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Three-Arm Randomized Phase II Study of Carboplatin and Paclitaxel in Combination With Cetuximab, IMC-A12 or Both in Patients With Advanced Non-Small Cell Lung Cancer Who Will Not Receive Bevacizumab-Based Therapy


Phase 2
18 Years
N/A
Not Enrolling
Both
Recurrent Non-small Cell Lung Cancer, Stage IIIB Non-small Cell Lung Cancer, Stage IV Non-small Cell Lung Cancer

Thank you

Trial Information

Three-Arm Randomized Phase II Study of Carboplatin and Paclitaxel in Combination With Cetuximab, IMC-A12 or Both in Patients With Advanced Non-Small Cell Lung Cancer Who Will Not Receive Bevacizumab-Based Therapy


PRIMARY OBJECTIVES:

I. To evaluate the progression-free survival of patients with NSCLC randomized to
carboplatin plus paclitaxel plus cetuximab or carboplatin plus paclitaxel plus IMC-A12
(cixutumumab) or carboplatin plus paclitaxel plus cetuximab plus IMC-A12.

SECONDARY OBJECTIVES:

I. To evaluate the response rate, disease control rate (complete response plus partial
response plus stable disease), and toxicities for each arm.

II. To evaluate EGFR by IHC, mutation, and gene copy number, IGF-1R and IGF-2R expression
(both phosphorylated and unphosphorylated states), expression of p-AKT by IHC, and k-ras
mutation.

III. Plasma-based biomarkers will be evaluated for total and free insulin-like growth factor
1 and 2, IGF-growth factor binding protein 3 (IGFBP3) and circulating levels of EGF and TGF
alpha.

IV. To evaluate overall survival on each of the three arms.

OUTLINE: This is a multicenter study. Patients are stratified according to gender and
histology (squamous cell vs non-squamous cell). Patients are randomized to 1 of 3 treatment
arms.

ARM I: Patients receive carboplatin intravenously (IV) over 15-30 minutes and paclitaxel IV
over 3 hours on days 1 and 22 and cetuximab IV over 1-2 hours on days 1, 8, 15, 22, 29, and
36. Treatment repeats every 42 days for 2 courses. Patients with stable or responding
disease after 2 courses proceed to maintenance therapy with cetuximab alone on days 1, 8,
15, 22, 29, and 36. Treatment with cetuximab repeats every 42 days in the absence of disease
progression or unacceptable toxicity.

ARM II: Patients receive carboplatin and paclitaxel as in arm I. Patients also receive
cixutumumab IV over 1 hour on days 1, 15, and 29. Treatment repeats every 42 days for 2
courses. Patients with stable or responding disease after 2 courses proceed to maintenance
therapy with cixutumumab alone on days 1, 15, and 29. Treatment with cixutumumab repeats
every 42 days in the absence of disease progression or unacceptable toxicity.

ARM III: Patients receive carboplatin, paclitaxel, and cetuximab as in arm I. Patients also
receive cixutumumab as in arm II. Treatment repeats every 42 days for 2 courses. Patients
with stable or responding disease after 2 courses proceed to maintenance therapy with
cetuximab as in arm I and cixutumumab as in arm II.

Tumor tissue samples are collected at baseline for analysis of EGFR expression by IHC,
mutation, and gene copy number; IGF-1R and IGF-2R expression (both phosphorylated and
unphosphorylated states); p-AKT expression by IHC; and k-ras mutation. Blood, serum, and
plasma samples are collected periodically for biomarker analysis.

After completion of study treatment, patients are followed up every 3 months for 2 years and
then every 6 months for 1 year.


