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A Phase III Study Evaluating the Role of Perioperative Chemotherapy in Patients With Potentially Resectable Hepatic Colorectal Metastases


Phase 3
18 Years
N/A
Not Enrolling
Both
Colorectal Cancer, Metastatic Cancer

Thank you

Trial Information

A Phase III Study Evaluating the Role of Perioperative Chemotherapy in Patients With Potentially Resectable Hepatic Colorectal Metastases


OBJECTIVES:

Primary

- To evaluate the difference in recurrence-free survival (RFS) of patients with
potentially resectable hepatic colorectal metastases receiving perioperative
(preoperative plus postoperative) adjuvant chemotherapy vs only postoperative adjuvant
chemotherapy following liver resection for colorectal metastases.

Secondary

- To compare the proportion of patients between study arms who are R0 or R1 resected,
alive, and free of recurrence at 6 months.

- To compare RFS between study arms in the cohort of patients event-free at 6 months.

- To compare overall survival between study arms.

- To evaluate the difference in R0 and combined R0 + R1 resection rates in patients
receiving neoadjuvant therapy and those undergoing initial surgical resection.

- To compare the postoperative morbidity profile between study arms.

- To evaluate the safety and toxicity profile of postoperative and perioperative
administration of chemotherapy and bevacizumab.

Tertiary

- To evaluate the relationship of baseline circulating tumor cells (CTC) to RFS.

- To evaluate the relationship of baseline CTC to R0 resection.

- To evaluate the relationship of pre-resection CTC in the preoperative therapy group
only with RFS and R0 resection.

OUTLINE: This is a multicenter study. Patients are stratified by number of liver metastases
(1-3 vs 4+), chemotherapy regimen* (mFOLFOX6 vs FOLFIRI), and synchronous** primary
colorectal cancer (yes vs no). Patients are randomized to 1 of 2 treatment arms.

NOTE: *Patients who have not received previous oxaliplatin receive mFOLFOX6 chemotherapy
comprising oxaliplatin IV over 2 hours, leucovorin calcium IV over 2 hours, and fluorouracil
IV over 46 hours on day 1. Patients who have received previous oxaliplatin receive FOLFIRI
chemotherapy comprising irinotecan hydrochloride IV over 2 hours, leucovorin calcium IV over
2 hours, and fluorouracil IV over 46 hours on day 1.

NOTE: **Synchronous is defined as the detection (by imaging) of suspicious liver metastases
within 90 days before or after the date of histologic diagnosis of the primary colon or
rectal cancer.

- Arm 1 (postoperative): Patients undergo hepatic resection. Beginning 31-56 days after
surgery, patients receive mFOLFOX6 or FOLFIRI chemotherapy IV on day 1 over 3 hours.
Patients receive an additional dose of fluorouracil over 46 hours using a portable
pump. Treatment repeats every 2 weeks for 12 courses.

- Arm 2 (perioperative): Patients receive mFOLFOX6 or FOLFIRI chemotherapy IV over 3
hours on day 1. Patients receive an additional dose of fluorouracil over 46 hours using
a portable pump. Treatment repeats for every 2 weeks for 6 courses. Patients then
undergo hepatic resection. Beginning 31-56 days after surgery, patients receive an
additional 6 courses of mFOLFOX6 or FOLFIRI chemotherapy.

Blood and tumor tissue samples may be collected periodically for correlative studies.

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

Inclusion Criteria


DISEASE CHARACTERISTICS:

- Histologically confirmed colorectal adenocarcinoma

- Hepatic metastasis (no histologic confirmation required) and no evidence of
extrahepatic metastatic disease within the past 4 weeks by one of the following
imaging studies*:

- PET/CT scan with contrast

- PET scan AND CT scan with contrast

- PET scan AND MRI with contrast

- PET/CT scan without contrast AND MRI with contrast NOTE: *If findings noted
in imaging study reports are equivocal, the determination of whether or not
the findings represent extrahepatic disease will be at the investigator's
discretion.

