Know Cancer

or
forgot password

A Randomized Phase III Trial of Neoadjuvant Therapy in Patients With Palpable and Operable Breast Cancer Evaluating the Effect on Pathologic Complete Response (pCR) of Adding Capecitabine or Gemcitabine to Docetaxel When Administered Before AC With or Without Bevacizumab and Correlative Science Studies Attempting to Identify Predictors of High Likelihood for pCR With Each of the Regimens


Phase 3
18 Years
N/A
Open (Enrolling)
Female
Breast Cancer

Thank you

Trial Information

A Randomized Phase III Trial of Neoadjuvant Therapy in Patients With Palpable and Operable Breast Cancer Evaluating the Effect on Pathologic Complete Response (pCR) of Adding Capecitabine or Gemcitabine to Docetaxel When Administered Before AC With or Without Bevacizumab and Correlative Science Studies Attempting to Identify Predictors of High Likelihood for pCR With Each of the Regimens


OBJECTIVES:

Primary

- Compare the efficacy of docetaxel followed by doxorubicin hydrocloride and
cyclophosphamide (AC) vs docetaxel and capecitabine followed by AC vs docetaxel and
gemcitabine hydrochloride followed by AC, with or without bevacizumab, in terms of an
increase in the rate of pathologic complete response (pCR) in the breast, in women with
palpable or operable breast cancer.

Secondary

- Compare docetaxel/capecitabine with AC vs docetaxel/gemcitabine hydrochloride with AC
vs docetaxel with AC, with or without bevacizumab, in terms of the rate of pCR in the
breast and all post-therapy lymph nodes evaluated histologically (pCR breast and
nodes).

- Determine whether the addition of bevacizumab to the docetaxel/anthracycline-based
regimens (docetaxel with AC, docetaxel and capecitabine with AC, and docetaxel and
gemcitabine hydrochloride with AC) will increase the rate of pCR of the breast and
nodes compared to the same docetaxel/anthracycline-based regimens without bevacizumab
in these patients.

- Determine whether the addition of capecitabine or gemcitabine hydrochloride to
docetaxel, with or without bevacizumab, will increase the rate of clinical overall
response (cOR) compared to docetaxel alone with or without bevacizumab in these
patients.

- Determine whether the addition of bevacizumab to the docetaxel/anthracycline-based
regimens will increase the rate of cOR compared to the same
docetaxel/anthracycline-based regimens without bevacizumab in these patients.

- Determine whether the addition of capecitabine or gemcitabine hydrochloride to
docetaxel, with or without bevacizumab, will increase the rate of clinical complete
response (cCR) compared to docetaxel alone with or without bevacizumab in these
patients.

- Determine whether the addition of bevacizumab to the docetaxel/anthracycline-based
regimens (docetaxel with AC, docetaxel/capecitabine with AC, and docetaxel/gemcitabine
hydrochloride with AC) will increase the rate of cCR compared to the same
docetaxel/anthracycline-based regimens without bevacizumab in these patients.

- Identify gene expression profiles that can predict pCR in patients treated with the
different sequential docetaxel/anthracycline-based regimens with or without
bevacizumab.

- Identify gene expression profiles that can predict cOR in patients treated with
docetaxel alone, docetaxel/capecitabine, or docetaxel/gemcitabine hydrochloride with or
without bevacizumab.

- Determine the accuracy of an in vitro chemoresponse assay (ChemoFx®) as a predictor of
pCR in patients treated with the different sequential docetaxel/anthracycline-based
regimens without bevacizumab.

- Determine the accuracy of ChemoFx® as a predictor of cOR in patients treated with
docetaxel alone, docetaxel/capecitabine, or docetaxel/gemcitabine hydrochloride without
bevacizumab in these patients.

- Determine the impact of preoperative bevacizumab and sequential chemotherapy regimens
and postoperative bevacizumab therapy on cardiac function in these patients.

- Determine the impact of bevacizumab on surgical complications in these patients.

- Determine the toxicity of the preoperative regimens and the toxicity of postoperative
bevacizumab in these patients.

- Compare the docetaxel/anthracycline-based regimens with vs without bevacizumab, in
terms of an increase in disease-free survival, of these patients.

OUTLINE: This is a randomized, multicenter study. Patients are stratified according to tumor
size (2-4 cm vs > 4 cm), nodal status (negative vs positive), hormone receptor status
(estrogen receptor [ER]-positive and/or progesterone-receptor [PgR]-positive vs ER- and
PgR-negative), and age (< 50 years vs ≥ 50 years). Patients are randomized to 1 of 6
treatment arms.

Core needle biopsies are performed at baseline. Tumor tissue samples are also collected
during definitive surgery. Samples are examined for gene expression and polymorphism by
reverse transcriptase-polymerase chain reaction analysis and chemoresponse assay (ChemoFx®).

After completion of study therapy, patients are followed periodically for 10 years.

PROJECTED ACCRUAL: A total of 1,200 patients will be accrued for this study.


Inclusion Criteria:



- The patient must have consented to participate and must have signed and dated an
appropriate Institutional Review Board (IRB)-approved consent form that conforms to
federal and institutional guidelines for the study treatment and submission of
pre-entry core biopsy material for correlative studies.

- Patients must be female.

