Know Cancer

or
forgot password

Phase I/Randomized Phase II Trial of Either Dasatinib or Placebo Combined With Standard Chemo-Radiotherapy for Newly Diagnosed Glioblastoma Multiforme (GBM)


Phase 1/Phase 2
18 Years
N/A
Open (Enrolling)
Both
Brain and Central Nervous System Tumors

Thank you

Trial Information

Phase I/Randomized Phase II Trial of Either Dasatinib or Placebo Combined With Standard Chemo-Radiotherapy for Newly Diagnosed Glioblastoma Multiforme (GBM)


OBJECTIVES:

- To establish a maximum-tolerated dose of dasatinib combined with radiation and
temozolomide in patients with newly diagnosed glioblastoma multiforme. (Phase I) (Phase
I study closed to patient accrual on April 29, 2011 and has been completed)

- To determine the efficacy of dasatinib in combination with radiotherapy and concomitant
adjuvant temozolomide, and compare it with the standard of care approach, consisting of
radiotherapy and temozolomide, followed by adjuvant temozolomide in these patients.
(Phase II) (Phase II study opened to patient accrualon August 5, 2011)

- To determine the relationship between tumor biomarkers and clinical outcome of patients
treated with the dasatinib/radiotherapy/temozolomide combination. (Phase II)

- To evaluate potential mechanisms of therapy resistance in recurrent tumor samples
obtained at the time of surgery for recurrent disease.

- To assess the impact of the addition of dasatinib to radiotherapy and temozolomide on
the quality of life (QOL) of these patients, as assessed by FACT-Br, EORTC QLQ-C15-PAL,
and EORTC QLQ-BN20. (Phase II)

- To compare the results of the two most commonly used QOL tools, FACT-Br and EORTC QLQ
C15-PAL plus BN20 and validate the use of EORTC QLQ-C15-PAL plus BN20 in these
patients.(Phase II)

OUTLINE: This is a multicenter, phase I dose-escalation study of dasatinib (Phase I study
closed to patient accrual on April 29, 2011 and has been completed) followed by a randomized
phase II study (Phase II study opened to patient accrual on August 5, 2011).

- Phase I:

- Course 1: Patients receive oral dasatinib once daily and oral temozolomide once
daily on days 1-42. Patients undergo external-beam radiotherapy (EBRT), including
intensity-modulated radiotherapy, 5 days a week for 6 weeks.

- Courses 2-7: Beginning 28-42 days after course 1, patients receive oral dasatinib
once daily on days 1-28 and oral temozolomide once daily on days 1-5. Treatment
repeats every 28 days for 6 courses in the absence of disease progression or
unacceptable toxicity.

- Phase II: Patients are stratified according to age (> 70 years vs ≤ 70 years). Patients
are randomized to 1 of 2 treatment arms.

- Arm I:

- Course 1: Patients receive oral dasatinib once daily and oral temozolomide
once daily on days 1-42. Patients undergo EBRT 5 days a week for 6 weeks.

- Courses 2-7: Beginning 28-42 days after course 1, patients receive oral
dasatinib once daily on days 1-28 and oral temozolomide once daily on days
1-5. Treatment repeats every 28 days for 6 courses in the absence of disease
progression or unacceptable toxicity.

- Arm II:

- Course 1: Patients receive oral placebo once daily on days 1-42 and
temozolomide as in arm I. Patients also undergo EBRT as in arm I.

- Courses 2-7: Beginning 28-42 days after course 1, patients receive oral
placebo once daily on days 1-28 and temozolomide as in arm I. Treatment
repeats every 28 days for 6 courses in the absence of disease progression or
unacceptable toxicity.

Tissue samples are collected for correlative studies.

Quality of life is assessed periodically using the FACT-Br, EORTC QLQ-C15-PAL v.1, and EORTC
BN-20 questionnaires.

After completion of study therapy, patients are followed up every 6 months for 5 years.