- No history of or concurrent evidence of extrahepatic metastases

- Patients with regional nodes that are suspicious on imaging and are
associated with the primary colorectal tumor are eligible provided the
nodes will be resected with the primary tumor after randomization

- No radiographic evidence of metastases to portal lymph nodes (node > 1 cm in
diameter) unless the node(s) are proven by biopsy to be negative

- No anal, small bowel, or appendiceal carcinoma

- No sarcoma, lymphoma, or carcinoid colorectal malignant diseases

- Within 4 weeks before randomization, the liver metastases must be determined by a
hepatic surgeon to be resectable based on meeting both of the following criteria:

- A complete resection can be performed in a single operation

- There are ≥ 2 uninvolved contiguous segments of the liver

- Meets one of the following criteria:

- Primary tumor and regional nodes resected with clear surgical margins and no
evidence of extrahepatic disease

- Unresected primary tumor with plans to resect the primary tumor before
randomization

- Unresected primary tumor with plans to resect the primary tumor and the liver
metastases in a single surgical procedure performed after randomization

- No unresected primary tumor in the colon or rectum with significant symptoms related
to obstruction or that will require radiotherapy

PATIENT CHARACTERISTICS:

- Eastern Cooperative Oncology Group (ECOG) performance status 0-1

- Life expectancy ≥ 5 years (excluding the diagnosis of metastatic CRC)

- absolute neutrophil count (ANC) ≥ 1,200/mm^3

- Platelet count ≥ 100,000/mm^3

- Hemoglobin ≥ 10 g/dL

- Total bilirubin ≤ upper limit of normal (ULN)

- aspartate aminotransferase (AST) ≤ 5.0 times ULN

- Alkaline phosphatase ≤ 5.0 times ULN

- Serum creatinine ≤ ULN OR calculated creatinine clearance ≥ 30 mL/min

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use effective contraception during and for ≥ 180 days after
completion of study treatment

- Considered a potential candidate for a major hepatic surgical procedure

- No grade 3 or 4 anorexia, grade 3 nausea, or vomiting ≥ grade 2 (per CTCAE v4.0)
related to metastatic disease

- No paresthesias, peripheral sensory neuropathy, or peripheral motor neuropathy ≥
grade 2 per Common Toxicity Criteria for Adverse Effects (CTCAE) v4.0 (patients with
grade 2 neuropathy who will receive FOLFIRI are eligible)

- No uncontrolled high BP defined as systolic BP ≥ 160 mm Hg OR diastolic BP ≥ 100 mm
Hg, with or without antihypertensive medication (patients with initial BP elevations
are eligible provided initiation or adjustment of BP medication lowers pressure to
meet this criteria)

- Documented history of congestive heart failure requiring chronic medical therapy

- No active inflammatory bowel disease

- No active infection or chronic infection requiring chronic suppressive antibiotics

- No known bleeding diathesis or coagulopathy

- No symptomatic interstitial pneumonitis OR definitive evidence of interstitial
pneumonitis described on CT scan, MRI, or chest x-ray in asymptomatic patients

- No other malignancies unless the patient is considered to be disease-free and has
completed therapy for the malignancy ≥ 1 year ago

- Patients with carcinoma in situ of the cervix, CRC in situ, melanoma in situ, or
basal cell or squamous cell carcinoma of the skin diagnosed and treated at any
time before study treatment are eligible

- No known Gilbert syndrome

- Not known to be homozygous for the UGT1A1 allele (for patients who will receive
FOLFIRI chemotherapy)

- No prior serious hypersensitivity reaction to any of the agents administered as part
of study treatment (determination of "serious" is at the investigator's discretion)

- No other serious concurrent medical condition that, in the opinion of the
investigator, would compromise the safety of the patient or compromise the patient's
ability to participate in the study, or cause a delay in the initiation of therapy
(surgery or chemotherapy) longer than 4 weeks following randomization

- No psychiatric or addictive disorders or other conditions that, in the opinion of the
investigator, would preclude the patient from meeting the study requirements

