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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 Medicine Bronx, New York  10461
Cleveland Clinic Foundation Cleveland, Ohio  44195
University of Iowa Hospitals and Clinics Iowa City, Iowa  52242
Washington University School of Medicine Saint Louis, Missouri  63110
Fox Chase Cancer Center Philadelphia, Pennsylvania  19111
Medical University of South Carolina Charleston, South Carolina  29425-0721
Bronson Methodist Hospital Kalamazoo, Michigan  49007
West Michigan Cancer Center Kalamazoo, Michigan  49007-3731
Borgess Medical Center Kalamazooaa, Michigan  49001
Fairview Ridges Hospital Burnsville, Minnesota  55337
Hutchinson Area Health Care Hutchinson, Minnesota  55350
United Hospital St. Paul, Minnesota  55102
Ridgeview Medical Center Waconia, Minnesota  55387
Geisinger Medical Center Danville, Pennsylvania  17822-0001
Loyola University Medical Center Maywood, Illinois  60153
Henry Ford Hospital Detroit, Michigan  48202
Marshfield Clinic Marshfield, Wisconsin  54449
Methodist Medical Center of Illinois Peoria, Illinois  61636
Memorial Hospital of South Bend South Bend, Indiana  46601
Waukesha Memorial Hospital Waukesha, Wisconsin  53188
North Shore University Hospital Manhasset, New York  11030
Hartford Hospital Hartford, Connecticut  06102-5037
Eastern Maine Medical Center Bangor, Maine  04401
Cancer Institute of New Jersey New Brunswick, New Jersey  08901
University of Nebraska Medical Center Omaha, Nebraska  68198-3330
Wesley Medical Center Wichita, Kansas  67214
Carolinas Medical Center Charlotte, North Carolina  28232-2861
Iowa Methodist Medical Center Des Moines, Iowa  50309
Iowa Lutheran Hospital Des Moines, Iowa  50316-2301
Weill Medical College of Cornell University New York, New York  10021
University of Wisconsin Hospital and Clinics Madison, Wisconsin  53792-0001
Great Falls Clinic Great Falls, Montana  59405
Thompson Cancer Survival Center Knoxville, Tennessee  37916
MetroHealth Medical Center Cleveland, Ohio  44109
Long Island Jewish Medical Center New Hyde Park, New York  11040
Mount Sinai Medical Center New York, New York  10029
Montefiore Medical Center Bronx, New York  10467-2490
Lewistown Hospital Lewistown, Pennsylvania  17044
Mount Nittany Medical Center State College, Pennsylvania  16803
Munson Medical Center Traverse City, Michigan  49684
Kalispell Regional Medical Center Kalispell, Montana  59901
Adena Regional Medical Center Chillicothe, Ohio  54601
Grady Memorial Hospital Delaware, Ohio  43015
Fairfield Medical Center Lancaster, Ohio  43130
Welch Cancer Center Sheridan, Wyoming  82801
University of New Mexico Cancer Center Albuquerque, New Mexico  87131-5636
Cancer Centers of the Carolinas Greenville, South Carolina  29605
Baylor University Medical Center Dallas, Texas  75246
Paoli Memorial Hospital Paoli, Pennsylvania  19301-1792
Elkhart General Hospital Elkhart, Indiana  46515
South Bend Clinic South Bend, Indiana  46617
Arthur G. James Cancer Hospital and Solove Research Institute at Ohio State University Medical Center Columbus, Ohio  43210-1240
University Medical Center of Southern Nevada Las Vegas, Nevada  89102
Beebe Medical Center Lewes, Delaware  19958
Memorial Hospital Carthage, Illinois  62321
Hematology and Oncology Associates Chicago, Illinois  60611
Galesburg Cottage Hospital Galesburg, Illinois  61401
Galesburg Clinic Galesburg, Illinois  61401
Mason District Hospital Havana, Illinois  62644
McDonough District Hospital Macomb, Illinois  61455
BroMenn Regional Medical Center Normal, Illinois  61761
Proctor Hospital Peoria, Illinois  61614
