Standard Risk B-precursor Acute Lymphoblastic Leukemia
- Compare event-free survival of pediatric patients with newly diagnosed, standard-risk
(SR)-average, B-precursor acute lymphoblastic leukemia (ALL) treated with induction
therapy followed by 1 of 4 intensified phases of post-induction therapy.
- Compare event-free survival of pediatric patients with SR-low ALL treated with
consolidation and interim maintenance therapy with or without additional pegaspargase.
- Correlate day 29 minimal residual disease (MRD) status with event-free survival and
overall survival of patients treated with these regimens.
- Correlate early marrow response with day 29 MRD status in patients treated with these
- Determine whether outcome is improved for SR-high patients by identifying these
patients by day 29 MRD status and subsequently treating these patients with a fully
augmented Berlin Frankfurt Munster regimen.
- Correlate relative contributions of genetic factors and early treatment response with
outcome in patients treated with these regimens.
OUTLINE: This is a 2-part, partially randomized, multicenter study. Patients are stratified
according to early response to study induction therapy (rapid early response [standard risk
(SR)-low or SR-average acute lymphoblastic leukemia (ALL)] vs slow early response [SR-high
ALL]). After completion of induction therapy but before proceeding to part II therapy,
patients are assigned to 1 of 3 groups based on stratification.
- Induction therapy: All patients receive cytarabine intrathecally (IT) on day 1;
vincristine IV on days 1, 8, 15, and 22; dexamethasone IV or orally twice daily on days
1-28; pegaspargase intramuscularly (IM) (may give IV over 1 to 2 hours) on day 4, 5, or
6; and methotrexate IT on days 8 and 29 (and days 15 and 22 for patients with CNS3
disease). Patients with Down syndrome (DS) receive oral leucovorin calcium at 48 and 60
hours after each dose of methotrexate IT .
Patients are assessed for response on day 29. Patients with M1 bone marrow AND minimal
residual disease (MRD) < 0.1% OR MRD ≥ 0.1% and < 1% proceed to therapy in part II. Patients
with M2 bone marrow OR M1 bone marrow AND MRD ≥ 1% proceed to extended induction therapy.
Patients with M3 bone marrow are removed from the study.
- Extended induction therapy: Patients receive dexamethasone IV or orally twice daily on
days 1-14; vincristine IV on days 1 and 8; pegaspargase IM on day 4, 5, or 6; and
daunorubicin hydrochloride IV over 15 minutes to 2 hours on day 1.
Patients with M1 bone marrow and MRD < 1% after extended induction therapy proceed to
therapy in part II. Patients with M2 or M3 bone marrow after extended induction therapy are
removed from the study.
- Group 1 (SR-low ALL): Patients are randomized to 1 of 2 treatment arms.
- Arm I:
- Standard consolidation therapy: Patients receive vincristine IV on day 1;
oral mercaptopurine on days 1-28; and methotrexate IT on days 1, 8, and 15.
Patients with Down syndrome (DS) receive oral leucovorin calcium at 48 and 60
hours after each dose of methotrexate IT.
- Standard interim maintenance therapy: Patients receive vincristine IV on days
1 and 29; dexamethasone IV or orally twice daily on days 1-5 and 29-33; oral
mercaptopurine on days 1-50; oral methotrexate on days 1, 8, 15, 22, 29, 36,
43, and 50; and methotrexate IT on day 29. Patients with DS receive oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.
- Standard delayed intensification (DI) therapy: Patients receive vincristine
IV on days 1, 8, and 15; dexamethasone IV or orally twice daily on days 1-21;
doxorubicin hydrochloride IV over 15 minutes to 2 hours on days 1, 8, and 15;
pegaspargase IM on day 4, 5, or 6; cyclophosphamide IV over 30 minutes on day
29; cytarabine IV or subcutaneously (SC) on days 29-32 and 36-39; oral
thioguanine on days 29-42; and methotrexate IT on days 1 and 29. Patients
with DS receive dexamethasone IV or orally twice daily on days 1-7 and 15-21
and oral leucovorin calcium at 48 and 60 hours after each dose of
- Arm II:
- Experimental consolidation therapy: Patients receive vincristine,
mercaptopurine, methotrexate, and leucovorin calcium as in arm I and
pegaspargase IM on days 1 and 22.
