Radiation Therapy With Cisplatin or Cetuximab in Treating Patients With Oropharyngeal Cancer
- Conditions
- Head and Neck CancerPrecancerous Condition
- Interventions
- Registration Number
- NCT01302834
- Lead Sponsor
- Radiation Therapy Oncology Group
- Brief Summary
RATIONALE: Radiation therapy uses high-energy x-rays to kill tumor cells and shrink tumors. Drugs used in chemotherapy, such as cisplatin, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as cetuximab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. It is not yet known whether radiation therapy is more effective with cisplatin or cetuximab in treating oropharyngeal cancer.
PURPOSE: This phase III trial is studying radiation therapy with cisplatin or cetuximab to see how well it works in treating patients with oropharyngeal cancer.
- Detailed Description
OBJECTIVES:
Primary
* To determine whether substitution of cisplatin with cetuximab will result in comparable 5-year overall survival.
Secondary
* To monitor and compare progression-free survival for "safety".
* To compare patterns of failure (locoregional vs distant).
* To compare acute toxicity profiles (and overall toxicity burden).
* To compare overall quality of life (QOL) short-term (\< 6 months) and long-term (1 year).
* To compare QOL Swallowing Domains short-term and long-term.
* To compare clinician-reported versus patient-reported CTCAE toxicity events.
* To explore differences in the cost effectiveness of cetuximab as compared to cisplatin.
* To explore differences in work status and time to return to work.
* To compare patient-reported changes in hearing.
* To compare CTCAE v. 4 late toxicity at 1, 2, and 5 years.
* To evaluate the effect of tobacco exposure (and other exposures) as measured by standardized computer-assisted self interview (CASI) on overall survival and progression-free survival.
* To pilot CASI collection of patient reported outcomes in a cooperative group setting.
* To determine whether specific molecular profiles are associated with overall or progression-free survival.
* To investigate associations between changes in serum biomarkers or human papilloma virus (HPV)-specific cellular immune responses measured at baseline and three months with overall or progression-free survival.
OUTLINE: This is a multicenter study. Patients are stratified according to T stage (T1-2 vs T 3-4), N stage (N0-2a vs N2b-3), Zubrod performance status (0 vs 1), and smoking history (≤ 10 pack-years vs \> 10 pack-years). Patients are randomized to 1 of 2 treatment arms.
Patients may complete quality-of-life questionnaires and risk factors for head and neck cancer surveys at baseline, periodically during study, and at follow-up for 1 year.
After completion of study therapy, patients are followed up at 1-3 months, every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 987
-
Pathologically (histologically or cytologically) proven diagnosis of squamous cell carcinoma (including the histological variants papillary squamous cell carcinoma and basaloid squamous cell carcinoma) of the oropharynx (tonsil, base of tongue, soft palate, or oropharyngeal walls).
-
Patients must be positive for p16, determined by central review prior to randomization.
-
Patients must have clinically or radiographically evident measurable disease at the primary site or at nodal stations. Tonsillectomy or local excision of the primary without removal of nodal disease is permitted, as is excision removing gross nodal disease but with intact primary site. Limited neck dissections retrieving ≤ 4 nodes are permitted and considered as non-therapeutic nodal excisions. Fine needle aspirations of the neck are insufficient due to limited tissue for retrospective central review. Biopsy specimens from the primary or nodes measuring at least 3-5 mm are required.
-
Clinical stage T1-2, N2a-N3 or T3-4, any N (AJCC, 7th ed.; see Appendix III), including no distant metastases, based upon the following minimum diagnostic workup:
-
General history and physical examination by a radiation oncologist and medical oncologist within 8 weeks prior to registration;
-
Examination by an ear, nose, and throat (ENT) or head and neck surgeon, including laryngopharyngoscopy (mirror and/or fiberoptic and/or direct procedure) within 8 weeks prior to registration;
-
One of the following combinations of imaging is required within 8 weeks prior to registration:
- A computerized tomography (CT) scan of the neck (with contrast) and a chest CT scan (with or without contrast);
- or a magnetic resonance imaging (MRI) scan of the neck (with contrast) and a chest CT scan (with or without contrast);
- or a CT scan of neck (with contrast) and a positron emission tomography (PET)/CT of neck and chest (with or without contrast);
- or an MRI of the neck (with contrast) and a PET/CT of neck and chest (with or without contrast).
Note: A CT scan of neck and/or a PET/CT performed for radiation planning and read by a radiologist may serve as both staging and planning tools.