Inclusion Criteria


DISEASE CHARACTERISTICS:

- Histologically confirmed glioblastoma multiforme (GBM)

- Grade 4 astrocytoma

- No grade 4 oligoastrocytoma or GBM with oligodendroglial features

- Newly diagnosed disease

- Measurable or evaluable disease by gadolinium MRI or contrast CT scan

- Patients who have had a gross total resection are eligible on the basis of
evaluable disease

- No pleural or pericardial effusion of any grade

- No prior surgery for CNS neoplasms other than surgery related to the current GBM
diagnosis

- If Gliadel wafers are placed at time of primary resection this would be
considered prior therapy and patient would be ineligible

PATIENT CHARACTERISTICS:

- ECOG performance status 0-2

- Absolute neutrophil count (ANC) ≥ 1,500/mm³

- Platelet count ≥ 100,000/mm³

- Hemoglobin > 9.0 g/dL

- Total bilirubin ≤ 1.5 times upper limit of normal (ULN)

- AST ≤ 2.5 times ULN

- Creatinine ≤ 1.5 times ULN

- INR ≤ 1.5

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception during and for ≥ 12 weeks after
completion of study treatment

- No immunocompromised patients (other than that related to the use of corticosteroids)
including patients known to be HIV positive and currently receiving antiretroviral
therapy

- Patients known to be HIV positive, but without clinical evidence of an
immunocompromised state, are eligible for this trial

- No uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements

- No history of any of the following conditions:

- Congestive heart failure requiring use of ongoing maintenance therapy for
life-threatening ventricular arrhythmias

- Congenital long QT syndrome

- Clinically significant ventricular arrhythmias (e.g., ventricular tachycardia,
ventricular fibrillation, or Torsades de pointes)

- Prolonged QTc interval on pre-entry electrocardiogram (> 450 msec)

- Hypokalemia or hypomagnesemia

- Patients may not have any clinically significant cardiovascular disease including the
following:

- Myocardial infarction or ventricular tachyarrhythmia within 6 months

- Ejection fraction less than institutional normal

- Major conduction abnormality (unless a cardiac pacemaker is present)

- New York Heart Association classification ≥ class II congestive heart failure

- Patients with any cardiopulmonary symptoms of unknown cause (e.g., shortness of
breath, chest pain, etc.) should be evaluated by a baseline echocardiogram with
or without stress test as needed in addition to electrocardiogram (ECG) to rule
out QTc prolongation

- Patients with underlying cardiopulmonary dysfunction should be excluded
from the study

- No comorbid systemic illnesses or other severe concurrent disease that, in the
judgment of the investigator, would make the patient inappropriate for entry into
this study or interfere significantly with the proper assessment of safety and
toxicity of the prescribed regimens including, but not limited to, any of the
following:

- History of bleeding diathesis

- Concurrent chronic systemic anticoagulation therapy that can not be discontinued
(i.e., antiplatelet agents or aspirin)

- Concurrent t chronic nonsteroidal anti-inflammatory drugs (NSAIDs) that cannot
be discontinued

- No other active malignancy ≤ 5 years prior to registration

- Exceptions: Non-melanotic skin cancer or carcinoma-in-situ of the cervix

- If there is a history of prior malignancy, they must not be receiving other
specific treatment (other than hormonal therapy) for their cancer

- No severe allergy to sulfa medications and dapsone

- Able to tolerate either intravenous or inhaled dapsone

- Able to take oral medication

- Willingness to abstain from eating grapefruit or drinking grapefruit juice for the
duration of the study treatment

PRIOR CONCURRENT THERAPY:

- See Disease Characteristics

- See Patient Characteristics

- At least 5 days since prior and no concurrent St. John wort

- No prior radiotherapy or chemotherapy for any CNS neoplasm (hormones, vitamins, and
growth factors are not considered chemotherapy for the purposes of this study)

- At least 7 days, but < 42 days, since prior stereotactic biopsy

- At least 14 days, but < 42 days, since prior open craniotomy

- Willing to forego other cytotoxic and non-cytotoxic drug therapy against the tumor
while being treated with dasatinib and temozolomide

- No other concurrent investigational agent considered as treatment for the primary
neoplasm

- Must not be currently taking any of the following medications:

- Enzyme-inducing anticonvulsants (EIACs)

- To be eligible, patient must be switched to non-EIAC medications ≥ 7 days
prior to registration

- Potent inhibitors of CYP3A4 that cannot be discontinued

- Medications that may possibly prolong QT interval and produce a QTc that is ≥ 60
msec or a QTcF that is ≥ 450 msec