- Experimental interim maintenance therapy: Patients receive vincristine,
dexamethasone, mercaptopurine, oral methotrexate, and methotrexate IT as in
arm I and pegaspargase IM on days 15 and 36.
- Standard DI therapy: Patients receive standard DI therapy as in arm I.
- Group 2 (SR-average ALL): Patients are randomized to 1 of 4 treatment arms.
- Arm I: Patients receive standard consolidation therapy, standard interim
maintenance therapy, and standard DI therapy as in group 1, arm I.
- Arm II:
- Standard consolidation therapy: Patients receive standard consolidation
therapy as in group 1, arm I.
- Augmented interim maintenance therapy: Patients receive vincristine IV and
methotrexate IV on days 1, 11, 21, 31, and 41; pegaspargase IM on days 2 and
22; and methotrexate IT on days 1 and 31. Patients with DS receive oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.
- Augmented DI therapy: Patients receive vincristine IV on days 1, 8, 15, 43,
and 50; dexamethasone IV or orally twice daily on days 1-21; doxorubicin
hydrochloride IV over 15 minutes to 2 hours on days 1, 8, and 15;
pegaspargase IM on day 4, 5, or 6 AND day 43; cyclophosphamide IV over 30
minutes on day 29; cytarabine IV or SC on days 29-32 and 36-39; oral
thioguanine on days 29-42; and methotrexate IT on days 1, 29, and 36.
Patients with DS receive dexamethasone on days 1-7 and 15-21 and oral
leucovorin calcium at 48 and 60 hours after each dose of methotrexate IT.
- Arm III:
- Intensified consolidation therapy: Patients receive cyclophosphamide IV over
30 minutes on days 1 and 29; cytarabine IV or SC on days 1-4, 8-11, 29-32,
and 36-39; oral mercaptopurine on days 1-14 and 29-42; vincristine IV on days
15, 22, 43, and 50; pegaspargase IM on days 15 and 43; and methotrexate IT on
days 1, 8, 15*, and 22*. Patients with DS receive oral leucovorin calcium at
48 and 60 hours after each dose of methotrexate IT*.
NOTE: *Patients with CNS3 disease at diagnosis do not receive methotrexate on days 15 and 22
or leucovorin calcium
- Standard interim maintenance therapy: Patients receive standard interim maintenance
therapy as in group 1, arm I.
- Standard DI therapy: Patients receive standard DI therapy as in group 1, arm I.
- Arm IV:
- Intensified consolidation therapy: Patients receive intensified consolidation therapy
as in group 2, arm III.
- Augmented interim maintenance therapy: Patients receive augmented interim maintenance
therapy as in group 2, arm II.
- Augmented DI therapy: Patients receive augmented DI therapy as in group 2, arm II.
- Group 3 (SR-high ALL): Patients receive the following therapy:
- Intensified consolidation therapy: Patients receive intensified consolidation
therapy as in group 2, arm III.
- Augmented interim maintenance* therapy: Patients receive augmented interim
maintenance therapy as in group 2, arm II. Treatment repeats every 56 days
for 2 courses.
NOTE: *As of Amendment #7, all SR-High patients currently receiving AIM 1 therapy should
complete this phase of therapy and proceed to ADI 1 therapy as originally planned including
Capizzi methotrexate during AIM 1. Upon completion of ADI 1, patients should receive a
second Interim Maintenance phase with high-dose methotrexate (IM HD) rather than Capizzi
methotrexate. Patients should then proceed to ADI 2 and then Maintenance.
- Augmented DI* therapy: Patients receive augmented DI therapy as in group 2, arm II.
Treatment repeats every 56 days for 2 courses**.
NOTE: *As of Amendment #7, all SR-High patients currently receiving ADI 1 therapy should
complete this phase of therapy as originally planned. Upon completion of ADI 1, patients
should receive a second Interim Maintenance phase with IM HD. Patients should then proceed
to ADI 2 and then Maintenance.
NOTE: **Patients with CNS3 disease at diagnosis also undergo cranial radiotherapy on days
29-33 and 36-40 during course 2 only; these patients do not receive methotrexate on day 36,
thioguanine, or leucovorin calcium.