-
-
Zubrod Performance Status 0-1 within 2 weeks prior to registration
-
Age ≥ 18;
-
Complete blood count (CBC)/differential obtained within 2 weeks prior to registration on study, with adequate bone marrow function, defined as follows:
- Absolute neutrophil count (ANC) > 1,500 cells/mm3;
- Platelets > 100,000 cells/mm3;
- Hemoglobin (Hgb) > 8.0 g/dl; Note: The use of transfusion or other intervention to achieve Hgb > 8.0 g/dl is acceptable.
-
Adequate hepatic function, defined as follows:
- Bilirubin < 2 mg/dl within 2 weeks prior to registration;
- Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) < 3 x the upper limit of normal within 2 weeks prior to registration;
-
Adequate renal function, defined as follows:
• Serum creatinine < 1.5 mg/dl within 2 weeks prior to registration or creatinine clearance (CCr) ≥ 50 ml/min within 2 weeks prior to registration determined by 24-hour collection or estimated by Cockcroft-Gault formula:
CCr male = [(140 - age) x (wt in kg)] [(Serum Cr mg/dl) x (72)] CCr female = 0.85 x (CCr male)
-
Patients must provide their smoking history (for stratification) via the computer-assisted self interview (CASI) head and neck risk factor survey tool.
-
Negative serum pregnancy test within 2 weeks prior to registration for women of childbearing potential;
-
Women of childbearing potential and male participants must agree to use a medically effective means of birth control throughout their participation in the treatment phase of the study and until at least 60 days following the last study treatment.
-
Patients who are human immunodeficiency virus (HIV) positive but have no prior acquired immune deficiency syndrome (AIDS) -defining illness and have CD4 cells of at least 350/mm3 are eligible. Patient HIV status must be known prior to registration. Patients must not be sero-positive for Hepatitis B (Hepatitis B surface antigen positive or anti-hepatitis B core antigen positive) or sero-positive for Hepatitis C (anti-Hepatitis C antibody positive). However, patients who are immune to hepatitis B (anti-Hepatitis B surface antibody positive) are eligible (e.g. patients immunized against hepatitis B). HIV-positive patients must not have multi-drug resistant HIV infection or other concurrent AIDS-defining conditions.
-
Patient must provide study specific informed consent prior to study entry, including consent for mandatory submission of tissue for required, central p16 review and consent to participate in the computer-assisted self interview (CASI) survey questions regarding smoking history.
-
Cancers considered to be from an oral cavity site (oral tongue, floor mouth, alveolar ridge, buccal or lip), nasopharynx, hypopharynx, or larynx, even if p16 positive, are excluded. Carcinoma of the neck of unknown primary site origin (even if p16 positive) are excluded from participation.
-
Stage T1-2, N0-1;
-
Distant metastasis or adenopathy below the clavicles;
-
Gross total excision of both primary and nodal disease; this includes tonsillectomy, local excision of primary site, and nodal excision that removes all clinically and radiographically evident disease.
-
Simultaneous primaries or bilateral tumors;
-
Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free for a minimum of 3 years (For example, carcinoma in situ of the breast, oral cavity, or cervix are all permissible);
-
Prior systemic chemotherapy for the study cancer; note that prior chemotherapy for a different cancer is allowable;
-
Prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields;
-
Severe, active co-morbidity, defined as follows:
- 9.1 Unstable angina and/or congestive heart failure requiring hospitalization within the last 6 months;
- 9.2 Transmural myocardial infarction within the last 6 months;
- 9.3 Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration;
- 9.4 Chronic Obstructive Pulmonary Disease exacerbation or other respiratory illness requiring hospitalization or precluding study therapy within 30 days of registration;
- 9.5 Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects; note, however, that laboratory tests for liver function and coagulation parameters are not required for entry into this protocol.
- 9.6 Acquired Immune Deficiency Syndrome (AIDS) based upon current Centers for Disease Control and Prevention (CDC) definition with immune compromise greater than that noted in Section 3.1.13; note, however, that HIV testing is not required for entry into this protocol. The need to exclude patients with AIDS from this protocol is necessary because the treatments involved in this protocol may be significantly immunosuppressive. Protocol-specific requirements may also exclude immuno-compromised patients.
-
Pregnancy or women of childbearing potential and men who are sexually active and not willing/able to use medically acceptable forms of contraception; this exclusion is necessary because the treatment involved in this study may be significantly teratogenic.
