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A Genetic Risk-Stratified, Randomized Phase II Study of Four Fludarabine/Antibody Combinations for Patients With Symptomatic, Previously Untreated Chronic Lymphocytic Leukemia


Phase 2
18 Years
N/A
Open (Enrolling)
Both
B-cell Chronic Lymphocytic Leukemia, Stage I Chronic Lymphocytic Leukemia, Stage II Chronic Lymphocytic Leukemia, Stage III Chronic Lymphocytic Leukemia, Stage IV Chronic Lymphocytic Leukemia

Thank you

Trial Information

A Genetic Risk-Stratified, Randomized Phase II Study of Four Fludarabine/Antibody Combinations for Patients With Symptomatic, Previously Untreated Chronic Lymphocytic Leukemia


PRIMARY OBJECTIVES:

I. To determine the two-year progression-free survival (PFS) after remission induction (RI)
with four different chemo-immunotherapy combinations for patients with untreated,
symptomatic, lower-risk and high-risk chronic lymphocytic leukemia (CLL) to decide which of
the four arms, if any, to take forward into a randomized phase III trial.

SECONDARY OBJECTIVES:

I. To determine the induction response to fludarabine phosphate and rituximab (FR) and
fludarabine phosphate, cyclophosphamide, and rituximab (FCR) in each of these arms, along
with the consolidation response to lenalidomide in patients with CLL.

II. To determine the toxicity from these four chemoimmunotherapy combinations and that of
consolidation therapy with lenalidomide.

III. To determine the induction response and toxicity of FCR in patients with del (11q22.3)
along with consolidation response, 2-year PFS and toxicity of lenalidomide in this specific
genetic group.

IV. To determine the effect of pretreatment biologic characteristics on clinical outcomes,
such as attaining a complete response to induction therapy and progression-free survival.

V. To collect relapse samples to determine the frequency of clonal evolution among patients
with IgVH mutated and unmutated disease and to study mechanisms of resistance to
chemoimmunotherapy.

VI. To determine if flow cytometry-negative status immediately post-therapy and at 24 months
after study entry is an effective surrogate marker for prolonged progression-free survival
and overall survival.

OUTLINE: This is a multicenter study. Patients are stratified according to risk group
(intermediate vs high). Patients are randomized to 1 of 3 treatment arms or assigned to arm
IV if found to be del (11q22.3) positive.

ARM I (remission-induction [RI] therapy with fludarabine and rituximab): Patients receive
rituximab IV on days 1, 3, and 5 of course 1 and on day 1 of all subsequent courses.
Patients also receive fludarabine phosphate IV over 30 minutes or orally on days 1-5.

Treatment repeats every 28 days for up to 6 courses in the absence of disease progression.

ARM II (RI therapy with fludarabine and rituximab followed by remission-consolidation [RC]
therapy with lenalidomide): Patients undergo RI therapy as in arm I. Patients with a
complete or partial response or stable disease proceed to RC therapy beginning approximately
4 months after completion of RI, comprising oral lenalidomide once daily on days 1-21.

Treatment repeats every 28 days for 3-6 courses in the absence of disease progression.

ARM III (RI therapy with fludarabine phosphate, rituximab, and cyclophosphamide): Patients
receive rituximab IV on days 1 and 3 of course 1 and on day 1 of all subsequent courses.
Patients also receive fludarabine phosphate IV over 30 minutes or orally followed by
cyclophosphamide IV over 30 minutes on days 1-3.

Treatment repeats every 28 days for up to 6 courses in the absence of disease progression.

ARM IV [del(11q22.3)-positive] (RI therapy with fludarabine, rituximab, and cyclophosphamide
followed by RC therapy with lenalidomide): Patients undergo the first course of RI therapy
as in arm I or II, followed by rituximab IV on day 1 of all subsequent courses, and
fludarabine IV over 30 minutes and cyclophosphamide IV over 30 minutes on days 1-3.

Treatment repeats every 28 days for up to 6 courses in the absence of disease progression.
Beginning approximately 4 months after completion of RI therapy, patients receive RC therapy
comprising oral lenalidomide as in arm II. Patients undergo bone marrow aspirate and blood
sample collection at baseline; 3 months after completion of RI therapy; 2 months after
completion of lenalidomide consolidation therapy (arm II and IV only); 2 years after study
enrollment; and then at the time of relapse.