- H2 blockers or proton pump inhibitors (PPIs), such as famotidine (Pepcid) and
omeprazole (Prilosec) respectively, that cannot be discontinued or switched to
locally acting agents, such as Maalox, Mylanta, or TUMS

- No concurrent treatment immunosuppressive agent, except corticosteroids

- No concurrent other anticancer agents

- No concurrent prophylactic leukocyte growth factors (e.g., filgrastim [G-CSF] and
sargramostim [GM-CSF])

- No concurrent live vaccines

- No concurrent therapeutic anticoagulation with warfarin

- No concurrent ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs)

Type of Study:

Interventional

Study Design:

Allocation: Randomized, Masking: Double-Blind, Primary Purpose: Treatment

Outcome Measure:

Overall survival

Safety Issue:

No

Principal Investigator

Nadia N. Laack, MD

Investigator Role:

Study Chair

Investigator Affiliation:

Mayo Clinic

Authority:

Unspecified

Study ID:

CDR0000637854

NCT ID:

NCT00869401

Start Date:

June 2009

Completion Date:

Related Keywords:

  • Brain and Central Nervous System Tumors
  • adult giant cell glioblastoma
  • adult glioblastoma
  • adult gliosarcoma
  • Glioblastoma
  • Nervous System Neoplasms
  • Central Nervous System Neoplasms