Inclusion Criteria:



- Histologically or cytologically confirmed non-small cell lung cancer (NSCLC)

- Stage IIIB disease

- T4, NX with nodule in ipsilateral lung lobe allowed provided patient is not
a candidate for combined chemotherapy and radiotherapy

- Stage IV disease (includes M1a and M1b)

- Measurable disease as defined by RECIST criteria

- Ineligible for or refused treatment with bevacizumab

- No small cell lung cancer or mixed small cell and NSCLC

- No untreated or symptomatic CNS metastases

- Patients with a history of CNS metastases that are definitively treated, stable,
and controlled are eligible provided the following criteria are met:

- Definitive therapy (surgery and/or radiotherapy) has been administered

- Not planning to undergo additional treatment for brain metastases

- Clinically stable

- Off corticosteroids or on a stable dose of corticosteroids for ≥ 14 days
before study entry

- ECOG performance status 0-1

- Leukocytes > 3,000/mm^3

- ANC > 1,500/mm^3

- Hemoglobin > 9 g/dL

- Platelet count > 100,000/mm^3

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

- AST < 3 times ULN (< 5 times ULN if elevations due to liver metastases)

- Creatinine < 1.5 times ULN OR creatinine clearance > 60 mL/min

- Fasting serum glucose < 120 mg/dL

- PTT ≤ 1.2 times ULN and INR ≤ 1.5 (unless patient is on anticoagulation therapy)

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception during and for 3 months after the
last dose of cixutumumab

- No poorly controlled diabetes mellitus

- Patients with a history of diabetes mellitus are eligible provided their blood
glucose is within normal range and they are on a stable dietary or therapeutic
regimen for this condition

- No peripheral neuropathy > grade 1 as per CTCAE v 4.0

- No history of or suspected interstitial pneumonitis or pulmonary fibrosis on imaging

- No significant uncontrolled cardiac disease within the past 6 months, including any
of the following:

- Uncontrolled hypertension (BP > 150/100 mm Hg)

- Unstable angina

- Recent myocardial infarction

- Uncontrolled congestive heart failure

- Cardiomyopathy with decreased ejection fraction

- No arterial thrombosis, pulmonary embolus, deep vein thrombosis, or hemorrhagic
disorders within the past 28 days

- No other prior or concurrent malignancy, except for the following:

- Curatively treated malignancy with no known active disease for ≥ 3 years AND is
considered to be at low risk for recurrence by the treating physician

- Adequately treated nonmelanoma skin cancer or lentigo maligna with no evidence
of disease

- Adequately treated cervical carcinoma in situ with no evidence of disease

- Prostatic intraepithelial neoplasia with no evidence of prostate cancer

- No history of any medical or psychiatric condition, addictive disorder, or laboratory
abnormality that, in the opinion of the investigator, may increase the risks
associated with study participation or study treatments or may interfere with the
conduct of the study or interpretation of study results

- No history of allergic reactions attributed to compounds of similar chemical or
biological composition to cixutumumab

- Concurrent therapeutic anticoagulation allowed provided there is no bleeding and
patient is on a stable dose of anticoagulation therapy (e.g., Warfarin with an INR of
2-3) for > 2 weeks prior to study entry

- No prior agents targeting the EGFR or IGFR pathways

- No prior therapy for advanced NSCLC, except for surgery and/or radiotherapy

- No prior systemic therapy, including bevacizumab for advanced stage NSCLC

- At least 21 days since prior radiotherapy

- More than 4 weeks since prior major surgery or hormonal therapy (other than hormone
replacement therapy) and recovered

- More than 1 year since prior neoadjuvant or adjuvant chemotherapy

Type of Study:

Interventional

Study Design:

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

Outcome Measure:

Progression-free survival (PFS)

Outcome Time Frame:

From randomization to death or disease progression, whichever occurs first, assessed up to 3 years

Safety Issue:

No

Principal Investigator

Nasser Hanna

Investigator Role:

Principal Investigator

Investigator Affiliation:

Eastern Cooperative Oncology Group

Authority:

United States: Food and Drug Administration

Study ID:

NCI-2011-01976

NCT ID:

NCT00986674

Start Date:

September 2009

Completion Date:

Related Keywords:

  • Recurrent Non-Small Cell Lung Cancer
  • Stage IIIB Non-Small Cell Lung Cancer
  • Stage IV Non-Small Cell Lung Cancer
  • Carcinoma, Non-Small-Cell Lung
  • Lung Neoplasms