- Maintenance therapy: All patients receive vincristine IV on days 1, 29, and 57; oral
dexamethasone twice daily on days 1-5, 29-33, and 57-61; oral methotrexate on days 8,
15, 22, 29, 36, 43, 50, 57, 64, 71, and 78; oral mercaptopurine on days 1-84; and
methotrexate IT* on day 1. Courses repeat every 84 days for a total of 2 years from the
start of interim maintenance therapy for female patients and 3 years from the start of
interim maintenance therapy for male patients.
NOTE: *SR-High or CNS3 patients should receive up to a maximum of 23 intrathecal treatments
for females and 26 intrathecal treatments for males.
After the completion of study treatment, patients are followed every 1-2 months for 2 years,
every 3 months for 1 year, and then every 6-12 months for 2 years.
PROJECTED ACCRUAL: A total of 3,381 patients (1,576 for group 1,278 for group 2, and 527 for
group 3) will be accrued for this study within 4.25 years.
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Event-free survival (EFS) for SR-average
All power calculations are based on the assumption of proportional hazards, and using the log rank test (alpha = 0.05) with four planned analyses of the data for interim monitoring purposes. The 95% confidence interval for EFS for standard risk-high will also be computed
Up to 6 years
Kelly Maloney, MD
Children's Hospital Colorado Center for Cancer and Blood Disorders
United States: Federal Government
|Roswell Park Cancer Institute||Buffalo, New York 14263|
|Memorial Sloan-Kettering Cancer Center||New York, New York 10021|
|Children's Hospital of Philadelphia||Philadelphia, Pennsylvania 19104|
|Mayo Clinic Cancer Center||Rochester, Minnesota 55905|
|Cardinal Bernardin Cancer Center at Loyola University Medical Center||Maywood, Illinois 60153-5500|
|Walter Reed Army Medical Center||Washington, District of Columbia 20307-5000|
|University of Chicago Cancer Research Center||Chicago, Illinois 60637|
|Barbara Ann Karmanos Cancer Institute||Detroit, Michigan 48201|
|Duke Comprehensive Cancer Center||Durham, North Carolina 27710|
|Tripler Army Medical Center||Honolulu, Hawaii 96859-5000|
|Hurley Medical Center||Flint, Michigan 48503|
|Medical City Dallas Hospital||Dallas, Texas 75230|
|University of Texas Health Science Center at San Antonio||San Antonio, Texas 78284-7811|
|CCOP - Kalamazoo||Kalamazoo, Michigan 49007-3731|
|Presbyterian - St. Luke's Medical Center||Denver, Colorado 80218|
|Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center||Farmington, Connecticut 06360-2875|
|Baystate Regional Cancer Program at D'Amour Center for Cancer Care||Springfield, Massachusetts 01199|
|Van Elslander Cancer Center at St. John Hospital and Medical Center||Grosse Pointe Woods, Michigan 48236|
|CCOP - MeritCare Hospital||Fargo, North Dakota 58122|
|Natalie Warren Bryant Cancer Center at St. Francis Hospital||Tulsa, Oklahoma 74136|
|Sanford Cancer Center at Sanford USD Medical Center||Sioux Falls, South Dakota 57117-5039|
|Vanderbilt-Ingram Cancer Center||Nashville, Tennessee 37232-6838|
|University of Wisconsin Paul P. Carbone Comprehensive Cancer Center||Madison, Wisconsin 53792-6164|
|Marshfield Clinic - Marshfield Center||Marshfield, Wisconsin 54449|
|Newark Beth Israel Medical Center||Newark, New Jersey 07112|
|New York Medical College||Valhalla, New York 10595|
|Holden Comprehensive Cancer Center at University of Iowa||Iowa City, Iowa 52242-1002|
|UMASS Memorial Cancer Center - University Campus||Worcester, Massachusetts 01605-2982|
|Ellis Fischel Cancer Center at University of Missouri - Columbia||Columbia, Missouri 65203|
|Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center||Lebanon, New Hampshire 03756-0002|
|Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill||Chapel Hill, North Carolina 27599-7570|