Name

Location

Mayo Clinic - Jacksonville Jacksonville, Florida  32224
Mayo Clinic Cancer Center Rochester, Minnesota  55905
CCOP - Wichita Wichita, Kansas  67214-3882
CCOP - Illinois Oncology Research Association Peoria, Illinois  61602
CCOP - Carle Cancer Center Urbana, Illinois  61801
CCOP - Iowa Oncology Research Association Des Moines, Iowa  50309-1016
CCOP - Metro-Minnesota Saint Louis Park, Minnesota  55416
Cedar Rapids Oncology Associates Cedar Rapids, Iowa  52403
Mercy Medical Center - Sioux City Sioux City, Iowa  51104
Siouxland Hematology-Oncology Associates, LLP Sioux City, Iowa  51101
St. Luke's Regional Medical Center Sioux City, Iowa  51104
MeritCare Bemidji Bemidji, Minnesota  56601
Fairview Ridges Hospital Burnsville, Minnesota  55337
Mercy and Unity Cancer Center at Mercy Hospital Coon Rapids, Minnesota  55433
CCOP - Duluth Duluth, Minnesota  55805
Miller - Dwan Medical Center Duluth, Minnesota  55805
Fairview Southdale Hospital Edina, Minnesota  55435
Mercy and Unity Cancer Center at Unity Hospital Fridley, Minnesota  55432
Hutchinson Area Health Care Hutchinson, Minnesota  55350
HealthEast Cancer Care at St. John's Hospital Maplewood, Minnesota  55109
Hennepin County Medical Center - Minneapolis Minneapolis, Minnesota  55415
Virginia Piper Cancer Institute at Abbott - Northwestern Hospital Minneapolis, Minnesota  55407
St. Francis Cancer Center at St. Francis Medical Center Shakopee, Minnesota  55379
Park Nicollet Cancer Center St. Louis Park, Minnesota  55416
Regions Hospital Cancer Care Center St. Paul, Minnesota  55101
United Hospital St. Paul, Minnesota  55102
Ridgeview Medical Center Waconia, Minnesota  55387
MeritCare Broadway 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
Avera Cancer Institute Sioux Falls, South Dakota  57105
Marshfield Clinic - Marshfield Center Marshfield, Wisconsin  54449
Marshfield Clinic - Indianhead Center Rice Lake, Wisconsin  54868
Rapid City Regional Hospital Rapid City, South Dakota  57709
Methodist Medical Center of Illinois Peoria, Illinois  61636
Memorial Hospital of South Bend South Bend, Indiana  46601
CCOP - Montana Cancer Consortium Billings, Montana  59101
CCOP - Columbus Columbus, Ohio  43206
CCOP - Dayton Kettering, Ohio  45429
CCOP - Greenville Greenville, South Carolina  29615
CCOP - Northern Indiana CR Consortium South Bend, Indiana  46601
Saint Joseph Regional Medical Center South Bend, Indiana  46617
Charles M. Barrett Cancer Center at University Hospital Cincinnati, Ohio  45267-0526
Wesley Medical Center Wichita, Kansas  67214
John Stoddard Cancer Center at Iowa Methodist Medical Center Des Moines, Iowa  50309
St. Vincent Mercy Medical Center Toledo, Ohio  43608
Via Christi Cancer Center at Via Christi Regional Medical Center Wichita, Kansas  67214
Mission Hospitals - Memorial Campus Asheville, North Carolina  28801
Medical University of Ohio Cancer Center Toledo, Ohio  43614
Toledo Hospital Toledo, Ohio  43606
CCOP - Hematology-Oncology Associates of Central New York East Syracuse, New York  13057
Hematology-Oncology Centers of the Northern Rockies - Billings Billings, Montana  59101
St. Peter's Hospital Helena, Montana  59601
Kalispell Regional Medical Center Kalispell, Montana  59901
Montana Cancer Center at St. Patrick Hospital and Health Sciences Center Missoula, Montana  59802
Montana Cancer Specialists at Montana Cancer Center Missoula, Montana  59802
Wayne Memorial Hospital, Incorporated Goldsboro, North Carolina  27534
Adena Regional Medical Center Chillicothe, Ohio  54601
Doctors Hospital at Ohio Health Columbus, Ohio  43228
Riverside Methodist Hospital Cancer Care Columbus, Ohio  43214
Grady Memorial Hospital Delaware, Ohio  43015
Fairfield Medical Center Lancaster, Ohio  43130
Strecker Cancer Center at Marietta Memorial Hospital Marietta, Ohio  45750
Licking Memorial Cancer Care Program at Licking Memorial Hospital Newark, Ohio  43055
Community Hospital of Springfield and Clark County Springfield, Ohio  45505
Genesis - Good Samaritan Hospital Zanesville, Ohio  43701
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis St. Louis, Missouri  63110
University of New Mexico Cancer Center Albuquerque, New Mexico  87131-5636
Gundersen Lutheran Center for Cancer and Blood La Crosse, Wisconsin  54601
Helen and Harry Gray Cancer Center at Hartford Hospital Hartford, Connecticut  06102-5037