-
Prior allergic reaction to cisplatin or cetuximab;
-
Prior cetuximab or other anti-EGFR therapy.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description IMRT + Cetuximab cetuximab Intensity-modulated radiotherapy (IMRT) with concurrent cetuximab IMRT + Cetuximab IMRT Intensity-modulated radiotherapy (IMRT) with concurrent cetuximab IMRT + Cisplatin IMRT Intensity-modulated radiotherapy (IMRT) with concurrent cisplatin IMRT + Cisplatin cisplatin Intensity-modulated radiotherapy (IMRT) with concurrent cisplatin
- Primary Outcome Measures
Name Time Method Overall Survival From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. An event for overall survival is death due to any cause. Survival time is defined as time from randomization to the date of death or last known follow-up (censored). Rates are estimated by the Kaplan-Meier method. The protocol endpoint is hazard ratio, which is reported in the statistical analysis results. Five-year rate is reported simply as summary data; it is not the outcome measure.
- Secondary Outcome Measures
Name Time Method Time to Local-regional Failure From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. Failure for local-regional failure endpoint was defined as local or regional progression, salvage surgery of the primary tumor with tumor present/unknown, salvage neck dissection with tumor present/unknown \> 20 weeks after the end of radiation therapy, death due to study cancer without documented progression, or death due to unknown causes without documented progression; distant metastasis and death due to other causes were considered competing risks. Local-regional failure time is defined as time from randomization to the date of progression/death or last known follow-up (censored). Rates are estimated by the cumulative incidence method. The protocol endpoint is the distribution of local-regional failure times, for which the hazard ratio is reported in the statistical analysis results. Five-year rate is reported simply as summary data; it is not the outcome measure.
Time to Secondary Primary Cancer From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. Failure for second primary endpoint was defined as reporting of a new primary cancer; death due to any cause was considered a competing risk. Second primary time is defined as time from randomization to the date of second primary or last known follow-up (censored). Rates are estimated by the cumulative incidence method. The protocol endpoint is the distribution of second primary cancer times, for which the hazard ratio is reported in the statistical analysis results. Five-year rate is reported simply as summary data; it is not the outcome measure.
Percentage of Participants Experiencing Early Death From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. Early death is defined as death due to adverse event or within 30 days of treatment completion.
Percentage of Participants With Acute Grade 3-4 Treatment-related Adverse Events: 3 Months After the End of Study Treatment From start of treatment to approximately 4.5 months (3 months after the end of treatment) Acute adverse events (AE) are defined as occurring within 180 days from the end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With Acute Grade 3-4 Treatment-related Adverse Events: 6 Months After the End of Study Treatment From start of treatment to approximately 7.5 months (6 months after the end of treatment) Acute adverse events (AE) are defined as occurring within 180 days from the end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Progression-free Survival From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. An event for progression-free survival is local, regional, or distant disease progression or death due to any cause. Progression-free survival time is defined as time from randomization to the date of progression/death or last known follow-up (censored). Rates are estimated by the Kaplan-Meier method. The protocol endpoint is the distribution of progression-free survival times, for which the hazard ratio is reported in the statistical analysis results. Five-year rate is reported simply as summary data; it is not the outcome measure.
Time to Distant Metastasis From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. Failure for distant metastasis endpoint was defined as distant progression; local-regional failure and death due to any cause were considered competing risks. Distant metastasis time is defined as time from randomization to the date of progression/death or last known follow-up (censored). Rates are estimated by the cumulative incidence method. The protocol endpoint is the distribution of distant metastasis times, for which the hazard ratio is reported in the statistical analysis results. Five-year rate is reported simply as summary data; it is not the outcome measure.
Distribution of First Progression Events From randomization to last follow-up. Analysis was to occur after 180 deaths were reported. Analysis occurred after 133 deaths were reported. Maximum follow-up at time of analysis was 6.5 years. The first event type for progression-free survival is counted for each participant. Possible first progression events are local, regional, or distant progression, any combination of these, or death. The frequency table of these events is also referred to as "Pattern of failure."
