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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

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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 Institute Buffalo, New York  14263
Fred Hutchinson Cancer Research Center Seattle, Washington  98109
CCOP - Wichita Wichita, Kansas  67214-3882
Hurley Medical Center Flint, Michigan  48503
CCOP - Missouri Valley Cancer Consortium Omaha, Nebraska  68131
CCOP - Christiana Care Health Services Wilmington, Delaware  19899
Veterans Affairs Medical Center - Atlanta (Decatur) Decatur, Georgia  30033
CCOP - Illinois Oncology Research Association Peoria, Illinois  61602
CCOP - Iowa Oncology Research Association Des Moines, Iowa  50309-1016
CCOP - Metro-Minnesota Saint Louis Park, Minnesota  55416
Hinsdale Hematology Oncology Associates Hinsdale, Illinois  60521
Mercy Medical Center - Sioux City Sioux City, Iowa  51104
Siouxland Hematology-Oncology Associates, LLP Sioux City, Iowa  51101
St. Luke's Regional Medical Center Sioux City, Iowa  51104
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
CCOP - Duluth 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
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
CCOP - MeritCare Hospital Fargo, North Dakota  58122
Case Comprehensive Cancer Center Cleveland, Ohio  44106-5065
Natalie Warren Bryant Cancer Center at St. Francis Hospital Tulsa, Oklahoma  74136
Sanford Cancer Center at Sanford USD Medical Center Sioux Falls, South Dakota  57117-5039
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
Methodist Medical Center of Illinois Peoria, Illinois  61636
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 - Columbus Columbus, Ohio  43206
CCOP - Dayton Kettering, Ohio  45429
CCOP - Greenville Greenville, South Carolina  29615
Joe Arrington Cancer Research and Treatment Center Lubbock, Texas  79410-1894
LDS Hospital Salt Lake City, Utah  84143
CCOP - Northern Indiana CR Consortium South Bend, Indiana  46601
Holden Comprehensive Cancer Center at University of Iowa Iowa City, Iowa  52242-1002
Kimmel Cancer Center at Thomas Jefferson University - Philadelphia Philadelphia, Pennsylvania  19107
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Baltimore, Maryland  21231-2410
Kaiser Permanente Medical Center - Vallejo Vallejo, California  94589
Utah Valley Regional Medical Center - Provo Provo, Utah  84604
Peninsula Regional Medical Center Salisbury, Maryland  21801
City of Hope Comprehensive Cancer Center Duarte, California  91010
John Stoddard Cancer Center at Iowa Methodist Medical Center Des Moines, Iowa  50309
Kaiser Permanente Medical Center - San Francisco Geary Campus San Francisco, California  94115
St. Vincent Mercy Medical Center Toledo, Ohio  43608
Swedish Cancer Institute at Swedish Medical Center - First Hill Campus Seattle, Washington  98104
Thompson Cancer Survival Center Knoxville, Tennessee  37916
Washington Cancer Institute at Washington Hospital Center Washington, District of Columbia  20010
Harry and Jeanette Weinberg Cancer Institute at Franklin Square Hospital Center Baltimore, Maryland  21237
Hulston Cancer Center at Cox Medical Center South Springfield, Missouri  65807
Central Baptist Hospital Lexington, Kentucky  40503
CCOP - Toledo Community Hospital Toledo, Ohio  43623-3456
Kaiser Permanente Medical Center - Oakland Sacramento, California  95825
Florida Hospital Cancer Institute at Florida Hospital Orlando Orlando, Florida  32803-1273
Advocate Christ Medical Center Oak Lawn, Illinois  60453
Via Christi Cancer Center at Via Christi Regional Medical Center Wichita, Kansas  67214
Breslin Cancer Center at Ingham Regional Medical Center Lansing, Michigan  48910
NYU Cancer Institute at New York University Medical Center New York, New York  10016
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
Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center - Dallas Dallas, Texas  75390
McCreery Cancer Center at Ottumwa Regional Ottumwa, Iowa  52501