Elkhart General Hospital Elkhart, Indiana  46515
Howard Community Hospital Kokomo, Indiana  46904
Lakeland Regional Cancer Care Center - St. Joseph St. Joseph, Michigan  49085
Mount Carmel Health - West Hospital Columbus, Ohio  43222
Morgan Cancer Center at Lehigh Valley Hospital - Cedar Crest Allentown, Pennsylvania  18105
St. Joseph Medical Center Bloomington, Illinois  61701
Eureka Community Hospital Eureka, Illinois  61530
BroMenn Regional Medical Center Normal, Illinois  61761
Community Cancer Center Normal, Illinois  61761
Community Hospital of Ottawa Ottawa, Illinois  61350
Oncology Hematology Associates of Central Illinois, PC - Ottawa Ottawa, Illinois  61350
Cancer Treatment Center at Pekin Hospital Pekin, Illinois  61554
Oncology Hematology Associates of Central Illinois, PC - Peoria Peoria, Illinois  61615
OSF St. Francis Medical Center Peoria, Illinois  61637
Proctor Hospital Peoria, Illinois  61614
Illinois Valley Community Hospital Peru, Illinois  61354
Valley Cancer Center Spring Valley, Illinois  61362
Center for Cancer Therapy at LaPorte Hospital and Health Services La Porte, Indiana  46350
Mercy Regional Cancer Center at Mercy Medical Center Cedar Rapids, Iowa  52403
John Stoddard Cancer Center at Iowa Lutheran Hospital Des Moines, Iowa  50316-2301
Medical Oncology and Hematology Associates at John Stoddard Cancer Center Des Moines, Iowa  50309
Medical Oncology and Hematology Associates at Mercy Cancer Center Des Moines, Iowa  50314
Mercy Cancer Center at Mercy Medical Center - Des Moines Des Moines, Iowa  50314
Medical Oncology and Hematology Associates - West Des Moines West Des Moines, Iowa  50266
Cancer Center of Kansas, PA - Dodge City Dodge City, Kansas  67801
Hickman Cancer Center at Bixby Medical Center Adrian, Michigan  49221
Community Cancer Center of Monroe Monroe, Michigan  48162
Coborn Cancer Center Saint Cloud, Minnesota  56303
CentraCare Clinic - River Campus St. Cloud, Minnesota  56303
Wood County Oncology Center Bowling Green, Ohio  43402
Samaritan North Cancer Care Center Dayton, Ohio  45415
Grandview Hospital Dayton, Ohio  45405
David L. Rike Cancer Center at Miami Valley Hospital Dayton, Ohio  45409
Good Samaritan Hospital Dayton, Ohio  45406
Blanchard Valley Medical Associates Findlay, Ohio  45840
Charles F. Kettering Memorial Hospital Kettering, Ohio  45429
Lima Memorial Hospital Lima, Ohio  45804
Northwest Ohio Oncology Center Maumee, Ohio  43537
Middletown Regional Hospital Middletown, Ohio  45044
Toledo Clinic - Oregon Oregon, Ohio  43616
St. Charles Mercy Hospital Oregon, Ohio  43616
Mercy Hospital of Tiffin Tiffin, Ohio  44883
Toledo Clinic, Incorporated - Main Clinic Toledo, Ohio  43623
UVMC Cancer Care Center at Upper Valley Medical Center Troy, Ohio  45373-1300
Fulton County Health Center Wauseon, Ohio  43567
Ruth G. McMillan Cancer Center at Greene Memorial Hospital Xenia, Ohio  45385
Altru Cancer Center at Altru Hospital Grand Forks, North Dakota  58201
John B. Amos Cancer Center Columbus, Georgia  31904
Michiana Hematology-Oncology, PC - Elkhart Elkhart, Indiana  46514
Elkhart Clinic, LLC Elkhart, Indiana  46514-2098
Michiana Hematology Oncology PC - La Porte La Porte, Indiana  46350
Michiana Hematology-Oncology, PC - South Bend Mishawaka, Indiana  46545-1470
Michiana Hematology Oncology PC - Plymouth Plymouth, Indiana  46563
Reid Hospital & Health Care Services Richmond, Indiana  47374
Cancer Center of Kansas, PA - Chanute Chanute, Kansas  66720
Cancer Center of Kansas, PA - El Dorado El Dorado, Kansas  67042
Cancer Center of Kansas - Fort Scott Fort Scott, Kansas  66701
Cancer Center of Kansas-Independence Independence, Kansas  67301
Cancer Center of Kansas, PA - Kingman Kingman, Kansas  67068
Lawrence Memorial Hospital Lawrence, Kansas  66044
Cancer Center of Kansas, PA - Liberal Liberal, Kansas  67905
Cancer Center of Kansas, PA - Newton Newton, Kansas  67114
Cancer Center of Kansas, PA - Parsons Parsons, Kansas  67357
Cancer Center of Kansas, PA - Pratt Pratt, Kansas  67124
Cancer Center of Kansas, PA - Salina Salina, Kansas  67401
Cancer Center of Kansas, PA - Wellington Wellington, Kansas  67152
Cancer Center of Kansas, PA - Wichita Wichita, Kansas  67214
Associates in Womens Health, PA - North Review Wichita, Kansas  67208
Cancer Center of Kansas, PA - Medical Arts Tower Wichita, Kansas  67208