Percentage of Participants With Acute Grade 3-4 Treatment-related Adverse Events: During Treatment From start of treatment to end of treatment, approximately 6 weeks Acute adverse events (AE) are defined as occurring within 180 days from the end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With Late Grade 3-4 Treatment-related Adverse Events: 1 Year After the End of Study Treatment From start of treatment to approximately 13.5 months (one year after the end of treatment) Late adverse events (AE) are defined as \> 180 days from end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With Acute Grade 3-4 Treatment-related Adverse Events: 1 Month After End of Study Treatment From start of treatment to approximately 2.5 months (1 month after the end of treatment) Acute adverse events (AE) are defined as occurring within 180 days from the end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With Late Grade 3-4 Treatment-related Adverse Events: 2 Years After the End of Study Treatment From 180 days after end of treatment to two years after end of treatment. Late adverse events (AE) are defined as \> 180 days from end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With Late Grade 3-4 Treatment-related Adverse Events: 5 Years After the End of Study Treatment From start of treatment to approximately 61.5 months (five years after the end of treatment) Late adverse events (AE) are defined as \> 180 days from end of treatment. "Treatment-related" means reported as definitely, probably, or possibly related to protocol treatment. AE were graded using the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Grade refers to the severity of the AE. The CTCAE v4.0 assigns Grades 1 through 5 with unique clinical descriptions of severity for each AE based on this general guideline: Grade 1 Mild, Grade 2 Moderate, Grade 3 Severe, Grade 4 Life-threatening or disabling, Grade 5 Death related to AE
Percentage of Participants With a Feeding Tube at 1 Year From randomization to 1 year. EORTC QLQ-C30 at Baseline, End of Treatment, 3, 6, and 12 Months From End of Treatment. From randomization to 1 year after end of treatment. EORTC QLQ-H&N35 at Baseline, End of Treatment, 3, 6, and 12 Months From End of Treatment. From randomization to 1 year after end of treatment. Percentage of Patients With Normal/Good Dental Health: Pretreatment Before treatment This study utilized a dental effects health scale from 0 (normal) to 4 (life-threatening dental condition). The percentage of participants with a value of 0 or 1 is reported: 0 = "Normal: Edentulous, with no gingival disease";
1 = "Mild changes/good dental health: mild periodontal inflammation-routine cleaning indicated; \< 5 restorations indicated; no extractions indicated." Ten year data is not yet available.Percentage of Patients With Normal/Good Dental Health: 10 Years After End of Treatment 10 years after end of treatment (approximately 121.5 months) his study utilized a dental effects health scale from 0 (normal) to 4 (life-threatening dental condition). The percentage of participants with a value of 0 or 1 is reported: 0 = "Normal: Edentulous, with no gingival disease";
1 = "Mild changes/good dental health: mild periodontal inflammation-routine cleaning indicated; \< 5 restorations indicated; no extractions indicated."Hearing Quality of Life Outcomes as Measured by the Hearing Handicap Inventory for Adults (HHIA-S) at Baseline, End of Treatment and at 3, 6, and 12 Months From End of Treatment. From randomization to 1 year after end of treatment. Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events for Head and Neck (PRO-CTCAE H&N) at Baseline, End of Treatment, 3, 6, and 12 Months From End of Treatment. From randomization to 1 year after end of treatment. EuroQol Five Dimension Scale (EQ-5D) at Baseline, End of Treatment, 3, 6, and 12 Months From End of Treatment. From randomization to 1 year after end of treatment. Work Status Questionnaire at Baseline, End of Treatment, 3, 6, and 12 Months. From randomization to 1 year after end of treatment. Translational Research Analysis From randomization to date of death or last follow-up. Percentage of Patients With Normal/Good Dental Health: 2 Years After End of Treatment 2 years after end of treatment (approximately 25.5 months) This study utilized a dental effects health scale from 0 (normal) to 4 (life-threatening dental condition). The percentage of participants with a value of 0 or 1 is reported: 0 = "Normal: Edentulous, with no gingival disease"; 1 = "Mild changes/good dental health: mild periodontal inflammation-routine cleaning indicated; \< 5 restorations indicated; no extractions indicated."
Behavioral Risk Assessment Survey (BRASS) at Baseline. Prior to randomization. Percentage of Patients With Normal/Good Dental Health: 1 Year After End of Treatment 1 year after end of treatment (approximately 13.5 months) This study utilized a dental effects health scale from 0 (normal) to 4 (life-threatening dental condition). The percentage of participants with a value of 0 or 1 is reported: 0 = "Normal: Edentulous, with no gingival disease";
1 = "Mild changes/good dental health: mild periodontal inflammation-routine cleaning indicated; \< 5 restorations indicated; no extractions indicated."Percentage of Patients With Normal/Good Dental Health: 5 Years After End of Treatment 5 years after end of treatment (approximately 61.5 months) This study utilized a dental effects health scale from 0 (normal) to 4 (life-threatening dental condition). The percentage of participants with a value of 0 or 1 is reported: 0 = "Normal: Edentulous, with no gingival disease"; 1 = "Mild changes/good dental health: mild periodontal inflammation-routine cleaning indicated; \< 5 restorations indicated; no extractions indicated."