- Patients must be 18 years of age or older.

- Patients must have an Eastern Cooperative Oncology Group (ECOG) performance status of
0 or 1.

- The diagnosis of invasive adenocarcinoma of the breast must have been made by core
needle biopsy.

- The primary breast tumor must be palpable and measure greater than or equal to 2.0 cm
on physical exam.

- All patients must have their left ventricular ejection fraction (LVEF) assessed by
multigated acquisition (MUGA) scan or echocardiogram within 3 months prior to study
entry. The LVEF must be greater than or equal to the lower limit of normal (LLN) for
the cardiac imaging facility performing the study. Note: If the cardiac imaging
facility cannot provide a LLN, use 50% as the LLN value.

- Note: Since the pre-entry LVEF serves as the baseline for comparing subsequent LVEF
assessments to determine if bevacizumab therapy can be continued, it is critical that
this baseline study be an accurate assessment of the patient's LVEF. If the baseline
LVEF is greater than 75%, the investigator should have the study reviewed for
accuracy prior to study entry. Following study entry, the LVEF determination may be
reviewed up until the time of the post-chemotherapy (preoperative) evaluation.
Please note that if a more accurate value is obtained from the review of the baseline
MUGA or echocardiogram, the correct value must be submitted to the NSABP before the
post-chemotherapy (preoperative) MUGA or echocardiogram is performed or it cannot be
used for managing postoperative bevacizumab.

- All patients must have an EKG within 3 months prior to study entry.

- At the time of randomization:

- Absolute neutrophil count (ANC) must be greater than or equal to 1200/mm3.

- Platelet count must be greater than or equal to 100,000/mm3.

- Hemoglobin must be greater than or equal to 10 g/dL.

- There must be evidence of adequate hepatic function by these criteria:

- Total bilirubin must be less than or equal to the ULN for the lab unless the
patient has a grade 1 bilirubin elevation (greater than ULN to 1.5 x ULN)
resulting from Gilbert's disease or similar syndrome due to slow conjugation of
bilirubin; and

- Alkaline phosphatase must be less than or equal 2.5 x ULN for the lab; and

- Aspartate Aminotransferase (AST) must be less than or equal to 1.5 x ULN for the
lab.

- Alkaline phosphatase and AST may not both be greater than the ULN. For example,
if the alkaline phosphatase is greater than the ULN but less than or equal 2.5 x
ULN, then the AST must be less than or equal the ULN. If the AST is greater
than the ULN but less than or equal 1.5 x ULN, then the alkaline phosphatase
must be less than or equal ULN.

- Patients with either skeletal pain or alkaline phosphatase that is greater than ULN
but less than or equal 2.5 x ULN are eligible for inclusion in the study if bone
scans do not demonstrate metastatic disease. Suspicious findings on bone scan must
be confirmed as benign by x-ray, MRI, or biopsy.

- Patients with AST or alkaline phosphatase greater than ULN are eligible for inclusion
in the study if liver imaging does not demonstrate metastatic disease and adequate
bone marrow and liver function results as described above are met.

- The following criteria for evidence of adequate renal function must be met:

- Serum creatinine less than or equal ULN for the lab.

- Calculated creatinine clearance must be greater than 50 mL/min.

- Urine protein/urine creatinine (UPC) ratio must be less than 1.0.

- Patient must be able to swallow oral medications.

Exclusion criteria:

- Tumor determined to be strongly human epidermal growth factor receptor 2
(HER2)-positive by immunohistochemistry (3+) or by fluorescent in situ hybridization
(positive for gene amplification).

- Excisional or incisional biopsy for this primary breast tumor.

- Surgical axillary staging procedure prior to study entry. Exceptions: 1) Fine
Needle Aspiration (FNA) or core biopsy of an axillary node is permitted for any
patient, and 2) although not recommended, a pre-neoadjuvant therapy sentinel lymph
node biopsy for patients with clinically negative axillary nodes is permitted.

- Tumors clinically staged as T4.

- Ipsilateral cN2b or cN3 disease. (Patients with cN1 or cN2a disease are eligible.)

- Definitive clinical or radiologic evidence of metastatic disease.

- Synchronous bilateral breast cancer (invasive or DCIS).

- Treatment including radiation therapy, chemotherapy, biotherapy, and/or hormonal
therapy for the currently diagnosed breast cancer prior to study entry.

- Any sex hormonal therapy, e.g., birth control pills, ovarian hormonal replacement
therapy, etc. (These patients are eligible if this therapy is discontinued prior to
randomization.)

- Therapy with any hormonal agent such as raloxifene, tamoxifen, or other selective
estrogen receptor modulator (SERM), either for osteoporosis or breast cancer
prevention. (Patients are eligible only if these medications are discontinued prior
to randomization.)

- Prior history of breast cancer, including DCIS. (Patients with a history of lobular
carcinoma in situ [LCIS] are eligible.)

- Prior therapy with anthracyclines, taxanes, capecitabine, 5-FU, gemcitabine, or
bevacizumab for any malignancy.

- Other malignancies unless the patient is considered to be disease-free for 5 or more
years prior to randomization and is deemed by her physician to be at low risk for
recurrence. Patients with the following cancers are eligible if diagnosed and
treated within the past 5 years: carcinoma in situ of the cervix, carcinoma in situ
of the colon, melanoma in situ, and basal cell and squamous cell carcinoma of the
skin.