Samples are assessed for interphase cytogenetic abnormalities; clonal evolution; IgV_H gene
mutational status; CD38, CD49d, and ZAP-70 expression; p53 dysfunction, gene expression
profile, and epigenetic changes in methylation. Samples are also assessed for flow cytometry
negativity status. Studies include fluorescence in situ hybridization, chromosomal
translocation, flow cytometry, and cytogenetics.

After completion of study therapy, patients are followed every 3 months for 1 year and then
every 6 months for up to 15 years.


Inclusion Criteria:



- Diagnosis of B-cell chronic lymphocytic leukemia (CLL) meeting the following
criteria:

- Absolute lymphocytosis > 5,000/μL

- Lymphocytes must appear mature with < 55% prolymphocytes

- Bone marrow aspirate smear must show > 30% of all nucleated cells as being
lymphoid OR bone marrow core biopsy must show lymphoid infiltrates compatible
with marrow involvement by CLL

- Overall cellularity must be normocellular or hypercellular

- Lymphocyte phenotype must reveal predominant B-cell monoclonal population
sharing a B-cell marker (i.e., CD19, CD20, or CD23) with the CD5 antigen, in the
absence of other pan-T-cell markers

- B-cells must be monoclonal with regard to expression of either kappa or
lambda light chains and have surface immunoglobulin expression of low
density

- Patients with bright surface immunoglobulin levels must have CD23
co-expression

- Must have symptomatic, active disease and meet 1 of the following risk criteria
according to the modified three-stage Rai staging system:

- Intermediate-risk disease (i.e., Rai stage I or II) with evidence of active
disease as demonstrated by at least one of the following criteria:

- Massive or progressive splenomegaly, hepatomegaly, and/or lymphadenopathy

- Presence of weight loss > 10% within the past 6 months

- Grade 2 or 3 fatigue

- Fevers > 100.5° F or night sweats for > 2 weeks without evidence of
infection

- Progressive lymphocytosis with an increase of > 50% over a 2-monthperiod or
an anticipated doubling time of < 6 months

- High-risk disease (i.e., Rai stage III or IV)

- Concurrent participation on CALGB-20702 (Leukemia Correlative Studies) required

- Performance status 0-2

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use two effective methods of contraception for ≥ 4 weeks prior
to, during, and for ≥ 4 weeks after completion of lenalidomide therapy (for patients
randomized to arm II or IV)

- Creatinine ≤ 1.5 times upper limit of normal

- No medical condition requiring chronic use of oral corticosteroids

- Patients with HIV infection may be eligible provided they meet the following
criteria:

- CD4-positive cell count > 350/mm³

- HIV viral load< 10,000 copies HIV RNA/mL (if not on anti-HIV therapy) OR < 50
copies HIV RNA/mL (if on anti-HIV therapy)

- No evidence of hepatitis B or C infection

- No evidence of resistant strains of HIV

- No history of AIDS-defining condition

- No prior therapy for CLL, including corticosteroids for autoimmune complications that
have developed since the initial diagnosis of CLL

- No concurrent zidovudine or stavudine

- No concurrent hormones or other chemotherapy, except steroids for hypersensitivity
reactions or new adrenal failure or hormones for non-disease-related conditions
(e.g., insulin for diabetes)

- No concurrent chronic oral steroids

- No concurrent palliative radiotherapy

- No concurrent epoetin alfa or darbepoetin alfa during remission consolidation therapy
(for patients randomized to arm II or IV)

- Concurrent participation on CALGB-9665 allowed

Type of Study:

Interventional

Study Design:

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

PFS rate

Outcome Description:

Rates within arm will be estimated with their exact 90% confidence intervals. The chi-square test will be used to test whether the 2-year PFS of Arm B is significantly better than that of Arm A, and, secondarily, the log-rank test will be used to test for arm differences in time-to-progression.