Name

Location

Hurley Medical CenterFlint, Michigan  48503
Boulder Community HospitalBoulder, Colorado  80301-9019
Porter Adventist HospitalDenver, Colorado  80210
Rose Medical CenterDenver, Colorado  80220
Swedish Medical CenterEnglewood, Colorado  80110
Sky Ridge Medical CenterLone Tree, Colorado  80124
North Suburban Medical CenterThornton, Colorado  80229
Bronson Methodist HospitalKalamazoo, Michigan  49007
West Michigan Cancer CenterKalamazoo, Michigan  49007-3731
Borgess Medical CenterKalamazooaa, Michigan  49001
Fairview Ridges HospitalBurnsville, Minnesota  55337
United HospitalSt. Paul, Minnesota  55102
Ridgeview Medical CenterWaconia, Minnesota  55387
Geisinger Medical CenterDanville, Pennsylvania  17822-0001
Abramson Cancer Center of the University of PennsylvaniaPhiladelphia, Pennsylvania  19104-4283
Marshfield ClinicMarshfield, Wisconsin  54449
Methodist Medical Center of IllinoisPeoria, Illinois  61636
Memorial Hospital of South BendSouth Bend, Indiana  46601
Newark Beth Israel Medical CenterNewark, New Jersey  07112
Via Christi Regional Medical CenterWichita, Kansas  67214
Scott and White Memorial HospitalTemple, Texas  76508
Medical Center of Central GeorgiaMacon, Georgia  31201
University of Wisconsin Hospital and ClinicsMadison, Wisconsin  53792-0001
North Colorado Medical CenterGreeley, Colorado  80631
McKee Medical CenterLoveland, Colorado  80539
Cancer Center of Kansas - ChanuteChanute, Kansas  66720
Cancer Center of Kansas - Dodge CityDodge City, Kansas  67801
Cancer Center of Kansas - NewtonNewton, Kansas  67114
Cancer Center of Kansas - SalinaSalina, Kansas  67042
Cancer Center of Kansas - WellingtonWellington, Kansas  67152
Associates in Womens HealthWichita, Kansas  67203
Cancer Center of Kansas - WinfieldWinfield, Kansas  67156
Adena Regional Medical CenterChillicothe, Ohio  54601
Grady Memorial HospitalDelaware, Ohio  43015
Fairfield Medical CenterLancaster, Ohio  43130
Paoli Memorial HospitalPaoli, Pennsylvania  19301-1792
Elkhart General HospitalElkhart, Indiana  46515
University Medical Center of Southern NevadaLas Vegas, Nevada  89102
Memorial HospitalCarthage, Illinois  62321
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
Community Cancer Center of MonroeMonroe, Michigan  48162
Creighton University Medical CenterOmaha, Nebraska  68131-2197
Lima Memorial HospitalLima, Ohio  45804
Mercy Hospital of TiffinTiffin, Ohio  44883
Fulton County Health CenterWauseon, Ohio  43567
Bryn Mawr HospitalBryn Mawr, Pennsylvania  19010
Exempla Lutheran Medical CenterWheat Ridge, Colorado  80033
Eureka HospitalEureka, Illinois  61530
Mercy HospitalCoon Rapids, Minnesota  55433
Graham Hospital AssociationCanton, Illinois  61520
Holy Family Medical CenterDes Plaines, Illinois  60016
Saint Joseph Medical CenterJoliet, Illinois  60435
Trinity Medical CenterMoline, Illinois  61265-1291
Pekin HospitalPekin, Illinois  61554
Bixby Medical CenterAdrian, Michigan  49221
Saint Joseph Mercy HospitalAnn Arbor, Michigan  48106
Fairview-Southdale HospitalEdina, Minnesota  55435
Abbott-Northwestern HospitalMinneapolis, Minnesota  55407
Saint Francis Regional Medical CenterShakopee, Minnesota  55379
Rice Memorial HospitalWillmar, Minnesota  56201
Saint Luke's HospitalMaumee, Ohio  43537
Lancaster General HospitalLancaster, Pennsylvania  17604-3555
