lovelace Medical Center-Saint Joseph Square
🇺🇸Albuquerque, New Mexico, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
Presbyterian Kaseman Hospital
🇺🇸Albuquerque, New Mexico, United States
Memorial Sloan Kettering Commack
🇺🇸Commack, New York, United States
Presbyterian Rust Medical Center/Jorgensen Cancer Center
🇺🇸Rio Rancho, New Mexico, United States
Southpointe-Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Albany Medical Center
🇺🇸Albany, New York, United States
Long Island Jewish Medical Center
🇺🇸New Hyde Park, New York, United States
Highland Hospital
🇺🇸Rochester, New York, United States
Duke Cancer Institute Cary
🇺🇸Cary, North Carolina, United States
Duke University Medical Center
🇺🇸Durham, North Carolina, United States
Memorial Sloan Kettering Westchester
🇺🇸Harrison, New York, United States
Northwell Health/Center for Advanced Medicine
🇺🇸Lake Success, New York, United States
North Shore University Hospital
🇺🇸Manhasset, New York, United States
Queens Cancer Center
🇺🇸Rego Park, New York, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Memorial Sloan Kettering Cancer Center
🇺🇸New York, New York, United States
University of Rochester
🇺🇸Rochester, New York, United States
Stony Brook University Medical Center
🇺🇸Stony Brook, New York, United States
Memorial Sloan Kettering Nassau
🇺🇸Uniondale, New York, United States
East Carolina University
🇺🇸Greenville, North Carolina, United States
Duke Raleigh Hospital
🇺🇸Raleigh, North Carolina, United States
Sanford Bismarck Medical Center
🇺🇸Bismarck, North Dakota, United States
Sanford South University Medical Center
🇺🇸Fargo, North Dakota, United States
Sanford Medical Center Fargo
🇺🇸Fargo, North Dakota, United States
Sanford Broadway Medical Center
🇺🇸Fargo, North Dakota, United States
Sanford Roger Maris Cancer Center
🇺🇸Fargo, North Dakota, United States
Indu and Raj Soin Medical Center
🇺🇸Beavercreek, Ohio, United States
Saint Elizabeth Boardman Hospital
🇺🇸Boardman, Ohio, United States
Dayton Physicians LLC-Miami Valley South
🇺🇸Centerville, Ohio, United States
TriHealth Cancer Institute-Anderson
🇺🇸Cincinnati, Ohio, United States
Miami Valley Hospital South
🇺🇸Centerville, Ohio, United States
Good Samaritan Hospital - Cincinnati
🇺🇸Cincinnati, Ohio, United States
Oncology Hematology Care Inc-Kenwood
🇺🇸Cincinnati, Ohio, United States
Bethesda North Hospital
🇺🇸Cincinnati, Ohio, United States
TriHealth Cancer Institute-Westside
🇺🇸Cincinnati, Ohio, United States
Orion Cancer Care
🇺🇸Findlay, Ohio, United States
Miami Valley Cancer Care and Infusion
🇺🇸Greenville, Ohio, United States
Wayne Hospital
🇺🇸Greenville, Ohio, United States
MetroHealth Medical Center
🇺🇸Cleveland, Ohio, United States
Miami Valley Hospital
🇺🇸Dayton, Ohio, United States
Premier Blood and Cancer Center
🇺🇸Dayton, Ohio, United States
Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Dayton Physician LLC - Englewood
🇺🇸Dayton, Ohio, United States
Armes Family Cancer Center
🇺🇸Findlay, Ohio, United States
Atrium Medical Center-Middletown Regional Hospital
🇺🇸Franklin, Ohio, United States
Miami Valley Hospital North
🇺🇸Dayton, Ohio, United States
Blanchard Valley Hospital
🇺🇸Findlay, Ohio, United States
Saint Joseph Warren Hospital
🇺🇸Warren, Ohio, United States
Legacy Mount Hood Medical Center
🇺🇸Gresham, Oregon, United States
Oregon Health and Science University
🇺🇸Portland, Oregon, United States
University of Pennsylvania/Abramson Cancer Center
🇺🇸Philadelphia, Pennsylvania, United States
Dayton Physicians LLC-Atrium
🇺🇸Franklin, Ohio, United States
Dayton Physicians LLC-Wayne
🇺🇸Greenville, Ohio, United States
Greater Dayton Cancer Center
🇺🇸Kettering, Ohio, United States
Kettering Medical Center
🇺🇸Kettering, Ohio, United States
Springfield Regional Cancer Center
🇺🇸Springfield, Ohio, United States
Springfield Regional Medical Center
🇺🇸Springfield, Ohio, United States
Dayton Physicians LLC - Troy
🇺🇸Troy, Ohio, United States
Mercy Hospital Oklahoma City
🇺🇸Oklahoma City, Oklahoma, United States
Saint Charles Health System
🇺🇸Bend, Oregon, United States
Upper Valley Medical Center
🇺🇸Troy, Ohio, United States
Providence Newberg Medical Center
🇺🇸Newberg, Oregon, United States
Saint Elizabeth Youngstown Hospital
🇺🇸Youngstown, Ohio, United States
Legacy Good Samaritan Hospital and Medical Center
🇺🇸Portland, Oregon, United States
Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Providence Cancer Institute Clackamas Clinic
🇺🇸Clackamas, Oregon, United States
Bay Area Hospital
🇺🇸Coos Bay, Oregon, United States
Providence Willamette Falls Medical Center
🇺🇸Oregon City, Oregon, United States
Providence Saint Vincent Medical Center
🇺🇸Portland, Oregon, United States
Saint Charles Health System-Redmond
🇺🇸Redmond, Oregon, United States
Legacy Meridian Park Hospital