Outcome Time Frame:

Interval between randomization and progression or death, whichever comes first, assessed up to 2 years

Safety Issue:

No

Principal Investigator

John Byrd

Investigator Role:

Principal Investigator

Investigator Affiliation:

Cancer and Leukemia Group B

Authority:

United States: Food and Drug Administration

Study ID:

NCI-2009-00441

NCT ID:

NCT00602459

Start Date:

January 2008

Completion Date:

Related Keywords:

  • B-cell Chronic Lymphocytic Leukemia
  • Stage I Chronic Lymphocytic Leukemia
  • Stage II Chronic Lymphocytic Leukemia
  • Stage III Chronic Lymphocytic Leukemia
  • Stage IV Chronic Lymphocytic Leukemia
  • Leukemia
  • Leukemia, Lymphocytic, Chronic, B-Cell
  • Leukemia, Lymphoid

Name

Location

Albert Einstein College of MedicineBronx, New York  10461
Cleveland Clinic FoundationCleveland, Ohio  44195
University of Iowa Hospitals and ClinicsIowa City, Iowa  52242
Washington University School of MedicineSaint Louis, Missouri  63110
Fox Chase Cancer CenterPhiladelphia, Pennsylvania  19111
Medical University of South CarolinaCharleston, South Carolina  29425-0721
Bronson Methodist HospitalKalamazoo, Michigan  49007
West Michigan Cancer CenterKalamazoo, Michigan  49007-3731
Borgess Medical CenterKalamazooaa, Michigan  49001
Fairview Ridges HospitalBurnsville, Minnesota  55337
Hutchinson Area Health CareHutchinson, Minnesota  55350
United HospitalSt. Paul, Minnesota  55102
Ridgeview Medical CenterWaconia, Minnesota  55387
Geisinger Medical CenterDanville, Pennsylvania  17822-0001
Loyola University Medical CenterMaywood, Illinois  60153
Henry Ford HospitalDetroit, Michigan  48202
Marshfield ClinicMarshfield, Wisconsin  54449
Methodist Medical Center of IllinoisPeoria, Illinois  61636
Memorial Hospital of South BendSouth Bend, Indiana  46601
Waukesha Memorial HospitalWaukesha, Wisconsin  53188
North Shore University HospitalManhasset, New York  11030
Hartford HospitalHartford, Connecticut  06102-5037
Eastern Maine Medical CenterBangor, Maine  04401
Cancer Institute of New JerseyNew Brunswick, New Jersey  08901
University of Nebraska Medical CenterOmaha, Nebraska  68198-3330
Wesley Medical CenterWichita, Kansas  67214
Carolinas Medical CenterCharlotte, North Carolina  28232-2861
Iowa Methodist Medical CenterDes Moines, Iowa  50309
Iowa Lutheran HospitalDes Moines, Iowa  50316-2301
Weill Medical College of Cornell UniversityNew York, New York  10021
University of Wisconsin Hospital and ClinicsMadison, Wisconsin  53792-0001
Great Falls ClinicGreat Falls, Montana  59405
Thompson Cancer Survival CenterKnoxville, Tennessee  37916
MetroHealth Medical CenterCleveland, Ohio  44109
Long Island Jewish Medical CenterNew Hyde Park, New York  11040
Mount Sinai Medical CenterNew York, New York  10029
Montefiore Medical CenterBronx, New York  10467-2490
Lewistown HospitalLewistown, Pennsylvania  17044
Mount Nittany Medical CenterState College, Pennsylvania  16803
Munson Medical CenterTraverse City, Michigan  49684
Kalispell Regional Medical CenterKalispell, Montana  59901
Adena Regional Medical CenterChillicothe, Ohio  54601
Grady Memorial HospitalDelaware, Ohio  43015
Fairfield Medical CenterLancaster, Ohio  43130
Welch Cancer CenterSheridan, Wyoming  82801
University of New Mexico Cancer CenterAlbuquerque, New Mexico  87131-5636
Cancer Centers of the CarolinasGreenville, South Carolina  29605
Baylor University Medical CenterDallas, Texas  75246
Paoli Memorial HospitalPaoli, Pennsylvania  19301-1792
Elkhart General HospitalElkhart, Indiana  46515
South Bend ClinicSouth Bend, Indiana  46617
Arthur G. James Cancer Hospital and Solove Research Institute at Ohio State University Medical CenterColumbus, Ohio  43210-1240