|CCOP - Scott and White Hospital||Temple, Texas 76508|
|Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins||Baltimore, Maryland 21231-2410|
|Cancer Research Center of Hawaii||Honolulu, Hawaii 96813|
|Cleveland Clinic Taussig Cancer Center||Cleveland, Ohio 44195|
|Sutter Cancer Center||Sacramento, California 95816|
|Children's Hospital of Orange County||Orange, California 92668|
|Children's National Medical Center||Washington, District of Columbia 20010-2970|
|Children's Mercy Hospital||Kansas City, Missouri 64108|
|St. Joseph's Hospital and Medical Center||Paterson, New Jersey 07503|
|Children's Hospital and Regional Medical Center - Seattle||Seattle, Washington 98105|
|University of California Davis Cancer Center||Sacramento, California 95817|
|Nemours Children's Clinic||Jacksonville, Florida 32207|
|Miami Children's Hospital||Miami, Florida 33155-4069|
|All Children's Hospital||St. Petersburg, Florida 33701|
|Children's Memorial Hospital - Chicago||Chicago, Illinois 60614|
|Saint Jude Midwest Affiliate||Peoria, Illinois 61637|
|Children's Hospital of New Orleans||New Orleans, Louisiana 70118|
|Cardinal Glennon Children's Hospital||Saint Louis, Missouri 63104|
|Schneider Children's Hospital||New Hyde Park, New York 11042|
|St. Christopher's Hospital for Children||Philadelphia, Pennsylvania 19134-1095|
|Driscoll Children's Hospital||Corpus Christi, Texas 78466|
|Cook Children's Medical Center - Fort Worth||Fort Worth, Texas 76104|
|Inova Fairfax Hospital||Falls Church, Virginia 22042-3300|
|City of Hope Comprehensive Cancer Center||Duarte, California 91010|
|Fletcher Allen Health Care - University Health Center Campus||Burlington, Vermont 05401|
|Phoenix Children's Hospital||Phoenix, Arizona 85016-7710|
|Southern California Permanente Medical Group||Downey, California 90242|
|Children's Hospital Central California||Madera, California 93638-8762|
|Kosair Children's Hospital||Louisville, Kentucky 40202-3830|
|Palmetto Health South Carolina Cancer Center||Columbia, South Carolina 29203|
|East Tennessee Children's Hospital||Knoxville, Tennessee 37901|
|Covenant Children's Hospital||Lubbock, Texas 79410|
|Children's Hospital of the King's Daughters||Norfolk, Virginia 23507|
|Midwest Children's Cancer Center at Children's Hospital of Wisconsin||Milwaukee, Wisconsin 53226|
|Arizona Cancer Center at University of Arizona Health Sciences Center||Tucson, Arizona 85724|
|Arkansas Cancer Research Center at University of Arkansas for Medical Sciences||Little Rock, Arkansas 72205|
|Kansas Masonic Cancer Research Institute at the University of Kansas Medical Center||Kansas City, Kansas 66160-7353|
|Blumenthal Cancer Center at Carolinas Medical Center||Charlotte, North Carolina 28232-2861|
|Overlook Hospital||Summit, New Jersey 07902-0220|
|Winthrop University Hospital||Mineola, New York 11501|
|Loma Linda University Cancer Institute at Loma Linda University Medical Center||Loma Linda, California 92354|
|Jonathan Jaques Children's Cancer Center at Miller Children's Hospital||Long Beach, California 90801|
|Kaiser Permanente Medical Center - Oakland||Sacramento, California 95825|
|Santa Barbara Cottage Children's Hospital||Santa Barbara, California 93105|
|Yale Cancer Center||New Haven, Connecticut 06520-8028|
|Lee Cancer Care of Lee Memorial Health System||Fort Myers, Florida 33901|
|Broward General Medical Center Cancer Center||Ft. Lauderdale, Florida 33316|
|University of Florida Shands Cancer Center||Gainesville, Florida 32610-0232|
|Baptist-South Miami Regional Cancer Program||Miami, Florida 33176|
|Nemours Children's Clinic - Orlando||Orlando, Florida 32806|
|Florida Hospital Cancer Institute at Florida Hospital Orlando||Orlando, Florida 32803-1273|
|Sacred Heart Cancer Center at Sacred Heart Hospital||Pensacola, Florida 32504|