- No pre-existing chronic hepatic disease (e.g., chronic active hepatitis, cirrhosis)
that, in the opinion of the investigator and hepatic surgeon, would limit the
patient's ability to undergo hepatic metastasectomy

PRIOR CONCURRENT THERAPY:

- See Disease Characteristics

- No previous hepatic-directed therapy, including hepatic resection and/or ablation,
hepatic arterial infusion therapy, or hepatic radiotherapy

- Patients who have only had an incision or excisional biopsy are eligible

- No previous chemotherapy or any other systemic therapy for metastatic colorectal
cancer (CRC)

- No prior or concurrent portal vein embolization or other hepatic preconditioning
techniques

- At least 30 days since prior investigational products

- No intent to use ablation to treat any hepatic lesion

- No concurrent therapeutic doses of coumadin or equivalent

Type of Study:

Interventional

Study Design:

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

Outcome Measure:

Recurrence-free Survival (RFS)

Outcome Description:

Time to recurrence or death

Outcome Time Frame:

From study entry until the date of recurrence or death or for a maximum of 5 years.

Safety Issue:

No

Principal Investigator

Norman Wolmark, MD

Investigator Role:

Principal Investigator

Investigator Affiliation:

NSABP Foundation, Inc.

Authority:

United States: Federal Government

Study ID:

NSABP C-11

NCT ID:

NCT01189227

Start Date:

August 2010

Completion Date:

December 2011

Related Keywords:

  • Colorectal Cancer
  • Metastatic Cancer
  • stage IV colon cancer
  • adenocarcinoma of the colon
  • stage IV rectal cancer
  • adenocarcinoma of the rectum
  • liver metastases
  • Colorectal Neoplasms
  • Neoplasm Metastasis
  • Neoplasms
  • Neoplasms, Second Primary