University Medical Center of Southern NevadaLas Vegas, Nevada  89102
Beebe Medical CenterLewes, Delaware  19958
Memorial HospitalCarthage, Illinois  62321
Hematology and Oncology AssociatesChicago, Illinois  60611
Galesburg Cottage HospitalGalesburg, Illinois  61401
Galesburg ClinicGalesburg, Illinois  61401
Mason District HospitalHavana, Illinois  62644
McDonough District HospitalMacomb, Illinois  61455
BroMenn Regional Medical CenterNormal, Illinois  61761
Proctor HospitalPeoria, Illinois  61614
Perry Memorial HospitalPrinceton, Illinois  61356
Salina Regional Health CenterSalina, Kansas  67401
Saint Francis Medical CenterCape Girardeau, Missouri  63701
Iredell Memorial HospitalStatesville, North Carolina  28677
Grandview HospitalDayton, Ohio  45405
Bryn Mawr HospitalBryn Mawr, Pennsylvania  19010
Mountainview MedicalBerlin, Vermont  05602
Danville Regional Medical CenterDanville, Virginia  24541
Eureka HospitalEureka, Illinois  61530
Mercy HospitalCoon Rapids, Minnesota  55433
Graham Hospital AssociationCanton, Illinois  61520
Hematology Oncology Associates of Illinois-Highland ParkHighland Park, Illinois  60035
Saint Joseph Medical CenterJoliet, Illinois  60435
Pekin HospitalPekin, Illinois  61554
Medical Oncology and Hematology AssociatesDes Moines, Iowa  50309
Ottumwa Regional Health CenterOttumwa, Iowa  52501
Fairview-Southdale HospitalEdina, Minnesota  55435
Abbott-Northwestern HospitalMinneapolis, Minnesota  55407
Regions HospitalSaint Paul, Minnesota  55101
Saint Francis Regional Medical CenterShakopee, Minnesota  55379
Rice Memorial HospitalWillmar, Minnesota  56201
Geisinger Medical GroupState College, Pennsylvania  16801
Swedish American HospitalRockford, Illinois  61104
Center for Cancer Care and ResearchSt. Louis, Missouri  63141
Miami Valley HospitalDayton, Ohio  45409
Lawrence Memorial HospitalLawrence, Kansas  66044
Menorah Medical CenterOverland Park, Kansas  66209
Shawnee Mission Medical CenterShawnee Mission, Kansas  66204
North Kansas City HospitalKansas City, Missouri  64116
Research Medical CenterKansas City, Missouri  64132
Saint Luke's East - Lee's SummitLee's Summit, Missouri  64086
Heartland Regional Medical CenterSaint Joseph, Missouri  64506
Bozeman Deaconess Cancer CenterBozeman, Montana  59715
Mary Rutan HospitalBellefontaine, Ohio  43311
Wayne HospitalGreenville, Ohio  45331
Knox Community HospitalMount Vernon, Ohio  43050
Marshfield Clinic Cancer Care at Regional Cancer CenterEau Claire, Wisconsin  54701
UW Cancer Center Johnson CreekJohnson Creek, Wisconsin  53038
Saint Joseph's HospitalMarshfield, Wisconsin  54449
Marshfield Clinic - Weston CenterWeston, Wisconsin  54476
Diagnostic and Treatment CenterWeston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids CenterWisconsin Rapids, Wisconsin  54494
Rocky Mountain OncologyCasper, Wyoming  82609
Greene Memorial HospitalXenia, Ohio  45385
Easton HospitalEaston, Pennsylvania  18042
Harold Alfond Center for Cancer CareAugusta, Maine  04330
Union Hospital of Cecil CountyElkton MD, Maryland  21921
Cancer Centers of the Carolinas - Grove CommonsGreenville, South Carolina  29605
Cancer Centers of the Carolinas - SenecaSeneca, South Carolina  29672
Cancer Centers of the Carolinas - SpartanburgSpartanburg, South Carolina  29307
Memorial Medical CenterSpringfield, Illinois  62781
McLeod Regional Medical CenterFlorence, South Carolina  29501
Vanderbilt UniversityNashville, Tennessee  37232-6305
University of North CarolinaChapel Hill, North Carolina  27599
Providence Medical CenterKansas City, Kansas  66112
Northwestern UniversityChicago, Illinois  60611
Hennepin County Medical CenterMinneapolis, Minnesota  