Trial Locations
- Locations (184)
John H. Stroger, Jr. Hospital of Cook County
🇺🇸Chicago, Illinois, United States
Roy and Patricia Disney Family Cancer Center at Providence Saint Joseph Medical Center
🇺🇸Burbank, California, United States
Radiation Oncology Centers - Cameron Park
🇺🇸Cameron Park, California, United States
Auburn Radiation Oncology
🇺🇸Auburn, California, United States
City of Hope Comprehensive Cancer Center
🇺🇸Duarte, California, United States
Rebecca and John Moores UCSD Cancer Center
🇺🇸La Jolla, California, United States
Enloe Cancer Center at Enloe Medical Center
🇺🇸Chico, California, United States
Rohnert Park Cancer Center
🇺🇸Rohnert Park, California, United States
Solano Radiation Oncology Center
🇺🇸Vacaville, California, United States
George Bray Cancer Center at the Hospital of Central Connecticut - New Britain Campus
🇺🇸New Britain, Connecticut, United States
Integrated Community Oncology Network
🇺🇸Jacksonville Beach, Florida, United States
Integrated Community Oncology Network at Southside Cancer Center
🇺🇸Jacksonville, Florida, United States
University of Miami Sylvester Comprehensive Cancer Center - Miami
🇺🇸Miami, Florida, United States
Integrated Community Oncology Network - Orange Park
🇺🇸Orange Park, Florida, United States
Sacred Heart Cancer Center at Sacred Heart Hospital
🇺🇸Pensacola, Florida, United States
Georgia Cancer Center for Excellence at Grady Memorial Hospital
🇺🇸Atlanta, Georgia, United States
Nancy N. and J. C. Lewis Cancer and Research Pavilion at St. Joseph's/Candler
🇺🇸Savannah, Georgia, United States
Robert H. Lurie Comprehensive Cancer Center at Northwestern University
🇺🇸Chicago, Illinois, United States
University of Chicago Cancer Research Center
🇺🇸Chicago, Illinois, United States
Evanston Hospital
🇺🇸Evanston, Illinois, United States
Cardinal Bernardin Cancer Center at Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Regional Cancer Center at Memorial Medical Center
🇺🇸Springfield, Illinois, United States
Parkview Regional Cancer Center at Parkview Health
🇺🇸Fort Wayne, Indiana, United States
Center for Cancer Care at Goshen General Hospital
🇺🇸Goshen, Indiana, United States
Community Regional Cancer Care at Community Hospital North
🇺🇸Indianapolis, Indiana, United States
Michiana Hematology-Oncology, PC - South Bend
🇺🇸Mishawaka, Indiana, United States
Cancer Center at Ball Memorial Hospital
🇺🇸Muncie, Indiana, United States
Memorial Hospital of South Bend
🇺🇸South Bend, Indiana, United States
McFarland Clinic, PC
🇺🇸Ames, Iowa, United States
Siouxland Hematology-Oncology Associates, LLP
🇺🇸Sioux City, Iowa, United States
CCOP - Kansas City
🇺🇸Prairie Village, Kansas, United States
Maine Center for Cancer Medicine and Blood Disorders - Scarborough
🇺🇸Scarborough, Maine, United States
St. Agnes Hospital Cancer Center
🇺🇸Baltimore, Maryland, United States
Greenebaum Cancer Center at University of Maryland Medical Center
🇺🇸Baltimore, Maryland, United States
NSMC Cancer Center - Peabody
🇺🇸Danvers, Massachusetts, United States
Hudner Oncology Center at Saint Anne's Hospital - Fall River
🇺🇸Fall River, Massachusetts, United States
Battle Creek Health System Cancer Care Center
🇺🇸Battle Creek, Michigan, United States
Butterworth Hospital at Spectrum Health
🇺🇸Grand Rapids, Michigan, United States
Genesys Hurley Cancer Institute
🇺🇸Flint, Michigan, United States
Lacks Cancer Center at Saint Mary's Health Care
🇺🇸Grand Rapids, Michigan, United States
Cancer Institute of Cape Girardeau, LLC
🇺🇸Cape Girardeau, Missouri, United States
Regional Cancer Center at Singing River Hospital
🇺🇸Pascagoula, Mississippi, United States
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis
🇺🇸Saint Louis, Missouri, United States
Barnes-Jewish West County Hospital
🇺🇸Saint Louis, Missouri, United States
Hulston Cancer Center at Cox Medical Center South