Name

Location

Roswell Park Cancer InstituteBuffalo, New York  14263
Fred Hutchinson Cancer Research CenterSeattle, Washington  98109
CCOP - WichitaWichita, Kansas  67214-3882
Hurley Medical CenterFlint, Michigan  48503
CCOP - Missouri Valley Cancer ConsortiumOmaha, Nebraska  68131
CCOP - Christiana Care Health ServicesWilmington, Delaware  19899
Veterans Affairs Medical Center - Atlanta (Decatur)Decatur, Georgia  30033
CCOP - Illinois Oncology Research AssociationPeoria, Illinois  61602
CCOP - Iowa Oncology Research AssociationDes Moines, Iowa  50309-1016
CCOP - Metro-MinnesotaSaint Louis Park, Minnesota  55416
Hinsdale Hematology Oncology AssociatesHinsdale, Illinois  60521
Mercy Medical Center - Sioux CitySioux City, Iowa  51104
Siouxland Hematology-Oncology Associates, LLPSioux City, Iowa  51101
St. Luke's Regional Medical CenterSioux City, Iowa  51104
CCOP - Michigan Cancer Research ConsortiumAnn Arbor, Michigan  48106
Saint Joseph Mercy Cancer CenterAnn Arbor, Michigan  48106-0995
Oakwood Cancer Center at Oakwood Hospital and Medical CenterDearborn, Michigan  48123-2500
Genesys Hurley Cancer InstituteFlint, Michigan  48503
Van Elslander Cancer Center at St. John Hospital and Medical CenterGrosse Pointe Woods, Michigan  48236
Bronson Methodist HospitalKalamazoo, Michigan  49007
West Michigan Cancer CenterKalamazoo, Michigan  49007-3731
Borgess Medical CenterKalamazooaa, Michigan  49001
Sparrow Regional Cancer CenterLansing, Michigan  48912-1811
St. John Macomb HospitalWarren, Michigan  48093
Fairview Ridges HospitalBurnsville, Minnesota  55337
Mercy and Unity Cancer Center at Mercy HospitalCoon Rapids, Minnesota  55433
CCOP - DuluthDuluth, Minnesota  55805
Fairview Southdale HospitalEdina, Minnesota  55435
Mercy and Unity Cancer Center at Unity HospitalFridley, Minnesota  55432
Hutchinson Area Health CareHutchinson, Minnesota  55350
Minnesota Oncology Hematology, PA - MaplewoodMaplewood, Minnesota  55109
HealthEast Cancer Care at St. John's HospitalMaplewood, Minnesota  55109
Hennepin County Medical Center - MinneapolisMinneapolis, Minnesota  55415
Virginia Piper Cancer Institute at Abbott - Northwestern HospitalMinneapolis, Minnesota  55407
St. Francis Cancer Center at St. Francis Medical CenterShakopee, Minnesota  55379
Park Nicollet Cancer CenterSt. Louis Park, Minnesota  55416
Regions Hospital Cancer Care CenterSt. Paul, Minnesota  55101
United HospitalSt. Paul, Minnesota  55102
Ridgeview Medical CenterWaconia, Minnesota  55387
Minnesota Oncology Hematology, PA - WoodburyWoodbury, Minnesota  55125
CCOP - MeritCare HospitalFargo, North Dakota  58122
Case Comprehensive Cancer CenterCleveland, Ohio  44106-5065
Natalie Warren Bryant Cancer Center at St. Francis HospitalTulsa, Oklahoma  74136
Sanford Cancer Center at Sanford USD Medical CenterSioux Falls, South Dakota  57117-5039
Medical X-Ray Center, PCSioux Falls, South Dakota  57105
Marshfield Clinic - Marshfield CenterMarshfield, Wisconsin  54449
Medical College of Wisconsin Cancer CenterMilwaukee, Wisconsin  53226
Marshfield Clinic - Indianhead CenterRice Lake, Wisconsin  54868
CCOP - OchsnerNew Orleans, Louisiana  70121
Methodist Medical Center of IllinoisPeoria, Illinois  61636
CCOP - Cancer Research for the OzarksSpringfield, Missouri  65807
CCOP - Montana Cancer ConsortiumBillings, Montana  59101
Newark Beth Israel Medical CenterNewark, New Jersey  07112
CCOP - ColumbusColumbus, Ohio  43206
CCOP - DaytonKettering, Ohio  45429
CCOP - GreenvilleGreenville, South Carolina  29615
Joe Arrington Cancer Research and Treatment CenterLubbock, Texas  79410-1894
LDS HospitalSalt Lake City, Utah  84143
CCOP - Northern Indiana CR ConsortiumSouth Bend, Indiana  46601