Saint Louis University HospitalSt. Louis, Missouri  63110-0250
University of RochesterRochester, New York  14642
Case Western Reserve UniversityCleveland, Ohio  44106
New Hampshire Oncology-Hematology PAHooksett, New Hampshire  03106
Riverside Methodist HospitalColumbus, Ohio  43214
Licking Memorial HospitalNewark, Ohio  43055-2899
Dartmouth Hitchcock Medical CenterLebanon, New Hampshire  03756
Columbus CCOPColumbus, Ohio  43206
Weiss Memorial HospitalChicago,, Illinois  60640
University Of VermontBurlington,, Vermont  05403
Montana Cancer Consortium CCOPBillings, Montana  59101
Metro-Minnesota CCOPSt. Louis Park, Minnesota  
Cancer Centers of the Carolinas - EasleyEasley, South Carolina  29640
Lakeview HospitalStillwater, Minnesota  55082
Decatur Memorial HospitalDecatur, Illinois  62526
Virginia Commonwealth UniversityRichmond, Virginia  
Lankenau HospitalWynnewood, Pennsylvania  19096
Montana Cancer SpecialistsMissoula, Montana  59807-7877
University of Chicago Comprehensive Cancer CenterChicago, Illinois  60637-1470
Northern Indiana Cancer Research ConsortiumSouth Bend, Indiana  
Norwalk HospitalNorwalk, Connecticut  06856
Penn State Milton S Hershey Medical CenterHershey, Pennsylvania  17033
Hays Medical CenterHays, Kansas  67601
Wake Forest University Health SciencesWinston-Salem, North Carolina  27157
OSF Saint Francis Medical CenterPeoria, Illinois  61637
Palo Alto Medical Foundation-Camino DivisionMountain View, California  94040
Palo Alto Medical Foundation Heath CarePalo Alto, California  94301
Saint Francis Hospital and Medical CenterHartford, Connecticut  06105
Lombardi Comprehensive Cancer Center at Georgetown UniversityWashington, District of Columbia  20057
M D Anderson Cancer Center- OrlandoOrlando, Florida  32806
Saint Anthony's HealthAlton, Illinois  62002
Cancer Institute at Alexian BrothersElk Grove Village, Illinois  60007
Evanston CCOP-NorthShore University HealthSystemEvanston, Illinois  60201
Hopedale Medical Complex - HospitalHopedale, Illinois  61747
Joliet Oncology-Hematology Associates LimitedJoliet, Illinois  60435
Midwest Center for Hematology OncologyJoliet, Illinois  60432
Provena Saint Mary's HospitalKankakee, Illinois  60901
North Shore Hematology OncologyLibertyville, Illinois  60048
Good Samaritan Regional Medical CenterMt. Vernon, Illinois  62864
Community Cancer Center FoundationNormal, Illinois  61761
Illinois CancerCare-Ottawa ClinicOttawa, Illinois  61350
Ottawa Regional Hospital and Healthcare CenterOttawa, Illinois  61350
Pekin Cancer Treatment CenterPekin, Illinois  61554
Illinois Oncology Research Association CCOPPeoria, Illinois  61615
Illinois CancerCare-PeoriaPeoria, Illinois  61615
Illinois Valley HospitalPeru, Illinois  61354
Hematology Oncology Associates of Illinois - SkokieSkokie, Illinois  60076
Saint Margaret's HospitalSpring Valley, Illinois  61362
Carle Clinic-Urbana MainUrbana, Illinois  61801
Saint Francis Hospital and Health CentersBeech Grove, Indiana  46107
Fort Wayne Medical Oncology and Hematology Inc - State BoulevardFort Wayne, Indiana  46845
Reid Hospital and Health Care ServicesRichmond, Indiana  47374
McFarland ClinicAmes, Iowa  50010
Medical Oncology and Hematology Associates-West Des MoinesClive, Iowa  50325
Iowa Oncology Research Association CCOPDes Moines, Iowa  50309
Mercy Medical Center - Des MoinesDes Moines, Iowa  50314
Medical Oncology and Hematology Associates-Des MoinesDes Moines, Iowa  50309
Mercy Medical Center-Sioux CitySioux City, Iowa  51104
Saint Luke's Regional Medical CenterSioux City, Iowa  51104
Saint Francis Hospital and Medical Center - TopekaTopeka, Kansas  66606
Grand Rapids Clinical Oncology ProgramGrand Rapids, Michigan  49503