🇺🇸Springfield, Missouri, United States
Seacoast Cancer Center at Wentworth - Douglass Hospital
🇺🇸Dover, New Hampshire, United States
Payson Center for Cancer Care at Concord Hospital
🇺🇸Concord, New Hampshire, United States
Cancer Institute of New Jersey at Cooper - Voorhees
🇺🇸Voorhees, New Jersey, United States
Kingsbury Center for Cancer Care at Cheshire Medical Center
🇺🇸Keene, New Hampshire, United States
Lourdes Regional Cancer Center
🇺🇸Binghamton, New York, United States
Mission Hospitals - Memorial Campus
🇺🇸Asheville, North Carolina, United States
Moses Cone Regional Cancer Center at Wesley Long Community Hospital
🇺🇸Greensboro, North Carolina, United States
FirstHealth Moore Regional Community Hospital Comprehensive Cancer Center
🇺🇸Pinehurst, North Carolina, United States
Charles M. Barrett Cancer Center at University Hospital
🇺🇸Cincinnati, Ohio, United States
Case Comprehensive Cancer Center
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Cancer Center at Fairview Hospital
🇺🇸Cleveland, Ohio, United States
Cleveland Clinic Taussig Cancer Center
🇺🇸Cleveland, Ohio, United States
Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at Ohio State University Comprehensive Cancer Center
🇺🇸Columbus, Ohio, United States
Northwest Ohio Oncology Center
🇺🇸Maumee, Ohio, United States
Lake/University Ireland Cancer Center
🇺🇸Mentor, Ohio, United States
Southwest General Health Center
🇺🇸Middleburg Heights, Ohio, United States
Flower Hospital Cancer Center
🇺🇸Sylvania, Ohio, United States
St. Charles Mercy Hospital
🇺🇸Oregon, Ohio, United States
St. Anne Mercy Hospital
🇺🇸Toledo, Ohio, United States
Precision Radiotherapy at University Pointe
🇺🇸West Chester, Ohio, United States
UHHS Westlake Medical Center
🇺🇸Westlake, Ohio, United States
Cancer Treatment Center
🇺🇸Wooster, Ohio, United States
Clackamas Radiation Oncology Center
🇺🇸Clackamas, Oregon, United States
Dubs Cancer Center at Rogue Valley Medical Center
🇺🇸Medford, Oregon, United States
Providence Cancer Center at PMCC
🇺🇸Medford, Oregon, United States
Natalie Warren Bryant Cancer Center at St. Francis Hospital
🇺🇸Tulsa, Oklahoma, United States
Rosenfeld Cancer Center at Abington Memorial Hospital
🇺🇸Abington, Pennsylvania, United States
Dale and Frances Hughes Cancer Center at Pocono Medical Center
🇺🇸East Stroudsburg, Pennsylvania, United States
Adams Cancer Center
🇺🇸Gettysburg, Pennsylvania, United States
Cherry Tree Cancer Center
🇺🇸Hanover, Pennsylvania, United States
Fox Chase Cancer Center - Philadelphia
🇺🇸Philadelphia, Pennsylvania, United States
St. Mary Regional Cancer Center
🇺🇸Langhorne, Pennsylvania, United States
McGlinn Family Regional Cancer Center at Reading Hospital and Medical Center
🇺🇸Reading, Pennsylvania, United States
York Cancer Center at Apple Hill Medical Center
🇺🇸York, Pennsylvania, United States
Gibbs Regional Cancer Center at Spartanburg Regional Medical Center
🇺🇸Spartanburg, South Carolina, United States
Cancer Centers of the Carolinas - Spartanburg
🇺🇸Spartanburg, South Carolina, United States
University of Texas Medical Branch
🇺🇸Galveston, Texas, United States
M. D. Anderson Cancer Center at University of Texas
🇺🇸Houston, Texas, United States
Jon and Karen Huntsman Cancer Center at Intermountain Medical Center
🇺🇸Murray, Utah, United States
Val and Ann Browning Cancer Center at McKay-Dee Hospital Center
🇺🇸Ogden, Utah, United States
Sentara Cancer Institute at Sentara Norfolk General Hospital
🇺🇸Norfolk, Virginia, United States
Coastal Cancer Center at Sentara Virginia Beach General Hospital
🇺🇸Virginia Beach, Virginia, United States
CCOP - Virginia Mason Research Center
🇺🇸Seattle, Washington, United States
St. Joseph Cancer Center
🇺🇸Bellingham, Washington, United States
North Star Lodge Cancer Center at Yakima Valley Memorial Hospital
🇺🇸Yakima, Washington, United States