Geisinger Medical GroupState College, Pennsylvania  16801
Fox Valley Hematology and OncologyAppleton, Wisconsin  54911
Cancer Center of Kansas - Fort ScottFort Scott, Kansas  66701
Cancer Center of Kansas-IndependenceIndependence, Kansas  67301
Lawrence Memorial HospitalLawrence, Kansas  66044
Mary Rutan HospitalBellefontaine, Ohio  43311
Knox Community HospitalMount Vernon, Ohio  43050
Fisher-Titus Medical CenterNorwalk, Ohio  44857
Marshfield Clinic Cancer Care at Regional Cancer CenterEau Claire, Wisconsin  54701
UW Cancer Center Johnson CreekJohnson Creek, Wisconsin  53038
Marshfield Clinic - Weston CenterWeston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids CenterWisconsin Rapids, Wisconsin  54494
Longmont United HospitalLongmont, Colorado  80501
Greater Baltimore Medical CenterBaltimore, Maryland  21204
Manchester Memorial HospitalManchester, Connecticut  06040-4188
University of VirginiaCharlottesville, Virginia  22908
University of PittsburghPittsburgh, Pennsylvania  15261
Case Western Reserve UniversityCleveland, Ohio  44106
Albert Einstein Medical CenterPhiladelphia, Pennsylvania  19141
Riverside Methodist HospitalColumbus, Ohio  43214
Licking Memorial HospitalNewark, Ohio  43055-2899
Columbus CCOPColumbus, Ohio  43206
Indiana University Medical CenterIndianapolis, Indiana  46202
Presbyterian - Saint Lukes Medical Center - Health OneDenver, Colorado  80218
Wichita CCOPWichita, Kansas  67214-3882
Alegent Health Immanuel Medical CenterOmaha, Nebraska  68122
Alegent Health Bergan Mercy Medical CenterOmaha, Nebraska  68124
Flower HospitalSylvania, Ohio  43560-2197
Metro-Minnesota CCOPSt. Louis Park, Minnesota  
Lankenau HospitalWynnewood, Pennsylvania  19096
Northern Indiana Cancer Research ConsortiumSouth Bend, Indiana  
OSF Saint Francis Medical CenterPeoria, Illinois  61637
The Medical Center of AuroraAurora, Colorado  80012
Penrose-Saint Francis HealthcareColorado Springs, Colorado  80907
Saint Anthony Central HospitalDenver, Colorado  80204
Exempla Saint Joseph HospitalDenver, Colorado  80218
Colorado Cancer Research Program CCOPDenver, Colorado  80224-2522
Saint Mary's Hospital and Regional Medical CenterGrand Junction, Colorado  81502
Saint Mary Corwin Medical CenterPueblo, Colorado  81004
Danbury HospitalDanbury, Connecticut  06810
Saint Francis Hospital and Medical CenterHartford, Connecticut  06105
Evanston CCOP-NorthShore University HealthSystemEvanston, Illinois  60201
Stoffel, Thomas J MD (UIA Investigator)Moline, Illinois  61265
Garneau, Stewart C MD (UIA Investigator)Moline, Illinois  61265
Sharis, Christine M MD (UIA Investigator)Moline, Illinois  61265
Porubcin, Michael MD (UIA Investigator)Moline, Illinois  61265
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
Saint Margaret's HospitalSpring Valley, Illinois  61362
Richard L. Roudebush Veterans Affairs Medical CenterIndianapolis, Indiana  46202
Wishard HospitalIndianapolis, Indiana  46202
Constantinou, Costas L MD (UIA Investigator)Bettendorf, Iowa  52722
Cedar Rapids Oncology AssociationCedar Rapids, Iowa  52403
Mercy HospitalCedar Rapids, Iowa  52403
Mercy Medical Center-Sioux CitySioux City, Iowa  51104
Saint Luke's Regional Medical CenterSioux City, Iowa  51104
Cancer Center of Kansas - El DoradoEl Dorado, Kansas  67042