Perry Memorial Hospital Princeton, Illinois  61356
Salina Regional Health Center Salina, Kansas  67401
Saint Francis Medical Center Cape Girardeau, Missouri  63701
Iredell Memorial Hospital Statesville, North Carolina  28677
Grandview Hospital Dayton, Ohio  45405
Bryn Mawr Hospital Bryn Mawr, Pennsylvania  19010
Mountainview Medical Berlin, Vermont  05602
Danville Regional Medical Center Danville, Virginia  24541
Eureka Hospital Eureka, Illinois  61530
Mercy Hospital Coon Rapids, Minnesota  55433
Graham Hospital Association Canton, Illinois  61520
Hematology Oncology Associates of Illinois-Highland Park Highland Park, Illinois  60035
Saint Joseph Medical Center Joliet, Illinois  60435
Pekin Hospital Pekin, Illinois  61554
Medical Oncology and Hematology Associates Des Moines, Iowa  50309
Ottumwa Regional Health Center Ottumwa, Iowa  52501
Fairview-Southdale Hospital Edina, Minnesota  55435
Abbott-Northwestern Hospital Minneapolis, Minnesota  55407
Regions Hospital Saint Paul, Minnesota  55101
Saint Francis Regional Medical Center Shakopee, Minnesota  55379
Rice Memorial Hospital Willmar, Minnesota  56201
Geisinger Medical Group State College, Pennsylvania  16801
Swedish American Hospital Rockford, Illinois  61104
Center for Cancer Care and Research St. Louis, Missouri  63141
Miami Valley Hospital Dayton, Ohio  45409
Lawrence Memorial Hospital Lawrence, Kansas  66044
Menorah Medical Center Overland Park, Kansas  66209
Shawnee Mission Medical Center Shawnee Mission, Kansas  66204
North Kansas City Hospital Kansas City, Missouri  64116
Research Medical Center Kansas City, Missouri  64132
Saint Luke's East - Lee's Summit Lee's Summit, Missouri  64086
Heartland Regional Medical Center Saint Joseph, Missouri  64506
Bozeman Deaconess Cancer Center Bozeman, Montana  59715
Mary Rutan Hospital Bellefontaine, Ohio  43311
Wayne Hospital Greenville, Ohio  45331
Knox Community Hospital Mount Vernon, Ohio  43050
Marshfield Clinic Cancer Care at Regional Cancer Center Eau Claire, Wisconsin  54701
UW Cancer Center Johnson Creek Johnson Creek, Wisconsin  53038
Saint Joseph's Hospital Marshfield, Wisconsin  54449
Marshfield Clinic - Weston Center Weston, Wisconsin  54476
Diagnostic and Treatment Center Weston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids Center Wisconsin Rapids, Wisconsin  54494
Rocky Mountain Oncology Casper, Wyoming  82609
Greene Memorial Hospital Xenia, Ohio  45385
Easton Hospital Easton, Pennsylvania  18042
Harold Alfond Center for Cancer Care Augusta, Maine  04330
Union Hospital of Cecil County Elkton MD, Maryland  21921
Cancer Centers of the Carolinas - Grove Commons Greenville, South Carolina  29605
Cancer Centers of the Carolinas - Seneca Seneca, South Carolina  29672
Cancer Centers of the Carolinas - Spartanburg Spartanburg, South Carolina  29307
Memorial Medical Center Springfield, Illinois  62781
McLeod Regional Medical Center Florence, South Carolina  29501
Vanderbilt University Nashville, Tennessee  37232-6305
University of North Carolina Chapel Hill, North Carolina  27599
Providence Medical Center Kansas City, Kansas  66112
Northwestern University Chicago, Illinois  60611
Hennepin County Medical Center Minneapolis, Minnesota  
Saint Louis University Hospital St. Louis, Missouri  63110-0250
University of Rochester Rochester, New York  14642
Case Western Reserve University Cleveland, Ohio  44106
New Hampshire Oncology-Hematology PA Hooksett, New Hampshire  03106
Riverside Methodist Hospital Columbus, Ohio  43214
Licking Memorial Hospital Newark, Ohio  43055-2899
Dartmouth Hitchcock Medical Center Lebanon, New Hampshire  03756