St. Vincent Hospital Regional Cancer Center
🇺🇸Green Bay, Wisconsin, United States
University of Wisconcin Cancer Center at Aspirus Wausau Hospital
🇺🇸Wausau, Wisconsin, United States
McGill Cancer Centre at McGill University
🇨🇦Montreal, Quebec, Canada
Kaiser Permanente - Division of Research - Oakland
🇺🇸Oakland, California, United States
Radiation Oncology Center - Roseville
🇺🇸Roseville, California, United States
Mercy Cancer Center at Mercy San Juan Medical Center
🇺🇸Carmichael, California, United States
Winship Cancer Institute of Emory University
🇺🇸Atlanta, Georgia, United States
Kaiser Permanente Medical Center - South San Francisco
🇺🇸South San Francisco, California, United States
Creticos Cancer Center at Advocate Illinois Masonic Medical Center
🇺🇸Chicago, Illinois, United States
Curtis and Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center
🇺🇸Savannah, Georgia, United States
Northeast Georgia Medical Center
🇺🇸Gainesville, Georgia, United States
Northwest Community Hospital
🇺🇸Arlington Heights, Illinois, United States
Decatur Memorial Hospital Cancer Care Institute
🇺🇸Decatur, Illinois, United States
Community Regional Cancer Care at Community Hospital East
🇺🇸Indianapolis, Indiana, United States
Cancer Institute at St. John's Hospital
🇺🇸Springfield, Illinois, United States
St. Francis Hospital and Health Centers - Beech Grove Campus
🇺🇸Beech Grove, Indiana, United States
Elkhart General Hospital
🇺🇸Elkhart, Indiana, United States
CCOP - St. Louis-Cape Girardeau
🇺🇸Saint Louis, Missouri, United States
Blumenthal Cancer Center at Carolinas Medical Center
🇺🇸Charlotte, North Carolina, United States
David C. Pratt Cancer Center at St. John's Mercy
🇺🇸Saint Louis, Missouri, United States
Hillcrest Cancer Center at Hillcrest Hospital
🇺🇸Mayfield Heights, Ohio, United States
Northwest Cancer Specialists at Vancouver Cancer Center
🇺🇸Vancouver, Washington, United States
Barberton Citizens Hospital
🇺🇸Barberton, Ohio, United States
Summa Center for Cancer Care at Akron City Hospital
🇺🇸Akron, Ohio, United States
Kinston Medical Specialists
🇺🇸Kinston, North Carolina, United States
UCSF Helen Diller Family Comprehensive Cancer Center
🇺🇸San Francisco, California, United States
Vanderbilt-Ingram Cancer Center
🇺🇸Nashville, Tennessee, United States
Utah Cancer Specialists at UCS Cancer Center
🇺🇸Salt Lake City, Utah, United States
Huntsman Cancer Institute at University of Utah
🇺🇸Salt Lake City, Utah, United States
Penrose Cancer Center at Penrose Hospital
🇺🇸Colorado Springs, Colorado, United States
Mercy and Unity Cancer Center at Unity Hospital
🇺🇸Fridley, Minnesota, United States
Park Nicollet Cancer Center
🇺🇸Saint Louis Park, Minnesota, United States
Mercy and Unity Cancer Center at Mercy Hospital
🇺🇸Coon Rapids, Minnesota, United States
McKee Medical Center
🇺🇸Loveland, Colorado, United States
Fairview Southdale Hospital
🇺🇸Edina, Minnesota, United States
Regions Hospital Cancer Care Center
🇺🇸Saint Paul, Minnesota, United States
Kansas Masonic Cancer Research Institute at the University of Kansas Medical Center
🇺🇸Kansas City, Kansas, United States
Kansas City Cancer Centers - Southwest
🇺🇸Overland Park, Kansas, United States
North Suburban Medical Center
🇺🇸Thornton, Colorado, United States
Providence Cancer Center
🇺🇸Anchorage, Alaska, United States
CCOP - Christiana Care Health Services
🇺🇸Newark, Delaware, United States
North Broward Medical Center
🇺🇸Deerfield Beach, Florida, United States
Billings Clinic - Downtown
🇺🇸Billings, Montana, United States
Mary Bird Perkins Cancer Center - Baton Rouge
🇺🇸Baton Rouge, Louisiana, United States
Flagler Cancer Center
🇺🇸Saint Augustine, Florida, United States
Renown Institute for Cancer at Renown Regional Medical Center
🇺🇸Reno, Nevada, United States
Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center