Baptist Cancer Institute - Jacksonville Jacksonville, Florida  32207
Hematology-Oncology Centers of the Northern Rockies - Billings Billings, Montana  59101
St. Peter's Hospital Helena, Montana  59601
Kalispell Regional Medical Center Kalispell, Montana  59901
Glacier Oncology, PLLC Kalispell, Montana  59901
Montana Cancer Center at St. Patrick Hospital and Health Sciences Center Missoula, Montana  59802
Adena Regional Medical Center Chillicothe, Ohio  54601
Doctors Hospital at Ohio Health Columbus, Ohio  43228
Riverside Methodist Hospital Cancer Care Columbus, Ohio  43214
Grady Memorial Hospital Delaware, Ohio  43015
Fairfield Medical Center Lancaster, Ohio  43130
Strecker Cancer Center at Marietta Memorial Hospital Marietta, Ohio  45750
Licking Memorial Cancer Care Program at Licking Memorial Hospital Newark, Ohio  43055
Community Hospital of Springfield and Clark County Springfield, Ohio  45505
Genesis - Good Samaritan Hospital Zanesville, Ohio  43701
Logan Regional Hospital Logan, Utah  84321
Group Health Central Hospital Seattle, Washington  98104
Kaiser Permanente Medical Center - Santa Clara Kiely Campus Santa Clara, California  95051-5386
Lucille P. Markey Cancer Center at University of Kentucky Lexington, Kentucky  40536-0093
Siteman Cancer Center at Barnes-Jewish Hospital - Saint Louis St. Louis, Missouri  63110
University of New Mexico Cancer Center Albuquerque, New Mexico  87131-5636
Oklahoma University Cancer Institute Oklahoma City, Oklahoma  73104
Kaiser Permanente Medical Center - Sacramento Sacramento, California  95825
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
Howard Community Hospital Kokomo, Indiana  46904
Mount Carmel Health - West Hospital Columbus, Ohio  43222
Parkland Memorial Hospital Dallas, Texas  75235
Lakeland Regional Cancer Center at Lakeland Regional Medical Center Lakeland, Florida  33805
UPMC Cancer Centers Pittsburgh, Pennsylvania  15232
Kaiser Permanente - Fremont Fremont, California  94538
Kaiser Permanente Medical Center - Hayward Hayward, California  94545
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
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
Saint Alphonsus Cancer Care Center at Saint Alphonsus Regional Medical Center Boise, Idaho  83706
St. Joseph Medical Center Bloomington, Illinois  61701
Graham Hospital Canton, Illinois  61520
Memorial Hospital Carthage, Illinois  62321
Eureka Community Hospital Eureka, Illinois  61530
Mason District Hospital Havana, Illinois  62644
McDonough District Hospital Macomb, Illinois  61455
BroMenn Regional Medical Center Normal, Illinois  61761
Community Cancer Center Normal, Illinois  61761
Community Hospital of Ottawa Ottawa, Illinois  61350
Cancer Treatment Center at Pekin Hospital Pekin, Illinois  61554
Oncology Hematology Associates of Central Illinois, PC - Peoria Peoria, Illinois  61615
OSF St. Francis Medical Center Peoria, Illinois  61637
Proctor Hospital Peoria, Illinois  61614
Illinois Valley Community Hospital Peru, Illinois  61354
Perry Memorial Hospital Princeton, Illinois  61356
St. Francis Hospital and Health Centers - Beech Grove Campus Beech Grove, Indiana  46107
John Stoddard Cancer Center at Iowa Lutheran Hospital Des Moines, Iowa  50316-2301
Medical Oncology and Hematology Associates at John Stoddard Cancer Center Des Moines, Iowa  50309
Medical Oncology and Hematology Associates at Mercy Cancer Center Des Moines, Iowa  50314
Mercy Cancer Center at Mercy Medical Center - Des Moines Des Moines, Iowa  50314
Medical Oncology and Hematology Associates - West Des Moines West Des Moines, Iowa  50266
Cancer Center of Kansas, PA - Dodge City Dodge City, Kansas  67801
Hickman Cancer Center at Bixby Medical Center Adrian, Michigan  49221
Providence Cancer Institute at Providence Hospital - Southfield Campus Southfield, Michigan  48075
St. Joseph's Medical Center Brainerd, Minnesota  56401
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
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
Middletown Regional Hospital Middletown, Ohio  45044
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