Lakeland HospitalSt. Joseph, Michigan  49085
Unity HospitalFridley, Minnesota  55432
Saint John's Hospital - HealtheastMaplewood, Minnesota  55109
Minnesota Oncology Hematology PA-MaplewoodMaplewood, Minnesota  55109
Minneapolis Veterans Medical CenterMinneapolis, Minnesota  55417
North Memorial Medical Health CenterRobbinsdale, Minnesota  55422
Park Nicollet Clinic - Saint Louis ParkSaint Louis Park, Minnesota  55416
Minnesota Oncology and Hematology PA-WoodburyWoodbury, Minnesota  55125
Saint Luke's Hospital of Kansas CityKansas City, Missouri  64111
Saint Joseph Health CenterKansas City, Missouri  64114
Liberty Radiation Oncology ClinicKansas City, Missouri  64116
Truman Medical CenterKansas City, Missouri  64108
Saint Louis-Cape Girardeau CCOPSaint Louis, Missouri  63141
Saint John's Mercy Medical CenterSaint Louis, Missouri  63141
Saint John's HospitalSpringfield, Missouri  65804
Hematology-Oncology Centers of the Northern Rockies PCBillings, Montana  59101
Saint Vincent HealthcareBillings, Montana  59101
Billings ClinicBillings, Montana  59107-7000
Benefis Healthcare- Sletten Cancer InstituteGreat Falls, Montana  59405
Saint Peter's Community HospitalHelena, Montana  59601
Glacier Oncology PLLCKalispell, Montana  59901
Saint Patrick Hospital - Community HospitalMissoula, Montana  59802
Nevada Cancer Research Foundation CCOPLas Vegas, Nevada  89106
New Hampshire Oncology Hematology AssociatesHooksett, New Hampshire  03106
LRGHealthcare-Lakes Region General HospitalLaconia, New Hampshire  03246
Cooper Hospital University Medical CenterCamden, New Jersey  08103
Veterans Adminstration New Jersey Health Care SystemEast Orange, New Jersey  07018-1095
Fox Chase Cancer Center at Virtua Memorial Hospital of Burlington CountyMount Holly, New Jersey  08060
Memorial Medical Center - Las CrucesLas Cruces, New Mexico  88011
New York University Langone Medical CenterNew York, New York  10016
State University of New York Upstate Medical UniversitySyracuse, New York  13210
Mission Hospitals IncAsheville, North Carolina  28801
Wayne Memorial HospitalGoldsboro, North Carolina  27534
Margaret R Pardee Memorial HospitalHendersonville, North Carolina  28791
Kinston Medical Specialists PAKinston, North Carolina  28501
Aultman Health FoundationCanton, Ohio  44710
Doctors HospitalColumbus, Ohio  43228
Grant Medical CenterColumbus, Ohio  43215
Mount Carmel Health Center WestColumbus, Ohio  43222
Good Samaritan Hospital - DaytonDayton, Ohio  45406
Dayton CCOPDayton, Ohio  45429
Samaritan North Health CenterDayton, Ohio  45415
Blanchard Valley HospitalFindlay, Ohio  45840
Atrium Medical Center-Middletown Regional HospitalFranklin, Ohio  45005-1066
Kettering Medical CenterKettering, Ohio  45429
Marietta Memorial HospitalMarietta, Ohio  45750
Upper Valley Medical CenterTroy, Ohio  45373
Saint Ann's HospitalWesterville, Ohio  43081
Genesis HealthCare SystemZanesville, Ohio  43701
Pottstown Memorial Medical CenterPottstown, Pennsylvania  19464
Geisinger Wyoming ValleyWilkes-Barre, Pennsylvania  18711
Mainline Health CCOPWynnewood, Pennsylvania  19096
Greenville CCOPGreenville, South Carolina  29615
Greenville Memorial HospitalGreenville, South Carolina  29605
West Virginia UniversityMorgantown, West Virginia  26506
Sacred Heart HospitalEau Claire, Wisconsin  54701
Saint Vincent HospitalGreen Bay, Wisconsin  54301
Saint Mary's HospitalGreen Bay, Wisconsin  54303
Bay Area Medical CenterMarinette, Wisconsin  54143
Marshfield Clinic-Minocqua CenterMinocqua, Wisconsin  54548
Oconomowoc Memorial Hospital-ProHealth Care IncOconomowoc, Wisconsin  53066-3896
Marshfield Clinic at James Beck Cancer CenterRhinelander, Wisconsin  54501