🇺🇸Lebanon, New Hampshire, United States
Swedish Medical Center
🇺🇸Englewood, Colorado, United States
Baptist Cancer Institute - Jacksonville
🇺🇸Jacksonville, Florida, United States
Baptist Medical Center South
🇺🇸Jacksonville, Florida, United States
Florida Cancer Center - Palatka
🇺🇸Palatka, Florida, United States
Monmouth Medical Center
🇺🇸Long Branch, New Jersey, United States
Frederick R. and Betty M. Smith Cancer Treatment Center
🇺🇸Sparta, New Jersey, United States
Schiffler Cancer Center at Wheeling Hospital
🇺🇸Wheeling, West Virginia, United States
Bay Area Cancer Care Center at Bay Area Medical Center
🇺🇸Marinette, Wisconsin, United States
Rapid City Regional Hospital
🇺🇸Rapid City, South Dakota, United States
Gundersen Lutheran Center for Cancer and Blood
🇺🇸La Crosse, Wisconsin, United States
St. Mary's Hospital Medical Center - Green Bay
🇺🇸Green Bay, Wisconsin, United States
CCOP - Greenville
🇺🇸Greenville, South Carolina, United States
Utah Valley Regional Medical Center - Provo
🇺🇸Provo, Utah, United States
Cancer Centers of the Carolinas - Faris Road
🇺🇸Greenville, South Carolina, United States
Edwards Comprehensive Cancer Center at Cabell Huntington Hospital
🇺🇸Huntington, West Virginia, United States
Porter Adventist Hospital
🇺🇸Denver, Colorado, United States
Josephine Ford Cancer Center at Henry Ford Hospital
🇺🇸Detroit, Michigan, United States
Oklahoma University Cancer Institute
🇺🇸Oklahoma City, Oklahoma, United States
Providence Cancer Center at Providence Portland Medical Center
🇺🇸Portland, Oregon, United States
Providence St. Vincent Medical Center
🇺🇸Portland, Oregon, United States
Knight Cancer Institute at Oregon Health and Science University
🇺🇸Portland, Oregon, United States
Nebraska Medical Center
🇺🇸Omaha, Nebraska, United States
Methodist Estabrook Cancer Center
🇺🇸Omaha, Nebraska, United States
Medical College of Wisconsin Cancer Center
🇺🇸Milwaukee, Wisconsin, United States
Veterans Affairs Medical Center - Milwaukee
🇺🇸Milwaukee, Wisconsin, United States
Radiological Associates of Sacramento Medical Group, Incorporated
🇺🇸Sacramento, California, United States
H. Lee Moffitt Cancer Center and Research Institute at University of South Florida
🇺🇸Tampa, Florida, United States
Mercy General Hospital
🇺🇸Sacramento, California, United States
Rocky Mountain Cancer Centers - Aurora
🇺🇸Aurora, Colorado, United States
Saint Joseph Mercy Cancer Center
🇺🇸Ann Arbor, Michigan, United States
Theda Care Cancer Institute
🇺🇸Appleton, Wisconsin, United States
CancerCare Manitoba
🇨🇦Winnipeg, Manitoba, Canada
Boulder Community Hospital
🇺🇸Boulder, Colorado, United States
Florida Hospital Cancer Institute at Florida Hospital Orlando
🇺🇸Orlando, Florida, United States
M.D. Anderson Cancer Center at Orlando
🇺🇸Orlando, Florida, United States
James Graham Brown Cancer Center at University of Louisville
🇺🇸Louisville, Kentucky, United States
Kansas City Cancer Centers - South
🇺🇸Kansas City, Missouri, United States
Kansas City Cancer Centers - North
🇺🇸Kansas City, Missouri, United States
Hollings Cancer Center at Medical University of South Carolina
🇺🇸Charleston, South Carolina, United States
Lahey Clinic Medical Center - Burlington
🇺🇸Burlington, Massachusetts, United States
CCOP - Ochsner
🇺🇸New Orleans, Louisiana, United States
Lucille P. Markey Cancer Center at University of Kentucky
🇺🇸Lexington, Kentucky, United States
Highland Hospital of Rochester
🇺🇸Rochester, New York, United States
John Stoddard Cancer Center at Iowa Methodist Medical Center
🇺🇸Des Moines, Iowa, United States
University of New Mexico Cancer Center
🇺🇸Albuquerque, New Mexico, United States
James P. Wilmot Cancer Center at University of Rochester Medical Center
🇺🇸Rochester, New York, United States
University of Wisconsin Paul P. Carbone Comprehensive Cancer Center
🇺🇸Madison, Wisconsin, United States