- Cardiac disease that would preclude the use of anthracyclines. This includes:

- angina pectoris that requires the use of anti-anginal medication;

- history of documented congestive heart failure;

- serious cardiac arrhythmia requiring medication;

- severe conduction abnormality;

- valvular disease with documented cardiac function compromise; and

- uncontrolled hypertension defined as BP greater than 150/90 on antihypertensive
therapy. (Patients with hypertension that is well controlled on medication are
eligible.)

- History of myocardial infarction documented by elevated cardiac enzymes or persistent
regional wall abnormalities on assessment of LV function.

- History of transient ischemic attack (TIA) or cerebrovascular accident (CVA).

- History of other arterial thrombotic event within 12 months before study entry.

- Symptomatic peripheral vascular disease.

- Any significant non-traumatic bleeding within 6 months before study entry.

- Serious or non-healing wound, skin ulcers, or incompletely healed bone fracture.

- Gastroduodenal ulcer(s) determined by endoscopy to be active.

- Invasive procedures defined as follows:

- Major surgical procedure, open biopsy, or significant traumatic injury within 28
days prior to planned start of study therapy. (Note: Placement of a vascular
access device is not considered a major surgical procedure.)

- Anticipation of need for major surgical procedures (other than the required
breast surgery) during the course of the study.

- Known bleeding diathesis or coagulopathy. (Patients on warfarin with an in-range
international normalized ration [INR] [usually between 2 and 3] are eligible.)

- Sensory/motor neuropathy greater than or equal grade 2, as defined by the NCI's
Common Terminology Criteria for Adverse Events Version 3.0 (CTCAE v3.0).

- Other non-malignant systemic disease (cardiovascular, renal, hepatic, etc.) that
would preclude treatment with any of the treatment regimens or would prevent required
follow-up.

- Conditions that would prohibit administration of corticosteroids.

- History of severe hypersensitivity reaction to drugs formulated with polysorbate 80.

- Administration of any investigational agents within 30 days before study entry.

- Pregnancy or lactation at the time of proposed randomization.

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:

Pathologic complete response (pCR) of the primary tumor in the breast

Outcome Description:

No histologic evidence of invasive tumor cells in the breast specimen removed at surgery

Outcome Time Frame:

Time of surgery, on average 6 or 13 months

Safety Issue:

No

Principal Investigator

Norman Wolmark, MD

Investigator Role:

Principal Investigator

Investigator Affiliation:

NSABP Foundation, Inc.

Authority:

United States: Food and Drug Administration

Study ID:

NSABP B-40

NCT ID:

NCT00408408

Start Date:

November 2006

Completion Date:

March 2016

Related Keywords:

  • Breast Cancer
  • stage I breast cancer
  • stage II breast cancer
  • stage IIIA breast cancer
  • Breast Neoplasms