Cancer Center of Kansas-KingmanKingman, Kansas  67068
Cancer Center of Kansas - ParsonsParsons, Kansas  67357
Cancer Center of Kansas - PrattPratt, Kansas  67124
Cancer Center of Kansas-Wichita Medical Arts TowerWichita, Kansas  67208
Cancer Center of Kansas - Main OfficeWichita, Kansas  67214
Hickman Cancer CenterAdrian, Michigan  49221
Michigan Cancer Research Consortium Community Clinical Oncology ProgramAnn Arbor, Michigan  48106
Oakwood HospitalDearborn, Michigan  48123
Saint John Hospital and Medical CenterDetroit, Michigan  48236
Green Bay Oncology - EscanabaEscanaba, Michigan  49431
Green Bay Oncology - Iron MountainIron Mountain, Michigan  49801
Allegiance HealthJackson, Michigan  49201
Sparrow HospitalLansing, Michigan  48912
Saint Mary Mercy HospitalLivonia, Michigan  48154
Mercy Memorial HospitalMonroe, Michigan  48162
Saint Joseph Mercy OaklandPontiac, Michigan  48341-2985
Saint Joseph Mercy Port HuronPort Huron, Michigan  48060
Saint Mary's of MichiganSaginaw, Michigan  48601
Lakeland HospitalSt. Joseph, Michigan  49085
Saint John Macomb-Oakland HospitalWarren, Michigan  48093
Miller-Dwan HospitalDuluth, Minnesota  55805
Unity HospitalFridley, Minnesota  55432
Saint John's Hospital - HealtheastMaplewood, Minnesota  55109
Minnesota Oncology Hematology PA-MaplewoodMaplewood, Minnesota  55109
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
Lincoln Medical Education Foundation Cancer Resource CenterLincoln, Nebraska  68510
Missouri Valley Cancer Consortium CCOPOmaha, Nebraska  68106
Nevada Cancer Research Foundation CCOPLas Vegas, Nevada  89106
Hunterdon Medical CenterFlemington, New Jersey  08822
Fox Chase Cancer Center at Virtua Memorial Hospital of Burlington CountyMount Holly, New Jersey  08060
Virtua West Jersey Hospital VoorheesVoorhees, New Jersey  08043
Doctors HospitalColumbus, Ohio  43228
Grant Medical CenterColumbus, Ohio  43215
Mount Carmel Health Center WestColumbus, Ohio  43222
Hematology Oncology Center IncorporatedElyria, Ohio  44035
Marietta Memorial HospitalMarietta, Ohio  45750
Toledo Radiation Oncology at Northwest Ohio Onocolgy CenterMaumee, Ohio  43537
Saint Charles HospitalOregon, Ohio  43616
North Coast Cancer CareSandusky, Ohio  44870
Toledo Community Hospital Oncology Program CCOPToledo, Ohio  43617
Mercy Cancer Center at Saint Anne Mercy HospitalToledo, Ohio  43623
University of ToledoToledo, Ohio  43614
Saint Vincent Mercy Medical CenterToledo, Ohio  43608
Saint Ann's HospitalWesterville, Ohio  43081
Genesis HealthCare SystemZanesville, Ohio  43701
Natalie W Bryant Cancer CenterTulsa, Oklahoma  74136
Pottstown Memorial Medical CenterPottstown, Pennsylvania  19464
Scranton Hematology OncologyScranton, Pennsylvania  18510
Mercy HospitalScranton, Pennsylvania  18501
Geisinger Wyoming ValleyWilkes-Barre, Pennsylvania  18711
Mainline Health CCOPWynnewood, Pennsylvania  19096
Fredericksburg Oncology IncFredericksburg, Virginia  22401
Wheeling HospitalWheeling, West Virginia  26003
Saint Vincent HospitalGreen Bay, Wisconsin  54301
Green Bay Oncology Limited at Saint Mary's HospitalGreen Bay, Wisconsin  54303
Saint Mary's HospitalGreen Bay, Wisconsin  54303
Green Bay Oncology at Saint Vincent HospitalGreen Bay, Wisconsin  54301-3526
UW Health Oncology - 1 South ParkMadison, Wisconsin  53715