Columbus CCOP Columbus, Ohio  43206
Weiss Memorial Hospital Chicago,, Illinois  60640
University Of Vermont Burlington,, Vermont  05403
Montana Cancer Consortium CCOP Billings, Montana  59101
Metro-Minnesota CCOP St. Louis Park, Minnesota  
Cancer Centers of the Carolinas - Easley Easley, South Carolina  29640
Lakeview Hospital Stillwater, Minnesota  55082
Decatur Memorial Hospital Decatur, Illinois  62526
Virginia Commonwealth University Richmond, Virginia  
Lankenau Hospital Wynnewood, Pennsylvania  19096
Montana Cancer Specialists Missoula, Montana  59807-7877
University of Chicago Comprehensive Cancer Center Chicago, Illinois  60637-1470
Northern Indiana Cancer Research Consortium South Bend, Indiana  
Norwalk Hospital Norwalk, Connecticut  06856
Penn State Milton S Hershey Medical Center Hershey, Pennsylvania  17033
Hays Medical Center Hays, Kansas  67601
Wake Forest University Health Sciences Winston-Salem, North Carolina  27157
OSF Saint Francis Medical Center Peoria, Illinois  61637
Palo Alto Medical Foundation-Camino Division Mountain View, California  94040
Palo Alto Medical Foundation Heath Care Palo Alto, California  94301
Saint Francis Hospital and Medical Center Hartford, Connecticut  06105
Lombardi Comprehensive Cancer Center at Georgetown University Washington, District of Columbia  20057
M D Anderson Cancer Center- Orlando Orlando, Florida  32806
Saint Anthony's Health Alton, Illinois  62002
Cancer Institute at Alexian Brothers Elk Grove Village, Illinois  60007
Evanston CCOP-NorthShore University HealthSystem Evanston, Illinois  60201
Hopedale Medical Complex - Hospital Hopedale, Illinois  61747
Joliet Oncology-Hematology Associates Limited Joliet, Illinois  60435
Midwest Center for Hematology Oncology Joliet, Illinois  60432
Provena Saint Mary's Hospital Kankakee, Illinois  60901
North Shore Hematology Oncology Libertyville, Illinois  60048
Good Samaritan Regional Medical Center Mt. Vernon, Illinois  62864
Community Cancer Center Foundation Normal, Illinois  61761
Illinois CancerCare-Ottawa Clinic Ottawa, Illinois  61350
Ottawa Regional Hospital and Healthcare Center Ottawa, Illinois  61350
Pekin Cancer Treatment Center Pekin, Illinois  61554
Illinois Oncology Research Association CCOP Peoria, Illinois  61615
Illinois CancerCare-Peoria Peoria, Illinois  61615
Illinois Valley Hospital Peru, Illinois  61354
Hematology Oncology Associates of Illinois - Skokie Skokie, Illinois  60076
Saint Margaret's Hospital Spring Valley, Illinois  61362
Carle Clinic-Urbana Main Urbana, Illinois  61801
Saint Francis Hospital and Health Centers Beech Grove, Indiana  46107
Fort Wayne Medical Oncology and Hematology Inc - State Boulevard Fort Wayne, Indiana  46845
Reid Hospital and Health Care Services Richmond, Indiana  47374
McFarland Clinic Ames, Iowa  50010
Medical Oncology and Hematology Associates-West Des Moines Clive, Iowa  50325
Iowa Oncology Research Association CCOP Des Moines, Iowa  50309
Mercy Medical Center - Des Moines Des Moines, Iowa  50314
Medical Oncology and Hematology Associates-Des Moines Des Moines, Iowa  50309
Mercy Medical Center-Sioux City Sioux City, Iowa  51104
Saint Luke's Regional Medical Center Sioux City, Iowa  51104
Saint Francis Hospital and Medical Center - Topeka Topeka, Kansas  66606
Grand Rapids Clinical Oncology Program Grand Rapids, Michigan  49503
Lakeland Hospital St. Joseph, Michigan  49085
Unity Hospital Fridley, Minnesota  55432
Saint John's Hospital - Healtheast Maplewood, Minnesota  55109
Minnesota Oncology Hematology PA-Maplewood Maplewood, Minnesota  55109