Name

Location

Cardinal Bernardin Cancer Center at Loyola University Medical Center Maywood, Illinois  60153-5500
CCOP - Upstate Carolina Spartanburg, South Carolina  29303
CCOP - Wichita Wichita, Kansas  67214-3882
Hurley Medical Center Flint, Michigan  48503
University of Texas Health Science Center at San Antonio San Antonio, Texas  78284-7811
CCOP - Kansas City Kansas City, Missouri  64131
CCOP - Missouri Valley Cancer Consortium Omaha, Nebraska  68131
CCOP - Christiana Care Health Services Wilmington, Delaware  19899
CCOP - Mount Sinai Medical Center Miami Beach, Florida  33140
CCOP - Illinois Oncology Research Association Peoria, Illinois  61602
CCOP - Metro-Minnesota Saint Louis Park, Minnesota  55416
Aurora Presbyterian Hospital Aurora, Colorado  80012
Boulder Community Hospital Boulder, Colorado  80301-9019
Penrose Cancer Center at Penrose Hospital Colorado Springs, Colorado  80933
CCOP - Colorado Cancer Research Program Denver, Colorado  80224-2522
Porter Adventist Hospital Denver, Colorado  80210
Presbyterian - St. Luke's Medical Center Denver, Colorado  80218
St. Joseph Hospital Denver, Colorado  80218
Rose Medical Center Denver, Colorado  80220
Swedish Medical Center Englewood, Colorado  80110
St. Mary's Regional Cancer Center at St. Mary's Hospital and Medical Center Grand Junction, Colorado  81502
Sky Ridge Medical Center Lone Tree, Colorado  80124
Hope Cancer Care Center at Longmont United Hospital Longmont, Colorado  80502
St. Mary - Corwin Regional Medical Center Pueblo, Colorado  81004
North Suburban Medical Center Thornton, Colorado  80229
Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center Farmington, Connecticut  06360-2875
CCOP - Michigan Cancer Research Consortium Ann Arbor, Michigan  48106
Saint Joseph Mercy Cancer Center Ann Arbor, Michigan  48106-0995
Oakwood Cancer Center at Oakwood Hospital and Medical Center Dearborn, Michigan  48123-2500
Genesys Hurley Cancer Institute Flint, Michigan  48503
Van Elslander Cancer Center at St. John Hospital and Medical Center Grosse Pointe Woods, Michigan  48236
Bronson Methodist Hospital Kalamazoo, Michigan  49007
West Michigan Cancer Center Kalamazoo, Michigan  49007-3731
Borgess Medical Center Kalamazooaa, Michigan  49001
Sparrow Regional Cancer Center Lansing, Michigan  48912-1811
St. John Macomb Hospital Warren, Michigan  48093
Fairview Ridges Hospital Burnsville, Minnesota  55337
Mercy and Unity Cancer Center at Mercy Hospital Coon Rapids, Minnesota  55433
Duluth Clinic Cancer Center - Duluth Duluth, Minnesota  55805-1983
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
Minnesota Oncology Hematology, PA - Maplewood Maplewood, Minnesota  55109
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
Hubert H. Humphrey Cancer Center at North Memorial Outpatient Center Robbinsdale, Minnesota  55422-2900
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
Minnesota Oncology Hematology, PA - Woodbury Woodbury, Minnesota  55125
Aultman Cancer Center at Aultman Hospital Canton, Ohio  44710-1799
Case Comprehensive Cancer Center Cleveland, Ohio  44106-5065
Penn State Cancer Institute at Milton S. Hershey Medical Center Hershey, Pennsylvania  17033-0850
Geisinger Medical Group - Scenery Park State College, Pennsylvania  16801
Frank M. and Dorothea Henry Cancer Center at Geisinger Wyoming Valley Medical Center Wilkes-Barre, Pennsylvania  18711
Sanford Cancer Center at Sanford USD Medical Center Sioux Falls, South Dakota  57117-5039
Medical X-Ray Center, PC Sioux Falls, South Dakota  57105
Marshfield Clinic - Marshfield Center Marshfield, Wisconsin  54449
Medical College of Wisconsin Cancer Center Milwaukee, Wisconsin  53226
Marshfield Clinic - Indianhead Center Rice Lake, Wisconsin  54868
CCOP - Ochsner New Orleans, Louisiana  70121
CCOP - Bay Area Tumor Institute Oakland, California  94609-3305
Methodist Medical Center of Illinois Peoria, Illinois  61636
Memorial Hospital of South Bend South Bend, Indiana  46601
CCOP - Cancer Research for the Ozarks Springfield, Missouri  65807
CCOP - Montana Cancer Consortium Billings, Montana  59101
Newark Beth Israel Medical Center Newark, New Jersey  07112
CCOP - Dayton Kettering, Ohio  45429
CCOP - Greenville Greenville, South Carolina  29615
LDS Hospital Salt Lake City, Utah  84143
Rush University Medical Center Chicago, Illinois  60612-3824
CCOP - Northern Indiana CR Consortium South Bend, Indiana  46601
Saint Joseph Regional Medical Center South Bend, Indiana  46617
Holden Comprehensive Cancer Center at University of Iowa Iowa City, Iowa  52242-1002
Ellis Fischel Cancer Center at University of Missouri - Columbia Columbia, Missouri  65203
MultiCare Regional Cancer Center at Tacoma General Hospital Tacoma, Washington  98405
Cancer Research Center of Hawaii Honolulu, Hawaii  96813
MBCCOP - LSU Health Sciences Center New Orleans, Louisiana  70112
CCOP - St. Louis-Cape Girardeau Saint Louis, Missouri  63141
CCOP - Northwest Tacoma, Washington  98405-0986
Kaiser Permanente Medical Center - Vallejo Vallejo, California  94589
Utah Valley Regional Medical Center - Provo Provo, Utah  84604