Bon Secours St. Francis Health System Greenville, South Carolina  29601
Dixie Regional Medical Center - East Campus Saint George, Utah  84770
Danville Regional Medical Center Danville, Virginia  24541
Welch Cancer Center at Sheridan Memorial Hospital Sheridan, Wyoming  82801
Missouri Baptist Cancer Center St. Louis, Missouri  63131
Cancer Resource Center - Lincoln Lincoln, Nebraska  68510
Allegheny Cancer Center at Allegheny General Hospital Pittsburgh, Pennsylvania  15212
Kaiser Permanente - Deer Valley Antioch, California  94531
Tunnell Cancer Center at Beebe Medical Center Lewes, Delaware  19958
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 - Liberal Liberal, Kansas  67905
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
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
Foote Memorial Hospital Jackson, Michigan  49201
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
St. Luke's Hospital Cancer Care Center Duluth, Minnesota  55805
Fergus Falls Medical Group, PA Fergus Falls, Minnesota  56537
Willmar Cancer Center at Rice Memorial Hospital Willmar, Minnesota  56201
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
Leo W. Jenkins Cancer Center at ECU Medical School Greenville, North Carolina  27834
Mary Rutan Hospital Bellefontaine, Ohio  43311
Grant Medical Center Cancer Care Columbus, Ohio  43215
Hematology Oncology Center Elyria, Ohio  44035
Community Cancer Center Elyria, Ohio  44035
Wayne Hospital Greenville, Ohio  45331
Knox Community Hospital Mount Vernon, Ohio  43050
Fisher-Titus Medical Center Norwalk, Ohio  44857
Flower Hospital Cancer Center Sylvania, Ohio  43560
St. Anne Mercy Hospital Toledo, Ohio  43623
Mount Carmel St. Ann's Cancer Center Westerville, Ohio  43081
McGlinn Family Regional Cancer Center at Reading Hospital and Medical Center Reading, Pennsylvania  19612-6052
Sandra L. Maxwell Cancer Center Cedar City, Utah  84720
Val and Ann Browning Cancer Center at McKay-Dee Hospital Center Ogden, Utah  84403
Fredericksburg Oncology, Incorporated Fredericksburg, Virginia  22401
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
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 - Weston Center Weston, Wisconsin  54476
Marshfield Clinic - Wisconsin Rapids Center Wisconsin Rapids, Wisconsin  54494
Regional Cancer Center at Memorial Medical Center Springfield, Illinois  62781-0001
Saint Louis University Cancer Center Saint Louis, Missouri  63110
St. Joseph Hospital Regional Cancer Center - Orange Orange, California  92868-3849
Union Hospital of Cecil County Elkton MD, Maryland  21921
Kinston Medical Specialists Kinston, North Carolina  28501
Manchester Memorial Hospital Manchester, Connecticut  06040-4188
Nalitt Cancer Institute at Staten Island University Hospital Staten Island, New York  10305
Galesburg Clinic, PC Galesburg, Illinois  61401
St. Vincent Healthcare Cancer Care Services Billings, Montana  59101
Berkshire Hematology Oncology, PC Pittsfield, Massachusetts  01201
Parvin Radiation Oncology Kansas City, Missouri  64116
Riddle Memorial Hospital Cancer Center Media, Pennsylvania  19063
Associates in Hematology-Oncology, PC at Crozer Regional Cancer Center Upland, Pennsylvania  19013
University of Colorado Cancer Center at UC Health Sciences Center Aurora, Colorado  80045
Ochsner Health Center - Covington Covington, Louisiana  70433
Self Regional Cancer Center at Self Regional Medical Center Greenwood, South Carolina  29646
Humphrey Cancer Center at North Memorial Outpatient Center Robbinsdale, Minnesota  55422-2900
Lakeview Hospital Stillwater, Minnesota  55082
CCOP - Kansas City Prairie Village, Kansas  66208
Goldschmidt Cancer Center Jefferson City, Missouri  65109
Comprehensive Cancer Care, PC Saint Louis, Missouri  63141
Butler Memorial Hospital Butler, Pennsylvania  16001
Overlake Cancer Center at Overlake Hospital Medical Center Bellevue, Washington  98004
Kaiser Permanente Medical Center - Vacaville Vacaville, California  95688
Mercy Cancer Center - West Lakes Clive, Iowa  50325