Marshfield Clinic-Rice Lake CenterRice Lake, Wisconsin  54868
Saint Michael's HospitalStevens Point, Wisconsin  54481
University of Maryland Greenebaum Cancer CenterBaltimore, Maryland  21201
Olathe Cancer CenterOlathe, Kansas  66061
Jupiter Medical CenterJupiter, Florida  33458
Stony Brook University Medical CenterStony Brook, New York  11794
Lahey Clinic Medical CenterBurlington, Massachusetts  01805
Elkhart ClinicElkhart, Indiana  46515
Mount Sinai Medical Center CCOPMiami Beach, Florida  33140
Illinois CancerCare-BloomingtonBloomington%, Illinois  61701
Illinois CancerCare-CantonCanton, Illinois  61520
Illinois CancerCare-EurekaEureka, Illinois  61530
Illinois CancerCare-MacombMacomb, Illinois  61455
Illinois CancerCare-Community Cancer CenterNormal, Illinois  61761
Illinois CancerCare-PekinPekin, Illinois  61603
Illinois CancerCare-PeruPeru, Illinois  61354
Illinois CancerCare-Spring ValleySpring Valley, Illinois  61362
Michiana Hematology Oncology PC-ElkhartElkhart, Indiana  46514
Michiana Hematology Oncology PC-PlymouthPlymouth, Indiana  46563
Michiana Hematology Oncology PC-South BendSouth Bend, Indiana  46601
Michiana Hematology Oncology-PC WestvilleWestville, Indiana  46391
Michiana Hematology Oncology PC-NilesNiles, Michigan  49120
University of Missouri - Ellis FischelColumbia, Missouri  65203
East Carolina UniversityGreenville, North Carolina  27858
Cancer Centers of the Carolinas - FarisGreenville, South Carolina  29605
Cancer Centers of the Carolinas-Greer Radiation OncologyGreer, South Carolina  29650
Cancer Centers of the Carolinas-Greer Medical OncologyGreer, South Carolina  29650
Marshfield Clinic-Chippewa CenterChippewa Falls, Wisconsin  54729
Holy Family Memorial HospitalManitowoc, Wisconsin  54221
Marshfield Clinic Cancer Care at Saint Michael's HospitalStevens Point, Wisconsin  54481
Monter Cancer CenterLake Success, New York  11042
Palchak David MDPismo Beach, California  93449
Central DuPage Hospital Cancer CenterWarrenville, Illinois  60555
Saint Luke's South HospitalOverland Park, Kansas  66213
Kansas City CCOPPrairie Village, Kansas  66208
Doctors Carrol, Sheth, RaghavanLouisville, Kentucky  40215
Heartland Hematology and Oncology Associates IncorporatedKansas City, Missouri  64118
Saint Joseph Oncology IncSaint Joseph, Missouri  64507
Memorial Hospital Of MartinsvilleMartinsville, Virginia  24115
Gundersen LutheranLa Crosse, Wisconsin  54601
Saint Nicholas HospitalMadison, Wisconsin  53715
Siouxland Hematology Oncology AssociatesSioux City, Iowa  51101
Walter Reed National Military Medical CenterBethesda, Maryland  20889
VA Medical Center - University of IowaIowa City, Iowa  52246
Norris Cotton Cancer Center-ManchesterManchester, New Hampshire  03104
Michiana Hematology Oncology PC-MishawakaMishawaka, Indiana  46545-1470
Marie Yeager Cancer CenterSaint Joseph, Michigan  49085
Hematology Oncology Associates of Central New York PCEast Syracuse, New York  13057
Geisinger Medical Center-Cancer Center HazeltonHazleton, Pennsylvania  18201
Community Howard Regional HealthKokomo, Indiana  46904
Indiana University Health La Porte HospitalLa Porte, Indiana  46350
Saint Joseph Regional Medical Center-MishawakaMishawaka, Indiana  46545-1470
Via Christi Hospital-PittsburgPittsburg, Kansas  66762
Christiana Care Health System-Christiana HospitalNewark, Delaware  19718
Illinois Cancer Specialists-NilesNiles, Illinois  60714
Springfield Regional Medical CenterSpringfield, Ohio  45505
Promise Regional Medical Center-HutchinsonHutchinson, Kansas  65702
Saint Louis Cancer and Breast Institute-South CitySaint Louis, Missouri  63109
Self Regional HealthcareGreenwood, South Carolina  29646