Bay Area Medical CenterMarinette, Wisconsin  54143
Marshfield Clinic-Minocqua CenterMinocqua, Wisconsin  54548
Green Bay Oncology - Oconto FallsOconto Falls, Wisconsin  54154
Marshfield Clinic at James Beck Cancer CenterRhinelander, Wisconsin  54501
Marshfield Clinic-Rice Lake CenterRice Lake, Wisconsin  54868
Green Bay Oncology - Sturgeon BaySturgeon Bay, Wisconsin  54235
Marshfield Clinic-Wausau CenterWausau, Wisconsin  54401
Illinois CancerCare-BloomingtonBloomington%, Illinois  61701
Illinois CancerCare-CantonCanton, Illinois  61520
Illinois CancerCare-CarthageCarthage, Illinois  62321
Illinois CancerCare-EurekaEureka, Illinois  61530
Illinois CancerCare-HavanaHavana, Illinois  62644
Illinois CancerCare-Kewanee ClinicKewanee, Illinois  61443
Illinois CancerCare-MacombMacomb, Illinois  61455
Illinois CancerCare-MonmouthMonmouth, Illinois  61462
Illinois CancerCare-Community Cancer CenterNormal, Illinois  61761
Illinois CancerCare-PekinPekin, Illinois  61603
Illinois CancerCare-PeruPeru, Illinois  61354
Illinois CancerCare-PrincetonPrinceton, Illinois  61356
Illinois CancerCare-Spring ValleySpring Valley, Illinois  61362
Cancer Center of Kansas-LiberalLiberal, Kansas  67901
North Coast Cancer Care-ClydeClyde, Ohio  43410
Vanderbilt-Ingram Cancer Center Cool SpringsFranklin, Tennessee  37067
Nashville Oncology Associates PCNashville, Tennessee  37203
West Virginia University CharlestonCharleston, West Virginia  25304
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
Riverview HospitalWisconsin Rapids, Wisconsin  54494
Hinsdale Hematology Oncology Associates IncorporatedHinsdale, Illinois  60521
Spector, David MD (UIA Investigator)Moline, Illinois  61265
UHHS-Chagrin Highlands Medical CenterOrange Village, Ohio  44122
UHHS-Westlake Medical CenterWestlake, Ohio  44145
Gundersen LutheranLa Crosse, Wisconsin  54601
New York Oncology Hematology PC -Albany Medical CenterAlbany, New York  12208
New York Oncology Hematology PC - AlbanyAlbany, New York  12206
New York Oncology Hematology PC - AmsterdamAmsterdam, New York  12010
New York Oncology Hematology PC-HudsonHudson, New York  12534
New York Oncology Hematology PC - LathamLatham, New York  12110
New York Oncology Hematology PC - RexfordRexford, New York  12148
New York Oncology Hematology PC - TroyTroy, New York  12180
Stanford University Hospitals and ClinicsStanford, California  94305
Siouxland Hematology Oncology AssociatesSioux City, Iowa  51101
IU Health ArnettLafayette, Indiana  
Oncology Associates at Mercy Medical CenterCedar Rapids, Iowa  52403
Marie Yeager Cancer CenterSaint Joseph, Michigan  49085
Summa Akron City HospitalAkron, Ohio  44304
The Toledo Hospital/Toledo Children's HospitalToledo, Ohio  43606
Genesys Regional Medical Center-West Flint CampusFlint, Michigan  48532
Essentia Health Duluth Clinic CCOPDuluth, Minnesota  55805
Essentia Health Saint Mary's Medical CenterDuluth, Minnesota  55805
Toledo Clinic Cancer Centers-OregonOregon, Ohio  43616
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
Springfield Regional Medical CenterSpringfield, Ohio  45505
Toledo Clinic Cancer Centers-Bowling GreenBowling Green, Ohio  43402
Toledo Clinic Cancer Centers-MaumeeMaumee, Ohio  43537-1839
Toledo Clinic Cancer Centers-ToledoToledo, Ohio  43623