Peninsula Regional Medical Center Salisbury, Maryland  21801
Wesley Medical Center Wichita, Kansas  67214
Fletcher Allen Health Care - University Health Center Campus Burlington, Vermont  05401
Kaiser Permanente Medical Center - San Francisco Geary Campus San Francisco, California  94115
St. Vincent Mercy Medical Center Toledo, Ohio  43608
Arkansas Cancer Research Center at University of Arkansas for Medical Sciences Little Rock, Arkansas  72205
Josephine Ford Cancer Center at Henry Ford Hospital Detroit, Michigan  48202
Thompson Cancer Survival Center Knoxville, Tennessee  37916
James Graham Brown Cancer Center at University of Louisville Louisville, Kentucky  40202
Blumenthal Cancer Center at Carolinas Medical Center Charlotte, North Carolina  28232-2861
Hulston Cancer Center at Cox Medical Center South Springfield, Missouri  65807
St. John's Regional Health Center Springfield, Missouri  65804
McDowell Cancer Center at Akron General Medical Center Akron, Ohio  44307
Cancer Institute of New Jersey at Hamilton Hamilton, New Jersey  08690
CCOP - Toledo Community Hospital Toledo, Ohio  43623-3456
Loma Linda University Cancer Institute at Loma Linda University Medical Center Loma Linda, California  92354
Kaiser Permanente Medical Center - Oakland Sacramento, California  95825
Broward General Medical Center Cancer Center Ft. Lauderdale, Florida  33316
Florida Hospital Cancer Institute at Florida Hospital Orlando Orlando, Florida  32803-1273
St. Vincent Indianapolis Hospital Indianapolis, Indiana  46260
Via Christi Cancer Center at Via Christi Regional Medical Center Wichita, Kansas  67214
Ochsner Cancer Institute at Ochsner Clinic Foundation New Orleans, Louisiana  70121
Breslin Cancer Center at Ingham Regional Medical Center Lansing, Michigan  48910
Presbyterian Cancer Center at Presbyterian Hospital Charlotte, North Carolina  28233-3549
Wake Forest University Comprehensive Cancer Center Winston-Salem, North Carolina  27157-1096
Medical University of Ohio Cancer Center Toledo, Ohio  43614
Toledo Hospital Toledo, Ohio  43606
Hollings Cancer Center at Medical University of South Carolina Charleston, South Carolina  29425
Mary Babb Randolph Cancer Center at West Virginia University Hospitals Morgantown, West Virginia  26506
Our Lady of Mercy Medical Center Comprehensive Cancer Center Bronx, New York  10466
Mount Nittany Medical Center State College, Pennsylvania  16803
Sibley Memorial Hospital Washington, District of Columbia  20016
Batte Cancer Center at Northeast Medical Center Concord, North Carolina  28025
North Colorado Medical Center Greeley, Colorado  80631
McKee Medical Center Loveland, Colorado  80539
Baptist Cancer Institute - Jacksonville Jacksonville, Florida  32207
Saint Anthony's Hospital at Saint Anthony's Health Center Alton, Illinois  62002
Good Samaritan Regional Health Center Mt. Vernon, Illinois  62864
Southwest Medical Center Liberal, Kansas  67901
David C. Pratt Cancer Center at St. John's Mercy St. Louis, Missouri  63141
Northern Rockies Radiation Oncology Center Billings, Montana  59101
Hematology-Oncology Centers of the Northern Rockies - Billings Billings, Montana  59101
Big Sky Oncology Great Falls, Montana  59405
St. Peter's Hospital Helena, Montana  59601
Kalispell Regional Medical Center Kalispell, Montana  59901
Glacier Oncology, PLLC 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
Community Medical Center Missoula, Montana  59801
Wayne Memorial Hospital, Incorporated Goldsboro, North Carolina  27534
American Fork Hospital American Fork, Utah  84003
Utah Cancer Specialists at UCS Cancer Center Salt Lake City, Utah  84106
Greenebaum Cancer Center at University of Maryland Medical Center Baltimore, Maryland  21201
Kaiser Permanente Medical Center - Santa Clara Kiely Campus Santa Clara, California  95051-5386
M.D. Anderson Cancer Center at Orlando Orlando, Florida  32806
Curtis and Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center Savannah, Georgia  31403-3089
Swedish-American Regional Cancer Center Rockford, Illinois  61104-2315
Lucille P. Markey Cancer Center at University of Kentucky Lexington, Kentucky  40536-0093
Cancer Institute of New Jersey at UMDNJ - Robert Wood Johnson Medical School New Brunswick, New Jersey  08903
Geisinger Cancer Institute at Geisinger Health Danville, Pennsylvania  17822-0001
Virginia Commonwealth University Massey Cancer Center Richmond, Virginia  23298-0037
West Virginia University Health Sciences Center - Charleston Charleston, West Virginia  25302
Gundersen Lutheran Center for Cancer and Blood La Crosse, Wisconsin  54601
Kaiser Permanente Medical Center - Sacramento Sacramento, California  95825
Huntsman Cancer Institute at University of Utah Salt Lake City, Utah  84112
Decatur Memorial Hospital Cancer Care Institute Decatur, Illinois  62526
Saint Francis/Mount Sinai Regional Cancer Center at Saint Francis Hospital and Medical Center Hartford, Connecticut  06105
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
South Bend Clinic South Bend, Indiana  46617
Harry & Jeanette Weinberg Cancer Institute at Franklin Square Hospital Center Baltimore, Maryland  21237