|St. Joseph's Cancer Institute at St. Joseph's Hospital||Tampa, Florida 33607|
|Kaplan Cancer Center at St. Mary's Medical Center||West Palm Beach, Florida 33407|
|Winship Cancer Institute of Emory University||Atlanta, Georgia 30322|
|St. Vincent Indianapolis Hospital||Indianapolis, Indiana 46260|
|Blank Children's Hospital||Des Moines, Iowa 50309|
|Alvin and Lois Lapidus Cancer Institute at Sinai Hospital||Baltimore, Maryland 21215|
|Floating Hospital for Children at Tufts - New England Medical Center||Boston, Massachusetts 02111|
|Breslin Cancer Center at Ingham Regional Medical Center||Lansing, Michigan 48910|
|Hackensack University Medical Center Cancer Center||Hackensack, New Jersey 07601|
|Albert Einstein Cancer Center at Albert Einstein College of Medicine||Bronx, New York 10461|
|NYU Cancer Institute at New York University Medical Center||New York, New York 10016|
|Mount Sinai Medical Center||New York, New York 10029|
|Stony Brook University Cancer Center||Stony Brook, New York 11794-8174|
|SUNY Upstate Medical University Hospital||Syracuse, New York 13210|
|Mission Hospitals - Memorial Campus||Asheville, North Carolina 28801|
|Presbyterian Cancer Center at Presbyterian Hospital||Charlotte, North Carolina 28233-3549|
|Wake Forest University Comprehensive Cancer Center||Winston-Salem, North Carolina 27157-1096|
|Cincinnati Children's Hospital Medical Center||Cincinnati, Ohio 45229-3039|
|Rainbow Babies and Children's Hospital||Cleveland, Ohio 44106-5000|
|Medical University of Ohio Cancer Center||Toledo, Ohio 43614|
|Toledo Hospital||Toledo, Ohio 43606|
|Rhode Island Hospital Comprehensive Cancer Center||Providence, Rhode Island 02903|
|Hollings Cancer Center at Medical University of South Carolina||Charleston, South Carolina 29425|
|Texas Tech University Health Sciences Center School of Medicine - Amarillo||Amarillo, Texas 79106|
|Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center - Dallas||Dallas, Texas 75390|
|Baylor University Medical Center - Houston||Houston, Texas 77030-2399|
|Methodist Children's Hospital of South Texas||San Antonio, Texas 78229-3993|
|Primary Children's Medical Center||Salt Lake City, Utah 84113-1100|
|Naval Medical Center - Portsmouth||Portsmouth, Virginia 23708-2197|
|Providence Cancer Center at Sacred Heart Medical Center||Spokane, Washington 99220-2555|
|St. Vincent Hospital Regional Cancer Center||Green Bay, Wisconsin 54307-3508|
|Saint Peter's University Hospital||New Brunswick, New Jersey 08901-1780|
|William Beaumont Hospital - Royal Oak Campus||Royal Oak, Michigan 48073|
|Greenebaum Cancer Center at University of Maryland Medical Center||Baltimore, Maryland 21201|
|UNMC Eppley Cancer Center at the University of Nebraska Medical Center||Omaha, Nebraska 68198-7680|
|Memorial Cancer Institute at Memorial Regional Hospital||Hollywood, Florida 33021|
|New York Weill Cornell Cancer Center at Cornell University||New York, New York 10021|
|University of South Alabama Mitchell Cancer Institute||Mobile, Alabama 36604|
|Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center||Los Angeles, California 90048-1865|
|Jonsson Comprehensive Cancer Center at UCLA||Los Angeles, California 90095-1781|
|Childrens Hospital Los Angeles||Los Angeles, California 90027|
|Children's Hospital and Research Center Oakland||Oakland, California 94609|
|Rady Children's Hospital - San Diego||San Diego, California 92123-4282|
|UCSF Helen Diller Family Comprehensive Cancer Center||San Francisco, California 94115|
|Children's Hospital Center for Cancer and Blood Disorders||Aurora, Colorado 80045|
|Alfred I. duPont Hospital for Children||Wilmington, Delaware 19803|
|Lombardi Comprehensive Cancer Center at Georgetown University Medical Center||Washington, District of Columbia 20007|
|M.D. Anderson Cancer Center at Orlando||Orlando, Florida 32806|