Holden Comprehensive Cancer Center at University of IowaIowa City, Iowa  52242-1002
Kimmel Cancer Center at Thomas Jefferson University - PhiladelphiaPhiladelphia, Pennsylvania  19107
Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsBaltimore, Maryland  21231-2410
Kaiser Permanente Medical Center - VallejoVallejo, California  94589
Utah Valley Regional Medical Center - ProvoProvo, Utah  84604
Peninsula Regional Medical CenterSalisbury, Maryland  21801
City of Hope Comprehensive Cancer CenterDuarte, California  91010
John Stoddard Cancer Center at Iowa Methodist Medical CenterDes Moines, Iowa  50309
Kaiser Permanente Medical Center - San Francisco Geary CampusSan Francisco, California  94115
St. Vincent Mercy Medical CenterToledo, Ohio  43608
Swedish Cancer Institute at Swedish Medical Center - First Hill CampusSeattle, Washington  98104
Thompson Cancer Survival CenterKnoxville, Tennessee  37916
Washington Cancer Institute at Washington Hospital CenterWashington, District of Columbia  20010
Harry and Jeanette Weinberg Cancer Institute at Franklin Square Hospital CenterBaltimore, Maryland  21237
Hulston Cancer Center at Cox Medical Center SouthSpringfield, Missouri  65807
Central Baptist HospitalLexington, Kentucky  40503
CCOP - Toledo Community HospitalToledo, Ohio  43623-3456
Kaiser Permanente Medical Center - OaklandSacramento, California  95825
Florida Hospital Cancer Institute at Florida Hospital OrlandoOrlando, Florida  32803-1273
Advocate Christ Medical CenterOak Lawn, Illinois  60453
Via Christi Cancer Center at Via Christi Regional Medical CenterWichita, Kansas  67214
Breslin Cancer Center at Ingham Regional Medical CenterLansing, Michigan  48910
NYU Cancer Institute at New York University Medical CenterNew York, New York  10016
Presbyterian Cancer Center at Presbyterian HospitalCharlotte, North Carolina  28233-3549
Wake Forest University Comprehensive Cancer CenterWinston-Salem, North Carolina  27157-1096
Medical University of Ohio Cancer CenterToledo, Ohio  43614
Toledo HospitalToledo, Ohio  43606
Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center - DallasDallas, Texas  75390
McCreery Cancer Center at Ottumwa RegionalOttumwa, Iowa  52501
Baptist Cancer Institute - JacksonvilleJacksonville, Florida  32207
Hematology-Oncology Centers of the Northern Rockies - BillingsBillings, Montana  59101
St. Peter's HospitalHelena, Montana  59601
Kalispell Regional Medical CenterKalispell, Montana  59901
Glacier Oncology, PLLCKalispell, Montana  59901
Montana Cancer Center at St. Patrick Hospital and Health Sciences CenterMissoula, Montana  59802
Adena Regional Medical CenterChillicothe, Ohio  54601
Doctors Hospital at Ohio HealthColumbus, Ohio  43228
Riverside Methodist Hospital Cancer CareColumbus, Ohio  43214
Grady Memorial HospitalDelaware, Ohio  43015
Fairfield Medical CenterLancaster, Ohio  43130
Strecker Cancer Center at Marietta Memorial HospitalMarietta, Ohio  45750
Licking Memorial Cancer Care Program at Licking Memorial HospitalNewark, Ohio  43055
Community Hospital of Springfield and Clark CountySpringfield, Ohio  45505
Genesis - Good Samaritan HospitalZanesville, Ohio  43701
Logan Regional HospitalLogan, Utah  84321
Group Health Central HospitalSeattle, Washington  98104
Kaiser Permanente Medical Center - Santa Clara Kiely CampusSanta Clara, California  95051-5386
Lucille P. Markey Cancer Center at University of KentuckyLexington, Kentucky  40536-0093
Siteman Cancer Center at Barnes-Jewish Hospital - Saint LouisSt. Louis, Missouri  63110
University of New Mexico Cancer CenterAlbuquerque, New Mexico  87131-5636
Oklahoma University Cancer InstituteOklahoma City, Oklahoma  73104
Kaiser Permanente Medical Center - SacramentoSacramento, California  95825