🇺🇸Tualatin, Oregon, United States
Penn State Milton S Hershey Medical Center
🇺🇸Hershey, Pennsylvania, United States
Thomas Jefferson University Hospital
🇺🇸Philadelphia, Pennsylvania, United States
Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
Sanford Cancer Center Oncology Clinic
🇺🇸Sioux Falls, South Dakota, United States
Sanford USD Medical Center - Sioux Falls
🇺🇸Sioux Falls, South Dakota, United States
Baptist Memorial Hospital and Cancer Center-Collierville
🇺🇸Collierville, Tennessee, United States
Vanderbilt-Ingram Cancer Center at Franklin
🇺🇸Franklin, Tennessee, United States
Vanderbilt-Ingram Cancer Center Cool Springs
🇺🇸Franklin, Tennessee, United States
University of Tennessee - Knoxville
🇺🇸Knoxville, Tennessee, United States
Baptist Memorial Hospital and Cancer Center-Memphis
🇺🇸Memphis, Tennessee, United States
Vanderbilt Breast Center at One Hundred Oaks
🇺🇸Nashville, Tennessee, United States
Vanderbilt University/Ingram Cancer Center
🇺🇸Nashville, Tennessee, United States
Saint Joseph Regional Cancer Center
🇺🇸Bryan, Texas, United States
Parkland Memorial Hospital
🇺🇸Dallas, Texas, United States
UT Southwestern/Simmons Cancer Center-Dallas
🇺🇸Dallas, Texas, United States
UT Southwestern Clinical Center at Richardson/Plano
🇺🇸Richardson, Texas, United States
University of Texas Health Science Center at San Antonio
🇺🇸San Antonio, Texas, United States
Inova Schar Cancer Institute
🇺🇸Fairfax, Virginia, United States
PeaceHealth Saint Joseph Medical Center
🇺🇸Bellingham, Washington, United States
Inova Fairfax Hospital
🇺🇸Falls Church, Virginia, United States
Providence Regional Cancer System-Aberdeen
🇺🇸Aberdeen, Washington, United States
Highline Medical Center-Main Campus
🇺🇸Burien, Washington, United States
Providence Regional Cancer System-Centralia
🇺🇸Centralia, Washington, United States
Harrison HealthPartners Hematology and Oncology-Bremerton
🇺🇸Bremerton, Washington, United States
Swedish Cancer Institute-Edmonds
🇺🇸Edmonds, Washington, United States
Saint Elizabeth Hospital
🇺🇸Enumclaw, Washington, United States
Providence Regional Cancer Partnership
🇺🇸Everett, Washington, United States
Saint Francis Hospital
🇺🇸Federal Way, Washington, United States
Swedish Cancer Institute-Issaquah
🇺🇸Issaquah, Washington, United States
Kadlec Clinic Hematology and Oncology
🇺🇸Kennewick, Washington, United States
Providence Regional Cancer System-Lacey
🇺🇸Lacey, Washington, United States
Saint Clare Hospital
🇺🇸Lakewood, Washington, United States
PeaceHealth Saint John Medical Center
🇺🇸Longview, Washington, United States
Harrison HealthPartners Hematology and Oncology-Poulsbo
🇺🇸Poulsbo, Washington, United States
Virginia Mason Medical Center
🇺🇸Seattle, Washington, United States
Pacific Gynecology Specialists
🇺🇸Seattle, Washington, United States
Swedish Medical Center-Ballard Campus
🇺🇸Seattle, Washington, United States
Swedish Medical Center-Cherry Hill
🇺🇸Seattle, Washington, United States
Swedish Medical Center-First Hill
🇺🇸Seattle, Washington, United States
PeaceHealth United General Medical Center
🇺🇸Sedro-Woolley, Washington, United States
Providence Regional Cancer System-Shelton
🇺🇸Shelton, Washington, United States
Saint Michael Cancer Center
🇺🇸Silverdale, Washington, United States
Franciscan Research Center-Northwest Medical Plaza
🇺🇸Tacoma, Washington, United States
Northwest Medical Specialties PLLC
🇺🇸Tacoma, Washington, United States
PeaceHealth Southwest Medical Center
🇺🇸Vancouver, Washington, United States
Legacy Cancer Institute Medical Oncology and Day Treatment
🇺🇸Vancouver, Washington, United States
Legacy Salmon Creek Hospital
🇺🇸Vancouver, Washington, United States
Providence Saint Mary Regional Cancer Center
🇺🇸Walla Walla, Washington, United States
Providence Regional Cancer System-Yelm
🇺🇸Yelm, Washington, United States
United Hospital Center
🇺🇸Bridgeport, West Virginia, United States
WVUH-Berkely Medical Center
🇺🇸Martinsburg, West Virginia, United States
West Virginia University Healthcare
🇺🇸Morgantown, West Virginia, United States
Camden Clark Medical Center
🇺🇸Parkersburg, West Virginia, United States
Marshfield Medical Center-EC Cancer Center
🇺🇸Eau Claire, Wisconsin, United States
Gundersen Lutheran Medical Center
🇺🇸La Crosse, Wisconsin, United States
University of Wisconsin Carbone Cancer Center - University Hospital
🇺🇸Madison, Wisconsin, United States
Marshfield Medical Center-Marshfield
🇺🇸Marshfield, Wisconsin, United States
Marshfield Medical Center-Rice Lake
🇺🇸Rice Lake, Wisconsin, United States
Marshfield Clinic-Minocqua Center
🇺🇸Minocqua, Wisconsin, United States
Marshfield Medical Center-River Region at Stevens Point
🇺🇸Stevens Point, Wisconsin, United States
Marshfield Medical Center - Weston
🇺🇸Weston, Wisconsin, United States