Minneapolis Veterans Medical Center Minneapolis, Minnesota  55417
North Memorial Medical Health Center Robbinsdale, Minnesota  55422
Park Nicollet Clinic - Saint Louis Park Saint Louis Park, Minnesota  55416
Minnesota Oncology and Hematology PA-Woodbury Woodbury, Minnesota  55125
Saint Luke's Hospital of Kansas City Kansas City, Missouri  64111
Saint Joseph Health Center Kansas City, Missouri  64114
Liberty Radiation Oncology Clinic Kansas City, Missouri  64116
Truman Medical Center Kansas City, Missouri  64108
Saint Louis-Cape Girardeau CCOP Saint Louis, Missouri  63141
Saint John's Mercy Medical Center Saint Louis, Missouri  63141
Saint John's Hospital Springfield, Missouri  65804
Hematology-Oncology Centers of the Northern Rockies PC Billings, Montana  59101
Saint Vincent Healthcare Billings, Montana  59101
Billings Clinic Billings, Montana  59107-7000
Benefis Healthcare- Sletten Cancer Institute Great Falls, Montana  59405
Saint Peter's Community Hospital Helena, Montana  59601
Glacier Oncology PLLC Kalispell, Montana  59901
Saint Patrick Hospital - Community Hospital Missoula, Montana  59802
Nevada Cancer Research Foundation CCOP Las Vegas, Nevada  89106
New Hampshire Oncology Hematology Associates Hooksett, New Hampshire  03106
LRGHealthcare-Lakes Region General Hospital Laconia, New Hampshire  03246
Cooper Hospital University Medical Center Camden, New Jersey  08103
Veterans Adminstration New Jersey Health Care System East Orange, New Jersey  07018-1095
Fox Chase Cancer Center at Virtua Memorial Hospital of Burlington County Mount Holly, New Jersey  08060
Memorial Medical Center - Las Cruces Las Cruces, New Mexico  88011
New York University Langone Medical Center New York, New York  10016
State University of New York Upstate Medical University Syracuse, New York  13210
Mission Hospitals Inc Asheville, North Carolina  28801
Wayne Memorial Hospital Goldsboro, North Carolina  27534
Margaret R Pardee Memorial Hospital Hendersonville, North Carolina  28791
Kinston Medical Specialists PA Kinston, North Carolina  28501
Aultman Health Foundation Canton, Ohio  44710
Doctors Hospital Columbus, Ohio  43228
Grant Medical Center Columbus, Ohio  43215
Mount Carmel Health Center West Columbus, Ohio  43222
Good Samaritan Hospital - Dayton Dayton, Ohio  45406
Dayton CCOP Dayton, Ohio  45429
Samaritan North Health Center Dayton, Ohio  45415
Blanchard Valley Hospital Findlay, Ohio  45840
Atrium Medical Center-Middletown Regional Hospital Franklin, Ohio  45005-1066
Kettering Medical Center Kettering, Ohio  45429
Marietta Memorial Hospital Marietta, Ohio  45750
Upper Valley Medical Center Troy, Ohio  45373
Saint Ann's Hospital Westerville, Ohio  43081
Genesis HealthCare System Zanesville, Ohio  43701
Pottstown Memorial Medical Center Pottstown, Pennsylvania  19464
Geisinger Wyoming Valley Wilkes-Barre, Pennsylvania  18711
Mainline Health CCOP Wynnewood, Pennsylvania  19096
Greenville CCOP Greenville, South Carolina  29615
Greenville Memorial Hospital Greenville, South Carolina  29605
West Virginia University Morgantown, West Virginia  26506
Sacred Heart Hospital Eau Claire, Wisconsin  54701
Saint Vincent Hospital Green Bay, Wisconsin  54301
Saint Mary's Hospital Green Bay, Wisconsin  54303
Bay Area Medical Center Marinette, Wisconsin  54143
Marshfield Clinic-Minocqua Center Minocqua, Wisconsin  54548
Oconomowoc Memorial Hospital-ProHealth Care Inc Oconomowoc, Wisconsin  53066-3896
Marshfield Clinic at James Beck Cancer Center Rhinelander, Wisconsin  54501
Marshfield Clinic-Rice Lake Center Rice Lake, Wisconsin  54868
Saint Michael's Hospital Stevens Point, Wisconsin  54481