Decatur Memorial Hospital Cancer Care InstituteDecatur, Illinois  62526
Saint Francis/Mount Sinai Regional Cancer Center at Saint Francis Hospital and Medical CenterHartford, Connecticut  06105
Howard Community HospitalKokomo, Indiana  46904
Mount Carmel Health - West HospitalColumbus, Ohio  43222
Parkland Memorial HospitalDallas, Texas  75235
Lakeland Regional Cancer Center at Lakeland Regional Medical CenterLakeland, Florida  33805
UPMC Cancer CentersPittsburgh, Pennsylvania  15232
Kaiser Permanente - FremontFremont, California  94538
Kaiser Permanente Medical Center - HaywardHayward, California  94545
Kaiser Permanente Medical Center - Redwood CityRedwood City, California  94063
Kaiser Permanente Medical Center - RichmondRichmond, California  94801
Kaiser Permanente Medical Center - RosevilleRoseville, California  95661
South Sacramento Kaiser-Permanente Medical CenterSacramento, California  95823
Kaiser Permanente Medical Office -Vandever Medical OfficeSan Diego, California  92120
Kaiser Permanente Medical Center - Santa TeresaSan Jose, California  95119
Kaiser Foundation Hospital - San RafaelSan Rafael, California  94903
Kaiser Permanente Medical Center - Santa RosaSanta Rosa, California  95403
Kaiser Permanente Medical Center - South San FranciscoSouth San Francisco, California  94080
Kaiser Permanente Medical Facility - StocktonStockton, California  95210
Kaiser Permanente Medical Center - Walnut CreekWalnut Creek, California  94596
Saint Alphonsus Cancer Care Center at Saint Alphonsus Regional Medical CenterBoise, Idaho  83706
St. Joseph Medical CenterBloomington, Illinois  61701
Graham HospitalCanton, Illinois  61520
Memorial HospitalCarthage, Illinois  62321
Eureka Community HospitalEureka, Illinois  61530
Mason District HospitalHavana, Illinois  62644
McDonough District HospitalMacomb, Illinois  61455
BroMenn Regional Medical CenterNormal, Illinois  61761
Community Cancer CenterNormal, Illinois  61761
Community Hospital of OttawaOttawa, Illinois  61350
Cancer Treatment Center at Pekin HospitalPekin, Illinois  61554
Oncology Hematology Associates of Central Illinois, PC - PeoriaPeoria, Illinois  61615
OSF St. Francis Medical CenterPeoria, Illinois  61637
Proctor HospitalPeoria, Illinois  61614
Illinois Valley Community HospitalPeru, Illinois  61354
Perry Memorial HospitalPrinceton, Illinois  61356
St. Francis Hospital and Health Centers - Beech Grove CampusBeech Grove, Indiana  46107
John Stoddard Cancer Center at Iowa Lutheran HospitalDes Moines, Iowa  50316-2301
Medical Oncology and Hematology Associates at John Stoddard Cancer CenterDes Moines, Iowa  50309
Medical Oncology and Hematology Associates at Mercy Cancer CenterDes Moines, Iowa  50314
Mercy Cancer Center at Mercy Medical Center - Des MoinesDes Moines, Iowa  50314
Medical Oncology and Hematology Associates - West Des MoinesWest Des Moines, Iowa  50266
Cancer Center of Kansas, PA - Dodge CityDodge City, Kansas  67801
Hickman Cancer Center at Bixby Medical CenterAdrian, Michigan  49221
Providence Cancer Institute at Providence Hospital - Southfield CampusSouthfield, Michigan  48075
St. Joseph's Medical CenterBrainerd, Minnesota  56401
Immanuel Medical CenterOmaha, Nebraska  68122
Creighton University Medical CenterOmaha, Nebraska  68131-2197
Cancer Institute of New Jersey at Cooper - VoorheesVoorhees, New Jersey  08043
Charles R. Wood Cancer Center at Glens Falls HospitalGlens Falls, New York  12801
Iredell Memorial HospitalStatesville, North Carolina  28677
Forsyth Regional Cancer Center at Forsyth Medical CenterWinston-Salem, North Carolina  27103
Grandview HospitalDayton, Ohio  45405
David L. Rike Cancer Center at Miami Valley HospitalDayton, Ohio  45409
Good Samaritan HospitalDayton, Ohio  45406