Lakeland Regional Cancer Care Center - St. Joseph St. Joseph, Michigan  49085
Hope A Women's Cancer Center Asheville, North Carolina  28801
Morgan Cancer Center at Lehigh Valley Hospital - Cedar Crest Allentown, Pennsylvania  18105
UPMC Cancer Centers Pittsburgh, Pennsylvania  15232
Eden Medical Center Castro Valley, California  94546
Kaiser Permanente - Fremont Fremont, California  94538
Kaiser Permanente Medical Center - Hayward Hayward, California  94545
Alta Bates Summit Medical Center - Summit Campus Oakland, California  94609
Valley Care Medical Center Pleasanton, California  94588
Kaiser Permanente Medical Center - Redwood City Redwood City, California  94063
Kaiser Permanente Medical Center - Richmond Richmond, California  94801
Kaiser Permanente Medical Center - Roseville Roseville, California  95661
South Sacramento Kaiser-Permanente Medical Center Sacramento, California  95823
Salinas Valley Memorial Hospital Salinas, California  93901
Kaiser Permanente Medical Office -Vandever Medical Office San Diego, California  92120
Kaiser Permanente Medical Center - Santa Teresa San Jose, California  95119
Kaiser Foundation Hospital - San Rafael San Rafael, California  94903
Kaiser Permanente Medical Center - Santa Rosa Santa Rosa, California  95403
Kaiser Permanente Medical Center - South San Francisco South San Francisco, California  94080
Kaiser Permanente Medical Facility - Stockton Stockton, California  95210
Kaiser Permanente Medical Center - Walnut Creek Walnut Creek, California  94596
Ella Milbank Foshay Cancer Center at Jupiter Medical Center Jupiter, Florida  33458
St. Joseph Medical Center Bloomington, Illinois  61701
Graham Hospital Canton, Illinois  61520
Memorial Hospital Carthage, Illinois  62321
Eureka Community Hospital Eureka, Illinois  61530
Galesburg Cottage Hospital Galesburg, Illinois  61401
Mason District Hospital Havana, Illinois  62644
McDonough District Hospital Macomb, Illinois  61455
Edward Hospital Cancer Center Naperville, Illinois  60540
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
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
Perry Memorial Hospital Princeton, Illinois  61356
St. Francis Hospital and Health Centers - Beech Grove Campus Beech Grove, Indiana  46107
Fort Wayne Medical Oncology and Hematology Fort Wayne, Indiana  46815
Center for Cancer Therapy at LaPorte Hospital and Health Services La Porte, Indiana  46350
Cancer Center of Kansas, PA - Dodge City Dodge City, Kansas  67801
Mary Bird Perkins Cancer Center - Baton Rouge Baton Rouge, Louisiana  70809
Medical Center of Louisiana - New Orleans New Orleans, Louisiana  70112
Hickman Cancer Center at Bixby Medical Center Adrian, Michigan  49221
Community Cancer Center of Monroe Monroe, Michigan  48162
Providence Cancer Institute at Providence Hospital - Southfield Campus Southfield, Michigan  48075
Saint Francis Medical Center Cape Girardeau, Missouri  63701
Immanuel Medical Center Omaha, Nebraska  68122
Creighton University Medical Center Omaha, Nebraska  68131-2197
Cancer Institute of New Jersey at Cooper - Voorhees Voorhees, New Jersey  08043
Charles R. Wood Cancer Center at Glens Falls Hospital Glens Falls, New York  12801
Iredell Memorial Hospital Statesville, North Carolina  28677
Forsyth Regional Cancer Center at Forsyth Medical Center Winston-Salem, North Carolina  27103
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
St. Luke's Hospital Maumee, Ohio  43537
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
North Coast Cancer Care, Incorporated Sandusky, Ohio  44870
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
Kaiser Permanente Health Care - Portland Portland, Oregon  97232
Bryn Mawr Hospital Bryn Mawr, Pennsylvania  19010
Lankenau Cancer Center at Lankenau Hospital Wynnewood, Pennsylvania  19096
Doctor's Hospital of Laredo Laredo, Texas  78041
Dixie Regional Medical Center - East Campus Saint George, Utah  84770
Mountainview Medical Berlin, Vermont  05602
Welch Cancer Center at Sheridan Memorial Hospital Sheridan, Wyoming  82801
St. Anthony Central Hospital Denver, Colorado  80204-1335
Exempla Lutheran Medical Center Wheat Ridge, Colorado  80033
St. Francis Hospital Federal Way, Washington  98003
St. Clare Hospital Lakewood, Washington  98499-0998
Providence St. Peter Hospital Regional Cancer Center Olympia, Washington  98506
Good Samaritan Cancer Center Puyallup, Washington  98371
Allenmore Hospital Tacoma, Washington  98411-0414
Highland General Hospital Oakland, California  94602
Northeast Georgia Medical Center Gainesville, Georgia  30501
Great Lakes Cancer Institute at McLaren Regional Medical Center Flint, Michigan  48532
Cancer Resource Center - Lincoln Lincoln, Nebraska  68510
Randolph Hospital Asheboro, North Carolina  27203
Moses Cone Regional Cancer Center at Wesley Long Community Hospital Greensboro, North Carolina  27401
Annie Penn Cancer Center Reidsville, North Carolina  27320
Altru Cancer Center at Altru Hospital Grand Forks, North Dakota  58201
Cancer Treatment Center Wooster, Ohio  44691
Allegheny Cancer Center at Allegheny General Hospital Pittsburgh, Pennsylvania  15212