|Curtis and Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center||Savannah, Georgia 31403-3089|
|Mountain States Tumor Institute at St. Luke's Regional Medical Center||Boise, Idaho 83712-6297|
|University of Illinois Cancer Center||Chicago, Illinois 60612-7243|
|Keyser Family Cancer Center at Advocate Hope Children's Hospital||Oak Lawn, Illinois 60453|
|Advocate Lutheran General Cancer Care Center||Park Ridge, Illinois 60068-1174|
|Simmons Cooper Cancer Institute||Springfield, Illinois 62794-9677|
|Indiana University Melvin and Bren Simon Cancer Center||Indianapolis, Indiana 46202-5289|
|Lucille P. Markey Cancer Center at University of Kentucky||Lexington, Kentucky 40536-0093|
|Tulane Cancer Center Office of Clinical Research||Alexandria, Louisiana 71315-3198|
|CancerCare of Maine at Eastern Maine Medical Center||Bangor, Maine 04401|
|Maine Children's Cancer Program at Barbara Bush Children's Hospital||Scarborough, Maine 04074-9308|
|C.S. Mott Children's Hospital at University of Michigan Medical Center||Ann Arbor, Michigan 48109-0286|
|Butterworth Hospital at Spectrum Health||Grand Rapids, Michigan 49503-2560|
|Masonic Cancer Center at University of Minnesota||Minneapolis, Minnesota 55455|
|Children's Hospitals and Clinics of Minnesota - Minneapolis||Minneapolis, Minnesota 55404|
|University of Mississippi Cancer Clinic||Jackson, Mississippi 39216-4505|
|Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis||St. Louis, Missouri 63110|
|Children's Hospital||Omaha, Nebraska 68114-4113|
|CCOP - Nevada Cancer Research Foundation||Las Vegas, Nevada 89109-2306|
|Cancer Institute of New Jersey at UMDNJ - Robert Wood Johnson Medical School||New Brunswick, New Jersey 08903|
|University of New Mexico Cancer Center||Albuquerque, New Mexico 87131-5636|
|Albany Medical Center Hospital||Albany, New York 12208-3419|
|Akron Children's Hospital||Akron, Ohio 44308-1062|
|Nationwide Children's Hospital||Columbus, Ohio 43205-2696|
|Dayton Children's - Dayton||Dayton, Ohio 45404-1815|
|Oklahoma University Cancer Institute||Oklahoma City, Oklahoma 73104|
|Knight Cancer Institute at Oregon Health and Science University||Portland, Oregon 97239-3098|
|Legacy Emanuel Hospital and Health Center and Children's Hospital||Portland, Oregon 97227|
|Geisinger Cancer Institute at Geisinger Health||Danville, Pennsylvania 17822-0001|
|Children's Hospital of Pittsburgh of UPMC||Pittsburgh, Pennsylvania 15213|
|Dell Children's Medical Center of Central Texas||Austin, Texas 78723|
|M. D. Anderson Cancer Center at University of Texas||Houston, Texas 77030-4009|
|Virginia Commonwealth University Massey Cancer Center||Richmond, Virginia 23298-0037|
|Carilion Medical Center for Children at Roanoke Community Hospital||Roanoke, Virginia 24014|
|Madigan Army Medical Center - Tacoma||Tacoma, Washington 98431|
|Mary Bridge Children's Hospital and Health Center - Tacoma||Tacoma, Washington 98405|
|West Virginia University Health Sciences Center - Charleston||Charleston, West Virginia 25302|
|University of Virginia Cancer Center||Charlottesville, Virginia 22908|
|Massachusetts General Hospital||Boston, Massachusetts 02114-2617|
|UAB Comprehensive Cancer Center||Birmingham, Alabama 35294|
|Stanford Cancer Center||Stanford, California 94305-5824|
|University of Miami Sylvester Comprehensive Cancer Center - Miami||Miami, Florida 33136|
|Leo W. Jenkins Cancer Center at ECU Medical School||Greenville, North Carolina 27834|
|Lehigh Valley Hospital - Muhlenberg||Bethlehem, Pennsylvania 18017|
|Penn State Hershey Cancer Institute at Milton S. Hershey Medical Center||Hershey, Pennsylvania 17033-0850|
|Greenville Hospital Cancer Center||Greenville, South Carolina 29605|
|T.C. Thompson Children's Hospital||Chattanooga, Tennessee 37403|
|Banner Desert Medical Center||Mesa, Arizona 85202|