Blanchard Valley Medical AssociatesFindlay, Ohio  45840
Charles F. Kettering Memorial HospitalKettering, Ohio  45429
Lima Memorial HospitalLima, Ohio  45804
Middletown Regional HospitalMiddletown, Ohio  45044
St. Charles Mercy HospitalOregon, Ohio  43616
North Coast Cancer Care, IncorporatedSandusky, Ohio  44870
Mercy Hospital of TiffinTiffin, Ohio  44883
Toledo Clinic, Incorporated - Main ClinicToledo, Ohio  43623
UVMC Cancer Care Center at Upper Valley Medical CenterTroy, Ohio  45373-1300
Fulton County Health CenterWauseon, Ohio  43567
Ruth G. McMillan Cancer Center at Greene Memorial HospitalXenia, Ohio  45385
Bon Secours St. Francis Health SystemGreenville, South Carolina  29601
Dixie Regional Medical Center - East CampusSaint George, Utah  84770
Danville Regional Medical CenterDanville, Virginia  24541
Welch Cancer Center at Sheridan Memorial HospitalSheridan, Wyoming  82801
Missouri Baptist Cancer CenterSt. Louis, Missouri  63131
Cancer Resource Center - LincolnLincoln, Nebraska  68510
Allegheny Cancer Center at Allegheny General HospitalPittsburgh, Pennsylvania  15212
Kaiser Permanente - Deer ValleyAntioch, California  94531
Tunnell Cancer Center at Beebe Medical CenterLewes, Delaware  19958
Kaiser Permanente - Moanalua Medical Center and ClinicHonolulu, Hawaii  96819
Elkhart Clinic, LLCElkhart, Indiana  46514-2098
Michiana Hematology-Oncology, PC - South BendMishawaka, Indiana  46545-1470
Reid Hospital & Health Care ServicesRichmond, Indiana  47374
McFarland Clinic, PCAmes, Iowa  50010
Cancer Center of Kansas, PA - ChanuteChanute, Kansas  66720
Cancer Center of Kansas, PA - El DoradoEl Dorado, Kansas  67042
Cancer Center of Kansas - Fort ScottFort Scott, Kansas  66701
Cancer Center of Kansas-IndependenceIndependence, Kansas  67301
Cancer Center of Kansas, PA - KingmanKingman, Kansas  67068
Lawrence Memorial HospitalLawrence, Kansas  66044
Cancer Center of Kansas, PA - LiberalLiberal, Kansas  67905
Cancer Center of Kansas, PA - NewtonNewton, Kansas  67114
Menorah Medical CenterOverland Park, Kansas  66209
Saint Luke's Hospital - SouthOverland Park, Kansas  66213
Cancer Center of Kansas, PA - ParsonsParsons, Kansas  67357
Cancer Center of Kansas, PA - PrattPratt, Kansas  67124
Cancer Center of Kansas, PA - SalinaSalina, Kansas  67401
Cancer Center of Kansas, PA - WellingtonWellington, Kansas  67152
Cancer Center of Kansas, PA - WichitaWichita, Kansas  67214
Associates in Womens Health, PA - North ReviewWichita, Kansas  67208
Cancer Center of Kansas, PA - Medical Arts TowerWichita, Kansas  67208
Cancer Center of Kansas, PA - WinfieldWinfield, Kansas  67156
Ochsner Health Center - BluebonnetBaton Rouge, Louisiana  70809
Foote Memorial HospitalJackson, Michigan  49201
St. Mary Mercy HospitalLivonia, Michigan  48154
Mercy Memorial Hospital - MonroeMonroe, Michigan  48162
St. Joseph Mercy OaklandPontiac, Michigan  48341-2985
Mercy Regional Cancer Center at Mercy HospitalPort Huron, Michigan  48060
Seton Cancer Institute at Saint Mary's - SaginawSaginaw, Michigan  48601
Lakeside Cancer Specialists, PLLCSaint Joseph, Michigan  49085
St. Luke's Hospital Cancer Care CenterDuluth, Minnesota  55805
Fergus Falls Medical Group, PAFergus Falls, Minnesota  56537
Willmar Cancer Center at Rice Memorial HospitalWillmar, Minnesota  56201
St. Joseph Medical CenterKansas City, Missouri  64114
Heartland Hematology Oncology Associates, IncorporatedKansas City, Missouri  64118
North Kansas City HospitalKansas City, Missouri  64116
Saint Luke's Cancer Institute at Saint Luke's HospitalKansas City, Missouri  64111
Research Medical CenterKansas City, Missouri  64132
Saint Luke's East - Lee's SummitLee's Summit, Missouri  64086
Liberty HospitalLiberty, Missouri  64068