Western Pennsylvania Cancer Institute at Western Pennsylvania Hospital Pittsburgh, Pennsylvania  15224-1791
Kaiser Permanente - Denver Denver, Colorado  80205
Kaiser Permanente - Lafayette Lafayette, Colorado  80026
Eastern Connecticut Hematology and Oncology Associates Norwich, Connecticut  06360
Tunnell Cancer Center at Beebe Medical Center Lewes, Delaware  19958
Herbert D. Kerman Regional Oncology Center - Daytona Beach Daytona Beach, Florida  32114
Michael and Dianne Bienes Comprehensive Cancer Center at Holy Cross Hospital Fort Lauderdale, Florida  33308
Nancy N. and J. C. Lewis Cancer and Research Pavilion at St. Joseph's/Candler Savannah, Georgia  31405
Kaiser Permanente - Moanalua Medical Center and Clinic Honolulu, Hawaii  96819
Elkhart Clinic, LLC Elkhart, Indiana  46514-2098
Michiana Hematology-Oncology, PC - South Bend Mishawaka, Indiana  46545-1470
Reid Hospital & Health Care Services Richmond, Indiana  47374
McFarland Clinic, PC Ames, Iowa  50010
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 - Newton Newton, Kansas  67114
Menorah Medical Center Overland Park, Kansas  66209
Saint Luke's Hospital - South Overland Park, Kansas  66213
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
Shawnee Mission Medical Center Shawnee Mission, Kansas  66204
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
Ochsner Health Center - Bluebonnet Baton Rouge, Louisiana  70809
Greater Baltimore Medical Center Cancer Center Baltimore, Maryland  21204
Foote Memorial Hospital Jackson, Michigan  49201
Haematology-Oncology Associates of Ohio and Michigan, PC Lambertville, Michigan  48144
St. Mary Mercy Hospital Livonia, Michigan  48154
Mercy Memorial Hospital - Monroe Monroe, Michigan  48162
St. Joseph Mercy Oakland Pontiac, Michigan  48341-2985
Mercy Regional Cancer Center at Mercy Hospital Port Huron, Michigan  48060
Seton Cancer Institute at Saint Mary's - Saginaw Saginaw, Michigan  48601
Lakeside Cancer Specialists, PLLC Saint Joseph, Michigan  49085
Truman Medical Center - Hospital Hill Kansas City, Missouri  64108
St. Joseph Medical Center Kansas City, Missouri  64114
Heartland Hematology Oncology Associates, Incorporated Kansas City, Missouri  64118
North Kansas City Hospital Kansas City, Missouri  64116
Saint Luke's Cancer Institute at Saint Luke's Hospital Kansas City, Missouri  64111
Research Medical Center Kansas City, Missouri  64132
Saint Luke's East - Lee's Summit Lee's Summit, Missouri  64086
Liberty Hospital Liberty, Missouri  64068
Heartland Regional Medical Center Saint Joseph, Missouri  64506
Billings Clinic - Downtown Billings, Montana  59107-7000
Bozeman Deaconess Cancer Center Bozeman, Montana  59715
St. James Healthcare Cancer Care Butte, Montana  59701
Great Falls Clinic - Main Facility Great Falls, Montana  59405
Sletten Cancer Institute at Benefis Healthcare Great Falls, Montana  59405
Kalispell Medical Oncology at KRMC Kalispell, Montana  59901
Alegant Health Cancer Center at Bergan Mercy Medical Center Omaha, Nebraska  68124
Summa Center for Cancer Care at Akron City Hospital Akron, Ohio  44309-2090
Barberton Citizens Hospital Barberton, Ohio  44203
North Coast Cancer Care - Clyde Clyde, Ohio  43410
Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at Ohio State University Comprehensive Cancer Center Columbus, Ohio  43210-1240
Hematology Oncology Center Elyria, Ohio  44035
Community Cancer Center Elyria, Ohio  44035
Wayne Hospital Greenville, Ohio  45331
Fisher-Titus Medical Center Norwalk, Ohio  44857
Flower Hospital Cancer Center Sylvania, Ohio  43560
St. Anne Mercy Hospital Toledo, Ohio  43623
Clinton Memorial Hospital Wilmington, Ohio  45177
Cleo Craig Cancer Research Clinic Lawton, Oklahoma  73505
St. Luke's Cancer Network at St. Luke's Hospital Bethlehem, Pennsylvania  18015
McGlinn Family Regional Cancer Center at Reading Hospital and Medical Center Reading, Pennsylvania  19612-6052
York Cancer Center at Apple Hill Medical Center York, Pennsylvania  17405
Sandra L. Maxwell Cancer Center Cedar City, Utah  84720
Jon and Karen Huntsman Cancer Center at Intermountain Medical Center Murray, Utah  84157
Val and Ann Browning Cancer Center at McKay-Dee Hospital Center Ogden, Utah  84403
Fredericksburg Oncology, Incorporated Fredericksburg, Virginia  22401
Providence Centralia Hospital Centralia, Washington  98531-9027
Franciscan Cancer Center at St. Joseph Medical Center Tacoma, Washington  98405-3004
Community Comprehensive Cancer Center at Camden-Clark Memorial Hospital Parkersburg, West Virginia  26102
Marshfield Clinic - Chippewa Center Chippewa Falls, Wisconsin  54729
Marshfield Clinic Cancer Care at Regional Cancer Center Eau Claire, Wisconsin  54701
Vince Lombardi Cancer Clinic - Green Bay at Aurora BayCare Medical Center Green Bay, Wisconsin  54311
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
Marshfield Clinic - Wausau Center Wausau, Wisconsin  54401
Marshfield Clinic - Weston Center Weston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids Center Wisconsin Rapids, Wisconsin  54494
Cancer Resource Center at King's Daughters Medical Center Ashland, Kentucky  41101