Cancer Center of Kansas, PA - Winfield Winfield, Kansas  67156
Mercy Memorial Hospital - Monroe Monroe, Michigan  48162
Lakeside Cancer Specialists, PLLC Saint Joseph, Michigan  49085
Willmar Cancer Center at Rice Memorial Hospital Willmar, Minnesota  56201
Billings Clinic - Downtown Billings, Montana  59107-7000
Bozeman Deaconess Cancer Center Bozeman, Montana  59715
St. James Healthcare Cancer Care Butte, Montana  59701
Grant Medical Center Cancer Care Columbus, Ohio  43215
Hematology Oncology Center Elyria, Ohio  44035
Community Cancer Center Elyria, Ohio  44035
Wayne Hospital Greenville, Ohio  45331
Knox Community Hospital Mount Vernon, Ohio  43050
Flower Hospital Cancer Center Sylvania, Ohio  43560
St. Anne Mercy Hospital Toledo, Ohio  43623
Mount Carmel St. Ann's Cancer Center Westerville, Ohio  43081
Fredericksburg Oncology, Incorporated Fredericksburg, Virginia  22401
Center for Cancer Treatment & Prevention at Sacred Heart Hospital Eau Claire, Wisconsin  54701
Marshfield Clinic Cancer Care at Regional Cancer Center Eau Claire, Wisconsin  54701
Saint Joseph's Hospital Marshfield, Wisconsin  54449
Marshfield Clinic - Lakeland Center Minocqua, Wisconsin  54548
Ministry Medical Group at Saint Mary's Hospital Rhinelander, Wisconsin  54501
Marshfield Clinic at Saint Michael's Hospital Stevens Point, Wisconsin  54481
Saint Michael's Hospital Cancer Center Stevens Point, Wisconsin  54481
Marshfield Clinic - Weston Center Weston, Wisconsin  54476
Mid Dakota Clinic, PC Bismarck, North Dakota  58501
Greenville Hospital Cancer Center Greenville, South Carolina  29605
Cancer Centers of the Carolinas - Grove Commons Greenville, South Carolina  29605
Cancer Centers of the Carolinas - Faris Road Greenville, South Carolina  29605
Cancer Centers of the Carolinas - Greer Medical Oncology Greer, South Carolina  29650
Cancer Centers of the Carolinas - Seneca Seneca, South Carolina  29672
Cancer Centers of the Carolinas - Spartanburg Spartanburg, South Carolina  29307
Resurrection Medical Center Chicago, Illinois  60631
Cancer Centers of the Carolinas - Eastside Greenville, South Carolina  29601
Lakes Region General Hospital Laconia, New Hampshire  03246
Galesburg Clinic, PC Galesburg, Illinois  61401
St. Vincent Healthcare Cancer Care Services Billings, Montana  59101
Illinois CancerCare - Bloomington Bloomington%, Illinois  61701
Illinois CancerCare - Canton Canton, Illinois  61520
Illinois CancerCare - Carthage Carthage, Illinois  62321
Illinois CancerCare - Eureka Eureka, Illinois  61530
Illinois CancerCare - Havana Havana, Illinois  62644
Illinois CancerCare - Kewanee Clinic Kewanee, Illinois  61443
Illinois CancerCare - Macomb Macomb, Illinois  61455
OSF Holy Family Medical Center Monmouth, Illinois  61462
Illinois CancerCare - Monmouth Monmouth, Illinois  61462
Illinois CancerCare - Community Cancer Center Normal, Illinois  61761
Illinois CancerCare - Pekin Pekin, Illinois  61603
Illinois CancerCare - Peru Peru, Illinois  61354
Illinois CancerCare - Princeton Princeton, Illinois  61356
Illinois CancerCare - Spring Valley Spring Valley, Illinois  61362
New Hampshire Oncology - Hematology, PA at Payson Center for Cancer Care Concord, New Hampshire  03301
New Hampshire Oncology - Hematology, PA - Hooksett Hooksett, New Hampshire  03106
Medcenter One Hospital Cancer Care Center Bismarck, North Dakota  58501
St. Alexius Medical Center Cancer Center Bismarck, North Dakota  58502
Precision Radiotherapy at University Pointe West Chester, Ohio  45069
Cancer Centers of the Carolinas - Easley Easley, South Carolina  29640
Cancer Centers of the Carolinas - Greer Radiation Oncology Greer, South Carolina  29650
Minnesota Oncology - Maplewood Maplewood, Minnesota  55109
Humphrey Cancer Center at North Memorial Outpatient Center Robbinsdale, Minnesota  55422-2900
Lakeview Hospital Stillwater, Minnesota  55082
Minnesota Oncology - Woodbury Woodbury, Minnesota  55125
Central Wisconsin Cancer Program at Agnesian HealthCare Fond du Lac, Wisconsin  54935
Southern Ohio Medical Center Cancer Center Portsmouth, Ohio  45662
St. Francis Hospital Cancer Care Services Indianapolis, Indiana  46237
Mercy Cancer Center - West Lakes Clive, Iowa  50325
Methodist West Hospital West Des Moines, Iowa  50266-7700
Benefis Sletten Cancer Institute Great Falls, Montana  59405
Essentia Health - Duluth Clinic Duluth, Minnesota  55805-1983