Heartland Regional Medical CenterSaint Joseph, Missouri  64506
Billings Clinic - DowntownBillings, Montana  59107-7000
Bozeman Deaconess Cancer CenterBozeman, Montana  59715
St. James Healthcare Cancer CareButte, Montana  59701
Great Falls Clinic - Main FacilityGreat Falls, Montana  59405
Sletten Cancer Institute at Benefis HealthcareGreat Falls, Montana  59405
Kalispell Medical Oncology at KRMCKalispell, Montana  59901
Alegant Health Cancer Center at Bergan Mercy Medical CenterOmaha, Nebraska  68124
Leo W. Jenkins Cancer Center at ECU Medical SchoolGreenville, North Carolina  27834
Mary Rutan HospitalBellefontaine, Ohio  43311
Grant Medical Center Cancer CareColumbus, Ohio  43215
Hematology Oncology CenterElyria, Ohio  44035
Community Cancer CenterElyria, Ohio  44035
Wayne HospitalGreenville, Ohio  45331
Knox Community HospitalMount Vernon, Ohio  43050
Fisher-Titus Medical CenterNorwalk, Ohio  44857
Flower Hospital Cancer CenterSylvania, Ohio  43560
St. Anne Mercy HospitalToledo, Ohio  43623
Mount Carmel St. Ann's Cancer CenterWesterville, Ohio  43081
McGlinn Family Regional Cancer Center at Reading Hospital and Medical CenterReading, Pennsylvania  19612-6052
Sandra L. Maxwell Cancer CenterCedar City, Utah  84720
Val and Ann Browning Cancer Center at McKay-Dee Hospital CenterOgden, Utah  84403
Fredericksburg Oncology, IncorporatedFredericksburg, Virginia  22401
Community Comprehensive Cancer Center at Camden-Clark Memorial HospitalParkersburg, West Virginia  26102
Marshfield Clinic - Chippewa CenterChippewa Falls, Wisconsin  54729
Marshfield Clinic Cancer Care at Regional Cancer CenterEau Claire, Wisconsin  54701
Marshfield Clinic - Lakeland CenterMinocqua, Wisconsin  54548
Ministry Medical Group at Saint Mary's HospitalRhinelander, Wisconsin  54501
Marshfield Clinic at Saint Michael's HospitalStevens Point, Wisconsin  54481
Marshfield Clinic - Weston CenterWeston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids CenterWisconsin Rapids, Wisconsin  54494
Regional Cancer Center at Memorial Medical CenterSpringfield, Illinois  62781-0001
Saint Louis University Cancer CenterSaint Louis, Missouri  63110
St. Joseph Hospital Regional Cancer Center - OrangeOrange, California  92868-3849
Union Hospital of Cecil CountyElkton MD, Maryland  21921
Kinston Medical SpecialistsKinston, North Carolina  28501
Manchester Memorial HospitalManchester, Connecticut  06040-4188
Nalitt Cancer Institute at Staten Island University HospitalStaten Island, New York  10305
Galesburg Clinic, PCGalesburg, Illinois  61401
St. Vincent Healthcare Cancer Care ServicesBillings, Montana  59101
Berkshire Hematology Oncology, PCPittsfield, Massachusetts  01201
Parvin Radiation OncologyKansas City, Missouri  64116
Riddle Memorial Hospital Cancer CenterMedia, Pennsylvania  19063
Associates in Hematology-Oncology, PC at Crozer Regional Cancer CenterUpland, Pennsylvania  19013
University of Colorado Cancer Center at UC Health Sciences CenterAurora, Colorado  80045
Ochsner Health Center - CovingtonCovington, Louisiana  70433
Self Regional Cancer Center at Self Regional Medical CenterGreenwood, South Carolina  29646
Humphrey Cancer Center at North Memorial Outpatient CenterRobbinsdale, Minnesota  55422-2900
Lakeview HospitalStillwater, Minnesota  55082
CCOP - Kansas CityPrairie Village, Kansas  66208
Goldschmidt Cancer CenterJefferson City, Missouri  65109
Comprehensive Cancer Care, PCSaint Louis, Missouri  63141
Butler Memorial HospitalButler, Pennsylvania  16001
Overlake Cancer Center at Overlake Hospital Medical CenterBellevue, Washington  98004
Kaiser Permanente Medical Center - VacavilleVacaville, California  95688
Mercy Cancer Center - West LakesClive, Iowa  50325