University of Maryland Greenebaum Cancer Center Baltimore, Maryland  21201
Olathe Cancer Center Olathe, Kansas  66061
Jupiter Medical Center Jupiter, Florida  33458
Stony Brook University Medical Center Stony Brook, New York  11794
Lahey Clinic Medical Center Burlington, Massachusetts  01805
Elkhart Clinic Elkhart, Indiana  46515
Mount Sinai Medical Center CCOP Miami Beach, Florida  33140
Illinois CancerCare-Bloomington Bloomington%, Illinois  61701
Illinois CancerCare-Canton Canton, Illinois  61520
Illinois CancerCare-Eureka Eureka, Illinois  61530
Illinois CancerCare-Macomb Macomb, Illinois  61455
Illinois CancerCare-Community Cancer Center Normal, Illinois  61761
Illinois CancerCare-Pekin Pekin, Illinois  61603
Illinois CancerCare-Peru Peru, Illinois  61354
Illinois CancerCare-Spring Valley Spring Valley, Illinois  61362
Michiana Hematology Oncology PC-Elkhart Elkhart, Indiana  46514
Michiana Hematology Oncology PC-Plymouth Plymouth, Indiana  46563
Michiana Hematology Oncology PC-South Bend South Bend, Indiana  46601
Michiana Hematology Oncology-PC Westville Westville, Indiana  46391
Michiana Hematology Oncology PC-Niles Niles, Michigan  49120
University of Missouri - Ellis Fischel Columbia, Missouri  65203
East Carolina University Greenville, North Carolina  27858
Cancer Centers of the Carolinas - Faris Greenville, South Carolina  29605
Cancer Centers of the Carolinas-Greer Radiation Oncology Greer, South Carolina  29650
Cancer Centers of the Carolinas-Greer Medical Oncology Greer, South Carolina  29650
Marshfield Clinic-Chippewa Center Chippewa Falls, Wisconsin  54729
Holy Family Memorial Hospital Manitowoc, Wisconsin  54221
Marshfield Clinic Cancer Care at Saint Michael's Hospital Stevens Point, Wisconsin  54481
Monter Cancer Center Lake Success, New York  11042
Palchak David MD Pismo Beach, California  93449
Central DuPage Hospital Cancer Center Warrenville, Illinois  60555
Saint Luke's South Hospital Overland Park, Kansas  66213
Kansas City CCOP Prairie Village, Kansas  66208
Doctors Carrol, Sheth, Raghavan Louisville, Kentucky  40215
Heartland Hematology and Oncology Associates Incorporated Kansas City, Missouri  64118
Saint Joseph Oncology Inc Saint Joseph, Missouri  64507
Memorial Hospital Of Martinsville Martinsville, Virginia  24115
Gundersen Lutheran La Crosse, Wisconsin  54601
Saint Nicholas Hospital Madison, Wisconsin  53715
Siouxland Hematology Oncology Associates Sioux City, Iowa  51101
Walter Reed National Military Medical Center Bethesda, Maryland  20889
VA Medical Center - University of Iowa Iowa City, Iowa  52246
Norris Cotton Cancer Center-Manchester Manchester, New Hampshire  03104
Michiana Hematology Oncology PC-Mishawaka Mishawaka, Indiana  46545-1470
Marie Yeager Cancer Center Saint Joseph, Michigan  49085
Hematology Oncology Associates of Central New York PC East Syracuse, New York  13057
Geisinger Medical Center-Cancer Center Hazelton Hazleton, Pennsylvania  18201
Community Howard Regional Health Kokomo, Indiana  46904
Indiana University Health La Porte Hospital La Porte, Indiana  46350
Saint Joseph Regional Medical Center-Mishawaka Mishawaka, Indiana  46545-1470
Via Christi Hospital-Pittsburg Pittsburg, Kansas  66762
Christiana Care Health System-Christiana Hospital Newark, Delaware  19718
Illinois Cancer Specialists-Niles Niles, Illinois  60714
Springfield Regional Medical Center Springfield, Ohio  45505
Promise Regional Medical Center-Hutchinson Hutchinson, Kansas  65702
Saint Louis Cancer and Breast Institute-South City Saint Louis, Missouri  63109
Self Regional Healthcare Greenwood, South Carolina  29646