Regional Cancer Center at Memorial Medical Center Springfield, Illinois  62781-0001
Saint Louis University Cancer Center Saint Louis, Missouri  63110
Auburn Regional Center for Cancer Care Auburn, Washington  98002
John H. Stroger, Jr. Hospital of Cook County Chicago, Illinois  60612-9985
Community Hospital Munster, Indiana  46321
Aurora Sinai Medical Center Milwaukee, Wisconsin  53201-0342
St. Joseph Hospital Regional Cancer Center - Orange Orange, California  92868-3849
Phoebe Cancer Center at Phoebe Putney Memorial Hospital Albany, Georgia  31702
Queen's Cancer Institute at Queen's Medical Center Honolulu, Hawaii  96813
MetroWest Medical Center - Framingham Union Hospital Framingham, Massachusetts  01702
Good Samaritan Cancer Center at Good Samaritan Hospital Kearney, Nebraska  68848-1990
Tucker Center for Cancer Care at Orange Regional Medical Center Middletown, New York  10940-4199
Rutherford Hospital Rutherfordton, North Carolina  28139
Gibbs Regional Cancer Center at Spartanburg Regional Medical Center Spartanburg, South Carolina  29303
St. Francis Hospital Evanston, Illinois  60202
Frederick Memorial Hospital Regional Cancer Therapy Center Frederick, Maryland  21701
Lapeer Regional Hospital Lapeer, Michigan  48446
St. John's Regional Medical Center Joplin, Missouri  64804
MBCCOP - Meharry Medical College - Nashville Nashville, Tennessee  37208-3599
Great Falls, Montana  59405
Guardian Oncology and Center for Wellness Missoula, Montana  59804
Roper St. Francis Cancer Center at Roper Hospital Charleston, South Carolina  29401
Louisville Oncology at Norton Cancer Institute - Louisville Louisville, Kentucky  40202
Scripps Cancer Center - San Diego San Diego, California  92121
Doctors Medical Center - San Pablo Campus San Pablo, California  94806
Galesburg Clinic, PC Galesburg, Illinois  61401
St. Vincent Healthcare Cancer Care Services Billings, Montana  59101
University of Tennessee Cancer Institute - Memphis Memphis, Tennessee  38104
Desert Regional Medical Center Comprehensive Cancer Center Palm Springs, California  92262
Parvin Radiation Oncology Kansas City, Missouri  64116
Midwest Hematology Oncology Group, Incorporated Saint Louis, Missouri  63109
East Bay Radiation Oncology Center Castro Valley, California  94546
Contra Costa Regional Medical Center Martinez, California  94553-3156
El Camino Hospital Cancer Center Mountain View, California  94040
Larry G Strieff MD Medical Corporation Oakland, California  94609
Tom K Lee, Incorporated Oakland, California  94609
Bay Area Breast Surgeons, Incorporated Oakland, California  94609
Valley Medical Oncology Consultants - Pleasanton Pleasanton, California  94588
Kapiolani Medical Center at Pali Momi Aiea, Hawaii  96701
Kapiolani Medical Center for Women and Children Honolulu, Hawaii  96826
Straub Clinic and Hospital, Incorporated Honolulu, Hawaii  96813
Hawaii Medical Center - East Honolulu, Hawaii  96817
OnCare Hawaii, Incorporated - Kuakini Honolulu, Hawaii  96817
OnCare Hawaii, Incorporated - Lusitana Honolulu, Hawaii  96813
Maui Memorial Medical Center Wailuku, Hawaii  96793
Pacific Cancer Institute - Maui Wailuku, Hawaii  96793
Illinois CancerCare - Bloomington Bloomington%, Illinois  61701
Illinois CancerCare - Canton Canton, Illinois  61520
Illinois CancerCare - Carthage Carthage, Illinois  62321
Alexian Brothers Radiation Oncology Elk Grove Village, Illinois  60007
Illinois CancerCare - Eureka Eureka, Illinois  61530
Illinois CancerCare - Galesburg Galesburg, Illinois  61401
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
York Hospital's Oncology Treatment Center York, Maine  03909
Hattiesburg Clinic, PA at Forrest General Hattiesburg, Mississippi  39401
Cancer Center of Paoli Memorial Hospital Paoli, Pennsylvania  19301-1792
CCOP - Main Line Health Wynnewood, Pennsylvania  19096
AnMed Cancer Center Anderson, South Carolina  29621
Cancer Care Center, Incorporated Salem, Ohio  44460
Center for Cancer Care at Goshen General Hospital Goshen, Indiana  46526
Valley Medical Oncology Consultants - Castro Valley Castro Valley, California  94546
Valley Medical Oncology Fremont, California  94538
Cancer Care Associates Fresno, California  93720
Memorial Hospital Cancer Center - Colorado Springs Colorado Springs, Colorado  80909
Mount Sinai Hospital Medical Center Chicago, Illinois  60608
Alamance Cancer Center at Alamance Regional Medical Center Burlington, North Carolina  27216
Marion L. Shepard Cancer Center at Beaufort County Hospital Washington, North Carolina  27889
Nashville Oncology Associates, PC Nashville, Tennessee  37203
Associates in Oncology and Hematology - Medical Center Drive Rockville, Maryland  20878
St. Agnes Hospital Cancer Center Baltimore, Maryland  21229
Aurora Women's Pavilion of West Allis Memorial Hospital West Allis, Wisconsin  53227
Vince Lombardi Cancer Clinic - Oshkosh Oshkosh, Wisconsin  54904
Kootenai Cancer Center - Coeur d'Alene Coeur d'Alene, Idaho  83814
Illinois CancerCare - Cottage Galesburg, Illinois  61401
Saint Francis Hospital Cancer Center Poughkeepsie, New York  12601
Cherry Tree Cancer Center Hanover, Pennsylvania  17331